Addressing bone loss in shoulder instability lennard funk

Lennard Funk

Addressing Bone Loss The Pragmatic

Approach

[email protected]

www.wrightington.com

Basil Vandegriend, 2006

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How best to measure Glenoid Bone Loss?

1. X-Rays

2. MRI

3. CT

4. Arthroscopy

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How much glenoid loss for Bony Reconstruction?

1. 5%

2. 10%

3. 20%

4. 25%


What is a significant Hill-Sachs Lesion?

1. 4cm long

2. 20% humeral head surface

3. 40% humeral head surface

4. Engaging at Arthroscopy

GLENOID BONE LOSS

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Where does 20-25% come from?

Itoi Cadaveric Studies - JBJS, 2000: Stability of repaired cadaveric shoulders

With no glenoid removed With 21% anterior glenoid removed ER and ABER

Yamamoto & Itoi - AJSM, 2009 Stability ratio mechanical test 8 cadavers At 20% stability ration greatly decreased

Yamamoto - JBJS, 2010 Same study (with 5 more shoulders)!!

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Pear

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Inverted Pear

www.wrightington.com 9

• Glenoid loss 20-30% • FU 34 months • 15% Recurrence rate

“requiring surgery”

• ‘Inverted Pear’ • FU 27 months • 67% Recurrence rate

(89% contact athletes)

HUMERAL HEAD BONE LOSS

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What is a significant Hill-sachs lesion?

Bigliani & Flatow (1996) [quoted in Cetik (2007)]:

Mild - <20% Moderate - 20-45% Severe - >45%

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> 30% = Needs Treatment


What is a significant Hill-sachs lesion?

Balg & Bouileau (2008) in ISIS: Visible on AP X-Ray in External Rotation

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Funky Pizza Method

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Remplissage“Fill-in / padding” Eugene Wolf (2008)

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Indications for Remplissage

Wolf (2008): Combined glenoid bone defect & large Hill-Sachs

Burkart (2009): Moderate to large Hill-Sachs (>3 mm depth) with bony glenoid loss of >25% Borderline cases where glenoid defect is close to 25% but Hill-Sachs is small to moderate in size

Boileau (2010):

Large, Calandra Grade 3 Hill-Sachs, without glenoid bone-loss

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Assessing Bone Loss

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Balance Stability Angle - Matsen

Effective Glenoid Arc = the area of the glenoid’s articular surface available for humeral head compression Balance Stability Angle = the angle between the centre of the glenoid and the end of the effective glenoid arc in any direction (18 degrees anterior)

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‘Glenoid Track’ - Itoi & Yamamoto

Yamamoto - Cadaver

Metzger - MRI/MRA

Omori - In-vivo

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Yamamoto N, Itoi E, Abe H, et al. JSES 2007 Metzger et al. AAOSM, 2010 Omori et al. AJSM. March 2014.

Defined as the contact area between the glenoid and the humeral head while keeping the arm in maximum external rotation, maximum horizontal extension, and 0° to 90° of abduction relative to the trunk. "If a Hill-Sachs lesion extends medially over the glenoid track, there is a risk of engagement.


Largest Track (contact) found in full ABER = 84% of glenoid width

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‘Glenoid Track’


‘Glenoid Track’If the medial margin of a Hill-Sach’s lesion lies outside the glenoid track, this will cause an engaging Hill-Sach’s. "Bony defect of the glenoid will narrow the glenoid track, which can cause the medial margin of a relatively small Hill-Sach’s lesion to be outside the glenoid track


1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan.

2. Determine the width of the anterior glenoid bone loss (d). 3. Calculate the width of the glenoid track (GT) by the following

formula: GT=0.83D-d 4. Calculate the width of the HSI, which is the width of the Hill-

Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI = HS + BB.

5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.

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Normal Glenoid Track

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83%


Anterior Glenoid Deficiency

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D

83%


The Formula:

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1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan (of Opposite shoulder).

2. Determine the width of the anterior glenoid bone loss (d).

3. Calculate the width of the glenoid track (GT) by the following formula: GT=0.83D-d

4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI = HS + BB.

5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.

D

83%


The Formula:

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1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan.

2. Determine the width of the anterior glenoid bone loss (d).

3. Calculate the width of the glenoid track (GT) by the following formula: GT=0.83D-d

4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI = HS + BB.

1. If HSI > GT, the HS is ‘off track’, or engaging.

2.If HSI < GT, the HS is ‘on track’, or non-engaging.


Treatment Paradigm

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Group Glenoid Defect Hill-Sachs Recommended

Treatment

1 <25% On Track Arthroscopic Bankart

2 <25% Off Track Arthroscopic Bankart + Remplissage

3 >25% On Track Latarjet

4 >25% Off TrackLatarjet +

Remplissage / Humeral Bone Graft

Decision Making

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Balg & Bouileau, JBJSB, 2007:

Instability Severity Score!

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Balg & Bouileau, JBJSB, 2007:

No difference between: Gender (p=0.32) Type of Sports (p=0.31)

Difference between: Age (p=0.001) Level of sport (p=0.03) Shoulder laxity (p=0.03) Hill-Sachs lesion (p=0.002)

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My approach to Latarjet:

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Considerations:


Pragmatic 1:

24yr male footballer First Traumatic Dislocation

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Final repair


Sugaya Technique

Sugaya et al. 2005


Pragmatic 2:

28yr male Multiple recurrent traumatic dislocations with reducing force. Dislocating dressing & sleep Now avoidance Unable to work as nurse

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“Soap and water and common sense are the best disinfectants”

William Osler


Thank You

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Clinical (Classification)

MR Arthrogram

Glenoid

Bankart

Repair(scope / open)

Deficiency

Latarjet / Eden-Hybinette

Humeral Head

Large Hill-Sachs

Remplissage / Allograft

Capsule

HAGL

Repair(open / Scope)

Hyperlax

Shift / Plication

Addressing bone loss in shoulder instability lennard funk

Health & Medicine

Transcript of Addressing bone loss in shoulder instability lennard funk