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Bone defects thessal2010
1. Treatment of
Glenoid and Humeral Head
Bone Defects
in Shoulder Instability
Nikolaos Tzanakakis
Orthopedic Surgeon
2nd
Orthopedic Dept.
Center for Shoulder Arthroscopy
IASO General Hospital
Athens, Greece
2. Background
There is a well-recognized association between
osseous defects of the glenoid or humerus
and shoulder dislocation, which often leads to
recurrent instability.
Boileau P., J Bone Joint Surg Am. 2006 Aug;88(8):1755-63.
Lynch JR., J Shoulder Elbow Surg. 2009 Mar-Apr;18(2):317-28.
Burkhart SS., Instr Course Lect. 2009;58:323-36.
www.shoulder.gr
3. Mechanism of Bone Defects
Hill-Sachs Glenoid bone
Loss
Normal Shoulder Bone contact
Dislocation
www.shoulder.gr
4. Bone defects after anterior dislocation
(unpublished data, 125 patients)
Hill-Sachs &
Glen. Defect
Hill-Sachs &
No Glen. Defect
No Hill-Sachs &
No Glen. Defect
No Hill-Sachs &
Glen. Defect
23.6%
45.5%
30.1%
0.8%
www.shoulder.gr
5. Bone Defects Frequency
Hill-Sachs: 65-71% first dislocation
Hill-Sachs: 93% recurrent dislocations
Glenoid bone loss: 5-56% traumatic instability
Possitive correlation between Number of
dislocations and depth/extend of the lesions
Lynch JR, J Shoulder Elbow Surg (2009) 18, 317-328
www.shoulder.gr
7. Hill-Sachs Lesion
•Impression fracture of the
posterolateral humeral head
•Present up to 90% of anterior
dislocations and 25% of
anterior subluxations
(Calandra JJ, Arthroscopy1989;5:254)
•Reverse Hill-Sachs
(posterior dislocations)
www.shoulder.gr
8. Hill-Sachs Arthroscopic Grading
Grade I: defect in the articular surface
down to subchondral bone
Grade II: includes the subchondral bone
Grade III: large subchondral defect
Calandra et. Al, 1989
www.shoulder.gr
9. Hill-Sachs Grading
MINOR: Less than 20% of head
MODERATE: 20-40% of head
SEVERE: Greater than 40% of head
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14. Guidelines for Hill-Sachs Treatment
Most Hill-Sachs lesions are small and don’t
require treatment
Each lesion should be evaluated during surgery
Treatment Required for:
- Lesions found to be engaging in a normal ROM
- Lesions representing >30%-40% of the
articular surface
Center for Shoulder
Arthroscopy
IASO GENERAL Hospital
17. Humeral Head Grafting for Hill-Sachs
Bushnell BD, Creighton RA, Herring MM. Hybrid treatment
of engaging Hill-Sachs lesions: Arthroscopic capsulolabral
repair and limited posterior approach for bone-grafting. Tech
Shoulder Elbow Surg 2007;8:194-203.
www.shoulder.gr
18. Trans-humeral head plasty
Re P, Gallo RA, Richmond JC. Transhumeral
head plasty for large Hill-Sachs lesions. Arthroscopy
2006;22:798.e1-798.e4
www.shoulder.gr
19. Hemi-CAP
Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeral
head resurfacing for fixed anterior glenohumeral dislocation.
Int Orthop 2007 Dec 19 [Epub ahead of print]
www.shoulder.gr
23. Background Knowledge
Considerable Glenoid defects
after shoulder dislocation
decrease the intrinsic
stability.
[Burkhart, De Beer, Itoi, Mologne]
In vitro, less forces need to
dislocate the shoulder.
[Burkhart SS. Arthroscopy, 2000]
www.shoulder.gr
24. Types of Glenoid bone defects
Bony Bankart Attritional bone loss
www.shoulder.gr
26. Glenoid Bone Defect
Considerable
Glenoid Bone
Loss
a > b/2
“Inverted Pear”
a b
Loss of 8.6mm of anterior radius of glenoidLoss of 8.6mm of anterior radius of glenoid
at the level of the bare spot corresponds toat the level of the bare spot corresponds to
35% of the normal anteroposterior width35% of the normal anteroposterior width
Lo IK, Parten PM, Burkhart SS:
Arthroscopy 2004;20:169-174.www.shoulder.gr
27. Bare Spot
b a
% Bone Loss
Lo IK, Parten PM, Burkhart SS: The
inverted pear glenoid: An indicator of
significant glenoid bone loss.
Arthroscopy 2004;20:169-174.
a
ba
2
−
=
www.shoulder.gr
28. Imaging Evaluation:
Pico Method (2D CT)
Taverna et al. Pico Method 2D CT – measurement of glenoid
surface
Critical Limit 25% loss of glenoid surface
www.shoulder.gr
29. Imaging Evaluation:
Glenoid Index (3D CT)
Glenoid Index in 3D CT scan of both shoulders
Critical Limit Glenoid index 0.75
SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
www.shoulder.gr
34. Bristow procedure
Young DC, Rockwood CA Jr. J Bone Joint Surg Am
1991;73:969-981.
Hovelius L,. J Shoulder Elbow Surg 2004;13:509-16.13.6%
recurrence
rate
www.shoulder.gr
36. Bone Graft from Acromion
Mochizuki Y, Hachisuka H, Kashiwagi K, Oomae H, Yokoya
S, Ochi M. Arthroscopic autologous bone graft with arthroscopic
Bankart repair for a large bony defect lesion caused by
recurrent shoulder dislocation. Arthroscopy 2007;23:677.e1-
677.e4.
www.shoulder.gr
39. What is the critical
Glenoid Bone Defect?
Critical bone loss:
>20-30%
6.8 mm width of resection 21%
to total length of the glenoid -
substantial loss of stability
Cadaveric biomechanical study
Itoi,et.al. JBJS 2000
www.shoulder.gr
40. Glenoid Bone Loss Algorithm
<15% (0-3.5mm) Soft Tissue Repair
15-(25)30% (5-6mm) Soft Tissue Repair +
Bony Bankart
Consider patient demands
>(25)30% (6.5-8.6mm) Bone Grafting procedures
Piasecki et al. AAOS J17 (8): 482. (2009)
www.shoulder.gr
43. Our Technique
Rotator Interval
Closure
Posterior Capsule
Plication
Rehabilitation Protocol:
from early passive movements to
propioception and return to sports.
www.shoulder.gr
44. Our Results
Period: 1999-2004
116 patients with anterior shoulder instability
Arthroscopic Treatment
At least 5 years follow-up (range 5-9.75 years)
Hill-Sachs 78/116 67.2%
Glenoid defect 36/116 31.0%
Invetred pear 8/116 6.8%
www.shoulder.gr
45. Our Results
Recurrence rate: 7/116 6.03%
(2 MVA, 2 Sports, 1 Fall, 1 No Comply, 1 Minor Trauma)
6/7 re-operated arthroscopicaly – No recurrence yet
Rowe-Zarins: Pre-Op 33 (15-80),Post-Op:95 (80-100)
Satisfaction
109/116 Very Satisfied 93.9%
6/116 Satisfied 5.2%
1/116 Did not answer 0.9%
Return to work: 116/116 100%
Return to sports: 45/116 38.8%
www.shoulder.gr
46. Handball player: 23y, 1st
dislocation 21y,
total 3 Dislocations
Typical Bankart No Considerable Glen Defect
Hill-Sachs Typical Repair
www.shoulder.gr
47. Typical Rehabilitation Program
…full return to sports 9 months later
…but 15 months after the operation….
Handball player: 23y, 1st
dislocation 21y,
Left shoulder, Total 3 Dislocations
www.shoulder.gr
48. Handball player: 23y, 1st
dislocation 21y,
Left shoulder, Total 3 Dislocations
www.shoulder.gr
51. Conclusions
Humeral Head bone loss (Hill-Sachs)
Graft reconstruction
Prosthetic replacement
Remplissage
Glenoid bone loss
Soft Tissue Repair (more than a simple Bankart
repair)
Bone Grafting (many methods)
Bristow or Laterjet
Open
Arthroscopic
www.shoulder.gr