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Shoulder dislocation
With Bone Defects
Manos Antonogiannakis
Orthopaedic Surgeon
Director of 3rd Orthopaedic Department
Centre for Arthroscopy & Shoulder Surgery
Hygeia General Hospital
7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery
Thessaloniki 2016 .

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Shoulder dislocation
With Bone Defects
Disclosures
Zimmer Biomet SportsMed course - Invited Speaker
7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery
Thessaloniki 2016 .

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The Shoulder
 Greatest Range of Motion in the Body
 Prone to instability
Sacrifices stability for mobility

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Types of instability
Not a black or white issue

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Contributors to stability
Static stabilizers
1. ligamentous structures labrum and
capsule
2. bony configuration of glenoid and
humeral head
Dynamic stabilizers
1. rotator cuff
2. scapula muscles

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Bone Defects
 Glenoid side
 Humeral side

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Glenoid Bone Defects

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The inferior 2/3 of the glenoid is nearly a perfect
circle with avg diameter 24mm
Huysman et al. JSES 2006

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Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim

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Traumatic Glenohumeral Bone Defects and Their
Relationship to Failure of Arthroscopic Bankart Repairs:
Significance of the Inverted-Pear Glenoid and the
Humeral Engaging Hill-Sachs Lesion
S.S. Burkhart and J. F. De Beer, M.D.
Arthroscopy,October 2000

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 Total group: 194 patients
 173 pt without significant bone defects :
7 pt sustained a recurrence (4%)
 21 pt with significant bone defects:
14 pt developed rec instability (67%)

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Loss of 8.6mm of anterior radius of glenoid at the
level of the bare spot corresponds to 35% of the
normal anteroposterior width
Lo, Burkhart Arthroscopy 2004

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>25 – 30% bone loss 6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)

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 Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid surface

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 Our practice
The percentage of the glenoid defect was evaluated on the en face reconstructed
view with the humeral head eliminated
Sugaya et al (2005) Joint Surg Am

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Glenoid Bone Loss >25%
open Latarjet
Arthroscopic Latarjet procedure
L. Lafosse
Arthroscopic Bristow procedure
P.Boilleau
Arthroscopic shoulder stabilization with a bone block
E. Taverna

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Humeral Bone Defects
Hill-Sachs lesion

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Humeral Bone Defects
Engaging
Non Engaging

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Engaging Hill Sachs

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Hill- Sachs Remplisage: An arthroscopic surgical
solution for the engaging Hill-Sachs
E.M. Wolf
Remplissage

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Remplissage

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From January 2007 to December 2010
(4 years)
48 patients
Average age: 28.9 ± 7.8 years
Average fu: 37.2 ± 9.9 months
Recurrence percentage: 6.3%

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Inclusion criteria
 Traumatic unidirectional anterior shoulder instability
 Hill-Sachs lesion of the humeral head
 Evidence of engaging Hill-Sachs lesion during dynamic evaluation under arthroscopy
 Arthroscopic Bankart repair in conjunction with arthroscopic remplissage
 Follow-up period longer than 2 years
Exclusion criteria
 Anterior glenoid rim defect or fracture exceeding 25% of the inferior glenoid diameter confirmed intra-operatively
 Humeral avulsion of the glenohumeral ligaments (HAGL) detected intra-operatively
 Psychological disease or epilepsy

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The outcome of the enhancement of the classic Bankart repair with tenodesis of the
infraspinatus and posterior capsular plication is very good as far as the management of
recurrent anterior shoulder instability is concerned, without significantly influencing the
range of motion of the shoulder

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The combination of the lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure

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From engaging Hill Sachs to
On-track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?

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From engaging Hill Sachs to
On-track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?
It is the combination of the existing lesions
Large Hill-Sachs lesion + No glenoid bone loss
=
Small Hill-Sachs lesion + 15% -20% glenoid bone loss

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head
The width of the glenoid track without a glenoid defect is 83% of the glenoid width.
B. Relation of glenohumeral joint in abduction and external rotation.
The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14% of the
glenoid width: F - M = 83% of glenoid width = glenoid track.

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A. 3D CT scan with en face view of a glenoid with bone loss of width d.
In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d.
B. Relation of glenohumeral joint in abduction and external rotation.
One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid.
In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill-Sachs
lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
How to Determine Whether Hill-Sachs Lesion Is “On Track” or “Off 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 = 0.83 D - 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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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment
1 <25% On track Arthroscopic Bankart repair
2 <25% Off track Arthroscopic Bankart repair plus remplissage
3 >25% On track Latarjet procedure
4 >25% Off track Latarjet procedure with or without humeral
sided procedure (humeral bone graft or
remplissage),
depending on engagement of Hill-Sachs lesion
after Latarjet procedure

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E.Taverna, et.al,Knee Surg
Sports Traumatol Arthrosc
(2008) 16:872–875

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Arthroscopic Bone Block
combined with Remplissage

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3 months
Post-op

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3 months
Post-op

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3 months
Post-op

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Our Results
15 cases
Impressive early outcomes

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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.

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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]

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 The combination of bone defects is
sighnificant
 If the loss is mainly from the humeral head the
remplissage procedure is very effective and
easy to perform
 If the defect is mainly in the glenoid side the
Latarget procedure or an iliac crest graft
combined with remplissage is very effective

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What is Instability
 Biomechanical Dysfunction
 Failure of static and dynamic stabilizers
 Ranges from mild subluxation to
traumatic dislocation

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T.U.B.S.
Traumatic
Unidirectional
Bankart lesion
Surgery
A.M.B.R.I.
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
A.I.O.S.
Acquired
Instability
Overstress
Surgery
Instability Profiles

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The most common presentation
A patient with some degree of laxity
genetically controlled dislocates his
shoulder after a minor or major accident

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History:
degree of violence
Level of athletic participation
number of dislocations
Age of the patient
Clinical examination:
Generalized Joint laxity
direction of aprehension
dictates treatment

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So what makes a shoulder
unstable
Degree of trauma and anatomic damage
Muscular dysfunction
Level of athletic activity
We must act in all of them

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Posterior instability
clinical presentation
in forward flexion and internal rotation sometimes after an anterior repair
of a lux shoulder
2. Locked posterior dislocation with loss of external rotation
1. Sense of insecurity and feeling of instability

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Locked posterior dislocation
is easily missed

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 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

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23 pt active military personel,
25y mean age 20-30% bone loss 7mm of ap width
34months mean fu,
14.2% rec rate
Mologne et al. AJSM 2007

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Parameter Pre-operatively Latest Follow-up Difference P value
Active forward flexion
mean value ± standard deviation
170 ± 25.8 degrees 179 ± 3.1 degrees + 9 degrees n.s.
External rotation beside the body
mean value ± standard deviation
73.6 ± 23.0 degrees 78.1 ± 13.1 degrees + 4.5 degrees n.s.
External rotation at 90 degrees of abduction
mean value ± standard deviation
89.2 ± 25.9 degrees 85.4 ± 9.3 degrees - 3.8 degrees n.s.
Internal rotation
median value, range
T10 level (range, T6-L2) T10 level (range, T7-T12) Same level n.s.
Mean ASES score
mean value ± standard deviation
67.7 ± 21.5 90.8 ± 21.7 + 23.1 p<0.01
Mean Rowe-Zarins score
mean value ± standard deviation
38 ± 17.3 93.8 ± 14.5 + 55.8 p<0.001
Mean Oxford Instability score
mean value ± standard deviation
27.6 ± 11.1 45.1 ± 8.3 + 17.5 p<0.01

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Bone loss <15% (0-3.5mm) of AP width
Soft tissue repair incorporating the bone
fragment if possible
Piasecki et al. AAOS J17 (8): 482. (2009)

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Sugaya et al. JBJS Am 2005