The Failed Instability Repair: What to do Now?

The Failed Instability Repair: What to do Now?
Dr. Fernando Radice
Centro de
Medicina del deporte
CLC
CHILE
Objectives of surgery
Mobility
Stability
Introduction
•  Something happens ...
•  Risk Factors associated with
recurrent dislocation
• 
• 
• 
• 
• 
Young patients
Contacts Sports
Hypermobility
Multidirectional instability
Bone defects
•  Inadequate postop rehabilitation
The Failed Instability Repair
•  New Trauma: 3600 surgeries 85 % high energy
trauma in children under 30 years ( 28.6 % vs
6.7% contact no contact ) Cho Ns .
•  Functional limitation : external rotation
restriction ; rotator strength, apprehension
(60 % vs 85.7 sport overhead contact) J. Ide
•  Bone defects : glenoid - Humeral Head
•  Patient Condition
•  Technical pitfall
Risk factors for recurrent instability after
Arthroscopic Bankart Procedure.
Age at surgery < 20 y
Competitive sport
Contact sport - collision
Hyperlaxity
Hill Sachs visible external rot
Glenoid bone defect in AP
31 %
26 %
33 %
19%
31 %
37 %
Balg, Boileau, JBJS Br 2007
Glenohumeral Instability
•  No differences between open surgery ( 6.7%) and
arthroscopic surgery (6% )
•  Athletes (contact) higher failure rate
Balg F, Boileau P (2007) The instability severity index score. A simple
pre-operative score to select patients for arthroscopic or open shoulder
stabilisation. J Bone Joint Surg Br 89(11): 1470–1477
ISIS
<= 3
<= 6
>6
Failure rate
5%
10%
70%
Instability Severity Index Score (ISIS)
Balg F, Boileau P (2007) The instability severity index score. A simple pre-operative score to
select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 89(11):
1470–1477
•  Age at surgery (yrs)
•  Degree of Sports
participation
•  Type of Sport
•  Shoulder Hiperlaxity
•  Hill-Sachs on AP
radiograph
Glenoid loss of contour
•  < 20
> 20
•  Competitive
Recreational or non
•  Contact or forced overhead
Other
•  Hiperlaxity Anterior or Inferior
Normal laxity
•  Visible in external rotation
Not visible
2
0
2
0
1
0
2
0
2
0
• 
• 
2
0
Loss of contour
No Lesion
Total = 10
Outcomes of Arthroscopic Bankart Repair
•  Overall Recurrent Instability
•  Average recurrent instability rates: beach chair:
•  Average recurrent instability rates Lateral Decubitus Position:
0-38%
14,6%
8,5%
Outcomes of Arthroscopic Anterior Shoulder Instability in the Beach Chair Versus Lateral Decubitus Position: A
Systematic Review and Meta-Regression Analysis Rachel M. Frank, M.D., Maristella F. Saccomanno, M.D., Lucas S.
McDonald, M.D., Mario Moric, M.S., Anthony A. Romeo, M.D., and Matthew T. Provencher, M.D. Arthroscopy 2014
•  Arthroscopic Bankart Repair
Boileau
Kandzina
Kim
Lafosse
Garstman
Tauro
Recurrent instability
15.3 %
16.5 %
10.0 %
18.5 %
8.0 %
8.0 %
Clinica Las Condes
16%
Gutierrez; Pinedo; Ekdahl; Radice
The Failed
Instability
Repair: What to
do Now?
Associated Lesions in Shoulder
Instability
Bankart lesion
.
Glenoid Bone
Defect
Hill-Sachs
Burkhart & De Beer, 2000
Open Surgery:
Latarjet Procedure
•  Dr. Michel Latarjet 1954
•  Latarjet M. Treatment of recurrent
dislocation of the shoulder. Lyon Chir 1954;
49(8):994–7. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/13234709.
Ac- cessed February 17, 2013.
Open Surgery :Latarjet
Triple blocking effect
A- Repair of the capsule to the stump of coracoacromial ligament
B- Increase or restore the glenoid bone
C- Conjoint tendon act as a sling on the subescapularis and capsule with the
arm in abduction and external rotation
Surgical Technique
Bhatia, Arthroscopy 2014
Surgical Technique
Bhatia, Arthroscopy 2014
Surgical Technique
Bhatia, Arthroscopy 2014
Surgical Technique
Surgical Technique
JBJS Am 2013
•  90° abd y external rotation):
–  Sling efect (Tendón conjunto + SScC:
–  Capsule repair and coracoacromial ligament
77%
23%
•  60° abd y neutral rotation):
–  Sling efect (Tendón conjunto + SSc):
–  Bone block:
62%
38%
Results
Latarjet
•  10 Studies
Arthroscopy 2014
Study
Evidence
N
FU (year)
Recurrent
Instability
Allain, 1988
IV
58
14
2%
Burkhart, 2007
IV
47
5
5%
Di Giacomo, 2011
IV
26
2,3
0%
Edouard, 2010
IV
20
1,7
5%
Elkousy, 2010
IV
30
1
0%
Fontanesi, 1996
IV
15
2
0%
Lafosse, 2010
IV
98
2
0%
Maynou, 2005
III
102
7,5
No rep.
Schmid, 2012
IV
49
3
No rep.
Shah, 2012
IV
48
3,2
8%
Comparative Studies
Nice Shoulder Course 2014
CORR 2014
Timing of recurrent:
•  Bankart: outcomes are worse over time
•  Latarjet: Recurrent instability during the first 2 years after surgery .
After 2 years same FU
Clinica Las Condes
Shoulder & Sports Medicine Department
•  2009 – 2013.
•  31 patients treated with open surgery :Latarjet
procedure
•  Material
–  Gender: 100% male.
–  Age: Average 25,74 ± 7,22 y. (Range 19-56 y)
–  Smoking: 4 pacientes (12,9%).
–  Laterality: right: 13 patients (42%).
left: 18 patients (58%).
–  Failed Arthroscopic Bankart repair:
16 patients (51,6%).
Clinica Las Condes
Shoulder & Sports Medicine Department Study
intraoperative incidents
Postop Complications
0%
3 hematomas (9,7%)
Delayed Union
0%
No unión
0%
Recurrent Shoulder instability
0%
Apprehension
2 (6,9%)
Clinica Las Condes
Shoulder & Sports Medicine Department
Study
SSV
Average : 90,26 ± 12,63 pts. (score= 50-100)
Rowe
Average: 93,75 ± 9,22 pts. (score= 75–100)
External Rotation 3 patients (18,75%) with ↓ de ER.
Sport Return
18,2 (4,55 months) ± 3,47 weeks
FollowUp
2,83 ± 1,17 years (28,6 months).
• 
Physical Rehabilitation in Latarjet
procedure
Recover Rotator
muscle loss of
strength
•  Correct increased
fatigability
especially internal
rotation present at
3 months postop
and recovered
fafter the sixth
months
•  Causes: disuse
atrophy ; pain,
functional
limitation, surgery
( subscapularis
injury )
PH Oscar Migueles
Rehabilitattion Program focuse in en
propioception, fatigability and strenght
Oscar Migueles Rehab Program
EVOLUTION (0 – 6 MONTHS)
NEURO PROPIOCEPTION
4W
SPORT
RETURN
POWER
FATIGABILITY
4W – 8W
FASE 3
FORTALECIMI
ENTO 4W – 8W
FASE 2
Repair Process
Healing Process
Stability
ANALGESYA
FLEXIBILITY
4W
FASE 1
MÁXIMA
PROTECTION
4W
FASE 0
Injury
Surgery
Pain
Edema
Instability
Apprehension
Retorno Deportivo
§  Los programas rehabilitación se
correlacionan con el tipo de deporte
§ Los programas son de 4 – 6M
§  Deben incluirse ejercicios propioceptivos o
de integración sensoriomotriz
§  Una Rehabilitación Adecuada
necesariamente debiera traducirse en menor
falla
Discusion
•  After surgical stabilization by the Bristow–Latarjet procedure,
previous studies reported a transitional post- surgical global reduction
in IR and ER strength (Dauty et al., 2007; Amako et al., 2008; Edouard
et al., 2012).
•  Associated with this overall strength rotator deficit ,
increased fatigability seen especially in internal rotation at
3 months postop and recovered from six months
•  Causes: disuse atrophy ; pain, functional limitation,
surgery ( subscapularis injury)
•  Development of rehabilitation program focused on
propioception , fatigue and strength.
•  Return sports related to functional recovery 4 – 6 months
Indication for Open Surgery
Latarjet Procedure
ABSOLUTE
•  Glenoid Bone defect
(> 20%)
RELATIVE
•  Shoulder Instability with Risk Factors
•  ISIS > 6
•  Contact Sport
•  Failed Arthroscopic Bankart Repair
•  Hill-Sachs Lesion
Home take message...
•  Latarjet-Bristow
–  Low rate of recurrent...
¿Gold Standard?
–  Low rate of
complication
–  Firts Choice of
Surgical treatment not
only in bone defect
–  Rehabilitation Program
is very important in
Sports Return
Thank You...