Addressing bone loss in shoulder instability lennard funk
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This document discusses approaches to measuring and treating bone loss in the glenoid and humeral head that can contribute to shoulder instability. It addresses how to measure glenoid and Hill-Sachs lesions using various imaging modalities and arthroscopy. It presents studies examining the amount of glenoid and humeral head bone loss that significantly increases instability risk. The document also introduces the "glenoid track" and "Funky Pizza method" to assess if a Hill-Sachs lesion is engaging or non-engaging. It concludes with an overview of treatment approaches based on the size of glenoid and Hill-Sachs defects.
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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%
11
> 30% = Needs Treatment](https://image.slidesharecdn.com/addressingbonelossininstability-lennardfunk-150118044212-conversion-gate01/85/Addressing-bone-loss-in-shoulder-instability-lennard-funk-11-320.jpg)
Addressing bone loss in shoulder instability lennard funk
- 1. Lennard Funk Addressing Bone Loss The Pragmatic Approach lenfunk@shoulderdoc.co.uk
- 3. www.wrightington.com How best to measure Glenoid Bone Loss? 1. X-Rays 2. MRI 3. CT 4. Arthroscopy 3
- 4. www.wrightington.com How much glenoid loss for Bony Reconstruction? 1. 5% 2. 10% 3. 20% 4. 25%
- 5. www.wrightington.com What is a significant Hill-Sachs Lesion? 1. 4cm long 2. 20% humeral head surface 3. 40% humeral head surface 4. Engaging at Arthroscopy
- 7. www.wrightington.com 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)!! 7
- 9. 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)
- 10. HUMERAL HEAD BONE LOSS 10
- 11. www.wrightington.com What is a significant Hill-sachs lesion? Bigliani & Flatow (1996) [quoted in Cetik (2007)]: Mild - <20% Moderate - 20-45% Severe - >45% 11 > 30% = Needs Treatment
- 12. www.wrightington.com What is a significant Hill-sachs lesion? Balg & Bouileau (2008) in ISIS: Visible on AP X-Ray in External Rotation 12
- 14. www.wrightington.com Remplissage “Fill-in / padding” Eugene Wolf (2008) 14
- 15. www.wrightington.com 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 15
- 17. www.wrightington.com 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) 17
- 18. www.wrightington.com ‘Glenoid Track’ - Itoi & Yamamoto Yamamoto - Cadaver Metzger - MRI/MRA Omori - In-vivo 18 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.
- 19. www.wrightington.com Largest Track (contact) found in full ABER = 84% of glenoid width 19 ‘Glenoid Track’
- 20. www.wrightington.com 20 ‘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
- 21. www.wrightington.com 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. 21
- 24. www.wrightington.com The Formula: 24 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%
- 25. www.wrightington.com The Formula: 25 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.
- 26. www.wrightington.com Treatment Paradigm 26 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 Track Latarjet + Remplissage / Humeral Bone Graft
- 28. www.wrightington.com Balg & Bouileau, JBJSB, 2007: Instability Severity Score! 28
- 29. www.wrightington.com 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) 29
- 30. www.wrightington.com My approach to Latarjet: 30 Considerations:
- 31. www.wrightington.com Pragmatic 1: 24yr male footballer First Traumatic Dislocation 31
- 33. www.wrightington.com Sugaya Technique Sugaya et al. 2005
- 34. www.wrightington.com Pragmatic 2: 28yr male Multiple recurrent traumatic dislocations with reducing force. Dislocating dressing & sleep Now avoidance Unable to work as nurse 34
- 36. www.wrightington.com 36 “Soap and water and common sense are the best disinfectants” William Osler
- 38. www.wrightington.com 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