Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Disclosures: Posterior Instability: Why is this important and How to Treat? 1. 2. 3. 4 4. 5. Anthony A. Romeo, MD Professor, Departments of Orthopedics Head, Section of Shoulder and Elbow Surgery Team Physician, Chicago White Sox and Bulls Chief Medical Editor, Orthopaedics Today 6. Outline 1. 2. 3 3. 4. 5. 6. Some definitions Pathoanatomy Diagnosis & Pertinent Physical Exam Proper surgical patient selection Arthroscopic posterior stabilization Management of posterior glenoid bone loss Royalties: Arthrex Consultant: Arthrex Miscellaneous Support: Arthrex B i Science/Research Basic S i /R h Support: S t Arthrex, A th S ith andd Smith Nephew, Ossur, Miomed, DJOrtho, Conmed Linvatech, Athletico Editorial Board: Orthopedics Today (Chief Medical Editor), Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow, Techniques in Sports Medicine, Sports Health, Orthopedics Publisher Support: Elsevier (Textbook) Definitions Laxity- excessive translation, asymptomatic Instability- SYMPTOMATIC translation Classification of Posterior Instability: 1. Traumatic 2. Atraumatic 3. Voluntary a. Voluntary Muscular (habitual) b. Voluntary Positional Screen for Voluntary PI Cause of Atraumatic PI 1. Collagen Disease Or Voluntary muscular- habitual, secondary gain Voluntary positional- no secondary gain, patient avoids provocative positions Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 2. Bony Deformity 1 Posterior Instability: Why is this important and How to Treat Traumatic PI AANA Fall Meeting November 2013 Who is at risk for traumatic posterior instability? Most common etiology requiring surgical tx Single Event Vs. Cumulative effect of multiple smaller traumatic episodes Bradley AJSM 2006 Single event traumatic posterior instability “Posterior-Inferior” Instability A Spectrum of Instability Posterior Stabilizers 1. Recurrent Subluxation- most common presentation as a result of single traumatic dislocation or repetitive p microtrauma 2. Recurrent dislocation- less common than anterior instability, Reverse Hills Sachs 3. Fixed posterior dislocation 4. Posterior glenoid bone loss a. Acquired (fracture or erosion) b. Developmental Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois Static: 1. Labrum- deepens socket by 50% 2 IGHLC2. IGHLC attaches from 2-4 2 4 to 7 7-9 9 o’clock o clock a. posterior band present in 63% 3. Rotator interval- “circle” concept a. CHL, SGHL, long head of bicep tendon Dynamic: 1. Rotator cuff, periscapular muscles 2 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Pathomechanics: loss of static stabilizer function Loss of chondrolabral containment 1. Labral deficiency 51-58% 1. Tearing/Attentuation 2. Healing in a recessed position p g laxity y 43-67% 2. Capsuloligamentous 1. Anterior/Posterior/”Circle Concept” 3. Glenoid deficiency/malpositioning 1. Retroversion/Dysplasia 2. Bone loss 3. Scapular dyskinesis Loss of chondrolabral containment is a consistent finding in shoulders with symptomatic posterior instability. Loss of chondrolabral containment: The rim-loading mechanism Savoie FH, Holt MS, Field LD, Ramsey JR. Arthroscopic management of posterior instability: evolution of technique and results. Arthroscopy. May 2008;24(4):389396. Bradley JP. Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder: A Prospective Study of 100 Shoulders. Am J Sports Med. Mar 21 2006;34(7):1061-1071. pathoanatomy Sites of failure of Posterior static stabilizers: Kim SH et al. JBJS 2005. Reverse Bankart Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 1 glenoid labral attachement1. attachement Reverse bankart- 4 types POALPSA Post GLAD lesion 2. Mid Capsule- capsular insufficiency 3. Humeral insertion of ligaments- RHAGL Kim Lesion 3 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 POLPSA Posterior GLAD lesion Posterior Capsular laxity RHAGL Physical Exam Generalized shoulder exam 1. Scapular Rhythm, ROM, strength Exam for laxity 1. hyperlaxity- load and shift (supine) 2. MDI- Sulcus sign Provocative maneuvers for symptomatic PI a. Jerk Test (upright) b. Kim Test (upright) Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois Jerk Test: Posterior Labrum Positive test: pain or discomfort Sitting position, axial directed force with arm flexed, adducted, IR. Bring arm into extension to reduce subluxated head 4 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Provocative tests interpretation Kim Test: Posteroinferior labrum Sitting position, arm in 90 degrees abduction, examiner holds elbow and lateral aspect of proximal arm, firm axial load is applied. Simultaneous 45 degree upward diagonal elevation is applied on the distal arm, while a downward and backward force is applied to the proximal arm. Jerk test more sensitive posterior labral lesion Kim test more sensitive to inferior labral lesions Combination of teststests 97% sensitive Pain without clunk– labral lesion Pain with clunk– labral lesion and instability Provocative exam drives treatment: Negative Jerk/Kim test– nonoperative treatment often successful Non-operative treatment Key points to dx and pt selection Postive test: pain or discomfort Indications: asymptomatic laxity and negative provocative exam findings (jerk/kim tests) Physical therapy therapy- rotator cuff strengthening, strengthening periscapular muscle strengthening Results: 93% responded to physical therapy alone in pts with negative jerk/kim tests 1. Activity related shoulder pain is most common presenting symptom of PI 2 Loss of chondrolabral containment results in 2. symptomatic posterior instability 3. A negative Jerk test/Kim test usually can be successfully treated non-operatively 4. MRI findings of posterior labral lesions are often less dramatic than anterior labral injury Kim SH et al. Painful Jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder: Am J Sports Med 32(8):1849-1855, 2004. Indications for Arthroscopic Stabilization 1. 2. 3 3. 4. Involuntary, symptomatic instability Postitive Jerk test/Kim test Failed non-operative non operative treatment Imaging consistent with loss of chondrolabral containment 5. Absence of glenoid dysplasia or excessive bone loss Arthroscopic Management: Options 1. 2. Capsulorrhaphy Labral repair -With suture anchors g reconstruction 3. “Sling” 4. Rotator interval closure? -Controversial, in our own laboratory biomechanically unhelpful 5. Osseous augmentation -Where indicated Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT. The addition of rotator interval closure after arthroscopic repair of either anterior or posterior shoulder instability: effect on glenohumeral translation and range of motion. Am J Sports Med. 2008 Jun;36(6):1123-31 Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 5 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Portals Lazy Lateral Position • Standard Posterior Anterosuperior 5 o’clock • Trans-subscapularis • Percutaneous only, no cannula 7 o’clock • Inferior to posterior cuff • 2-3cm lateral to glenoid rim • 8.25 cannula, dilators necessary • • • • 7- 0’Clock Portal Diagnostic Arthroscopy (Right shoulder) 1. Labrum 2. Capsule/ligaments – Reverse HAGL 3. 4. 5. 6. 7. 8. Posterior bone loss Chondral surfaces Reverse Hill Sachs Biceps Rotator cuff Rotator interval Capsulolabral Pathology is variable… (Harryman 1999) •Labral detachment •Chondral/labral erosion •Capsular stripping •Labral split (Kim) Bradley et al AJSM 2006. Intraoperative capsulolabral pathology of 100 shoulders with symptomatic PI 43% patulous capsule with no evidence of labral detachment 27% incomplete labral tear 30% complete detachment of posterior labrum •Laxity Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 6 Posterior Instability: Why is this important and How to Treat Posterior Instability with Extensive Labral and Cartilage Injury AANA Fall Meeting November 2013 Probe labrum for Kim lesion • 22 yyear old • Offensive Lineman • NFL Combine 2013 A concealed complete detachment of the posterior labrum. very benign appearing on imaging and initial diagnostic arthroscopy. Look for RHAGL Chondrolabral junctional preparation 1. Elevators 2. Hooded/”SLAP” burr 3. Shaver 4. Anteriorly continue until it “floats” 5. Posteriorly “autoreduction” anecdotally less reliable Anchor placement 1. 3-4 anchors 2. 6 o’clock and beyond 3 Superiorly 3. S i l (above equator) • Knotless anchors Labral Tear Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois Knotless suture anchor fixation Biomechanical testing at our institution showed: Cyclic loading up to 25N showed no difference to failure compared with knotanchor configurations All stitches- single, horizontal, double loaded performed similar to knotless Nho SJ et al. A biomechanical analysis of anterior bankart repair using suture anchors. Am J Sports Med. 2010 Jul;38(7):1405-12. 7 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Suture passage Arthroscopic Posterior Labral Repair Capsular Plication: Can the labrum be used as an anchor? Postoperative Protocol • • • • • Provencher MT, Verma N, Obopilwe E, Rincon LM, Tracy J, Romeo AA, Mazzocca A. A biomechanical analysis of capsular plication versus anchor repair of the shoulder: can the labrum be used as a suture anchor? Arthroscopy. 2008 Feb;24(2):210-6. Arthroscopic capsulolabral repair Multiple recent studies have demonstrated excellent outcomes Surgeon: N Recurrence Abrams (2002) 34 4/34 (11%) Romeo (2005) 45 4/45 (10%) Bradley (2006) 100 11/100 (11%) Snyder (2010) 29 1/29 (3.4%) 75 – 90% Good / Excellent Results Bradley, J. P. Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder: A Prospective Study of 100 Shoulders. American Journal of Sports Medicine 34, 1061–1071 (2006).Provencher, M. T. Arthroscopic Treatment of Posterior Shoulder Instability: Results in 33 Patients. American Journal of Sports Medicine 33, 1463–1471 (2005). Bahk, M. S., Karzel, R. P. & Snyder, S. J. Arthroscopic posterior stabilization and anterior capsular plication for recurrent posterior glenohumeral instability. Arthroscopy 26, 1172–1180 (2010). Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois • 0-3 weeks: Splint in ER 3-6 wks: ER, FF to 90°, isometrics 6 wks: ER, FF, IR, strengthening 3 mon: ROM as tolerated 4 mon: return to noncontact sports 6-9 mon: return to all sports Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder: A Prospective Study of 100 Shoulders Bradley, et al; AJSM March 2006 •100 shoulders, 91 patients •51 Contact Athletes •> Chondrolabral changes and retroversion •ASES Scores: 50  86 •89% Return to Sport (67% at same level) Outcomes analysis now includes >200 Shoulder 8 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Recurrence (Failure) James Bradley – Posterior Stabilization Traumatic re-tear Be are of: Beware • Occult multidirectional instability • Bone loss Glenoid bone loss • Recurrent Instability • Epilepsy • Collision Sports • Dysplasia Glenoid Bone Loss Not important Important Osseus Augmentation Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois Bradley JP. Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder: A Prospective Study of 100 Shoulders. Am J Sports Med. Mar 21 2006;34(7):1061-1071. Krishnan SG, Hawkins RJ, Horan MP, Dean M, Kim Y-K. A soft tissue attempt to stabilize the multiply operated glenohumeral joint with multidirectional instability. Clin Orthop Relat Res. Dec 2004(429):256261. • Biomechanical Study • • HH translation with varying degrees of posterior glenoid bone loss 5° posterior glenoid bone loss • Significant posterior HH translation during simulated FF Osseous Augmentation 9 Posterior Instability: Why is this important and How to Treat AANA Fall Meeting November 2013 Osseous Augmentation Results Appropriate indications and meticulous surgical technique crucial, as results of traditional “bone block” procedures at 18 years demonstrate 1. 100% radiographic DJD 2. 73% persistent subjective instability Meuffels DE, Schuit H, van Biezen FC, Reijman M, Verhaar JAN. The posterior bone block procedure in posterior shoulder instability: A long-term follow-up study. J Bone Joint Surg Br. Jun 01 2010;92-B(5) Osseous Augmentation Results • • • • 19 cases Mean 20 mo f/u Autologous ICBG Recurrent posterior instability • Humeral or Glenoid bone loss • Dysplasia • Hyperlaxity Improved Rowe and Walch-Duplay scores 100% radiographic healing rate No cases of recurrent dislocation • • • Case Case • 29yo M, RHD • Computer Technician • Recurrent posterior instability • • Seizure disorder Now controlled • “Dislocated when I flex my arm above shoulder level” Case Case • • • • Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 2 years post-op Full ROM No apprehension No instability events 10 Posterior Instability: Why is this important and How to Treat Beware of “guide services” from Matt Provencher… AANA Fall Meeting November 2013 Thank you! Midwest Orthopaedics at Rush Thank you! Chicago Anthony A. Romeo, MD Rush University Medical Center Chicago, Illinois 11