关节镜Bankart修复用于慢性肱骨前盂不稳定.ppt

Arthroscopic Bony Bankart Repair for Chronic Anterior Glenohumeral Instability,Funabashi Orthopaedic Sports Medicine Center,Bony Bankart Lesion,Prevalence 50% if evaluated by 3DCT 40% erosion 10% normal Sugaya, JBJS-85A, 2003,Bony Bankart Lesion,Treatment Soft tissue repair Open bone-grafting if glenoid bone defect is large,Large Glenoid Defect,3DCT & arthroscopy A bony fragment remains without smoothing out!,Bony Bankart Lesion,“Displaced” old avulsion fracture Fragment connected firmly with the labrum Forms a “Fragment-labroligamentous” complex Restoration of glenoid rim morphology may be possible!?,Purpose,To evaluate post-op outcomes of an arthroscopic bony Bankart repair for chronic traumatic recurrent anterior glenohumeral instability,Subjects,Inclusion criteria Chronic traumatic recurrent anterior glenohumeral instability Bony fragment confirmed both by 3DCT and during arthroscopic surgery,Subjects,42 shoulders in 41 patients 37 males, 4 females Average age at surgery 22.9 yrs (range, 15-36) 38 active sports participants 30 contact/collision 4 thrower,Methods,Quantification of bone loss Inferior glenoid circle on 3DCT Quantification #1: Fragment size (%) Sugaya, JBJS, 2003 #2: Defect rate (%) Lo, Arthroscopy, 2004,Quantification #1,Sugaya, et al. JBJS 85A, 2003.,Fragment size (%) =Area Fragment /Area Circle,Quantification #2,Lo, et al. Arthroscopy, 2004.,b,A,Defect rate (%) =b/A b: defect width A: circle diameter *Modified method described by Lo, et al.,Glenoid Bone Loss,#1: Average fragment size 9.2% (range, 2.1-20.9) #2: Average defect rate 24.8% (range, 11.4-38.6) 22 more than 25%: inverted pear? 20 less than 25%,Methods,General anesthesia Beach-chair position Bilateral EUA Diagnostic arthroscopy Arthroscopic stabilization using suture anchors,Arthroscopic Appearance,34y, male,Posterior view,Anterior view,Complex Mobilization,Posterior view,Posterior view,After Bony Bankart Repair,Posterior view,Posterior view,Post-op Schedule,Immobilization: 3 weeks Isometric muscle exercises ADL: 6 weeks Sports activity: 3 months Throwing: 6 months Collision/contact: 6 months,Outcome Measures,The Rowe score The UCLA score Pre-op & at the final follow-up 33 months (24-45) on average Sports return Statistics,Results,Rowe score 33.694.513.9 (40-100) UCLA score 20.533.62.5 (22-35) 39 excellent or good (93%) 2 poor (4.8%),Results,Sports return 36 (94.7%) returned to sports 32 (84%) preinjury level 4 (11%) lower level 2 (5.3%) unable to return suffered re-injury,Results,2 failures (4.8%) 1 non-compliant patient experienced a redislocation 3 months post-op during soccer 1 experienced a redislocation 12 months post-op during Rugby,Post-op 3DCT,16y, male, baseball thrower,Post-op 3DCT,16y, male, baseball player,Discussion,The inverted-pear glenoid Not indicated for arthroscopy Requires open bone-grafting Burkhart, et al. Arthroscopy, 2000 Minimum of 25 to 27% of the entire width of the inferior glenoid Lo, et al. Arthroscopy, 2004,Discussion,The inverted-pear glenoid Bony fragment present Size and shape variable Somewhere along the antero-inferior portion of the neck If evaluated by 3DCT Unpublished data,Discussion,The present study 22 patients quantified with more than 25% of glenoid bone loss Outcome favorable Restoration of glenoid morphology through this technique works,Discussion,Fragment/labrum junction intact Blood supply can be preserved Histological study Fragment osteonecrosis less likely Fujii, et al, JSES, 2000 Bony union can be expected,Discussion,Analysis of failure Re-injury before bony union Initial fixation strength Permanent strong sutures Double loaded suture anchors Augmentation Rotator Interval closure, etc,Conclusions,Arthroscopic bony Bankart repair can provide a successful outcome even in shoulders with a significant bony defect This technique could be an alternative for open bone-grafting in patients with a large glenoid defect,References,Bigliani LU, Newton PM, Steinmann SP, Connor PM, McIlveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26:41-5. Burkhart SS, De Beer JF. 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. Arthroscopy. 2000;16:677-94. Burkhart SS, DeBeer JF, Tehrany, AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy. 2002;18:488-91. FujiiY, Yoneda M, Miyazaki Y, Obata M, Wakiya S. Histological study of bony Bankart lesion in recurrent dislocation and subluxation of the shoulder. The Shoulder Joint (Katakansetsu). 2000;24:175-7. Japanese. J Shoulder Elbow Surg. 2000;9:457 (abstract). Gartsman GM, Taverna E, Hammerman SM. Arthroscopic rotator interval repair in glenohumeral instability: description of an operative technique. Arthroscopy. 1999; 15: 330-2. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five year follow-up. J Bone Joint Surg Am. 2000;82:991-1003. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am. 2000; 82:35-46.,References,Karas SG. Arthroscopic rotator interval repair and anterior portal closure: an alternative technique. Arthroscopy. 2002; 18: 436-9. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up. J Bone Joint Surg Am. 2003;85:1511-8. Lo, IY, Parten, PM, Burkhart, SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004;20:169-74. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Jo