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Arthroscopic Repair of Combined Capsular and Bankart Lesions in Traumatic Anterior Shoulder Instability (SS-17)
ABSTRACTS outcome scores could be obtained for 85 patients (89 shoulders). Results: Forward elevation, external rotation at the side, and internal rotation to the back improved from 118⫾21 to 152⫾15, 30⫾18 to 46⫾11, and from the gluteal region to the T12 spinous process, respectively (p⬍0.0001). Similar improvements in mobility were observed for both operative and non-operative groups, but the improvement in forward elevation was greater for the operative group (p⬍0.05). Mean SST improved from 4.0⫾2.7 to 9.9⫾2.8 (p⬍0.0001) and mean final ASES score was 85⫾15. Female patients had a lower mean initial SST than male patients (3.3⫾3.6 compared with 5.2⫾2.6, p⬍0.005), but mean final SSTs were similar (9.7⫾2.9 compared with 10.3⫾2.6). Improvement in SST and final ASES scores did not appear to vary by gender, diabetes, or depression. Younger patients (p⬍0.001) and those with lower initial SST scores (p⬍0.05) were more likely to undergo surgery. For the entire cohort, initial SST score predicted final SST score (p⬍0.05) and shorter duration of symptoms predicted a higher final ASES score (p⬍0.05). Non-operative and operative groups demonstrated similar final SST (10.0⫾2.8 and 9.7⫾2.9) and ASES scores (86⫾13 and 82⫾12). Following non-operative treatment, patients with diabetes had a lower mean final SST score than patients without diabetes (8.9 compared with 10.6, p⬍0.05), but following surgery the mean scores were identical (9.7). For patients undergoing non-operative treatment, absence of diabetes (p⬍0.005), shorter duration of symptoms (p⫽0.05), and young age (p⬍0.01) predicted a higher final SST. Conclusions: Adhesive capsulitis usually responds favorably to therapeutic exercise, but manipulation and arthroscopic capsular release are effective for refractory cases. The results of non-operative and operative treatment for adhesive capsulitis are similar, but patients with diabetes and more limited function appear to benefit the most from capsular release. Compared with older patients, younger patients respond better to non-operative treatment, but they are also more likely to undergo surgery.
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Arthroscopic Stabilization of Acute Distal Clavicle Fractures and Dislocations Using Tightrope (SS-16) Duncan Tennent, FRCS (Orth), Andrew Richards, FRCS (Orth)
94(⫹/-7.14), DASH score was 2.5(⫹/-3.25) and Walch score was 17.5(⫹/- 1.67). There were no infections or failures. Two patients required removal of a palpable clavicle button. This new technique is a safe, simple, cosmetically acceptable method of reducing and stabilising the distal clavicle allowing for healing of the coracoclavicular ligaments or the distal clavicle. Introduction: The aim of this study was to evaluate the primary series of acute acromio-clavicular joint (ACJ) dislocations and distal clavicle fractures treated arthroscopically using Tightrope (Arthrex, Naples, Fla). Methods: Study Type: Prospective cohort series. Inclusion criteria: 19 consecutive patients with an acute grade 4 or 5 ACJ dislocation or distal clavicle fracture Neer Type II who sustained the injury between December 2004 and January 2006. All had either the acromioclavicular joint reduced or a distal clavicle fracture reduced and stabilised arthroscopically using the Tightrope Syndesmosis Repair system which had been adapted to be used arthropscopically. Exclusion criteria: unable to consent to surgery, multiple injuries, unable to undergo arthroscopic surgery. Results: All patients were evaluated at a mean of 2 years (range 12-32 months) post operatively by an independent observer. Outcome measures: DASH, ASES, Constant and Walch ACJ scores and radiographic review with AP and Axial xrays. Two patients were lost to follow up (1 died, 1 emigrated). 17 patients underwent clinical review. Complications:1 transient adhesive capsulitis. No infections, no failures. Two female patients required removal of the clavicle button as it was palpable. The mean ASES score was 95.6(⫹/-6.5), the mean Constant score was 94(⫹/-7.14), the mean DASH score was 2.5(⫹/-3.25) and the mean Walch ACJ score was 17.5(⫹/- 1.67). 2 patients demonstrated slight loss of ACJ position on AP X-ray (grade 2 subluxation), not clinically noticeable. Conclusions: Our results demonstrate that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coracoclavicular ligaments or the distal clavicle. Using a minimally invasive technique but ensuring accurate reduction and secure stabilisation. This is clinically relevant because traditional techniques have required a brastrap incision and often require late removal of the metalwork.
Summary: The initial series of 19 acute ACJ dislocations and fractures stabilised arthroscopically using Tightrope was reviewed at a mean of 2 years. The mean ASES score was 95.6(⫹/-6.5), Constant score was
Arthroscopic Repair of Combined Capsular and Bankart Lesions in Traumatic Anterior Shoulder Instability (SS-17) Seung-Ho Kim, MD, Jin Heun Kwak, MD, Jin Hyup Shin, MD, and Min Soo Lee, MD
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ABSTRACTS
Summary: 457 shoulders with traumatic anterior instability were review for capsular lesion in MR-arthrogram and arthroscopic findings. Twenty-seven shoulders (6%) were identified to have combined capsular and Bankart lesions. There were 8 mid-capsular tears, 11 HAGL, and 8 reverse HAGL. Patients with combined lesion had indistinctive Bankart lesion and were older than those with isolated Bankart lesion. Shoulders with reverse HAGL had larger Hill-Sach’s lesion. Arthroscopic repair of capsular and Bankart lesions improved outcomes. There were 2 recurrent instability. The capsular lesion should be suspected in shoulders with indistinctive Bankart lesion in MR-arthrogram. Arthroscopic repair of both lesions provides successful outcomes. Introduction: Although the capsular lesion was sporadically reported to occur in the traumatic anterior instability of the shoulder, there has not been systematically evaluated in a large series. The purpose of this study was to evaluate characteristics of shoulders with combined capsular and Bankart lesions in shoulders with traumatic anterior instability. Methods: 457 shoulders in 443 patients with traumatic anterior instability were review for capsular lesion in MR-arthrogram and arthroscopic findings. Various parameters including age, depth of Hill-Sach’s lesion, and displacement of Bankart lesion were compared between shoulders with combined lesion and isolated Bankart lesion. The depth of Hill-Sach’s lesion was measured as percentage of humeral head in axial MR image. Distinctive Bankart lesion in MR-arthrogram was defined as gap between glenoid and labrum greater than 2 mm, medial displacement of anterior labrum greater than 5mm or deficit of anterior labrum. Outcome of arthroscopic repair were evaluated using shoulder (UCLA, ASES, and Rowe scores) and functional scores. Results: Twenty-seven shoulders (6%) were identified to have the combined capsular and Bankart lesions. There were 8 mid-capsular tears, 11 HAGL, and 8 reverse HAGL. Patients with a combined lesion were older than those with isolated Bankart lesion (30 and 21 years old, respectively) (p⬍0.05). Shoulders with a reverse HAGL had larger Hill-Sach’s lesion (p⬍0.05). The distinctive Bankart lesion was found in 74 % of shoulders with isolated lesion and 15% of those with combined lesion. MR-arthrogram showed less distinctive Bankart lesion in shoulders with a combined lesion in the blind measurement (p⬍0.05). Arthroscopic repair of Bankart lesion using suture anchors together with side-to-side repair of HAGL or capsular lesion as well as suture anchor repair of reverse HAGL improved shoulder scores and functional outcome (p⬍0.05) at the latest follow-up (11 to 37 months, mean 25 months). Repair of
capsular and Bankart lesion resulted average of 8 degree loss of external rotation. Twenty-four patients returned to previous working activity and 22 to previous sports activity. There were 2 shoulders with recurrent instability including one shoulder with positive anterior apprehension and the other with a single episode of frank dislocation. Conclusions: The capsular lesion is not uncommon in traumatic anterior instability and should be suspected in shoulders with an indistinctive Bankart lesion in MRarthrogram. The reverse HAGL may be associated with a large Hill-Sach’s lesion. Arthroscopic repair of both Bankart and capsular lesions provides successful outcomes. Arthroscopic Posterior Stabilization and Anterior Capsular Plication for Recurrent Posterior Glenohumeral Instability (SS-18) Michael Bahk, MD, Ronald P. Karzel, MD, and Stephen J. Snyder, MD Introduction: Posterior shoulder instability is less common than anterior shoulder instability and consists of a broad spectrum of clinical presentations and pathology. Recurrent, traumatic, involuntary, unidirectional posterior instability is the most common form. Arthroscopic techniques are currently employed as treatment for these patients. The purpose of this study is to evaluate the outcomes of arthroscopic posterior Bankart reconstruction with modern suture anchor repair in a well-defined patient population and to evaluate preoperative and operative factors as determinants of success. Methods: Thirty patients with an average age of 26.9 years (range 15.7-43.4) all had traumatic detachment of the posterior labrum and underwent suture anchor repair with posterior capsulolabral plication. Supplemental anterior capsulolabral plication and additional surgeries were performed as required. Patients were evaluated an at an average follow-up of 5.5 years (range 2.0-12.4 years) with shoulder outcomes scores including the American Shoulder and Elbow Surgeons (ASES) Rating Scale, the Western Ontario Shoulder Instability (WOSI) Index, the University of California at Los Angeles (UCLA) score and the Simple Shoulder Test (SST). Subjective patient evaluations for success, strength, range of motion, instability, pain and return to sport were also recorded. Results: All patients had posterior Bankart lesions that required suture anchor repair. The average postoperative ASES score was 90.0 (range 53.3-100), UCLA score of 32.6 (range 24-35), SST of 11.7 (10-12), WOSI of 366 (0-1033) or 82.6% of normal (50.8-100%). Ninety-seven percent of patients (29/30) reported they were
e9
Arthroscopic Stabilization of Acute Distal Clavicle Fractures and Dislocations Using Tightrope (SS-16) Duncan Tennent, FRCS (Orth), Andrew Richards, FRCS (Orth)
94(⫹/-7.14), DASH score was 2.5(⫹/-3.25) and Walch score was 17.5(⫹/- 1.67). There were no infections or failures. Two patients required removal of a palpable clavicle button. This new technique is a safe, simple, cosmetically acceptable method of reducing and stabilising the distal clavicle allowing for healing of the coracoclavicular ligaments or the distal clavicle. Introduction: The aim of this study was to evaluate the primary series of acute acromio-clavicular joint (ACJ) dislocations and distal clavicle fractures treated arthroscopically using Tightrope (Arthrex, Naples, Fla). Methods: Study Type: Prospective cohort series. Inclusion criteria: 19 consecutive patients with an acute grade 4 or 5 ACJ dislocation or distal clavicle fracture Neer Type II who sustained the injury between December 2004 and January 2006. All had either the acromioclavicular joint reduced or a distal clavicle fracture reduced and stabilised arthroscopically using the Tightrope Syndesmosis Repair system which had been adapted to be used arthropscopically. Exclusion criteria: unable to consent to surgery, multiple injuries, unable to undergo arthroscopic surgery. Results: All patients were evaluated at a mean of 2 years (range 12-32 months) post operatively by an independent observer. Outcome measures: DASH, ASES, Constant and Walch ACJ scores and radiographic review with AP and Axial xrays. Two patients were lost to follow up (1 died, 1 emigrated). 17 patients underwent clinical review. Complications:1 transient adhesive capsulitis. No infections, no failures. Two female patients required removal of the clavicle button as it was palpable. The mean ASES score was 95.6(⫹/-6.5), the mean Constant score was 94(⫹/-7.14), the mean DASH score was 2.5(⫹/-3.25) and the mean Walch ACJ score was 17.5(⫹/- 1.67). 2 patients demonstrated slight loss of ACJ position on AP X-ray (grade 2 subluxation), not clinically noticeable. Conclusions: Our results demonstrate that this new technique is a safe, simple, cosmetically acceptable and reproducible method of reducing and stabilising the distal clavicle allowing for healing of either the coracoclavicular ligaments or the distal clavicle. Using a minimally invasive technique but ensuring accurate reduction and secure stabilisation. This is clinically relevant because traditional techniques have required a brastrap incision and often require late removal of the metalwork.
Summary: The initial series of 19 acute ACJ dislocations and fractures stabilised arthroscopically using Tightrope was reviewed at a mean of 2 years. The mean ASES score was 95.6(⫹/-6.5), Constant score was
Arthroscopic Repair of Combined Capsular and Bankart Lesions in Traumatic Anterior Shoulder Instability (SS-17) Seung-Ho Kim, MD, Jin Heun Kwak, MD, Jin Hyup Shin, MD, and Min Soo Lee, MD
e10
ABSTRACTS
Summary: 457 shoulders with traumatic anterior instability were review for capsular lesion in MR-arthrogram and arthroscopic findings. Twenty-seven shoulders (6%) were identified to have combined capsular and Bankart lesions. There were 8 mid-capsular tears, 11 HAGL, and 8 reverse HAGL. Patients with combined lesion had indistinctive Bankart lesion and were older than those with isolated Bankart lesion. Shoulders with reverse HAGL had larger Hill-Sach’s lesion. Arthroscopic repair of capsular and Bankart lesions improved outcomes. There were 2 recurrent instability. The capsular lesion should be suspected in shoulders with indistinctive Bankart lesion in MR-arthrogram. Arthroscopic repair of both lesions provides successful outcomes. Introduction: Although the capsular lesion was sporadically reported to occur in the traumatic anterior instability of the shoulder, there has not been systematically evaluated in a large series. The purpose of this study was to evaluate characteristics of shoulders with combined capsular and Bankart lesions in shoulders with traumatic anterior instability. Methods: 457 shoulders in 443 patients with traumatic anterior instability were review for capsular lesion in MR-arthrogram and arthroscopic findings. Various parameters including age, depth of Hill-Sach’s lesion, and displacement of Bankart lesion were compared between shoulders with combined lesion and isolated Bankart lesion. The depth of Hill-Sach’s lesion was measured as percentage of humeral head in axial MR image. Distinctive Bankart lesion in MR-arthrogram was defined as gap between glenoid and labrum greater than 2 mm, medial displacement of anterior labrum greater than 5mm or deficit of anterior labrum. Outcome of arthroscopic repair were evaluated using shoulder (UCLA, ASES, and Rowe scores) and functional scores. Results: Twenty-seven shoulders (6%) were identified to have the combined capsular and Bankart lesions. There were 8 mid-capsular tears, 11 HAGL, and 8 reverse HAGL. Patients with a combined lesion were older than those with isolated Bankart lesion (30 and 21 years old, respectively) (p⬍0.05). Shoulders with a reverse HAGL had larger Hill-Sach’s lesion (p⬍0.05). The distinctive Bankart lesion was found in 74 % of shoulders with isolated lesion and 15% of those with combined lesion. MR-arthrogram showed less distinctive Bankart lesion in shoulders with a combined lesion in the blind measurement (p⬍0.05). Arthroscopic repair of Bankart lesion using suture anchors together with side-to-side repair of HAGL or capsular lesion as well as suture anchor repair of reverse HAGL improved shoulder scores and functional outcome (p⬍0.05) at the latest follow-up (11 to 37 months, mean 25 months). Repair of
capsular and Bankart lesion resulted average of 8 degree loss of external rotation. Twenty-four patients returned to previous working activity and 22 to previous sports activity. There were 2 shoulders with recurrent instability including one shoulder with positive anterior apprehension and the other with a single episode of frank dislocation. Conclusions: The capsular lesion is not uncommon in traumatic anterior instability and should be suspected in shoulders with an indistinctive Bankart lesion in MRarthrogram. The reverse HAGL may be associated with a large Hill-Sach’s lesion. Arthroscopic repair of both Bankart and capsular lesions provides successful outcomes. Arthroscopic Posterior Stabilization and Anterior Capsular Plication for Recurrent Posterior Glenohumeral Instability (SS-18) Michael Bahk, MD, Ronald P. Karzel, MD, and Stephen J. Snyder, MD Introduction: Posterior shoulder instability is less common than anterior shoulder instability and consists of a broad spectrum of clinical presentations and pathology. Recurrent, traumatic, involuntary, unidirectional posterior instability is the most common form. Arthroscopic techniques are currently employed as treatment for these patients. The purpose of this study is to evaluate the outcomes of arthroscopic posterior Bankart reconstruction with modern suture anchor repair in a well-defined patient population and to evaluate preoperative and operative factors as determinants of success. Methods: Thirty patients with an average age of 26.9 years (range 15.7-43.4) all had traumatic detachment of the posterior labrum and underwent suture anchor repair with posterior capsulolabral plication. Supplemental anterior capsulolabral plication and additional surgeries were performed as required. Patients were evaluated an at an average follow-up of 5.5 years (range 2.0-12.4 years) with shoulder outcomes scores including the American Shoulder and Elbow Surgeons (ASES) Rating Scale, the Western Ontario Shoulder Instability (WOSI) Index, the University of California at Los Angeles (UCLA) score and the Simple Shoulder Test (SST). Subjective patient evaluations for success, strength, range of motion, instability, pain and return to sport were also recorded. Results: All patients had posterior Bankart lesions that required suture anchor repair. The average postoperative ASES score was 90.0 (range 53.3-100), UCLA score of 32.6 (range 24-35), SST of 11.7 (10-12), WOSI of 366 (0-1033) or 82.6% of normal (50.8-100%). Ninety-seven percent of patients (29/30) reported they were