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Modified bankart repair in capsular reconstruction for shoulder instability
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J. Shoulder Elbow Surg. March/April 1996
Abstracts
KINEMATICS OF THE NORMAL AND PROSTHETICALLY RECONSTRUCTED GLENOHUMERAL JOINT: AN ACTIVE AND PASSIVE CADAVER MODEL. Iannoeti, J.P., Karduna, A.R. , Williams, G.R., Williams, J. #1 - T o m e a s u r e t h e m a g n i t u d e o f h u m e r a l h e a d
HEMYARTHROPLASTY FOR ACUTE INVETERATED FRACTURES OF THE PROXIMAL HUMERUS. F.Odella M.D.,A.Giraldi M.D.,& G.Bernabe M.D. 3rd Dept. of Orthop.Surg.,G.Pini Orthop.lnst.,Milan,ltaly.
translation in an active and passive cadaveric shoulder mOdel and determia~m the i n f l u x e s of the arc of motion, arm position, effect ef rotator cuff mUs~lature, g l ~ u R e r a l =ongTuence and ligament tension an the magnitude and direction of humeral head translation. #2 ~ To study the effect of these same factors on the proetheti=ally E e = o n ~ a ~ G e d mhoulder end measure humeral h e a d t r a x m l a t i o n a n d glenoid component strain at the bone ~ement interface.
PURPOSE We reviewed patients with inveterated fractures(previously treated&nonunion included) and compared them with patients treated with prostheses for acute fragmented fractures. METHOD From 1984 to 1992,62hemiarthroplasties were performed for fractures of the proximal humerus:30 patients were in acute pathological condition,while 32 were in chronic condition.On follow-up patients were evaluated according to Constant's score. RESULTS In both groups of patients there were no complaints of severe pain.Generally speaking,the final results on pain were satisfactory and rather homogeneous in both groups,variable as regards function.Delayed prosthetic procedure in patients who had been previously treated(surgically or not surg.) seemed l e s s successful;there was a higher percentage of complication and revision surgery.Poor results were mainly due to retraction of soft tissues and weakness of rotator cuff and deltoid muscle. CONCLUSION Success in arthroplasty for fractures of the proximal humerus requires careful selection of patients suitable for this treatment and skilled surgical technique in order to avoid poor results and complications.
6
A PROSPECTIVE OUTCOME STUDY COMPARING H H R VS. TSR FOR PRIMARY OA. T.R.Norris, MD, CPMC, San Francisco, CA & J.P.Iannotti, MD, Univ. of PA, Philadelphia, PA. A prospective multicentcr Global TM Shoulder Study evaluated 220 (176 TSR/44 HHR) in 141 males/79 females shoulders with primary OA without prior open surgery. Methods: Patients were evaluated for motion, strength, stability, function (48 questions), and 6 visual analog scales (VAS) tor pain and use. Normal or thinned rotator cuffs were present in 75% HHR/95% TSR. Of those with large supraspinatus cuff tears, 9/11 had HHR. Discussion: Preliminary observation: 1)Few patients had significant cuff pathology. Minor thinning or small tears addressed at surgery did not affect outcome, pain, patient satisfaction, ROM. Data does not support use of MRI or arthrograms to evaluate patients with primary OA. 2)Preop ROM loss adversely affects outcome. 3)Signit'icant (p<.05) improvements were obtained in both TSR and HHR for all the top 16/48 functiona[ parameters, 6 VAS sca(es, ROM and strengdl. The t6/48 most sensitive parameters are defined as those which applied to > 90% of the respondents and demonstrate the greatest percentage change from pro to postoperative. 4)The significant differences between H H R and TSR in thinned to normal intact cuffs included greater active elevation for TSR/HHR (144/131 ~ (p<.01) and increased IR up back 4.9/3.4 vertebral segments (p<.05). 5)VAS scales significantly (p<.05) favored TSR over H H R for pain reduction, during sleep, and overall shoulder function. Otherwise, there were no statistical diffcrences between HHR and TSR. lntra and early postoperative complications occurred in 17/220 (7,9%) shoulders: 9 fractures (2 HHR, 7 TSR), in TSR a~one instahility 4, vascular dan)age 1. fixation unsatisfactory 1, CV problem 1. Conclusions: I)HHR & TSR both significantly (p<.05) improve OA patients with motion, strength, function, and pain with TSR favored in several categories. 2)Shoulder OA rarely has cuff pathology. 3)The most sensitive functional categories are identified. 4)Preop ROM affects outcome. Early surgery is favored in a patient with appropriate symptoms and pathology.
Kether z Eight normal and eight prosthetlcally reconstructed shoulder~ were s ~ d i e d nelng the Polhemus Nagnetic Tracklng Sys~e,n in an active and passive shoulder model. ~he humeral head was placed through 9 full az~ of ~ t e r n a l and external rotation in the plane of the ~.apula as well
as
30 ~
anterior
or
30 ~
posterior
to
the
plane of the scapula. RemLttal
In the
normal
shoulder,
the
humeral head
is
wJ":~,'ttainad within one to ~ RilliReters of the anatomic Qente~ of t h e humeral head with either
passive or active range of ~ i o n in the plane of the scapula. At the extremes of shoulder rotation anterior or posterior to the plane Of the scapula, there is eignlficant translation anteriorly end posteriorly, which is due to asymmetric capsular tightening. These translations o c c u r most eIGniZicant ly with passive positioning of the arm share a greater arc of humeral rotation is achieved. This greater arc of rotation cannot be achieved with active Positioning of the shoulder t ~ n a g h simulated contrac~:Ure of the rotator cuff end deltsld musculat~u~e.
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MODIFIED BANKART REPAIR IN CAPSULAR RECONSTRUCTION FOR SHOULDER INSTABILITY. M. Pritsch, S. Velkes, O. Levy, A. Greental. The Shoulder services, Sheba Medical Center, Soroka Medical Center and Barzilai Medical Center, Israel Since Neer's description of the capsular shift procedure in the surgical treatment of the unstable shoulder, capsular reconstruction has become the preferred procedure in the treatment of this pathology. RE-insertion of the labru-eapsular complex must still be performed in the presence of a Bankart lesion. A prospective study was undertaken to test the effectiveness of a modified Bankart repair. 65 patients, average age 27 years with an average follow up of four years (range 2-5 years), in whom a Bankart lesion was observed during surgical stabilization of the shoulder, underwent a modified Bankart repair. Instead of suturing the labro-capsular complex to the glenoid tim, the horizontal limb of the T capsular incision, as part of the capsular shift, is extended medially to Include the labrum and the periosteum of the gleunid neck. After the glenoid neck is freshened the labrum and capsule are plicated and thereby shortened and tightly opposed to the glenoid neck and tim. A formal capsuloplasty is then performed. Results were excellent in 59 patients (91%) and good in 5 patients (7%), this was due to a loss of up to 15% of external rotation. One patient (2%) suffered recurrent subluxations. The results of the modified Bankart repair has been shown to be excellent and reliable. The technique permits simplification of the standard Bankart repair and preservation of glenoid articular cartilage by dispensing with the need for holes in the glenoid surface.
J. Shoulder Elbow Surg. March/April 1996
Abstracts
KINEMATICS OF THE NORMAL AND PROSTHETICALLY RECONSTRUCTED GLENOHUMERAL JOINT: AN ACTIVE AND PASSIVE CADAVER MODEL. Iannoeti, J.P., Karduna, A.R. , Williams, G.R., Williams, J. #1 - T o m e a s u r e t h e m a g n i t u d e o f h u m e r a l h e a d
HEMYARTHROPLASTY FOR ACUTE INVETERATED FRACTURES OF THE PROXIMAL HUMERUS. F.Odella M.D.,A.Giraldi M.D.,& G.Bernabe M.D. 3rd Dept. of Orthop.Surg.,G.Pini Orthop.lnst.,Milan,ltaly.
translation in an active and passive cadaveric shoulder mOdel and determia~m the i n f l u x e s of the arc of motion, arm position, effect ef rotator cuff mUs~lature, g l ~ u R e r a l =ongTuence and ligament tension an the magnitude and direction of humeral head translation. #2 ~ To study the effect of these same factors on the proetheti=ally E e = o n ~ a ~ G e d mhoulder end measure humeral h e a d t r a x m l a t i o n a n d glenoid component strain at the bone ~ement interface.
PURPOSE We reviewed patients with inveterated fractures(previously treated&nonunion included) and compared them with patients treated with prostheses for acute fragmented fractures. METHOD From 1984 to 1992,62hemiarthroplasties were performed for fractures of the proximal humerus:30 patients were in acute pathological condition,while 32 were in chronic condition.On follow-up patients were evaluated according to Constant's score. RESULTS In both groups of patients there were no complaints of severe pain.Generally speaking,the final results on pain were satisfactory and rather homogeneous in both groups,variable as regards function.Delayed prosthetic procedure in patients who had been previously treated(surgically or not surg.) seemed l e s s successful;there was a higher percentage of complication and revision surgery.Poor results were mainly due to retraction of soft tissues and weakness of rotator cuff and deltoid muscle. CONCLUSION Success in arthroplasty for fractures of the proximal humerus requires careful selection of patients suitable for this treatment and skilled surgical technique in order to avoid poor results and complications.
6
A PROSPECTIVE OUTCOME STUDY COMPARING H H R VS. TSR FOR PRIMARY OA. T.R.Norris, MD, CPMC, San Francisco, CA & J.P.Iannotti, MD, Univ. of PA, Philadelphia, PA. A prospective multicentcr Global TM Shoulder Study evaluated 220 (176 TSR/44 HHR) in 141 males/79 females shoulders with primary OA without prior open surgery. Methods: Patients were evaluated for motion, strength, stability, function (48 questions), and 6 visual analog scales (VAS) tor pain and use. Normal or thinned rotator cuffs were present in 75% HHR/95% TSR. Of those with large supraspinatus cuff tears, 9/11 had HHR. Discussion: Preliminary observation: 1)Few patients had significant cuff pathology. Minor thinning or small tears addressed at surgery did not affect outcome, pain, patient satisfaction, ROM. Data does not support use of MRI or arthrograms to evaluate patients with primary OA. 2)Preop ROM loss adversely affects outcome. 3)Signit'icant (p<.05) improvements were obtained in both TSR and HHR for all the top 16/48 functiona[ parameters, 6 VAS sca(es, ROM and strengdl. The t6/48 most sensitive parameters are defined as those which applied to > 90% of the respondents and demonstrate the greatest percentage change from pro to postoperative. 4)The significant differences between H H R and TSR in thinned to normal intact cuffs included greater active elevation for TSR/HHR (144/131 ~ (p<.01) and increased IR up back 4.9/3.4 vertebral segments (p<.05). 5)VAS scales significantly (p<.05) favored TSR over H H R for pain reduction, during sleep, and overall shoulder function. Otherwise, there were no statistical diffcrences between HHR and TSR. lntra and early postoperative complications occurred in 17/220 (7,9%) shoulders: 9 fractures (2 HHR, 7 TSR), in TSR a~one instahility 4, vascular dan)age 1. fixation unsatisfactory 1, CV problem 1. Conclusions: I)HHR & TSR both significantly (p<.05) improve OA patients with motion, strength, function, and pain with TSR favored in several categories. 2)Shoulder OA rarely has cuff pathology. 3)The most sensitive functional categories are identified. 4)Preop ROM affects outcome. Early surgery is favored in a patient with appropriate symptoms and pathology.
Kether z Eight normal and eight prosthetlcally reconstructed shoulder~ were s ~ d i e d nelng the Polhemus Nagnetic Tracklng Sys~e,n in an active and passive shoulder model. ~he humeral head was placed through 9 full az~ of ~ t e r n a l and external rotation in the plane of the ~.apula as well
as
30 ~
anterior
or
30 ~
posterior
to
the
plane of the scapula. RemLttal
In the
normal
shoulder,
the
humeral head
is
wJ":~,'ttainad within one to ~ RilliReters of the anatomic Qente~ of t h e humeral head with either
passive or active range of ~ i o n in the plane of the scapula. At the extremes of shoulder rotation anterior or posterior to the plane Of the scapula, there is eignlficant translation anteriorly end posteriorly, which is due to asymmetric capsular tightening. These translations o c c u r most eIGniZicant ly with passive positioning of the arm share a greater arc of humeral rotation is achieved. This greater arc of rotation cannot be achieved with active Positioning of the shoulder t ~ n a g h simulated contrac~:Ure of the rotator cuff end deltsld musculat~u~e.
8
MODIFIED BANKART REPAIR IN CAPSULAR RECONSTRUCTION FOR SHOULDER INSTABILITY. M. Pritsch, S. Velkes, O. Levy, A. Greental. The Shoulder services, Sheba Medical Center, Soroka Medical Center and Barzilai Medical Center, Israel Since Neer's description of the capsular shift procedure in the surgical treatment of the unstable shoulder, capsular reconstruction has become the preferred procedure in the treatment of this pathology. RE-insertion of the labru-eapsular complex must still be performed in the presence of a Bankart lesion. A prospective study was undertaken to test the effectiveness of a modified Bankart repair. 65 patients, average age 27 years with an average follow up of four years (range 2-5 years), in whom a Bankart lesion was observed during surgical stabilization of the shoulder, underwent a modified Bankart repair. Instead of suturing the labro-capsular complex to the glenoid tim, the horizontal limb of the T capsular incision, as part of the capsular shift, is extended medially to Include the labrum and the periosteum of the gleunid neck. After the glenoid neck is freshened the labrum and capsule are plicated and thereby shortened and tightly opposed to the glenoid neck and tim. A formal capsuloplasty is then performed. Results were excellent in 59 patients (91%) and good in 5 patients (7%), this was due to a loss of up to 15% of external rotation. One patient (2%) suffered recurrent subluxations. The results of the modified Bankart repair has been shown to be excellent and reliable. The technique permits simplification of the standard Bankart repair and preservation of glenoid articular cartilage by dispensing with the need for holes in the glenoid surface.