1. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar, Scapular Dyskinesis related to shoulder pathology
Athens, 9&10 June 2017 .
Manos Antonogiannakis
Orthopaedic Surgeon
Director of 3rd Orthopaedic Department
Centre for Arthroscopy & Shoulder Surgery
Hygeia General Hospital
Traumatic glenohumeral
instability
2. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
The Shoulder
Greatest Range of Motion in the Body
Motion in all 3 planes of movement
Prone to instability
Sacrifices stability for mobility
3. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
What is Instability
Biomechanical Dysfunction
Failure of static and dynamic stabilizers
Ranges from mild subluxation to
traumatic dislocation
4. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
T.U.B.S.
Traumatic
Unidirectional
Bankart lesion
Surgery
A.M.B.R.I.
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
A.I.O.S.
Acquired
Instability
Overstress
Surgery
Instability Profiles
5. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
The most common presentation
A patient with some degree of laxity
genetically controlled dislocates his
shoulder after a minor or major accident
6. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
History:
degree of violence
Level of athletic participation
number of dislocations
Age of the patient
Clinical examination:
Generalized joint laxity
direction of apprehension
dictates treatment
7. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Contributors to stability
Static stabilizers
1. ligamentous structures labrum and
capsule
2. bony configuration of glenoid and
humeral head
Dynamic stabilizers
1. rotator cuff
2. scapula muscles
8. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
So what makes a shoulder
unstable
Degree of trauma and anatomic damage
Muscular dysfunction
Level of athletic activity
We must act in all of them
9. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Bone Defects
Glenoid side
Humeral side
10. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Humeral Bone Defects
Hill-Sachs lesion
11. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
The combination of the lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
12. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
From engaging Hill Sachs to
On-track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?
13. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Humeral Bone Defects
Engaging
Non Engaging
14. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Engaging Hill Sachs
15. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
16. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment
1 <25% On track Arthroscopic Bankart repair
2 <25% Off track Arthroscopic Bankart repair plus remplissage
3 >25% On track Latarjet procedure
4 >25% Off track Latarjet procedure with or without humeral
sided procedure (humeral bone graft or remplissage),
depending on engagement of Hill-Sachs lesion
after Latarjet procedure
17. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A.Three-dimensional CT scan with a view of a normal glenoid, with subtraction of the humeral head
The width of the glenoid track without a glenoid defect is 83% of the glenoid width.
B. Relation of glenohumeral joint in abduction and external rotation.
The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14%
of the glenoid width: F - M = 83% of glenoid width = glenoid track.
18. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A. 3D CT scan with en face view of a glenoid with bone loss of width d.
In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d.
B. Relation of glenohumeral joint in abduction and external rotation.
One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid.
In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill-
Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.
19. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
How to Determine Whether Hill-Sachs Lesion Is “On Track” or “Off Track”
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 = 0.83 D - 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.
20. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
21. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
22. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
From engaging Hill Sachs to
On-track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?
It is the combination of the existing lesions
Large Hill-Sachs lesion + No glenoid bone loss
=
Small Hill-Sachs lesion + 15% -20% glenoid bone loss
23. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Hill- Sachs Remplissage: An arthroscopic surgical
solution for the engaging Hill-Sachs
E.M. Wolf
Remplissage
25. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
From January 2007 to December 2010
(4 years)
48 patients
Average age: 28.9 ± 7.8 years
Average fu: 37.2 ± 9.9 months
Recurrence percentage: 6.3%
27. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Inclusion criteria
Traumatic unidirectional anterior shoulder instability
Hill-Sachs lesion of the humeral head
Evidence of engaging Hill-Sachs lesion during dynamic evaluation under arthroscopy
Arthroscopic Bankart repair in conjunction with arthroscopic remplissage
Follow-up period longer than 2 years
Exclusion criteria
Anterior glenoid rim defect or fracture exceeding 25% of the inferior glenoid diameter confirmed intra-operatively
Humeral avulsion of the glenohumeral ligaments (HAGL) detected intra-operatively
Psychological disease or epilepsy
28. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Parameter Pre-operatively Latest Follow-up Difference P value
Active forward flexion
mean value ± standard deviation
170 ± 25.8 degrees 179 ± 3.1 degrees + 9 degrees n.s.
External rotation beside the body
mean value ± standard deviation
73.6 ± 23.0 degrees 78.1 ± 13.1 degrees + 4.5 degrees n.s.
External rotation at 90 degrees of abduction
mean value ± standard deviation
89.2 ± 25.9 degrees 85.4 ± 9.3 degrees - 3.8 degrees n.s.
Internal rotation
median value, range
T10 level (range, T6-L2) T10 level (range, T7-T12) Same level n.s.
Mean ASES score
mean value ± standard deviation
67.7 ± 21.5 90.8 ± 21.7 + 23.1 p<0.01
Mean Rowe-Zarins score
mean value ± standard deviation
38 ± 17.3 93.8 ± 14.5 + 55.8 p<0.001
Mean Oxford Instability score
mean value ± standard deviation
27.6 ± 11.1 45.1 ± 8.3 + 17.5 p<0.01
30. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
The outcome of the enhancement of the classic Bankart repair with tenodesis of the
infraspinatus and posterior capsular plication is very good as far as the management of recurrent
anterior shoulder instability is concerned, without significantly influencing the range of motion
of the shoulder
31. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Glenoid Bone Defects
32. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
The inferior 2/3 of the glenoid is nearly a perfect
circle with avg diameter 24mm
Huysman et al. JSES 2006
33. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim
34. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Loss of 8.6mm of anterior radius of glenoid at the
level of the bare spot corresponds to 35% of the
normal anteroposterior width
Lo, Burkhart Arthroscopy 2004
35. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
>25 – 30% bone loss 6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)
36. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Bone loss <15% (0-3.5mm) of AP width
Soft tissue repair incorporating the bone fragment
if possible
Piasecki et al. AAOS J17 (8): 482. (2009)
37. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Glenoid Index in 3D CT scan of both shoulders
Critical Limit Glenoid index 0.75
SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
38. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid surface
40. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Our practice
The percentage of the glenoid defect was evaluated on the en face reconstructed
view with the humeral head eliminated
Sugaya et al (2005) Joint Surg Am
41. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Sugaya et al. JBJS Am 2005
42. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
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
S.S. Burkhart and J. F. De Beer, M.D.
Arthroscopy,October 2000
43. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Total group: 194 patients
173 pt without significant bone defects :
7 pt sustained a recurrence (4%)
21 pt with significant bone defects:
14 pt developed rec instability (67%)
44. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
23 pt active military personel,
25y mean age 20-30% bone loss 7mm of ap width
34months mean fu,
14.2% rec rate
Mologne et al. AJSM 2007
45. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Glenoid Bone Loss >25%
Arthroscopic Latarjet procedure
L. Lafosse
Arthroscopic shoulder stabilization with a bone block
E. Taverna
54. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
3 months
Post-op
55. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
3 months
Post-op
56. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Arthroscopic Bone Block
combined with Remplissage
57. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Our Results
15 cases
Impressive early outcomes
58. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Bushnell BD, Creighton RA, Herring MM. Hybrid treatment
of engaging Hill-Sachs lesions: Arthroscopic capsulolabral
repair and limited posterior approach for bone-grafting. Tech
Shoulder Elbow Surg 2007;8:194-203.
59. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Humeral
head resurfacing for fixed anterior glenohumeral dislocation.
Int Orthop 2007 Dec 19 [Epub ahead of print]
60. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Posterior instability
clinical presentation
1. Sense of insecurity and feeling of instability in forward
flexion and internal rotation
2. Locked posterior dislocation with loss of external rotation
61. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Locked posterior dislocation
is easily missed
65. www.shoulder.gr
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Athens Seminar - Scapular Dyskinesis related to shoulder pathology
E. Antonogiannakis 09.06.2017
Thank you for your attention!!!
Save the date: 1-3 February 2018