GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Director of Arthroscopic Surgery Dpt Director of...
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Transcript of GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Director of Arthroscopic Surgery Dpt Director of...
GIORGOS - GRIGORIS KARACHALIOS GIORGOS - GRIGORIS KARACHALIOS Orthopaedic Surgeon Orthopaedic Surgeon
Director of Arthroscopic Surgery DptDirector of Arthroscopic Surgery Dpt
Iatriko Kentro Athinon P.FalirouIatriko Kentro Athinon P.Falirou
P. Faliro , Athinai , Hellas . P. Faliro , Athinai , Hellas .
GLENOID FRACTURES :
ARTHROSCOPIC TREATMENT
Confusing literatureConfusing literature
• Complex anatomy and function .Complex anatomy and function .• There is no generally accepted There is no generally accepted
classification classification ( ( Euler & Ruedi , Goss , Ideberg , Euler & Ruedi , Goss , Ideberg , Thompson , Zdravkovic & Damholt )Thompson , Zdravkovic & Damholt ) . .
• The decision on treatment is mainly based The decision on treatment is mainly based on personal experience , since these are on personal experience , since these are rare .rare .
• Very often indicators of major trauma – Very often indicators of major trauma – the # is often neglectedthe # is often neglected
EpidemiologyEpidemiology
5% 5% of all fractures to the shoulder girdleof all fractures to the shoulder girdle
3% 3% of all injuries to the shoulder girdleof all injuries to the shoulder girdle
0.4 – 1% 0.4 – 1% of all fracturesof all fractures
Mean age Mean age 35 - 35 - 45 45 yearsyears
One per 3000 operated One per 3000 operated fractures fractures
~ 10% of glenoid fractures ~ 10% of glenoid fractures internal fixationinternal fixation
Scapular fractures classificationScapular fractures classification
• Intra-articular - extra-articularIntra-articular - extra-articular
• Body and spineBody and spine 50% 50% glenoid neckglenoid neck 25% 25% glenoid cavityglenoid cavity 10% 10% acromionacromion 7% 7% coracoidcoracoid 7% 7%
intra-articular intra-articular IdebergIdeberg
Glenoid fossa GossGlenoid fossa Goss
• Types II through V : Types II through V : closed reduction under closed reduction under anaesthesia ALWAYS unsuccessful . anaesthesia ALWAYS unsuccessful . Late Late improvement . improvement . 75% good results by early 75% good results by early mobilization . mobilization . European literature more aggressive European literature more aggressive
Type IType I to be distinguished to be distinguished fromfrom 1.1. Bony Bankart lesion Bony Bankart lesion
2.2. Type II Type II joint surface joint surface << glenoid neckglenoid neck
Mechanism of dislocationMechanism of dislocation
sometimes redislocation after sometimes redislocation after reductionreduction
riskrisk : :
Instability Instability ( ( late dislocation or subluxationlate dislocation or subluxation ) )
Joint degenerationJoint degeneration
TREATMENT ?TREATMENT ?
TARGETTARGET retain retain congruity of the articular surfacecongruity of the articular surface
stabilitystability of the joint of the joint
indications for internal fixationindications for internal fixation
displacementdisplacement > 10 > 10 mmmm.. & & fragmentfragment > ¼ > ¼ of the of the glenoidglenoid
internal fixationinternal fixation ( De Palma )( De Palma )
fragmentfragment > ¼ > ¼ of the glenoid of the glenoid & & instabilityinstability internal fixation internal fixation ( ( Rockwood )Rockwood )
indications for internal fixationindications for internal fixation
Type Type I fractureI fracture ( ( Ideberg )Ideberg )
> 21% > 21% of the length of the glenoid ( av. 26,2 % in of the length of the glenoid ( av. 26,2 % in his pts )his pts )
One fragmentOne fragment
Step Step > 2 > 2 mmmm
No neurological deficitNo neurological deficit
Fragment ‘s size 27 % Fragment ‘s size 27 % Sugaya 2005 Sugaya 2005
Tauber 2008Tauber 2008
indications for internal fixationindications for internal fixation
( A x 96,5% - B ) / A x 100( A x 96,5% - B ) / A x 100
fragmentfragment > > 21% 21% of the length of the of the length of the glenoid ( av. width 6.8 mm ) glenoid ( av. width 6.8 mm )
resecting a fragment > 6,8 mm resecting a fragment > 6,8 mm and refixing the capsular-ligamentous and refixing the capsular-ligamentous complex to the glenoid defect ,complex to the glenoid defect , creates instability and creates instability and reduces the ext. rotation reduces the ext. rotation Itoi 2000Itoi 2000
21%
openopen reduction and internal reduction and internal fixationfixation
failurefailure 10 % 10 % complicationscomplications 10% 10% Schandelmaier Schandelmaier
2002 2002
good- excellent functional outcomegood- excellent functional outcome 8 822 % % anatomic reduction 89 % anatomic reduction 89 % Mayo 1998Mayo 1998
implant impingement - looseningimplant impingement - loosening
neural injury neural injury infection infection stiffness stiffness
potential potential advantages of advantages of arthroscopic fixationarthroscopic fixation
Initial diagnostic arthroscopy to exclude / Initial diagnostic arthroscopy to exclude / assess associated injuriesassess associated injuries
Reduced soft tissue damage ( particulary of Reduced soft tissue damage ( particulary of the subscapularis tendon)the subscapularis tendon)
Overall lower postop morbidityOverall lower postop morbidity
the arthroscopic assessment , the arthroscopic assessment , offers offers ::
<< no need >> of C - arm<< no need >> of C - arm
Confirmation of the reduction …Confirmation of the reduction …
… … and the stability of the jointand the stability of the joint
Attempts of arthroscopic fixation using Attempts of arthroscopic fixation using ::
Suture anchorsSuture anchors
Percutaneous wire fixationPercutaneous wire fixation
Screw fixationScrew fixation
Sugaya 2005Sugaya 2005
Bauer 2006Bauer 2006
1
2
3
Assesement of the injury and mobility of the Assesement of the injury and mobility of the fragmentfragment
4
5
6
7
mobilizationdebridement
8
9
10
11
reduction
Temporary fixation by k-wire
average glenoid average glenoid length : 35 mm length : 35 mm average average glenoid width : 25 mm glenoid width : 25 mm
ACUTRAK – ACUMED ACUTRAK – ACUMED tapered tapered
cannulatedcannulated
HEADLESSHEADLESS
self-tapingself-taping
usually length of usually length of 25 – 30 mm is 25 – 30 mm is adequate adequate
length – length – instrumentation instrumentation ??? ??? Arthroscopic useArthroscopic use
12
13
drilling
Screw placement
Assesement of the injury and mobility of the Assesement of the injury and mobility of the fragmentfragment
reductionreduction
insertion of two screws – at the proximal and distal insertion of two screws – at the proximal and distal edges of the fractures - edges of the fractures -
Suture passing around the bony element of the Suture passing around the bony element of the fragment and reduction - temporary fixation by a fragment and reduction - temporary fixation by a guide K-wire , before the knot tying guide K-wire , before the knot tying
Knot tyingKnot tying
Self – tappingSelf – tapping
Threaded headThreaded head
Longer pitch of the Longer pitch of the distal threadsdistal threads
Smooth proximal Smooth proximal sectionsection
10/10 k-wire10/10 k-wire
Barouk screw Barouk screw DePuy DePuy
Drilling screw placementDrilling screw placement
Check of reduction Check of screw Check of reduction Check of screw impingementimpingement posterior portal anterior portalposterior portal anterior portal
displacementdisplacement
meticulus mobilization meticulus mobilization
bioabsorbable “ anchor “bioabsorbable “ anchor “ transosseous transosseous suturesuture
screw ( Barouk – DePuy ) screw ( Barouk – DePuy ) check check
Male , 47 , r shoulder
What was the problem ?What was the problem ?
Probably the Probably the orientation of the orientation of the fragment : upper edge fragment : upper edge bellow 3 ‘ clockbellow 3 ‘ clock
Longer distanceLonger distance
Higher riskHigher risk
Difficult reduction Difficult reduction
Ευχαριστώ και καλή σας ημέρα
Thank you and … Thank you and … have a nice have a nice day day
Male , 44 left side , nondom. Attempt to hold heavy item , ? dislocationPain , movement restriction
Male , 44 , right side – dom . Male , 44 , right side – dom . Dislocation . Closed reduction . Dislocation . Closed reduction . Pain , restriction of movements . Pain , restriction of movements .
14
ΤΕΛΙΚΟΣ ΕΛΕΓΧΟΣ
Type IIType II
• Transverse or Transverse or oblique # oblique #
• Inf glenoid : free Inf glenoid : free fragmentfragment
• Humeral head : Humeral head : sublux inferiorlysublux inferiorly
• ORIFORIF
Type IIIType III
• Upper third of the Upper third of the glenoid and coracoidglenoid and coracoid
• Assoc. injuries : Assoc. injuries : acromion # , clavicle acromion # , clavicle # , acromioclavicular # , acromioclavicular separation .separation .
• ORIF : > 5 mm step-ORIF : > 5 mm step-off , two incisions .off , two incisions .
Type IVType IV
• Horizontal # “ all Horizontal # “ all the way “ to the the way “ to the vertebral border .vertebral border .
• ORIF : separated or ORIF : separated or displaced # displaced #
Type VType V
• Combinaton of Combinaton of type II – IVtype II – IV
• ORIF , more ORIF , more conservative if h.h. conservative if h.h. is well centered .is well centered .