APPROACH TO

A FAILED
INSTABILITYS
URGERY

DR.V.CHANDAN NOEL
MOHTADI
JBJS -2014

LEVEL -1

OPEN – 11%

ARTHROSCOPIC – 23%
 OJSM
-2017

BURKHART-10.8%
KIM-10%
BOILEAU-14.8%
LAFOSSE- 18%
IMHOFF-14.2%

CASTAGNA-23%
VAN DER LINDE- 35%
FLINKILLA-20%
 OPEN A’SCOPY

<2005 10.7% 16.8%

>2005 10.8% 14.2%

WHAT IS FAILURE …..???

1.INSTABILITY

2.PERSISTENT PAIN
3.MOTION LOSS
4.N/A RETURN TO WORK
5.OA CHANGES
CAUSES COMBINATION

1.INTRINSIC FACTORS

2.INACCURATE DIAGNOSIS

3.TECHNICAL ERRORS
 KANDZIORA
INTRINSIC FACTORS – NON
ET AL ANATOMICAL
INJURY TO SURGERY TIME >6 MO’S

AGE RATE OF NUMBER OF RATE OF

RECURRENCE DISLOCATIONS RECURRENCE
20 years 25 %
21–30 years 20 % 1-2 11.1%
31–40 years 7.1 % 3-4 17.8%
6-10 43%
41 years 0%
11-20 43.4%
>20 55.5%
COLLISION GROUP- 29%
VS
NON-COLLISION-6%
 KSSTA
2012

1. AGE <20-33% VS >20-11.8%

2. GENDER MALES-15% VS FEMALES-8.7%
3. HIGHER PRE-OP DISLOCATIONS RISK FOR RECURRENCE
4. COLLISION/CONTACT SPORTS VS OTHERS (15% VS 11%)- NO DIFFEREN
5. LEVEL OF SPORTS ( 29% VS 11.5%)
6. LIGAMENTOUS LAXITY
ANATOMICAL
>250MM3

VOLUME OF THE HILL SACHS- LENGTH X DEPTH X HEIGHT

633MM 3

VS
233MM 3
LIGAMENTOUS
LAXITY… 18.9% VS 4.9%

3 TIMES RISK
ALPSA HIGHER
12.5%
RISK OF
FAILURE Vs
6.5%
ERRORS IN TECHNIQUE

– INFERIOR CAPSULELAXITY IS NOT ADDRESSED

– POOR RE-TENSIONING
– POOR ANCHOR PLACEMENT
– TOO FEW ANCHORS
– POOR KNOTS
– STICH PATTERN
– BONY BANKART (NOT INCORPORATING IN REPAIR)
– HILL SACHS NOT ADDRESSED
– SHORTER IMMOBILIZATION
TECHNICAL ERRORS
SICOT 2016
 37% 61% 11%

REPAIR OF INFERIOR LABRUM CRITICAL TO JOINT

VOLUME REDUCTION
 LEVEL II
KSSTA-2012

– LESS THAN 3 ANCHORS , HIGHER RECURRENCE

– INADEQUATE RE-TENSIONING OF THE INFERIOR CAPSULE
– MOST REPAIRS LACKED ANCHORS AFTER 4’O CLOCK.
ERRORS IN DIAGNOSIS

– PAN-LABRAL TEARS
– BONE LOSS
– ALPSA
– HAGL’S
– CAPSULAR TEARING
– SLAP
– CUFF PATHOLOGY
• 55% BONY BANKART’S MISSED OR NOT
INCORPORATED IN REPAIR
• 22% LAX CAPSULE NOT DIAGNOSED PRE-OP, MISSED
• 5% HUMERAL SIDED LESIONS
EVALUATION
 HISTORY
– TRAUMATIC OR A TRAUMATIC
– NUMBER OF DISLOCATIONS
– NIGHT INSTABILITY
– SPORTS
– PREVIOUS OP RECORDS / IMAGES ( MISSED
PATHOLOGIES)
– INFECTIONS, HARDWARE
EXAMINATIONS

– HYPERLAXITY ( GENERALIZED & SHOULDER)

– ROMS – STIFFNESS
– CUFF DYSFUNCTION ( SUB SCAPULARIS, SLAP-BICEPS)
– INSTABILITY IN MID RANGE
– APPREHENSION
– MDI
– NEUROLOGY- BRACHIAL PLEXUS
IMAGING
MANAGEMENT
REVISION BANKARTS REPAIR

– BANKARTS LESION (QUALITY…??)

– LAX CAPSULE (NOT ADDRESSED IN
PRIMARY SURGERY…??)
– NEGLIGIBLE BONE LOSS
– HILL SACHS< 25 % OF HEAD, ENGAGING
– SPORTING/ HYPERLAXITY/ ANCHORS
REOPERATIONS POORER OUTCOMES
– 56 REVISION
STABILIZATIONS
– 6 FAILURES (11%)
– ALL FAILURES HAD
POOR CAPSULOLABRAL
QUALITY
– BONE LOSS 15-20%
SCOI – HOSPITAL CORNER STICH
 4 –SA
3- PLICATION
STICHES

– 18 patients with recurrent instability

– Bone loss >25% excluded
– Anterior capsulolabral repair + capsular plications
posteriorly
– Rotator interval closure sulcus in er
– 13/18 good results
– 3 recurrence of instability and 2- continued pain
• LEVEL 3
• PRIMARY VS REVISION (20 PATIENTS)
• NO REDISLOCATIONS
• POORER FUNCTIONAL OUTCOMES IN REVISION GROUP
 2012

– MULTIDIRECTIONAL SHOULDER
INSTABILITY
– GREATER THAN 25% GLENOID
BONE LOSS
– A HILL SACHS LESION INVOLVING
MORE THAN ONE-THIRD OF THE
ARTICULAR SURFACE OF THE
HUMERAL HEAD.
– PATIENTS ELECTING TO CONTINUE
PURSUING CONTACT SPORTS
 CONCLUSION
– ARTHROSCOPIC BANKARTS REPAIR HAVE SIGNIFICANT RECURRENCES
– SCOPY RECURRENCES FAIRLY SAFE TO ADDRESS WITH REVISION SCOPY
– PROVIDED EVALUATE THE PATIENT AS A WHOLE- SPORTING, AGE, LAXITY,BONE LOSS,
NUMBER OF DISLOCATIONS
– PLAN OF MANAGEMENT – BASED ON THE PROBLEMS AT HAND, ADDRESS LAXITY AND
ACCOMPANYING PATHOLOGIES
– CRITICAL BONE LOSS - 25%, SUB CRITICAL BONE LOSS….?????
– RETURN TO SPORT AFTER BANKART WITH A PINCH OF SALT
BONE LOSS > 25 % - LATARJET
 3.3%
DISLOCATION FREQUENT
AFTER OPEN SURGERY VS
0.3%
 CAUSES OF FAILURE IN
LATARJETS
– IMMEDIATE- WOUND RELATED COMPLICATIONS
– NEUROVASCULAR
– RECURRENCE OF INSTABILITY
– GRAFT NON UNION
– OSTEOLYSIS OF GRAFT
– GRAFT TOO MEDIAL-JOB NOT DONE..!!!
– TOO LATERAL – OSTEOARTHROSIS…JOB OVER DONE…!!!
 RETURN TO
SPORT – 47%

5 PATIENTS WITH ARTHRITIS

3PROGRESSED BY ONE
GRADE
• 319 PATIENTS – 23 REVISION SURGERIES
• RECURRENCE 17%
• RECURRENCE IN REVISION CASES- 26% ( 1 DISLOCATION,5
SUBLUXATION)
• 95% SATISFIED
 JBJS
2012

– 49 PATIENTS- 32(SINGLE), 12(DOUBLE),5 (TRIPLE)

– 2 (4.1%) ONLY SUBLUXATION, NO DISLOCATIONS
– 88% REPORTED GOOD RESULTS
• 34 PATIENTS
• 75% GOOD REULTS
• 85 % RETURN TO SPORTING
•
 AJSM-2008

47 PATIENTS , NO
RECURRENCES AT 10
YRS FOLLOWUP.