Bankart & Hill Sachs lesions and their repairs

Bankarts lesion

1. I nstability : Bankart & Hill Sachs Dr. Pavankumar Ravi Vijayawada

2. Shouder Instability Anteroinferior Posterior Posterosuperior / SLAP

3. Acute vs Chronic Isolated vs Recurrent Subluxation vs Dislocation Direction Past treatment taken History 5 basic questions to be answered

4. Onset – violent injury or trivial injury Ease of reduction Number of episodes Sleep dislocations Seizures Assess the overall functional disability and requirements History Sleep dislocations = Beware!!!

5. DEFINITIONS LAXITY Range of motion of the center of the humeral head with respect to the glenoid fossa due to a external force INSTABILITY Symptomatic inability to maintain the humeral head in the glenoid fossa

6. DEFINITIONS SUBLUXATION Partial dislocation Incomplete separation of joint DISLOCATION Frank separation of joint

7. CLASSIFICATION MECHANISMS TUBS - T raumatic U nidirectional B ankart S urgery AMBRI – A traumatic M ultidirectional B ilateral R ehabilitation I nferior shift Matsen et al

8. Labrum Capsule – Plastic deformation / HAGL Ligaments - IGHL Hill Sach’s lesion – PL or AM Glenoid margin - Anterior / Posterior Rotator cuff - >40yrs 40% prevalence Structures @ risk

9. Labrum Capsule – Plastic deformation / HAGL Ligaments - IGHL Hill Sach’s lesion – PL or AM Glenoid margin - Anterior / Posterior Rotator cuff - >40yrs 40% prevalence Structures @ risk

10. Bumper (anterior labrum) Bicipital anchor

11. Capsule SGHL MGHL IGHL Hammock concept Static Stabilisers

12. Inferior glenohumeral ligament complex Hammock Principle

13. IGHL

14. Imaging Xrays CT Scans MRI Always Possibly Most likely Do we need all of the above?

15. True AP (Grashey) Glenoid AP (True AP) - causes no overlap of glenoid and humerus - makes evaluation of glenohumeral joint easier

16. Loss of double cortical sign

17. Special views West Point view Assess glenoid rim fractures

18. Special views Stryker Notch view Assess the Hill Sachs defect

19. Essential lesion Bankart Lesion: Detachment of the anterior capsulolabral complex

20. Bankart lesion Hill Sachs lesion

21. HAGL lesion ‘J’ Sign

22. AXIAL SAG

23. Bipolar pathology

24. Glenoid track - zone of contact between glenoid and humeral head as the arm is raised Glenoid track= 83% AP dimension of normal shoulder Hill Sach’s index [HSI] = HS + BB (dist from medial margin rotator cuff attachment till medial margin Hill Sach’s lesion HSI > Glenoid track: Off track lesion HSI < Glenoid track: On track lesio n Clin Orthop Surg. 2015 Dec;7(4):425-429

25. <25% Glenoid defect On track <25% Glenoid defect Off track >25% Glenoid defect On track > 25 % Glenoid defect Off track Calculation of Bipolar bone loss Arthroscopic Bankart Artroscopic Bankart Remplissage Latarjet Latarjet with or without humeral sided procedure Remplissage/ Humeral head allograft

26. Need for CT scans Acute bony Bankart

27. 3D reconstructions

28. Sugaya et al JBJS (Am) 2003

29. Max AP dimension normal shoulder [A] Max AP dimension affected shoulder [B] Glenoid bone loss = A-B /A X 100 2.41-2.11/2.41 X 100 13 % approx [mild] A B Clin Orthop Relat Res.  2013 Apr;471(4):1251-6. doi: 10.1007/s11999-012-2607-x. Epub 2012 Sep 21. 3-D CT is the most reliable imaging modality when quantifying glenoid bone loss. Bishop JY 1 ,  Jones GL ,  Rerko MA ,  Donaldson C ;  MOON Shoulder Group

30. Glenoid bone loss = 26.1-21.4 / 26.1 X 100 =18 % Approx [mod] Fractured bone fragment measures 12 x 5 x 5 mm

31. Assessment of glenoid bone loss Assessment of Hill Sach’s bone loss Assessment of bipolar bone loss….on track/off track glenoid Fractures…size, displacement

32. Treatment Arthroscopic Bankart Remplissage Latarjet Cuff repair Bone grafting Shoulder Arthroplasty

33. Summary Clinical evaluation starts with an apt history Management relies more on clinical rather than imaging findings Assessment of the direction and severity of instability should aid in advising the correct investigations In patients >40 yrs always assess cuff function

34. Thank you