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 .