Shoulder

Sam Ahkavan, MD (Pittsburgh, PA), presents a complex case of recurrent anterior shoulder instability in a young contact athlete treated with a labral scaffold dermal augmentation technique. The presentation details the use of an ArthroFlex® dermal allograft to augment the revision labral repair, highlighting the surgical technique and pearls for graft positioning and fixation using knotless anchors. Clinical outcomes, postoperative MRI findings, and histologic evidence are discussed, demonstrating graft incorporation, restoration of glenoid anatomy, and improved stability in this case and other similar cases of high-risk complex instability.
ArthroFlex is a registered trademark of LifeNet Health.

Not Hidden

English  - en

video

VID1-009262-en-US | A | Labral Scaffold Dermal Allograft Augmentation for High-Risk Shoulder Instability

Sam Ahkavan, MD (Pittsburgh, PA)

Human

Surgeons presenting one or more clinical cases

Chirurg:innen präsentieren einen oder mehrere klinische Fälle

Videos von Fallpräsentationen

Case Presentation Videos

Cirurgiões que apresentam um ou mais casos clínicos.

Vídeos apresentações de casos

Cirujanos que presentan uno o más casos clínicos.

Video presentaciones de casos

Labral Scaffold Dermal Allograft Augmentation for High-Risk Shoulder Instability

Speaker  Hello. My name is Sam Akhavan from Pittsburgh, Pennsylvania. And today we're going to be talking about a labral scaffold procedure, a dermal augmentation for high risk shoulder instability. We're going to start off with a case. This was a young patient of mine. First time dislocation while playing football. He played two more games and had two additional dislocations before coming in to get this taken care of. At the time of his surgery, he did receive a three anchor labral repair anteriorly. We did extend the repair posteriorly with two additional anchor to provide additional stability to the inferior capsule. Following surgery, he did return to sport with a relatively uncomplicated postoperative course eight months post-surgery. However, during his first football game, he did re dislocate, given the fact that he had just come off a ready a season where he was not playing, he decided to play for an additional whole year and had multiple dislocations during the season. At the conclusion of the season, he did come in and his MRI did demonstrate that he did re dislocate his shoulder with a labral tear and a fracture through his previous anchor lines. At the time of the surgery, this was confirmed with a fairly large labral tear. Our concern was that if we were to proceed with a standard revision repair, in this case, there would be a very high risk of recurrence. The other potential option was to proceed with a bone block procedure. However, we were concerned about his young age. While this would lower his risk of recurrence, the potential for osteoarthritis in the future. Speaker  Instead, we decided to proceed with a labral scaffold procedure. In this procedure, we use a dermal allograft to augment the anterior aspect of the shoulder while performing a labral repair, essentially performing an augmented labral repair. The concept for this procedure is very similar to that of a double row repair. A knotless FiberTak anchor is placed just below the articular surface, and we use a probe to measure the pocket where the dermal allograft will eventually sit. In this case, we used a three millimetres ArthroFLEX dermal allograft, although four and five millimetres ArthroFLEX is available as well and can be used for this procedure. The ArthroFlex is cut in one by one centimetre block and stacked and used to augment the anterior aspect of the glenoid. Once we have determined the size of our graft, passing sutures are passed through the graft. Two suture anchors are passed in opposite direction before the graft is brought up to the field. Once it is brought up to the field, the repair stitch from the ArthroFLEX is slid through these link anchors, essentially creating a mattress through the graft in the loop created by the mattress. We will take one of these sutures and actually use it as a traction stitch, in order to help us bring the graft into the appropriate position. Once everything is set up, we will then shuttle the graph down by pulling on the repair stitch to shuttle it through the cannula. And then we use that traction stitch on the back end of the graph to take any slack out of the repair, in order to get the graft in the appropriate position in between the glenoid and the capsule. Speaker  Once the graft is in the appropriate position, we are going to pass our sutures through the capsule and labrum. I prefer to pass the link suture through the capsule and a repair stitch through the labrum, bringing both over the top of the graft into a PushLock anchor. In essence, what this does is it puts the graph in an extra articular position, sealing it from the intra-articular environment. Our clinical results for this procedure were previously presented. It included 20 patients, 17 males, three females, of which 11 were contact athletes and 13 were revision cases. These patients were followed up for an average of 18 months, and all patients had an MRI at one year post-surgery. Our UCLA Vas, as well as Ases scores, showed significant improvement in all of these patients, and post-operative MRIs demonstrated excellent incorporation of the graph with our ability to restore the glenoid to almost 102% of its native size. In all these cases, here's an example of a patient six months post MRI. You can see the dermal allograft sitting neatly against the glenoid in an extra articular position covered by the overlying labrum and capsule. Here's an example of a college running back 18 months post surgery. Again, you can see that the dermal allograft is well incorporated with no edema surrounding the graft. Here's another example of a college linebacker. Again 12 months post surgery. You can see that the graft is well incorporated and still present with no signs of resorption. Speaker  We did have one failure in a patient. This was a football player that failed 13 months post-surgery. He actually did not fail while playing football, but instead failed while bow hunting following his football season. At the time, his bow misfired and he dislocated his shoulder. He was treated with allergy at the time of his surgery. However, we did harvest a graft that we had placed at the time of his index procedure and sent that off for histology. What we did find is that the graph was not only decellularized and revascularized, but showed evidence of ingrowth to the native tissue within growth of the bone from the glenoid side into the graft. In our current case outcome, our patient returned to sports the following football season and played starting linebacker. No issues. Had no evidence of recurrent instability. You can see on his MRI that we were able to once again restore his glenoid and had no evidence of graft resorption. In summary, our scaffold procedure provides a safe and effective treatment option even in complicated instability cases. Our clinical outcome demonstrated a low recurrence rate even when we were dealing with revision cases and cases with subcritical bone loss. It can be performed with other procedures as well should you want to do a Remplissage. This doesn't keep you from doing it, as you're dealing with two different issues in the setting of instability. Finally, our histological retrieval information on one failure demonstrated excellent incorporation of the graft cellular infiltration, as well as tissue remodeling seen with the ArthroFlex dermal allograft.

Labral Scaffold Dermal Allograft Augmentation for High-Risk Shoulder Instability

Related Pages

Shoulder

Técnica de anclaje todo sutura FiberTak® sin nudos - Anterior

Procedure