-

1. Manos Antonogiannakis
O r t h o p a e d i c S u r g e o n
Director Center for Shoulder Arthroscopy
IASO General Hospital
Athens, Greece
www.shoulder.gr

6. Restore the anatomy even partially in an atraumatic way

8. And by bad tissue quality we mean

9.  Demonstrate the extent and the configuration of rot cuff abnormalities
 Suggest mechanical imbalance of the cuff
 Document abnormalities of the adjacent muscles.
With the use of the pre-operative MRI the surgeon is able to predict the rotator cuff tear pattern, the appropriate
method for repairing and the prognosis .

10. Field strength : High field strength 1, 1.5, 3 Tesla
Low field strength 0.5 Tesla
Low field strength : longer time to generate images
High signal to noise ratio
Surface coils (transmitter and receiver of radiofrequency pulses) that generate
Pulse sequences
T1-weighted sequence (fat bright,- water , muscle intermediate – fibrous, calcioum
dark)
T2-weighted sequence(water ,fat bright-muscle intermediete-fibrous, calcioum dark
Proton density
Gradient echo
Fat saturation techniques (supress the signal from fat so that pathology to be more
obvious)
MRI nomenclature
The patient is placed into a magnetic field created by a strong
magnet

11. A: Articular B: Bursal C: Intresubstance

12. Partial tears are better imaged by MR direct
arthrography
High(fluid) signal intensity due to Gadolinioum through a portion of the tendon
Common in young athletes in combination with SLAP tears

13. Many classification systems have been described
But we use the 2-dimensional classification system described by S. Burkhart that links
preoperative MRI imaging to operative treatment and prognosis

14. Measure L (medial to lateral length)
Blunt
Taper
ed
Wisp
y
Measure from here
Measure W (anterior to posterior length)
Measurment in two dimensions Length medial to lateral. Width anterior to posterior
Good quality T2 weighted fat suppressed coronal
oblique and sagital oblique MRI images are used for the
calculations

15. Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear
End-to-bone
repair
Good to excellent
2
Longitudinal
(L or U)
Long and narrow tear
Margin
convergence
Good to excellent
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval
slides or
partial repair
Fair to good
4
Cuff tear
arthropathy
Cuff tear arthropathy Arthroplasty Fair to good.

16. Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent
Short and wide tear
L < W
End-to-bone
repair
Good to
excellent

17. Bursal
side
Articular
side
Final repair

18. Type Description Preoperative MRI Findings Treatment Prognosis
2
Longitudinal
(L or U)
Long and narrow tear
L > W
Margin
convergence
Good to
excellent

20. Type Description Preoperative MRI Findings Treatment Prognosis
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval slides
or partial repair
Fair to good

23. Preoperative estimation of fatty infiltration of
infraspinatus and supraspinatus muscle bellies
affects the prognosis

24. 0 Normal
1
Some
fatty
streaks
2
More
muscle
3
Muscle =
Fat
4 More fat
According to Goutallier et
al. in C/T scan

26. Arthroscopic repair of massive rot cuff tears with stage 3 and 4
fatty degenaration
S.S. Burkhart et al Arthroscopy 2007
22 patients,
Mean age 66.5
Massive 2 and 3 tendon tears
Mean F.U. 39 months
Mean UCLA score; pre-op 12.3 post-op 29.5
Mean active FF: preoperative 103.2° and postoperatively: 156.9°).
Mean active ext rot: preoperative 35.7° and postoperative: 54.8°
Better results in patients with 50-75% Fatty degeneration of infraspinatus than in
more than 75%
Fair to good prognosis

27.  2 years (January 2011– December 2012)
 28 patients with an average age of 66 years
 Chronic tears: 57% - Acute on chronic tears: 43%
 Tangent sign positive: 82%
 Repair: Complete - 68%, Medialized – 20% - Partial 12%
Following these guidelines and classification system
We had similar results

28.  Mean VAS: from 7 pre-op to 0.3 post-op
From preoperatively to One year postoperatively
 Mean active FF: from 141 to 171 degrees
 Mean active ER in 0 degrees abduction: from 54 to 69 degrees
 Mean active IR: from L3 to Th11
 Mean Constant Score: from 35 to 73
 Mean ASES: from 48 to 93
 Mean Power in ER: from 1.6 to 6

29. Important is that by preoperative MRI imaging we can
plan the operation and have a fairly accurate
prediction of the outcome

30. Visible in plain X-rays

31. FROZEN SHOULDER
when overestimation of MRI reports can lead to clinical
mistakes

32.  Thickened coracohumeral ligament
 Thickening of soft tissue in the rotator interval
 Thickened inferior glenohumeral ligament

33. The diagnosis of frozen shoulder is clinical
Be aware of MRI reports of tendinosis or partial thickness
rot cuff tears or narrow subacromial space in a clinically
diagnosed frozen shoulder
They are misleading and can drive the surgeon to wrong decisions regarding the
best treatment
The signs of frozen shoulder in MRI are subtle but very obvious in clinical
examination
And remember the radiologist has not examined the patient and usually has very litle
information about the clinical condition of the patient

34. There is no need for evaluating with MRI in order to be detected
even though the accuracy of MRI for finding calcification is more than 95%.
Only an x-ray of the shoulder is needed for the diagnosis of calcific tendonitis
especially in the acute face

35. Interpreting MR images of the post-operative shoulder can be daunting
because of the artifacts from implants that often make the study harder to
evaluate.

37. Conventional MRI provides a good
overview of shoulder lesions and anatomy,
particularly the soft-tissue structures.
However, it is less accurate than MR
arthrography for depiction of small
labroligamentous lesions associated with
shoulder dislocation.
MR arthrography is the imaging modality of
choice to evaluate the labrum. It has the
highest sensitivity and specificity of all
available modalities.
But it is invasive and inconvenient for the
patient

38. Differences in the type of soft tissue lesions have little influence
to the planning of the operation ,but significant bone loss either
of the glenoid or the humeral head has

39. Traumatic Glenohumeral bone defects and Their
relationship to failure of arthroscopic Bankart repairs:
Significance of the inverted-pear glenoid and the
humeral engaging Hill-Sachs lesion
S.S. Burkhart and J. F. De Beer, M.D.
Arthroscopy,October 2000

40.  Total group: 194 patients
 173 pt without significant bone defects :
7 pt sustained a recurrence (4%)
 21 pt with significant bone defects:
14 pt developed rec instability (67%)

41. The inferior 2/3 of the glenoid is nearly a perfect
circle with avg diameter 24mm
Huysman et al. JSES 2006

42. Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim

43. Loss of 8.6mm of anterior radius of glenoid at the level
of the bare spot corresponds to 35% of the normal
anteroposterior width
Lo, Burkhart Arthroscopy 2004

44. >25 – 30% bone loss
6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)

45. Although a bony bankart and glenoid and
humeral bone defects are being depicted on
MRI at present CT-scans are better for the
quantification of the defects

46.  Glenoid Index in 3D CT scan of both shoulders
 Critical Limit Glenoid index 0.75
SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382

47.  Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid
surface

48.  Our practice
The percentage of the glenoid defect was evaluated on the en face reconstructed
view with the humeral head eliminated
Sugaya et al (2005) Joint Surg Am

49.  Glenoid Bone Loss >25-30%
Arthroscopic or open Latarjet procedure
L. Lafosse
Arthroscopic shoulder stabilization with a bone
block
E. Taverna

52. Engaging Hill-Sachs

53.  Engaging Hill-Sachs-glenoid bone loss
Hill- Sachs Remplisage: An arthroscopic surgical
solution for the engaging Hill-Sachs
E.M. Wolf

54. OOF
SHOULDER1
2 Midterm outcomes of arthroscopic remplissage
3 for the management of recurrent anterior shoulder instability
4 Emmanouil Brilakis • Elias Mataragas •
5 Anastasios Deligeorgis • Vasilios Maniatis •
6 Emmanouil Antonogiannakis
7 Received: 14 April 2013/Accepted: 12 January 2014
8 Ó Springer-Verlag Berlin Heidelberg 2014
9 Abstract 27returned to their previous everyday activities while 70.8 %
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-2848-1
AuthorProof

55.  4 years (January 2007– December 2010)
 48 patients with an average age of 28.9 ± 7.8 years
 Positive apprehension sign pre-operatively
 79% of these patients were involved in sport activities
of different levels.
 Mean follow-up period: 37.2 ± 9.9 months
UNCO
RRECTED
PRO
O
F
SHOUL DER1
2 M idter m outcomes of ar thr oscopic r emplissage
3 for the management of r ecur r ent anter ior shoulder instability
4 Emmanouil Br ilakis • Elias M atar agas •
5 Anastasios Deligeor gis • Vasilios M aniatis •
6 Emmanouil Antonogiannakis
7 Received: 14 April 2013 / Accepted: 12 January 2014
8 Ó Springer-Verlag Berlin Heidelberg 2014
9 Abstr act
10 Purpose The purpose of the study was to present midterm
11 results concerning the management of recurrent anterior
12 shoulder instability with the remplissage technique in
13 addition to the classic Bankart repair, in patients with
14 engaging Hill–Sachs lesions.
15 Methods During a time period of 4 years (January 2007–
16 December 2010), 48 patients with an average age of
17 28.9 ± 7.8 years were operated on in our department.
18 They all had a positive apprehension sign pre-operatively
19 and satisfied the inclusion criteria of this study. Seventy-
20 nine per cent of these patients were involved in sport
21 activities of different levels. The mean follow-up period
22 was 37.2 ± 9.9 months.
23 Results Three patients (6.3 %) had suffered a new dis-
24 location: one of them after a low-energy trauma and the
25 two other after a high-energy trauma. The rest of the
26 patients (93.7 %) were satisfied with the surgical result and
27returned to their previous everyday activities while 70.8 %
28continued to participate in sporting activities without
29restrictions. The ASES score increased from 67.7 ± 21.5
30points pre-operatively to 90.8 ± 21.7 points post-opera-
31tively (p 0.01), the modified Rowe score from 38 ± 17.3
32to 93.8 ± 14.5 (p 0.001) and the Oxford Instability score
33from 27.6 ± 11.1 to 45.1 ± 8.3 (p 0.001). No signifi-
34cant restriction in shoulder range of motion was
35documented.
36Conclusions The outcome of the enhancement of the
37classic Bankart repair with tenodesis of the infraspinatus
38and posterior capsular plication is very good as far as the
39management of recurrent anterior shoulder instability is
40concerned, without significantly influencing the range of
41motion of the shoulder.
42Level of evidence Therapeutic study—case series with no
43comparison group, Level IV. 44
45K eywor ds Arthroscopy Shoulder Remplissage
46Recurrent anterior shoulder instability Engaging Hill–
47Sachs lesion
48I ntr oduction
49Arthroscopic Bankart repair is nowadays widely accepted
50as the treatment of choice for the management of patients
51with traumatic unidirectional anterior shoulder instability.
52However, when a marked glenoid defect is discovered, the
53Bristow, the Latarjet or other bone grafting procedures are
54indicated. On the other hand, when large Hill–Sachs
55lesions exist, the optimal treatment is controversial.
56According to Burkhart and De Beer [2], large osseous
57defects of the postero-superior aspect of the humeral head
58can engage the glenoid rim and cause recurrent instability
A1 E. Brilakis (& ) E. Mataragas A. Deligeorgis
A2 E. Antonogiannakis
A3 2nd Orthopaedic Department, Shoulder Arthroscopy and Surgery
A4 Center, IASO General Hospital, 44-46 Str. Sevastopoulou,
A5 115 24 Athens, Greece
A6 e-mail: emmanuel.brilakis@gmail.com
A7 E. Mataragas
A8 e-mail: eliasmataragas@gmail.com
A9 A. Deligeorgis
A10 e-mail: delitasos@hotmail.com
A11 E. Antonogiannakis
A12 e-mail: manosanton@gmail.com
A13 V. Maniatis
A14 Department of Radiology, IASO General Hospital, Athens,
A15 Greece
A16 e-mail: vmaniatis67@gmail.com
123
Journal : L ar ge 167 Dispatch : 23-1-2014 Pages : 8
Article No. : 2848 h LE h TYPESET
MS Code : K SST-D-13-00348 h CP h DISK4 4
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-2848-1
AuthorProof

56.  Failure rate: 6.3 %
 93.7 % satisfied with the surgical result and returned to their previous
everyday activities
 70.8 % continued to participate in sporting activities without restrictions.
 ASES score: increased from 67.7 ± 21.5 29 to 90.8 ± 21.7 points (p<0.01),
 Modified Rowe score increased from 38 ± 17.3 to 93.8 ± 14.5 (p<0.001)
 Oxford Instability score increased from 27.6 ± 11.1 to 45.1 ± 8.3 (p<0.001).
 No significant restriction in shoulder range of motion
UNCO
RRECTED
PRO
O
F
SHOUL DER1
2 M idter m outcomes of ar thr oscopic r emplissage
3 for the management of r ecur r ent anter ior shoulder instability
4 Emmanouil Br ilakis • Elias M atar agas •
5 Anastasios Deligeor gis • Vasilios M aniatis •
6 Emmanouil Antonogiannakis
7 Received: 14 April 2013 / Accepted: 12 January 2014
8 Ó Springer-Verlag Berlin Heidelberg 2014
9 Abstr act
10 Purpose The purpose of the study was to present midterm
11 results concerning the management of recurrent anterior
12 shoulder instability with the remplissage technique in
13 addition to the classic Bankart repair, in patients with
14 engaging Hill–Sachs lesions.
15 Methods During a time period of 4 years (January 2007–
16 December 2010), 48 patients with an average age of
17 28.9 ± 7.8 years were operated on in our department.
18 They all had a positive apprehension sign pre-operatively
19 and satisfied the inclusion criteria of this study. Seventy-
20 nine per cent of these patients were involved in sport
21 activities of different levels. The mean follow-up period
22 was 37.2 ± 9.9 months.
23 Results Three patients (6.3 %) had suffered a new dis-
24 location: one of them after a low-energy trauma and the
25 two other after a high-energy trauma. The rest of the
26 patients (93.7 %) were satisfied with the surgical result and
27returned to their previous everyday activities while 70.8 %
28continued to participate in sporting activities without
29restrictions. The ASES score increased from 67.7 ± 21.5
30points pre-operatively to 90.8 ± 21.7 points post-opera-
31tively (p 0.01), the modified Rowe score from 38 ± 17.3
32to 93.8 ± 14.5 (p 0.001) and the Oxford Instability score
33from 27.6 ± 11.1 to 45.1 ± 8.3 (p 0.001). No signifi-
34cant restriction in shoulder range of motion was
35documented.
36Conclusions The outcome of the enhancement of the
37classic Bankart repair with tenodesis of the infraspinatus
38and posterior capsular plication is very good as far as the
39management of recurrent anterior shoulder instability is
40concerned, without significantly influencing the range of
41motion of the shoulder.
42Level of evidence Therapeutic study—case series with no
43comparison group, Level IV. 44
45K eywor ds Arthroscopy Shoulder Remplissage
46Recurrent anterior shoulder instability Engaging Hill–
47Sachs lesion
48I ntr oduction
49Arthroscopic Bankart repair is nowadays widely accepted
50as the treatment of choice for the management of patients
51with traumatic unidirectional anterior shoulder instability.
52However, when a marked glenoid defect is discovered, the
53Bristow, the Latarjet or other bone grafting procedures are
54indicated. On the other hand, when large Hill–Sachs
55lesions exist, the optimal treatment is controversial.
56According to Burkhart and De Beer [2], large osseous
57defects of the postero-superior aspect of the humeral head
58can engage the glenoid rim and cause recurrent instability
A1 E. Brilakis (& ) E. Mataragas A. Deligeorgis
A2 E. Antonogiannakis
A3 2nd Orthopaedic Department, Shoulder Arthroscopy and Surgery
A4 Center, IASO General Hospital, 44-46 Str. Sevastopoulou,
A5 115 24 Athens, Greece
A6 e-mail: emmanuel.brilakis@gmail.com
A7 E. Mataragas
A8 e-mail: eliasmataragas@gmail.com
A9 A. Deligeorgis
A10 e-mail: delitasos@hotmail.com
A11 E. Antonogiannakis
A12 e-mail: manosanton@gmail.com
A13 V. Maniatis
A14 Department of Radiology, IASO General Hospital, Athens,
A15 Greece
A16 e-mail: vmaniatis67@gmail.com
123
Journal : L ar ge 167 Dispatch : 23-1-2014 Pages : 8
Article No. : 2848 h LE h TYPESET
MS Code : K SST-D-13-00348 h CP h DISK4 4
Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-014-2848-1
AuthorProof

57.  Evolving Concept of Bipolar Bone Loss and
the Hill-Sachs Lesion:
 From “Engaging/Non-Engaging” Lesion to “On-
Track/Off-Track” Lesion
 Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Or when to perform a soft tissue Bankart repair only
Or in combination with Remplisage or a Latarget procedure

58. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Three-dimensional CT scan with en face view of a normal glenoid, with
subtraction of the humeral head
The width of the glenoid track without a glenoid defect is 83% of the glenoid width.
Glenoid track= the width
of the posterior lateral
part of the humeral that
is in contact with the
glenoid in abduction –
ext rotation

59. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A. 3D CT scan with en face view of a glenoid with bone loss of width d.
In such a case with glenoid bone loss, the glenoid track will be 83% of the normal
glenoid width minus d.
.

60. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
The width of the glenoid track of the humeral head
bigger than the Hill-Sachs= non engaging ,on track

61. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
The width of the glenoid track of the humeral head
smaller than the Hill-Sachs= engaging ,off track

62. Off track = Engaging Hill-Sachs
Evaluation during arthroscopy
Engagement of the Hill-Sachs can be evaluated
preoperatively

63. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment
1 <25% On track Arthroscopic Bankart repair
2 <25% Off track Arthroscopic Bankart repair plus remplissage
3 >25% On track Latarjet procedure
4 >25% Off track Latarjet procedure with or without humeral-sided
procedure (humeral bone graft or remplissage),
depending on engagement of Hill-Sachs lesion
after Latarjet procedure
and the operation planned accordingly
At present we are evaluating the preoperative calculation with direct arthoscopic
confirmation of engagement but the results are promising

64.  Benign tumors around the shoulder
 Primary and metastatic malignant tumors
 Subtle fractures of the upper part of the humerous or
the scapula
 Sinovial diseases ( osteochondromatosis , PVS)
 Neuropathies of the peripheral nerves that innervate
the muscles of the scapula and the shoulder
Be especially suspicious when the clinical presentation is not
familiar

67. 1. MRI is helpful in Rot Cuff tears
depicting not only the existence but also the size, morphology,
condition of the rot cuff muscles and prognosis
2.In frozen shoulder the diagnosis may be missed
beware of reports of supraspinatus tendinosis or calcifications
of the supraspinatus in a clinical diagnosed frozen shoulder
3. Partial rot cuff tears and labral tears especially in young
overhead athletes are best depicted with MR Arthrogram
4. Although Glenoid bone loss and Hill-Sachs lesions are depicted
with MRI, are better quantitated at present by a 3D CT-scan
5.Unfamiliar clinical presentations need further imaging

69. Thank you for staying awake