Transcript Shoulder Dislocation

Acute Shoulder Dislocation Surgery
Acute anterior dislocation of the shoulder
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Acute Shoulder Dislocation Surgery
Anatomy
• Stability:
• Bone
• Menisci
• Ligaments
- ball & socket
= compression in concavity effect
- big head – small cup
= unstable
- labium
= ↑ depth of cup by 20%
- glenohumeral & capsule
• Muscles
- rotator cuff & biceps
= holds ball in cup
• Primary Movers - Deltoid, Pec. major & Lat. Dorsy
= subluxing forces
• Dynamic
- proprioceptive feedback
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Acute Shoulder Dislocation Surgery
Pathophysiology (Lazarus 1996)
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Chondro-labral defect causes a 65% reduction in
stability in the direction of the defect
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Deficiency of the ant. inf. capsulolabral complex
Fracture of ant. lip of glenoid = 15%
Detachment of labarum/capsule = 15%
Tear of glenohumeral ligaments = 54%
Avulsion of subscapularis and ligs of humerus (HAGL)
•
To prevent the persistence of the defect it needs to be
repaired
Arthroscopically
Open
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Acute Shoulder Dislocation Surgery
Acute Injury
• Something breaks or tears and therefore can be repaired.
• Repair is better than reconstruct
• Repair is easier than reconstruct
Chronic
• Instability has additional plastic deformation of the capsule
and glenohumeral ligaments therefore needs to be shortened
• Restoring the normal functional anatomy is impossible
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Acute Shoulder Dislocation Surgery
Conservative Treatment
Rowe – JBJS, 1957
324 young patient with ant. dislocations
• 94% had recurrence if < 20 years old
• 62% had recurrence if < 30 years old
• 14% had recurrence if > 40 years old
Burkhead & Rockwood (text book)
40 patients with acute dislocation & vigorous rehabilitation
• Only 16% had good or excellent result (1 in 6)
Deny & Drew – Injury, November 2002
• 21% of all patients presenting with shoulder dislocation had
previous dislocation in 1 year
• 43% in patients 15-22 years had re-dislocations
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Acute Shoulder Dislocation Surgery
Non operative treatment of shoulder dislocation
in young athletes
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Arciera – J Arthroscopy, 1995
De Beardino – J South Orthopaedic Ass, 1996
Haelen – J Arch Orthopaedic Trauma Surgery, 1990
Hovelius – J Orthopaedic Science, 1999
Wheeler – J Arthroscopy, 1998
Kirkby – J Arthroscopy, 1999
all over 80% recurrence rate
Non operative treatment is unacceptable
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Acute Shoulder Dislocation Surgery
Prospective Randomised Study
Bottani etc.–Military Personnel Medicine Vol 30 No 4 2000
First Time Acute Traumatic Shoulder Dislocation
Stabilisation V’s Non Operative:
Follow up in 36 months
24 patients aged 18-26y.
• 14 Non Operative – rehab immobilised 4 weeks
• 9 of 12 non operative had instability (75%) (6 open Bankart repair)
• 10 ASC Bankart repair with bioabsorbable tack <10 days
• 1 of 9 operated patients had instability (11%)
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Acute Shoulder Dislocation Surgery
Chronic anterior instability
Comparison of Arthroscopic & Open Stabilisation
Sample Size
Follow Up
Recurrence
ASC Open
ASC Open
ASC Open
Steinbeck 1998
Field 1999
Cole 1999
Hayes etc 1999
30
50
37
44
32
50
22
13
36
33
52
29
40
30
55
29
17
8
16
12
5
0
9
4
Conclusion
Arthroscopic repair for chronic instability is inferior to open repair
? Due to plastic deformation
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Acute Shoulder Dislocation Surgery
Arthroscopic Techniques for Primary Dislocations
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1982 Johusa – with staples
1987 Morgen & Badenstab – transglenoid sutures
1991 Caspari -Cannulated bio-absorbable tacks
1993 Wolf & Snyder – suture anchors = difficult
1989 Wheller - ASC staple
1993 Gohlke - Suture anchors
1994 Arciera - ASC transglenoid
1996 Speer - Bio-absorbable tack
1999 Wintzell - ASC lavage
2000 Introduction of a multitude of new gadgets
& anchors
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Acute Shoulder Dislocation Surgery
Arthroscopic Repairs
Einoder, 1984 Knee Club
• Described Arthroscopic transglenoid sutures using:
– K wire with eye (ACL) introduced via anterior portal
– Sucking tube
– Sutures tied over infraspinatus fascia or spine of scapula
Results
– 4 out 5 patients returned to the same level of sport with no re-dislocations
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Acute Shoulder Dislocation Surgery
Arthroscopic Repair
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Acute Shoulder Dislocation Surgery
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Acute Shoulder Dislocation Surgery
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Acute Shoulder Dislocation Surgery
Boszotta & Helperstorfer – Arthroscopy, July 2000
Transglenoid suture repair for initial Ant. dislocation
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72 patients (1988-95)
61 ♂ 11 ♀Aged 19-39
34% = Bankart lesion (6 with bone)
66% = Avulsion of capsulolabral complex
Results
• 7% = Redislocation all due to trauma (severe in 2 out of 5)
• 85% = Returned to unrestricted pre injury sporting activities
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Acute Shoulder Dislocation Surgery
Randomised Studies
Asc. Stabilisation V’s Non Operative
Arciera et. al. – A.J. Sports Med., 1994
• 32 military men with acute 1st up dislocation, Average of 32 months
follow up
15 patients – non operative – 80% redislocated
21 patients – transglenoid suture – 14% redislocated
Bottony & Wilkings etc. A.J. Sports Medicine 2000
• Patients with acute traumatic first time shoulder dislocation
14 young patients – non op, 75% redislocation
10 young patients – Asc. Bankart repair, 10% redislocation
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Acute Shoulder Dislocation Surgery
Asc. stabilisation
Dara & Gerber – Journal of Shoulder & Elbow, 2000
• 20 shoulders
– Av 3 year follow up
– Recurrences occurred in patients who were chronic dislocators
i.e. <30%
– Therefore now
do open surgery for recurrent dislocations
Asc. surgery for acute dislocations
De Beardino et al – An J. Sports Med., 2000
• 49 1st up acute post traumatic Shoulders dislocation
– Average 37 months follow up
– Tack anchor.
– 6 Patients re-dislocated (13%) +4 had open surgery
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Acute Shoulder Dislocation Surgery
Bozzotta & Helpastorger (Austria) – J. Arthroscopy, 2000
Arthroscopic Transglenoid Suture Repair
for Initial Ant. Shoulder Dislocation
• 72 Patients 61♂ 11♀ - Sporting ambitious patients
25 Patients
Bankart lesion (6 with bone)
43 Patients
Capsulolabral avulsion
Results
• 5 patients Re dislocated
2 had significant trauma
3 had insignificant trauma = 4%
• Therefore results of primary repair are better than surgery for
recurrent dislocation
• But transgleniod repairs are obsolete
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Acute Shoulder Dislocation Surgery
Against …Arthroscopic Repair
Roberts, Taylor, Brown, Hayes, Saies (Adelaide)
Journal of Shoulder & Elbow, September 1999
• 56 acute 1st up shoulder dislocations
• 2½ year post operative and return to Australian Rules Football
• Operations:
– Asc. suture repair – 70% recurrence
– Asc. Bankart repair with tack – 38% recurrence,..
– Open repair & copsular shift – 30% recurrence
• Therefore Asc. treatment alone not good enough
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Acute Shoulder Dislocation Surgery
Cole & Warner – Clinical Sports Medicine 2000
Arthroscopic V’s Open Bankart Repair
For Traumatic Anterior Shoulder Instability
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% Asc. treatment modalities are increasing due to:
1. Better understanding of the pathophysiology
2. Better pre operative evaluation of the injury (i.e. patient
selection)
3. New surgical techniques
4. Better instrumentation
5. Better anchors
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Acute Shoulder Dislocation Surgery
Protocol for Acute Repair
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Mature & active person
15 to 50 years old
First episode of glenohumeral dislocation
Reduced on field, first aid, club Dr or DEM
4. Examination & X-ray
5. Informed consent – time off work - outcome
6. Examination under GA
7. ASC of glenohumeral joint, check rotator cuff as well
8. Acute repair of all demonstrable tears or fractures
 restore normal anatomy
11. Rehab activity – collar & cuff, physiotherapy
12. Avoid ext. rotation and abduction for 6 weeks
13. Return to contact sport in 12 weeks
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Acute Shoulder Dislocation Surgery
Investigations
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Plain x-rays
CT scans if complicated associated feature
MRI rarely – get more information from Asc.
Examination Under GA
Supine load shift test with arm at 80° abducted compared with
normal shoulder
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ball to rim
2+
ball riding over rim with spontaneous reduction
3+
ball stays dislocated
Arthroscopy
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Acute Shoulder Dislocation Surgery
Arthroscopic Repair Procedure
Patient Position
General Anaesthetic
Beach Chair with arm held by assistant
Lateral position with arm in traction & shoulder abducted
Shoulder examined, degree & direction of instability noted
Portals = 2 or 3
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Posterior portal
Ant. sup portal
Ant inf portal (occasionally)
Injury assessed & debrided
Repair method selected
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Acute Shoulder Dislocation Surgery
Rehabilitation
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2.
3.
Minimal in first 4 weeks
No ext rotation
Abduction less than 45°
Pendulum exercises
Isometric resistance exercises
Graduated in 4 – 8 weeks
↑ ROM
Graduated weight training
Return to sport
Non contact = 6 weeks
contact = 12 weeks
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Acute Shoulder Dislocation Surgery
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Arthroscopic V’s Open Bankart Repair
Advantages
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Accurate diagnosis of all structures
Less morbidity/pain
Small scars
Faster recovery
Sooner return to activities
Less restriction of movement
Disadvantages
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Need all the equipment
Technically demanding
Long learning curve
Lack of versatility
Higher failure rate arthroscopic = up to 33% open = less than 10%
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Acute Shoulder Dislocation Surgery
Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002
Advantages V’s Disadvantages of Asc. Repair
Advantages
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↑ cosmesis
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↓ morbidity
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↓ stiffness
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Easy revision
Disadvantages
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1) Reluctance to refer patient immediately
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2) Difficult operation
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3) Expensive instrumentation
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4) Biological healing time is not accelerated
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5) Same post operative restrictions
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Acute Shoulder Dislocation Surgery
Problems
1. Difficulty convincing Club Trainers, Physicians,
sporting club Doctors & DEM staff to refer the young
athlete within 2-3 days.
2. Time consuming discussions convincing patient to
have the operation rather than early return to sport.
No problem advising a recurrent dislocators to have a
stabilisation procedure at the end of a sporting
season.
3. Mostly after hours surgery with staff who are not
familiar with the operation and instrumentation.
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Acute Shoulder Dislocation Surgery
Arthroscopy of Shoulder
• 1935 – Japanese Surgeons arthroscoped, shoulders
• 1960s – Curiosity activity in the western world
• 1970s – Diagnostic Asc. examination  open surgery
• 1980s – Simple Asc. techniques for simple problems
• 1990s – ↑ Instrumentation & tacks  more tried it.
• 2000s – ↑ Techniques & anchors
– Can be done by any surgeon skilled in
arthroscopic techniques
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Acute Shoulder Dislocation Surgery
Shoulder reduced on field, first aid room or DEM then referred
Treatment History
1970s -
Conservative for all 1st up unless fractures with
Bristows or Bankart repair for recurrences
1980s -
Asc. transglenoid sutures
tied over spine of scapula or muscle fascia
1990s -
patient in lateral position with arm in traction
or patient in Beach chair position
multiple, tacks and sutures
surtac screw tack anchors etc.
2000 -
better anchors and sutures have made the
procedure available for all surgeons
experienced in arthroscopic technique
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Acute Shoulder Dislocation Surgery
Acute Labral Tear
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Acute Shoulder Dislocation Surgery
Acute Repair of Anterior Labral Tear
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Acute Shoulder Dislocation Surgery
Conclusion
• Asc. repair of the Capsulo-ligamentous injury to the shoulder
is a simple procedure for a surgeon skilled in arthroscopic
technique
• Chronic instabilities have associated plastic deformity of the
tissues that need to be addressed and this makes the result
of a simple procedure unpredictable.
• An active young person with a first traumatic dislocation of
the shoulder should have the damage repaired arthroscopically
within 10 days of the injury
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