肩关节前脱位Anterior-Shoulder-Dislocation

AcuteanteriordislocationoftheshoulderAnatomyStability: -ball&socket =compressioninconcavityeffectBone-bighead–smallcup =unstableMenisci -labium =↑depthofcupby20%Ligaments -glenohumeral&capsuleMuscles -rotatorcuff&biceps =holdsballincupPrimaryMovers-Deltoid,Pec.major&Lat.Dorsy =subluxingforcesDynamic-proprioceptivefeedbackPathophysiology(Lazarus1996)Chondro-labraldefectcausesa65%reductioninstabilityinthedirectionofthedefectDeficiencyoftheant.inf.capsulolabralcomplex Fractureofant.lipofglenoid=15%Detachmentoflabarum/capsule=15%Tearofglenohumeralligaments=54%Avulsionofsubscapularisandligsofhumerus(HAGL)

Topreventthepersistenceofthedefectitneedstoberepaired

Arthroscopically

OpenAcuteInjurySomethingbreaksortearsandthereforecanberepaired.RepairisbetterthanreconstructRepairiseasierthanreconstructChronicInstabilityhasadditionalplasticdeformationofthecapsuleandglenohumeralligamentsthereforeneedstobeshortenedRestoringthenormalfunctionalanatomyisimpossibleConservativeTreatmentRowe–JBJS,1957324youngpatientwithant.dislocations94%hadrecurrenceif<20yearsold62%hadrecurrenceif<30yearsold14%hadrecurrenceif>40yearsoldBurkhead&Rockwood(textbook)40patientswithacutedislocation&vigorousrehabilitationOnly16%hadgoodorexcellentresult(1in6)Deny&Drew–Injury,November200221%ofallpatientspresentingwithshoulderdislocationhadpreviousdislocationin1year43%inpatients15-22yearshadre-dislocationsNonoperativetreatmentofshoulderdislocationinyoungathletesArciera–JArthroscopy,1995DeBeardino–JSouthOrthopaedicAss,1996Haelen–JArchOrthopaedicTraumaSurgery,1990Hovelius–JOrthopaedicScience,1999Wheeler–JArthroscopy,1998Kirkby–JArthroscopy,1999allover80%recurrencerateNonoperativetreatmentisunacceptableProspectiveRandomisedStudyBottanietc.–MilitaryPersonnelMedicineVol30No42000FirstTimeAcuteTraumaticShoulderDislocationStabilisationV’sNonOperative:Followupin36months24patientsaged18-26y.14NonOperative–rehabimmobilised4weeks9of12nonoperativehadinstability(75%)(6openBankartrepair)10ASCBankartrepairwithbioabsorbabletack<10days1of9operatedpatientshadinstability(11%)ComparisonofArthroscopic&OpenStabilisation SampleSize FollowUp Recurrence ASC Open ASC Open ASC OpenSteinbeck1998 30 32 36 40 17 5Field1999 50 50 33 30 8 0Cole1999 37 22 52 55 16 9Hayesetc1999 44 13 29 29 12 4ConclusionArthroscopicrepairforchronicinstabilityisinferiortoopenrepair?DuetoplasticdeformationChronicanteriorinstabilityArthroscopicTechniquesforPrimaryDislocations1982Johusa–withstaples1987Morgen&Badenstab–transglenoidsutures1991Caspari-Cannulatedbio-absorbabletacks1993Wolf&Snyder–sutureanchors=difficult1989Wheller-ASCstaple1993Gohlke-Sutureanchors1994Arciera-ASCtransglenoid1996Speer-Bio-absorbabletack1999Wintzell-ASClavage2000Introductionofamultitudeofnewgadgets &anchorsArthroscopicRepairsEinoder,1984KneeClubDescribedArthroscopictransglenoidsuturesusing:Kwirewitheye(ACL)introducedviaanteriorportalSuckingtubeSuturestiedoverinfraspinatusfasciaorspineofscapulaResults4out5patientsreturnedtothesamelevelofsportwithnore-dislocations

ArthroscopicRepairBoszotta&Helperstorfer–Arthroscopy,July2000TransglenoidsuturerepairforinitialAnt.dislocation72patients(1988-95)61

♂11♀ Aged19-3934%=Bankartlesion(6withbone)66%=AvulsionofcapsulolabralcomplexResults7%=Redislocationallduetotrauma(severein2outof5)85%=ReturnedtounrestrictedpreinjurysportingactivitiesRandomisedStudiesAsc.StabilisationV’sNonOperativeArcieraet.al.–A.J.SportsMed.,199432militarymenwithacute1stupdislocation,Averageof32monthsfollowup 15patients–nonoperative–80%redislocated 21patients–transglenoidsuture–14%redislocatedBottony&Wilkingsetc.A.J.SportsMedicine2000Patientswithacutetraumaticfirsttimeshoulderdislocation 14youngpatients–nonop,75%redislocation 10youngpatients–Asc.Bankartrepair,10%redislocationAsc.stabilisation

Dara&Gerber–JournalofShoulder&Elbow,200020shouldersAv3yearfollowupRecurrencesoccurredinpatientswhowerechronicdislocatorsi.e.<30%Thereforenow doopensurgeryforrecurrentdislocations Asc.surgeryforacutedislocationsDeBeardinoetal–AnJ.SportsMed.,2000491stupacuteposttraumaticShouldersdislocationAverage37monthsfollowupTackanchor.6Patientsre-dislocated(13%)+4hadopensurgeryBozzotta&Helpastorger(Austria)–J.Arthroscopy,2000

ArthroscopicTransglenoidSutureRepairforInitialAnt.ShoulderDislocation72Patients 61♂11♀-Sportingambitiouspatients 25Patients Bankartlesion(6withbone)

43Patients CapsulolabralavulsionResults

5patients Redislocated 2hadsignificanttrauma 3hadinsignificanttrauma=4%

ThereforeresultsofprimaryrepairarebetterthansurgeryforrecurrentdislocationButtransgleniodrepairsareobsoleteAgainst…ArthroscopicRepairRoberts,Taylor,Brown,Hayes,Saies(Adelaide)JournalofShoulder&Elbow,September199956acute1stupshoulderdislocations2½yearpostoperativeandreturntoAustralianRulesFootballOperations:Asc.suturerepair–70%recurrenceAsc.Bankartrepairwithtack–38%recurrence,..Openrepair&copsularshift–30%recurrenceThereforeAsc.treatmentalonenotgoodenoughCole&Warner–ClinicalSportsMedicine2000ArthroscopicV’sOpenBankartRepairForTraumaticAnteriorShoulderInstability%Asc.treatmentmodalitiesareincreasingdueto:BetterunderstandingofthepathophysiologyBetterpreoperativeevaluationoftheinjury(i.e.patientselection)NewsurgicaltechniquesBetterinstrumentationBetteranchorsProtocolforAcuteRepairMature&activeperson15to50yearsoldFirstepisodeofglenohumeraldislocation Reducedonfield,firstaid,clubDrorDEMExamination&X-rayInformedconsent–timeoffwork-outcomeExaminationunderGAASCofglenohumeraljoint,checkrotatorcuffaswellAcuterepairofalldemonstrabletearsorfractures restorenormalanatomyRehabactivity–collar&cuff,physiotherapyAvoidext.rotationandabductionfor6weeksReturntocontactsportin12weeksInvestigationsPlainx-raysCTscansifcomplicatedassociatedfeatureMRIrarely–getmoreinformationfromAsc.ExaminationUnderGA Supineloadshifttestwitharmat80°abductedcomparedwithnormalshoulder 1+ balltorim 2+ ballridingoverrimwithspontaneousreduction 3+ ballstaysdislocatedArthroscopyPatientPositionGeneralAnaestheticBeachChairwitharmheldbyassistantLateralpositionwitharmintraction&shoulderabductedShoulderexamined,degree&directionofinstabilitynotedPortals=2or3PosteriorportalAnt.supportalAntinfportal(occasionally)Injuryassessed&debridedRepairmethodselectedArthroscopicRepairProcedureRehabilitationMinimalinfirst4weeks Noextrotation Abductionlessthan45° Pendulumexercises IsometricresistanceexercisesGraduatedin4–8weeks ↑ROM GraduatedweighttrainingReturntosport Noncontact=6weeks contact=12weeksArthroscopicV’sOpenBankartRepairAdvantagesAccuratediagnosisofallstructuresLessmorbidity/painSmallscarsFasterrecoverySoonerreturntoactivitiesLessrestrictionofmovementDisadvantagesNeedalltheequipmentTechnicallydemandingLonglearningcurveLackofversatilityHigherfailureratearthroscopic=upto33%- open=lessthan10%SternJozrawiRastolazzi–ArthroscopyOct.2002AdvantagesV’sDisadvantagesofAsc.RepairAdvantages ↑cosmesis ↓morbidity ↓stiffness Easyrevision

Disadvantages1)Reluctancetoreferpatientimmediately2)Difficultoperation 3)Expensiveinstrumentation4)Biologicalhealingtimeisnotaccelerated5)SamepostoperativerestrictionsProblemsDifficultyconvincingClubTrainers,Physicians,sportingclubDoctors&DEMstafftorefertheyoungathletewithin2-3days.Timeconsumingdiscussionsconvincingpatienttohavetheoperationratherthanearlyreturntosport. Noproblemadvisingarecurrentdislocatorstohaveastabilisationprocedureattheendofasportingseason.Mostlyafterhourssurgerywithstaffwhoarenotfamiliarwiththeoperationandinstrumentation.ArthroscopyofShoulder1935–JapaneseSurgeonsarthroscoped,shoulders1960s–Curiosityactivityinthewesternworld1970s–DiagnosticAsc.examinationèopensurgery1980s–SimpleAsc.techniquesèforsimpleproblems1990s–↑Instrumentation&tacksèmoretriedit.2000s–↑Techniques&anchors –Canbedonebyanysurgeonskilledin arthroscopictechniques Shoulderreducedonfield,firstaidroomorDEMthenreferred

TreatmentHistory1970s- Conservativ