acute anterior dislocation of the shoulder
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Acute Shoulder Dislocation Surgery
Einoder
Anatomy• Stability: - ball & socket
= compression in concavity effect• Bone - big head – small cup
= unstable• Menisci - labium
= ↑ depth of cup by 20%• Ligaments - glenohumeral & capsule
• Muscles - rotator cuff & biceps = holds ball in cup
• Primary Movers - Deltoid, Pec. major & Lat. Dorsy= subluxing forces
• Dynamic - proprioceptive feedback
Acute Shoulder Dislocation Surgery
Einoder
Pathophysiology (Lazarus 1996)
• Chondro-labral defect causes a 65% reduction in stability in the direction of the defect
• 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
Acute Shoulder Dislocation Surgery
Einoder
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
Acute Shoulder Dislocation Surgery
Einoder
Conservative TreatmentRowe – 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
Acute Shoulder Dislocation Surgery
Einoder
Non operative treatment of shoulder dislocation in young athletes
1. Arciera – J Arthroscopy, 19952. De Beardino – J South Orthopaedic Ass, 19963. Haelen – J Arch Orthopaedic Trauma Surgery, 19904. Hovelius – J Orthopaedic Science, 19995. Wheeler – J Arthroscopy, 19986. Kirkby – J Arthroscopy, 1999
all over 80% recurrence rateNon operative treatment is unacceptable
Acute Shoulder Dislocation Surgery
Einoder
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%)
Acute Shoulder Dislocation Surgery
Einoder
Comparison of Arthroscopic & Open StabilisationSample Size Follow Up RecurrenceASC Open ASC Open ASC
Open
Steinbeck 1998 30 32 36 40 17 5Field 1999 50 50 33 30 8 0Cole 1999 37 22 52 55 16 9Hayes etc 1999 44 13 29 29 12 4
ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plastic deformation
Chronic anterior instability
Acute Shoulder Dislocation Surgery
Einoder
Arthroscopic Techniques for Primary Dislocations
• 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
Acute Shoulder Dislocation Surgery
Einoder
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
Acute Shoulder Dislocation Surgery
Einoder
Boszotta & Helperstorfer – Arthroscopy, July 2000 Transglenoid suture repair for initial Ant. dislocation
• 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
Acute Shoulder Dislocation Surgery
Einoder
Randomised Studies
Asc. Stabilisation V’s Non OperativeArciera 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
Acute Shoulder Dislocation Surgery
Einoder
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 dislocationsAsc. 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
Acute Shoulder Dislocation Surgery
Einoder
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 trauma3 had insignificant trauma = 4%
• Therefore results of primary repair are better than surgery for recurrent dislocation
• But transgleniod repairs are obsolete
Acute Shoulder Dislocation Surgery
Einoder
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
Acute Shoulder Dislocation Surgery
Einoder
Cole & Warner – Clinical Sports Medicine 2000
Arthroscopic V’s Open Bankart Repair
For Traumatic Anterior Shoulder Instability
• % 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
Acute Shoulder Dislocation Surgery
Einoder
Protocol for Acute Repair1. Mature & active person2. 15 to 50 years old3. First episode of glenohumeral dislocation
Reduced on field, first aid, club Dr or DEM4. Examination & X-ray5. Informed consent – time off work - outcome6. Examination under GA7. ASC of glenohumeral joint, check rotator cuff as well8. Acute repair of all demonstrable tears or fractures
restore normal anatomy11. Rehab activity – collar & cuff, physiotherapy12. Avoid ext. rotation and abduction for 6 weeks13. Return to contact sport in 12 weeks
Acute Shoulder Dislocation Surgery
Einoder
Investigations1. Plain x-rays
2. CT scans if complicated associated feature
3. MRI rarely – get more information from Asc.
4. Examination Under GA
Supine load shift test with arm at 80° abducted compared with normal shoulder
1+ ball to rim
2+ ball riding over rim with spontaneous reduction
3+ ball stays dislocated
5. Arthroscopy
Acute Shoulder Dislocation Surgery
Einoder
Patient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction & shoulder abductedShoulder examined, degree & direction of instability noted
Portals = 2 or 3• Posterior portal• Ant. sup portal• Ant inf portal (occasionally)• Injury assessed & debrided• Repair method selected
Arthroscopic Repair Procedure
Acute Shoulder Dislocation Surgery
Einoder
Rehabilitation1. Minimal in first 4 weeks
No ext rotation
Abduction less than 45°
Pendulum exercises
Isometric resistance exercises
2. Graduated in 4 – 8 weeks
↑ ROM
Graduated weight training
3. Return to sport
Non contact = 6 weeks
contact = 12 weeks
Acute Shoulder Dislocation Surgery
Einoder
Arthroscopic V’s Open Bankart Repair• Advantages
– Accurate diagnosis of all structures– Less morbidity/pain– Small scars– Faster recovery– Sooner return to activities– Less restriction of movement
• Disadvantages– Need all the equipment– Technically demanding– Long learning curve– Lack of versatility– Higher failure rate arthroscopic = up to 33% -
open = less than 10%
Acute Shoulder Dislocation Surgery
Einoder
Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002Advantages V’s Disadvantages of Asc. Repair
Advantages• ↑ cosmesis• ↓ morbidity• ↓ stiffness• Easy revisionDisadvantages• 1) Reluctance to refer patient immediately• 2) Difficult operation• 3) Expensive instrumentation• 4) Biological healing time is not accelerated• 5) Same post operative restrictions
Acute Shoulder Dislocation Surgery
Einoder
Problems1. 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.
Acute Shoulder Dislocation Surgery
Einoder
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
Acute Shoulder Dislocation Surgery
Einoder
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 suturestied over spine of scapula or muscle fascia
1990s - patient in lateral position with arm in tractionor patient in Beach chair position multiple, tacks and suturessurtac screw tack anchors etc.
2000 - better anchors and sutures have made the procedure available for all surgeons experienced in arthroscopic technique
Acute Shoulder Dislocation Surgery
Einoder
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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