shoulder instability in patients with eds...for the shoulder girdle is paramount esp in mdi. •...
TRANSCRIPT
![Page 1: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/1.jpg)
Keith Kenter, MD Associate Professor
Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program
Department of Orthopaedic Surgery University of Cincinnati
SHOULDER INSTABILITY IN
PATIENTS WITH EDS
EDNF 2012 CONFERENCE LIVING WITH EDS
![Page 2: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/2.jpg)
DISCLOSURE KEITH KENTER
I HAVE NOTHING TO DISCLOSE AND NO CONFLICT OF INTEREST AS IT RELATES TO
THIS PRESENTATION
INSTITUTIONAL SUPPORT NIH (RESEARCH)
SMITH & NEPHEW (EDUCATION GRANT)
JOURNAL REVIEWER/EDITORIAL BOARDS JBJS, AJSM, BJSM
![Page 3: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/3.jpg)
Single Dislocation
≠ Recurrent Instability
INDIVIDUALIZED TREATMENT
![Page 4: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/4.jpg)
DEFINITIONS
LAXITY Range of motion of the center of the humeral
head with respect to the glenoid fossa due to a external force
INSTABILITY
Symptomatic inability to maintain the humeral head in the glenoid fossa
![Page 5: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/5.jpg)
DEFINITIONS
SUBLUXATION Partial dislocation
Incomplete separation of joint
DISLOCATION Frank separation of joint
![Page 6: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/6.jpg)
CLASSIFICATION
DIRECTIONAL
• Anterior
• Posterior
• Multidirectional
![Page 7: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/7.jpg)
CLASSIFICATION
MECHANISMS
• TUBS - Traumatic Unidirectional Bankart Surgery
• AMBRI – Atraumatic Multidirectional
Bilateral Rehabilitation Inferior shift
![Page 8: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/8.jpg)
GLENOHUMERAL INSTABILITY
Complex interaction between physiologic laxity to provide range of motion and joint stability.
STABILITY MOBILITY
EDS
![Page 9: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/9.jpg)
THE EDS SHOULDER INCREASED LAXITY
HIGHER RISKS FOR INSTABILITY (MDI)
![Page 10: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/10.jpg)
ANATOMIC CONSIDERATIONS
• Passive
• Static
• Dynamic
CONSTRAINTS
![Page 11: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/11.jpg)
PASSIVE CONSTRAINTS
• Humeral head
• Glenoid fossa
BONY ANATOMY
![Page 12: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/12.jpg)
PASSIVE CONSTRAINTS
INTRA-ARTICULAR PHYSICS
• Negative pressure
• Joint fluid cohesion
![Page 13: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/13.jpg)
PASSIVE CONSTRAINTS
Fibrocartilagenous lip that
increases glenoid depth and increases humeral contact area
• 75% superoinferior • 50% anteroposterior
LABRUM
Clin Orthop 243; 1989
![Page 14: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/14.jpg)
STATIC CONSTRAINTS
• Capsular envelope
• Glenohumeral ligaments
![Page 15: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/15.jpg)
GLENOHUMERAL LIGAMENTS
• SUPERIOR - restraint for inferior translation in adducted shoulder
• MIDDLE - restraint for anterior translation in 45º abducted shoulder
• INFERIOR - restraint for anterior and inferior translation in abducted shoulder
![Page 16: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/16.jpg)
GLENOHUMERAL LIGAMENTS
IGHL
MGHL
SGHL
![Page 17: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/17.jpg)
DYNAMIC CONSTRAINTS
• Rotator cuff group
• Biceps tendon
• Scapular rotators
![Page 18: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/18.jpg)
BIOMECHANICS
ANTERIOR TRANSLATION
FLEXION ‘CROSS BODY’
MOTION
JBJS 72A; 1990
POSTERIOR TRANSLATION
EXTENSION EXTERNAL ROTATION
HARRYMAN
![Page 19: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/19.jpg)
BIOMECHANICS
Anterior Tightening
Abduction Forward Flexion ER No Translation
KENTER
ASES; 1999
![Page 20: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/20.jpg)
TREATMENT
• Immediate reduction of the dislocated shoulder • Physical therapy program Rotator Cuff strengthening Scapular stabilizer strengthening • Surgical intervention
![Page 21: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/21.jpg)
EDS SHOULDER INSTABILITY • Patient education and defining the collagen disorder
are paramount
• Modification on activity and work on mechanics
• Core strength, spine posture, RC strength, and scapular muscle strength
• Surgical results about 30% recurrence in patients without anatomic lesions
![Page 22: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/22.jpg)
REHABILITATION
![Page 23: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/23.jpg)
REHABILITATION
![Page 24: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/24.jpg)
REHABILITATION
![Page 25: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/25.jpg)
REHABILITATION
![Page 26: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/26.jpg)
MULTI-DIRECTIONAL INSTABILITY
MISAMORE
• 64 patients ave 16 year (9-30) at 8 years 43 female / 21 male
• PT program with RC and parascapular strengthening • 57 patients available at follow-up
63% (36/57) without surgery Pain – 23 good-excellent Instability – 17 good-excellent
• Poor response: (unilateral/ADLs/hyperlaxity/3months)
JSES 14; 2005
![Page 27: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/27.jpg)
SURGICAL MANAGEMENT
• WHEN TO OPERATE
• HOW TO DO IT Open Arthroscopic
ADDRESS THE PATHOANATOMY
![Page 28: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/28.jpg)
ANTERIOR DISLOCATION
NATURAL HISTORY • Age related
< 22 years – 60-90% 30-40 years – 50-65% > 50 years – RC Tears
60+ years about 40% • Pathology related
< 25 years up to 85% with Bankart labral tear JBJS 88A; 2006
JBJS 89A; 2007
![Page 29: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/29.jpg)
SO WHAT ?? DOES RECURRENCE CAUSE DAMAGE
HABERMEYER
76 patients with anterior dislocations evaluated with arthroscopy
9 with 1 dislocation Labrum 12 with 1- 2 dislocations Ligament 23 with 3-5 dislocations Double ligament 32 with 6+ dislocations Articular cartilage
JSES 8; 1999
![Page 30: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/30.jpg)
CARTILAGE BREAKDOWN
FIRST TIME DISLOCATION
![Page 31: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/31.jpg)
ARTHROSCOPIC ADVANCES
• Rapid evolution in techniques
• Early techniques secure labrum to bone • Address capsular laxity Capsular shift Capsular split Capsular plication Thermal ‘shrinkage’
![Page 32: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/32.jpg)
ARTHROSCOPIC TECHNIQUES
• PRO Visualize all pathology Less stiffness Easier to revise • CON Less reliable/technically demanding Higher failure rates (some authors) Portal scars
![Page 33: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/33.jpg)
SURGICAL TECHNIQUE
![Page 34: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/34.jpg)
SURGICAL TECHNIQUE
![Page 35: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/35.jpg)
SURGICAL TECHNIQUE
![Page 36: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/36.jpg)
SURGICAL TECHNIQUE
![Page 37: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/37.jpg)
SURGICAL TECHNIQUE
![Page 38: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/38.jpg)
ARTHROSCOPIC TECHNIQUES
CONTRAINDICATIONS
• Capsular deficiency • Glenoid bone loss • Humeral head defect • Collision athlete ? • Surgeon’s skill level
![Page 39: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/39.jpg)
CAPSULAR PLICATION
![Page 40: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/40.jpg)
THERMAL
• Addresses residual laxity
• Repair labrum first
• Avoid suture line
• Paint in grid fashion
![Page 41: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/41.jpg)
SUMMARY • Complex interaction between stability and mobility.
• Neuromuscular training and strengthening program
for the shoulder girdle is paramount esp in MDI.
• Surgical emphasis is to restore anatomy and capsular tension.
• Arthroscopic challenge today is reproducibility of quantifying amount of capsular redundancy during repair.
![Page 42: SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge](https://reader033.vdocument.in/reader033/viewer/2022060311/5f0aba347e708231d42d0bbc/html5/thumbnails/42.jpg)
THANK YOU