Presentation on theme: "Shoulder Instability Department of Orthopaedics, CKUH Sen-Jen Lee"— Presentation transcript:
1Shoulder Instability Department of Orthopaedics, CKUH Sen-Jen Lee Reference: Orthopaedic Knowledge Update 6
2Natural HistoryThe most common sequela of traumatic anterior shoulder instability is recurrence90% for those 11 to 20 years of ageAveraging between 55% and 66%87% recurrent instability after nonsurgical treatmentIn the skeletally immature individualBankart lesion (labral detachment of the inferior glenohumeral ligament complex, IGHLC)Length of immobilization, avoidance of overhead activity, and supervised physical therapy had no effect on outcomePatients over 40 years of ageNeurologic injury and rotator cuff tears
7Biomechanics Dynamic Stabilizers Rotator cuff musclesCenter the humeral head on the glenoidMaintain joint stabilityThe capsuloligamentous structures (proprioception) provide afferent feedback for reflexive muscular control of the rotator cuff and biceps
8Patient Evaluation History Physical examination Imaging Specific provocative testsApprehension/relocation test and sulcus sign testImagingScapula (AP and lateral [y-view])Axillary viewWest point axillary viewCT arthrogram or MRIExamination under anesthesia and arthroscopy
14Clasification of Anterior Instability DirectionAnteriorPosteriorInferiorMultidirectionalCauseTraumaticAcuteRepetitiveNontraumaticDegreeSubluxationDislocationFrequencyAcuteRecurrentPatient controlVoluntaryInvoluntary
15Matsen’s Classification of Anterior Instability AMBRIAtraumaticMultidirectionalBilateralRehabilitationInferior capsular shiftTUBSTraumaticUnidirectionalBankar lesionSurgery
16Redislocation Rates After Initial Dislocation (< 35 Y/O) InvestigatorsPatients (%)No. of patientsAge (years)Rowe9453< 20Mclaughlin95181Simonet6632Henry88121< 32Hovelius64102< 22Wheeler9238Marans10021
17Causes of Anterior Shoulder Instability Bankart lesionAvulsion of the anteroinferior capsulolabral complexHill-Sachs lesionCompression fracture of the posterosuperior humeral headSLAP lesionSuperior labrum anterior posteriorHAGL lesionHumeral avulsion of glenohumeral ligamentsALPSA lesionAnt. labroligamentous periosteal sleeve avulsionLaxity of the joint capsule
18Treatment of Anterior Glenohumeral Instability Nonsurgical treatment:Closed reductionImmobilization (3 to 6 weeks) rehabilitationRate of recurrence : (less than 20 years old)60% to 90%
19Treatment of Anterior Glenohumeral Instability Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.14 % versus 80% recurrent instabilityArciero RA, wheeler JH, Ryan JB, et al: am J sports med 1994;22:
20Treatment of Anterior Glenohumeral Instability Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes.Satisfactory results: 94%Returned to sports: 92% (75% at the same level).The rate of recurrence: 3%.Bigliani LU, Kurzweil PR, Schwartzbach CC, et al: am JSports med 1994;22:
21Treatment of Anterior Glenohumeral Instability Arthroscopic Bankart suture repair.Recurrent instability: 44%The authors recommend: caution in the use of arthroscopic stabilization for the competitive athlete.Grana WA, Buckley PD, Yates CK: am J sports med 1993;21:
22Treatment of Anterior Glenohumeral Instability Reduction inSurgical timeBlood lossPostoperative narcotic usePostoperative feversDuration of hospitalizationWork days missedArthroscopic versus open Bankart procedures: A comparison of early morbidity and complications.Green MR, Christensen KP: arthroscopy1993;9:
23Treatment of Anterior Glenohumeral Instability Treatment of instability of the shoulder with an exercise program.Response to treatment:Atraumatic versus traumatic instability: 80% versus 15%Burkhead WZ Jr, Rockwood CA Jr: J bone joint Surg 1992;74a:
25Selective capsular tightening Selective capsular tightening. A, The inferior capsule is tightened with the arm in 10° flexion, 60° abduction, and 45° to 60° external rotation. B, The superior capsule is tightened with the arm in 0° abduction and 45° external rotation.
26Treatment of Posterior Instability Nonsurgical treatment with exercise program. (First choice)Surgical treatmentProvide bony stability:Posterior bone block, opening wedge osteotomy of the posterior glenoid (glenoplasty), and rotational osteotomy of the humerusSoft-tissue repairs:Posterior labral repair, a posterior capsular plication, and posterior capsulorrhaphy.
27Instability in Throwing Athletes Anterior instabilityDuring the late cocking phasePosterior capsular tightness, pain, or impingement signsPosterior instabilityDuring the follow-through phase."Dead arm" syndromeTransient neurological symptoms
29Acromioclavicular Instability MechanismImpact directly at the lateral edge of the acromionClassification (Rockwood)Type I: a sprain of the AC jointType II: partial rupture of the AC ligaments and the coracoclavicular ligaments with subluxation of the AC jointType III: dislocation of the AC joint with complete disruption of the coracoclavicular and AC ligamentsType IV: dislocation of the AC joint with posterior displacement of the clavicle into or through the trapezius muscleType V: dislocation of the AC joint with marked superior displacement of the clavicle greater than twice the normal coracoclavicular distanceType VI: inferior dislocation of the AC joint with subcoracoid displacement of the clavicle
30Rockwood classification of ligamentous injuries to the acromioclavicular joint.
31Treatment A-C Instability Types I and II: nonsurgicalSling for 2 weeksGood results in over 90% of casesType III: controversialSurgical treatment for acute injuries in laborers or high demand overhead athletes, and for chronic injuries in which initial nonsurgical treatment failsTypes IV, V, and VI : surgical managementAC fixation with pins or plates and coracoclavicular fixation with nonabsorbable suture or metallic screws
32Chronic symptomatic A-C instability: The modified Weaver-Dunn procedure. (C-C fixation + transfer of the C-A ligament to the distal clavicle)