1、Acute anterior dislocation of the shoulder,Anatomy Stability: - ball & socket= compression in concavity effect Bone - big head small cup = unstable Menisci - labium = depth of cup by 20% Ligaments - glenohumeral & capsuleMuscles - rotator cuff & biceps = holds ball in cup Primary Movers - Deltoid, P
2、ec. major & Lat. Dorsy= subluxing forces Dynamic - proprioceptive feedback,Pathophysiology (Lazarus 1996)Chondro-labral defect causes a 65% reduction in stability in the direction of the defectDeficiency of the ant. inf. capsulolabral complex Fracture of ant. lip of glenoid = 15% Detachment of labar
3、um/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 repairedArthroscopically Open,Acute Injury Something breaks or tears and therefore can be repaired. Repair is better than reconstruct Rep
4、air is easier than reconstructChronic Instability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortened Restoring the normal functional anatomy is impossible,Conservative Treatment Rowe JBJS, 1957 324 young patient with ant. dislocations 94% had
5、 recurrence if 40 years oldBurkhead & 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 p
6、atients 15-22 years had re-dislocations,Non operative treatment of shoulder dislocation in young athletesArciera 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 Arth
7、roscopy, 1999 all over 80% recurrence rate Non operative treatment is unacceptable,Prospective Randomised Study Bottani etc.Military Personnel Medicine Vol 30 No 4 2000 First Time Acute Traumatic Shoulder DislocationStabilisation Vs Non Operative: Follow up in 36 months24 patients aged 18-26y. 14 No
8、n 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%),Comparison of Arthroscopic & Open StabilisationSample Size Follow Up RecurrenceASC Open ASC Op
9、en ASC OpenSteinbeck 1998 30 32 36 40 17 5 Field 1999 50 50 33 30 8 0 Cole 1999 37 22 52 55 16 9 Hayes etc 1999 44 13 29 29 12 4Conclusion Arthroscopic repair for chronic instability is inferior to open repair ? Due to plastic deformation,Chronic anterior instability,Arthroscopic Techniques for Prim
10、ary Dislocations1982 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 19
11、99 Wintzell - ASC lavage 2000 Introduction of a multitude of new gadgets & anchors,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 scap
12、ula Results 4 out 5 patients returned to the same level of sport with no re-dislocations,Arthroscopic Repair,Boszotta & Helperstorfer Arthroscopy, July 2000 Transglenoid suture repair for initial Ant. dislocation72 patients (1988-95) 61 11 Aged 19-39 34% = Bankart lesion (6 with bone) 66% = Avulsion
13、 of capsulolabral complexResults 7% = Redislocation all due to trauma (severe in 2 out of 5) 85% = Returned to unrestricted pre injury sporting activities,Randomised Studies Asc. Stabilisation Vs Non Operative Arciera et. al. A.J. Sports Med., 1994 32 military men with acute 1st up dislocation, Aver
14、age of 32 months follow up15 patients non operative 80% redislocated21 patients transglenoid suture 14% redislocated Bottony & Wilkings etc. A.J. Sports Medicine 2000 Patients with acute traumatic first time shoulder dislocation14 young patients non op, 75% redislocation10 young patients Asc. Bankar
15、t repair, 10% redislocation,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 Beardi
16、no 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,Bozzotta & Helpastorger (Austria) J. Arthroscopy, 2000 Arthroscopic Transglenoid Suture Repair for Initial Ant. Shoulder D
17、islocation72 Patients 61 11 - Sporting ambitious patients25 Patients Bankart lesion (6 with bone)43 Patients Capsulolabral avulsionResults5 patients Re dislocated 2 had significant trauma3 had insignificant trauma = 4%Therefore results of primary repair are better than surgery for recurrent dislocat
18、ionBut transgleniod repairs are obsolete,Against Arthroscopic RepairRoberts, Taylor, Brown, Hayes, Saies (Adelaide) Journal of Shoulder & Elbow, September 199956 acute 1st up shoulder dislocations 2 year post operative and return to Australian Rules FootballOperations: Asc. suture repair 70% recurre
19、nce Asc. Bankart repair with tack 38% recurrence, Open repair & copsular shift 30% recurrenceTherefore Asc. treatment alone not good enough,Cole & Warner Clinical Sports Medicine 2000 Arthroscopic Vs Open Bankart Repair For Traumatic Anterior Shoulder Instability% Asc. treatment modalities are incre
20、asing due to: Better understanding of the pathophysiology Better pre operative evaluation of the injury (i.e. patient selection) New surgical techniques Better instrumentation Better anchors,Protocol for Acute Repair Mature & active person 15 to 50 years old First episode of glenohumeral dislocation
21、Reduced on field, first aid, club Dr or DEM Examination & X-ray Informed consent time off work - outcome Examination under GA ASC of glenohumeral joint, check rotator cuff as well Acute repair of all demonstrable tears or fractures restore normal anatomy Rehab activity collar & cuff, physiotherapy A
22、void ext. rotation and abduction for 6 weeks Return to contact sport in 12 weeks,Investigations Plain x-rays CT scans if complicated associated feature MRI rarely get more information from Asc. Examination Under GASupine load shift test with arm at 80 abducted compared with normal shoulder1+ ball to
23、 rim2+ ball riding over rim with spontaneous reduction3+ ball stays dislocated Arthroscopy,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 notedPortals = 2 or 3
24、Posterior portal Ant. sup portal Ant inf portal (occasionally)Injury assessed & debrided Repair method selected,Arthroscopic Repair Procedure,Rehabilitation Minimal in first 4 weeksNo ext rotationAbduction less than 45Pendulum exercisesIsometric resistance exercises Graduated in 4 8 weeks ROMGraduat
25、ed weight training Return to sportNon contact = 6 weekscontact = 12 weeks,Arthroscopic Vs Open Bankart Repair Advantages Accurate diagnosis of all structures Less morbidity/pain Small scars Faster recovery Sooner return to activities Less restriction of movementDisadvantages Need all the equipment T
26、echnically demanding Long learning curve Lack of versatility Higher failure rate arthroscopic = up to 33% - open = less than 10%,Stern Jozrawi Rastolazzi Arthroscopy Oct. 2002 Advantages Vs Disadvantages of Asc. Repair Advantages cosmesis morbidity stiffness Easy revision Disadvantages 1) Reluctance
27、 to refer patient immediately 2) Difficult operation 3) Expensive instrumentation 4) Biological healing time is not accelerated 5) Same post operative restrictions,Problems Difficulty convincing Club Trainers, Physicians, sporting club Doctors & DEM staff to refer the young athlete within 2-3 days.
28、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. Mostly after hours surgery with staff who are not familiar with the operation and instr
29、umentation.,Arthroscopy of Shoulder1935 Japanese Surgeons arthroscoped, shoulders 1960s Curiosity activity in the western world1970s Diagnostic Asc. examination open surgery1980s Simple Asc. techniques for simple problems1990s Instrumentation & tacks more tried it.2000s Techniques & anchors Can be d
30、one by any surgeon skilled in arthroscopic techniques,Shoulder reduced on field, first aid room or DEM then referredTreatment History1970s - Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences1980s - Asc. transglenoid suturestied over spine of scapula or musc
31、le fascia1990s - 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 Labral Tear,Ac
32、ute Repair of Anterior Labral Tear,Conclusion Asc. repair of the Capsulo-ligamentous injury to the shoulderis 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 ofthe shoulder should have the damage repaired arthroscopically within 10 days of the injury,
