肩关节前脱位AnteriorShoulder Dislocation

Acute anterior dislocation of the shoulder,AnatomyStability: - ball & socket = compression in concavity effectBone - big head small cup = unstableMenisci - labium = depth of cup by 20%Ligaments - glenohumeral & capsuleMuscles - rotator cuff & biceps = holds ball in cupPrimary Movers - Deltoid, Pec. 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 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 repairedArthroscopically Open,Acute InjurySomething breaks or tears and therefore can be repaired.Repair is better than reconstructRepair is easier than reconstructChronicInstability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortenedRestoring the normal functional anatomy is impossible,Conservative TreatmentRowe JBJS, 1957324 young patient with ant. dislocations94% had recurrence if 20 years old62% had recurrence if 40 years oldBurkhead & Rockwood (text book)40 patients with acute dislocation & vigorous rehabilitationOnly 16% had good or excellent result (1 in 6)Deny & Drew Injury, November 200221% of all patients presenting with shoulder dislocation had previous dislocation in 1 year43% in patients 15-22 years had re-dislocations,Non operative treatment of shoulder dislocation in young athletesArciera J Arthroscopy, 1995De Beardino J South Orthopaedic Ass, 1996Haelen J Arch Orthopaedic Trauma Surgery, 1990Hovelius J Orthopaedic Science, 1999Wheeler J Arthroscopy, 1998Kirkby J Arthroscopy, 1999 all over 80% recurrence rateNon operative treatment is unacceptable,Prospective Randomised Study Bottani etc.Military Personnel Medicine Vol 30 No 4 2000First Time Acute Traumatic Shoulder DislocationStabilisation Vs Non Operative: Follow up in 36 months24 patients aged 18-26y. 14 Non Operative rehab immobilised 4 weeks9 of 12 non operative had instability (75%) (6 open Bankart repair)10 ASC Bankart repair with bioabsorbable tack 10 days1 of 9 operated patients had instability (11%),Comparison of Arthroscopic & Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbeck 199830323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plastic deformation,Chronic anterior instability,Arthroscopic Techniques for Primary Dislocations1982 Johusa with staples1987 Morgen & Badenstab transglenoid sutures1991 Caspari -Cannulated bio-absorbable tacks 1993 Wolf & Snyder suture anchors = difficult1989 Wheller - ASC staple1993 Gohlke - Suture anchors1994 Arciera - ASC transglenoid1996 Speer - Bio-absorbable tack1999 Wintzell - ASC lavage2000 Introduction of a multitude of new gadgets & anchors,Arthroscopic RepairsEinoder, 1984 Knee ClubDescribed Arthroscopic transglenoid sutures using:K wire with eye (ACL) introduced via anterior portalSucking tubeSutures tied over infraspinatus fascia or spine of scapula Results4 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 19-3934% = Bankart lesion (6 with bone)66% = Avulsion of capsulolabral complexResults7% = Redislocation all due to trauma (severe in 2 out of 5)85% = Returned to unrestricted pre injury sporting activities,Randomised StudiesAsc. Stabilisation Vs Non OperativeArciera et. al. A.J. Sports Med., 199432 military men with acute 1st up dislocation, Average of 32 months follow up15 patients non operative 80% redislocated21 patients transglenoid suture 14% redislocatedBottony & Wilkings etc. A.J. Sports Medicine 2000Patients with acute traumatic first time shoulder dislocation14 young patients non op, 75% redislocation10 young patients Asc. Bankart repair, 10% redislocation,Asc. stabilisation Dara & Gerber Journal of Shoulder & Elbow, 200020 shouldersAv 3 year follow upRecurrences occurred in patients who were chronic dislocators i.e. 30%Therefore now do open surgery for recurrent dislocationsAsc. surgery for acute dislocationsDe Beardino et al An J. Sports Med., 200049 1st up acute post traumatic Shoulders dislocationAverage 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 Dislocation72 Patients61 11 - Sporting ambitious patients25 Patients Bankart lesion (6 with bone)43 Patients Capsulolabral avulsionResults5 patientsRe dislocated 2 had significant trauma3 had insignificant trauma = 4%Therefore results of primary repair are better than surgery for recurrent dislocationBut transgleniod repairs are obsolete,Against Arthroscopic RepairRoberts, Taylor, Brown, Hayes, Saies (Adelaide)Journal of Shoulder & Elbow, September 199956 acute 1st up shoulder dislocations2 year post operative and return to Australian Rules FootballOperations:Asc. suture repair 70% recurrenceAsc. 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 RepairFor Traumatic Anterior Shoulder Instability% Asc. treatment modalities are increasing due to:Better understanding of the pathophysiologyBetter pre operative evaluation of the injury (i.e. patient selection)New surgical techniquesBetter instrumentationBetter anchors,Protocol for Acute RepairMature & active person15 to 50 years oldFirst episode of glenohumeral dislocationReduced on field, first aid, club Dr or DEMExamination & X-rayInformed consent time off work - outcomeExamination under GAASC of glenohumeral joint, check rotator cuff as wellAcute repair of all demonstrable tears or fractures restore normal anatomyRehab activity collar & cuff, physiotherapyAvoid ext. rotation and abduction for 6 weeksReturn to contact sport in 12 weeks,InvestigationsPlain x-raysCT scans if complicated associated featureMRI rarely get more information from Asc.Examination Under GASupine load shift test with arm at 80 abducted compared with normal shoulder1+ball to rim2+ball riding over rim with spontaneous reduction3+ball stays dislocatedArthroscopy,Patient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction & shoulder abductedShoulder examined, degree & direction of instability notedPortals = 2 or 3Posterior portalAnt. sup portalAnt inf portal (occasionally) Injury assessed & debridedRepair method selected,Arthroscopic Repair Procedure,RehabilitationMinimal in first 4 weeksNo ext rotationAbduction less than 45Pendulum exercisesIsometric resistance exercisesGraduated in 4 8 weeks ROMGraduated weight trainingReturn to sportNon contact = 6 weekscontact = 12 weeks,Arthroscopic Vs Open Bankart RepairAdvantagesAccurate diagnosis of all structuresLess morbidity/painSmall scarsFaster recoverySooner return to activitiesLess restriction of movementDisadvantagesNeed all the equipmentTechnically demandingLong learning curveLack of versatilityHigher failure rate arthroscopic = up to 33% - open = less than 10%,Stern Jozrawi Rastolazzi Arthroscopy Oct. 2002Advantages Vs Disadvantages of Asc. RepairAdvantages cosmesis morbidity stiffnessEasy revisionDisadvantages1) Reluctance to refer patient immediately2) Difficult operation3) Expensive instrumentation4) Biological healing time is not accelerated5) Same post operative restrictions,ProblemsDifficulty convincing Club Trainers, Physicians, sporting club Doctors & DEM staff to refer the young athlete within 2-3 days.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 instrumentation.,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 done by any surgeon skilled in arthroscopic techniques,Shoulder reduced on field, first aid room or DEM then referred Tr