Acute anterior dislocation of the shoulder
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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 & capsule

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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


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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


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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


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Conservative Treatment

Rowe – 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


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Non operative treatment of shoulder dislocation

in young athletes

Arciera – 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 Arthroscopy, 1999

all over 80% recurrence rate

Non operative treatment is unacceptable


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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%)


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Comparison of Arthroscopic & Open Stabilisation

Sample Size Follow Up Recurrence

ASC Open ASC Open ASC Open

Steinbeck 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 4

Conclusion

Arthroscopic repair for chronic instability is inferior to open repair

? Due to plastic deformation

Chronic anterior instability


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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


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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



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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


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Randomised Studies

Asc. Stabilisation V’s Non Operative

Arciera 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


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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 dislocations

Asc. 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


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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 trauma

    3 had insignificant trauma = 4%

  • Therefore results of primary repair are better than surgery for recurrent dislocation

  • But transgleniod repairs are obsolete


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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


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Cole & Warner – Clinical Sports Medicine 2000

Arthroscopic V’s Open Bankart Repair

For Traumatic Anterior Shoulder Instability

% Asc. treatment modalities are increasing 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


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Protocol for Acute Repair

Mature & active person

15 to 50 years old

First episode of glenohumeral dislocation

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

Avoid ext. rotation and abduction for 6 weeks

Return to contact sport in 12 weeks


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Investigations

  • Plain x-rays

  • CT scans if complicated associated feature

  • MRI rarely – get more information from Asc.

  • 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

  • Arthroscopy


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Arthroscopic Repair Procedure

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 noted

Portals = 2 or 3

  • Posterior portal

  • Ant. sup portal

  • Ant inf portal (occasionally)

  • Injury assessed & debrided

  • Repair method selected


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Rehabilitation

  • Minimal in first 4 weeks

    No ext rotation

    Abduction less than 45°

    Pendulum exercises

    Isometric resistance exercises

  • Graduated in 4 – 8 weeks

    ↑ ROM

    Graduated weight training

  • Return to sport

    Non contact = 6 weeks

    contact = 12 weeks


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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%


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Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002

Advantages V’s Disadvantages of Asc. Repair

Advantages

↑ cosmesis

↓ morbidity

↓ stiffness

Easy revision

Disadvantages

1) Reluctance to refer patient immediately

2) Difficult operation

3) Expensive instrumentation

4) Biological healing time is not accelerated

5) Same post operative restrictions


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Problems

  • Difficulty 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.


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Arthroscopy of Shoulder

1935 – Japanese Surgeons arthroscoped, shoulders

1960s – Curiosity activity in the western world

1970s – Diagnostic Asc. examination è open surgery

1980s – Simple Asc. techniques èfor simple problems

1990s – ↑ Instrumentation & tacks è more tried it.

2000s – ↑ Techniques & anchors

– Can be done by any surgeon skilled in

arthroscopic techniques


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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 sutures

tied over spine of scapula or muscle fascia

1990s - patient in lateral position with arm in traction

or patient in Beach chair position

multiple, tacks and sutures

surtac screw tack anchors etc.

2000 - better anchors and sutures have made the procedure available for all surgeons experienced in arthroscopic technique




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Conclusion referred

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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