acute anterior dislocation of the shoulder

Acute Shoulder Dislocation Surgery

Einoder

Acute anterior dislocation of the shoulder


Einoder

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


Einoder

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


Einoder

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


Einoder

Conservative TreatmentRowe – 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


Einoder

Non operative treatment of shoulder dislocation in young athletes

1. Arciera – J Arthroscopy, 19952. De Beardino – J South Orthopaedic Ass, 19963. Haelen – J Arch Orthopaedic Trauma Surgery, 19904. Hovelius – J Orthopaedic Science, 19995. Wheeler – J Arthroscopy, 19986. Kirkby – J Arthroscopy, 1999

all over 80% recurrence rateNon operative treatment is unacceptable


Einoder

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%)


Einoder

Comparison of Arthroscopic & Open StabilisationSample Size Follow Up RecurrenceASC Open ASC Open ASC

Open

Steinbeck 1998 30 32 36 40 17 5Field 1999 50 50 33 30 8 0Cole 1999 37 22 52 55 16 9Hayes etc 1999 44 13 29 29 12 4

ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plastic deformation

Chronic anterior instability


Einoder

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


Einoder

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


Einoder

Arthroscopic Repair


Einoder


Einoder

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


Einoder

Randomised Studies

Asc. Stabilisation V’s Non OperativeArciera 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


Einoder

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 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


Einoder

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 trauma3 had insignificant trauma = 4%

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

• But transgleniod repairs are obsolete


Einoder

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


Einoder

Cole & Warner – Clinical Sports Medicine 2000

Arthroscopic V’s Open Bankart Repair

For Traumatic Anterior Shoulder Instability

• % Asc. treatment modalities are increasing due to:

1. Better understanding of the pathophysiology

2. Better pre operative evaluation of the injury (i.e. patient selection)

3. New surgical techniques

4. Better instrumentation

5. Better anchors


Einoder

Protocol for Acute Repair1. Mature & active person2. 15 to 50 years old3. First episode of glenohumeral dislocation

Reduced on field, first aid, club Dr or DEM4. Examination & X-ray5. Informed consent – time off work - outcome6. Examination under GA7. ASC of glenohumeral joint, check rotator cuff as well8. Acute repair of all demonstrable tears or fractures

restore normal anatomy11. Rehab activity – collar & cuff, physiotherapy12. Avoid ext. rotation and abduction for 6 weeks13. Return to contact sport in 12 weeks


Einoder

Investigations1. Plain x-rays

2. CT scans if complicated associated feature

3. MRI rarely – get more information from Asc.

4. 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

5. Arthroscopy


Einoder

Patient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction & shoulder abductedShoulder 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

Arthroscopic Repair Procedure


Einoder

Rehabilitation1. Minimal in first 4 weeks

No ext rotation

Abduction less than 45°

Pendulum exercises

Isometric resistance exercises

2. Graduated in 4 – 8 weeks

↑ ROM

Graduated weight training

3. Return to sport

Non contact = 6 weeks

contact = 12 weeks


Einoder

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%


Einoder

Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002Advantages V’s Disadvantages of Asc. Repair

Advantages• ↑ cosmesis• ↓ morbidity• ↓ stiffness• Easy revisionDisadvantages• 1) Reluctance to refer patient immediately• 2) Difficult operation• 3) Expensive instrumentation• 4) Biological healing time is not accelerated• 5) Same post operative restrictions


Einoder

Problems1. Difficulty convincing Club Trainers, Physicians,

sporting club Doctors & DEM staff to refer the young athlete within 2-3 days.

2. 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.

3. Mostly after hours surgery with staff who are not familiar with the operation and instrumentation.


Einoder

Arthroscopy of Shoulder

• 1935 – Japanese Surgeons arthroscoped, shoulders

• 1960s – Curiosity activity in the western world

• 1970s – Diagnostic Asc. examination open surgery

• 1980s – Simple Asc. techniques for simple problems

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

• 2000s – ↑ Techniques & anchors

– Can be done by any surgeon skilled in

arthroscopic techniques


Einoder

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 suturestied over spine of scapula or muscle fascia

1990s - 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


EinoderAcute Labral Tear


EinoderAcute Repair of Anterior Labral Tear


Einoder

Conclusion• 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

acute anterior dislocation of the shoulder

Documents