keith kenter, md associate professor sports medicine & shoulder reconstruction director,...
TRANSCRIPT
![Page 1: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/1.jpg)
Keith Kenter, MDAssociate Professor
Sports Medicine & Shoulder ReconstructionDirector, Orthopaedic Residency Program
Department of Orthopaedic SurgeryUniversity of Cincinnati
SHOULDER INSTABILITY IN
PATIENTS WITH EDS
EDNF 2012 CONFERENCELIVING WITH EDS
![Page 2: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/2.jpg)
DISCLOSURE
KEITH KENTERI HAVE NOTHING TO DISCLOSE AND NO CONFLICT OF INTEREST AS IT RELATES TO
THIS PRESENTATION
INSTITUTIONAL SUPPORTNIH (RESEARCH)
SMITH & NEPHEW (EDUCATION GRANT)
JOURNAL REVIEWER/EDITORIAL BOARDSJBJS, AJSM, BJSM
![Page 3: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/3.jpg)
Single Dislocation
≠
Recurrent Instability
INDIVIDUALIZED TREATMENT
![Page 4: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/4.jpg)
DEFINITIONS
LAXITY
Range of motion of the center of the humeral head with respect to the glenoid fossa due to a external force
INSTABILITY
Symptomatic inability to maintain the humeral head in the glenoid fossa
![Page 5: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/5.jpg)
DEFINITIONS
SUBLUXATION
Partial dislocation
Incomplete separation of joint
DISLOCATION
Frank separation of joint
![Page 6: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/6.jpg)
CLASSIFICATION
DIRECTIONAL
• Anterior
• Posterior
• Multidirectional
![Page 7: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/7.jpg)
CLASSIFICATION
MECHANISMS
• TUBS - Traumatic Unidirectional Bankart Surgery
• AMBRI – Atraumatic Multidirectional Bilateral Rehabilitation Inferior shift
![Page 8: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/8.jpg)
GLENOHUMERAL INSTABILITY
Complex interaction between physiologic laxity to provide range of motion and joint stability.
STABILITY MOBILITY
EDS
![Page 9: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/9.jpg)
THE EDS SHOULDER
INCREASED LAXITY
HIGHER RISKS FOR INSTABILITY(MDI)
![Page 10: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/10.jpg)
ANATOMIC CONSIDERATIONS
• Passive
• Static
• Dynamic
CONSTRAINTS
![Page 11: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/11.jpg)
PASSIVE CONSTRAINTS
• Humeral head
• Glenoid fossa
BONY ANATOMY
![Page 12: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/12.jpg)
PASSIVE CONSTRAINTS
INTRA-ARTICULAR PHYSICS
• Negative pressure
• Joint fluid cohesion
![Page 13: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/13.jpg)
PASSIVE CONSTRAINTS
Fibrocartilagenous lip that increases glenoid depth and increases humeral contact area
• 75% superoinferior • 50% anteroposterior
LABRUM
Clin Orthop 243; 1989
![Page 14: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/14.jpg)
STATIC CONSTRAINTS
• Capsular envelope
• Glenohumeral ligaments
![Page 15: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/15.jpg)
GLENOHUMERAL LIGAMENTS
• SUPERIOR - restraint for inferiortranslation in adducted shoulder
• MIDDLE - restraint for anterior translation in 45º abducted shoulder
• INFERIOR - restraint for anterior and inferior translation in
abducted shoulder
![Page 16: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/16.jpg)
GLENOHUMERAL LIGAMENTS
IGHL
MGHL
SGHL
![Page 17: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/17.jpg)
DYNAMIC CONSTRAINTS
• Rotator cuff group
• Biceps tendon
• Scapular rotators
![Page 18: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/18.jpg)
BIOMECHANICS
ANTERIOR TRANSLATION
FLEXION
‘CROSS BODY’ MOTION
JBJS 72A; 1990
POSTERIOR TRANSLATION
EXTENSION
EXTERNAL ROTATION
HARRYMAN
![Page 19: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/19.jpg)
BIOMECHANICS
Anterior Tightening
Abduction
Forward Flexion
ER
No Translation
KENTER
ASES; 1999
![Page 20: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/20.jpg)
TREATMENT
• Immediate reduction of the dislocated shoulder
• Physical therapy program
Rotator Cuff strengthening
Scapular stabilizer strengthening
• Surgical intervention
![Page 21: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/21.jpg)
EDS SHOULDER INSTABILITY• Patient education and defining the collagen disorder
are paramount
• Modification on activity and work on mechanics
• Core strength, spine posture, RC strength, and scapular muscle strength
• Surgical results about 30% recurrence in patients without anatomic lesions
![Page 22: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/22.jpg)
REHABILITATION
![Page 23: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/23.jpg)
REHABILITATION
![Page 24: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/24.jpg)
REHABILITATION
![Page 25: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/25.jpg)
REHABILITATION
![Page 26: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/26.jpg)
MULTI-DIRECTIONAL INSTABILITY
MISAMORE
• 64 patients ave 16 year (9-30) at 8 years43 female / 21 male
• PT program with RC and parascapular strengthening• 57 patients available at follow-up
63% (36/57) without surgeryPain – 23 good-excellentInstability – 17 good-excellent
• Poor response:(unilateral/ADLs/hyperlaxity/3months)
JSES 14; 2005
![Page 27: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/27.jpg)
SURGICAL MANAGEMENT
• WHEN TO OPERATE
• HOW TO DO IT
Open
Arthroscopic
ADDRESS THE PATHOANATOMY
![Page 28: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/28.jpg)
ANTERIOR DISLOCATION
NATURAL HISTORY• Age related
< 22 years – 60-90%
30-40 years – 50-65%
> 50 years – RC Tears
60+ years about 40%• Pathology related
< 25 years up to 85% with Bankart labral tear
JBJS 88A; 2006JBJS 89A; 2007
![Page 29: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/29.jpg)
SO WHAT ??
DOES RECURRENCE CAUSE DAMAGEHABERMEYER
76 patients with anterior dislocations evaluated with arthroscopy
9 with 1 dislocation Labrum12 with 1- 2 dislocations Ligament23 with 3-5 dislocations Double ligament32 with 6+ dislocations Articular cartilage
JSES 8; 1999
![Page 30: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/30.jpg)
CARTILAGE BREAKDOWN
FIRST TIME DISLOCATION
![Page 31: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/31.jpg)
ARTHROSCOPIC ADVANCES
• Rapid evolution in techniques
• Early techniques secure labrum to bone • Address capsular laxity
Capsular shiftCapsular splitCapsular plicationThermal ‘shrinkage’
![Page 32: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/32.jpg)
ARTHROSCOPIC TECHNIQUES
• PRO Visualize all pathology
Less stiffnessEasier to revise
• CONLess reliable/technically demandingHigher failure rates (some authors)Portal scars
![Page 33: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/33.jpg)
SURGICAL TECHNIQUE
![Page 34: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/34.jpg)
SURGICAL TECHNIQUE
![Page 35: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/35.jpg)
SURGICAL TECHNIQUE
![Page 36: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/36.jpg)
SURGICAL TECHNIQUE
![Page 37: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/37.jpg)
SURGICAL TECHNIQUE
![Page 38: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/38.jpg)
ARTHROSCOPIC TECHNIQUES
CONTRAINDICATIONS
• Capsular deficiency• Glenoid bone loss• Humeral head defect • Collision athlete ?• Surgeon’s skill level
![Page 39: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/39.jpg)
CAPSULAR PLICATION
![Page 40: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/40.jpg)
THERMAL
• Addresses residual laxity
• Repair labrum first
• Avoid suture line
• Paint in grid fashion
DO NOT RECOMMEND
![Page 41: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/41.jpg)
SUMMARY
• Complex interaction between stability and mobility.
• Neuromuscular training and strengthening program for the shoulder girdle is paramount esp in MDI.
• Surgical emphasis is to restore anatomy and capsular tension.
• Arthroscopic challenge today is reproducibility of quantifying amount of capsular redundancy during repair.
![Page 42: Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery](https://reader035.vdocuments.net/reader035/viewer/2022062712/56649c9d5503460f9495ced7/html5/thumbnails/42.jpg)
THANK YOU