1、Acute Shoulder Dislocation SurgeryEinoderAcute anterior dislocation of the shoulderAcute Shoulder Dislocation SurgeryEinoderAnatomy Stability:-ball&socket =compression in concavity effect Bone -big head small cup =unstable Menisci -labium =depth of cup by 20%Ligaments -glenohumeral&capsule Muscles -
2、rotator cuff&biceps =holds ball in cup Primary Movers-Deltoid,Pec.major&Lat.Dorsy=subluxing forces Dynamic -proprioceptive feedbackAcute Shoulder Dislocation SurgeryEinoderPathophysiology(Lazarus 1996)Chondro-labral defect causes a 65%reduction in stability in the direction of the defectDeficiency o
3、f 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 Shoulder Dislocation
4、 SurgeryEinoderAcute Injury Something breaks or tears and therefore can be repaired.Repair is better than reconstruct Repair is easier than reconstructChronic Instability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortened Restoring the normal
5、 functional anatomy is impossibleAcute Shoulder Dislocation SurgeryEinoderConservative TreatmentRowe JBJS,1957324 young patient with ant.dislocations 94%had recurrence if 20 years old 62%had recurrence if 40 years oldBurkhead&Rockwood(text book)40 patients with acute dislocation&vigorous rehabilitat
6、ion 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-dislocationsAcute Shoulder Dislocation SurgeryEinoderNon operative treatment of shoulder disloca
7、tion in young athletes1.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 unacceptableAc
8、ute Shoulder Dislocation SurgeryEinoderProspective 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 weeks 9 of 12 n
9、on 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%)Acute Shoulder Dislocation SurgeryEinoderComparison of Arthroscopic&Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbec
10、k 199830323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair?Due to plastic deformationChronic anterior instabilityAcute Shoulder Dislocation SurgeryEinoderArthroscopic Techniques for Primary Disloc
11、ations1982 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 Intro
12、duction of a multitude of new gadgets&anchorsAcute Shoulder Dislocation SurgeryEinoderArthroscopic RepairsEinoder,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 scapul
13、a Results 4 out 5 patients returned to the same level of sport with no re-dislocations Acute Shoulder Dislocation SurgeryEinoderArthroscopic RepairAcute Shoulder Dislocation SurgeryEinoderAcute Shoulder Dislocation SurgeryEinoderAcute Shoulder Dislocation SurgeryEinoderBoszotta&Helperstorfer Arthros
14、copy,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 complexResults 7%=Redislocation all due to trauma(severe in 2 out of 5)85%=Returned to unrestricted pre injury sporting activitiesAc
15、ute Shoulder Dislocation SurgeryEinoderRandomised StudiesAsc.Stabilisation Vs Non OperativeArciera et.al.A.J.Sports Med.,1994 32 military men with acute 1st up dislocation,Average of 32 months follow up15 patients non operative 80%redislocated21 patients transglenoid suture 14%redislocatedBottony&Wi
16、lkings etc.A.J.Sports Medicine 2000 Patients with acute traumatic first time shoulder dislocation14 young patients non op,75%redislocation10 young patients Asc.Bankart repair,10%redislocationAcute Shoulder Dislocation SurgeryEinoderAsc.stabilisation Dara&Gerber Journal of Shoulder&Elbow,2000 20 shou
17、lders 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 dislocationsDe Beardino et al An J.Sports Med.,2000 49 1st up acute post traumatic Shoulders dislocation Average 37 months foll
18、ow up Tack anchor.6 Patients re-dislocated(13%)+4 had open surgeryAcute Shoulder Dislocation SurgeryEinoderBozzotta&Helpastorger(Austria)J.Arthroscopy,2000 Arthroscopic Transglenoid Suture Repair for Initial Ant.Shoulder Dislocation 72 Patients 61 11-Sporting ambitious patients25 Patients Bankart le
19、sion(6 with bone)43 Patients Capsulolabral avulsionResults 5 patientsRe 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 obsoleteAcute Shoulder Dislocation SurgeryEinoder
20、Against Arthroscopic RepairRoberts,Taylor,Brown,Hayes,Saies(Adelaide)Journal of Shoulder&Elbow,September 1999 56 acute 1st up shoulder dislocations 2 year post operative and return to Australian Rules Football Operations:Asc.suture repair 70%recurrence Asc.Bankart repair with tack 38%recurrence,.Ope
21、n repair&copsular shift 30%recurrence Therefore Asc.treatment alone not good enoughAcute Shoulder Dislocation SurgeryEinoderCole&Warner Clinical Sports Medicine 2000 Arthroscopic Vs Open Bankart RepairFor Traumatic Anterior Shoulder Instability%Asc.treatment modalities are increasing due to:1.Better
22、 understanding of the pathophysiology2.Better pre operative evaluation of the injury(i.e.patient selection)3.New surgical techniques4.Better instrumentation5.Better anchorsAcute Shoulder Dislocation SurgeryEinoderProtocol for Acute Repair1.Mature&active person2.15 to 50 years old3.First episode of g
23、lenohumeral dislocationReduced 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&
24、cuff,physiotherapy12.Avoid ext.rotation and abduction for 6 weeks13.Return to contact sport in 12 weeksAcute Shoulder Dislocation SurgeryEinoderInvestigations1.Plain x-rays2.CT scans if complicated associated feature3.MRI rarely get more information from Asc.4.Examination Under GASupine load shift t
25、est with arm at 80 abducted compared with normal shoulder1+ball to rim2+ball riding over rim with spontaneous reduction3+ball stays dislocated5.ArthroscopyAcute Shoulder Dislocation SurgeryEinoderPatient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in t
26、raction&shoulder abductedShoulder examined,degree&direction of instability notedPortals=2 or 3 Posterior portal Ant.sup portal Ant inf portal(occasionally)Injury assessed&debrided Repair method selectedArthroscopic Repair ProcedureAcute Shoulder Dislocation SurgeryEinoderRehabilitation1.Minimal in f
27、irst 4 weeksNo ext rotationAbduction less than 45Pendulum exercisesIsometric resistance exercises2.Graduated in 4 8 weeks ROMGraduated weight training3.Return to sportNon contact=6 weekscontact=12 weeksAcute Shoulder Dislocation SurgeryEinoderArthroscopic Vs Open Bankart RepairAdvantagesAccurate dia
28、gnosis 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%Acute Shoulder Disloc
29、ation SurgeryEinoderStern 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 acceler
30、ated5)Same post operative restrictionsAcute Shoulder Dislocation SurgeryEinoderProblems1.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 r
31、eturn 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.Acute Shoulder Dislocation SurgeryEinoderArthroscopy of Shoulder 1935 Japan
32、ese 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 techni
33、quesAcute Shoulder Dislocation SurgeryEinoderShoulder reduced on field,first aid room or DEM then referred Treatment History1970s-Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences1980s-Asc.transglenoid suturestied over spine of scapula or muscle fascia1990s
34、-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 techniqueAcute Shoulder Dislocation SurgeryEinode
35、rAcute Labral TearAcute Shoulder Dislocation SurgeryEinoderAcute Repair of Anterior Labral TearAcute Shoulder Dislocation SurgeryEinoderConclusion 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 of the shoulder should have the damage repaired arthroscopically within 10 days of the injury
