Acute Shoulder Dislocation Surgery Acute anterior dislocation of

Acute Shoulder Dislocation Surgery Acute anterior dislocation of the shoulder Einoder

Acute Shoulder Dislocation Surgery Anatomy • Stability: • Bone • Menisci • Ligaments - ball & socket = compression in concavity effect - big head – small cup = unstable - labium = ↑ depth of cup by 20% - glenohumeral & capsule • Muscles - rotator cuff & biceps = holds ball in cup • Primary Movers - Deltoid, Pec. major & Lat. Dorsy = subluxing forces • Dynamic - proprioceptive feedback Einoder

Acute Shoulder Dislocation Surgery 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 Shoulder Dislocation Surgery 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

Acute Shoulder Dislocation Surgery 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 Einoder

Acute Shoulder Dislocation Surgery Non operative treatment of shoulder dislocation in young athletes 1. 2. 3. 4. 5. 6. 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 Einoder

Acute Shoulder Dislocation Surgery 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 -26 y. • 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

Acute Shoulder Dislocation Surgery Chronic anterior instability Comparison of Arthroscopic & Open Stabilisation Sample Size Follow Up Recurrence ASC Open Steinbeck 1998 Field 1999 Cole 1999 Hayes etc 1999 30 50 37 44 32 50 22 13 36 33 52 29 40 30 55 29 17 8 16 12 5 0 9 4 Conclusion Arthroscopic repair for chronic instability is inferior to open repair ? Due to plastic deformation Einoder

Acute Shoulder Dislocation Surgery 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

Acute Shoulder Dislocation Surgery 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

Acute Shoulder Dislocation Surgery Arthroscopic Repair Einoder

Acute Shoulder Dislocation Surgery Einoder

Acute Shoulder Dislocation Surgery Einoder

Acute Shoulder Dislocation Surgery 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

Acute Shoulder Dislocation Surgery Randomised Studies Asc. Stabilisation V’s Non Operative Arciera et. al. – A. J. Sports Med. , 1994 • 32 military men with acute 1 st 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

Acute Shoulder Dislocation Surgery 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 1 st up acute post traumatic Shoulders dislocation – Average 37 months follow up – Tack anchor. – 6 Patients re-dislocated (13%) +4 had open surgery Einoder

Acute Shoulder Dislocation Surgery 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 Einoder

Acute Shoulder Dislocation Surgery Against …Arthroscopic Repair Roberts, Taylor, Brown, Hayes, Saies (Adelaide) Journal of Shoulder & Elbow, September 1999 • 56 acute 1 st 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

Acute Shoulder Dislocation Surgery 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

Acute Shoulder Dislocation Surgery Protocol for Acute Repair 1. 2. 3. Mature & active person 15 to 50 years old First episode of glenohumeral dislocation Reduced on field, first aid, club Dr or DEM 4. Examination & X-ray 5. Informed consent – time off work - outcome 6. Examination under GA 7. ASC of glenohumeral joint, check rotator cuff as well 8. Acute repair of all demonstrable tears or fractures restore normal anatomy 11. Rehab activity – collar & cuff, physiotherapy 12. Avoid ext. rotation and abduction for 6 weeks 13. Return to contact sport in 12 weeks Einoder

Acute Shoulder Dislocation Surgery Investigations 1. 2. 3. 4. 5. 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 Einoder

Acute Shoulder Dislocation Surgery 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 Einoder

Acute Shoulder Dislocation Surgery Rehabilitation 1. 2. 3. 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 Einoder

Acute Shoulder Dislocation Surgery • 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

Acute Shoulder Dislocation Surgery 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 Einoder

Acute Shoulder Dislocation Surgery Problems 1. 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

Acute Shoulder Dislocation Surgery Arthroscopy of Shoulder • 1935 – Japanese Surgeons arthroscoped, shoulders • 1960 s – Curiosity activity in the western world • 1970 s – Diagnostic Asc. examination èopen surgery • 1980 s – Simple Asc. techniques è for simple problems • 1990 s – ↑ Instrumentation & tacks èmore tried it. • 2000 s – ↑ Techniques & anchors – Can be done by any surgeon skilled in arthroscopic techniques Einoder

Acute Shoulder Dislocation Surgery Shoulder reduced on field, first aid room or DEM then referred Treatment History 1970 s - Conservative for all 1 st up unless fractures with Bristows or Bankart repair for recurrences 1980 s - Asc. transglenoid sutures tied over spine of scapula or muscle fascia 1990 s - 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 Einoder

Acute Shoulder Dislocation Surgery Acute Labral Tear Einoder

Acute Shoulder Dislocation Surgery Acute Repair of Anterior Labral Tear Einoder

Acute Shoulder Dislocation Surgery 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 Einoder