The Treatment of Primary Anterior Shoulder Dislocations(10.03.16)
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Transcript of The Treatment of Primary Anterior Shoulder Dislocations(10.03.16)
The treatment of primary an-terior shoulder dislocations
ICL vol 58, 2009Symposium 30
Pathology of initial dislocation
Avulsion of ant. Labrum & capsuleHigh rate of recurrent instability after
dislocation d/t failure of labrum to heal• on biomechanical studiesDislocation not occur after Bankart le-
sion or sectioning of ant. joint capsuleCircumferential division of capsule post. Dislocation!!
Pathology of initial dislocation(2)
Pouliart & et al. in 50 cadaver• 18 Anteroinferior dislocation after 3 zones sectioned• 14 anteroinferior dislocation after all 4 Zones sectionedconclusion: ant. D/L 위해서는 Bankart
lesion+superior+posterior structure injury 필요 !!
Pathology of initial dislocation(3)
Injuries following ant. Dislocation Hill-Sachs lesion, GT Fx., capsular tear, sup. Labral
lesion, RC tearTaylor et al.Immediate arthroscopic stabilization shortly after
primary ant. Shoulder D/L : 63ptsHemarthrosis: 100%(63pts)Ant. Capsuloligamentous complex detachment :
97%(61pts)Hill-Sachs lesion : 90%(57pts)SLAP : 10%(6pts)IGHL avulsion : 2%(1pt)Interstitial capsular tear : 2% (1pt)
Pathology of initial dislocation(4)
Baker et al. (45 shoulders) : A/S exam after primary dislocation
Group I(6): minimal hemarthrosis capsular tear, no labral teraGroup II(11): moderate hemarthrosis,
capsular tear, partial labral detachmentGroup III(28): large hemarthrosis, capsular
tear, complete labral detachment
Intraarticular pathology finding: not predictive of recurrent rate!!
Risk factors for recurrence
Traumatic dislocation: 94% of recurrent rate
Prophylactic surgical stabilization 위해Prognostic factor 분석 필요
Age and Gender
Young age : the most consistent & sig-nificant factor
66% age 12~22: recurrent D/L 24% age 30~40: recurrent D/L1/3 pts who had initial D/L before age
30Ultimately Surgical stabilizationBilat. Dislocation: much higher
younger than 29 yrs
Age and Gender(2)
Young, athletic pts : 94% recurrence rateSachs et al.Age younger than 25 yrs: the only strong predictor!
GenderMale 57% recurrence rateFemale 42% recurrence rate
Sports activity
Bankart’s report:“peculiar to athletics & epilep-
tics”
Simonet et alAthlete: 82% Nonathlete: 30%
Recent studiesSachs, Kralinger & Slaa
No correlation be-tween sports activity & recurrence
Using arm above chest level likely to have subsequent instability
Hill-Sachs Lesion
Lesion 의 존재 : recurrence rate get high
Size & severity of osseous defect 도 중요
Kralinger et al.Grade I defect: 23%Grade II defect: 16%Grade III defect: 67% of recurrence
rate
Greater tuberosity frac-ture
Slaa et al.GT fx. 가 있는 19% 의 환자에서 recurrence rate:
0%!! Lessen!! Risk of recurrent instability( 수상 당시의 에너지가 capsule 이나 labrum 대신
GT fracture 로 흡수되는 것으로 생각 )Kralinger et al결과 비슷원인 : secondary reduction in attainable ER at 0
degree of abduction in the injured shoulder
Nonsurgical treatment
Duration of immobilization or rehab affect outcome?
Typical Nonsurgical Tx. : closed reductionvariable period of
immobilizationPT to strengthen ro-tator cuff and scapular stabilizers.
:::anecdotal & controversial !!
Duration of immobilizationor rehab.(2)
Aronen & ReganImmobilization Intense rehab : prevents recurrent instabilityRehab. emphasizing IR muscles & adductors
+ rigid activity restrictionIsometric to isotonic and isokinetics
Duration of immobilizationor rehab.(3)
Late study reveals the oppositeNo correlation between duration of
immobilization and recurrence rateNo benefit from supervised PT from home-based PT
ER immobilization
Recent studiesER immobilization reduces recurrence
than sling immobilizationMRI studies:Bankart lesion 의 position 과 coapta-
tion 도 ER 상태에서 훨씬 안정적Biomechanical study max. contact force at 45 degree of
ER
ER immobilization (2)
3 randomized clinical trialsItoi et al (40 pts)3wks to conventional immobilization in
IR or immobilization in 10 to 30 of ERAt a mean 15.5 month F/U 30% with IR recurred, none of ERAmong pts lower than 30 yrs, relative
risk reduction even greater.
Surgical treatment
• Goal : restore native anatomy, by repairing Bankart lesion or capsular injury
• Pain free, stable shoulder with maxi-mal ROM
Arthroscopic lavage after in-jury
30 pts in SwedenAt 2 yr F/U
20% recurred with lavage
60% recurred with treated nonsurgi-cally
Saah et al.No benefit of isolated
arthroscopy with-out repair
Should high risk pts receive early surgical stabilization?
• Historically, primary shoulder D/L • treated nonsurgically • Surgery considered after recurrence
• Several studies promoted• Role of early surgical stabilization after
primary D/L• 18~67 months F/U• A/S repair effective reducing recurrence
Should high risk pts receive early surgical stabilization?(2)
Young, active male with dominant side first time D/L recur rate : 90%
immediate surgical repair very attractiveLarrain, Wheeler, ArcieroSurgery: 4~22% of recurrenceNonsurgery: 80~95% of recurrenceSeveral studies documented:Reducing risk of recurrence, improving
QOL & functional outcome
Primary shoulder D/L analogous to ACL injury?
Recently, reached to consensus as to surgical reconstruction of ACL in high-risk young, ac-tive patients.
ACL recons. Prevents knee OAEarly surgical intervention may prevent glenoid
& humeral bone loss, capsular attenuation, and rotator cuff tears
ACL recons. & Bankart repair needed for young, active pts to lower recurrence risk & secondary intraarticular injury, expedite re-turn to function.
Treatment of contact athlete
Contact athlete 에서 recurrence risk 높다고 생각되어 왔음
open Bankart repair 시행되어옴(A/S repair 는 failure rate high)Several studies (Mazzocca, Larrain,
Bacilla)A/S with Bankart repair c suture an-
chor 로도 충분히 좋은 결과
Treatment of contact athlete
• Boileau et al.• Postsurgical recurrence related to
bone defect, bony Bankart or Hill-Sachs lesion.
• Recurrence rate higher in inf. Shoul-der hyperlaxity or ant. Shoulder hy-perlaxity
• 4 개 이상의 suture anchor fixation 필요 !!
summary
Tx. Should be individualized by age, oc-cupation, functional demand, sports participation, physical characteristics, compliance, & expectations.
High risk young man c active physical activity
early surgical stabilizationLow recurrent population early surgery
not needed!!