Posterior gleno-humeral-instability

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  • 1. POSTERIOR GLENO-HUMERAL INSTABILITY
  • 2. INTRODUCTION
    2-12% of all shoulder instability
    Isolation / MDI
    Symptoms are usually mild and can be overlooked
    Athletes
  • 3. ETIOLOGY
    Congenital
    - Ligamentous laxity
    - Scapulohumeral anatomy
    Acquired
    - Athletes
    - Repetitive stress to the posterior capsule resulting in laxity
     Traumatic
    - Fall or blow to arm in “at risk” position
    (forward flexion, abduction and internal rotation)
     
  • 4. ASSOCIATED ATHLETIC ACTIVITIES
    ACTIVITY MOTION
    Weightlifting Bench press, push-ups
    Pitching Follow-through phase
    Swimming Butterfly and freestyle
    Racquet sports Backhand stokes
    Golf Motions of lead arm
    Gymnastics Parallel bars, rings
    Boxing Axial load with punching
  • 5. CLASSIFICATION
    Voluntary /Involuntary
    Habitual Instability
    Results from underlying neuromuscular imbalance
    Underlying psychiatric problems common
    Often refractory to surgery
    Positional Dislocator
    Demonstrate instability by placing the arm in a position of risk
    Usually do not have psychiatric illness or secondary gain
    Ordinary avoid provocative manoeuvres
    Physiotherapy still first-line treatment but surgery gives good results
  • 6. CLINICAL PRESENTATION
    Pain rather than instability
    Usually mild
    Occur during or after activity
    Traumatic event may precede onset of symptoms
    Rarely is there a history of frank posterior dislocation
    Slip, pop or click out and in
  • 7. EXAMINATION - 1
    Posterior joint line tenderness
    ROM - Normal
    Rotator cuff strength - Normal
    Scapular winging
    secondary to scapula muscle dysfunction
    Ligamentous laxity?
    Examine unaffected shoulder
  • 8. EXAMINATION - 2
    Load and Shift Test (posterior drawer)
    Examiner grasps humeral head and pulls directly backward with the shoulder muscles relaxed.
    Humeral head subluxates posteriorly (<50% normal)
    Patients reaction to translation more important than amount
    Posterior Apprehension
    Uncommon
    Arm brought into forward flexion and internal rotation with posterior stress applied
    Sense of instability, pain or painful subluxation is suggestive of the diagnosis
  • 9. INVESTIGATIONS
    Shoulder XR
    AP in ER/IR
    Lateral
    Axillary view
    Dynamic XR with shoulder subluxed
    CT
    Arthrogram
    MRI
    Labral changes
    Capsular Damage
    EUA +/- arthroscopy
    Doubt regarding direction or extent of instability
  • 10. MANAGEMENT
    NON-SURGICAL TREATMENT
    SURGICAL TREATMENT
    ARTHROSCOPIC
    OPEN
  • 11. SURGERY - 1
    INDICATIONS
    Recurrent, symptomatic, unidirectional subluxation that has failed to respond to a comprehensive non-operative program
    Posterior instability itself is not an indication for surgery
    2/3 will respond to a proper exercise program
    No patient who has not had 6/12 of an exercise program should have surgery
  • 12. SURGERY - 2
    CONTRA-INDICATIONS
    Psychiatric disorder
    Significant degenerative gleno-humeral arthritis
    Failure to undergo or co-operate in physiotherapy program
    Ligamentous laxity
    Multidirectional instability
  • 13. ARTHROSCOPY
     Capsular shift
    25% recurrence at 2 year follow-up in one study on 20 patients
     Capsulo-labral augmentation
    41 patients in study – 86% improved stability
    Thermal capsulorrhaphy
    Thin posterior capsule which is less responsive to shrinkage
    Complicated by necrosis
  • 14. SURGICAL PROCEDURES
    OPEN
    SOFT TISSUE BONE
    Posterior capsulorrhaphy Glenoid osteotomy
    Inferior capsular shift Posterior bone block
    (anterior/posterior)
    Infraspinatus advancement
    Posterior Bankart repair
    Staple capsulorrphaphy
    Biceps tendon transfer
    Subscapularis transfer
     
    ARTHROSCOPIC
    Posterior Capsulolabral Augmentation
    Posteroinferior Capsular Shift
    Thermal Capsulorrhaphy
  • 15. OPEN TECHNIQUES - 1
    Soft tissue
    Soft tissue abnormalities are the predominant cause of posterior instability
    Posterior capsular shift
    Anterior/posterior approach
    Posterior capsule thin 1.5mm
    Staples fallen out of favour
    Recent report 13/14 patients were satisfied at 44/12 follow-up
    Recurrence rate 30% some studies
    50% high level athletes return to sports
  • 16. OPEN TECHNIQUES - 2
    Bone
    Glenoplasty
    Glenoid retroversion/hypoplasia
    Opening wedge osteotomy
    Cadaveric studies confirm effective change in Glenoid shape and increased stability
    Recent study 17 patients atraumatic posterior instability at 5 year follow-up
    81% rated good to excellent
    12.5% had a recurrence
    Post-op degenerative changes were seen in 25%
    Recommended glenoplasty if glenoid retroversion 7-10° radiographically
    Humeral Osteotomy
    External rotation osteotomy
    Indicated if symptoms worsened on internal rotation
    Few reports in literature
  • 17. POSTERIOR STABILISATION - 1
    Lateral decubitus position
    +/- arthroscopic evaluation – rule out anterior labral injury
    A 10cm saber cut incision from posterior aspect AC joint to posterior axillary fold
  • 18. POSTERIOR STABILISATION - 2
    Deltoid split in line with its fibres from scapular spine 5cm distally
    +/- detachment deltoid
  • 19. POSTERIOR STABILISATION - 3
    Fascial layer covering teres minor and infraspinatus divided
    Two choices
    Develop interval between infraspinatus and teres minor
    Develop interval between two heads infraspinatus identified by fat stripe
  • 20. POSTERIOR STABILISATION - 4
    Divided from tendon insertion to just medial to glenoid
    beware branches suprascapular nerve 1.5cm from glenoid
    Infraspinatus dissected free from capsule
  • 21. POSTERIOR STABILISATION - 5
    Capsule divided lateral to medial in mid-portion +/- labral repair
    T-capsular incision based medially along edge of labrum
    Superior and inferior flaps tagged
  • 22. POSTERIOR STABILISATION - 6
    Inferior capsular flap advanced superiorly and medially and sutured to labrum
  • 23. POSTERIOR STABILISATION - 7
    Superior flap brought over inferior flap inferior and medially
    Sutures tied in neutral rotation
  • 24. POSTERIOR STABILISATION - 8
    Split in capsule repaired
    Wound closed
  • 25. POST-OPERATIVE MANAGEMENT
    Abduction pillow for 3/52 in neutral rotation
    At 3/52
    - Standard sling
    - ROM exercises
    - No forward flexion
    At 6/52
    - Full ROM
    At 12/52
    - Return to sport
  • 26. COMPLICATIONS
    Loss internal rotation secondary to over-tight posterior capsular repair
    Suprascapular/axillary nerve injury
    Hardware problems
    Recurrence - 30%