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Mdi verona final

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Mdi verona final

  1. 1. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Multidirectional Instability: Diagnosis and Treatment Manos Antonogiannakis Orthopaedic Surgeon Director of 3rd Orthopaedic Department Centre for Arthroscopy & Shoulder Surgery Hygeia General Hospital ESSKA Advanced Shoulder Arthroscopy Course All About Instability & Other Glenohumeral Disorders Verona, 12-13 June 2017 .
  2. 2. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 The Shoulder  Greatest Range of Motion in the Body  Motion in all 3 planes of movement  Prone to instability Sacrifices stability for mobility
  3. 3. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 What is Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  4. 4. www.shoulder.gr First described in detail in 1980 by Charles S. Neer and Craig R. Foster www.shoulder.g
  5. 5. www.shoulder.gr  NOT associated with severe trauma Congenital hyperlaxity of the joint capsule or generalized joint laxity in association with failure of dynamic stabilizers and minor trauma www.shoulder.g Ehlers-Danlos Syndrome
  6. 6. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 T.U.B.S. Traumatic Unidirectional Bankart lesion Surgery A.M.B.R.I. Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift A.I.O.S. Acquired Instability Overstress Surgery Instability Profiles
  7. 7. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 TUBS AIOS AMBRI
  8. 8. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Types of instability Not a black or white issue
  9. 9. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 The most common presentation A patient with some degree of laxity genetically controlled dislocates his shoulder after a minor or major accident
  10. 10. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Laxity: physiologic and multidirectional Instability: pathologic, mono-/bi-/tridirectional usually anteroinferior or posteroinferior
  11. 11. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
  12. 12. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
  13. 13. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
  14. 14. www.shoulder.gr LOOSE SHOULDER Definition A joint with excessive range of motion in all planes but with no symptoms of pain or instability www.shoulder.gr
  15. 15. www.shoulder.gr Definitions: unstable loose joint  A symptomatic loose joint  Usually, the patient experiences symptoms of apprehension or subluxation in one direction, but the examination reveals more directions of instability  minimum trauma or microtrauma precipitates the initiation of symptoms  A confusion in terminology exists: multidirectional instability , hyperlaxity with pain , unstable painful shoulder www.shoulder.gr
  16. 16. www.shoulder.gr Atraumatic multidirectional instability clinical presentation  Frank dislocations with minimum violence often reduced by the patient  Subluxations and positive apprehension sign in one or more directions in a loose joint individual usually teenager  Pain and functional impairment in a loose joint individual, the patient mainly complaining for pain and not for instability
  17. 17. www.shoulder.gr Types of multidirection instability  Voluntary dislocation  Involuntary dislocation should be recognized early www.shoulder.gr
  18. 18. www.shoulder.gr Voluntary dislocation  Patients with good muscle control who can dislocate and relocate their shoulder at will from an early age . That may lead to gradual strain of the capsule and loss of control of the dislocations  Voluntary dislocators with psychiatric problems www.shoulder.gr
  19. 19. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Symptomatic glenohumeral joint subluxation or dislocation occuring in more than one directions MDI: 20-30 years old with non-specific activity-related pain
  20. 20. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Clinical examination: Generalized joint laxity 1. Elbow or metacarpophalangeal joint hyperextension 1. Genu recurvatum 1. Patellar instability 1. Ability to rest the thumb on the ipsilateral forearm 2. Hyperabduction test
  21. 21. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Positive sulcus sign AND  Positive Load-and-Shift Test or  Positive Apprehension Test in at least 1 of the positions that stress the anterior (abduction, external rotation) or posterior (flexion, adduction) joint complex Symptomatic instability in at least 2 directions AND Warby et al, BMJ Open, 2016
  22. 22. www.shoulder.gr Clinical examination 16 years old dislocating the shoulder for fun Minor trauma producing involuntary painful dislocation-subluxation
  23. 23. www.shoulder.gr Clinical examination
  24. 24. www.shoulder.gr Highly clinical diagnosis  History  Clinical examination  Marginal help of imaging studies (plain radiographs, MRI, MRI-arthrography)  Highly supportive:  Arthroscopic findings www.shoulder.g
  25. 25. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 ‚ABER‘ images Crescent sign: enhancing layer between HH and AIGHL Triangle sign: triangular space between HH, AIGHL, glenoid Good sensivity: 48-62% Excellent specifity: 94-100% MDI diagnosis Schaeffler et al., Eur Radiol., 2014
  26. 26. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 a) Normal appearance of anteroinferior labral ligamentous complex b) Crescent sign c) Sigmoid shape of the redundant AIGHL d) Triangle sign Schaeffler et al., Eur Radiol., 2014
  27. 27. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Schaeffler et al., Eur Radiol., 2014 Measurement of HH centring to the glenoid fossa Crescent sign Triangle sign / posterosupirior decentring
  28. 28. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Rotator interval herniation on sagital oblique MRA Herniation of RI beyond the circle outlining the SSP/SSC Schaeffler et al., Eur Radiol., 2014
  29. 29. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 MRA and labro-capsular distance Lim et al., Skeletal Radiol, 2015 mid-glenoid cut Line A-B: humeral head center- glenoid center Line C-D: parallel to A-B from the point that the anterior capsule extended the farthest Line E-F: anterior or posterior labrum to the C-D line (vertically) Anterior LC Distance Posterior LC Distance
  30. 30. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Inferior LC Distance Lim et al., Skeletal Radiol, 2015 MRA and labro-capsular distance
  31. 31. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Inferior LC distance: statistically significant different Anterior and posterior LC distance: not statistically significant different Inferior LC distance > 16,88mm suspicion of MDI Lim et al., Skeletal Radiol, 2015
  32. 32. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Arthroscopic findings Lim et al., Skeletal Radiol, 2015 Drive-through Sign Inferior capsular laxity • Usually, no true Bankart lesion
  33. 33. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Loose Shoulder
  34. 34. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Exercise-based managenent  most commonly primarily recommended treatment Goal: Strengthening scapular and RC muscles (active control of the shoulder, humeral head centering) + proprioceptive exercises
  35. 35. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Watson MDI Programme: focuses on scapular control (typically scapular upward rotation) prior to any RC or deltoid strengthening 12-week exercise programme Watson, Warby et al. Shoulder Elbow, 2016
  36. 36. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 80% of the pat. have good to excellent results with physiotherapy
  37. 37. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017  After capsuloplasty surgical techniques: 7,5%-10% recurrence rate  21% of the pat. undergoing physiotherapy for MDI subsequently required surgical intervention Longo et al., Arthroscopy, 2015
  38. 38. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Patient with MDI with • atraumatic history • poor muscle patterning • poor scapula biomechanics • intact glenohumeral complex Exercise management Patient with MDI with • significant trauma Rö/CT/MRT Exercise management or surgery Longo et al., Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2015
  39. 39. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Patient with MDI with • no definitive structural lesion • failure after 3-6 months of conservative therapy large capsular volumes surgery Longo et al., Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2015
  40. 40. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Arthroscopic capsular plication Anterio-inferior capsular plication 5:30 4:30 Posterio-inferior capsular plication 6:30 7:30 1cm of plication 10% volume reduction Witney-Lagen, J Shoulder Elbow Surg, 2016
  41. 41. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Positioning the patient Lateral decubitus My preferred position
  42. 42. www.shoulder.gr Capacious axillary pouch www.shoulder.g
  43. 43. Arthroscopic Findings Usually, no true Bankart lesion www.shoulder.gr
  44. 44. www.shoulder.gr Arthroscopic Treatment Options  Thermical Shrinkage  Capsular plication www.shoulder.gr
  45. 45. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Posterior capsule reefing
  46. 46. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Fine Instrumentation- gentle handling
  47. 47. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Arthroscopic pancapsular capsulorrhaphy Raynor et al., Am J Sports Med, 2016 2-3 anchors anterior 2-3 anchors posterior Closure of RI
  48. 48. www.shoulder.gr Arthroscopic Treatment www.shoulder.gr
  49. 49. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017
  50. 50. www.shoulder.gr Arthroscopic Treatment www.shoulder.gr
  51. 51. www.shoulder.gr What to expect  Painless shoulder  Full ROM  No atrophies  Return to the same sport level Rowe scores: 78% excellent / good [Snyder, 2001] 75% excellent / good [Wolf, 1999] 88% excellent / good [Treacy, 2002] www.shoulder.gr
  52. 52. www.shoulder.gr What to expect 2 years post op. www.shoulder.gr
  53. 53. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Arthroscopic labral augmentation  Glenoid labrum reconstruction with a resorbable surgical mesh  Increase glenoid height and surface  Additional step to the traditional capsuloplasty procedures – not an alternative to them  Graft acts as a barrier against humerus translation Gervasi et al, Arthroscopy Techniques, Feb 2017
  54. 54. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Labrum augmentation Indication Atraumatic or voluntary instability in symptomatic patients Multidirectional recurrent instability with laxity Revision in patients with no bone deficiency
  55. 55. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Gervasi et al, Arthroscopy Techniques, Feb 2017
  56. 56. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Conclusions –Take home message • Although the terminology is confusing a shoulder may dislocate with no trauma or after minimal trauma • In most cases this type of instability is best treated nonoperatively • Regaining scapula control and rot cuff strengthening is very important • Surgery is indicated in cases of failure of the rehab program • Arthroscopic pancapsular plication yields very good results >80-85% • cases
  57. 57. www.shoulder.gr  Most patients present in their late teens  Complaints of pain during athletic activities or ADL  Uncountable dislocations and subluxations even at sleep reduced by the patient in a tall thin loose joint individual  Excessive ROM in more joints www.shoulder.g Conclusions –Take home message
  58. 58. www.shoulder.gr  Excesive translation of the joint anterior posterior and inferior at clinical examination with aprehension in one or more directions  At arthroscopy a patulous thin capsule with few other findings. Conclusions –Take home message
  59. 59. www.shoulder.gr  Treatment should address all factors of instability mainly the dynamic stabilizers with an aggressive rehabilitation program and if this fails arthoscopic or open capsulorraphy in order to reduce the volume of the capsule Conclusions –Take home message
  60. 60. www.shoulder.gr E. Antonogiannakis Multidirectional Instability: Diagnosis and Treatment Verona 12.06.2017 Thank you for your attention!!! Save the date: 1-3 February 2018

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