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Multidirectional shoulder instability

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Multidirectional shoulder instability

  1. 1. MMultiDDirectional Shoulder IInstability (MDI) Manos Antonogiannakis Director 2nd Orthopedic Dept. IASO General Hospital www.shoulder.gr
  2. 2. The Shoulder  Greatest Range of Motion in the Body  Motion in all 3 planes of movement  Prone to injuries  8-20% of all sports injuries
  3. 3. Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  4. 4. Mechanisms of Glenohumeral Stability • Static • Dynamic • Negative Intra- articular pressure Labrum (50% of Glenoid depth) Capsule Ligaments- Glenohumeral- Superior, Middle & Inferior (stability & proprioception) Rotator cuff tension-scapula stabilizers
  5. 5. Classification Schemes • Mechanism – Traumatic – Atraumatic – Congenital – Neuromuscular • Frequency – Acute – Chronic – Recurrent – Involuntary – Voluntary • Direction – Anterior (and inferior) – Posterior (and inferior) – Superior? – Multidirectional • Extent – Subluxation – Dislocation
  6. 6. Types of instability Not a black or white issue WWW.SHOULDER.GR
  7. 7. 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
  8. 8. TUBS AIOS AMBRI
  9. 9. MDI Definition The presence of inferior instability in combination with anterior and or posterior instability
  10. 10. Definitions • MDI implies subluxation or dislocations in at least two directions either anteriorly, posteriorly, or inferiorly • Usually, the patient experiences symptoms in one direction, but the examination reveals more directions of instability www.shoulder.gr
  11. 11. MDI History First described in detail in 1980 by Charles S. Neer and Craig R. Foster www.shoulder.gr
  12. 12. MDI types • Anterior-inferior dislocation with posterior subluxation • Posterior-inferior dislocation with anterior subluxation • Recurrent dislocation posterior and inferior Neer and Foster
  13. 13. MDI Characteristics • Relatively common • Generally bilateral • Atraumatic condition affecting shoulder function • Excessive translation in all directions but with the predominance of ONE direction, typically anteroinferior or posteroinferior. www.shoulder.gr
  14. 14. MDI Characteristics • Usually in overhead active sports • gymnastics, swimming, throwing, racquet sports www.shoulder.gr
  15. 15. MDI Characteristics • Repetitive stretch of the shoulder capsule to extreme ranges of motion www.shoulder.gr
  16. 16. MDI Characteristics • 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.gr Ehlers-Danlos Syndrome
  17. 17. MDI 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
  18. 18. Types of dislocation • Voluntary dislocation • Involuntary dislocation should be recognized early
  19. 19. 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 • True voluntary dislocators with psychiatric problems
  20. 20. MDI Diagnostic Tools Highly clinical diagnosis • History • Clinical examination • Marginal help of imaging studies (plain radiographs, MRI, MRI-arthrography) • Highly supportive: – Examination under anesthesia (EUA) – Arthroscopic findings www.shoulder.gr
  21. 21. MDI Clinical Examination • Bilateral physical findings • Usually, rotator cuff (dynamic stabilizers) weakness • Drawer and load-shift tests (anterior and posterior) reveal displacement with an elastic feeling • Pathognomonic “sulcus sign” • Apprehension test may be positive, usually in the direction of the chief component of instability www.shoulder.gr
  22. 22. Clinical examination • Usually vague symptoms with activity • Associated conditions: collagen disorders • Look for generalized hyper-elasticity (thumbs can be hyperextended to the distal radius, elbow hyperextended ,knee recurvatum) www.shoulder.gr
  23. 23. Clinical examination SULCUS sign with the arm in adduction that persists in external rotation or abduction is a major clinical sign Anterior and posterior load and sift tests
  24. 24. Examination Under Anesthesia • To demonstrate increased glenohumeral anterior, posterior and inferior translation • Usually, symmetrical www.shoulder.gr
  25. 25. MDI Examination Under Anesthesia
  26. 26. Treatment Options • Conservative • Intensive RC strengthening (dynamic stabilizers) • Scapular Stabilizers strengthening • Dynamic Upper Limb Propioception • Surgical • Open Surgery – Inferior Capsular Shift • Arthroscopy www.shoulder.gr
  27. 27. Treatment: Address all factors • Dynamic stabilizers: rotator cuff and scapula muscles • Static stabilizers: plication of capsuloligamentus stactures
  28. 28. treatment • Open treatment first described by Neer as the glenoid inferior capsular sift based laterally on the humeral head • Arthroscopic management was pioneered by Gaspari using a transglenoid technique
  29. 29. Contraindications for Surgical Treatment • Voluntary shoulder instability • Collagen disorders (eg, Ehlers-Danlos syndrome, Marfan syndrome) • Noncompliance with a supervised rehabilitation program www.shoulder.gr
  30. 30. MDI Arthroscopic Findings • Usually, no true Bankart lesion www.shoulder.gr
  31. 31. Loose Shoulder
  32. 32. MDI Arthroscopic Findings Capacious axillary pouch www.shoulder.gr
  33. 33. MDI Arthroscopic Findings • “Drive-through" sign: • Subluxation without much traction www.shoulder.gr
  34. 34. MDI Arthroscopic Findings
  35. 35. MDI Surgical Treatment The goal is "addressing the capsular laxity and redundancy to restore anatomic capsuloligamentous tension without overconstraining the shoulder." [Caprise and Sekiya, 2006] www.shoulder.gr
  36. 36. Arthroscopic Treatment Options • Thermical Shrinkage • Capsular plication www.shoulder.gr
  37. 37. MDI Arthroscopic Treatment
  38. 38. Possible problems • Axillary nerve injury • Loose repair • Healing problems (collagen diseases: Ehlers-Danlos, Marfan) • Postoperative noncompliance • Overtensioning is not a common problem www.shoulder.gr
  39. 39. Rehabilitation Program • 0-3 weeks Relaxing phase • 3-6 weeks Passive movements to ROM • 6w – 3 m Assisted Active movement to ROM • 3-6 m Active movement to ROM • >4m Propioception improvements • >4m Strengthening exercises • >9 Return to sports www.shoulder.gr
  40. 40. 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
  41. 41. What to expect 2 years post op.
  42. 42. What to expect 2 years post op.
  43. 43. Conclusions • 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.gr
  44. 44. Conclusions • 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.
  45. 45. Conclusion • 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
  46. 46. Thank you
  47. 47. Posterior Instability
  48. 48. Posterior Instability
  49. 49. Natural History Of MDI After 8 years: • 48.7% pain 46.1% instability • Mod. Rowe/Zarris: • 13.8% excellent • 33% good • 52.7% poor [Misamore, JSES 2005] www.shoulder.gr

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