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Traumatic shoulder dislocation 2017 kat

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Traumatic shoulder dislocation 2017 kat

  1. 1. www.shoulder.grwww.shoulder.gr Traumatic anterior shoulder dislocation Changing concepts of management Manos Antonogiannakis O r t h o p a e d i c S u r g e o n Director 3rd Orthopaedic department Centre of Shoulder Arthroscopy & Surgery Hygeia Hospital Athens Seminar, Scapular Dyskinesis related to shoulder pathology Athens, 9&10 June 2017 .
  2. 2. www.shoulder.grwww.shoulder.gr 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.grwww.shoulder.gr What is Instability  Biomechanical Dysfunction  Failure of static and dynamic stabilizers  Ranges from mild subluxation to traumatic dislocation
  4. 4. www.shoulder.gr Shoulder dislocation is a dramatic event with dare consequences especially in athletic young individuals
  5. 5. www.shoulder.gr And rather common problem 2% of the population 90% anterior dislocation
  6. 6. www.shoulder.grwww.shoulder.gr History: degree of violence Level of athletic participation Age of the patient Clinical examination: Generalized Joint laxity direction of aprehension dictates treatment
  7. 7. www.shoulder.gr Intra-articular Lesions in Acute and Chronic Anterior Shoulder Instability C.K. Yiannakopoulos, E Mataragas Emm Antonogiannakis Arthroscopy 2007 Level IV, prognostic case series 127 patients with acute and chronic traumatic anterior instability were recorded
  8. 8. www.shoulder.grwww.shoulder.gr Our findings in Traumatic shoulder dislocation  Hemarthrosis 100%  Bankart 78.2%  Bony Bankart 13.04%  Hill-Sachs 65.21%  capsular laxity 8.69%  SLAP lesions 21.73% C. Yiannakopulos E Mataragas E.Antonogiannakis Arthroscopy Sep 2007
  9. 9. www.shoulder.grwww.shoulder.gr BONY LESIONS • Humeral Head • Glenoid rim LABRAL - LIGAMENTOUS INJURY • Bankart lesion • A.L.P.S.A. • H.A.G.L. • Capsular Tear INCREASED CAPSULAR VOLUME • Atraumatic elongation • Traumatic stretch Associated Lesions we learned to recognize BICEPS LESIONS ROTATOR CUFF TEARS • Partial thickness • Full thickness ROTATOR INTERVAL PATHOLOGY • Widening • Synovitis • Rupture
  10. 10. www.shoulder.gr  Major lesions discovered from the first dislocation  Becoming worse as the episodes are being repeated What is important
  11. 11. www.shoulder.grwww.shoulder.gr • Multicenter study • 245 patients aged 12-40 years • 10 years follow up • 52% recurrence rate • 23% were operated Prognosis of recurrence after traumatic first time dislocation Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study - Hovelius 1996 JBJS(A)
  12. 12. www.shoulder.grwww.shoulder.gr The major prognostic factor of recurrence after acute traumatic anterior shoulder dislocation is the age of the patient and the degree of participation to high risk sports
  13. 13. www.shoulder.grwww.shoulder.gr Redislocation rate in patients<20 years Larrain Rowe Simonet and Cofield Slaa •90% • 94% • 94.5% • 90%
  14. 14. www.shoulder.grwww.shoulder.gr Post-Reduction Immobilization Is immobilization necessary? What Method is Best?
  15. 15. www.shoulder.grwww.shoulder.gr Does immobilization reduce recurrence?  Prospective multi-center study  257 primary anterior shoulder dislocations  25 year follow up  Results: Immobilization for 3-4 weeks after shoulder dislocation does NOT change the prognosis compared with immediate mobilization Hovelius JBJS 2008
  16. 16. www.shoulder.grwww.shoulder.gr Internal vs External Rotation Itoi JBJS 2007  ER for 3 weeks  Recurrence rate: 32%  IR for 3 weeks  Recurrence rate: 60%
  17. 17. www.shoulder.grwww.shoulder.gr Is shoulder arthroscopy the best treatment of traumatic shoulder dislocation?
  18. 18. www.shoulder.grwww.shoulder.gr Better understanding of the pathology Reduction of recurrence rate Treatment of rotator cuff lesions in older individuals Easier rehabilitation Why arthroscopy?
  19. 19. www.shoulder.grwww.shoulder.gr Even the first dislocation is not a trivial injury
  20. 20. www.shoulder.grwww.shoulder.gr Bankart Lesion the essential lesion  Avulsion of the IGHL from the glenoid rim from 2 o’clock to 6 o’clock  Primary restraint to anterior translation at 90o of abduction  85% in traumatic anterior dislocations  Not the only lesion usually.
  21. 21. www.shoulder.grwww.shoulder.gr Bankart Lesion
  22. 22. www.shoulder.grwww.shoulder.gr What is successful Treatment Avoid recurrence No limitations in Range of motion Minor morbidity Few complication Return to preinjury activity level Reproducible results These are possible with arthroscopic treatment of traumatic shoulder dislocation in selected patients
  23. 23. www.shoulder.grwww.shoulder.gr Treatment: Address all factors  Dynamic stabilizers: rotator cuff and scapula muscles  Static stabilizers: repair of capsuloligamentous structures
  24. 24. www.shoulder.gr Arthroscopic Shoulder Reconstruction Goal of the Operation:  Restoration of the Labrum to its anatomic attachment  Reestablishment of the appropriate tension in the GH ligaments and capsule Address bone deficiencies
  25. 25. www.shoulder.gr Define pathology
  26. 26. www.shoulder.gr Evaluation of the repair Plication of the posterior capsule Remplissage if needed
  27. 27. www.shoulder.gr Glenoid Bone Loss >20-30%
  28. 28. www.shoulder.gr The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  29. 29. www.shoulder.gr Normal Glenoid inverted pear Bony Bankart pear Compressio n Bankart loss of anterior rim
  30. 30. www.shoulder.gr >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  31. 31. www.shoulder.gr  Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface
  32. 32. www.shoulder.gr Bony Bankart
  33. 33. www.shoulder.gr Soft tissue repair incorporating the bone fragment if possible Piasecki et al. AAOS J17 (8): 482. (2009)
  34. 34. www.shoulder.gr Engaging Non Engaging Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739 Hill-Sachs lesion
  35. 35. www.shoulder.grwww.shoulder.gr Engaging Hill Sachs
  36. 36. www.shoulder.gr  Engaging Hill-Sachs-glenoid bone loss Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf
  37. 37. www.shoulder.gr
  38. 38. www.shoulder.gr
  39. 39. www.shoulder.gr From January 2007 to December 2010 (4 years) 48 patients Average age: 28.9 ± 7.8 years Average fu: 37.2 ± 9.9 months Recurrence percentage: 6.3%
  40. 40. www.shoulder.grwww.shoulder.gr The combination of the lesions No Bone Loss Arthroscopic Bankart Repair Glenoid Bone Loss > 25% Arthroscopic Bankart Repair + Bone grafting procedure
  41. 41. www.shoulder.grwww.shoulder.gr Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
  42. 42. www.shoulder.gr Glenoid Bone Loss >25% Arthroscopic Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna
  43. 43. www.shoulder.gr
  44. 44. www.shoulder.gr
  45. 45. www.shoulder.gr E.Taverna, et.al,Knee Surg Sports Traumatol Arthrosc (2008) 16:872–875
  46. 46. www.shoulder.gr Arthroscopic Bone Block combined with Remplissage
  47. 47. www.shoulder.gr
  48. 48. www.shoulder.gr 3 months Post-op
  49. 49. www.shoulder.gr 3 months Post-op
  50. 50. www.shoulder.gr Our Results 25 cases Impressive early outcomes
  51. 51. www.shoulder.gr
  52. 52. www.shoulder.gr Postoperative Rehabilitation  Sling for comfort  Isometrics and pendulum exercises immediately  Active forward elevation may begin after 3/52  External rotation to 30° to 40° at 4/52  Progressive strengthening at 8/52  Return to sport at 18 to 36 weeks supervised and individualized
  53. 53. www.shoulder.grwww.shoulder.gr Findings after shoulder dislocation in patients older than 40 years  52 pts follow up more than 2 years  Redislocation rate 4%  Rotator cuff tears 35% T Penvy, R Hunter, J Freeman Arthroscopy 1998
  54. 54. www.shoulder.grwww.shoulder.gr In older patients rotator cuff tears are common The arthroscopic treatment of acute rotator cuff tears is easy with minimum morbidity Conclusions
  55. 55. www.shoulder.grwww.shoulder.gr Modern arthroscopic techniques are probably the treatment of choice in traumatic shoulder dislocation Conclusions
  56. 56. www.shoulder.grwww.shoulder.gr  Arthroscopy can be performed in an outpatient setting  The anatomy can be restored with minimum morbidity and pain for the patient  Careful assessment will allow repair of all lesions  The patient can resume most of his every day activities early in the rehabilitation program Conclusions
  57. 57. www.shoulder.grwww.shoulder.gr Thank you for your attention!!! Save the date: 1-3 February 2018

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