Atraumatic Shoulder Instability Management
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This document discusses atraumatic shoulder instability and treatment options. It presents the Stanmore classification system for shoulder instability, which categorizes types of instability as traumatic structural (Polar I), atraumatic structural (Polar II), or motor control (Polar III). For atraumatic structural instability (Polar II), options include small lesion repair, capsular plications, or large lesion repair/reconstruction along with rehabilitation. The document outlines a proposed randomized controlled trial to determine whether surgical stabilization plus physiotherapy improves outcomes for atraumatic instability compared to physiotherapy alone.
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Atraumatic Shoulder Instability Management
- 1. Lennard Funk Atraumatic Instability What is it? Should we Operate? @thearmclinic
- 3. www.wrightington.comwww.wrightington.com Stanmore Classification 3 Polar I Traumatic Structural Polar II Atraumatic Structural Polar III Motor Control Atraumatic
- 4. Factors in Instability Anju Jaggi Motor Control & Rotator Cuff Imbalance / Weakness Co-activation Chain ineffective for normal RC recruitment Scapula Dyskinesis Poor Kinetic Chain Structural insufficiency Capsulolabral damage Hyperlaxity Fear Avoidance Belief Disuse
- 5. www.wrightington.comwww.wrightington.com Stanmore Classification 5 Small lesion Repair Capsular Plications Polar I Traumatic Structural Polar II Atraumatic Structural Polar III Motor Control Large lesion Repair Bony Reconstructions Rehab +/- Capsular Plication Specialist Rehab. Atraumatic
- 7. www.wrightington.com Proprioception 7www.wrightington.com Mechanoreceptors in GHL Jerosch et al. 1997 Gohlke et al 1998
- 9. www.wrightington.com Capsular Plication / Shift 9www.wrightington.com
- 12. www.wrightington.com Post-op Rehab ER Sling for comfort (approx. 3 weeks) Avoid forcing or stretching Proprioceptive Scapula Core Functional 13www.wrightington.com
- 13. www.wrightington.comwww.wrightington.com 14 Capsular Plication Results Arthroscopic 88-94% success at 2-5yrs Gartsmann Open 94% good/excellent at 5yrs Bigliani 59% good/excellent 83% satisfactory Hamada
- 14. www.wrightington.comwww.wrightington.com Arthroscopic Plication Audit Clinical outcome of arthroscopic capsular plication for atraumatic instability (Stanmore II) of the shoulder by a single surgeon, with >12 month follow-up. 15 Tablot, Carter & Funk, BESS 2012
- 15. www.wrightington.comwww.wrightington.com Patients • 23 patients (16 ) • Average age 27 (19 – 41 years) • Follow-up – 15.6 months (range 4 - 40 months) • Previous Thermal Capsular Shrinkage: 6 • Average Pre-Op Specialist Physio: 5.4 months 16
- 16. www.wrightington.com 17www.wrightington.com * Statistically significantly improved score (p<0.001) 26 16 54 39 32 29 0. 15. 30. 45. 60. OSS OIS DASH Pre-op Post-op * * *
- 17. www.wrightington.comwww.wrightington.com Patient Satisfaction • Pre-op: 3.2/10 • Post-op: 8.6 / 10 • with average 82.4% improvement in symptoms 18
- 18. www.wrightington.comwww.wrightington.com Stanmore Classification 19 Small lesion Repair Capsular Plications Polar I Traumatic Structural Polar II Atraumatic Structural Polar III Motor Control Large lesion Repair Bony Reconstructions Rehab +/- Capsular Plication Specialist Rehab. Atraumatic
- 19. Atraumatic shoulder instability Randomized Controlled Trial Does stabilisation surgery followed by physiotherapy improve short & long term outcomes compared with physiotherapy alone? Associate Professor Karen Ginn Associate Professor Karen Ginn Ms Anju Jaggi Dr Susan Alexander Professor Len Funk Professor Rob Herbert
- 20. Karen Ginn Rob Herbert Anju Jaggi Susan Alexander Len Funk
- 21. Clinical Trial aim a robust randomised controlled clinical trial to determine whether surgical intervention followed by physiotherapy improves outcomes in patients suffering from atraumatic shoulder instability associated with capsulolabral damage compared with physiotherapy alone design double blind (patient & physiotherapist) randomised controlled clinical trial sham-controlled surgical arm in order to account for the strong placebo effect associated with “the high levels of stress and rituals involved with surgery” Dowrick & Bhandari 2012 22 ethics approval granted data collection commenced April 2013
- 22. Methodology - Procedure 23 patients with a feeling of insecurity in their shoulder, not associated with a high collision injury, which is provoked by physical examination tests, who do not have upper limb nerve damage identified MRI examination • sign consent to participate prior to undergoing diagnostic arthroscope • undergo baseline outcome measurements diagnostic arthroscope • subjects recruited • randomly allocation stabilisation surgery no further intervention post-operative physiotherapy maximum 12 treatment sessions over 6 months 6 months post-randomisation all outcome measurements re-assessed 1 & 2 years post-randomisation WOSI, participant perceived improvement & dislocation episodes re-assessed exclude – bony damage & RC tear exclude – no capsulolabral damagesubjects blinded therapists blinded assessor blinded assessor blinded
- 24. www.wrightington.comwww.wrightington.com References: 1. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am . 1991;73: 105-12.Abstract/FREE Full Text 2. Bak K, Spring BJ, Henderson JP. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med . 2000;28: 466-71.Abstract/FREE Full Text 3. Flatow EL, Miniaci A, Evans PJ, Simonian PT, Warren RF. Instability of the shoulder: complex problems and failed repairs: Part II. Failed repairs. Instr Course Lect . 1998;47: 113-25.Medline 4. Gerber C. Observations on the classification of instability. In: Warner JJP, Iannotti JP, Gerber C, editors. Complex and revision problems in shoulder surgery . Philadelphia: Lippincott-Raven; 1996. p 9-18. 5. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup. Am J Sports Med . 1996;24: 459-67. 6. Jobe FW, Tibone JE, Pink MM, Jobe CM, Kvitne RS. The shoulder in sports. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder . 2nd ed. Philadelphia: WB Saunders; 1996. p 1214-38. 7. Neer CS 2nd. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect . 1985;34: 232-8 8. Pollock RG, Owens JM, Flatow EL, Bigliani LU. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am . 2000;82: 919-28 25
Editor's Notes
- ST4-6 am session 'Instability' 11.00am - Instability - Arthroscopic Techniques for Repair, Indications for Open Surgery, Dealing with Glenoid Deficiency
- As a result suture plication techniques have more widely applied, both open and arthroscopically…..
- The aim of the study was to assess the surgical role in the management of patients with atraumatic instability of the shoulder who remained unstable despite assessment and treatment by specialist shoulder physiotherapy.
- As above Many had previous episodes of physiotherapy elsewhere but all patients were seen pre-op for a mean of 5.4 months by one of 2 specialist shoulder therapists in our unit
- This table shows pre and post op scores with ranges in brackets. Statistically significantly improved scores were noted in the OS, OI and quick DASH scores