Multidirectional instability of the shoulder 2014
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Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.
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Multidirectional instability of the shoulder 2014
- 1. MDI What is it? Should we Operate? Lennard Funk @theshoulderdoc lenfunk@shoulderdoc.co.uk
- 3. ? MDI www.wrightington.com 3 22yr secretary, asymptomatic Hyperlax in all directions ANTERIOR POSTERIOR INFERIOR
- 4. ?MDI www.wrightington.com 4 17yr old swimmer - overstretch in pool Subluxing posterior in flexion and painful
- 5. ?MDI 20 year old rugby player - tackling impact injury Pain & dead arm; feels unstable Large anterior and posterior labral tears wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 5
- 6. MDI - Definitions? 1. Shoulder Instability in patients who have generalised looseness of the ligaments of the shoulder [Web Dictionary] 2. Generalised looseness of the shoulder joint 3. Abnormal excursion of the humeral head on the glenoid in all directions [Neer] 4. Instability in TWO directions [1,2,3,4] 5. Instability in THREE directions [5,6,7] 6. Motor Control Trouble - the less surgery the best wwwwww.w.wrigrhigtinhgttionng.ctoomn.com (Olivier Gagey - 20min ago!) 6
- 7. wwwwww.w.wrigrhigtinhgttionng.ctoomn.com nferior shift eh abilitation ilateral ultidirection al traumatic Range AMBRI TUBS 7 urgery ankart nidirectional umatic ra
- 8. The use of laxity testing tends to result in an overestimation of the number of patients with this condition. This observation is important because the results of studies may vary if patients with traumatic instability are considered to have multidirectional instability on the basis of laxity testing. Investigators studying patients with multidirectional instability should carefully define the inclusion criteria that they used. wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 8
- 9. Uncontrollable, involuntary inferior subluxation or dislocation, associated with both anterior and posterior dislocations or subluxations of the shoulder. wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 9
- 10. Stanmore Classification Atraumatic wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 11 Polar I Traumatic Structural Polar II Atraumatic Structural Polar III Motor Control
- 11. What is it? www.wrightington.com 12 • Shoulder Instability in patients who have generalised looseness of the ligaments of the shoulder [Web Dictionary] • Atraumatic • Multidirectional laxity • Uni/Multidirectional Instability
- 12. Stanmore Classification Atraumatic wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 13 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.
- 13. Rehab Optimise: Core Scapula Kinetic Chain Psychology Proprioception wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 14
- 14. Proprioception www.wrightington.com 15 Mechanoreceptors in GHL Jerosch et al. 1997 Gohlke et al 1998
- 15. www.wrightington.com 16 Capsular Plication / Shift
- 16. Capsular Plication / Shift www.wrightington.com 17
- 18. Capsular Plication Results Arthroscopic 88-94% success at 2-5yrs Gartsmann Open 94% good/excellent at 5yrs Bigliani 59% good/excellent 83% satisfactory Hamada wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 25
- 19. 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. wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 26 Tablot, Carter & Funk, BESS 2012
- 20. 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 wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 27
- 21. Pre-op Post-op * www.wrightington.com 28 * Statistically significantly improved score (p<0.001) 26 16 54 39 * 32 * 29 60. 45. 30. 15. 0. OSS OIS DASH
- 22. Patient Satisfaction • Pre-op: 3.2/10 • Post-op: 8.6 / 10 • with average 82.4% improvement in symptoms wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 29
- 23. Stanmore Classification Atraumatic wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 30 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.
- 24. 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 Ms Anju Jaggi Dr Susan Alexander Professor Len Funk Professor Rob Herbert Associate Professor Karen Ginn
- 25. Karen Ginn Rob Herbert Anju Jaggi Susan Alexander Len Funk
- 26. 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 33 ethics approval granted data collection commenced April 2013
- 27. Methodology - Procedure exclude – bony damage & RC tear subjects blinded no capsulolabral damage 34 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 exclude – WOSI, participant perceived improvement & dislocation episodes re-assessed therapists blinded assessor blinded assessor blinded
- 28. Thank You www.wrightington.com 39 lenfunk@shoulderdoc.co.uk
- 29. http://www.salford.ac.uk/spd/coursede www.wrightington.com 40 tails?courseid=THESCAfQ7Q
- 30. 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 wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 41
Editor's Notes
- ST4-6 am session 'Instability' 11.00am - Instability - Arthroscopic Techniques for Repair, Indications for Open Surgery, Dealing with Glenoid Deficiency
- Background: There currently is a wide variation in the definition of multidirectional instability of the shoulder in the literature. The purpose of this study was to determine if these variations influence the distribution of the diagnoses in a cohort of patients with shoulder instability. Methods: A cohort of 168 patients who underwent shoulder surgery for instability of any type was studied. Statistical analysis was performed in two steps. First, the instability of the shoulder in each patient was classified with the use of four existing systems, and the number of patients classified as having multidirectional instability was compared among the classification systems. Second, the definition of multidirectional instability was modified so that the result of laxity testing was the criterion for making the diagnosis, and the changes in the distribution of patients with a diagnosis of multidirectional instability were analyzed. Results: Classification with the four existing systems resulted in significant differences in the number of patients diagnosed as having multidirectional instability, with two (1.2%), seven (4.2%), thirteen (7.7%), and fourteen patients (8.3%) so diagnosed (p < 0.05). Modification of the definition of multidirectional instability so that it was based on laxity testing resulted in a wide variation in the number of patients diagnosed as having multidirectional instability; these numbers ranged from fourteen (8.3%) to 139 (82.7%) (p < 0.05). Conclusions: This study demonstrated that variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis. The use of laxity testing tends to result in an overestimation of the number of patients with this condition. This observation is important because the results of studies may vary if patients with traumatic instability are considered to have multidirectional instability on the basis of laxity testing. Investigators studying patients with multidirectional instability should carefully define the inclusion criteria that they used.
- In thirty-six patients (forty shoulders) with involuntary inferior and multidirectional subluxation and dislocation, there had been failure of standard operations or uncertainty regarding diagnosis or treatment. Clinical evaluation of these patients stressed meticulous psychiatric appraisal, conservative treatment, and repeated examination of the shoulder. All patients were treated by an inferior capsular shift, a procedure in which a flap of the capsule reinforced by overlying tendon is shifted to reduce capsular and ligamentous redundancy on all three sides. This technique offers the advantage of correcting multidirectional instability through one incision without damage to the articular surface. One shoulder began subluxating again within seven months after operation, but there have been no other unsatisfactory results to date. Seventeen shoulders were followed for more than two years.
- 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