Multidirectional instability of the shoulder 2014

Multidirectional instability of the shoulder 2014

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  MDI What isit? Should we Operate? Lennard Funk @theshoulderdoc lenfunk@shoulderdoc.co.uk
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  www.wrightington.com 2
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  ? MDI www.wrightington.com 3 22yr secretary, asymptomatic Hyperlax in all directions ANTERIOR POSTERIOR INFERIOR
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  ?MDI www.wrightington.com 4 17yr old swimmer - overstretch in pool Subluxing posterior in flexion and painful
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  ?MDI 20 yearold rugby player - tackling impact injury Pain & dead arm; feels unstable Large anterior and posterior labral tears wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 5
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  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
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  wwwwww.w.wrigrhigtinhgttionng.ctoomn.com nferior shift eh abilitation ilateral ultidirection al traumatic Range AMBRI TUBS 7 urgery ankart nidirectional umatic ra
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  The use oflaxity 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
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  Uncontrollable, involuntary inferiorsubluxation or dislocation, associated with both anterior and posterior dislocations or subluxations of the shoulder. wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 9
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  Stanmore Classification Atraumatic wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 11 Polar I Traumatic Structural Polar II Atraumatic Structural Polar III Motor Control
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  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
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  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.
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  Rehab Optimise: Core Scapula Kinetic Chain Psychology Proprioception wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 14
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  Proprioception www.wrightington.com 15 Mechanoreceptors in GHL Jerosch et al. 1997 Gohlke et al 1998
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  www.wrightington.com 16 CapsularPlication / Shift
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  Capsular Plication /Shift www.wrightington.com 17
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  Capsular Plication wwwwww.w.wrigrhigtinhgttionng.ctoomn.com 20
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  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
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  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
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  Patients • 23patients (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
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  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
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  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
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  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.
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  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
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  Karen Ginn RobHerbert Anju Jaggi Susan Alexander Len Funk
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  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
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  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
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  Thank You www.wrightington.com 39 lenfunk@shoulderdoc.co.uk
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  http://www.salford.ac.uk/spd/coursede www.wrightington.com 40 tails?courseid=THESCAfQ7Q
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  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