This document discusses shoulder instability and rotator cuff disease. It covers the anatomy and biomechanics of shoulder instability, the natural history and treatment options for anterior and posterior instability, as well as multidirectional instability. It also discusses the natural history and treatment of rotator cuff tears, including surgical repair techniques and biologic augmentation options. Key points include that young patients with first-time dislocations often benefit from surgical intervention to prevent recurrence, and early intervention is recommended for rotator cuff tears in younger patients to prevent fatty degeneration.

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Presenter: Chun Tseng
OKU 11 READING
Ch27 Shoulder instability and Rotator
cuff disease

2. SHOULDER INSTABILITY- ANATOMYI LITY
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• Static
• Osteochondral anatomy
• Capsulolabral complex: labrum,. Capsule,
Glenohumeral ligment, Coracohumeral ligment
• negative intra-articular pressure
• synovial fluid adhesion-cohesion
• Dynamic: rotator cuff, biceps long head,
scapulothoracic rhythm, concavity compression,
proprioceptive feed back

3. BIOMECHANICS
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• Traumatic anterior instability  arm in an abducted and externally rotated position 
anteroinferior glenohumeral ligament injury.
• Posterior dislocation the arm in a forward flexed, adducted position  posterior
capsulolabral complex and the posterior glenoid rim.
• Glenoid bone loss:
• Substantial bone loss arthroscopic repair效果不佳
• >21% glenoid bone loss severe instability
• Humeral bone loss:
• Hill-Sachs lesion  > 25% 對於 joint translation, capsular force, and bony
contact force 有顯著的差異 可補capsule & labral來穩定肩關節
• Reverse Hill-Sachs lesion

4. ANTERIOR INSTABILITY
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• The most common direction of shoulder dislocation is anterior
• Injury of the glenoid labrum (Bankart lesion)
• injury of the anterior glenoid rim (bony Bankart lesion)
• Treatment
• Closed reduction / Open reduction.
• Sling immobilization. External/ Internal/ Neutral Position 都
可以

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6. NATURAL HISTORY
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• young, active patient  Recurrence rates as high as 92% have been
reported with nonsurgical treatment.
• >40 y/o Patients  increased risk of rotator cuff tears and neurologic injury
(axillary nerve)
• >60 y/o Patients  dislocation 常與 greater tuberosity fracture, rotator cuff
tear, and neurologic injury 合併
• <22 y/o Patients with a first-time dislocation high recurrent instability rates
 surgical intervention.

7. NATURAL HISTORY
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• Data suggest that patients treated with an arthroscopic Bankart
repair after initial dislocation had an 82% reduction in the risk of
recurrent instability
• 近十年共識，16-25y/o pt with first time dislocation 68 %
surgeons offering surgery
• 需要做open bankart repair 的病人中有1/4 (26%)發生
Osteoarthritis
• 手術後有1/3 (32%) 病人有 Osteoarthritis
• Progression Risk Factors: 術前脫臼次數，男性

8. ARTHROSCOPIC VERSUS OPEN REPAIR
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• Outcome scores and recurrence rate 兩種一樣
• Long term outcomes 發現scope 組有14.3% 的recurrence rate.
• Patients treated with two or fewer suture
anchors had a higher dislocation rate than
patients treated with three or four suture anchors.

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• For contact athletes, a recurrence rate of 89% was noted in patients with a lesion to
the anterior glenoid rim of 20% to 30% when treated with arthroscopic labral repair
and capsular shift alone.
• > 25~30%的 anterior glenoid defects bony procedure is often necessary
• Latarjet procedure (transfers the coracoid process to the glenoid bony defect)
• 加強前面glenoid
• 當手Abd or Ext 時
Conjoined tendon 可以當sling

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• Hill- Sachs lesions larger than 25% of the total surface area of the glenoid
cavity  Open Treatment with
• Osteochondral allograft,
• Remplissage
(to fill in with infraspinatus)
• Infraspinatus transfer
• >40% lesion
• Humeral arthroplasty or bone graft

11. POSTERIOR INSTABILITY
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• Less common than anterior dislocations
• Commonly missed
• Posterior dislocations, usually self-limited.
• Approximately 17% of patients will develop a recurrent
dislocation in the first year following a dislocation.
• Risk factor:
• < 40 y/o , seizure disorder, large humeral head defects

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• Surgical Treatment Open and scope
The repair should address the torn posterior labrum and/or bony defect,
capsular redundancy, and ligament tears
• Chronic Posterior Dislocation~~several weeks
• Subscapularis or lesser tuberosity transfer into the reverse Hill-
Sachs lesion,
• Osteochondral bone grafting
• Segmental humeral head replacement
• Humeral head replacement
• Humeral head replacement is indicated for chronic dislocations in
which the patient has developed clinically significant osteoarthritis,
osteonecrosis with head collapse, or damage of more than 50% of the
humeral head.

13. MULTIDIRECTIONAL INSTABILITY (MDI)
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• Genetic hyperlaxity
(Ehlers- Danlos syndrome= rubber man syndrome)
皮膚有高度伸展性，皮膚和血管脆弱，
傷口癒合比較慢，關節活動範圍的過度增加
• Nonsurgical Treatment~ success rates as high as 80%.
• Open capsular shift
• Arthroscopic capsular shift techniques

14. ROTATOR CUFF DISEASE
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• 症狀會比 MRI 出現 fatty changes 更早發生
• Supraspinatus Muscle 早3~5 年
• Infraspinatus Muscle 早2.5~4 年
• Pt <60 y/o or 有症狀仍在工作的人應該早早REPAIR
• 破掉的位子在偏後(relatively hypovascular zone)
比較容易有fatty change
• 破掉的SIZE與 疼痛, function score 情況正相關
• Risk factor: AGE, Shoulder overhead and abducted.

15. RCT~~ TREATMENT
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• Earlier intervention should be considered for full-thickness
rotator cuff tears in younger patients who have not yet
developed significant tendon retraction, fatty infiltration, and
atrophy.

16. SURGICAL TREATMENT
SINGLE-ROW V.S. DOUBLE-ROW REPAIR
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• Smaller tears and double-row repairs had a greater healing rate.
• No differences in the functional or quality-of-life outcome score
• Cost-effectiveness DR<SR.
• Repair failure 多發生在前期

17. BIOLOGIC AUGMENTATION OF ROTATOR CUFF
REPAIR
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• Several graft augmentation devices are currently available, but little evidence substantiates
their efficacy.
• Platelet-rich plasma has also been evaluated, but most randomized
studies have not shown a benefit.
• There is little evidence at this time to support the routine use of
platelet-rich plasma or PRFM in rotator cuff repair.
• Platelet-rich fibrin matrix (PRFM) 離心加CaCl2
• Porcine intestinal submucosal graft(豬小腸) worse results
• porcine dermal graft better outcome scores and healing
• Polyurethane patch (PU)

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Thanks for Your
Listening
2015/02/11