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Post instability echte
This document discusses posterior shoulder instability, including classification, etiology, diagnosis, and treatment options. It identifies several types of posterior instability such as traumatic dislocation, subluxation, and voluntary instability. Diagnostic tests include the jerk test and posterior load and shift test. Treatment depends on the type of instability and may include closed or open reduction, labral repair, capsulorrhaphy, bone block procedures, or glenoid osteotomy. Both open surgical techniques and arthroscopic surgery can effectively treat posterior instability, though open procedures may have higher complication rates.
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Post instability echte
- 1. POSTERIOR INSTABILITY W.JaapWillems, Lairesse Kliniek Amsterdam, The Netherlands
- 2. Disclosures Consultant -Smith and Nephew - Tornier Reearch grants - Tornier
- 3. Classification • Completetraumatic dislocation - locked - recurrent • Traumatic subluxation: (involuntary instability) • Voluntary instability • Voluntary turned into involuntary instability
- 4. Etiology • traumaticmicrotrauma atraumatic Posterior shoulder instability • less laxity more laxity • rec. dislocation provocative test * Bigliani 1995, Bottoni 2005, Kim 2003 McIntyre 1997, Robinson 2005
- 5. Etiology • unidirectionalmultidirectional Posterior shoulder instability • involuntary voluntary * Bigliani 1995, Bottoni 2005, Kim 2003 McIntyre 1997, Robinson 2005
- 6. Complete traumatic dislocation • Dislocation w or w/o fractures CM Robinson et al JBJS(A), 2007 • CT mandatory !
- 7. Traumatic dislocation •Locked posterior dislocation often missed at the Emergency department ! • Recurrent dislocation
- 8. M,57yrs, fall frombike Only AP X rays taken 1 yr later……..
- 9. Treatment locked dislocation • Acute without fracture: closed reduction, aneasthesia or plexus block • Chronic: - open reduction - allograft - Mclaughlin (minor tuberosity transfer) - HSA
- 10. Acute locked dislocation “knocking out”
- 11. Chronic locked dislocation: reconstruction • Allograft Gerber, 1996,Miniaci, 2001
- 12. Recurrent traumatic dislocation • Posterior Labro Periosteal Sleeve • Avulsion (POLpsa) • 45 yrs old alcoholic refused a’scopy
- 13. Recurrent traumatic subluxation • Etiology: acute trauma or recurrent microtrauma • Symptoms : - posterior shoulder pain - instability symptoms
- 14. Diagnostic tests •Jerk test • Posterior load and shift • Sulcus sign • Posterior apprehension test • Hyperlaxity tests
- 15. Jerk test •Dynamic test, simulates posterior subluxation and reproduces symptoms • Axial posterior load onto a arm flexed at 90°, adducted and internally rotated • Predictive measure for non-operative treatment Kim, 2001
- 16.
- 17. Pathophysiology • Bonyanatomic deformities • Excessive capsular laxity • Labral lesions
- 18. Bony changes inpost instability
- 19. Labrum lesions •Bankart lesion
- 20. Labrum lesions •Perthes-like lesion • Reversed H-Sachs (edema)
- 21. • Capsule lesions • Reverse HAGL
- 22. Kim’s Lesion •Incomplete and concealed avulsion postero-inferior labrum
- 23. Kim’s Lesion •Paralabral cyst
- 24. Voluntary instability •No indication for surgery • However: subset of patients, who start with VI turning into involuntary instability
- 25. Treatment of posteriorinstability • Open treatment modalities • open capsulorraphy • glenoid osteotomy • bone block procedure
- 26. Open approach Brodskyet al 1987
- 27. Open approach Brodskyet al 1987
- 28. Glenoid osteotomy •32 pat ,5 yrs f-up • 81% good or excellent, • 25% degenerative changes Graitchen et al,Int Orthop 1999
- 29. Glenoid osteotomy •29% complication • 41% recurrence Hawkins JBJSA 1984
- 30. Glenoid osteotomy •Coracoid impingement • Coracoplasty ? Gerber et al, ClinOrthop 1987
- 31. Bone block •20 patients with involuntary instability • Posterior bone block, 5-10 mm overhang • 3 failures; 60% very satisfied, 40% satisfied Walch et al, KSSTA 2007
- 32. Bone block •High rate of osteoarthritis with longer follow-up Sirveaux RCO 2004, Meuffels JBJSB 2010
- 33. Open capsulorraphy •Neer, 1981
- 34. Arthroscopic treatment •with or without labral detachment • labral repair +/- capsulorraphy • rotator interval ?
- 35.
- 36. How much shouldwe plicate ? • Arthroscopy: Each stitch of 1 cm 10% volume reduction Ponce et al, 2011
- 37.
- 38. • Comprehensive analysisopen and @ soft tissue repair of posterior instability Kakar et al Am.J Orthop 2007 open : 173 ( 9 studies) @ : 186 ( 7 studies) satisfaction and return to sports : equal
- 39. Thank you foryour attention
- 40. POSTERIOR TRAUMATIC SUBLUXATION • Bankart type lesion • Cartilaginous reversed Hill Sachs
- 41. • Bennet lesion,1941: post.bony spur in throwers
- 42. Bennett lesion •Symptomatic when : -posterior joint laxity - no deficit of int. rot. Nakagawa et al, 2006
- 43. Posterior subluxations •Jerk test : most reliable in post. Instability Kim, 2004
- 44. POSTERIOR TRAUMATIC SUBLUXATION • posterior Bankart, superficial rev H-S
- 45. POSTERIOR TRAUMATIC SUBLUXATION • Reverse GARD, superficial rev H-S
- 46. POSTERIOR LABRUM AVULSION COMBINED WITH CAPSULAR TEAR
- 47.
- 48. ANATOMY OF POSTERIORLABRUM • Detrisac and Johnson: • 2 types: -wedge labrum -firmly attached
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