Shoulder Exam and Instability.

Transkrypt

1 Shoulder Exam and Instability

2 History Duration <2wks => dislocation, fracture, RCT >2wks => chronic symptoms; m/c Mechanism of injury Football player w/ fall onto shoulder; pain and deformity at AC joint Age and chief complaint

3 Chief Complaint Pain at night; can t t sleep on shoulder Rotator cuff tear Pain localized to top of shoulder Arthritis, AC joint separation Pain in deltoid region; radiates down lateral arm Bursitis Tingling sensation; aggravated by lifting arm Rotator cuff tear Shoulder slips out of joint instability

4 Patient Age Young patient Instability, AC joint separation, dislocation Middle-aged patient Impingement syndrome, RCT, adhesive capsulitis (female) Older patient RCT, degenerative arthritis, adhesive capsulitis

5 Neer Impingement Sign Patient seated Forcibly flex arm to overhead position Pain => humerus impinges against CA arch

6 Acromioclavicular joint Palpate posterior margin of AC joint Exaggerated w/ cross arm adduction

7 Subacromial bursa Palpate from antero- lateral acromion down deltiod Acromiohumeral sulcus Pain => bursitis, RCT

8 Internal shoulder rotation Patient seated Place dorsum of hand against back Note vertebra pt reaches

9 Supraspinatus strength test 90 deg abduction 30 deg forward flexion Thumbs down Push down as patient resists Pain => RCT

10 Inferior instability Arm abducted 90 deg Apply direct pressure downward to midhumerus

11 Posterior instability Shoulder flexion 90 deg Push posterior

12 Hawkin s impingement sign Throwing position Flex forward 30 deg Forcibly int. rotate Pain => impingement of supraspinatous against CA ligament

13 External rotation Patient seated ext rotate both arms Restricted => adhesive capsulitis

14 Crossed arm adduction Arm across chest as far as comfortably possible Restricted => tight posterior capsule AC joint pain

15 Apprehension sign Throwing position Pull into ext rotation and extension Pt will drop arm to avoid subluxation or dislocation

16 Sulcus sign Arm at side Pull inferiorly Deepening of acromiohumeral sulcus => inferior GH instability

17 Abduction coronal plane Extend shoulder posteriorly Abduct shoulder Pain => impingement of greater tuberosity against lateral acromion

18 Shoulder Instability

19 Shoulder Instability- Anatomynatomy Glenoid Labrum adds 50% depth to glenoid; ; passive stability ant labrum acts as attachment for middle and sup. glenohumeral ligaments post. sup. labrum acts as the attachment of the post. capsule and anchor for biceps

20 Shoulder Instability- Anatomynatomy Superior labrum + biceps contribute to stability (dynamic) Pagnani (JBJS, 1995) Rodosky (Am J Sports Med, 1994) resist ant and sup translation of humeral head SLAP lesion

21 Shoulder Instability- Anatomy IGHLC Anterior band of inf glenohumeral lig. primary restraint against anterior translation with the arm in 90 deg abduction O Brien, Am J Sports Med, 1990

22 Shoulder Instability- Anatomynatomy Superior Gleno- humeral Ligament + Coracohumeral Lig restraint to inferior translation and ER w/ arm in adduction Middle Gleno- humeral Ligament limits ER + inferior translation in adduction and ant translation in mid abduction

23 Shoulder Instability - Anatomy Dynamic stabilizers: Rotator cuff Shoulder girdle musculature Biceps tendon

24 Shoulder Instability- Anatomynatomy Others factors affecting stability Congruency of articular surface» concavity-compression compression effect Negative intraarticular pressure» vacuum effect» Warner et al, J Shoulder and Elbow Surg,, 1993 (1cc free fluid) Rotator Cuff

25 Classification of Instability Frequency Acute Recurrent fixed Direction Anterior Posterior Multidirectional Onset Traumatic Atraumatic Overuse Volition Voluntary Involuntary Degree Dislocation Subluxation

26 Shoulder Instability TUBS Traumatic Unidirectional Bankart lesion Surgery AMBRI Atraumatic Multidirectional Bilateral Rehab If f surgery, then Inferior capsular shift

27 Diagnosis of instability Torn loose Instability in position of injury Painless except in position of injury PE: apprehension, decreased resistance to load and shift X-ray: Hill-Sachs, glenoid lip lesion Suggests ligament avulsion

28 Diagnosis of instability Born loose Instability in multiple positions Painful in mid positions Diminished resistance to load and shift X-ray: no bony lesion Suggests that glenoid is flattened

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30 Anterior Shoulder Instability Pathophysiology Bankart Lesion first described by A. Blundell Bankart in 1920 s, JBJS(Br) avulsion of the anteroinferior glenohumeral ligament-labral labral complex from the anterior glenoid rim and scapular neck present in about 85% of cases

31 The Bankart Lesion

32 Anterior Shoulder Instability Speer et al, JBJS, 1994 Simulated Bankart lesion in cadaveric model Applied a 50-N N ant load at various shoulder positions Max translation of 2.3mm at 0 degrees abd the Bankart lesion alone is unable to account for ant shoulder dislocation» capsular stretch or ligamentous insufficiency is necessary for complete dislocation

33 Anterior Shoulder Instability Hintermann and Gachter,, Am J Sports Med, 1995 arthroscopically assessed 212 shoulders w/ >1 dislocation 55% had glenohumeral ligament insufficiency or stretching Capsular Laxity stretch injury to the capsule during dislocation may be plastically deformed

34 Anterior Shoulder Instability The Standard: Open Bankart repair with Capsulorrhaphy 3% recurrence rate Rockwood, in Fractures in Adults, 1984 Review of the literature on 2,300 pts

35 Anterior Shoulder Instability Open Procedures Bankart Putti-Platt Platt Mag-Stack Bristow description subscap advancement subscap-- --> Gr tub coracoid-- -->inf glenoid problem gold standard limits ER limits ER nonunion, migration, recurrence

36

37 Arthroscopic Stabilization Staples Transglenoid sutures Biodegradable tacks Suture anchors

38 Arthroscopic Staple Repair- Results Redislocation Hawkins 10% 3% Matthews 8.3% - Johnson 15% - Morgan 5.2% - Sweeney 10% - Coughlin 17% 9% Wilson 27% - Resubluxation

39 Shoulder Instability Problems with staple repair broken and migrated staples» 10% reoperation rate to remove staples articular injury high rate of recurrence

40 Arthroscopic Transglenoid Suture Capsulorraphy

41 Arthroscopic Transglenoid Suture Capsulorraphy Arciero,, Am J Sports Med, 1994 Prospective, nonrandomized 36 athletes w/ acute ant. shoulder disloc. Nonoperative (Gr I) vs Arthroscopic repair (Gr( II) using transglenoid suturing Group I: 80% recurrent instability Group II: 86% no recurrent instability 1 pt required open repair 32 mo f/u

42 Arthroscopic Stabilization using the Bioabsorbable Tack

43 Arthroscopic Stabilization using Bioabsorbable Tack Speer, Warren, et al (JBJS, 1996) 52 pts; ave age 28 traumatic dislocation in 49 pts Bankart lesion present in 50 pts 79% asymptomatic at ave 42 mo post op 21% failed (4 from traumatic injury) 8 pts required open glenoid based capsulorrhaphy

44 Arthroscopic Stabilization using Suture Anchors Koss et al

45 Arthroscopic Stabilization using Suture Anchors Koss et al, Am J Sports Med, 1997 Retrospective rev. 27 pts; ave f/u 40 mo 70% good-excellent results 30% had recurrent ant. instability (7 from repeat traumatic event) Higher success in pts w/ 5 or fewer dislocations before surgical reconstruction

46 Assessment of Failed Arthroscopic Anterior Labral Repairs Mologne et al, Am J Sports Med, pts underwent open stabilization after failed arthroscopic procedure 10 transglenoid sutures 7 bioabsorbable tacks 2 suture anchors 1 arthroscopic screw 25% had reinjured the shoulder ave time to open procedure was 18 mo

47 Arthroscopic stabilization- Advantages reduced postop morbidity decreased hospital stay improved assessment of intraarticular pathology decreased loss of ROM improved cosmesis

48 Multidirectional Instability Bi-directional Anterior inferior Posterior inferior Global (Neer( Neer) Anterior, inferior and posterior

49 Multidirectional Instability Neer and Foster, JBJS, 1980 described anterior inferior capsular shift Reduces capsule volume on three sides Thickens / tensions capsule Altchek and Warren, JBJS, 1990 T-plasty modification of the Bankart procedure for MDI of the ant/inf type Bankart repair and medial capsular shift Jobe,, Am J Sports Med, 1991 subscap split (sparring); capsular shift on glenoid side imbricate sup over inf leaflet- bumper effect

50 Multidirectional Instability Inferior capsular shift from ant approach

51 Multidirectional Instability Duncan and Savoie Arthroscopy, 1993 preliminary report on arthroscopic repair described advancing the inferior capsule superiorly

52 Arthroscopic Capsular Plication for MDI of the Shoulder Wichman and Snyder, Operative Techniques in Sports Medicine, pts w/ >2 yr f/u ave age 26 no documented dislocations preserve ER to w/in 10 degr preop in 92% 79% satisfactory results 3/4 unsatisfactory results were worker s comp

53 Arthroscopic Capsular Plication for MDI of the Shoulder

54 Arthroscopic Capsular Plication for MDI of the Shoulder

55 Capsular Shrinkage: The Laser and Electrothermal Techniques Non-ablative heat Contraction of collagen is time and temp dependent degrees C Pathophysiology increased cross-linking between fibrils changing helical structure thermal denaturization of collagen

56 Electrothermal Shrinkage Increasing common procedure Patients recover quicker; less morbidity Immobilization critical for success! Prevents re-stretch 3 wks ant; 4 wks post; 6 wks - MDI Axillary nerve neuritis

57 Capsular Shrinkage: Electrosurgical Techniques 3 devices commercially available Oratec Mitek Arthrocare: : bipolar effect which limits the depth of heat penetration No clinical or basic science studies published

58 Capsular Shrinkage: Electrosurgical Techniques

59 Capsular Shrinkage: The Laser LACS: Laser assisted capsular shrinkage Ho:YAG (m/c type) Holmium doped crystal rod of Yttrium, Aluminum, and Garnet energy source: Krypton flash lamp Temperature control is difficult many studies show collagen shortening disrupts molecular bond stabilizing triple helix (dec( tensile strength; inc stiffness)

60 Tissue Shrinkage w/ Ho:YAG First clinical series reported 1993/1994 Multicenter study (5 practices) using Versa- Pulse Holmium laser (not peer reviewed) Unidirectional and MDI without Bankart 1 joule, 10hz defocused beam, tangential application w/ a 30 degr probe 6 mo f/u 93% good-excellent, 5% fair, 2% poor Better results in younger, subluxators, nondominant arm

61 Tissue Shrinkage w/ Ho:YAG Schaefer et al, Am J Sports Med, rabbit patellar tendons 300 J/cm2 dose to one tendon contralateral tendon as control harvested tendons at 0 and 8 wks signif shrinkage (6.6% +/- 0wks inc d tendon length at wks dec d tendon 8 wks fibroblastic response w/ inc d cellularity

62 Tissue Shrinkage w/ Ho:YAG