Goals Traumatic, Locked, Anterior Shoulder Dislocation Define - PDF document

Shoulder Instability: Many Types Must be clear always what we are Traumatic Shoulder Instability: referring to… Treatment Options for • Atraumatic Instability • Traumatic instability � Subluxations � Locked dislocation Physicians � Ligamentously lax � Requires patient reduction Julie Y Bishop, MD � Typically no � Structural damage Assistant Professor structural lesion � Surgery common � Multidirectional OSU Department of Orthopaedics � Unidirectional � Surgery rare September 25, 2009 • Anterior • Posterior Most Common: Goals Traumatic, Locked, Anterior Shoulder Dislocation • Define traumatic anterior shoulder instability • Common problem that is sports specific • Review the pathology involved with instability � Football • Review the pathology of recurrent instability � Basketball • Review the long-term outcomes of instability � Hockey • Discuss treatment options based on patient demographics � Wrestling • Traumatic fall 20% of shoulder injuries 1

Recurrence vs. Age The Concern for our Natural History Patients Author P ublis hed Age R ecurrence Recurrent Instability M cLaughlin (1950) 1950 <20 90% <40 60% >40 10% R ow e 1980 <20 94% Simonet/C ofield 1984 <30 82% Arciero 1994 <20 80% More Recent Studies Confirm These Results Pathology of an Recurrent Instability Anterior Dislocation Predictors • Bankart lesion • Age � Ant/inf labrum Torn � <20 • Hill-Sachs lesion • Gender � Impaction of Humeral � Male head • Activity level • Capsular deformation � Contact sports � Capsule stretches 4-7% Robinson, et al. JBJS, 2006 Prognostic Level I Evidence 2

Humeral Pathology Labrum Initial Dislocation • Hill-Sachs � 90% Arciero 1997 � 100% Kirkley 1999 Defect on � 56% Larrain 2001 glenoid Humeral Increase contact surface area Anchor for Capsule/Ligaments Head Bankart: Capsulolabral Avulsion Recurrent Dislocations Initial Dislocation Author P ublis hed B ankart • The more dislocations, the worse the Baker 1990 87% pathology N orlin 1993 100% � Increase ligament/labral damage West Point 2001 97% � More capsular stretch � Increased Hill-Sachs lesions HH � Glenoid bone loss – erodes glenoid labrum � Cartilage damage glenoid Larrain, et al. Arthroscopy, 2006 Burkhart and De Beer, Arthroscopy, 2000 Cetik, et al. Acta Orthop Belg, 2007 Boileau, et al. JBJS, 2006. 3

Ramifications? Glenoid Bone Loss Short Term Long Term • Easier to dislocate • Higher risk for arthritis • Fail arthroscopy • More severe arthritis • Require open surgery Anterior • Seen at earlier age Posterior • Bone grafting • Uncertain outcomes Cartilage Damage Glenoid Bone Loss Glenoid bone loss Nl glenoid 4

What if They Fail Treatment Options Conservative Tx? • Patient Age > 40 @ 1 st dislocation • c/o Recurrent anterior dislocation – � Check x-rays: make sure no fractures � Halt contact sports � Sling for comfort (typically 1-2 weeks) � MRI/gadolineum � Check rotator cuff exam! � Refer for surgical evaluation � Start physical therapy soon • c/o Subluxations – � Determine if it c/o is true instability • Higher risk for post-dislocation stiffness � MRI � When do they occur – Sports versus ADL’s � Progress all activities to tolerance � May be willing to give up sport – but need to shower! PE Findings with Treatment Options Anterior Instability • Patient Age > 20 yo; <40 yo • Many of the exam techniques are difficult � Follow same principles just outlined • Often the patient is guarding during exam � Unlikely to have any rotator cuff pathology • Apprehension test very reliable: � Sedentary lifestyle – unlikely to recur � Athletes: • return to sports when full motion/strength and no pain � Counsel patients accordingly: • Age – closer to 20? • Gender – male higher risk • Activity level – contact sports/martial arts/etc POSTERIOR PRESSURE: ABD/ER: FEAR • MORE LIKELY TO HAVE A RECURRENT RELIEVES FEAR DISLOCATION 5

Treatment Options Evaluation and Treatment of Rotator • Age < 20 yo @ 1 st dislocation � High chance of recurrence Cuff Tears � Still controversial � Rehab/finish season • Surgery if sustain a recurrence Grant L. Jones, M.D. • Surgery at end of season Associate Professor � OR: Stop season – proceed with surgery Department of Orthopaedic Surgery The Ohio State University � Surgery? • Confirm pathology with an MRI Should the Bankart Rotator Cuff Tendons Lesion be Viewed as the ACL of the Shoulder?? • Supraspinatus • Infraspinatus • Teres minor • Subscapularis 6

Supraspinatus Infraspinatus Etiology of Rotator Ant Ant Cuff Tears Subscapularis Teres Minor Lateral View Function of the Intrinsic Factors Rotator Cuff • Degenerative or tendinosis problem, rather than true tendinitis • Maintenance of humeral head position in the glenoid � Compresses humeral head into fossa, stabilizing • Vascular factors against superior migration and providing stable � Watershed or critical zone 1 cm medial to fulcrum against which rotational forces can be applied. insertion of supraspinatus tendon • Rotational power of the shoulder � Differential vascularity between • Anterior and posterior aspects of bursal and articular surfaces the cuff work in concert • 5 layer structure predisposes to • Loss of one or the other creates internal shear forces resulting in translation movement and reduces intra-substance tears the effect of compression 7

Extrinsic (Impingement) History Factors • Age- tears more common in older patients • Acromial morphology • Trauma- dislocation in patients over 35, high incidence of rotator cuff tear • Anterior acromial • Overhead activities cause pain enthesophytes • Night Pain • Unstable os acromiale • Pain over deltoid/ lateral shoulder • Degenerative acromioclavicular joint • Weakness/ loss of endurance • Internal impingement in overhead athletes • Crepitation Physical Examination • Inspection- atrophy, asymmetry, deformity (long head biceps rupture) • Palpation- AC joint, bicipital groove, greater Evaluation of Rotator tuberosity, crepitation • Active and passive range of motion Cuff Disorders • Strength testing • Neck exam- Spurling’s maneuver 8

Plain Radiographs Impingement Examination • Hawkins’ sign • Neer impingement sign/test MRI Imaging • Plain radiographs- AP, low-voltage AP joint view, outlet view, axillary view, internal rotation AP • Arthrogram • Ultrasound • MRI • MR Arthrogram- assess for labral tears or integrity of rotator cuff repair 9

Rotator Cuff Tears in Non-Surgical Management Asymptomatic Patients • PT to develop stabilizing rotator cuff force couple, strengthen scapular stabilizers, and stretch tight areas of the joint capsule • Prevalence of rotator cuff tears is extremely high • NSAID’s • MRI of asymptomatic volunteers • Corticosteroid injections ? demonstrates partial or complete tears in 54% of people > 60 y.o. � Wei et al, JBJS- rat study; (Sher et al, 1995) single dose of steroid may not have long term effects • Ultrasound of asymptomatic subjects detected a prevalence on collagen gene expression, of rotator cuff tears in 40% of but collagen composition subjects > 50 y.o. may be acutely by an injection • Rotator cuff disease is found commonly in asymptomatic people Success of Non-Operative Treatment Multi-Center Orthopaedic Outcomes Network (MOON) Group (2009) • 327 patients enrolled with chronic full-thickness rotator cuff tears Treatment • 3 months (including surgery or cured at 6 weeks) � 49/214 (22.89%) • 1 year � 10/162 (6%) went to surgery • 2 years � 0/28 have gone on to surgery • A trial of rehabilitation may be indicated prior to proceeding with surgery in those patients with chronic full-thickness rotator cuff tears. 10

Surgical Indications Repair Techniques • Surgery indicated if acute trauma associated with significant weakness of the • Open shoulder and posterior cuff involvement (infraspinatus, teres minor) or • Mini-open- combination of open and subscapularis involvement as seen with an arthroscopic surgery anterior shoulder dislocation • Young patients with higher functional • All arthroscopic demands • Failure of 3-6 months of conservative management Prognostic Factors for Success Mini-Open Rotator Cuff Repair of Rotator Cuff Repair • A number of retrospective studies have identified features associated with poor outcome after surgical management: • Duration of symptoms • Fatty infiltration of the atrophied muscle • Larger rotator cuff tears • Age of the patient • Worker’s Compensation claims • Limited pre-operative ROM • Multiple comorbitities 11