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1、Acute anterior dislocation of the shoulder,Anatomy Stability: - ball & socket = compression in concavity effect Bone - big head small cup = unstable Menisci - labium = depth of cup by 20% Ligaments - glenohumeral & capsule Muscles - rotator cuff & biceps = holds ball in cup Primary Movers - Deltoid,
2、 Pec. major & Lat. Dorsy = subluxing forces Dynamic - proprioceptive feedback,Pathophysiology (Lazarus 1996) Chondro-labral defect causes a 65% reduction in stability in the direction of the defect Deficiency of the ant. inf. capsulolabral complex Fracture of ant. lip of glenoid = 15% Detachment of
3、labarum/capsule = 15% Tear of glenohumeral ligaments = 54% Avulsion of subscapularis and ligs of humerus (HAGL) To prevent the persistence of the defect it needs to be repaired Arthroscopically Open,Acute Injury Something breaks or tears and therefore can be repaired. Repair is better than reconstru
4、ct Repair is easier than reconstruct Chronic Instability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortened Restoring the normal functional anatomy is impossible,Conservative Treatment Rowe JBJS, 1957 324 young patient with ant. dislocations
5、94% had recurrence if 40 years old Burkhead & Rockwood (text book) 40 patients with acute dislocation & vigorous rehabilitation Only 16% had good or excellent result (1 in 6) Deny & Drew Injury, November 2002 21% of all patients presenting with shoulder dislocation had previous dislocation in 1 year
6、 43% in patients 15-22 years had re-dislocations,Non operative treatment of shoulder dislocation in young athletes Arciera J Arthroscopy, 1995 De Beardino J South Orthopaedic Ass, 1996 Haelen J Arch Orthopaedic Trauma Surgery, 1990 Hovelius J Orthopaedic Science, 1999 Wheeler J Arthroscopy, 1998 Kir
7、kby J Arthroscopy, 1999 all over 80% recurrence rate Non operative treatment is unacceptable,Prospective Randomised Study Bottani etc.Military Personnel Medicine Vol 30 No 4 2000 First Time Acute Traumatic Shoulder Dislocation Stabilisation Vs Non Operative: Follow up in 36 months 24 patients aged 1
8、8-26y. 14 Non Operative rehab immobilised 4 weeks 9 of 12 non operative had instability (75%) (6 open Bankart repair) 10 ASC Bankart repair with bioabsorbable tack 10 days 1 of 9 operated patients had instability (11%),Comparison of Arthroscopic & Open Stabilisation Sample Size Follow Up Recurrence
9、ASC Open ASC Open ASC Open Steinbeck 1998 30 32 36 40 17 5 Field 1999 50 50 33 30 8 0 Cole 1999 37 22 52 55 16 9 Hayes etc 1999 44 13 29 29 12 4 Conclusion Arthroscopic repair for chronic instability is inferior to open repair ? Due to plastic deformation,Chronic anterior instability,Arthroscopic Te
10、chniques for Primary Dislocations 1982 Johusa with staples 1987 Morgen & Badenstab transglenoid sutures 1991 Caspari -Cannulated bio-absorbable tacks 1993 Wolf & Snyder suture anchors = difficult 1989 Wheller - ASC staple 1993 Gohlke - Suture anchors 1994 Arciera - ASC transglenoid 1996 Speer - Bio-
11、absorbable tack 1999 Wintzell - ASC lavage 2000 Introduction of a multitude of new gadgets & anchors,Arthroscopic Repairs Einoder, 1984 Knee Club Described Arthroscopic transglenoid sutures using: K wire with eye (ACL) introduced via anterior portal Sucking tube Sutures tied over infraspinatus fasci
12、a or spine of scapula Results 4 out 5 patients returned to the same level of sport with no re-dislocations,Arthroscopic Repair,Boszotta & Helperstorfer Arthroscopy, July 2000 Transglenoid suture repair for initial Ant. dislocation 72 patients (1988-95) 61 11 Aged 19-39 34% = Bankart lesion (6 with b
13、one) 66% = Avulsion of capsulolabral complex Results 7% = Redislocation all due to trauma (severe in 2 out of 5) 85% = Returned to unrestricted pre injury sporting activities,Randomised Studies Asc. Stabilisation Vs Non Operative Arciera et. al. A.J. Sports Med., 1994 32 military men with acute 1st
14、up dislocation, Average of 32 months follow up 15 patients non operative 80% redislocated 21 patients transglenoid suture 14% redislocated Bottony & Wilkings etc. A.J. Sports Medicine 2000 Patients with acute traumatic first time shoulder dislocation 14 young patients non op, 75% redislocation 10 yo
15、ung patients Asc. Bankart repair, 10% redislocation,Asc. stabilisation Dara & Gerber Journal of Shoulder & Elbow, 2000 20 shoulders Av 3 year follow up Recurrences occurred in patients who were chronic dislocators i.e. 30% Therefore now do open surgery for recurrent dislocations Asc. surgery for acu
16、te dislocations De Beardino et al An J. Sports Med., 2000 49 1st up acute post traumatic Shoulders dislocation Average 37 months follow up Tack anchor. 6 Patients re-dislocated (13%) +4 had open surgery,Bozzotta & Helpastorger (Austria) J. Arthroscopy, 2000 Arthroscopic Transglenoid Suture Repair for Initial Ant. Shoulder Dislocation 72 Patients 61 11 - Sporting ambitious patients 25 Patients Bankar
