Transcript Shoulder Instability

Shoulder Instability
Department of Orthopaedics, CKUH
Sen-Jen Lee
Reference: Orthopaedic Knowledge Update 6
Natural History

The most common sequela of traumatic anterior shoulder
instability is recurrence
 90% for those 11 to 20 years of age
 Averaging between 55% and 66%
 87% recurrent instability after nonsurgical treatment

In the skeletally immature individual
 Bankart lesion (labral detachment of the inferior glenohumeral ligament
complex, IGHLC)
 Length of immobilization, avoidance of overhead activity, and
supervised physical therapy had no effect on outcome

Patients over 40 years of age
 Neurologic injury and rotator cuff tears
Biomechanics Static Stabilizers
Articular curvature between the glenoid and
humeral head
 Superior glenohumeral ligament (SGHL) and
coracohumeral ligament (CHL)

 To resist inferior translation

Middle glenohumeral ligament (MGHL)
 To limit anterior translation

IGHLC
 Primary restraint to anterior and posterior translation
 Secondary restraint to inferior translation
Biomechanics Dynamic Stabilizers

Rotator cuff muscles
 Center the humeral head on the glenoid
 Maintain joint stability

The capsuloligamentous structures
(proprioception) provide afferent feedback for
reflexive muscular control of the rotator cuff
and biceps
Patient Evaluation
History
 Physical examination

 Specific provocative tests
 Apprehension/relocation test and sulcus sign test

Imaging





Scapula (AP and lateral [y-view])
Axillary view
West point axillary view
CT arthrogram or MRI
Examination under anesthesia and arthroscopy
Apprehension test
Relocation test
Load shift test
Sulcus sign
True anteroposterior view
West Point view (axillary)
Computed tomography scan of
glenohumeral joint with significant
anterior bone loss and presence of
Hill-Sachs lesion.
Magnetic resonance image with
arthrogram of large Bankart lesion.
Arthroscopic Findings of Patients With
Instability
Bankart lesions: 87%
 Capsular insufficiency :79%
 Hill-Sachs lesions: 68%

 (posterosuperior humeral head impression fracture )

Glenohumeral ligament insufficiency: 55%
Clasification of Anterior Instability

Direction





Anterior
Posterior
Inferior
Multidirectional

 Subluxation
 Dislocation

Frequency
 Acute
 Recurrent
Cause
 Traumatic
 Acute
 Repetitive
 Nontraumatic
Degree

Patient control
 Voluntary
 Involuntary
Matsen’s Classification of Anterior
Instability

TUBS




Traumatic
Unidirectional
Bankar lesion
Surgery

AMBRI





Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
Redislocation Rates After Initial
Dislocation (< 35 Y/O)
Investigators
Patients (%)
No. of patients
Age (years)
Rowe
94
53
< 20
Mclaughlin
95
181
< 20
Simonet
66
32
< 20
Henry
88
121
< 32
Hovelius
64
102
< 22
Wheeler
92
38
Marans
100
21
Causes of Anterior Shoulder Instability

Bankart lesion
 Avulsion of the anteroinferior capsulolabral complex

Hill-Sachs lesion
 Compression fracture of the posterosuperior humeral head

SLAP lesion
 Superior labrum anterior posterior

HAGL lesion
 Humeral avulsion of glenohumeral ligaments

ALPSA lesion
 Ant. labroligamentous periosteal sleeve avulsion

Laxity of the joint capsule
Treatment of Anterior Glenohumeral
Instability
 Nonsurgical
treatment:
 Closed reduction
 Immobilization (3 to 6 weeks) rehabilitation
 Rate of recurrence : (less than 20 years old)
 60%
to 90%
Treatment of Anterior Glenohumeral
Instability
 Arthroscopic
Bankart repair versus
nonoperative treatment for acute, initial
anterior shoulder dislocations.
 14 % versus 80% recurrent instability
Arciero RA, wheeler JH, Ryan JB, et al: am J sports med 1994;22:589-594.
Treatment of Anterior Glenohumeral
Instability
 Inferior
capsular shift procedure for
anterior-inferior shoulder instability in
athletes.
 Satisfactory results: 94%
 Returned to sports: 92% (75% at the same level).
 The rate of recurrence: 3%.
Bigliani LU, Kurzweil PR, Schwartzbach CC, et al: am JSports med
1994;22:578-584.
Treatment of Anterior Glenohumeral
Instability
 Arthroscopic
Bankart suture repair.
 Recurrent instability: 44%
 The authors recommend: caution in the
use of arthroscopic stabilization for the
competitive athlete.
Grana WA, Buckley PD, Yates CK: am J sports med 1993;21:348-353.
Treatment of Anterior Glenohumeral
Instability

Arthroscopic versus open
Bankart procedures: A
comparison of early
morbidity and
complications.
Green MR, Christensen KP:
arthroscopy1993;9:371-374.

Reduction in
 Surgical time
 Blood loss
 Postoperative narcotic
use
 Postoperative fevers
 Duration of
hospitalization
 Work days missed
Treatment of Anterior Glenohumeral
Instability
 Treatment
of instability of the shoulder
with an exercise program.
 Response to treatment:
Atraumatic
versus traumatic instability:
80% versus 15%
Burkhead WZ Jr, Rockwood CA Jr: J bone joint Surg 1992;74a:890-896.
Selective capsular tightening. A, The
inferior capsule is tightened with the
arm in 10° flexion, 60° abduction, and
45° to 60° external rotation. B, The
superior capsule is tightened with the
arm in 0° abduction and 45° external
rotation.
Treatment of Posterior Instability


Nonsurgical treatment with exercise program. (First
choice)
Surgical treatment
 Provide bony stability:
 Posterior bone block, opening wedge osteotomy of the
posterior glenoid (glenoplasty), and rotational osteotomy of
the humerus
 Soft-tissue repairs:
 Posterior labral repair, a posterior capsular plication, and
posterior capsulorrhaphy.
Instability in Throwing Athletes

Anterior instability
 During the late cocking phase
 Posterior capsular tightness, pain, or impingement signs

Posterior instability
 During the follow-through phase.

"Dead arm" syndrome
 Transient neurological symptoms
Acromioclavicular Instability

Mechanism
 Impact directly at the lateral edge of the acromion

Classification (Rockwood)
 Type I: a sprain of the AC joint
 Type II: partial rupture of the AC ligaments and the coracoclavicular
ligaments with subluxation of the AC joint
 Type III: dislocation of the AC joint with complete disruption of the
coracoclavicular and AC ligaments
 Type IV: dislocation of the AC joint with posterior displacement of the
clavicle into or through the trapezius muscle
 Type V: dislocation of the AC joint with marked superior displacement
of the clavicle greater than twice the normal coracoclavicular distance
 Type VI: inferior dislocation of the AC joint with subcoracoid
displacement of the clavicle
Rockwood classification of ligamentous
injuries to the acromioclavicular joint.
Treatment A-C Instability

Types I and II: nonsurgical
 Sling for 2 weeks
 Good results in over 90% of cases

Type III: controversial
 Surgical treatment for acute injuries in laborers or high
demand overhead athletes, and for chronic injuries in
which initial nonsurgical treatment fails

Types IV, V, and VI : surgical management
 AC fixation with pins or plates and coracoclavicular
fixation with nonabsorbable suture or metallic screws
Chronic symptomatic A-C instability: The modified
Weaver-Dunn procedure. (C-C fixation + transfer of the CA ligament to the distal clavicle)