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Shoulder instability (anatomy,types, management )

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Shoulder instability (anatomy,types, management )

  1. 1. DR Harpreet Singh Bhatia DMCH,Ludhiana,Punjab
  2. 2. DEFINITION: Instability: • Inability to maintain the humeral head in the glenoid fossa. • Includes a spectrum of disorders Dislocation Complete loss of glenohumeral articulation Subluxation Partial loss of glenohumeral articulation with symptoms Laxity Incomplete loss of glenohumeral articulation unassociated with pain
  3. 3. STABILITY Static Factors  Articular Congruence  Articular Version  Glenoid Labrum  Capsule and Ligament Dynamic Factors  Rotator Cuff  Biceps Tendon  Scapulothoracic Motion  Negative Pressure  Propioception
  4. 4. OSTEOLOGY  Glenoid fossa  Pear shaped  7 deg. of retroversion  5 deg. of sup tilt  Glenoid version  30o anterior  Humerus  Neck-shaft – 130o to 140o  Retrotorsion – 30o
  5. 5. Normal glenoid is about 7 degrees retroverted If the retroversion is excessive, it leads to posterior instability of shoulder STATIC FACTORS
  6. 6. GLENOHUMERAL JOINT  Humeral head 3x larger than glenoid fossa  Ball and socket with translation  3 degrees of freedom  Flex/Ext  Abd/Add  Int/Ext rot  Plus Cricumduction
  7. 7. GLENOID LABRUM  Static stabilizer  contributes 20% to GH stability  Fibro cartilaginous tissue  Deepens glenoid(50%)  3purposes:  Inc. surface contact area  Buttress  Attachment site for GH ligaments
  8. 8. The labrum increases the superoinferior diameter of the glenoid by 75% and the anteroposterior (AP) diameter by 50%
  9. 9. CAPSULE AND LIGAMENTS Capsule  Attached medially glenoid fossa  laterally to anatomical neck of humerus  Ant cap thicker than post.  2-3 mm of distraction  Little contribution to joint stability  Strengthened by GHLs and RC tendons
  10. 10. LIGAMENTS
  11. 11. GLENOHUMERAL LIGAMENTS (Superior, Middle , Inferior) SGHL  O = tubercle on glenoid just post to long head biceps  I = upper end of lesser tubercle  Resists inf. subluxation and contributes to stability in post and inf. directions
  12. 12. MGHL  O= sup glenoid and labrum  I = blends with subscapularis tendon  Limits ant. instability especially in 45 deg abduction position  Limits ext rotation
  13. 13. IGHL  O= ant. glenoid rim and labrum  I= inf. aspect of humeral articular surface and anatomic neck  3 bands, anterior, axillary and posterior  Acts like a sling ,the most important single ligamentous stabilizer .  Primary restraint is at 45-90 deg abduction.
  14. 14. Coracoacromial ligament  secondary stabilizer. Coracohumeral ligament  Contribute to restraining inferior subluxation with arm at side,
  15. 15. Dynamic Factors  Rotator Cuff  Biceps Tendon  Negative Pressure  Scapulothoracic motion  Proprioception
  16. 16. ROTATOR CUFF  Compression enhances conformity  Greater than static stabilizers  Coordinated contractions/steering effect  Supraspinatus most important  Dynamization
  17. 17. Biceps long head, Deltoid  secondary stabilizer head depressor Periscapular Muscles  help position scapula and orient glenohumeral joint contributes compressive force across joint
  18. 18. SCAPULOTHORACIC MOTION  2:1 glenohumeral to scapulothoracic motion  Scapulothoracic muscle (trapezius, serratus anterior, teres major, levator scapulae)  less stable platform
  19. 19. NEGATIVE INTRA-ARTICULAR PRESSURE  -42 cm H2O in cadaver  Secondary to high osmotic pressure in interstitial tissues  Only clinically important in the arm at rest in adduction  Lost with lax capsule or defect
  20. 20. INSTABILITY Classification:  Frequency  Cause  Direction  Degree
  21. 21. Classification of instability
  22. 22. SPECTRUM Traumatic Microtrauma Atraumatic Less laxity More laxity Unidirectional Multidirectional
  23. 23. PATHOANATOMY OF SHOULDER INSTABILITY Laberal Lesions  – Bankart  – Reverse Bankart  – SLAP lesions Capsular Injury  – Intrasubstance Tear  – HAGL  – Capsular Laxity Bone Loss  – Glenoid  – Humeral Head-Hill-Sachs Lesion
  24. 24. BANKART LESION.  The traumatic detachment of the glenoid labrum has been called the Bankart lesion. 85%
  25. 25. BANKART LESION-labral tear at anterior half of glenoid rim
  26. 26. Reverse Bankart lesion
  27. 27. Anchor used for repair
  28. 28. HILL-SACHS LESION This is a defect in the posterolateral aspect of the humeral head.
  29. 29. Hill Sach Lesion
  30. 30. EVALUATION OF INSTABILITY History  Age  Trauma-Duration  Associated Pain  Sports, throwing or overhead activities  Voluntary subluxation  “Clunk” or knock  Fear-Limitation of Movements  Hx dislocationsand energy associated  Hx 1st dislocation or injury  Subsequent dislocations/ subluxations
  31. 31. Physical Examination  Inspection  Palpation  ROM  Winging  Neurovascular testing  Generalized ligamentous laxity  Instability tests
  32. 32.  Sulcus sign  Drawer tests  Load & Shift test
  33. 33.  Apprehension test  Jobe’s Relocation  Jerk test  Fulcrum Grade = 1 - 4
  34. 34. DIAGNOSIS  X-rays  CT Scan  MRI  Arthroscopy
  35. 35. RADIOLOGY  X-Rays  Identify Bankart or Hill-Sachs Lesion
  36. 36. AP VIEW
  37. 37. Normal Shoulder AP view
  38. 38. Axillary View
  39. 39. Scapular Y-View
  40. 40. Stryker view Humeral Head Defect
  41. 41. Apical Oblique view Glenoid rim lesion
  42. 42. West Point Axillary view Anteroinferior glenoid rim
  43. 43. ANTERIOR DISLOCATION 97% of recurrent dislocation  abduction, extension and external rotation  subcoracoid  subglenoid  subclavicular Associated Injuries: Fractures  Head & Neck Rotator Cuff Tears  > 40 y/o = 30 %  > 60 y/o = 80%
  44. 44. Neurologic Injury  Axillary nerve  10-25% incidence 1st time.  2-5% in recurrent dislocators  Tx: “watchful expectancy”  Poor prognosis if no recovery by 10 wks Vascular Injury  Axillary artery  2nd part thoracoacromial trunk
  45. 45. POSTERIOR DISLOCATION  Incidence: < 5% all shoulder dislocations  Axial load  Flexed/Adduction  Bench press-“lock out”  Swimming- pull thru  Rowing  Football Offensive Lineman
  46. 46. Examination  Shift & load test  Post. Apprehension test  Jerk test  Kim test Imaging studies  X-ray  CT  MRI
  47. 47. TREATMENT Non Operative  Immobilization  Protection  Rehabilitation  70-90% improve  Functional disability improved  Instability not eliminated
  48. 48. Operative Management  Overall 50-95 % success  Higher recurrence vs ant. instability procedures Soft Tissue Procedures  Posterior Capsulorrhaphy  Reverse Putti-Platt (IS Capsular Tenodesis)  McLaughlin Bone Procedures  Posterior Glenoid Osteotomy  Posterior Bone Block
  49. 49. MATSEN'S CLASSIFICATION TUBS:  Traumatic  Unidirectional  Bankart lesion  Surgery is often necessary. AMBRI:  Atraumatic  Multidirectional  Bilateral  Rehabilitation is the primary mode of treatment.  Inferior capsular shift & internal closure often performed.
  50. 50. OPERATIVE TREATMENT: Capsulolabral Repair  Bankart  Modified Bankart Subscapularis Procedures  Putti-Platt  Magnuson-Stack Coracoid Transfer Procedures  Bristow  Latarjet
  51. 51. TREATMENT OPTIONS TYPE OF INSTABILITY PREFERRED SURGERY Traumatic anterior, with Bankart Lesion Open / arthroscopic Bankart repair Traumatic anterior , with no labral lesion, just capsular laxity Open / arthroscopic capsular imbrication AMBRI lesions Lateral capsular shift( modified Neer and Foster ) with closure of rotator interval Recurrent posterior dislocation in association with a reverse Hill-Sachs lesion modified McLaughlin procedure Head defect > 30 – 45 % > 45 % Acute disimpaction / Weber osteotomy Prosthetic replacement Glenoid defect Bristow – Latarjet coracoid transfer Structural bone graft
  52. 52. Procedures Procedure Description Results Neer’s Capsulorrraphy Posterior capsular tightening Generally unsatisfactory, upto 50 % recurrence Staple capsulorraphy Tightening done with staples Small study group Tieborne and bradley procedure Capsular Imbrication with a horizontal T approach Upto 20 % recurrence Hawkins and Janda procedure Subscapularis advancement and shortening 0 – 5 % recurrence Rockwood Glenloid Plasty with Biceps Tenodesis to the posterior capsule Combined bony and soft tissue procedure Not often done
  53. 53. OPEN BONY PROCEDURES FOR ANTERIOR INSTABILITY Bristow procedure Latarjet procedure
  54. 54. Helfet first described the Bristow procedure in 1958 and named it after his late mentor . In the Bristow procedure and its variants, the coracoid process is transferred through the subscapularis tendon as a method of treating recurrent anterior instability of the shoulder. 1) The coracoid tip is transferred to the anteroinferior glenoid neck and likely serves as a bone block in front of the humeral head. The transferred short head of the biceps and coracobrachialis are placed so as to produce a strong dynamic buttress across the anterior and inferior aspects of the joint when the shoulder is in the vulnerable abducted and externally rotated position. The transfer was held in place by sutures through the conjoined tendon and subscapularis. 2) Latarjet described a similar procedure in 1954, in which he transferred the tip of the coracoid along with the conjoined tendon through a horizontal slit in the subscapularis and fixed it with a screw
  55. 55. The procedure involves transfer of the coracoid with it's attached muscles to the deficient area over the front of the glenoid. This replaces the missing bone and the transferred muscle also acts as an additional muscular strut preventing further dislocations. The procedure has a high success rate (recurrence rate of less than 1%4) and this is due to the ‘triple effect’ described by Patte. These are: 1) Increase or restore the glenoid contact surface area; 2) The conjoint tendon stabilises the joint when the arm is abducted and externally rotated, by reinforcing the inferior subscapularis and anteroinferior capsule 3) Repair of the capsule. This triple effect is why the Latarjet is such a successful procedure.
  56. 56. Latarjet procedure
  57. 57. AMBRI Lesions-Idea of management  Primary treatment nonoperative  Operative management recommended for patients who have continued pain or disability despite an adequate rehabilitation  The gold standard is open stabilization
  58. 58. Capsular shift( modified Neer and Foster )
  59. 59. OPEN ANTERIOR PROCEDURES FOR POSTERIOR INSTABILITY  McLaughlin procedure  Neers modification of McLaughlin procedure
  60. 60. McLaughlin technique  subscapularis
  61. 61. Neer’s modification
  62. 62. Putty Platt Operation Surgical procedure for stabilizing the glenohumeral joint after recurrent anterior shoulder dislocations. The subscapularis tendon is detached near its insertion on the humerus, the joint opened, and the stump of the tendon on the lesser tuberosity is sutured to the glenoid labrum. Sometimes the procedure is combined with reattachment of the glenoid labrum. Technically an easy procedure Disadvantages: The Putti-Platt procedure is not to be performed on throwers because it can reduce the range of movement in the shoulder. 30 – 35 % incidence of late OA
  63. 63. Magnuson Stack procedure
  64. 64. ADVANTAGES AND DISADVANTAGES OF ARTHROSCOPIC STABILIZATION  ADVANTAGES DISADVANTAGES -Improved cosmesis -Technically demanding -Shorter operative time -Difficult in revision case -Short hospital stay -Difficult in altered anatomy -Decreased morbidity -Cannot address bony defect -Decreased complication -Lower cost
  65. 65. PHASES OF REHABILITATION  Phase I Rest and immobilization. Pain control with nonsteroidal anti-inflammatory drugs and ice applied to the shoulder  Phase II Isometric strengthening Isotonic strengthening. Begin exercises with shoulder in adducted, forward- flexed position, progressing to abducted position  Phase III Endurance building along with strengthening exercises. Goal: the patient reaches 90% strength in the injured shoulder compared with the uninjured shoulder  Phase IV Increase activity to sport- or job-specific activities
  66. 66. THANKS

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