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Posterior gleno-humeral-instability

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Posterior gleno-humeral-instability

  2. 2. INTRODUCTION<br />2-12% of all shoulder instability<br />Isolation / MDI<br />Symptoms are usually mild and can be overlooked<br />Athletes<br />
  3. 3. ETIOLOGY<br />Congenital<br /> - Ligamentous laxity<br /> - Scapulohumeral anatomy<br />Acquired<br /> - Athletes<br /> - Repetitive stress to the posterior capsule resulting in laxity<br /> Traumatic<br /> - Fall or blow to arm in “at risk” position <br /> (forward flexion, abduction and internal rotation)<br /> <br />
  4. 4. ASSOCIATED ATHLETIC ACTIVITIES<br />ACTIVITY MOTION<br />Weightlifting Bench press, push-ups<br />Pitching Follow-through phase<br />Swimming Butterfly and freestyle<br />Racquet sports Backhand stokes<br />Golf Motions of lead arm<br />Gymnastics Parallel bars, rings<br />Boxing Axial load with punching<br />
  5. 5. CLASSIFICATION<br />Voluntary /Involuntary <br />Habitual Instability<br />Results from underlying neuromuscular imbalance<br />Underlying psychiatric problems common<br />Often refractory to surgery<br />Positional Dislocator<br />Demonstrate instability by placing the arm in a position of risk<br />Usually do not have psychiatric illness or secondary gain<br />Ordinary avoid provocative manoeuvres<br />Physiotherapy still first-line treatment but surgery gives good results<br />
  6. 6. CLINICAL PRESENTATION<br />Pain rather than instability<br />Usually mild <br />Occur during or after activity<br />Traumatic event may precede onset of symptoms<br />Rarely is there a history of frank posterior dislocation<br />Slip, pop or click out and in<br />
  7. 7. EXAMINATION - 1<br />Posterior joint line tenderness <br />ROM - Normal<br />Rotator cuff strength - Normal<br />Scapular winging <br />secondary to scapula muscle dysfunction<br />Ligamentous laxity?<br />Examine unaffected shoulder<br />
  8. 8. EXAMINATION - 2<br />Load and Shift Test (posterior drawer)<br />Examiner grasps humeral head and pulls directly backward with the shoulder muscles relaxed.<br />Humeral head subluxates posteriorly (<50% normal)<br />Patients reaction to translation more important than amount<br />Posterior Apprehension<br />Uncommon<br />Arm brought into forward flexion and internal rotation with posterior stress applied<br />Sense of instability, pain or painful subluxation is suggestive of the diagnosis<br />
  9. 9. INVESTIGATIONS<br />Shoulder XR<br />AP in ER/IR<br />Lateral<br />Axillary view<br />Dynamic XR with shoulder subluxed<br />CT<br />Arthrogram<br />MRI <br />Labral changes<br />Capsular Damage<br />EUA +/- arthroscopy<br />Doubt regarding direction or extent of instability<br />
  11. 11. SURGERY - 1<br />INDICATIONS<br />Recurrent, symptomatic, unidirectional subluxation that has failed to respond to a comprehensive non-operative program <br />Posterior instability itself is not an indication for surgery<br />2/3 will respond to a proper exercise program<br />No patient who has not had 6/12 of an exercise program should have surgery<br />
  12. 12. SURGERY - 2<br />CONTRA-INDICATIONS<br />Psychiatric disorder<br />Significant degenerative gleno-humeral arthritis<br />Failure to undergo or co-operate in physiotherapy program <br />Ligamentous laxity<br />Multidirectional instability<br />
  13. 13. ARTHROSCOPY<br /> Capsular shift<br />25% recurrence at 2 year follow-up in one study on 20 patients<br /> Capsulo-labral augmentation<br />41 patients in study – 86% improved stability<br />Thermal capsulorrhaphy<br />Thin posterior capsule which is less responsive to shrinkage<br />Complicated by necrosis<br />
  14. 14. SURGICAL PROCEDURES<br />OPEN<br />SOFT TISSUE BONE <br />Posterior capsulorrhaphy Glenoid osteotomy<br />Inferior capsular shift Posterior bone block<br />(anterior/posterior) <br />Infraspinatus advancement<br />Posterior Bankart repair<br />Staple capsulorrphaphy<br />Biceps tendon transfer<br />Subscapularis transfer<br /> <br />ARTHROSCOPIC<br />Posterior Capsulolabral Augmentation<br />Posteroinferior Capsular Shift<br />Thermal Capsulorrhaphy<br />
  15. 15. OPEN TECHNIQUES - 1<br />Soft tissue<br />Soft tissue abnormalities are the predominant cause of posterior instability<br />Posterior capsular shift<br />Anterior/posterior approach<br />Posterior capsule thin 1.5mm<br />Staples fallen out of favour<br />Recent report 13/14 patients were satisfied at 44/12 follow-up<br />Recurrence rate 30% some studies<br />50% high level athletes return to sports<br />
  16. 16. OPEN TECHNIQUES - 2<br />Bone<br />Glenoplasty<br />Glenoid retroversion/hypoplasia <br />Opening wedge osteotomy<br />Cadaveric studies confirm effective change in Glenoid shape and increased stability<br />Recent study 17 patients atraumatic posterior instability at 5 year follow-up<br />81% rated good to excellent<br />12.5% had a recurrence<br />Post-op degenerative changes were seen in 25%<br />Recommended glenoplasty if glenoid retroversion 7-10° radiographically<br />Humeral Osteotomy<br />External rotation osteotomy<br />Indicated if symptoms worsened on internal rotation<br />Few reports in literature<br />
  17. 17. POSTERIOR STABILISATION - 1<br />Lateral decubitus position<br />+/- arthroscopic evaluation – rule out anterior labral injury<br />A 10cm saber cut incision from posterior aspect AC joint to posterior axillary fold<br />
  18. 18. POSTERIOR STABILISATION - 2<br />Deltoid split in line with its fibres from scapular spine 5cm distally<br />+/- detachment deltoid<br />
  19. 19. POSTERIOR STABILISATION - 3<br />Fascial layer covering teres minor and infraspinatus divided<br />Two choices<br />Develop interval between infraspinatus and teres minor<br />Develop interval between two heads infraspinatus identified by fat stripe<br />
  20. 20. POSTERIOR STABILISATION - 4<br />Divided from tendon insertion to just medial to glenoid<br />beware branches suprascapular nerve 1.5cm from glenoid<br />Infraspinatus dissected free from capsule<br />
  21. 21. POSTERIOR STABILISATION - 5<br />Capsule divided lateral to medial in mid-portion +/- labral repair<br />T-capsular incision based medially along edge of labrum<br />Superior and inferior flaps tagged<br />
  22. 22. POSTERIOR STABILISATION - 6<br />Inferior capsular flap advanced superiorly and medially and sutured to labrum<br />
  23. 23. POSTERIOR STABILISATION - 7<br />Superior flap brought over inferior flap inferior and medially<br />Sutures tied in neutral rotation<br />
  24. 24. POSTERIOR STABILISATION - 8<br />Split in capsule repaired<br />Wound closed<br />
  25. 25. POST-OPERATIVE MANAGEMENT<br />Abduction pillow for 3/52 in neutral rotation<br />At 3/52<br /> - Standard sling<br /> - ROM exercises<br /> - No forward flexion<br />At 6/52<br /> - Full ROM<br />At 12/52<br /> - Return to sport<br />
  26. 26. COMPLICATIONS<br />Loss internal rotation secondary to over-tight posterior capsular repair<br />Suprascapular/axillary nerve injury<br />Hardware problems<br />Recurrence - 30%<br />