SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. •...
Transcript of SHOULDER INSTABILITY IN PATIENTS WITH EDS...for the shoulder girdle is paramount esp in MDI. •...
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Keith Kenter, MD Associate Professor
Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program
Department of Orthopaedic Surgery University of Cincinnati
SHOULDER INSTABILITY IN
PATIENTS WITH EDS
EDNF 2012 CONFERENCE LIVING WITH EDS
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DISCLOSURE KEITH KENTER
I HAVE NOTHING TO DISCLOSE AND NO CONFLICT OF INTEREST AS IT RELATES TO
THIS PRESENTATION
INSTITUTIONAL SUPPORT NIH (RESEARCH)
SMITH & NEPHEW (EDUCATION GRANT)
JOURNAL REVIEWER/EDITORIAL BOARDS JBJS, AJSM, BJSM
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Single Dislocation
≠ Recurrent Instability
INDIVIDUALIZED TREATMENT
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DEFINITIONS
LAXITY Range of motion of the center of the humeral
head with respect to the glenoid fossa due to a external force
INSTABILITY
Symptomatic inability to maintain the humeral head in the glenoid fossa
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DEFINITIONS
SUBLUXATION Partial dislocation
Incomplete separation of joint
DISLOCATION Frank separation of joint
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CLASSIFICATION
DIRECTIONAL
• Anterior
• Posterior
• Multidirectional
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CLASSIFICATION
MECHANISMS
• TUBS - Traumatic Unidirectional Bankart Surgery
• AMBRI – Atraumatic Multidirectional
Bilateral Rehabilitation Inferior shift
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GLENOHUMERAL INSTABILITY
Complex interaction between physiologic laxity to provide range of motion and joint stability.
STABILITY MOBILITY
EDS
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THE EDS SHOULDER INCREASED LAXITY
HIGHER RISKS FOR INSTABILITY (MDI)
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ANATOMIC CONSIDERATIONS
• Passive
• Static
• Dynamic
CONSTRAINTS
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PASSIVE CONSTRAINTS
• Humeral head
• Glenoid fossa
BONY ANATOMY
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PASSIVE CONSTRAINTS
INTRA-ARTICULAR PHYSICS
• Negative pressure
• Joint fluid cohesion
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PASSIVE CONSTRAINTS
Fibrocartilagenous lip that
increases glenoid depth and increases humeral contact area
• 75% superoinferior • 50% anteroposterior
LABRUM
Clin Orthop 243; 1989
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STATIC CONSTRAINTS
• Capsular envelope
• Glenohumeral ligaments
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GLENOHUMERAL LIGAMENTS
• SUPERIOR - restraint for inferior translation in adducted shoulder
• MIDDLE - restraint for anterior translation in 45º abducted shoulder
• INFERIOR - restraint for anterior and inferior translation in abducted shoulder
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GLENOHUMERAL LIGAMENTS
IGHL
MGHL
SGHL
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DYNAMIC CONSTRAINTS
• Rotator cuff group
• Biceps tendon
• Scapular rotators
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BIOMECHANICS
ANTERIOR TRANSLATION
FLEXION ‘CROSS BODY’
MOTION
JBJS 72A; 1990
POSTERIOR TRANSLATION
EXTENSION EXTERNAL ROTATION
HARRYMAN
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BIOMECHANICS
Anterior Tightening
Abduction Forward Flexion ER No Translation
KENTER
ASES; 1999
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TREATMENT
• Immediate reduction of the dislocated shoulder • Physical therapy program Rotator Cuff strengthening Scapular stabilizer strengthening • Surgical intervention
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EDS SHOULDER INSTABILITY • Patient education and defining the collagen disorder
are paramount
• Modification on activity and work on mechanics
• Core strength, spine posture, RC strength, and scapular muscle strength
• Surgical results about 30% recurrence in patients without anatomic lesions
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REHABILITATION
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REHABILITATION
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REHABILITATION
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REHABILITATION
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MULTI-DIRECTIONAL INSTABILITY
MISAMORE
• 64 patients ave 16 year (9-30) at 8 years 43 female / 21 male
• PT program with RC and parascapular strengthening • 57 patients available at follow-up
63% (36/57) without surgery Pain – 23 good-excellent Instability – 17 good-excellent
• Poor response: (unilateral/ADLs/hyperlaxity/3months)
JSES 14; 2005
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SURGICAL MANAGEMENT
• WHEN TO OPERATE
• HOW TO DO IT Open Arthroscopic
ADDRESS THE PATHOANATOMY
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ANTERIOR DISLOCATION
NATURAL HISTORY • Age related
< 22 years – 60-90% 30-40 years – 50-65% > 50 years – RC Tears
60+ years about 40% • Pathology related
< 25 years up to 85% with Bankart labral tear JBJS 88A; 2006
JBJS 89A; 2007
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SO WHAT ?? DOES RECURRENCE CAUSE DAMAGE
HABERMEYER
76 patients with anterior dislocations evaluated with arthroscopy
9 with 1 dislocation Labrum 12 with 1- 2 dislocations Ligament 23 with 3-5 dislocations Double ligament 32 with 6+ dislocations Articular cartilage
JSES 8; 1999
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CARTILAGE BREAKDOWN
FIRST TIME DISLOCATION
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ARTHROSCOPIC ADVANCES
• Rapid evolution in techniques
• Early techniques secure labrum to bone • Address capsular laxity Capsular shift Capsular split Capsular plication Thermal ‘shrinkage’
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ARTHROSCOPIC TECHNIQUES
• PRO Visualize all pathology Less stiffness Easier to revise • CON Less reliable/technically demanding Higher failure rates (some authors) Portal scars
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SURGICAL TECHNIQUE
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SURGICAL TECHNIQUE
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SURGICAL TECHNIQUE
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SURGICAL TECHNIQUE
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SURGICAL TECHNIQUE
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ARTHROSCOPIC TECHNIQUES
CONTRAINDICATIONS
• Capsular deficiency • Glenoid bone loss • Humeral head defect • Collision athlete ? • Surgeon’s skill level
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CAPSULAR PLICATION
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THERMAL
• Addresses residual laxity
• Repair labrum first
• Avoid suture line
• Paint in grid fashion
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SUMMARY • Complex interaction between stability and mobility.
• Neuromuscular training and strengthening program
for the shoulder girdle is paramount esp in MDI.
• Surgical emphasis is to restore anatomy and capsular tension.
• Arthroscopic challenge today is reproducibility of quantifying amount of capsular redundancy during repair.
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THANK YOU