1、Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationAcute anterior dislocation of the shoulder第一頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationAnatomyStability: - ball & socket = compression in concavity effectBone - big head small cup = u

2、nstableMenisci - labium = depth of cup by 20%Ligaments - glenohumeral & capsuleMuscles - rotator cuff & biceps = holds ball in cupPrimary Movers - Deltoid, Pec. major & Lat. Dorsy= subluxing forces Dynamic - proprioceptive feedback第二頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Sho

3、ulder-DislocationPathophysiology (Lazarus 1996)Chondro-labral defect causes a 65% reduction in stability in the direction of the defectDeficiency of the ant. inf. capsulolabral complex Fracture of ant. lip of glenoid = 15%Detachment of labarum/capsule = 15%Tear of glenohumeral ligaments = 54%Avulsio

4、n of subscapularis and ligs of humerus (HAGL) To prevent the persistence of the defect it needs to be repairedArthroscopically Open 第三頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationAcute InjurySomething breaks or tears and therefore can be repaired.Repair is bett

5、er than reconstructRepair is easier than reconstructChronicInstability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortenedRestoring the normal functional anatomy is impossible第四頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Sh

6、oulder-DislocationConservative TreatmentRowe JBJS, 1957324 young patient with ant. dislocations94% had recurrence if 20 years old62% had recurrence if 40 years oldBurkhead & Rockwood (text book)40 patients with acute dislocation & vigorous rehabilitationOnly 16% had good or excellent result (1 in 6)

7、Deny & Drew Injury, November 200221% of all patients presenting with shoulder dislocation had previous dislocation in 1 year43% in patients 15-22 years had re-dislocations第五頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationNon operative treatment of shoulder disloca

8、tion in young athletesArciera J Arthroscopy, 1995De Beardino J South Orthopaedic Ass, 1996Haelen J Arch Orthopaedic Trauma Surgery, 1990Hovelius J Orthopaedic Science, 1999Wheeler J Arthroscopy, 1998Kirkby J Arthroscopy, 1999 all over 80% recurrence rateNon operative treatment is unacceptable第六頁，共三十

9、二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationProspective Randomised Study Bottani etc.Military Personnel Medicine Vol 30 No 4 2000First Time Acute Traumatic Shoulder DislocationStabilisation Vs Non Operative: Follow up in 36 months24 patients aged 18-26y. 14 Non Ope

10、rative rehab immobilised 4 weeks9 of 12 non operative had instability (75%) (6 open Bankart repair)10 ASC Bankart repair with bioabsorbable tack 10 days1 of 9 operated patients had instability (11%)第七頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationComparison of Ar

11、throscopic & Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbeck 199830323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plastic deformationChronic anterior ins

12、tability第八頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationArthroscopic Techniques for Primary Dislocations1982 Johusa with staples1987 Morgen & Badenstab transglenoid sutures1991 Caspari -Cannulated bio-absorbable tacks 1993 Wolf & Snyder suture anchors = difficul

13、t1989 Wheller - ASC staple1993 Gohlke - Suture anchors1994 Arciera - ASC transglenoid1996 Speer - Bio-absorbable tack1999 Wintzell - ASC lavage2000 Introduction of a multitude of new gadgets & anchors第九頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationArthroscopic R

14、epairsEinoder, 1984 Knee ClubDescribed Arthroscopic transglenoid sutures using: K wire with eye (ACL) introduced via anterior portal Sucking tube Sutures tied over infraspinatus fascia or spine of scapula Results4 out 5 patients returned to the same level of sport with no re-dislocations 第十頁，共三十二頁。A

15、cute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationArthroscopic Repair第十一頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-Dislocation第十二頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-Dislocation第十三頁，共三十二頁。Acute Shoulder Disloc

16、ation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationBoszotta & 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 bone)66% = Avulsion of capsulolabral complexResults 7% = Redislocation al

17、l due to trauma (severe in 2 out of 5) 85% = Returned to unrestricted pre injury sporting activities第十四頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationRandomised StudiesAsc. Stabilisation Vs Non OperativeArciera et. al. A.J. Sports Med., 199432 military men with a

18、cute 1st up dislocation, Average of 32 months follow up15 patients non operative 80% redislocated21 patients transglenoid suture 14% redislocatedBottony & Wilkings etc. A.J. Sports Medicine 2000Patients with acute traumatic first time shoulder dislocation14 young patients non op, 75% redislocation10

19、 young patients Asc. Bankart repair, 10% redislocation第十五頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationAsc. stabilisation Dara & Gerber Journal of Shoulder & Elbow, 2000 20 shoulders Av 3 year follow up Recurrences occurred in patients who were chronic dislocato

20、rs i.e. 30% Therefore now do open surgery for recurrent dislocationsAsc. surgery for acute dislocationsDe Beardino et al An J. Sports Med., 200049 1st up acute post traumatic Shoulders dislocation Average 37 months follow up Tack anchor. 6 Patients re-dislocated (13%) +4 had open surgery第十六頁，共三十二頁。A

21、cute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationBozzotta & Helpastorger (Austria) J. Arthroscopy, 2000 Arthroscopic Transglenoid Suture Repair for Initial Ant. Shoulder Dislocation72 Patients61 11 - Sporting ambitious patients25 Patients Bankart lesion (6 with bone)43 Pati

22、ents Capsulolabral avulsionResults5 patientsRe dislocated 2 had significant trauma3 had insignificant trauma = 4%Therefore results of primary repair are better than surgery for recurrent dislocationBut transgleniod repairs are obsolete第十七頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterio

23、r-Shoulder-DislocationAgainst Arthroscopic RepairRoberts, Taylor, Brown, Hayes, Saies (Adelaide)Journal of Shoulder & Elbow, September 199956 acute 1st up shoulder dislocations2 year post operative and return to Australian Rules Football Operations: Asc. suture repair 70% recurrence Asc. Bankart rep

24、air with tack 38% recurrence,. Open repair & copsular shift 30% recurrence Therefore Asc. treatment alone not good enough第十八頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationCole & Warner Clinical Sports Medicine 2000 Arthroscopic Vs Open Bankart RepairFor Traumatic

25、 Anterior Shoulder Instability% Asc. treatment modalities are increasing due to:Better understanding of the pathophysiologyBetter pre operative evaluation of the injury (i.e. patient selection)New surgical techniquesBetter instrumentation1.Better anchors第十九頁，共三十二頁。Acute Shoulder Dislocation SurgeryE

26、inoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationProtocol for Acute RepairMature & active person15 to 50 years oldFirst episode of glenohumeral dislocationReduced on field, first aid, club Dr or DEMExamination & X-rayInformed consent time off work - outcomeExamination under GAASC of glenohumeral joint, chec

27、k rotator cuff as wellAcute repair of all demonstrable tears or fractures restore normal anatomyRehab activity collar & cuff, physiotherapyAvoid ext. rotation and abduction for 6 weeks1.Return to contact sport in 12 weeks第二十頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-Dis

28、locationInvestigationsPlain x-raysCT scans if complicated associated featureMRI rarely get more information from Asc.Examination Under GASupine load shift test with arm at 80 abducted compared with normal shoulder1+ball to rim2+ball riding over rim with spontaneous reduction3+ball stays dislocated1.

29、Arthroscopy第二十一頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationPatient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction & shoulder abductedShoulder examined, degree & direction of instability notedPortals = 2

30、or 3Posterior portalAnt. sup portalAnt inf portal (occasionally) Injury assessed & debridedRepair method selectedArthroscopic Repair Procedure第二十二頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationRehabilitationMinimal in first 4 weeksNo ext rotationAbduction less th

31、an 45Pendulum exercisesIsometric resistance exercisesGraduated in 4 8 weeks ROMGraduated weight trainingReturn to sportNon contact = 6 weekscontact = 12 weeks第二十三頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationArthroscopic Vs Open Bankart RepairAdvantagesAccurate

32、diagnosis of all structuresLess morbidity/painSmall scarsFaster recoverySooner return to activitiesLess restriction of movementDisadvantagesNeed all the equipmentTechnically demandingLong learning curveLack of versatilityHigher failure rate arthroscopic = up to 33% - open = less than 10%第二十四頁，共三十二頁。

33、Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationStern Jozrawi Rastolazzi Arthroscopy Oct. 2002Advantages Vs Disadvantages of Asc. RepairAdvantages cosmesis morbidity stiffnessEasy revisionDisadvantages1) Reluctance to refer patient immediately2) Difficult operation3) Expe

34、nsive instrumentation4) Biological healing time is not accelerated5) Same post operative restrictions第二十五頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationProblemsDifficulty convincing Club Trainers, Physicians, sporting club Doctors & DEM staff to refer the young a

35、thlete within 2-3 days.Time consuming discussions convincing patient to have the operation rather than early return to sport.No problem advising a recurrent dislocators to have a stabilisation procedure at the end of a sporting season.1.Mostly after hours surgery with staff who are not familiar with

36、 the operation and instrumentation.第二十六頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationArthroscopy of Shoulder 1935 Japanese Surgeons arthroscoped, shoulders 1960s Curiosity activity in the western world 1970s Diagnostic Asc. examination open surgery 1980s Simple

37、Asc. techniques for simple problems 1990s Instrumentation & tacks more tried it. 2000s Techniques & anchors Can be done by any surgeon skilled in arthroscopic techniques第二十七頁，共三十二頁。Acute Shoulder Dislocation SurgeryEinoder肩關(guān)節(jié)前脫位Anterior-Shoulder-DislocationShoulder reduced on field, first aid room or DEM then referred Treatment History1970s -Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences1980s -Asc. transglenoid suturestied over spine of scapula or muscle