Current concepts in the management of shoulder instability
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This document discusses the current concepts in the management of shoulder instability. It covers the causes, classifications, investigations, and treatment options for shoulder instability. For treatment, it emphasizes the importance of a systematic approach that considers the patient's age, activity level, and nature of the soft tissue and bony injuries. Non-operative treatments include physiotherapy, while operative options depend on the specific injuries and may include arthroscopic bankart repair, open latarjet procedure, remplissage, or capsular shift procedures. The goal of treatment and rehabilitation is to return the patient to their prior level of function and activity.
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Current concepts in the management of shoulder instability
- 1. Current Concepts in the Management of Shoulder Instability By Dr.PONNILAVAN ORTHO RESIDENT PIMS PONDICHERRY
- 3. SI causes pain and dysfunction in young active pts, more so in athletes. Optimal Mx of SI is challenging in young adult as well as the professional sportsperson. Increase in the no. of shoulder D/L being identified & managed in the last 2 to 3 decades.
- 5. Stages of evolution of pathological lesion in post traumatic AI • Habermeyer et al Staging :
- 8. Transcapular Y view of GH jt
- 10. AXILLARY VIEW
- 13. CT & MR arthrogram Give details of soft tissue & bony pathology Help to decide b/w arthroscopic & open procedures Recurrent shoulder d/l Larribe et al MRI – SENSITIVITY – 91 -100%
- 14. Mx • Non - operative – PHYSIOTHERAPY • Operative Mx - a} Anterior instability- key factors- < 20yrs - activity of the person [sports person , active military personal,climbers] - pts expectations
- 15. Decision making in chronic SI 2 key question – - what is the problem ? – soft tissue, bony or both -if bony – where is the problem ?( glenoid or humerus or both ) If in doubt abt the quality of soft tissue & bony defect & based on intraoperative assessement , a latarjet procedure described by him in 1954 would more reliably stabilize the jt esp. in contact sportsmen.
- 16. Coracoid osteotomy Transferred anterior to glenoid rim Done for instability due to glenoid bone loss
- 17. • Latarjet - > 25% glenoid osseous defect • Modified congruent arc latarjet procedure developed by de Beer in atheletes with recurrent anterior instability . • Colegate et al found that complication rate – 7% & 89% pts return to sports activity in a mean of 3.2 mts
- 18. • Current std of care for bankart lesion is arthroscopic bankart repair named after the person who 1st described open anterior stabilization in 1923.
- 19. Bessiere et al Arthroscopic bankart Open latarjet Incidence of recurrent instability favored latarjet group No diff. b/w reoperation rate & return to sports
- 20. The bipolar bone loss has emerged the concept of taking Hills Sachs lesion into consideration Bankart & Hill- Sachs lesions should be considered in combination as a continuum of the spectrum.
- 22. Yamamoto et al CONCEPT OF GLENOID TRACKING This takes into account the glenoid width +/- bone loss & the amt of glenoid articulation with capsule & humeral head
- 23. • In instability due to large Hill- Sachs lesion, there is a role for arthroscopic reimplissage procedure [ French to fill up] • This involves using the capsule & infraspinatus to fill up a large engaging Hill- Sachs defect usually in combination with anterior bankart repair. • It makes the defect extrarticular so that it does not engage against glenoid edge
- 24. • The Instability severity index score[ ISIS] < 6pts meant an acceptably rate of 10% instability recurrence & potentially good candidates for bankart procedure. • Phandnis et al study with 141 pts, found a 7-% risk of failure of arthroscopic ant. Stabilization if ISIS >4 vs 4% risk if score < 4
- 25. Multidirectional instability Rx of choice is open or arthroscopic plication and capsular shift if conservative management fails.
- 26. - no diff. in open or arthroscopic management -based on 24 studies with a mean age of 24 yrs & mean FU of 4 yrs in a 790pt with 861 shoulders Longo et al - systematic review
- 27. Posterior instability Patients often do not present with typical history and could describe the posterior joint pain and/or clicking. They are also likely to be missed on scans unless specifically looked for. Principles of Mx & Sx stabilization are same as anterior instability, i.e., if there is posterior soft tissue injury, then capsular shift and posterior labral repair is indicated.
- 28. Antoniou and Harryman reported successful achievement of stability for PI instability using their techniques of arthroscopic posterior capsulolabral repair and shift. For bony injuries, McLaughlin procedure has been described historically. The posterior bone block could be considered in very carefully selected cases
- 29. Rehabilitation Rehabilitation aims are to return the patient to the previous level of functional status before injury. Healing and recovery of sportspersons may be much quicker due to better muscle conditioning, motivation, facilities with therapy input and compliance, as compared to nonathletes.
- 30. Conventionally, a time-based approach has been used by most surgeons in the postoperative rehabilitation phase. Protect the repair with the arm in a sling, for 3 weeks avoid rotations, especially external rotation and taking the arm backwards. After 3 weeks, progressive mobilization is started till 6 weeks when sling comes off and active mobilization along with strengthening commences.
- 31. Summary Shoulder instability requires a meticulous and systematic management plan. All aspects of instability should be sought for and thoroughly assessed. Investigations (MRA, CT scan) are adjuncts to a comprehensive history, examination, and good diagnostic arthroscopy
- 32. Thank u
Editor's Notes
- Movt of rotator cuff m/s contribute negative pressure
- -92%. - trauma, uncontrolled epilepsy and symptomatic hyperlaxity
- - staged evolution of intraarticular findings in patients with posttraumatic SI progressing from isolated lesion to a quadruple lesion
- replaces TUBS & AMBRI matsen classification (traumatic, unilateral, bankart, and surgery (atraumatic, multi-directional, bilateral, rehabilitation, and inferior capsular shift is done if sx is needed) main stay of muscle patterning instability remains physiotherapy
- Allows assessment of humeral head location in relation to glenoid cavity
- Lines through acromion, corocoid process & scapular body intersect at the center of glenoid Humeral head is centered on tis intersection
- Axillary view locates humeral head relative to glenoid cavity
- Hill-Sachs lesion
- Anteroinferior glenoid, bony bankart, proximal humerus fx
- L et al suggested advanced imaging suct as ct & magnetic resonance arthrogram for recurrent shoulder d/l
- FOR STANMORE TRIANGLE POLAR TYPE 3 INSTABILITY FOR ALL 1ST TIME DISLOCATORS