肩关节前脱位 PPT课件.ppt

Acute Shoulder Dislocation SurgeryEinoderAcute anterior dislocation of the shoulderAcute Shoulder Dislocation SurgeryEinoderAnatomyStability:-ball&socket =compression in concavity effectBone -big head small cup =unstableMenisci -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 feedbackAcute Shoulder Dislocation SurgeryEinoderPathophysiology(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%Avulsion of subscapularis and ligs of humerus(HAGL)To prevent the persistence of the defect it needs to be repairedArthroscopically Open Acute Shoulder Dislocation SurgeryEinoderAcute InjurySomething breaks or tears and therefore can be repaired.Repair is better 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 impossibleAcute Shoulder Dislocation SurgeryEinoderConservative 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)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-dislocationsAcute Shoulder Dislocation SurgeryEinoderNon operative treatment of shoulder dislocation in young athletes1.Arciera J Arthroscopy,19952.De Beardino J South Orthopaedic Ass,19963.Haelen J Arch Orthopaedic Trauma Surgery,19904.Hovelius J Orthopaedic Science,19995.Wheeler J Arthroscopy,19986.Kirkby J Arthroscopy,1999 all over 80%recurrence rateNon operative treatment is unacceptableAcute Shoulder Dislocation SurgeryEinoderProspective 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 Operative 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%)Acute Shoulder Dislocation SurgeryEinoderComparison of Arthroscopic&Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbeck 199830323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair?Due to plastic deformationChronic anterior instabilityAcute Shoulder Dislocation SurgeryEinoderArthroscopic Techniques for Primary Dislocations1982 Johusa with staples1987 Morgen&Badenstab transglenoid sutures1991 Caspari-Cannulated bio-absorbable tacks 1993 Wolf&Snyder suture anchors=difficult1989 Wheller-ASC staple1993 Gohlke-Suture anchors1994 Arciera-ASC transglenoid1996 Speer-Bio-absorbable tack1999 Wintzell-ASC lavage2000 Introduction of a multitude of new gadgets&anchorsAcute Shoulder Dislocation SurgeryEinoderArthroscopic RepairsEinoder,1984 Knee ClubDescribed Arthroscopic transglenoid sutures using:K wire with eye(ACL)introduced via anterior portalSucking tubeSutures tied over infraspinatus fascia or spine of scapula Results4 out 5 patients returned to the same level of sport with no re-dislocations Acute Shoulder Dislocation SurgeryEinoderArthroscopic RepairAcute Shoulder Dislocation SurgeryEinoderAcute Shoulder Dislocation SurgeryEinoderAcute Shoulder Dislocation SurgeryEinoderBoszotta&Helperstorfer Arthroscopy,July 2000 Transglenoid suture repair for initial Ant.dislocation72 patients(1988-95)61 11 Aged 19-3934%=Bankart lesion(6 with bone)66%=Avulsion of capsulolabral complexResults7%=Redislocation all due to trauma(severe in 2 out of 5)85%=Returned to unrestricted pre injury sporting activitiesAcute Shoulder Dislocation SurgeryEinoderRandomised StudiesAsc.Stabilisation Vs Non OperativeArciera et.al.A.J.Sports Med.,199432 military men with acute 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 young patients Asc.Bankart repair,10%redislocationAcute Shoulder Dislocation SurgeryEinoderAsc.stabilisation Dara&Gerber Journal of Shoulder&Elbow,200020 shouldersAv 3 year follow upRecurrences occurred in patients who were chronic dislocators 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 dislocationAverage 37 months follow up Tack anchor.6 Patients re-dislocated(13%)+4 had open surgeryAcute Shoulder Dislocation SurgeryEinoderBozzotta&Helpastorger(Austria)J.Arthroscopy,2000 Arthroscopic Transglenoid Suture Repair for Initial Ant.Shoulder Dislocation72 Patients 61 11-Sporting ambitious patients25 Patients Bankart lesion(6 with bone)43 Patients Capsulolabral avulsionResults 5 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 obsoleteAcute Shoulder Dislocation SurgeryEinoderAgainst 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 FootballOperations:Asc.suture repair 70%recurrenceAsc.Bankart repair with tack 38%recurrence,.Open repair&copsular shift 30%recurrenceTherefore Asc.treatment alone not good enoughAcute Shoulder Dislocation SurgeryEinoderCole&Warner Clinical Sports Medicine 2000 Arthroscopic Vs Open Bankart RepairFor Traumatic Anterior Shoulder Instability%Asc.treatment modalities are increasing due to:1.Better understanding of the pathophysiology2.Better pre operative evaluation of the injury(i.e.patient selection)3.New surgical techniques4.Better instrumentation5.Better anchorsAcute Shoulder Dislocation SurgeryEinoderProtocol for Acute Repair1.Mature&active person2.15 to 50 years old3.First episode of glenohumeral dislocationReduced on field,first aid,club Dr or DEM4.Examination&X-ray5.Informed consent time off work-outcome6.Examination under GA7.ASC of glenohumeral joint,check rotator cuff as well8.Acute repair of all demonstrable tears or fractures restore normal anatomy11.Rehab activity collar&cuff,physiotherapy12.Avoid ext.rotation and abduction for 6 weeks13.Return to contact sport in 12 weeksAcute Shoulder Dislocation SurgeryEinoderInvestigations1.Plain x-rays2.CT scans if complicated associated feature3.MRI rarely get more information from Asc.4.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 dislocated5.ArthroscopyAcute Shoulder Dislocation SurgeryEinoderPatient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction&shoulder abductedShoulder examined,degree&direction of instability notedPortals=2 or 3Posterior portalAnt.sup portalAnt inf portal(occasionally)Injury assessed&debridedRepair method selectedArthroscopic Repair ProcedureAcute Shoulder Dislocation SurgeryEinoderRehabilitation1.Minimal in first 4 weeksNo ext rotationAbduction less than 45Pendulum exercisesIsometric resistance exercises2.Graduated in 4 8 weeks ROMGraduated weight training3.Return to sportNon contact=6 weekscontact=12 weeksAcute Shoulder Dislocation SurgeryEinoderArthroscopic Vs Open Bankart RepairAdvantagesAccurate 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%Acute Shoulder Dislocation SurgeryEinoderStern Jozrawi Rastolazzi Arthroscopy Oct.2002Advantages Vs Disadvantages of Asc.RepairAdvantages cosmesis morbidity stiffnessEasy revisionDisadvantages1)Reluctance to refer patient immediately2)Difficult operation3)Expensive instrumentation4)Biological healing time is not accelerated5)Same post operative restrictionsAcute Shoulder Dislocation SurgeryEinoderProblems1.Difficulty convincing Club Trainers,Physicians,sporting club Doctors&DEM staff to refer the young athlete within 2-3 days.2.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.3.Mostly after hours surgery with staff who are not familiar with the operation and instrumentation.Acute Shoulder Dislocation SurgeryEinoderArthroscopy of Shoulder1935 Japanese Surgeons arthroscoped,shoulders 1960s Curiosity activity in the western world1970s Diagnostic Asc.examination open surgery1980s Simple Asc.techniques for simple problems1990s Instrumentation&tacks more tried it.2000s Techniques&anchors Can be done by any surgeon skilled in arthroscopic techniquesAcute Shoulder Dislocation SurgeryEinoderShoulder 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 fascia1990s-patient in lateral position with arm in tractionor patient in Beach chair position multiple,tacks and suturessurtac screw tack anchors etc.2000-better anchors and sutures have made the procedure available for all surgeons experienced in arthroscopic techniqueAcute Shoulder Dislocation SurgeryEinoderAcute Labral TearAcute Shoulder Dislocation SurgeryEinoderAcute Repair of Anterior Labral TearAcute Shoulder Dislocation SurgeryEinoderConclusionAsc.repair of the Capsulo-ligamentous injury to the shoulderis a simple procedure for a surgeon skilled in arthroscopic technique Chronic instabilities have associated plastic deformity of the tissues that need to be addressed and this makes the result of a simple procedure unpredictable.An active young person with a first traumatic dislocation of the shoulder should have the damage repaired arthroscopically within 10 days of the injury