The treatment of primary an-terior shoulder dislocations

ICL vol 58, 2009Symposium 30

Pathology of initial dislocation

Avulsion of ant. Labrum & capsuleHigh rate of recurrent instability after

dislocation d/t failure of labrum to heal• on biomechanical studiesDislocation not occur after Bankart le-

sion or sectioning of ant. joint capsuleCircumferential division of capsule post. Dislocation!!

Pathology of initial dislocation(2)

Pouliart & et al. in 50 cadaver• 18 Anteroinferior dislocation after 3 zones sectioned• 14 anteroinferior dislocation after all 4 Zones sectionedconclusion: ant. D/L 위해서는 Bankart

lesion+superior+posterior structure injury 필요 !!

Pathology of initial dislocation(3)

Injuries following ant. Dislocation Hill-Sachs lesion, GT Fx., capsular tear, sup. Labral

lesion, RC tearTaylor et al.Immediate arthroscopic stabilization shortly after

primary ant. Shoulder D/L : 63ptsHemarthrosis: 100%(63pts)Ant. Capsuloligamentous complex detachment :

97%(61pts)Hill-Sachs lesion : 90%(57pts)SLAP : 10%(6pts)IGHL avulsion : 2%(1pt)Interstitial capsular tear : 2% (1pt)

Pathology of initial dislocation(4)

Baker et al. (45 shoulders) : A/S exam after primary dislocation

Group I(6): minimal hemarthrosis capsular tear, no labral teraGroup II(11): moderate hemarthrosis,

capsular tear, partial labral detachmentGroup III(28): large hemarthrosis, capsular

tear, complete labral detachment

Intraarticular pathology finding: not predictive of recurrent rate!!

Risk factors for recurrence

Traumatic dislocation: 94% of recurrent rate

Prophylactic surgical stabilization 위해Prognostic factor 분석 필요

Age and Gender

Young age : the most consistent & sig-nificant factor

66% age 12~22: recurrent D/L 24% age 30~40: recurrent D/L1/3 pts who had initial D/L before age

30Ultimately Surgical stabilizationBilat. Dislocation: much higher

younger than 29 yrs

Age and Gender(2)

Young, athletic pts : 94% recurrence rateSachs et al.Age younger than 25 yrs: the only strong predictor!

GenderMale 57% recurrence rateFemale 42% recurrence rate

Sports activity

Bankart’s report:“peculiar to athletics & epilep-

tics”

Simonet et alAthlete: 82% Nonathlete: 30%

Recent studiesSachs, Kralinger & Slaa

No correlation be-tween sports activity & recurrence

Using arm above chest level likely to have subsequent instability

Hill-Sachs Lesion

Lesion 의 존재 : recurrence rate get high

Size & severity of osseous defect 도 중요

Kralinger et al.Grade I defect: 23%Grade II defect: 16%Grade III defect: 67% of recurrence

rate

Greater tuberosity frac-ture

Slaa et al.GT fx. 가 있는 19% 의 환자에서 recurrence rate:

0%!! Lessen!! Risk of recurrent instability( 수상 당시의 에너지가 capsule 이나 labrum 대신

GT fracture 로 흡수되는 것으로 생각 )Kralinger et al결과 비슷원인 : secondary reduction in attainable ER at 0

degree of abduction in the injured shoulder

Nonsurgical treatment

Duration of immobilization or rehab affect outcome?

Typical Nonsurgical Tx. : closed reductionvariable period of

immobilizationPT to strengthen ro-tator cuff and scapular stabilizers.

:::anecdotal & controversial !!

Duration of immobilizationor rehab.(2)

Aronen & ReganImmobilization Intense rehab : prevents recurrent instabilityRehab. emphasizing IR muscles & adductors

+ rigid activity restrictionIsometric to isotonic and isokinetics

Duration of immobilizationor rehab.(3)

Late study reveals the oppositeNo correlation between duration of

immobilization and recurrence rateNo benefit from supervised PT from home-based PT

ER immobilization

Recent studiesER immobilization reduces recurrence

than sling immobilizationMRI studies:Bankart lesion 의 position 과 coapta-

tion 도 ER 상태에서 훨씬 안정적Biomechanical study max. contact force at 45 degree of

ER

ER immobilization (2)

3 randomized clinical trialsItoi et al (40 pts)3wks to conventional immobilization in

IR or immobilization in 10 to 30 of ERAt a mean 15.5 month F/U 30% with IR recurred, none of ERAmong pts lower than 30 yrs, relative

risk reduction even greater.

Surgical treatment

• Goal : restore native anatomy, by repairing Bankart lesion or capsular injury

• Pain free, stable shoulder with maxi-mal ROM

Arthroscopic lavage after in-jury

30 pts in SwedenAt 2 yr F/U

20% recurred with lavage

60% recurred with treated nonsurgi-cally

Saah et al.No benefit of isolated

arthroscopy with-out repair

Should high risk pts receive early surgical stabilization?

• Historically, primary shoulder D/L • treated nonsurgically • Surgery considered after recurrence

• Several studies promoted• Role of early surgical stabilization after

primary D/L• 18~67 months F/U• A/S repair effective reducing recurrence

Should high risk pts receive early surgical stabilization?(2)

Young, active male with dominant side first time D/L recur rate : 90%

immediate surgical repair very attractiveLarrain, Wheeler, ArcieroSurgery: 4~22% of recurrenceNonsurgery: 80~95% of recurrenceSeveral studies documented:Reducing risk of recurrence, improving

QOL & functional outcome

Primary shoulder D/L analogous to ACL injury?

Recently, reached to consensus as to surgical reconstruction of ACL in high-risk young, ac-tive patients.

ACL recons. Prevents knee OAEarly surgical intervention may prevent glenoid

& humeral bone loss, capsular attenuation, and rotator cuff tears

ACL recons. & Bankart repair needed for young, active pts to lower recurrence risk & secondary intraarticular injury, expedite re-turn to function.

Treatment of contact athlete

Contact athlete 에서 recurrence risk 높다고 생각되어 왔음

open Bankart repair 시행되어옴(A/S repair 는 failure rate high)Several studies (Mazzocca, Larrain,

Bacilla)A/S with Bankart repair c suture an-

chor 로도 충분히 좋은 결과

Treatment of contact athlete

• Boileau et al.• Postsurgical recurrence related to

bone defect, bony Bankart or Hill-Sachs lesion.

• Recurrence rate higher in inf. Shoul-der hyperlaxity or ant. Shoulder hy-perlaxity

• 4 개 이상의 suture anchor fixation 필요 !!

summary

Tx. Should be individualized by age, oc-cupation, functional demand, sports participation, physical characteristics, compliance, & expectations.

High risk young man c active physical activity

early surgical stabilizationLow recurrent population early surgery

not needed!!