Skulderinstabilitet

Cecilie Piene Schrøder Lovisenberg Diakonale Sykehus

Labrum Skade (‘Bankart lesjon’)

… regnet som den ‘vesentlige lesjon ’

Bankart Lesion

Kapselskift (Syd-Nord) er nødvendig !

Skulderinstabilitet er ikke fremre, men en fremre, nedre instabilitet

Hovedårsak til svikt :

Vår manglende evne til å addressere den plastiske deformasjon av kapselen

Artroskopisk Bankart

Kapselskiftet kan individualiseres :

• Medial Plication (Øst-Vest)

• Proximal Shift (Syd - Nord)

Medial kapselplikasjon (Øst- Vest) i

Kirurgisk Teknikk

Isolated Reinsertion of Labrum

Associated Capsular Plication

Apprehensiom/Relocation test

Apprehension Relocation

Instabilitet; fremre, bakre, SLAP

Se etter for kapselutvidelse:

• Asymetrisk Inferior Drawer (> 2cm)

• Asymetrisk Ext. Rot. (>20°)

• Asymetrisk Hyperabduction (> 20°)

Klinisk Undersøkelse

Hyperabduction Test (Gagey)

Asymetrisk Hyperabduction +++

Traumatisk fremre instabilitet

ISIS scoreAlder under 20 år 2 poeng Konkurranseidrett 2 poeng Kontaktidrett 1 poeng Hyperlaxiditet nedre el fremre 1 poeng Hill-Sachs synlig i utadrot ,AP rtg 2 poeng Tap av nedre glenoid kontur 2 poeng

Ved < 3 poeng; 5% residivrate Ved ≤ 6 poeng; 10% Ved > 6 poeng; 70%

Hyperlaksiditet + bakre /fremre instabilitet

Hvordan er våre resultater ?

140 pasienter i en retrospektiv studie (operert 2006-2008)

Uavhengig undersøker – Magnus Wallumrød Rowe score, WOSI score, pasientfornøydhet 120/123 har svart; 5 på telefon, 115med klinisk undersøkelse (93.5% follow-up)

ResultaterResidiv instabilitet :

Artroskopisk prosedyre: 123 pasienter

11 residivluksasjon: 8.9% 5 apprehensive 4.1% Totalt 13.0%

Latarjet prosedyre: 1/17 patients 5.9%

Total residiv instabilitet: 17/140: 12.1%

Konklusjon @-stabilisering

Residivinstabilitet : 13.0 % Residivinstabilitet totalt : 12.1% Postoperativ Rowe-score : 93 Pasientfornøydhet : ex/good 87.8 % SSV : 86.3 Redusert ext rotasjon : 31.8% , mean 13.5º Tilbake til samme nivå sport: 78 %

KonklusjonMed 13 % residivinstabilitet etter 2-4, hva blir Resultatet etter lengre tids oppfølging?

Fra 2008-2010 : 158 pasienter

42(33%) Primær Latarjet, 79 (62.2%) Artroskopisk Bankart, 6(4.8%)% Remplissage + Bankart

31 Latarjet pga av residivinstabilitet

Operativ teknikk Latarjet

Delto-pectoral approach

Operativ teknikkCA-ligament sectioned Pec.Minor Coracoid osteotomy

Operativ teknikkSubscap division horisontal

Capsulotomy

Glenoid exposure

2 parallel bicortical screws

Materiale og metode2002 – 2008, 46 Latarjetstabiliseringer 18 med primær Latarjet because of a high ISIS score 28 Latarjet pga residivinstabilitet etter tidligere åpne

eller @-Bankartoperasjoner

Materiale og metode

Median alder: 26 år (16-45) 5 kvinner/40 menn Mean follow-up: 51mnd (21-80) 1 alkoholiker, 2 med stoffmisbruk, 1 fengslet i 5 år ,

KonklusjonResidiv instabilitet : 1/46 Aprehensive 7(15,5%) Pasient fornøydhet: 88% ex/good. Skruebrekkasje : 1/46 Non-union: 2 Usikker grafttilheling : 3. Infeksjon: 1 overfladisk, AB Nerveskade: ingen

Remplissage

,

Hill –Sachs, lite eller intet Bentap glenoid

@ Hill-Sachs Remplissage

WolfetalNSC2004,Arthroscopy2008

• Wolfe et al.; a modification of Conolly`s open procedure, the arthroscopic technique of Hill-Sachs „remplissage“,

• Performed in combination with Bankart repair.

Fremre, nedre instabilitet med beintap glenoid og humerus

- 21 år gammel kvinne - Traumatisk fremre luksasjon - Hyperlaks > 100° utadrotasjon - Positiv sulcus, også i utadrotasjon - Generell laxitet - Bankartfraktur - Hill-Sachs fraktur - Fremre, nedre instabilitet

Kirurgisk prosedyre

• @- remplissage • Åpen Latarjet • Fremre

kapselplikasjon med 2 resorberbare ankre

SLAP skader

O`Brien Test

Apprehension/relocation Crank test

Sham Surgery Trial for SLAP Lesions of the shoulderA double-blind, randomized study with blinded analysis and manuscript at 6 months

CP Schrøder MD, Ø Skare MT, PhD, P Mowinkel, MSc,

O Reikerås MD, PhD, JI Brox, MD, PhD

! We have conducted a prospective, double-blind, sham controlled trial

! The aim of the study was to compare the efficacy of labral repair, biceps tenodesis and sham surgery for alleviating and improving function in patients with type II SLAP tears

Methods! From January 2008 to January 2014

! 118 patients, age 18-60

! History & clinical signs suspecting a Type II SLAP lesion, verified by arthro-MRI

! Randomization to labral repair, biceps tenodesis or sham surgery if the arthroscopy revealed an isolated Type II lesion

! All three groups had similar postoperative physiotherapy

! Endpoint 6 months and 2 years

! Primary outcomes: Rowe score and WOSI score

! Secondary outcomes: Oxford Instability Shoulder Score (OISS), EQ-5D, EQ-VAS and patient satisfaction

! The results were analyzed and interpreted blindly

Postoperative rehabilitation

! Standardized, but individually adjusted ! Sling used for 3 weeks ! Local physio/manual physiotherapists ! Exercise to improve scapula-humeral rhythm,

coordination and mobility using sling-exercise therapy ! Exercise to improve functional stability, rotor cuff and

scapular strength, progressively emphasized after 6 weeks.

! Rehab continued for 3 to 6 months, 12-16 sessions, 20 self-administered sessions.

Assessed for eligibility (n=445 )

Excluded (n= 262 ) ♦ Not meeting inclusion criteria (n=227 )♦ Declined to participate (n= 14 )♦ Other reasons (n= 21 )

Lost to follow-up (did not show up for 6 months control) (n= 1 )

Allocated to sham-surgery (n= 39 )

Lost to follow-up (give reasons) (n= 0 )

Allocated to labral repair (n= 40 )

Underwent arthroscopy (n= 183 )

Allocated to biceps tenodesis (n= 39 )

Lost to follow-up (did not show up for 6 months control) (n= 1 )

Excluded peroperatively (n=65 ) •No SLAP tear (n= 19 ) •Large posterior labral tear (n= 11 ) •Cufftear (n= 8 ) •360° labral tear (n= 7) •Bankart lesion (n= 7) •Partial biceps tear (n= 7) •Bucket handle tear (n= 3) •Capsulitis (n= 3)

Underwent randomisation (n= 118 )

Mean age 40 years, 40% females

ResultsProlonged postoperative stiffness

(<30° ext.rot, <90° abduction):

Labral repair: 5

Biceps tenodesis: 4

Sham surgery: 1

Reoperations

! 7 patients in the sham group; 6 with labral repair and one with a biceps tenodesis.

! 4 patients in the biceps tenodesis group: 2 with a labral repair and one 2 with a capsular release

! One patient in the labral repair group: AC resection

! Intention to treat analysis

Results 1 year Rowe Score

Results 1 year Western Ontario Shoulder Index

Results 1 year Oxford Instability Shoulder Score

Patient satisfaction 1 yearExcellent Good Fair Poor Total

Sham Surgery

13 13 7 3 36

Biceps Tenodesis

18 15 4 1 39

Labral Repair

19 12 5 3 39

Conclusion

! At 6 months 2/3 of the patients in the sham group were satisfied with their shoulder function. These patients would in our ordinary practice have been operated with a SLAP repair or biceps tenodesis.

! There is a significant improvement from 6 months to one year for all groups, both for objective scores and subjective patient satisfaction

! There are no significant in-between group differences at 6 months or 1 year in the intention to treat analysis

! 7 patients in the sham group have been re-operated ; 4 patients in the biceps tenodesis group and one in the labral repair group