Skulderinstabilitet
Cecilie Piene Schrøder
Lovisenberg Diakonale Sykehus
Labrum Skade (‘Bankart lesjon’)
… regnet som den ‘vesentlige lesjon ’
Bankart Lesion
Skulderinstabilitet er ikke fremre, men
en fremre, nedre instabilitet
Kapselskift (Syd-Nord) er nødvendig !
Artroskopisk Bankart
Hovedårsak til svikt :
Vår manglende evne til å addressere
den plastiske deformasjon av kapselen
Kapselskiftet
kan individualiseres :
•
Medial Plication
(Øst-Vest)
•
Proximal Shift
(Syd - Nord)
Kirurgisk Teknikk
Isolated Reinsertion
of Labrum
Associated
Capsular
Plication
Medial kapselplikasjon (Øst- Vest) i
Apprehensiom/Relocation test
Apprehension
Relocation
Instabilitet; fremre, bakre, SLAP
Klinisk Undersøkelse
Se etter for kapselutvidelse:
• Asymetrisk Inferior Drawer (> 2cm)
• Asymetrisk Ext. Rot. (>20°)
• Asymetrisk Hyperabduction (> 20°)
Asymetrisk Hyperabduction +++
Hyperabduction Test (Gagey)
Traumatisk fremre instabilitet
ISIS score
Alder 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)
Resultater
Residiv instabilitet :
Artroskopisk prosedyre: 123 pasienter
11 residivluksasjon:
5 apprehensive 4.1%
8.9%
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 %
Konklusjon
Med 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 teknikk
CA-ligament
sectioned
Pec.Minor
Coracoid
osteotomy
Operativ teknikk
Subscap division
horisontal
Capsulotomy
Glenoid exposure
2 parallel bicortical screws
Materiale og metode
2002 – 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
,
Konklusjon
Residiv 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
Wolfe et al.; a modification of Conolly`s open
procedure, the arthroscopic technique of HillSachs „remplissage“,
.
Performed in combination with Bankart repair
WolfetalNSC2004,
Arthroscopy2008
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
shoulder A 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 )
Underwent arthroscopy
(n= 183 )
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 )
Allocated to sham-surgery
(n= 39 )
Lost to follow-up (did not show up
for 6 months control) (n= 1 )
Allocated to biceps tenodesis
(n= 39 )
Lost to follow-up (did not show
up for 6 months control) (n= 1 )
Allocated to labral repair
(n= 40 )
Lost to follow-up (give reasons)
(n= 0 )
Mean age 40 years,
40% females
Results
Prolonged 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 year
Excellent
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