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Presenter: Chun Tseng

OKU 11 READING

Ch27 Shoulder instability and Rotator cuff disease

SHOULDER INSTABILITY- ANATOMYI LITY

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• Static• Osteochondral anatomy • Capsulolabral complex: labrum,. Capsule,

Glenohumeral ligment, Coracohumeral ligment

• negative intra-articular pressure• synovial fluid adhesion-cohesion

• Dynamic: rotator cuff, biceps long head, scapulothoracic rhythm, concavity compression, proprioceptive feed back

BIOMECHANICS

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• Traumatic anterior instability arm in an abducted and externally rotated position anteroinferior glenohumeral ligament injury.

• Posterior dislocation the arm in a forward flexed, adducted position posterior capsulolabral complex and the posterior glenoid rim.

• Glenoid bone loss:

• Substantial bone loss arthroscopic repair 效果不佳• >21% glenoid bone loss severe instability

• Humeral bone loss:

• Hill-Sachs lesion > 25% 對於 joint translation, capsular force, and bony contact force 有顯著的差異 可補 capsule & labral 來穩定肩關節

• Reverse Hill-Sachs lesion

ANTERIOR INSTABILITY

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• The most common direction of shoulder dislocation is anterior

• Injury of the glenoid labrum (Bankart lesion)

• injury of the anterior glenoid rim (bony Bankart lesion)

• Treatment

• Closed reduction / Open reduction.

• Sling immobilization. External/ Internal/ Neutral Position 都可以

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NATURAL HISTORY

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• young, active patient Recurrence rates as high as 92% have been reported with nonsurgical treatment.

• >40 y/o Patients increased risk of rotator cuff tears and neurologic injury (axillary nerve)

• >60 y/o Patients dislocation 常與 greater tuberosity fracture, rotator cuff tear, and neurologic injury 合併

• <22 y/o Patients with a first-time dislocation high recurrent instability rates surgical intervention.

NATURAL HISTORY

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• Data suggest that patients treated with an arthroscopic Bankart repair after initial dislocation had an 82% reduction in the risk of recurrent instability

• 近十年共識， 16-25y/o pt with first time dislocation 68 % surgeons offering surgery

• 需要做 open bankart repair 的病人中有 1/4 (26%) 發生Osteoarthritis

• 手術後有 1/3 (32%) 病人有 Osteoarthritis

• Progression Risk Factors: 術前脫臼次數，男性

ARTHROSCOPIC VERSUS OPEN REPAIR

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• Outcome scores and recurrence rate 兩種一樣• Long term outcomes 發現 scope 組有 14.3% 的 recurrence rate.

• Patients treated with two or fewer suture anchors had a higher dislocation rate than patients treated with three or four suture anchors.

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• For contact athletes, a recurrence rate of 89% was noted in patients with a lesion to the anterior glenoid rim of 20% to 30% when treated with arthroscopic labral repair and capsular shift alone.

• > 25~30% 的 anterior glenoid defects bony procedure is often necessary

• Latarjet procedure (transfers the coracoid process to the glenoid bony defect)

• 加強前面 glenoid

• 當手 Abd or Ext 時Conjoined tendon 可以當 sling

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• Hill- Sachs lesions larger than 25% of the total surface area of the glenoid cavity Open Treatment with

• Osteochondral allograft,

• Remplissage (to fill in with infraspinatus)

• Infraspinatus transfer

• >40% lesion

• Humeral arthroplasty or bone graft

POSTERIOR INSTABILITY

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• Less common than anterior dislocations

• Commonly missed

• Posterior dislocations, usually self-limited.

• Approximately 17% of patients will develop a recurrent dislocation in the first year following a dislocation.

• Risk factor:• < 40 y/o , seizure disorder, large humeral head defects

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• Surgical Treatment Open and scopeThe repair should address the torn posterior labrum and/or bony defect, capsular redundancy, and ligament tears

• Chronic Posterior Dislocation~~several weeks

• Subscapularis or lesser tuberosity transfer into the reverse Hill-Sachs lesion,

• Osteochondral bone grafting

• Segmental humeral head replacement

• Humeral head replacement

• Humeral head replacement is indicated for chronic dislocations in which the patient has developed clinically significant osteoarthritis, osteonecrosis with head collapse, or damage of more than 50% of the humeral head .

MULTIDIRECTIONAL INSTABILITY (MDI)

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• Genetic hyperlaxity (Ehlers- Danlos syndrome= rubber man syndrome)皮膚有高度伸展性，皮膚和血管脆弱，傷口癒合比較慢，關節活動範圍的過度增加

• Nonsurgical Treatment~ success rates as high as 80%.

• Open capsular shift

• Arthroscopic capsular shift techniques

ROTATOR CUFF DISEASE

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• 症狀會比 MRI 出現 fatty changes 更早發生• Supraspinatus Muscle 早 3~5 年• Infraspinatus Muscle 早 2.5~4 年

• Pt <60 y/o or 有症狀仍在工作的人應該早早 REPAIR

• 破掉的位子在偏後 (relatively hypovascular zone) 比較容易有 fatty change

• 破掉的 SIZE 與 疼痛 , function score 情況正相關• Risk factor: AGE, Shoulder overhead and abducted.

RCT~~ TREATMENT

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• Earlier intervention should be considered for full-thickness rotator cuff tears in younger patients who have not yet developed significant tendon retraction, fatty infiltration, and atrophy.

SURGICAL TREATMENTSINGLE-ROW V.S. DOUBLE-ROW REPAIR

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• Smaller tears and double-row repairs had a greater healing rate.

• No differences in the functional or quality-of-life outcome score

• Cost-effectiveness DR<SR.

• Repair failure 多發生在前期

BIOLOGIC AUGMENTATION OF ROTATOR CUFF REPAIR

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• Several graft augmentation devices are currently available, but little evidence substantiates their efficacy.

• Platelet-rich plasma has also been evaluated, but most randomized studies have not shown a benefit.

• There is little evidence at this time to support the routine use of platelet-rich plasma or PRFM in rotator cuff repair.

• Platelet-rich fibrin matrix (PRFM) 離心加 CaCl2

• Porcine intestinal submucosal graft( 豬小腸 ) worse results

• porcine dermal graft better outcome scores and healing

• Polyurethane patch (PU)

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Thanks for Your Listening

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