The treatment of first shoulder dislocation

Manos AntonogiannakisDirector center for shoulder arthroscopyIASO gen hospital

Winter sports are becoming more popular in Greece

Better and more Ski Centres. Better organization and equipment advances turns more people to Winter sports

Athletes of every age and level

Athletes of all ages

Ski injuries 3 per 1000 Skier per day

Hunter REAm J Sport Med 1999

Ski injuries 4.33 per 1000 skier per day

Shoulder Injuries 0.51 per 1000 skier per day

Kocher MS Feagin JAAm J Sport Med 1996

The Shoulder

Greatest Range of Motion in the Body

Motion in all 3 planes of movement

Prone to injuries

8-20% of all sports injuries

Shoulder dislocation

2% of the population

90% anterior dislocation

First shoulder dislocation is a dramatic eventwith dare consequences especially in athletic

individuals

17% to 96% (mean 67%)

Redislocation after acute traumatic anterior dislocation of the shoulder

• Multicenter study

• 245 patients aged 12-40 years

• 10 years follow up

• 52% recurrence rate

• 23% were operated

Prognosis of recurrence after traumatic first time dislocation

Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study - Hovelius 1996 JBJS(A)

The major prognostic factor of recurrence after acute traumatic anterior shoulder dislocation is the age of the patient and the degree of participation to athletic endeavors

Redislocation rate in patients < 20 years

LarrainRoweSimonet and Cofield Slaa

•90%

• 94%

• 94.5%

• 90%

Ηovelius, 1996

Athletes hockey on ice

Recurrence rate:

90% in athletes < 20 years old

65% in athletes 20-25 years old

Age and athletic participation

The West Point experience

 

127 patients

55 conservative treatment

Recurrence rate 85%

De Barandino et al. 1996

Is shoulder arthroscopy the best treatment of the first shoulder dislocation?

Arthroscopy in the treatment of

first dislocation

What does it offer?

To what kind of patients?

Better understanding of the pathology

Reduction of recurrence rate

Treatment of rotator cuff lesions in older individuals

What does shoulder arthroscopy offers

The patient

Young professional athlete General population First dislocation in: Athletically oriented individual Loose joint individual

• Bankart lesion

• Tears of the anterior capsule

• Plastic deformation of the posterior capsule

• Hill-Sachs lesion, Bony Bankart

• rotator cuff tears

• SLAP lesions

Lesions after first shoulder dislocation

Our findings in first shoulder dislocation

Hemarthrosis 100% Bankart 78.2% Bony Bankart 13.04% Hill-Sachs 65.21% capsular laxity 8.69% SLAP lesions 21.73%

C. Yiannakopulos E Mataragas E.AntonogiannakisArthroscopy Sep 2007

Arthroscopic Shoulder Reconstruction

Goal of the Operation: Define the pathology

Restoration of the Labrum to its anatomic attachment

Reestablishment of the appropriate tension

in the IGHL complex and capsule

Repair bony Bankart and large Hill-Sachs lesions

Repair SLAP lesions

Repair rot cuff tears

EUA

Arthroscopy

Suture anchor technique

Treatment of all the lesions

Surgical technique

Joint Inspection

Arthroscope in Anterior-Superior Portal

Mobilization of Anterior Labrum

1st Anchor Placement

suture passage

Knot Tying

Evaluation of Repair

Plication of the posterior capsule

SLAP repair

Arthroscopic success rate

Savoie 1997 93% Burchart, De Bear 2000 96% J Tauro 2000 93% Kim 2003 96% Snyder 2006 93% Fabbriciani 2004 100%

Wheeler et al 1989 NO 92% O 22%

Arciero et al 1994 NO 80% O 14%

Arciero et 1995 O 10%

The West Point experience

40 patients < 30 years old prospective randomized study Transglenoid technique Same postoperative protocol Follow up > 34 months-75months

Arthroscopic stabilization or non operative treatment for the first shoulder

dislocation?

Κirkley et al 1999-2005

Sandy Κirkley 1999

Recurrence rate:

Arthroscopic treatment 16%

Conservative treatment 47%

Quality of life (WOSI)

Better in the arthroscopy group

Range of motion

The same with both methods

Larrain et al. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy,April 2001

First shoulder dislocation

Young athletes

Transglenoid technique

Follow Up 60 months

Arthroscopic treatment 96 % excellent results

Conservative treatment 5.5 % excellent results

Treatment success

Avoid recurrence Range of motion Minor morbidity Few complication Return to preinjury activity level Reproducible results

These are possible with arthroscopic treatment of the first shoulder dislocation in selected

patients

First traumatic shoulder dislocation in patients older than 40 years

Rotator cuff tears 63%

Ribbans et alJBJS 1990

Different lesionsDifferent problems to be solved

Findings after 1st shoulder dislocation in skiers older than 40 years

52 pts follow up more than 2 years Redislocation rate 4% Rotator cuff tears 35%

T Penvy, R Hunter, J Freeman Arthroscopy 1998

Conclusions

The conservative treatment produces a unacceptable high recurrence rate in young athletic individuals

Arthroscopic treatment has a high success

Arthroscopy can be performed in an outpatient setting

The anatomy can be restored with minimum morbidity and pain for the patient

Careful assessment will allow repair of all lesions after the first dislocation

Conclusions

In older patients rotator cuff tears are common The arthroscopic treatment of symptomatic rotator cuff tears is fissible with minimum morbidity

ConclusionsConclusions

Indications for arthroscopic stabilization of first shoulder dislocation

• young patients

• professional athletes

• athletically inclined individuals

• dominant shoulder

• avoidance of motion loss

• return to the same activity level

• overhead activity and activity in AB-ER

• rotator cuff tears in older patients

Modern arthroscopic techniques are probably the treatment of choice in these patients

Conclusions