Skulderinstabilitet. Cecilie Piene Schrøder Lovisenberg Diakonale Sykehus

Transkript

1 Skulderinstabilitet Cecilie Piene Schrøder Lovisenberg Diakonale Sykehus

2 Labrum Skade ( Bankart lesjon ) regnet som den vesentlige lesjon Bankart Lesion

3 Skulderinstabilitet er ikke fremre, men en fremre, nedre instabilitet Kapselskift (Syd-Nord) er nødvendig!

4 Artroskopisk Bankart Hovedårsak til svikt : Vår manglende evne til å addressere den plastiske deformasjon av kapselen

5 Kapselskiftet kan individualiseres : Medial Plication (Øst-Vest) Proximal Shift (Syd - Nord)

6 Kirurgisk Teknikk Isolated Reinsertion of Labrum Associated Capsular Plication Medial kapselplikasjon (Øst- Vest) i

7 Apprehensiom/Relocation test Apprehension Relocation Instabilitet; fremre, bakre, SLAP

8 Klinisk Undersøkelse Se etter for kapselutvidelse: Asymetrisk Inferior Drawer (> 2cm) Asymetrisk Ext. Rot. (>20 ) Asymetrisk Hyperabduction (> 20 )

9 Asymetrisk Hyperabduction +++ Hyperabduction Test (Gagey)

10 Traumatisk fremre instabilitet

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12 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%

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14 Hyperlaksiditet + bakre /fremre instabilitet

15 Hvordan er våre resultater? 140 pasienter i en retrospektiv studie (operert ) Uavhengig undersøker Magnus Wallumrød Rowe score, WOSI score, pasientfornøydhet 120/123 har svart; 5 på telefon, 115med klinisk undersøkelse (93.5% follow-up)

16 Resultater Residiv 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%

17 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 %

18 Konklusjon Med 13 % residivinstabilitet etter 2-4, hva blir Resultatet etter lengre tids oppfølging? Fra : 158 pasienter 42(33%) Primær Latarjet, 79 (62.2%) Artroskopisk Bankart, 6(4.8%)% Remplissage + Bankart 31 Latarjet pga av residivinstabilitet

19 Operativ teknikk Latarjet Delto-pectoral approach

20 Operativ teknikk CA-ligament sectioned Pec.Minor Coracoid osteotomy

21 Operativ teknikk Subscap division horisontal Capsulotomy Glenoid exposure 2 parallel bicortical screws

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

23 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,

24 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

25 Remplissage, Hill Sachs, lite eller intet Bentap glenoid

26 @ Hill-Sachs Remplissage Wolfe et al.; a modification of Conolly`s open procedure, the arthroscopic technique of Hill- Sachs remplissage, Performed in combination with Bankart repair. Wolf et al NSC 2004, Arthroscopy 2008

27 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

28 Kirurgisk remplissage Åpen Latarjet Fremre kapselplikasjon med 2 resorberbare ankre

29 SLAP skader O`Brien Test Apprehension/relocation Crank test

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31 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

32 ! 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

33 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

34 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, sessions, 20 self-administered sessions.

35 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 ) Allocated to biceps tenodesis (n= 39 ) Allocated to labral repair (n= 40 ) Lost to follow-up (did not show up for 6 months control) (n= 1 ) Lost to follow-up (did not show up for 6 months control) (n= 1 ) Lost to follow-up (give reasons) (n= 0 ) Mean age 40 years, 40% females

36 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

37 Results 1 year Rowe Score

38 Results 1 year Western Ontario Shoulder Index

39 Results 1 year Oxford Instability Shoulder Score

40 Patient satisfaction 1 year Sham Surgery Biceps Tenodesis Labral Repair Excellent Good Fair Poor Total

41 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

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