2022年医学专题—肩关节前脱位Anterior-Shoulder-Dislocation(1).ppt

Acute anterior dislocation of the shoulder,第一页，共三十二页。,AnatomyStability:-ball&socket=compression in concavity effectBone-big head small cup=unstableMenisci-labium=depth of cup by 20%Ligaments-glenohumeral&capsuleMuscles-rotator cuff&biceps=holds ball in cupPrimary Movers-Deltoid,Pec.major&Lat.Dorsy=subluxing forces Dynamic-proprioceptive feedback,第二页，共三十二页。,Pathophysiology(Lazarus 1996)Chondro-labral defect causes a 65%reduction in stability in the direction of the defectDeficiency of the ant.inf.capsulolabral complex Fracture of ant.lip of glenoid=15%Detachment of labarum/capsule=15%Tear of glenohumeral ligaments=54%Avulsion of subscapularis and ligs of humerus(HAGL)To prevent the persistence of the defect it needs to be repairedArthroscopically Open,第三页，共三十二页。,Acute InjurySomething breaks or tears and therefore can be repaired.Repair is better than reconstructRepair is easier than reconstructChronicInstability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortenedRestoring the normal functional anatomy is impossible,第四页，共三十二页。,Conservative TreatmentRowe JBJS,1957324 young patient with ant.dislocations94%had recurrence if 40 years oldBurkhead&Rockwood(text book)40 patients with acute dislocation&vigorous rehabilitationOnly 16%had good or excellent result(1 in 6)Deny&Drew Injury,November 200221%of all patients presenting with shoulder dislocation had previous dislocation in 1 year43%in patients 15-22 years had re-dislocations,第五页，共三十二页。,Non operative treatment of shoulder dislocation in young athletesArciera J Arthroscopy,1995De Beardino J South Orthopaedic Ass,1996Haelen J Arch Orthopaedic Trauma Surgery,1990Hovelius J Orthopaedic Science,1999Wheeler J Arthroscopy,1998Kirkby J Arthroscopy,1999 all over 80%recurrence rateNon operative treatment is unacceptable,第六页，共三十二页。,Prospective Randomised Study Bottani etc.Military Personnel Medicine Vol 30 No 4 2000First Time Acute Traumatic Shoulder DislocationStabilisation Vs Non Operative:Follow up in 36 months24 patients aged 18-26y.14 Non Operative rehab immobilised 4 weeks9 of 12 non operative had instability(75%)(6 open Bankart repair)10 ASC Bankart repair with bioabsorbable tack 10 days1 of 9 operated patients had instability(11%),第七页，共三十二页。,Comparison of Arthroscopic&Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbeck 199830323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair?Due to plastic deformation,Chronic anterior instability,第八页，共三十二页。,Arthroscopic Techniques for Primary Dislocations1982 Johusa with staples1987 Morgen&Badenstab transglenoid sutures1991 Caspari-Cannulated bio-absorbable tacks 1993 Wolf&Snyder suture anchors=difficult1989 Wheller-ASC staple1993 Gohlke-Suture anchors1994 Arciera-ASC transglenoid1996 Speer-Bio-absorbable tack1999 Wintzell-ASC lavage2000 Introduction of a multitude of new gadgets&anchors,第九页，共三十二页。,Arthroscopic RepairsEinoder,1984 Knee ClubDescribed Arthroscopic transglenoid sutures using:K wire with eye(ACL)introduced via anterior portalSucking tubeSutures tied over infraspinatus fascia or spine of scapula Results4 out 5 patients returned to the same level of sport with no re-dislocations,第十页，共三十二页。,Arthroscopic Repair,第十一页，共三十二页。,第十二页，共三十二页。,第十三页，共三十二页。,Boszotta&Helperstorfer Arthroscopy,July 2000 Transglenoid suture repair for initial Ant.dislocation72 patients(1988-95)61 11 Aged 19-3934%=Bankart lesion(6 with bone)66%=Avulsion of capsulolabral complexResults7%=Redislocation all due to trauma(severe in 2 out of 5)85%=Returned to unrestricted pre injury sporting activities,第十四页，共三十二页。,Randomised StudiesAsc.Stabilisation Vs Non OperativeArciera et.al.A.J.Sports Med.,199432 military men with acute 1st up dislocation,Average of 32 months follow up15 patients non operative 80%redislocated21 patients transglenoid suture 14%redislocatedBottony&Wilkings etc.A.J.Sports Medicine 2000Patients with acute traumatic first time shoulder dislocation14 young patients non op,75%redislocation10 young patients Asc.Bankart repair,10%redislocation,第十五页，共三十二页。,Asc.stabilisation Dara&Gerber Journal of Shoulder&Elbow,200020 shouldersAv 3 year follow upRecurrences occurred in patients who were chronic dislocators i.e.30%Therefore now do open surgery for recurrent dislocationsAsc.surgery for acute dislocationsDe Beardino et al An J.Sports Med.,200049 1st up acute post traumatic Shoulders dislocationAverage 37 months follow up Tack anchor.6 Patients re-dislocated(13%)+4 had open surgery,第十六页，共三十二页。,Bozzotta&Helpastorger(Austria)J.Arthroscopy,2000 Arthroscopic Transglenoid Suture Repair for Initial Ant.Shoulder Dislocation72 Patients61 11-Sporting ambitious patients25 Patients Bankart lesion(6 with bone)43 Patients Capsulolabral avulsionResults5 patientsRe dislocated 2 had significant trauma3 had insignificant trauma=4%Therefore results of primary repair are better than s