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SHOULDER INSTABILITY IN PATIENTS WITH EDS

EDNF 2012 CONFERENCE LIVING WITH EDS. SHOULDER INSTABILITY IN PATIENTS WITH EDS. Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery University of Cincinnati. DISCLOSURE.

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SHOULDER INSTABILITY IN PATIENTS WITH EDS

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  1. EDNF 2012 CONFERENCE LIVING WITH EDS SHOULDER INSTABILITY INPATIENTS WITH EDS Keith Kenter, MD Associate Professor Sports Medicine & Shoulder Reconstruction Director, Orthopaedic Residency Program Department of Orthopaedic Surgery University of Cincinnati

  2. DISCLOSURE KEITH KENTER I HAVE NOTHING TO DISCLOSE AND NO CONFLICT OF INTEREST AS IT RELATES TO THIS PRESENTATION INSTITUTIONAL SUPPORT NIH (RESEARCH) SMITH & NEPHEW (EDUCATION GRANT) JOURNAL REVIEWER/EDITORIAL BOARDS JBJS, AJSM, BJSM

  3. INDIVIDUALIZED TREATMENT Single Dislocation ≠ Recurrent Instability

  4. DEFINITIONS LAXITY Range of motion of the center of the humeral head with respect to the glenoid fossa due to a external force INSTABILITY Symptomatic inability to maintain the humeral head in the glenoid fossa

  5. DEFINITIONS SUBLUXATION • Partial dislocation • Incomplete separation of joint DISLOCATION Frank separation of joint

  6. CLASSIFICATION DIRECTIONAL • Anterior • Posterior • Multidirectional

  7. CLASSIFICATION MECHANISMS • TUBS - Traumatic Unidirectional Bankart Surgery • AMBRI – AtraumaticMultidirectional Bilateral Rehabilitation Inferior shift

  8. GLENOHUMERAL INSTABILITY Complex interaction between physiologic laxity to provide range of motion and joint stability. STABILITY MOBILITY EDS

  9. THE EDS SHOULDER INCREASED LAXITY HIGHER RISKS FOR INSTABILITY (MDI)

  10. ANATOMIC CONSIDERATIONS CONSTRAINTS • Passive • Static • Dynamic

  11. PASSIVE CONSTRAINTS BONY ANATOMY • Humeral head • Glenoid fossa

  12. PASSIVE CONSTRAINTS INTRA-ARTICULAR PHYSICS • Negative pressure • Joint fluid cohesion

  13. PASSIVE CONSTRAINTS LABRUM Fibrocartilagenous lip that increases glenoid depth and increases humeral contact area • 75% superoinferior • 50% anteroposterior ClinOrthop243; 1989

  14. STATIC CONSTRAINTS • Capsular envelope • Glenohumeral ligaments

  15. GLENOHUMERAL LIGAMENTS • SUPERIOR - restraint for inferiortranslation in adducted shoulder • MIDDLE - restraint for anteriortranslation in 45º abducted shoulder • INFERIOR - restraint for anterior andinferior translation in abducted shoulder

  16. GLENOHUMERAL LIGAMENTS MGHL SGHL IGHL

  17. DYNAMIC CONSTRAINTS • Rotator cuff group • Biceps tendon • Scapular rotators

  18. ANTERIOR TRANSLATION FLEXION ‘CROSS BODY’ MOTION POSTERIOR TRANSLATION EXTENSION EXTERNAL ROTATION BIOMECHANICS HARRYMAN JBJS 72A; 1990

  19. BIOMECHANICS KENTER Anterior Tightening Abduction Forward Flexion ER No Translation ASES; 1999

  20. TREATMENT • Immediate reduction of the dislocated shoulder • Physical therapy program Rotator Cuff strengthening Scapular stabilizer strengthening • Surgical intervention

  21. EDS SHOULDER INSTABILITY • Patient education and defining the collagen disorder are paramount • Modification on activity and work on mechanics • Core strength, spine posture, RC strength, and scapular muscle strength • Surgical results about 30% recurrence in patients without anatomic lesions

  22. REHABILITATION

  23. REHABILITATION

  24. REHABILITATION

  25. REHABILITATION

  26. MULTI-DIRECTIONAL INSTABILITY MISAMORE • 64 patients ave 16 year (9-30) at 8 years • 43 female / 21 male • PT program with RC and parascapular strengthening • 57 patients available at follow-up • 63% (36/57) without surgery • Pain – 23 good-excellent • Instability – 17 good-excellent • Poor response: • (unilateral/ADLs/hyperlaxity/3months) JSES 14; 2005

  27. SURGICAL MANAGEMENT • WHEN TO OPERATE • HOW TO DO IT Open Arthroscopic ADDRESS THE PATHOANATOMY

  28. ANTERIOR DISLOCATION NATURAL HISTORY • Age related • < 22 years – 60-90% • 30-40 years – 50-65% > 50 years – RC Tears 60+ years about 40% • Pathology related • < 25 years up to 85% with Bankart labral tear JBJS 88A; 2006 JBJS 89A; 2007

  29. SO WHAT ?? DOES RECURRENCE CAUSE DAMAGE HABERMEYER 76 patients with anterior dislocations evaluated with arthroscopy • 9 with 1 dislocation Labrum • 12 with 1- 2 dislocations Ligament • 23 with 3-5 dislocations Double ligament • 32 with 6+ dislocations Articular cartilage JSES 8; 1999

  30. CARTILAGE BREAKDOWN FIRST TIME DISLOCATION

  31. ARTHROSCOPIC ADVANCES • Rapid evolution in techniques • Early techniques secure labrum to bone • Address capsular laxity Capsular shift Capsular split Capsular plication Thermal ‘shrinkage’

  32. ARTHROSCOPIC TECHNIQUES • PRO Visualize all pathology Less stiffness Easier to revise • CON Less reliable/technically demanding Higher failure rates (some authors) Portal scars

  33. SURGICAL TECHNIQUE

  34. SURGICAL TECHNIQUE

  35. SURGICAL TECHNIQUE

  36. SURGICAL TECHNIQUE

  37. SURGICAL TECHNIQUE

  38. ARTHROSCOPIC TECHNIQUES CONTRAINDICATIONS • Capsular deficiency • Glenoid bone loss • Humeral head defect • Collision athlete ? • Surgeon’s skill level

  39. CAPSULAR PLICATION

  40. THERMAL • Addresses residual laxity • Repair labrum first • Avoid suture line • Paint in grid fashion DO NOT RECOMMEND

  41. SUMMARY • Complex interaction between stability and mobility. • Neuromuscular training and strengthening program for the shoulder girdle is paramount esp in MDI. • Surgical emphasis is to restore anatomy and capsular tension. • Arthroscopic challenge today is reproducibility of quantifying amount of capsular redundancy during repair.

  42. THANK YOU

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