Dr Arthur van Noort Orthopedisch Chirurg Spaarne Ziekenhuis. Behandelstrategie van anterieure schouderinstabiliteit na een ski ongeval

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1 Dr Arthur van Noort Orthopedisch Chirurg Spaarne Ziekenhuis Behandelstrategie van anterieure schouderinstabiliteit na een ski ongeval

2 Disclosure information I disclose the following financial relationships with commercial entities that produce health-care related products or services: Consultant for: DePuy Synthes

3 INTRODUCTIE H SOCHI 2014: Anterieure schouderluxaties? Epidemiologie Klassieke beeld of uitgebreider letsel Behandelstrategie (glenoid/humeruskop) Conclusies/Aanbevelingen

4 Aantal geblesseerde atleten in Sochi is te vergelijkbaar met vorige Spelen. (IOC) Ondanks verschillende zware valpartijen in het Rosa Khutor Extreme Park. De afgelopen dagen liepen enkele atleten zware blesssures op, voornamelijk bij het freestyleskiën en het snowboarden. KRASNAYA POLYANA, Russia American snowboarder Arielle Gold will not compete in the Olympics after suffering an unspecified shoulder injury in training on Wednesday.

5 There s no fracture, Ansermoz said. No nerve damage. She s a fighter. She has a second chance at the Olympics, and she s going to take the chance. Skier Marie-Michele Gagnon dislocates shoulder, plans to race slalom

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7 KLASSIEK LETSEL: LABRUM LESIE MET PLASTISCHE DEFORMATIE VAN LIGAMENTAIR COMPLEX?

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9 Benige Bankart lesie

10 EPIDEMIOLOGIE Meest voorkomend luxerend gewricht ( 50%) 95.8% van de glenohumerale luxaties van het anterieure type en 4.2% overige H type = gelijke verdeling algemene populatie. Letsels bovenste extremiteit: snowboarders > skiërs 5.5% van alle letsels en 71% van alle luxaties per 1000 participant days in snowboarders en per 1000 participant days in skiërs. (Luxatie kans alg populatie/jaar) Factoren: leeftijd; geslacht; ervaring; snelheid; sneeuwconditie. Ernstig (geassocieerde) letsels (botverlies glenoid/luxatie fracturen) Ogawa H, Sumi H, Sumi Y, et al. Glenohumeral dislocations in snowboarding and skiing. Injury 2011; 42:

11 BEHANDELSTRATEGIE De vraag is: wat is de correcte H behandelstrategie

12 Dr Ron te Slaa Prof. Pascal Boileau

13 BEHANDELSTRATEGIE De juiste Operatie voor de juiste patient H Arthroscopische Bankart Repair Level 3 (Case Control) Cohort 131 pat. Follow up 32 maanden. Geen pat. Selectie 15% recidief RISICOFACTOREN??? 75% recidief glenoid botverlies + hyperlaxiteit Boileau P et al. Risk Factors for Recurrence of Shoulder Instability After Arthroscopic Bankart Repair Shoulder Instability After Arthroscopic Bankart Repair JBJS (Br) 88-A 2006; 8:

14 BEHANDELSTRATEGIE: Instability Severity Index Score (ISIS) Balg F, Boileau The instability severity index score. JBJS (Br) 89-B 2007; 11: Resultaten van operatieve behandeling diteit in vergelijking met een open techniek Lenters e.a. beschrijven in een recente meta-analy- Dit betreft overigens specifiek de patiëntengroep prognostische factoren punten punten < 20 jaar: 31% recidief >30 jaar: 4% leeftijd op moment van de operatie 20 2 > 20 0 niveau sportparticipatie Competitief: 50% competitief H recidief 2 recreatief/geen sport 0 type sport contact-/bovenhandse sport 1 Contact sports: 33% recidief overige sport 0 Hill-Sachs-laesie op AP-röntgenopname zichtbaar op exorotatieopname 2 Hyperlaxiteit: niet 19% zichtbaar recidief op exorotatieopname 0 botverlies glenoïd op AP-röntgenopname verlies van contour 2 normale contour 0 Totale puntenaantal: Hills Sachs bij exo opname: 31% Bij een ISIS boven de 5 punten is volgens Boileau een artroscopische stabilisatie gecontra-indiceerd. Glenoid subst verlies: 37 % (11%) Tabel 1. Instability severity index score (ISIS).

15 graphics Hyperlaxiteit THE INSTABILITY SEVERITY INDEX SCORE 1471 Number (%) 103 (78.6) 28 (21.4) Anterieur: Exorotatie 73 (55.7) 58 (44.3) >90 82 (62.6) 49 (37.4) 27.3 (14 to 62) 34 (26.0) Inferieur: 1472 F. BALG, P. BOILEAU 48 (36.6) 49 (37.4) 17.9 (2 to 200) 2.6 (0 to 40) 15.2 (0 to 20) 110 (84.0) 21 (16.0) 110 (84.0) 21 (16.0) 30 (22.9) 86 (65.6) 15 (11.5) Fig. 1 External rotation of more than 85 with the arm at the side demonstrates anterior shoulder hyperlaxity. months follow-up. Exclusion criteria were: patients with a concomitant rotator cuff lesion (7) or an acute first-time dislocation (3); surgery for recurrent instability after a previous anterior stabilisation (14); surgery for a painful, unstable shoulder without true dislocation or subluxation (18), and multidirectional instability. No patient was excluded for bone loss, high-risk sports and activities or Hyperabductie > 20

16 n and Exclusion Criteria er to evaluate the value of this arthroscopic Bankart dure, we decided to perform this operation only in a consecutive patients with traumatic, recurrent anterior ty, regardless of the preoperatively identified lesions. eria for inclusion were (1) the presence of traumatic, reanteroinferior shoulder instability, (2) labral repair and retensioning with use of a single arthroscopic technique ure anchors, (3) surgery performed by the senior sur- B.) or under his direction, and (4) a clinical examinainterview with the patient performed at least two years gery by independent observers. clusion criteria were (1) arthroscopic stabilization for irst) anterior dislocation or subluxation; (2) arthrotabilization after a previous failed instability repair; (3) preference for open stabilization; (4) other types of ty such as voluntary instability, posterior instability, ltidirectional instability (defined as instability in three ns) 24. tween July 1999 and August 2001, 100 consecutive who had arthroscopic Bankart repairs for traumatic, t anterior shoulder instability, with use of suture anet the inclusion criteria. Fig. 4a strated anterior hyperlaxity. Inferior shoulder laxity was defined as a difference of >20 between sides on hyperabduction (the Gagey test) 28,29. This sign is usually unilateral and is an indicator of a stretched inferior capsule because of plastic deformation of the inferior glenohumeral ligament secondary to instability 29. Twenty-six patients demonstrated such inferior laxity. Sixteen patients were considered to have a stretched inferior glenohumeral ligament. THE INSTABILITY SEVERITY INDEX SCORE 1473 Evaluation of Osseous Lesions and Bone Loss All patients underwent a preoperative radiographic evaluation, including anteroposterior radiographs made with the arm in three different rotations (neutral, external, and internal), a scapular lateral radiograph, and an axillary radiograph. Assuming that bone loss was a risk factor for the recurrence of instability, we asked our patients to have a preoperative computed tomographic scan, unless they already had a magnetic resonance imaging scan. Preoperative computerized tomography scans were available for sixty-six patients. All patients had an arthroscopic examination, with the arthroscope placed first in the posterior portal and then in the anterior portal. Evaluation was initially performed with use of 20 ml of air insufflation Fig. 4b to gauge the humeral transla- Fig. 4c Glenoid lesions on anteroposterior radiographs showing a) normal shoulders, b) avulsion fracture, and c) loss of inferior contour. opulation tients were lost before two years of follow-up, leaving a f ninety-one patients available at the time of the final GLENOID SUBSTANTIE VERLIES vated from the anterior glenoid, the aim being to shift the labrum proximally and laterally. Visualisation of the subscapularis fibres and a feeling of elasticity of the inferior glenohumeral ligament were thought to indicate satisfactory soft-tissue mobilisation. The aim of the procedure was to retension the anterior capsule. After decorticating the glenoid neck, holes were sited at the edge of the anterior articular surface. A hooked needle (Spectrum, ConMed Seventy-one patients (78%) were male. The mean age atients was 21.5 ± 3.5 years (range, twelve to forty-nine t the time of injury and 26.4 ± 5.4 (range, seventeen to o years) at the time of surgery. The dominant side was in fifty-three patients (58%). Bilateral anterior instaas present in fifteen patients (16%). The diagnosis of instability was made when there was a history of subwith spontaneous reduction or a history of disloequiring manual reduction, and all patients had a anterior apprehension and relocation test 25,26. Twentyients had recurrent dislocations, thirty-nine had resubluxations, and thirty had both subluxations and ions. The average number of instability episodes varh seven episodes (range, two to forty) for the patients locations, twenty-three episodes (range, two to 150) for ents with subluxations, and twenty episodes (range, Fig. 1 Linvatec, Largo, Florida) was used to pass a suture (PDS II Paired Student s t-tests were used to compare means. A score was calculated with this information, keeping factors with a p-value < 0.05 and those with strong support in the literature. The score was then re-applied to the study population and a stepwise scale with associated recurrence rate was tested. Analysis was performed using SPSS statistical software version 11.0 (SPSS Inc., Chicago, Illinois). Results

17 Hills Sachs Lesie Fig. 2 Labral detachment from the glenoid rim was divided into six zones (A, B, C, D, E, and F). head with computed tomography scans because a standardized protocol was not used. The term humeral bone defect was arbitrarily applied if a clinically important part of the humeral head surface was missing on assessment during the arthroscopic procedure. Evaluation of Labral and Ligamentous Lesions Arthroscopic examination was used to evaluate the extent of the labral detachment around the glenoid, the degree of capsular laxity, and the quality of the tissue by direct visualization Fig. 2a Fig. 2b A difference in hyperabduction of 20 or more between the sides demonstrates inferior shoulder hyperlaxity (i.e. a stretched inferior axillary pouch). Fig. 3-A Fig. 3-B A humeral bone defect (a large Hill-Sachs lesion involving >25% of the articular head surface) can be appreciated on the anteroposterior radiograph made with the shoulder in internal rotation (Fig. 3-A) and during arthroscopy (the arthroscope is posterior) (Fig. 3-B). Downloaded From: by a Spaarne Ziekenhuis User on 09/19/2013

18 HILLS SACHS LESIE Aangezien de meeste Hill-Sachs-laesies klein (0-2 cm) of gemiddeld (2-4 cm) zijn, lijken ze geen invloed te hebben op recidiefinstabiliteit. Klinische relevantie? H Groot defect: mogelijkheid contact hills sachs lesie en glenoid (engaging hills sachs lesie). Groter dan 60% vd radius Chuang TY, Adams Fig. CR, 1 Burkhart SS. Use of preoperative three- dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy. 2008;24:

19 BEHANDELSTRATEGIE Waarde van ISIS Score H aangetoond Validation of the ISIS Score in a multicenter reliability study in 114 consecutive cases Rouleau et al. Am J Sports Med 2013 Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score. Thomazeau et al. Orthop Trauma Surg Res 2010 Omslagpunt? < 5 < 3?

20 BEHANDELSTRATEGIE: de praktijk Eerste posttraumatische anterieure luxatie bij niet-topsporter volgens de richtlijn: conservatief Recidief luxatie: persisterende instabiliteit positieve apprehension/ relocation ISIS (< 5) geen substantieverlies op X Aanvullend MRI arthro: ARTHROSCOPISCHE STABILISATIE Nederlandse Orthopaedische Vereniging. Richtlijn Acute primaire schouderluxatie: diagnostiek en behandeling. Alphen aan den Rijn: Van Zuiden, 2005.

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22 BEHANDELSTRATEGIE: de praktijk Recidief luxatie: persisterende instabiliteit positieve apprehension/ relocation ISIS (> 5?) wel substantieverlies op X Aanvullend 3d CT-wegscannen humeruskop: < of >20% verlies Voorheen Open Bankart Repair Tendens richting (open) Latarjet Techniek (congruent arch techniek- Joe de Beer)

23 BEHANDELSTRATEGIE: de praktijk g. 2-A Recidief luxatie: persisterende instabiliteit positieve apprehension/ relocation ISIS (> 5?) wel substantieverlies op X van glenoid en humeruskop Fig. 2-B Testen bij scopie: engaging hills sachs? Engaging Hills Sachs: Latarjet Alleen substantie verlies humerus Remplissage? g. 3-A Fig. 3-B Wolf EM et al. Hill-Sachs 2014, remolissage: 4(1):e4 an arthroscopic solution for the 6 engaging Hill-Sachs lesion ed From: by a UVA UNIVERSITEITSBIBLIOTHEEK SZ User on 03/23/2014 Arthroscopy 2004; 20:e (Suppl)

24 BEHANDELSTRATEGIE: de praktijk Porcellini, Solomonsson Evaluation of a treatment algorithm for acute traumatic osseous Bankart lesions resulting from first time dislocation of the shoulder with a two year follow-up. Spiegl et al. BMC Musculoskelet Disord. 2013; 14: 305.

25 Conclusies/aanbevelingen Skiën: Hoog risico sport mbt voorste schouderluxatie/instabiliteit Skiërs (snowboarders) meer kans op uitgebreider letsel na een voorste schouderluxatie Mbt behandelingsstrategie is het van belang de risicofactoren bij het individu te her- en erkennen: leeftijd, type sport, niveau, hyperlaxiteit en substantieverlies van glenoid en humeruskop Naar mate het aantal risicofactoren afneemt, neemt de voorspelbaarheid op een goede afloop na een arthroscopische stabilisatie toe.

26 Anterieure schouder luxatie persisterende instabiliteit Benig letsel (niet acuut) GLENOID VERSUS HUMERUSKOP Geen Benig letsel (alpsa,hagl,bankart) ISS (<5) X: geen ossale afw Glenoid: >20%: Latarjet <20%:? Latarjet- Scopisch Humeruskop: >60% radius: Latarjet <:?/geen consequenties Arthroscopische stabilisatie

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