Dr Arthur van Noort Orthopedisch Chirurg
Spaarne Ziekenhuis
Behandelstrategie van anterieure
schouderinstabiliteit na een ski ongeval
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I disclose the following financial relationships with
commercial entities that produce health-care
related products or services:
Consultant for: DePuy Synthes
INTRODUCTIE
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H
SOCHI 2014: Anterieure schouderluxaties
?
Epidemiologie
Klassieke beeld of uitgebreider letsel
Behandelstrategie (glenoid/humeruskop)
Conclusies/Aanbevelingen
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.
Skier Marie-Michele
Gagnon dislocates
shoulder, plans to
race slalom
“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.”
KLASSIEK LETSEL:
LABRUM LESIE MET PLASTISCHE DEFORMATIE VAN
LIGAMENTAIR COMPLEX ?
Benige Bankart lesie
EPIDEMIOLOGIE
•  Meest voorkomend luxerend gewricht (≈ 50%)
•  95.8% van de glenohumerale luxaties van
H type
het anterieure type en 4.2% overige
= gelijke verdeling algemene populatie.
•  Letsels bovenste extremiteit: snowboarders > skiërs
•  5.5% van alle letsels en 71% van alle luxaties
•  0.0676 per 1000 “participant days” in snowboarders en 0.0295 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: 1241-1247
BEHANDELSTRATEGIE
De vraag is: wat is de correcte
behandelstrategie
H
Prof. Pascal Boileau Dr Ron te Slaa 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: 1755-1463
BEHANDELSTRATEGIE:
Instability Severity Index Score (ISIS)
prognostische factoren
punten
< 20 jaar: 31%≤ 20recidief >30 jaar:2 4%
punten
leeftijd op moment van de operatie
> 20
competitief
H
recreatief/geen sport
contact-/bovenhandse sport
overige sport
zichtbaar op exorotatieopname
niet zichtbaar op exorotatieopname
verlies van contour
normale contour
Competitief: 50% recidief
niveau sportparticipatie
type sport
Contact sports: 33% recidief
Hill-Sachs-laesie op AP-röntgenopname
Hyperlaxiteit: 19% recidief
botverlies glenoïd op AP-röntgenopname
0
2
0
1
0
2
0
2
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).
Balg F, Boileau The instability severity index score. JBJS (Br) 89-B 2007; 11: 1470-1477
Resultaten van operatieve behandeling
Lenters e.a. beschrijven in een recente meta-analy-
diteit in vergelijking met een open techniek.64-66
Dit betreft overigens specifiek de patiëntengroep
THE INSTABILITY SEVERITY INDEX SCORE
Hyperlaxiteit
1471
ographics
Number (%)
103 (78.6)
28 (21.4)
Anterieur:
Exorotatie
>90°
73 (55.7)
58 (44.3)
82 (62.6)
49 (37.4)
27.3 (14 to 62)
Inferieur: 1472
34 (26.0)
48 (36.6)
49 (37.4)
F. BALG, P. BOILEAU
Fig. 1
External rotation of more than 85˚ with the arm at the side demonstrates
anterior shoulder hyperlaxity.
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)
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°
on and Exclusion Criteria
rder to evaluate the value of this arthroscopic Bankart
edure, we decided to perform this operation only in a
f consecutive patients with traumatic, recurrent anterior
ity, regardless of the preoperatively identified lesions.
teria for inclusion were (1) the presence of traumatic, reanteroinferior shoulder instability, (2) labral repair and
retensioning with use of a single arthroscopic technique
ture anchors, (3) surgery performed by the senior surP.B.) or under his direction, and (4) a clinical examinad interview with the patient performed at least two years
rgery by independent observers.
xclusion criteria were (1) arthroscopic stabilization for
first) anterior dislocation or subluxation; (2) arthrostabilization after a previous failed instability repair; (3)
preference for open stabilization; (4) other types of
ity such as voluntary instability, posterior instability,
ultidirectional instability (defined as instability in three
ons)24.
etween July 1999 and August 2001, 100 consecutive
s who had arthroscopic Bankart repairs for traumatic,
nt anterior shoulder instability, with use of suture anFig. 4a
met the inclusion criteria.
strated anterior hyperlaxity.
Inferior shoulder laxity was defined as a difference of
INSTABILITY SEVERITY INDEX SCORE
>20° THE
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 instability29. Twenty-six
patients demonstrated such inferior laxity. Sixteen patients were
considered to have a stretched inferior glenohumeral ligament.
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
Fig. 4b to gauge the humeral translause of 20 mL of air insufflation
1473
Fig. 4c
Population Glenoid lesions on anteroposterior radiographs showing a) normal shoulders, b) avulsion fracture, and c) loss of inferior contour.
atients were lost before two years of follow-up, leaving a
of ninety-one patients available at the time of the final
Seventy-one patients (78%) were male. The mean age
patients was 21.5 ± 3.5 years (range, twelve to forty-nine
at the time of injury and 26.4 ± 5.4 (range, seventeen to
wo years) at the time of surgery. The dominant side was
d in fifty-three patients (58%). Bilateral anterior instavated
frompatients
the anterior
glenoid,
was present
in fifteen
(16%). The
diagnosisthe
of aim being to shift the Paired Student’s t-tests were used to compare means. A
r instability
was made
when there and
was a laterally.
history of sublabrum
proximally
Visualisation of the sub- score was calculated with this information, keeping factors
n with spontaneous reduction or a history of disloscapularis fibres and a feeling of elasticity of the inferior with a p-value < 0.05 and those with strong support in the
requiring manual reduction, and all patients had a
25,26 thought to indicate satisfacwere
literature. The score was then re-applied to the study pop. Twentye anteriorglenohumeral
apprehension andligament
relocation test
tients had
recurrent
dislocations,
thirty-nineThe
had aim
re- of the procedure was ulation and a stepwise scale with associated recurrence rate
tory
soft-tissue
mobilisation.
subluxations,
and thirtythe
had anterior
both subluxations
andAfter decorticating the was tested. Analysis was performed using SPSS statistical
to retension
capsule.
tions. The average number of instability episodes varneck,two
holes
were
at the edge of the anterior software version 11.0 (SPSS Inc., Chicago, Illinois).
th seven glenoid
episodes (range,
to forty)
forsited
the patients
slocations,
twenty-three
episodes A
(range,
two to 150)
for (Spectrum, ConMed
articular
surface.
hooked
needle
Fig. 1
ients with
subluxations,
and Florida)
twenty episodes
(range,to pass
Linvatec,
Largo,
was used
a suture (PDS II Results
GLENOID
SUBSTANTIE
VERLIES 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.
Hills Sachs Lesie
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. 2
Labral detachment from the glenoid rim was divided into six zones
(A, B, C, D, E, and F).
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: http://jbjs.org/ by a Spaarne Ziekenhuis User on 09/19/2013
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.
H
•  Klinische relevantie ?
•  Groot defect: mogelijkheid contact hills sachs lesie en glenoid
(engaging hills sachs lesie). Groter dan 60% vd radius
Fig. CR,
1 Burkhart SS. Use of preoperative three- dimensional
Chuang TY, Adams
computed tomography to quantify glenoid bone loss in shoulder instability.
Arthroscopy. 2008;24:376-82.
BEHANDELSTRATEGIE
Waarde van ISIS Score
“aangetoond”
H
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 ?
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.
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)
ig. 2-A
ig. 3-A
BEHANDELSTRATEGIE: de praktijk
•  Recidief luxatie: persisterende instabiliteit – positieve apprehension/
relocation – ISIS (> 5 ?) – wel substantieverlies op X van glenoid en
humeruskopFig. 2-B
•  Testen bij scopie: engaging hills sachs ?
Engaging Hills Sachs: Latarjet
•  Alleen substantie
verlies humerus
Remplissage ?
Fig. 3-B
2014,
4(1):e4
Wolf EM et al. Hill-Sachs
remolissage:
an arthroscopic solution for the
6 engaging Hill-Sachs lesion
Arthroscopy
2004; 20:e 14-15 (Suppl)
ded From: http://surgicaltechniques.jbjs.org/ by a UVA UNIVERSITEITSBIBLIOTHEEK
SZ User on 03/23/2014
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.
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.
Anterieure schouder luxatie
persisterende instabiliteit
Benig letsel (niet
acuut)
GLENOID
VERSUS
HUMERUSKOP
Glenoid: >20%:
Latarjet
<20%: ?
LatarjetScopisch
Geen Benig letsel
(alpsa,hagl,bankart)
ISS (<5)
X: geen ossale afw
Humeruskop:
>60% radius:
Latarjet
<: ?/geen
consequenties
Arthroscopische
stabilisatie
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