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multidirectional instability of the shoulder 2014

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Post on 01-Jul-2015

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Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.

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2. www.wrightington.com2 3. ? MDIwww.wrightington.com322yr secretary, asymptomaticHyperlax in all directionsANTERIORPOSTERIOR INFERIOR 4. ?MDIwww.wrightington.com417yr old swimmer - overstretch in poolSubluxing posterior in flexion and painful 5. ?MDI20 year old rugby player - tackling impact injuryPain & dead arm; feels unstableLarge anterior and posterior labral tearswwwwww.w.wrigrhigtinhgttionng.ctoomn.com5 6. MDI - Definitions?1. Shoulder Instability in patients who have generalisedlooseness of the ligaments of the shoulder [Web Dictionary]2. Generalised looseness of the shoulder joint3. Abnormal excursion of the humeral head on the glenoid in alldirections [Neer]4. Instability in TWO directions [1,2,3,4]5. Instability in THREE directions [5,6,7]6. Motor Control Trouble - the less surgery the bestwwwwww.w.wrigrhigtinhgttionng.ctoomn.com(Olivier Gagey - 20min ago!)6 7. wwwwww.w.wrigrhigtinhgttionng.ctoomn.comnferiorshiftehabilitationilateralultidirectionaltraumaticRange AMBRITUBS7urgeryankartnidirectionalumaticra 8. The use of laxity testing tends to result in an overestimation of thenumber of patients with this condition.This observation is important because the results of studies may varyif patients with traumatic instability are considered to havemultidirectional instability on the basis of laxity testing.Investigators studying patients with multidirectional instability shouldcarefully define the inclusion criteria that they used.wwwwww.w.wrigrhigtinhgttionng.ctoomn.com8 9. Uncontrollable, involuntary inferior subluxationor dislocation, associated with both anterior andposterior dislocations or subluxations of theshoulder.wwwwww.w.wrigrhigtinhgttionng.ctoomn.com9 10. Stanmore ClassificationAtraumaticwwwwww.w.wrigrhigtinhgttionng.ctoomn.com11Polar ITraumatic StructuralPolar IIAtraumatic StructuralPolar IIIMotor Control 11. What is it?www.wrightington.com12 Shoulder Instability in patients who have generalisedlooseness of the ligaments of the shoulder [Web Dictionary] Atraumatic Multidirectional laxity Uni/Multidirectional Instability 12. Stanmore ClassificationAtraumaticwwwwww.w.wrigrhigtinhgttionng.ctoomn.com13Small lesion RepairCapsular PlicationsPolar ITraumatic StructuralPolar IIAtraumatic StructuralPolar IIIMotor ControlLarge lesion RepairBony ReconstructionsRehab +/-Capsular PlicationSpecialistRehab. 13. RehabOptimise:CoreScapulaKinetic ChainPsychologyProprioceptionwwwwww.w.wrigrhigtinhgttionng.ctoomn.com14 14. Proprioceptionwww.wrightington.com15Mechanoreceptors in GHLJerosch et al. 1997Gohlke et al 1998 15. www.wrightington.com16Capsular Plication / Shift 16. Capsular Plication / Shiftwww.wrightington.com17 17. Capsular Plicationwwwwww.w.wrigrhigtinhgttionng.ctoomn.com20 18. Capsular Plication ResultsArthroscopic 88-94% success at 2-5yrs GartsmannOpen94% good/excellent at 5yrs Bigliani59% good/excellent83% satisfactoryHamadawwwwww.w.wrigrhigtinhgttionng.ctoomn.com 25 19. Arthroscopic Plication AuditClinical outcome of arthroscopic capsularplication for atraumatic instability (Stanmore II)of the shoulder by a single surgeon, with >12month follow-up.wwwwww.w.wrigrhigtinhgttionng.ctoomn.com26Tablot, Carter & Funk, BESS 2012 20. Patients 23 patients (16 ) Average age 27 (19 41 years) Follow-up 15.6 months (range 4 - 40 months) Previous Thermal Capsular Shrinkage: 6 Average Pre-Op Specialist Physio: 5.4 monthswwwwww.w.wrigrhigtinhgttionng.ctoomn.com27 21. Pre-op Post-op*www.wrightington.com28* Statistically significantly improved score (p


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