RISK ANALISYS IN FIRST RISK ANALISYS IN FIRST

TIME SHOULDER DISLOCATIONTIME SHOULDER DISLOCATION

COMPARED WITH MULTIPLECOMPARED WITH MULTIPLE

DISLOCATIONS: PROSPECTIVE STUDY ONDISLOCATIONS: PROSPECTIVE STUDY ON

ARTHROSCOPIC BANKART REPAIRARTHROSCOPIC BANKART REPAIR

F.AllegraF.Allegra

Arthroscopic Surgery Dept.-Villa Silvana ClinicArthroscopic Surgery Dept.-Villa Silvana Clinic

Aprilia- ItalyAprilia- Italy

FIRST TIME SHOULDER FIRST TIME SHOULDER

DISLOCATION:DISLOCATION:

RISK ANALYSIS TO AVOIDRISK ANALYSIS TO AVOID

MULTIPLE DISLOCATIONSMULTIPLE DISLOCATIONS

Francesco AllegraFrancesco Allegra

Arthroscopic Surgery Dept.- Villa Silvana ClinicArthroscopic Surgery Dept.- Villa Silvana Clinic

Rome-ItalyRome-Italy

Gleno-humeral first time dislocationGleno-humeral first time dislocation

- relocation w/wo general anesthesia- relocation w/wo general anesthesia- immobilization with sling device- immobilization with sling device

DOGMADOGMA

dogma: conservative treatmentdogma: conservative treatment

verify!verify!

analysis with comparative, analysis with comparative, prospective, randomized studiesprospective, randomized studies

recurrence: acquired instability pathologyrecurrence: acquired instability pathology

G-H factors influencing recurrence in gleno-humeralG-H factors influencing recurrence in gleno-humeralfirst time dislocationfirst time dislocation

RECURRENCERECURRENCE

patientpatient

activityactivity pathologypathology

treatmenttreatment

##1 G-H first time dislocation’s risk factor: pt.’s age 1 G-H first time dislocation’s risk factor: pt.’s age

PATIENTPATIENT

Hovelius (JBJS-a,1987) #Hovelius (JBJS-a,1987) #1 risk factor: age1 risk factor: age(not considered contraindication)(not considered contraindication) >22 yy: >55% recurrences>22 yy: >55% recurrences 22-29 yy: >37% recurrences22-29 yy: >37% recurrences 30-40 yy: >12% recurrences30-40 yy: >12% recurrences

Walton (AJSM,2002)Walton (AJSM,2002)“current concept”:risk at 2 age peak“current concept”:risk at 2 age peak >20 yy: 70% recurrences>20 yy: 70% recurrences >60 yy: 65% recurrences>60 yy: 65% recurrences

Hattrup (JSES,2001) age: one of the 5 factors with Hattrup (JSES,2001) age: one of the 5 factors with a negative influence on resultsa negative influence on results

Kralinger(AJSM,2002) age 21-30yy: only risk factorKralinger(AJSM,2002) age 21-30yy: only risk factor

#2 G-H#2 G-H first time dislocation risk factor: first time dislocation risk factor:overhead activity and sports high recurrence rateoverhead activity and sports high recurrence rate

Recurrence rate:Recurrence rate:Henry (AJSM,1982): 95%Henry (AJSM,1982): 95%Simonet (AJSM,1984): 82% Simonet (AJSM,1984): 82% Wheeler (Arthroscopy,1989): 92% Wheeler (Arthroscopy,1989): 92% Arciero (AJSM,1994): 80% Arciero (AJSM,1994): 80% Miniaci (AAOS,1999): correlation between sport, age,Miniaci (AAOS,1999): correlation between sport, age, kind of therapy in determining recurrencekind of therapy in determining recurrence

ACTIVITYACTIVITY

#3#3 G-H first time dislocation risk factor: variability G-H first time dislocation risk factor: variability

PATHOLOGYPATHOLOGY

Baker (AJSM,1990)Baker (AJSM,1990)45 cases G-H first time dislocation: 45 cases G-H first time dislocation: 6 pts G-H subluxation, w GHL elongation, wo labral tears6 pts G-H subluxation, w GHL elongation, wo labral tears 11 pts moderate instability,w elongation, partial labral tears11 pts moderate instability,w elongation, partial labral tears 28 pts severe instability,w GHL elongation, total labral tears28 pts severe instability,w GHL elongation, total labral tears

Habermayer (JSES,1999)Habermayer (JSES,1999)first time dislocation: after 5 episodes:first time dislocation: after 5 episodes: 89% Bankart lesion 42% Bankart lesion89% Bankart lesion 42% Bankart lesion 22% labral tears, GHL lesion 34% ALPSA lesion 22% labral tears, GHL lesion 34% ALPSA lesion 33% GHL elongation 53% GHL lesions33% GHL elongation 53% GHL lesions

DiBerardino (AJSM,2001): poor tissue quality + recurrentDiBerardino (AJSM,2001): poor tissue quality + recurrenttrauma are negative influencing factors on recurrence (12%)trauma are negative influencing factors on recurrence (12%)

##4 G-H first time dislocation risk factor: correct therapy4 G-H first time dislocation risk factor: correct therapydo conservative and physical therapy reduce the risk? do conservative and physical therapy reduce the risk?

TREATMENTTREATMENT

BankartBankart

anterioranterior

instabilityinstability

Bankart + GHLBankart + GHL

postero-inferiorpostero-inferiorinstabilityinstability

““circle conceptcircle concept”(Warren)”(Warren)

first time traumatic dislocationfirst time traumatic dislocation

##4 G-H first time dislocation risk factor: correct therapy4 G-H first time dislocation risk factor: correct therapy Qstn: do conservative and physical therapy reduceQstn: do conservative and physical therapy reduce the recurrence risk? Is it the correct first treatment?the recurrence risk? Is it the correct first treatment?

TREATMENTTREATMENT

Kralinger(AJSM,2002) group of pts. aged 21-30yy: noneKralinger(AJSM,2002) group of pts. aged 21-30yy: noneconfirmation on efficacy of standard treatment such as confirmation on efficacy of standard treatment such as immobilization and phys. therapy in preventing recurrence immobilization and phys. therapy in preventing recurrence

Arciero et al.(AJSM,1994: JSouOrthAs,1996)Arciero et al.(AJSM,1994: JSouOrthAs,1996)big recurrence reduction(12%) in pts. stabilized by scope big recurrence reduction(12%) in pts. stabilized by scope compared with pts. submitted to a conservative treatmentcompared with pts. submitted to a conservative treatment

Bottoni, Arciero et al.(AJSM,2002)Bottoni, Arciero et al.(AJSM,2002)examining 2 groups of pts.the conservative treatment groupexamining 2 groups of pts.the conservative treatment groupdeveloped 75% recurrence, the surgical group 11,1%developed 75% recurrence, the surgical group 11,1%

- conservative treatment (Itoi, JSES,2004) - conservative treatment (Itoi, JSES,2004) - surgical arthroscopic repair- surgical arthroscopic repair

TREATMENTTREATMENT

Itoi (ASES,2003, JSES,2004) Itoi (ASES,2003, JSES,2004) first time dislocation: first time dislocation: Whole 2 groups 20pts. >29yy. 2 groups 11pts.Whole 2 groups 20pts. >29yy. 2 groups 11pts. 6pts.(30%) IR group 6pts. (45%) IR group 6pts.(30%) IR group 6pts. (45%) IR group none (0%) ER group none (0%) ER groupnone (0%) ER group none (0%) ER group

courtesy E.Itoi

Arciero et al.(AJSM,1994: JSouOrthAs,1996)Arciero et al.(AJSM,1994: JSouOrthAs,1996)Bottoni, Arciero et al.(AJSM,2002)Bottoni, Arciero et al.(AJSM,2002)Kralinger et al.(AJSM,2002)Kralinger et al.(AJSM,2002)Habermayer et al.(JSES,1999)Habermayer et al.(JSES,1999)Baker et al.(AJSM,1990)Baker et al.(AJSM,1990)

Correct treatment to avoid recurrence risks: Correct treatment to avoid recurrence risks: RATIONALERATIONALE- better tissue- better tissue- lesser anatomic damage- lesser anatomic damageshould avoid:should avoid:- evolution into ALPSA lesion- evolution into ALPSA lesion- deeper and larger Hill-Sachs lesion- deeper and larger Hill-Sachs lesion- capsular elongation- capsular elongation- evolution into chronic joint instability- evolution into chronic joint instability

TREATMENTTREATMENT

the more the dislocation episodes the more the the more the dislocation episodes the more the damage to the anatomic joint structures (end-points)damage to the anatomic joint structures (end-points)

Evaluation prospectively the anatomic lesions Evaluation prospectively the anatomic lesions differences at the arthroscopic repair in two groupsdifferences at the arthroscopic repair in two groupsof patients:of patients:- first time dislocation compared to - first time dislocation compared to - multiple dislocations- multiple dislocations

INCLUSION CRITERIAINCLUSION CRITERIApatients with good level activity beforepatients with good level activity beforeaged no more 45yyaged no more 45yyhigh level request high level request no associated lesionno associated lesionno DJDno DJD

PURPOSE OF THE STUDYPURPOSE OF THE STUDY

anatomic differences in 2 groups of selected patients:anatomic differences in 2 groups of selected patients:- minimum f.u. 2 yy.- minimum f.u. 2 yy.- all submitted to surgery 2 mo. later the last episode - all submitted to surgery 2 mo. later the last episode - arthroscopic treatment with anchors- arthroscopic treatment with anchors- Rowe score scale evaluation- Rowe score scale evaluation

MATERIALSMATERIALS

group #1group #1first time dislocationfirst time dislocation13 patients 13 patients average age: 21 (18-24)average age: 21 (18-24)

high functional needshigh functional needs

(carrier or high level sport)(carrier or high level sport)

none shoulder problem beforenone shoulder problem before

group #2group #2multiple dislocationsmultiple dislocations90 patients (60m., 20f.) 90 patients (60m., 20f.) average age: 28 (17-40)average age: 28 (17-40)

main side prevalence main side prevalence

2 dislocations at minimum2 dislocations at minimum

none shoulder problem beforenone shoulder problem before

anatomic differences in 2 groups of selected patients:anatomic differences in 2 groups of selected patients:

MATERIALSMATERIALS

group #1group #1first time dislocationfirst time dislocation

group #2group #2multiple dislocationsmultiple dislocations

anatomic differences in 2 groups of selected patients:anatomic differences in 2 groups of selected patients:

MATERIALSMATERIALS

group #1group #1first time dislocationfirst time dislocation

group #2group #2multiple dislocationsmultiple dislocations

anatomic differences in 2 groups of selected patients:anatomic differences in 2 groups of selected patients:

MATERIALSMATERIALS

group #1group #1first time dislocationfirst time dislocation

group #2group #2multiple dislocationsmultiple dislocations

anatomic differences in 2 groups of selected patients:anatomic differences in 2 groups of selected patients:

MATERIALSMATERIALS

group #1group #1first time dislocationfirst time dislocation

group #2group #2multiple dislocationsmultiple dislocations

anatomic differences in progression of the episodes anatomic differences in progression of the episodes of dislocation:of dislocation:

MATERIALSMATERIALS

All the groups All the groups

First time dislocationFirst time dislocation2 episodes2 episodes4 episodes4 episodes6 episodes6 episodes< 6 episodes< 6 episodes

intra-operative findings and associated injuries:intra-operative findings and associated injuries:

RESULTSRESULTS

Kind of lesionsKind of lesions- partial cuff lesions - partial cuff lesions - rotatory interval - rotatory interval - SGHL- SGHL- MGHL / IGHLab- MGHL / IGHLab- SLAP lesions- SLAP lesions- anterior labral - anterior labral - absent- absent - Bankart- Bankart- inferior labral- inferior labral- bony lesions- bony lesions- bony loss- bony loss

group #1group #1 15,3% (2/13)15,3% (2/13) 30,6% (4/13)30,6% (4/13) 23,1% (3/13)23,1% (3/13) 38,4% (5/13)38,4% (5/13) 53,8% (7/13)53,8% (7/13)100 % (13/13)100 % (13/13) 0,0%0,0% 84,6% (11/13)84,6% (11/13) 30,7% (4/13)30,7% (4/13) 84,6% (11/13)84,6% (11/13) 0,0%0,0%

group #2group #214,4%(13/90)14,4%(13/90)58,8%(52/90)58,8%(52/90)52,2%(47/90)52,2%(47/90)58,8%(53/90)58,8%(53/90)21,1%(19/90)21,1%(19/90)80,0%(72/90)80,0%(72/90)18,8%(18/90)18,8%(18/90)63,3%(57/90)63,3%(57/90)51,1%(46/90)51,1%(46/90)78,8%(71/90)78,8%(71/90)36,5%(33/90)36,5%(33/90)

Rowe score evaluation:Rowe score evaluation:

p=0,004p=0,004

p=0,002p=0,002

RESULTSRESULTS

group #1 pre-op post-op %group #1 pre-op post-op %excellent 75-51 100-90 76,9excellent 75-51 100-90 76,9good 74-51 89-75 15,4good 74-51 89-75 15,4fair 51-45 75-55 7,7fair 51-45 75-55 7,7poor 46-30 56-45 0,0poor 46-30 56-45 0,0

group #2 pre-op post-op %group #2 pre-op post-op %excellent >50 100-90 66,7excellent >50 100-90 66,7good <50 89-75 21,1good <50 89-75 21,1fair <40 75-55 8,9fair <40 75-55 8,9poor 40-30 56-45 3,3poor 40-30 56-45 3,3

group #1 first time dislocation group #1 first time dislocation - better tissue: restoration not repair- better tissue: restoration not repair - Bankart lesion prevalence - Bankart lesion prevalence - none plication surgery- none plication surgery - high % of SLAP lesions- high % of SLAP lesions - homogeneous population - homogeneous population - bony lesions (Hill Sachs), no important loss- bony lesions (Hill Sachs), no important lossgroup #2 multiple dislocationsgroup #2 multiple dislocations - worst tissue quality - worst tissue quality - higher % associated lesions compared with #1- higher % associated lesions compared with #1 - capsuloligament complex laxity - capsuloligament complex laxity - important labral and rotatory interval lesions- important labral and rotatory interval lesions - less homogeneous population- less homogeneous population - bony lesions and loss (> 25% glenoid surface, not eng.H-S)- bony lesions and loss (> 25% glenoid surface, not eng.H-S)

DISCUSSIONDISCUSSION

- first time anterior dislocators at high risk need - first time anterior dislocators at high risk need immediate appropriate stabilizationimmediate appropriate stabilization- surgery suggested - surgery suggested - young motivated patients (>25yy.old)- young motivated patients (>25yy.old)- high functional request of the joint (work or sport)- high functional request of the joint (work or sport)- clinical joint instability after the first episode - clinical joint instability after the first episode - MRI evidence of capsulolabral lesion(s)- MRI evidence of capsulolabral lesion(s)- less frequency of severe engaging bony loss- less frequency of severe engaging bony loss- numerous skilled and experienced arthroscopic- numerous skilled and experienced arthroscopic surgeons have achieved single digit recurrence surgeons have achieved single digit recurrence ratesrates

CONCLUSIONSCONCLUSIONS

CONCLUSIONSCONCLUSIONS

young patients >25yy old

young patients >25yy old

high functional request of the joint

high functional request of the joint

joint instability after 1°episode

joint instability after 1°episode

when do we suggest immediate when do we suggest immediate arthroscopic stabilization?arthroscopic stabilization?

MRI evidence of capsulolabral lesionsMRI evidence of capsulolabral lesions

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