Atraumatic Shoulder Instability Management

Lennard Funk

Atraumatic InstabilityWhat is it?

Should we Operate?@thearmclinic

www.wrightington.comwww.wrightington.com


Stanmore ClassificationPolar I

Traumatic Structural

Polar IIAtraumatic Structural

Polar IIIMotor Control

Atraumatic

Factors in InstabilityAnju Jaggi

Motor Control & Rotator Cuff

Imbalance / Weakness Co-activation

Chain ineffective for normal RC recruitment

Scapula Dyskinesis Poor Kinetic Chain

Structural insufficiency

Capsulolabral damage Hyperlaxity

Fear Avoidance

Belief Disuse


Stanmore Classification

Small lesion RepairCapsular Plications

Polar ITraumatic Structural



Large lesion RepairBony Reconstructions

Rehab +/-Capsular Plication

SpecialistRehab.

Atraumatic


RehabOptimise:

CoreScapulaKinetic ChainPsychologyProprioception

www.wrightington.com

Proprioception


Mechanoreceptors in GHL

Jerosch et al. 1997Gohlke et al 1998


Capsular Plication / Shift


Capsular Plication / Shift



IGHL Hammock


Capsular Plication


Post-op Rehab ER Sling for comfort (approx. 3 weeks) Avoid forcing or stretching Proprioceptive Scapula Core Functional



Capsular Plication Results

Arthroscopic 88-94% success at 2-5yrs Gartsmann

Open

94% good/excellent at 5yrs Bigliani

59% good/excellent83% satisfactory Hamada


Arthroscopic Plication Audit

Clinical outcome of arthroscopic capsular plication for atraumatic instability (Stanmore II) of the shoulder by a single surgeon, with >12 month follow-up.

Tablot, Carter & Funk, BESS 2012


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 months


* Statistically significantly improved score (p<0.001)

OSS OIS DASH0

15

30

45

60

26

16

54

3932 29

Pre-op Post-op

* *

*


Patient Satisfaction

• Pre-op: 3.2/10

• Post-op: 8.6 / 10

• with average 82.4% improvement in symptoms


Stanmore Classification

Small lesion RepairCapsular Plications

Polar ITraumatic Structural



Large lesion RepairBony Reconstructions

Rehab +/-Capsular Plication

SpecialistRehab.

Atraumatic

Atraumatic shoulder instabilityRandomized Controlled TrialDoes stabilisation surgery followed by

physiotherapy improve short & long term outcomes compared with physiotherapy

alone?

Associate Professor Karen Ginn

Associate Professor Karen GinnMs Anju JaggiDr Susan AlexanderProfessor Len FunkProfessor Rob Herbert

Karen GinnRob Herbert

Anju JaggiSusan AlexanderLen Funk

Clinical Trial

aima robust randomised controlled clinical trial to determine whether

surgical intervention followed by physiotherapy improves outcomes in patients suffering from atraumatic shoulder instability associated with capsulolabral damage compared with physiotherapy alone

designdouble blind (patient & physiotherapist) randomised controlled

clinical trialsham-controlled surgical arm

in order to account for the strong placebo effect associated with “the high levels of stress and rituals involved with surgery”

Dowrick & Bhandari 2012

ethics approval granted data collection commenced April 2013

Methodology - Procedurepatients with a feeling of insecurity in their shoulder, not associated with a high collision injury, which

is provoked by physical examination tests, who do not have upper limb nerve damage identified

MRI examination

• sign consent to participate prior to undergoing diagnostic arthroscope• undergo baseline outcome measurements

diagnostic arthroscope• subjects recruited • randomly allocation

stabilisation surgery no further intervention

post-operative physiotherapymaximum 12 treatment sessions over 6 months

6 months post-randomisationall outcome measurements re-assessed

1 & 2 years post-randomisationWOSI, participant perceived improvement & dislocation episodes re-assessed

exclude – bony damage & RC tear

exclude – no capsulolabral damage subjects blinded

therapists blinded

assessor blinded

assessor blinded


Thank You


[email protected]

mailto:[email protected]


References:1. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for

multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am . 1991;73: 105-12.Abstract/FREE Full Text

2. Bak K, Spring BJ, Henderson JP. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med . 2000;28: 466-71.Abstract/FREE Full Text

3. Flatow EL, Miniaci A, Evans PJ, Simonian PT, Warren RF. Instability of the shoulder: complex problems and failed repairs: Part II. Failed repairs. Instr Course Lect . 1998;47: 113-25.Medline

4. Gerber C. Observations on the classification of instability. In: Warner JJP, Iannotti JP, Gerber C, editors. Complex and revision problems in shoulder surgery . Philadelphia: Lippincott-Raven; 1996. p 9-18.

5. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup. Am J Sports Med . 1996;24: 459-67.

6. Jobe FW, Tibone JE, Pink MM, Jobe CM, Kvitne RS. The shoulder in sports. In: Rockwood CA Jr, Matsen FA 3rd, editors. The shoulder . 2nd ed. Philadelphia: WB Saunders; 1996. p 1214-38.

7. Neer CS 2nd. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect . 1985;34: 232-8

8. Pollock RG, Owens JM, Flatow EL, Bigliani LU. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg Am . 2000;82: 919-28

Atraumatic Shoulder Instability Management

Health & Medicine