The treatment of first shoulder dislocation Manos Antonogiannakis Director center for shoulder arthroscopy IASO gen hospital

Winter sports are becoming more popular in Greece Better and more Ski Centres. Better organization and equipment advances turns more people to Winter sports

Athletes of every age and level

Athletes of all ages

Ski injuries 3 per 1000 Skier per day Hunter RE Am J Sport Med 1999 Ski injuries 4.33 per 1000 skier per day Shoulder Injuries 0.51 per 1000 skier per day Kocher MS Feagin JA Am J Sport Med 1996

The Shoulder Greatest Range of Motion in the Body Motion in all 3 planes of movement Prone to injuries 8-20% of all sports injuries

Shoulder dislocation 2% of the population 90% anterior dislocation

First shoulder dislocation is a dramatic event with dare consequences especially in athletic individuals

17% to 96% (mean 67%) Redislocation after acute traumatic anterior dislocation of the shoulder

Multicenter study 245 patients aged years 10 years follow up 52% recurrence rate 23% were operated Prognosis of recurrence after traumatic first time dislocation Primary anterior dislocation of the shoulder in young patients. A 10 year prospective study - Hovelius 1996 JBJS(A)

The major prognostic factor of recurrence after acute traumatic anterior shoulder dislocation is the age of the patient and the degree of participation to athletic endeavors

Redislocation rate in patients < 20 years Larrain Rowe Simonet and Cofield Slaa 90% 94% 94.5% 90%

Ηovelius, 1996 Athletes hockey on ice Recurrence rate: 90% in athletes < 20 years old 65% in athletes years old Age and athletic participation

The West Point experience 127 patients 55 conservative treatment Recurrence rate 85% De Barandino et al. 1996

Is shoulder arthroscopy the best treatment of the first shoulder dislocation?

Arthroscopy in the treatment of first dislocation What does it offer? To what kind of patients?

Better understanding of the pathology Reduction of recurrence rate Treatment of rotator cuff lesions in older individuals What does shoulder arthroscopy offers

The patient Young professional athlete General population First dislocation in: Athletically oriented individual Loose joint individual

Bankart lesion Tears of the anterior capsule Plastic deformation of the posterior capsule Hill-Sachs lesion, Bony Bankart rotator cuff tears SLAP lesions Lesions after first shoulder dislocation

Our findings in first shoulder dislocation  Hemarthrosis 100%  Bankart 78.2%  Bony Bankart 13.04%  Hill-Sachs 65.21%  capsular laxity 8.69%  SLAP lesions 21.73% C. Yiannakopulos E Mataragas E.Antonogiannakis Arthroscopy Sep 2007

Arthroscopic Shoulder Reconstruction Goal of the Operation: Define the pathology Restoration of the Labrum to its anatomic attachment Reestablishment of the appropriate tension in the IGHL complex and capsule Repair bony Bankart and large Hill-Sachs lesions Repair SLAP lesions Repair rot cuff tears

EUA Arthroscopy Suture anchor technique Treatment of all the lesions Surgical technique

Joint Inspection

Arthroscope in Anterior-Superior Portal

Mobilization of Anterior Labrum

1 st Anchor Placement

suture passage

Knot Tying

Evaluation of Repair

Plication of the posterior capsule

SLAP repair

Arthroscopic success rate  Savoie %  Burchart, De Bear %  J Tauro %  Kim %  Snyder %  Fabbriciani %

Wheeler et al 1989 NO 92% O 22% Arciero et al 1994 NO 80% O 14% Arciero et 1995 O 10% The West Point experience

40 patients < 30 years old prospective randomized study Transglenoid technique Same postoperative protocol Follow up > 34 months-75months Arthroscopic stabilization or non operative treatment for the first shoulder dislocation? Κirkley et al

Sandy Κirkley 1999 Recurrence rate: Arthroscopic treatment 16% Conservative treatment 47% Quality of life (WOSI) Better in the arthroscopy group Range of motion The same with both methods

Larrain et al. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy,April 2001 First shoulder dislocation Young athletes Transglenoid technique Follow Up 60 months Arthroscopic treatment 96 % excellent results Conservative treatment 5.5 % excellent results

Treatment success Avoid recurrence Range of motion Minor morbidity Few complication Return to preinjury activity level Reproducible results These are possible with arthroscopic treatment of the first shoulder dislocation in selected patients

First traumatic shoulder dislocation in patients older than 40 years Rotator cuff tears 63% Ribbans et al JBJS 1990 Different lesions Different problems to be solved

Findings after 1 st shoulder dislocation in skiers older than 40 years  52 pts follow up more than 2 years  Redislocation rate 4%  Rotator cuff tears 35% T Penvy, R Hunter, J Freeman Arthroscopy 1998

Conclusions The conservative treatment produces a unacceptable high recurrence rate in young athletic individuals Arthroscopic treatment has a high success

 Arthroscopy can be performed in an outpatient setting  The anatomy can be restored with minimum morbidity and pain for the patient  Careful assessment will allow repair of all lesions after the first dislocation Conclusions

In older patients rotator cuff tears are common The arthroscopic treatment of symptomatic rotator cuff tears is fissible with minimum morbidity Conclusions

Indications for arthroscopic stabilization of first shoulder dislocation young patients professional athletes athletically inclined individuals dominant shoulder avoidance of motion loss return to the same activity level overhead activity and activity in AB-ER rotator cuff tears in older patients

Modern arthroscopic techniques are probably the treatment of choice in these patients Conclusions