Axelledsinstabilitet. Treatment and outcome of a first time traumatic Anterior shoulder dislocation

Transkript

1 Axelledsinstabilitet. Treatment and outcome of a first time traumatic Anterior shoulder dislocation L. Hovelius Division of Surgery and Perioperative Science, Departments of Orthopedics, Umeå University Hospital, Gävle Hospital, Sweden

2 I slutet av 60-talet blev jag Hockeyspelare intresserad av hockeyskador luxerar ofta axlarna Hos hokeyspelare

3 Scapula viktig för axelns funktion glenoidale som nosen på en säl balanserande en boll

4 Rowe huvudgrupper av instabilitet 1. Traumatiska 2. Atraumatiska 3. Voluntära = 4.Traumatiska recidiv. subluxationer 4. Traumatiska recidiverande subluxationer 5. Involuntära subluxationer och luxationer Alla dessa kan vara akuta eller recidiverande, bakre eller främre

5 Klassifikation- praktisk 1. Vanlig främre luxation(subluxation), primär -recidiverande. >90% av de vi ser i vår verksamhet 2. Bakre luxationer, <5% 3. Flerriktad, (=multidirectionell), instabilitet < 5%, innehåller dom kvistiga fallen, blandning 1+2 ( ledlaxa, voluntära )

6 Neer, Foster sulcus sign

7 Diagnos främre luxation: Anamnes Subluxationer Apprehension Rtg

8 Apprehension

9 Fingeravtryck främre luxation Hill-Sachs, Hermodsson, Malgaigne

10 Glen.kantsfraktur Fingerprint 2

11 Bankartskadan oftast orsaken till att axeln fortsätter att hoppa ur led! Bankartskadan innebär att ledkapseln lossnat från ledpannekanten

12 Reposition främre axelledsluxation Cave! Hippokrates Kocher Använd! andra varianter

13 Milch

14 Modifierad Stimson

15 Storlien -metoden

16 Shoulder dislocation in Swedish ice hockey players Hovelius, Am. J. Sports Med players, all anterior dislocations

17 Sidodominans - hockey - axelledsluxation Högerhänt- vänsterfattning Vänsterhänt- högerfattning 80% op i vä axel 80% op i hö axel

18 Some results of this study: Hovelius, Am. J. Sports Med Incidence 8% in highest league. Instability did not exclude playing. Instability could heal by time. Inspiration for further studies

19 SM-Guld med Brynäs

20 Disputerade 1982 Incidencen SIFO -studie Prognosen inleddes en multicenterstudie på patienter med förstagångsluxation Bristow-Latarjet patienter opererade med i Sverige ny metod analyserades

21 Av 2092 av SIFO utfrågade: svarade 67 ja, axel ur led Dessa kontaktades per telefon 37 återstod Incidencen: 1,7% Män 2,5% Kvinnor 0,8% Clinical Orthopedics 1982

22 Studies on the prognosis of primary SJD Recurrence rate in the young, %! Rowe, 1956 McLaughlin and Maclellan, 1967 Kazar and Relovszky, 1969 Henry and Genung, 1982 Simonet and Cofield, 1984 Milgrom, Mann & Finestone, 1998 Itoi et al 2007, JBJS Am Most of the studies are retrospective!

23 In 1978 we started a Swedish multicenter study on shoulder dislocations During 2 years ( ) all first time dislocations were included in the study All had conservative treatment Immobilization 3-4 weeks or Early movement, = symptomatic treament sling for some days

24 Study inclusion criteria Age, 40 years or younger True first time dislocations Verified at hospital by an experienced surgeon

25 Parts of Sweden covered by the study 257 shoulders were included (JBJS-Am,1983) 1/3 of Sweden covered by the study

26 Number of cases in different ages 162 younger 29 yrs yrs yrs yrs

27 Etiology, when allocated to two age groups percent yrs yrs 10 0 sports fall NUD traffic various

28 Percent females in different ages percent Age yrs First time Dislocations are more common in females 50 years

29 I have followed these patients during 25 years! Anastasia lost to Follow-up 10 years JBJSAm, 1983 (2 years) Clin Orthop, 1983 (2 years) JBJSAm, 1987 (5 years) JBJSAm, 1996 (+x-ray, 10 years) Acta Orthopedica, 2007 ( 25 years) JBJSAm, 2008 (prognosis, 25 years) JSES, 2009 (x-ray, 25 years)

30 Results at 2-year follow-up immobilization versus symptomatic treatment in sling Group l immobiliz Group. 2 sling Mixed Not recurred 71% 69% 71% Over 25 years of observation immobilization or symptomatic treatment: the same prognosis Also when analyzed according to age! Surgery or scheduled 11% 10% 12%

31 1987 landslagsläkare VM-Guld direkt Sen blev det flera VM-guld! Kronan på verket OS-guld 2006

32 4 activity levels when the primary dislocation occurred(10 years) Level 1 Level 2 Level 3 Level 4 High risk for recurrence, soccer, ice-hockey etc. Moderate recurrence risk gymnastics, swimming etc. Minor risk for recurrence running, golf etc. No physical activity

33 10-year follow-up Ages Kkkkkkkkkkkkkkkkkkkkkkk 29 years or younger kkkkankad? high hi bru No activity

34 In 2003 the 25-year follow-up started! In February 2005 ALL patients alive, 229, had had the F-up Mean 25,3 yrs, Median 25,2 yrs Anastasia, found in Greece 223 with X-ray (97,4%) 28 patients had died (Acta Ort Scand 2007)

35 We used these classification endpoints at 25 years Surgically stabilized Solitary or rec. once = nonrecurrent Recurrent = 2 redislocations A. Still recurrent B. Became stable over time = No redisloc last 10 years

36 25-years prognosis (JBJS-Am, 2008) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 50% did not recur or stabilized by time 50% surg 8% endpoints solitary* nonrecurrent spont.healed Stable by time still Still recurrent surg.stabilized surgery years

37 Classification of arthropathy (Samilson and Prieto. 1983) mild moderate severe

38 1986 Recidiverande luxationer Samilsen- Prieto moderat <7 mm

39 1997 Samilson- Prieto, severe 2007 protes >7 mm

40

41

42 Zlatan På San Siro

43 After 25 yrs we found OUT OF 223 SHOULDERS Mild moderate severe 65(29%) 21(9,4%) 38(17%) 26,4% had moderate or severe arthropathy after 25 years

44 Stability endpoints, 25 yrs and % moderate/severe arthropathy Solitary Surgically stab 17% 21% Solitary shoulders less A-Y than healed rec. (P<0.001) and still rec. (P=0.048) 1 recurrence Persist. Recur. Stabi. by time 35% 29% 45%

45 Surgically stabilized shoulders Less arthropathy (mild, moderate or severe) than those with 1 recurrence or more P=0,0002 Possibly the evolution of Arthropathy is reduced by surgery?

46 What happened between 10 and 25 years? Normal 76% Mild 16 % Moderate or Severe 8 %? After 25 years 31 shoulders no X-ray at 10 years F-Up

47 What happened between 10 and 25 years? hhhhhbbhhhh 9 % Mod/Sev 63 % Mod/Sev 32% mild 33% = No patient had surgery because of arthropathy! However some will have had it after 40 years! mild arthropathy at 10 yrs = mod/severe at 25 yrs in 2/3 (63%)

48

49 Immobilization 3-4 weeks Did not change the prognosis Other options? Itoi et al JBJS, 2007, Immobilization of the shoulder in external rotation reduces the risk of recurrence

50 Itoi in comparision- our study Itoi Internal rot redislocation Itoi External rot redislocation Our study All redislocation Age 20 y Age y 68% 52% 41% 24% P= P= 0,638 55% 31%

51 Finestone, Milgrom et al JBJS-Br 2009 Bracing in external rotatation 51 patients Age yrs, mean F-up 33,4 months 24 internal, 27 external rotation External group 37% recurrence Internal group 41% recurrence To me the effect of treatment in external fixation is still not verified P=0.74

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53 First time shoulder dislocations in Young athletes. To operate or not, that s the Question

54 In retrospect; would you have preferred surgery when the first dislocation occurred? yrs yrs yes no can not answer 22% 63% 14% 22% 62% 16% Consequently: <1/4 should have preferred surgery!

55 10 athletes, aged 25, first time dislocation No, 5 will have surgery unnecessarily! Will all need surgery???

56

57 Kronwall

58 Antal döda The risk to die within 25 years 28 was personer increased with hade 108%(p<0,001) avlidit! (Acta Orthopedica, 2007) Increased mortality in our series of dislocations 10 5 Risk to die, average Swedish population same age/sex Years F-up

59 Acta Orthop Scand 2007 Dödsorsaker Vad dog man av i Sverige ? Malignitet cardiovaskulärt CNS, Endkrint, Genito-U Skada-Intoxication(S00-T98) UNS 4(15%) 6(22%) 4(15%) 11(41%) 2(7%) 20% 44% 7% 5% 0,4% P<0,001 Då förstagångsluxationer samlas på en akutmottagning får man med ett ökat antal alkoholister!

60 How is it possible to find all patients after 25 years? Anastasia, who in 1985 moved to some island in Greece? the patient, who stayed abroad, wanted by interpool? the patient that lived in Spain since 12 years, address unknown?

61 N E E R A W A R D

62 SWE-FIN 3-2

63 In year 2018? Will I take care of Hovfaksen? Or am I starting the 40 years Follow-up? THANKS!

64 Itoi in comparision- Anders Olofsson Ongoing study 47 shoulders, 2 Yrs external rot our study Itoi Internal rot redislodation Our study All redislodation Itoi External rot redislodation Age 20 y 68% 55% 41% 39% Age y 52% 35% 31% 24%

65 Prognosis after 2 years Both groups of treatment together % years no recurrence one recurrence two or >recurrences surgery or waiting

66 Sport activity - Trauma (%, Arthropathy, moderate/severe) No sports Traumatic sports non-traum.sports 22% 37% 15% Trauma by first/recurrent dislocation! P=0.009