Sports Flashcards
Mutltidirectional instability
- is characterized by generalized instability of the shoulder in at least 2 planes of motion.
- also known as AMBRI (Atraumatic Multidirectional, frequently Bilateral, often responds to Rehabilitation, if non responding to non-op intervention may require Inferior capsular shift)
- Often no trauma, often due to microtrauma from overuse (athletes with throwing/overhead types of sports)
- Often multiple direction instability
- Often involving bilateral shoulder
- May have underlying generalized joint laxity (physiological hyperlaxity, connective tissue disorders eg Ehlers-Danlos or Marfan’s)
MRI (with arthrogram):
- patulous/redundant inferior capsule (IGHL, anterior and posterior bands of it)
- may have features of Bankart (anteroinferior labral tear) or Kim lesion (posteroinferior labral avulsion), from repetitive microtrauma)
- bony erosion of glenoid from chronic anterior instability
Management
1. Non-operative
- Rehabilitation for 3-6 months
* strengthen dynamic stabilisers - RCT, periscapular muscles.
* Closed kinetic chain exercises - to safely stimulate co-contraction of RCT and scapular mus.
- Operation
-If still unstable despite extensive non-op
- pain and instability interferes with ADLS/sports
Intraop diagnosis
“drive-through sign” may be present
a positive drive-through sign is considered the ability to pass an arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the IGHL
also associated with shoulder laxity
Options
I) inferior capsular shift/plication
- open or arthroscopic
ii) Capsular reconstruction using allograft
- in refractory cases, in patients with collagen disorders.
Explain principles in managing TUBS instability.
TUBS
Ix
1) Plain radiograph
Shoulder
AP-true/IR/ER- dislocation/subluxation, GT fracture, ER- Hillsach lesion
scapula Y-view, axilla- dislocation/subluxation
West point- glenoid bone loss
Stryker notch- Hillsach lesion – posterosuperior humeral head
2) MRI with arthrogram
- Visualize labral tear, classify types (simple Bankart, bony Bankart, GLAD)
- Rule out other injuries - Cartilage injury, HAGL, RCT
- Can also assess bone loss
Otherwise
3) CT scan (plain)
- Assess bone loss, calculate Glenoid Track
- Assess size of Hillsach lesion
- To determine if Glenoid lesion is On-track or Off-track
Management
Acute event
- CMR, immobilize – 1 week, Analgesias with NSAIDS
- TCA for reassessment
At follow up
1. Any dislocation event since the last one.
2. Determine if patient has risk of recurrent dislocation
At risk patients
- age < 20 (highest risk)
- male
- contact sports
- hyperlaxity
- glenoid bone loss >20-25%
- greater tuberosity fractures
- Assess for any multidirectional instability & evidence due to hyperlaxity shoulder AMBRI mx
- If TUBS picture, with risk factors present, consider surgery, order the necessary Ix to guide management
has glenoid bone loss, < or > 25 %
HS on-track or off-track
ISS (Instability Severity Score) score, < or > 6
Latarjet – address bone loss
Remplissage – address Hillsac that is OFF-TRACK, converting it to ontrack.
What is Latarjet?
- A procedure that is performed to address a glenoid bone deficiency of > 20-25% of glenoid width.
- Involves transfer of distal corocoid & its attached muscle through a split in distal 1/3 or middle ½ of subscapularis, to the anterior bony defect of the glenoid with screws.
- To achive a triple blocking effect
- Increases glenoid bony support and excursion distance prior to dislocation/gives a bone blocking effect.
- Conjoint tendon that passes through the subscap has a supporting sling effect.
- Capsular reconstruction achieved through suturing of the coracoacromial ligament to capsular tissue.
What is Remplissage?
- A procedure involving tenodesis of posterior capsule and infraspinatus into Hilsach lesion.
- To convert off track to on track
When to do arthroscopic shoulder?
ISS < 6
Bone loss < 25%
When to do open shoulder?
ISS > 6
Latarjet procedure for glenoid bone loss > 25%
