Labral Patolojiler
Özet
Omuz ekleminde glenoid çevresine yapışan fibrokartilaj yapıdaki labrum, eklem yüzeyini derinleştirerek stabilite sağlar, eklemi besler, kayganlığa yardımcı olur ve alttaki kıkırdağı korur. Labral patolojiler; süperior (SLAP), anterior, antero-inferior ve posterior yırtıklar olarak sınıflandırılır. SLAP lezyonları, dejeneratif tiplerden kova sapı yırtıklara ve biseps tendonu uzanımlarına kadar sekiz farklı tipte ve atıcılarda görülen Andrew lezyonu gibi spesifik formlarda klinik olarak ayrışır. Akut veya kronik instabiliteyle ilişkili antero-inferior yırtıklar Perthes, GLAD, Bankart ve ALPSA lezyonları olarak çeşitlenirken; posterior yırtıklar ise yinelemeli mikrotravmalar veya nadir görülen posterior instabilite sonucu (Kim lezyonu gibi) gelişir. Tanıda Relokasyon, Biseps Yük, IRRT, Kim, Jerk ve Krank gibi spesifik muayene testlerinin yanı sıra yüksek hassasiyetli O'Brien ve Gagey gibi bulgular kullanılır. Tedavide öncelikle NSAİİ, aktivite modifikasyonu ve omuz çevresi kaslarını güçlendirmeye yönelik fizik tedavi gibi konservatif yaklaşımlar tercih edilir. Bu süreçten fayda görmeyen hastalar ile instabilitenin eşlik ettiği durumlarda ise yırtığın tipine göre artroskopik labral debridman, rezeksiyon, tamir, biseps tenodezi/tenotomisi veya posterior/anterior stabilizasyon cerrahileri uygulanmaktadır.
The fibrocartilage labrum attaching around the glenoid in the shoulder joint deepens the joint surface to provide stability, nourishes the joint, assists lubrication, and protects the underlying cartilage. Labral pathologies are classified into superior (SLAP), anterior, antero-inferior, and posterior tears. SLAP lesions differentiate clinically into eight distinct types, ranging from degenerative types to bucket-handle tears and biceps tendon extensions, as well as specific forms like the Andrew lesion observed in throwing athletes. While antero-inferior tears associated with acute or chronic instability vary as Perthes, GLAD, Bankart, and ALPSA lesions, posterior tears develop due to repetitive microtraumas or rare posterior instability, such as Kim's lesion. Specific examination tests like Relocation, Biceps Load, IRRT, Kim, Jerk, and Crank are utilized for diagnosis, along with highly sensitive findings such as O'Brien and Gagey. Regarding treatment, conservative approaches like NSAIDs, activity modification, and physical therapy aimed at strengthening the muscles around the shoulder are primarily preferred. For patients who do not benefit from this process or when instability accompanies, arthroscopic labral debridement, resection, repair, biceps tenodesis/tenotomy, or posterior/anterior stabilization surgeries are performed according to the type of the tear.
Referanslar
Cooper DE, Arnoczky SP, O’brien SJ, Warren RF, Dicarlo E, Allen AA. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am. 1992;74(1):46–52.
HOWELL SM, GALINAT BJ. The glenoid–labral socket: A constrained articular surface. Clin Orthop Relat Res. 1989;243:122–5.
Chang D, Mohana-Borges A, Borso M, Chung CB. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. Eur J Radiol. 2008;68(1):72–87.
Bencardino JT, Beltran J. MR imaging of the glenohumeral ligaments. Magn Reson Imaging Clin. 2004;12(1):11–24.
Beltran J, Rosenberg ZS, Chandnani VP, Cuomo F, Beltran S, Rokito A. Glenohumeral instability: evaluation with MR arthrography. Radiographics. 1997;17(3):657–73.
Clavert P. Glenoid labrum pathology. Orthop Traumatol Surg Res. 2015;101(1):S19–24.
Chang EY, Fliszar E, Chung CB. Süperior labrum anterior and posterior lesions and microinstability. Magn Reson Imaging Clin. 2012;20(2):277–94.
Connell DA, Potter HG. Magnetic resonance evaluation of the labral capsular ligamentous complex: a pictorial review. Australas Radiol. 1999;43(4):419–26.
Beltran J, Bencardino J, Mellado J, Rosenberg ZS, Irish RD. MR arthrography of the shoulder: variants and pitfalls. Radiographics. 1997;17(6):1403–12.
Huber WP, Putz R V. Periarticular fiber system of the shoulder joint. Arthrosc J Arthrosc Relat Surg. 1997;13(6):680–91.
Nishida K, Hashizume H, Toda K, Inoue H. Histologic and scanning electron microscopic study of the glenoid labrum. J shoulder Elb Surg. 1996;5(2):132–8.
Iwasaki K, Tafur M, Chang EY. High Resolution Qualitative and Quantitative MR Evaluation of the Glenoid Labrum. J Comput Assist Tomogr. 2015;39(6):936.
Zlatkin MB, Sanders TG. Magnetic resonance imaging of the glenoid labrum. Radiol Clin. 2013;51(2):279–97.
Arai R, Kobayashi M, Toda Y, Nakamura S, Miura T, Nakamura T. Fiber components of the shoulder süperior labrum. Surg Radiol Anat. 2012;34(1):49–56.
Ilahi OA, Labbe MR, Cosculluela P. Variants of the anterosüperior glenoid labrum and associated pathology. Arthrosc J Arthrosc Relat Surg. 2002;18(8):882–6.
Williams MM, Snyder SJ, Buford Jr D. The Buford complex—the “cord-like” middle glenohumeral ligament and absent anterosüperior labrum complex: a normal anatomic capsulolabral variant. Arthrosc J Arthrosc Relat Surg. 1994;10(3):241–7.
Maffet MW, Gartsman GM, Moseley B. Süperior labrum-biseps tendon complex lesions of the shoulder. Am J Sports Med. 1995;23(1):93–8.
Choi N-H, Kim S-J. Avulsion of the süperior labrum. Arthrosc J Arthrosc Relat Surg. 2004;20(8):872–4.
Andrews JR, Carson JR WG, Mcleod WD. Glenoid labrum tears related to the long head of the biseps. Am J Sports Med. 1985;13(5):337–41.
Terry GC, Friedman SJ, Uhl TL. Arthroscopically treated tears of the glenoid labrum: Factors influencing outcome. Am J Sports Med. 1994;22(4):504–12.
Neviaser TJ. The GLAD lesion: another cause of anterior shoulder pain. Arthrosc J Arthrosc Relat Surg. 1993;9(1):22–3.
Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder‐joint. Br J Surg. 1938;26(101):23–9.
Broca A. Contribution à l’étude des luxations de l’épaule. Impr. Lemale et Cie; 1890.
Milano G, Grasso A, Russo A, Magarelli N, Santagada DA, Deriu L, et al. Analysis of risk factors for glenoid bone defect in anterior shoulder instability. Am J Sports Med. 2011;39(9):1870–6.
Kim D-S, Yoon Y-S, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. Am J Sports Med. 2010;38(10):2071–6.
Magee T. Prevalence of HAGL lesions and associated abnormalities on shoulder MR examination. Skeletal Radiol. 2014;43(3):307–13.
Boileau P, Villalba M, Héry J-Y, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. JBJS. 2006;88(8):1755–63.
Boileau P. Instabilité antérieure de l’épaule. Apport et place de l’arthroscopie. Cah d’enseignement la SOFCOT. 2002;79:77–112.
Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion: a cause of anterior instability of the shoulder. Arthrosc J Arthrosc Relat Surg. 1993;9(1):17–21.
Lee BG, Cho NS, Rhee YG. Anterior labroligamentous periosteal sleeve avulsion lesion in arthroscopic capsulolabral repair for anterior shoulder instability. Knee Surgery, Sport Traumatol Arthrosc. 2011;19(9):1563.
Jobe CM. Evidence for a süperior glenoid impingement upon the rotator cuff. J Shoulder Elb Surg. 1993;2:S19.
Walch G, Liotard JP, Boileau P, Noel E. Le conflit glénoïdien postéro-supérieur: un autre conflit de l’épaule. Rev Chir Orthop Reparatrice Appar Mot. 1991;77(8):571–4.
Gaber S, Zdravkovic V, Jost B. Die Werferschulter. Orthopade. 2014;43(3):223–9.
Lévigne C, Garret J, Grosclaude S, Borel F, Walch G. Surgical technique arthroscopic posterior glenoidplasty for posterosüperior glenoid impingement in throwing athletes. Clin Orthop Relat Res. 2012;470(6):1571–8.
Fronek J, Warren RF, Bowen M. Posterior subluxation of the glenohumeral joint. J Bone Joint Surg Am. 1989;71(2):205–16.
Kim S-H, Ha K-I, Yoo J-C, Noh K-C. Kim’s lesion: an incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthrosc J Arthrosc Relat Surg. 2004;20(7):712–20.
Munro W, Healy R. The validity and accuracy of clinical tests used to detect labral pathology of the shoulder–a systematic review. Man Ther. 2009;14(2):119–30.
Kanatlı U, Kütük AT, Öztürk BY. SLAP lezyonları. Omuz Hast ve Artroskopisi. 1:541–54.
Boileau P, Maynou C, Balestro JC, Brassart N, Clavert P, Cotten A, et al. Long head of the biseps pathology. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(8 Suppl):5S19-53.
Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: bisepstenodesis as an alternative to reinsertion. Am J Sports Med. 2009;37(5):929–36.
