Omuz İnstabiliteleri Ve Tedavi Yöntemleri
Özet
Omuz eklemi, geniş hareket kabiliyeti sebebiyle instabiliteye eğilimlidir ve eklem dengesi statik ile dinamik faktörlerce sağlanır. Humerus başının glenoid kenardan aşırı ve semptomatik translasyonu olarak tanımlanan omuz instabilitesi; hafif subluksasyondan tam dislokasyona kadar uzanan bir spektrumda ve anterior, posterior veya multidirectional (çok yönlü) yönlerde gelişebilir. İnstabiliteler TUBS, AMBRİ, AIOS ve istemli instabilite olmak üzere dört ana başlık altında sınıflandırılmakta olup, genç yaş grubu, spor aktiviteleri ve kemik kayıpları nüks açısından en önemli risk faktörleridir. Teşhis sürecinde kapsamlı öykü ve fizik muayene (Beighton hipermobilite, sulcus, hiperabdüksiyon ve endișe testleri) ile birlikte röntgen, BT ve altın standart olan MRI gibi görüntüleme yöntemlerinden yararlanılır. Tedavi protokolü instabilitenin yönüne ve hastanın özelliklerine göre belirlenir. Belirgin kemik kaybı olmayan ilk anterior çıkıklarda konservatif tedavi denense de aktif hastalarda nüks oranı yüksektir; bu nedenle artroskopik Bankart onarımı instabilite yönetiminde altın standart olarak kabul edilir. Posterior ve multidirectional instabilitelerde ise ilk tercih her zaman 4-6 aylık konservatif rehabilitasyon programlarıdır. Fizik tedaviden yanıt alınamayan, günlük yaşam fonksiyonları sınırlanan seçilmiş vakalarda kapsüler daraltma, kaydırma veya kemik blok prosedürleri gibi cerrahi yöntemlere başvurulmaktadır.
The shoulder joint is highly prone to instability due to its wide range of motion, and joint balance is maintained by both static and dynamic factors. Defined as the excessive and symptomatic translation of the humeral head from the glenoid rim, shoulder instability can occur in a spectrum ranging from mild subluxation to complete dislocation and is categorized as anterior, posterior, or multidirectional. Instabilities are classified under four main headings: TUBS, AMBRI, AIOS, and voluntary instability; furthermore, young age, sports activities, and bone loss represent the most significant risk factors for recurrence. The diagnostic process utilizes a comprehensive history and physical examination (including Beighton hypermobility, sulcus, hyperabduction, and apprehension tests) combined with imaging modalities such as radiography, CT, and MRI, which is considered the gold standard. The treatment protocol is determined based on the direction of the instability and patient characteristics. Although conservative treatment can be attempted for initial anterior dislocations without significant bone loss, recurrence rates are high in active patients; therefore, arthroscopic Bankart repair is accepted as the gold standard in instability management. In contrast, conservative rehabilitation programs lasting 4 to 6 months are always the first choice for posterior and multidirectional instabilities. Surgical methods, such as capsular plication, shift, or bone block procedures, are utilized in selected cases where patients fail to respond to physical therapy and daily life functions are limited.
Referanslar
Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop Scand. 1971;42(6):491-505
Gil JA, DeFroda S, Owens BD. Current concepts in the diagnosis and management of traumatic, anterior glenohumeral subluxations. Orthop J Sports Med. 2017;5(3):2325967117694338
Anıl T,Ulunay K. Glenohumeral eklem insttabilitesine giriş. Kanatlı U.(ed) Omuz artroskopisi.İzmir:Us Akademi :2019 p.363-370
Liavaag S, Svenningsen S, Reikerås O, et al.. The epidemiology of shoulder dislocations in Oslo. Scand J Med Sci Sports 2011;21:e334–e340.
Owens BD, Duffey ML, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB. The incidence and characteristics of shoulder instability at the United States Military Academy. American Journal of Sports Medicine.
Robinson CM, Dobson RJ. Anterior instability of the shoulder after trauma. Journal of Bone and Joint Surgery. British Volume. 2004;86(4):469–479
Gil JA, DeFroda S, Owens BD. Current concepts in the diagnosis and management of traumatic, anterior glenohumeral subluxations. Orthop J Sports Med. 2017 ;5(3)
Huber H, Gerber C. Voluntary subluxation of the shoulder in children: a long-term follow-up study of 36 shoulders. J Bone Joint Surg Br. 1994 ;76(1):118–122.
Gombera MM, Sekiya JK. Rotator cuff tear and glenohumeral instability: a systematic review. Clin Orthop Relat Res. 2014;472(8):2448–2456.
Smits-Engelsman B, Klerks M, Kirby A. Beighton score: a valid measure for generalized hypermobility in children. J Pediatr. 2011;158(1):119–23, 23 e1-4.
Vincent A, Fabien M Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability Curr Rev Musculoskelet Med 2017 Dec;10(4):434-441.
Gagey OJ, Gagey N. The hyperabduction test. J Bone Joint Surg Br. 2001;83(1):69–74.
Walter WR, Samim M, LaPolla FWZ, Gyftopoulos S. Imaging quantification of glenoid bone loss in patients with glenohumeral instability: a systematic review. AJR. American Journal of Roentgenology.
Edwards SL, Lee JA, Bell J-E, Packer JD, Ahmad CS, Levine WN, et al. Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. American Journal of Sports Medicine. 2010;38(7):1456–1461.
Wheeler JH, Ryan JB, Arciero RA, Molinari RN. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 1989;5(3):213–217
Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. American Journal of Sports Medicine. 2011;39(9):1865–1869.
Gao B, DeFroda S, Bokshan S, Ready LV, Sullivan K, Etzel C, et al. Arthroscopic versus open Bankart repairs in recurrent anterior shoulder instability: a systematic review of the association between publication date and postoperative recurrent instability in systematic reviews. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2020;36(3):862–871.
Aboalata M, Plath JE, Seppel G, Juretzko J, Vogt S, Imhoff AB. Results of arthroscopic Bankart repair for anterior-inferior shoulder instability at 13-year follow-up. American Journal of Sports Medicine. 2017;45(4):782–787.
Robinson CM, Seah M, Akhtar MA. The epidemiology, risk of recurrence, and functional outcome after an acute traumatic posterior dislocation of the shoulder. J Bone Joint Surg Am 2011;93(17):1605–13.
Millett PJ, Clavert P, Hatch GF 3rd, Warner JJ. Recurrent posterior shoulder instability. J Am Acad Orthop Surg 2006;14(8):464–76
Nyiri P, Illyés A, Kiss R, Kiss J. Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability. J Shoulder Elbow Surg 2010;19(6):802–13
