professor eirik johan solheim aleris nesttun, haraldsplass ... · “it is usually believed that...
TRANSCRIPT
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Frossen skulderProfessor Eirik Johan Solheim
Aleris Nesttun, Haraldsplass og [email protected]
mobil 922 20 318dagkirurgi.no
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30+ år etter Palmer sutur
Mølster & Strand
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Acromion etter reseksjon
Cuffruptur ettter gnag++
++ +
++
+ + +++ +
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Ultralyd diagnostikk
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Vanligste inngrep• Subacromial dekompresjon
• Claviculareseksjon
• Cuffsutur (supra- og infraspinatus)
• Kapsulotomi ved frossen skulder
• Fjerne kalk (fra supraspinatus)
• SLAP reparasjon
• Bankart plastikk
• Biceps tenotomi/tenodese
• Subscapularis sutur
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Indikasjon kirurgi• Betydelige plager
• Kronisk - eller fare for forverring
• Orker ikke vente (FS)
• Rehab. ikke ført frem
• Positiv MR (evt. UL)
• FS klinisk diagnose
• Motivert og ellers frisk
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I. H. Dørum, S. Heir, E. Solheim, and L. H. Magnussen, “Implementation of conservative treatment prior to arthroscopic subacromial decompression of the shoulder.,” Knee Surg Sports Traumatol Arthr, vol. 25, no. 7, pp. 2060–2066, Jul. 2017.
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Epidemiologi FS
• 2% av befolkningen
• Sjelden før 40 år
• Vanligst 40-60 år (“50-års-skulder”)
• Hyppigst hos kvinner
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Etiologi
• Idiopatisk
• Immunologiske og endokrine faktorer
• Posttraumatisk
• Postoperativ
• Artrose
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Patologi
• Inflammasjon (smerter)
• Fibrose (stivhet)
• Kontraktur kapsel og ligamenter
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Patologi
• Global
• Lokalisert
• Ant.sup. (utadrotasjon)
• Ant.inf. (abduksjon)
• Bakre (innadrotasjon)
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kirurgitraumerartrose
ideopatisk/uflaks
tynn og elastisk kapsel
tykk bacon svor kapsel
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W. A. THOMPSON, “The components of the frozen shoulder.,” Bull N Y Acad Med, vol. 36, no. 8, pp. 501–509, Aug. 1960.
Naturlig forløp ?Codman 1934
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D. F. Simmonds, “Shoulder pain with particular reference to the frozen shoulder.,” J Bone Joint Surg Br, vol. 31, no. 3, pp. 426–432, Aug. 1949.
“It is usually believed that the prognosis is excellent and that there is nearly always complete recovery (Codman 1934); but this has not been our experience. In a small series of twenty-one patients, only six regained normal function.”
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C. K. Wong, W. N. Levine, K. Deo, R. S. Kesting, E. A. Mercer, G. A. Schram, and B. L. Strang, “Natural history of frozen shoulder: fact or fiction? A systematic review.,” Physiotherapy, vol. 103, no. 1, pp. 40–47, Mar. 2017.
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Of 508 citations, 13 articles were reviewed and seven were included in this review. Low-quality evidence suggested that no treatment yielded some, but not complete, improvement in range of motion after 1 to 4 years of follow-up.
No evidence supported the theory of progression through recovery phases to full resolution without treatment. On the contrary, moderate-quality evidence from three randomised controlled trials with longitudinal data demonstrated that most improvement occurred early, not late.
C. K. Wong, W. N. Levine, K. Deo, R. S. Kesting, E. A. Mercer, G. A. Schram, and B. L. Strang, “Natural history of frozen shoulder: fact or fiction? A systematic review.,” Physiotherapy, vol. 103, no. 1, pp. 40–47, Mar. 2017.
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C. K. Wong, W. N. Levine, K. Deo, R. S. Kesting, E. A. Mercer, G. A. Schram, and B. L. Strang, “Natural history of frozen shoulder: fact or fiction? A systematic review.,” Physiotherapy, vol. 103, no. 1, pp. 40–47, Mar. 2017.
Fig. 2. Improvement in shoulder range of motion without treatment in studies reporting objective longitudinal data.
Average values extracted from Kivimäki et al. J Shoulder Elbow Surg 2007;16:722–6 and Russell et al. J Shoulder Elbow Surg 2014;23:500–7, and presented with standard error bars.
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C. K. Wong, W. N. Levine, K. Deo, R. S. Kesting, E. A. Mercer, G. A. Schram, and B. L. Strang, “Natural history of frozen shoulder: fact or fiction? A systematic review.,” Physiotherapy, vol. 103, no. 1, pp. 40–47, Mar. 2017.
Pasient med 6 mnd. sykehistorie kommer på kontoret…
Hva skal du si om prognosen ?…
“Du har allerede opplevd fasen med mest forbedring…”
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45 år gammel fysioterapeut.
Verken hun selv eller fysio-terapeuten hennes var klar over at hun hadde en (PO) FS…
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Mange forblir helt stive i glenohumeralleddet,
men lærer seg å leve med tilstanden…
Ved å bevege scapula og overkropp… Og tilpasse aktiviteter…
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FØR ETTER
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Caput
Biceps
Subscapularis
Gjengrodd rotatorintervall
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Behandling
• Ekspektering, smertestillende
• Fysikalsk behandling
• Corticosteroider
• Dele kapselen (væske/manipulasjon/kirurgi)
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Fylle med vann til det sprekker?
Slite i stykker?
Eller klippe !?
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“You got to ask yourself one question…”
Harry Callahan AKA Dirty Harry
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Hva er beste redskap for å skjære opp bacon?
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Kapsulotomived FS
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H. E. Segmüller, D. E. Taylor, C. S. Hogan, A. D. Saies, and M. G. Hayes, “Arthroscopic treatment of adhesive capsulitis,” J Shoulder Elbow Surg, vol. 4, no. 6, pp. 403–408, 1995.
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H. E. Segmüller, D. E. Taylor, C. S. Hogan, A. D. Saies, and M. G. Hayes, “Arthroscopic treatment of adhesive capsulitis,” J Shoulder Elbow Surg, vol. 4, no. 6, pp. 403–408, 1995.
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J. J. Warner, A. Allen, P. H. Marks, and P. Wong, “Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder,” vol. 78, no. 12, pp. 1808–1816, Dec. 1996
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Bakre portal
Lateral portal
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Skop-hylse med mandreng presses (innenfra-ut)gjennom rotatorintervall og fremre portal
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Mandreng fjernes.Skopes settes nesten helt inn i hylsen.
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Tupp av shaver plasseres i enden av hylsen.
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Skyv shaveren inn (og skop skubbes tilbake).
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Stopp når du kjenner at begge ligger fritt i leddet.
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Caput
Biceps
Subscapularis
Gjengrodd rotatorintervall
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Shaverblad (5,5mm full radius)på plass i rotatorintervall
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Reseksjon inflamert synovium og fortykket kapsel
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Coracoid
Coracohumeral ligamentet
Subscapularis
Deler CH ligament
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CH ligament løsnet fra coracoid
Shaver
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Caput
Glenoid
Labrum
Upbite stansetang
Subscap.
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Klipper langs labrum klokken 4
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Stansetang
Kapsulotomi åpner seg og avstand mellom caput og glenoid øker
Kapselklipp-bit
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Labrum
Klokken 6
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Fjerner løse kapselklipp biter med shaver
58
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Ferdig fremre kapsulotomi
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Postoperativt regime
• 40ml Marcain 0.25%
• Demonstrere bevegelsesutslagene
• Kuldepakning
• Voltaren, Paracet, Pinex forte, OxyNorm
• Egenøvelser/tøyning
• Fysioterapeut
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Komplikasjoner
• Ny tilstivning
• Instabilitet
• Helst når FS etter stabilisering
• Nerveskader
• N. axillaris
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Kapselløsning ved FS• Gjennomgått smertefase, > 3 mnd
sykehistorie
• Nedsatt bevegelighet i skulderen
• Fleksjon og abduksjon < 45 grader
• Utadrotasjon < 20 grader
• Samtykke til dagkirurgisk behandling
• Alder 18-70, BMI < 33, ASA 1-2
O. K. Austgulen, J. Øyen, J. Hegna, and E. Solheim, “[Arthroscopic capsular release in treatment of primary frozen shoulder].,” vol. 127, no. 10, pp. 1356–1358, May 2007.
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Resultater• 79 av 83 (95%) ville latt seg operere på nytt
• Fornøydhet med resultat (10=best): 8,6 ± 1,8
• Bedret bevegelighet, arbeidsevne og nattesøvn
• Oxford shoulder score (12 best, 60 dårligst) sank fra 41 preop til 18 postop (p<0,001)
• Tre reoperert, Ingen komplikasjoner
O. K. Austgulen, J. Øyen, J. Hegna, and E. Solheim, “[Arthroscopic capsular release in treatment of primary frozen shoulder].,” vol. 127, no. 10, pp. 1356–1358, May 2007.
![Page 65: Professor Eirik Johan Solheim Aleris Nesttun, Haraldsplass ... · “It is usually believed that the prognosis is excellent and that there is nearly always complete recovery (Codman](https://reader030.vdocuments.us/reader030/viewer/2022021723/5c7f582a09d3f23d428c8304/html5/thumbnails/65.jpg)
O. K. Austgulen, J. Øyen, J. Hegna, and E. Solheim, “[Arthroscopic capsular release in treatment of primary frozen shoulder].,” vol. 127, no. 10, pp. 1356–1358, May 2007.
![Page 66: Professor Eirik Johan Solheim Aleris Nesttun, Haraldsplass ... · “It is usually believed that the prognosis is excellent and that there is nearly always complete recovery (Codman](https://reader030.vdocuments.us/reader030/viewer/2022021723/5c7f582a09d3f23d428c8304/html5/thumbnails/66.jpg)
Suksessrate
• 94% idiopatisk FS
• 80-90% postoperativ
Warner, Jon J.P. Diverse reviewartikler og bokkapitler