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1. Dislokasi Sendi Bahu

DISLOKASI SENDI BAHU

Oleh Dr H. Subagyo  SpB - SpOT

3.1     Definisi

Dislokasi bahu adalah suatu kerusakan yang terjadi saat bagian atas tulang humerus tidak menempel lagi dengan skapula.1,2Hal ini terjadi saat caput humerus keluar dari soket, glenoid. Maka dislokasi bahu ini fokus pada dislokasi dari sendi glenohumeral.3Bahu yang dislokasi menyebabkan gejala bahu yang sangat sakit dan diperlukan pengobatan dari rumah sakit untuk mengembalikan bentuk anatomi yang normal dari bahu tersebut.20

3.2    Epidemiologi

         Dislokasi primer

  Dislokasidansubluksasisendiglenohumeralrelatif seringterjadipada atlet. Seorang peneliti mengidentifikasidistribusi bimodaldislokasibahuprimer denganpuncakdalamdekadekedua dan keenam.11Dalam95% kasus, dislokasi bahu yang terjadi mengarah ke anterior.2,4,5,6 Terdapat beberapa fraktur yang berhubungan dengan dislokasi bahu anterior yaitu kelainan Hill-Sachs dengan kasus sebanyak 35-40% dari kasus yang ada, lesi Bankart dan fraktur dari greater tuberosity dengan kasus sebanyak 10-15% dari kasus yang ada.7Sekitar 4% dari kasusyang ada, dislokasi terjadi ke arah posterior.5,6,8 Sekitar 0.5% dari semua dislokasi yang ada, terjadi dislokasi ke arah inferior (luxatio erecta).5,6 Dan dislokasi ke arah superior jarang sekali ditemukan, angka kejadiannya lebih kecil dari dislokasi ke arah inferior.9

          Penyebabutama daridislokasi bahuprimer adalahcedera traumatik. Hampir95% dari dislokasi bahu yang terjadipertama kaliadalah akibatdari beberapa kejadian seperti benturankuat,jatuhpada lenganterulur, atau gerakantiba-tibayang dapat mengakibatkan bahu terkilir.5,11Pada individu-individu ini, struktur yang berfungsi menstabilkan gerakan ditarik paksa secaramendadak.Sekitar 5% dari dislokasi yang ada disebabkan oleh kejadian yang atraumatik(misalnya, insiden kecilseperti mengangkatlenganatau bergeraksaat tidur).5,11Individu-individu ini mungkin memilikikelemahankapsuleratauperubahan dari pengontrolan ototpada kompleksbahu ataudapat disebabkan oleh keduanya.

 

Dislokasiberulang

Komplikasipenting daridislokasiprimeradalah dislokasiberulangberikutnya.Berdasarkan studiyang dilakukan oleh seorang peneliti,sekitar 70%dari mereka yangtelahmengalami dislokasi memiliki kemungkinan untuk mengalami dislokasi berulangdalam waktu 2 tahunsejak cederapertama.11

Penderitayang lebih muda danlebih tuamemiliki insidendislokasi bahuprimer yang sebanding.Namun keadaan dislokasiberulangsangatbergantungpada usiadan lebih seringterjadi pada populasiremajadibandingkan dengan populasi yang lebih tua. Telahdilaporkan bahwa dislokasirekuren pada66% sampai 100% pada individu berusia20 tahunatau lebih muda, 13% sampai 63% dari individu berusiaantara 20dan 40tahun, dan0% sampai 16% dari individu berusia40tahun atau lebih.                                

Pasien yangmengalami robekan pada rotator cuffataufrakturpada glenoidsaat terjadi dislokasi bahumemilikiinsiden dislokasi berulang yang lebih tinggidibandingkanpasien tanpamasalah ini.3

Dislokasi bahucenderung lebih seringterjadi pada priadibandingkan dengan wanita.Hal ini mungkin disebabkan karena tipe olahraga yang dilakukan.7

3.3   Jenis Dislokasi Bahu

          Terdapat 4 jenis dislokasi pada bahu yaitu dislokasi anterior, dislokasi posterior, dislokasi inferior dan dislokasi superior.

3.3.1.     Dislokasi Anterior

Gambar 3.1

Mekanisme Cedera

Sekitar 95% dari dislokasi bahu yang terjadi, bagian atas humerus berada di depan shoulder blade dan menyebabkan dislokasi anterior.2,4 Mekanisme umum dari kerusakan yang terjadi yaitu abduksi yang ekstrim, exorotasi, ekstensi, dan suatu tekanan langsung dari posterior terhadap humerus. Abduksi atau rotasi eksternal secara paksa sendiri dapat menyebabkan dislokasi (sekitar 30% dari kasus yang ada), begitu juga suatu tekanan kuat langsung terhadap bagian posterior humerus (29%), elevasi dan exorotasi yang terjadi secara paksa (24%), dan jatuh dengan tangan yang terbuka lebar. (17%).27

Gejala Klinis

Pasien yang mengalami dislokasi bahu akan merasa sangat kesakitan dan mencegah untuk siapapun untuk melakukan pemeriksaan karena sakitnya itu.28Jika pasienmengalamidislokasi bahu, rentang gerak(ROM) dari pasien itu tidak luas. Jikabahuterdislokasi ke arah anterior, lenganberada dalam posisi sedikitabduksi dan exorotasi. Pada pasienyangkurus,caput humerusyang menonjoldapat dirasakanberada di anteriordan cekungan dapat dilihatposterior pada bahu.3Rotator cuffseringkali mengalami kerusakan danharus diperiksasetelah dilakukan reduksi.7Pentinguntuk menilaifungsi neurovaskularaksiladenganmeraba nadi dan melakukan uji sensasi padadaerah bahu.6Gerakanbiasanyasangat menyakitkanakibat darispasmeotot.27Lokasi dislokasi anterior yang paling sering terjadi yaitu subkorakoid. Dapat juga terjadi dislokasi subglenoid, subklavikula, dan yang sangat jarang yaitu intratorakal atau retroperitoneal.27

 

 

Gambar 3.2

 

              Komplikasi

              Dislokasi bahu anterior rekuren

              Karena stabilitas dari bahu bergantung pada intergritas dari kapsul sendi, dan karena kapsul dan labrum anterior hampir selalu mengalami cedera atau terlepas dari glenoid dan leher dari skapula pada saat dislokasi bahu yang pertama kali terjadi, maka tidaklah mengagetkan jika pada beberapa individu dapat terjadi dislokasi berulang yang lebih sering akibat tekanan yang semakin lama semakin kecil. Selain cekungan jaringan lunak yang dapat menyebabkan caput humerus untuk bergeser, sering juga ditemukan cekungan pada aspek posterior dari caput humerus akibat fraktur kompresi saat dislokasi pertama terjadi. Cekungan ini (lesi Hill-Sachs) menyebabkan caput humerus yang exorotasi untuk bergeser ke arah margin anterior dari rongga glenoid.8,29

              Pada pasien remaja, dislokasi berulang sangatlah merugikan dan mengganggu. Pasien sangat waspada jika lengan abduksi dan exorotasi maka akan terjadi dislokasi kembali. Kondisi ini merupakan indikasi dilakukannya perbaikan secara pembedahan pada jaringan lunak. Dari berbagai macam dan banyaknya tipe operasi yang ada, dua tipe operasi yang paling sering dilakukan yaitu operasi Bankart, dimana labrum dan kapsul disambungkan kembali pada margin anterior dari rongga glenoid; dan operasi Putti-Platt, dimana kapsul dan otot subskapularis dipotong kemudian disambung secara bertumpuan sehingga mengurangi gerak exorotasi. Setelah operasi, lengan pasien akan diberikan sling dan diperban pada badan dengan bahu yang berada dalam keadaan endorotasi selama 6 minggu. Pasien dapat beraktifitas seperti normal kembali jika perbaikan ini berhasil dilakukan dengan baik.29

              Selain dislokasi anterior rekuren, dislokasi bahu anterior biasanya berhubungan dengan fraktur dari tuberositas mayor, lesi Bankart (fraktur dari glenoid rim) (15%) dan defek Hill-Sachs (fraktur impaksi pada permukaan posterolateral dari caput humerus karena impaksi dari caput humerus dengan glenoid rim anterior saat terjadi dislokasi) (50%).8

              Komplikasi yang cukup umum terjadi akibat dislokasi inisial yaitu cedera traksi pada N.aksilaris. Pasien tidak dapat abduksi bahu karena paralisis deltoid dan terdapat daerah kecil dengan sensasi kulit yang berkurang.Prognosis penyembuhan baik.Kadang-kadang dapat terjadi secara bersamaan yaitu robekan pada musculotendinous cuff yang dapat memperburuk dislokasi yang ada, dimana pada keadaan ini bahu yang sudah direduksi perlu untuk dilakukan imobilisasi selama 3 minggu dalam posisi abduksi. Jarang terjadi interposisi tendon dari otot biseps longus yang memerlukan reduksi terbuka yaitu secara pembedahan.29

 

3.3.2       Dislokasi Posterior


Gambar 3.3

              Mekanisme Cedera

              Dalam kurang dari 5% dari kasus yang ada, bagian atas humerus berada di belakang shoulder blade, suatu dislokasi posterior.2 Dislokasi posterior terjadi akibat berat axial yang ditumpukan pada lengan yang sedang berada dalam keadaan adduksi dan endorotasi. Seperti jatuh dalam posisi lengan adduksi dan endorotasi, atau adanya tekanan langsung pada bagian depan bahu.28 Dislokasi posterior yang klasik dapat juga terjadi akibat tersengat listrik ataupun kejang karena ketidakseimbangan kekuatan antara otot internal rotators (subskapularis, latissimus dorsi, pektoralis mayor), yang menekan otot-otot external rotators (teres minor dan otot infrasupinatus).6,27 jika terjadi kejang, perlu dilihat adanya dislokasi bilateral.5

Gejala Klinis

Dislokasi bahuposteriormudahuntuk terlewatkan dalam diagnosa, karena lengan pasienbiasanyaterletak dalam keadaan endorotasi dan adduksi(yaitu, pasienmemeganglengannya dan meletakkannya padaperutnya).3Pasientidak dapatmelakukan supinasi pada tangannya.7,30Pada lengantidak dapatdilakukanexorotasi ke posisi netral.7Pada pasienyangkurus,caput humerusyang menonjoldapat dilihat danteraba diposteriordi bawahprosesusakromion, bahuanteriormenjadi rata, dan prosesuskorakoidlebih menonjol.3,7,27Dislokasi bahuposterior seringkali terlewatkan, karena pasienhanya tampak seperti memegang ekstremitasnya.

Sebelumnya, dislokasi inipernah terlewatkan atau disalah-diagnosiskansebagaifrozen shoulder.27Jikagambaran radiografiyang tepat tidakdapat diperoleh, diagnosisakanterlewatkan.3cedera pada sarafdanvaskulartidak umum terjadi.30

Komplikasi

Komplikasi yang dapat terjadi pada dislokasi bahu posterior yaitu dislokasi yang tidak dapat direduksi.Sekurang-kurangnya setengah dari pasien dengan dislokasi posterior memiliki lesi yang tidak dapat direduksi saat pertama kali ditemukan. Tipikalnya pasien memegang lengan dalam keadaan endorotasi, pasien tidak dapat mengabduksi lengannya lebih dari 70-80º, dan jika pasien mengangkat lengannya ke arah depan, ia tidak dapat memutar telapak tangannya ke arah atas.28 Komplikasi lainnya yaitu dislokasi bahu posterior rekuren dan habitual.

Jika bahu yang sebelumnya pernah terdislokasi mengalami dislokasi berulang oleh karena suatu cedera lain, dislokasi kedua dan seterusnya disebut sebagai dislokasi rekuren. Perbaikan jaringan lunak posterior secara pembedahan dianjurkan.Akan tetapi jika pasien dapat melakukan dislokasi bahu sesuai dengan keinginannya ataupun mereduksi kembali bahu tersebut, maka kondisi ini disebut sebagai dislokasi habitual, dan biasanya berhubungan dengan kelainan kongenital yaitu kelemahan umum kongenital dari ligamen yang membentuk bahu.Atau hal ini dapat berhubungan dengan remaja atau orang dewasa yang mencari perhatian. Maka perhatian khusus harus diberikan pada mereka agar tidak melakukan hal itu secara sengaja.29

3.3.3 Dislokasi Inferior

 

Gambar 3.4

Mekanisme Cedera

Dislokasi inferior jarang ditemukan dan dapat terjadi akibat suatu tekanan hiperabduksi yang menyebabkan bagian leher dari humerus terangkat/menekan melawan akromion.Mekanisme cedera dari dislokasi bahu inferior adalah adanya berat axial yang ditumpukan saat lengan sedang abduksi atau hiperabduksi secara paksa seperti menangkap/ menggenggam suatu objek yang berposisi di atas kepala saat jatuh.6

Gejala Klinis

Dislokasi inferior akan menjadi kondisi yang disebut sebagai luxatio erecta, yang menjelaskan mengenai presentasi klasik dimana lengan atas abduksi 110-160° dengan lengan bawah diistirahatkan pada atau di belakang kepala pasien.27 Pada pemeriksaan, ditemukan lengan yang berada di atas kepala pada posisi yang tetap dengan siku yang fleksi. 6,8Caput humerus teraba pada atau di bawah aksila.28

Komplikasi

Mendiagnosa dislokasi inferior sangatlah penting oleh karena tingginya angka kejadian untuk komplikasi. Sebanyak 60% dari kasus yang ada, kerusakan neurologi (biasanya lesi pada N. aksilaris) berhubungan dengan dislokasi inferior.6,27 Kerusakan vaskularisasi terjadi dalam 3,3% dari kasus yang ada, robekan rotator cuff terjadi dalam 80-100% dari kasus yang ada, dan fraktur greater tuberosity dan avulsipektoralis major juga berhubungan dengan dislokasi inferior.27

3.3.4      Dislokasi Superior

Mekanisme Cedera :Pada dislokasi bahu superior, caput humerus terdorong ke atas melewati rotator cuff. Dislokasi superior sangatlah jarang dan dapat terjadi akibat tekanan yang ekstrim ke arah atas pada lengan yang adduksi.

Fitur Klinis :Pada pemeriksaan dapat ditemukan caputhumerusyang menonjolyang dapat dirasakanberada di superior.

Komplikasi

Kerusakan yang dapat terjadi bersamaan dengan dislokasi superior yaitu kerusakan pada akromioklavikular, fraktur pada akromion, klavikula, dan tuberositas.8,27

3.4     Diagnosis

3.4.1      Anamnesa dan Pemeriksaan Fisik31

              Anamnesa dan pemeriksaan fisik tanpa diragukan adalah alat paling penting bagi dokter untuk mendiagnosa suatu kerusakan pada rotator cuff ataupun fraktur tulang. Kerusakan pada hal-hal yang terdapat pada bahu dapat menyebabkan (dan akan terdapat bersamaan dengan) dislokasi bahu.

              Pertama, dokter akan melakukan inspeksi secara visual pada bahu penderita. Ketika terdapat dislokasi bahu, bentuk kebundaran bahu dan lengan atas yang normal akan hilang. Bagian luar yang mengelilingi bahu terlihat datar.

              Terdapat perubahan dari permukaan anatomi yang normal.Sebagai contoh, terdapat jarak di bawah akromion yang pada keadaan normal seharusnya terdapat greater tuberosity (tonjolan tulang yang terdapat di sepanjang bagian atas bahu).Caput humerus dapat diobservasi dan dirasakan sebagai suatu tonjolan yang besar di depan atau di belakang bahu. Area ini biasanya sangat sakit saat dipalpasi.

              Cakupan gerakan, kekuatan, dan sensasi akan di periksa jika memungkinkan. Suatu perubahan atau hilangnya sensasi dapat menunjukkan adanya kerusakan saraf. Dokter juga akan memeriksa denyut nadi pada lengan pasien untuk mendeteksi kemungkinan adanya komplikasi vaskular.

              Terdapat banyak pemeriksaan klinis yang dapat dilakukan untuk mengidentifikasi struktur jaringan lunak yang rusak atau lepas.Apprehension test yang positif dapat menjadi acuan diagnostik adanya bahu yang tidak stabil yang dapat terdislokasi kembali setelah kejadian dislokasi yang pertama. Pada tes ini lengan di abduksi (di jauhkan dari tubuh) dan di rotasi ke arah eksternal. Sesaat sebelum sendi akan terdislokasi, pasien akan menjadi sangat gelisah. Pada titik ini, tes ini dianggap positif untuk ketidakstabilan bahu dan kemudian pemeriksaan dihentikan.


Gambar 3.5

              X-ray adalah alat diagnostik yang penting untuk menunjukkan caput humerus yang bergeser dan adanya fraktur tulang. Beberapa gambaran mungkin diperlukan untuk menunjukkan arah sebenarnya dari dislokasi yang ada dan garis fraktur yang ada.Magnetic resonance imaging (MRI) digunakan untuk mendiagnosa dan melihat perluasan dari lesi.MRI sangat akurat dalam mendeteksi lesi Hill-Sachs.

              Jika diperlukan pembedahan, maka dokter bedah akan melakukan pemeriksaan diagnostik dengan arthroskopi. Suatu teropong yang tipis dengan kamera tv optic yang sangat ketil pada ujung akhir dari teropong yang dimasukkan ke dalam sendi bahu, dimana dokter ahli bedah ortopedik dapat melihat struktur di dalam sendi secara langsung.

3.4.2      Pemeriksaan Penunjang

              Radiologi

              X-rays diperlukan untuk memeriksa adanya fraktur di sekitar sendi, dan untuk melihat pola dari dislokasi bahu yang ada.

3.4.2.1      Dislokasi Anterior

                Gambaran X-ray untuk suspek dislokasi anterior termasuk anteroposterior (AP) dan gambaran aksilaris atau skapula 'Y' lateral.tanda-tandanya yaitu:7

  • Caput humerus terletak di bawah coracoids process pada gambaran AP.
  • Gambaran aksilaris menunjukkan caput humerus terletak anterior dari glenoid.

Gambar 3.6.AP view6

 

  • caput humerus dapat dilihat terletak anterior dari ‘Y’ pada gambaran skapula ‘Y’ lateral (dengan glenoid terletak di bagian tengah ‘Y’ tersebut)

 

Gambar 3.7 Gambaran aksilaris

                  

Gambar 3.8 (17) Gambaran skapula‘Y’ lateral

Dislokasi anterior dari caput humerus: gambaran paling atas menunjukkan caput humerus yang bergeser dari glenoid dan terletak inferior dari coracoid process (panah merah).

 

Gambaran di tengah menunjukkan suatu kelainan sepanjang aspek posterolateral dari caput humerus, yaitu deformitas Hill-Sachs (panah hijau)

Gambaran di bawah adalah gambaran skapular Y (garis biru menunjukkan skapula).Caput humerus terletak subkorakoid (lokasi anterior). Panah putih menunjuk ke arah akromion.(24)

Gambar 3.9

 

Fraktur yang berhubungan dengan dislokasi bahu anterior termasuk: 7

  • Deformitas Hill-Sachs – fraktur depresi caput humerus ketika menabrak batas dari glenoid; paling baik terlihat secara endorotasi pada gambaran AP.

Gambar 3.10 Lesi Hill sach

  • Lesi Bankart – disrupsi dari glenoid labrum juga dapat mengakibatkan lepasnya fragmen tulang yang disebut sebagai “Bony Bankart”. walaupun fraktur Bankart tidak begitu terlihat secara radiologi, fraktur Bankart merupakan suatu kerusakan dimana bagian inferior dari glenoid terlepas/ patah. Hilangnya glenoid labrum akan mengurangi stabilitas dari sendi glenohumeral dan dapat menyebabkan dislokasi berulang.32

Gambar 3.12 Lesi Bankart 6

Gambar 3.13 Fraktur Bankart32

  • Fraktur Greater Tuberosity 

 

Gambar 3.14 greater tuberosity fracture6

 

3.4.2.2     Dislokasi Posterior

                Pada dislokasi bahu posterior dapat dilakukan pemeriksaan radiologi sebagai berikut:

  • Gambaran X-ray untuk suspek dislokasi posterior termasuk AP dan aksilaris lateral. 7 gambaran AP dapat meleset hingga 50% dari dislokasi posterior yang ada, lebih terlihat pada gambaran aksilaris dan scapula ‘Y’ lateral.6
  • Pada gambaran AP, caput humerus terlihat seperti bentuk normalnya (seperti tongkat untuk berjalan). Namun kadang-kadang dapat menyerupai “lightbulb” atau “ice cream cone“ akibat endorotasi.(2)(3)(40)
  • Gambaran skapula 'Y' lateral menunjukkan caput humerus posterior dari potongan kaki dari gambaran ‘Y’ 7
  • Gambaran aksilaris menunjukkan caput humerus posterior dari glenoid. 7

Tanda radiologi yang ditemukan pada dislokasi bahu posterior yaitu: (17)

  • Tanda Lightbulb – tampilan sirkular dari caput humerus yang menetap pada endorotasi. Glenoid dan caput humerus tumpang tindih. (16)(17)
  • Tanda Rim -  jarak antara caput humerus bagian medial dan gleniod rim anterior lebih dari 6mm (16)
  • Dapat berhubungan dengan: (16)
    • Tanda Trough line - “Reverse Hill Sachs”; dua garis parallel terlihat pada korteks medial yang mewakili fraktur impaksi dari caput humerus bagian anterior/ fraktur kompresi dari caput humerus bagian anteromedial. 6,8
    • Fraktur pada glenoid rim posterior 6
    • Fraktur terlepasnya lesser tuberosity.

 

Adanya fraktur dari lesser tuberosity sendiri dapat berhubungan dengan dislokasi posterior.6

Gambar 3.15 Gambaran AP dislokasi bahu posterior

 

Dislokasi bahu posterior tidak sering ditemukan dan sulit untuk di diagnosa dengan hanya satu foto AP. Walaupun diagnosanya tidak begitu terlihat dalam gambaran ini, tanda lightbulb serta tidak adanya gambaran caput humerus dan glenoid yang biasanya tumpang tindih dapat membantu dalam mendiagnosa tipe dislokasi ini.32

 

Gambar 3.16

Dislokasi bahu posterior terlihat jelas dengan gambaran scapula ‘Y’ lateral ini. Hal ini menunjukkan pentingnya untuk dilakukan foto dalam posisi lain untuk medapatkan gambaran lateral skapula atau gambaran axilla. 32

Gambar 3.17 Tanda RimdanLightbulb6

 

Tanda Rimpositif.Ukuran jarak sendi 7 mm. Humerus terdapat pada posisi rotasi internal. Terdapat Trough line (panah).33


 

Gambar 3.18

Gambar 3.19Trough line33

Proyeksi anteroposterior menunjukkan adanya fraktur impaksi (panah) sebagai garis vertikal.

Walaupun temuan pemeriksaan fisik yang umumnya telah diketahui, hal ini seringkali tidak digunakan sebagai acuan untuk diagnosis.Gambaran radiografi AP dari bahu dapat terlihat normal, dimana hal ini berhubungan dengan tingginya tingkat kesalahan dalam mendiagnosa adanya dislokasi.

Gambaran radiografi AP dari bahu kiri (Gambar 3.20) tampak normal. Gambaran radiografi aksilaris dari bahu kiri yang sama (Gambar 3.21) menunjukkan adanya dislokasi posterior tanpa fraktur.34

 

Gambar 3.20. Gambaran radiografi AP dari bahu kiri tampak normal tanpa adanya dislokasi posterior.

Gambaran sendi yang benar pada kasus suspek dislokasi bahu posterior sangatlah penting.Gamabran radiografi AP dapat tampak normal, seperti pada pasien ini (gambar 3.20). Dari 40 orang, hanya 50% dari kasus dislokasi posterior yang ada dapat terlihat dengan hanya menggunakan gambaran AP dan lateral.37 tambahan gambaran aksilaris dapat meningkatkan tingkat keberhasilan diagnosis hingga 100%.37

 

Fig. 3.21 Gambaran aksilaris dari bahu kiri yang sama menunjukkan dislokasi posterior.

 

3.4.2.3      Dislokasi Inferior

                Luxatio Erecta.Caput humerus (panah biru) menghadap ke inferior dan terletak di bawah batas dari glenoid (panah merah) pada dislokasi bahu inferior yang jarang terjadi ini, dimana lengan menetap pada pasisi lurus dan biasanya dengan siku yang fleksi.8

Gambar 3.22

3.4.2.4     Dislokasi Superior

  • Paling jarang ditemukan
  • Caput humerus terdorong keatas melewati rotator cuff
  • Kemungkinan berhubungan dengan fraktur pada humerus, klavikula atau akromion

Gambar 3.23

        Gambaran radiografi AP menunjukkan dislokasi superior dari sendi glenohumeral kanan dengan caput humerus terletak di depan sendi akromioklavikular.

3.5     Tatalaksana Non-Operatif

          Perawatan pada dislokasi bahumeliputi:39

  • Reduksi tertutup-Dokter akan memindahkancaputhumeruskembalike dalam soketsendi bahudengan cara menerapkantraksi pada lengan yang terdislokasi. Obatnyeriakan diberikan sebelumprosedur inidimulai.
  • Imobilisasi-Setelah reduksi, perluuntuk memakai arm slingatau perangkatyang disebutimmobilizerbahuuntuk menjagabahubergerak. Bahuumumnyabergerakselama sekitar empatminggu, danpemulihan penuhmembutuhkan waktu beberapa bulan.
  • Istirahat-Penting untuk mengistirahatkanbahu dantidak memberikanteganganpada daerahsendi tersebut.
  • Es danpanas -Aplikasikanes atau kemasanyang dingin padabahu selama 15-20 menit, empat kali sehari, selama duahari pertama. Setelahhari ketiga, gunakanbantalan pemanasselama 20menitatau kuranguntuk membantudalam mengurangi nyeri padaotot. Hal ini dapat membantu mengurangi pembengkakanjuga.Bungkuses ataukemasan dingindengan handuk. Janganmenempelkan eslangsung padakulit.
  • Latihan rehabilitasi -Setelah pelepasan slingbahu,latihan dimulai untukmengembalikan kekuatandan rentang gerakpada bahusebagaimana direkomendasikan olehtenaga kesehatan profesional.
  • Obatpereda sakit – obat anti-inflamasi non-steroid (NSAID) atau asetaminofen(Tylenol) dapat membantu mengurangi rasa sakit.
  • Pembedahan-Pembedahan jarang diperlukan untukdislokasiyang baru terjadi pertama kali. Hal ini lebihdiperlukan untukbahu yangsudah terdislokasi berulang kali.

      Pemeriksaan Pra-reduksi:40

1.     N.Aksilaris: palsi 8%

        Persarafan otot deltoid: tidak dapat diuji

        Sensoric Overcadet’s patch: deltoid bawah

2.     N.Radialis: ekstensi pergelangan tangan

        Sensasi pada dorsum manus

        Berbagi aspek posterior dari pleksus brakialis

3.     A. brakialis: denyut radialis

3.5.1      Tatalaksana Dislokasi Anterior

              Terdapat berbagai macam metode reduksi tertutup yang digunakan untuk tatalaksana dislokasi anterior.Beberapa dari metode-metode tersebut sekarang hanya berupa sejarah saja.28

              Reduksi tertutup41

Teknik reduksidapat diklasifikasikandalam beberapa macam yaituteknik leverage,manipulasiskapula, atautraksi. Traksidapat dibagi lagimenurutletak dimanalenganditempatkansaattraksi diaplikasikan. Yang termasuk Leverage yaituKocher, MilchdanExorotasi bahu.TraksiTermasukHippocratic, Stimson, Matsen, Spaso, Eskimodan Manes.Selain itu dapat dilakukan manipulasi skapula.

Pilihantekniktergantungpadapengalaman danpreferensiDokter, fasilitas yang tersedia, jumlah asistenyang ada, waktu yang tersediadan kondisipasien.

3.5.1.1     Teknikleverage:

  1. 1.              MetodeKocher

            MetodeKocherpertama kali dijelaskanpada tahun 1870meskipunsatu tulisan mencatatbahwa metodeini mungkinsetua3000tahun, hampir bersamaan dengan lukisan dindingdalammakamMesirIpuy.

            Selama bertahun-tahunbanyak buku tekstelah memasukkanelemen baru keteknik ini, yang pernah dikaitkandengan komplikasi. Namun,pada teknikaslitercatatbahwa teknik ini tidak menyakitkandan tidak termasuktraksi, hanya menggunakan leveragesaja: "Tekuk lengan yang terdislokasi 90º pada siku, adduksiterhadap tubuh, pergelangan tangandan titiksikudapat digenggam oleh dokter bedah.Secara perlahanlakukan exorotasi antara70º sampai85ºsampaidapat dirasakan adanya tahanan;pada pasienyang sadargunakanwaktu yang banyakserta tidak terburu-burudanmencoba untukmengalihkan perhatianpasien denganpercakapan dankemudian melanjutkan pelaksanaannya.

            Angkatlengan atasyang sudah dilakukan exorotasipada bidangsagitalsejauhmungkinke depan, sekaranglakukan endorotasi pada bahu, halini akan membawatanganpasienke arah bahulainnya". Caput humerusseharusnya sudah kembali ke dalamfossaglenoiddan rasa sakithilangselama proses ini.

            Komplikasidapat terjadipada teknik inijika prosedurtidak dilakukandengan benar, yaitu ketikadilakukan traksi dan ketika proseduritu dilakukanterburu-buru. Komplikasi yang dapat terjadi yaitu robeknyaototsubskapularisdan frakturspiralcaput humerus.Selain itu terdapat laporan mengenaikerusakanvenaaksilarisdan kematian.(28)Tingkat keberhasilannya mencapai80%.42

 

Gambar 3.24

  1. 2.              TeknikMilch

            Teknik ini telahdiadaptasikanselama bertahun-tahunnamundeskripsi asli dari teknik ini yaitu hanya denganmenggunakanleverage saja.Dokter bedahberdiri disisi yang sama denganlenganyang terdislokasisementarapasien berbaringdalam posisi telentang.

            Jaridokter bedahditempatkan di atasbahuyang terdislokasi, untuk memantapkancaput humerus yang terdislokasi,ibu jari ditekankan pada bahu itu. Berikutnyatangan sisi laindokter bedah secaralembutmelakukan abduksi dan exorotasipada lengan pasienkeposisiatas,sementaraitu memperbaikicaput humerisehinggatidak bergerakdariposisiterdislokasinya.Dokter bedahsekarangdengan lembutmendorongcaput humerikembali kefossaglenoiddengan ibujari mereka.

            TeknikMilchjuga dapat dilakukandalam posisipronasi. Denganpasiendalam posisi pronasidi atas meja, bantalditempatkan di bawahototpektoralisdari bahuyang terdislokasi, lengandibiarkan menggantungbebas. Reduksi karenarelaksasidapat terjadi secara spontandalam posisi ini.

            Namun jikatidak terjadireduksi, sikuditekuk sampai90º, dan tangandari lenganpasien yang terdislokasikemudian diletakkan di ataslengan dokter bedah, yang memegang siku pasien  dengan erat menggunakan jari-jaridan ibu jarinya.Dokter bedahkemudian melakukantraksilongitudinal yanglembut, abduksidan exorotasi. Tangan lainnya daridokter bedahmemegangbagianproksimaldari humeruspasien, dokter bedahmeningkatkanabduksi secaralembutdan exorotasi bahu.(28)Tingkat keberhasilannya yaitu70-95%.42

Gambar 3.25 Teknik Milch

  1. 3.        Exorotasi Bahu

        digunakan. Pasien pada posisi terlentang dan menahan lengan mereka dalam keadaan adduksi, menekuk siku pada lengan yang terdislokasi pada sudut 90 º, ahli bedah menggenggam siku dan pergelangan tangan pada sisi yang terdislokasi. Lengan bawah dilakukan exorotasi dengan sangat lembut; biasanya reduksi pada bahu sudah dapat tercapai pada saat lengan berada pada bidang koronal. Tingkat keberhasilan hingga 80%. 40

 

Gambar 3.26 Exorotasi Bahu

3.5.1.2     Teknik Traksi:

1.         Metode Hippocratic

            Metode Hippocratic dimulai dengan pasien dalam posisi telentang, dokter bedah memegang sisi yang terdislokasi pada bagian tangan dan lengan bawah. Tumit ahli bedah yang berstoking ditempatkan di ketiak (tidak ditekan keras) hal ini bertindak sebagai titik tumpu saat dilakukan adduksi pada lengan. Komplikasi yang dapat terjadi yaitu kerusakan pada N. aksilaris.

 

Gambar 3.27 Metode Hippocratic

2.         MetodeStimson

            MetodeStimsonbiasanyamemerlukan anagelsikkuatterlebih dahulu, danpasienpronasi di atas mejadenganlengan pada sisi yang terdislokasimenggantung ke bawahpada posisi fleksi ke depan. Sebuahkarung pasirditempatkandi bawahklavikulapada sisi yang terdislokasi, dan sebuah beban sekitar 20 kgdiaplikasikandipergelangan tangan sisi yang terdislokasi. Otot-ototyang spasme akan menjadi rileks danbiasanya reduksi sendi dapat terjadi secaraspontan. (28)Prosedur ini dapatmemakan waktu hingga15-20menit. Prosedur inimemerlukanpemantauan yang cermatkarenaresikonyaadalah jatuh.40

 

Gambar 3.28 Metode Stimson

3.         Matsen’s Traction Counteraction

            Matsen's Traction Counteractiondimulaidengan pasien dalamposisi terlentang.Teknik initermasuk traksi yang diaplikasikan pada lengan di sisi bahu yang terdislokasi sementara bahu dalam posisi abduksi, seorang asisten mengaplikasikantraksi berlawanan secara erat ke dada menggunakan lembaran kain yang dilipat. Ahli bedah dapat melakukan endorotasi dan exorotasi pada bahu untuk melepaskan engsel caput humerus yang terdislokasi.

 

Gambar 3.29 Matsen’s Traction Counteraction

 

4.             TeknikSpaso

                TeknikSpasodimulaidengan pasien dalamposisi terlentang. Lenganpada sisi yang terdislokasidigenggampadapergelangan tangan ataulengan bawahdistal dandiangkatsecara vertikal dengan lembut, sambil mengaplikasikan traksi denganlembut. Kemudian dilakukan exorotasipada bahu, biasanya reduksi dapat terjadisecara spontan.Mendorongcaput humerikembali keposisinormal dapat sangat membantusambil mempertahankantraksi.

 

 Gambar 3.30 TeknikSpaso

 

Pada teknik reduksiSnowbird,pasienduduktegakselurus mungkin; seorang AsistenMembantumempertahankan  posisi inidengan berdiri disisi yang berlawanandengan tanganmencengkeram sekitardada pasienkeaksila.Lenganpada sisi yang terdislokasi flexipada 90º danstockinettediletakkandi sekitarlengan bawahproksimal, diputarsatu kali, sehinggakakidokter bedahdapat ditempatkan diloopdistal dantraksidapat diaplikasikan dengan kuat ke arah bawah. Tangan dokter bedahbebasuntuk mengaplikasikanrotasiatau tekananyang diperlukan sampaireduksiberhasil.41Tingkat keberhasilannya yaitu87,5%.42

Gambar 3.31 TeknikSnowbird

5.             TeknikEskimo

                TeknikEskimodimulai denganpasienberbaring padabahu yang tidak terdislokasidi tanah. Duaorang mengangkatpasien dengan menarik lenganpada sisi yang terdilokasi, memeganglengan bawahdistalatau pergelangan tangan. Menahanbahuyang berlawananbeberapasentimeterdi atas tanah, reduksi biasanya dapat terjadi dalambeberapa menit. Ahli bedah dapatmembantu prosedur ini dengan caramengerahkansedikittekanan langsungterhadap caputhumeri, yang biasanyaterabadi ketiak.

Gambar 3.32

6.             MetodeManes

                Metode baru iniditemukan setelahpenulis mengenai teknik-teknik inimenemukan bahwa beberapateknikyang ada bersifat terlalutraumatisbila dilakukan padapasienlansia. Setelah memberikananalgesiayang memadai danrelaksanotot,ahli bedahberdiri di belakangpasien danmemasukkanlengan bawah mereka yang fleksi keaksilapada bahuyang terdislokasi. Tangan lainnyaditempatkan padalengan bawahpasien yang fleksi dandilakukan traksi secara lembut.Lenganbawahdokter bedahmenarikke arahproksimal danlateral danmengungkitcaput humerike dalam soketglenoid. Traksikemudian dilepaskan.

Gambar 3.33

 

3.5.1.3     Manipulasi Skapula

                Manipulasiskapuladimulaidengan pasien dalamposisi pronasidi atasmeja pemeriksaan, lengan pada sisi yang terdislokasi menggantung secara vertikaldi sekitar tepimejapada posisi fleksi ke depan 90ºdanexorotasi.

            adapergelangan tangan diberikanbeban seberat 10 sampai20 kgyangdigunakan untuk mempertahankantraksi dandiikat dengan menggunakanbidaipergelangan tangan.Ketika pasienmulairileks, reduksi kemudiandicoba dengan caramendorongdi ujungskapula ke arahmedial, dengan rotasidariaspeksuperiorskapulake arah lateral41Tingkat keberhasilannya mencapai 85%.38

 

Gambar 3.34

                Perawatan setelahdilakukan reduksi tertutup:43

  • Harus dilakukan Xray pascareduksi.
  • Penilaian neurovaskularharus diulang.
  • Observasijikaobatpenenang dengan waktu kerja yang lama sepertimidazolamtelahdiberikan.
  • Immobilisasiselama 3-4 minggu.Meskipunhanya terdapat sedikit buktimengenai durasi yang baik. Posisirotasieksternal mungkinterbaik untukrobekankapsulakan tetapi tapi tidak dapat dilakukan.
  • Analgesiayang memadaiharus diberikankepada pasien untukdibawa pulang.
  • Biasanya mulai dilakukan latihan fisioterapi.


Setelah reduksi, biasanya dianjurkan untuk imobilisasilengandengan slingyang dilampirkan terhadap dada. Imobilisasibahuyang sudah direduksi diterapkanselama beberapa minggusampai satu bulan. Hal inidilakukan untuk memberikankesempatan bagijaringan lunak untuk sembuh.Untuk orang dewasayang lebih tua, latihan pasifyang disebutlatihanCodmanataupendulumdapatdilakukan untuk mencegahkekakuan.Latihan ini biasanya dilakukansekali ataudua kali seharidengan sling yang dilepaskan. 44

 

3.5.2        Tatalaksana Dislokasi Posterior

                Tatalaksana pada dislokasi posterior yang akut dilakukan dengan cara reduksi (biasanya dilakukan dengan anestesi umum) dengan cara menarik lengan ketika bahu dalam posisi adduksi. Kemudian lengan didiamkan selama beberapa menit hingga caput humerus terlepas, setelah itu pada lengan dilakukan exorotasi secara lembut dan pada saat yang bersamaan caput humerus didorong ke depan. Jika reduksi terasa stabil, maka lengan dapat diimobilisasi menggunakan sling.Jika tidak, maka bahu dipegang dalam posisi abduksi secara lebar dan dilakukan exorotasi dengan menggunakan plester spica selama 3 minggu yang berguna untuk penyembuhan kapsul posterior pada posisi yang sependek mungkin. Pergerakan yang normal pada bahu dapat dikembalikan dengan melakukan latihan secara aktif.28

 

3.5.3        Tatalaksana Dislokasi Inferior

                Dislokasi inferior biasanya dapat direduksi dengan cara menarik ke atas segaris dengan lengan yang berada dalam posisi abduksi, dengan countertraction ke bawah dari bagian atas bahu. Jika caput humerus macet atau melekat erat di dalam jaringan lunak, maka perlu dilakukan reduksi terbuka.Penting sekali untuk melakukan pemeriksaan kembali setelah dilakukan reduksi untuk melihat bukti adanya kerusakan neurovaskular.

            Kemudian lengan diistirahatkan dengan menggunakan sling hingga nyeri berkurang dan hilang, setelah itu lengan diperbolehkan untuk bergerak, akan tetapi gerakan abduksi harus dihindari selama 3 minggu agar dapat terjadi penyembuhan jaringan lunak dengan baik.28

 

Gambar 3.35

3.6     Tatalaksana Operatif

          Dalam kasusbahutidak stabil yangtidakefektif dengan pengobatanfisioterapi, terdapat beberapaprosedur bedahyang dapat dilakukanuntuk memulihkanstabilitas bahu itu kembali.Tipe prosedur yang dilakukan tergantung dari tipe dislokasi yang terjadi.Jenisprosedur yang digunakanoleh konsultanbahu tergantungdari sifat cedera yang terjadi, pekerjaandan aktivitasolahraga daripasien, danpreferensidari konsultan.45

          Beberapa jenis prosedur yang dapat dilakukan yaitu prosedur Bankart, Bristow, Putti Platt dan Magnuson Stack.

 

3.6.1    Prosedur Artroskopi Bankart

            Pada umumnya, operasi bahu dapat dilakukan dengan 2 dasar cara yang berbeda: dengan menggunakan teknik operasi tertutup (operasi artroskopi) atau dengan teknik operasi terbuka. 46


Gambar 3.36 Prosedur artroskopi

            Artroskopi bahu adalah operasi yang menggunakan kamera kecil yang disebut sebagai artroskop.Artroskop dimasukkan melalui insisi kecil pada kulit.Artroskopidiagnostikjuga sering digunakanuntuk mengkonfirmasi keberadaandan tingkatketidakstabilanbahu.Dalam prosedur ini, fibreoptic scopeyang tipis dimasukkanke dalam ruangsendi bahuuntuk memungkinkanvisualisasilangsung daristrukturinternal. Sebuahelektromiogramjuga dapatdiperoleh jikadokter mencurigai adanya kemungkinancedera saraf.47

            Pertama, dokter bedah akan memeriksa bahu dengan artroskop. Yang akan dilakukan yaitu:

  • Memasukkan artroskop ke dalam bahu penderita melalui insisi kecil. Artroskop tersambung ke monitor video di kamar operasi.
  • Inspeksi pada semua jaringan di sendi bahu dan di area di atas sendi – kartilago, tulang, tendon, dan ligamen.
  • Perbaikan pada jaringan yang rusak. Untuk melakukan ini, akan dilakukan 1 sampai 3 lagi insisi kecil dan alat lain akan dimasukkan ke dalamnya. Robekan pada otot, tendon, atau kartilago akan dapat diperbaiki. Jaringan yang rusak akan dibuang.

 

Gambar 3.37

Artroskopi dapat digunakan untuk memperbaiki ketidakstabilan bahu yaitu ketika terjadi robekan pada labrum yang merupakan batas dari sendi bahu yang terbuat dari tulang rawan. Ligamen yang menempel pada daerah ini juga akan diperbaiki. Lesi Bankart adalah robekan pada labrum dibagian bawah dari sendi bahu.Pada lesi SLAP terjadi kerusakan pada labrum dan ligamen pada bagian atas sendi bahu.

Pada operasi dengan artroskopi ini akan digunakan tube kecil terbuat dari plastik atau metal dimasukkan ke dalam bahu. Tube ini tersambung dengan pompa yang terhubung melalui tube plastic yang steril.Tube kecil satu lagi berguna untuk membuang cairan dari sendi.Pompa ini terus menerus mengisi sendi bahu dengan cairan saline steril (air garam). Aliran cairan yang konstan melewati sendi dan mengembangkan sendi serta membersihkan darah dan debris dari sendi ketika dilakukan operasi.48

Terdapat banyak instrumen kecil yang dibuat secara istimewa untuk melakukan operasi pada bahu.Beberapa alat ini berguna untuk membuang jaringan yang robek atau degeneratif.Beberapa alat lainnya dapat digunakan untuk mengambil sedikit demi sedikit jaringan dan menyedotnya keluar dari sendi.Yang lainnya dibuat untuk mengebor jaringan tulang dan menyedotnya keluar dari sendi.Alat-alat ini berguna untuk membuang jaringan tulang yang menggesek tendon dan berguna untuk menghaluskan permukaan akromion dan sendi akromioklavikular.

Setelah jaringan degeneratif dan jaringan tulang dibuang, ligamen yang robek yang befungsi untuk menstabilkan bahu dilekatkan kembali ke tulang di sekitar soket bahu, glenoid. Alat yang dibuat secara istimewa untuk melekatkan kembali ligament ini, alat ini disebut sebagai suture anchors.

 

Gambar 3.38

Suture anchors adalah alat istimewa yang dibentuk untuk melekatkan jaringan pada tulang. Suture anchors mempermudah proses penempelan ini dan menciptakan jalan yang lebih kuat untuk melekatkan jaringan lunak pada tulang. Alat ini cukup kecil sehingga dapat dimasukkan melalui insisi kecil menggunakan artroskop. Alat ini terbuat dari metal atau material seperti plastik yang dapat larut dengan berjalannya waktu. Ini adalah bagian anchor dari alat tersebut.Anchor ini dibor ke dalam tulang dimana jaringan lunak akan dilekatkan. Sutura dilekatkan pada anchor, melewati jaringan lunak dan diikat pada tulang.48

Setelah operasi dengan artroskopi, insisi akan ditutup dengan jahitan dan balutan. Kebanyakan dari dokter bedah akan mengambil foto dari monitor video saat dilakukan prosedur untuk menunjukkan apa yang telah ditemukan dan perbaikan apa yang sudah dilakukan. (68)

Gambar dibawah ini merupakan langkah-langkah yang dilakukan dalam prosedur artroskopi Bankart:


Gambar 3.39                                                    Gambar 3.40


Gambar 3.41                                                    Gambar 3.42

Resiko dari artroskopi bahu yaitu:

  • Kekakuan bahu
  • Kegagalan operasi dalam menghilangkan gejala klinis
  • Kegagalan dari perbaikan untuk sembuh
  • Kelemahan dari bahu
  • Cedera pada pembuluh darah atau saraf

 

Pasca prosedur

  • Penyembuhan memakan waktu sekita 1 sampai 6 bulan. Pasien mungkin harus memakai sling untuk minggu pertama. Jika perbaikan yang dilakukan banyak, maka penggunaan sling harus lebih lama.
  • Pengobatan untuk mengontrol rasa sakit akan diberikan.
  • Jangka waktu hingga pasien dapat kembali bekerja atau berolahraga dapat bervariasi dari 1 minggu hingga beberapa bulan.
  • Pada banyak prosedur, terutama jika telah dilakukan suatu perbaikan, terapi fisik akan membantu dalam mengembalikan gerakan dan kekuatan pada bahu yang diperbaiki.

ProsedurBankartartroskopik mencoba untuk meniruprosedurBankartterbuka.Artroskopi adalahsuatu teknikmikrodimanaahli bedah menggunakanendoskopiuntuk melihat ke dalam sendi bahu melalui lubangkecil. Endoskopiadalah instrumenberukuranseperti pena, yang terdiri dari tabungyang dilengkapi dengancahaya danminiatur videokamera,yangmentransmisikangambardari sendi di interiorke dalam monitortelevisi.Bagianlabrum yang terpisah danligamenyang berhubungan disambungkan kembali ketulangdi sepanjangtepironggaglenohumeralmelalui sayatan sekecil"lubang kunci". Hal ini dilakukan denganhanya sedikitgangguanpada strukturbahu lainnya dan tanpa perluuntuk melepaskandanmenempelkan kembaliototbahuatasnya(subskapularis).47

3.6.2    Prosedur Bankart Terbuka

            Prosedur Bankart, yang juga dikenal sebagai prosedur Broca-Perthes-Bankart, adalah teknik bedah yang berguna untuk memperbaiki dislokasi sendi bahu yang berulang. Dalam prosedur ini, ligamen yang robek dilekatkan kembali pada tempat yang benar di sendi bahu, dengan tujuan mengembalikan fungsi yang normal.46

            Tujuan dari prosedur Bankart adalah untuk melekatan kembali ligamen yang robek secara aman ke ujung glenoid dimana ligamen tersebut terlepas. Operasi ini memiliki keuntungan yaitu memungkinkan pasien untuk dapat kembali melakukan kegiatan mereka sehari-hari, sementara perbaikannya menyembuh. Operasi ini juga meminimalkan kekakuan sendi yang tidak diinginkan yang berhubungan dengan cedera yang ada.

Teknik

Operasi ketidakstabilan bahu adalah prosedur yang sangat teknis; setiap langkah memainkan peran penting dalam hasilnya. Setelah anestesi diberikan dan bahu telah disiapkan, sayatan kosmetik dibuat pada lipatan kulit alami di depan bahu seperti yang ditunjukkan pada gambar 3.43.49

 

Gambar 3.43 Insisi aksilaris

Sayatanini memungkinkanakseske lapisan diantaradeltoiddan otot-ototpektoralismayor.Pemisahan lapisanini memungkinkanakses kebahutanpamelepaskanatau merusakotot deltoid yangpenting,yang bertanggung jawabbagi sebagian besarkekuatanbahu.Semuajaringan parutdibuangdari ruang dibawahdeltoid.

Tendondari ototsubskapularisdiinsisi, memberikan aksesyang sangat baik untuksendibahuinterior dantampilan darilabrum danligamen yang terlepasdarisoketglenoid, seperti yang ditunjukkanpada gambar3.44.

 

Gambar 3.44

Tujuan dariprosedurini adalah untukmemasang kembali secaraamanlabrumdan ligamenke daerahrobekannya.Hal ini dilakukan denganmembuattepisoketglenoid menjadi kasardan dengan melakukan pengeboranlubangkecil melaluibibirdi wilayahrobekan(lihatgambar 3.40). Meletakkan benang bedahmelaluilubang tersebut(lihatgambar 3.41)dan kemudian melaluilabrumdan ligamen yang terlepas (lihat gambar 3.42). Hal iniakanmengembalikananatomibahudan kedalamanyang normal dari soketglenoidketikabenang bedah sudah terikat, seperti yang ditunjukkanpada gambar3.45.

Gambar 3.45

Kemudian, tendonm. subskapularisdiperbaikisecara anatomis, seperti yang ditunjukkan dalam gambar3.46.

Gambar 3.46

Setelah itu dilakukan penutupansecara kosmetik padasayatan kulit, lalu dipasangkan balutan, danlenganditempatkandi dalam sling.

Anestesi

Prosedur anestesi yang dapat dilakukan pada operasi ketidakstabilan bahu yaitu prosedur anestesi umumatau bloksaraf pleksusbrakialis. Blokpada pleksus brakialis masihdapat memberikanefek anestesiselama beberapa jamsetelah operasi.Pasiendapat mendiskusikanpreferensimereka dengandokter anestesisebelum operasi.

Pasca Prosedur

Jangka waktu perbaikan

Prosedur inibiasanyamemakan waktu sekitarsatu jam, tapi persiapanpra operasi danpemulihan pasca operasidapat menambahkanbeberapa jam. Pasienseringkali menghabiskan waktu selamadua jamdi ruangpemulihan dansekitar duaharidi rumah sakitsetelah operasi.

Komplikasi

Resiko dan komplikasi yang berhubungan dengan prosedur Bankart yaitu:

·         Operatif: kerusakan saraf saat dilakukan operasi dan penempatan sutura yang tidak baik.

·         Dalam waktu 6 minggu setelah operasi: infeksi luka dan ruptur dari perbaikan yang dilakukan

·         Antara 6 minggu dan 6 bulan: kekakuan bahu, ketidakstabilan berulang dan kegagalan perbaikan yang disebabkan oleh kelemahan bahu dan kegagalan sutura.

3.6.3 Prosedur Bristow

Pada prosedurBristow, dan variannya, proseskorakoiddipindahkan melaluitendonmuskulus subskapularissebagai metodepengobatanketidakstabilananterior yang berulangpada bahu. Ujungkorakoiddipindahkan keleherglenoidanteroinferiordan kemungkinanberfungsi sebagai suatu bloktulangdi depancaput humerus. Biseps brevis dan korakobrakialis ditempatkan seperti itu sehingga menghasilkandinamikayang kuat untukmenopangseluruhaspekanterior daninferior darisendiketika bahudalam posisi rentan yaitu abduksi dan exorotasi.50

Teknik

Latarjet awalnya menjelaskan prosedur ini pada tahun 1954 dan Helfet memodifikasinya pada tahun 1958. Penjelasan asli dari prosedur telah dimodifikasi berkali-kali. Meskipun teknik yang digunakan sekarang sedikit berbeda dari yang dijelaskan pada awalnya, teknik inidilakukanberdasarkanpemindahan dari bagian ujung korakoid bersama dengan perlekatan dari otot gabungan melaluicelahhorizontal padasubskapularis, ke leherskapula. Teknik yang dijelaskan di sini berasal dari Campbell"Orthopaedics Operatif".

 

Pendekatan deltopektoralis

Pertama, insisi dibuat mulai dari proses korakoid berjalan sepanjang deltopektoralis groove menuju insersi deltoid. Deltopektoralisgroove dapat ditemukan dengan mengidentifikasi arah vena sefalika. Vena sefalika harus dilindungi selama pembedahan untuk mengurangi edema pascaoperasi. Tarik vena sefalika ke lateral atau medial dan buka sepanjang groove. Tarik deltoid ke lateral dan pektoralis mayor ke medial.

 

Korakoid osteotomi

Selanjutnya, proses korakoid dipaparkan bersama dengan otot gabungannya. Terlihat insersi dari ligamentum korakoakromial dan pektoralis minor dari permukaan superior korakoid. Proses korakoid kemudian di osteotomi dengan osteotom atau dipotong dengan pemotong tulang rusuk yang bersudut. 1cm sampai 3 cm bagian dari tulang dibuang bersama dengan otot-otot yang melekat. Ujung korakoid dengan biseps brevis dan korakobrakialis yang melekat beberapa sentimeter di bawah ujung korakoid dimobilisasi ke distal (lihat gambar di bawah). Nervus muskulokutaneus menembus korakobrakialis beberapa sentimeter di bawah ujung korakoid, oleh karena itu, penting untuk melindungi saraf dengan hati-hati saat melakukanpembedahan. Saraf dapat ditemukan dengan meraba dengan jari yang bersarung tangan atau dengan memperhatikan adanya jaringan lemak areolar di sepanjang jalannya.


Gambar 3.47                                                                                          Gambar 3.48


Gambar 3.49Proseskorakoid(C) dan conjoinedtendon(CT) setelah osteotomi.

Paparanleherskapula

Berikutnya, identifikasibatas atas dan bawahdari ototsubskapularis; pleksuspembuluh darah anteriorsirkumfleksahumerimenunjukkan batas bawahotot. Jarak antara ototsubskapularisdansupraspinatusmenandaibatas atasdari ototsubskapularis.Bagi subskapularissejalan denganseratnya darilateral ke medialpada daerah sekitartengah ke sepertiga bawahdariotot. Sekarangpengangkat periostealdapat digunakanuntuk mencerminkansubskapularisdaripermukaan luar kapsulbahu.Kapsulanteriorkemudiandibagi dengan cara yangmirip sebagaimanasubskapularisitu dibagi. Paparanmedial dari leherskapulaanteriordiperlukan untukpenempatan yang tepatdarikorakoidyang telah dipindahkan (lihatgambar di bawah).


Gambar 3.50

 

Subskapularis dibagi dan kapsul dibuka untuk memaparkan bagian depan dari glenoid/leher skapula. Hal ini dilakukan untuk mempersiapkan pemindahan korakoid.51

Diseksisubperiostealmembantuuntuk memaparkan leherskapula. Situspemindahannya haruslebih rendah daripadaekuatorglenoiddan kurang dari5mm daritepinya. Lubangsebesar 3,2mmharusdibormelalui leherskapulaposteriorpada posisidi bagiananteroinferiordari leherskapula. Selanjutnya,borsuatu lubangyang mirip di ujungkorakoid. Permukaannyaleherskapula dibuat menjadi kasar dan dipastikan bahwa semuajaringan lunaktelah dibuang.Posisikan ujungkorakoidyang dipindahkan denganototnya yang menempel melaluicelahhorizontal pada subskapulariskeleherskapula.

Pemasangankorakoid

Sekarang, perkirakankapsuldengan jahitanyang terputus. Gunakanscrew maleolarSwiss dengan panjang yang sesuaiuntuk melekatkan ujungkorakoidke leherskapula. Ketikascrew dan bloktulangsudah dipasang, pastikan bahwa tidak adayang menggantung di luar tepianterior dariglenoid.

 
Gambar 3.51

N.muskulokutaneusharus diperiksauntuk memastikanbahwa saraf tidak tegang(lihatgambar 3.52).


Gambar 3.52N.

muskulokutaneus(M) ditemukan dekatconjoinedtendon(CT) untuk memastikan bahwa saraf ini tidakdalam keteganganyang tidak semestinya.

Tutuppembagian longitudinal padasubskapularisdenganjahitanterputusdari tepilateraldari tempat pemindahan kebicipitalgroove (lihatgambar 3.53). Terakhir, perkirakanfasiadeltopektoralis, jaringan subkutan, dan kulitsecara tepat.


Gambar 3.53

Ujungkorakoidtelahdipasangkan ke leherskapula, dankapsul danm. Subskapularistelahdiperbaiki.

 

Gambar 3.54 Posisi akhir

 

Pasca Prosedur

Pasca operasi, pasien harus ditempatkan dalam alat immobilisasi bahu untuk sekitar satu minggu.Setelah satu minggu, pasien kemudian diberikan sling bahu standar selama 3-4 minggu.Ekstensi siku aktif atau pasif seharusnya tidak boleh dilakukan, tetapi dianjurkan untuk melakukan fleksi pasif.Latihan pendulum dapat dimulai antara 3-6 minggu.Setelah 6 minggu, gerakan pasif dan aktif dari bahu sudah dapat dimulai.

Gambaran radiografi pasca operasi harus diperoleh secara berkala untuk memastikan penempatan yang stabil dari korakoid yang dipindahkan dan screw.

 

Komplikasi

Komplikasi dari prosedur Bristow dan variannya termasuk ketidakstabilan anterior bahu yang berulang, kehilangan exorotasi, tidak menyambungnya korakoid yang dipindahkan, masalah terkait screw, cedera neurovaskular, dan ketidakstabilan posterior bahu.
3.6.4 Prosedur Putti – Platt

 

Prosedur Putti-Platt adalah prosedur non-anatomik bersejarah untuk ketidakstabilan bahu dengan hasil awal yang menjanjikan tetapi mengecewakan dengan tindak lanjutjangka panjang. Dasar prosedur ini terdapat pada ide untuk mengencangkan kapsul anterior dan m. subskapularis dengan kerugian yaitu hilangnya exorotasi untuk meningkatkan stabilitas dari bahu.Prosedur ini telah digambarkan sebagai "rompi di atas celana" yang dipadukan bersama dengan teknik "double-breasted".52

Sejarah

Putti-Platt kapsulorafi pertama kali diterbitkan oleh Osmond-Clarke pada bulan Februari 1948.Dr Platt pertama kali melakukan operasi ini di Rumah Sakit Ancoats pada tanggal 13 November 1925.Ia membagi tendon m. subskapularis, melekatkan ujung distalnya pada batas glenoid dan ujung proksimalnya pada kapsul anterior. Dr Putti melakukan operasi yang sama, secara independen dari Platt, sejak 1923, dan teknik itu mungkin juga dilakukan oleh guru Putti yaitu Codivilla. Brav mencatat keunggulan spesifik dari prosedur ini yaitu kesederhanaan teknis dan penerapan yang terlepas dari etiologi ketidakstabilan.Ia juga mencatat kerugian spesifik yang ada yaitu hilangnya kemampuan untuk exorotasi. Hilangnya exorotasi dan terbentuknya jaringan parut pada kapsul anterior merupakan mekanisme peningkatan stabilitas untuk bahu anterior.

Terdapat 3 alasan mengapa prosedur ini efektif, yaitu sebagai berikut:

1.     Pemendekan subskapularis yang membentang.

2.     Pembentukan lapisan ganda otot dan kapsul di depan sendi, membentuk dinding penopang fibrosa yang kuat.

3.     Bagian medial dari m. subskapularis dijahit ke bagian lateral, memungkinkan terbentuknya bagian yang lebih luas dari subskapularis untuk mencegah terjadinya dislokasi anterior caput humeri dalam posisi abduksi dan exorotasi.

Kunci pertimbangan

Karena hilangnya exorotasi, penerapan prosedur ini terbatas.Atlet dan buruh yang membutuhkan rentang gerak normal dalam melakukan rotasi eksternal menjadi terbatas dengan prosedur ini.Prosedur ini juga membatasi aktifitas dari altlet pelempar.Prosedur Putti-Platt hanya memperbaiki ketidakstabilan anterior dan penting untuk mengeksklusi tipe ketidakstabilan volunter, dislokasi posterior dan dislokasi berbagai arah sebelum dilakukan prosedur ini.Glenohumeral artritis juga merupakan kontraindikasi dari prosedur ini.

Anestesi
Pada prosedur ini dilakukan anestesi umum.

Posisi
Pasiendiposisikantelentangdalam posisibeach-chair.Ruanganharus diaturuntuk memungkinkanlenganagar dapat sepenuhnyaabduksi danexorotasi selama prosedur.

Pencegahan komplikasi

Bantalanyang memadaipentingdalam pencegahankomplikasiintraoperatif. Dan jugaidentifikasidari strukturneurovaskulardalam approach subskapularis.

Teknik

Teknik ini telahdiambillangsung darimakalah Osmond-Clarke yang asli.Secara umum, pendekatan subskapularis yaitu melaluiintervaldelto-pektoral. Subskapularisdibagipada persimpanganmuskulotendinous. Bagiandistaldilekatkan kebatas glenoiddan bagianproksimaldilekatkan padaaspek medialdari bicipitalgroove.53

Gambar3.55 Pada tahap awal prosedur, bagian dari kapsul anterior dan tendon dari m.subskapularis dipotong menjadi potongan medial (A) dan lateral (B).

 


Gambar3.56Pada tahap kedua, potongan tendon lateral (B) dilekatkan pada struktur jaringan lunak disekitar pinggir anterior dari rongga glenoid. Potongan tendon medial (A) ditarik agar tumpang tindih di atas potongan tendon lateral dan dilekatkan pada tuberositas minor dari humerus. Dengan ini m. subskapularis telah diperpendek secara efektif dan kapsul telah dirapatkan.

Teknik dari prosedur Putti-Platt:

  • Pendekatananteriordarisepertigaluarklavikula, diperpanjang ke bawah untuk 6inci.
  • Bukagrooveantaram. deltoiddan muskulus pektoralis secara luas.
  • Bagilahbagian klavikulardari ototdeltoid3/8"distal dari tulang(tidaksecara subperiosteal).
  • Ligasi vena sefalika.
  • Identifikasidan ikat pembuluh darah yang terdapat di wilayahsubakromialyang melintasibatas atasdari delto-pektoralgroove.
  • Paparkan proseskorakoiddan bebaskan conjoined tendondari korakobrakialis dan muskulus bisep brevis.
  • Bagilahsatu inci bagian atasmargindari tendonmuskulus pektoralis mayor.
  • Bukainterval antaraconjoined tendondanmuskulus pektoralis minordengan hati-hatiuntuk menghindarikerusakan padaN.muskulokutaneus,  cabang-cabangnya, ataugabungan persarafan aksila yang utama.
  • Tarik ke bawah conjoinedtendon dengan jahitan, tapi tidak terlalu keras
  • Bagilah tendon padamuskulus subskapularis. Batas atas dan bawahnya mudah diidentifikasi dengan memutar lengankeluar. Batas bawahnya mencolok karena terdapat 3 vena yang menyertai arteri sirkumfleksaanterior humeri berjalan bawahnya. Bagi dan ligasipembuluh ini.
  • Lewati lonjakan tumpul di bawah tendon dari atas atau bawah, dan bagilah tendon 1 inci dari insersi. Kapsul, yang biasanya melekat pada permukaan dalam dari tendon dekat insersinya, seringkali dibuka.
  • Tarik subskapularis ke medial dengan 3 atau 4 jahitan yang dimasukkan melalui otot tersebut.
  • Dengan sengaja buka kapsul jika belum dibuka. Periksa batas glenoid dan caput humerus untuk kerusakan yang ada.
  • Puntung distal tendon m. subskapularis dilekatkan pada struktur jaringan lunak yang paling dekat di sepanjang batas anterior dari rongga glenoid, yang mungkin adalah labrum itu sendiri. Puntung ini juga dapat ditempatkan di permukaan dalam dari kapsul dan muskulus subskapularis.
  • Permukaan anterior leher skapula dibuat menjadi kasar sehingga tendo-kapsul yang telah dijahit dapat menempel pada permukaan tersebut.
  • Empat benang bedah dimasukkan dan diikat sementara ibu jari diputar secara internal
  • Bagian medial dari kapsul ditarik keluar agar tumpang tindih dengan tendon m. subskapularis, menghasilkan efek " double-breast coat".
  • "Sebuah mantel" dibuat dengan menjahit ototdari subskapularis ke tendinuous cuff yang telah membentuk jaringan parut, yang menutupi tuberositas mayor, atau bicipital groove.
  • Memutar lengan ke arah luar ke posisi netral seharusnya masih memungkinkan.
  • Conjoined tendon dilekatkan kembali pada korakoid, deltoid pada klavikula dan pektoralis mayor, dan luka ditutup.
  • Setelah pengobatan: Balut lengan ke badan dengan lengan di dada dan jari-jari ke bahu yang berlawanan. Pertahankan rotasi internal selama 3-4 minggu.

Approach tambahan telahdijelaskan olehZenni. Approach aksila dengankeuntungan paparanyang memadai denganhilangnya darahsecara minimal danbekas lukayang lebih diinginkan,yaitu sebagai berikut: (60)

  • Pasienditempatkanterlentang denganhandukdi bawahskapula.
  • Lenganditempatkanpada 90° danadduksike samping.
  • Sayatan kulitmemanjanganterior1inci di ataslipatanaksiladandiperpanjang4incike posteroinferior.
  • Denganlengansepenuhnyadalam posisi abduksi, bukatepikulit danidentifikasipektoralis mayor.
  • GunakanklemKelly untuklewat di bawahpektoralis mayordan identifikasiv. sefalika.
  • Potongtendonpektoralismayor dibagianmusculotendinousdan tarik kembali tendon tersebutketepiluka.
  • Buang sebagianm. korakobrakialisdariperlekatannya pada proseskorakoid.
  • Identifikasim. subskapularis;identifikasisatu arteridandua venadi inferiordanligasi pembuluh tersebut.
  • Potong1,5"lipatan dari m.subskapularispadaperlekatanhumeri. Naikkanbagian lateral dari lipatan iniuntuk memaparkan sendi bahu.
  • Lekatkanlipatan lateralsubskapulariske glenoidlabrum.
  • Letakkanbagianmediallipatansubskapularisdi ataslipatanlateral.
  • Perbaikim. korakobrakialisdan m.pektoralis mayor.

Pasca Prosedur

Post-op dan rehabilitasi

Imobilisasi diperlukan segera setelah operasi dengan posisi adduksi dan endorotasi. Waktu imobilisasibervariasi dari 3-6 minggu.Setelah imobilisasi, rehabilitasi diperlukan dan dikembangkan dengan latihan bertahap volunter untuk meningkatkan rentang gerak dan kekuatan selama 2 bulan berikutnya. Rowe mencatat bahwa dalam satu tahun pascaoperasi, sebagianbesar pasien sudah mendapatkan rentang gerak fungsionalnya kembali dan memiliki bahu yang kuat.

 

Komplikasi

Terdapat 4 alasan yang menyebabkan kegagalan pembedahan: prosedur bedah yang tidak tepat, ketidakmampuan teknis, waktu imobilisasi pasca operasi yang terlalu pendek, dan aktivitas atletik yang terlalu intens setelah perbaikan. Mereka juga mencatat 4 karakteristik pasien yang memberi kecenderungan untuk terjadinya kegagalan pembedahan: pemuda, gejala bilateral, riwayat keluarga yang positif, dan ketidakstabilan posterior.

Selain itu ditemukan komplikasi lainnya seperti adanya nyeri persisten, subluksasi atau dislokasi berulang, atau sisa kelemahan dari bahu, parestesia saraf muskulokutaneus, dan infeksi.

3.6.5 Prosedur Magnuson-Stack

ProsedurMagnuson-Stack adalah prosedurnon-anatomikbersejarah bagiketidakstabilan bahu. Prosedur inididasarkan padapengencanganm. subskapularisdengan mengubahsitusinsersidarituberositasminor kealuryang dibuatlateral daribicipitalgroove. Hal inimenghasilkan"efeksling" pada caputhumerus.54

Sebuah gambaryang menggambarkanprosedurMagnuson-Stack dapat dilihatdi bawah ini.

 

Gambar 3.57 prosedur Magnuson Stack

Sejarah
ProsedurMagnuson-Stack pertama kaliditerbitkanoleh Paul B.dan JamesK.Magnuson-Stackpada bulan Desember 1943.Keuntungandari prosedur iniatas prosedurlain untukketidakstabilananteriorbahutermasukkemudahanpelaksanaanprosedurdanlebih rendahtingkatpembatasanbahufungsional. Kelemahandari prosedur initermasuk hilangnyadiprediksiexorotasiselain tidakmenangani setiapkapsulataulabralpatologi.

Kuncipertimbangan

Karenahilangnyaexorotasi, penerapanprosedur initerbatas.Atlet danburuhmembutuhkanrentang normalgerak dalamrotasi eksternalakanterbatas denganprosedur ini. Hal inijuga akanmembatasi penggunaanuntukpelempardan atletoverhead.
Prosedur inisejak awaldiindikasikan untuk pasiendengan ketidakstabilansearahanteriorbahu.Prosedur ini dikontraindikasikan untuk tipe dislokasi volunteer, dislokasi posterior dan dislokasi berbagai arah.

 

Anestesi
Anestesi umum digunakan untuk prosedur ini.

Posisi
Pasien diposisikan telentang dalam posisi beach-chair. Ruangan harus diatur untuk memungkinkan lengan sepenuhnya dalam keadaan abduksi dan exorotasi pada saat prosedur dilakukan.

Pencegahan komplikasi

Bantalan yang memadai adalah penting dalam pencegahan komplikasi intraoperatif. Juga, identifikasi struktur neurovaskular dalam pendekatan untuk subskapularis tersebut.

Teknik

Teknik ini telahdiambillangsung darimakalahMagnuson-Stack yang asli. Secara umum, approachsubskapularisyaitu melaluiintervaldelto-pektoral. Insersisubskapularisdiidentifikasidandipisahkan denganbloktulang, kemudian dilekatkan padaalurlateral kebicipitalgroove pada tuberositasmayor darihumerus.

  • Buatlahsayatandi persimpangananterior dansepertiga medial darideltoid, sepanjang akromionke bawah.
  • Paparkanpermukaananteriorkapsul(lihat gambar 3.58).

Gambar 3.58Bahu anterior.

  • Lakukan exorotasipada lengandan identifikasimuskulussubskapularis.
  • Tariktendonm.subskapularissecara erat daninsisi muskulus subskapularisdari persimpanganmuskulotendinouske perlekatannya di sepanjangbibiranteriordari bicipitalgroove.
  • Masukkanchiselsepanjang sisidistaldari perlekatan,medialdari bibirbicipitalgroove(lihatgambar di bawah).

 

Gambar 3.59Penggunaan chisel untuk melepaskan subskapularis.

  • Angkatperlekatan tendondengan irisantulang dangerakkan ke medialuntuk memaparkan caput humerusdan tepianterior darihumerus.
  • Periksa caput glenoiddan caput humerus
  • Lakukan endorotasi pada lengandan regangkantendonm. Subskapularis di seluruh bicipitalgroove hingga tuberositasmayor.
  • Memanipulasilengan. Penempatanyang idealmemungkinkanrotasi eksternalseluas 50%.
  • Chiseltipis-berbilah tajamdidorongsejajar dengansumbu panjangtulang. Chisel digerakkan ke depan dan ke belakangke arah lateraluntuk melebarkan tulangkanselusdan meninggalkansaluranberbentuk baji, di manatulangsecara paksa dilekatkan padatendonm. subskapularis(lihatgambar di bawah).


Gambar 3.60Pembentukan saluran pada sisi lateral dari bicipitalgroove.

  • Jahittendondenganbenang bedah doubled00chromic catgut, jahitandiulangdi kedua sisisaluran berbentuk baji itu.
  • Lekatkan kebawahbatas bawahdari muskulussubskapularisdengan jahitanterputuscukup jauhdi bawahcaput humerussehinggaotot dantendonkapsulermemiliki peganganyang kuatdi sekitar caput(lihat gambar di bawah).


Gambar 3.61Jahit subskapularis dengan blok tulang ke baji yang telah dibuat, lateral dari bicipitalgroove.

PascaProsedur

Post-op dan rehabilitasi

Imobilisasidiperlukandengan segera setelahoperasidan dilanjutkan selama3-6 mingguRehabilitasidilakukan setelahimobilisasi, tapiexorotasi dibatasiselama 4-6 minggusetelah operasi.

Komplikasi

Komplikasi yang dapat terjadipada prosedur ini yaitu hilangnya kemampuan fungsional karena hilangnya kemampuanexorotasi, ketidakstabilan yang berulang, dan cedera neurovaskular. Ketidakstabilan yang berulang dapatdilihat pada pasien yang dapatmelakukan exorotasi secara normal kembali.

 

3.7 Prognosis

Pemantauan yang baik adalah dasar untuk mencegah terjadinya dislokasi berulang dan untuk kesembuhan jaringan yang rusak.Bahkan dengan perawatan yang terbaik pun dislokasi dapat berulang. Sekitar 90% dari orang-orang yang pernah mengalami dislokasi bahu pada usia lebih muda dari 20 tahun biasanya akan mengalami dislokasi kedua. Setelah usia 40 tahun, sebanyak 14% orang dapat mengalami dilokasi kedua. Jika dislokasi terjadi kedua kalinya pada bahu yang sama, terutama jika disebabkan oleh trauma yang lebih ringan, maka pasien harus dievaluasi mengenai kemungkinan terjadinya kerusakan ligamen pada bahunya. Jika terdapat kerusakan, maka pasien munkin perlu untuk menjalani operasi untuk mencegah terjadinya dislokasi berulang.

 

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便所が近くなる原 としてあげられることは、飲み物を一度 多く飲んでしまうからだと思います。喉 乾きやすいから、ペットボトルを手放せ いのです。



いつもにトイレが 頭にあることも、原因なのではないかと思 われます。


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