Acute anterior dislocation of the shoulder

Acute Shoulder Dislocation Surgery

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Acute anterior dislocation of the shoulder


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Anatomy• Stability: - ball & socket

= compression in concavity effect• Bone - big head – small cup

= unstable• Menisci - labium

= ↑ depth of cup by 20%• Ligaments - glenohumeral & capsule

• Muscles - rotator cuff & biceps = holds ball in cup

• Primary Movers - Deltoid, Pec. major & Lat. Dorsy= subluxing forces

• Dynamic - proprioceptive feedback


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Pathophysiology (Lazarus 1996)

• Chondro-labral defect causes a 65% reduction in stability in the direction of the defect

• Deficiency of the ant. inf. capsulolabral complex Fracture of ant. lip of glenoid = 15%

Detachment of labarum/capsule = 15%Tear of glenohumeral ligaments = 54%Avulsion of subscapularis and ligs of humerus (HAGL)

• To prevent the persistence of the defect it needs to be repaired

Arthroscopically Open


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Acute Injury• Something breaks or tears and therefore can be repaired.

• Repair is better than reconstruct

• Repair is easier than reconstruct

Chronic• Instability has additional plastic deformation of the capsule

and glenohumeral ligaments therefore needs to be shortened

• Restoring the normal functional anatomy is impossible


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Conservative TreatmentRowe – JBJS, 1957

324 young patient with ant. dislocations• 94% had recurrence if < 20 years old• 62% had recurrence if < 30 years old• 14% had recurrence if > 40 years old

Burkhead & Rockwood (text book)40 patients with acute dislocation & vigorous rehabilitation• Only 16% had good or excellent result (1 in 6)

Deny & Drew – Injury, November 2002• 21% of all patients presenting with shoulder dislocation had

previous dislocation in 1 year• 43% in patients 15-22 years had re-dislocations


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Non operative treatment of shoulder dislocation in young athletes

1. Arciera – J Arthroscopy, 19952. De Beardino – J South Orthopaedic Ass, 19963. Haelen – J Arch Orthopaedic Trauma Surgery, 19904. Hovelius – J Orthopaedic Science, 19995. Wheeler – J Arthroscopy, 19986. Kirkby – J Arthroscopy, 1999

all over 80% recurrence rateNon operative treatment is unacceptable


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Prospective Randomised Study

Bottani etc.–Military Personnel Medicine Vol 30 No 4 2000

First Time Acute Traumatic Shoulder Dislocation

Stabilisation V’s Non Operative:

Follow up in 36 months

24 patients aged 18-26y.

• 14 Non Operative – rehab immobilised 4 weeks

• 9 of 12 non operative had instability (75%) (6 open Bankart repair)

• 10 ASC Bankart repair with bioabsorbable tack <10 days

• 1 of 9 operated patients had instability (11%)


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Comparison of Arthroscopic & Open StabilisationSample Size Follow Up RecurrenceASC Open ASC Open ASC

Open

Steinbeck 1998 30 32 36 40 17 5Field 1999 50 50 33 30 8 0Cole 1999 37 22 52 55 16 9Hayes etc 1999 44 13 29 29 12 4

ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plastic deformation

Chronic anterior instability


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Arthroscopic Techniques for Primary Dislocations

• 1982 Johusa – with staples• 1987 Morgen & Badenstab – transglenoid sutures• 1991 Caspari -Cannulated bio-absorbable tacks • 1993 Wolf & Snyder – suture anchors = difficult• 1989 Wheller - ASC staple• 1993 Gohlke - Suture anchors• 1994 Arciera - ASC transglenoid• 1996 Speer - Bio-absorbable tack• 1999 Wintzell - ASC lavage• 2000 Introduction of a multitude of new gadgets

& anchors


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Arthroscopic Repairs

Einoder, 1984 Knee Club• Described Arthroscopic transglenoid sutures using:

– K wire with eye (ACL) introduced via anterior portal

– Sucking tube

– Sutures tied over infraspinatus fascia or spine of scapula

Results– 4 out 5 patients returned to the same level of sport with no re-dislocations


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Arthroscopic Repair


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Boszotta & Helperstorfer – Arthroscopy, July 2000 Transglenoid suture repair for initial Ant. dislocation

• 72 patients (1988-95)

• 61 ♂ 11 ♀ Aged 19-39

• 34% = Bankart lesion (6 with bone)

• 66% = Avulsion of capsulolabral complex

Results• 7% = Redislocation all due to trauma (severe in 2 out of 5)

• 85% = Returned to unrestricted pre injury sporting activities


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Randomised Studies

Asc. Stabilisation V’s Non OperativeArciera et. al. – A.J. Sports Med., 1994• 32 military men with acute 1st up dislocation, Average of 32 months

follow up

15 patients – non operative – 80% redislocated

21 patients – transglenoid suture – 14% redislocated

Bottony & Wilkings etc. A.J. Sports Medicine 2000• Patients with acute traumatic first time shoulder dislocation

14 young patients – non op, 75% redislocation

10 young patients – Asc. Bankart repair, 10% redislocation


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Asc. stabilisation

Dara & Gerber – Journal of Shoulder & Elbow, 2000• 20 shoulders

– Av 3 year follow up– Recurrences occurred in patients who were chronic dislocators

i.e. <30%– Therefore now

do open surgery for recurrent dislocationsAsc. surgery for acute dislocations

De Beardino et al – An J. Sports Med., 2000• 49 1st up acute post traumatic Shoulders dislocation

– Average 37 months follow up – Tack anchor.– 6 Patients re-dislocated (13%) +4 had open surgery


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Bozzotta & Helpastorger (Austria) – J. Arthroscopy, 2000 Arthroscopic Transglenoid Suture Repair

for Initial Ant. Shoulder Dislocation• 72 Patients 61♂ 11♀ - Sporting ambitious patients

25 Patients Bankart lesion (6 with bone)

43 Patients Capsulolabral avulsion

Results• 5 patients Re dislocated

2 had significant trauma3 had insignificant trauma = 4%

• Therefore results of primary repair are better than surgery for recurrent dislocation

• But transgleniod repairs are obsolete


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Against …Arthroscopic Repair

Roberts, Taylor, Brown, Hayes, Saies (Adelaide)Journal of Shoulder & Elbow, September 1999

• 56 acute 1st up shoulder dislocations• 2½ year post operative and return to Australian Rules Football

• Operations:– Asc. suture repair – 70% recurrence– Asc. Bankart repair with tack – 38% recurrence,..– Open repair & copsular shift – 30% recurrence

• Therefore Asc. treatment alone not good enough


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Cole & Warner – Clinical Sports Medicine 2000

Arthroscopic V’s Open Bankart Repair

For Traumatic Anterior Shoulder Instability

• % Asc. treatment modalities are increasing due to:

1. Better understanding of the pathophysiology

2. Better pre operative evaluation of the injury (i.e. patient selection)

3. New surgical techniques

4. Better instrumentation

5. Better anchors


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Protocol for Acute Repair1. Mature & active person2. 15 to 50 years old3. First episode of glenohumeral dislocation

Reduced on field, first aid, club Dr or DEM4. Examination & X-ray5. Informed consent – time off work - outcome6. Examination under GA7. ASC of glenohumeral joint, check rotator cuff as well8. Acute repair of all demonstrable tears or fractures

restore normal anatomy11. Rehab activity – collar & cuff, physiotherapy12. Avoid ext. rotation and abduction for 6 weeks13. Return to contact sport in 12 weeks


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Investigations1. Plain x-rays

2. CT scans if complicated associated feature

3. MRI rarely – get more information from Asc.

4. Examination Under GA

Supine load shift test with arm at 80° abducted compared with normal shoulder

1+ ball to rim

2+ ball riding over rim with spontaneous reduction

3+ ball stays dislocated

5. Arthroscopy


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Patient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction & shoulder abductedShoulder examined, degree & direction of instability noted

Portals = 2 or 3• Posterior portal• Ant. sup portal• Ant inf portal (occasionally)• Injury assessed & debrided• Repair method selected

Arthroscopic Repair Procedure


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Rehabilitation1. Minimal in first 4 weeks

No ext rotation

Abduction less than 45°

Pendulum exercises

Isometric resistance exercises

2. Graduated in 4 – 8 weeks

↑ ROM

Graduated weight training

3. Return to sport

Non contact = 6 weeks

contact = 12 weeks


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Arthroscopic V’s Open Bankart Repair• Advantages

– Accurate diagnosis of all structures– Less morbidity/pain– Small scars– Faster recovery– Sooner return to activities– Less restriction of movement

• Disadvantages– Need all the equipment– Technically demanding– Long learning curve– Lack of versatility– Higher failure rate arthroscopic = up to 33% -

open = less than 10%


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Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002Advantages V’s Disadvantages of Asc. Repair

Advantages• ↑ cosmesis• ↓ morbidity• ↓ stiffness• Easy revisionDisadvantages• 1) Reluctance to refer patient immediately• 2) Difficult operation• 3) Expensive instrumentation• 4) Biological healing time is not accelerated• 5) Same post operative restrictions


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Problems1. Difficulty convincing Club Trainers, Physicians,

sporting club Doctors & DEM staff to refer the young athlete within 2-3 days.

2. Time consuming discussions convincing patient to have the operation rather than early return to sport.No problem advising a recurrent dislocators to have a stabilisation procedure at the end of a sporting season.

3. Mostly after hours surgery with staff who are not familiar with the operation and instrumentation.


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Arthroscopy of Shoulder

• 1935 – Japanese Surgeons arthroscoped, shoulders

• 1960s – Curiosity activity in the western world

• 1970s – Diagnostic Asc. examination open surgery

• 1980s – Simple Asc. techniques for simple problems

• 1990s – ↑ Instrumentation & tacks more tried it.

• 2000s – ↑ Techniques & anchors

– Can be done by any surgeon skilled in

arthroscopic techniques


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Shoulder reduced on field, first aid room or DEM then referred

Treatment History

1970s - Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences

1980s - Asc. transglenoid suturestied over spine of scapula or muscle fascia

1990s - patient in lateral position with arm in tractionor patient in Beach chair position multiple, tacks and suturessurtac screw tack anchors etc.

2000 - better anchors and sutures have made the procedure available for all surgeons experienced in arthroscopic technique


EinoderAcute Labral Tear


EinoderAcute Repair of Anterior Labral Tear


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Conclusion• Asc. repair of the Capsulo-ligamentous injury to the shoulder

is a simple procedure for a surgeon skilled in arthroscopic technique

• Chronic instabilities have associated plastic deformity of the tissues that need to be addressed and this makes the result

of a simple procedure unpredictable.

• An active young person with a first traumatic dislocation of

the shoulder should have the damage repaired arthroscopically within 10 days of the injury

Acute anterior dislocation of the shoulder

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