2. Chronic dislocations
Learning how to think anatomically, understand patho-anatomy, plan logically and
sequentially to safely solve very difficult problems
3. Anatomy is the key
to understanding Patho-anatomy
iliopsoas
4. Your patients push you to solutions
• Most common shoulder problem
that we see in Ethiopia outside
of acute fractures
• Chronic shoulder dislocation
• “cut the rotator cuff and put it
back in place”
• 1st one in Cameroon, vivid
memory late ~2000
• CRUSHED HEAD...
5. 2021
• 24 chronic elbow dislocations
• 14 chronic shoulder dislocations
• 7 chronic hip dislocations
• Chronic means anything past 6
weeks for our practice in reality
its 3….
• common at 3-9 months
• 18-36 months infrequent,
• Recently reduced an elbow at 10
years post injury (inaccurate
history, patient lied)
6. General Orthopaedic Surgeon
• If I have a specialty its treatment
of chronic dislocations
• Shoulder
• Elbow
• Hip
• Knee
• ankle
3.5 months
7. Each has its unique anatomy and challenges
• Elbow, hip, ankle
• Shoulder and knee
• Boney architecture gives a lot of
stability
• Not the same boney stability,
more soft tissue stability
• More translation in normal
motion
8. Over arching principles
• Muscles, nerves shorten and
fibrose with time
• Bones soften, abnormal
articulations can erode and cause
bone loss or distortion
• Cartilage degenerates at variable
rates, strength of its attachment to
underlying bone also weakens
• Scar tissue matures and
strengthens
• 2 Examples of distal humerus
• Orange peel, crushed walnut
9. Distal humerus, bone has softened, cartilage
attachment has weakened, what could go wrong??
10. Goals in chronic dislocation surgery
• Reduce the joint concentrically
• Produce stability on the OR table if
possible, to begin ROM in the
immediate post-op period
• Do ROM in a “safe zone” as
determined on the table SOON
• Pin the joint (cast, etc) if necessary
to keep reduced in the immediate
post- op period
• Prevent NV injury
• Stability and motion essential
11. History of Chronic elbow dislocation surgery
• 1925 Speed described his approach, V-Y of the triceps
• 1940 JBJS, excision of the elbow
• 1977 Krishnawoorthy med & lat sparing the triceps ½ good results
• 1982, Speeds (V-Y takedown) posterior approach 21 patients, 3
wounds couldn’t be closed, 5 ulnar n. resolving, 2 weeks pinned, ROM
½ good, ½ fair
• 2002 Jupiter elbow fixator, no medial soft tissue repair, 3/5 lateral soft
tissue repair
• 2015 many complications of ex/fix
• 2017 JOT paper from U of U, Mayo Clinic, 2 institutions in ET.
12. • 32 patients,
• Age 7-56
• Mean preop ROM 8 degrees
• Mean post op arc 101 degrees
• Mean dislocation period 6 months, range 1-34 months
• Mean follow-up 22 months
• No infections or repeat dislocations
• One temporary ulnar n injury
• 97% good or excellent result
13. Elbow
• Divide into flexors and extenders
M, L approaches
• Remove all soft tissue attachments
to the distal humerus
• Remove scar within the olecranon
and adjacent to it
• Reduce it concentrically
• Close the soft tissues around the
epicondyles “ligament reconstr”
• ALWAYS TRANSPOSE THE ULNAR
NERVE, ITS SHORT!!!!
• Move it in an arc where its stable
16. Elbow, dislocated for 13 months
• 20 yr old male, dislocated 13 months, ROM 25 degrees, preop
• 8 month f/u, Mayo score 95, ROM 35-150 Full Supination and
Pronation
17. Elbow reduced but doesn’t want to flex more,
what do I do?
• Force it to 90?
18. Elbow reduced but doesn’t want to flex more,
what do I do?
• Force it to 90? NO
• Barbitage the triceps tendon
with 18 gauge needle
19. The triceps is your FRIEND
• Treat it wisely
• Don’t cut something that is short
and try to make it work for you
20. Elbow
• Get it concentrically REDUCED, scar around the olecranon is the key
• Repair the soft tissues, you don’t need a fixator a artificial ligament
• MOVE it in a range where it is STABLE early
• Transpose the nerve
• Barbitage the triceps if its too short
22. History of Treatment Chronic posterior hip dislocations
• 1976 JBJS B, Nixon 3 cases posterior approach “easy operation” good
results
• 1979 JBJS Epstein, good results with THA, 3/10 good with femoral
head sparing operations
• 1984 Injury, heavy traction (10-30 KG) for 3 weeks children and
adults, India and Nigeria
• 2020 J Ped Ortho, Gardner, Cure Ethiopia, Posterior approach, 4-36
months, age 5-10, 2 cm shortening osteotomy, f/u 33-51 months, all
excellent results
23. Chronic P Hip dislocation
• The head sits out between the
piriformis and the conjoined
tendon usually
• The iliopsoas lies over the
acetabulum…
• The anterior capsule sits like a well
developed ¼”unyielding trampoline
over the acetabulum
• The limbus is inverted
• ALL OF THE MUSCLES ARE
SHORTENED
24. Hip is unique in the power of the muscles
around it
• Head softens
• While the scaring process
matures
• V strong attachments of the peri
articular bone to the abductors
and external rotators
• Extends for 6 cm or more
25. What does this show you about approach?
• Tried posterior approach
between the pirformis and
conjoined tendons
• “KEYHOLE”
• it was frustrating and difficult
• Then it dawned on me the
acetabulum is TOTALLY
ACCESSIBLE if you go anterior to
the femur….
26. Gluteus medius released for 2.5 cm along
anterior/inferior insertion
Vastus lateralis
Gluteus medius
Greater troch
28. hip
• Expose the acetabulum
• Excise the capsule over the tab
• Evert the labrum by quartering it
• Mobilize the periarticular
muscles
• Try to reduce it
29. Approach??
• Started doing them from a
posterior approach trying to
spare the external rotators
• Then did them through a
“Gluteus medias” snip anterior
approach
• Then my son Lucas came 2014
and suggested THE way
• The Ganz flip
30. Done a Ganz flip and still can’t get it reduced!
• Detached the abductors
• BUT… most of the hamstrings,
adductors, gluteus max ,
iliopsoas, pectineus are STILL
SHORT
31. Femoral shortening as an essential
• Head is soft, sometimes you can
make an impression in the head
with finger pressure…..
• You’re 2 cm from even getting
close to reduction
• If it is sits on the edge for 1
second it has a huge defect
• 2 cm subtrochanteric shortening
makes it easy to reduce WITH
FINGER PRESSURE
32. Summary of chronic elbow and hip dislocations
• Bony anatomy by itself creates some
inherent stability
• Muscles, nerves, etc. shorten making
reduction difficult, NERVE INJURY
POSSIBLE
• Bones soften with time out of joint
making joint collapse a serious risk
• Extensile exposure, preserving blood
supply, use the Ganz flip
• Femoral shortening to reduce joint
forces
• Preserve muscles that cross the joint
to maintain compression for stability,
ie. the triceps
34. History of Chronic Shoulder dislocations
• 1911 German paper, describing
the need to take the subscap
down, pathology described
• 1935 JBJS 14 cases over 15
years, casted in salute position,
poor results
• Nevaiser JBJS 1948, Screw for 3-
4 weeks, kept reduced, stiff
• Rowe JBJS 1982, neglect, head
resection, Open reduction,
hemiarthroplasty,
• Last 20 years many methods
with varied results
• Li JBJS 2016,Laterjet by itself is
not adequate for chronic
anterior dislocations 50% re-
dislocation rate
35. 15 months with an anterior dislocation
• You have never faced this
situation before
• Information available is limited
and not cohesive, poor results
• How do you plan for this
operation?
• Patho-anatomy, where are
things now?
36. What will be the surgical challenges in this
patient?
• Anatomy is screwed up
• What approach?
• Extensile, limited?
• Subscap takedown?
• soft tissuerelease or osteotomy
• WHERE IS the axillary nerve?
37. Experience should change how you do things
• If you are 2 hours into your
surgery and you look down and
the anterior deltoid is all beat up
and you realize you have caused
irreversible damage to the ant
deltoid
• The next operation you decide
to take the deltoid down so that
you don’t damage it
• And it no longer gives you
trouble of exposure
• Just past the AC joint
39. Steps for Chronic dislocation greater than 6
weeks
• Take down the anterior deltoid
from the clavicle
• Osteotomize the coracoid
• Takedown the subscapularis
• Mobilize the soft tissues around
the base of the coracoid
• Mobilize the head
• Circumferential release of
capsule and rotator cuff at least
1 cm back from the rim
40. Coracoid osteotomy
• The head is fixed below the
coracoid base
• It doesn’t move
• The musculotaneous nerve and
the NV bundle is VERY CLOSE
• Moving the coracoid opens an
inner door similar to what the
deltoid take-down does more
superficially
• Makes retraction, exposure
easier
43. Avoiding injury to the supraspinatus
• Its wrapped around the base of
the coracoid
• Its course is very distorted
• You don’t know where you are!
• Don’t destroy it
44. Subscapularis takedown? Osteotomy? Or?
• An osteotomy is intuitive that
it’s a stronger more robust repair
• BUT it also makes the head
softer, it crushes easier
• Like a crack in an egg
46. steps
• Mobilize the interval between
the posterior cuff and posterior
deltoid
• Release the undersurface of the
acromium of scar pulling the
posterior deltoid anteriorly
• Mobilize the subscap as far
medially as possible
• Excise HO on the anterior
surface of the blade of the
scapula, false joint
47. Stretching the cuff
• Stretch the posterior and
superior cuff by pulling the shaft
laterally as hard as you can
• See where the head sits without
reattaching the subscap
• Pin the head if you are at all
unsure of getting a concentric
reduction (common)
• Repair the subscap, coracoid,
deltoid
49. Chronic Shoulder Dislocation Challenges
• Extreme scarring especially of
the subscap (shortened,
attached to HO that is forming a
new glenoid) and the
supraspinatus
• Multiple adhesions between
layers, massive scarball
50. Factors favoring anterior subluxation in the
early post op period
• Posterior deltoid adhered to the
undersurface of the acromium
• Scarring between the deltoid
and the post cuff
• Tight posterior cuff
• Soft tissue(memory)
• Glenoid bone loss
• Hill Sachs??????? Doubt it.
53. Approval for a prospective study
• CT both shoulders for glenoid size
• Follow protocol
• Pin all Gleno humeral joints before closure of the subscap
• CT shoulder after to be sure it is concentrically reduced
• Pull the pin at one week
• Follow for one year
54. Questions remain
• Hill-Sachs & glenoid loss?? Most of them do
• When does bone grafting the glenoid and implassage or bone grafting
make sense?
• Soft tissue balancing in my mind is the critical issue
• Laterjet in my hands in a chronic situation does not work
56. • 60 yo Female with chronic right knee dislocation after a
hyperextension injury 3.5 months prior
• Presents with inability to ambulate, severely limited painful ROM
• Normal vascular exam (DP/PT pulses)
• Normal neurologic exam
• Palpable prominence in Popliteal fossa consistent with femoral condyles
Case Summary
57.
58. NV? , what do I preserve?, Incision(s)????,
what do I cut?
• Try to preserve muscles crossing
joint, they provide compression
• You can’t cut them and repair
them, they’re SHORT
• Preserve all the hamstrings,
quad, and if possible the gastroc
• Look for clues on ligament
attachments fragments
• Preserve the menisci if possible
59. • From my experienced of the elbow I decided to do
medial and lateral incisions
• Left lateral position
• Lateral incision:
• Find the nerve, extensive prox and distal release
• Expose the lateral pseudo capsule
• Preserve the lateral gastroc, IT insertion, look for
remnants of the LCL
• Goal of Peroneal nerve identification &
Procedure
61. • Patient moved to supine position
• Medial Incision
• Incision made in line with hamstring tendons
• VMO exposed & followed distally along a ‘medial para-
patellar arthrotomy’ direction
• Tibial plateau exposed. Medial & Lateral menisci identified
as intact though subluxed. Joint surfaces consistant with
age related changes
• Posterior capsular tissue identified. Split into two arms &
tied with #1 Vicryl suture, one medial/lateral
• Medial collateral ligamentous tissue removed
• No ligamentous attachments left on femur. Anterior and
posterior soft tissue left intact on femur. Gastroc attached
to posterior femur
Procedure
72. • Neurovascularly intact (Normal pulses, neuro exam nl)
• X-Ray Critique
• Lateral Xray with good reduction
• AP: Increased medial joint space compared to lateral. Decided to
leave alone because of risk of affecting reduction.
• Plan
• 0-3 wks: Leave in Ex-Fix @ 50 degrees flexion x 3 weeks
• 3 wks: Adjust Ex-Fix to 30 degrees flexion x 3 more weeks
• 6 wks: Remove Ex-Fix to assess stability of reduction & motion
• Goal: Stable, reduced knee with painless ROM 30-45 degrees.
Postoperative Assessment & Plan
74. • No previous literature reported a similar case as ours (i.e.
chronic anterior knee dislocation)
• Case reports are about knee subluxations, not frank
dislocations
• Chronic was approx 6 weeks
• One case report of knee dislocation was posterior and
approached via midline parapatellar arthrotomy
• No prior case reports / studies of chronic (> 6 weeks)
anterior knee dislocations
• No report of prior medial and lateral incisions to address
knee dislocation
• Author’s prior experience with chronic dislocated elbows
involved skeletonizing the distal humerus via medial and
lateral incisions to facilitate reduction with excellent
results– same principle adapted to this case.
Literature Review
75. • Similar approach as this one, medial and lateral incisions
• I think that it is helpful to turn the patient on their side to do the
lateral approach.
• I had to take down the gastroc on that patient off of the femur to be
able to reduce the knee
• That patient I had to keep the knee flexed at 70 degrees to protect
the NV structures and then did a similar approach to getting the knee
straight.
One additional case
76. Knee summary
• Med and lateral incisions
• Expose the release the peroneal nerve
• Keep everything that crosses the joint for nl function and joint
compression, only cut when its impossible to reduce and do it
stepwise
• Repair the menisci and any ligaments you feel you can
• Reconstruct if you have the ability and the time
• Avoid NV injury
77. Vu-medi videos
• 2 on the shoulder one is an cadaver
• 2 on the elbow, watch the more recent one its more complete
• 2 on the hip, watch the Ganz flip
