The document discusses a surgical technique for the open reduction of chronic shoulder dislocation, especially in under-resourced settings, highlighting the need for extensive capsular release and rotator cuff mobilization. It presents early results from various cases, showing that with adequate exposure and addressing multiple contractures, significant functional improvements can be achieved. The findings emphasize the complexity of the procedure and the importance of managing adhesions and bony loss in these patients.

1. Open Reduction of Chronic Shoulder Dislocation
by circumferential capsular release and posterior
cuff mobilization, its technique and early results
Duane Anderson, MD
Lucas Anderson, MD
Stephen Aoki, MD
Segni Bekele, MD
Abebe Chala PT
Soddo Christian Hospital
Soddo Wolaitta Ethiopia
University of Utah Department of Orthopaedics
Open reduction of chronic shoulder dislocations
through an extensile approach,
circumferential capsular release and
mobilization of the rotator cuff muscles
Technique and Early Results
Duane Anderson, MD (1)
Lucas Anderson, MD (2)
Stephen Aoki, MD (2)
Segni Bekele, MD (1)
Abebe Chala, PT (1)
Edit Jan 2024
(1) Soddo Christian Hospital
Soddo Wolaitta Ethiopia
(2) University of Utah Department of
Orthopaedics, Salt Lake City, Utah USA

3. The problem
• Chronic shoulder dislocation not uncommon
in the third world
• Old literature advocates complete rotator cuff
release.
• As time progresses with chronic dislocation
– larger Hill-Sachs
– more contracted capsule and rotator cuff

4. The problem is big
• As more time passes in chronic dislocations:
– the head becomes softer because there is no head-glenoid contact
– Increased bone loss of anterior glenoid
– The Hill-Sachs gets bigger
– Internal adhesions between deltoid, cuff, and neo-capsule strengthening the patho-
anatomy
– Shortening of the posterior cuff occurs, this is counter intuitive but true
– The supraspinatus becomes adherent to the coracoid and sits in a precarious
surgical position for the naïve surgeon
– The posterior deltoid moves anteriorly and scars in place
– Heterotopic ossification occurs to make a new glenoid on the anterior surface of the
scapular neck
– Subscapularis is locked in place with adhesions to the coracoid, HO, and neo-capsule

5. The solution in the West
• Anterior delto-pectoral shoulder approach
• Hemi arthroplasty if the head collapses or
hemiarthroplasty with a smaller head due to
joint contracture
• Total shoulder if there is joint destruction

6. The solution in Africa
1. An extensile approach to the chronically dislocated head that
allows access globally to the head and glenoid
2. Circumferential capsular release
3. Reduction of the posterior cuff shortening without disruption of
the posterior cuff tendon by stripping the cuff from the scapula
4. Release of supraspinatus adhesions from coracoid and superior
glenoid
5. Release of the subscapularis from corocoid, HO, neo-capsule,
scapular body and brachial plexus
6. Mobilization of the posterior cuff from the attached deltoid by
breaking up dense adhesions

7. The solution in Africa
7. Release of the posterior deltoid contracture
and scar
8. break adhesions between the deltoid and
rotator cuff muscles
9. Stretching of the rotator cuff
10. avoidance of head collapse
11. Replace significant bony loss of the glenoid
12. reduce the head and keep it there

8. The solution in Africa
• Options for treatment then are:
1. Hemiarthroplasty for those few who have it
2. Open reduction
3. Do nothing, unfortunately this is what I
believe most of us do
4. Shoulder fusion

9. Objectives of the rest of this talk
• Cadaver dissection demonstrating the
operative procedure
• Four case presentations
• Conclusions

10. Materials and Methods
• Hand written and electronic operative logs of
all chronic shoulder dislocations =,> than one
month
• Chart review
• Pts phoned and visited to ask them to come
back
• Oxford and Constant scores, photos

11. Cadaveric operative demonstration

12. Delto-pectoral approach

13. Takedown of anterior deltoid to the lateral
acromium

14. 2.5mm drill into the coracoid for later
fixation

15. Osteotomize the coracoid

16. Reflect the coracoid medially

17. Take down the subscapularis off the lesser
tuberosity

18. Cut the long biceps tendon

19. Begin circumferential capsulotomy

20. Anteriorly cut capsule off neck

21. Inferiorly switch to releasing capsule off
inferior glenoid: concern for ax n.

22. Cut inferior capsule directly off glenoid: bone
is home

23. Finger dissect adhesions between posterior
cuff and deltoid

24. Posterior capsule and cuff released from posterior
glenoid; injury to suprascapular n. possible

25. bone of posterior glenoid goes anterior

26. Suprascapular nerve over the top of the
glenoid posteriorly

27. Real surgery, left shoulder
anterior
head
deltoid

28. Assessments
• Make sure the dissection is circumferential
• Inferiorly is important as there are bands of
scar, Axillary nerve is at risk, stay on inferior
glenoid!
• Mobilize the whole rotator cuff

29. Mobilization of the rotator cuff
• Subscapularis needs mobilization from the
anterior scapula as far medial as possible, excise
heterotopic ossification that is becoming a neo-
glenoid
• Mobilize the subscapularis off of the base of the
coracoid
• Mobilize the subscapularis off of the posterior
aspect of the coracobrachialis and NV bundle
• The subscapularis need to move!

30. Mobilize the supraspinatus
• If you are not careful you will cut it as it winds
around the base of the coracoid
• Mobilize it off of the base of the coracoid and
superior glenoid
• There will be dense adhesion between the
subscap and the HO forming on the anterior neck
and body. This needs mobilization
• There will be neo capsule that has formed as well

31. Mobilize the posterior cuff
• It has adhesions to the posterior glenoid and
also the posterior deltoid
• Dissect with a Cob between the posterior
glenoid and cuff with preservation of the
suprascapular nerve as it winds around the
spine of the scapula
• Finger dissect the adhesions between the
posterior cuff and the deltoid! This is important

32. Create space posteriorly
• With anterior translation of the head a void was
created posteriorly that is now filled with scar
• The undersurface of the Acromium posterior is
filled with scar and the posterior deltoid is
drawn anteriorly
• Cut this with electrocautery to allow the head
to go superior and posteriorly, This is
important!

33. Additional steps
• Stretch the posterior cuff by pulling the humeral head
laterally as hard as you can
• Assess the size of the glenoid, add bone anteriorly from the
iliac crest if needed, fix with screws, we have only rarely done
this, DJD is likely if you do this with iliac crest
• Assess the posterior tightness, stretch the cuff again
• IF there is any suggestion of anterior instability pin the head
to the glenoid at this point for one week
• I don’t think the Laterjet is an option in this setting it adds a
level of difficulty and dissection that is not warranted, I have
done it once and will not repeat it.

34. Closure
• Mobilize the subscapularis and repair it to the
lesser tuberosity, incorporate the long head of
the biceps in the repair
• Fix the coracoid anatomically with a 35 mm
3.5 screw
• Repair the deltoid with interrupted suture to
the clavicle using the trapezius fascia

35. TR surgery 2months after injury

36. Good function, 14 mo po

37. DT 6 weeks dislocated, easier operation no coracoid
osteotomy, no circumferential capsulotomy

38. Open reduction and Bankart

39. DT 11 months post-op

40. AJ 60 yr old, subscap tear as well as
chronic dislocation, surgery 5 mo post
injury, F/u 3 yrs post surgery

41. 3 yrs post surgery

42. TN Dislocated for one year

43. Dislocated for 1 yr, 2 year f/u

44. TN at F/U 2 yrs post op

45. TK 2 months dislocation

46. TK F/u 18 months

47. FL 4 months post injury

48. FL 16 months f/u

49. Results using Constant and Oxford Shoulder
Scores
• Constant score: 100 possible points
– 15 pts pain, 20 function, 40 motion, 25 strength
• Oxford score: 48 possible points
– Patient questionnaire on pain and function
– Excellent: 40-48
– Satisfactory: 30-39
– Fair: 20-29
– Poor: below 20

50. Other patients who did not come for F/U for
this study
• 6-10 other cases, one case 1.5yr dislocation
• No infections
• 2 head collapses, one old and one young
patient (both intraop early in this series)
• 2 takebacks to the OR for re-dislocation on the
post op x-ray, pinned at second surgery

51. Results: Oxford and Constant
Oxford Constant
0
20
40
60
80
100
120
TN
TR
AJ
DT
FL

52. Chart of results
Name Delay from
injury to OP
Months F/U Constant Score Oxford Score
TR 2 months 14 77
AJ 5 months 36 53
TN 12 months 24 100
DT 6 weeks 11 77
TK 2 months 18 98 48
FL
AD
Abda
4 months
8months
1 yrs&7months
16 77 41

53. Conclusions
• It is possible to relocate a chronically
dislocated shoulder
• Wide exposure is necessary
• The surgical challenges are multiple and each
contracture must be addressed
• Good functional improvement is possible

54. See it on Vumedi