This document discusses the pathology and management of recurrent shoulder dislocations. It begins with an introduction covering the epidemiology and risk factors for recurrence. It then covers the surgical anatomy of the shoulder joint and stabilizing structures. The main pathological findings associated with recurrence include Bankart lesions, Hill-Sachs lesions, and ligamentous laxity. Treatment involves both surgical and non-surgical options depending on the individual case. The most common surgical procedures are Bankart repair and Latarjet procedure. Post-operative rehabilitation is important for recovery. Recurrence rates can be reduced with proper identification and treatment of the underlying causes.

1. DISCUSS THE PATHOLOGY AND
MANAGEMENT OF RECURRENT
SHOULDER DISLOCATION
PRESENTER- SANUSI A.A
SUPERVISOR:-
DR T. SOUGH
CONSULTANT ORTHOPAEDICS AND TRAUMA SURGEON
UNIVERSITY OF ABUJA TEACHING HOSPITAL
06/02/2020 1

2. OUTLINE
• Introduction
• Surgical anatomy
• Aetiology
• Pathology
• Classification
• Clinical features
• Investigations
• Treatment
• Rehabilitation
• Complications
• Prognosis
• Conclusion
• References
06/02/2020 2

3. INTRODUCTION
• Dislocation of the shoulder is a common orthopaedic injury
• It is usually the result of trauma, although "atraumatic“ and even
voluntary dislocation of the shoulder may occur
• One of the most unstable and frequently dislocated joints in the body
• Greatest range of motion at expense of stability
• Recurrent shoulder dislocation is 2 or more repeated involuntary
dislocations in the same shoulder
• Recurrent shoulder dislocations are more commonly a problem seen
in young adults
06/02/2020 3

4. INTRODUCTION
• Epidemiology
• Incidence of shoulder dislocation
• 2% in general population
• About 50% of all dislocations
• Recurrence
• About 90% in patients <20 years
• 60% in patients 20-40 years
• 10% in patients > 40 years
06/02/2020 4

5. SURGICAL ANATOMY
• Ball and socket joint
• Articulations- humeral head and glenoid cavity
• At any given time, only one fourth of large humeral head articulates
with glenoid
• The labrum deepens the glenoid by about 50% and increases humeral
contact to about 75%
• Joint stability
• The major stabilizers can be classified as
• Static
• Dynamic
06/02/2020 5

6. SURGICAL ANATOMY
06/02/2020 6

7. SURGICAL ANATOMY
• Static stabilizers
• Superior glenohumeral ligament: Most important restraint at zero
degree of abduction
• Middle glenohumeral ligament: Most important restraint at lower
and middle range of abduction
• Inferior glenohumeral ligaments: Most important restraint at
more than 45 degrees of abduction
06/02/2020 7

8. SURGICAL ANATOMY
06/02/2020 8

9. SURGICAL ANATOMY
• Dynamic stabilizers
• Rotator cuff muscles
• Biceps tendon
• Deltoid muscle
06/02/2020 9

10. SURGICAL ANATOMY
06/02/2020 10

11. SURGICAL ANATOMY
06/02/2020 11

12. AETIOLOGY
• Risk Factors for Recurrent
Dislocation
• Patient-related
• Young age
• Male gender
• Contact/Collision sport
• Surgeon-related
• Misdiagnosis (posterior
instability/MDI/IGHL)
• Technical factors
• Failure to address pathology
• Non-anatomic labral repair
• < 3 anchors used
• incorrect drill hole placement
• inadequate restoration of
glenoid concavity
06/02/2020 12

13. AETIOLOGY
• Pathology-related
• Glenoid bone loss > 25%
• Stretched IGHL
• Anterior hyperlaxity
• Large Hill-Sachs
• Concomitant pathology (SLAP tears, rotator cuff tears, HAGL lesions,
etc.)
06/02/2020 13

14. PATHOLOGY
• No single deformity is responsible
for recurrent dislocation of shoulder
• Triad of essential lesions
• Labral injury
• Bankart lesion
• Impression fracture
• Hill Sach’s lesion
• Avulsion of glenohumeral
ligaments usually off the glenoid
• Others
• Capsular
laxity/stretching/tearing of
capsule
• Rotator cuff tear
06/02/2020 14

15. PATHOLOGY
• Bankart’s lesion
• Most commonly observed pathologic lesion
• Tear of the fibrocartilaginous labrum from almost the anterior half
of the rim of the glenoid cavity
• Also tear of the capsule and periosteum from the anterior surface
of the neck of the scapula
• Sometimes bony Bankart
• Loss of the labrum can reduce this stabilizing effect by 20%
06/02/2020 15

16. PATHOLOGY
06/02/2020 16

17. PATHOLOGY
• Hill Sach’s lesion
• A defect in the posterolateral aspect of the humeral head
• Instability results when the defect engages the glenoid rim
• Humeral head defects of 35% to 40% were shown to decrease
joint stability
• Secondary deficiencies from repeated dislocations
• Erosion of the anterior glenoid rim
• Stretching of the anterior capsule and subscapularis tendon, and
• Fraying and degeneration of the glenoid labrum
06/02/2020 17

18. PATHOLOGY-Hill-Sach’s lesion
06/02/2020 18

19. PATHOLOGY
06/02/2020 19

20. CLASSIFICATION
• According to direction of dislocation/instability
• Unidirectional
• Bidirectional
• Multidirectional
• Degree of injury
• Subluxation
• Dislocation
• Duration
• Acute /sub acute/chronic
06/02/2020 20

21. CLASSIFICATION
• Type of trauma
• Macro trauma
• Micro trauma
• Atraumatic (secondary trauma)
• Age of initial dislocation
• < 20 years- 90% recurrence
• 20-40 years
• >40 years
06/02/2020 21

22. CLASSIFICATION
• Masten’s classification
06/02/2020 22

23. CLASSIFICATION
• Stanmore classification
06/02/2020 23

24. CLINICAL FEATURES
• History
• Age
• Trauma
• The amount of initial trauma, if any, should be determined
• Hx of 1st dislocation
• Subsequent dislocations/subluxations
• Contact Sports, swimming, throwing or overhead activities
• Dislocation during sleep
06/02/2020 24

25. CLINICAL FEATURES
• Associated pains
• Position of dislocation
• The ease of relocation
• The signs and symptoms of any nerve injury should be elicited
• The physical limitations caused by the recurrent dislocation should be
documented
• The mental set of the patient must be evaluated
• History of underlying pathology
06/02/2020 25

26. CLINICAL FEATURES
• Physical examination
• Both shoulder should be thoroughly examined
• Look
• Atrophy or asymmetry, scapula winging, ecchymosis
• Previous scar
• Feel
• Differential warmth/Tenderness
• Palpable mass/bony defect
06/02/2020 26

27. CLINICAL FEATURES
• Move
• ROM (both active and passive)
• Evaluate for strength of the dynamic stabilizers
• Laxity and instability tests
• Sulcus sign
• Drawer test
• Apprehension test
• Load and shift test
• Jobe’s relocation test
Sulcus
sign
06/02/2020 27

28. CLINICAL FEATURES
Anterior drawer test Posterior drawer
test
06/02/2020 28

29. CLINICAL FEATURES
• Anterior and posterior apprehension test
06/02/2020 29

30. INVESTIGATIONS
• x-ray
• initial views
• AP and Lateral
• Special views
• AP in internal rotation
• West point view
• Stryker notch view
• Garth oblique view
• 3D CT Scan (for suspected
complex bony Aetiology)
• MRI (Gadolinium enhanced)
• Double contrast arthrography for
capsular laxity
• Arthroscopy
06/02/2020 30

31. INVESTIGATIONS
• West point view • Stryker Notch view
06/02/2020 31

32. TREATMENT
• Decision making
• Key questions
• What is the problem? Soft tissue, bony or both
• If bony, where is the problem? Glenoid, humeral or both
• Also consider the mental state of the patient
06/02/2020 32

33. TREATMENT
• Treatment for recurrent anterior dislocation
• Non operative treatment
• Indications
• Long interval of recurrence
• Recurrent instability without prior treatment
• Recurrent atraumatic instability
• Chronic dislocation with good function and no pain
• Patient medically unstable for surgery
• Unstable epilepsy
06/02/2020 33

34. TREATMENT
• Non operative treatment
• Mainstay of non operative treatment is physical therapy
• It involves muscle strengthening exercises especially for
atraumatic multidirectional recurrent shoulder dislocation
• Avoidance of provocative activities and some specific voluntary
maneuvers.
• Pre and post-operative physiotherapy
• Psychiatric evaluation for voluntary habitual dislocators
06/02/2020 34

35. TREATMENT
• Operative treatments
• Factors favouring surgical treatment
• Young age
• High activity level
• Frequent dislocation
• There is no single best procedure
06/02/2020 35

36. TREATMENT
• Ideally, the procedure for
recurrent dislocation/instability
should include the following
factors:
• Low recurrence rate
• Low complication rate
• Low reoperation rate
• Does no harm (arthritis)
• Maintains motion
• Applicable in most cases
• Allows observation of the joint
• Corrects the pathologic
condition, and
• Is not too difficult
06/02/2020 36

37. TREATMENT
• Procedures
• Open Bankart repair ± capsular shift
• Arthroscopic Bankart repair ± capsular plication
• Open capsular shift
• Putti-platt procedure
• Latarjet procedure
• Bristow procedure
• Remiplissage procedure
06/02/2020 37

38. TREATMENT
• Bankart repair
• Most commonly performed procedure
• Anterior labral defect identified, mobilized and re attached to
original anatomic site with suture anchor
• Can be done open or arthroscopic
• Modifications available
• Capsular repair also recommended
06/02/2020 38

39. TREATMENT
06/02/2020 39

40. TREATMENT
• Putti-Platt operation
• Subscapularis and capsule
incised vertically
• Lateral leaf sutured to the
labrum & medial leaf
imbricated
• Subscapularis is advanced
laterally
• Gross limitation of ext.
rotation
06/02/2020 40

41. TREATMENT
• Bristow operation
• Involves osteotomy and re-
implantation of coracoid
process to the anterior
scapular neck to deepen the
glenoid cavity
• The transferred short head of
biceps and coracobrachialis
serve as strong buttress
across the anterior and
inferior aspects of the joint
06/02/2020 41

42. TREATMENT
• Procedures for recurrent posterior dislocation
• Open or arthroscopic posterior labral repair
• Open or arthroscopic capsular shift and rotator interval closure
• Capsular shift reconstruction and posterior glenoid opening wedge
osteotomy
06/02/2020 42

43. REHABILITATION
• Phase I (Post op to 3 weeks)
• Rest and immobilization
• Pain control with nonsteroidal anti-inflammatory drugs and ice
applied to the shoulder
• Phase II (3 to 6 weeks)
• Isometric strengthening, Isotonic strengthening
• Begin exercises with shoulder in adducted, forward- flexed
position, progressing to abducted position
06/02/2020 43

44. REHABILITATION
• Phase III ( 6 weeks to 3 months)
• Endurance building along with strengthening exercises
• Goal: the patient reaches 90% strength in the injured shoulder
compared with the uninjured shoulder
• Phase IV (3 months to 6 months)
• Increase activity to sport- or job-specific activities
06/02/2020 44

45. COMPLICATIONS
• Early
• Rotator cuff tear
• Nerve injury
• Vascular injury
• Fracture dislocation
• Recurrence
• Late
• Shoulder stiffness
• Degenerative joint disease
• Adhesive capsulitis
• Hardware complications
• Anchor pull out/screw pull
out
• Graft lysis
06/02/2020 45

46. PROGNOSIS
• Good if the aetiological factor is properly identified and properly
treated
• Traumatic structural type is better than other types
• Inferior instability has very good prognosis if well attended to
• Poor prognosis for non-structural types esp. for individuals seeking
compensation from work places or other sources
06/02/2020 46

47. CONCLUSIONS
• Recurrent shoulder dislocation requires a meticulous and systematic
management plan
• Good understanding of the pathological anatomy will enhance better
diagnosis and adequate treatment for a good outcome
• The trend now is towards anatomic repair of aetiologic structural
lesions
• Prognosis is good if proper diagnosis is made and adequate treatment
and rehabilitation given
06/02/2020 47

48. REFERENCES
• Andrew Cole; The Shoulder and Pectoral Girdle, in Apley and
Solomon’s System of Orthopaedics and Trauma, 10th ed. 2018; 13:
367-372
• Barry B. Phillips; Recurrent Dislocations, in Campbell’s Operative
Orthopaedics, 13th ed. 2017; 47:2364-2390
• CDR Mathew T. Provencher et al; Recurrent Shoulder Instability:
Current Concepts for Evaluation and Management of Glenoid Bone
loss, in The Journal of Bone and Joint Surgery; 2010;92:133-151
06/02/2020 48

49. REFERENCES
• Chris Sinopidi; Chronic Instability of Shoulder, in Textbook of
Orthopaedics and Trauma, 2nd ed. Vol 3, 2008;266:2560-2568
• J. Crawford Adams; Recurrent Dislocation of the Shoulder, in the
Journal of Bone and Joint Surgery, vol 30B, No.1, February 1948; 26-
38
• James V. Nepola, MD; Recurrent Shoulder Dislocation, in The Iowa
Orthopaedics Journal, vol 13:97-106
06/02/2020 49

50. REFERENCES
• John Ebenezer; Injuries of the Shoulder Joint, in Textbook of
Orthopaedics, 5th ed. 2010; 12:121-130
• Williams H. Rossy et al; Current Trend in the management of
Recurrent Anterior Shoulder Instability, in Bulletinof the Hospital for
Joint Diseases; 2014; 72(3)210-6
06/02/2020 50

51. 06/02/2020 51
THANK YOU FOR LISTENING