This document discusses the management of traumatic anterior shoulder dislocations. It begins by describing the shoulder's anatomy and how its mobility makes it prone to instability. It then reviews the history and clinical examination findings that help determine appropriate treatment. Arthroscopic findings from studies of acute and chronic dislocations are presented, showing common lesions like Bankart tears. Treatment options are explored, including arthroscopic stabilization which can address all lesions with minimal morbidity. Arthroscopy allows accurate diagnosis and repair of injuries while facilitating early rehabilitation. The conclusion is that arthroscopy is now often the treatment of choice for traumatic shoulder dislocations.

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Traumatic anterior shoulder
dislocation
Changing concepts of
management
Manos Antonogiannakis
O r t h o p a e d i c S u r g e o n
Director 3rd Orthopaedic department
Centre of Shoulder Arthroscopy & Surgery
Hygeia Hospital
Athens Seminar, Scapular Dyskinesis related to shoulder pathology
Athens, 9&10 June 2017 .

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The Shoulder
 Greatest Range of Motion in the Body
 Motion in all 3 planes of movement
 Prone to instability
Sacrifices stability for mobility

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What is Instability
 Biomechanical Dysfunction
 Failure of static and dynamic stabilizers
 Ranges from mild subluxation to
traumatic dislocation

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Shoulder dislocation is a dramatic event
with dare consequences especially in athletic
young individuals

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And rather common problem
2% of the population
90% anterior dislocation

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History:
degree of violence
Level of athletic participation
Age of the patient
Clinical examination:
Generalized Joint laxity
direction of aprehension
dictates treatment

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Intra-articular Lesions in Acute and Chronic Anterior
Shoulder Instability
C.K. Yiannakopoulos, E Mataragas
Emm Antonogiannakis
Arthroscopy 2007
Level IV, prognostic case series
127 patients
with acute and chronic traumatic
anterior instability were recorded

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Our findings in Traumatic shoulder
dislocation
 Hemarthrosis 100%
 Bankart 78.2%
 Bony Bankart 13.04%
 Hill-Sachs 65.21%
 capsular laxity 8.69%
 SLAP lesions 21.73%
C. Yiannakopulos E Mataragas E.Antonogiannakis
Arthroscopy Sep 2007

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BONY LESIONS
• Humeral Head
• Glenoid rim
LABRAL - LIGAMENTOUS INJURY
• Bankart lesion
• A.L.P.S.A.
• H.A.G.L.
• Capsular Tear
INCREASED CAPSULAR VOLUME
• Atraumatic elongation
• Traumatic stretch
Associated Lesions we learned to recognize
BICEPS LESIONS
ROTATOR CUFF TEARS
• Partial thickness
• Full thickness
ROTATOR INTERVAL
PATHOLOGY
• Widening
• Synovitis
• Rupture

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 Major lesions discovered from the first
dislocation
 Becoming worse as the episodes are being
repeated
What is important

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• Multicenter study
• 245 patients aged 12-40 years
• 10 years follow up
• 52% recurrence rate
• 23% were operated
Prognosis of recurrence after
traumatic first time dislocation
Primary anterior dislocation of the shoulder in
young patients. A 10 year prospective study -
Hovelius 1996 JBJS(A)

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The major prognostic factor of recurrence after
acute traumatic anterior shoulder dislocation is
the age of the patient and the degree of
participation to high risk sports

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Redislocation rate in patients<20
years
Larrain
Rowe
Simonet and Cofield
Slaa
•90%
• 94%
• 94.5%
• 90%

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Post-Reduction Immobilization
Is immobilization
necessary?
What Method
is Best?

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Does immobilization
reduce recurrence?
 Prospective multi-center study
 257 primary anterior shoulder dislocations
 25 year follow up
 Results:
Immobilization for 3-4 weeks after shoulder
dislocation does NOT change the prognosis
compared with immediate mobilization
Hovelius JBJS 2008

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Internal vs External Rotation
Itoi JBJS 2007
 ER for 3 weeks
 Recurrence rate: 32%
 IR for 3 weeks
 Recurrence rate: 60%

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Is shoulder arthroscopy the best
treatment of traumatic shoulder
dislocation?

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Better understanding of the pathology
Reduction of recurrence rate
Treatment of rotator cuff lesions in older individuals
Easier rehabilitation
Why arthroscopy?

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Even the first dislocation is not a trivial
injury

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Bankart Lesion
the essential lesion
 Avulsion of the IGHL from the glenoid rim
from 2 o’clock to 6 o’clock
 Primary restraint to anterior translation
at 90o of abduction
 85% in traumatic anterior dislocations
 Not the only lesion usually.

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Bankart Lesion

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What is successful Treatment
Avoid recurrence
No limitations in Range of motion
Minor morbidity
Few complication
Return to preinjury activity level
Reproducible results
These are possible with arthroscopic treatment
of traumatic shoulder dislocation in selected
patients

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Treatment: Address all factors
 Dynamic stabilizers: rotator cuff and scapula muscles
 Static stabilizers: repair of capsuloligamentous structures

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Arthroscopic Shoulder Reconstruction
Goal of the Operation:
 Restoration of the Labrum to
its anatomic attachment
 Reestablishment of the appropriate tension
in the GH ligaments and capsule
Address bone deficiencies

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Define pathology

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Evaluation of the repair
Plication of the posterior capsule
Remplissage if needed

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Glenoid Bone
Loss >20-30%

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The inferior 2/3 of the glenoid is nearly a perfect
circle with avg diameter 24mm
Huysman et al. JSES 2006

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Normal Glenoid
inverted
pear
Bony Bankart
pear
Compressio
n Bankart
loss of
anterior rim

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>25 – 30% bone loss 6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)

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 Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid surface

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Bony Bankart

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Soft tissue repair incorporating the bone
fragment if possible
Piasecki et al. AAOS J17 (8): 482. (2009)

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Engaging
Non Engaging
Burkhart SS, De Beer JF : Arthroscopy 2003;19 : 732–739
Hill-Sachs lesion

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Engaging Hill Sachs

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 Engaging Hill-Sachs-glenoid bone loss
Hill- Sachs Remplisage: An arthroscopic surgical
solution for the engaging Hill-Sachs
E.M. Wolf

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From January 2007 to December 2010
(4 years)
48 patients
Average age: 28.9 ± 7.8 years
Average fu: 37.2 ± 9.9 months
Recurrence percentage: 6.3%

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The combination of the lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure

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Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart

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Glenoid Bone Loss >25%
Arthroscopic Latarjet procedure
L. Lafosse
Arthroscopic shoulder stabilization with a bone block
E. Taverna

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E.Taverna, et.al,Knee Surg
Sports Traumatol Arthrosc
(2008) 16:872–875

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Arthroscopic Bone Block
combined with Remplissage

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3 months
Post-op

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3 months
Post-op

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Our Results
25 cases
Impressive early outcomes

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Postoperative Rehabilitation
 Sling for comfort
 Isometrics and pendulum exercises immediately
 Active forward elevation may begin after 3/52
 External rotation to 30° to 40° at 4/52
 Progressive strengthening at 8/52
 Return to sport at 18 to 36 weeks
supervised and individualized

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Findings after shoulder dislocation in
patients older than 40 years
 52 pts follow up more than 2 years
 Redislocation rate 4%
 Rotator cuff tears 35%
T Penvy, R Hunter, J Freeman
Arthroscopy 1998

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In older patients rotator cuff tears are
common
The arthroscopic treatment of acute
rotator cuff tears is easy with minimum
morbidity
Conclusions

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Modern arthroscopic techniques
are probably the treatment of choice
in traumatic shoulder dislocation
Conclusions

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 Arthroscopy can be performed in an outpatient
setting
 The anatomy can be restored with minimum
morbidity and pain for the patient
 Careful assessment will allow repair of all lesions
 The patient can resume most of his every day
activities early in the rehabilitation program
Conclusions

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Thank you for your attention!!!
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