1principles of Chronic dislocations.pptx

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1. Principles of Chronic Dislocations Duane Anderson, MD Soddo Christian Hospital

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” 1 st 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 Chronic Dislocations 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

14. Medial and lateral approaches,

15. Repair of Anterior and Posterior sleeves to the epicondyles

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

21. Chronic posterior hip dislocations

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

27. Ilio psoas and Hip capsule in clear view

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

33. Chronic Shoulder Dislocation LESS INHERENT STABILITY, LIKE THE KNEE

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

38. Take down the anterior deltoid from the clavicle

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

41. Pre-drill and osteotomize the coracoid

42. After coracoid osteotomy Green, subscap Blue base of the coracoid Grey, supraspinatus Elbow>

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

45. Posterior tightness

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

48. Remove the pin 7-10 days later

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.

51. Open reduction 12 months after dislocation

52. F/U 2 yrs post op Shoulder score 100

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

55. Chronic knee dislocation, 2 in my career

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. 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

58. 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

59. Feet   Hip Prominence is the femoral condyle behind the tibia Peroneal Nerve

60. 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

61. Medial Incision & Arthrotomy VMO Femur  Medial tibial plateau Lateral meniscus Anterior/Dorsal Distal Femur

62. Reduction Large ¼” proximal tibial traction pin placed, Manual traction Posterior capsule limbs (with sutures) placed posterior to femur Lateral meniscus freed from soft tissues, reduced, and repaired with two #1 Vicryl sutures Procedure

63. reduction Anterior spanning External Fixator applied & reduction confirmed Neurovascular structures identified – Normal DP/PT pulses MCL avulsion fx repaired/sutured to medial femoral condyle through drill hole Minimal joint capsule left medially. Medial/Lateral Ex-Fixes applied. Knee at 50-60 degrees of flexion Posterior POP splint applied to decrease posterior dead space.

64. Lateral Side of the Knee (Reduced) after Open Meniscal Repair Peroneal n. IT Band Incision Lateral Meniscal Repair

65. Medial Knee (Reduced) after MCL Avulsion Repair VMO MCL Avulsion Repair

66. 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

67. Literature Review

68. 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

69. 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

70. 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

71. 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