Recurrent shoulder dislocation and management

Recurrent shoulder dislocation evaluation treatment options and management options

1. RECURRENT SHOULDER DISLOCATION

2. INTRODUCTION One of the most unstable and frequently dislocated joint in the body. Greatest range of motion at expense of stability. 50% of all dislocations In a study of 101 acute dislocations, recurrence developed in 90% of the patients younger then 20 yrs old , in 60% of 20-40 yrs old and in only 10% of patients older than 40yrs of age.

3. FACTORS INFLUENCING RECURRENT DISLOCATION AGE RETURN TO CONTACT OR COLLISION SPORTS HYPERLAXITY PRESENCE OF SIGNIFICANT BONY DEFECT IN GLENOID OR HUMERAL HEAD

4. ANATOMY SHOULDER STABILIZERS DYNAMIC STABILIZER S STATIC STABILIZER

5. Static stabilizers Articular congruence Glenoid labrum Capsule and ligaments Negative intra articular pressure Adhesive cohesive forces

6. Dynamic stabilisers Rotator cuff muscles Biceps tendon Scapulo -thoracic motion

7. ARTICULAR CONGRUENCE Glenoid fossa Pear shaped 7 degrees retroversion 5-10 degrees superior tilt Humerus Neck shaft angle 130- 140 degrees Retroversion 30 degrees

8. Humeral head is 3 times larger than glenoid fossa and covers only 25-30% of humeral head during any range of motion. Large humeral head articulating with small and shallow glenoid.

9. Glenoid Labrum Wedge shaped fibrous ring attached to the glenoid articular surface through a fibrocartilaginous transition zone. Contributes 20% to glenohumeral stability. It deepens glenoid cavity by 50% Serve as attachment site for glenohumeral ligaments and biceps tendon. Increases surface contact area

10. CAPSULE AND GLENOHUMERAL LIGAMENTS Capsule : Glenohumeral joint capsule is loose and redundant. Attached medially to the glenoid fossa Laterally to anatomical neck of humerus Anterior capsule is thicker than posterior

11. GLENO HUMERAL LIGAMENTS It is the localised thickening of the capsule Named according to their attachments on the glenoid rim Actions- limits of rotation preventing excess gleno humeral translation Their function is dependent on the arm position and on the direction of the applied force on the joint.

12. Superior Gleno-humeral ligament Origin- tubercle on glenoid, just posterior to long head of biceps Insertion – upper end of lesser tubercle Present in > 90% Resists inferior subluxation and contributes to stability in posterior and inferior directions.

13. Middle glenohumeral ligament Origin- superior glenoid labrum Insertion- blends with sub scapularis tendon Present in 60-80% Limits anterior instability, specially in 45 degrees. Also limits external rotation

14. Inferior gleno humeral ligament Origin- anterior glenoid rim and labrum Insertion- inferior aspect of humeral articular surface and anatomical neck Consists of three bands: anterior ,axillary and posterior Primary restraint to anterior and posterior stresses at 45-90 degree abduction.

15. Inferior GH ligament for hammock type model Most important ligamentous stabilizer

16. Negative intraarticular pressure The osmotic action of the synovium to remove fluid creates a negative intra-articular pressure in the joint. This makes the pliable labrum centered by a non-compliant osseous glenoid stick to the humeral head like a suction cup. This negative pressure is lost in capsular tear or excessive capsular laxity.

17. Dynamic stabilizer – rotator cuff Fibrous sheath formed by the 4 flattened tendons. These tendons blend with each other and with the capsule of shoulder joint before reaching their point of insertion Usually consist of- Subscapularis –internal rotation and adduction of arm Supraspinatu s-abduction of the arm Infraspinatu s-external rotation of the arm Teres minor -external rotation of arm

18. Rotator cuff Active contraction of the rotator cuff contributes to joint stabilization by coordinated muscular activity and by secondary tightening of the ligamentous constraints. This effect works in combination with the concavity-compression mechanism, in which muscle contraction causes compression of nearly congruent articular surfaces into one another. This coordinated compressive function of the rotator cuff muscles is required to counteract the upward shearing force of the strong deltoid muscle during abduction and/or flexion.

19. Biceps tendon Long head of biceps tendon- has variable origin 30-40% originating from the supraglenoid tubercle 45-60% directly from the labrum 25-30% from both Long head of biceps helps limit anterior, posterior and inferior translation of the humeral head, specially in adduction.

20. Scapulo -thoracic motion Primarily achieved by the serratus anterior and trapezius muscles, which provide overall rhythm of the shoulder motion. Maintains the glenoid as a stable platform underneath the humeral head as the shoulder rotates into positions required for overhead motions such as throwing.

21. CLASSIFICATION ACCORDING TO DIRECTION UNIDIRECTIONAL BIDIRECTIONAL MULTIDIRECTIONAL DEGREE OF INSTABILITY SUBLUXATION DISLOCATION DURATION OF INSTABILITY ACUTE CHRONIC (>6 WEEKS)

22. TYPE OF TRAUMA MACROTRAUMA MICROTRAUMA SECONDARY TRAUMA AGE OF INTIAL DISLOCATION <20 YEAR – 90% REOCCURENCE 20-40 YEAR – >40 YEAR – 10% REOCURRENCE

23. MATTSONS CLASSIFICATION TUBS Traumatic Unidirectional Bankart lesion Surgery is often necessary AMBRII Atraumatic Multidirectional Bilateral Rehabilitation is the primary mode of treatment Inferior capsular shift Internal closure often performed

24. SHOULDER DISLOCATION TYPES ANTERIOR POSTERIOR INFERIOR INCIDENCE 95-98% (SUBCORACOID MOST COMMON) 3-4% 1-2% MECHANISM OF INJURY ABDUCTION ; EXTERNAL ROTATION ADDUCTION ; INTERNAL ROTATION HYPERABDUCTION CONDITION PAINFUL MINIMAL PAINFUL (OVERLOOKED) (LIGHT BULB SIGN ON X RAY) SALUTE POSTURE EXAMPLE THROWING A BALL ASSOCIATED WITH ELECTRIC SHOCK OR SEIZURE DISORDER

25. PATHO ANTOMY Labral lesion Bankart Reverse- bankart SLAP Capsular Injury Intra-substance tear HAGL (humeral avulsion of glenohumeral ligament) Capsular laxity Bone loss Humeral head – Hill Sach’s Glenoid

26. BANKART LESION Traumatic detachment of the glenoid labrum has been called the Bankart lesion. This disruption is between the antero-inferior labrum, and the glenoid. Mechanism The humeral head is forced anteriorly out of the glenoid cavity and tears not only the fibrocartilaginous labrum from almost the entire anterior half of the rim of the glenoid cavity but also the capsule and periosteum from the anterior surface of the neck of the scapula .

27. The IGHLC detaches with a small piece of avulsed glenoid, the lesion is called a bony Bankart. Posterior labral pathology /disruption. Reverse Bankart-detached posterior labral flap Kim lesion- marginal crack without labral detachment

28. Excessive capsular laxity

29. HILL SACH’S LESION A compression fracture of the posterosupero -lateral humeral head, is known as a Hill–Sachs lesion. It is a sequela of an anterior dislocation. The lesion is created with the arm in abduction and external rotation with the posterior humeral head crushed on the anterior glenoid rim

30. Hill Sachs lesion are present 80% of anterior dislocations, 25% of anterior subluxations, and 100% of cases of recurrent anterior instability. Engaging Hill–Sachs lesions- Defects which are parallel to the long axis of the glenoid rim in positions of function (abduction and external rotation) and therefore “engage” or contribute to glenohumeral instability. Nonengaging lesions - are not parallel to the rim and therefore do not effect stability in positions of function.

31. “ Reverse” Hill– Sachs on the anterior medial humeral head defect is an important predictor of posterior recurrent instability. (TROUGH SIGN) These articular humeral lesions rarely contribute to instability, as they are usually small; however, when the lesion includes more than 20% of the articular surface and associated with instability, it may be an important indication for surgery .

32. History Amount of initial trauma (high or low energy) Recurrence with minimal trauma in the mid range of motion – a/w with bony lesion Position in which the dislocation has occurred If dislocation that occur during sleep or with the arm in an overhead position- a/w significant glenoid defect. Ease with which shoulder is relocated is determined Associated nerve injury Physical limitations caused by this instability

33. Be careful for subluxation – commonly overlooked Patient may complain of dead arm as a result of the axillary nerve stretching. Posterior shoulder instability may present as posterior pain or fatigue with repeated activity(like in swimming, blocking in basketball, rowing)

34. Physical examination Begins with asking the patient which arm position creates instability,direction of subluxation Look for atrophy,asymmetry . Tenderness- at anterior or posterior joint capsule,rotator cuff ,AC joint Active and passive ROM Power of muscles Winging of scapula

35. STABILITY OF SHOULDER JOINT SHIFT AND LOAD TEST PATIENT SITTING SUPINE WITH ARM SLIGHTLY ABDUCTED AND PLACING ONE HAND ALONG SCAPULA TO STABILIZE IT GRASP HUMERAL HEAD WITH OTHER HAND AND APPLYING A SLIGHT COMPRESSION FORCE QUANTIFY THE AMOUNT OF ANTERIOR AND POSTERIOR TRANSLATION OF HUMERAL HEAD IN GLENOID EASY SUBLUXATION INDICATES LOSS OF CONCAVITY OF GLENOID

36. SULCUS SIGN It is positive when there is increased inferior translation of the humeral head relative to the glenoid, with traction applied downward in patients with inferior and multi-directional instability. The sulcus should be measured at both neutral and 45 deg of abduction. Subluxation at 0 deg of abduction is more indicative of laxity at the rotator interval, and subluxation at 45 deg indicates laxity of inferior GHL.

37. Anterior Drawer test: Quantifies the amount of anterior translation . Patient lying supine, examiner stands on the ipsilateral side. The patient’s hand is positioned in the examiner’s axilla. Scapula is stabilized by one hand, the other hand grasps the proximal humeral shaft and exerts an anterior force. The amount of translation is quantified.

38. Posterior Drawer Test: Quantifies posterior translation; Patient in supine position. For left shoulder, the patient’s left wrist and forearm is held with elbow flexed to 120º. With the shoulder in 80-120º abduction, and 60-80º of forward flexion and internal rotation, a posterior force is applied on the arm. The amount of posterior translation is assessed by the hand, stabilizing the scapula.

39. In performing these tests for anterior and posterior instability, the amount of instability is graded from 0 to 3. Grade 1: Humeral head slips up to the rim of glenoid Grade 2: Head slips over the labrum , but spontaneously relocates Grade 3: Indicates dislocation.

40. Gagey hyperabduction test: Measure of laxity of the inferior glenohumeral ligament complex. Patient sitting, and the examiner standing behind him, with one hand stabilizing the scapula and the other hand passively abducting the affected shoulder. A side to side difference of more than 20 deg is suggestive of inferior capsular laxity

41. Apprehension test Patient in supine or upright position Anterior apprehension test: Affected shoulder is passively moved to abduction and maximum external rotation and a gentle anterior force is placed on the posterior humeral head. Test is positive when the patient becomes apprehensive and experiences pain . Posterior apprehension test: The affected shoulder is adducted and internally rotated.

42. DIAGNOSIS Radiographs CT Scan MRI Arthroscopy

43. X-RAY VIEWS AP view Axillary view Scapular Y-view Apical oblique view AP in ER/IR views Strykar notch view West point view

44. IT IT HELPS IN DETECTING HILL SACH’S LESION

45. WEST POINT VIEW FOR BANKART LESION

46. Scapular Y view Evaluate relationship of humeral head with glenoid Humeral head should be located at bifurcation of the Y shape formed by scapula

47. CT SCAN Useful for assessing bony lesions such as Hill-Sachs lesions, glenoid rim fracture’s, glenoid version, etc. CT scans with three-dimensional reconstructions are the gold standard as MRI may underestimate the degree of bone loss Indications: Blunting of the glenoid cortical outline or an obvious bone defect on plain radiographs. Evaluating recurrences that occur with trivial trauma, low-angle instability, and failed surgical procedures

48. MRI Gold standard for evaluating capsulo -labral structures, especially Bankart lesion. Addition of contrast improves ability of MRI to show Rotater cuff pathology, humeral avulsion of inferior glenohumeral ligament, and capsular tears.

49. TREATMENT procedure for recurrent instability should include the following factors : (1) low recurrence rate (2) low complication rate (3) low reoperation rate (4) does no harm (arthritis) (5) maintains motion, (6) is applicable in most cases, (7) allows observation of the joint, (8) corrects the pathologic condition (9) is not too difficult.

50. TREATMENT Operative procedures can be done both – open, or arthroscopically, with comparable results. Open procedures include: Jobe capsulolabral reconstruction, or Neer capsular shift Arthroscopic procedures Arthroscopic Bankart repair Capsular plication procedure. For glenoid bony defects that cannot be repaired Bristow- Latarjet procedure Iliac Crest Autograft or Allograft Glenoid Reconstruction Webers osteotomy.( subcapital rotational osteotomy of proximal humerus).

51. Case NAME : SHIV KUMAR AGE 28 YEAR MALE PRESENTED TO OPD WITH COMPLAIN OF : PAIN AND INSTABILITY IN RIGHT SHOULDER HISTORY OF RECURRENT DISLOCATION OF RIGHT SHOULDER FROM LAST 2 YEARS K/C/O SEIZURE DISORDER WITH LAST ATTACK 10 MONTHS BACK DIAGNOSED AS RECURRENT SHOULDER DISLOCATION RIGHT SIDE

52. ON EXAMINATION RIGHT LEFT DUGAS TEST - - GAGEY HEPERABDUCTION TEST - - SHIFT AND LOAD TEST + - SULCUS SIGN - - APPREHENSION TEST - - GERBER LIFT OFF TEST (SUBSCAPULARIS) - - DROP ARM TEST (SUPRASPINATOUS ) + - JOBE EMPTY CAN TEST + -

53. RADIOGRAPHIC IMAGES

54. BRISTOW-LATARJET PROCEDURE Indication – when bony deficiency is more then 20 percent on glenoid Transfer of coracoid bone with attached conjoined tendon provides sling effect Technique-coracoid bone transfer to anterior inferior glenoid bone defect .

55. The Latarjet procedure reconstructs the glenoid depth and width with the bone block and creates a dynamic reinforcement of the inferior capsule through the coracobrachialis muscle, particularly while the arm is abducted and externally rotated. In the Bristow procedure, only the tip of the coracoid process and attached coracobrachialis is transferred to the anterior glenoid

56. TREATMENT:LATERJET SURGERY patient secured in a beach-chair position and after induction of general endotracheal anesthesia, place a small pillow behind the scapula to position the glenoid surface perpendicular to the operative table. Part scrubbed painted and drapped 4 to 7-cm skin incision beginning under the tip of the coracoid process is made.

57. Delto -pectoral plane is made and cephalic vein is retracted laterally , a self-retaining retractor into the deltopectoral interval and a Hohmann retractor on the top of the coracoid process. Position the patient’s arm in 90 degrees of abduction and external rotation, and section the coracoacromial ligament 1 cm from the coracoid. release the pectoralis minor insertion from the coracoid, osteotome or small angulated saw to osteotomize the coracoid process from medial to lateral at the junction of the horizontal-vertical parts

58. Grasp the bone graft firmly with forceps and carefully release it from its deep attachments,avoiding potential damage to the musculocutaneous nerve. With a 3.2-mm drill, drill two parallel holes in the deep surface of the bone graft. Measure the thickness of the bone graft with a caliper and place the graft under the pectoralis major for subsequent use Upper limb in full external rotation, identify the inferior and superior margins of the subscapularis tendon. Use electrocautery and then Mayo scissors to divide the muscle at the superior two-thirds or inferior one-third junction in line with its fibers, carefully obtaining hemostasis at each step.

59. exposing the subscapular fossa upper limb in neutral rotation to provide full exposure of the capsule, and make a 1.5-cm vertical capsulotomy at the level of the anteroinferior margin of the glenoid. arm into full internal rotation to allow insertion of a humeral head retractor, which rests on the posterior margin of the glenoid. Retract the superior two thirds of the subscapularis superiorly with a Steinmann pin impacted at the superior part of the scapular neck; retract the inferior part inferiorly with a Hohmann retractor pushed under the neck of the scapula between the capsule and the subscapularis

60. expose the anteroinferior margin of the glenoid and decorticate it with a curet or osteotome Insert the bone block through the soft tissues and position it flush to the anteroinferior margin of the glenoid. Check the position of the bone block with the arm in internal rotation Insert a 3.2-mm drill through the inferior hole in the bone graft and into the glenoid neck in an anteroposterior and superior direction. Check the orientation of the articular surface and direct the drill parallel to this plane. Place cancellous screw into the posterior cortex to secure the bone block to the glenoid. Tighten this screw loosely to allow easy rotation and proper positioning of the superior part of the bone block

61. When positioning is correct, insert a second cancellous screw through the superior hole in the bone block and tighten both screws firmly . Arm in external rotation, repair the remnant of the coracoacromial ligament to the lateral capsular flap . Move the arm through all ranges of motion to evaluate mobility. close the superficial soft-tissue layers.

62. POST OP REHABILATION immobilization in a sling or shoulder immobilizer for 2 weeks Forward flexion is begun thereafter, and external rotation is begun at 6 weeks. Strengthening exercises are started at 8 weeks after surgery.

63. Post op x ray

64. Stabilization of the glenohumeral joint occurs by three mechanisms with the Latarjet procedure: A bony effect by correcting the anterior glenoid deficiency. Muscular (“sling”) effect created by maintaining the inferior third of the subscapularis in an inferior position by the conjoined tendon . Capsular effect by the capsular repair.

65. Thanks!!!!