Recurrent shoulder dislocation

ACUTE & RECURRENT
SHOULDER
DISLOCATION
Dr.sagar a. Savsani
Junior resident, dept. of orthopaedics,
Jss medical college , mysuru

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

ANATOMY
• SURGICALANATOMY
• Static stabilizers - anatomic constraints to
shoulder motion
• Dynamic stabilisers – normal physiological
function creates a stabilizing effect

• BONY ANATOMY – has minimal constraints –
large range of motion
Scapula – hence glenoid anterverted 30 – 40
Humeral head - retroverted
¼ of head articulates with bony glenoid
Labrum – one of the most important stabilizing
structures .
- Effectively enlarges & deepens the glenoid
surface by 1 cm & 50% respectively .
- Increases humeral contact to 75 %

• CAPSULE : loose and redundant at most
positions
- At extremes – tightens , provides stability .
• GLENOHUMERAL LIGAMENTS
- Superior , Middle , Inferior
• CORACOHUMERAL LIGAMENT –
-Passes in the Rotator Interval ( between
Subscapularis & Supraspinatus )

DYNAMIC STABILIZERS
• ROTATOR CUFF MUSCLES
• BICEPS TENDON : along the rotator interval
• CORACO-ACROMIALARCH -limits
superior translation

Recurrent shoulder dislocation

Anterior
• Subcoracoid (Anterior):
– Humeral head sits anterior and
medial to the glenoid, just
inferior to the coracoid.
– ~ 60% of cases.
• Subglenoid (Anteroinferior):
– humeral head sits inferior and
slightly anterior to the glenoid,
that the humeral head has also
travelled medially.
– ~ 30% of cases.

MECHANISM OF INJURY
• DIRECT – less common
INDIRECT – more common
• Susecptible position –
Anterior dislocation : Abd. , Ext. rotation & Extension
Post. Dislocation : Flexion, Add . & Int. rotation
In Seizures & Electrical shock – all the muscles are contracted ,
ext. rotators overpower int. rotators
• ASS0CIATED INJURIES :
• Humeral head & neck # , tuberosity # , glenoid # , rotator cuff
tears( older age) , neurological ( axillary N.) and vascular injuries
• Any pt. with weakness after shoulder dislocation must be evaluated
for rotator cuff tear

Presentation of Acute dislocation
• Pain , Typical attitude ,
• In Ant . Dis- limitation of int. rotation & abd.
• In Post. Disl. – “ of ext. rotation
• In Inferior disl. – in fully abducted position
• PHYSICAL EXAMINATION
• Flattening of shoulder
• Fullness in delto-pectoral area
• Axillary fold at lower level
• Able to insinuate finger beneath acromion
• Dugas test
• Hamilton ruler test

Axillary N. tested for both sensory &
motor components

Xray
• The AP x-ray will show the overlapping shadows of
the humeral head and glenoid fossa, with the head
usually lying below and medial to the socket.

NONOPERATIVE TREATMENT
• CLOSED REDUCTION FOR ACUTE
DISLOCATION
- Under i.v. analgesia + sedation
- Under intra-articular lignocaine
- If initial closed reduction unsucessful , degree of
sedation & analgesia evaluated , if not successful ,
under G.A for closed / open reduction

Traction-Countertraction
• Note how the clinician
on the left has the sheet
wrapped around him,
allowing him to use his
body weight to create
traction.
• Some clinicians employ
gentle external rotation
to the affected arm
while providing traction.

Stimpson’s Technique
• The patient is placed
prone on the stretcher
with the affected
shoulder hanging off
the edge.
• Weights (10-15 lbs)
are fastened to the
wrist to provide
gentle, constant
traction.

Scapular Manipulation
• The patient sits upright and
leans the unaffected shoulder
against the stretcher.
• The physician stands behind
the patient and palpates the tip
of the scapula with his thumbs
and directs a force medially.
• The assistant stands in front of
the patient and provides gentle
downward traction on the
humerus as shown.
• The patient is encouraged to
relax the shoulder as much as
possible.

Milch’s Technique
• The arm is abducted and
the physician's thumb is
used to push the humeral
head into its proper
position.
• Gentle traction in line
with the humerus is
provided with the
physician's opposite hand.

Spaso Technique
• The arm is flexed
forward and gentle
traction and external
rotation forces are
applied.

Management
• The arm is rested in a sling for about three weeks in
those under 30 years of age (who are most prone to
recurrence) and for only a week in those over 30
(who are most prone to stiffness).
• Then movements are begun, but combined
abduction and lateral rotation must be avoided for at
least 3 weeks.
• Throughout this period, elbow and ﬁnger
movements are practised every day.

OPERATIVE TREATMENT
• SURGICAL STABILISATION FOR ANT .
INSTABILITY
In – Failed appropriate nonoperative treatment
- Recurrent dislocation at young age
- Irreducible dislocation
- Open dislocation
- Unstable joint reduction
- 1st dislocation in young pt with high demand activity
• SURGICAL OPTIONS
- Arthroscopic surgery
- Open tech. with soft tissue repair
- Open tech. with bony augmentation

OPEN PROCEDURES
• BANKART OPERATION
- MC performed surgery
- Ant. Labral defect identified , mobilized &
reattached to original anatomic site with suture
anchor .
- Capsular reconstruction also recommended
- Subscapularis tendon is split at junction of upper
2/3rd & lower 2/3rd

• BRISTOW OPERATION
- Suturing of coracoid process with the conjoint tendon to
the ant. Portion of scapular neck through a transversely
sectioned subscapularis M.
- The transferred short head of biceps &
corachobrachialis – strong buttress across the anterior &
inferior aspects of joint
- Tendon also holds the lower half of subscapularis M.
thus prevents slipping over the humeral head when
abducted

• PUTTI-PLAT OPERATION
- Subscapularis and capsule incised vertically
- Lateral leaf sutured to the labrum & medial leaf
imbricated
- Subscapularis is advanced laterally
- Gross limitation of ext. rotation
- Rarely indicated

POSTERIOR DISLOCATION OF
THE SHOULDER
• Posterior dislocation is rare, accounting for less than
2% of all dislocations around the shoulder.

CLINICAL FEATURES
• The diagnosis is frequently missed – partly because
reliance is placed on a single AP x-ray (which may
look almost normal) and partly because those
attending to the patient fail to think of it.
• There are, in fact, several well-marked clinical
features.

• The arm is held in Internal Rotation and is locked in
that position.
• The front of the shoulder looks ﬂat with a
prominent coracoid, but swelling may obscure this
deformity; seen from above, however, the posterior
displacement is usually apparent.

XRAY
• In the AP ﬁlm the humeral head, because it is
medially rotated, looks abnormal in shape (like an
electric light bulb) and it stands away somewhat
from the glenoid fossa (the ‘empty glenoid’ sign).
• An Axillary view is essential; it shows posterior
subluxation or dislocation and sometimes a deep
indentation on the anterior aspect of the humeral
head.

POSTERIOR SHOULDER
DISLOCATION REDUCTION
• The underlying approach to
the traction-countertraction
technique demonstrated in
this photograph is similar to
that employed in the
reduction of anterior
dislocations.
• The notable difference is
positioning. Note that the
patient is upright and the
clinician providing traction
is standing in front of the
patient.

INFERIOR DISLOCATION OF THE
SHOULDER
(LUXATIO ERECTA)
• Inferior dislocation is rare but it demands early recognition
because the consequences are potentially very serious.
• Dislocation occurs with the arm in nearly full
abduction/elevation.
• The humeral head is levered out of its socket and pokes into
the axilla; the arm remains ﬁxed in abduction.

MECHANISM OF INJURY AND
PATHOLOGY
• The injury is caused by a severe hyper-abduction force.
• With the humerus as the lever and the acromion as the
fulcrum, the humeral head is lifted across the inferior
rim of the glenoid socket; it remains in the subglenoid
position, with the humeral shaft pointing upwards.
• Soft-tissue injury may be severe and includes avulsion
of the capsule and surrounding tendons, rupture of
muscles, fractures of the glenoid or proximal humerus
and damage to the brachial plexus and axillary artery.

CLINICAL FEATURES
• The startling picture of a patient with his arm locked
in almost full abduction should make diagnosis quite
easy.
• The head of the humerus may be felt in or below the
axilla.
• Always examine for neurovascular damage.

XRAY
• The humeral shaft is shown in the abducted position
with the head sitting below the glenoid.
• It is important to search for associated fractures of the
glenoid or proximal humerus.
– NOTE: True inferior dislocation must not be confused with
postural downward displacement of the humerus, which
results quite commonly from weakness and laxity of the
muscles around the shoulder, especially after trauma and
shoulder splintage; here the shaft of the humerus lies in the
normal anatomical position at the side of the chest.
– The condition is harmless and resolves as muscle tone is
regained.

TREATMENT
• Inferior dislocation can usually be reduced by
pulling upwards in the line of the abducted arm,
with counter-traction downwards over the top of the
shoulder.
• If the humeral head is stuck in the soft tissues, open
reduction is needed.
• It is important to examine again, after reduction, for
evidence of neurovascular injury.
• The arm is rested in a sling until pain subsides and
movement is then allowed, but avoiding abduction
for 3 weeks to allow the soft tissues to heal.

COMPLICATIONS
• EARLY COMPLICATIONS
• Rotator cuff tear:
– This commonly accompanies anterior dislocation,
particularly in older people.
– The patient may have difﬁculty abducting the arm after
reduction; palpable contraction of the deltoid muscle
excludes an axillary nerve palsy.
– Most do not require surgical attention, but young active
individuals with large tears will beneﬁt from early repair.

• Nerve injury:
– The axillary nerve is most commonly injured; the patient
is unable to contract the deltoid muscle and there may be
a small patch of anaesthesia over the muscle.
– The inability to abduct must be distinguished from a
rotator cuff tear.
– The nerve lesion is usually a neuropraxia which recovers
spontaneously after a few weeks; if it does not, then
surgery should be considered as the results of repair are
less satisfactory if the delay is more than a few months.

– Occasionally the radial nerve, musculocutaneous nerve,
median nerve or ulnar nerve can be injured.
– Rarely there is a complete infra-clavicular brachial
plexus palsy.
– This is somewhat alarming, but fortunately it usually
recovers with time.

• Vascular injury:
– The axillary artery may be damaged, particularly in old
patients with fragile vessels.
– This can occur either at the time of injury or during
overzealous reduction.
– The limb should always be examined for signs of
ischaemia both before and after reduction.

• Fracture-dislocation
– If there is an associated fracture of the proximal humerus,
open reduction and internal ﬁxation may be necessary.
– The greater tuberosity may be sheared off during
dislocation.
– It usually falls into place during reduction, and no special
treatment is then required.
– If it remains displaced, surgical reattachment is
recommended to avoid later subacromial impingement.

• LATE COMPLICATIONS
• Shoulder stiffness
– Prolonged immobilization may lead to stiffness of the
shoulder, especially in patients over the age of 40.
– There is loss of lateral rotation, which automatically
limits abduction.
– Active exercises will usually loosen the joint.
– They are practised vigorously, bearing in mind that full
abduction is not possible until lateral rotation has been
regained.
– Manipulation under anaesthesia or arthroscopic capsular
release is advised only if progress has halted and at least
6 months have elapsed since injury.

RECURRENT SHOULDER
DISLOCATION
Factors that influence the probability of recurrent
dislocations are –
• Age,
• Return to contact or collision sports,
• Hyper laxity, and
• The presence of a significant bony defect in the
glenoid or humeral head
The duration of immobilization also does not seem
to affect stability

Patho - anatomy
Humeral head is forced through the capsule where
it is weakest , generally anteriorly and inferiorly .
• Acute
Shoulder
Dislocation
Humeral head is forced anteriorly out of the glenoid
and tear labrum from almost entire half of rim of
glenoid and also capsule and periosteum . This traumatic
detachment of the glenoid labrum has been called
Bankart lesion .

• Hill – sach’s lesion – impaction
fracture on humeral head on
posterolateral aspect can be
produced as the shoulder is
dislocated due to impaction of
humeral head against glenoid
rim
• Instability results when the
defect engages the glenoid rim
in the functional arc of motion at
90 degrees abduction and
external rotation
• defects of 35% to 40% of head
were shown to decrease stability,

• Capsular laxity - Excessive laxity can be caused by a
congenital collagen deficiency, shown by hyper laxity of
other joints, or by plastic deformation of the
capsuloligamentous complex from a single macro traumatic
event or repetitive micro traumatic events.
• Hyperlaxity has been implicated as a cause of failure in
surgical correction of chronic shoulder instability .

• An arthroscopic study of anterior shoulder dislocations
found that 38% of the acute injuries were intrasubstance
ligamentous failures, and 62% were disruptions of the
capsuloligamentous insertion into the glenoid neck.
• The “circle concept” of structural damage to the capsular
structures was suggested by cadaver studies that showed
that humeral dislocation does not occur unless the posterior
capsular structures are disrupted in addition to the anterior
capsular structures. Posterior capsulolabral changes
associated with recurrent anterior instability often are
identified by arthroscopy.

CLASSIFICATION
• According to direction of instability –
unidirectional
bidirectional
multidirectional
• Degree of instability –
sublaxation
dislocation
• Duration of instability –
acute
sub acute
chronic > 6 weeks

• Type of trauma –
macro trauma
micro trauma
secondary trauma
• Age of initial dislocation –
< 20 year - 90% recurrence
20 – 40 year
> 40 year - 10% recurrence

• Repetitive trauma at the extremes of motion results in
plastic deformation of the capsulolabral complex.
• Secondary trauma to the rotator cuff and biceps tendon
may cause asynchronous rotator cuff function.
• These injuries most commonly occur in pitchers,
batters, gymnasts, weightlifers, tennis players and
others who play racquet sports, and swimmers,
especially with the backstroke or butterfly stroke.
• The flexibility that allows an athlete to compete at a
high level may be attributed to a generalized
ligamentous laxity, which also predisposes the athlete to
injury.
• Trauma may cause decompensation of a previously
stable capsuloligamentous complex.

• Matsen’s simplified classification system -
1 - TUBS (Traumatic Unidirectional Bankart Surgery )
2 - AMBRII (Atraumatic, Multidirectional, Bilateral,
Rehabilitation, Inferior capsular shift, and Internal closure)
• Micro traumatic or developmental lesions fall between the
extremes of macro traumatic and atraumatic lesions and can
overlap these extreme lesions .

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

• Be careful for subluxation - commonly overlooked by
physicians .
• The patient may complain of having a “dead arm” as a
result of stretching of the axillary nerve.
• Posterior shoulder instability may present as posterior pain
or fatigue with repeated activity (e.g., blocking in football,
swimming, bench press, rowing, and sports requiring
overhead arm movement).
• Mental status - Some patients with posterior instability
learn to dislocate their shoulder through selective muscular
contractions. Although voluntary dislocation does not
indicate pathological overlay, some of these patients have
learned to use voluntary dislocation for secondary gain, and
in these patients surgical treatment is doomed to failure.

PHYSICAL EXAMINATION
• Begins with asking the patient which arm position creates
the instability , what direction the shouldr subluxes and if
he/she can safely demonstrate the subluxation .
• Both shoulders should be thoroughly examined, with the
normal shoulder used as a reference for –
Atrophy
Asymmetry
Tenderness – at anterior or posterior joint capsule,
rotator cuff, AC joint
Active and passive ROM
Power of muscles
Winging or Dyskinesia of scapula

SHIFT AND LOAD TEST
Patient sitting with arm slightly abducted placing one hand along the
edge of the scapula to stabilize it
Grasping the humeral head with the other hand and applying a slight
compressive force
The amount of anterior and posterior translation of the humeral head in
the glenoid is observed
Easy subluxation of the shoulder indicates loss of the glenoid concavity

SULCUS TEST
• Arm in 0 degrees and 45 degrees of abduction.
• This test is done by pulling distally on the extremity and
observing for a sulcus or dimple between the humeral head
and the acromion that does not reduce with 45 degrees of
external rotation.
• The distance between the humeral head and acromion
should be graded from 0 to 3 with the arm in 0 degrees and
45 degrees of abduction,

APPREHENSION TEST
Anterior Posterior
Shoulder in 90 abduction and Shoulder in 90 degree abduction and
elbow in 90 degree flexion brought to a forward flexion
External rotation of the extremity Internal rotation of the extremity
with Anterior Stress applied with Posterior Stress applied
to the humerus to the humerus
Clunk is felt as humeral head subluxes , producing pain or a feeling
of apprehension or instability is produced

DRAWER TEST
Anterior Posterior
In supine position -Anterior stress In supine postion – Posterior stress
is applied to the proximal humerus is applied to the proximal humerus
The amount of translation and the end point are evaluated .
Grade 1 - means that the humeral head slips up to the rim of the glenoid,
Grade 2 - means that it slips over the labrum but then spontaneously
relocates.
Grade 3 - indicates dislocation

JOBES RELOCATION TEST
• Used for evaluating instability in athletes involved in sports requiring
overhead motion .
• Patient in supine position and shoulder in 90 degrees of abduction and
external rotation
• At various degrees of abduction anterior stress is applied by
examiner’s hand to the posterior part of humerus .
• Check for pain and apprehension ,
• Posterior directed force is applied to relocate the humeral head in the
joint while shoulder is placed in abduction and external rotation .

• Bony deformity of the glenoid or humerus is indicated by
apprehension or instability at low ranges of motion (<90 degrees of
abduction) and when inferior instability is prominent .
• Hyperlaxity is indicated by – 1) A positive sulcus test,
2) A positive Gagey hyperabduction test,
3) The Beighton hyperlaxity scale .
• The hyperabduction test is done by stabilizing the scapula with one
hand placed superiorly while passively abducting the shoulder with
the other hand.
• A side-to-side diﬀerence of more than 20 degrees is suggestive of
inferior capsular laxity.
• External rotation of more than 85 degrees at 0 degrees of abduction is
indicative of hyperlaxity, which may need to be corrected with
rotator interval closure.

• Also rule out –
Scapular dysfunction
Primary / Secondary rotator cuff impingement
Neck problems

RADIOLOGICAL EVALUATION
X rays –
AP VIEW AXILLARY VIEW

GARTH AP OBLIQUE VIEW WEST POINT VIEW

• STRYKER VIEW -
• Simplest is AP view in internal rotation – often shows a
Hill –Sachs lesion that may not be apparent on routine
views .

• Standard double-contrast arthrography – helpful if
excessive capsular capacity with an enlarged axillary pouch
is noted .
• CT with 3D reconstruction – effectively shows bony
lesions such as Hill-Sachs lesions , glenoid rim #s , glenoid
version , some soft tissue abnormalities .
• Double-contrast CT arthrography – especially useful in
patients without clear cut clinical signs of subluxation or
dislocation , also showing soft tissue and labral defects .
• Gadolinium-enhanced MRI – best minimally invasive
view of capsular or labral damage , detecting humeral
avulsion of gleno humeral ligament (HAGL) lesions , which
require repair .

• Examination using anesthetic and arthroscopy –
support the clinical diagnosis or sometimes show
unsuspected planes of instability , especially in
multidirectional instability patterns .
• The most significant findings of instability are
demonstrable at 40 degrees and 80 degrees of
external rotation .

Treatment
• 1) TUBS (Traumatic Unilateral dislocations
with a Bankart lesion requiring Surgery)
Nonoperative or Operative

NONOPERATIVE
• Acute reduction, ± immobilization, followed by therapy
– Indications
• management of first time dislocators remains controversial
– Reduction
• simple traction-countertraction is most commonly used
• relaxation of patient with sedation or intraarticular lidocaine is essential
– Immobilization
• some studies show immobilization in external rotation decreases recurrence
rates
• thought to reduce the anterior labrum to the glenoid leading to more
anatomic healing
• subsequent studies have refuted this finding and the initially published
results have not been reproducible
– Physical therapy
• strengthening of dynamic stabilizers (rotator cuff and periscapular
musculature)

OPERATIVE
• Arthroscopic Bankart repair +/- capsular shift
• Open Bankart repair +/- capsular shift
• Latarjet (coracoid transfer) and Bristow Procedures for
glenoid bone loss
• Autograft (tricortical iliac crest) or allograft (iliac crest or
distal tibia) for glenoid bone loss
• Remplissage technique for Hill Sachs defects
• Bone graft reconstruction for Hill Sachs defects
• Putti-Platt / Magnuson-Stack / Boyd-Sisk

ARTHROSCOPIC BANKART REPAIR +/-
CAPSULAR SHIFT
• Indications
– Relative indications
• first-time traumatic shoulder dislocation with Bankart
lesion confirmed by MRI in athlete younger than 25 years
of age
• high demand athletes
• Technique - drive through sign might be present prior to
labral repair and capsulorraphy
Studies support use of ≥ 3 anchors (< 3 anchors is a risk
factor for failure)
• Outcomes
– results now equally efficacious as open repair with the
advantage of less pain and greater motion preservation

OPEN BANKART REPAIR +/-
CAPSULAR SHIFT
• Indications
– Bankart lesion with glenoid bone loss < 20%
– humeral avulsion of the glenohumeral ligament (HAGL)
• Can also be performed arthroscopically but is
technically challenging
• Technique - Subscapularis transverse split or
tenotomy
Open labral repair and capsulorraphy

Bankart Repair
• In original Bankart operation , Subscapularis and shoulder
capsule are opened vertically
• The lateral leaf of the capsule is reattached to the anterior
glenoid rim. A medial leaf of the capsule is imbricated, and
the subscapularis is approximated
• The procedure can be done through a subscapularis split, in
larger, more muscular individuals, the subscapularis split can
be extended superiorly approximately 1 cm medial to the
biceps tendon in L shaped fashion .
• This L type release provides excellent exposure of the rotator
interval , the inferior third of the subscapular muscle can be
retracted inferiorly to expose the inferior capsule ,
• This approach preserves neuromuscular function and
minimizes the possibilities of post operative tendon
detachment .

• The advantage of this procedure is that it corrects the labral
defect and imbricates the capsule without requiring any
metallic internal fixation devices .
• The main disadvantage is its technical difficulty .

Modified Bankart procedure
• INCISION - along the Langer lines, beginning 2 cm distal and lateral
to the coracoid process and going inferiorly to the anterior axillary
crease
• Develop the deltopectoral interval, retracting the deltoid and cephalic
vein laterally and the pectoralis major muscle medially. Leave the
conjoined tendon intact, and retract it medially .
• Split subscapularis tendon transversely in line with fibers at upper 2/3
and lower 1/3

• Make a horizontal anterior capsulotomy in line with split tendon
• Drill holes near glenoid rim at 3-,4-, 5:30-o’clock position
• Place suture anchors in each hole and pulled to set anchors
• Each individual suture is pulled to ensure suture slides in anchor

• Make a horizontal anterior capsulotomy in line with split
tendon
• Drill holes near glenoid rim at 3-,4-, 5:30-o’clock position
• Place suture anchors in each hole and pulled to set anchors
• Each individual suture is pulled to ensure suture slides in
anchor

• Approximation of capsule to freshened neck
• Two or three suture anchors are used to secure inferior capsule
firmly to scapular neck
• Superior and Middle suture anchors are used to secure and
advance superior flap in inferior direction
• Final closure of capsule is done with inturrepted nonabsorbable
sutures
• Extremity is maintained in 45 degrees of abduction and 45
degrees external rotation during closure

LATARJET (CORACOID TRANSFER) AND
BRISTOW PROCEDURES FOR GLENOID
BONE LOSS
• Indications
– Bony deficiencies with >20% glenoid deficiency
(inverted pear deformity to glenoid)
– Transfer of coracoid bone with attached conjoined tendon
provides sling effect
• Technique - Coracoid transfer to anterior inferior
glenoid bone defect
Traditional or congruent arc technique for
coracoidgraft placement
After harvest, coracoid is passed through a split in
the proximal 1/3 subscapularis

• Latarjet (coracoid transfer) and Bristow
Procedures for glenoid bone loss
• Beach-chair position ,
• Vertical incision under tip of
coracoid process

HARVESTING AND PREPARING
BONE BLOCK
• Harvest of bone block corresponding to horizontal
part of coracoid process , retaining conjoined
coracobrachial tendon and coracoacromial ligament

DIVISION OF THE SUBSCAPULARIS,
CAPSULOTOMY, AND EXPOSURE
• 1 - limb in full external rotation, identify the inferior and superior
margins of the subscapularis tendon. divide the muscle at the superior
two-thirds or inferior one-third
• 2 -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
anterior-inferior margin of the glenoid.

Use a scalpel to expose the
anterior-inferior 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 anterior-inferior
margin of the glenoid.

AUTOGRAFT (TRICORTICAL ILIAC CREST)
OR ALLOGRAFT (ILIAC CREST OR DISTAL
TIBIA) FOR GLENOID BONE LOSS
• Indications
– bony deficiencies with >20-25% glenoid deficiency
(inverted pear deformity to glenoid)
– revision to failed latarjet

REMPLISSAGE TECHNIQUE FOR HILL
SACHS DEFECTS
• Indication -
– Engaging large (>25%) Hill-Sachs defect
• Technique
– posterior capsule and infraspinatus tendon sutured into
the Hill-Sachs lesion
– may be performed with concomitant Bankart repair

BONE GRAFT RECONSTRUCTION FOR
HILL SACHS DEFECTS
• Indication
– Engaging large (>25%) Hill-Sachs lesions
• Technique
– Allograft reconstruction
– Arthroplasty
– Rotational osteotomy

PUTTI-PLATT / MAGNUSON-STACK
/ BOYD-SISK
• Indications
– Historic purposes only
– Led to over-constraint and arthrosis
• Technique - Putti-Platt is performed by lateral advancement
of subscapularis and medial advancement of the shoulder
capsule
• Magnuson-Stack is performed with lateral advancement of
subscapularis (lateral to bicipital groove and at times to
greater tuberosity)
• Boyd-Sisk - Transfer of biceps laterally and posteriorly

COMPLICATIONS
• Recurrence
– often due to unrecognized glenoid bone loss treated with a soft tissue only procedure
– can be due to poor surgical technique (ie, < 3 suture anchors)
– increased risk with preoperative risk factors including age < 20, male sex,
contact/collision sport
• Shoulder pain
• Nerve injury
– musculocutaneous
– axillary
• Stiffness
– especially in external rotation
• Infection
• Graft lysis (Latarjet)
• Hardware complications
– anchor pull-out (Bankart repair)
– screw pull-out (Latarjet)
• Chondrolysis
– historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular
pain pumps (now contraindicated)

TREATMENT
• 2) Posterior Instability and Posterior Dislocation
Lesions Associated with Posterior Instability
Avulsion of posterior band of IGHL Associated with acute subluxations
Posterior Bankart lesions Characterized by detachment of
posterior inferior capsulolabral complex
Reverse Hill-Sachs lesions Associated with nonreducible and
difficult to reduce dislocations
Posterior labral cyst Associated with chronic reverse
Bankart lesion
Posterior glenoid rim fracture Associated with chronic reverse
Bankart lesion
Lesser tuberosity fracture Associated with posterior dislocation
Large capsular pouch Can see with MRI with contrast

NONOPERATIVE
• Acute reduction and immobilization in external
rotation for 4 to 6 weeks
– Indications
• Should be initially attempted for all acute traumatic posterior
dislocations
– Most dislocations reduce spontaneously
– Technique
• Immobilize in 10-20 degrees of external rotation with elbow at
side
• After 6 weeks advance to physical therapy (rotator cuff
strengthening and periscapular stabilization) and activity
modification (avoid activities that place arm in high-risk
position)

OPEN OR ARTHROSCOPIC
POSTERIOR LABRAL REPAIR
(BANKART)
• Indications
– Recurrent posterior shoulder instability
– Continued pain with loading of arm in forward flexed
position (bench press, football blocking)
– Negative Beighton score
• Goal - is to repair any labral detachment or capsular tears,
and/or reduce the posterior capsule volume
• Outcomes
– 80% to 85% success at 5- to 7-year follow-up after open
repair
– Similar outcomes with arthroscopic repair after shorter
follow-ups

POSTERIOR SHOULDER
STABILIZATION

OPEN OR ARTHROSCOPIC
POSTERIOR CAPSULAR SHIFT AND
ROTATOR INTERVAL CLOSURE
• Indications
– Positive Beighton score
• Closure of rotator interval - augments posterior
capsular shift

POSTERIOR GLENOID OPENING
WEDGE OSTEOTOMY
• Indications -
Excessive glenoid retroversion

OPEN REDUCTION WITH SUBSCAPULARIS
AND LESSER TUBEROSITY TRANSFER TO
THE DEFECT (MCLAUGHLIN)
• Indications
– Chronic dislocation < 6 months old
– Reverse Hill-Sachs defect < 50%
• Technique to repair defect –
1) Subscapularis and lesser tuberosity transfer
– used by most (modified McLauglin procedure)
2) Iliac crest bone graft
– can be used for any glenoid bone loss
3) Disimpaction and bone grafting of the defect
– if < 3 weeks the surgeon can try disimpaction and bone grafting of the
defect
4) Opening wedge glenoplasty
– may be indicated with glenoid hypoplasia

• McLaughlin described transfer of the subscapularis tendon
into the defect. Neer and Foster subsequently described
transfer of the subscapularis with the lesser tuberosity into
the defect and securing it with a bone screw.

HEMIARTHROPLASTY
• Indications
– Chronic dislocation > 6 months old
– Severe humeral head arthritis
– Collapse of humeral head during reduction
– Reverse Hill-Sachs defect > 50% of articular surface
TOTAL SHOULDER
ARTHROPLASTY
• Indications
– Significant glenoid arthritis in addition to one of the
hemiarthroplasty indications

COMPLICATIONS
• Stiffness
– Most common complication after labral repair
• Recurrence
– 2nd most common (7% to 50%)
• Degenerative joint disease
– 3rd most common
• Adhesive capsulitis
• Overtightening of posterior capsule
– may lead to anterior subluxation or coracoid impingement
• Nerve injury
– axillary or suprascapular

TREATMENT
3) MULTIDIRECTIONAL SHOULDER
INSTABILITY
Also referred to as AMBRI-
• Araumatic
• Multidirectional
• Bilateral (frequently)
• Rehabilitation (often responds to)
• Inferior capsular shift (best alternative to nonop)

NONOPERATIVE
• Dynamic stabilization physical therapy
– Indications
• First line of treatment
• Vast majority of patients
– Technique
• 3-6 month regimen needed
• Strengthening of dynamic stabilizers (rotator cuff and
periscapular musculature)
• Closed kinetic chain exercises are used early in the
rehabilitation process to safely stimulate co-contraction of the
scapular and rotator cuff muscles

OPERATIVE
• CAPSULAR SHIFT / STABILIZATION
PROCEDURE (OPEN OR ARTHROSCOPIC)
– Indications
• Failure of extensive nonoperative management
• Pain and instability that interferes with ADLs of sports
activities
– Contraindications
• Voluntary dislocators
• CAPSULAR RECONSTRUCTION
(ALLOGRAFT)
– Rare, described in refractory cases and patients with
collagen disorders

• Approach
– Arthroscopic approach to shoulder
• Stabilization
– Must address capsule +/- rotator interval
– Inferior capsular shift (capsule shifted superiorly)
– Plication of redundant capsule in a balanced fashion
– Rotator interval closure (open or arthroscopic)
• Produces the most significant decrease in range of motion in external
rotation with the arm at the side
– Address any anterior or posterior labral pathology if present
– Thermal capsulorrhaphy (historical)
• is contraindicated because of complications including capsular
thinning/insufficiency and attenuation, and chondrolysis

COMPLICATIONS
• Subscapularis deficiency
– More common after open anterior-inferior capsular shift
– May be caused by injury or failed repair
– Postop physical exam will show a positive lift off test and excessive external rotation
• Loss of motion
– May be due to asymmetric tightening or overtightening of capsule
– Leads to loss of ER
• Axillary nerve injury
– Iatrogenic injury with surgery (abduction and ER moves axillary nerve away from
glenoid)
– Usually a neuropraxia that can be observed postoperatively
– Can occur with anterior dislocation of shoulder
• Late arthritis
– Usually wear of posterior glenoid
– May have internal rotation contracture
• Recurrence

Recurrent shoulder dislocation

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