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RECURRENT RIGHT SHOULDER DISLOCATION INTRODUCTION

Shoulder dislocation is the commonest dislocation than any other joints in the body and traumatic anterior dislocation of the glenohumeral joint is the most common type of shoulder dislocation. The glenohumeral joint is the most mobile joint in the body due to the disproportionate size of the glenoid and the humeral head. The instability can be unidirectional or multi-directional (anterior, posterior and inferior). The development of recurrence depends greatly on the site and nature of the damage at the time of the initial dislocation. Young, athletes have higher incidence of recurrent dislocation as reported by ovelius ! and he noted that duration of immobilization did not affect stability but the degree and the initial trauma determine the fre"uency of recurrence. Treatment of instability includes the non-operative and operative, #ith immobilization and rehabilitation therapy. $n the operative management, arthroscopic and open techni"ues are described for glenohumeral stabilization.

CASE REPORT
T% is a &'-year-old e(ecutive presented to the Sports clinic in )*+ for recurrent

right shoulder dislocation for the past one year. She is right handed and had started playing badminton about one year ago and #hile trying to hit the shuttlecoc, #ith her rac"uet she heard a -pop. sound from her right shoulder associated #ith an acute pain. She sustained a traumatic dislocation of the right shoulder and reduction #as done spontaneously. Subse"uently she has had multiple episodes of dislocations over the past one-year follo#ing a trivial injury or normal daily activities and had even occurred during her sleep. She is able to reduce the dislocation herself and she has pain on each

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episodes. She has been on the Sports clinic follo#-up for the past 0 months and has been referred to physiotherapist. o#ever the dislocation had persisted and +agnetic resonance imaging (+1$) for the right shoulder #as done. 2n e(amination she has no deltoid muscle #asting, and range of motion of the shoulder #as full. 3pprehension test, posterior anterior dra#er test and relocation test #as positive. Sulcus sign #as negative and she has no other ligamentous la(ity. 4eurological e(amination of the upper limb #as normal. 1adiographic evaluation noted that she has a bony 5an,art lesion of the right shoulder #ith positive ill-Sach lesion. +agnetic 3 diagnostic resonance imaging (+1$) #as performed confirms the presence of the 5an,art lesion and the impression of the posterolateral surface of the head of humerus. arthroscopy of the shoulder #as performed and proceeded to open techni"ue of 5an,art repair #hich #ill be discussed later. She #as regular physiotherapy and also on regular follo#-up.

CLINICAL ASSESSMENT
$n patients #ith recurrent instability of the shoulder joint, a complete history must be obtained including the initial trauma, the fre"uency of trauma, mechanism of injury and direction of injury forces. 1ecurrent dislocation may be traumatic or atraumatic, voluntary or involuntary and may presents as recurrent dislocations, sublu(ations or both. The position of the arm in abduction, e(ternally rotated and e(tended signifies anterior instability. The dislocation usually re"uires reduction by another person and can be "uite painful or in some cases the patients develop the techni"ue to self reduce the dislocation. Shoulder e(amination is done by comparing #ith the normal shoulder. 6eneralised ligamentous la(ity is tested #ith thumb to forearm test, elbo# and metacarpopahalangeal joints hypere(tension. 3trophy of the deltoids and the rotator cuff muscles is carefully inspected. Scapular #inging is usually due to posterior glenohumeral instability. 7oint line tenderness is elicited through anterior and posterior palpation to determine posterior

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or anterior instability. 1ange of motion is then measured and typically patients are usually apprehensive during terminal e(ternal rotation in an abducted arm. There are several maneuvers to produce patient9s instability symptoms. The sulcus test is done by pulling do#n the arm inferiorly in neutral and arm in abducted position: useful in detecting inferior instability. The anterior and posterior la(ity is assessed by grasping the pro(imal humerus and manual force is e(erted. The anterior apprehension test is done by placing the arm 8; o abducted and progressively e(ternal rotate the shoulder, at the same time an anterior force e(erted at the humeral head. <atients #ith anterior instability #ill manifest as pain or apprehension #ith this maneuver. 7obe described a relocation test by e(erting a posterior force to the pro(imal humerus to stabilize the joint. The posterior stress test is then elicited by stabilizing the scapula and the arm adducted, fle(ed 8;o and internally rotated and a posterior force is e(erted to the humerus. 3 positive test produces sublu(ation #ith pain signifies a posterior instability. =(amination under anaesthesia may support the clinical diagnosis, especially in patients #ith unsuspected planes of instability and also heavily muscled athletes #ho are unable to rela( their muscle. >ombined #ith arthroscopic e(amination the anatomic lesions such as labral tear, labral #ear or fraying and capsular la(ity can be visualized. The under surface of damaged rotator cuff can also be seen.

Surgical technique (Ban art O!erati"n# The surgical techni"ue described by 1o#e et al
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#ith the patient under general

anaesthesia in supine position. >omplete muscle rela(ation during general anaesthesia is important for careful layer-by-layer e(posure of shoulder into the rim of glenoid. 5oth shoulders #ere e(amined and revealed anterior instability of the right shoulder. Sandbag placed in the bet#een the shoulder blades. 3rea #as cleaned and draped. S,in incision made from the coracoid process along the deltopectoral groove and ends near the a(illa. The shoulder approached through the deltopectoral interval. The cephalic vein is identified and retracted laterally and pectoralis major #as retracted

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medially. The coracobrachialis muscle and musculocutaneous nerve retracted medially e(posing the subscapularis tendon. The subscapularis tendon is dissected carefully from the anterior part of the capsule. The arm is e(ternally rotated and the capsule opened by a vertical incision !.? cm lateral to the anterior glenoid rim. The 5an,art lesion #as identified at the anteroinferior aspect of the glenoid labrum. The capsule #as reattached to the glenoid rim through three holes made on the anterior part of the glenoid at !, @, ? o9cloc, position. 2verlapping of the cut margins of the capsule #as repaired through the holes made using non-absorbable sutures. The capsule incision closure #ith interrupted absorbable sutures and the subscapularis tendon repaired. <ostoperatively, a sling applied for & to @ days and subse"uently started on pendular e(ercises. 3t si( #ee,s the shoulder motion had improved #ith continuation of physiotherapy #ith limitation of e(ternal rotation. 2n further follo#-up she had no episode of recurrent dislocation.

DISCUSSION
6lenohumeral instability encompasses a spectrum of disorder of varying degree, direction and etiology. >lassification of shoulder instability is based onA!. Birection of instability i) )nidirectional divided into anterior, posterior or inferior and superior ii) +ultidirectional 3nterior dislocations account for about 8'C of recurrent dislocations and posterior dislocations account for appro(imately @C. &. Begree of instability i) Sublu(ation (<artial separation of the humeral head from the glenoid) ii) Bislocation (>omplete separation of humeral head from the glenoid)

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Buration of symptoms i) 3cute ii) >hronic (dislocation remained longer than D #ee,s)

$ncreased attention to the active athletics individuals has lead to improved operative reconstruction, maintaining the full motion, strength and restoration of stability. Thus evaluation of patients #ith recurrent dislocation begins #ith a complete history and physical e(amination. +anagement of patients #ith recurrent dislocation of the shoulder re"uires the understanding of the biomechanics and anatomy of the shoulder joint. Shoulder joint being the most mobile joint in the body it is also an unstable joint due to the surface area of the humeral head and the glenoid fossa do not match. The stabilizer of the shoulder includes static and dynamic stabilizers. Static stabilizers consist of the articular anatomy and the capsuloligamentous structures of the shoulder joint. The glenoid labrum increases the depth of the articular surface by ?;C as described by o#ell et al &. The shoulder joint capsule is thin and la( and it is reinforced by collagenous thic,ening or ligament consists of three bands: superior, middle and inferior glenohumeral ligaments. (Eig. !)

Eigure

!A

6lenoid

and

surrounding capsule, ligaments, and tendons.

Buring different phases of rotation, the ligaments and capsule tighten and loosen reciprocally limiting the translation and rotation in a load sharing fashion. $n mid range rotation, the ligaments and capsule are la( and the stability maintained by rotator cuff and

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the biceps. 3s seen in this patient the dislocations occurs during the arm abducted and e(ternally rotated in #hich the subscapularis muscle displaces superiorly and the joint is supported only be the inferior glenohumeral ligament causing the shoulder at its most instability anteriorly. The dynamic stabilizer includes the rotator cuff muscles and the long head of biceps. The rotator cuff consists of four muscles (supraspinatus, infraspinatus, teres minor and subscapularis) conjoined to the regions of the joint capsule. $t stabilizes the humeral head in the glenoid and moves the joint surfaces relative to the other. The long head of biceps, #hich is intracapsular plays an important role in stabilizing the shoulder preventing anterior and superior translation of the humeral head. 3dditional factors affecting the glenohumeral stability are the negative intraarticular pressure created by the sealed compartment of the joint and the scapulothoracic motion maintains a normal glenohumeral function. Ra$i"gra!hic e%aluati"n The history and the physical e(amination are essential in the diagnosis of shoulder instability. o#ever there are several radiographic vie#s to assist in the diagnosis. ill-Sachs lesion is a Standard shoulder radiographs include anteroposterior vie# in neutral, internal and e(ternal rotation, lateral scapular vie# and a(illary vie#s. The posterolateral impression defect: can be visualize in the anteroposterior radiograph #ith the shoulder in internal rotation. $t signifies the multiple injuries to the posterolateral aspect of the humeral head indicate that this patient has multiple episodes of glenohumeral dislocation. 1o#e et al in !8'/
@

reported positive

ill-Sachs lesion in

''C of traumatic dislocations, 0;C in recurrent dislocations and 'DC sho#ed failure of surgical repair. $t sho#s that this defect signifies reduced stability of the glenohumeral joint. $n the a(illary vie#, glenoid fractures or deficiencies can be detected. >T scan of the shoulder is obtained to evaluate the bony anatomy, ho#ever in the identifying anterior labral pathology: an +1$ (+agnetic resonance imaging) is usually performed. The ill-Sachs lesion (Eig. &) is seen as an indentation of the humeral head and if the patient presents #ith a recent history of anterior instability, there may be high

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signal intensity in the cancellous bone surrounding the defect on T&-#eighted image. 0 3 5an,art lesion can be seen due to tear of the anterior capsulolabral comple( occurring #ith anterior dislocation of the shoulder. 3 bony or osseous 5an,art as seen in this patient signifies a fracture of the anterior part of the glenoid rim.0

Eig.&A Befect in posterolateral aspect of humeral head ( ill-Sachs lesion). Fhen shoulder is abducted and e(ternally rotated, this defect lies #ithin glenoid cavity and stability of joint is decreased .

1o#e and Garins !; classified the 5an,art lesions into three typesAType $ Type $$ Type $$$ avulsion of the capsule and cartilaginous labrum of the anterior part of the glenoid rim #ithH#ithout eburnation of the rim avulsion of the anterior part of the capsule, labrum and a fragment of the glenoid rim (less than !H/ #idth of the glenoid) as type $$ #ith fragment of glenoid rim greater than !H/ #idth of the glenoid.

N"n&"!erati%e Treat'ent 4on-operative management consists of closed reduction of the shoulder dislocation and follo#ed by a period of immobilization and subse"uently rehabilitative e(ercises. The period of immobilization of the shoulder remains a controversy. ovelius et al ! reported in patients less than && years old the recurrence of dislocation is nearly ?;C regardless of

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immobilization for three to four #ee,s or early mobilization as tolerated by patients. Similarly in the ages above &@ to 0; years old the recurrence #as at &?C. Yoneda et al and limited abduction e(ercise program for D #ee,s. <olloc, and 5igliani D advocated the period of immobilization of younger patients (less than @; years old) for three #ee,s #ith active e(ercises of the elbo#. $n older patients due to lo#er ris,s of recurrence and higher ris, of developing shoulder stiffness, a shorter period of immobilization is advocated. (less than ! #ee,) The goals of conservative treatment are to strengthen the dynamic stabilizers of the shoulder, to regain full range of motion and avoidance of provocation position of the shoulder. 5ur,head et al ' have outlined a simple e(ercise program using surgical tubing #ith varying resistance and #eight attached to a pulley. patients. Arthr"(c"!) The use of arthroscopic techni"ues in treatment of glenohumeral instability has been evolving besides its effective use as a diagnostic tool. Bebridement of labral flaps through arthroscopy has reported favorable results. (3ltche, et al)
/ ?

also reported a recurrence rate of !'C in patients treated #ith a ? #ee,s immobilization

They reported /;C of

atraumatic onset of instability had satisfactory results compared #ith !DC of traumatic

<atients develop

reduced pain and therefore #ill enable the patients to actively participate in the rehabilitation e(ercise programs. 3rthroscopic stabilization is done if detachment of the ligaments from the glenoid insertion is encountered i.e 5an,art lesion usually indicated in anterior instability and for inferior and multidirectional instability, open repair is recommended. Several methods have been described using staples, sutures and
/

biodegradable tac,s. 3ltche, et al

have reported e(cellent results #ith arthroscpic

stabilization using transglenoid suture techni"ue and biodegradable tac,s. +atthe#s et al8 reported the use of staple in repairs in sublu(ation and dislocation group has sho#ed e(cellent results in only D'C of cases #ith 0 out of D failure are the sublu(ation group. 1esults #ith arthroscopic staple capsulorraphy have been associated #ith high rates of failures and complications.

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O!erati%e treat'ent (O!en re!air# $ndications for surgery are based on the patient9s symptoms and disability. activity, presence of sublu(ation or apprehension. $t is dependant on the fre"uency of dislocations, reduction difficulty, age and patient9s $n younger patients healing of damaged glenohumeral structures is unreliable. $f the initial dislocation caused by a greater trauma, and #ith difficult reduction the rate of recurrence is lo#er compared to dislocation caused by a trivial trauma and easily reduced, in #hich the recurrence is higher. $f surgery is indicated, +atsen9s simplified classification of system of shoulder dislocation as: $ $$ T)5S (Traumatic, unidirectional, 5an,art Surgery) 3+51$$ (3traumatic, multidirectional, bilateral, rehabilitation, $nferior capsular shift and internal closure)

3traumatic instability is due to overuse as seen in athletes ma,ing repetitive overhead shoulder movements e.g javelin thro#ers, baseball pitchers. $n these athletes, repeated micro-trauma leading to la(ity of the capsule and presents as mechanical shoulder instability #ith no history of acute dislocation. 4umerous operative procedures have been described for the repair of the anterior glenohumeral instability #ith the goal of each operation is to prevent recurrent instability of the glenohumeral joint. The repair includes the 5an,art repair of detached glenoid labrum using sutures or staples (du Toit). 2ther methods of repair are by muscle transposition of the subscapularis (+agnuson-Stac,), shortening of the anterior capsule and subscapularis (<utti-<latt), transfer of the coracoid process to the anterior glenoid through subscapularis tendon (5risto#), osteotomy of the pro(imal humerus (Feber) or of the glenoid (+eyer-5urgdorff) and reconstruction of glenoid using fascia lata (6allie). The <utti-<latt and +agnuson-Stac, procedure are seldom used in vie# of the complications of limitation of e(ternal rotation and development of degenerative changes #ithin the glenohumeral joint. The 5risto# techni"ue also causes distortion of the

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normal anatomy of the shoulder.

Therefore the most common techni"ue of repair

currently being used is the 5an,art repair. 6ill et al !! conducted a study on the long term outcome of anterior glenohumeral instability using the 5an,art techni"ue of repair #ith a mean duration of follo#-up #as !!.8 years. They noted that 8@C had good or e(cellent results, 8/C of the patients return to their preoperative level of activity and 8DC stated that they #ould #ant the 5an,art procedure performed if they had the same problem again. The 5an,art repair can also be performed arthroscopically in #hich it has become increasingly popular as the treatment of glenohumeral instability. 3 comparison study #as done by >ole et al in &;;; findings at the time of surgery.
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reported that the arthroscopic repair and open repair

yields comparable results if the procedure #as selected on the basis of pathological

SUMMAR*

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The commonest form of shoulder instability is of the anterior glenohumeral instability and understanding the entity of this pathology continues to evolve. 3s patient demands increases and #ith the increase of sports related injury leading to glenohumeral instability, techni"ues of treatment need to be tailored to the needs of the individual patients. Treatment includes non-operative and operative depending on the severity of the instability. The 5an,art repair is the commonest type of repair #idely used either via open techni"ues or the arthroscopic techni"ues in #hich there are increasing interest in this method of repair. =ither operative or non-operative treatment, one of the important aspects of management is a strict rehabilitative program to prevent complications such as redislocation, stiffness and loss of function of the shoulder joint.

RE+ERENCE

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!. &. @. 0. ? D. '. /. 8. !;. !!.

ovelius %.A 3nterior dislocation of the shoulder in teenagers and young adults. 7 5one 7oint Surg. (3m) !8/'AD8-3A@8@-@88 o#ell S.+., and 6alinat 5.7.A The glenoid-labral soc,et. 3 constrained articular surface. >lin 2rthop. !8/8:&0@A!&&-!&?. 1o#e >.1., <atel B., Southmayd F.+.A The 5an,art <rocedure. 7 5one 7oint Surg. (3m) !8'/:D;-3:!-!D. erzog 1.7.A +agnetic resonance imaging of the shoulder. $nstr >ourse %ect. 7 5one 7oint Surg. (3m) !88':'8-3:8@0-?@ Yoneda 5., Felsh 1.<., +ac$ntosh B.%.A >onservative treatment of shoulder dislocation in young males.. 7 5one 7oint Surg. (5r) !8/&:D05:&?0-&??. <olloc, 1.6., 5igliani %.).A 6lenohumeral instabilityA =valuation and treatment. 7 3m 3cad 2rthop Surg !88@:!A&0-@&. 5ur,head F.G.7r., 1oc,#ood >.3.7r.A Treatment of instability of the shoulder #ith an e(ercise program. 7 5one 7oint Surg (3m) !88&:'03A/8;-/8D 3ltche, B.F., S,yhar +.7., Farren 1.E.A Shoulder arthroscopy for shoulder instability. $nstr >ourse %ect !8/8:@/A!/'-!8/. +atthe#s %.S., Ietter F.%., 2#eida S.7. et alA 3rthroscopic staple capsulorraphy for recurrent anterior shoulder instability. 3rthroscopy !8//:0A!;D-!!! 1o#e >.1., Garins 5.A 1eccurent transient sublu(ation of the shoulder. 7 5one 7oint Surg. (3m) !8/!:D@3A/D@-/'!. 6ill T.7., +icheli %.7., 6ebhard E., 5inder 5.3., >hristian 5.3.A 5an,art repair for anterior instability of the shoulder. %ong term outcome. 7 5one 7oint Surg (3m) !88':'83A/?;-/?'

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>ole 5.7., %9$nsalata 7.%., $rrgang 7., Farner 7.7.<.A >omparison of arthroscopic and open anterior shoulder stabilization. 7 5one 7oint Surg (3m) &;;;:/&3A!!;/!!;0