give complete information of shoulder dislocation ,types,risks fracture, different management methods and recent advanced .also include management merthod of posterior and inferior stability

1. SHOULDER
DISLOCATION
AND SURGICAL
MANAGEMENT
DR CHANDU
JUNIOR RESIDENT OF ORTHOPEDICS JIPMER,PUDDUCHERRY

2. OBJECTIVES
• INTRODUCTION
• SURGICAL ANATOMY AND SHOULDER STABILITY
• TYPES OF DISLOCATION
• MANAGEMENT
• RECENT CONCEPT
• TAKE HOME MESSAGE

3. INTRODUCTION
• One of most unstable and frequently dislocated joint in body
• 50% of all dislocation
• Recurrent dislocation rate is very high ,near 100% in skeletally immature athletes
• > 90% in < 20 yr age
• 60% in 20-40 yr old
• > 10 % in patient > 40 yr after 1 st episode of dislocation

4. • Laxity – Incomplete loss of glenohumeral articulation unassociated
with pain
• Subluxation – Partial loss of glenohumeral articulation with
symptoms
• Dislocation- Complete loss of glenohumeral articulation

5. ANATOMY

7. SHOULDER JOINT
STABILIZERS
STATIC STABILIZERS :
Bone shape –shallow concave surface of glenoid
Labrum – fibrocartilaginous rim markedly increase
glenoid depth.
Joint capsule – anterior casule act as restraint to
terminal external rotation.
Capsular ligaments –thickening of capsule as
superior, middle and inferior glenohumeral
ligaments .
Vaccum effect : this is produced by the intact
closed joint, 42 cm H2O in cadavers
Second next to high osmotic pressure in interstitial
tissues
Only significant in arm in rest and adduction
Lost with lax capsule and defect

8. DYNAMIC STABILIZERS
Rotator cuff muscles :
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Long head of bicep brachi
Latssimus and pectoralis major muscle

9. CLASSIFICATION

10. ANTERIOR DISLOACTION
MOST COMMON TYPE
96% OF TOTAL SHOULDER DISLOCATION
Posterior dislocation - 2–4%, while inferior
dislocation is reported as low as 0.5%.

11. TREATMENT : CLOSED /OPEN REDUCTION

12. FACTORS LEADING TO RECURRENT DISLOCATION
• AGE
• RETURN TO CONTACT /COLLISION SPORTS
• HPERLAXISITY
• PRESENCE OF SIGNIFICANT BONY DEFECT IN GLENOID OR HUMERAL HEAD
• IN PATIENT WITH PRIMARY NEUROMUSCULAR DISORDERS

13. MASTEN’S CLASSIFICATION SYSTEM
• INSTABILITY : categorized as unidirectional , bidirectional or multi direction
• Masten’s simplified classification in 2 insatiability patterns
• TUBS ( traumatic, unidirectional , Bankart surgery)
• AMBRII (atraumatic ,multidirectional ,bilateral , rehabilitation, inferior capsular
shift and internal closure)

14. • Stanmore classification
-is a triangular model with three polar types.
• Type I is traumatic and structural (resembling TUBS),
• Type II is atraumatic structural (resembling AMBRI),
• Type III is muscle patterning nonstructural instability.
• The highlight of this classification is that it incorporates
muscle patterning as a distinguished problem.

16. • Gerber and Nyffeler
• class A (static instability),
• class B (dynamic instability),
• class C (voluntary dislocators).
Class B -the young and active population that are
seen every day in the clinic where a certain
degree of trauma has been involved.

17. BANKART LESION
Bone loss of the glenoid is known as a Bony
Bankart lesion. 80% of patients with anterior
instability have both Hill-Sachs and glenoid bone
lesions, called a ‘bipolar lesion’.

18. Bankart-lesions and variants like Perthes and ALPSA are injuries to the anteroinferior
labrum.
These injuries are always located in the 3-6 o'clock position because they are caused
by an anterior-inferior dislocation.
The only exception to this rule is the reverse Bankart(6-9 o’oclock), which is the result
of a posterior dislocation and injury to the inferoposterior labrum.
Bankart tears may extend to superior, but this is uncommon.
ALPSA = Anterior Labral Periosteal Sleeve Avulsion.
Medially displaced labroligamentous complex with absence of the labrum on the
glenoid rim.
GLAD = GlenoLabral Articular Disruption.
Represents a partial tear of anteroinferior labrum with adjacent cartilage damage.

20. HILLSACK LESION
Bone loss of the humeral head is known as a Hill-Sachs
lesion (HSL). This is a compression fracture of the
humeral head caused by the anterior rim of the glenoid
when the humeral head is dislocated anteriorly in front
of the glenoid (The humeral head is softer than the
glenoid). HSLs are seen after two thirds of initial
dislocations and 90% of recurrent dislocations.

21. GLENOID TRACK ,ON TRACK /OF TRACK LESION
• For the purpose of evaluating the size of the Hill-Sachs lesion
together with the size of the glenoid, new concept was introduced :
the glenoid track (ETOI et al)
The glenoid track is a contact zone of the glenoid on the humeral
head with the arm at the end range of motion, e.g., in various degrees
of elevation with the arm in maximum external rotation and
maximum horizontal extension.

23. • CADAVERIC STUDY
• As the arm was elevated along
the end range of motion, the
glenoid moved from inferomedial
to superolateral portion of the
humeral head, along the
posterior margin of the articular
surface of the humeral head .
During this movement, the
glenoid created a zone of contact
with the humeral head This zone
of contact is the glenoid
track.

24. • If the Hill-Sachs lesion is always
covered by the glenoid at this end
range of motion, or in other
words, if the Hill-Sachs lesion
stays within the glenoid track, the
lesion does no harm, because it is
always covered by the glenoid
even at the end range of motion.
On the other hand, if the lesion
comes out of the glenoid
coverage, it engages with the
anterior rim of the glenoid and
causes a dislocation.

26. CALCULATIONS

30. CHARECTERICS OF IDEAL PROCEDURE FOR RECURRENT
INSTABILITY
• Low recurrence rate
• Low complication rate
• Low reoperation rate
• Doesn’t harm (arthritis)
• Maintain motion
• Is applicable in most cases
• Allows observation of joints
• Correct pathological conditions
• Is not too difficult

31. SURGICAL OPTIONS
• Traumatic Bankart : Jobe capsulolabral reconstruction
• Acute bony Bankart : Screw or anchor fixation (+ Hyperlaxity- Rotator interval closure)
• HAGL(Humeral avulsion glenohumeral ligament ) : Suture anchor repair
• MULTIDIRECTIONAL : REPAIR BANKART/KIM LESIONS
Anteroinferior prominent : Humeral side Neer capsular shift
Posterior prominent— glenoid side Glenoid side shift
• BONE LOSS—GLENOID
• Erosional bone loss >25% : Laterjet procedure
• Erosional bone loss >40% : Eden-Hybinette procedure

32. • BONE LOSS—HUMERAL HEAD
20% + glenoid defect : Jobe capsular reconstruction + capsular shift + remplissage
25% (6 mm deep) : Remplissage
40% Laterjet to increase glenoid rotational arc
BONE LOSS—ANTERIOR HUMERAL HEAD
>30% : McLaughlin
Capsular deficiency : Achilles allograft capsular reinforcement

33. BANKART REPAIR
(ARTHROSCOPY )
Indications
• first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than
25 years of age
• high demand athletes
• recurrent dislocation/subluxation (> one dislocation) following nonoperative management
• < 20-25% glenoid bone loss
• remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track"

34. techniques
• at least three (preferably four) anchor points shoulder be used
• paramount that labrum is fully mobilized prior to repair
outcomes
• results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
• increased failure rates seen in patients with global hyperlaxity, glenoid bone loss, or too few fixation points
• too many anchors does pose a risk for fracture through the anchor holes (postage stamp fracture)

35. BANKART REPAIR
(OPEN )
• Indications
often employed in the setting of failed arthroscopic stabilization
some surgeons prefer an open procedure if the patient is found to have a HAGL lesion
• approach :shoulder anterior (deltopectoral) approach
Technique
• subscapularis transverse split or tenotomy
• open labral repair and capsulorraphy
• capsular shift
• inferior capsule is shifted superiorly

36. COMPLICATIONS
• Recurrence : most often due to unrecognized glenoid bone loss
• subscapularis injury or failed repair : post-operative physical exam will show a positive lift off and excessive ER
• stiffness :
caused by overtightening of capsule
leads to loss of external rotation
treat with Z lengthening of subscapularis
• axillary nerve injury :
iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure)
• Arthritis:
usually wear of posterior glenoid
may have internal rotation contracture
seen with Putti-Platt and Magnuson-Stack procedures

37. 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 of the original procedure is its technical difficulty

38. SUBSCAPULARIS SPLIT

39. Montgomery and Jobe technique

40. INSTABILITY SEVERITY INDEX
SCORE
An acceptable recurrence risk of 10% with arthroscopic
stabilization.
< 6 points
A score of > 6 points has an unacceptable recurrence risk of
70% and should be advised to undergo open surgery (i.e.
Laterjet procedure).
> 6 points

41. LATARJET OR BRISTOW PROCEDURE
• indications
vary on geographic region
European surgeons aggressively employ the latarjet
young, high-demand contact athletes or athletes of consequence (mountain climbers, big wave surfers)
anterior instability with critical (>20-25%) or subcritical (>13.5%) bone loss
patients at high-risk of failure with soft-tissue procedures alone (ISIS > 4-6 points)
• approach
shoulder anterior (deltopectoral) approach
can be performed arthroscopically

42. TECHNIQUE
coracoid transfer to anterior inferior glenoid bone defect:
traditional or congruent arc technique
• after harvest, coracoid is passed through a split in the distal 1/3 or middle 1/2 subscapularis
• in the congruent arc technique, the undersurface of the coracoid ends up articulating with the humeral head
• congruent arc technique lengthens glenoid track more than traditional
• congruent arc technique lengthens glenoid track approximately 15 mm
• graft can be placed intraarticularly (capsular repaired to CA ligament stump) or extraarticular (capsule repaired to native glenoid rim)
• concerns exist for increased rates of subsequent osteoarthritis with intraarticular placement
• no difference in outcomes between open and arthroscopic procedures,( although literature has identified a profound learning curve for the arthroscopic latarjet )
• Lafosse and Boyle et al,- arthroscopic Latarjet procedure, with same as the open technique, with a reported recurrence rate
between 2–4.9% and a 98% satisfaction index

44. COMPLICATIONS
• generally higher than arthroscopic or open Bankar( up to 25% incidence of complications)
• Nonunion
• graft lysis :
up to 90% of patients undergo some degree of resorption within the first six months
hardware problems : stiffness, particularly in external rotation
• glenohumeral osteoarthritis
will rapidly occur with lateral overhang of graft into the joint space
occurs in up to 38% of patients

45. • nerve injury
• majority are traction or contusion neuropraxias and resolve spontaneously
• treat with observation for 3-6 weeks; delayed EMG if deficits persist
• musculocutaneous nerve
occurs during instrumentation around the conjoint tendon
pieces conjoint tendon, on average, 5.6 cm distally to the tip of the coracoid
• axillary nerve
occurs during graft fixation
located, on average, 12mm from infra-glenoid tubercle
• vascular injury
axillary artery
runs 1-2 cm from inferior glenoid on average
can get as close as 4-5mm to inferior glenoid with arm at 90° external rotation

46. EDEN HYBINETTE PROCEDURE
INDICATIONS
• area of research
• ideal patient for latarjet versus bone block is yet to be identified
• indications similar to those of latarjet
critical or subcritical glenoid bone loss
patients at high risk of failure with soft-tissue procedures alone
loss graft resoprtion overall when compared to latarjet
can be used to revise a failed latarjet
Glenoid bone loss approaching 40% of the anterior glenoid or posterior bone loss of 25% with recurrent posterior
dislocation

47. • approach
shoulder anterior (deltopectoral) approach
arthroscopic
• technique
can use iliac crest( most common) , medial aspect of acromion , lateral aspect of distal tibia, allograft glenoid or allograft distal tibia.
can secure with screws or buttons
• complications
hardware failure
subscapularis repair failure

48. • Suture-button Eden Hybinette technique :
• Through rotator interval
• Using a posterior drill guide system ,
• Accurate drill tunnel placement
• Both open and arthroscopically
• has the advantage over both an open and arthroscopic Latarjet
procedure as,
- flexibility of sutures,
- purely intra-articular procedure through the rotator interval without
without compromising subscapularis.

49. SUTURE-BUTTON EDEN-HYBINETTE

50. MULTIDIRECTIONAL INSTABILITY OF THE SHOULDER
• Neer and Foster introduced the term multidirectional instability in 1980.
• The primary abnormality in multidirectional instability is a loose, redundant
inferior pouch.
• It is important to distinguish multidirectional instability from routine
unidirectional dislocation because the former problem is not correctable by
standard repairs.
• Surgery in these patients is not indicated unless disability is frequent and
significant, an adequate trial of conservative treatment emphasizing muscular and
rotator cuff rehabilitative exercises has failed, and the patient is not a voluntary
dislocator

51. CAPSULAR SHIFT
• The principle of the procedure is to detach the capsule from the neck of the humerus and shift it to the opposite side
of the calcar (inferior portion of the neck of the humerus), not only to obliterate the inferior pouch and capsular
redundancy on the side of the surgical approach but also to reduce laxity on the opposite side.
• To reduce inferior laxity with the arm in 0 degrees of abduction, closure of the rotator interval is indicated.
• Internal closure also has been shown to decrease posterior translation.
• The approach can be anterior or posterior depending on the direction of greatest instability.
• When the findings include a 3+ sulcus sign and symptoms related to inferior instability, associated with anterior or
posterior instability, an anterior capsular shift and closure of the rotator interval allow better correction of inferior
laxity.
• If the finding is posterior instability with a 1+ to 2+ sulcus sign and only mild inferior symptoms, a posterior capsular
procedure is indicated.

53. • Remplissage procedure:
Arthroscopic posterior capsulodesis
Infraspinatus tenodesis to fill the Hill-Sachs lesion
Arthroscopic Bankart repair.

56. POSTERIOR INSTABILITY OF THE SHOULDER
• The initial treatment of posterior shoulder instability should be nonoperative.
• If at least 4 to 6 months of an appropriate rehabilitation program has failed, if
habitual dislocation has been ruled out, and if the patient is emotionally stable,
surgery may be indicated if the pain and instability preclude adequate function of
the involved shouider.
• various types of procedures have been proposed to correct posterior instability,
including soft-tissue procedures such as
• the “reverse” Bankart and Putti-Platt procedures, muscle transfers and
capsulorrhaphies, bone blocks, and glenoid osteotomies.

57. • most successful is the inferior capsular shift procedure through a posterior
approach. preferly either the capsular shift technique of Tibone or that of Neer
and Foster
• An athlete with recurrent posterior subluxation who requires overhead
movement, prefer method is the muscle-splitting technique with medial shift as
described by Tibone et al.
• The technique described by Hawkins and Janda is best reserved for a laborer or
an athlete involved in contact sports, such as football or ice hockey.

58. NEER INFERIOR CAPSULAR SHIFT PROCEDURE
THROUGH A POSTERIOR APPROACH

60. TIBONE AND
BRADLEY
TECHNIQUE

61. CAPSULAR SHIFT RECONSTRUCTION WITH
POSTERIOR GLENOID OSTEOTOMY
• Posterior glenoplasty rarely is indicated.
• a it can be used if severe developmental or traumatic glenoid retroversion of
more than 20 degrees is confirmed on CT reconstructed films.
• High recurrence rates of up to 53% have been reported with this procedure.
• complication rate of upto 29%, including osteonecrosis of the glenoid and
degenerative arthritis of the glenohumeral joint. similar but simpler procedure
using a glenoid osteotomy is preferred for severe glenoid dysplasia, whether
traumatic or congenital

62. ROCKWOO
D
TECHNIQUE

63. MCLAUGHLIN PROCEDURE
• For recurrent posterior dislocation associated with a large anterior medial Hill-Sachs
lesion,
• 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.
• In a rare reverse Hill-Sachs lesion with involvement of 20% to 25% of the articular
surface, transfer of the subscapularis with the tuberosity placed into the defect has
been shown to produce satisfactory results in moderate-size defects.
• also, allografts in case reports involving larger lesions have provided satisfactory

64. Neer and Foster modification of
McLaughlin technique
McLaughlin technique

65. 3D printing in the treatment of
glenohumeral instability
• Surgeons are used to working with X-rays, 2D CT scans , and
magnetic resonance images to evaluate patients’ anatomy.
• With emerging 3D renderings improve the diagnostic of some
pathologies and deformities
• .

66. • They allow the surgeon to define the optimal implant location better
and accurately execute the surgical plan decreasing errors related to
implant malposition .
• Three-dimensional printing will undoubtedly become an essential
tool to achieve the best results in glenohumeral instability surgery.

67. 3D PRINTED MODEL OF A HUMERAL HEAD DEFECT

68. 3D PRINTED MODEL OF A GLENOID WITH THE
LOCATION FOR SCREWS AND A 3D PRINTED
MODEL OF A PATIENT-SPECIFIC GUIDE TO
POSITION THE SCREW

69. REFERENCES
• 1. Moya D, Aydin N, Yamamoto N, Simone JP, Robles PP, Tytherleigh-Strong G, et al. Current concepts in anterior glenohumeral
instability: diagnosis and treatment. SICOT-J. 2021;7:48.
• 2. DeFroda SF, Perry AK, Bodendorfer BM, Verma NN. Evolving Concepts in the Management of
Shoulder Instability. Indian J Orthop. 2021 Apr;55(2):285.
• 3. S B, P C, Ma Z, L N, Wg B. Current concepts in chronic traumatic anterior shoulder instability. EFORT Open Rev [Internet]. 2023
Jun 8 [cited 2024 May 8];8(6). Available from: https://pubmed.ncbi.nlm.nih.gov/37289134/
• 4. Zj H, Em N, L K, Rp R, M C, Jd H, et al. Bipolar bone loss and distance to dislocation. Ann Jt [Internet]. 2024 Jan 5 [cited 2024
May 7];9. Available from: https://pubmed.ncbi.nlm.nih.gov/38529290/
• 5 Campbell 14th edition

70. • Thanks

71. THANKS !!!