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Dislocated Shoulders
Shoulder Dislocations are a common problem. 90% of the time the shoulder dislocates anteriorly (in front). This is often seen after falls, motor vehicle accidents and sporting injuries. In 10 % of patients, the shoulder dislocates posteriorly (at the back), mostly due to epileptic seizures and electric shocks. Our Orthopedicians in Baner, Pune are experts in treating such cases with efficiency.
Recurrence of shoulder dislocation can arise due to another injury to the injured shoulder, neglected or inadequate treatment after initial shoulder dislocation and ignorance about the seriousness of the first dislocation. The recurrence rate is high if
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Patients are younger than 20 years of age
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Have generalized ligamentous hyperlaxity
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Have had a bad fall
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Involved in contact sports or repeated overhead activities
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Having bony lesions (defects) of the glenoid (socket) or the humeral head (ball)
Younger patients tend to have higher recurrence rates and shorter intervals between the initial injury and recurrent instability. Chronic shoulder instability eventually leads to degenerative shoulder arthritis.
For the best possible outcomes after shoulder instability episodes, proper shoulder x-rays, MRI scans and CT with 3-D reconstruction scans are needed. These essential investigations help the clinicians thoroughly understand the dynamics of the damage caused to the shoulder joint by repeated episodes of shoulder instability. This knowledge helps them plan the best possible line of management for their patient and provide them with a stable shoulder.
The essential lesion seen after a traumatic shoulder dislocation is called the Bankart lesion. It is the detachment of the labrum, a stabilizing soft tissue ring from the front of the glenoid. There may be a bony piece detached from the labrum (Bony Bankart). There is also stretching of the shoulder joint capsule and its tough ligaments. This is akin to loosening an elastic band. The impact of the humeral head with the glenoid also causes varying depth and width of defects in the humeral head. This is called as Hill-Sach’s lesion. All these lesions must be taken into account when planning for surgical management of recurrent shoulder instability.
In repeated shoulder instability the CT scans help in quantifying the bony defects of the glenoid as well as the humeral head. The front rim of the glenoid is routinely eroded. After comparing the lower glenoid diameter with the normal side, the percentage of glenoid wear on the affected side is calculated by the CT scan using various techniques.
Studies have shown that glenoid rim loss of under 15 % can be successfully managed with routine soft tissue arthroscopic surgery to reposition the detached labrum and re-tension the stretched-out capsular ligaments in the front (Arthroscopic Bankart Repair). Special small size suture anchors (3 to 4 in number) are used for this procedure. This centralizes the humeral head over the glenoid and has a success rate is 90-95 %. Patients can return to sports after 4 to 6 months.
For patients with glenoid bone loss of more than 15 % and have other risk factors like young age, ligamentous hyperlaxity and demanding activities, a bone reconstruction type surgery is needed. Here the area of the glenoid wear is filled up with a block of extra bone with or without attached soft tissues. 2 screws are used to fix this bone to the glenoid socket which widens its arc and creates an additional soft tissue sling to prevent shoulder dislocations. This surgery is called the Latarjet procedure and can be done by mini-open as well as arthroscopic technique.
In those patients, where there is a substantial Hill- Sach’s lesion, additional procedures are warranted. If the Hill Sach’s lesion is seen to be engaging and levering on the edge of the glenoid with the arm in the overhead position, then a surgery called the Remplissage procedure is performed arthroscopically. Herein a part of the shoulder rotator cuff is filled into the humeral head defect with suture anchors to prevent it from engaging on the edge of the glenoid and levering out of the shoulder joint. Massive size defects however need filling up with osteochondral allograft or metallic caps to match the defect circumference.
Recurrent shoulder instability is easily manageable with arthroscopic surgeries if timely surgical treatment and subsequent shoulder rehabilitation are done. Manipal Hospitals at Baner has the best setup and arguably the best orthopedic hospital in Pune for dealing with such complex patients.
Department of Orthopaedics
Manipal Hospitals, Baner, Pune
