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Recurrent shoulder dislocation treatments

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Recurrent shoulder dislocation treatments

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Recurrent shoulder dislocation treatments

Nonsurgical treatment of recurrent shoulder dislocation

Generally, after an initial dislocation in a young subject, conservative treatment (immobilization for a few weeks followed by physiotherapy) is sufficient, although it is worth keeping in mind that dislocation in a patient under the age of 20 carries a 90% risk that it will recur in the future.

In people over 25 years of age, short-term immobilization and physiotherapy can be started rapidly.

In subjects over 45 years of age, if muscle weakness is noted after the shoulder has been repositioned, urgent investigation by MRI or ultrasound is important to ensure that the rotator cuff has not been torn (in patients over 45, the tendon is weaker and more brittle, and dislocation can cause a tear.) Tears of this kind are easily overlooked in emergency treatment and a major cuff tear will require prompt surgery.

For a dislocation caused by a trauma (a fall or accident), the axillary (or circumflex) nerve that travels through the deltoid muscle may be stretched, resulting in loss of strength. The nerve usually heals on its own over a period of several days to six months (in 90% of cases). Nerve study (EMG) is usually prescribed 3 months after injury to confirm the diagnosis and monitor the recovery.

If the dislocation occurred without a trauma – for example, during a normal movement or while sleeping – and the patient has abnormally loose ligaments (a structural issue), the usual treatment is intensive physiotherapy for as long as several months. The aim is to restore muscular stability to compensate for capsule/ligament insufficiency.

Surgical treatment of recurrent glenohumeral dislocation

The goal is to reconstruct the anatomy as it was before the first dislocation. The nature of the injury will already have been diagnosed by CT arthrography, MRI or, better still, MR arthrography.
The decision for or against surgery in recuring cases of dislocation must consider several factors:

  • Studies done over several years have shown that subjects who waited the longest before opting for surgery had a higher incidence of early osteoarthritis.
  • It would appear that more frequent recurrent dislocations lead to greater damage and increase the severity of osteoarthritis over time.

As such, it is preferable to repair the instability before the shoulder condition worsens. For a first-time surgery, if bone damage isn’t extensive, I prefer the arthroscopic approach. The procedure involves the repair or reinsertion of the capsulolabral complex and, in some cases, capsular “plication.” Usually, small implants are inserted in the glenoid (shoulder blade) to anchor the labrum or capsule in the bone structure. In the event of a defect in the humeral head (Hill-Sachs lesion), the gap is “filled” by connecting the tendon of the adjacent rotator cuff (the “remplissage technique”).

Glenoid repair or bone grafts

I use the open approach for bone repair or bone grafts and in cases where the condition has recurred after arthroscopic repair.
The open approach has a higher rate of complications (mainly neurological), as it causes more scarring, further solidifies the “anterior wall” of the shoulder and often results in loss of movement and an increased risk of developing osteoarthritis.

  • The open approach has a success rate of close to 95%.

If a large bone fragment has separated from the glenoid (scapula), reattachment of the fragment or a bone graft will be necessary (Latarjet or Bristow procedure). This is a more complex procedure than a basic labrum repair.

In cases of ligament tear or detached labrum and no bone breakage, surgical repair can be open or arthroscopic. Each has arguments in its favour, and should be discussed with the surgeon, who will base the decision on a physical exam, X-rays, and the specialist’s opinion.

Reconstruction of the anatomy

The procedure, which is a reconstruction of the anatomy as it was before the initial dislocation, may be performed under locoregional (which I prefer) or general anesthesia.

  • The procedure takes 30 to 90 minutes.
  • The patient can leave the clinic within a few hours of the surgery.
  • The surgeon determines the immobilization period (usually, 2-4 weeks) and the physiotherapy program.
  • Complete healing usually takes 4 -6 months.
  • The long-term success rate is 85 to 90% and range of motion is gradually restored until it returns to normal.

Ligament hyperlaxity

In cases of ligament hyperlaxity without tissue damage, surgery may be open or arthroscopic. However, surgery is rarely necessary, since nonsurgical treatment is effective in almost 90% of patients if followed for six consecutive months. The success rate of open and arthroscopic surgery is lower, since the capsule and ligaments tend to stretch again over time.

Posterior dislocations

Posterior dislocations are much rarer and their treatment is a posterior version of the treatment for anterior dislocation. It should be noted that when posterior dislocation occurs as a result of a seizure, electric shock or acute state of inebriation, there is often destruction of the humeral head as well, which could require prosthetic replacement. A CT scan is always recommended in these situations.

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