Shoulder Dislocation

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With trauma to the shoulder the joint may dislocate, and this is the most commonly dislocated joint in the body (also the joint in the body that has the most amount of range of motion).  Most commonly the shoulder dislocates anteriorly.  When this happens, the anatomy of the shoulder is disrupted.  The labrum, which acts like a bumper to the glenoid (cup of the shoulder), may tear predisposing the shoulder to recurrent instability. While anterior shoulder dislocations are definitely much more common than posterior shoulder instability (somewhere between 90% of dislocations will be anterior), posterior dislocations can still occur and a lot of the treatment principles are similar.  Posterior shoulder dislocations are commonly associated with seizures and possibly electrocution.  This is because the force required to dislocate posteriorly is much more than anteriorly, so stronger muscle contractions must occur for this to happen which can occur with seizure activity or electrocution.    

Probably even more common than a real pure shoulder dislocation, is something called a shoulder subluxation.  This occurs when the shoulder just reaches the edge of cup, and rather than dislocating completely, it clicks back into the shoulder.  This can have deleterious effects on the shoulder as well, although usually shoulder subluxators will have gone through several more instability events than a pure dislocating patient might. These can be rehabilitated with some strengthening of some shoulder muscles, and if indicated can be treated with a type of shoulder dislocation surgery called arthroscopy where most likely the labrum of the glenoid would be repaired.  Some of the shoulder’s capsule can be tucked in as well, which can help to destabilize the shoulder.  This is called a capsulorrhaphy which is literally just sewing a portion of the capsule to the labrum.

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Treatment may be non-operative depending on treatment goals. If the recurrence of shoulder instability is a low level concern, it is likely that surgery is not going to be indicated.  The risk of recurrence is the highest the younger a patient is when they dislocate.  So teenagers are most likely (greater than 90%) to develop a shoulder that recurrently dislocates.  A 60 or 70 year old patient is much less likely and therefore may not care as much.  

Furthermore, while the pain may quickly fade from a dislocation, the event in itself is not at all benign (which is why a lot of people move on to not have any surgical treatment because the pain fades relatively quickly, and therefore they forget or block out their problem…until they dislocate again).  One dislocation event can predispose a patient to an increased risk of developing an arthritic shoulder later in life, and this risk of arthritis increases with the higher number of dislocations.  Couple this with an increased risk of recurrence after a single dislocation in a younger person, and this can quickly develop into a problem.  The pendulum in the United States has started to swing towards aggressive early treatment of these conditions to insure better shoulder health in the future with less risk of recurrence of instability.

Shoulder dislocation surgery, also known as arthroscopic surgery may be indicated depending on some variables.  In operative cases, there are many stabilization procedures with advocates for each.  A simple bankart repair may be indicated depending on activity level and age of the patient.  Certain surgeons may advocate doing this with open surgery rather than arthroscopically, due to a perceived decreased failure (redislocation) rate.  The literature demonstrates both approaches to be equivocal, however, given the less invasive nature of it, Dr. Schwartz prefers to treat these conditions arthroscopically.  The recurrence rate can be expected to be 10-20% after a bankart repair, even in the best hands in the entire world.  Other surgical procedures have been developed to help decrease recurrence rates.  

Unlike nearly any other surgeon in the United States, I have spent a year training in France with Drs. Laurent Lafosse and Pascal Boileau whom have both redefined how this problem is treated. 

Recurrence rates fall into the single digits with boney transfer ( a coracoid process transfer ) or the so called Latarjet procedure.  While in France, I learned how to do this arthroscopically and now do it regularly in my practice.  I prefer to use this procedure when glenoid bone loss has occurred.  Additionally, another procedure may be indicated where I tuck in a part of the rotator cuff tendon into the impression fracture (Hill-Sachs remplissage) and may be indicated when a large Hill-Sachs lesion (a dent in the humeral head, or ball portion of the ball and socket type joint) is present.  Sometimes even a combination of procedures is indicated to restabilize the shoulder.  

Regardless, I believe the treatment decisions for shoulder dislocation surgery to be complex – patient expectations, patient activity levels, and patient anatomy all play a role – and am uniquely positioned to provide expertise to my patients drawing on a surgical experience that is unparalleled.