1. Acute anterior dislocation of the shoulder

2. Anatomy Stability: - ball & socket = compression in concavity effect
Bone big head – small cup
= unstable
Menisci labium
= ↑ depth of cup by 20%
Ligaments glenohumeral & capsule
Muscles rotator cuff & biceps = holds ball in cup
Primary Movers - Deltoid, Pec. major & Lat. Dorsy
= subluxing forces
Dynamic proprioceptive feedback

3. Pathophysiology (Lazarus 1996)
Chondro-labral defect causes a 65% reduction in stability in the direction of the defect
Deficiency of the ant. inf. capsulolabral complex
Fracture of ant. lip of glenoid = 15%
Detachment of labarum/capsule = 15%
Tear of glenohumeral ligaments = 54%
Avulsion of subscapularis and ligs of humerus (HAGL)
To prevent the persistence of the defect it needs to be repaired
Arthroscopically Open

4. Acute Injury
Something breaks or tears and therefore can be repaired.
Repair is better than reconstruct
Repair is easier than reconstruct
Chronic
Instability has additional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortened
Restoring the normal functional anatomy is impossible

5. Conservative Treatment Rowe – JBJS, 1957
324 young patient with ant. dislocations
94% had recurrence if < 20 years old
62% had recurrence if < 30 years old
14% had recurrence if > 40 years old
Burkhead & Rockwood (text book)
40 patients with acute dislocation & vigorous rehabilitation
Only 16% had good or excellent result (1 in 6)
Deny & Drew – Injury, November 2002
21% of all patients presenting with shoulder dislocation had previous dislocation in 1 year
43% in patients years had re-dislocations

6. Non operative treatment of shoulder dislocation in young athletes
Arciera – J Arthroscopy, 1995
De Beardino – J South Orthopaedic Ass, 1996
Haelen – J Arch Orthopaedic Trauma Surgery, 1990
Hovelius – J Orthopaedic Science, 1999
Wheeler – J Arthroscopy, 1998
Kirkby – J Arthroscopy, 1999
all over 80% recurrence rate
Non operative treatment is unacceptable

7. Prospective Randomised Study
Bottani etc.–Military Personnel Medicine Vol 30 No
First Time Acute Traumatic Shoulder Dislocation
Stabilisation V’s Non Operative:
Follow up in 36 months
24 patients aged 18-26y.
14 Non Operative – rehab immobilised 4 weeks
9 of 12 non operative had instability (75%) (6 open Bankart repair)
10 ASC Bankart repair with bioabsorbable tack <10 days
1 of 9 operated patients had instability (11%)

8. Chronic anterior instability
Comparison of Arthroscopic & Open Stabilisation
Sample Size Follow Up Recurrence
ASC Open ASC Open ASC Open
Steinbeck
Field
Cole
Hayes etc
Conclusion
Arthroscopic repair for chronic instability is inferior to open repair
? Due to plastic deformation

9. Arthroscopic Techniques for Primary Dislocations
1982 Johusa – with staples
1987 Morgen & Badenstab – transglenoid sutures
1991 Caspari -Cannulated bio-absorbable tacks
1993 Wolf & Snyder – suture anchors = difficult
1989 Wheller - ASC staple
1993 Gohlke - Suture anchors
1994 Arciera - ASC transglenoid
1996 Speer - Bio-absorbable tack
1999 Wintzell - ASC lavage
2000 Introduction of a multitude of new gadgets & anchors

10. Arthroscopic Repairs Einoder, 1984 Knee Club Results
Described Arthroscopic transglenoid sutures using:
K wire with eye (ACL) introduced via anterior portal
Sucking tube
Sutures tied over infraspinatus fascia or spine of scapula
Results
4 out 5 patients returned to the same level of sport with no re-dislocations

11. Arthroscopic Repair

14. Boszotta & Helperstorfer – Arthroscopy, July 2000
Transglenoid suture repair for initial Ant. dislocation
72 patients ( )
61 ♂ 11 ♀ Aged 19-39
34% = Bankart lesion (6 with bone)
66% = Avulsion of capsulolabral complex
Results
7% = Redislocation all due to trauma (severe in 2 out of 5)
85% = Returned to unrestricted pre injury sporting activities

15. Asc. Stabilisation V’s Non Operative
Randomised Studies
Asc. Stabilisation V’s Non Operative
Arciera et. al. – A.J. Sports Med., 1994
32 military men with acute 1st up dislocation, Average of 32 months follow up
15 patients – non operative – 80% redislocated
21 patients – transglenoid suture – 14% redislocated
Bottony & Wilkings etc. A.J. Sports Medicine 2000
Patients with acute traumatic first time shoulder dislocation
14 young patients – non op, 75% redislocation
10 young patients – Asc. Bankart repair, 10% redislocation

16. Dara & Gerber – Journal of Shoulder & Elbow, 2000 20 shoulders
Asc. stabilisation
Dara & Gerber – Journal of Shoulder & Elbow, 2000
20 shoulders
Av 3 year follow up
Recurrences occurred in patients who were chronic dislocators i.e. <30%
Therefore now
do open surgery for recurrent dislocations
Asc. surgery for acute dislocations
De Beardino et al – An J. Sports Med., 2000
49 1st up acute post traumatic Shoulders dislocation
Average 37 months follow up
Tack anchor.
6 Patients re-dislocated (13%) +4 had open surgery

17. Arthroscopic Transglenoid Suture Repair
Bozzotta & Helpastorger (Austria) – J. Arthroscopy, 2000
Arthroscopic Transglenoid Suture Repair
for Initial Ant. Shoulder Dislocation
72 Patients 61♂ 11♀ - Sporting ambitious patients
25 Patients Bankart lesion (6 with bone)
43 Patients Capsulolabral avulsion
Results
5 patients Re dislocated
2 had significant trauma
3 had insignificant trauma = 4%
Therefore results of primary repair are better than surgery for recurrent dislocation
But transgleniod repairs are obsolete

18. Against …Arthroscopic Repair
Roberts, Taylor, Brown, Hayes, Saies (Adelaide)
Journal of Shoulder & Elbow, September 1999
56 acute 1st up shoulder dislocations
2½ year post operative and return to Australian Rules Football
Operations:
Asc. suture repair – 70% recurrence
Asc. Bankart repair with tack – 38% recurrence,..
Open repair & copsular shift – 30% recurrence
Therefore Asc. treatment alone not good enough

19. Cole & Warner – Clinical Sports Medicine 2000
Arthroscopic V’s Open Bankart Repair
For Traumatic Anterior Shoulder Instability
% Asc. treatment modalities are increasing due to:
Better understanding of the pathophysiology
Better pre operative evaluation of the injury (i.e. patient selection)
New surgical techniques
Better instrumentation
Better anchors

20. Protocol for Acute Repair
Mature & active person
15 to 50 years old
First episode of glenohumeral dislocation
Reduced on field, first aid, club Dr or DEM
Examination & X-ray
Informed consent – time off work - outcome
Examination under GA
ASC of glenohumeral joint, check rotator cuff as well
Acute repair of all demonstrable tears or fractures
 restore normal anatomy
Rehab activity – collar & cuff, physiotherapy
Avoid ext. rotation and abduction for 6 weeks
Return to contact sport in 12 weeks

21. Investigations Plain x-rays CT scans if complicated associated feature
MRI rarely – get more information from Asc.
Examination Under GA
Supine load shift test with arm at 80° abducted compared with normal shoulder
1+ ball to rim
2+ ball riding over rim with spontaneous reduction
3+ ball stays dislocated
Arthroscopy

22. Arthroscopic Repair Procedure
Patient Position
General Anaesthetic
Beach Chair with arm held by assistant
Lateral position with arm in traction & shoulder abducted
Shoulder examined, degree & direction of instability noted
Portals = 2 or 3
Posterior portal
Ant. sup portal
Ant inf portal (occasionally)
Injury assessed & debrided
Repair method selected

23. Rehabilitation Minimal in first 4 weeks No ext rotation
Abduction less than 45°
Pendulum exercises
Isometric resistance exercises
Graduated in 4 – 8 weeks
↑ ROM
Graduated weight training
Return to sport
Non contact = 6 weeks
contact = 12 weeks

24. Arthroscopic V’s Open Bankart Repair
Advantages
Accurate diagnosis of all structures
Less morbidity/pain
Small scars
Faster recovery
Sooner return to activities
Less restriction of movement
Disadvantages
Need all the equipment
Technically demanding
Long learning curve
Lack of versatility
Higher failure rate arthroscopic = up to 33% -
open = less than 10%

25. Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002
Advantages V’s Disadvantages of Asc. Repair
Advantages
↑ cosmesis
↓ morbidity
↓ stiffness
Easy revision
Disadvantages
1) Reluctance to refer patient immediately
2) Difficult operation
3) Expensive instrumentation
4) Biological healing time is not accelerated
5) Same post operative restrictions

26. Problems
Difficulty convincing Club Trainers, Physicians, sporting club Doctors & DEM staff to refer the young athlete within 2-3 days.
Time consuming discussions convincing patient to have the operation rather than early return to sport.
No problem advising a recurrent dislocators to have a stabilisation procedure at the end of a sporting season.
Mostly after hours surgery with staff who are not familiar with the operation and instrumentation.

27. Arthroscopy of Shoulder
1935 – Japanese Surgeons arthroscoped, shoulders
1960s – Curiosity activity in the western world
1970s – Diagnostic Asc. examination è open surgery
1980s – Simple Asc. techniques èfor simple problems
1990s – ↑ Instrumentation & tacks è more tried it.
2000s – ↑ Techniques & anchors
– Can be done by any surgeon skilled in
arthroscopic techniques

28. Shoulder reduced on field, first aid room or DEM then referred
Treatment History
1970s - Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences
1980s - Asc. transglenoid sutures
tied over spine of scapula or muscle fascia
1990s - patient in lateral position with arm in traction
or patient in Beach chair position
multiple, tacks and sutures
surtac screw tack anchors etc.
better anchors and sutures have made the procedure available for all surgeons experienced in arthroscopic technique

29. Acute Labral Tear

30. Acute Repair of Anterior Labral Tear

31. Conclusion
Asc. repair of the Capsulo-ligamentous injury to the shoulder
is a simple procedure for a surgeon skilled in arthroscopic technique
Chronic instabilities have associated plastic deformity of the tissues that need to be addressed and this makes the result
of a simple procedure unpredictable.
An active young person with a first traumatic dislocation of
the shoulder should have the damage repaired arthroscopically within 10 days of the injury