SHOULDER: Dislocation / Instability John W. Gibbs, DO Orthopaedic Surgeon Rochester Regional Health Orthopaedics at Red Creek

Shoulder Dislocation / Instability Anterior Dislocation Posterior Dislocation Instability Patterns Current Surgical Techniques

Dislocations  Anterior Dislocation <40 y/o »Probable capsular and labral injury »Possible bone injury Hills Sachs lesion (impression fracture of posterior humeral head) Bony Bankart (Anterior glenoid fracture) >40 y/o »Other associated injuries Rotator cuff Long head bicep Proximal humerus fracture Neurovascular injury

Dislocations  Anterior Dislocation Treatment »Closed Reduction »Operative vs. non-operative Primary Surgical Repair » Acute repair in young, active, high-demand shoulder » Increased risk for recurrence with non-op Rugby study - recurrent 18 months Non-op: 95% Operative: 5% » Maximum biologic potential

Dislocations  Posterior Dislocation Less common (2% of all glenohumeral dislocations) >50% associated with seizure Mechanism »Arm is adducted with an axial force applied anterior to posterior Reverse Hill-Sachs lesion »anterior humeral head impression fracture

Dislocations  Posterior Dislocation Reduction Immobilizer Considerations »Non-operative vs operative management Large humeral head impression fractures may require bone graft

Glenohumeral Instability Patterns  Anterior Instability  Posterior Instability  Multidirectional Instability

Glenohumeral Instability Patterns  Thorough history is crucial Pain Functional impairment Dead-arm syndrome Positional symptoms  Consider anatomic deficit / problems Bone Paralabral cysts Soft tissue »Capsular, labral, ligamentous, neurologic

Current Surgical Techniques  Primary goal: Anatomic Reconstruction  Trend away from non-anatomic reconstructive options  Trend towards arthroscopic techniques Capsular plication Suture anchors (knots & knotless)  Trend away from thermal capsulorraphy  Controversial: managing bone loss

Current Surgical Techniques  Intraoperative positioning Beach chair Lateral Decubitus  Bio-absorbable vs. metal anchors

Case Presentation - 1  21 y/o male, starting running back, college football, aspirations to play in the NFL Traumatic anterior shoulder dislocation junior year  Reduced – unable to complete season  Recurrent instability symptoms with attempted rehabilitation  Diagnostic / Treatment options:

Case Presentation - 1  Diagnostic / Treatment options: MRI: »Anterior-Inferior labral tear »Superior Labral Tear Anterior to Posterior (SLAP) Surgical Repair »Suture anchors and plication  Outcome: Unable to play senior year / continued rehab Current status: NFL running back with a Super Bowl ring

Case Presentation - 2  33 y/o male, firefighter, former swimmer  Subluxation /Dislocation event while fighting a fire pulling on a hook Hooked a rafter while clearing the soffits  Immediate pain and felt a reduction event  Seen at urgent care: no fracture / dislocation noted, normal x-rays  8 weeks of physical therapy  Persistent symptoms Pain, and achiness recurrent subluxation event times two  Presents to office 8 weeks s/p injury  Diagnostic / Treatment options:

Case Presentation - 2  Diagnostic / Treatment options: MRI »Bankart lesion »Superior-Anterior Labral tear anterior to bicep anchor Operative Intervention » Arthroscopic Anterior-inferior labral repair & capsulorraphy Anterior-superior labral repair Currently rehabilitating »avoid extreme abduction / external rotation

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