reduction of a fixed anterior shoulder dislocation, rational, technique, early results. rational, cadaver photo dissections, six patient followups, link to a video on Vumedi

1. Open Reduction of Chronic
Shoulder Dislocation by
circumferential capsular release and
posterior cuff mobilization, its
technique and early resultsDuane Anderson, MD
Lucas Anderson, MD
Stephen Aoki, MD
Segni Bekele, MD
Abebe Chala PT
Soddo Christian Hospital
Soddo Wolaitta Ethiopia
University of Utah Department of Orthopaedics
Open reduction of chronic shoulder dislocations
through an extensile approach,
circumferential capsular release and
mobilization of the rotator cuff muscles
Technique and Early Results
Duane Anderson, MD (1)
Lucas Anderson, MD (2)
Stephen Aoki, MD (2)
Segni Bekele, MD (1)
Abebe Chala, PT (1)
(1) Soddo Christian Hospital
Soddo Wolaitta Ethiopia
(2) University of Utah Department of
Orthopaedics, Salt Lake City, Utah USA

3. The problem
• Chronic shoulder dislocation not uncommon
in the third world
• Old literature advocates complete rotator cuff
release.
• As time progresses with chronic dislocation
– larger Hill-Sachs
– more contracted capsule and rotator cuff

4. The problem
• As more time passes in chronic dislocations:
– softer the head becomes because there is no head-glenoid contact
– more damage to the glenoid especially anteriorly with reduction in size of
the glenoid
– The Hill-Sachs gets bigger
• combination of contracted capsule, shortened posterior cuff, and soft head
– leads to head collapse when head located and internally rotate a located
head in the glenoid
• Posterior cuff shortening is the critical problem!

5. The solution in the West
• Anterior delto-pectoral shoulder approach
• Hemi arthroplasty if the head collapses or
hemiarthroplasty with a smaller head due to
joint contracture
• Total shoulder if there is joint destruction

6. The solution in Africa
1. An extensile approach to the chronically dislocated
head that allows access globally to the head and
glenoid
2. Circumferential capsular release
3. Reduction of the posterior cuff shortening without
disruption of the posterior cuff tendon by stripping
the cuff from the scapula
4. Release of supraspinatus adhesions from coracoid and
superior glenoid
5. Mobilization of the posterior cuff from the attached
deltoid by breaking up dense adhesions

7. The solution in Africa
• Options for treatment then are:
1. Hemiarthroplasty for those few who have it
2. Open reduction
3. Do nothing, unfortunately this is what I
believe most of us do
4. Shoulder fusion

8. Objectives of the rest of this talk
• Cadaver dissection demonstrating the
operative procedure
• Four case presentations
• Conclusions

9. Materials and Methods
• Hand written and electronic operative logs of
all chronic shoulder dislocations =,> than one
month
• Chart review
• Pts phoned and visited to ask them to come
back
• Oxford and Constant scores, photos

10. Cadaveric operative demonstration

11. Delto-pectoral approach

12. Takedown of anterior deltoid to the
lateral acromium

13. 2.5mm drill into the coracoid for later
fixation

14. Osteotomize the coracoid

15. Reflect the coracoid medially

16. Take down the subscapularis off the
lesser tuberosity

17. Cut the long biceps tendon

18. Begin circumferential capsulotomy

19. Anteriorly cut capsule off neck

20. Inferiorly switch to releasing capsule
off inferior glenoid: concern for ax n.

21. Cut inferior capsule directly off
glenoid: bone is home

22. Finger dissect adhesions between
posterior cuff and deltoid

23. Posterior capsule and cuff released;
injury to suprascapular n. possible

24. bone of posterior glenoid goes
anterior

25. Suprascapular nerve over the top of
the glenoid posteriorly

27. TR surgery 2months after injury

28. Good function, 14 mo po

29. DT 6 weeks dislocated, easier operation no coracoid
osteotomy, no circumferential capsulotomy

30. Open reduction and Bankart

31. DT 11 months post-op

32. AJ 60 yr old, subscap tear as well as
chronic dislocation, surgery 5 mo post
injury, F/u 3 yrs post surgery

33. 3 yrs post surgery

34. TN Dislocated for one year

35. TN at F/U 2 yrs post op

36. TK 2 months dislocation

37. TK F/u 18 months

38. FL 4 months post injury

39. FL 16 months f/u

40. Results using Constant and Oxford
Shoulder Scores
• Constant score: 100 possible points
– 15 pts pain, 20 function, 40 motion, 25 strength
• Oxford score: 48 possible points
– Patient questionnaire on pain and function
– Excellent: 40-48
– Satisfactory: 30-39
– Fair: 20-29
– Poor: below 20

41. Other patients who did not come for
F/U for this study
• 6-10 other cases, one case 1.5yr dislocation
• No infections
• 2 head collapses, one old and one young
patient (both intraop early in this series)
• 2 takebacks to the OR for re-dislocation on the
post op x-ray, pinned at second surgery

42. Results: Oxford and Constant
0
20
40
60
80
100
120
Oxford Constant
TN
TR
AJ
DT
FL

43. Chart of results
Name Delay from
injury to OP
Months F/U Constant Score Oxford Score
TR 2 months 14 77
AJ 5 months 36 53
TN 12 months 24 100
DT 6 weeks 11 77
TK 2 months 18 98 48
FL
AD
Abda
4 months
8months
1 yrs&7months
16 77 41

44. Conclusions
• It is possible to relocate a chronically
dislocated shoulder
• Wide exposure is necessary
• The surgical challenges are multiple and each
contracture must be addressed
• Good functional improvement is possible

45. See it on Vumedi