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The role of arthroscopy in chronic anterior shoulder dislocation: technique and early results

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The role of arthroscopy in chronic anterior shoulder dislocation: technique and early results
  Case Report The Role of Arthroscopy in Chronic Anterior ShoulderDislocation: Technique and Early Results I˙brahim Yanmis¸, M.D., Mahmut Ko¨mu¨rcu¨, M.D., Erbil Og˘uz, M.D., Mustafa Bas¸bozkurt, M.D.,and Ethem Gu¨r, M.D. Abstract:  Dislocation that lasts longer than 3 weeks is called chronic or unreduced shoulderdislocation. Treatment alternatives can be closed reduction, open reduction, resection arthroplasty,prosthesis, arthrodesis, and no therapy. The English-language literature includes no evidence onarthroscopic reduction for the treatment of unreduced shoulder dislocation. The goal of our study wasto present our technique and period results on the arthroscopic reduction we performed in 2 cases 4and 5 weeks after anterior shoulder dislocation. Reduction could not be achieved by closed reductionunder anesthesia. With arthroscopic visualization, adhesions within the joint were released with bluntdissection. Repeat reduction attempts were unsuccessful in these 2 cases. Labroligamentous lesionsof the inferior glenohumeral ligament were repaired using 3 absorbable tacks. On the second day afterthe surgery, isometric exercises were started. The results were evaluated using a 100-unit testrecommended by Rowe and Zarins (80 units in case 1; 85 units in case 2). Reduction of chronicunreduced shoulder dislocations using arthroscopy is an alternative technique for selected patients. Italso allows repair and treatment of the intra-articular pathology in the joint and makes earlypostoperative rehabilitation possible.  Key Words:  Unreduced—Anterior shoulder dislocation—Arthroscopy. S houlder dislocations that last longer than 3 weeksare termed chronic or unreduced shoulder dislo-cation. 1-4 These are often seen in patients with epi-lepsy, mental retardation, or elderly age, or in patientswith multitrauma. 5-7 Unreduced shoulder dislocationcauses significant structural deterioration in additionto functional loss. 1,8-10 Treatment alternatives includeclosed reduction, open reduction, resection arthro-plasty, prosthesis, arthrodesis, and no therapy. 1,5-8,10,11 Closed reduction of the dislocation generally cannotbe achieved after 3 weeks. 1,7 The reasons for this areintra-articular fibrosis, the glenoid cavity filling by pos-terior capsule, muscle contracture, and osteochondraldefects locking the humeral head and glenoid ring. 6,9,10 In such cases, reduction can be achieved by release of intra-articular adhesion and the part that fills intra-artic-ular joint of the posterior capsule with open surgery.No information is found in the English literature onperforming reduction using arthroscopy in treatingunreduced shoulder dislocation. We present our tech-nique and early results for arthroscopic reduction in 2cases at 4 and 5 weeks after shoulder dislocation,respectively. CASE REPORTSCase 1 A 28-year-old patient with epilepsy was seen forleft shoulder pain and limitation in motion after a From the Department of Orthopaedics and Traumatology, Gu¨l-hane Military Medical Academy, Ankara, Turkey. Address correspondence and reprint requests to I ˙brahim Yan-mis¸, M.D., Department of Orthopaedics and Traumatology, G¨ ul-hane Military Medical Academy, Etlik-Ankara 06018, Turkey E-mail: iyanmis@yahoo.com ©  2003 by the Arthroscopy Association of North America0749-8063/03/1910-3591$30.00/0doi:10.1016/j.arthro.2003.10.021 1129  Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 10 (December), 2003: pp 1129-1132  seizure. A shoulder sling was applied to the patientafter the shoulder was reduced. The pain continuedafter 4 weeks, and the patient presented to our clinicfor examination. Apprehension sign was positive, andshoulder range of motion was limited. The patient wasdiagnosed with chronic anterior shoulder dislocationas a result of the examination and was hospitalized.Reduction was achieved under general anesthesia withthe help of arthroscopy. Case 2 A 30-year-old man did not see a doctor after anepileptic seizure. He presented at our clinic aftershoulder pain and limited motion continued for 5weeks. Radiographs revealed that the glenoid cavitywas empty and the head of humerus was dislocatedanteriorly. Range of shoulder motion was found to bepainful and limited. The patient underwent surgery. SURGICAL TECHNIQUE Closed reduction was attempted under anesthesia onboth patients, but reduction could not be achieved.Patients were placed in the lateral decubitus position.The standard posterior portal was used, and entry intothe glenohumeral joint was achieved. We used thelong head of the biceps tendon to orientate during thearthroscopy (Fig 1). Adhesions within the joint werereleased with blunt dissection, without damaging thecartilage (Fig 2). Repeat reduction attempts were thensuccessful in these 2 cases.After this stage was completed, arthroscopic exam-ination was performed through the anterior portal.Arthro fi brosis and adhesions in the joint were cleanedwith the shaver (Fig 3). Labroligamentous lesions of the inferior glenohumeral ligament were repaired us-ing a second anterior portal and 3 absorbable tacks.On the second day after the surgery, isometric ex-ercises were started. A sling was used to immobilizethe arm for 3 weeks. Active motion was begun in thethird week after the surgery.Follow-up evaluations for these 2 patients wereperformed at 13 and 17 months. Pathologies detectedwithin the joint during surgery are summarized inTable 1. The patients were evaluated functionally 12months after the surgery. The results were evaluatedusing 100-unit test recommended by Rowe and Za-rins. 1 The results were 80 units in case 1 and 85 unitsin case 2. Shoulder limitations of 10 °  in abductionwere seen in case 1; 15 °  were seen in the abduction-external rotation in case 2. Minimal shoulder painduring the motion was detected in case 1. No major F IGURE  1.  In the entry into the shoulder joint from the posteriorportal, the insertion of the long head of biceps tendon was used asthe cornerstone. Thus the scope is recognized within the shoulder joint. F IGURE  2.  Adhesion within the joint was released with blunt dissection with a blunt trocar. 1130  YANMIS   ¸  ET AL.  complications were encountered in our cases duringthe follow-up period. The patients started to performdaily activities at the end of the third month. DISCUSSION Chronic or unreduced shoulder dislocation is a con-dition that is seen more often in patients with epilepsy,mental retardation, advanced age, multiple trauma,and in societies with low socioeconomic levels. 1 Dis-location frequently becomes chronic because of amissed diagnosis. 1,8,10,12 Despite the fact that it ismore dif  fi cult to diagnose posterior shoulder disloca-tion, chronic or unreduced dislocation is seen morefrequently anteriorly. 1 Functional de fi cit is higher inunreduced anterior dislocation than in posterior dislo-cations; 1 however, rare asymptomatic unreduced an-terior shoulder dislocations are also reported in theliterature. 13 When deciding on treatment, the clinician shouldconsider the patient ’ s age, bone quality, medical state,current functional capacity, condition of the vascularstructures, and degree of deterioration at the joint. 1,5,10,11 Researchers have reported that perform-ing reduction affects function positively, even in pa-tients with extreme structural deformation in the joint. 1,7 Reduction can be recommended in all cases inwhich general status and joint surfaces are appropri-ate. Arthroplasty is indicated in patients with extremedeterioration and large bone defects in the joint sur-face. 1,9,10 Closed reduction should be tried in all caseswith indications for reduction, and cases in which thereduction can be achieved by manipulations withoutusing forceful strength. Generally, closed reduction isachieved within a few days to 3 to 6 weeks of thedislocaton. 14 However, closed reduction was reportedup to 6 weeks in the literature. 1,7 Intra-articular joint  fi brosis, ligament and musclecontraction, and big bone lesions in unreduced shoul-der dislocation hinder closed reduction. 9,10 The forceused for closed reduction may cause fractures aroundthe shoulder, as well as neurovascular injuries. 1 Openreduction is recommended for patients for whomclosed reduction could not be achieved using slightmanipulation. 1,7,9,10 Arthroscopic reduction can alsobe performed before contractures do not become per-manent in the cases for which closed reduction couldnot be achieved using manipulation. At the same time,stability can be achieved by treating joint pathology.This can accelerate rehabilitation after the surgery andprotect joint cartilage.After performing the release within the joint byblunt trocar, we have noticed that reduction wasachieved easily in both of the cases described. Werepaired the anterior part of separated labroligamen-tous lesions using absorbable tacks. This process is thesame technique used for the arthroscopic Bankart re-pair. However, achieving good visualization in theglenohumeral joint, which is full of capsule and  fi bro-sis at the beginning of the arthroscopic surgery, isdif  fi cult. In these cases, considering the insertion of  F IGURE  3.  Fibrosis and adhesions in the joint were cleaned witha shaver. T ABLE  1.  Characteristics of 2 Unreduced Shoulder Dislocation Cases CaseAge/ SexIntra-articular PathologyUnreducedPeriod (wk)100-UnitTestLabroligamentousLesion (o ’ clock)Hill-SachsCartilageDefectFractureGlenoid Rim1 28/M From 3 to 9 3  2 cm Grade 1 Minimal 4 802 30/M From 2 to 7 4  1 cm Grade 1  —  5 85 1131  ROLE OF ARTHROSCOPY IN CHRONIC ANTERIOR SHOULDER DISLOCATION   the biceps tendon, entry into the shoulder joint can beachieved. A good view can be achieved after adhe-sions and the capsule within the joints are releasedcarefully. Great caution should be taken not to damage joint cartilage during this process. Some authors rec-ommend temporary acromiohumeral or glenohumeral fi xation after closed or opened reduction, 5,9,12 but thiscondition will lead to new injuries in the joint carti-lage. Other researchers do not recommend it. 6,8 Re-searchers reported that bandages or a shoulder slingwere ef  fi cient for the initial  fi xation. 6 Repairing labroligamentous lesion after reductioncan contribute to initial stability. We performed  fi xa-tion for 3 weeks using an arm sling attached to thebody after the surgery in both cases. We did not seeinstability in either case after the surgery. We believethat the most appropriate cases for arthroscopic reduc-tion are patients whose soft tissue contractures do notbecome rigid and who do not have large bone defectsin the glenoid cavity and humeral head. In patientswhose muscular contractures become rigid, open re-duction is recommended. In cases with large bonedefects, arthroplasty is the appropriate treatment op-tion.Reduction of unreduced shoulder dislocations usingarthroscopy is an alternative treatment technique forselected patients. In this technique, after the reductionprocess, arthroscopic repair of the anterior labroliga-mentous lesion can be performed. This process cannot only contribute to initial stability but also providepermanent treatment by repairing labroligamentouspathologies. Arthroscopic reduction protects patientsfrom complications that may occur during closed re-duction and from possible additional morbidity causedby open reduction surgery. It also makes early post-operative rehabilitation possible. However, studies in-cluding more cases and longer follow-up times areneeded to con fi rm the results. REFERENCES 1. Rowe CR, Zarins B. Chronic unreduced dislocation of theshoulder.  J Bone Joint Surg Am  1982;64:494.2. Bennett GE. Old dislocations of the shoulder.  J Bone Joint Surg  1936;18:549-606.3. Mosely HF.  Shoulder lesions.  Edinburgh: Churchill-Living-stone, 1969;155-161.4. Neviaser JS. Treatment of old unreduced dislocations of theshoulder.  Surg Clin North Am  1963;43:1671-1678.5. DePalma AF.  Surgery of the shoulder.  Philadelphia: JB Lip-pincott, 1973.6. Bateman JE.  The shoulder and neck.  Philadelphia: WB Saun-ders, 1972.7. Flatow EL, Neer CS, Miller SR. Chronic unreduced anteriordislocation of the shoulder. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Or-leans, February 1990.8. Mc Laughlin HL. Posterior dislocation of the shoulder.  J Bone Joint Surg Am  1952;34:584.9. Neviaser TJ. Old unreduced dislocation of the shoulder.  Or-thop Clin North Am  1982;11:287.10. Rockwood CA Jr. Fractures and dislocation about the shoul-der. In: Rockwood CA Jr, Green DP, eds.  Fractures in adults .Ed 2. Philadelphia, JB Lippincott, 1984.11. Schultz TJ, Jacobs B, Patterson RL Jr. Unrecognized Disloca-tions of the shoulder.  J Trauma  1969;9:1009-1023.12. Wilson JC, Mc Keever FM. Traumatic posterior (retroglenoid)dislocation of the humerus.  J Bone Joint Surg Am  1949;31:160.13. Jerosch J, Riemer R, Schoppe R. Asymptomatic chronic ante-rior posttraumatic dislocation in a young male patient.  J Shoul-der Elbow Surg  1999;8:492-494.14. Hejna WF, Fossier CH, Goldstein TB, Ray RD. Anteriordislocations of the shoulder: Proceedings of the AmericanAcademy of Orthopaedic Surgeons.  J Bone Joint Surg Am 1969;51:1030-1031. 1132  YANMIS   ¸  ET AL.
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