Chronic locked posterior shoulder dislocation with severe head involvement

A Case of Neglected Posterior Fracture Dislocation of the Shoulder Treated With Greater Tuberosity Osteotomy

Posterior dislocation of the shoulder joint is a rare condition. It is often misdiagnosed owing to a lack of evident clinical features compared with anterior shoulder dislocation, and inappropriate radiological examination. We present a case of chronic posterior fracture dislocation treated with greater tuberosity osteotomy. A 66-year-old man was injured in a fall while carrying a drone. He was referred to our hospital following 3 months of conservative treatment at a nearby clinic, without reduction of the posterior dislocation. Physical examination revealed a prominent reduction in shoulder joint range of motion and shoulder pain. Radiological examination revealed posterior shoulder dislocation associated with greater tuberosity malunion and a small bone fracture of the posterior portion of the glenoid. Open reduction and internal fixation, including greater tuberosity osteotomy, were performed. Although subluxation of the posterior dislocation persisted postoperatively, the humeral head gradually returned to its centric shoulder joint position owing to rotator cuff force coupling. At 24-month follow-up, the patient showed excellent shoulder results.

From Diagnosis to Decision-Making: A Systematic Review of the Management of Reverse Hill-Sachs Lesions after Posterior Shoulder Dislocations

(1) Background: The aim of this study is to describe all of the possible surgical procedures that intend to treat the McLaughlin lesion (or Reverse Hill-Sachs) in posterior shoulder dislocation. (2) Methods: Google Scholar, Pubmed, and Embase were used as databases in our research. Studies reporting the results of posterior shoulder dislocations surgically treated with procedures addressing the humeral lesion were evaluated. The studies reporting results after fracture-dislocation and multidirectional instability were excluded. (3) Results: A total of 16 studies were included in our review for a total of 207 shoulders with a mean age of 41.7 years that were evaluated at a mean of 62.1 months. The Modified McLaughlin procedure and the Graft procedures were the most commonly performed. No statistically significant difference was found between the two at the evaluation of the clinical score. (4) Conclusions: Our review highlights the importance of a correct diagnosis and an accurate surgical treatment choice based on the surgeon's experience and on the patients' characteristics.

Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts

» Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.» Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.» For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.» For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

Anterior Shoulder Instability and Open Procedures: History, Indications, and Clinical Outcomes

The shoulder, being the most mobile joint in the human body, is often susceptible to dislocations and subluxations more so than other joints. As such, shoulder instability constitutes a common complaint among patients worldwide, especially those who are young, participate in contact sports, and have increased innate flexibility in their joints. Management options in the setting of instability vary between conservative and surgical options that aim to mitigate symptoms and allow return of function. Surgical options can be arthroscopic and open, with a general shift among surgeons towards utilizing arthroscopic surgery in the past several decades. Nevertheless, open procedures still play a role in managing shoulder instability patients, especially those with significant bone loss, recurrent instability, coexisting shoulder pathologies, and high risk of failure with arthroscopic surgery. In these clinical settings, open procedures, like the Latarjet procedure, open Bankart repair, glenoid bone augmentation using iliac crest autograft or distal tibial allograft, and salvage options like glenohumeral arthrodesis and arthroplasty may show good clinical outcomes and low recurrence rates. Each of these open procedures possesses its own set of advantages and disadvantages and entails a specific set of indications based on published literature. It is important to cater treatment options to the individual patient in order to optimize outcomes and reduce the risk of complications. Future research on open shoulder stabilization procedures should focus on the long-term outcomes of recently utilized procedures, investigate different graft options for procedures involving bone augmentation, and conduct additional comparative analyses in order to establish concrete surgical management guidelines.

Bilateral locked posterior shoulder dislocation overlooked for 15 months treated with the modified McLaughlin procedure: A case report

Neglected bilateral posterior shoulder dislocation is a rare injury caused primarily by an epileptic seizure. The injury is usually associated with a reverse Hill-Sachs lesion in the anteromedial aspect of the humeral head. The modified McLaughlin technique may avoid instability and osteoarthritis when 20 to 40% of the articular surface is affected by reverse Hill-Sachs. In this article, we present the clinical results of a case overlooked in the literature for the longest time, i.e., for 15 months. A 46-year-old male patient was receiving treatment for epilepsy for five years. There was no fall or trauma in the four seizures he had during this time. The last seizure was 15 months ago. When the patient presented to our clinic, both shoulders were symmetrically deformed, the anterior shoulder contour disappeared (empty socket sign), and there was a loss of upper contour. The computed tomography (CT) scan revealed a posteriorly locked dislocation with a reverse Hill-Sachs lesion in 32% of the left shoulder and 36% of the right shoulder. We applied the modified McLaughlin procedure to the dominant right shoulder and, two months later, we used it to the left shoulder (with a graft taken from the anterior superior iliac spine). At one-year of follow-up, both shoulders were moderately functional: forward elevation left 70° and right 50°, abduction left 40° and right 60°, and internal rotation: the back of the hand could touch the fifth lumbar vertebra. Meanwhile, the patient did not suffer from recurrent dislocation. The pre- and postoperative Constant-Murley Scores for the right and left shoulder were 30/52 and 11/48, respectively. Although the operational outcomes using the modified McLaughlin technique were not ideal, with no recurrence, the patient seemed to be satisfied with this outcome. In conclusion, in neglected locked shoulder fracture-dislocations, the modified McLaughlin technique is a method that can respond to the pathophysiology by eliminating reverse Hill-Sachs lesion.

Asymmetric Bilateral Chronic Shoulder Dislocation in a Young Patient - A Rare Case Report

Introduction

Chronic shoulder dislocations are infrequent and can be easily overlooked unless a carefully clinical history, physical examination, and radiographic evaluation are undertaken. Bilateral simultaneous instability is almost pathognomonic for a convulsive disorder. To the best of our knowledge, we describe the first case of asymmetric bilateral chronic dislocation.

Case Report

A 34-year-old male patient with a history of epilepsy and schizophrenia and multiple seizure episodes, suffered a bilateral asymmetric shoulder dislocation. Radiological examination revealed a posterior shoulder dislocation of the right shoulder with a severe reverse Hill-Sachs lesion comprising more than 50% of the humeral head surface, while on the left shoulder, a chronic anterior shoulder dislocation with a Hill-Sachs lesion of moderate dimension. On the right shoulder, a hemiarthroplasty was performed, and on the left, a stabilization with Remplissage Technique, subscapularis plication, and temporary trans-articular Steinmann pin fixation was done. After bilateral rehabilitation, the patient showed residual pain in the left shoulder and slight range of motion limitation. There were no new episodes of shoulder instability.

Conclusion

Our aim is to emphasize the importance of being alert to flag patients and make a prompt and accurate diagnosis of acute shoulder instability episodes, to avoid unnecessary morbidity, as well as of a high index of suspicion when a history of seizures is present. Despite the uncertain prognosis of a bilateral chronic shoulder dislocation functional results, the surgeon must take into consideration the patient's age, functional demand, and expectations to define the best treatment strategy.

Chronic glenohumeral dislocations treated with arthroplasty: a systematic review

Background

The aim of this systematic review was to summarize the clinical outcomes and associated predictors of outcomes for chronic glenohumeral dislocations treated with arthroplasty.

Methods

A systematic literature search was performed with Embase, PubMed, CENTRAL, BIOSIS, and CINAHL databases from the inception of these databases through January 1, 2021 to identify all articles that examined outcomes or predictors of outcomes of arthroplasty in patients with chronic glenohumeral dislocations. Studies that examined outcomes for patients with a chronic glenohumeral dislocation (≥3 weeks) treated with hemiarthroplasty, anatomic total shoulder arthroplasty, or reverse total shoulder arthroplasty were included. Those with acute or subacute dislocations (<3 weeks), fracture dislocations, and those treated with joint preserving treatment modalities were excluded.

Results

We identified 195 articles; of which, 22 (201 patients/205 shoulders) met our inclusion criteria. A total of 14 studies reported outcomes of hemiarthroplasty, 10 studies reported outcomes of anatomic total shoulder arthroplasty, and 9 studies reported outcomes of reverse total shoulder arthroplasty. All studies documented clinical improvement after arthroplasty. Among 16 studies that measured range of motion, all 16 studies demonstrated improvement in range of motion postoperatively. Thirty-one reoperations (15%) were performed across all studies.

Conclusion

We found improved clinical outcomes after arthroplasty for the treatment of chronic glenohumeral fewer dislocations at a long-term follow-up. Some evidence suggests that reverse total shoulder arthroplasty may have superior outcomes and less complications compared with hemiarthroplasty and anatomic total shoulder arthroplasty. There is insufficient evidence regarding the potential influence that duration of dislocation, direction of dislocation, addition of concomitant procedures, or humeral component retroversion have on outcomes.

Posterior shoulder dislocation with reverse Hill-Sachs lesion. A technical note and report of two cases

Posterior shoulder dislocation (PSD) with a reverse Hill-Sachs lesion is a rare injury with challenging management. This article is a technical note, describing the combination of both, modified McLaughlin procedure with posterior Bankart repair, for the surgical treatment of traumatic PSD associated with a substantial reverse Hill-Sachs lesion. Two patients with mid-term follow-up are presented. Approaching and repairing both sides of the joint, balance and congruency are restored, the humeral head is centralized in the glenoid and the patient starts early mobilization and rehabilitation safely.

Posterior shoulder fracture-dislocation: A systematic review of the literature and current aspects of management

PURPOSE

Posterior fracture-dislocation of shoulder is an infrequent traumatic event; however, most orthopaedic surgeons may face the challenge of treating it. The aim of this study is to review and summarise systematically the current principles of the management of this complex injury, and create a treatment algorithm.

METHODS

Both PubMed and Scopus Databases were systematically searched for the terms "posterior shoulder fracture-dislocation" or "posterior glenohumeral fracture-dislocation" or "posterior glenoid fracture-dislocation" for articles written in English and published in the last decade.

RESULTS

A total of 900 articles were identified, of which 13 were retained for analysis. A total of 153 patients (161 shoulders) were identified. These patients were treated either with open reduction and internal fixation, modified McLaughlin procedure, allograft/autograft humeral head reconstruction or shoulder arthroplasty. The mean age was 40.15 years. The mean postoperative Constant score in cases treated by open reduction and internal fixation was 86.45, whereas by bone graft was 84.18. Further, the mean postoperative Constant score was between 79.6 and 67.1 in those that were managed by modified McLaughlin and arthroplasty procedure, respectively.

CONCLUSION

The management of posterior shoulder fracture-dislocation may be challenging, and the best surgical option depends on many variables such as the chronicity of the injury, the presence of a fracture at the level of the surgical neck or tuberosities and the extend of the Hill-Sachs lesion if any. A treatment algorithm is proposed, based on the current literature in an effort to create a consensus for these injuries. For the acute shoulder fracture-dislocations, an open reduction should be performed. For the chronic fracture/dislocations in the elderly low-demand patients, conservative treatment should be performed. For the rest of the patients, depending on the severity of the Hill-Sachs lesion different surgical options are available such as the McLaughlin technique, the use of an allograft, osteotomy or arthroplasty.

Instability, complications, and functional outcomes after reverse shoulder arthroplasty and anatomic shoulder arthroplasty for chronic neglected shoulder dislocation: a systematic review

Background

Chronic shoulder dislocation has been treated by either anatomic shoulder arthroplasty (ASA) or reverse shoulder arthroplasty (RSA) with encouraging results. Although good results have been reported after both the procedures, several complications such as instability and glenoid failures have also been highlighted. The aim of this study was to aggregate the results that have been reported with the use of ASA or RSA in chronic shoulder dislocation and analyze the instability rates, complication rates, and functional outcomes.

Methods

A comprehensive search was performed in May 2020 using PubMed, EMBASE, and Cochrane Library databases. Studies that reported on the outcomes after either ASA or RSA for chronic anterior dislocation (CAD) or chronic posterior dislocation (CPD) were included in the systematic review. Methodologic quality was assessed using the Methodological Index for Nonrandomized Studies appraisal tool for observational studies.

Results

We aggregated 13 studies that included data on 128 patients with CAD and 51 patients with CPD. The combined weighted postoperative instability rate in the CAD group was significantly higher after ASA than after RSA (P = .04). There was no significant difference in the combined weighted instability rate between ASA in the CAD group and ASA in the CPD group (P = .37). The complications of RSA in CAD included glenoid base plate loosening, humeral shaft fractures, late infection, acromion fractures, and instability. The complications of the ASA in CAD and CPD included glenoid loosening and erosions, severe pain necessitating revision, severe superior migration of the head, redislocation with rupture of the cuff tendons, bone graft migration, instability, and 2 cases of neuropathies (median nerve and axillary nerve) that eventually resolved.

Conclusion

Postoperative instability was significantly more common after ASA than after RSA for chronic shoulder dislocations, but both RSA and ASA had a high complication rate in CAD. Shoulder arthroplasty improved the range of motion, functional outcomes, and pain in patients with chronic shoulder dislocation.

All-Arthroscopic McLaughlin's Procedure in Patients with Reverse Hill-Sachs Lesion Caused by Locked Posterior Shoulder Dislocation

Purpose  This study aims to investigate the clinical and functional outcomes of the all-arthroscopic McLaughlin procedure in a clinical series of patients suffering by neglected locked posterior shoulder dislocation. Methods  A retrospective clinical study based on prospectively collected data was conducted in a single center regarding 10 patients with neglected locked posterior shoulder dislocation and concomitant reverse Hill-Sachs lesion, who were treated with the all-arthroscopic Mclaughlin procedure. The average humeral bone defect was 39 ± 7% according to the preoperative computed tomography evaluation. The mean time of follow-up was 77 ± 16 months (range, 63-104 months). Results  No patient had suffered a new dislocation, whereas all of them were satisfied with the surgical outcome and returned to their previous activities of daily living. External rotation was restored to every patient studied from 0 degrees at the baseline. At the last follow-up, the median external rotation beside the body was 90 degrees (range, 50-90 degrees; p  < 0.01) and the respective measurement at 90 degrees of abduction was 90 degrees (range, 80-90 degrees; p  < 0.01). The active forward flexion was increased ( p  < 0.01), from 60 degrees (range, 30-180 degrees) at the baseline to 180 degrees (range, 160-180 degrees) at the last follow-up and the internal rotation was gained ( p  < 0.01) from the level of buttock (range, lateral thigh-T12) at the baseline to the T11 level (range, T7-L3) at the last follow-up. The median UCLA score was increased from 8 (range, 4-22) to 35 (range, 33-35; p  < 0.01) and the Oxford instability score from 5 (range, 3-16) to 46 (range, 43-48; p  < 0.01), respectively. Conclusion  The arthroscopic McLaughlin procedure in substantial reverse Hills-Sachs lesion caused by locked posterior dislocation leads to excellent clinical and functional results in the long-term follow-up. Level of Evidence  This is a therapeutic study, case series with no comparison group, Level IV.

Arthroscopically Assisted Reduction in a Chronic Locked Posterior Shoulder Dislocation

Neglected posterior shoulder dislocation is a difficult condition in terms of decision making and surgical technique. Not only the bony deformity but also the soft tissue and patient's underlying disease are of concern. Whether the poor results are associated with a time delay or the treatment method is not clear yet. To date, there is neither a consensus nor treatment guidelines. We describe an arthroscopically assisted reduction and open McLaughlin procedure. The advantage of this procedure is preservation of the soft tissue of the anterior part of the shoulder during the surgical reduction technique for chronic neglected posterior shoulder dislocation cases.

Traumatic Anterior Instability: Treatment Options for Initial Instability

Because of the lack of bony restraints and minimal articular contact, the glenohumeral joint can attain significant range of motion; however, this results in the propensity for instability. The most generic form of instability, traumatic anterior instability, reliably produces a series of pathoanatomic findings. While reliable, these findings contribute to the complexities of caring for patients after an initial instability event. Numerous studies have examined this issue and determined that careful consideration of patient factors can guide successful treatment, whether it be surgical or nonsurgical, after initial instability. Such forms of treatment have shown to provide a good functional outcome and decreases morbidity. To be able to provide successful treatment requires a thorough understanding of the pathoanatomic of an instability event and the intricacies of the evaluation of a patient after an initial instability event.

Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation

Background

Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19^th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated.

Methods

We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder.

Results

Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons.

Conclusion

We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.

Locked posterior dislocation of the shoulder: A systematic review

Locked posterior dislocation of the shoulder is very rare. Seizures and trauma are the most common causes of this injury.There is no current benchmark treatment strategy for these rare cases.This study has shown that reconstruction of the shoulder joint in an anatomical way in acute and chronic cases up to 16 weeks provides good results.The purpose of this study is to evaluate the results of different treatment procedures with outcomes and to compare the results of the same procedures in acute and chronic cases. Cite this article: EFORT Open Rev 2017;3:15-23. DOI: 10.1302/2058-5241.3.160089.

Transfer of the lesser tuberosity for reverse Hill-Sachs lesions after neglected posterior dislocations of the shoulder: A retrospective clinical study of 13 cases

Objective

This study aimed to present middle-term functional and radiological outcomes of the transfer of the lesser tuberosity in the management of reverse Hill-Sachs lesions following posterior dislocations of the shoulder.

Patients and methods

With a diagnosis of neglected posterior shoulder dislocation (8 locked, 5 recurrent), 13 male patients (age range: 28–72; mean age: 39.3 years) who underwent the transfer of the lesser tuberosity due to reverse Hill-Sachs lesions, were retrospectively reviewed based on functional and radiological data. The etiologies were: epilepsy in 9 patients, a traffic accident in 2 patients, and fall in 2 patients. To assess the patients' functional level, American Shoulder and Elbow Surgeons (ASES) and Constant Scores were used, and the patients' range of motion at the last follow-up was measured. To evaluate the development of arthrosis, the final follow-up control plain radiographs were examined. The average size of the defects calculated from the axial computed tomography sets was 27% (range: 20%–40%).

Results

The average length of follow-up was 30 months (range: 12–67 months). At the last follow-up visit, the main ASES and Constant Scores were 78 and 85, respectively, and the average degrees of flexion, abduction, and external rotation were 163°, 151°, and 70° respectively. The concentric reduction was observed postoperatively.

Conclusion

McLaughlin procedure appears to be a safe and effective method in the treatment of neglected posterior shoulder dislocations with reverse Hill-Sachs lesion.

Level of Evidence

Level IV, Therapeutic study.

Treatment of The Posterior Unstable Shoulder

BACKGROUND

It is estimated that approximately 5% of glenohumeral instabilities are posterior. There are a number of controversies regarding therapeutic approaches for these patients.

METHODS

We analyse the main surgery alternatives for the treatment of the posterior shoulder instability. We did a research of the publications related with posterior glenohumeral instability.

RESULTS

There are conservative and surgical treatment options. Conservative treatment has positive results in most patients, with around 65 to 80% of cases showing recurrent posterior dislocation. There are multiple surgical techniques, both open and arthroscopic, for the treatment of posterior glenohumeral instability. There are procedures that aim to repair bone defects and others that aim to repair soft tissues and capsulolabral injuries. The treatment should be planned according to each case on an individual basis according to the patient characteristics and the injury type. Surgical treatment is indicated in patients with functional limitations arising from instability and/or pain that have not improved with rehabilitation treatment. The indications for arthroscopic treatment are recurrent posterior subluxation caused by injury of the labrum or the capsulolabral complex; recurrent posterior subluxation caused by capsuloligamentous laxity or capsular redundancy; and multidirectional instability with posterior instability as a primary component. Arthroscopic assessment will help identify potential injuries associated with posterior instability such as bone lesions or defects and lesions or defects of soft tissues. The main indications for open surgery would be in cases of Hill Sachs lesions or broad reverse Bankart lesions not accessible by arthroscopy. We indicated non-anatomical techniques (McLaughlin or its modifications) for reverse Hill-Sachs lesions with impairment of the articular surface between 20% and 50%. Disimpaction of the fracture and placement of bone graft (allograft or autograft) is a suitable treatment for acute lesions that do not exceed 50% of the articular surface and with articular cartilage in good condition. Reconstruction with allograft may be useful in lesions affecting up to 50% of the humeral surface and should be considered when there is a situation of non-viable cartilage at the fracture site. For defects greater than 50% of the articular surface or in the case of dislocations over 6 months in duration where there is poor bone quality, some authors advocate substitution techniques as a treatment of choice. The main techniques for treating glenoid bone defects are posterior bone block and posterior opening osteotomy of the glenoid.

CONCLUSIONS

The treatment of the posterior glenohumeral instability has to be individualized based on the patient´s injuries, medical history, clinical exam and goals. The most important complications in the treatment of posterior glenohumeral instability are recurrent instability, avascular necrosis and osteoarthritis.

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.

A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.

Atraumatic Bilateral Neglected Anterior Shoulder Dislocation: Case Report of a Jehovah's Witness 28-Year-Old Male Affected by Iron-Deficiency Anemia and Treated with Bilateral Latarjet Procedure

Introduction:

Neglected bilateral anterior shoulder dislocation is a very rare condition, often related to seizures or major trauma. Open reduction is recommended whenever Hill-Sachs lesion is >25% of the joint and the dislocation is elder than 3 weeks.

Case Report:

We describe a case report of a 28-year-old man left handed Jehovah’s Witness laborer assessed 12 weeks after bilateral anterior shoulder dislocation. The patient was evaluated with clinical examination, and it was observed an asymptomatic intrarotation of both shoulders with a mild left circumflex nerve deficit. He was able to perform flexion and abduction of both arms up to 60° and 10° of extrarotation. Pre-operative constant scores were 49 in left and 55 in right shoulder, pre-operative disabilities of the arm, shoulder, and hand (DASH) scores were 57 in left and 53 in right shoulder, and visual analogue scales (VAS) was 2. Radiological examination were bilateral anteroposterior shoulder X-rays and computer tomography scan. The surgeon treated both shoulder (not simultaneously) by open reduction and Bristow-Latarjet coracoids transfer procedure. A 1 year after operations, left flexion was 180° while right was 160, bilateral abduction was 180. He was able to return to his pre-injury activities, the constant score was 89 left and 83 right, DASH score was 17 left and 13 right and VAS was 0.

Conclusion:

Atraumatic bilateral neglected anterior shoulder dislocation can be treated with open Bristow-Latarjet procedure to provide a stable glenohumeral joint in laborer patient and permit a return to the pre-injury activities, to create a greater extension of the glenoid arc and to avoid future dislocation.

Management and Prognostic Factors for Delayed Reconstruction of Neglected Posterior Shoulder Fracture-Dislocation

Introduction:

Posterior fracture-dislocations of the shoulder are rare conditions. Misdiagnosis can occur in 50% - 80% of the patients. Due to the size of the lesion, stability of the joint could not be achieved with transfer of subscapular tendon or tuberosity.

Case Presentation:

A 54-year-old male patient was referred to our hospital with a neglected posterior shoulder fracture-dislocation. Functional results of the patient, and technical informations were explained in this case report. The reverse Hill-Sachs lesion involved 40% of the articular surface. Depressed and malunited fragment was elevated, and fixated to the humeral head.

Conclusions:

Glenohumeral joint reduction with reconstruction of the humeral head seems to be possible even in a neglected locked posterior shoulder fracture-dislocation. If the depressed osteochondral fragment is still spheric, signs of the avascular necrosis are absent on CT, and malunion of the fragment has occurred, it is quite possible to reconstruct the head. Although results of the case are good, it is worthwhile to follow these patients for long-term complications.

Balloon-guided inflation osteoplasty in the treatment of Hill-Sachs lesions of the humeral head: case report of a new technique

Background

The use of the extra-vertebral balloon osteoplasty is increasing and in the meanwhile it has become a safe surgical technique in the treatment of tibial head, distal radius and calcaneus fractures. In addition, we already could show in a biomechanical setup that the balloon osteoplasty might be a safe tool for reduction in the treatment of Hill-Sachs lesions, but clinical application has not been performed so far.

Case presentation

We report the case of a 53 year- old male patient who was referred to our Trauma department (level I trauma center) after the first manifestation of a posterior shoulder dislocation due to an epileptic seizure, originated in a- up to this date unknown -glioblastoma. After closed reduction of the dislocated shoulder the X-ray showed a subcapital fracture of the proximal humerus with a large reversed Hill-Sachs lesion. We performed an open surgery via a deltoideopectoral approach and balloon osteoplasty was used to reduce the impression fracture (Hill-Sachs lesion) before fixing the fracture with a locking plate. In the post-operative CT scan we could show an anatomical reduction of the Hill-Sachs lesion. At the follow-up examination one year after surgery the patient reached full range of motion and stated no re-dislocation of the shoulder nor instability or pain.

Conclusion

The reduction of an impressed humeral head fracture by use of balloon osteoplasty is a safe technique. This technique could be a new option in the treatment of Hill-Sachs lesions and might be an alternative to well known standard procedures like the remplissage or tendon transfers without affecting rotation.

Bone loss in patients with posterior gleno-humeral instability: a systematic review

PURPOSE

The aim of this systematic review was to analyse outcomes of surgical procedures for glenoid and/or humeral bony defects, performed singularly or in combination, in patients with posterior gleno-humeral instability. A secondary aim was to establish in clinical settings which percentage of glenoid or humeral bone loss should be treated with a bony procedure to avoid recurrence of dislocation.

METHODS

A systematic review of the literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid, and Google Scholar databases was performed using various combinations of the keywords "shoulder", "posterior instability", "dislocation", "bone loss", "reversed bony Bankart", "osseous glenoid defects", "glenoid bone grafting", "glenoid", "humeral head", "surgery", "gleno-humeral", "reversed Hill-Sachs", over the years 1966-2014. Data were independently extracted by all the investigators: demographics, previous surgery, imaging assessment, bone defect measurement, diagnosis, surgical management, return to sport, complications, and outcome measurements. The outcome parameters were recurrence of dislocation and clinical scores.

RESULTS

Nineteen articles, describing patients with glenoid bony defects, humeral bony defects, or both in the setting of posterior gleno-humeral instability were included. A total of 328 shoulders in 321 patients were included, with a median age at surgery of 33.4 years, ranging from 14 to 79 years. Patients were assessed at a median follow-up period of 3.6 years (ranging from 8 months to 22 years). A redislocation event occurred in 32 (10 %) shoulders. The redislocation event occurred in 2 (10 %) of 20 shoulders with glenoid bony defect and in 12 (11 %) of 114 shoulders with humeral bony defect.

CONCLUSION

Even though the general principle of treating recognized glenoid and humeral bone defects in patients with posterior gleno-humeral instability is widely accepted, to date few studies in the literature accurately establish which bone defects should be treated with bony procedures and the exact correlation between percentage of bone loss and higher risk of redislocation in clinical settings. A limitation to the present systematic review is the small number of included patients, due to the rare entity of posterior bone defects/reversed Hill-Sachs. The clinical relevance is that the results of this systematic review can be helpful to guide clinicians in the management of patients with posterior gleno-humeral instability and glenoid and/or humeral bony defects. This manuscript also highlights the need for accurate description of results in further investigations. The main drawback of the available articles in the topic is that they rarely clarify the percentage of bone loss in patients undergoing a redislocation event.

LEVEL OF EVIDENCE

IV.

Locked Posterior Shoulder Dislocation Associated With Isolated Fractures of the Lesser Tuberosity: A Clinical Study of 22 Cases With a Minimum of 2-Year Follow-up

OBJECTIVES

To evaluate the clinical and radiographic outcomes of 2-part lesser tuberosity fracture with a locked posterior dislocation.

DESIGN

Retrospective case series study.

SETTING

Beijing Jishuitan Hospital ("first-level teaching hospital").

PATIENTS/PARTICIPANTS

Between April 2003 and June 2010, 29 patients received surgical treatment for 2-part lesser tuberosity fractures with an associated locked posterior shoulder dislocation. At the final follow-up, 22 of these patients were available for evaluation.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

The shoulder range of motion and visual analog scale pain score were recorded. The postoperative outcomes were evaluated using Score of University of California in Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) Scale score. The degree of humeral head necrosis was analyzed according to plain radiographs. The effects of patients' age, dominant-side involvement, as well as time from initial injury to surgery (TFIS) on clinical outcomes and the degree of humeral head necrosis were evaluated.

RESULTS

There were 21 men and 1 woman. The average age was 41.7 years. The dominant side was involved in 12 of 22 cases (54.5%). The average TFIS was 49.5 (range, 4-148) days. The mean follow-up period was 38.1 months. The TFIS was identified as the only risk factor regarding postoperative shoulder outcome scores.

CONCLUSIONS

Acceptable outcomes can be achieved with surgical treatment for 2-part lesser tuberosity fracture with locked posterior shoulder dislocations. The TFIS has a negative impact on the final outcome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Neglected posterior dislocation of the shoulder: A systematic literature review

Posterior dislocation of the shoulder (PSD) is a rare injury; the diagnosis is often missed on initial examination. We present a systematic review of the current literature and discuss the key of the diagnosis of PSD. We searched the MEDLINE, PubMed, EMBASE, MD Consult, and the Cochrane Controlled Trial Register databases for the articles according to our eligibility criteria. Finally, 53 articles were included in our systematic review. There were 242 shoulders in 205 patients. In total, in the initial assessment with anteroposterior radiographs in 166 cases, only 19 (11.4%) cases confirmed the right diagnosis. When anteroposterior combined with axillary or Y view radiographs or computed tomography were present as the initial assessments in 36 cases, the diagnoses were made correctly and timely (100%). When axillary or Y view radiographs or computed tomography were taken subsequently, the diagnosis was confirmed in all 205 patients.

Influence of defect size and localization on the engagement of reverse Hill-Sachs lesions

BACKGROUND

Reverse Hill-Sachs (RHS) lesions can cause recurrent posterior shoulder instability because of engagement with the posterior glenoid rim; however, the effect of defect size and localization have yet to be determined.

HYPOTHESIS

Both size and localization are critical for the engagement of an RHS defect with the posterior glenoid rim.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten RHS defects with predefined extent and localization were created through an anterolateral rotator cuff sparing approach in 10 fresh-frozen cadaveric shoulder specimens using a custom-made saw guide. Computed tomography scans of all specimens were completed, and standardized measurements were performed to determine the size (alpha angle) and localization (beta angle) of the defect as well as a combination of both parameters (gamma angle). Internal rotation motions were imposed on the shoulder joint in different arm positions and with varying amount of posterior translation by means of a robot-assisted shoulder simulator. The association between engagement of the defects and the defined parameters (alpha, beta, and gamma angles) was analyzed.

RESULTS

In 0° of abduction, a cutoff value between engaging and nonengaging defects of 37.5° for the alpha angle (100% sensitivity; 75% specificity; area under the curve [AUC], 0.875; P = .055) and 36.5° for the beta angle (100% sensitivity; 25% specificity; AUC, 0.708; P = .286) was determined. The gamma angle showed the highest discriminatory power (AUC, 0.938; P = .025) with a cutoff value of 85.5° rendering 100% sensitivity and 75% specificity in the prediction of engagement. An increase in the applied posterior translation force decreased the degrees of internal rotation necessary before engagement occurred. No engagement occurred during internal rotation with the arm in 60° of abduction or 60° of flexion.

CONCLUSION

The size and localization of RHS defects are both critical factors for engagement. The combination of both parameters in terms of the gamma angle measurement might be a helpful tool to identify defects prone to engagement.

CLINICAL RELEVANCE

Not only the size but also the localization is decisive for engagement of RHS defects. The standardized measurement of the gamma angle combines both factors and might be a helpful tool to identify defects prone to engagement warranting surgical treatment.

Remplissage, humeral osteochondral grafts, weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: systematic review and quantitative synthesis of the literature

PURPOSE

The aim of this study was to evaluate clinical outcomes, rate of recurrence, complications, and range of movement after remplissage, Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty in patients with anterior or posterior shoulder instability associated with humeral bone loss.

METHODS

A systematic review of published studies on the management of dislocation of the shoulder with humeral bony procedures was performed. A comprehensive search of the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "dislocation," "treatment," "remplissage," "hemiarthroplasty," "arthroplasty," "allograft," "osteotomy," "bone," "loss," "clinical," "outcome," and "Hill Sachs" since inception of the databases to 2014. The following data were extracted: demographic characteristics, bone defects and other lesions, type of surgery, outcome measurement, range of motion, recurrence of instability, and complications.

RESULTS

Twenty-six studies were included, in which 769 shoulders were evaluated. The mean value of the Coleman Methodology Score was 69.2 points. Preoperatively, the most detected injuries were Hill-Sachs and Bankart lesions. Shoulder arthroplasty procedures had the highest rate of postoperative recurrence and the lowest scores for postoperative clinical outcomes. The combination of remplissage and Bankart procedures was associated with a lower rate of recurrence when compared with Bankart repair alone (odds ratio, 0.05; 95% confidence interval, 0.01 to 0.25; P = .0002). A high heterogeneity (I(2) = 85%) across the study results was found.

CONCLUSIONS

Arthroscopic remplissage is the safest technique for the management of patients with shoulder instability with humeral bone loss. Remplissage-Bankart procedures are associated with a lower rate of recurrence when compared with Bankart repair alone. Weber osteotomy, humeral allograft reconstruction, shoulder arthroplasty, and hemiarthroplasty are characterized by a high rate of recurrence, complications, and poor outcome scores.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Long-term outcome of segmental reconstruction of the humeral head for the treatment of locked posterior dislocation of the shoulder

BACKGROUND

Locked posterior glenohumeral dislocations with impaction fractures involving less than 30% to 35% of the humeral head are most frequently treated with lesser tuberosity transfer into the defect, whereas those involving more than 35% to 40% are treated with humeral head arthroplasty. As an alternative, reconstruction of the defect with segmental femoral or humeral head allograft has been proposed, but the long-term outcome of this joint-preserving procedure is unknown.

METHODS

Twenty-two shoulders in 21 patients with a locked posterior shoulder dislocation and an impaction of at least 30% (mean, 43%) of the humeral head were treated with segmental reconstruction of the humeral head defect. They were reviewed clinically and radiographically at a minimum follow-up of 5 years.

RESULTS

Of the 22 shoulders, 19 could be followed up at 128 months (range, 60-294 months) postoperatively. Only 2 of the 19 patients needed a prosthesis more than 180 months after the index operation. Of the other 17, 4 had radiographically advanced osteoarthritis (OA), 4 had mild OA, and 9 had no or minimal OA. Eighteen shoulders were rated as subjectively excellent, none were rated as good, and one was rated as fair. The final Constant-Murley score averaged 77 points (range, 52-98 points), the Subjective Shoulder Value averaged 88% (range, 75%-100%), and only 2 patients had mild to moderate pain. Mean active anterior elevation was 145°, and mean external rotation with the arm at the side was 42°.

CONCLUSION

Segmental reconstruction of humeral head defects for large anteromedial impaction fractures caused by locked posterior dislocations durably restores stability and freedom from pain with an excellent subjective long-term outcome.

Combination of a floating clavicle and a posterior shoulder dislocation: An "Unhappy Triad" of the shoulder girdle

We present a case of a 31-year-old man who suffered from a floating clavicle in combination with a reverse Hill-Sachs lesion of his right shoulder girdle after a bicycle accident. Operative treatment was performed using minimal-invasive and arthroscopically assisted techniques. We strongly recommend an early CT scan with later 3-dimensional reconstruction to detect and fully understand these complex injuries.

Anatomic shoulder arthroplasty as treatment for locked posterior dislocation of the shoulder

BACKGROUND

Chronic locked shoulder dislocations account for 2% to 5% of all shoulder dislocations. There is little information regarding the mid-term to long-term results of anatomic shoulder arthroplasty for treatment of this problem.

METHODS

Thirty-two shoulder arthroplasties were performed in thirty-two patients who had chronic locked posterior dislocation of the shoulder. Eighteen patients were treated with a hemiarthroplasty and fourteen, with a total shoulder arthroplasty. Inclusion criteria included moderate or severe pain and functional limitations. Structural indications included an impression fracture involving ≥45% of the humeral head, fibrosis of the articular cartilage, and/or severe osteopenia of the humeral head. When one-third or more of the glenoid was devoid of articular cartilage, a glenoid component was placed. All patients were followed for a minimum of two years (mean, 8.2 years) or until a reoperation.

RESULTS

The operations led to pain relief, with the median pain score decreasing from 4 (on a 5-point scale) preoperatively to 3 postoperatively (p < 0.01), and improvement in shoulder external rotation, from a preoperative median of -15° to a postoperative median of 50° (p < 0.001). Instability recurred in three patients in the early postoperative period. Nine patients underwent a reoperation for various reasons. According to a modified Neer rating system, there were four excellent, fifteen satisfactory, and thirteen unsatisfactory outcomes.

CONCLUSIONS

Although shoulder arthroplasty for locked posterior dislocation can provide pain relief, improved shoulder external rotation, and a low risk of recurrent instability, the overall rate of satisfaction is inferior to that following anatomic arthroplasty for treatment of glenohumeral osteoarthritis.

Reliability of a new standardized measurement technique for reverse Hill-Sachs lesions in posterior shoulder dislocations

PURPOSE

The purpose of this study was to determine whether standardized measurements are more reliable than mere estimation in determining the extent of the defect in reverse Hill-Sachs lesions.

METHODS

Twelve patients with 13 reverse Hill-Sachs lesions and available computed tomographic scans were included in this study. Based on the computed tomographic scans, estimation and measurement of the defect size in reverse Hill-Sachs lesions using a novel standardized method were carried out twice by 6 observers (3 experts and 3 residents), with an interval of 3 months between observations. To assess and compare the reliability of the estimation of the defect size and the measurement of the defect size, intraclass correlation coefficients were computed.

RESULTS

Estimation of the defect size showed a low interobserver reliability of 0.61 (95% confidence interval [CI], 0.38 to 0.83) and 0.47 (95% CI, 0.24 to 0.74) and a moderate intraobserver reliability of 0.71 (95% CI, 0.51 to 0.89). The estimations of the different observers showed statistically significant differences (P < .001). The standardized measurements reached high interobserver reliability (at least ≥0.81) and excellent intraobserver reliability (at least ≥0.88). Residents provided less reliable estimations compared with experts; however, they obtained similarly high reliability when applying the standardized measurements.

CONCLUSIONS

The mere estimation of the size of reverse Hill-Sachs lesions showed poor reliability, raising the concern for potential overestimation or underestimation in clinical practice. Standardized measurements, which showed good reliability, should be used whenever analyzing the size of a reverse Hill-Sachs defect.

LEVEL OF EVIDENCE

Level IV, diagnostic case series.

Balloon osteoplasty--a new technique for minimally invasive reduction and stabilisation of Hill-Sachs lesions of the humeral head: a cadaver study

PURPOSE

Traumatic shoulder dislocation may be complicated by concomitant bony injury of the glenoid rim or the humeral head. In Hill-Sachs lesions, reconstruction techniques vary widely and range from open reduction to tendon transposition or humeral head derotation. These operations are extensive and have questionable outcomes. With the expertise from vertebral compression fracture reduction by kyphoplasty, we examined in a cadaver feasibility study whether reduction of the Hill-Sachs lesion via hydraulic lift might be an anatomical and minimally invasive treatment option. We postulated that the use a of a balloon- assisted kyphoplasty reduction could achieve almost anatomical correction of the defect.

METHODS

We created Hill-Sachs lesions in six humeral specimens and performed a computed tomography (CT) scan before and after reduction with the kyphoplasty system. The entry point at the greater tuberosity and balloon positioning was visualised by fluoroscopy. The size of the Hill-Sachs lesion before and after reduction was measured using CT scans in the axial orientation.

RESULTS

Using the balloon kyphoplasty system, we achieved a statistically significant reduction (80 % ) of the Hill-Sachs lesion.

CONCLUSION

In a preliminary cadaver study we show that using a balloon kyphoplasty system might be an alternative treatment option for Hill-Sachs lesions, with reduced collateral damage that can occur with other minimally invasive techniques. Future work is needed to evaluate the technique under arthroscopic conditions.

Failed arthroscopic repair of a large reverse Hill-Sachs lesion using bone allograft and cannulated screws: a case report

Anterior impression fractures of the humeral head (reverse Hill-Sachs lesions) are typical concomitant bony injuries of posterior shoulder dislocations. When more than 20% of the humeral articulating surface is affected, surgical treatment is required, typically necessitating open surgery. Recently, cases of successful arthroscopic treatment of small reverse Hill-Sachs lesions involving less than 30% of the articulating surface have been reported. This article presents a case of a large reverse Hill-Sachs lesion affecting over 40% of the articulating surface that was treated arthroscopically by retrograde elevation, bone allografting, and cannulated screw insertion. The postoperative radiographic images showed a successful reduction of the impacted articulating surface of the humeral head. However, at 6 months' follow-up, the patient presented with pain and symptoms of a frozen shoulder. Cross-sectional imaging showed necrosis, partial absorption, and loss of reduction of the formerly elevated segment requiring humeral head replacement. This case report shows that even though the arthroscopic retrograde elevation of large reverse Hill-Sachs lesions is technically achievable, the outcome can be unsatisfactory because of the limitations in biologic healing response associated with large lesions of the humeral articulating surface.

Posterior shoulder dislocation: systematic review and treatment algorithm

PURPOSE

Posterior shoulder dislocations (PSDs) comprise a small subset of shoulder dislocations, and there are few evidence-based treatment protocols and no actual algorithm for the treatment of PSDs available in the literature. This article provides a systematic review of the literature, as well as an overview of clinical and radiologic diagnostic techniques, and presents an algorithm for treatment of PSDs, including minimally invasive treatment options.

METHODS

For a systematic review of current literature, a systematic search was performed in the Medline and Cochrane databases. Journal articles published between January 1940 and June 2010 were taken into account. Studies that only existed as abstracts were not included in the analysis. Broad exclusion criteria consisted of radiologic reports, review articles, case reports, and technical notes. Refined exclusion criteria consisted of a minimum of 4 patients with PSDs operated on by the same surgical technique and clinical outcome documented by a functional shoulder score.

RESULTS

The final set of articles for evaluating closed or open techniques included 5 prospective case series and 6 retrospective studies. Within this group, there was no study with a level of evidence higher than Level IV. We present a descriptive comparison of these studies because of the heterogeneity and/or number of patients and the level of evidence. Case reports illustrate the different surgical approaches according to the literature.

CONCLUSIONS

PSDs are still a challenge for the treating physician. There are few articles available about PSDs in evidence-based literature, with a limited number of cases. Our algorithm provides guidelines for decision making including minimally invasive treatment options according to the available literature.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Cemented humeral surface replacement for a locked posterior fracture-dislocation: a case report

Posterior fracture-dislocations of the shoulder are uncommon and challenging lesions. We present the case of a 76-year-old male patient who sustained a locked posterior humeral head fracture-dislocation during a convulsion. Because more than 40% of the articular surface was involved, preserving the head was not possible. We treated the fracture with a cemented humeral surface replacement. The patient demonstrated good shoulder function and no instability on short-term follow-up. Surface replacement may be a valuable treatment option for fracture-dislocations of the shoulder with articular surface involvement.

Posterior shoulder instability: current concepts review

PURPOSE

Posterior shoulder instability has been difficult to diagnose and even more challenging to manage. However, it is being diagnosed and treated more frequently, particularly after sports injuries. The purpose of this article is to review literature concerning the management of these pathologies.

METHODS

A literature review was carried out in the main medical databases to evaluate the several studies concerning the open and arthroscopic treatment of posterior shoulder instability.

RESULTS

Because of better awareness of the pathology, better technical investigations, and a better understanding of shoulder biomechanics, more and more mechanical factors that can cause posterior instability have been described. Structural abnormalities can be divided into bony abnormalities and soft-tissue abnormalities. Each group can also be divided into abnormalities caused by trauma (macro- or microtrauma) or congenital. These abnormalities can be treated with non-anatomic and anatomic stability procedures. During the last decades, the latter have been described more frequently, most of them arthroscopically.

CONCLUSION

For surgical treatment to be successful, the instability must be attributable to mechanical factors that can be modified by surgery. Because of better knowledge of the pathology, a more specific surgery can be performed. This lesion-specific surgery has improved clinical results compared to non-anatomic stability procedures, particularly when that surgery has been performed arthroscopically.

Locked posterior shoulder dislocation: treatment options and clinical outcomes

BACKGROUND

Posterior dislocation of the shoulder is a rare injury and often misdiagnosed during the initial presentation to a physician. Misdiagnosis is due to a lack of clear clinical signs compared to anterior dislocation and inappropriate radiographs. In contrast to anterior dislocations, the humeral head defect accounts for recurrent instability. Depending on the size of the defect and the duration of dislocation, different treatment options include elevation of the defect, bone grafting, McLaughlin procedure, rotation osteotomy or arthroplasty.

METHODS

We reviewed 35 patients who presented to our institution with a locked posterior dislocation of the shoulder between January 1999 and August 2009. In 6 patients, the shoulder remained stable after closed reduction, so the treatment was conservative; 29 patients underwent surgery.

RESULTS

The mean follow-up was 55 months (range 11-132 months). The interval between trauma and the diagnosis of posterior shoulder dislocation was 66 days (min. 0, max. 365). Patients treated conservatively achieved a Constant Score of 85 points; patients who underwent operative treatment had a slightly worse outcome with an average Constant Score of 79 points. There was a high correlation between the time to the correct diagnosis and the outcome.

CONCLUSION

Although locked posterior shoulder dislocation is uncommon and often initially misdiagnosed, satisfying results can be achieved by different surgical treatment options. Early diagnosis by detailed clinical examination and sufficient radiographic evaluation with true anterior-posterior and axillary views is essential to improve clinical results. Levl of evidence: IV.

Treatment of chronic anterior shoulder dislocation by open reduction and simultaneous Bankart lesion repair

BACKGROUND

Untreated chronic shoulder dislocation eventually leads to functional disability and pain. Open reduction with different fixation methods have been introduced for most chronic shoulder dislocation. We hypothesized that open reduction and simultaneous Bankart lesion repair in chronic anterior shoulder dislocation obviates the need for joint fixation and leads to better results than previously reported methods.

METHODS

Eight patients with chronic anterior dislocation of shoulder underwent open reduction and capsulolabral complex repair after an average delay of 10 weeks from injury. Early motion was allowed the day after surgery in the safe position and the clinical and radiographic results were analyzed at an average follow-up of one year.

RESULTS

The average Rowe and Zarin's score was 86 points. Four out of eight shoulders were graded as excellent, three as good and one as fair (Rowe and Zarins system). All patients were able to perform their daily activities and they had either mild or no pain. Anterior active forward flexion loss averaged 18 degrees, external active rotation loss averaged 17.5 degrees and internal active rotation loss averaged 3 vertebral body levels. Mild degenerative joint changes were noted in one patient.

CONCLUSION

The results show that the overall prognosis for this method of operation is more favorable than the previously reported methods and we recommend concomitant open reduction and capsulolabral complex repair for the treatment of old anterior shoulder dislocation.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]).

Total shoulder arthroplasty in dislocation arthropathy

Follow-up examinations of 45 patients who received shoulder arthroplasty for osteoarthritis following shoulder instability were conducted after 44 months. The goal of this study was to describe the clinical findings associated with advanced glenohumeral arthritis due to shoulder instability and instability repairs and to present the clinical results and complications of treating this with shoulder arthroplasty. The weighted average Constant score increased significantly from 49.4 to 81.3 points. There was no significant difference in the type of arthroplasty with 35 cases of total shoulder replacements and ten cases of hemiarthoplasty. The rate of complications was 40% (18/45 patients) with 20% (9/45 patients) requiring an operative revision. Patients with arthritis after instability repair showed great improvement in all qualities of the Constant score. Nonetheless, further analyses are required to determine why such a relatively young group of patients showed high complication rates.