My shoulder popped out what now?
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1 My shoulder popped out what now? Richard Dallalana Epworth Shoulder Symposium June 2017
2 Shoulder Dislocation First event Best approach?
3 Manual Reduction Should it be put back on field? - YES Prone lying Very safe Least pain Kocher (ER method) Reliable OK without sedation / pain killers
4 Traction
5 Normal Labrum
6 Tear Anterior Labrum (Bankart) Permanent Fixture i.e. Doesn t heal by itself Increased risk of repeat dislocation
7 The Dilemma Conservative treatment vs. Early reconstructive surgery Key determinants Likelihood of repeat dislocation Ability to change lifestyle to avoid at risk situations May not be possible or desired work or sporting commitments
8 Risk Factors for Repeat Dislocation? Male Odds ratio 2.68 Age < 20 years Odds ratio Systematic Literature review, Wasserstein, Arthroscopy, 2016 (Odds ratio of 2 = twice the risk ) Overall chance of recurrence of dislocation > 80% Usually within the first 12 months
9 Risk Factors Joint hyperlaxity (No labral tear) Contact / collision sports Aussie Rules Football, Rugby, Basketball Lifestyle risks Surfing, rock climbing, water skiing Electrician, storeman, roofing plumber
10 Re-dislocation: not the only Issue Focus should not be on re-dislocation alone Subluxation events Lack of confidence in the arm Reduced sporting participation or overhead work Pain (Posterior instability) = Symptomatic instability Reduced quality of life without further dislocation
11 Imaging All first time shoulder dislocations should have an MRI Extent of damage? Simple labral tear Both sides or circumferential Bone glenoid fracture? CT
12 Extent of damage 19 y.o. Prof. Rugby Type III SLAP Anterior labral separation Full thickness rotator cuff tear
13 Sling and return to activity Sling or brace 1 3 weeks Restricted ABER activity 6 weeks Return to pre-injury sports when Normal strength Full ROM Confident with shoulder in at risk positions No evidence for any of the above!
14 Non-operative Management Immobilisation in ER? Worked for Itoi - re-dislocation Not for others (Whelan, CORR, 2014) Physiotherapy Improvement in QoL and functional scores seen Specific supervised target-led neuromuscular programs + compliance Re-dislocation rates with athletic activity remain high Lifestyle changes / education Strapping, taping, braces
15 Surgery 3 randomised prospective trials : Immediate reconstructive surgery vs. conservative management of first time shoulder dislocation Bottoni, AJSM; Kirkley, Arthroscopy; Jakobsen, Arthroscopy All show reduced rates of re-dislocation Better patient reported outcome scores in surgical group Re-dislocation rates from 80% to 15%
16 Are there risks in not operating? Consequences of recurrent dislocation More time missed (work and sport) due to recurrent episodes of instability More collateral damage to chondral surfaces within the joint Larger Hill Sachs lesion and worsened glenoid bone loss Higher chance of arthritis later (Hovelius 56% at 25 years )
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25 Post Surgical Rehab Success of surgery depends on labrum sticking to the bone it is attached to 3 months Can t cheat the biological requirement to heal The repair needs protection in this time No place for accelerated early rehab
26 Post Surgery Stepwise return to function - physiotherapy ROM Strengthen Training (3 months) and return to sport - 6 months Lengthy recovery season gone / impact on work Operative risks Low with arthroscopy Frozen shoulder / hardware issues Re-dislocation despite surgery
27 Bony bankart Glenoid bone loss
28 Instability due to bone loss Higher chance of redislocation Reduced success with labral repair surgery
29 Latarjet Coracoid bone transfer to glenoid
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31 Latarjet Improved bone support Subscapularis and conjoint tendon sling
32 Hill Sachs lesion Humeral bone loss
33 Hill Sachs Pre- post- Latarjet transfer
34 Latarjet Low failure rate 1% (Including contact sport) Why not do it in everyone? More problems than labral repair Stiffness loss ER and abduction Non-union pain +/- recurrent dislocation Metalware failure nerve palsy (musculocutaneous) OA Infection
35 What to do?? First-time dislocation Get a specialist opinion Get an MRI
36 First Time Dislocation Non-professional sports / active lifestyle Young male Stop sport and have shoulder reconstruction (Cochrane review, 2012) Older (>30) or female Non-operative management No labral tear (hyperlaxity) Non-operative : lifestyle change + physio Bone damage or whole labrum avulsion Early shoulder reconstruction, any age
37 First Time Dislocation Professional Sports Timing : immediate, end of season, never? Extensive damage (MRI and / or CT scan) e.g. glenoid fracture Early surgery Important point in career / Important player Roll the dice and play on - Reconstruct at end of season. Accept collateral damage?? Established / Expendable player Consider reconstruction immediately avoid extra damage Plan for next season Subluxation only (vs full dislocation) Push on without surgery initially
38 Thank you
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R. Frank Henn III, MD. Associate Professor Chief of Sports Medicine Residency Program Director
R. Frank Henn III, MD Associate Professor Chief of Sports Medicine Residency Program Director Disclosures No financial relationships to disclose 1. Labral anatomy 2. Adaptations of the throwing shoulder