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/PRIKAZ SLU^AJA UDK 616.727.2-001.6-08 DOI: 10.2298/ACI1201095R Rehabilitation of a patient after operationally treated idiopathic recurrent, posterior shoulder subluxation.

1 /PRIKAZ SLU^AJA UDK DOI: /ACI R Rehabilitation of a patient after operationally treated idiopathic recurrent, posterior shoulder subluxation... Tatjana Radovanovi} 1, Vladimir Vukov 2, Marko Bumbaširevi} 2,3, Zoran Ra natovi} 4, Aleksandar Leši} 2,3, Ljubomir Djuraši} 1 1 Clinic for Physical Medicine and rehabilitation, CCS, Belgrade 2 Clinic for Orthopaedic Surgery and Traumatology, CCS, Belgrade 3 Faculty of Medicine, University of Belgrade, Serbia 4 Clinic for Digestive Surgery - First Surgical Clinic, CCS, Belgrade Introduction: involuntary, idiopathic, recurrent posterior shoulder subluxation is a rare entity. Subluxation of the shoulder joint occurs with every elevation movement of the hand with a certain level of pain. Active abduction and anteflexion are possible only to 90 o. Only surgical treatment produces results. Goal: The goal is to show that timely commenced, continuously conducted rehabilitation of the shoulder after surgically repaired involuntary, idiopathic, recurrent posterior subluxation of the shoulder, leads to restitution of function. Case outline R.M. patient 24 years old, was admitted to the Institute for Orthopaedic Surgery and Traumatology, Clinical Center in Belgrade, for surgical treatment. Previously was treated conservatively. ROM (anteflexion 700 abduction 60 o ) with persistant pain in shoulder. Rehabilitation started first postoperative day. Result: months post surgery - ROM (active movement) anteflexion 165 o, abduction 140 o, without pain and no tendency of posterior subluxation months post surgery,full active movements were achieved, except external rotation of -20 o - 5 months post surgery, the patient had full range of motion in all directions.the last control was performed one year after surgery. The patient has no symptoms, lives normal life and is engaged with sports. Keywords: shoulder, recurrent posterior subluxation, surgical treatment, rehabilitation. rezime INTRODUCTION Dislocations of glenohumeral joint represent 50% of dislocations of all joints of the body. Anterior dislocations are represented by 90-98%, and posterior dislocations with only 2-10%. Posterior dislocations of the shoulder can be: acute posterior luxations-with or without anteromedial defect on the humeral head. inverted posterior dislocations - with a large defect on the humeral head. They are called "locked" and they are one of the most overlooked dislocations of joints in the body. recurrent posterior subluxations, which are rare and represent less than 5% of shoulder dislocations. Recurrent posterior subluxations can be: Willing - they occur during adolescence. Painless, performed consciously, usually on both shoulders and described as "habitual." Involuntary - occurring in less than 2% of dislocations in the shoulder. Positional - provoked by the certain hand position (elevation with internal rotation). They are accompanied by pain in the shoulder. Muscular - They appear in early adulthood, usually between 20 and 25 years. They are accompanied by pain and result in elevation of the hand, between 60 o and 90 o. This group is the rarest and occurs in less than 1% of shoulder dislocations. 1,2,3,4,5,6,8,9,10 Goal - The goal is to show that timely commenced, continuously conducted rehabilitation of the shoulder after surgically repaired involuntary, idiopathic, recurrent posterior subluxation of the shoulder, leads to restitution of function. CASE OUTLINE Involuntary, posterior shoulder subluxation we diagnosed with the patient R.M., age 24. The patient was treated by physical procedures for several months because of painful blockage of movement in the right shoulder, i.e due to dislocation of the shoulder joint, which occurs with each raising of the arm. She was examined previously in another hospital, but was dropped out from the surgery. First symptoms in her right shoulder occured at 22 years, and gradually, with no obvious cause progressed over several months.

joint occurs, accompanied by pain. Further elevation was disabled by resulted malposition of the humeral head. When returning hands along the body, spontaneous repositioning of the joint occurs.

2 96 T. Radovanovi} et al. ACI Vol. LIX FIGURE 1 NORMAL POSITION OF THE SHOULDER JOINT WHEN THE ARM IS NEAR THE BODY We found that with the elevation of the right hand of about 60 o involuntary, posterior subluxation of the shoulder joint occurs, accompanied by pain. Further elevation was disabled by resulted malposition of the humeral head. When returning hands along the body, spontaneous repositioning of the joint occurs. Comparative AP recordings do not indicate bone changes. MR imaging of the right shoulder was performed. Horizontal section of the shoulder joint confirmed partially increased retroversion of the glenoid. Is that the cause of this involuntary subluxation remains a question. General attitude of litereature is that the causes of posterior shoulder instability are still not documented and proved enough, and that in practice it is very difficult to identify them preoperatively. Possible causes of posterior shoulder subluxation: laxity of the posterior part of joint capsule and labrum increased retroversion of the glenoid erosion or avulsion of the posterior edge of the glenoid - existence of anteromedial defect on the humeral head localized posteroinferior hypoplasia of the glenoid increased retroversion of the humeral head METHODS OF TREATMENT FOR POSTERIOR SUBLUXATIONS OF THE SHOULDER: Most patients respond by reducing or disappearance of symptoms with physical therapy. Therefore, physical therapy remains the initial treatment. Surgical treatment has a bad reputation, due to frequent failure and complications, however, for patients whose symptoms do not disappear with non-operational procedures, surgery remains the only option 11,12,13,14,15,16,17,18,19 When examining the patient R.M. we noticed that she can elevate extended hand, which is in full supination, up to 140 o, with no tendency for the dislocation of the humeral FIGURE 2 POSTERIOR SUBLUXATION OF THE SHOULDER JOINT AT THE BEGINING OF THE ARM ELEVATION head. Based on this observation, the idea of derotational osteotomy of proximal humerus have imposed, as a way of solution of this disorder. In respect of the doubt that increased retroversion of the glenoid is the reason for posterior subluxation, neck scapula osteotomy, through posterior approach, was the expected technique. However, from derotational subcapital osteotomy- we expected more. R.M. was operated on at the Department of Shoulder Surgery, Clinic for Orthopedic Surgery and Traumatology, Clinical Center, Belgrade. The joint was explored. There were no signs of clear changes that could explain the instability of the joint. Then,??subcapital osteotomy of the humerus was performed. The humeral head was rotated way outwards by 30 degrees. The place of osteotomy was bridged with "T" plate and bolts. The shoulder of our patient was immobilized by triangle scarf after the surgery. During the rehabilitation was applied the protocol from Johan Hopkins University in Baltimore. The specific rehabilitation protocol was initiated on the first postoperative day - with active exercises for the distal parts of the operated limb exercises and general fitness exercises. Passive shoulder exercises were carried out on the second postoperative day. Then, self-assisting exercises, isometric exercises, active exercises, then stretching exercises and strength exercises. By initiating active movements (3.5 weeks post operation), the patient was discharged from the department to outpatient physical therapy at the Clinic for Physical Medicine and Rehabilitation CCS. DISCUSSION Since that this entity is rare, that causes of occurrence can be various; published papers describe various surgical procedures, but on the small series of patients. Bone operating procedures have varying degrees of success and many failures.

Br. 1 Rehabilitation of a patient after operationally treated 97 idiopathic recurrent, posterior choulder subluxation FIGURE 3 ANY DIFFERENCE ON THE X-RAYS OF BOTH SHOULDERS.

the shoulder joint (15-20%) pain and limitation of movement due to excessive tightening of posterior musculo capsular structures of the bone block errors during glenoid or humeral osteotomy

axillaris injuries due to inadequate rehabilitation Based on results published in the literature, we notice that also with successfully operated patients, in which stability of the shoulder

It is achieved with thoracobrachial orthosis with a hand in neutral rotation and abduction between 45 o and 60 o, to achieve complete relaxation of the muscle structures.

5 months post surgery - ROM (active movement) anteflexion 165 o, abduction 140 o, without pain and no tendency of posterior subluxation. - 3.

3 Br. 1 Rehabilitation of a patient after operationally treated 97 idiopathic recurrent, posterior choulder subluxation FIGURE 3 ANY DIFFERENCE ON THE X-RAYS OF BOTH SHOULDERS. POSTERIOR SUBLUHATION OF HUMERAL HEAD FIGURE 4 THE INCREASE RETROVERSION OF THE GLENOID SURFACE The most common complications associated with surgery treatment are: renewed instability of the shoulder joint (15-20%) pain and limitation of movement due to excessive tightening of posterior musculo capsular structures of the bone block errors during glenoid or humeral osteotomy pseudoarthrosis at the place of osteotomy injuries of n. axillaris injuries due to inadequate rehabilitation Based on results published in the literature, we notice that also with successfully operated patients, in which stability of the shoulder joint is achieved, more than 50% of them have more or less restricted movements in the operated shoulder. Recommendations from the literature are that immobilization lasts about 6 weeks. It is achieved with thoracobrachial orthosis with a hand in neutral rotation and abduction between 45 o and 60 o, to achieve complete relaxation of the muscle structures. After 6 weeks begins the physical treatment. 21,22,23,24 RESULTS FIGURE 5 THE POSSIBILITY OF ARM ELEVATION WITH SUPI- NATION OF THE HAND months post surgery - ROM (active movement) anteflexion 165 o, abduction 140 o, without pain and no tendency of posterior subluxation months post surgery,full active movements were achieved, except external rotation of -20 o - 5 months post surgery, the patient had full range of motion in all directions. The place of osteotomy healed after one month of operation, and removal of osteofixational material was performed after 10 months of operation. The last control was performed one year after surgery. The patient has no symptoms, feels great, lives normal life and is engaged in sports.

derotational subcapital osteotomy of the humerus as an ideal way of solving the problem.

4 98 T. Radovanovi} et al. ACI Vol. LIX FIGURE 6 X-RAY AFTER OPERATION-DEROTATION OSTEO- TOMY CONCLUSION The decision and the plan of the surgical treatment of posterior shoulder subluxation, should be based on anamnesis, and detailed examination of patients. During examination, the possibility of elevation of the hand at full supination should be examined, because this test, if the elevation is feasible without subluxation of the joint, indicates derotational subcapital osteotomy of the humerus as an ideal way of solving the problem. Timely commenced, continuously conducted rehabilitation of the shoulder after surgically repaired involuntary, idiopathic, recurrent posterior subluxation of the shoulder, leads to restitution of function. SUMMARY REHABILITACIJA BOLESNICE NAKON OPERATIVNO LE^ENE IDIOPATSKE RECIDIVANTNE ZADNJE SUBLUKSACIJE RAMENA FIGURE 7 THREE STAGES OF OPERATION Uvod: Nevoljna, idiopatska, recidivantna zadnja subluksacija ramena je redak entitet. Subluksacija zgloba ramena nastaje pri svakom pokretu elevacije ruke uz odredjen nivo bola. Aktivna antefleksija i abdukcija mogu}e su samo do 90 o. Jedino operativno le~enje daje rezultate. Cilj rada je da se poka e da pravovremeno zapo~eta, kontinuirano sprovedena rehabilitacija ramena posle operativno sanirane nevoljne, idiopatske, recidivantne zadnje subluksacije ramena, dovodi do restitucije funkcije. Prikaz bolesnika - Bolesnica R.M. stara 24 godine, primljena na Klniku za ortopedsku hirurgiju i traumatologiju KCS u Beogradu, radi operativnog zbrinjavanja. Predhodno je le~ena konzervativno. ROM (antefleksija 70 o abdukcija 60 o ), uz stalno prisutan bol u ramenu. Rehabilitacija je zapo~eta prvog postoperativnog dana. Rezultat: - 2,5 meseca od operacije- ROM (aktivan pokret) antefleksija 165 o ; abdukcija 140 o, bez bolova i bez tendencije zadnje subluksacije - 3,5 meseca od operacije, postignuti su puni aktivni pokreti osim spoljašnje rotacije od - 20 o. - 5 meseci od operacije bolesnica je imala pun obim pokreta u svim pravcima. Poslednja kontrola u~injena je godinu dana nakon operacije. Bolesnica nema nikakvih tegoba, ivi normalno i bavi se sportom. Klju~ne re~i: rame, recidivantna zadnja subluksacija, operativno le~enje, rehabilitacija

5 Br. 1 Rehabilitation of a patient after operationally treated 99 idiopathic recurrent, posterior choulder subluxation REFERENCES 1. Ahlgren, S-A. ; Hedlund, Thomas; and Nistor, Lars: Idiopathic Posterior Instability of the Shoulder Joint. Results of Operation with Posterior Bone Graft. Acta Orthop. Scandinavica, 49: , Bateman, J. E.: The Shoulder and Neck. Ed. 2, pp Philadelphia, W. B. Saunders, Blasier, R. B., and Burkus, J. K. : Management of Posterior Fracture-Dislocations of the Shoulder. Clin. Orthop., 232: , Boyd, H. B., and 515K, D. T.: Recurrent Posterior Dislocation of the Shoulder. J. Bone and Joint Surg., 54- A: , June Brewer, B. J. ; Wubben, R. C. ; and Carrera, G. F. : Excessive Retroversion of the Glenoid Cavity. A Cause of Non-Traumatic Posterior Instability of the Shoulder. J. Bone and Joint Surg., 68-A: , June Cofield, R. H., and Irving, J. F. : Evaluation and Classification of Shoulder Instability. With Special Reference to Examination under Anesthesia. Clin. Orthop., 223: 32-43, Cyprien, J. M.; Vasey, H. M.; Burdet, A. ; Bonvin, J. C. ; Kritsikis, N.; and Vuagnat, P.: Humeral Retrotorsion and Glenohumeral Relationship in the Normal Shoulder and in Recurrent Anterior Dislocation (Scapulometry). Clin. Orthop., 175: 8-17, Dimon, J. H., III: Posterior Dislocation and Posterior Fracture Dislocation of the Shoulder: A Report of 25 Cases. Southern Med. J., 60: , English, Edward, and Macnab, IAN: Recurrent Posterior Dislocation of the Shoulder. Canadian J. Surg., 17: , Hawkins, R. J. ; Koppert, G. ; and Johnston, G. : Recurrent Posterior Instability (Subluxation) of the Shoulder. J. Bone and Joint Surg., 66-A: , Feb Hernandez, A., and Drez, D. : Operative Treatment of Posterior Shoulder Dislocations by Posterior Glenoidplasty, Capsulorrhaphy, and Infraspinatus Advancement. Am. J. Sports Med., 14: , McLaughlin, H. L.: Follow-up Notes on Articles Previously Published in the Journal. Posterior Dislocation of the Shoulder. J. Bone and Joint Surg., 44-A: 1477, Oct May, V. R., JR.: Posterior Dislocation of the Shoulder: Habitual, Traumatic, and Obstetrical. Orthop. Clin. North America, 11: , Mowery, C. A. ; Garfin, S. R. ; BooTH, R. E. ; and Rothman, R. H.: Recurrent Posterior Dislocat,on of the Shoulder: Treatment Using a Bone Block. J. Bone and Joint Surg., 67-A: , June Norwood, L. A., and Terry, G. C.: Shoulder Posterior Subluxation. Am. J. Sports Med., 12: 25-30, Ovesen, Jorgen, and Sojbjerg, J. 0. : Posterior Shoulder Dislocation. Muscle and Capsular Lesions in Cadaver Experiments. Acta Orthop. Scandinavica, 57: , Rowe, C. R.; Patel, Dinesh; and Southmayd, W. W.: The Bankart Procedure. A Long-Term End-Result Study. J. Bone and Joint Surg., 60- A: 1-16, Jan Rowe, C. R.; Pierce, D. S.; and Clark, J. G.: Voluntary Dislocation of the Shoulder. A Preliminary Report on a Clinical, Electromyographic, and Psychiatric Study of Twenty-six Patients. J. Bone and Joint Surg., 55-A: , April Saha, A. K.: Dynamic Stability of the Glenohumeral Joint. Acta Orthop. Scandinavica, 42: , Scott, D. J., JR. : Treatment of Recurrent Posterior Dislocations of the Shoulder by Glenoplasty. Report of Three Cases. J. Bone and Joint Surg., 49-A: , April Weber, B. G.; Simpson, L. A.; and HARDEGGER, F.: Rotational Humeral Osteotomy for Recurrent Anterior Dislocation of the Shoulder Associated with a Large Hill- Sachs Lesion. J. Bone and Joint Surg., 66-A: , Dec Rotational osteotomy of the humerus for posterior instability of the shoulder V Surin, S Blader, G Markhede and K Sundholm J. Bone Joint Surg. Am. 72: , Walch G, Boileau P, martin B, et al. Luxation et fractures-luxations posterieures inveterees de l epaule: apropos de 30 cas. Rev Chir Orthop 1990;76: Gerber C. Lambert S. Allograft reconstraction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. JBone Joint Surg 1996;78A: Hersche O, Berber C. Iatrogenic displacement of fractuire - dislocations of the shoulder. J Bone Joint Surg 1994;76B: Lewis, Kitamura & Bayley. Current Orthopaedics. 18: Weishaupt D. posterior glenoid rim deficiency in recurrent (atraumatic) posterior shoulder instability. Skeletal Radiol. 01-apr-2000; 29(4): Variability of measurement of glenoid version on computed tomography scan. Bokor DJ - J Shoulder Elbow Surg - 01-nov-1999; 8(6): Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 74:53-66, Antoniou J, Harryman DT. Orthop Clin North Am. 01-jul-2001; 32(3): , ix.

A 4-portal arthroscopic stabilization in posterior shoulder instability

A 4-portal arthroscopic stabilization in posterior shoulder instability J.-N. Goubier, MD, a A. Iserin, MD, b L.-D. Duranthon, MD, b E. Vandenbussche, PhD, MD, b and B. Augereau, MD, b Paris, France The