RECURRING DISLOCATION OF THE SHOULDER

Abstract

Twenty-five years ago I had the honour of presenting to fellows and members of this College a report of various uses made of the principle of transplantation of fibrous tissues. In that report it was suggested that, as recurring dislocation of the shoulder seemed to result from some defect in the ligaments, it should be possible to repair the defect either by plicating the supposedly loose ligaments with living sutures of fascia, or by replacing them with new ones. Soon afterwards an opportunity arose to try out this suggestion and from it there developed the method which I wish to discuss to-day. It is most gratifying that in this Moynihan Lecture I am to have the opportunity of reporting once more to the Royal College a further application of the principles I presented in the Hunterian Lecture of 1924. A Moynihan Lecture would be incomplete without reference to the founder. I had hoped to find that at some period in his distinguished career the great man had said or written something which would indicate that he might have been interested in what we are discussing to-day. I have been unable to find any such reference, and I must content myself with telling you that once, long ago, he came into my operating room while an operation such as I shall describe was going on, and showed great interest in those features of it which to him were novel, and in the anatomical exercise involved. A kindly word of encouragement from the great is a priceless thing to the young. When Le Mesurier and I first became interested in recurring dislocation of the shoulder we were quite ignorant of the cause, and quite without any original idea of how to prevent it. We did notice, however, in performing the various operations that had been recommended, such as Clairmont’s operation, Joseph’s operation, and plication of the capsule, that we were never able to see a defect in the ligaments through which the head of the humerus had passed at the first dislocation. It gradually dawned on us, as the result of watching a dislocation produced on the operating table with the capsule exposed, that the head of the humerus did not pass out through a rent in the ligaments in the lower part of the joint, but that it simply slipped over the anterior rim of the glenoid into a cavity, lined with synovial membrane, which had resulted from detachment of the capsule and glenohumeral ligament. This pathological picture has been clearly and forcibly described by Bankart (1923, 1938) who on many occasions opened the joint and observed that the capsule and the glenoid labrum were not attached to the rim of the glenoid, and that the head of the humerus could slip over its smooth anterior rim with the greatest ease. While the study of our cases did not involve opening the joint, except in a few instances in which we wished to confirm Bankart’s observation, we did notice that in the great majority we could feel the thick edge of the anterior ligaments quite loose from the anterior lip of the glenoid, and occasionally, by rotating the head of the humerus outward, we could see that nothing covered it but synovial membrane. Careful study of the method of production of the first dislocation in a large number of our cases (nearly 200) has led to some definite observations: 1. It occurs chiefly in young men. \Ve have seen only nine women in 200 cases. The great majority have been in healthy athletic young men of nineteen or twenty years of age. 2. It is frequently double.