Initial Anterior Dislocation Research Articles

Review of Arciero's article (1994) on arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations: does the same hold true in 2016?

This classic reexamines the landmark publication ‘Arthroscopic Bankart repair versus non-operative treatment for acute, initial anterior shoulder dislocations’ by Arciero et al, published in 1994 in The American Journal of Sports Medicine. The authors provided pertinent evidence to support the use of arthroscopy to repair associated Bankart lesions found after acute, initial anterior shoulder dislocations in the young, athletic patient population. The recommendations put forth were a departure from the established teachings at the time. The article demonstrated a significantly reduced rate of recurrence after arthroscopic stabilisation compared with non-operative management in US Military Academy cadets. The majority of patients who failed non-operative treatment required subsequent open repair. At the time of arthroscopy, a Bankart lesion was diagnosed in all patients, which the authors postulated are consistently present after acute first-time dislocations. The authors concluded that in young athletes, particularly in this case, military cadets, return to previous levels of activity and training is imperative. These findings remain relevant today and provided the impetus for the evolution in surgical techniques and implants over the past 20 years. Subsequent randomised controlled trials have largely supported the use of arthroscopic stabilisation in the young, high-demand population. Other subsequent studies have further reviewed the risk factors for failure after surgery to continue to refine the treatment algorithm. The treatment of initial anterior dislocations of the shoulder remains a challenging endeavour, with an ever-expanding list of options. This classic work challenged the established treatment approach in a particular patient group, the young athlete. The teachings imparted in the article, and reiterated in subsequent research studies, have taught us treatment decisions should be personalised and formulated on an individual basis.

Ten-year follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocation in young patients

IntroductionEarly treatment of initial anterior glenohumeral dislocation in young patients is controversial and the interest of surgery, and notably arthroscopic stabilization, has not been demonstrated. A prospective study was therefore performed to assess (1) short-to-medium-term recurrence rate, (2) functional outcome, and (3) and medium-term osteoarthritis rate. HypothesisEarly arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with low recurrence rate. Materials and methodsTwenty-one patients with initial anterior dislocation were included between June 2002 and February 2004. All patients underwent arthroscopic Bankart repair within 30 days of dislocation. Patients were followed up prospectively, with clinical (Duplay and Constant scores) and radiological assessment (osteoarthritis). ResultsThere were 5 recurrent dislocations (25%); 2 patients reported sensations of subluxation: i.e., 7 failures (35%). Mean Walch-Duplay score at 10 years was 88±1 (range, 30–100) and mean Rowe score 86±22 (range, 35–100). There was significant internal rotation deficit of one vertebral level between operated and contralateral shoulder (P < 0.005). At 10 years, 3 shoulders (15%) showed Samilson grade 1 centered glenohumeral osteoarthritis. ConclusionEarly arthroscopic capsule-labrum reinsertion by the Bankart technique in the month following initial anterior dislocation of the shoulder in patients under 25 years of age provided a low recurrence rate (35%) compared to the literature, including dislocation (25%) and subluxation (10%). Functional outcome was satisfactory, and osteoarthritis rate was low (15% Samilson grade 1). Level of evidenceIV, prospective non-comparative study.

A case report of frozen shoulder after first-time traumatic initial anterior dislocation of the shoulder

A case report of frozen shoulder after first-time traumatic initial anterior dislocation of the shoulder

Irreducible anterior and posterior dislocation of the shoulder due to incarceration of the biceps tendon

Mechanical obstacles may infrequently impede closed reduction of anterior shoulder dislocation. Imaging techniques such as arthrography, computed tomography (CT) and magnetic resonance imaging (MRI) complement conventional radiography by allowing identification of obstacles to reduction. We present a case of irreducible anterior glenohumeral dislocation resulting from an initial anterior dislocation, converted to a posterior dislocation with an attempt at reduction, then converted back to anterior dislocation with a second reduction attempt. Soft tissue obstacles to shoulder reduction should be suspected when plain films do not identify a bony fragment as the culprit. CT and MRI are useful for identifying the cause of irreducibility and for operative planning.

Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence

An initial anterior dislocation of the shoulder becomes recurrent in 66% to 94% of young patients after immobilization of the shoulder in internal rotation. Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation. Our aim was to determine the benefit of immobilization in external rotation in a randomized controlled trial. One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were randomly assigned to be treated with immobilization in either internal rotation (ninety-four shoulders) or external rotation (104 shoulders) for three weeks. The primary outcome measure was a recurrent dislocation or subluxation. The minimum follow-up period was two years. The follow-up rate was seventy-four (79%) of ninety-four in the internal rotation group and eighty-five (82%) of 104 in the external rotation group. The compliance rate was thirty-nine (53%) of seventy-four in the internal rotation group and sixty-one (72%) of eighty-five in the external rotation group (p = 0.013). The intention-to-treat analysis revealed that the recurrence rate in the external rotation group (twenty-two of eighty-five; 26%) was significantly lower than that in the internal rotation group (thirty-one of seventy-four; 42%) (p = 0.033) with a relative risk reduction of 38.2%. In the subgroup of patients who were thirty years of age or younger, the relative risk reduction was 46.1%. Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation. This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger.

Immobilizatio in External Rotation for Initial Anterior Dislocation of the Glenohumeral Joint

Immobilizatio in External Rotation for Initial Anterior Dislocation of the Glenohumeral Joint

Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging.

Glenohumeral dislocations often recur, probably because a Bankart lesion does not heal sufficiently during the period of immobilization. Using magnetic resonance imaging, we assessed the position of the Bankart lesion, with the arm in internal and external rotation, in shoulders that had had a dislocation. Coaptation of a Bankart lesion was examined with use of magnetic resonance imaging, with the arm held at the side of the trunk and positioned first in internal rotation (mean, 29 degrees) and then in external rotation (mean, 35 degrees), in nineteen shoulders. Six shoulders (six patients) had had an initial anterior dislocation, and thirteen shoulders (twelve patients) had had recurrent anterior dislocation. Fast-spin-echo T2-weighted axial images were made when the dislocation had occurred less than two weeks earlier, and spin-echo T1-weighted axial images after intra-articular injection of gadolinium-diethylenetriamine pentaacetic acid were made when the dislocation had occurred more than two weeks earlier. Separation and displacement of the anteroinferior portion of the labrum from the glenoid rim were measured on the axial images, and coaptation of the anterior part of the capsule to the glenoid neck was assessed by measurement of the detached area, opening angle, and detached length. Separation and displacement of the labrum were both significantly less (p = 0.0047 and p = 0.0017, respectively) when the arm was in external rotation than when it was in internal rotation. The detached area and the opening angle of the anteroinferior portion of the capsule were both significantly smaller (p = 0.0003 and p < 0.0001, respectively), and the detached length was significantly shorter (p < 0.0001) with the arm in external rotation. Immobilization of the arm in external rotation better approximates the Bankart lesion to the glenoid neck than does the conventional position of internal rotation.

Arthroscopic Finding and Treatments of Initial Anterior Dislocation of the Shoulder.

Arthroscopic Finding and Treatments of Initial Anterior Dislocation of the Shoulder.

Acute Shoulder Dislocation: Indications and Techniques for Operative Management

The acute management of the initial, anterior shoulder dislocation is dependent on the age and activity demands of the patient. After a thorough examination and appropriate radiographs, a gentle closed reduction is the initial treatment. Previous authors have recommended a period of immobilization followed by a rehabilitation program emphasizing rotator cuff strengthening. Restricting return to athletic activities to allow adequate soft tissue healing is also recommended. This will effectively treat the vast majority of patients with this injury. In patients older than 25 years of age, one would expect a relatively low recurrence rate, especially in patients with low activity demands or in patients willing to modify activity. In active, young patients desiring a return to strenuous activity, however, most studies and our own experience demonstrate high recurrence rates. In the authors' experience, the examination under anesthesia and arthroscopic evaluation have confirmed an avulsion of the anterior-inferior capsulolabral complex as the primary injury component. The special circumstances of an initial dislocation with a hemarthrosis and excellent tissue quality make it ideal for arthroscopic stabilization. Our early results are encouraging and we believe this approach is a viable option in the management of this common injury in young athletes. As arthroscopic techniques for glenohumeral instability improve, we would expect an improvement on these initial results. Acute operative stabilization for the initial anterior dislocation is considered for: (1) initial dislocation that requires a reduction; (2) a young, athletic, high demand patient (<25 years of age) who is unwilling to modify his lifestyle; (3) subjects with no prior shoulder subluxation or impingement history; (4) subjects with no neurologic injury; and (5) subjects with no greater tuberosity fracture.

Finding of CT Arthrograms and Arthroscopy in Traumatic Initial Anterior Dislocations and Recurrent Anterior Dislocations of the Shoulder

Finding of CT Arthrograms and Arthroscopy in Traumatic Initial Anterior Dislocations and Recurrent Anterior Dislocations of the Shoulder

Recent Advances and Perspectives on Arthroscopic Stabilization of the Shoulder

The goal of surgical stabilization of the unstable glenohumeral joint is to produce a stable yet mobile joint that can return to preinjury function. Open surgical procedures (in particular, the Bankart procedure) have evolved to a point where stability and mobility are being attained with a low complication rate, but the rate of return to preinjury function, particularly in overhead athletes, has not been ideal. Arthroscopic stabilization is an attractive alternative to open procedures, particularly in those patients who have a history of traumatic and unidirectional recurrent dislocations with a labral detachment. A variety of techniques for reattaching a detached labro-ligamentous complex have been described. Longer follow-up is needed to assess the efficacy of these procedures fully, particularly in light of the good results now being obtained with the open Bankart procedure. Longer-term studies have shown a higher rate of recurrence of dislocation with the arthroscopic technique than with the open technique. Arthroscopic stabilization offers the potential advantages of shorter hospitalization, less traumatic treatment of the soft tissues, more thorough examination of the glenohumeral joint and subacromial bursa, and greater cosmesis. It could also provide a means by which selective stabilization of those initial anterior dislocations that might be prone to recurrence could be performed. Long-term follow-up and randomized studies comparing open and arthroscopic techniques are needed to further define the best role of arthroscopic shoulder stabilization and to determine which of the several techniques described provides the best results with the fewest complications.