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Habitual dislocation of the shoulder

A full range of orthopedic services, from diagnosis to full recovery

Every year, millions of patients around the world undergo arthroscopic surgery on the shoulder joint. The surgical technique of Bankart surgery on the shoulder joint is in most cases a standard procedure. With adequate technical equipment, sufficient qualifications and conscientiousness of the surgeon, performing such an operation is not a big problem. However, the operation is only one of the "three whales" that ensure a good result of the entire recovery process. The other two are preparation for surgery and postoperative rehabilitation. Preparation for the operation consists in familiarizing the patient with the main aspects of the upcoming surgery and the recovery program. Only the cooperation of the doctor and the patient in the postoperative period can lead to good results in the optimal time.

ARTICULAR LIP INJURY, ANTERIOR SHOULDER DISLOCATION, AND BANKART SURGERY

The shoulder joint consists of the head of the humerus and the articular cavity of the scapula and has the greatest mobility among all the joints of the human body. This is provided by a significant discrepancy between the shape of the head of the humerus, which has an almost spherical shape, and the flat depression of the scapula (Fig. 1).

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Figure 1 Left shoulder joint (front view)

The compliance of the articular surfaces of the shoulder joint increases the articular lip. The articular lip is a cartilage-like structure that is firmly connected to the scapula (Fig. 2). The articular lip increases the congruence of the humerus head and the articular cavity of the scapula, and is a mechanical barrier to the sliding of the humerus head from the articular cavity of the scapula. The capsule of the shoulder joint is attached to the articular lip.

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Articular lip of the shoulder shoulder-scapular ligaments

The joint capsule has a thickening zone in its composition. These are the shoulder – scapular ligaments-upper, middle and lower, first described by the famous scientist Galen in the Middle Ages. Each of the ligaments resists dislocation of the shoulder at a certain angle of abduction.

Thus, the articular lip and the joint capsule, together with the shoulder-scapular ligaments, are anatomically and functionally a single whole, providing a significant percentage of joint stability. If there is a separation of the articular lip from the scapular cavity, the stabilizing function of the shoulder-scapular ligament complex is also lost.

WHY IS THERE DAMAGE TO THE ARTICULAR LIP AND DISLOCATION OF THE SHOULDER?

The mechanism of the injury is excessive external rotation of the withdrawn shoulder. Why the allotted one? Because the displacement of the head of the reduced humerus beyond the boundaries of the articular cavity of the scapula is hindered by the beak-like process. As a result of the withdrawal, the larger segment of the head of the humerus is located below the level of the beak process. Under the action of the displacement force, damage occurs to the anterior stabilizing structures of the capsule (most often, the separation of the articular lip from the periosteum of the articular cavity of the scapula).

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Fig. 3 Mechanism of articular lip detachment (right shoulder joint, front view)

As the displacement force continues, the posterior part of the head of the humerus jumps over the anterior edge of the articular cavity of the scapula, which is often accompanied by the formation of a dent (impact fracture) on its posterior surface (the so-called Hill-Sachs defect). There is a complete separation of the articular surfaces with the shoulder head jammed on the leading edge of the articular cavity of the scapula - anterior dislocation of the shoulder (Fig. 4). If the head of the humerus is stronger, there is a fracture of the articular cavity of the scapula, but damage to the bones that make up the shoulder joint with anterior dislocation occurs in the vast majority of cases.

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Fig. 4. Anterior shoulder dislocation



If there is an anterior dislocation, there is a sharp pain and a characteristic deformation of the contour of the shoulder joint (Fig. 5).

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Fig. 5. View of a patient with a dislocation of the right shoulder joint.



Dislocation of the shoulder joint must be immediately eliminated. This can only be done by a trained doctor. There are dozens of ways to correct a dislocation of the shoulder joint. However, this procedure is sometimes quite difficult even in the hands of an experienced traumatologist (Fig. 6).


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After the dislocation of the shoulder is corrected, a plaster or polymer bandage is applied to immobilize the arm and create conditions for the fusion of the damaged parts of the joint. The average duration of the immobilization period is 4 weeks.

However, as you already know, shoulder dislocation cannot occur without a rupture of the articular lip and the occurrence of a defect on the head of the shoulder and/or fractures of the articular cavity of the scapula. Without a full examination of the shoulder after the dislocation is corrected, we cannot know exactly what structures of the joint are and how badly damaged. Full information about the condition of the shoulder joint can be given by magnetic resonance imaging (MRI) on modern devices from 1.5 Tesla and higher. If after the scan, we can see that the severed part of the articular lips are close to normal, defects in the head, shoulder, and/or glenoid fossa of scapula is negligible, we can treat the effects of dislocation without surgery through immobilization.

If, after the dislocation is corrected, the torn parts of the articular lip are not in place and there are large bone defects, it is necessary to perform an operation to restore the damaged structures of the joint, since the probability of repeated dislocation and the formation of the so-called "habitual shoulder dislocation" is very high.

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Arthur Sydney Blundell Bankart

1879 - 1951

The separation of the articular lip from the periosteum of the scapula is called the Bankart injury, in honor of the outstanding British surgeon Arthur Bankart. He is also the author of the operation of the same name, namely, sewing (refixing) the articular lip to the articular cavity of the scapula (Fig. 7).

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Currently, the operation to sew on the articular lip is performed without incision of the joint – under arthroscopic control. Instead of drilling holes, metal or polymer absorbable anchors are installed in the front edge of the blade.

WHAT IS AN ANCHOR?

An arthroscopic anchor is a device designed to hold threads in the bone, just as a ship's anchor, when sunk into the ground, holds the ship in place by means of an anchor rope or chain. Anchors can be screwed into the bone or hammered into a pre-made small hole (Fig. 8). To the threads fixed in the anchors, sew the parts of the articular bag, the articular lip or tendons torn from the bone (Fig.9). It should be understood that the anchors perform only a temporary function, since the sewn structures after some time are fused to the bone by means of a strong scar tissue. After that, the anchors made of absorbable polymers gradually disappear, and the metal ones remain for life. Metal anchors for the Bankart operation have a diameter of about 3 mm and are made of titanium alloy, so they allow you to pass MRI and other examinations without hindrance in the future.

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Figure 8. Introduction of a titanium anchor into the bone.

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Fig. 9. Stages of fixation to the anchor of the articular lip.

The strength of the articular lip fixation depends on the correct choice of anchors, the correct technique of their installation and a sufficient volume of soft tissues. The number of anchors required for the Bankart operation depends on the size of the gap. Usually 2 or 3 anchors are installed.



It should be noted that isolated refixation of the articular lip (Bankart surgery) can be used only for the treatment of the same injury and in very rare cases with the usual dislocation of the shoulder.



If there is a Hill-Sachs defect on the posterior surface of the shoulder head, the Bankart operation should be supplemented with a procedure for filling in this defect (the so-called "reimplessage") Fig. 10.


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Fig. 10. The principle of combining the Bankart operation and the reimplessage procedure.

Thus, the choice of treatment method after subluxation or dislocation in the shoulder joint is based on a thorough study of the results of magnetic resonance imaging.

Surgical treatment of the consequences of subluxation or dislocation in the shoulder joint in our conditions is performed without incision of the joint – under arthroscopic control.

A properly performed operation allows for a sufficiently active rehabilitation, which prevents the development of complications and optimizes the recovery time.

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Advantages of treatment in Orthopedics by Ruslan Sergienko

  • 10 years on medical services in Ukraine
  • > 25 years of experience with leading specialists
  • Anna Vovchenko and Ruslan Sergienko are recognized opinion leaders among the orthopedic traumatologists
  • > 150,000 consultations were held
  • > 7,500 surgeries were performed
  • All types of pain management
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  • Postoperative rehabilitation by certified specialists
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