Chronic Locked Anterior Dislocation

 

 

Definition

 

A glenohumeral dislocation which has been missed for a significant period of time

- time period is arbitrary

- > 3-6 weeks

 

Pathology

 

Anterior glenoid bone deficiency

Large Hill Sachs lesions

Rotator cuff tears

 

Etiology

 

Poor historians

- developmental delay

- dementia

 

Issues

 

Closed reduction may be unsuccessful / locked

Open reduction - unstable due to bony deficiency / rotator cuff tears

 

Xray

 

Signs of chronic shoulder dislocation

 

 

CT

 

Assess bone stock / glenoid bone loss / Hill Sachs lesions

 

Chronic shoulder dislocation with large Hill Sachs and minimal glenoid deficiency

 

Chronic shoulder dislocation with large Hill Sachs and significant glenoid deficiency

 

MRI

 

Rotator cuff tears

 

MRI with massive supraspinatus tear, subscapularis tear, and large Hill Sachs lesion

 

MRI with supraspinatus tear, Hill Sachs lesion and significant glenoid bony deficiency

 

Nonoperative management

 

Indications

 

Elderly with significant medial issues

 

Operative management

 

Options

 

1.  Humeral head preservation: open reduction +/- glenoid bone graft +/- Hill Sachs allograft +/- rotator cuff repair

2.  Arthroplasty +/- glenoid bone graft

 

Results

 

Latarjet

 

Li et al JBJS Am 2016

- 25 patients undergoing latarjet for chronic locked anterior dislocations

- Latarjet procedure: recurrent instability 50%

- Latarjet + humeral head replacement: recurrent instability 80%

 

Humeral head replacement v reverse TSA

 

Statz et al Int Orthop 2017

- 19 chronic locked anterior dislocations

- 10 hemiathroplasties / anatomic TSA: 6/10 unstable

- 9 reverse TSA: 0/10 unstable

 

reverse TSA

 

Kurowicki et al JSES 2106

- 24 cases of chronic locked anterior dislocations treated with rTSA

- compared to control rTSA

- increased need for glenoid bone graft

- increased used of larger glenospere

- increase rate of acromial stress fractures

 

Open reduction +/- glenoid bone graft +/- Hill Sachs allograft +/- rotator cuff repair

 

 

Humeral head replacement + glenoid autograft + rotator cuff repair

 

 

Post humeral head replacement / glenoid autograft / rotator cuff repair

 

Rotator cuff failure and development of anterosuperior escape

 

 Reverse TSA +/- glenoid bone graft

 

Chronic locked with large Hill Sachs treated with rTSA + glenoid bone graft

 

Chronic locked with large Hill Sachs and normal glenoid treated with rTSA + glenoid bone graft