Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

Aims. The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model. Methods. A total of 1,293 patients with PTASD managed nonoperatively were identified from a trauma database (mean age 23.3 years (15 to 35); 14.3% female). We assessed the prevalence of RI, and used multivariate regression modelling to evaluate which demographic- and injury-related factors were independently predictive for its occurrence. Results. The overall rate of RI at a mean follow-up of 34.4 months (SD 47.0) was 62.8% (n = 812), with 81.0% (n = 658) experiencing their first recurrence within two years of PTASD. The median time for recurrence was 9.8 months (IQR 3.9 to 19.4). Independent predictors increasing risk of RI included male sex (p < 0.001), younger age at PTASD (p < 0.001), participation in contact sport (p < 0.001), and the presence of a bony Bankart (BB) lesion (p = 0.028). Greater tuberosity fracture (GTF) was protective (p < 0.001). However, the discriminative ability of the resulting predictive model for two-year risk of RI was poor (area under the curve (AUC) 0.672). A subset analysis excluding identifiable radiological predictors of BB and GTF worsened the predictive ability (AUC 0.646). Conclusion. This study clarifies the prevalence and risk factors for RI following PTASD in a large, unselected patient cohort. Although these data permitted the development of a predictive tool for RI, its discriminative ability was poor. Predicting RI remains challenging, and as-yet-undetermined risk factors may be important in determining the risk. Cite this article: Bone Joint J 2024;106-B(10):1111–1117

Introduction: This study was performed to assess the incidence of generalized ligament laxity in patients presented with 1st time anterior shoulder dislocation. Patients and Methods: Prospective data was collected for patients presented with 1st time anterior shoulder dislocation and clavicle fracture as a control group between Aug 2008 and Feb 2009 under the care of a specialist shoulder surgeon. Data included demographic details, mechanism of injury and generalized ligament laxity using Beighton score. Laxity is scored on a 0–9 scale. Scores of 4 or above are indicative of generalized ligament laxity. Brighton criteria was used to diagnose Benign Joint Hypermobility Syndrome (BJHS). Results: Data was collected for 44 patients with first time anterior shoulder dislocation and 43 patients with clavicle fracture. There was no difference in the demographics of the groups. There were 40 male (91%) and 4 (9%) female patients in the dislocation group. Mean age was 25 years with a range from 15–55. Most common cause of shoulder dislocation was sports related injuries in 26 patients (60%). The average Beighton score for dislocation group was 3.6 with a range from 0–9 as compared to 2.1 with a range from 0–7 in the control group. Twenty one patients (48%) in the dislocation group had a Beighton score of 4 or more indicating generalized ligament laxity as compared to 12 patients (28%) in the control group. This difference was statistically significant with a P value of 0.009. Six patients (14%) fulfilled the Brighton criteria for BJHS in the dislocation group as compared to 3 patients (7%) in the control group. Conclusion: We found that there is a high incidence (48%) of generalized ligament laxity in patients presented with first time anterior shoulder dislocation. Appropriate advice should be given to these patients about rehabilitation, risk of recurrent dislocations and timing of shoulder stabilization

[Hong Kong Orthopaedic Association, Travelling Fellow]. Glenoid bone loss predisposes to further dislocation and failure of arthroscopic Bankart repair in patients with recurrent shoulder dislocation. This study investigates quantification of glenoid bone loss in anterior shoulder dislocation using computerized tomography (CT). CT was performed in 40 patients (average age 31 years, range 16–82 years) with anterior shoulder dislocation. Of this group, 42 shoulders with anterior dislocation and 38 contralateral normal shoulders were examined. In addition, twenty shoulders in ten normal subjects were examined. CT technique comprised 1mm acquisition, pitch 1.0, simultaneously of both shoulders. Reformatted images en face to the glenoid fossa were obtained. Ten different measures of the glenoid fossa were obtained including cross sectional area, maximum height, and width and flattening of the anterior curvature of the glenoid. In normal subjects, maximum side to side difference in cross-sectional area was 14% and maximum glenoid width 4.1mm. For dislocating shoulders, flattening of the anterior edge of the glenoid fossa and a reduction in maximum glenoid width were the best objective criteria of bone loss. Flattening of the anterior glenoid curvature was a feature of 95% dislocated shoulders though was only seen in 1.5% of normal shoulders. Glenoid cross-sectional area was not a useful measure of glenoid bone deficiency. Variable glenoid bone loss is a measurable feature of anterior shoulder dislocation. CT can be used to objectively assess this preoperatively. This should help when deciding on whether to perform an arthroscopic Bankart repair or open bone block procedure

Purpose: To determine whether generalized ligamentous laxity is a predisposing factor for primary traumatic anterior shoulder dislocation in young, active patients. Method: Prospective case series with age and sex matched controls. The Hospital Del Mar Criteria was utilized to measure generalized ligamentous laxity. Fifty-seven (n=57) consecutive individuals (age< 30) sustaining a primary traumatic anterior shoulder dislocation between 2003 and 2006 were examined for hyperlaxity. The control group was comprised of seventy-two (n=72) undergraduate university students without a prior history of shoulder dislocation or anterior cruciate ligament injury. Results: After adjusting for age and sex, the prevalence of hyperlaxity in the study group was 32.8% compared with 10.4% in the control group (p< 0.01). The prevalence of increased contralateral shoulder external rotation (> 85o) was 40.3% in the study group compared with 20.8% in the control group (p< 0.03). Among males, the prevalence of hyperlaxity was 28.3% in the study group and 5.3% in the controls (p< 0.01). Conclusion: Although several studies have looked at the variables affecting shoulder instability, generalized ligamentous laxity (as measured by validated criteria) has not previously been identified as a predisposing factor for primary traumatic shoulder dislocation. This study demonstrates that generalized joint laxity and increased external rotation in the contralateral shoulder were found to be more common in patients who had sustained a primary shoulder dislocation. These observations may suggest a role for shoulder-specific proprioceptive and strength training protocols in hyperlax individuals participating in high-risk sports. Furthermore, the implications of hyperlaxity on the surgical management of traumatic primary shoulder instability are uncertain

Introduction and purpose: One of the sequelae that patients with recurrent shoulder dislocation must face is a significant limitation of their capacities for daily living and sports activities. The purpose of treatment is the recovery of stability in order that patients can return to their activities with the as little loss of mobility and strength as possible. The aim of our study was to analyze the evolution of physical activity and correlate final stability with postoperative sports activity. Materials and methods: We carried out a retrospective study on a sample of 30 patients diagnosed with recurrent shoulder dislocation who underwent surgery between January 2001 and May 2005. After a minimum 2 years’ follow-up, mobility and strength in the operated shoulder was assessed, comparing it to the contralateral limb; the stability and possible recurrence in the affected limb were also evaluated. Furthermore, at that time, data was collected on the sports activities of the patients. Results: After more than 2 years’ follow-up a statistically significant decrease in the number of patients who performed high-risk sports was observed. Furthermore, in those patients who continued to practice high-risk sports after surgery, greater stability was seen in comparison with those patients who did not (p> 0.05). Conclusions: Patients that undergo surgery for recurrent shoulder dislocation decrease their sports activities in comparison with their preoperative activities and the results of surgery are independent of postoperative sports activity

The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation. Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group. The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069). This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder

Introduction: Preliminary data suggest that immobilization in external rotation may be effective in lowering the incidence of recurrence after first traumatic shoulder dislocation, with a zero reoccurrence rate reported at 15 months follow-up. The purpose of the present study was to ascertain whether this method could lower the incidence of recurrent dislocation in a young, very physically active population. Methods: In an IRB approved prospective study, young males who sustained first traumatic shoulder dislocation were randomized to be treated for four weeks either using a traditional internal rotation brace or a new device which immobilizes the shoulder at 15 to 20 degrees of external rotation. Subjects were then treated according to a standard physical therapy protocol. Follow-up was done at five time points in the first year post dislocation. Subjects with clinically stable shoulders resumed full activity after three months. Differences in outcome were assessed by the chi square test. Results: Thirty nine subjects participated in the study. Thirty of them were soldiers. Twenty four subjects were treated with external rotation braces. At follow-up of between 4 to 28 months, a new dislocation was documented in 8 of the 24 subjects immobilized in external rotation (33%) and in 5 of the 15 subjects immobilized in internal rotation (33 %). No statistical difference (p=1.0) was found between the instability rates of the two treatment groups. Discussion: The present study indicates that even in a short-term follow-up the technique of immobilizing a first dislocation in external rotation was not effective in lowering the incidence of recurrent shoulder dislocations in a young, physically active population

Aims: The re-dislocation rates in adults (< 30 years) in the initial 12 months after FAT (first,anterior,traumatic) shoulder dislocations treated non-operatively vary from 25% to 95%. Some surgeons advocate early arthroscopic surgery following such dislocations as this appears to reduce recurrent instability. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability after such dislocations when compared to non-operative treatment. Material and Methods: Specific search terms were used to retrieve relevant studies from MEDLINE, EMBASE, and CINAHL extending from 1966 to October 2003. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed. Adults under 30 years of age, with clinical and radiological confirmation of anterior dislocation following trauma with a minimum follow-up of 12 months were included. Patients with previous shoulder problems, generalised joint laxity, neurological injury, impingement and a history of substance abuse were excluded. Results: 13 studies involving 433 shoulders were reviewed. Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84). Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179). Recurrent instability (subluxation /dislocation) following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]. Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of recurrent instability was 70% (119/170). Recurrent instability following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24]. Conclusion: Early arthroscopic surgery reduces recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic treatment should be offered to young, athletic patients especially those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after initial shoulder dislocation. Further randomised control trials reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of FAT shoulder dislocation

To discover how traumatic anterior shoulder dislocation in the young patient (17–25) is managed by shoulder surgeons in the UK. A comprehensive postal questionnaire was sent to 164 orthopaedic consultants, all members of BESS. Questions were asked about the initial reduction, investigations undertaken, timing of any surgery, preferred stabilization procedure, arthroscopic or open, detail of surgical technique, period of immobilization and rehabilitation programmes instigated in first-time and recur- rent traumatic dislocaters. The response rate was 82% (n=135). The most likely treatment of a young traumatic shoulder dislocation:. It will be reduced under sedation in A& E by the A& E doctor. Apart from x-ray, no investigations will be performed. It will be immobilised for 3 weeks, then given course of physiotherapy. Upon their second dislocation, they will be listed directly for an open Bankart procedure (with capsular shift as indicated) during which subscapularis will be detached and metallic bone anchors used. Following surgery, they will be immobilised for 3 to 4 weeks, before being permitted full range of movement at 2 to 3 months and allowed to return to contact sports at 6 to 12 months. On the other hand, 54% of surgeons indicated they would investigate prior to surgery, 18% said their first choice operation would be arthroscopic stabilisation, the number of dislocations normally permitted before surgery ranged from 1 to more than 4, and the period of immobilisation post operation from nil to 6 weeks. We now know how shoulder surgeons in the UK are treating this common injury. The results reveal that in Britain, we do not have a consistent approach, raising many discussion points. Open stabilisation remains the firm favourite. Does this mean arthroscopic stabilisation is regarded as an experimental procedure?

Aims. To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years. Methods. The same postal questionnaire was sent in 2002 and 2009 to 164 shoulder surgeons. Questions were asked about initial reduction, investigation undertaken, timing of surgery, preferred stabilisation procedure, period of immobilisation and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results. Response rate - 92% (2009), 83% (2002). The most likely management of a young traumatic shoulder dislocation:. Reduction under sedation in A&E by A&E doctor (80%). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68% would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% (2002). Of them, nearly 90% would perform an arthroscopic stabilisation vs. 57.5% (2002). For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% (2002). 77% would perform arthroscopic stabilisation vs. 18% (2002), commonest procedure-arthroscopic Bankart repair using biodegradable bone anchors (62% 2009 vs. 27% in 2002). Immobilisation for 3 weeks, full range of motion 1-2 months and return to contact sports 6 - 12 months. Conclusion. There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first-time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery, namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2002

Aim: The re-dislocation rates in adults (< 30 years) in the initial 12 months after first, anterior, traumatic (FAT) shoulder dislocations treated non-operatively vary from 25% to 95%. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability (failure) after such dislocations when compared to non-operative treatment. Material and Methods: Specific search terms were used to retrieve relevant studies from various databases extending from 1966 to May 2004. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed. Results: 13 studies involving 433 shoulders were reviewed. Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84). Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179). Failure following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]. Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of failure was 70% (119/170). Failure following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24]. Conclusion: Early arthroscopic surgery appears to reduce recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic stabilisation may be considered for young, athletic patients and those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after FAT shoulder dislocation. RCTs reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of traumatic anterior shoulder dislocation

Aims: To discover how the management of traumatic anterior shoulder dislocation in the young patient (17–25) has changed, if at all, over the past six years. Methods: The same postal questionnaire was used in 2003 and 2009, sent out to 164 members of British Elbow and Shoulder Society. Questions were asked about the initial reduction, investigation undertaken, timing of any surgery, preferred stabilization procedure, arthroscopic or open, detail of surgical technique, period of immobilization and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results: The response rate were 92% (n=151) – 2009, 83% (n=131) – 2003 The most likely management of a young traumatic shoulder dislocation in the UK would be:. Reduction under sedation in A& E by the A& E doctor (80% of respondents). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68 % of respondents would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% in 2003. Out of them nearly 90% would perform an arthroscopic stabilization vs. 57.5% in 2003. For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% in 2003 that would chose to investigate. 77% would choose to perform arthroscopic stabilisation compared to 18% in 2003, the commonest procedure being arthroscopic Bankart repair using biodegradable bone anchors (62% compared to 27% in 2003). Following surgery, immobilisation would be for 3 weeks, full range of motion at 1 to 2 months and return to contact sports at 6 to 12 months. Conclusions: There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2003

Aim: To survey how acute, traumatic, first-time anterior shoulder dislocation (AFSD) is managed amongst trauma clinicians in the current clinical setting in UK hospitals. Design: Postal Questionnaire. Method: 228 questionnaires were sent out to list of active consultant member of the British Trauma Society practising in various hospitals around United Kingdom. Questions were laid out in two workgroups. In work-group one, an assortment of questions were asked with the emphasis on management in AFSD from the point of entry in a casualty department to departure and after-care. In workgroup two, case scenarios were included to look in the ‘aftercare’ management in three distinct age groups; young (< 25 years old), middle age (30–65 years old) and elderly (> 65 years old). Results: The response rate of the questionnaires was 51%. Twenty-two per cent of respondents have local protocol for managing AFSD. All respondents recommended pre-and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia with ‘airways monitoring’, as opposed to intra-articular anaesthesia (68 versus 9). Kocher and Hippocrates were the most popular methods of reduction. Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only a small number of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury (16 of 84). Conclusion: This survey revealed the current practice of trauma clinicians in managing AFSD on the ‘front-line’. We conclude that there is significant variation in response to the issues incorporated in this survey. There is a need to address the issues of intra-articular analgesia, immobilisation technique and management of AFSD amongst young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised controlled clinical trial prior to the introduction of a protocol for managing this problem

Introduction: Various surgical methods have been described to manage the problem of recurrent anterior dislocation of the shoulder. Older procedures Putti-Platt’s, Magnuson-Stack’s or Bristow;’s and Boytchev’s repair are not used today due to a high percentage of failure of 7%–17% incidence of recurrence associated with limited ROM. However, in the last decade the goal of treatment has changed. It is directed now towards restoration of normal function with full ROM of the affected shoulder, based mainly on arthroscopic stabilization or on “open” Neer’s capsular shift procedures combined with Bankart’s repair. However, during the last few years there are more and more papers dealing with a surprising unexpected high number of patients with shoulder instability following arthroscopic repair. The purpose of this study is to review the long term results of “open” Neer’s capsular shift procedure. Materials & Methods: This is a presentation of 87 (78M; 9F) consecutive patients, 19 to 47 year old (mean 23 Y) with a length of follow-up of 4Y–15Y (mean 6Y). 45 of them with traumatic recurrent anterior dislocation of the shoulder had a capsular shift procedure according to Rockwood’s modification. In 42 other patients that had a multidirectional instability with proved dislocations of the affected shoulder a Protzman’s modified capsular shift procedure was used. Results: 82/87 patients had a stable shoulder without recurrent dislocation. 3 patients had an episode of traumatic shoulder dislocation within 2 months following operation. Two other patients of 42 with multidirectional instability had a recurrence of traumatic dislocation. One patient developed partial brachial plexus injury, most probably due to traction of the affected limb following operation. 78/87 had at follow-up normal shoulder function with full ROM, and the remaining 9 patients had only a slight limitation in shoulder abduction and in external rotation. Conclusions: Based on this study, it is suggested that capsular shift procedure is an excellent method for repair of recurrent anterior shoulder dislocation, preferable to the “older” procedures, and allows restoration of shoulder stability with better functional results. This is suitable mainly for patients with structural hyperlaxity and multidirectional instability, whereas arthroscopic stabilization might be used in patients with true traumatic instability

Most of surgical methods, suggested for habitual shoulder instability treatment provide almost similar percentage of successful results, being 90–95%. However, some investigations show unequal efficiency of standard methods in dependence on bone-cartilage lesions presence. It is revealed that redislocations number after arthroscopic Banckart operation in group of patients with insignificant bone-cartilage lesions is 4%, however, in group of patients with significant lesion this figure becomes 67%. In this case – an actual problem is to find new treatment procedure for patients with habitual shoulder instability with bone-cartilage lesion. We aimed to demonstrate our results of treatment of patients with habitual anterior shoulder instability and arthroscopically revealed bone-cartilage lesions using rotational osteotomy by Saha-Weber. In 99 patients with massive bone-cartilage lesion of back surface of humeral head (arthroscopically proved), we have applied rotational osteotomy of the humerus with subscapularis tendon transposition (male/female ratio - 3:1, middle age - 34.6 years). Average duration of disease before the operation was 4.2 years (from 1.2 years to 24 years). In each clinical case the quantity of shoulder dislocations exceeded 6. Long-term result of treatment is studied at 55 patients. Good and excellent clinical results have been reached at 48 patients (87.2%). The moderate functional disorders are revealed in 6 patients (10.9 %). There was one case of redislocation after repeated trauma. There were no cases of nonunion, evident contracture or avascular necrosis of humeral head. These data were compared with the results of surgical technique of strengthening of anterior wall of shoulder joint according to Boychev-I in treatment of 56 patients with an anterior habitual shoulder dislocation with clinical manifestations of bone- cartilage lesion (high number of dislocations with signs of severe instability, average term of supervision - 7 years). Insufficiency of applied technique almost at each third patient is determined. The unsatisfactory result of treatment (redislocation) is found in 4 cases (7.1%), satisfactory (the moderate and expressed functional deficiency) - in 12 (21.4%). Rotational osteotomy of a humerus with subscapularis tendon transposition is an effective operation with rather simple postoperative conducting and low frequency of complications. Obtained data show its advantages in comparison with soft-tissue operations. This operation can be recommended in cases of pronounced Hill-Sacks lesion with severe instability of humeral joint and after failed plastic procedures on the soft tissues

A comprehensive postal questionnaire was sent to 164 orthopaedic consultants, all members of the Brit-ish Elbow and Shoulder Society. Questions were asked about the initial reduction, investigations undertaken, timing of any surgery, preferred stabilization procedure, arthroscopic or open, detail of surgical technique, period of immobilization and rehabilitation programmes instigated in first-time and recurrent traumatic dislocators. The response rate was 83% (n=136). The most likely treatment of a young traumatic shoulder dislocation:. It will be reduced under sedation in A& E by the A& E doctor. Apart from x-ray, no investigations will be performed. It will be immobilised for 3 weeks, then given course of physiotherapy. Upon their second dislocation, they will be listed directly for an open Bankart procedure (with capsular shift as indicated) during which subscapularis will be detached and metallic bone anchors used. Following surgery, they will be immobilised for 3 to 4 weeks, before being permitted full range of movement at 2 to 3 months and allowed to return to contact sports at 6 to 12 months. On the other hand, 54% of surgeons indicated they would investigate prior to surgery, 16% said their first choice operation would be arthroscopic stabilisation, the number of dislocations normally permitted before surgery ranged from 1 to more than 3, and the period of immobilisation post operation from nil to 6 weeks. The results reveal a wide variation in practice and no clear consensus on how to best manage these patients. Open stabilisation remains the firm favourite. Does this mean arthroscopic stabilisation is regarded as an experimental procedure?

Hypothesis. Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions. Material and methods. We dissected 14 cadaveric shoulders. A bony Bankart lesion was created in form of an inverted pear glenoid. The humeral head was attached to a pulley system that was sequentially loaded until the shoulder dislocated anteriorly. The force needed to dislocate was noted. This was repeated after coracoid transfer with two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. Results. The mean force required to dislocate shoulder post-Classical Latarjet technique was 325.71N, compared to 123.57 N in uncorrected shoulder. Similarly, the mean force required to dislocate shoulder post Congruent-Arc Latarjet technique was 327.14 N compared to 123.57 N in uncorrected shoulder. The two-tailed P value in either case was less than 0.0001, thus statistically significant. Unpaired t-test was done to compare the force required to dislocate the shoulder post procedure. Mean force required to dislocate shoulder post-Classical Latarjet, was 325.7N compared to 327N in post-Congruent Arc. The two-tailed P value equals 0.9020 and the 95% confidence interval was from −25.05 to 22.19, thus the difference was not statistically significant. Conclusion. The results confirm that both (Classical and Congruent-Arc Latarjet) techniques are good for addressing the shoulder instability, however bone block effect provided by one is not superior to other

The incidence of nerve injuries in primary shoulder dislocation and humeral neck fracture is uncertain. We made a prospective study of 101 patients, using clinical examination and extensive electrophysiological assessment when there was suspicion of nerve damage. We found electrophysiological evidence of nerve injury in 45%, most involving the axillary, suprascapular, radial and musculocutaneous nerves. There were significantly more nerve injuries in older patients and those with a haematoma. Most patients recovered partially or completely in less than four months, and only eight had persistent motor loss. Early diagnosis and physiotherapy are recommended

The purpose of this study was to determine arthroscopically the pathology following anterior shoulder dislocation and assess visually whether rotation of the arm affected the reduction of the capsulolabral complex in cases where this was detached. Over a sixteen month period from December 2000 to March 2002 we have arthroscoped and followed up prospectively a cohort of thirty patients. All patients were immobilised in a sling for four weeks and rehabilitated in a similar fashion with physiotherapy. The average age of the patients was 31 years and all patients were arthroscoped within six weeks of injury. The Hill Sachs lesion and capsulolabral complex injury were the most common pathology and were seen in two thirds of the patients. In the remaining group capsular tears and stretching were the most frequent injuries seen. Injuries to the capsulolabral complex were seen in 22 patients. In seventeen of these the capsulolabral complex was still mobile and the time to arthroscopy averaged 10.3 days (Range 0–25). In the remaining five patients the labrum had healed in a malreduced position. The average time to arthroscopy in these patients was 30.8 days (Range 19–42). In the patients where the capsulolabral complex had not reattached 14/17 (82%) patients demonstrated a better reduction of the labrum onto the glenoid with the arm in external rotation. Based on these findings we conclude that:. The traditional use of a sling with the arm internally rotated may contribute to the capsulolabral complex healing in a malreduced position. This may be a contributory factor to the high redislocation rates found in young adults. Splinting the arm in a position of external rotation for four weeks may allow better reduction of the capsulolabral complex onto the glenoid