Surgery for habitual dislocation of the shoulder

Shoulder dislocation is one type of shoulder injury. At first glance, it may seem that this kind of pathology affects only athletes or people whose lives are associated with heavy and dangerous physical exertion. Actually, this point of view is wrong.

Injury, including dislocation, of the articular apparatus of the shoulder is a condition in which the connection of the surfaces of its elements is broken. Even minor loads, a hard hit, a bad fall, lifting a heavy load, light exercise, or a game of beach volleyball with friends can cause a dislocated shoulder. As a result, the affected person feels severe pain, and the mobility of the joint and limb is significantly limited.

The device of the shoulder joint, the causes of dislocations

The shoulder joint is a system that connects the upper limb of the human body with the shoulder girdle of the body, namely with the scapula.

The spherical head of the humerus, an element that forms the skeleton of the hand, is involved in the formation of the joint. The articular cavity articulates with it – the concave zone of the scapula, which looks like a fossa with a flat bottom. Along the edge of the circumference of the fossa is the articular lip, formed by cartilaginous tissue. This element is designed to increase the area of ​​the cavity without limiting the mobility of the joint head. In addition, the lip of the joint softens shocks and shocks when the head moves, acting as a shock absorber.

Between the bone edge of the head of the joint, a capsule is attached to the articular cavity – it covers the humeral head and ends at the anatomical neck.

From the base of the coracoid process, a dense bundle of fibers is woven into the articular capsule – it plays the role of an additional ligament of articular surfaces.

Strengthening and maintenance of the elements of the joint occurs, for the most part, due to the muscular corset. It would be impractical to tie them together with dense strong ligaments, since the working mobility of the shoulder is achieved precisely due to the free rotation of the articular head in the cavity on the shoulder blade.

A dislocation implies that the normal state of the joint is disturbed, and its elements are in places that do not correspond to their usual location. The structural parts of the joint are displaced, shifted or completely leave their intended place (this applies mainly to the articular head).

The main causes of shoulder dislocation are joint diseases, physical exertion, shocks, falls, inflammation, unnatural rotation of the limb.

Symptoms and types of dislocations of the shoulder joint

Dislocation of the shoulder in an acute condition is quite simple to determine by its manifestations:

• persistent pain syndrome;
• the formation of swelling in the shoulder area;
• stiffness of the joint, violation of its motor function;
• loss of sensation in the shoulder and arm;
• if the dislocation is significant, the doctor can feel the deformity of the articular apparatus.

Depending on how exactly the system of joint elements is disturbed, there are anterior, inferior and posterior dislocations.

The first of these is considered the most common. In an anterior dislocation, the head of the humerus moves forward toward the coracoid process or clavicle. Inferior dislocation refers to the downward displacement of the head, which prevents the person from lowering their arm. A person can get a rear type of injury by falling forward on outstretched arms. In this case, in the articular apparatus, the articular lip is separated from the cavity.

What is habitual dislocation of the shoulder

For some people who have experienced this unpleasant injury, it becomes a common condition when, first, after the treatment, the articular apparatus returns to normal. The affected person complies with all the requirements of the rehabilitation period, protects the shoulder from stress, and fulfills all the requirements of the doctor. It seems that the injury is over, recovery has come, and you can return to a normal lifestyle again.

However, as soon as a person loads the recovered shoulder with the usual mode of his life, the joint again strikes a dislocation.

If the patient develops a pathology called “habitual dislocation of the shoulder”, with any load or sudden movement, he will experience dislocations after once cured dislocation. The root cause of this condition in most cases is damage to the articular lip, due to which the constituent elements of the joint cannot normally be fixed in relation to each other.

Methods of treatment of habitual dislocation

The doctor who is usually treated by patients with such an injury is a traumatologist or surgeon. These specialists, after conducting an initial examination and questioning of the patient, having determined his state of habitual dislocation, can prescribe treatment regimens that are based on conservative therapy or surgical intervention.

Conservative treatment, most often, is ineffective in case of habitual dislocation. If their number in a patient did not exceed two or three cases, you can try massage courses in combination with a complex of physiotherapy exercises. At the time of this type of treatment, measures must be taken to limit abduction and external rotation in the joint.

If conservative methods fail, and dislocations recur, the only effective way to get rid of them is surgery. This method is aimed at eliminating the cause of constantly recurrent dislocation, with the condition of maximum preservation of joint mobility. In this way, it is possible to achieve the prevention of recurrence of pathology.

Main types of shoulder surgery

Pathology treatment includes up to 200 types of surgical intervention in the articular apparatus. In general, all types of operations for habitual shoulder dislocation can be divided into 4 main groups:

• strengthening the joint capsule;
• plastic interventions on muscles and tendons;
• osteoplastic procedures with implantation of grafts;
• mixed types of operations.

Indications and process of preparation for surgery

The appointment of an operative intervention of this nature is usually preceded by the establishment of a diagnosis and the number of recurrences of dislocation, an examination of the state of the joint and the degree of its damage. Thus, the referral of a patient to such an operation is possible subject to several conditions:

• the presence of a confirmed repeatedly repeated dislocation of the shoulder joint;
• failure of conservative treatments.

Accordingly, the indication for surgery is a habitual shoulder dislocation – such that it is constantly repeated with any type of load on the joint.

Preparatory measures include the delivery of some tests that are necessary for the doctor to properly plan the use of anesthesia, as well as to select the technique for performing the operation. So, the surgeon can refer the patient to the delivery of a general blood test, coagulogram and blood biochemistry.

At the time of the appointment of the operation, the doctor must have on hand the actual results of radiography or MRI of the affected joint.

The intervention can take place using several types of anesthesia, namely local or general anesthesia, so the day before, for 8-10 hours, the patient needs to refrain from eating and drinking.

How the surgical procedure works: modern methods of arthroscopy

Surgery on the joints, if possible, is carried out through arthroscopy. Arthroscopy refers to the way the surgeon accesses the operating field. It eliminates the need for large incisions, respectively, and significant tissue injury. In addition, it takes into account the peculiarities of the complex structure of the articular apparatus more than the classic open operation.

The operation process looks like this: the patient is fixed on a couch or in a special chair. It should take the most comfortable position, and to fully ensure immobility, it is additionally fixed with rollers and belts.

After the introduction of anesthesia, the surgeon processes the operating field in accordance with the requirements of asepsis. When the anesthesia works, the doctor makes a small incision and through it inserts an arthroscope, a flexible hollow tube with sensitive optics, into the shoulder.

In order for the surgeon to have a better view of the field of activity, a sterile fluid is injected through the tube into the joint, due to which it swells somewhat, and it becomes easier to see it. Several small incisions are made in order to insert instruments and cannulas through them.

Having done the necessary manipulations, the doctor removes the arthroscope and all his tools, processes the incisions, puts sutures or special patches on them.

Basic techniques for intervention in the shoulder joint

Most often, in surgery of the shoulder joints, doctors resort to several methods of intervention, which are named after the surgeons who proposed them – operations according to Seidel, according to Bankart, according to Weinstein, according to Boychev, Andreev, Latarje or Gendeson.

Operation according to Seidel

Such treatment is based on cutting the tendon of the subscapularis muscle – in this way the surgeon achieves mutual muscle balance. In addition, this method makes it possible to strengthen the anterior-lower section of the capsule. It can be exposed by applying a longitudinal excision of the anterior-inner humeral surface, from the acromial process to the deltoid muscle.

If the patient has external rotation of the shoulder, the incision of the subscapularis muscle is made transversely in the area where it is attached to the lesser tubercle of the humerus. The fascial flap from the thigh is taken in sizes up to 10 centimeters in length and up to 3 centimeters in width. This fascia is first fixed to the capsule in the place of the lower polar zone of the joint cavity with one of the ends, and then gradually laid on the capsule from the bottom up and from the inside outward in an oblique direction. The fascia is fixed to the capsule along its entire length up to the outer upper edge of the dissected deltoid muscle, after which the free end of the tape is brought under the muscle bundle of the fascia and fixed in the region of the shoulder process of the scapula.

The wound is sutured in layers, and then a removal plaster is applied to it – in this way it is possible to achieve immobilization of the joint during recovery and recovery.

After about a month and a half, the period of postoperative rehabilitation ends.

Operation Bankarta

In this case, the capsule is strengthened by moving the long head of the biceps muscle to the anterior section of the joint head. The subscapularis muscle is lengthened. This type of surgery is considered minimally invasive, and makes it possible to qualitatively strengthen the articular apparatus by re-fixing the damaged lip of the joint. Using special anchors, a new lip is formed from the joint capsule, after which it is fixed on the bone with anchor fixators. The ruptures of the biceps muscle or the lip itself, determined during the operation, must be removed.

Operation Weinstein

In the process, the surgeon lengthens the subscapularis, and moves the tendon of the long head of the biceps brachii muscle to the anterior surface of the head of the bone. Access for the operation is formed along the groove separating the pectoralis major and deltoid muscles, while they must be parted to the sides. The deep fascia is subjected to a longitudinal excision, after which the short head of the biceps muscle and the beak-brachial muscle are displaced inwards.

The intertubercular groove is subject to opening – in this way, the tendon part is exposed with the length of the head of the biceps muscle. With external rotation of the shoulder, it is thrown over the lesser tubercle inward, and placed in front of the humeral head. The upper part of the tendon is fixed in the zone of the proximal segment of the excised subscapularis muscle, the lower part is attached to the lesser tubercle. The subscapularis muscle is sutured with the implementation of its lengthening over the used tendon. The wound is sutured, a soft bandage is applied to it. A week later, the doctor removes the stitches, and after that, the patient needs to gradually begin therapeutic exercises.

Surgical intervention according to Boychev

It is produced to create a thickening in the area of ​​the anterior edge of the articular process. Thus, the tendons of the short head of the biceps muscle and the coracobrachial muscle, as well as the outer region of the pectoralis minor, are cut off from the coracoid process. A tunnel is formed from top to bottom, through which the cut-off muscles are passed behind the subscapularis. Then they are fixed in place, strengthening on the coracoid process.

After suturing, a person needs to ensure complete immobilization of the upper limb for 10-12 days.

Operation Andreeva

Its essence is similar to the previous operation algorithm, except that the outer part of the pectoralis minor muscle in this case cannot be cut off.

Operation Latarjet

It is prescribed if the patient has a loss of the bone lobe of the anterior edge of the glenoid cavity on the scapula. The operation is performed with the movement of the coracoid process and the muscle fixed on it to the anterior-lower edge of the articular cavity. In this place it is subject to fixation. So it is possible to replenish the missing bone mass in this place. The Latarge operation is considered one of the most effective – it is successful in 97-98% of cases.

Operation Henderson

It is prescribed for the formation of the tendon ligament between the shoulder and the acromial process. The incision in this case has an epaulet-like shape – the clavicular-acromial joint and the deltoid muscle are exposed through it. After stratification of the muscle, in the acromial process and the large bone shoulder tubercle, drilling is performed along the channel into which the tendon of the long peroneal muscle is passed. The tendon is taken about half its thickness in length. It is pulled tight and the ends are sewn together. After suturing, it is required to ensure complete rest of the limb for 10-12 days.

Features of the rehabilitation period

Recovery after surgery of any type has one general requirement – rehabilitation at first occurs only if the joint is completely immobilized. In some cases, the very next day, you can gradually move your hand in the hand, elbow and wrist joint.

If the limb must be completely immobilized, a bandage is applied to it that fixes it to the body and does not allow it to move. After about 1-3 weeks, the joint itself gradually returns to motor activity. Full recovery occurs within three months. All this time, a person needs to engage in special physical therapy, if necessary, attend physiotherapy.

For athletes and workers whose activities involve intense physical activity, it can take up to a year to return to a normal lifestyle.

If a person has been diagnosed and confirmed habitual dislocation of the shoulder, surgery is the only really effective way to get rid of it. Medicine knows many schemes for the surgical treatment of pathology – some are considered more successful and minimally invasive, others, judging by the feedback from surgeons, are already outdated and are used much less frequently. The type and algorithm of surgical intervention, first of all, depend on the type of injury and the causes that provoke it.