What is the management approach for recurrent shoulder dislocations?

Management of Recurrent Shoulder Dislocations

MR arthrography is the preferred diagnostic imaging modality for recurrent shoulder dislocations, followed by surgical stabilization as the definitive treatment to prevent further dislocations, reduce morbidity, and improve quality of life. 1

Diagnostic Approach

Initial Evaluation

• Standard radiographs should be the first imaging study performed, including anteroposterior (AP) views in internal and external rotation, plus an axillary or scapula-Y view to properly assess glenohumeral alignment 1
• Special radiographic views can help identify specific pathology:
  • Westpoint view for bony Bankart lesions 1
  • Stryker notch view for Hill-Sachs deformities 1

Advanced Imaging

• MR arthrography is the gold standard for evaluating recurrent shoulder instability with a rating of 9/9 in appropriateness criteria 1
• MR arthrography offers superior assessment of:
  • Labroligamentous injuries (Bankart lesions) 1
  • Hill-Sachs lesions on the humeral head 1
  • Glenohumeral ligament injuries 1
  • Glenoid bone loss assessment 1
• Non-contrast MRI is a reasonable alternative (rated 7/9) when MR arthrography is not available 1
• CT arthrography can be considered if MRI is contraindicated (rated 5/9) 1

Common Pathologic Findings

• Bankart lesion (avulsion of capsule and labrum from anterior glenoid rim) - present in up to 84% of recurrent dislocations 2
• Hill-Sachs lesion (compression fracture of posterolateral humeral head) - found in 76% of cases 2
• Excessive capsular laxity - present in 83% of cases 2
• Glenoid bone loss - found in up to 10% of patients with recurrent instability 1
• Rotator cuff tears - more common in older patients with recurrent dislocations 3

Treatment Algorithm

Young Patients (<25 years)

• Surgical stabilization is strongly recommended due to:
  • High recurrence rates (up to 90%) with non-operative management 4, 5
  • Lower risk of developing osteoarthritis compared to those with recurrent instability 5
  • Better long-term functional outcomes 4

Older Patients (>40 years)

• Surgical approach should address both anterior stabilization and any associated rotator cuff pathology 3
• Combined procedures that address both pathologies have shown excellent results:
  • 70% excellent outcomes
  • 20% good outcomes
  • No recurrence of dislocations in properly selected patients 3

Surgical Timing Considerations

• Early surgical intervention is preferred as delayed surgery is associated with:
  • Elongation of the capsule
  • Progressive labro-ligamentous injury
  • Increased prevalence and severity of glenoid bone loss 5
  • More technically demanding procedures 5

Surgical Options Based on Pathology

• Arthroscopic Bankart repair - for isolated labral tears without significant bone loss 4
• Latarjet procedure - when significant glenoid bone loss is present (>20%) 1
• Capsular shift techniques - for patients with excessive capsular laxity 3
• Combined procedures - for older patients with both instability and rotator cuff tears 3

Post-Surgical Considerations

• Physical therapy focusing on rotator cuff strengthening and proprioception 6
• Gradual return to activities with sport-specific rehabilitation for athletes 5
• Long-term follow-up to monitor for recurrence or development of osteoarthritis 5

Pitfalls and Caveats

• Failure to recognize and address bone loss is a common cause of recurrent instability after surgical repair 2
• Technical errors during surgery can lead to recurrent instability 2
• Ultrasound has no defined role in the assessment of shoulder instability and should not be used as a primary diagnostic tool 1
• Delaying surgical intervention increases the risk of further damage and makes subsequent repair more challenging 5