In reviewing the literature there are few studies about the results of operative treatment of chronic anterior shoulder dislocation. Most authors have recommended allograft reconstruction or arthroplasty in large head defects following chronic shoulder dislocation. Gavriilidis stated that shoulder arthroplasty resulted in good midterm results for 12 patients with severe head involvement with benefits for range of motion, pain and patient satisfaction [11]. The average duration of dislocation was 14 months in this report. In 13 patients with locked chronic posterior dislocation of shoulder and defect of between 25-50% of head, Diklic and coworkers reported good results with allograft reconstruction [12]. In our series Hill-Sach's defect was less than 40% and all were non-engaging. We suppose the reason is that the mean duration of dislocation in our cases (10 weeks) was less than that of the mentioned reports.
One fair result in our study was in a case whose shoulder had Subluxation postoperatively. Anterior glenoid bone defect was the reason for subluxation in this patient which shows the necessity of bone grafting or coracoid transfer to the glenoid bone defects in such cases (Figure 2, 3). Perniceni and Augereau described reinforcement of the anterior shoulder complex in three patients after reduction of neglected anterior dislocation of the shoulder [13]. They used the Gosset technique [14] which places a rib graft between the coracoid and the glenoid rim.
Most reports have recommended shoulder joint transfixation to prevent redislocation following open reduction. Neviaser proposed transfixing the shoulder joint with a Swiss screw for three to four weeks [4]. Wilson and Mckeever recommended acromiohumeral crossed transfixing pins to prevent recurrence of the dislocation5. Rockwood and Green also suggested using smooth pins through the head into the glenoid for ten to fourteen days [6]. According to our study the results after capsulolabral complex repair appears to be more favorable than previously reported studies which have used metallic fixation methods. Postacchini et al reported good results in all four cases of operatively reduced chronic anterior and posterior dislocation [15]. Goga have reported three excellent, five good and two fair results in ten operatively reduced anterior shoulder dislocation [16]. Acromiohumeral k-wire fixation was used for 4 weeks in that group and the results were evaluated according to Rowe and Zarins system.
Supporting the arm at the side in a safe position was first stated by Rowe and Zarins in 1982 [10]. They recommended simply maintaining the arm at the side anterior to the coronal plane of the body for anterior dislocations and posterior to the coronal plane for posterior dislocations. In a report of seven operatively treated chronic shoulder dislocation with a mean duration of dislocation of 12 weeks, they had no postoperative dislocation using this simple method. Two shoulders were graded as excellent, three as good and two as fair with the mean Rowe score of 78 points.
Capsulolabral complex repair allows early range of motion in a safe range without the fear of redislocation. We began up to 90 degrees of flexion and 0 degree of external rotation immediately in our patients. Although the average duration of dislocation have not pointed in Goga's study and it is difficult to compare his results with the present study, it seems that our patients as the patient in figures 4 & 5 had much better range of motion at the end of follow up period and the average Rowe score in our patients was higher than Goga 's series. It should be mentioned that acromiohumeral fixation method had been used in Goga's study.
Our review of literature revealed just one report similar to our study. Mansat et al reported five patients with old anterior shoulder dislocation with average duration of 14 months [17]. All were treated with open reduction and capsulolabral insertion. At the end of follow up the average Rowe score was 75 points. The duration of dislocation in this group of patients was more than our study and this may be the reason for low Rowe score comparing with our series.
Mild degenerative joint changes were noted in only one patient. Although in the literature there is no report for the true incidence of osteoarthritis after operative reduction of old dislocations, it appears that early osteoarthritis rate is reasonable in our study and we think that the reason may be early motion and not using transfixing implants.
The present study had some important limitations. Although the present study is one of the largest reports in the literature it is confined to only eight patients. Another potential source of uncertainty in this study arises from the duration of follow up period. Longer follow up is needed for the detection of the true incidence of degenerative changes following open reduction of old shoulder dislocations.
In conclusion the authors of this article recommend concomitant open reduction and capsulolabral complex repair, when possible, in the treatment of old anterior shoulder dislocations.