Indications and benefits of arthroscopy
Arthroscopic surgery has a key advantage: it provides high diagnostic accuracy for intra-articular defects and allows for their minimally invasive reconstruction.
Main indications for the procedure (structures being repaired):
- Ruptures of the joint capsule.
- Injuries to the rotator cuff elements.
- Detachment of the labrum.
The main task of the procedure is reliable prevention of recurrences. It is important to note that in modern traumatology, indications for arthroscopic treatment are constantly expanding, and it may be recommended even in cases where the initial closed reduction of the dislocation was successful.
Alternative: open reduction and its challenges
If a acute dislocation cannot be managed by closed reduction, open surgery is indicated. Closed reduction can be hindered by serious anatomical obstacles:
- Entrapment of the long head of the biceps tendon.
- Interposition of the muscle around the humeral head.
- Detachment of the greater tubercle.
- Entrapment of the head in the slit of the ruptured capsule.
- Soft tissue interposition.
Surgical technique: the procedure is performed strictly under general anesthesia. The surgeon resects the coracoid process, cuts the subscapularis muscle, and opens the capsule. After excision of scars and adhesions, the head is reduced, the tissues are sutured, and the process is fixed to its anatomical site. In the postoperative period, a thoracobrachial bandage is applied, and passive movements in the joint are allowed to begin after 8–10 days.
Management of patients after dislocation reduction
Regardless of the treatment method, the joint requires proper rehabilitation and protection.
- Immobilization: lasts at least one month. This is critically important for the prevention of recurrent episodes.
- Radiological control: is strictly mandatory to confirm reduction and rule out concomitant bone injuries.
- Rehabilitation: physical therapy and therapeutic exercises (PT) are prescribed on days 5–7.
- Timeline: basic working capacity returns after 4–6 weeks, however, heavy physical labor is strictly prohibited for 3 months.
Treatment specifics depending on age
Management tactics depend heavily on the patient's age and functional demands.
Young and active patients: in case of an injury to the tendon of the long head of the biceps, its fixation to the humerus is recommended. Arthroscopic suprapectoral or open subpectoral tenodesis is used, utilizing transosseous sutures, suture anchors, suture buttons, or interference screws.
Elderly patients: the outcomes of open surgery in this group are significantly worse than in young patients. In cases of unreduceable dislocation without symptoms of neurovascular bundle injury and low activity demands, surgery is abandoned. Functional treatment is used: in the acute period, a sling bandage, analgesics, and physical therapy are applied. As pain subsides, therapeutic exercises and light massage are added. The range of motion is compensated for by the scapula, which is sufficient for a sedentary lifestyle. Emergency surgery on the biceps is also not indicated for them.
Complications and recurrent dislocation
Treatment errors or the severity of the trauma itself can lead to serious consequences.
Causes of complications:
- Injury or compression of blood vessels and nerves (both at the time of trauma and during rough reduction attempts).
- Treatment defects: overly traumatic manipulations, inadequate immobilization, or failure to follow its duration.
- Early functional loading (raising the arm vertically upwards is especially dangerous).
These factors lead to restricted function and the development of chronic instability — recurrent dislocation (a condition in which dislocation regularly recurs in the same joint).
Timing for closed reduction: up to 3 days — standard; from 3 days to 3 weeks — only under anesthesia; more than 4 weeks — not reducible (chronic/neglected dislocations).
Class and exam questions
In what cases is closed reduction of a shoulder dislocation performed exclusively under anesthesia?
If 3 days to 3 weeks have passed since the injury. For neglected injuries (more than 4 weeks), closed methods are generally no longer used.
Why is it forbidden to actively move the arm immediately after shoulder reduction?
Early functional loading, especially raising the arm vertically upwards, disrupts tissue healing. This is the main reason for the development of chronic instability and recurrent dislocation.
Is it always necessary to operate on a rupture of the long head of the biceps tendon?
No. Surgery is recommended for young patients with a high functional level. In elderly people with low activity demands, emergency intervention is not indicated.
Is refraining from dislocation reduction justified in elderly people?
Yes, if the dislocation is unreduceable, there are no vascular and nerve injuries, and the patient leads a sedentary lifestyle. In such cases, conservative functional treatment is prescribed.
What else to study on this topic
- Technique of arthroscopic suprapectoral and open subpectoral tenodesis.
- Types of anchors in tendon surgery: anchor sutures, buttons, interference screws.
- Principles of immobilization and rehabilitation for complete ruptures of lower extremity muscles (0–6 weeks).
- Evidence base for conservative treatment of lateral collateral ligament ruptures of the ankle joint.
- Thoracobrachial bandage: application rules and postoperative care.
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