A normal shoulder consists of three joints. These are the glenohumeral joint (which is the primary joint that moves our shoulder and is in the form of a ball and socket), the acromioclavicular joint, the sternoclavicular joint, and the scapulothoracic joints between the chest cavity and the shoulder blade.
The rotator cuff consists of four muscles that connect the shoulder blade to the arm bone. These muscles are called rotator cuffs since they surround this ball-and-socket joint in the form of a cuff. The rotator cuff muscles press the ball into the socket during shoulder movements and provide a stable platform for circular movements during this activity.
The head of the shoulder is like a golf ball on a tee as shown below
In other words, we can think of the shoulder joint as a balloon kept in balance by a seal, which has a gap, and where the ball (larger) and the socket (smaller) are not compatible in size.
The socket is extended with a meniscus-like tissue in the knee called the labrum.
Thanks to the labrum and the ligaments (glenohumeral) mentioned above, the end of the shoulder rests firmly in the socket. The labrum and the ligaments can be compared to the "airbags" in cars, which protect us from sudden collisions.
This mismatched relationship between the ball and the socket in the shoulder joint paves the way for shoulder dislocations with the contribution of some special circumstances (such as trauma, ligament laxity or familial factors).
Some general cases of ligament laxity can be seen below
The meniscus-like labrum which is mentioned above, and the strong ligaments in particular, try to keep the big ball in the socket through a hammock effect as seen below.
Shoulder dislocations can be described as the exit of the ball from the socket.
Shoulder is in Place
Shoulder is Dislocated
Shoulder is in place
Shoulder is Dislocated
During the dislocation of the shoulder, the meniscus-like labrum and the ligaments tear, creating a "Bankart lesion" that typically leads to the recurrence of the dislocations.
During shoulder dislocations (usually at the first dislocation!), bone fractures can also occur at the socket section called the glenoid, along with the Bankart lesion
Normal socket (GLENOID)
Fracture !in the socket
Where the presence of a fracture in the socket (GLENOID) is suspected in patients with recurrent shoulder dislocations, this should DEFINITELY be confirmed by a computed tomography scan.
Treatment of Traumatic Anterior Dislocations
Non-surgical treatment followed by physical therapy
In the first sudden dislocations, the shoulder is fixed with a sling to reduce the buildup of fluids and the pain. Many experts, including me, recommend a shoulder-arm sling to be worn for a maximum of 3 weeks so that the dislocation doesn't reoccur. We believe that prolonging this period does not prevent the recurrence of the dislocation. After the fixation of the shoulder, physical therapy is initiated, which enables shoulder muscles to be strengthened. The recurrence of shoulder cuff tears and dislocations is observed in spite of all efforts in some of the patients (less than 50%) over 40 years of age, while the recurrence of dislocations is observed in more than 90% of the patients who are 17-18 years of age.
Surgical Treatment of Shoulder Dislocations
If shoulder dislocations are recurring and if this problem has become chronic, i.e. continuous, surgical treatment is a must. The decision of a surgical treatment after the first shoulder dislocation depends on a number of factors. For example, if there is a bone deficiency in the socket, i.e. the glenoid bone, that holds the ball, i.e. the end of the shoulder, in place, surgery should be considered immediately. If there is no bone deficiency in the socket, the decision for surgery is made considering personal factors such as age, activity level and sporting activities.
Open and Arthroscopic (CLOSED) treatment of shoulder dislocations
If there is no bone loss, the goal of the treatment is to maintain the joint stability by repairing the above-mentioned Bankart lesion and the capsule tissue. The surgical treatment can be performed arthroscopically, i.e. in a closed manner, in almost all patients. Arthroscopic (closed) treatment is performed by re-stitching the torn meniscus-like soft tissue to the edges of the socket, i.e. the glenoid, through absorbable small screws with secure threads coming out of their back-ends
Advantages of the arthroscopic (closed) repair over the open treatment
Today, with advancing techniques, the results of the closed treatment and the open treatment have become equal. Advantages such as less pain and the ability to be discharged on the same day as the day of the operation caused arthroscopic, i.e. closed treatment to become preferable. In the arthroscopic treatment, normal tissues such as the rotator cuff don't need to be separated as they do in an open treatment. Therefore, not only the pain is reduced, but the physical therapy process also runs more smoothly, expediting the patient's return to his/her normal life. Infection rates in the closed treatment are lower than those in the open treatment.
Under which circumstances is the open treatment necessary?
Arthroscopic, i.e. closed treatments can be applied in 90% of the patients. However, open surgery may be required for the remaining 10% of patients, particularly in cases of socket (glenoid) fractures and bone losses that occur in first dislocations, irreparable capsule tears or failures in closed treatments. In such cases, the bone deficiency in the socket is eliminated through a method called Latarjet which involves the transfer of a bone that will serve as a wedge. Therefore, the exit of the ball from the socket is prevented through a bone transplantation. This method is very effective when performed properly as an open surgery.
The wound and movements of the patient who was operated with the Latarjet method (bone block method), 3 weeks after the operation can be seen below.