what are the options for you if you've had your shoulder
fixed after a shoulder dislocation and then it keeps coming out again and again and again so
i'm dr chris this is a little bit informal today because i am on call for those of you who are mma
fight fans this past weekend was the fight between brian ortega and yair rodriguez two excellent
mexican fighters fight was stopped prematurely in the first round because brian ortega suffered an
injury to his right shoulder oh you see it there it is oh yeah you can see it on the shoulder
you can see the shoulder out there are other videos on youtube including a video by brian
sutterer and a video by dr david abassi that talk more about the injury and i'll briefly summarize
that but what i really want to focus on today is just on what are the options if this kind of
thing has happened and you've had surgery coming into this fight brian ortega has already had
apparently two surgeries to his right shoulder because he has had
a number of shoulder dislocations in the past so if we look at the video here
here we can see that brian ortega is trying to bring yair rodriguez to the ground using a move
that's known as the whizzer and when he does that yair retains a hold of ortega's right arm
and he attempts to perform an arm bar and you can see that when he's upside down holding ortega's
arm he has his thigh pressed against the back of ortega's shoulder and you can see the moment when
the pressure of his thigh on the back of ortega's shoulder while ortega's arm is extended is enough
to push the humeral head anteriorly out of the glenoid socket so this is a shoulder dislocation
after ortega has already had two surgeries for his shoulder so normally if you are a first time
dislocator then we will perform what's called a shoulder stabilization and this can be done
in either an open or a closed fashion and if we do it in a closed fashion what i mean by that
is that we're doing it arthroscopically through little small incisions so we'll put a camera in
find the damaged structure which is usually the anterior labrum which is a soft tissue structure
which is pulled off the front of the glenoid we will find the the labrum which is usually
ripped off and down the front of the neck and we'll bring it back and place it on top
so that's the typical procedure that we'll perform and usually for first time dislocators it's only
the labrum that is involved although sometimes a small piece of bone otherwise known as a
bony bankart can be involved as well so we will arthroscopically bring those structures back and
place them on the front of the the labor however for some people this is not enough either because
the labrum was deficient we were not able to reattach it where it was supposed to go or there
is some amount of bone that is missing from the front of the glenoid the other problem is if you
have a large divot in the back of the head and so normally when your head comes out of the joint and
then it sits on the front of the glenoid you get a divot in the back of the head which is called
the hill sachs and if that's large then sometimes even though we've fixed the labrum in the front
when you externally rotate your arm that can still slide out and engage that hill sachs lesion and
then your arm is out of the socket and dislocated give me one second yeah so like i said i'm on call
now we have somebody who's been fixed and they've redislocated again on some occasions
if the imaging which is usually going to be mri or mri arthrogram shows that the labrum has retorned
we can reattach that labrum a second time it's not going to be as good as it was the first time
but we can do that we can sometimes also back up the initial stabilization by doing what's called
a remplissage and that just means that we're going to take some anchors and attach the capsule that's
on the back side of the humeral head into that divot that i talked about the rem plessage allows
the posterior capsule or the capsule on the back side of the shoulder joint to act as a tether so
now when the head goes to come out it's actually attached to the back so the back of the capsule
stops it from fully engaging with the front and then allowing that shoulder to slide out for some
people when they do open shoulder stabilization they will also do what's called an imprecation of
the capsule and that just means that they'll cut the capsule or the bag that's around the outside
of the joint that holds the fluid in from top to bottom and then they will overlap the edges and
sew it together so now you are tightening down the capsule so not only have you repaired the labrum
but you're stopping the humor head from coming out the front because you've made the capsule
there tighter so those are all soft tissue options if all of those fail what next we can do what's
called a later j procedure and this is where we take the coracoid which is a structure on
the front of the scapula which sticks out on the front of the joint just medial to the humeral head
we can cut that coracoid at its base and then move the coracoid from its current location to
a location on the front aspect of the glenoid so that we've now extended the bony surface that the
humeral head engages with to prevent that humeral head from coming to the edge and then falling out
so we've actually just put a shelf here and so now the humeral head can actually move further
before it comes out of the joint this is what we call a salvage procedure because it's not the
first line procedure that we would do and we do it for people who have had recurrent dislocation
after they have had a shoulder stabilization in the past and if all of that failed the next option
that is available which again is another salvage option is a humeral head osteotomy and this is
where we actually cut the humerus just below the humeral head and we rotate the humeral head
so that that hill sacs divot on the back is now facing more towards the back so that it is less
likely to come out when you externally rotate your arm that's another bony procedure but
that requires the humeral head to be severed from the shaft and then reattached and stabilized with
a plate so that's a much bigger procedure and again it's a salvage procedure given that ortega
had two procedures already i'm going to assume that he had a shoulder stabilization a soft tissue
procedure and then either a revision stabilization on its own or a revision stabilization with a
remplissage however he may have had a laterjet and if he's already had a laterae then he is
in trouble because there are not that many options left if he hasn't then a laterjet would be the
next option and then after that we're talking humeral head osteotomy and if all of that fails
oh well then he is sol without a paddle either live with the instability or a shoulder fusion and
i'm not sure but i don't think he'll be able to do mma if he has a shoulder fusion that being said
that's it for today as always that's been a word from dr chris
not your everyday ortho where we see one do one and teach one
you