Current Issue Search Articles Instructions for authors
 

 HOME | Login   

 

 Small font sizeDefault font sizeIncrease font size Print this article Email this article Bookmark this page
 Users online: 7


  In this article
    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1993    
    Printed228    
    Emailed2    
    PDF Downloaded14    
    Comments [Add]    
    Cited by others 4    

Recommend this journal

 
 
 Table of Contents  
Year : 2010  |  Volume : 4  |  Issue : 4  |  Page : 88-92   


 
ORIGINAL ARTICLE

Shoulder dislocation in patients older than 60 years of age

1 Department of Orthopedic Surgery, Hospital Son Llàtzer, Palma de Mallorca, Spain
2 Department of Radiology, Hospital Son Llàtzer, Palma de Mallorca, Spain
3 Department of Epidemiology, Hospital Son Llàtzer, Palma de Mallorca, Spain

Correspondence Address:
Jose M Rapariz
Vista Alegre 23, 1 D, 07015 Palma de Mallorca
Spain
Login to access the Email id


DOI: 10.4103/0973-6042.79792

PMID: 21655003

Get Permissions

 

 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Article in PDF (643 KB)
Reader Comments
Access Statistics
Citation Manager
Add to My List *
* Registration required (free)

Date of Web Publication20-Apr-2011

   Abstract 

Purpose: Recurrent anterior shoulder dislocation in elderly patients is a little studied condition. The goal of this paper is to clarify the role of associated injuries with respect to loss of function and recurrence of dislocation.
Materials and Methods: We have conducted a retrospective, descriptive study on 29 patients older than 60 years at the moment they suffered their first dislocation episode. All patients were assessed clinically (Constant test) and by imaging testing (X-ray, MRI).
Results: Nine (31.03%) out of 29 patients had a recurrent dislocation. Four of them required reconstructive surgery to maintain joint stability. Injury to the anterior support (anterior labrum, anterior glenoid rim) showed a statistically significant relation to the recurrence of dislocations. The occurrence or non-occurrence of a rotator cuff tear does have an impact on the shoulder function. The degree of rotator cuff involvement on the coronal plane does not significantly affect the shoulder's functional outcome. The tear extension on the sagittal plane does cause impairment on the Constant test.
Conclusions: Labrum and/or anterior glenoid involvement should be suspected in elderly patients presenting with recurrent shoulder dislocation. Recurrence is due to an injury in the anterior support or both (anterior and posterior), even though shoulder function gets impaired when a rotation cuff tear occurs with anterior extension on the sagittal plane. Evidence level: IV Case series.


Keywords: Shoulder dislocation, shoulder instability, elderly


How to cite this article:
Rapariz JM, Martin-Martin S, Pareja-Bezares A, Ortega-Klein J. Shoulder dislocation in patients older than 60 years of age. Int J Shoulder Surg 2010;4:88-92

How to cite this URL:
Rapariz JM, Martin-Martin S, Pareja-Bezares A, Ortega-Klein J. Shoulder dislocation in patients older than 60 years of age. Int J Shoulder Surg [serial online] 2010 [cited 2014 Dec 22];4:88-92. Available from: http://www.internationalshoulderjournal.org/text.asp?2010/4/4/88/79792



   Introduction Top


The natural history of shoulder dislocation varies greatly according to the age when the injury occurs. In patients younger than 40 years of age, the recurrence of instability is relatively frequent and results from an injury in the labrum/anterior capsule complex. In patients older than 40 years of age, recurrence of instability is infrequent, but dislocation is associated with injuries to the rotator cuff. [1] McLaughlin [2] explained these differences through the hypothesis that two dislocation supports exist: the anterior support (labrum-anterior capsule) and the posterior support (rotator cuff - greater tuberosity). An injury to the anterior support occurs in young patients, recurrence being frequent, whereas in older patients the posterior support is injured, with the recurrence being infrequent.

Although the instability in young patients has been widely discussed in the literature, there are few publications focusing on the dislocation in patients older than 60 years of age, and we did not find any paper that specifically analyzes recurrence at that age.

This paper shows that in patients older than 60 years of age, recurrence is due to an injury to the anterior support, and an isolated lesion to the posterior support is insufficient to cause recurrence.

The goal of this paper is to clarify the role of associated injuries with respect to loss of function and recurrence of dislocations in such patients.


   Materials and Methods Top


During the period ranging from January 2002 to 2007, we received in our Emergency Department a total of 64 patients older than 60 years of age, presenting with a first episode of glenohumeral dislocation.

We conducted a retrospective descriptive study where we reviewed these patients' background, checking that there was imaging evidence showing dislocations, and that these were not associated with fractures (except for glenoid rim fractures or isolated greater tuberosity fractures). All patients were given an appointment for a physical examination by the first author, and they accepted to be enrolled in the study.

Patients had to comply with the following criteria to be enrolled in our study:

  1. First episode of dislocation at an age older than 60 years
  2. One-year minimum follow-up
  3. Not having prior surgeries in the dislocated shoulder
  4. Not having fractures associated with the dislocation, except for glenoid rim fractures and isolated greater tuberosity fractures
  5. Attending visits
  6. Accepting the performance of at least one magnetic resonance imaging (MRI) study of the shoulder in question


All patients, who were alive, (58), were given an appointment for visit. All patients included in the study signed a consent form, and accepted performance of imaging tests. No additional follow-up was performed for nonattendees.

The list of excluded patients and the causes for exclusion are shown on [Table 1].
Table 1: Patients excluded from initial recruitment

Click here to view


Following these criteria, we enrolled 29 patients in the study, out of 64 patients. The 29 patients enrolled in this study who suffered a first glenohumeral dislocation at an age older than 60 years were referred to the Clinic and accepted to have an MRI study done on the affected shoulder.

  1. We call the following structures the "anterior support:"
  2. Anterior labrum
  3. Subscapular tendon
  4. Anterior rim of the glenoid cavity
  5. We call the following structures the "posterior support"
  6. Supraspinatus tendon
  7. Infraspinatus tendon
  8. Greater tuberosity
Imaging assessment

To assess the lesion degree of the rotator cuff by MRI images, we classified fractures according to their extension on the coronal plane (Stages 1 and 2) and on the sagittal plane (infraspinatus (B), supraspinatus (A), and/or subscapular (C) involvement), this being a modification to the classification utilized by other authors [3] [Figure 1]. Just full-thickness tears were considered in this study. Partial-thickness tears were not included.
Figure 1: (a) Cuff involvement on the coronal plane. In Stage I, the cuff edge is distal to the highest point of the humeral head. In Stage II, the torn end of the cuff is medial to that point. (b) Cuff involvement on the sagittal plane, depending on the involvement of the supraspinatus/rotator interval (A), the infraspinatus/teres minor (B), or the subscapular tendon (C)

Click here to view


For the assessment of fat tissue atrophy, we used Goutalier's classification. [4] Imaging assessment was performed by a single musculoskeletal radiologist, coauthor of the paper, who knew neither the functional impact nor the number of dislocations suffered by the patient.

Functional assessment

The shoulder's functional assessment was conducted by means of the Constant test. [5] A Rapala® dynamometer, with a capacity of up to 25 kg and digital determination, was used to measure strength.

Statistical analysis

In the univariable analysis, if variables are continuous they are described as mean and standard deviation (SD), and if they are qualitative, as ratios/percentages. For the bivariable analysis, the χ2 test or Fisher's exact test was used (according to application conditions) for qualitative variables, or Student's t-test for continuous variables that followed a normal distribution. The strength of the association between the dependent variable and the remaining independent variables was obtained by odds ratio estimated from the contingency tables and was expressed by the confidence interval (95%). The statistical analysis was performed with the SPSS, version 12.0 (SPSS Inc., 2003) statistical package, for Windows.


   Results Top


All dislocations were anterior. All patients were right-handed. The mean follow-up from the first dislocation episode to the assessment in the clinic was of 27 months (range 13-59 months). The mean age of these patients at the moment of dislocation was 72.68 years (range 61-93 years).

A total of 9 (31.03%) patients had recurrent dislocation (more than one episode) [Table 2]. Four of these recurrent cases required reconstructive surgery to maintain joint stability. These four patients had suffered more than two dislocations when they underwent reconstructive surgery [Table 3].
Table 2: Relationship among recurrence, age, gender, and support involved

Click here to view
Table 3: List of patients with a recurrent shoulder dislocation

Click here to view


Relationship between injury support and recurrence

Analysis of contingency tables that relate the affected support and recurrence shows a statistically significant relationship for the involvement of the anterior support (P=0.001; OR 34.2; IC 95% 1.74-673.73). In contrast, the posterior support involvement did not show statistical significance in relation to recurrence (P=0.37; OR 4.3; IC 95% 0.44-41.82). The involvement of both supports has demonstrated statistical significance with respect to recurrence (P=0.0033), even though recurrence has not occurred in any case in which the anterior support was not affected.

When the anterior support is affected, the injuries that tend to cause relapse are the anterior labrum injury and the injury of the anterior glenoid rim. A subscapular injury is not related to recurrence [Table 4].
Table 4: Injuries that affect the anterior support

Click here to view


Relationship among functional outcome, rotator cuff involvement, and recurrence

The global incidence of rotator cuff tears has been 75.86% (22 cases). The prevalence of the full-thickness rotator cuff tear was higher in patients who had recurrent dislocation (88.8%) than in those who suffered just one episode of dislocation (70%) [Table 5].
Table 5: Relationship between the rotator cuff tear and dislocation recurrence

Click here to view


The functional outcome, according to Constant's scale, was not significantly modified, as there was only one dislocation (Constant's mean 63.6; DT 17.2) and it was recurrent (Constant's mean 59.6; DT 23.6). Nonetheless, the function of the shoulder deteriorated when the patient suffered more than two dislocations [Figure 2].
Figure 2: Constant score versus the number of dislocations. Vertical axis: number of dislocations: horizontal axis, Constant score

Click here to view


The degree of the rotator cuff involvement on the coronal plane did not significantly influence the affected shoulder functional outcome. When the end of the supraspinatus tendon was in Stage I on the coronal plane [Figure 1], Constant's mean was 57, DT 19.4; patients in Stage II showed a Constant mean of 58, DT 19.8.

The occurrence or nonoccurrence of a rotator cuff tear did have a significant impact on the shoulder function. Constant's scale value was significantly higher when the rotator cuff was spared (mean 76.9; DT 8.6) than when it was torn (mean 57.7; DT 19.3).

Analyzing the sagittal plane, the extension of the tear anteriorly (subscapular) caused considerable deterioration of the functional outcome, whereas this detriment was not apparent when the tear extended posteriorly (infraspinatus) [Table 6].
Table 6: Relationship between rotator cuff involvement on the sagittal plane and Constant's test

Click here to view



   Discussion Top


In this study, we have found that the main factor for the recurrence of dislocation in patients older than 60 years of age is anterior or combined (anterior or posterior) support's involvement. The isolated injury of the posterior support is not related to recurrence. Our findings put into question the role of the posterior support in a dislocation's recurrence in the adult population, the theory being advocated by McLaughlin. [2] The main lesion leading to recurrence in elderly patients is the glenoid rim and/or anterior rim injury. The frequent accompanying injury of the posterior support may deteriorate the functional outcome, but it is not the main cause of recurrence. The important role of the anterior support in recurrence has already been emphasized by other authors. [6] But which of the anterior support components cause recurrence? Araghi [6] reports 100% capsulolabral injuries in 11 patients older than 40 years of age with relapsing dislocations. However, Neviaser [7] does not find the Bankart lesion but anterior capsule and subscapular tears in 11 patients older than 50 years of age with recurrent dislocations. In our series, all patients who suffered a recurrent dislocation presented a Bankart lesion in MRI. This discrepancy is probable due to the method used for diagnosis (plain arthrography, [1] MRI or surgery. [6] It is also probable that performing an arthro-MRI may increase diagnosis of anterior capsule lesions that may be overlooked when a contrast agent is not used.

The extension of the rotator cuff tear should be evaluated carefully on the sagittal plane. The extension of the tear on the coronal plane did not correlate with the functional outcome, probably due to the fact that the coronal view could not see how many tendons were involved. The extension of the tear on the sagittal plane correlated with a significant decrease in the Constant score, especially in cases of anterior extension [Table 6]. This fact emphasizes the key role of the subscapularis tendon integrity. Nevertheless, we did not find any relationship between subscapularis involvement and recurrence [Table 4]. From our data, the subscapularis involvement had much more influence on the shoulder function than the recurrence rate.

Age (taking into account the population over the age of 60) is not related to 'recurrence'. However, recurrence in this age range is not a rare event in the literature (19-31%). [1],[7],[8],[9],[10],[11] The pattern of recurrence probably differs from the one that young individuals present: in the Neviaser series, [7] recurrence is immediate, and the second episode of dislocation occurs by 1 week following the initial episode. This has not been analyzed in our series.

The function of the shoulder deteriorates when the patient suffers more than two dislocations. This is probably due to the extension of rotator cuff tear involvement.

Regarding cuff lesions in this patient population, we have drawn three conclusions:

  1. The outcome is better when the cuff is spared following a dislocation
  2. The degree of rotator cuff involvement on the coronal plane does not influence the functional outcome
  3. The degree of rotator cuff involvement on the sagittal plane does influence the functional outcome, especially when the rupture extends anteriorly toward the subscapular tendon
It is not easy to know if the rotator cuff was torn during the dislocation episode, if it was torn before, or if there was an acute tear on a previous chronic tear. Nonetheless, if the imaging studies performed after the dislocation show that the cuff is not compromised, functional prognosis is promising. If MRI shows a cuff tear, we should carefully review the extension on the sagittal plane, often overlooked, because the anterior extension of the tear is a poor prognosis factor.

When these patients present a massive rupture of the cuff with an anterior support injury, which lesion should we repair? It is not the aim of this paper to know which type of repair regains the stability of the shoulder. Some authors indicate that repairing the Bankart lesion is not necessary in elderly patients, and that repairing the cuff is enough to stabilize the shoulder, [12] whereas others advocate in favor of repairing both supports. [13] We share the idea that both supports should be repaired as we know that we repair the posterior support to improve the function and that we repair the anterior support to improve the instability and function (in the case of subscapularis involvement).

This study has the following limitations: (1) a small number of patients due to difficulties in the recruitment and performance of complementary tests in this population group and (2) imaging study sensitivity. Performing an arthro-MRI with an intra-articular contrast agent would probably allow us to diagnose capsular injuries that may be overlooked in MRI without a contrast medium.

New multicenter studies are necessary to corroborate these findings.

 
   References Top

1.Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-11.  Back to cited text no. 1
[PUBMED]    
2.McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II. A comparative study. J Trauma 1967;7:191-201.  Back to cited text no. 2
    
3.Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-40.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty infiltration of disrupted rotator cuff muscles. Rev Rhum Engl Ed 1995;62:415-22.  Back to cited text no. 4
[PUBMED]    
5.Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.  Back to cited text no. 5
[PUBMED]    
6.Araghi A, Prasarn M, St Clair S, Zuckerman JD. Recurrent anterior glenohumeral instability with onset after forty years of age: The role of the anterior mechanism. Bull Hosp Jt Dis 2005;62:99-101.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;291:103-6.  Back to cited text no. 7
[PUBMED]    
8.Toolanen G, Hildingsson C, Hedlund T, Knibestol M, Oberg L. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study. Acta Orthop Scand 1993;64:549-52.  Back to cited text no. 8
    
9.Gumina S, Postacchini F. Anterior dislocation of the shoulder in elderly patients. J Bone Joint Surg Br 1997;79:540-3.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Sonnabend DH. Treatment of primary anterior shoulder dislocation in patients older than 40 years of age. Conservative versus operative. Clin Orthop Relat Res 1994;304:74-7.  Back to cited text no. 10
[PUBMED]    
11.Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-9.  Back to cited text no. 11
[PUBMED]    
12.Itoi E, Tabata S. Rotator cuff tears in anterior dislocation of the shoulder. Int Orthop 1992;16:240-4.  Back to cited text no. 12
[PUBMED]    
13.Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ. Anterior dislocation of the shoulder in the older patient. Clin Orthop Relat Res 1986;206:192-5.  Back to cited text no. 13
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


This article has been cited by
1 Glenohumeral instability in patients over 40 years-old: injuries, treatment and complications
A. López-Hualda,M.A. Marín-Aguado,H. Valencia-García,D. López-González,C. Gavín-González
Revista Española de Cirugía Ortopédica y Traumatología (English Edition). 2014; 58(1): 38
[Pubmed]
2 Shoulder surgery in older patients: recommendations and techniques
M. Valencia,E. Calvo
Reviews in Clinical Gerontology. 2013; 23(04): 295
[Pubmed]
3 Inestabilidad glenohumeral en pacientes mayores de 40 años: lesiones, tratamiento y complicaciones
A. López-Hualda,M.A. Marín-Aguado,H. Valencia-García,D. López-González,C. Gavín-González
Revista Española de Cirugía Ortopédica y Traumatología. 2013;
[Pubmed]
4 Shoulder instability in the middle-aged and elderly patients: Pathology and surgical implications
De Beer, J. and Bhatia, D.N.
International Journal of Shoulder Surgery. 2010; 4(4): 87
[Pubmed]



 

Top
Print this article  Email this article