neglected bilateral anterior shoulder dislocation is a very rare condition , often related to seizures or major trauma .
open reduction is recommended whenever hill - sachs lesion is > 25% of the joint and the dislocation is elder than 3 weeks .
we describe a case report of a 28-year - old man left handed jehovah s witness laborer assessed 12 weeks after bilateral anterior shoulder dislocation .
the patient was evaluated with clinical examination , and it was observed an asymptomatic intrarotation of both shoulders with a mild left circumflex nerve deficit .
he was able to perform flexion and abduction of both arms up to 60 and 10 of extrarotation .
pre - operative constant scores were 49 in left and 55 in right shoulder , pre - operative disabilities of the arm , shoulder , and hand ( dash ) scores were 57 in left and 53 in right shoulder , and visual analogue scales ( vas ) was 2 .
the surgeon treated both shoulder ( not simultaneously ) by open reduction and bristow - latarjet coracoids transfer procedure . a 1 year after operations , left flexion was 180 while right was 160 , bilateral abduction was 180 .
he was able to return to his pre - injury activities , the constant score was 89 left and 83 right , dash score was 17 left and 13 right and vas was 0 .
atraumatic bilateral neglected anterior shoulder dislocation can be treated with open bristow - latarjet procedure to provide a stable glenohumeral joint in laborer patient and permit a return to the pre - injury activities , to create a greater extension of the glenoid arc and to avoid future dislocation .
bilateral anterior shoulder dislocation is rare , because almost always one extremity takes the brunt of the impact during trauma incidence .
usually happen almost always secondary to major trauma ( 50% ) , affect mainly young men ( 70% ) and it is associated with other injuries ( greater tuberosity fractures in 15% , rotator cuff tears , neurological associated lesions ) . muscle contractions due to neurological or psychiatric spasm or electrocution were identified like alternative cause . neglected bilateral anterior shoulder dislocation is very rare condition , often related to seizures or major trauma . for anterior dislocation ,
open reconstructive options include infraspinatus tendon transfer , disimpaction grafting or allograft repair , bankart repair and shoulder replacement . the goal of surgical treatment is repair of articular defects and maintenance of shoulder stability to allow an early rehabilitation .
a 28-year - old male jehovah s witness laborer , affected by iron - deficiency anemia , was evaluated in orthopedic office for restricted mobility and pain ( during daily activities ) in both shoulders from about 12 weeks .
he reported that previously these inabilities were interpreted as paraspinal cervical muscle contracture and treated only with muscle relaxant drugs . at the time of evaluation , patient showed mild pain and inabilities in shoulders external rotation and abduction .
physical examination revealed : bilateral normal internal rotation ; bilateral 10 external rotation , abduction and flexion about 60 and axillary nerve numbness .
anteriorposterior x - ray images evidenced bilateral anterior shoulder dislocation and computer tomography - scan showed bilateral hill - sachs lesion ( < 25% ) ( fig .
1 ) . the surgeon suggested a step - by - step surgical treatment conscious about patient s medical history and refusal of whatever blood transfusion for religious reasons .
the first step was surgical treatment of dominant limb and then right side after 1 month .
surgical procedures were both performed under general anesthesia , beach chair position and fluoroscan aid . the deltopectoral approach was used and for both cases were evidenced a glenoid fossa deficiency with hypoplasia of scapular neck and glenoid .
bleeding was controlled and intraoperative blood salvage was used to accommodate wishes of the patient to refuse homologous and autologous transfusions , as required his confession of faith . through post - operatively management ,
shoulders were supported by a sling with 15 of abduction and maintained for 3 weeks .
a 4 weeks later , clinical and radiographic evaluation were performed , and the patient was introduced to passive shoulder motion , while 2 weeks later he started an active controlled shoulder motion .
he was followed for next 6 months by upper extremities therapist team . the 1 year after last operations ,
the patient was clinical and radiographical evaluated and he was able to perform left flexion up to 180 and 160 in right , bilateral abduction was 180 ( fig .
the constant score was 89 left and 83 right , disabilities of the arm , shoulder and hand ( dash ) score was 17 left and 13 right and visual analogue scales were 0 .
anterioposterior and axillary x - ray images evidenced bilateral anterior shoulder dislocation and computer tomography - scan showed bilateral hill - sachs lesion . clinical evaluation and x - ray images 1-year
as expressed by other authors , this type of lesion can be present in 4% of all shoulder dislocation , even if the most of cases were related to medical conditions including myasthenia gravis , cerebral palsy and scapular myopathy .
neglected anterior shoulder dislocation is an exceptional condition whose treatment has not guidelines mutually agreed . in our opinion ,
treatment of this type of lesion depends on many factors : time of dislocation , age of patient , functional limitation , success of reduction , presence and amount of the hill - sachs lesion and glenoid fossa defect and surgeon s experience .
conservative treatment should be considered in patient without shoulder pain or low functional demands and in case of surgical or anesthesiological contraindications . however , in young , active , high demands patients , conservative choice without stabilization should be not the proper procedure due to possible concurrent hill - sachs lesion , to possible concurrent glenoid defect and resulting high risk of instability .
solomon et al .   suggested closed reduction only up to 6 weeks post - injury due to high risk of iatrogenic fracture or neurovascular damage .
open reduction is the recommended procedure with hill - sachs lesion more than 25% of articular surface and after 3 weeks . for anterior dislocation ,
open reconstructive options include infraspinatus tendon transfer , disimpaction grafting or allograft repair , bankart repair and shoulder replacement .
the goal of surgical treatment is repair of articular defects and maintenance of shoulder stability to allow an early rehabilitation .
many surgical solutions were proposed like eden - hybinette , arthroscopical bristow - latarjet procedure but recently , longo et al . showed how eden - hybinette procedure has clinical outcomes very similar to the bristow - latarjet with a higher rate of post - operative osteoarthritis and recurrence .
authors treated the young patient with an open bristow - latarjet procedure primarily to repair the old dislocation and remedy the glenoid fossa defect .
hill - sachs lesions were not treated during surgery because involved < 25% and intraoperatively glenohumeral joint was stable after reduction .
author s opinion is to refer surgical treatment of hill - sachs lesion in case of lesion involving over 25% of articular surface to maintain glenohumeral stability by open remplissage with the infraspinatus tendon ( in this technique the head defect was filled with the infraspinatus tendon , by tying the sutures from the anchor , so bringing the tendon down to the defect )   or shoulder arthroplasty if the lesion is over 50% of humeral head . currently , however , literature reports only few studies about results of operative treatment of chronic anterior shoulder dislocation with arthroplasty and this type of surgery should be considered in selected cases : elderly patients ; intraoperatively instability due to severe humeral head cortical depression and/or glenoid defect and degenerative arthropathy .
gavriilidis recommended this surgical procedure with large head defects and experienced good mid - term results with benefits for a range of motion , pain and patient satisfaction .
this case report showed that anterior shoulder dislocation could also occur without a trauma mechanism due to glenoid fossa dysplasia . despite ethical and religious positions of patient about blood transfusions ,
open bristow - latarjet procedure may be performed with recovery of good upper extremity function ( constant score and dash score ) , low of recurrence and good clinical outcomes .
atraumatic bilateral neglected anterior shoulder dislocation can be treated with an open bristow - latarjet procedure to provide a stable glenohumeral joint in laborer patient .
this open surgical procedure is reliable , secure and burdened with fewer complications over time , especially even in special cases ( jehovah s witness ) to create a greater extension of the glenoid arc and to avoid future dislocation .
though very rare , atraumatic bilateral neglected anterior shoulder dislocation does occur and may present to orthopedic evaluation .
 introduction : neglected bilateral anterior shoulder dislocation is a very rare condition , often related to seizures or major trauma . 
 open reduction is recommended whenever hill - sachs lesion is > 25% of the joint and the dislocation is elder than 3 weeks.case report : we describe a case report of a 28-year - old man left handed jehovah s witness laborer assessed 12 weeks after bilateral anterior shoulder dislocation . 
 the patient was evaluated with clinical examination , and it was observed an asymptomatic intrarotation of both shoulders with a mild left circumflex nerve deficit . 
 he was able to perform flexion and abduction of both arms up to 60 and 10 of extrarotation . 
 pre - operative constant scores were 49 in left and 55 in right shoulder , pre - operative disabilities of the arm , shoulder , and hand ( dash ) scores were 57 in left and 53 in right shoulder , and visual analogue scales ( vas ) was 2 . 
 radiological examination were bilateral anteroposterior shoulder x - rays and computer tomography scan . 
 the surgeon treated both shoulder ( not simultaneously ) by open reduction and bristow - latarjet coracoids transfer procedure . a 1 year after operations , left flexion was 180 while right was 160 , bilateral abduction was 180 . 
 he was able to return to his pre - injury activities , the constant score was 89 left and 83 right , dash score was 17 left and 13 right and vas was 0.conclusion:atraumatic bilateral neglected anterior shoulder dislocation can be treated with open bristow - latarjet procedure to provide a stable glenohumeral joint in laborer patient and permit a return to the pre - injury activities , to create a greater extension of the glenoid arc and to avoid future dislocation . 
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Introduction
Case report
Discussion
Conclusion