Arthroscopic Shoulder Stabilisation

The most common cause of shoulder instability is a shoulder injury. Falling or running into something, a sporting tackle or lifting something a long way can over stretch your shoulder joint. This loosens the part of the joint which keeps it tight in a way which does not allow it to heal. Once the shoulder has been out of joint once it is very likely to slip out of the socket again and again.

The treatment of shoulder instability is to get your shoulder back under control. This removes the sensation that the shoulder is slipping out of place. For some patients this will mean a physiotherapy program and for others it will involve an operation. After you shoulder is stabilised, regular exercise can help keep it that way.

The Shoulder Joint

The shoulder is the most flexible joint in the body, allowing you to throw balls, lift heavy objects and reach in almost any direction. The shoulder is made up of bony parts and soft tissue parts. The shoulder “stabilisers” hold the humeral head and glenoid together to keep the shoulder stable.

The Capsule

The capsule is called the static stabiliser. It encloses the humeral head and the glenoid and stabilises the joint, stopping the humeral head from leaving the glenoid when you raise your arm.

The Rotator Cuff

The rotator cuff is called the dynamic stabiliser. The rotator cuff muscles and tendons pull the humeral head into the glenoid when you raise your arm and thus helps stabilise the shoulder.

The Labrum

The labrum is a ring of tough and flexible tissue on the rim of the glenoid. It attaches the glenoid to the capsule and makes the glenoid socket deeper, thus making shoulder dislocation less likely.

If the humeral head shifts completely off the glenoid because the shoulder joint is too flexible this is called a dislocation. When the head is pushed only part way out of the glenoid it is called subluxation. Subluxing or dislocating a shoulder can stretch or tear the capsule and damage other parts of the joint. This makes the humeral head more likely to slip out of the glenoid again.

Injury can happen to the capsule, the bone, the glenoid labrum and rarely to the muscles. If the capsule is torn, it cannot stop the humeral head from moving out of the glenoid, allowing the head to slip out over and over again.

When the shoulder dislocates the humeral head can hit the bone of the glenoid rim, fracturing the glenoid or denting the humeral head. This, again, makes the humeral head more likely to slip out again and again.If the humeral head pushes only part way out of the glenoid, the capsule may stretch rather than tear. The stretched capsule is too loose to stop the humeral head from leaving the glenoid when you raise your arm. When it pushes all or part way out of the glenoid, the humeral head can tear the labrum. Since the labrum helps hold the humeral head inside the glenoid, a torn labrum means the humeral head may slip out of the glenoid.

In most patients it will be true that as a result of the dislocations you have stretched the capsule of the shoulder joint and it is larger and more voluminous than the normal capsule. In addition you may have torn a small piece of tissue known as the labrum off the bone and this allows the humeral head to dislocate forwards.

Treatment

Physiotherapy can help restore stability, strength and control of your shoulder. It helps you regain control of strengthening your dynamic stabilisers – the rotator cuff and other shoulder muscles – and training them to take over from the parts of the shoulder that are damaged and are no longer doing their job. There are some types of instability where physiotherapy alone is enough to stabilise the shoulder. For most sports-people physiotherapy is only effective when used in conjunction with surgery.

Surgery

Surgery helps restore shoulder stability by tightening and repairing the shoulders static stabilisers. The principles of the operation are to reduce the size of the stretched capsule of the shoulder joint and to reattach the torn labrum back to the bone. The procedure is designed to tighten and repair the shoulder joint which means that physiotherapy after the procedure is often necessary to help you regain flexibility. It also helps regain strength while the shoulder is healing.

Factors that are Important in the Determination of Treatment are:

• How long you have had an unstable shoulder.
• The direction in which your shoulder is slipping.
• The extent of damage to the joint.
• Whether there is any damage to muscles or nerves.
• What kind of lifestyle you lead and/or sporting activity you want to be able to get back to.

You have elected to undergo an operation to stabilise your shoulder for recurrent dislocations or subluxations of your shoulder.

There are several different techniques available to stabilise your shoulder.

The arthroscopic procedure has excellent results in cases where there have been few dislocations The arthroscopic procedure can be done in contact athletes but the success rate may not be as good as an open operation in certain cases. This operation has a success rate of about 90%.

The open operation, commonly known as a “full reconstruction”has a higher success rate especially in people who have had several dislocation over many years or who are very active and play elite contact sport. The success rate of the open operation is greater than 90% but usually involves a moderate loss of movement in certain positions of the shoulder. The rehabilitation following both procedures approximate 6 months but hospitalisation may be shorter with the arthroscopic procedure.

The open operation is preferable when there has been significant bony damage as it allows for bone grafting procedures to be performed.

The operation is necessary because your shoulder keeps coming out of joint and the risk of it continuing to come out of joint is very high. Each time the shoulder dislocates more damage is done to the joint itself and this might increase the risk of arthritis in the future.

You will be admitted to the hospital on the morning of surgery and you will be visited by the anaesthetist who will examine you and make sure you are fully fit to undergo a general anaesthetic. In many cases the anaesthetist will explain to you the option of having a “block” which is an injection in and around the neck which will reduce pain for 12 to 18 hours post operatively. The nursing staff will also explain the use of “patient controlled analgesia” (or PCA) where you regulate the amount of pain relieving medication that you use. You must remove all rings from your hand prior to surgery.

This operation takes about 120 minutes. You will have two small incisions at the back and front of your shoulder. The labrum, or cartilage, which is torn off the bone and is repaired with either a dissolving screw or a metal screw with stitches attached to the end. In cases where the capsule (or lining of the shoulder) has stretched there is the added option of dividing the capsule and then tightening the capsule with arthroscopic stitches, which acts like tightening a double-breasted coat.

You will wake up in the ward in a sling and you will be given adequate pain killers to keep you comfortable.

The day after surgery a waterproof dressing will be placed on the shoulder and you will be allowed to shower. When showering take the sling off but leave your arm adjacent to your body – do not attempt to lift or rotate the arm – and then put the sling back on after you are dry. Make sure the armpit is as dry as possible because of the risk of a sweat rash or an armpit infection. It is important to sit out of bed and walk around as soon as you are comfortable and able.

You will be discharged from hospital. In the immediate post operative period you will experience pain about the shoulder. On discharge from hospital it is likely you will be given analgesics as well as tablets to help you sleep at night.

The sling will need to remain on for at least 4 weeks. The sling must remain on 24 hours a day including at night. The sling only comes off to have a shower and get dressed and on those occasions the arm needs to be kept adjacent to the body. The Roads and Traffic Authority does not permit driving a vehicle while you are in a sling. It is recommended that  you do not drive for 4 to 6 weeks.

At about 10 days after surgery you will be seen to take out your stitches and check that the wound is clean and that there is no infection.

You will again be reviewed at the 4 week mark, to be taken out of the sling and start an exercise program.

Under NO circumstances can you return to any sports for 5 to 6 months. Doing so may compromise the result. Fitness can be maintained by using an exercise bike or jogging, with care not to fall. I allow some supervised swimming after 10 to 12 weeks but tennis, basketball, touch football, soccer, weights training and ALL sports should not be started until you are permited to do so at about 6 months following surgery.

At about 6 months, providing you have sufficient muscle control of the shoulder, you will be permitted to resume full activity, including contact sports. You will however need to continue the exercise program for at least 9 months following surgery. Your shoulder may be a little stiff for up to 12 months following surgery. Please note that in most cases there will be minor but permanent loss of motion at the extremes of movement but this usually does not cause any functional impairment.

Persons who return to contact sport (especially professional athletes) should use a brace for the first season when they return to playing. This is to protect the repair. The brace is usually fitted by the team physio. All patients who return to doing weights should permanently avoid training in positions that can stretch the shoulder (such as shoulder presses and full extension in bench presses). This should be discussed with your trainer where possible.

The recurrence rate following surgery is about 10% in persons who do not return to contact sport, but is a little higher  in persons who return to contact sport and this includes snow and water skiing. This operation does not give you a super strong shoulder and just as you dislocated your shoulder the first time, you may dislocate it again with violent sporting activity.

Reasons to consider operative stabilization after one dislocation:

1. Young age – as high rate of recurrence
2. Participation in activities that may be life threatening if the shoulder
   – Ocean swimming (10% of drownings associated with dislocation)
   – Surfing
   – Rock Climbing
   – Sky Diving / Base Jumping
3. If planning to join the armed services