Arthroscopic shoulder surgery for shoulder dislocation, subluxation, and instability: why, when and how it is done.
Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Tuesday, January 25, 2005
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Considering surgery
Who should consider arthroscopic shoulder surgery?
Arthroscopic or open shoulder surgery is considered for instability when:
- the episodes of instability represent a significant problem for the
patient, and inhibit his or her ability to perform the activities of
daily living, overhead activities, or sporting activities
- the patient is sufficiently healthy to undergo the procedure
- the patient understands and accepts the risks and alternatives to the procedure
- the patient has truly exhausted non-operative treatments, like physical therapy
- an appropriate and comprehensive diagnostic evaluation has been performed and the nature of the problem is clear
- the patient does not willfully or voluntarily dislocate their shoulder
- the surgeon is experienced and familiar with several techniques and
treatments for shoulder instability, including arthroscopic surgery and
open (traditional surgery)
- the patient is capable and willing to undergo a comprehensive post-operative rehabilitation (physical therapy) program
The results of arthroscopic and open shoulder stabilization
procedures are most effective when the patient follows a simple
post-operative rehabilitation program. Thus, the patient’s motivation
and dedication are important elements of the partnership.
What happens without surgery?
Persons who subluxate or dislocate their shoulder on a frequent
basis (on a weekly or daily basis) may lose valuable time from work,
progress to more frequent subluxations or dislocations, or worse: do
permanent damage to the shoulder joint or develop premature arthritis.
It is impossible to know if a person who suffers a single
dislocation or subluxation will continue to have this problem. Persons
who are young (less than 20 years old) are likely to suffer from recurrent events. Persons who are older (older than 40 years old) are unlikely
to have recurrent events. However, it is advisable to have the shoulder
evaluated after any significant event of instability to be sure that
there has been no significant damage to the joint. After an initial
dislocation or subluxation, an experienced surgeon will usually
recommend bracing and physical therapy to try and limit the possibility
of recurrence.
Surgical options
Several options are available to the patient and the surgeon,
depending on the problem that causes the instability. In most cases,
the problem to be treated will dictate the nature of the surgical
procedure performed. In the hands of a surgeon who is experienced with
arthroscopic shoulder surgery, almost all of the following procedures
can be performed alone or together to restore joint stability and
eliminate pain using arthroscopic techniques:
- labral repair (anterior or posterior)
- repair of the capsular ligaments (Bankart repair)
- repair of the rotator cuff
- repair of the biceps anchor or SLAP lesion
- tightening of the shoulder capsule (capsulorraphy or capsular shift)
Patients who have large bony fractures at the glenoid socket
or humeral head (“bony Bankart lesions” or “Hill-Sach’s defects) or
those who have true multi-directional instability (MDI) may require an
open procedure (using a larger incision) to adequately stabilize the
shoulder.
Effectiveness
In the hands of an experienced surgeon, shoulder stabilization can be
very effective in eliminating instability and restoring comfort and
function to the shoulder of a well-motivated patient. The greatest
benefits are often the ability to perform the usual activities of daily
living, overhead activities, and sports without the fear of
subluxation, dislocation or pain. As long as the shoulder is cared for
properly and subsequent traumatic injuries are avoided, the benefits on
stabilization should be permanent.Urgency
A dislocated shoulder (one that is “out of joint”) must be relocated on an emergent
basis. Any patient who thinks they have had a dislocation, or who can
not move the shoulder appropriately after an injury must be evaluated
in the emergency room as soon as possible to avoid a possible permanent
injury to the nerves or blood vessels around the shoulder. Most often,
the dislocated shoulder can be relocated into the joint with a mild
sedative in the emergency room. X-rays must be taken to confirm that
the shoulder has been appropriately relocated.
Unless the shoulder can not be relocated or is stuck “out of joint”, surgical shoulder stabilization is not
an emergency. The relocated shoulder is likely to remain in the joint
as long as the patient is willing to wear a sling or brace and avoid
motions that create un “unstable” feeling. Many persons who suffer
their first episode of instability (particularly persons over the age
of 30-40 years) may never require surgery to have a fully-functional,
stable shoulder after an adequate period of bracing and physical
therapy. Persons who suffer frequent or multiple dislocations may wish
to have surgery to stabilize the shoulder, but such patients have time
to adequately become informed about the surgical options and select an
experienced surgeon.
Before surgery is undertaken, the patient needs to:
- be in optimal health
- understand and accept the surgical alternatives, options, risks and benefits
- have discussed and or attempted non-operative measures to treat the problem (i.e. rehabilitation/physical therapy)
- have undergone a comprehensive examination, X-ray and usually MRI work-up to define the factors contributing to the problem
Risks
The risks of arthroscopic or open shoulder stabilization procedures
include but are not limited to the following:
Infection, temporary or permanent injury to the nerves and blood
vessels around the shoulder, excessive stiffness of the joint,
recurrent instability or loosening of the joint, recurrent tears of the
rotator cuff, pain, allergic reactions to any implants or suture
materials used to stabilize the joint, the need for additional
surgeries. The anaesthesia used during the procedure also has some
risks, that can be addressed by the anaesthesiologist. The experienced
and cautious surgical team uses special techniques to minimize all the
above risks. Adverse events following shoulder surgery are extremely
rare, but they can not be completely eliminated.Managing risk
Many of the risks of surgical stabilization can be effectively managed
if they are promptly identified and treated. Infections may require a
wash-out of the joint, and rarely require removal of any implanted
materials. Blood vessel or nerve injuries are rare, and most resolve
spontaneously. Occasionally, such an injury may require surgical
repair. Excessive stiffness of the joint is rare in the person who is
cooperative with the postoperative rehabilitation program, and most of
the stiffness will respond to exercises. Excessive laxity or loosening
of the joint is a sign that the surgery has not completely addressed
the instability, and may require further evaluation and management. If
a patient has questions or concerns about the “normal” course after
surgery, the surgeon should be informed as soon as possible and be
available to explain the expected course and outcome.Surgery for shoulder dislocation, subluxation, and instability at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-543-1552 or 425-646-7777 to make an appointment. Our clinical center is located in Seattle Washington, USA
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