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
About the procedureTechnical details Shoulder stabilization, either arthroscopic or through an open
incision is a highly technical procedure; each step plays a critical
role in the outcome.
After the patient is comfortably positioned in a seated position and
anesthetic has been administered, the shoulder is given a sterile
washed and draped for surgery. The surgeon begins by examining the
shoulder while the patient is asleep or the shoulder relaxed so he or
she can assess the relative stability of the joint, the range of
motion, and feel for any abnormal grinding or catching of the joint.
Next, one or two very small (1cm) incisions, or “portals” are made,
usually one in the front and one behind the shoulder joint. Through
these small portals, hollow instruments called “canulas” are placed
that irrigate the inside of the shoulder joint with sterile saline and
“inflate” the joint with clear fluid. The canulas allow the placement
of an arthroscopic camera and specially designed instruments within the
shoulder joint. Figure 6 shows the 2 healed incisions several weeks
following an instability repair.
The surgeon maneuvers the camera around the joint while he or she
watches a video monitor of what the camera “sees”. A highly-skilled
surgeon can evaluate all of the important structures within the joint,
test their stability and integrity, and look for signs of ligament
injuries, cartilage wear (or arthritis), and bony injuries that can be
caused by or lead to shoulder instability or dislocation. (see video 2)
Most often, the surgeon will take photographs of the interior of the
joint to help to explain to the patient what was found, and how it was
corrected. This portion of the surgery is called a “diagnostic
arthroscopy” and is absolutely necessary to assure the success of any
surgical procedure for shoulder instability (even if an MRI had been
obtained prior to the procedure). This is because the arthroscopic
examination of the joint is still the “gold standard”, or best way to
understand ALL of the factors that could be present and may need to be
addressed to treat the problem.
Once the surgeon understands what structures within the joint are
injured or torn, he or she will choose the best possible surgical
approach to treat the problem. A highly-skilled surgeon who is
comfortable with the anatomy of the joint and who has exceptional
skills with specially-designed arthroscopic instruments and implants
can usually address the problem without the need for large incisions.
For the most common types of shoulder instability or dislocation,
the ligaments at the front of the shoulder that hold the head in the
glenoid socket are torn or loose from the lip of the glenoid (or labrum).
Using special implants called “suture anchors” the surgeon can repair
the ligaments and labrum in place and tighten them as necessary. These
anchors are buried into the bone, and most are made of absorbable
materials that will disintegrate over time after the shoulder has
healed. Figure 7a shows the labrum (L) torn away from the glenoid
surface. Figure 7b shows the labrum (L) repaired to the glenoid using
three suture anchors.
Other injuries, such as tears of the origin of the biceps muscle tendon (called a SLAP lesion)
can also be seen and addressed during the procedure. Figure 8a shows
the biceps (bi) and labrum torn away from the top of the glenoid.
Figure 8b shows the biceps (bi) and labrum repaired to the labrum using
a suture anchor.
Very rarely, a patient will have severe dislocation is multiple directions (multidirectional instability or MDI)
and will require an “open” approach to the shoulder joint through and
incision in the front (or in very rare cases, in the back) of the
joint. This incision is made in such a way to access the joint without
damaging the important deltoid or pectoralis muscles that are important
for the shoulder’s power. The open surgical approach requires that one
of the rotator cuff muscles be moved or split to access the joint and
repaired after the procedure is completed. During this open approach,
the capsule of the joint is tightened by repositioning the excess or
loose ligament tissue into a more suitable position, akin to making a
pleat in a pant. The indications for open shoulder stabilization
procedures differ according to the degree of instability, and the
comfort level and skill of the surgeon with arthroscopic approaches.
At the conclusion of the procedure, any incisions are closed using
absorbable or removable sutures. Frequently, a surgeon will insert a
temporary, easily-removable catheter (a tiny, flexible plastic tube)
into the shoulder joint that is connected to an automatic pump filled
with anesthetic solution. This “pain pump” can help considerably with
postoperative discomfort, and is removed by the patient or their family
2 or 3 days after surgery. The patient’s shoulder is placed into a
postoperative sling to protect the shoulder during the early
postoperative period.
The absorbable “suture anchors” or implants are gradually absorbed
and the sutures attached are incorporated into the healing tissues.
When metallic anchors are used (a matter of surgeon preference), these
are buried in the bone, and do not affect the integrity of the bone or
the shoulder joint. Further surgery is NOT normally required to remove
the suture anchors after healing. Anesthetic Arthroscopic and traditional open shoulder stabilization procedures
may be performed under a general anesthetic or under a brachial plexus
regional block that makes the shoulder and arm numb during and for
several hours after the procedure. The patient may wish to discuss
their preferences with the anesthesiologist prior to surgery.
Length of arthroscopic shoulder surgery The procedure takes approximately 2 to 2 1/2 hours, however, the
preoperative preparation and postoperative recovery can easily double
this time. Patients usually spend 1 or 2 hours in the recovery room.
Patients who undergo arthroscopic procedures almost always are
comfortable enough to be discharged home. Those undergoing more
traditional open procedures may require one night’s hospitalization.Surgery for shoulder dislocation, subluxation, and instability at the University of Washington If you are interested in making an appointment to discuss this procedure, 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.
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