Treating Shoulder Dislocation / Subluxation (Instability) and Associated Pain with Minimally Invasive Arthroscopy
Last updated Thursday, May 29, 2008
Considering surgeryWhat kinds of surgery are recommended for cartilage and ligament tears in the shoulder? Many patients with torn labrum or
shoulder cartilage will benefit from arthroscopic repair. The procedures can be
done concurrently, if needed; oftentimes the labral cartilage tears away from
the bone but is still connected to the ligament. So when the cartilage is
repaired, the ligament is tightened, as well.
Patients’ injuries might require an open
procedure (using a larger incision than arthroscopy) to adequately stabilize
the shoulder. Such injuries would include large, bony fractures of the glenoid
socket (“bony Bankart lesions”), for instance.Who should consider arthroscopic labral repair/capsulorraphy for cartilage and ligament tears in the shoulder and in what cases? Arthroscopic repair is appropriate
and usually effective for a patient whose pain and/or instability suggests a
torn cartilage and/or capsular ligament.
However, in cases of more substantive injury to
the humerus or glenoid, or to surrounding bones, muscles or tendons, the
surgeon might be more likely to recommend an open approach to the procedure.What happens if nothing is done for cartilage and ligament tears in the shoulder (best case/worst case scenarios)? Without surgery, in the best-case
scenario, the patient would adapt to the condition and any corresponding loss
of motion, or satisfactorily change their lifestyle and activities. Pain and/or
instability would plateau at a degree that the patient finds bearable, and the
injury would not worsen.
In the worst-case scenario, the
tear or tears worsen, causing more pain, or the ligament stretches more, making
the shoulder less stable. Either of these conditions can damage the articular
cartilage – the smooth, almost frictionless cartilage on the surfaces of the
bones – and this can lead to arthritis. As well, frequent dislocations of the
humerus can, over time, break down the outer edge of the glenoid socket, much
as the top edge of a golf tee is worn down or chipped. This accelerates the
frequency with which the humerus subluxates or dislocates from the glenoid with
decreasing amounts of force, sometimes even occurring in their sleep. What options exist for surgery for cartilage and ligament tears in the shoulder? The two main options are
arthroscopic repair and open repair. The open technique for years has been the
standard approach.The surgeon makes a longer (10 cm) vertical incision to the patient’s shoulder, above the armpit. The bigger incision gives easy visual access to the joint and its surrounding tissues but requires the surgeon to divide tendons to gain instrumental access to the joint.
This more invasive procedure is
performed, appropriately, when the humerus or glenoid bones are severely damaged,
or when large, bony fractures of the glenoid socket (“bony Bankart lesions”)
exist. The open approach requires an overnight stay at the hospital after
surgery. Postoperative pain can be greater for patients undergoing an open
procedure.
With arthroscopic repair, a series
of three or four small (1 cm) incisions around the shoulder gives a surgeon
minimally invasive access to the injured tissues. Fewer surgeons have significant
experience with this technique, as it is more technically demanding. Data
suggests that, for many shoulder procedures, an arthroscopic approach yields
similarly positive patient outcomes as the open approach.
The bonuses of arthroscopic technique, if it is
appropriate to the patient’s injury, are less postoperative pain and scarring.
Additionally since no tendons are divided, the risk of late tendon weakness or
failure is avoided.When performed by an experienced surgeon, how effective is arthroscopic labral repair/capsulorraphy for cartilage and ligament tears in the shoulder likely to be and how long will the benefit last? The effectiveness of the arthroscopic
procedure depends on the health and motivation of the patient, the condition of
the shoulder, and the expertise of the surgeon. When performed by an
experienced surgeon, arthroscopic labral repair and/or capsulorraphy usually provides
improved shoulder comfort and function, and the patient ultimately can return
to sports activities, if he or she desires.
The arthroscopic procedure’s
success rate is above 90 percent. An experienced surgeon performing this repair
can provide a patient with decades of reduced or no pain, and/or with much
improved shoulder stability.
The open repair has had a
longstanding, well-documented rate of success also above 90 percent. For
traumatic anterior shoulder instability, the most dependable results have been
achieved with an open repair. One trade-off is that the open repair is more
likely to create residual minor stiffness.
The return to athletic activities after open
surgery is at least as fast as with arthroscopic repair, but most patients
return to work faster after the arthroscopic approach.How urgent is arthroscopic labral repair/capsulorraphy for cartilage and ligament tears in the shoulder?
Surgery
for cartilage tears or instability is not an emergency. Labral repair or capsulorraphy
are an elective outpatient procedure that can be scheduled when circumstances
are optimal. The patient has time to become informed and to select an
experienced surgeon. It is advisable to consider surgical repair even after a first-time dislocation. Recurrent instability occurs variably but is more frequent in young, aggressive athletes; that population has a rate of recurrence above 80 percent. Older, more sedentary people have lower rates of repeat dislocation. While the traditional wisdom has been to wait-and-see whether instability becomes a recurrent problem, each patient should make the decision about surgery based on available information. For example, a traditional weekend athlete who plays pickup ball might decide to wait-and-see, but the kayaker, skydiver or rock-climber might be at considerably more risk with a sudden re-dislocation in a precarious situation.
Before
surgery is undertaken, the patient needs to be in optimal health, understand
and accept the risks and alternatives of surgery, and understand the
postoperative rehabilitation program.
Surgery should be performed when conditions are
optimal. In some cases, particularly with non-traumatic instability, an
extended effort at non-operative management is suggested. Usually a six- to twelve-week
attempt at strengthening exercises is sufficient to determine whether exercises
are likely to be effective. However, in many cases, therapy will strengthen the
surrounding muscles and improve function, though it will not heal the torn
tissues.What are the most frequent and most serious risks of arthroscopic labral repair/capsulorraphy for cartilage and ligament tears in the shoulder? How common are they? The complications of arthroscopic shoulder surgery for cartilage and ligament tears are infrequent. Risks include but are not limited to the following: infection, injury to cartilage, nerves and blood vessels, fracture, stiffness or recurrent instability of the joint, pain, blood clots and the need for additional surgeries. There are also risks in having anesthesia and the administration of a variety of medications. Blood clots in the legs (deep venous thrombosis, or DVT) can form and travel to the lungs and make breathing difficult. This is also very rare unless the patient has a predilection to clotting.
An experienced shoulder surgical
team will use special techniques to minimize these risks, but cannot totally
eliminate them. If risks occur during or after arthroscopic labral repair/capsulorraphy for cartilage and ligament tears in the shoulder how are they managed? Many risks of shoulder arthroscopic surgery for cartilage
and ligament tears can be effectively managed if they are promptly identified
and treated. Infections, while rarely seen, may be treated with antibiotics or
require a cleansing in the operating room.
Injuries to nerves or blood vessels are
exceedingly rare, but may require repair. DVTs are usually treated with
medications.Surgery for Cartilage and ligament tears in the shoulder 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 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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