Arthroscopic shoulder surgery for shoulder dislocation, subluxation, and instability: why, when and how it is done.

Edited By: Suzanne L. Slaney, PA-C, ATC, MMS, Christopher J. Wahl, M.D.
Last updated Tuesday, January 25, 2005

Figure 6

Figure 7a & 7b

Figure 8a & 8b

About the procedure

What are the technical details of arthroscopic shoulder surgery for shoulder dislocation, subluxation, and instability? What is actually done?

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.

What is the typical anesthetic used for arthroscopic shoulder surgery for shoulder dislocation, subluxation, and instability?

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.

How long does arthroscopic shoulder surgery for shoulder dislocation, subluxation, and instability usually take?

Surgery for shoulder dislocation, subluxation, and instability at the University of Washington

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