Surgery for Traumatic Instability of the Shoulder.
Last updated Thursday, February 10, 2005
Figure 1 - Glenohumeral ligaments Figure 2 - Bankart lesion Figure 3 - The knots are tied so that they come to rest over the capsule About surgery for traumatic instability
Here is some patient information typically given to a patient before a
repair for traumatic instability. However, this will vary with the
surgeon, the patient and the repair. If you have are going to have such
a repair, only your surgeon can give you specific information relative
to your procedure.Traumatic instability When a major force is applied to the arm, the supporting ligaments
of the shoulder joint may be torn. Sometimes these ligaments heal
spontaneously in the proper location so that the stability of the
shoulder is regained. On other occasions, strong healing to the
appropriate location does not occur, leaving the shoulder unstable when
it is put in certain specific positions. We refer to this as traumatic
instability of the shoulder.
These injuries most commonly arise from situations in which the
elevated arm is forced violently backward such as in a fall while
skiing. If this is the situation, one may elect to avoid the positions
in which the shoulder feels unstable, recognizing that this may require
giving up certain activities. Alternatively, one may seek a surgical
repair of the torn structures with a goal to regain some of the
functional abilities that were lost.
Who should consider this surgery We consider surgical treatment for informed patients who are unwilling
to accept the functional limitations imposed by recurrent traumatic
instability.Goals of surgery The ligaments are almost always torn from the front bottom part of the
socket of the shoulder. We can often repair this injury by sewing the
ligaments back to the bone from which they were torn. We make an
incision in the lower front skin creases of the shoulder and gain
access to the joint between two of its major muscles: the deltoid and
the pectoralis major. The ligaments are reattached by roughening up the
edge of the bony socket and placing small drill holes in the lip of
this socket. Sutures are passed through these drill holes and through
the ligaments so that when the sutures are tied the ligaments are held
in the appropriate place for healing.Risks of surgery The risks of this surgery include, but are not limited, to:
- infection,
- injury to nerves and blood vessels around the shoulder,
- unwanted shoulder stiffness,
- persistent instability of the shoulder,
- pain,
- complications of anesthesia,
- and the need for revision surgery.
Post-surgery limitations For three to four weeks after the surgery one must protect the
shoulder from elevation above the horizontal and from rotation away
from the body. It is important to carry out isometric strengthening
exercises which are done with the arm in a sling. After this first
period of protection, gentle range of motion and additional
strengthening exercises are added.
During the second six weeks we emphasize shoulder range of motion,
strength, endurance, and coordination. Usually patients can resume
rigorous physical activities three months after the operation provided
they have regained excellent strength, coordination, endurance, and a
near-normal range of motion of the shoulder.
About the surgery Here are some details regarding surgery for the management of traumatic anterior glenohumeral instability.
This section on surgical treatment concerns the management only of
patients who have traumatic anterior inferior glenohumeral instability
that has been established preoperatively by careful history and
physical examination. The indications for surgical treatment of this
lesion are persistent significant functional deficits (apprehension,
subluxation, dislocation) in abduction, external rotation, and
extension resulting from an initial episode which was sufficiently
traumatic to tear part of the major capsuloligamentous supporting
structures of the glenohumeral joint. For patients not meeting these
strict criteria, we use the methods of treatment for atraumatic instability.
The goals of treating traumatic anterior inferior glenohumeral
instability are to repair the traumatic lesion safely, restoring the
attachment of the glenohumeral ligaments, capsule, and labrum to the
rim of the glenoid. By assuring that reattachment occurs to the rim,
the effective depth of the glenoid is restored. By definition these
patients do not have a functional problem with capsular laxity, thus,
capsular reefing is not a part of this procedure. Surgical technique The goal of the surgical treatment for traumatic anterior
glenohumeral instability is the safe and secure reattachment of the
detached glenohumeral ligaments to the lip of the glenoid from which
they were avulsed. No attempt is made to modify the normal laxity of
the anterior capsule. This anatomic reattachment should reestablish not
only the capsuloligamentous check rein but also the fossa-deepening
effect of the glenoid labrum. A repair that is secure from the time of
surgery is highly desirable in that it allows patients to resume many
of their activities of daily living while the repair is healing. A
repair that is secure from the time of surgery also allows controlled
mobilization, thereby minimizing the possibility of unwanted stiffness.
In traumatic anterior instability, the absence of the normal
anterior glenoid lip can often be demonstrated by the lack of
resistance to anterior glenohumeral translation on the sheer test.
The patient is positioned in a 30 degree inclined beach chair
position with the arm free over the edge of the table. No sand bag is
used underneath the shoulder blade. Prepping and draping allow the arm
to be freely moveable and allows generous exposure to the anterior
aspect of the shoulder.
The skin incision is marked in the dominant anterior axillary crease
which is revealed when the arm is adducted. After the incision is
marked, an adhesive drape is applied and the incision is made. The
deltopectoral groove is entered, retracting the cephalic vein laterally
with the deltoid. The clavipectoral fossa is incised just lateral to
the short head of the biceps, up to but not through the coracoacromial
ligament. We routinely palpate the axillary nerve as it crosses the
anteroinferior border of the subscapularis. A Balfour retractor is
useful in the exposure. The anterior humeral circumflex vessels can
usually be protected by bluntly dissecting them off of the
subscapularis muscle at its inferior border. The subscapularis tendon
and the subjacent capsule are incised 5 mm medial to their insertion at
the lesser tuberosity. This incision starts superiorly at the upper
rolled edge of the subscapularis and extends inferiorly to the bottom
of the lesser tuberosity. It is important that the incision through the
subscapularis tendon leaves strong tendinous material on both sides of
the incision to facilitate a secure repair at the conclusion of the
procedure. We examine the joint for loose bodies, for displaced
fragments of glenoid labrum and particularly in older patients for
evidence of rotator cuff tears. We can usually palpate a posterior
lateral humeral head defect. The capsule and subscapularis are then
retracted medially as a unit and a humeral head retractor is placed in
the joint. An angled retractor is used to expose the glenoid lip and to
identify the capsuloligamentous avulsion know as the Bankart defect.
Occasionally flimsy attempts to heal the lesion will temporarily
obliterate the defect. However, in these cases a blunt elevator will
easily reveal the typical lesion in the anterior-inferior quadrant of
the glenoid. A spiked retractor is then placed through the ligamentous
avulsion to expose the defect at the glenoid lip.
We roughen the anterior, non-articular aspect of the glenoid lip
with a curette or a motorized burr, taking care not to compromise the
bony strength of the glenoid lip. We mark the intended sites for holes
in the glenoid lip with cautery. A i.7 mm drill is then used to make
holes on the articular aspect of the glenoid 3 to 4 mm back from the
edge of the lip to ensure a sufficiently strong bony bridge. We place
these holes 5 to 6 mm apart; thus the size of the defect dictates the
number of holes used for reattachment of the avulsed capsule.
Corresponding slots are placed on the anterior non-articular aspect of
the glenoid. Using a 000 angled curette, we establish continuity
between the corresponding slots and holes.
We then pass a strong number 2 absorbable braided suture through the
holes in the glenoid lip using a trocar needle and an angled needle
holder. After each suture is placed through the glenoid lip, the
integrity of the bony bridge is checked by a firm pull on the suture.
At this point in the procedure it is again useful to verify the
location of the axillary nerve.
The spiked retractor is then removed from the lesion and an angled
retractor is used to expose the trailing medial edge of the avulsed
capsule. Next, using the trocar needle, we pass the end of the suture,
exiting the anterior non-articular aspect of the glenoid lip through
the trailing medial edge of the capsule, taking care to include the
glenoid labrum, if present. We avoid including any more capsule than
necessary to obtain a firm purchase; this prevents unwanted tightening
of the anteroinferior capsule. In larger glenohumeral ligament
avulsions, the detached medial edge of the capsule tends to sag
inferiorly; thus, in these larger lesions an effort needs to be made to
pass the needle through the capsule slightly inferior to the bony holes
in the glenoid. At the time of closure the inferiorly sagging medial
capsule will be repositioned anatomically.
Once the sutures have been passed through the capsule, they are tied
so that the labrum and medial edge of the capsule are positioned on the
glenoid lip. The knots are tied so that they come to rest over the
capsule, rather than on the articular surface of the glenoid.
Once these sutures are tied, the smooth continuity between the
articular surface of the glenoid fossa and the capsule should be
reestablished. No stepoff or discontinuity in the capsule should be
present. If such a discontinuity is noted, the sutures are replaced so
that they obliterate the defect.
At the conclusion of the surgical repair the capsule and
subscapularis tendon are repaired anatomically to their mates at the
lesser tuberosity. The integrity of the axillary nerve, which has been
monitored through the case, is again verified on closure.
Movies
After the surgery The sheer test is checked again after the repair.
The shoulder should have at least 30 degrees of external rotation at
the side after the subscapularis/capsular repair. A standard wound
closure is carried out, using a subcuticular suture, which is removed
at three days.
Within the first few days after surgery, reliable patients are
encouraged to use the arm up to 90 degrees of elevation in the anterior
plane and out to zero degrees of external rotation. This allows
sufficient range of motion to perform most activities of daily living,
such as eating and personal hygiene, as well as certain vocational
activities, such as writing and typing. Gripping, isometric external
rotation, and isometric abduction exercises are started immediately
after surgery to minimize effects of disuse. If a patient does not
appear able to comply with this restricted use program, we require that
the arm be kept in a sling for three weeks.
At three weeks the patient should return for an examination and
should have at least 90 degrees of elevation and external rotation to
zero degrees. From three weeks to six weeks postoperatively, the
patient is instructed to increase the range of motion to 140 degrees of
elevation and 40 degrees of external rotation. At six weeks after
surgery, if there is good evidence of active control of the shoulder,
gentle repetitive activities such as swimming and using a rowing
machine may be instituted to help with coordination, strength, and
endurance of the shoulder. More vigorous activities such as basketball,
volleyball, throwing, and serving in tennis should not be started until
three months and only then if there is excellent strength, endurance,
range of motion, and coordination of the shoulder.
Movies
Avoid stiffness Patients are usually able to conduct their own postoperative
rehabilitation program with instructions from a physical therapist or a
physician.
Vigilance must be exercised for patients over 35 years of age to be
sure that they do not develop unwanted postoperative stiffness. Thus,
particularly for these patients, the three-week and six-week checks are
very important to make sure that the ranges of elevation and external
rotation are respectively 90 and 0 degrees at three weeks, and 140 and
40 degrees at six weeks. Instructions for rehabilitation These are typical instructions given to a patient after a repair for
traumatic instability. However, the program will vary with the surgeon,
the patient, and the repair. If you have had such a repair, only your
surgeon can give you instructions on the postoperative management. Do
not do any exercises after surgery except after consultation with your
physician.
After your surgical repair, your arm is in a sling to assure that it
heals properly. If this sling is not comfortable, be sure to let your
doctor know immediately.
You may remove your arm from the sling to perform your exercises.
These include lying down on your back and lifting your arm so that the
elbow points straight up. In the second exercise, also performed lying
on your back, you rotate your forearm away from your stomach until it
points straight ahead.
You need to start exercises in your sling right away. First you need
to maintain the strength of your grip by squeezing a ball, sponge, or
putty several hundred times a day. Second you should perform three
minutes of gentle isometric exercises at least three times a day
against some fixed object - pushing your wrist outward, pushing your
hand forward, pushing your elbow outward, and pushing the elbow back.
These exercises are designed to maintain your muscle tone. The shoulder
is not moved during these exercises. They should be comfortable.
You will return to the office three weeks after surgery. If
everything is healing properly, you will begin weaning yourself from
the sling at that time.
At three weeks after surgery, you can increase your overhead reach
until your arm is close to your ear and until your forearm can be
externally rotated 40 degrees from the straight ahead position. You
need to continue your previous isometric exercises and can add internal
and external rotation strengthening using rubber tubing.
You then progress by using your arm for light activities of daily
living, avoiding the positions that used to be unstable. Always avoid
"checking" your shoulder to see if it is stable. You must not lift over
10 pounds for the first six months after your surgery.
After six weeks you can begin gentle, well-controlled, repetitive
activities with your shoulder such as swimming or using a rowing
machine, provided that these activities are comfortable for you.
At three months it is often appropriate to implement the full home exercise program.
You cannot return to contact sports or heavy work for at least three
months after this surgery, and then only if you have excellent strength
and coordinated control of your shoulder.
If you have any questions at any time, please let your doctor know.
In summary This article has described the pathology, diagnosis, and management of
patients with traumatic instability. This diagnosis is made
predominately on the basis of the history of the initial and subsequent
episodes of instability and is corroborated by the physical examination
and often by bony changes on plain radiographs. The goal of the
surgical repair is to restore anatomically the continuity of the
capsuloligamentous and labral complex with the cartilage of the glenoid
fossa and to avoid limitation of range of motion from unnecessary
capsular tightening. It is also important that the surgical repair be
sufficiently strong that early protected use of the shoulder can be
instituted while the tissues are held in secure anatomic position to
the bone of the glenoid. With this approach, more complicated and
complication-prone procedures such as capsular tightening, coracoid
osteotomy, coracoid transfer, metal fixation, bone blocks, and
osteotomies can be avoided. It is to be reemphasized that satisfactory
treatment of this entity depends on a precise diagnosis, which is
established by the history and physical examination prior to taking the
patient to the operating room.
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