Shoulder anterior stabilization: arthroscopic

Pre-Operation

Patient positioning

Position of the surgical "portals"

This procedure is performed to correct the unstable shoulder. It may be done following the first ever dislocation (acute instability), or following a number of dislocations (recurrent instability), or for longer term symptoms related to the instability (chronic instability). In most cases and MRA of the shoulder is required for operative planning.

The operation is performed with the patient under a general anesthetic, in an operating theatre. The operation is usually performed as an arthroscopic (that is “key hole”) surgery. The initial stage of the operation is a routine arthroscopy, during which the entire shoulder is assessed, the damage documented, and the corrective procedure planned. Read the description of shoulder arthroscopy on the “shoulder surgery” page.

In most cases the procedure is performed for anterior instability (shoulder dislocating out the front), and/or inferior instability. In some cases the shoulder is unstable in the posterior direction (out the back) also, and on rare occasions in all directions.

The corrective procedure usually involves repairing the “labrum” which acts as a step at the edge of the glenoid (the socket of this ball and socket joint), and which has usually be damaged by the humeral head (the ball of the joint) riding up over it, as it dislocates. During the dislocation, the capsule and ligaments of the shoulder joint are usually also damaged and have to be re-tensioned.

The photographs above demonstrate the typical appearances of the anterior labrum (the step at the front of the shoulder) and anterior capsule, found in the unstable shoulder. The instrument is placed beneath the torn anterior labrum of a right shoulder, two separate cases.

The photographs above demonstrates the labrum being repaired using sutures that are passed through the labrum and capsule, and then repaired to bone. The same shoulders as above.

The photographs above demonstrate the labrum following repair back to bone with re-tensioning of the anterior capsule of the shoulder joint. The same shoulders as above.

The portals are sutured closed at the end of the operation, dressings applied and the arm placed in a sling.

You will usually go home the day of the operation and will be reviewed by your surgeon 7-10 days following surgery.

There is a set protocol that you will be asked to follow. This is designed to allow the repaired structures to heal correctly. To learn more about this read the appropriate section on the “post-operative guidelines” and “physiotherapy guidelines” pages of this website.

Potential
complications

Despite our best attempts, potential complications are a risk with any injury or surgical procedure. You need to be aware of these rare potential complications.

The more common ones are listed here, but please ask the surgeon if there are any you are particularly concerned about.

1. Infection

If this only involves the skin, this will respond to antibiotics (sometimes intravenous and requiring admission to hospital). If the infection is deeper and involves the joint, then the joint may have to be washed out in the operating theatre to cure the infection. The risk of infection is less than 1%.

2. Wound healing

Sometimes this is delayed, and/ or may produce and thickened scar. The latter is more likely if you have a history of “keloid” formation following other skin lesions or surgery.

3. Post-operative stiffness/frozen shoulder

This can take 18 months to resolve, is poorly understood, can occur after any shoulder injury. Stiffness which improves during the rehabilitation, is common, while frozen shoulder is rare following a shoulder stabilization.

4. Post-operative pain

Pain after surgery

5. Recurrence of the injury

Although the repair is very solid, it is possible to redo the injury if sufficient force was to be exerted on the repair, especially during the first 6 weeks following surgery. Return to the sport which caused the injury obviously can result in recurrence of the original injury. It takes 5-6 months to be able to return to full contact sport, and as long as the rehabilitation has been completed. The younger the age at initial dislocation, and the more easily it dislocated, the higher the risk of recurrence. The recurrence rate following arthroscopic surgery, is now similar to that following open shoulder stabilization (3-5%).

6. Vascular injury

Vascular injury and bleeding

7. Nerve injury

On rare occasions one of the nerves close to the shoulder joint can be damaged by accidental contact with a sharp instrument or suture. The axillary nerve is most at risk. Damage to the nerve may be permanent, with permanent weakness, and is a serious complication. Fortunately it is very rare.

8. Regional pain syndrome

This rare complication is poorly understood and difficult to treat. It manifests as disproportionate pain following the surgery, and slow recovery. There may be symptoms of swelling, color changes and stiffness also.

9. Complications related to the anaesthetic

In a young healthy patient these are also rare, but in the presence of poor health and other medical conditions they may be significant. Your anaesthetist will review you prior to surgery and will only proceed with surgery if it is reasonably safe to do so. Usually your surgeon will have ordered some preliminary tests if he has any concerns and will liaise with the anaesthetist prior to surgery.

Post-Operation

Immediately post-operation

You will wake up in the recovery ward with a nurse looking after you. Your arm will be in a sling and there will be dressings on your shoulder. The wounds will be closed with stitches.
You will be kept in the recovery ward until you have recovered from the anaesthetic, and have managed to have something to eat and drink.
Your surgeon will review you before discharge to explain to you what was found during surgery and the details of the operation performed, as well as the expected outcome

Discharge to first post-operative review

You will be asked to phone your surgeon’s rooms to make an appointment for your first post-operative review, usually 7-14 days following surgery.
Between discharge and first review, you will be instructed to perform some simple exercises for the elbow, wrist and hand to prevent them from become stiff. Simply take the arm out of the sling, and while keeping the elbow close to your side, move the elbow, wrist and hand in all directions for 2 minutes. Repeat this at last 4 times each day. When not performing your exercises, keep the arm in the sling.
You are only allowed to lift the elbow away from your side far enough for cleaning your arm-pit and applying de-odorant.
Take the medication as prescribed by your anaesthetist for pain.
Leave the dressings intact and keep the wounds dry until your first review.

First post-operative review (7-14 days post surgery)

At this review your surgeon will check the wound and remove the stitches.
He will go over the operative findings and procedure performed.
He will also refer you for physiotherapy to supervise your rehabilitation.
A second review appointment will be made for 6 weeks post surgery

First post-operative review to second post-operative review

You will be able to externally rotate your shoulder to neutral (ie the position required for using a key board or eating at a meal)
You will also be able to lift your elbow slightly away from your side.
No formal physiotherapy can be commenced yet.

Second post-operative review

At this review the surgeon will assess your progress and re-examine the shoulder.
He will also organize some formal physiotherapy to implement and supervise your rehabilitation.

Rehab / Physio

General guidelines

Strengthening work – can be gently introduced when 6 weeks post-surgery. This will commence with isometric exercises and will be supervised by the physiotherapist. The range of motion for resisted exercises will only be progressed as your scapular control improves.
Convention weight training – should be possible around 4 months post surgery
Return to full contact sport – is usually possible after 5 months, with the patient making a graded return to contact work and strength has been 10% restored.

Final review

Your surgeon will review you at the completion of your rehabilitation and prior to your return to full sports activities

Complications

If at any stage you experience significant pain that is not relieved by resting the arm in the sling and taking the analgesics, shortness of breath, fever, chills, loss of power or sensation in the arm, significant swelling or colour changes in the arm, contact your surgeon by phoning the rooms or private hospital. If you are unable to contact your surgeon, see your local GP or the local A&E department.

Click on the link below for a PDF version of the post-operative guidelines.

https://www.cosm.net.au/wp-content/uploads/2018/04/Shoulder-stabilization.pdf