Martin R. Coleman, MD
In my last article, I discussed the causes of shoulder instability, its symptoms, and conservative treatment options that could be tried to prevent repetitive episodes of subluxations or dislocations. While many patients will have success with non-operative therapies, others will continue to have issues with shoulder instability without more aggressive intervention. In this article, I will briefly describe the usual surgical procedures, and what should be expected in the recovery and rehabilitation.
Arthroscopic Bankart Repairs – The vast majority of cases of recurrent dislocations will have a specific defect with a tear of the labrum in the front of the shoulder. The labrum is a ring of cartilage around the socket that makes the flat socket into a shape more like a bowl and is the attachment point for the ligaments around the shoulder This soft tissue acts like a hammock to create a barrier that keeps the ball on the socket.
This labrum repair is usually performed using an arthroscopic technique using multiple small incisions rather than one large one to visualize the inside of the shoulder joint. If the socket is seen as a clock face, in a right shoulder the labrum is torn away from the bone from 3 o’clock to 6 o’clock. We rough up the original attachment area with a high-speed burr, loop three thick sutures around the loose material and securely reattach the torn portion of the labrum back to the bone edge. In some cases, a small sliver of bone is included in the repair. If the bone fragment is large, an open technique may be needed. The arthroscopic Bankart Repair typically is performed as an outpatient procedure and the patient is sent home to recover. A sling is necessary for comfort and as a reminder to limit motion and to protect the repair. If the shoulder is allowed to move too early into a throwing position, the repair can be damaged. This can be disastrous and very difficult to repair again.
Open Procedures – In some cases, the labrum is torn away along with a large portion of the socket, leaving a large cavity into which the humeral head will fall easily when the shoulder is put into a throwing position. If the fracture fragment is not replaced precisely, the uneven joint surface will create more friction and can result in severe arthritis in the shoulder joint. In these cases, it may be necessary to make an open incision over the shoulder and fix the bony fragment with screws to recreate the original anatomy.
In cases with chronic bone loss, it may be necessary to recreate more stable bony support for the socket by transferring another bone to the area. Currently, the most successful technique for this is known as a Latarjet Procedure. A bony projection from the front of the shoulder is removed and attached to the area of the defect with screws and this recreates a more stable base upon which the ball of the shoulder can rest more securely.
Post-op – The goal of these procedures is to restore normal function. There is a fine line between making the repair too loose, leaving the patient with persistent instability and making it too tight, which can cause arthritis. Our current solution is to deliberately slightly over-tighten the repair, knowing that it will tend to loosen with time. This is one of the reasons that expert Physical Therapy is so critical to the recovery process. We want to gently regain full motion without damaging the repair. Each month the therapists will add new maneuvers involving stretching and strengthening to complete the recovery. It requires patience and hard work to get through this process. It is vital that our patients fully commit to doing the difficult and sometimes frustrating therapy to accomplish our goal: a stable, comfortable shoulder