Conversation with a patient suffering from frequent shoulder dislocations
- Patient: My shoulder jumped out of place more than 5 times, the first time was after a fall, the second time after a fall as well, but later even when I swinged my arm a bit stronger.
- Doctor: Who repositioned it back into place?
- Patient: Every time it was done by a hospital doctor.
- Doctor: Was the arm immobilized?
- Patient: I had a cast for 3 weeks each time.
- Doctor: How old were you when your shoulder jumped out of place for the first time?
- Patient: I was 16 years old.
- Doctor: How old are you now?
- Patient: I am 18.
- Doctor: Are you active in sports?
- Patient: I train football.
- Doctor: I must tell you right away that you cannot avoid surgery. If the cause of shoulder disclocation is injury, especially in persons under 20 years of age, there is a high probability regardless of the type and duration of immobilization, that the shoulder will jump out of socket again, which happed to you too. You needed surgery already after the first dislocation.
- Patient: Why?
- Doctor: You had the first luxation at the age of 16, you are into sports, football, which is a contact sport, which increases the possibility of another luxation, which was also your case. Persons above 40 have a much smaller possibility of another shoulder luxation and they don’t necessarily require surgery.
- Patient: Which type of surgery do you recommend?
- Doctor: Up until a few years ago, open, classic surgery was the golden standard. The best known is Bankart surgery. An incision of about 8 cm is made on the front side of the shoulder. Tendon of the subscapularis muscle and joint capsule must be cut through. The capsule with glenoidal labrum is fixed with sutures to the anterior shoulder blade rim, and reinforced. After the surgery the patient is usually left with an ugly scar. In our hospital we perform the arthroscopic method only, there is no slicing of tissue and no scarring. In a leading world magazine in arthroscopic surgery, we published an original method for anterior and multi-directional shoulder instability. Both methods are used routinely in our everyday work. Three little holes, 5-6 mm each are made on the shoulder, they are used for inserting the camera and canules, little tubes for introducing instruments. The fixation principle resembles the open method. Three suture anchors are place on the anterior scapular rim. We use absorbable anchors with non-absorbable sutures to fix the joint capsule with glenohumeral ligaments and labrum to the anterior scapular neck, prepared in advance.
- Patient: What are the complications?
- Doctor: In arthroscopic shoulder stabilization there practically aren’t any. There is a minimum possibility of damage to the blood vessels and nerves.
- Patient: How long would I stay in the hospital?
- Doctor: One day, the surgery is performed on the day you arrive, and you go home the day after.
- Patient: Would there be some sort of arm immobilization?
- Doctor: You will have a shoulder sling for 3 weeks, you will be allowed to take the arm out of it and perform slight elbow motions. External rotation of the arm is not allowed. After 3 weeks the arm easily becomes used in everyday activities, personal hygene primarily. More or less normal shoulder mobility is expected within two months. There is no formal physical therapy.
- Patient: When can I go back to sport and begin training?
- Doctor: After the third month you can start running and maintaining general fitness, and you can begin training 4 months after the surgery, but there must be no contacts. Full usage is allowed 6 months after the surgery.
- Patient: What is the success percentage of the arthroscopic surgery, what is the guarantee that the shoulder will never jump out of socket again?
- Doctor: If the patient is not active in sport the guarantee that the shoulder will never jump out again is 95%. If the patient is active in sports or if the tissue quality is weak, if the capsule is thin or if glenohumeral ligaments are poorly developed, or in case there is lack of a part of bone of the anterior glenoid rim, then this percentage is about 92%.
- Patient: Is the open method safer and when is it performed?
- Doctor: No, the percentage of another luxation after open surgery is practically identical as in case of the arthroscopic method. However, this percentage depends essentially on the operator and shoulder stabilization method. Open method is used only in cases where there is a fracture of the anterior shoulder blade rim. Bone block is done, surgery is performed according to Latarjet procedure; coracoid ending is separated with the corresponding tendons and fixed with two screws to the anterior side of the scapular neck (the entire surgery is performed through one incission, 8 cm in size).
Shoulder instability in short
Shoulder joint is the most mobile and the most instable joint of the human body. Shoulder mobility is enabled by the joint capsule and the disproportion between the size of the humeral head and the socket of the shoulder blade. The humeral head is 3 times larger than the socket. Glenohumeral ligaments which are the constituent part of the joint capsule are the chief shoulder stabilizers. Glenoidal labrum provides further stability to the shoulder (it is the cartilage rim which surrounds the shoulder blade socket). Injury to the glenohumeral ligaments and labrum causes shoulder instability. The shoulder can be instable in any direction. Most common is anterior shoulder instability (95%).
In anterior instability of the shoulder, the humeral head is partially (subluxation) or completely (luxation) in front of the socket (Fig. 1), and in posterior instability of the shoulder, the humeral head is partially or completely behind the socket. When apart for the inferior shoulder instability, there is also the anterior or posterior, or both, this kind of instability is then called multi-directional shoulder instability.
The most common cause of shoulder instability is trauma; falling and landing on the arm strecthed out, or landing on the shoulder or elbow. When training sports where overhead activities are common, microtraumas are frequent as well as injury to the ligament-labral complex of the shoulder.
A frequent consequence of the anterior traumatic shoulder luxation is injury to the labral complex known as the Bankart lesion; the anterior rim of the labrum is injured and capsule is separated from the anterior glenoid rim (Fig. 2). In case of anterior shoulder luxation, the humeral head strikes the anterior glenoid rim whereby bringing about the defect of the posterior part of the humeral head know as Hill-Sachs lesion. Both lesions are found in over 80% of the cases. However, in atraumatic luxation both lesions are found rarely. Atraumatic shoulder instability is often combined with multi-directional instability. In atraumatic instability, subluxation or a luxation occur when performing natural motions, for instance launching a spear, swimming etc.
Treating anterior shoulder instability
Acute shoulder luxation should be repositioned as fast and as easy as possible. We recommend traction technique, pulling the arm in the direction of the body axis.
Non-surgical treatment of the traumatic anterior habitual luxation is not sucessful. Nevertheless, in atraumatic luxations it is necessary to start the conservative treatment which includes 6 months of rehabilitation based on strengthening rotator cuff muscles and shoulder blade stabilizers. If this therapy is unsucessful, surgical treatment is recommended.
Arthroscopic stabilization of the shoulder is a standard surgical method nowadays for all types of shoulder instability. Open methods are used in fractures of the anterior glenoid rim. The progress of arthroscopic technologiy in the last few years has enabled a vast expansion in shoulder arthroscopy application. Arthroscopy is used to diagnose and at the same time treat the current pathological changes. There are numerous advantages of arthroscopic shoulder stabilizations in comparison with open techniques. Maximum visualization with minimum surgical incission (5-6 mm), shorter surgery duration and hospital stay, less complications, smaller post-operational scarring, better mobility and shoulder function. Subtle shoulder instability is difficult to recognize clinically. Such instability is found in sportsmen who only complain of pain in case of a certain arm motion. The only sure diagnistic method to recognize such instability is arthroscopy. Injuries within the joint in such an unstabile shoulder can be recognized and at the same time repaired arthroscopically.
Arthroscopic shoulder stabilization is today’s leading method in treatment of the anterior instability of the shoulder. Initial failures were results of bad surgical methods, especially the ones which were founded on non-anatomic shoulder instability repairs. By introducing suture anchor, metal or absorbent, the results came close to open methods. At present, the leading method is intra-articular technique which uses a metal or absorbent anchor (screw) with intra-articular knot (knot within the joint) (Fig. 3 A and 4). Apart for this technique, we use our original method with the extra-articular knot (Fig. 3 B). The advantages of this technique in relation to the intra-articular knot is in the simultaneous fixation of the labrum and tightening the joint capsule, better healing process for the joint capsule since the external, fibrous layer of the capsule is fixed as well as in the fact that the arthroscopic knot is outside the joint. In cases where the quality of glenohumeral ligaments is extremenly low, or they are insufficient, intra-articular technique is used.
Posterior shoulder instability
Posterior shoulder luxation is very rare, but very often it is diagnosed late. Patients spend weeks and months in therapy without any result. Treatment method depends on the time passed and the size of the humeral head defect. In minor defects, transposition of a part of the humeral head into the defect is performed. Shoulder endoprosthesis is implanted in larger defects and glenoid destruction; and in posterior shoulder luxation what is performed is arthroscopic posterior capsulorafia.
Multi-directional shoulder instability
Inferior instability with anterior or posterior instability attached is key in multi-directional shoulder instability. Most patients with multi-directional shoulder instability have generally loose joints and often suffer from an emotional disorder as well. The first step in treating multi-directional shoulder instability is intensive reinforcement of the rotator cuff muscles and shoulder blade stabilizer. If there is no improvement after 6 months, then surgery is recommended. Open method had advantage up until a few years ago, but today arthroscopic shoulder stabilization in multi-directional and posterior shoulder instability is performed routinely. Shoulder stabilization in case of multi-directional instability is achieved through arthroscopic capsuloraphy which includes shrinking the posterior, inferior and anterior part of the joint capsule and closing the rotator interval (Fig. 5).