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The normal shoulder is a marvel of mobility and stability. It provides more motion than any other joint in the human body. Throughout the wide range of shoulder activities, the humeral head (ball of the shoulder joint) remains precisely centered in the glenoid (the socket of the joint). The concavity of the shoulder socket is deepened by a fibrous ring known as the glenoid labrum. The glenoid labrum greatly increases the stability of the shoulder. Another stabilizing mechanism is ligament restraint, in which the motion of the shoulder is kept within the proper range by ligaments that span the joint.
The glenoid labrum and the ligaments can be torn when the arm is forced backwards, allowing the humeral head to dislocate from the glenoid. If the labrum and the ligaments do not heal, the shoulder may continue to be unstable, allowing the ball to slip from the center of the glenoid even with minimal force.
The patient with an unstable shoulder requires a thorough history and physical examination along with proper x-rays, MRI and sometimes CT scan as well.
The most common form of ligament injury is the Bankart lesion, in which the ligaments are torn from the front of the socket. A solid surgical repair requires that the torn tissue be sewn back to the rim of the socket. Failure to secure this lesion solidly can result in failure of the repair.
Individuals with shoulder instability usually notice that the shoulder feels unsteady or the ball may actually slip out of the joint in certain positions, such as when the arm is out to the side or across the body. People with anterior (frontward) instability of the shoulder have difficulty throwing because this action depends on normal ligaments across the front of the joint.
Shoulder instability must be distinguished from other causes of shoulder dysfunction such as arthritis, rotator cuff tear, and snapping scapula. Arthritis usually results in shoulder stiffness and pain; X-rays show the loss of the joint space. Rotator cuff tear results in shoulder weakness. In snapping scapula, the shoulder pops when the shoulder blade is moved on the chest wall.
Shoulder dislocations are among the most common conditions of the shoulder. They are more likely to be found in people from 15 to 35 years of age. Individuals over the age of 40 who dislocate their shoulders are likely to also have a tear of the rotator cuff. Those who have instability of one shoulder are somewhat more likely to have instability of the opposite shoulder. People with loose joints are more likely to have a traumatic instability.
Fig: Traumatic anterior instability.
Radiological tests such as MRI and CT scan are usually necessary to make the diagnosis. It is essential that we establish the diagnosis of shoulder instability before shoulder replacement surgical treatment is considered.
Medications cannot help the healing of a torn labrum or ligament. Mild pain-relieving medications can be used to make shoulders with instability more comfortable.
Shoulder exercises to strengthen the rotator cuff may help control an unstable shoulder. Particularly in atraumatic instability, rotator cuff strengthening and training the shoulder for stability are the mainstays of treatment.
In traumatic instability, the repair of the labrum and the ligaments can usually restore stability to the joint. The restoration of stability often allows patients to return to their usual activities.
In atraumatic instability, there is no single lesion to repair. Thus, if exercises do not restore joint stability, careful consideration needs to be given to the advisability of any surgical procedure. While tightening or burning the ligaments and capsule of the joint have been used for this condition, it is recognized that these procedures may not specifically address the cause of the instability.
The effectiveness of any surgical procedure depends on the health and motivation of the patient and the condition of the shoulder. When performed properly, surgery for shoulder instability usually leads to improved shoulder comfort and function. This is particularly the case for individuals with traumatic instability where the injury can be specifically repaired. The goal of surgery for traumatic anterior instability is to repair the ligaments and the labrum that are torn from the lower front part of the glenoid socket. The opportunity for a secure and anatomic repair is best when the repair is done through shoulder arthroscopic surgery. The greatest improvements are in the ability of the patient to sleep, to perform activities of daily living, and to engage in recreational activities.
Surgery is considered for patients with:
Surgery for instability is not an emergency. Such a repair is an elective procedure that can be scheduled when circumstances are optimal. Before shoulder replacement surgery in India, undertaken the patient needs to:
The risks of surgery for shoulder instability include but are not limited to the following:
There are also risks associated with anesthesia. An experienced shoulder surgery team will use special techniques to minimize these risks but cannot totally eliminate them.
Patients should optimize their health so that they will be in the best possible condition for this Arthroscopic shoulder surgery in India. Smoking should be stopped before surgery and not resumed for at least three months afterwards–ideally never. This is because smoking interferes with healing of the repair. All heart, lung, kidney, bladder, tooth, or gum problems should be managed before surgery. Any infection may be a reason to delay the operation.
The patient needs to plan on being less functional than usual for up to twelve weeks after the shoulder repair. Lifting, pushing, pulling, and some activities of daily living can place stresses on the repair. Performing usual work or chores may be difficult during this time. Plans for necessary assistance need to be made before surgery.
Shoulder instability surgery may be performed under a general anaesthetic or a brachial plexus nerve block. A brachial plexus block can provide anaesthesia for several hours after key hole shoulder surgery. The patient may wish to discuss their preferences with the anesthesiologist before surgery.
Bankart surgery is performed by a minimally invasive surgical technique called arthroscopy. During an arthroscopic Bankart procedure, we make few small incisions over your shoulder joint. An arthroscope, a slender tubular device attached with a light and a small video camera at the end is inserted through one of the incisions into your shoulder joint. The video camera transmits the image of the inside of your shoulder joint onto a television monitor for us to view. We then use small surgical instruments through the other tiny incisions to trim the edges of your glenoid cavity. Suture anchors are then inserted to reattach the detached labrum to the glenoid. The tiny incisions are then closed and covered with a bandage.
Arthroscopy causes minimal disruption to the other shoulder structures and does not require to detach and reattach the overlying shoulder muscle (subscapularis) as with the open technique. The procedure usually takes approximately one hour but the preoperative preparation and the postoperative recovery may add several hours to this time. Patients often spend two hours in the recovery room and about one day in the hospital after Arthroscopic (key hole) shoulder surgery.
Initially pain medication is administered usually intravenously or intramuscularly. Sometimes patient controlled analgesia (PCA) is used to allow the patient to administer the medication as it is needed. Oral pain medications are needed usually for only the first two weeks after the procedure.
Early, protected motion after shoulder instability surgery is helpful for achieving optimal shoulder function. Depending on the nature of the procedure, we will often prescribe some gentle motion exercises within a limited range of movement.
Gentle activities of daily living are often permitted, however lifting anything heavier than a cup of coffee or using the arm for forceful activities must avoided for six to twelve weeks depending on the procedure. We check the mobility of the shoulder two or three weeks after surgery to assure that the shoulder has not become too stiff.
A progressive rehabilitation program after instability surgery is critical for achieving optimal shoulder function. Unstable shoulders may become stiff after surgery. Early, protected motion is often suggested to prevent the shoulder from becoming stiff. However, the repair needs to be protected from re-injury, especially during the healing period. Thus, we will often prescribe limited early motion for three to six weeks and then strengthening exercises for a second six-week period.
It is often most effective for patients to carry out their own exercises so that they are done frequently, effectively and comfortably. Usually a physical therapist or the surgeon instructs the patient in the exercise program and advances it at a rate that is comfortable for the patient.
For the first six weeks after surgery, emphasis is placed on protected motion. For the second six weeks, emphasis is placed on strengthening exercises so that strong muscles will protect the shoulder as it returns to normal activities.
Once the range of motion and strength goals are achieved, the exercise program can be cut back to a minimal level. However, gentle stretching is recommended on an ongoing basis.
If the exercises are uncomfortable, difficult, or painful, the patient should contact the surgeon promptly. Stressful activities and activities with the arm in extreme positions must be avoided until healing is almost complete–often for three months after the surgery.
Patients should avoid activities that involve major impact (chopping wood, contact sports, sports with major risk of falls) or heavy loads (lifting of heavy weights, heavy resistance exercises) until three months after surgery and until the shoulder has excellent strength and range of motion–essentially equivalent to the opposite side. In this way the risk of re-injury is minimized.
Recovery of comfort and function after shoulder instability surgery continues for many months after the surgery. Improvement in some activities may be evident as early as three months. With persistent effort, patients make progress for as long as a year after surgery.