Shoulder Stabilization Procedures
If, after an appropriate amount of rest and physical therapy, the shoulder continues to be unstable or painful, arthroscopic surgery becomes an option to repair (sew back together) or debride (remove torn or frayed tissue) the labrum and capsule. Occasionally, surgery is recommended after a first or second dislocation due to the size of the tear, the age or activity level of the patient, athletic season, or the presence of an associated injury (loose body, bone fracture, rotator cuff tear, or biceps tendon tear).
This is outpatient surgery with an arthroscope (a camera used to look into the joint). Three to six small incisions are made around the shoulder to look inside the shoulder joint and the sub-acromial bursa (the space above the rotator cuff).
The goal of surgery depends on your problem. In general, the goals of surgery fall into a few broad categories:
- For the unstable shoulder: the labral and capsular tissue is generally repaired back to the glenoid, while tightening the capsule/ligaments at the same time (like taking in the waste of a pair of pants). The location and extent of the repair depends on your pattern of instability (anterior or posterior, or generalized laxity) as well as the exact pathology that is discovered at the time of surgery. In general, if there have been many episodes of dislocation or subluxation, the results of surgery are less predictable.
- Special circumstances:
- Glenoid bone loss: With many repetitive dislocations, the front of the glenoid rim can be worn away (think broken golf tee). A CT scan may be ordered before surgery to check for this. If the glenoid bone loss is significant (> ~ 20%), an open bone graft procedure called a Latarjet may be required.
- Large Hill-Sachs defect: if there is a very large dent in the back of the humerus that still catches on the front of the glenoid after we repair and tighten your ligaments, a procedure called a Replissage may be performed. The back portion of your rotator cuff will be repaired into the defect, to prevent it catching on the glenoid. This can result is some minor loss of external rotation, but will help make sure the shoulder is stable.
- For the painful shoulder:
- If the primary problem is pain from a SLAP tear, the typical treatment depends on your age and activity demands on your shoulder:
- For most patients over age 25, the most reliable method to relieve pain is to reroute the biceps out of the shoulder, attaching it instead to your upper humerus. This is called a biceps tenodesis. Your strength after rehab should be the same as before surgery, but the constant tugging of the biceps on the labral tear will be relieved.
- For elite level throwers or overhead athletes, a SLAP repair is performed. The upper labrum and biceps are repaired back to their original location. The rehab after this procedure is longer, and healing is more unpredictable than with a tenodesis. If it heals, however, it will restore more normal throwing mechanics to your shoulder. It should be understood that the results of returning pitchers and elite overhead athletes to their former level of competition is unpredictable, however.
Risks
Although most patients have significant relief after shoulder surgery, it is not uncommon to have occasional stiffness or soreness in the shoulder after the operation. The risks associated with shoulder surgery are generally low, but there are some specific complications that can occur:
- Continued pain or significant stiffness due to scarring in the shoulder, occasionally requiring more surgery to release scar and manipulate the shoulder
- Re-dislocation
- Re-tear or progression of labral tearing
- Non-healing of the labrum (if a repair was attempted)
- Development of sub-acromial bursitis, rotator cuff tear, or acromio-clavicular (AC joint) arthritis
A more general complication of surgery can also occur. These include:
- Deep venous thrombosis (aka “blood clot” or DVT)
- Infection (all patients receive antibiotics at the time of surgery to decrease this risk)
- Nerve injury (associated with numbness, weakness, or paralysis)
- Vascular injury or compartment syndrome
- Complications associated with the anesthesia