Mr Apurv Sinha 

Consultant Trauma and orthopaedics 

 

 

SHOULDER STABILISATION

 

What is a Shoulder Stabilisation?

 

The shoulder joint is a ball and socket joint, which is held together by a combination of ligaments and muscles. There is also a rim of cartilage around the socket called the labrum. The labrum acts to deepen the socket to make the shoulder even more stable.

When a shoulder is dislocated, sometimes the rim of cartilage is pulled away from the socket damaging the labrum. This often does not heal and therefore the shoulder can remain unstable. Once your shoulder has been damaged in this way, you may find that your shoulder dislocates again fairly easily. This damage to the labrum is often called a 'Bankart lesion'; named after the doctor who first described this injury. Sometimes, if enough force is present during a dislocation, a small part of bone from the shoulder socket (glenoid fossa) may break off with the labrum. This is often called a 'Bony Bankart lesion'.

Shoulder stabilisation surgery is an operation to repair the damage to the labrum and therefore restabilise the shoulder joint. This type of repair may also be called a Bankart repair or a Latarjet procedure by your surgeon.

What is 'Bankart Repair'?

A 'Bankart repair' is the name of the operation often used to repair the damaged labrum.

 

What is a 'Latarjet procedure'?

 

If the bone has also been damaged along with the labrum a simple arthroscopic Bankart repair is usually not sufficient. The Latarjet procedure involves the transfer of a section of the coracoid process from the shoulder blade and its attached muscles to the front of the socket or glenoid. This placement of the coracoid acts as a bone block which, combined with the transferred muscles acting like a strut, prevents further dislocations of the joint.

What is a ‘Hill Sachs Lesion’?

 

You may also be told by your doctor that you have sustained a Hill Sachs lesion following your dislocation. A Hill Sachs lesion is the term used to describe a compression fracture to the humeral head. As your shoulder dislocates, the humeral head is forced out of the shoulder socket (glenoid fossa) and as it does so it hits the hard edge of the socket.

This can cause an indentation of the humeral head. If this indentation (Hill Sachs lesion) is fairly small, it may not cause you any problems. Occasionally a large Hill Sachs lesion may cause your shoulder to dislocate again, and if this happens your surgeon may recommend another procedure to correct this defect.

 

How are these operations carried out?

 

Shoulder stabilisation surgery is carried out under a general anaesthetic. Repair work to the labrum (Bankart Repair) and the humeral head is usually carried out as key-hole (arthroscopic) surgery. An arthroscopy is an operation using a specially designed small telescope linked to a TV camera which allows your surgeon to look inside your shoulder joint. This allows the surgeon to examine the shoulder joint and then use very small instruments to repair the damaged labrum.

 

Arthroscopic surgery will leave you with 2 - 4 small scars on the back, side and front of your shoulder. Arthroscopic surgery is usually performed as a day case procedure. This means you will go home on the day of your operation. Some patients who have other medical conditions may require an overnight stay in hospital.

 

Very occasionally there are technical reasons why we cannot carry out the operation arthroscopically. In this case it will be done in the traditional way - called an open procedure. A Latarjet procedure is usually carried out by an open procedure. An open procedure involves an incision along the front of your shoulder and will leave a scar about 4 - 7cms in length. This is usually along the bra or vest strapline, or over the top of your shoulder. If you are having an open procedure you will probably require an overnight stay in hospital.

What are the benefits of having shoulder stabilisation surgery?

 

The aim of shoulder stabilisation surgery is to restore the stability of the shoulder joint and therefore reduce the chance of it dislocating again. It is normal to feel discomfort following the operation but this will usually settle as your wounds heal.

It can take up to three months for the repair to fully heal, and you may still be seeing improvements in your shoulder up to 12 months post surgery.

Are there any complications of having shoulder stabilisation surgery? As with most types of surgery there are risks involved and complications can occur unrelated to the shoulder surgery.

These include:

  1. Anaesthetic risks (such as sickness, nausea or rarely cardiac, respiratory or neurological - less than 1%)

  2. Chest infections

  3. Blood clots in the legs (deep vein thrombosis)

  4. Blood clots in the lungs (pulmonary embolus)

Some other complications, which can occur specifically following this type of shoulder surgery, are:

  1. Re-dislocation

  2. Infection (less than 1%)

  3. Ongoing pain and stiffness in the shoulder (less than 1%)

  4. Nerve damage

  5. The need to re-do surgery

These risks are very small but if any occur, further treatment or an operation may be necessary.

  1. Re-dislocation can occur if the repair fails. This can occur if high levels of activity are undertaken before the repair has healed fully - your physiotherapist or surgeon will guide you on when it is safe to start using your arm more. It may also occur if you have another injury to your arm.

  2. Infection can be a serious complication. Some infections show up immediately whilst you are still in hospital, others are not apparent until you have gone home. If you are at particular risk your surgeon may recommend that you take antibiotics.

  3. Ongoing pain and stiffness of your shoulder is possible especially if you do not continue with your individual home exercise plan.

  4. Nerve damage can occur as many of the large nerves and blood vessels that enter the arm pass close to the site of the operation; but it is very rare for any permanent damage to occur.

  5. Need to re-do surgery. The repair may fail and the shoulder becomes unable again. This occurs in 3-20% of cases. Rarely, one of the anchors used to repair the tissues can back out, resulting in shoulder damage. This is an extremely rare occurrence.

What will happen if I decide not to have surgery?

If you decide not to have this surgery, other treatment options are:

Physiotherapy: exercises can strengthen up your shoulder muscles to help improve the muscle control of your shoulder - you may have already tried this if you have reached the stage of discussing surgery.

Activity modification: changing the way you do activities or stopping activities which involve stretching your arm into end of range positions may reduce the number of times you dislocate.

What happens if I agree to having shoulder stabilisation surgery?

If you and your surgeon agree that this type of shoulder surgery is necessary, you will be asked to attend a Pre-Assessment Clinic a few weeks before your surgery to ensure you are fit for the operation and to record some baseline information. During your clinic appointment, the pre-operative assessment nurse will discuss your stay in hospital and organise any other necessary tests. These may include a blood test, urine test, an ECG (heart tracing) and x-rays.

Your surgeon or one of his team will check you are still happy to go ahead with surgery and to sign a consent form. We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent. If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information. Another purpose of this clinic visit is for you to ask any further questions about the forthcoming surgery.

How long will I be in hospital for?

If your surgery is to be carried out arthroscopically (key-hole surgery), it will generally be carried out as a day case procedure unless you have any other medical conditions which may require you to stay overnight. If you are having your operation as day surgery, you will need to ensure someone can collect you from the hospital and stay with you overnight to check that you are okay. If your surgery is to be carried out as an open procedure, you will generally be kept in hospital overnight.

 

What will I need to do before coming in for surgery?

You will receive a letter which will confirm your admission date and it will include specific instructions you need to follow before coming in to hospital. Please remove any body piercings and nail varnish before coming into hospital. If you take regular medication you will be told at pre-assessment clinic whether you should continue taking it as normal.

 

Will I have any pain after the operation?

Your anaesthetist may decide to perform a nerve block during the surgery. This involves an injection of a local anaesthetic, guided by an ultrasound scan, into your neck to numb the nerves going into your arm. The purpose of this is to provide immediate pain relief to your shoulder. The injection usually lasts for 12 - 24 hours, during which time your shoulder and arm will feel numb and heavy. It is important to take regular painkillers on your discharge from the hospital to avoid any unpleasant pain as the nerve block wears off. If you require further medication, please see your GP.

After your stabilisation surgery:

Will I have any stitches?

Your shoulder wounds will have dressings on them and if you have had stitches they can be removed at your GP's surgery, usually 10 days after the operation. An arthroscopic wound does not usually need stitches, only small sticking plasters over the wounds. It is normal for your shoulder to appear swollen after surgery and you may also find that your shoulder leaks a watery blood stained fluid, this usually settles after 24 - 48 hours. Keep all wounds dry until well healed. Avoid using spray deodorants, talcum powder or perfumes near the scar.

 

Will I have to wear a sling?

Your arm will be supported in a sling straight after your operation. This is to protect the repair to your shoulder. If you have had a Bankart Repair your shoulder will be in a polysling for 4 weeks in total. During this time, you will be shown some gentle exercises for the shoulder, using your good arm to assist the movement. You will be asked not to lift your arm at all, and will effectively be ‘one-handed’ for 4 weeks. Before you are discharged from hospital the staff will help you plan for how you will manage when you leave. If you are having particular problems with aspects of self-care an occupational therapist can suggest ways to help you. A physiotherapist will see you on the ward to advise you what exercises you can do and an out-patient appointment will be made for you within 1 week from leaving the ward. The physiotherapist you will see as an outpatient will advise you further on when you can discard the sling and progress your exercises.

What clothes should I wear with the sling?

Most people find it difficult to manage ordinary clothes immediately after surgery, due to limitation of shoulder movements; therefore you are advised to wear a loose fitting button through shirt. A bra may be uncomfortable in the early days so it would be advisable to bring an underslip or loose fitting underwear to put on after surgery. You may find your armpit uncomfortable whilst wearing a sling. Try using a dry pad or cloth to absorb the moisture.

How will I sleep?

You must sleep in your sling until directed not to by your surgeon or therapist. Sleeping can be a little uncomfortable. We recommend that you lie on your back or on the opposite side. Ordinary pillows can be used to give you comfort and support. (Feather pillows are easier to mould than foam ones). We do not recommend trying to sleep in a sitting position. If lying on your side, a pillow tucked along your back helps to prevent you rolling onto your operated shoulder in the night.

Will I have to come for physiotherapy?

Physiotherapy is very important following a shoulder stabilisation if you are to get the most out of your shoulder following your operation.

The main aim of physiotherapy during the initial sling wearing stage is to prevent your shoulder joint stiffening up. A physiotherapist on the ward will tell you what you can do after the operation. These exercises will be supported so to limit the tension on your shoulder repair. You will also be given an appointment to attend your nearest outpatient physiotherapy department one week after your discharge from the ward, in order to progress your exercises. Whilst waiting for your physiotherapy appointment. It is important to keep your elbow and hand moving, and also to make sure your neck muscles don't stiffen up.

Your physiotherapist or surgeon will advise you when to remove the sling. Following this there will be a gradual emphasis on strengthening the muscles in your shoulder and increasing your movement further. Depending on your progress, you may also be referred to our occupational therapists for additional rehabilitation.

 

How often will I need to have physiotherapy?

Initially you should expect to have physiotherapy once a week. As you improve this may reduce to once a fortnight. Is that the end of my treatment? You will be seen in orthopaedic clinic at approximately four to six weeks following your operation. This may be your surgeons specialist physiotherapist to check that your rehabilitation is going to plan. Your surgeon may see you at about 3 months after your operation.

 

When can I drive?

Driving is a potentially hazardous activity and people will vary as to how soon they are able to perform this task safely. We would advise you not to drive until you have enough movement and strength in your arm to control the car safely. Check your insurance policy. You may need to inform the insurance company of your operation.

 

When can I return to normal activities? This depends upon your symptoms. Most people feel comfortable enough to perform light day to day activities between four to six weeks after surgery.

Soon after surgery your physiotherapist will discuss with you the type of activity you wish to return to in order to tailor your rehabilitation exercises appropriately. As a general guide, non-contact sports can be commenced at around 3 months following surgery and contact sports at around 4 months. Please ensure you check with your physiotherapist or surgeon before recommencing any activities. As a general guide, non-contact sports can be commenced at around 3 months following surgery and contact sports at around 4-6 months. Please ensure you check with your physiotherapist or surgeon before recommencing any activities.

A rough guide for returning to activities:

Desk work: 4 - 6 weeks

Light work (below shoulder level) 4-6 weeks

Cycling 8 - 10 weeks

Swimming - Breaststroke 12 weeks

Front crawl 12 weeks

Golf 12 weeks

Rock climbing 12 - 16 weeks

Racquet sports 16 weeks

Rugby/Football 6 months

Heavy manual work (above shoulder level) 12 weeks onwards