Luxation of the shoulder - Instability of the shoulder

Apart from luxations, which are extremely painful, instability causes a functional limitation of the shoulder due to the patient’s apprehension of the particular movements which are responsible for the luxation (typically the arm movement made during a tennis or hand ball smash), so the patient limits his own everyday gestures or sporting activities. We use the term chronic instability only after 2 to 3 episodes of luxation.

Diagnosis

Diagnosis is made during examination by the practitioner, where the patient clearly displays apprehension or pain at abduction with external rotation movement (when the hand is behind the head).

A generalised hyper-laxity may be detected, which can cause chronic instability of the shoulder. Complementary examinations are generally necessary with X-rays and arthro-scanner.

This examination consists in realising a scan after injection of the contrast product allowing us to visualise the different tendinous or cartilaginous elements which are non visible from the X-ray or from a simple scanner, and this enables us to estimate the size of the lesions which will guide the choice of surgical technique to be proposed.

Treatment

After 3 luxations, or more depending on the case, surgical treatment is generally proposed so as to avoid further repetitive luxations and associated degenerative lesions and to allow the patient the « normal » use of his shoulder, with notably the possibility of taking up sports activities again.

In cases involving single luxation or episodes of sub-luxation with moderate functional disturbance, surgical treatment is not indispensable and simple physical therapy may be proposed initially.

The two main surgical techniques are the positioning of a bone block, the LATARJET Procedure, or the reinsertion and tightening of the ligaments and torn joint capsule, best realised by arthroscopy and known as the BANKART Arthroscopic Procedure.

Latarjet procedure

Principal

This procedure consists in positioning a bone abutment in front of the glenoid, so as to create on the one hand a real abutment effect at the usual luxation point of the shoulder, but also to transpose the tendons and muscles which will then place themselves in front of the head of the humerus keeping it in position during the habitually luxating movements such as during the smashing movement of a volleyball match.

This abutment is removed by the same incision at the coracoïd process, which will then simply be moved a few centimetres.

The surgical operation

• Anaesthetic: general
• Length of hospital stay: approximately three days on average
• Immobilisation: arm in a sling for 3 to 4 weeks
• Physical therapy: passive by the patient from the beginning and then with a physiotherapist from 4 to 6 weeks after the operation.

This procedure is carried out under general anaesthetic and necessitates a hospital stay of two to three days. A vertical incision of 5 to 8 cm is made on the front of the shoulder. Once the coracoïd process has been removed and after exploration of the entire joint cavity of the shoulder, and removing the different fragments of deteriorated cartilage, it is screwed in place just in front of the joint surface. The joint capsule will also be re-tightened. The opening is closed using a resorbable wire and an intra dermic surjet, i.e. a non-visible stitching in the thick layer of the skin in order to achieve the best possible aesthetic result. An aspirating Redon drain will be kept in place 24 to 48 hours and removed before the patient is released from the clinic.

After-surgery care

The arm is kept immobile in a sling for 3 to 4 weeks with physical therapy exercises practised by the patient himself daily. The patient will be instructed as to these movements by a physiotherapist before leaving the clinic.

At the end of this immobilisation period, a physical therapy programme is commenced in a specialised centre usually for 1 to 3 months to regain function and range of movements in the best conditions.

Resuming contact sports is permitted three months after the operation and jogging can be started after approximately one month. Pain and cracking may persist for several months and improve progressively.

In general, external rotation movements are the most difficult to recover and a deficit of a few degrees may persist in comparison with the other side.

Dressings will be changed by a nurse in the patient’s home every 2 days for two weeks after the operation. Bathing will then be permitted.

Complication

infection, sub cutaneous haematoma are rare and unforeseeable and may require further surgery Recurrence of the condition is always possible, even if the LATARJET Procedure is considered to be one of the surest techniques from this point of view.

Pain may persist with cracking sensations, even if the latter generally tend to improve with time. Stiffening of the shoulder may persist, predominantly on external rotation and it may be aggravated in patients with algoneurodystrophy.

In cases caused by a brutal knock, the abutment or screw may be broken. By observing possible check-up X-rays several years after surgery, a complete disappearance of the bone of the abutment may be seen. The instability of the shoulder is nevertheless still ensured by the transposed tendinous elements and the situation is therefore not too problematic.

The screw must only be removed in the very rare cases where the materiel is causing discomfort.

Algoneurodystrophy, which is unpredictable, remains a possibility and causes pain and stiffening of the shoulder which can spread to the arm. Development of the condition is often long and difficult and may continue for several years, leaving restricting after effects in terms of shoulder mobility. This phenomenon is not possible to predict.

The scar may become enlarged due to the particular nature of the skin on this part of the human body. In some people the scar can become cheloid, i.e. inflamed and swollen and there is no particular preventative treatment to be prescribed.

The Bankart arthroscopic procedure

Principal

This procedure involves reinserting or re-tightening the different elements of the capsule, tendons or labrum which have been torn and this in order to re-stabilise the shoulder. The procedure may be realised using arthroscopy, i.e. simply by means of 2 small orifices of less than one centimetre. This causes less post operative pain and contributes to a more rapid recovery of shoulder function. It is proposed as an alternative to the LATARJET bone abutment procedure depending on the individual case. Even if it has the advantage of allowing for a more rapid recovery and reduced scarring, its main disadvantage is its rate of recurrence which is higher than for the abutment procedure.

An abutment procedure may always be undertaken as a second step after recurrence in treatment of this type.

The surgical operation

• Anaesthetic: general
• Length of hospital stay: two days on average
• Immobilisation: arm in a sling for 3 to 4 weeks
• Physical therapy: passive by the patient from the beginning and then with a physiotherapist from 6 weeks after the operation.

This procedure is carried out under general anaesthetic and usually necessitates a hospital stay of two days. A hole is made behind and another one in front to allow the surgeon to insert the camera and instruments. The various elements connected to the capsule, ligaments or labrum are reinserted and tightened over the bone of the glenoid using several usually resorbable anchors, placed inside the bone. Wires are then attached to attach the elements torn from the bone.

After-surgery care

The arm is kept immobile in a sling for four weeks and the patient performs physical therapy exercises several times a day. The patient will be taught these exercises by a physiotherapist before leaving the clinic. Dressings are changed by a nurse every other day in the patient’s home over a two week period. Once the sling is removed a physical therapy programme is commenced.

Complications

Infection-linked complications are rare but remain possible, and may require further surgery or adapted treatment Recurrence is the main complication. The problem may recur rapidly or after several years and may also include episodes of sub-dislocation, i.e. pain and the sensation of the initial stage of dislocation with spontaneous repositioning of the shoulder during particular movements. In cases of extreme discomfort another arthroscopy or abutment procedure may be proposed. Recurrence of dislocation cannot be foreseen prior to surgery and this type of arthroscopic treatment will only be proposed in certain particular cases, in order to limit the risk of recurrence to the minimum and this risk will always be explained to the patient. The latter will then be able to decide whether or not to opt for an abutment technique with its advantages and disadvantages.

Algoneurodystrophy is unpredictable but always possible, leading to pain and a stiffness in the shoulder which can also spread to the arm. The recovery process is often long and difficult and can last for several years, leaving diminished mobility in the shoulder.

Conclusion

An operation to re-stabilise the shoulder is strongly recommended after two to three episodes of dislocation and depending on the activity profile of the patient. The choice for the technique is made taking into account the lesions and background individual to each patient.

I will explain to you the advantages and disadvantages of each technique depending on your case and together we will decide on the solution which best corresponds to your expectations of the operation.