The shoulder comprises a ball and socket joint which is highly mobile and allows a large range of motion of the entire upper limb.
Traumatic Shoulder Instability
The ball can dislocate out of the socket after a traumatic injury such as a rugby/football tackle, hard fall or accident. When the shoulder dislocates it can cause a tear in the labrum (labral tear). This ‘soft tissue bumper’ surrounds the socket and usually prevents the ball from coming out of
the socket. If the shoulder dislocates with an extremely heavy force the socket itself can also crack as well as a labral causing bone loss.
Both a labral tear and/or bone loss can cause recurrent dislocations without any significant trauma.
Non-traumatic Shoulder Instability
A few patients present with shoulder dislocation without any trauma. This is usually due to the natural tissues being extremely loose and stretchy.
Post-Traumatic Arthritis
This is seen in younger patients who have suffered an injury to the shoulder such as a fracture or a dislocation. The effects are seen several years after the injury and frequently come on slowly in the period following the traumatic event.
A true dislocation of ball out of the socket is extremely painful. The shoulder will look misshapen. An x-ray will show the ball to be sitting out of socket. Sometimes people can manoeuvre the shoulder back into joint however commonly one needs to be sedated in the emergency department for the shoulder to be manipulated back into joint. Once the shoulder is back into joint, a course of physiotherapy is undertaken to regain stability.
Recurrent instability happens when your shoulder continues to dislocate and can happen with simple movements such as putting your coat on or in severe cases just rolling over in bed.
When you come to clinic a thorough history and examination is usually sufficient to diagnose the problem. You will be sent for an Xray and occasionally a special MR scan called an MRI Arthrogram. During this procedure you will be called back to the radiology department and a dye injected in your shoulder. The dye then fills the shoulder joint and can highlight labral tears on the MRI scan.
Traumatic Dislocations
If you have dislocated your shoulder for the first time then you generally be sent for a course of physiotherapy. Unless you take part in high level contact sports and are under 30 years old it is unlikely to dislocate again. If the shoulder continues to dislocate then you may require surgery to stabilise the shoulder.
Non-traumatic Dislocations
If you have not had any trauma to your shoulder a course of at least 6-12 months of physiotherapy is required to rehabilitate the shoulder. This is usually enough to prevent any further instability. Very rarely you may require an operation to try and help with the physiotherapy, to reduce the chance of dislocations.
Labral Tear
If your shoulder just has a labral tear then this can managed with keyhole surgery to repair the labrum and ‘tighten’ the shoulder back up so that it prevents any further dislocation. This is day case surgery and you can go home after the procedure.
Bone Loss
If the preoperative scans have shown that you also have bone loss then it likely you will require bone grafting to replace the lost bone. This is done using ‘The Latarjet Procedure’. This involves using the coracoid bone which is located next to the shoulder to fill in the gap caused by the bone loss. This procedure requires a small incision at the front of the shoulder to gain access to the shoulder joint.
Non-traumatic Dislocations
In these patients the tissue quality is usually very poor and stretchy. The operation involved tightening the loose tissue to help physiotherapy to prevent further dislocations.
Aftercare
Following the operation, you will normally have a bulky dressing covering your wound for 48 hours. This is then removed to reveal the sticky dressing at 48 hours until 14 days following your operation. The stitches will dissolve and do not require removal. You will require a wound check either at the hospital or your GP practice at 14 days.
Compliance with physiotherapy is crucial to your outcome. You will be in a sling for the best part of 6 weeks whilst the tissues heal. You will be allowed to remove the sling during these 6 weeks for basic everyday activities, and gentle mobility exercises to keep the shoulder loose but if you intend on leaving the house you will need to wear your sling. At 6 weeks the tissues will be strong enough to start more progressive exercises. Between 6 to 12 weeks you will given physiotherapy to strengthen the shoulder up. After 3 months you can fully strengthen your shoulder with weights.
This depends on the nature of your work. For a sedentary occupation the time off is normally 2-6 weeks. For a manual occupation this can be as long as 3-4 months.
It is normally safe to drive within 6 weeks of your operation but can take up to 12 weeks before you are completely comfortable to start driving.
Further Dislocations
There is small risk of further dislocation with surgery. This is lowest in the Latarjet procedure at 5%. With labral repair the rate is 10%. With non-traumatic instability the risk can be as high as 30%.
Stiffness
Due to pain after surgery, patients may be reluctant to perform their exercises. If you do not gently rehabilitate your shoulder it can become stiff and you can develop a frozen shoulder.
Anaesthetic Risk
Anaesthetic in the modern era are extremely safe however there are still minor risks associated with the different techniques which the anaesthetist will discuss with you before your surgery.
Infection
(1%) is a risk with all surgery. In the majority of cases these are infections around the wound and can be treated with a course of antibiotics. The more unusual deep-seated infections however can require admission to hospital and surgery to clean the wound out if necessary.
Nerve Injury
Is a potential but very rare risk with this surgery. Often the nerves at greatest risk are the tiny nerves supplying skin in the area of the wound and cutting through these may result in an area of numbness that is not often troublesome.
