Reading
Berkshire
Harley Street
London
Shoulder dislocation/ Instability
What?
Shoulder instability is when your humeral head 'upper arm bone' either dislocates 'pops out' or 'slides' in and out of the Glenoid 'Socket that part of your shoulder blade'.
Why?
The shoulder joint can be thought of as a Football 'Humeral head' resting on a Golf Tee 'Glenoid'. The shoulder joint is mobile to allow you to do all the things you need to do for daily life and sports, which makes it susceptible to dislocation.
To keep the humeral head balanced there are important structures (Labrum, Ligaments, Rotator cuff) which help keep the joint in place when moving it. If any of these structures are damaged after an injury/ dislocation then you shoulder will feel unstable.
Some patient may feel like there shoulder is clicking/ clunking or sliding out but have never injured the shoulder. In this case patients either have hyper mobility 'lax joints' or muscle co-ordination problems.
Who?
Anyone can dislocate there shoulder after an injury. However, shoulder dislocations are much more common in people who are < 35 years of age, participate in contact sport or collision sports such as rugby, boxing or foot ball.
The shoulder commonly dislocates anteriorly 'pops out the front' after a fall onto your shoulder. In a small proportion of people the shoulder may dislocate posteriorly ' out the back' from a seizure. You will have attended Accident and Emergency to have it reduced 'put back in.
Generally if your shoulder continues to dislocate, you lack confidence with using it fully or you feel clicking/ clunking with it after undergoing a physiotherapy program you will need to consult a shoulder specialist.
If you are 25 years or younger or engage in high level contact sports you should see a shoulder specialist soon as your chance of re-dislocating is high after sustaining a first time shoulder dislocation.
If your are 40 years or older you should see a shoulder specialist soon as a Rotator cuff tendon tear is much more common in this age group after a first time dislocation.
How?
The treatment of shoulder instability can be complex and in some cases requires joint assessment in an MDT (Multi-disciplinary team) with a shoulder surgeon, shoulder specialist physiotherapist and a Musculoskeletal radiologist. The aim being to identify and treat the underlying problem which may not always require surgery especially in cases of no previous trauma and hypermobility. In many cases the are multiple subtle factors that need to be addressed in a step wise manner. The fine line of treatment generally beginning with physiotherapy.
In broad terms the treatment of shoulder instability after a traumatic episode (Dislocation) is either to repair the torn tissues ' labrum' at the front of the glenoid 'socket' or reconstruct the anterior glenoid rim 'front edge of the socket' due to bone loss caused by the dislocation.
A MRI scan and CT scan help confirm a tear of the labrum and assess if there is any critical bone loss.
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If you have been advised to undergo arthroscopic stabilisation (Labral repair) please see below
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f you have been advised to undergo a LATARJET procedure please click the link.
ARTHROSCOPIC STABILISATION
Arthroscopic 'keyhole' stabilisation also known as a 'Bankart repair'. This procedure repairs the torn tissue/ ligament most commonly at the front of the shoulder joint a after a shoulder dislocation. This tissue ' labrum' encircles the glenoid 'socket' of the shoulder joint and is important for shoulder stability.
Specially designed suture anchors which are made from bio- compatible plastic are used to pin the labrum back to the front edge of the glenoid.
Ref: Arthrex Push Lock Labral repair https://youtu.be/TMytPkQeblM
Me?
The decision to undergo an arthroscopic labral repair is yours and my duty as your surgeon is to help guide you. My general guidance to patients is that surgery is advised if you have failed rehabilitation. Pain, fear of your shoulder dislocating during daily activities or sports, recurrent dislocations or subluxations then surgery should be considered. If your first shoulder dislocation was not due to an injury but has always been an issue it may require you to be referred to a very specialised unit that has more resources needed to help treat your condition.
After a first time shoulder dislocation the chance of another dislocation over 2 years is about 50-80 % in males under 30 years and 20-50% in females.
Arthroscopic stabilisation has a success rate of 85-90%. Surgery is performed whilst you under a general anaesthetic which will be performed a Consultant anesthetist. You will also be offered a intrascalene nerve block to help with pain. In some circumstances the surgery can be performed whilst you are awake under a nerve block.
General anaesthesia is very safe but still carries a small risk (<1%) of Heart Attack, Stroke, Deep Vein Thrombosis, Pulmonary embolism. It is important to have all details of your medications and past medical history so you can be optimised for surgery and these risks can be assessed individually.
It is important that you understand the risk of surgery which are outlines below:
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Infection (<1%)
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Nerve & Vessel damage (<1%)
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Persistent pain
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Re-dislocation/Failure (10-15%)
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Stiffness/ Frozen shoulder (1%)
Help?
How long do I wear a polysling after my operation?
The length of time of shoulder immobilisation is 3 weeks.
Is it normal for my shoulder to be swollen & wound to leak fluid?
You will notice that after surgery that your shoulder has a bulky padded dressing. This is designed to absorb excess fluid from the arthroscopy (Saline is pumped into your shoulder to allow visualisation) for 24 hours and then can be taken off. Your shoulder will appear swollen which is very normal and this will reduce over a few days. Leaking fluid from your key hole wounds will be blood tinged but not frank blood.
Can I take my sling off for showering/ changing clothes?
You may take your sling for axillary hygiene and showering. However, for the first 7 days you must keep your dressings/ wounds dry. You should keep your arm as close to your body as possible when changing your clothes.
When Can I start driving?
It is illegal to drive while wearing a sling. You may start to drive once the sling has been discarded but not until you can safely control the vehicle. This is normally between 6 and 8 weeks after the operation. It is advisable to start with short journeys.
When can I go back to work?
This will depend on the type of work you do and the extent of the surgery. If you have a non-manual job and do not need to drive you may be able to return within 2 weeks. If you have a heavy lifting job or one with sustained overhead arm movement you may require 3 or more months off.
How am I likely to progress?
By 3 to 4 months after the operation, most people have noticed an improvement in their symptoms and are pleased with their progress.
When can I resume heavy lifting/ recreational activities?
Generally around the 3 month mark once your physiotherapist and surgeon are satisfied with your recovery (Strength & range of motion). For return to collision sports such as rugby you will a graduated return to full play.
LATARJET/ BONE BLOCK
The Latarjet procedure is done through a 2-3 inch wound at the front of your shoulder. The 'Corcoid bone, which is a small bony prominence where one of your tendon call the ' Conjoint tendon' attaches is used to reconstruct the front part of your glenoid 'socket' . The bone graft is held usually with two screws / a specially designed plate.
The bone block procedure uses bone from your pelvis.
In some patients we can offer an arthroscopic ' keyhole' bone graft procedure can be offered which uses donated human bone. This procedure is relatively new and long term outcomes are not known. There are specific criteria that need to be met which can be discussed during your consultation.
Me?
Help?
Useful external info links for Patients/
Club Physio:
The decision to undergo a Latarjet/Bone block is yours and my duty as your surgeon is to help guide you. My general guidance to patients is that surgery is advised if you have failed rehabilitation. Pain, fear of your shoulder dislocating during daily activities or sports, recurrent dislocations or subluxations then surgery should be considered.
If your first shoulder dislocation was not due to an injury but has always been an issue it may require you to be referred to a very specialised unit that has more resources needed to help treat your condition.
After a first time shoulder dislocation the chance of another dislocation over 2 years is about 50-80 % in males under 30 years and 20-50% in females. This is particularly higher if you play any collisions sports such as rugby.
The success rate of a Latarjet/ Bone block procedure is 95%.
Surgery is performed whilst you under a general anaesthetic which will be performed a Consultant anesthetist. You will also be offered a intrascalene nerve block to help with pain.
General anaesthesia is very safe but still carries a small risk (<1%) of Heart Attack, Stroke, Deep Vein Thrombosis, Pulmonary embolism. It is important to have all details of your medications and past medical history so you can be optimised for surgery and these risks can be assessed individually.
It is important that you understand the risk of surgery which are outlines below:
-
Infection (<1%)
-
Nerve & Vessel damage (<1%)
-
Re-dislocation/Failure (5%)
-
Stiffness/ Frozen shoulder (5%)
-
Progression of arthritis (5-10%)
How long do I wear a polysling after my operation?
The length of time of shoulder immobilisation is 6 weeks. 3 weeks day and night and 3 weeks night time only.
Can I take my sling off for showering/ changing clothes?
You may take your sling for axillary hygiene and showering. However, for the first 7 days you must keep your dressings/ wounds dry. You should keep your arm as close to your body as possible when changing your clothes.
When Can I start driving?
It is illegal to drive while wearing a sling. You may start to drive once the sling has been discarded but not until you can safely control the vehicle. This is normally between 6 and 8 weeks after the operation. It is advisable to start with short journeys.
When can I go back to work?
This will depend on the type of work you do and the extent of the surgery. If you have a non-manual job and do not need to drive you may be able to return within 2 weeks. If you have a heavy lifting job or one with sustained overhead arm movement you may require 3 or more months off.
How am I likely to progress?
By 3 to 4 months after the operation, most people have noticed an improvement in their symptoms and are pleased with their progress.
When can I resume heavy lifting/ recreational activities?
Generally around the 3 month mark once your physiotherapist and surgeon are satisfied with your recovery (Strength & range of motion). For return to collision sports such as rugby you will a graduated return to full play.