Can Chronic Shoulder Dislocations Be Treated Arthroscopically?Having a shoulder that repeatedly dislocates can be a major problem -- especially for overhead throwing athletes. The shoulder can be surgically repaired but that's major surgery. Surgeons are working to find arthroscopic ways to accomplish the same long-term results provided by open surgery. In this report, surgeons from Italy present the long-term results of 43 shoulders treated with arthroscopic Bankart suture-anchor repair.
The study is important because until now the standard surgical procedure to repair forward (anterior) dislocating shoulder has been an open Bankart repair. The Bankart procedure is done to reattach the labrum (a rim of fibrous cartilage) when it is torn away from the shoulder socket. When the force of injury is enough to tear the labrum, a piece of bone attached to the labrum comes with it. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) are also damaged and must be stitched back together layer by layer.
Chronic, recurring shoulder dislocations mean the shoulder is unstable. In other words, the shoulder joint is too loose and is able to slide around too much in the socket. If not treated, instability can lead to arthritis of the shoulder joint.
One of the questions the surgeons who conducted this study asked was, Will patients treated arthroscopically have arthritis later? They also wanted to know if shoulder function improved with the surgery and if the patients would be satisfied with the results. The final question was whether or not they could predict who might have a good (or poor) response to the arthroscopic Bankart repair using suture-anchors. Suture-anchors are stitches that reattach the labrum back onto the bone.
Here are a few details to give you an idea of just who these patients were. Most were men (only four women in the study). All but two were competitive athletes in contact or overhead sports. Everyone had at least one dislocation after the first injury. Some patients had as many as 10 more dislocations. Surgery to perform the Bankart procedure was done by the same surgeon in all patients included in the study.
The surgeon carefully described the procedure including patient position, type of anesthesia used (including an interscalene block), and portals used to insert the scope into the joint. Step-by-step surgical technique was outlined. Placement of each suture-anchor was also described.
As with most Bankart repair procedures, the postoperative management is as important as the surgical procedure. The healing area must be protected but without causing a frozen shoulder from lack of movement. For this reason, patients are placed in a sling with the shoulder slightly abducted (away from the body). The sling is worn for four weeks.
Elbow and wrist movements are allowed. Special shoulder exercises called Pendulum or Codman exercises are done everyday. These exercises are designed to keep the shoulder joint moving smoothly without stressing the repair. In this study, patients were progressed to passive shoulder motion two weeks after surgery. Passive motion means that someone else moves the shoulder for them. No shoulder muscle contraction is allowed -- again, this prevents any stress on the healing tissue.
Sometime between six and eight weeks, patients were allowed to move from passive to active motion (moving on their own without help). At three months post-op, they started strengthening exercises for the rotator cuff (muscles around the shoulder). By the end of five months, most patients had returned to their full sports activity.
How did this group do with the arthroscopic Bankart repair? Well, the problem of recurrent shoulder dislocation wasn't eliminated. A fair number of patients (16 per cent) had redislocation spontaneously (meaning without trauma). Adding in those who dislocated again due to trauma, there was an overall recurrent rate of 22.5 per cent (that's almost one-fourth of the entire group).
The surgeons tried to tell if there was some specific reason why these athletes were still dislocating after surgical repair. It didn't appear to be related to their age or the number of times they dislocated before surgery. Certainly, overhead throwing athletes had the greatest number of problems. Not having enough shoulder external (outward) rotation seemed to be a factor for some of the patients.
What about arthritis? Did these patients develop degenerative changes in the joint despite the surgery? Some did but the majority (two-thirds) did not have any signs of arthritic changes on X-ray. Those who did have changes were mild to moderate. There were no cases of severe degenerative arthritis -- at least not at the end of the first 10 years.
And were the patients happy with the results? Eighty-four per cent (84%) said, Yes, they would have the same surgery over again. Most of them based this response on the fact that they could return to their previous level of sports participation. Those who were not satisfied with the results had recurrent dislocation(s) and/or experienced what is referred to as apprehension -- feeling like the shoulder is going to dislocate with certain movements (external rotation, overhead throwing).
In summary, the authors note that arthroscopic stabilization does have acceptable long-term results when used to do a Bankart repair on unstable shoulders. Shoulder osteoarthritis isn't really a big concern in the first 10 years after surgery. This group of patients will continue to be followed to see what happens over the next 10 years. Surgeons expect continued good results as surgical techniques improve over time.
Alessandro Castagna, MD, et al. Arthroscopic Bankart Suture-Anchor Repair. In The American Journal of Sports Medicine. October 2010. Vol. 38. No. 10. Pp. 2012-2016.
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