It seems like this isn't my year. After dislocating my pitching arm a half dozen times, I went ahead and had surgery. Well, wouldn't you know it? It didn't work. I guess they call it a failed shoulder stabilization. Bummer. What do I do now? I'm not ready to throw the towel in yet.
Chronic shoulder dislocations (usually in the forward or anterior direction) can be a challenge, but they are not insurmountable. The first thing the surgeon will want to do is evaluate your situation and see what went wrong. There are multiple things that could have contributed to the failure. Finding them all and treating the whole package is essential for a successful result.
The majority of failed shoulder surgeries are attributed to misdiagnosis. It's not that the surgeon didn't know what was wrong with the shoulder. In 84 per cent of all cases, there was more than one problem. And the additional problems weren't recognized or repaired, leaving the shoulder at risk for failed surgery. The surgeon evaluating patients with shoulder instability following surgery must go back to the beginning. With a thorough history, physical exam, and review of risk factors, the full scope of problems can be identified. Then a treatment plan to address each one is developed.
Finding the source (or sources) of the failure is important before just going back in with more surgery. There are some routine questions that must be asked like what kind of surgery was done, did it have any effect, and was there another injury or athletic event that led up to a reinjury and now the current instability? The surgeon will also look for common risk factors such as the patient's age, inappropriate activity level (too much, too soon), or inadequate rehab after surgery.
There's always a list in the back of the surgeon's mind of other risk factors out of the patient's control. This could include poor quality of soft tissue or bone, damage to the joint cartilage, and technical problems from the surgery. A careful physical exam will show how much motion the athlete has, strength and function, as well as the degree of instability (mild-moderate-severe). By comparing the unstable side to the uninvolved, stable shoulder, it's possible to get an idea of ligamentous integrity and just where the instability is coming from.
Loss of motion, too much motion, and/or loss of strength in any particular direction provides helpful information. For example, the patient who can externally rotate the arm past 90 degrees is showing some shoulder joint instability from lax or loose ligaments. If the shoulder capsule is stretched out too much, the patient will be able to move the arm away from the body (a motion called abduction) 20-degrees or more on the unstable side compared to the other (uninvolved) side.
Testing shoulder muscle strength is a good way to look for rotator cuff tears or nerve damage. Loss of normal muscle function from either of these problems can lead to biomechanical dysfunction. With as many as 30 per cent of shoulder surgery failure, it's not uncommon to find both muscle and nerve injury or damage to more than one muscle.
Once the physical exam has been completed, the surgeon puts the whole picture together and decides what kind of imaging might be helpful. Sometimes the original misdiagnosis occurred because there was inadequate imaging. Certain X-ray view may be needed or a three-dimensional (3-D) CT scan to look for specific types of lesions. Bone loss, location of that bone loss, and extent of bone loss are all important variables to look for before attempting another operation.
Those are all a lot of what ifs. For now, getting a follow-up appointment is the next step. Sometimes when there are so many factors to consider, patients seek a second and even third opinion before going forward with the proposed treatment plan. Surgeons are often in practice with other surgeons and have access to colleagues to review cases like this. This makes it easier and less expensive for you to get that second opinion. Stepping outside of that loop is always an option as well.
Neil Ghodadra, et al. Failed Shoulder Stabilization Surgery: What to Do? In Current Orthopaedic Practice. July/August 2009. Vol. 20. No. 4. Pp.365-373.
*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.