I'd like to be a little more educated about surgical treatment for a shoulder I have that keeps dislocating. When I see the orthopedic surgeon next week, what might I expect to have happen?
The surgeon will ask you questions and interview you about your medical history and especially the details of your current complaints. The problem has to be identified and recognized for what it is. With chronic shoulder dislocations, treatment will fail if the full extent of the injury isn't treated. Next, a physical examination and then appropriate imaging tests are used to define the problem. X-rays can show bone loss, MRIs show how much bone loss is present, and CT scans detect rim fractures.
From this information, it is possible to calculate how much of the humeral head is actually in contact with the glenoid surface. The surgeon may use an arthroscopic exam to examine the joint more fully. If there are any bare spots on the glenoid surface. The surgeon can get measurements of the defects and compute the percent of bone loss.
Treatment is based on the percentage of bone loss. What is considered an insignificant amount (less than 15 per cent of the surface area) may respond to conservative (nonoperative) care. Bracing, strengthening exercises, and modifying activity level may work well for athletes who are not involved in overhead sports. Rehab supervised by a physical therapist helps the patients understand which movements should be avoided in order to prevent another dislocation from occurring.
If this approach fails to restore motion and function, then surgery to repair the damage and/or reconstruct the shoulder may be required. Anyone with moderate bone loss (15 to 25 per cent) or severe bone loss (25 to 30 per cent or more) will need surgery. The exact surgery planned depends on what type of damage is involved (e.g., bone factures with fragments, labral (rim) tears, amount and location of bone loss, or other defects). Sometimes the surgeon is able to piece the bone fragments back together. This is most likely when the defects are small -- limited in number and size and providing that the bone fragments can be found.
Surgical treatment becomes more complex when bone loss affects one-fourth (or more) of the joint surface. In such cases, the surgeon must look at the patient's activity level, how long it's been since the injury, the condition of the surrounding soft tissues, number of bone fragments, and potential for healing. Research shows that whenever possible, any bone fragments should be reattached. The risk of failure goes down for patients who are treated in this way.
There are numerous ways the surgeon can approach this problem. It may be necessary to graft bone to the shoulder socket to make up for defects in the rim. This procedure is called a glenoid augmentation. The surgeon tries to match the bone graft to the contoured (curved) surface of the glenoid. Screws are used to hold the graft in place.
It's not enough to just wire bone fragments together and reattach them. The surgeon must pay attention to the biomechanics of the shoulder as well. Restoring the normal bony arc of motion is essential for stability. Do tyou want to return to everyday activity and function as your main goal? Or are you expecting to return-to-competitive sports participation? This is a key determining factor in patient satisfaction. Surgeons are still looking for the best way to restore the joint to near normal. They can't always guarantee 100 per cent recovery and return to sports at a preinjury level.
Sometimes surgery fails to correct the problem. The patient continues to experience symptoms of pain and repeat dislocations. A second (
revision) surgery is needed. The biggest predictor of failed surgery the first time is just how much bone loss is present because it's this bone loss that results in a failed stabilization. The more bone loss, the greater the risk of a failed repair.
Your surgeon will go over all of the treatment possibilities, their pros and cons, and what might be best for you given your age, activity level, extent of damage in the shoulder, and so forth.
Dana P. Piasecki, MD, et al. Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. In Journal of the American Academy of Orthopaedic Surgeons. August 2009. Vol. 17. No. 8. Pp.482-493.
*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.