Arthroscopic Shoulder Stabilisation
What does this surgery involve?
This is a keyhole operation that allows direct repair of damaged internal structures within the shoulder that are responsible for recurrent dislocations or instability symptoms. The aim of the surgery is to make the patient’s shoulder more stable and thereby to reduce the risk of future dislocations, as well as improving associated pain symptoms if present. Multiple small keyholes (portals) are used; usually a minimum of 3.
Prior to the surgery an examination of the shoulder under anaesthetic takes place. This is an important step to clarify the direction (to the front, back or below) in which the shoulder is unstable. A full keyhole internal assessment with a camera is then carried out to determine which structures have been damaged.
In the majority of keyhole shoulder stabilisation procedures, the key structure that is repaired is the labrum, which is a ring of cartilage that encircles the glenoid and deepens it. This is the structure that tends to be damaged when a shoulder dislocates. The labrum is released and mobilised into the correct position. A device is then used to pass high strength sutures through the torn labrum. These sutures are then introduced into small devices called anchors which are then tapped into drill holes on the edge of the shoulder socket, much like a Rawl plug. The torn labrum is hence repaired back to its correct position on the edge of the shoulder socket.
Labrum and capsule healed in abnormal position back from the edge of the glenoid
Labrum and capsule following sharp release from glenoid
Labrum mobilised and edge of socket prepared with a rasp
Anchor being introduced into glenoid edge
Final repair with labral “bumper” restored to edge of glenoid
What happens after the operation?
For most patients this operation will be a day case procedure. Patients who have their surgery carried out in the afternoon will, in all likelihood, be booked for an overnight stay. Depending on the individual’s recovery most will still go home the same day.
All patients require a sling after surgery in order to protect the repaired labrum whilst it heals back to the bone. Usually the period of time in a sling is 3 weeks after this procedure but may differ according to individual circumstance. Driving is not possible whilst in a sling, therefore the earliest that patients may drive after this surgery is usually between 4-6 weeks, although some may take longer.
Once the sling is removed and the mobility of the shoulder starts a degree of stiffness is to be expected. This will improve gradually. Strength then needs to be built with the help of regular physiotherapy sessions and home exercising.
Office or non-manual workers may go back to work after 2-4 weeks but those who have manual occupations will need at least 3 months off work or on light duties, possibly longer. I will discuss this with you prior to the surgery.
The overall recovery after surgery until full improvement in your symptoms has been achieved is between six months to a year, and possibly even longer than this. Return to contact sport is possible only after 6 months, but this is an individualised decision.
What are the potential complications involved in this procedure?
Scars: There will be multiple keyholes (or portals) which heal well and rarely cause problems. Fine stitches are used and removed between ten to fourteen days after the surgery.
Bleeding: There is very little blood loss. The dressings may be blood stained however most of this is the fluid used to wash through the joint during the operation.
Infection: This is a very rare although potentially serious risk. Most studies suggest the infection rate is between 0.5-1% for arthroscopic shoulder surgery. The real risk for this operation may well be less. The majority of infections are superficial (in the skin around the keyholes) and will settle with a course of antibiotics. However, if you are unfortunate enough to get a deeper infection involving the anchors or suture materials, this is generally managed with further surgery to wash the joint out and potentially to remove the anchors. The main advantage of arthroscopic (keyhole) procedures over open procedures is a significantly lower infection rate, but the risk cannot be eliminated completely. You will be given antibiotics prior to the surgery by the anaesthetist to try to reduce the risk of infection as much as possible.
Swelling: The shoulder may get quite swollen during the operation. The fluid used to expand the space during surgery will leak into the surrounding tissues. Most of this drains into the dressings or gets absorbed by the body. Usually the shoulder is of normal size by the next day.
Stiffness: This is a common complication. It takes between six to eight weeks for the labral tissue to attach relatively firmly to the bone, and 12 weeks for full bonding. In view of this the shoulder is protected by means of a sling in the early post-operative period. Understandably, after a period of immobilisation the joint will be stiff. This is variable but usually improves with time.
Variable recovery: Some patients never take a painkiller after the operation and others have to for six weeks or longer. Most will fall between these two extremes.
Failure of the repair or re-dislocation: The rate of the operation failing (ie your shoulder dislocating again in the future) is approximately 10%. If this happens it does not automatically mean that further surgery is required although this may be an option if your shoulder remains unstable. The rate of re-dislocation is usually much higher in those who return to contact sport, particularly rugby. The failure rate can be as high as 30-40% in those returning to rugby after a soft tissue stabilisation.
Very rare complications
Nerve/Blood vessel injury: The risk of injury to these structures is much less than 1 in 100 but if damaged these are potentially serious complications and may necessitate further procedures.
Deep Vein Thrombosis and Pulmonary Embolus: The overall risk for such a complication is estimated 1 in 2000, i.e. very rare. A thrombosis is a clot that can form in the veins due to immobility. When it travels to the lungs it is called an embolus. You will be given special stockings that compress your calf and compression cuffs whilst on the operating table. There is usually no need for medication or injections to thin the blood unless you have significant risk factors. Usually the risk of bleeding by far outweighs that of a blood clot.
Implant complications: Modern anchoring devices hold well within bone and it is rare for these to fail. The anchors that we use are partially absorbable and, over a long time, are incorporated into the bone.