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Surgery for Anterior Instability

ARTHROSCOPIC ANTERIOR STABILISATION

This operation is usually performed as a day case procedure under general anaesthetic. Patients are normally admitted on the morning of surgery and may go home later that evening. Three small incisions (5-10mm), are used.
The aim of surgery is to restore near normal anatomy to the shoulder to allow harmonious balanced interaction between all structures within the joint.
Frequently the antero-inferior labrum has been torn off the glenoid (socket) and gets stuck down elsewhere. This de-tensions the anterior capsule leading to both structural insufficiency and loss of proprioceptive feedback from the shoulder joint capsule to the brain. The aim of surgery is to both restore the structural anatomy and re-tension the capsule ( a bit like tightening up a guitar string).

The procedure
The anaesthetist will administer a general anaesthetic.
Pre-operative antibiotics are given to reduce the chances of post operative infection. Precautions are taken to reduce the chance of venous thromboembolism. An examination and assessment of laxity within the joint is
made. The skin is prepared with an antiseptic solution. A suprascapular nerve block is performed to reduce postoperative pain. The arthroscope (camera) is inserted into the shoulder joint through a small posterior portal.
Direct visualisation of all structures is performed.

Glenohumeral Joint – Deficient Labrum

A further two 10 – 15 mm incisions are made anteriorly to
allow access for surgical instruments.
The labrum is mobilised from its abnormal position.
Suture anchors are inserted into the edge of the glenoid to
secure the labrum back to its original position, at the same
time tightening some of the anterior capsule.
Care is taken not to overtighten the anterior capsule
thereby limiting external rotation.

Repair of Labrum to Glenoid (socket)

A further two 10 – 15 mm incisions are made anteriorly to
allow access for surgical instruments.
The labrum is mobilised from its abnormal position.
Suture anchors are inserted into the edge of the glenoid to
secure the labrum back to its original position, at the same
time tightening some of the anterior capsule.
Care is taken not to overtighten the anterior capsule
thereby limiting external rotation.

Repaired Labrum

When the labrum is repaired, further local anaethetic is
administered and the two anterior portals are sutured.
Dressings , icepack and sling are applied before transfer to
the recovery ward.

Complications
Complications following arthroscopic stabilisation are not common.
They include:
1. Failure / recurrence: 5 %
2. Infection: < 1%
3. Clots - in the deep veins of the leg and the lungs: rare in upper limb surgery
4. Nerve Injury: rare
5. Stiffness. Most shoulders are a little stiffer following repair, but with arthroscopic surgery this is
usually minimal

Post Operative Care
1. You will wake up in recovery with your arm in a sling.
2. You will have an absorbent dressing and Icepack applied to your shoulder.
3. The absorbent dressing can be removed after 24hours. The underlying adhesive plasters should not
be removed.
4. The icepack should be worn for 30 minutes on, 90 minutes off. This cycling of cold therapy can be
beneficial in reducing inflammation and pain for up to 72 hours.
5. You may require regular analgesia for several days post surgery.
Paracetamol and codeine are usually prescribed. I prefer not to use non-steroidal anti-inflammatory
medication as these may interfere with the healing of the labrum to the bone.
6. Two weeks post surgery the sutures from the anterior portals are removed.
7. The sling is worn for a total of four weeks.
8. Following surgery you will undergo as supervised physiotherapy program.
Rehabilitation Guide: Anterior Shoulder Stabilisation – Arthroscopic (LINK)

Return to Functional Activities
Driving: 8 Weeks.
Swimming: Breaststroke: 8 weeks.
Freestyle: 3 months.
Golf: 3 months.
Lifting: Light lifting: 3 weeks.
Heavy lifting: Avoid for 3 months.
Return to work: Sedentary job: as tolerated.
Light duties: as tolerated after 6 weeks.
Heavy duties: 3 months.
Contact sports: 6 months.

OPEN ANTERIOR STABILISATION

Open stabilisation is performed if arthroscopic repair is not advisable e.g.
1. Large glenoid fracture > 25 %
2. Engaging Hill Sachs
3. HAGL (Humeral Avulsion of inferior Gleno-Humeral Ligament).
The most common open procedure that I perform is a combined procedure of Bankart (labral) repair
and inferior capsular shift. This procedure is different from arthroscopic surgery in that
1. An 8 – 12 cm anterior incision is made.
2. The subscapularis tendon is divided and dissected free from the underlying capsule.
3. An L – shaped incision is made in the capsule to allow access to the shoulder joint.
4. The labrum is repaired back to the glenoid and then the inferior capsule, together with the anterior
band of the Inferior Glenohumeral Ligament is pulled superiorly and tightened
5. The rotator interval is closed.
6. The subscapularis tendon is repaired.

Open Bankart Repair and Capsular Shift

Recovery
Post op care and rehabilitation differs from arthroscopic stabilisation because the subscapularis repair needs time to heal. When fully rehabilitated, the shoulder will have lost some of its external rotation