Arthroscopic and open stabilization

Shoulder instability - shoulder luxation

There are two types of joint instability:

• Congenital, so-called habitual instability. In this case, the entire supporting tissue of the body is weak and the capsule/ligament system especially of the glenohumeral joint is instable so that the head of humerus has too much clearance in all directions and may jump the joint without much violent intervention (luxation). This type of instability is operated in exceptional cases only but is treated by means of a physiotherapeutic exercise and training program.

• The second type, so-called chronic-traumatic instability is caused by an injury to the capsule/ligament system due to luxation of the arm during an accident. In this case, the joint lip, the so-called labrum, which is similar to the meniscus in the knee joint, is typically sheared off the joint cavity rim by the head of humerus during luxation. In addition, the lower joint capsule in front is strongly overextended and may also crack. Due to this damage, the shoulder may luxate spontaneously without any new accident.

After luxation, the head of humerus stands below the joint cavity and must be repositioned. Due to the painfulness, this is done under anesthesia. Then the arm is immobilized in neutral rotation on an abduction splint. This way, the tissue is in anatomically correct position and may heal. Subsequently, a physiotherapeutical training program is performed which aims at the muscular stabilization of the joint. If an instability remains despite of intensive and long physiotherapy, surgical stabilization of the joint is indicated. If an instability remains untreated, this may lead to premature wear of the joint cartilage.
The physically active patient is an exception with regard to the time of surgery. After a luxation, surgery should be performed immediately in order to allow an early return to sports competition.

Surgery technique

Basically, there are two different surgical options available:

Arthroscopic

If during examination (MRI) and arthroscopy a detached labrum (joint lip) without material capsule injury is detected, the labrum may be refixed to the cavity rim using bone anchors.
At first, diagnostic arthroscopy of the joint is performed to be able to assess the extent of the injury to the cavity rim and the capsule/ligament structures and to identify additional damage. Then, arthroscopic stabilization is carried out, if possible. During this procedure, the detached joint lip (labrum) and the capsule/ligament system are fixed to their original position.

Fig. 27: Mobilization of the labrum until the 6-o'clock position using a blunt rasp.

Fig. 28: Screwing in the suture anchor.

Fig. 29: Loading of the detached labrum.

Fig. 30: Refixed labrum-capsule-ligament complex. 

Open (surgery with cut)

If the joint capsule is strongly overextended or cracked or if accompanying injuries have occurred (tear of the rotator cuff), an open procedure is indicated. The lower front area of the joint is opened by means of a cut of about 6-8 cm, the labrum is refixed and the joint capsule is tightended. Possibly torn tendons are sutured.

Fig. 31: Skin incision.

 

Abb. 32: Ablösung der Sehne des M. subscapularis

 

Fig. 33: Exposition of the joint capsule and opening of the joint space along the red line.

 

Fig. 34: Preparation of the bony glenoid rim to improve the healing of the refixed labrum.

Fig. 35: Screwing in the suture anchor.

Fig. 36: Refixed labrum-capsule-ligament complex

Abb. 37: Closure of the joint capsule and refixation of the tendon of the subscapularis muscle.

Inpatient treatment

The patient has to stay at the clinic for about 4 - 5 days.

Follow-up treatment

As a matter of course, the sutures must not be put under much strain, and the shoulder has to be immobilized for about 3 - 4 weeks after surgery. At the same time, a phase-oriented rehabilitation program is started (see the section about rehabilitation).

Ability to work and to do sports

In particular with surgically stabilized shoulders, resumption of professional sports activity strictly depends on the individual activity. As a rule, training in all sports without much activity above the head may be resumed after 3 months.