Open Shoulder Stabilisation

This information is intended for patients who have elected to undergo an operation to stabilise their shoulder for recurrent dislocations or subluxations of the joint.

There are several different techniques available to stabilise the shoulder. The two most common are an open (i.e. with a cut) operation or an arthroscopic (minimally invasive or keyhole) procedure.

The arthroscopic procedure achieves good results in cases where there have been fewer dislocations or if you are not going to return to “collision” sports. The arthroscopic operation has a success rate of about 90%. The open operation has a higher success rate, especially in people who have had multiple dislocations, or who are very active and play high level contact sports. The success rate of the open operation is greater than 90%. The rehabilitation following both procedures is about 6 months but hospitalisation is shorter and the amount of pain is generally less with the arthroscopic procedure.

The operation is necessary because your shoulder keeps coming out of joint and the risk of it continuing to come out of joint is very high. Each time the shoulder dislocates more damage is done to the joint itself and this increases the risk of arthritis in the future.

As a result of the dislocations, you have stretched the capsule of the shoulder joint and it is larger and more voluminous than the normal capsule. In addition you may have torn a small piece of tissue (known as the labrum) off the bone, allowing the humeral head to dislocate forwards.

The principle of both operations is to reduce the size of the stretched capsule of the shoulder joint and to reattach the torn labrum back to the bone (if it is torn).

The Open Stabilisation

This operation takes about 90 minutes. The incision is adjacent to the crease in the armpit and unfortunately it can spread with time. You will have some permanent numbness around the scar, which is usually not noticeable. The operation involves cutting down to the shoulder joint and reattaching the torn labrum back to the bone with either stitches (that do not dissolve) or small screws which are sunk into the bone and do not require removal. A T-shaped incision is made in the capsule and it is then tightened. This reduces the volume of the capsule and stops the shoulder moving in abnormal directions. There will be some mild permanent stiffness but usually this is not noticeable and does not cause any functional deficit.

You will wake up in the ward in a sling and you will have a drain coming out of your armpit. You will be given adequate pain killers to keep you comfortable.

The Arthroscopic Stabilisation

This operation takes about 120 minutes. You will have one small cut at the back of your shoulder and two small cuts at the front. The labrum (or cartilage) which is torn off the bone is repaired with either a dissolving screw or a metal screw with a stitch attached to the end. In cases where the capsule (or lining of the shoulder) has stretched, there is the added option of dividing the capsule and then tightening the capsule with arthroscopic stitches. This acts like closing a double-breasted coat. Occasionally a technique known as Thermal Capsular Shrinkage can be used to shrink the capsule (where we run a hot current through the capsule) but this can also weaken the capsule.

Post Operative Management
For Both Operations

The day after surgery you will be seen you and the surgery discussed with you. Your drain will be removed if you have had an open procedure. A waterproof dressing will be placed on the shoulder and you will be allowed to shower. When showering take the sling off but leave your arm adjacent to your body – do not attempt to lift or rotate the arm – and then put the sling back on after you are dry. Make sure the armpit is as dry as possible because of the risk of a sweat rash or an armpit infection. It is important to sit out of bed and walk around as soon as you are comfortable and able.

If you have had an arthroscopic procedure you can leave hospital that day.

If you have had an open operation you generally leave on the second postoperative day but can leave on the first postoperative day if your pain level is well controlled.

In the immediate post operative period you will experience pain about the shoulder. There will also be significant pain at night as a result of the surgery. On discharge from hospital you will be given pain killers as well as tablets to help you sleep at night. It is common to get swelling about the arm, forearm, hand and fingers. Please endeavour to keep the armpit as dry as possible – once the wound has healed at about 10 days you can use talcum powder, which will help.

The sling will need to remain on for at least 4 weeks but sometimes 6 weeks depending on what we find at the time of surgery. The sling must remain on 24 hours a day including at night. The sling only comes off to have a shower and get dressed and on those occasions the arm needs to be kept adjacent to the body. The Roads and Traffic Authority does not permit driving of a motor vehicle while you are in a sling. It is therefore recommended that you do not drive for 4 to 6 weeks.

You will be reviewed about 10 days following surgery to take out your stitches and check that the wound is clean and that there is no infection.

You will be reviewed at the 4 or 6 week mark, whichever is appropriate, to take you out of the sling and start a passive exercise program which lasts for 2 weeks. You will be taught the exercises and given an exercise sheet, which clearly outlines the exercises required.

Two weeks later you will be started on an active exercise program. By this time your shoulder movements will be about half normal and you will still have some pain and discomfort.

At 10 to 12 weeks following the operation you may start some breaststroke swimming and also will progress on the exercise program. The rate of progression of the exercise program will depend on how you are doing.

Under No circumstances can you return to any sports for 6 months. Doing so may compromise the result. Fitness can be maintained by using an exercise bike or jogging, with care not to fall. Some supervised swimming is allowed after 10 to 12 weeks. Tennis, basketball, touch football, soccer, weights training and ALL sports should not be started until your surgeons permits it at about 6 months following surgery.

At about 5 months you will commence a supervised physiotherapy program incorporating light weights. At about 6 months, providing you have sufficient muscle control of the shoulder, you will resume full activity, including contact sports. You will however need to continue the exercise program for at least 9 months following surgery. Your shoulder may be a little stiff for up to 12 months following surgery. Please note that in most cases there will be minor but permanent loss of motion at the extremes of movement but this does not cause any functional impairment.

Persons who return to contact sport, especially professional athletes, should use a brace for the first season on returning to play. This is to protect the repair. The brace is usually fitted by the team physio. All patients who return to doing weights should permanently avoid training in positions that can stretch the shoulder, such as shoulder presses and full extension in bench presses. This should be discussed with your trainer.

The recurrence rate following open surgery is about 5% in persons who do not return to contact sport, but climbs to 10% in persons who return to contact sport and this includes snow and water skiing. The recurrence rate following the arthroscopic procedure is about 10% which climbs to 20% if you return to contact sport which includes snow and water skiing.

These operations do not give you a super strong shoulder and just as you dislocated your shoulder the first time, you may dislocate it again with violent sporting activity.

Comparison Of Open
And Arthroscopic Surgery

	Arthroscopic	Open
Incisions	3 small 1cm incisions	One larger 4cm incision
Post Operative Pain	Mild	Significant
Hospitalisation	Overnight	2 days
Time In Sling	Four weeks	Four weeks
Exercises/Physio	6 months	6 months
Off Sport/Lifting	6 months	6 months
Slight Permanent Loss Of Motion	Rare	Usual
Success Rate	90% ( 80% contact sports)	95% ( 90% contact sports)
Complications	Rare	Rare