To view a video of a Labral/Bankart Repair , click here.

To view a video of a Stabilisation For Multi-Directional Instability , click here.

To view a video of a Slap Repair, please click here.

The Labrum

The labrum is a ring of tough and flexible tissue on the rim of the glenoid. It attaches the glenoid to the capsule and makes the glenoid socket deeper, thus making shoulder dislocation less likely.

If the humeral head shifts completely off the glenoid because the shoulder joint is too flexible this is called a dislocation. When the head is pushed only part way out of the glenoid it is called subluxation. Subluxing or dislocating a shoulder can stretch or tear the capsule and damage other parts of the joint. This makes the humeral head more likely to slip out of the glenoid again.

Injury can happen to the capsule, the bone, the glenoid labrum and rarely to the muscles. If the capsule is torn, it cannot stop the humeral head from moving out of the glenoid, allowing the head to slip out over and over again.

When the shoulder dislocates the humeral head can hit the bone of the glenoid rim, fracturing the glenoid or denting the humeral head. This, again, makes the humeral head more likely to slip out again and again.

If the humeral head pushes only part way out of the glenoid, the capsule may stretch rather than tear. The stretched capsule is too loose to stop the humeral head from leaving the glenoid when you raise your arm. When it pushes all or part way out of the glenoid, the humeral head can tear the labrum. Since the labrum helps hold the humeral head inside the glenoid, a torn labrum means the humeral head may slip out of the glenoid.

In most patients it will be true that 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 and this allows the humeral head to dislocate forwards.

TREATMENT

Physiotherapy can help restore stability, strength and control of your shoulder. It helps you regain control of strengthening your dynamic stabilisers - the rotator cuff and other shoulder muscles - and training them to take over from the parts of the shoulder that are damaged and are no longer doing their job. There are some types of instability where physiotherapy alone is enough to stabilise the shoulder. For most sports-people physiotherapy is only effective when used in conjunction with surgery.

SURGERY

Surgery helps restore shoulder stability by tightening and repairing the shoulders static stabilisers. The principles of the operation are to reduce the size of the stretched capsule of the shoulder joint and to reattach the torn labrum back to the bone. The procedure is designed to tighten and repair the shoulder joint which means that physiotherapy after the procedure is often necessary to help you regain flexibility. It also helps regain strength while the shoulder is healing.

Factors that are Important in the Determination of Treatment are...

• How long you have had an unstable shoulder.
• The direction in which your shoulder is slipping.
• The extent of damage to the joint.
• Whether there is any damage to muscles or nerves.
• What kind of lifestyle you lead and/or sporting activity you want to be able to get back to.

You have elected to undergo an operation to stabilise your shoulder for recurrent dislocations or subluxations of your shoulder.

There are several different techniques available to stabilise your shoulder. I have suggested that an arthroscopic stabilization (minimally invasive) would be more appropriate in your case than an open (with a cut) stabilization. The arthroscopic procedure has reasonably good results in cases where there have been few dislocations or if you are not going to return to "contact" sports. This operation has a success rate of about 90%. The open operation has a higher success rate especially in people who have had several dislocation over many years or who are very active and play elite contact sport. The success rate of the open operation is greater than 90% but usually involves a very slight loss of movement in certain positions of the shoulder. The rehabilitation following both procedures approximate 6 months but hospitalisation may be shorter 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 might increase the risk of arthritis in the future.

You will be admitted to the hospital on the morning of surgery and you will be visited by the anaesthetist who will examine you and make sure you are fully fit to undergo a general anaesthetic. In many cases the anaesthetist will explain to you the option of having a "block" which is an injection in and around the neck which will reduce pain for 12 to 18 hours post operatively. The nursing staff will also explain the use of "patient controlled analgesia" (or PCA) where you regulate the amount of pain relieving medication that you use. You must remove all rings from your hand prior to surgery.

This operation takes about 120 minutes. You will have one small incision at the back of your shoulder and two small incisions at the front. The labrum, or cartilage, which is torn off the bone and 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, which acts like tightening a double-breasted coat. I occasionally use a technique known as Thermal Capsular Shrinkage where we run a hot current through the capsule and shrink the capsule. This however can also weaken the capsule.

You will wake up in the ward in a sling. You will be given adequate pain killers to keep you comfortable.

The day after surgery 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.

You will be discharged from hospital. In the immediate post operative period you will experience pain about the shoulder. On discharge from hospital you will be given analgesics as well as tablets to help you sleep at night.

The sling will need to remain on for at least 4 weeks. 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 a vehicle while you are in a sling. I therefore recommend you do not drive for 4 to 6 weeks.

About 10 days following surgery you will be seen to take out your stitches and check that the wound is clean and that there is no infection.

You will again be reviewed at the 4 week mark, to be taken out of the sling and start an exercise program.

Under NO circumstances can you return to any sports for 5 to b6 months. Doing so may compromise the result. Fitness can be maintained by using an exercise bike or jogging, with care not to fall. I allow some supervised swimming after 10 to 12 weeks but tennis, basketball, touch football, soccer, weights training and ALL sports should not be started until I permit you to do so at about 6 months following surgery.

At about 6 months, providing you have sufficient muscle control of the shoulder, you will be permitted to 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 usually does not cause any functional impairment.

Persons who return to contact sport (especially professional athletes) should use a brace for the first season when they return to playing. 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 where possible.

The recurrence rate following surgery is about 10% in persons who do not return to contact sport, but climbs to 20% in persons who return to contact sport and this includes snow and water skiing. This operation does 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.