Shoulder Dislocation

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With trauma to the shoulder the joint may dislocate, and this is the most commonly dislocated joint in the body (also the joint in the body that has the most amount of range of motion).  Most commonly the shoulder dislocates anteriorly.  When this happens, the anatomy of the shoulder is disrupted.  The labrum, which acts like a bumper to the glenoid (cup of the shoulder), may tear predisposing the shoulder to recurrent instability. While anterior shoulder dislocations are definitely much more common than posterior shoulder instability (somewhere between 90% of dislocations will be anterior), posterior dislocations can still occur and a lot of the treatment principles are similar.  Posterior shoulder dislocations are commonly associated with seizures and possibly electrocution.  This is because the force required to dislocate posteriorly is much more than anteriorly, so stronger muscle contractions must occur for this to happen which can occur with seizure activity or electrocution.    

Probably even more common than a real pure shoulder dislocation, is something called a shoulder subluxation.  This occurs when the shoulder just reaches the edge of cup, and rather than dislocating completely, it clicks back into the shoulder.  This can have deleterious effects on the shoulder as well, although usually shoulder subluxators will have gone through several more instability events than a pure dislocating patient might. These can be rehabilitated with some strengthening of some shoulder muscles, and if indicated can be treated with a type of shoulder dislocation surgery called arthroscopy where most likely the labrum of the glenoid would be repaired.  Some of the shoulder’s capsule can be tucked in as well, which can help to destabilize the shoulder.  This is called a capsulorrhaphy which is literally just sewing a portion of the capsule to the labrum.

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Treatment may be non-operative depending on treatment goals. If the recurrence of shoulder instability is a low level concern, it is likely that surgery is not going to be indicated.  The risk of recurrence is the highest the younger a patient is when they dislocate.  So teenagers are most likely (greater than 90%) to develop a shoulder that recurrently dislocates.  A 60 or 70 year old patient is much less likely and therefore may not care as much.  

Furthermore, while the pain may quickly fade from a dislocation, the event in itself is not at all benign (which is why a lot of people move on to not have any surgical treatment because the pain fades relatively quickly, and therefore they forget or block out their problem…until they dislocate again).  One dislocation event can predispose a patient to an increased risk of developing an arthritic shoulder later in life, and this risk of arthritis increases with the higher number of dislocations.  Couple this with an increased risk of recurrence after a single dislocation in a younger person, and this can quickly develop into a problem.  The pendulum in the United States has started to swing towards aggressive early treatment of these conditions to insure better shoulder health in the future with less risk of recurrence of instability.

Shoulder dislocation surgery, also known as arthroscopic surgery may be indicated depending on some variables.  In operative cases, there are many stabilization procedures with advocates for each.  A simple bankart repair may be indicated depending on activity level and age of the patient.  Certain surgeons may advocate doing this with open surgery rather than arthroscopically, due to a perceived decreased failure (redislocation) rate.  The literature demonstrates both approaches to be equivocal, however, given the less invasive nature of it, Dr. Schwartz prefers to treat these conditions arthroscopically.  The recurrence rate can be expected to be 10-20% after a bankart repair, even in the best hands in the entire world.  Other surgical procedures have been developed to help decrease recurrence rates.  

Unlike nearly any other surgeon in the United States, I have spent a year training in France with Drs. Laurent Lafosse and Pascal Boileau whom have both redefined how this problem is treated. 

Recurrence rates fall into the single digits with boney transfer ( a coracoid process transfer ) or the so called Latarjet procedure.  While in France, I learned how to do this arthroscopically and now do it regularly in my practice.  I prefer to use this procedure when glenoid bone loss has occurred.  Additionally, another procedure may be indicated where I tuck in a part of the rotator cuff tendon into the impression fracture (Hill-Sachs remplissage) and may be indicated when a large Hill-Sachs lesion (a dent in the humeral head, or ball portion of the ball and socket type joint) is present.  Sometimes even a combination of procedures is indicated to restabilize the shoulder.  

Regardless, I believe the treatment decisions for shoulder dislocation surgery to be complex – patient expectations, patient activity levels, and patient anatomy all play a role – and am uniquely positioned to provide expertise to my patients drawing on a surgical experience that is unparalleled.

When is surgery required?

There are three assessments an orthopedic surgeon will use to determine whether or not shoulder dislocation surgery is required. These assessments include:

  1. An inventory of the patient’s medical history
  2. Physical evaluations
  3. Imaging tests

After these assessments are performed, your healthcare provider will be able to determine the type of injury that has occured, the implications of the injury, and the best available treatment options.

Sometimes, an entire shoulder dislocation surgery may not be required.

For example, a less-intrusive treatment option is a bankart repair, which may be indicated depending on activity level and age of the patient. During a bankart repair, the torn piece of cartilage is re-anchored and sutured in order to secure and preserve the shoulder. Certain surgeons may advocate doing this with open surgery rather than arthroscopically, due to a perceived decreased redislocation rate. However, literature demonstrates both approaches to be equivocal. As a rule of thumb, Dr. Schwartz prefers to use arthroscopy, due to it’s less-invasive nature. With that being said, the likelihood of recurrence after a bankart repair is 10-20 percent, even when the procedure is performed by the most proficient hands in the world.

What to expect after shoulder dislocation surgery

One of the first questions potential shoulder dislocation surgery patients ask is “How long does it take to recover?”.

The truth is, shoulder dislocation recovery times vary depending on the type of injury and the recommended treatment. However, the average recovery time is typically around 12-16 weeks.

Here is a general guide to the post shoulder dislocation surgery recovery process:

Phase 1 – Going Home

After the surgery is complete, the patient will not be able to drive home. It is required that all patients who undergo shoulder dislocation surgery arrange a ride home after the procedure, either from a family member, or via a taxi.

Once at home, the patient will have to avoid submerging the shoulder in water. Thus, showering is recommended rather than bathing in a tub.

The bandage dressings will need to remain intact for up to five days. After five days, the dressings can be removed, but the patient must avoid scrubbing the incision area, or allowing any soaps or shampoos to come in contact with the wound.

The arm will remain in a sling for 3-6 weeks post-surgery, with the patient removing the sling three times per day to lightly exercise the arm.

The surgeon will also recommend a physiotherapy program that the patient must adhere to.

Phase 2 – Mild Strengthening

Approximately one month after the shoulder dislocation surgery, a physical therapist will begin implementing strengthening exercises that will enhance the performance of the shoulder blade, rotator cuff muscles, and biceps.

The patient will also be encouraged to perform light cardiovascular exercise, either on a stationary bike or stairmaster, or by walking during their own time.

Phase 3 – Moderate Strengthening

This phase is typically reached around the 12-week mark. This is when higher velocity movements are introduced, and normal rotator cuff strength is restored.

The physiotherapist will introduce dumbbell and medicine ball exercises that restore range of motion. However, weights should not be lifted above and behind the head. All weights should be kept in front of the body during this time.

If the patient works a relatively inactive job, say at a desk, for example, they may be able to return to work at this point with the approval of their healthcare providers.

Phase 4 – Return to Full Activity

Patients enter this phase in the recovery process between 12-24 months post-surgery. This is when the patient returns to normal activities, as long as they have clearance from their physiotherapist.

The patient will still engage in stretching and range of motion exercises, such as supine cross-chest stretches and bicep curls.

If the patient works a job that involves manual labor, they will likely be able to return to work upon the completion of this stage.

Remember: The shoulder dislocation surgery success rate is 90 percent.

And with the unrivaled expertise of Dr. Schwartz and his highly-skilled team, you can enjoy peace of mind, knowing both your surgery and your recovery process are under the management of reputable, highly-refined professionals.