If your physiotherapy program doesn't stabilize your shoulder after a period of time, you may need surgery. There are many different types of shoulder operations that have been developed and used in the past to stabilize the shoulder. Almost all of these operations attempt to tighten the ligaments that are loose. The loose ligaments are usually along the front or bottom part of the shoulder capsule.
Surgery on the shoulder has improved dramatically over the past two decades. many of the procedures that have been developed in the past have been abandoned altogether. Today, surgery that is performed for stabilizing an unstable shoulder is most commonly done using the arthroscope.
The most common method for surgically stabilizing a shoulder that is prone to anterior dislocations is the Bankart repair. In the past, the Bankart repair was done through a large incision made in the front (anterior) shoulder joint. This required damage to a great deal of normal tissue in order for the surgeon to be able to see the damaged portion of the joint capsule. The procedure was difficult and usually involved an attempt to sew or staple the ligaments on the front side of the joint back into their original position.
The arthroscope has changed all that.
An arthroscope is a special type instrument designed to look into a joint, or other space, inside the body. The arthroscope itself is a slender metal tube smaller than a pencil. Inside the metal tube are special strands of glass called fiberoptics. These small strands of glass form a lens that allows one to look into the tube on one end and see what is on the other side - inside the space. This is similar to a microscope or telescope. In the early days of arthroscopy, the surgeon actually looked into one end of the tube. Today, the arthroscope is attached to a small TV camera. The surgeon can watch the TV screen while the arthroscope is moved around in the joint. Using the ability to see inside the joint, the surgeon can then place other instruments into the joint and perform surgery while watching what is happening on the TV screen.
The arthroscope lets the surgeon work in the joint through a very small incision. This may result in less damage to the normal tissues surrounding the joint, leading to faster healing and recovery. If your surgery is done with the arthroscope, you may be able to go home the same day.
To perform the Bankart type repair using the arthroscope, several small incisions are made to insert the arthroscope and special instruments needed to complete the procedure. These incisions are small, usually about one-quarter inch long. It may be necessary to make three or four incisions around the shoulder to allow the arthroscope to be moved to different locations to see different areas of the shoulder.
A small plastic, or metal, tube is inserted into the shoulder and connected with sterile plastic tubing to a special pump. Another small tube allows the fluid to be removed from the joint. This pump continuously fills the shoulder joint with sterile saline (salt water) fluid. This constant flow of fluid through the joint inflates the joint and washes any blood and debris from the joint as the surgery is performed.
There are many small instruments that have been specially designed to perform surgery in the joint. Some of these instruments are used to remove torn and degenerative tissue. Some of these instruments nibble away bits of tissue and then vacuum them up from out of the joint. Others are designed to burr away bone tissue and vacuum it out of the joint. These instruments are used to remove any bone spurs that are rubbing on the tendons of the shoulder and smooth the under surface of the acromion and AC joint.
Once any degenerative tissue and bone spurs are removed, the torn ligaments that stabilize the shoulder are reattached to the bone around the socket of the shoulder, the glenoid. Special devices have been designed to reattach these ligaments. These devices are called suture anchors.
Suture anchors are special devices that have been designed to attach tissue to bone. In the past, many different ways were used to attach soft tissue (such as ligaments and tendons) to bone. The usual methods have included placing stitches through drill holes in the bone, special staples and screws with special washers – all designed to hold the tissue against the bone until healing occurred. Most of these techniques required larger incisions to be able to see what was going on and to get the hardware and soft tissue in the right location.
Today, suture anchors have simplified the process and created a much stronger way of attaching soft tissue to bone. These devices are small enough that the can be placed into the appropriate place in the bone through a small incision using the arthroscope. Most of these devices are made of either metal or a special plastic-like material that dissolves over time. This is the “anchor” portion of the device. The anchor is drilled into the bone where the surgeon wished to attach the soft tissue. Sutures are attached to the anchor and threaded through the soft tissue and tied down against the bone.
Another surgery to tighten a loose shoulder joint is a procedure called a capsular shift. The lining of any joint is called the joint capsule. The joint capsule forms a pocket, or bag that is made up of the ligaments and connective tissue around the joint. The shoulder joint has a fairly large joint capsule that is necessary to allow the joint to move in such a wide range.
Sometimes the problem causing the shoulder instability is because the joint capsule is simply too large. This is sometimes referred to as a redundant, or patulous joint capsule. This may cause shoulder instability in multiple directions. This is sometimes referred to as multi-directional instability. In order to fix this type of instability, the joint capsule needs to be made smaller and tightened.
This procedure also can be performed using the arthroscope. The surgeon pulls the flap of tissue over the front of the capsule and connects it together. This is similar to when a tailor tucks loose fabric by overlapping and sewing the two parts together. Once the appropriate degree of tightness is achieved, the surgeon uses a combination of sutures and suture anchors to hold the joint capsule in this position until healing occurs.
Portions of this document copyright MMG, LLC.