OPDDr.L H Hiranandani Hospital, Powai
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The shoulder joint has got a high degree of mobility and is surrounded by muscles and ligaments that make this possible. Sprains are the most common form of injury However this predisposes the shoulder to various sprains and ‘muscle pulls’ when it is subjected to akward movements.
Strong connective tissue, called the shoulder capsule, is the ligament system of the shoulder and keeps the head of the upper arm bone centered in the glenoid socket. This tissue covers the shoulder joint and attaches the upper end of the arm bone to the shoulder blade.
Normal Shoulder Stabilizers
Your shoulder also relies on strong tendons and muscles to keep your shoulder stable.Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.complete dislocation means the ball comes all the way out of the socket.
There are three common ways that a shoulder can become unstable:
Severe injury, or trauma, is often the cause of an initial shoulder dislocation. When the head of the humerus dislocates, the socket bone (glenoid) and the ligaments in the front of the shoulder are often injured. The labrum — the cartilage rim around the edge of the glenoid — may also tear. This is commonly called a Bankart lesion. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability.labrum and capsule around its rim (similar to a meniscus). The labrum is wedge-shaped and attaches almost completely around the edge of the glenoid. This creates a deeper cup for the glenoid socket. This is important because the glenoid socket is so flat and shallow that the ball of the humerus does not fit tightly. The labrum creates a deeper cup for ball of the humerus to fit into. This makes a contribution to the stability of the join
Some people with shoulder instability have never had a dislocation. Most of these patients have looser ligaments in their shoulders. This increased looseness is sometimes just their normal anatomy. Sometimes, it is the result of repetitive overhead motion.Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments. Many jobs also require repetitive overhead work.Looser ligaments can make it hard to maintain shoulder stability. Repetitive or stressful activities can challenge a weakened shoulder. This can result in a painful, unstable shoulder.
A Bankart Leison (tear of the labrum) affecting the shoulder
Patients aged 21-30 years have a 40-79% recurrence rate.
Patients aged 31-40 years have a 40-72% recurrence rate.
Patients aged 41-50 years have a 0-24% recurrence rate.
Surgical intervention for recurrent shoulder dislocation/ Subluxation
The essential pathology in most of the cases of shoulder dislocation is a tear in the labrum and a resultant bony defect on the head of humerus(the ball)
The severity of these problems for which you may need to undergo imaging assessment in form of MRI and CT scan.
Essentially the surgical treatment consists of relplacing the bony loss on the glenoid and repairing the soft tissue injury to the labrum, both of which may be done through the keyhole porcedure.
Arthroscopic Bankart Repair
Arthroscopic bankart repair is a procedure in which the torn labrum is repaired back to bone in the keyhole procedure. The surgey is done on an in-patient as well as on a day care basis.
The Arthroscopic Bankart Repair is an effective procedure to treat patients that have anterior shoulder instability. The majority of patients who suffer a traumatic anterior dislocation of their shoulder will tear the fibrocartilage labrum at the front of the shoulder. Many of these patients will go on to develop recurrent instability in their shoulder and keep dislocating. This will have a significant effect on the ability to participate in sport and sometimes also their work. It is the tear in the labrum that is largely responsible for allowing their shoulder to continue to dislocate.
It has been established that if only patients with a pure labral tear are treated with an arthroscopic bankart repair then the results are as high as an open repair. The aim of surgery is to return people to full normal sporting and work activities and the risk of a redislocation in this situation is less than 5% with a well-performed arthroscopic procedure.
The Arthroscopic Bankart procedure repairs this tear in the labrum and by doing so restores stability to the shoulder. This procedure can be performed either open or arthroscopically.
A Video of an arthroscopic Bankart repair
Patients that have torn not just the labral cartilage at the front of the shoulder but have also chipped off a segment of bone when they dislocated need a surgical procedure that will deal with the loss of bone. My preference in this situation is a bone grafting procedure.
Recovery from an Arthroscopic Bankart Repair
The Arthroscopic Bankart repair is one of the most commonly performed procedures and gives excellent results in both professional and recreational athletes. Post surgery a supervised physiotherapy program is implimented and people are able to join back to a desk job by 2 weeks. Joining back to contact sports takes anywhere between 4-6 months.
Procedures to address the bone loss in shoulder- Latarjet and bone grafting
This procedure is done for recurrent shoulder instability where the instability is associated with bone loss at the front of the glenoid (socket). It can also be used as a salvage procedure in revision cases. The bony prominence at the front of the shoulder (coracoid) is transferred to the front of the socket.
The operation works by deepening the socket of the shoulder and the soft tissue attachments of the coracoid process then form a protective sling to prevent dislocation when the arm is imoved into the typical at risk position of abduction external rotation.
Anterior Glenoid J-Bone Grafting
This is a procedure that has been devised considering the fact that the Laterjet procedure significantly alters the shoulder anatomy and biomechanics. Long term studies have shown an increase in shoulder arthritis. Additionally if the Latarjet procedure fails in a recurrent dislocator of the shoulder, both the surgeon and the individual are left with little options. The advantage of bone grafting the glenoid is that it is essentially an Implantless procedure and does not significantly alter the shoulder anatomy and mechanics.
Sling will remain for 4 weeks, with pendular exercises immediately. Active assist exercises start at 4weeks. Confirmation of the bone grafting healing is required before heavy activities occur