Dislocation (Bankart, Latarjet, TCS)

Operation for a Dislocated Shoulder

You are young, sporty, have dislocated your shoulder and after discussing the options you have decided to go for the surgery now in order to get back to full activities as soon as possible. Or this is your second or third dislocation and you know its only going to happen again so its time for surgery. Or the shoulder has only dislocated once but hasn’t really settled as we’d hoped and feels wobbly and painful and you haven’t been able to get back to your normal activities. So lets discuss your operation.

What are you going to do?

In most traumatic dislocations what has happened is that the labrum (the lip of cartilage running round the edge of the socket) has been torn off when the ball was forced out of the socket and hasn’t reattached itself. So I will put it back where it came from and fix it back in place.

Is this a key-hole operation or through a big scar?

It is an arthroscopic or keyhole operation which means it is done through 3 small holes – 2 at the front and 1 at the back. Sometimes though, if I know that the labrum has been too badly damaged – perhaps because you have had lots of dislocations – then I do a different operation through an incision in the front of the shoulder but we will come to that later.

And is it a general anaesthetic because I’d rather have a regional if possible?

As with all shoulder operations, I much prefer to use a general anesthetic. It is more comfortable and less stressful for you; it allows the anaesthetist to control your blood pressure which can go up quite a lot if you get anxious and then the bleeding obscures my view and it means you won’t move around at vital moments! A modern general anaesthetic usually means that you wake up quickly and with no feeling of sickness and are ready to go home a few hours after the surgery.

Do I get that dead-arm thing?

The Interscalene Block? Yes you do. This is a special injection that the anaesthetist gives you which makes your whole arm go numb and therefore there is no pain in the shoulder when you wake up and that can last up to 20 hours or so. It is a bit of a strange sensation (I am told – I haven’t had it done!) but it’s much better than being in pain. Most people who have experienced shoulder surgery with the block and without the block would chose to have it again.

How do you reattach the labrum? (see video Labral Repair)

The first stage is to pass a loop of suture through the labrum which will become the stitch that pulls it down back onto the bone. Once I have that in position then I drill a hole in the bone on the edge of the socket. The ends of the sutures are then fed through an eyelet in a ‘suture anchor’ and the anchor is pushed into that hole. A suture anchor is a bit like a rawlplug – it provides a solid fixation in the bone that the sutures can be attached to.  The suture loop is tensioned so that the labrum gets pulled back to the edge of the socket – where it came off when the shoulder dislocated – and the anchor is hammered down into the hole pulling the suture with it and cinching it down very tightly on the labrum. I do the same thing 2 or 3 times along the socket depending on the size of the labral tear.

What if the labrum is too damaged to fix back? (see photos Latarjet Procedure)

Excellent question! Sometimes that is the case and because the shoulder has dislocated multiple times the labrum has been shredded or has completely eroded away so there isn’t anything to reattach. But don’t worry there is a different and equally good procedure I can do to stabilise your shoulder. I also do it in the occasional case where the bone on the front of the socket has been damaged, eroded away or broken off.

This is called a Latarjet Procedure and is done through an 8 cm (or so) incision in the front of the shoulder. We know that your shoulder dislocates when it comes up into the ‘apprehension’ position (the throwing position). So what I need to do is put some sort of seat-belt across the shoulder that tightens up in that position and holds the ball on the socket. And thankfully there just happens to be a spare tendon at the front of the shoulder that I can divert to do that job.

The tendon is attached to a prong of bone coming off the shoulder blade. I saw off about 1.5 cm of the prong with the tendon attached and move it out sideways and screw it to the front of the socket. Now when the arm comes up and out that tendon acts as a tight sling across the front of the shoulder and holds the ball in place. The rehabilitation is exactly the same as for the labral repair.

Are there stitches in those skin incisions?

There are. The stitches come out about 10 days after the surgery.

And a sling?

Yes. The shoulder has to be held quite still (not rigidly still) while the labrum rebonds back onto the bone. The sling is mainly to stop you lifting your arm up and outwards (as if you were going to throw something) because that is the position which puts the most stress on the repaired labrum.

Can I do much in the sling?

For the first 2 weeks there is also a body strap that holds the arm across your tummy and you only come out of that to shower. Yes – you do wear the sling at night! However, if you are sensible, then when you are safe and sound at home and sitting watching TV, you can take the whole sling off and rest the forearm on a cushion on your lap. This helps take some of the tension off your neck and back. But before you get up – put the sling back on!!

After 2 weeks you can get rid of the body-strap and start to use the arm (still in  the sling) gently and carefully in front of you – using a keyboard, holding a book – that sort of thing.

How long am I in the sling in total.

4 weeks. And then you can either go cold turkey and get rid of it completely straight away or, more usually, spend the next 2 weeks weaning yourself out of it. It can be a bit much to go from the security of the sling to nothing in one step so most people will spend longer and longer periods out of it and less and less time in it so that by the 6 week mark they are completely rid of it.

When can I drive?

You can’t drive while you are in the sling. And once you come out of it you need to be sensible and only drive when you are confident that you can control the vehicle. That is usually at least 6 weeks after the operation.

I suppose I need physiotherapy?

That is essential. You need to get over what I have done to you and also, now the shoulder is stable, you need to get rid of all the bad habits that you will have developed over the months or years when your shoulder has been wonky.

The steps you go through are to recover movement, control of that movement and, finally, strength. In that order. I know there is a great temptation to start building your strength back up but there is no point in having a strong shoulder if it doesn’t move! And there is no point in having full movement if it is badly controlled with all sorts of bad patterns and wobbles.

So, listen to your physiotherapist and do your exercises regularly.

They will usually see you weekly starting after 4 weeks and that will continue until you are back to normal.

How long is that? What are the timescales for work and sports?

Well returning to work depends on what you do and how you get there. If you are an office worker then you may be able to do a lot from home on the laptop and if you don’t have to drive to work you can go back as soon as you like. But this is a big operation so don’t rush things! You will feel tired and the shoulder can be uncomfortable so try and wangle 2 weeks off if you can.

The more physical your job then the longer it’s going to take and for painting and decorating; plumbing; electrics; driving/loading etc it will be 8 weeks before you will be much good and out to 12 before you are back to normal.

And sports? How can I keep fit until I can use the arm again?

The best, and really only way, is to use an exercise bike and the best of those is the recumbent type where you pedal with your legs out in front of you.

You can start running at about 6 weeks but just go a little way and build up slowly.

That 6 week mark also holds good for things like swinging a golf club or a tennis or squash racquet – if its your non-dominant shoulder – and a bit longer for your dominant arm. But it is just a starting point and don’t expect to be back to normal straight away.

For rugby it is usually 4 months to start running drills and working on the tackle bags and 5 months for full impact.

OK – so take things slowly and build up bit by bit?

That’s the key. I know you will be desperate to get back to all the things you’ve had to give up but the key element is doing the rehabilitation to get good movement, good control and proper deep-seated strength back in the joint first and you have to sacrifice the sports bit for a while in order to get the maximum result from the surgery.

I was really wary about using my shoulder over head height before the operation. Will that recover? Will I get my confidence back?

That is a very important point. If you have only had one dislocation then you won’t have lost confidence in the shoulder or developed any bad habits in the way you use it and your brain won’t put up barriers to you using it. On the other hand if you have had lots of dislocations then you are right – your confidence will be shot and you will be scared of putting the arm in some positions because you known it may pop out.

With the operation I can deal with the hardware problem and give you a stable joint but that can be the easy part. When you come out of the sling and start moving the shoulder, your brain will still think that is going to dislocate so will still try and prevent you getting into what it sees as dangerous positions. But don’t worry because as time passes and as you do more with the shoulder and perhaps inadvertently let it get into a dodgy position and the shoulder stays in joint, the brain will realise that it is now okay to be in that position and drop that barrier.

Can my shoulder dislocate again?

I’m afraid so. The operation doesn’t give you a super shoulder but just a ‘normal’ one. So if you do something that would dislocate a normal shoulder it could dislocate the one that has been operated on.

If you have torn the labrum off and it is still in reasonable condition then I can do the same keyhole procedure again. If it is too tattered then I will do a Latarjet.

So should I be careful afterwards?

That is up to you. But remember you are going through a lot in terms of surgery and rehabilitation to give yourself a normal shoulder and the end result should be that you can then do what you want with it.  If you damaged it doing something you love you will want to get back to doing that again. So there are no ‘don’ts’.