Repairing shoulder instability: arthroscopic or open?

Shoulder instability is a common pathology encountered in the orthopaedic and sports medicine. There are differences between a high school baseball player who feels like his shoulder is loose when throwing and a 40 year old who fell on stairs onto an outstretched arm and dislocated his shoulder? Obviously, they’re both “shoulder instability,” but there are differences, right?

There exists a wide range of symptomatic shoulder instabilities from traumatic dislocations to subtle recurrent subluxations. In general, shoulder instability develops in two different ways: traumatic (injury related) onset or atraumatic onset.  Understanding the pathology of how the instability has evolved is essential in choosing the best course of treatment.

Common ways that a shoulder can become unstable:

Traumatic onset instability begins when an injury causes a shoulder to develop recurrent (repeated) dislocations, Subluxation and labral tear (the labrum is torn or peeled off of the glenoid). Meanwhile, the patient with atraumatic instability has general laxity (looseness or spacious capsule) in the joint as a part of their normal anatomy and the shoulder can become unstable without a history of injury or repetitive strain.

The most common dislocation that leads to traumatic onset is in the anterior (forward) and posterior (downward) direction. A fall on an outstretched arm that is forced overhead, a direct blow on the shoulder, or a forced external rotation force to the arm elevated near the coronal plane are frequent causes of this type of dislocation.

An inferior or posterior(backward) dislocation is not as common as anterior traumatic instability, which is usually related to a electrocution or seizure disorder, events in which the muscular forces of the shoulder cause the dislocation.

Treatment for shoulder instability:

Recurrent or chronic Shoulder instability is often first treated with nonsurgical options. If physical therapy and activity modification do not relieve the pain and instability, surgery may be needed. In certain instances, such as in contact athletes who plan on continuing to participate in sports that put their shoulders at risk and in young persons who have a higher risk of re-dislocation, surgery may be performed after the first dislocation.

Surgical treatment is also considered in patients in whom instability occurs during routine daily activities (dressing, sleeping, etc.). There are basically two methods used in shoulder instability surgery - open and arthroscopic repairs.  A detailed discussion with the surgeon of the treatment options is essential. The rehabilitation following surgery is the same, irrespective of the technique used in the surgery.

Shoulder instability open surgery: Open surgery is often required to correct severe instability. A larger incision is made above the shoulder and the muscles are moved to gain access to the joint capsule, labrum and ligaments under direct visualization.Patients who are contact athletes with a bone defect fail with arthroscopy are better candidates for open procedures.

Arthroscopic Techniques

Although the medical literature has indicated through years of results and analyses that the open procedure is the gold standard, Instability surgery has evolved to the point where many surgeons suggest that the minimally invasive arthroscopic repair is a very viable option.

Recently, arthroscopic procedures are used in capsular shift surgery - when there is a need to tighten up the joint capsule and Bankart repair to repair the torn labrum and reduce capsular laxity. Arthroscopic surgery for Shoulder Instability are performed with visualization through a small fiberoptic scope. Through two or three small incisions, Instruments are inserted into the joint to repair the labrum and the surgical technique is similar to the one used in an open repair. A loose or spacious capsule is harder to address arthroscopically. Procedures using laser or radiofrequency energy to shrink the loose capsule have been developed (Thermal capsulorrhaphy), and are still being evaluated.

Best candidates for arthroscopic stabilization include first-time dislocators, recurrent dislocators and recurrent subluxators. Contraindications include those with large osteochondral humeral defects or significant glenoid bone loss. The results for arthroscopic surgery, in general, are equivalent to the open surgery.  

Arthroscopic vs. Open Surgery

Patients often contemplate - arthroscopic or 'open' surgery which is better? The debate about open or arthroscopic repairs for shoulder instability has been in progress for at least two decades. Open surgery, a procedure using larger incisions and enabling the surgeon to look inside the joint, may be better under certain circumstances for certain procedures. Arthroscopic surgery has also some advantages--smaller incisions, less tissue damage— short- and mid-term results of this technique have been very satisfactory. Several reports recently suggests that long-term results (>5 years follow-up) also remain quite satisfactory, particularly in the absence of significant glenoid bone loss.

The truth is that the choice to have an open or arthroscopic repair depends on patient-specific factors and surgeon specific factors such as the onset of the instability, causes, the total number of dislocations, the surgeon’s experience and preference are important considerations. Depending on these factors (or combination of factors), one surgery may be best for your particular situation. You may also discuss with your surgeon if a particular procedure can be done arthroscopically.

Chennai Orthopaedics at Vanagaram, chennai is a world class healthcare institute for Orthopaedic Treatment in Chennai and provides comprehensive healthcare services with care and dedication. The center is managed by Dr Bharani Kumar Dayanandam, a prominent Orthopaedic Surgeon and Trauma Consultant currently serving as the Consultant Trauma & Orthopaedic Surgeon at Apollo Hospitals, Ayanambakkam, Chennai. The institute has state-of-the-art technology and delivers top-notch healthcare to facilitate the best and shortest road to recovery for every patient. The center offers the entire spectrum of services in trauma and orthopaedics, and also includes shoulder arthritis treatment chennai, trauma surgery, hand surgery, paediatric orthopaedics, arthroscopic surgery and Shoulder Joint Dislocation Treatment Chennai. With world class facility at affordable cost in all orthopedic Sub-specialties, the hospital is committed to provide good quality orthopedic and trauma care to patients from simple fracture treatment to sophisticated joint replacement and arthroscopic procedures.

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