 Diagnosis (Shoulder) |
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 Instability of the shoulder |
The shoulder joint only has a minimal amount of guiding bone. Its stability is thanks to the perfect interaction of the capsule ligament system and the muscles. If these important components do not function in an optimum manner, the shoulder may become instable. We essentially differentiate between traumatic and atraumatic instability. Atraumatic instability means that no trauma has been experienced. Often, minor traumas due to hypermobile and capsular predispositions are the cause of typical instability problems. Traumatic instability is both well-known and imposing; it is the triggering of luxation by an accident (e.g. a sporting accident). The shoulder has to be repositioned, if necessary under the influence of medicinal relaxation or under anaesthetic in a hospital. The initial accident leads to damage to the joint capsule, the supporting ligament structures and the labrum. The latter deepens and expands the relatively small and flat joint socket. The labrum fulfils a type of sealing ring function. The often separately damaged, i.e. overstretched or torn capsule ligament system, rests on top of it. However, in the event of a traumatic luxation, the labrum always tears in the direction of the instability, i.e. the prominent front instability around the front edge of the socket. Damage to bone and cartilage on the joint socket and head of the humerus are also common. The probability of a relapse is firstly dependent on the age of the patient at the time of the first luxation. This means that there is an almost 100 percent relapse rate for an 18 year old patient, whilst for a patient who experiences the initial luxation at 30 years of age, the chance of a relapse is ca. 85 percent. Older patients on the other hand have a better chance of healing with regards to the probability of a recurrence of the luxation, so any arthroscopic intervention will be kept to a minimum. We initially advise against an early operative reconstruction if the dominant arm (e.g. the throwing arm) is affected, if the patient has sporting ambitions or practices high risk sports or if the relatively young age of the patient implies a high chance of relapse. The timing of an operation must be individually coordinated with the patient.
Unfortunately, there is no way of healing a traumatic instability using a specific therapeutic rehabilitation program or individual fitness training. |
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Atraumatic instability is generally less critical. It affects patients who are usually very mobile. As a result, the joint structure is considerably more susceptible to injuries and it only requires a relatively minor trauma to render it unstable. Paradoxically, this has the relative advantage that the reduced pressure on the joint means it is subjected to less shearing and frictional force, and thus the extent of damage to the cartilage surfaces of the joint and labrum structures is less in comparison. Treatment and stabilisation by means of physiotherapy has a much greater significance for this group. Nevertheless, they cannot sufficiently stabilise a joint with multiple luxations; arthroscopic reconstruction represents the only effective therapy. It is important to note that with the first luxation and further luxations, the capsule ligament structures are overstretched. However, unlike in the case of an elastic band, this overstretching is not reversible. The capsule-ligament system remains deformed and the volume of the joint is thus clearly increased. From a biomechanical point of view, this condition has a considerably greater significance than the actual tearing of the labrum which, however, must be addressed during the operation. |
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More than 100 different surgical techniques and modifications are already documented in the literature available today. We have vast experience in the field of arthroscopic surgery. Even patients with more than 20 luxations can be stabilised well using this minimally invasive technique. The action radius for the arthroscopic operation is considerably larger than with open stabilisation operations. The arthroscopic stabilisation technique does of course require a high degree of experience and technical know-how. The principle of the operation is to reduce the joint capsule and the supporting ligament structures to a normal size and thus normalise the highly overstretched and extended volume of the capsule. The second essential aspect is sewing up the torn labrum on the socket edge. |
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Very often the labrum is no longer existent and a new labrum has to be constructed / reconstructed as the base / source of the capsule-ligament system. One decisive factor for the relative success of the operation is three dimensional reconstruction of the static stabilisation structures. One dimensional arthroscopic reconstruction, which is the norm, has a relapse rate of up to 40 percent, which nowadays is unacceptable. It is therefore neither suitable for restoring basic function, nor for the treatment of high performance athletes, revision cases, or even "simple" instability cases. |
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An open soft tissue procedure is rarely necessary. For us, this is only the case if there is a major injury to the socket. However, even smaller tears in the socket bone can nowadays be reconstructed arthroscopically. The advantages of an arthroscopic surgical technique are the assessment and therapy of the accompanying damage to the rotator cuff and the fixing of biceps injuries, which often occur in combination. These types of injury are difficult to analyse within the scope of open operations and even more difficult to treat with therapy. |
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Functional rehabilitation begins early. The arm is however protected by a comfortable shoulder cushion for three to four weeks. This merely serves the purpose of preventing the shortened and reconstructed joint capsule from overstretching and damage being caused by the weight of the otherwise potentially hanging arm. Nonetheless, after four weeks the arm can hang free again. Unlimited physiotherapy and training therapy start as early as six weeks after the operation. Starting to exercise early on in water, including breaststroke, is beneficial. An “over the head” athlete will be able for the strains of competitive sport again five to six months after the operation. |
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| Labrum tear on the front edge of the socket |
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| Reconstruction principle for the labrum and capsule |
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| Capsule labrum reconstruction at rear edge of the socket |
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