The shoulder is made up of four separate joints.
The glenohumeral joint is the ball and socket joint that connects the humerus bone (upper arm bone) to the scapula (shoulder blade).
The acromioclavicular joint is the joint between the end of the clavicle (collarbone) and the scapula.
The sternoclavicular joint is the joint between the sternum (breastbone) and the clavicle. The scapulothoracic joint is the joint between the scapula and the ribcage.
The glenohumeral joint is the most mobile joint in the body. The humeral head (ball) sits in a very shallow socket in the shoulder blade, known as the glenoid fossa, allowing large multidirectional directional movements.
However, due to the excessive amount of movement available the glenohumeral joint can be very unstable, leaving it prone to dislocation. There are two different types of shoulder dislocation: partial dislocation (subluxation) means the humeral head is partially out of the glenoid socket, and complete dislocation means the humeral head comes all the way out of the socket.
Partial and complete shoulder dislocation result in extreme pain, loss of shoulder movement, feelings of instability or looseness of the shoulder and numbness, tingling or weakness of the arm. The most common cause of shoulder dislocation is trauma, such as falls or high speed impact, usually when the shoulder is in a vulnerable position such as when your arm is stretched out to the side.
Occasionally, however, shoulder dislocation can occur due to underlying instability, which can develop as a result of previous dislocation or intensive repetitive overhead shoulder movements, such as throwing and swimming.
Diagnosing shoulder dislocations is usually relatively easy based on the mechanism of injury and symptoms, and can be confirmed through physical examination by a doctor or physiotherapist. It might also be necessary to have imaging, such as an X-ray or CT scan to rule out fracture, or an MRI scan to see the extent of the damage.
Shoulder dislocation is initially treated by relocating the humeral head into the glenoid socket as quickly as possible in order to reduce the amount of muscle spasm and limit the chance of nerve compression or irritation.
Shoulder dislocations are then treated conservatively once relocated, with treatments including: pain relief, ice therapy, immobilisation with a sling and progressive range of movement and strengthening shoulder exercises. Even if treated successfully shoulder dislocations can cause instability and damage within the shoulder joint which makes them much more susceptible to re-dislocation.
In the event that conservative management is not effective then surgery may be necessary. This is usually the case if extensive cartilage and even bone damage occurs as a result of a dislocation, or if recurrent dislocations occur.
The most appropriate surgery in this instance is known as Latarjet shoulder stabilisation surgery, in which the coracoid process, one of the bony prominences of the scapula, is transferred to the front of the shoulder joint in order to provide more stability for the shoulder joint.
Prior to having Latarjet shoulder stabilisation surgery you will be invited to a pre-admission clinic, usually two to three weeks before your surgery.
This will allow you to discuss any questions you may have and to find out more about the surgery. This will also allow us to perform a physical examination to ensure you are well enough for the surgery and anaesthetic, as well as taking measurements such as blood pressure and collecting a full past medical history of any other relevant medical conditions and medications.
Latarjet shoulder stabilisation surgery is performed under general anaesthetic as day surgery, meaning you will usually be operated on and released on the same day, but sometimes you may have to stay in overnight depending how you are doing.
Usually a nerve block will be administered in order to reduce the feeling in your shoulder. A 5cm incision will be made at the front of your shoulder around the coracoid process and running down.
Soft tissue structures such as blood vessels and the deltoid muscles are then retracted exposing the shoulder joint. The coracoid process is then divided at the base and some muscles/tendons are released. The coracoid is then brought down to the shoulder joint at which point the humeral head is retracted and the coracoid is fixed to the front of the glenoid socket.
At the end of the surgery the structure will be preserved and closed using dissolvable sutures. After the operation you will return to the ward wearing a sling.
The risks of Latarjet shoulder stabilisation surgery will be discussed with you in detail at your pre-admission clinic appointment. Risk factors for the surgery which can affect a very small percentage of patients include:
- Infection: There is a risk of infection with Latarjet shoulder stabilisation surgery. However, infection is very rare. Our theatres use industry standard ultra-high flow air systems which results in highly filtered and very rapid changes in air pressure ensuring the environment is as clean as possible. We also have fixed antibiotic treatment protocols drawn up by microbiologists to help reduce the risk of infection.
- Nerve injury/damage: There is a small risk of nerve injury or damage during shoulder surgery as the surgeon is operating so close to the nerves. They know where they are and make every effort to avoid injuring or damaging the nerves but it is important to understand there is a small risk and the damage can be permanent.
- Stiffness: there is a risk of stiffness following your Latarjet shoulder stabilisation surgery.
- Pain: Initially following your Latarjet shoulder stabilisation surgery you will feel some pain. This is a natural part of the healing process. We will help you to manage this with medication and advice. The pain will generally subside with time and recovery.
- Thrombosis/blood clot: There is a small risk of thrombosis or blood clotting following your surgery. In this case you may be given compression sleeves in order to improve circulation and reduce the risk.
- Recurrent dislocation: There is a very small chance that the surgery will not prevent recurrent shoulder dislocations; however the chance of this being the case is under 2%.
Once the effects of the anaesthetic and nerve block have worn off pain killers will be used to control your pain. You will be required to wear a sling for up to 2-3 weeks following your surgery. Full recovery from Latarjet shoulder stabilisation surgery can take up to 3-6 months. Avoid forced gripping or heavy lifting for 2-3 weeks.
In terms of returning to work it will depend on your work environment. Returning to heavy manual labour should be prevented for approximately 8 weeks. Early return to heavy work may cause problems with your recovery. You will be given advice on your own particular situation.
You will be reviewed by your consultant approximately 6-8 weeks after your surgery. Immediately after your surgery you will be referred for outpatient physiotherapy. If you are a private patient you will be able to back to your original physiotherapist out in the community if you wish. However, if you are an NHS patient then your physiotherapy will be set up as part of your post-operative care in house. You will follow a regimented physiotherapy programme that will allow you to start to regain movement in your shoulder and then strengthen the muscles in order to return to all of your normal activities as follows;
- 0-3 weeks: Surgical site protection, ice, compression, elevation, pain relief, pendular shoulder exercises, active assisted range of movement below shoulder height, maintenance exercises for the elbow, wrist and hand.
- 3-6 weeks: Progression to active range of movement exercises below shoulder height, gentle isometric strengthening exercises, scapular setting exercises and weaning off of the sling.
- 6-12 weeks: Continued range of movement and stretching exercises to regain full shoulder range of movement, emphasis on strengthening exercises for the shoulder and rotator cuff and progressive resistance exercises, function activities including those related to work or leisure activities that you are aiming to return to.