Is surgery the right option after one shoulder dislocation?

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By Mr Harry Brownlow, November 2018

The conundrum continues!

Imagine Ben. Ben is a 20 year old man who plays rugby for a good local team. It is early in the season and he has just sustained his first ever shoulder dislocation during an awkward tackle. The shoulder was put back into joint by the physio on the touchline and a subsequent MRI scan confirmed a dislocation with a significant labral injury (Bankhart lesion) but without significant bone loss of the socket (glenoid). He wants to return to rugby as soon as possible.

Should he have an operation?

In days gone by you had to ‘earn’ your operation. Most surgeons felt you needed to have dislocated at least 3 times before subjecting you to a stabilising operation. But this ‘earnt’ idea had no basis in science or research, rather it was an idea plucked from the air. However as surgical techniques improved, and in particular as arthroscopic (keyhole) technology advanced, we became better at doing stabilisation surgery (Bankhart repair) and its outcome became more reliable. Nowadays many people will be offered surgery after their first dislocation. This makes sense as we know, from MRI studies, that the first dislocation tends to tear the major stabilising ligaments of the shoulder (Bankhart lesion) and that these torn ligaments seldom heal back in the correct place which means that further instability is common.

So it’s clear that Ben should have the operation?

In 2008 a Swedish study found that over 50% of young people who dislocated for the first time did not progress to further dislocations even without surgery. But other studies, most notably from Edinburgh, found high rates of recurrent instability after a first dislocation particularly in young men. So, the statistics suggest that without an operation Ben probably will dislocate again but it is not inevitable. He might just be one of the few lucky ones who gets away without ever needing surgery. But if he were to have an operation it would not come with 100% guarantee to prevent further dislocations. Indeed surgery is probably, on average, successful in about 90% of selected cases. But even that figure is not completely accurate. The truth is we don’t really know how successful we are at stopping further dislocations because the group of people who need this operation are really hard to keep a track of over the years post surgery!

And then there are other things to think about. With surgery there are potential complications including infection (rare), stiffness (uncommon) and nerve injury (very rare). And on top of all that most surgeons would not allow you to return to collision sport for up to 6 months from this type of surgery.

Oh, so then perhaps he should not have the operation! It might not be necessary, it can go wrong, and it means a long time off the field.

We are now starting to recognise the limitations of arthroscopic Bankhart surgery. While this technique seems to work well even if there is a significant soft tissue injury (capsule and ligament disruption) it is less successful when there is significant bone loss, especially in the context of a collision or contact sportsperson. In this particular group there has been a growing interest in rekindling an old operation called the Latarjet procedure in which a piece of bone (coracoid) with its attached tendons are cut, moved and screwed into the front of the socket to rebuild the area of bone loss. In the past this operation fell out of favour because it seemed to be associated with early onset arthritis in the shoulder joint. However we now feel that the arthritis reflected poor technique and poor patient selection – back then the operation was only performed in people who had had multiple dislocations which itself causes arthritis. The other advantages of this operation over the arthroscopic soft tissue Bankhart repair is a quicker postop rehab programme and a quicker return to collision sport. This operation has suddently exploded in popularity for all the above reasons.

OK, so then is a Latarjet procedure the best solution for Ben? A robust operation and a quicker recovery.

I believe there is still need for caution. It is a big operation with a higher risk profile than an arthroscopic stabilisation. In particular there can be major longterm complications with nerve injury, infection and sometimes the bone block and screws cause problems. And if the operation fails to stabilise the shoulder then revision of a Latarjet becomes a very complicated procedure with high risk to important nerves. And, soberingly, a recent publication from the USA suggests that only 50% of patients manage to return to their pre-injury sporting level after a Latarjet procedure.

I’m confused! What are you recommending then?

I think the pragmatic solution for Ben would be to try rehabilitation with physiotherapy and then a slow progressive return to rugby. If he fails to rehab or suffers a further dislocation then he might give up on the season and have an arthroscopic Bankhart repair, or, depending on the time of year, try to cope with strapping and padding and wait until a good moment to have the procedure. I would recommend the Latarjet procedure only if the MRI or CT scan showed significant bone loss of the glenoid or if Ben had previously had a Bankhart repair but this had failed.