Surgery Options for Acute Anterior Shoulder Dislocation--
Open and Arthroscopic Anterior Capsulolabral Reconstruction Rehabilitation Program

Treatment for patients with a first-time acute anterior shoulder dislocation is somewhat controversial. Although there are no well-controlled prospective studies in the literature, the retrospective studies that do exist have shown recurrence rates as high as 90 percent in patients younger than 20 or 25 years of age who have a first-time dislocation and are treated non operatively.

Athletes involved in contact sports appear to have a higher rate of recurrent instability after an acute dislocation. Therefore, the decision to perform surgery after an acute dislocation can be difficult in these young patients, as many physicians have traditionally treated them non operatively. The patient’s age and activity level should, however, have a significant influence on deciding the appropriate treatment for a patient with a first-time traumatic anterior dislocation. Although patients younger than 25 years are at the highest risk for recurrence, a sedentary, less-active lifestyle may protect them from having recurrent instability.

The patient’s age and activity
level should be a factor in
considering whether to repair a
first-time dislocation surgically.

Open and Arthroscopic Repair

A Bankart-type capsulolabral reconstruction is the “gold standard” surgical treatment for acute dislocators and patients with chronic instability who decide to have surgery. This can be performed as an open procedure or with an arthroscopic technique. The goal is to restore the normal anatomy of the anterior portion of the inferior glenohumeral ligament that is torn away from the labrum in patients with traumatic anterior instability.

The open technique has been used for many years and has a proven, highly-predictable success rate. More recently, surgeons have utilized the arthroscopic technique of Bankart repair. Initially, these arthroscopic procedures had a much higher failure rate as compared to the open technique. But as experience with arthroscopic shoulder reconstruction has evolved, the technique now has results similar to the open procedure. However neither technique provides a clear advantage in terms of rehabilitation and return to sports activities.

Advantages and Disadvantages

The primary advantage to an arthroscopic Bankart repair is that patients have less postoperative pain and it is much easier to regain full shoulder motion. The technique usually involves the placement of bioabsorbable arthroscopic tack or suture anchors. A tack-type device such as the Suretac (Acufex, Smith & Nephew Endoscopy) may actually result in a higher rate of failure. These failures may occur because this implant loses 50 percent of its strength two weeks postoperatively and is nearly completely dissolved by six weeks (as shown in animal studies). Nevertheless, many surgeons utilize this device because it is much easier to place than arthroscopic suture anchors.

The primary disadvantage of a suture anchor is that it requires a high degree of skill to appropriately pass the sutures through the tissue and to tie secure knots using an arthroscopic technique. Because of concerns about the security of the knot, rehab may actually be slower during the first six to eight weeks after surgery as compared to an open reconstruction. The time to return to sports activities, however, is very similar when comparing both techniques.

In addition to addressing the lesion, capsular laxity or redundancy should also be treated. Traditionally, arthroscopic techniques have not done this and therefore have had higher failure rates as compared to open reconstruction. Thermal capsular shrinkage or capsular tucks with suture can be used to address this as well as decrease the overall intra-articular volume.

Rehabilitation