Complex Shoulder Instability: Arthroscopic Treatment of Glenoid Fracture

Complex Shoulder Instability: Arthroscopic Treatment of Glenoid Fracture

Shoulder instability xray with fracture of the glenoid socket requiring surgery

Chief Complaint/Injury

Susan came in to our office after an acute left shoulder dislocation, which resulted in recurrent shoulder instability. Even the slightest movement caused her shoulder to painfully sublux or dislocate. She felt as if her shoulder was constantly slipping out of its socket. At 70 years old, this can be a challenging problem to treat.  Considerations include bone quality, rotator cuff status, and overall medical health.

Work Up/Imaging

3-Dimensional CT scan of Glenoid fracture

An MRI and CT Scan of the left shoulder demonstrated a large bony Bankart lesion, which is a fracture to the anterior rim of glenoid socket of the scapula(shoulder blade). She did not have a full-thickness rotator cuff tear (which can also be a source of recurrent instability in patients > 45).

Discussion

These are interesting cases which present a challenging scenario.  Most shoulder dislocations in patients over 45 can be treated conservatively in the absence of a rotator cuff tear.  When there is a significant fracture of the socket, and recurrent instability, then surgery is indicated.  One approach is to replace the shoulder with a reverse shoulder replacement.  This is an excellent procedure but fixation of the glenoid component can be affected by the fracture of the glenoid and a reverse shoulder replacement is a larger, open surgery with a higher risk of complications.  A Latarjet procedure involves a transfer of the coracoid portion of the scapula to the socket to enhance stability but is less well-suited for this patient.  An open repair is quite reasonable but has a greater risk of infection and may distort the quality of the subscapularis tendon and anterior soft tissues.  As a result we felt an arthroscopic approach, if possible, could confer stability to the shoulder with less risk and preserve the native anatomy about the shoulder should she need another procedure in the future.

Surgery

Susan expressed a strong desire to avoid a total shoulder replacement, and the plan was to proceed with an arthroscopic procedure to stabilize the shoulder and repair the capsule to prevent future shoulder instability. Susan underwent a successful arthroscopic anterior inferior shoulder stabilization procedure with repair of the fractured bone at the rim of the socket at the Bethesda Chevy Chase Surgery Center. Her procedure went well and her progress after surgery was closely monitored with repeat radiographs to ensure her stable shoulder position and frequent follow-up to oversee her care and physical therapy.

Arthroscopic repair of fracture fragment, labrum, and ligaments

 

Arthroscopic photo of completed repair

Testimonial

“Success!

As a veteran of multiples fractures over my lifetime, I thought I knew how to manage, but this was a different kind of break.  My shoulder was dislocated with a Bankart lesion.  Though it was reduced and resting in a sling, any bending forward dislodged the bones until I leaned back and they fell into place.  Surgery was imperative:  arthroscopic repair of glenoid fossa onto 70 year-old bones.  The goal was to restore the anatomy and avoid a total shoulder replacement or reverse total shoulder replacement.

Pain was my guide while I used a sling full-time for months, slept in a recliner, and kept the incisions dry. Unlike my knee replacements, these smaller bones needed to be protected with quiet rest, proper positioning, and guarded movement.  Frequent x-rays confirmed that the bones stayed in place. 

Living alone was both blessing and challenge.  It took constant attitude adjustment to endure five months of no driving, one-handed activities of daily living, grocery delivery, taxi transportation, and part-time work (much of it from home). Being able to remain independent with the help of friends was motivating.  I changed my expectations to align with what movement I did have, reminding myself not to mourn the losses but to look forward.

The outcome is incredibly encouraging. I have good range of motion and now focus on strengthening in physical therapy.  I have functional reach, lift and carry, bilateral coordination, and self-care instead of the limitations inherent in joint replacement. I can sleep without pain and celebrate each small improvement in quality of life.  Most of all, I have immense gratitude for Dr. Rudzki and his team who made all this possible.”– Susan

Successful result of arthroscopic repair for complex shoulder instability with fracture of glenoid socket X-ray image of healed fracture after arthroscopic repair

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