Shoulder instability Part IV: Post-Operative Management

What are the primary surgical procedures for the management of shoulder instability

- Arthroscopic Bankart Repair and Latarjet procedure

- Posterior labral repair

- SLAP repair

What are key points about the management of SLAP repairs

- In general, all post-operative rehabilitation should be individually tailored and progressed

- Rehabilitation protocols are guidelines only

- Understand what was done in surgery, surgeon's preferences, and individual patient characteristics

what are the surgical procedures for Anterior Instability

- Arthroscopic Bankart procedure is the most commonly performed surgery for anterior instability. Suture anchors used to repair the anterior capsule and labrum

- The Latarjet procedure is a viable alternative and is also used for revision surgery after failed Bankart procedures. Coracoid process transfer to stabilize the anterior shoulder

TRUE or FALSE: In cases of Anterior instability, patients can do well with non-operative management, but the general consensus is that surgery is more effective for younger patients ( age < 25) and high-risk individuals to prevent recurrent dislocation.

True

What does research say about Bankart versus Latarjet for recurrent anterior dislocation?

- Recent research is trending towards less recurrence of instability following return to sport for people undergoing the Latarjet procedure compared to a Bankart.

- Functional outcome scores are the same for the two procedures

What are the Post-Op guidelines for Bankart and Latarjet surgeries for anterior instability

- Obtain protocol, op-report if available

- Screen for signs of infection, DVT, neurovascular injury

- Follow up imaging, medication, consult

- Respect tissue healing times

- Do not considerably stress anterior soft-tissue structures early on

Post-Op Arthroscopic Bankart Repair - Phase 1: Acute Post Op (0-6wk)

- Sling immobilization (2-4 weeks)

- Elbow, wrist, hand, and CT spine mobility while in a sling.

- Shoulder PROM/AAROM:

- Shoulder AROM progress as comfortable after week 3

- Do not combine ER in Abduction

- RTC isometrics

- Scapular muscle setting

during phase 1 of acute post op management of Arthroscopic Bankart Repair what are the recommendations for Shoulder PROM/AAROM:

- Forward elevation starting at 90 degrees,

- ER starting at 30 degrees in 10 degrees abd, progress as tolerated

- Do not combine ER in Abduction

What are Shoulder 'safe zones'

- Zone A is the safest. You can move in this zone as guided by your therapist and surgeon.

- Zone B is next safest. You should be careful moving in this zone without supervision and guidance.

- Zone C is the least safe and must be avoided. Your shoulder is most vulnerable to stressing a repair

or an injury when your elbow is in this zone

Post-Op Arthroscopic Bankart Repair - Phase 2: Intermediate Phase (6-12 weeks)

- Progress to full ROM, do not force stretch

- Initiate strengthening to RTC, periscapular muscles

Post-Op Arthroscopic Bankart Repair - Phase 3: Late Phase (12-20 weeks)

- Progressive strengthening (principles of endurance, power, function)

- Sport specific rehab as needed

What are key considerations for Rehabilitation post-Latarjet procedure

- Almost identical rehabilitation to Bankart repair

- High degree of variability in the literature

- Slightly higher risk of infection and screw complication compared to Bankart

- Bony union thought to occur 6-8 weeks compared to up to 12 weeks for labral fixation.

- Able to start ROM, strengthening, and return to sports earlier

What are the proposed return to sport criteria post-op Bankart repair

- Pain free shoulder ROM adequate of performing sport activity, no signs of instability, full strength (HHD)

- Confidence with UQ WB and moving in and out of 90 deg AB/ER

- Functional performance tests (CKCUEST, UE Y Balance, SFMA)

- Sport performance testing

- MD clearance

What are the proposed return to sport timelines post-op Bankart repair

- Mean time for sport-specific activity as part of rehab 15±4.2 wk

- Mean time for throwing not recommended until 19.3 wk

- Mean return to sport 32.4±9.3 wk, with return to game at 39.3±7.6 wk

- Minimum of 12 wk threshold should be used for guiding return to contact sports

What are the most common reasons for not returning to sport: psychological readiness

- Fear of reinjury

- Lack of confidence in shoulder

- Concern about new rehabilitation process if recurrent dislocation

What are key points about the Surgery for Posterior Instability

- Failure of surgical stabilization 12-50%

- Posterior approach/incision

- Posterior capsule and infraspinatus are tightened

- Glenoid reconstruction by osteotomy may be performed

- Immobilized for 6 weeks followed by ROM and strengthening exercises

what are the main findings of the study comparing a sham surgery to labral repair or biceps tenodesis for type II SLAP lesions of the shoulder

Labral repair, biceps tenodesis and sham surgery for patients with an isolated SLAP II lesion all led to significant improvement in both objective and subjective scores. There was no significant difference among (1) labral repair, (2) biceps tenodesis and (3) sham surgery in the population studied.

what does phase 1 (0-3 weeks) of SLAP repair rehabilitation entail

- Sling immobilization

- PROM/AAROM do not force stretch

- RTC isometrics and scapular setting

what does phase 2 (3-6 weeks) of SLAP repair rehabilitation entail

- Progress to AROM as tolerated

- Begin strengthening RTC and scapular muscles

what does phase 3 (6+ weeks) of SLAP repair rehabilitation entail

- Progress strengthening

- Progress biceps strengthening very gradually without significant loading until week 12

Summary: Shoulder instability post-operative management

- Traumatic dislocation: Surgery generally seen as providing superior outcomes for young (