Shoulder Surgery

Arthroscopic (Keyhole) Labral Repair

Arthroscopic (Keyhole) Labral Repair

Arthroscopic Labral repair is a minimally invasive keyhole procedure to repair the torn labrum at the front and/or back of the shoulder joint. Patients wear a sling for six weeks and start therapy two weeks after surgery. Strengthening and training for your sport commences at 3 months and full, unrestricted contact is possible at 6 months after surgery.

An arthroscopic labral repair is a surgical procedure where small keyhole incisions are used to access the shoulder using specialised instruments. For most patients who sustain shoulder dislocations that require a labral repair, we are able to undertake this utilising an arthroscopic technique.

Using a minimally invasive approach means faster recovery time, minimal blood loss, and fewer complications from surgery. Arthroscopic labral repair is a common procedure and is done either as a day only case or with an overnight stay in hospital. The results are excellent and most patients return to their previous level of function.

Medical diagram showing an Arthroscopic labral repair being performed

The main indication for an Arthroscopic labral repair is to treat patients after anterior shoulder dislocations. These patients have torn the labrum at the front of the shoulder and surgery will repair the torn labrum. In a small number of cases (<5%) the dislocation is posterior (back of the shoulder) and thus the posterior labrum can be repaired arthroscopically.

It is important for your surgeon to address tears circumferentially around the glenoid if they are suspected based on your history, examination, and MRI. It is not uncommon for an anterior labrum tear to extend in a posterior direction and even superiorly (resulting in a SLAP tear). Depending on the age of the patient and functional demands the repair will be individualised to them. For example, throwing athletes should be treated differently to overhead collision athletes.

  • The procedure is under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder.
  • Small key-hole incisions (about 1cm) are made and the camera and surgical instruments are placed inside the shoulder. Usually, 2-3 incisions are enough to carefully repair the Labrum
  • A thorough 15-point examination of the shoulder joint and torn Labrum is made via the arthroscopic camera and pictures are taken to document findings.
  • The torn Labrum is carefully prepared, scar tissue is cleaned up and stitches are placed around the Labrum which are in turn anchored back to the socket (2.9mm anchors). Usually 2-3 anchors in the front and/or  2-3 anchors in the back of the shoulder are needed.
  • Any other unexpected injuries/tears are noted and repaired via key-hole at the same time if needed.
  • The key-hole incisions are closed with sutures, dressings applied and a custom sling used to position the arm correctly.
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Team Doctor/Physiotherapist to maximise your recovery

Medical diagrams showing a torn labrum, an repaired labrum and the process of repairing a torn labrum

Medical diagram close up of a labral repair

Watch a surgical animation demonstrating how Dr Pant performs a Shoulder Labrum Repair to fix shoulder dislocations.

There are three essential components to a good outcome from surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement:

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the labral repair to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the labral repair begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post labral repair surgery.

Sling

  • A sling is required for the first 6 weeks after your surgery
  • The sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery)

The type of sling is selected specific to you and your shoulder surgery

  • Anterior labral repair – Normal sling
  • Posterior labral repair – ER sling (with a triangular wedge at the front)

Cropped image of two women showing the difference between a normal sling and a abduction sling used after labral repair surgery

When can I drive?

  • After shoulder surgery, you will be in a sling and you may be unable to drive for at least 6-8 weeks
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2-4 weeks, and some may not be able to drive for the full 12 weeks. This will be discussed at your follow up appointments.

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually, before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection – Do not be concerned just yet; please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications.

The risk of complications after Labral repair surgery (shoulder stabilisation) are less than 1% in the Sydney Shoulder Unit experience. General risks include:

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to Labral repair surgery (shoulder stabilisation):

  • Frozen shoulder (5% risk)
  • Improves over 3-6 months and will generally not affect your outcome or need further surgery.
  • Reoperation and failure of surgery. When performing a shoulder reconstruction, your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is your own tissue.
  • The longer the history of damage and frequency of dislocations/instability prior to surgery, the more likely the tissue quality is poor.

There are three areas where your Labral repair (shoulder stabilisation) may fail:

  • Bone-Anchor interface
  • The anchors today are very high in quality and usually do not fail; sometimes if your bone is soft (older patients), the anchor may pull out of the bone.
  • The Anchor-Suture interface is typically very strong and not a source of common failure
  • The Suture-Tissue interface is the weakest point and the most common reason for the failure of surgery (usually due to poor tissue quality). There are special techniques in tissue management and suture choice to reduce failure rates.
  • Delays/Inability to return to the previous level of sport. The published return to sport rate after shoulder stabilisation surgery (key-hole) is 70-90%. With stabilisation surgery, patients are 5-6 times more likely to return to play.
  • The risk of re-dislocation with overhead contact after soft tissue key-hole stabilisation is between 5-20% (depending on a number of factors)

Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing.

Most healthy patients, however, cope well with keyhole labral repair shoulder surgery and are unlikely to have complications.

The published return to sport rate after shoulder stabilisation surgery (key-hole) is 70-90%. With stabilisation surgery, patients are 5-6 times more likely to return to play.

The risk of re-dislocation with overhead contact after soft tissue key-hole stabilisation is between 5-20% (depending on a number of factors).

Patient results

Shoulder Dislocation – Instability

A 32 year old gentleman presented with several years of shoulder instability symptoms. He had the other shoulder reconstructed some years ago and was doing well. The recurrent instability symptoms led to him being not able to trust his shoulder overhead. He also complained of pain at rest and was unable to sleep on the affected shoulder.

A CT scan with 3D reconstructions demonstrated a bony bankart (bone fragment at the front of the socket) with glenoid bone loss (long term bone erosion at the front of the socket). The MRI interestingly revealed a posterior labral tear.

Given his inability to work overhead and be active – he elected to proceed with surgery.

The surgery commenced with arthroscopy of the shoulder and repair of the posterior labral tear with three anchors. Once the posterior labrum was repaired an open approach was used over the front of the shoulder to complete the latarjet procedure, with the graft secured using two screws.

Post-operatively he was placed in an external rotation sling and underwent JPL rehabilitation starting at two weeks. By three months he had closed to full range of motion and a CT scan at 6 months confirmed the coracoid graft had healed and he commenced all activities including contact sport.

Shoulder Dislocation – Latarjet

After a shoulder dislocation some patients may be a candidate for a “bone transfer” procedure: a Latarjet. This is a good procedure for high level athletes, those who participate in overhead contact type sport, those with significant bone loss, and revision cases of failed previous “key-hole” stabilisation surgery.

This 16 year old high level wakeboarder dislocated his shoulder and sustained both a rotator cuff tear and an anterior labral tear. This is an uncommon injury pattern and presents unique decision making and surgical challenges.

Given his high level sporting ambitions and demands we repaired the Rotator Cuff and did a Latarjet procedure to treat his instability. He was in a sling for six weeks and commenced JPL rehabilitation at two weeks post surgery. He commenced formal Physiotherapy at 3 months, eventually regaining full ROM and function with his shoulder. He is back to his active lifestyle and riding waves around the waterways of Australia.

Shoulder Dislocation & Labral Tear

This 30 year old gentleman had a several year history of recurrent shoulder dislocations. He had exhausted a period of activity modification and physiotherapy. He was apprehensive to use his shoulder overhead, so he elected to proceed with surgery.

The images taken from surgery demonstrate a tear in the Labrum at the front of the shoulder. This has been carefully prepared and repaired back to the glenoid (socket) using 2.9mm anchors and suture-tape: achieving a nice “bumper” at the front of the shoulder joint.

He underwent JPL therapy and then physiotherapy to strengthen the shoulder. He no longer feels unstable and is back to participating in the sports he loves.

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