Daniel D. Buss and William C. Jacobsen

1. Recurrent anterior shoulder instability with pain that limits activities

1. Voluntary shoulder instability

2. History of psychiatric disease

3. Active infection

4. Multidirectional shoulder instability or generalized ligamentous laxity (relative)

5. Glenohumeral arthritis (relative)

6. Presence of a large Hill-Sachs lesion or glenoid deficiency may alter approach

1. Shoulder radiographs

a. True anteroposterior (AP) view

b. Axillary lateral view

c. Consider an AP view with internal rotation of the humerus.

d. Consider Stryker-notch view.

e. Consider West Point modified axillary view.

f. Consider scapular “Y” views.

2. Consider computed tomography (CT) arthrography, magnetic resonance imaging (MRI), or magnetic resonance (MR) arthrogram (if necessary).

3. Assess passive and active range of motion.

4. Document neurovascular examination.

5. Consider diagnostic arthroscopy (if examination under anesthesia [EUA] is not consistent with clinical diagnosis).

6. Appropriate medical and anesthesia preoperative evaluation.

1. Specialized shoulder retractors for soft tissues and humeral head

2. Suture anchors

3. Beach chair position with beanbag

4. If available, a McConnell arm holder is helpful (McConnell Surgical Mfg., Greenville, TX).

5. All pressure points should be well padded.

6. The procedure can be done with regional anesthesia (interscalene block) and/or general anesthesia.

1. Intravenous antibiotics are administered prior to the skin incision.

2. A concealed anterior axillary skin incision is preferred The arm is adducted across the body after sterile prepping and draping is completed This helps define the natural axillary skin folds, which can then be marked with a sterile pen.

4. EUA is performed to assess the direction and degree of shoulder instability and the results compared with the contralateral shoulder.

1. Avoid incisions outside the natural skin lines.

2. If possible, avoid injury to the cephalic vein. Commonly, it is preserved and retracted laterally with the deltoid.

3. Attempt to avoid injury to the axillary and musculo-skeletal nerves by protecting them at all times.

4. Avoid damaging the glenohumeral articular cartilage.

5. Avoid “overtightening” the shoulder during the capsular shift and/or repair of the subscapularis tendon.

1. The neurovascular examination should be performed and documented. The examination may be affected by regional anesthesia in the immediate postoperative period.

2. Consider using an ice and compression device, which helps with swelling and pain control.

3. The shoulder is immobilized in a sling for up to 3 to 4 weeks for comfort only. The patient may use the elbow and hand normally for light activity.

4. Postoperative rehabilitation begins by working on achieving adequate range of shoulder motion, then progresses to strengthening of the shoulder muscles, and finally to a functional program to reestablish proprioception and muscular coordination.

5. Exercises commence with pendulum exercises, forward flexion in the plane of the scapula using pulleys and wands, and passive range-of-motion exercises including external rotation in the predetermined safe zone. The safe zone is determined by the surgeon at the time of surgical repair.

6. Active and active-assisted range-of-motion exercises are started at 4 to 6 weeks postoperatively to strengthen the deltoid, rotator cuff, and scapular muscles.