I had an arthroscopic bankart repair on my shoulder in


Q: I had an arthroscopic bankart repair on my shoulder in March 2015 with 2 anchors inserted. Within 4 months it was apparent to me that my shoulder was still unstable, so I underwent another arthroscopic surgery in July 2015. After the surgery I was informed that my shoulder did not feel unstable when examined, however, the labrum was torn between the 2 anchors so another anchor was inserted to repair this.
For 6 months after this second surgery I felt fantastic, my shoulder felt very stable. Once released for full activity at 6 months I tentatively got back to normal, however, my shoulder started to feel like it was slipping with certain movements. By the 8 month mark my shoulder was worse than it was before the other 2 surgeries, slipping with every day activities - but not in regular positions, always while reaching or moving in odd directions. It was something that I could never re-produce, it often happened while getting dressed or reaching to the side to grab something off my desk. As a result avoiding certain positions didn't help, I couldn't predict what actions would cause my shoulder to slip, and therefore I became very fearful of my shoulder and tried not to use it where possible. I had varying degrees of movement, ranging from clicking/clunking, slipping, to feeling like it had almost completely come out (which happened less frequently).
I decided I might just need some more physiotherapy. I got 3 different opinions and all 3 told me that my shoulder was highly unstable and I needed a surgeon - physio couldn't help me. So I booked in to see a surgeon, and in the 3 month wait continued with physio on a fortnightly basis to manage the constant, often severe pain. On every single appointment my physio was blown away at how much movement was in my shoulder, she kept pushing me to try and get an earlier appointment with my surgeon because she just didn't know how to help me. She actually told me my shoulder was just flapping around in the joint.
So I eventually made it to my surgeon's appointment. I'd had a CT scan and that showed cysts around my anchor sites, as well as a small hill sachs lesion. He had not seen that before with modern anchors, so he was fascinated by that. He believed the cysts had caused the anchors to come loose, causing my instability. He did a few basic tests and I told him the history of my shoulder but got to speak very little about what I actually feel now. He said I needed 2 surgeries. The first one would remove the anchors and cysts, and get pathology to see what the cysts are. Once the results are in we would plan a second surgery to correct the instability.
I had surgery 1 week ago, and was very surprised and disappointed to be told my shoulder was not unstable when examined under anesthesia. Biopsies were taken of the cysts and a capsular release was done to improve my external rotation (which went as soon as my shoulder issues started again), but my shoulder is considered stable. The existing anchors were in tact, and therefore were not removed as originally planned. When I discussed the surgery the surgeon he admitted that he thought he understood my shoulder but clearly doesn't, so when I see him again in a few weeks for the biopsy results we will have to start from scratch. I asked him how 3 physical therapists and himself could feel my shoulder as unstable when I was tested awake, only to be told now my shoulder is stable. He said he didn't know, but shoulders are most relaxed when the patient is asleep, and he couldn't get my shoulder to dislocate - therefore it's stable.
I am at a loss at what to do now. My shoulder slips out multiple times a day and as a result my entire shoulder constantly flares up. Some days the pain is so bad I can barely lift my shoulder. If the slipping wasn't causing so much pain I wouldn't worry about it, but it is extraordinarily painful. My shoulder also has a sensation of not sitting in the right place, however, this is only when I'm upright. I find that my shoulder actually feels more stable when I'm lying on my back (but it's worse when lying on either side as it feels like it's going to fall out). I'm wondering if this is why my shoulder felt stable while I was examined while I was asleep? I can't fight this overwhelming feeling that something has been missed with my shoulder all along, and I don't know how to communicate how bad it is. How can a shoulder that slips around all the time and be assessed as unstable by multiple people while awake be now considered stable due to the EUA alone?
This shoulder has been a problem since October 2014, and almost 2 yrs on it doesn't seem any closer to being revolved - I'm mentally and physically exhausted from having to think about my shoulder constantly. I know it's difficult when you can't feel what the patient is feeling, but I'm not stupid, I am 100% certain that my shoulder is slipping multiple times a day. I don't know what medically defines an unstable shoulder, but I have no hesitation in saying my shoulder is unstable, and multiple physiotherapists also felt this.
My question is, if I was your patient how would you approach this situation?

Should I accept being told that my shoulder is stable even though I know it's not? How much importance is put on the EUA - can stability be diagnosed by that alone? Should I give up on trying to fix this and go down a pain management route? I'm only 37 and this is already affecting my life significantly. I've done everything I can to be proactive with this shoulder, I can't seem to find anyone to help me. Any advice would be appreciated.

Symptoms:  Shoulder pain, clicking and clunking, slipping with everyday activities. Shoulder feels out of place.
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A:   Hello,

Thank you for posting your query at ATD.

I have gone through your history and understood your concern. EUA holds very high value to determine whether shoulder is stable or not but if there are multiple episodes of shoulder dislocation, I would certainly like to reassess the condition.

The approach is correct in taking biopsy of the cyst and leaving the anchors behind as they were stable on examination as per your treating surgeon.

My recommendation for you is to wait for the biopsy report and then depending upon the pathology further treatment plan can be formulated. Secondly, you should take the help of a psychiatrist to alleviate the apprehension caused by multiple episodes of dislocation. This will help in improvement of your daily living.

There is some pathological lesion in the glenoid as well in addition to the humeral head. Once the biopsy report is available only then comment can be given on the nature of the lesion.

Feel free to discuss your doubts.

Comments / Follow Ups

Patient: Thank you for your response. I understand the plan moving forward would depend on the biospy results. I'm just wondering what the possibilities are? My surgeon was confident that there's no infection, and I don't understand at all what else the biospy may show. Isn't a cyst merely a collection of fluid? I'm trying to understand exactly what waiting on the biopsy results means in terms of treatment going forward. It would be great if you could outline what the most likely possibility are, and would the treatment for each would be.
Doctor: I'm sorry but biopsy of cyst can give a wide array of results ranging from infection or simple resorption cyst to tumour. Its not just collection of fluid, it can be collection of fluid as well as small radiolucent mass appearing as empty cavity on xray/CT. If the consecutive sextion are seen, it can be determined whether there is fluid in the cavity or not. Secondly, operative finding of visualisation of the lesion also helps in forming a provisional diagnosis. Both of these things are lacking here so its difficult to give a provisional diagnosis and suggest a treatment for it.
In general if cyst is of simple nature (non malignant, non infective) then cyst cavity is curettaged and the resulting cavity is filled with bone graft or both bone graft and its substitute.
Bone biopsy results are usually obtained within 3 weeks, will like to hear from you in short while.
Patient: You have been incredibly helpful, thank you! I have just one more quick question if that's ok. It seems as though the anchors will need to be removed either way, so why would they not just have been removed during my first surgery?
Doctor: Your doctor has taken minimal amount of tissue for diagnosing the lesion. Once the diagnosis is obtained then one can go forward with complete treatment, its treatment protocol to either go with sampling biopsy or if the lesion is peripheral and small the entire piece of bone is removed along with adjacent bone which cannot be done in your case as the bone involved is articular.
Your treating doctor has worked correctly as per treatment guidelines.
Patient: Hi. I finally got my biopsy results and I have a p.acnes infection. I was immediately referred to an infectious disease specialist, who confirmed the infection through the lab results and my worsening pain symptoms. He has put me on a 6 wk course of penicillin and has instructed my surgeon to remove the anchors and clean out the infection. Is this the appropriate form of action? I don't like the thought of removing the anchors, it seems like everything I've been through will have been for nothing. Would my shoulder need to be stabilised again or should the labrum be healed by now?
Doctor: Hello
P. acnes is a kind of subacute infection and with any infection the foreign body (implant /anchor) have to be removed along with the antibiotic coverage. This is standard line of management.
Without the removal of the anchors, infection will not settle down. During removal your doctor can access the status of the labrum under vision. It cannot be commented by a theoretical scenario discussion or a shoulder examination.

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