Speaking at the course
Dr Kenneth Cutbush will be a guest speaker at the B&B Shoulder Arthroscopy Course in Kathmandu, Nepal, on 5 and 6 July.
The talks
The presentation covers arthroscopic options in instability surgery, with particular attention to clinical examination for posterior instability. A live surgery session is also planned.
The emphasis on examination is deliberate. Posterior instability is considerably less common than anterior instability and is frequently missed, and the examination findings that distinguish it are the practical starting point for getting the diagnosis right.
With thanks to the organising committee, and to Ashish Gupta. Affiliations: St Andrew's War Memorial Hospital, QUASR, QUT and The University of Queensland.
What shoulder arthroscopy is
Arthroscopy is surgery performed through small portals using a camera and fine instruments, rather than through an open incision. A camera a few millimetres across is passed into the joint, the image is displayed on a screen, and instruments are introduced through other portals to work on the structures inside. For the shoulder this allows the joint surfaces, the ring of cartilage around the socket, the ligaments of the capsule and the rotator cuff tendons to be inspected directly and repaired.
A course teaching arthroscopy has to cover more than the repair itself. Portal placement, patient positioning, management of the fluid and the view, and recognising normal variation from genuine damage all have to be taught, because an arthroscopic repair done through poorly placed portals is considerably harder than it needs to be. Whether arthroscopic surgery is appropriate for a particular shoulder depends on the examination and the imaging. Individual results vary.
Anterior and posterior instability
An unstable shoulder is one that dislocates or partly dislocates, or feels as though it is going to. Most commonly the joint moves forwards out of the socket, which is anterior instability, and it usually follows an identifiable dislocation. Posterior instability, where the joint moves backwards, is much less common and often has no single dramatic event behind it. Patients may describe pain, clicking, or the shoulder giving way when pushing forwards rather than a frank dislocation.
That is why it gets missed. The history can be vague and plain x-rays may look normal, so the diagnosis rests largely on examination tests that load the joint backwards and reproduce the symptoms, supported by appropriate imaging. Getting the direction of instability right matters because the operation differs: the structures that need repair or reinforcement are on the opposite side of the joint. Individual results vary.
Related information
- Our shoulder instability page
- Our post on posterior shoulder instability
- Stabilisation
- Arthroscopic Bankart repair