Shoulder Arthroscopy

Contents:

1. General information about arthroscopy
2. Reasons for performing shoulder arthroscopy
3. Planning the procedure
4. Performing the procedure 
5. The procedure
6. Complications and recovery
7. Rehabilitation

General information about arthroscopy

Shoulder injuries are a common problem that involve muscles, ligaments and tendons, not just bones. Shoulder trouble is common among athletes when problems like this can develop over time because of repetition, intense training and minor injuries (e.g. weightlifting, tennis, or swimming), and also the simplest daily activities such as putting up curtains, cleaning windows, painting, or other actions that involve raising the arm above the head. 

Arthroscopy is a procedure performed in order to assess, diagnose and treat internal problems of the shoulder joint. What exactly is arthroscopy? The name comes from two Latin words – ‘arthros’ - joint, and ‘skope’ - look. The word literally means taking a look at the inside of the joint. During arthroscopy, the doctor inserts an arthroscope with a camera on the end into the shoulder joint, which then sends an image from the inside of the joint that is visible on the screen. This allows the surgeon to precisely guide the surgical instruments. The incision made to insert the arthroscope and other surgical instruments is small compared to the larger incisions needed for standard surgery. Therefore this procedure causes less damage, is the least painful option, and shortens the time it takes to regain full mobility. Arthroscopy of the shoulder has been performed since 1970. Since then, it has allowed us to diagnose, treat, and help patients regain full mobility more easily and quickly than was ever before possible. Thanks to new technology and instruments, the procedure is being developed further each year.

Shoulder Anatomy 

The arm constitutes a set of joints that perform more movements than any other part of the body. The shoulder is made up of three bones: the humerus (the upper part of the arm bone), the scapula (shoulder blade), and the clavicle.    

The head and the socket. The head of the upper bone is positioned inside the socket in the scapula. The socket is called the glenoid. A smooth tissue called cartilage forms the link between the joints and covers the surface of the head and the socket. It is a smooth surface, which allows the bones to glide against one another.

The glenoid is surrounded by strong tissue cartilage called the rotator cuff. The cuff is connected to the socket and allows us to stretch out our arms. It forms a seal around the socket and strengthens stability and cushions the joint.

Shoulder capsule. The joint is surrounded by strips of tissue called ligaments. They form a capsule that holds the joint together. Underneath the surface of the capsule is a thin membrane called the synovial membrane, which produces synovial fluid to lubricate the shoulder joint.

The rotator cuff is a group of four flat tendons which cover the head of the arm bone. It resembles a cuff in the sleeve of a shirt which is where it gets its name from. These tendons are connected by short but very important muscles which are connected to the scapula. These tendons play an extremely important role in stabilising the shoulder. 

Bursa. This is a closed, fluid-filled sac between the rotator cuff and the acromion. This allows the tendons to move correctly and smoothly during arm movement. 

Reasons for performing shoulder arthroscopy

Doctors may recommend shoulder arthroscopy if patients are still experiencing knee pain despite having undergone non-surgical treatment such as rest, physiotherapy, medication and injections that can reduce inflammation. Inflammation is the body’s standard reaction to injury or pain. Inflammation causes swelling, pain, and rigidity in the affected shoulder joint.  

Injuries, too much pressure on the shoulder and also age-related damage are the most common causes of the majority of shoulder problems. Arthroscopy can alleviate pain caused by many problems that damage the rotator cuff, glenoid ligament, articular cartilage and other soft tissues surrounding the joint.

Arthroscopy can be recommended to treat the following problems:

• Calcaneal spur or inflammation of the rotator cuff
• Removal or repair of the glenoid ligament
• Repair of damaged ligaments and tendons
• Removal of inflamed tissue or loose cartilage
• Repair of recurring dislocation of the shoulder
• Torn or damaged rotator cuff or ligament
• Instability of the shoulder – when the shoulder joint is loose and comes out too much or changes position (it slips out of the ball joint and socket)
• Inflammation or damage to the synovium. This is often caused by disease, e.g. rheumatoid arthritis
• Less common procedures such as nerve release and repairing or removing ruptured cysts can also be performed with the use of arthroscopy. Some surgical procedures such as shoulder replacement surgery still require open surgery through a larger incision. 

Planning the procedure

The orthopaedic surgeon can recommend you make an appointment with a GP in order to check that there are no other health problems that need to be treated before the procedure. Sometimes other tests such as blood tests, an EKG or a chest X-ray are also performed. In the case of some health problems it may be necessary to have more thorough tests before the procedure. 

It is important to tell your doctor about any medication or supplements that you take. It is possible that you will have to stop taking some medications for a while before and after the operation. If you are in good health, arthroscopy is often performed as an out-patient procedure and it is not necessary to stay in hospital overnight. 

The different options regarding anaesthesia are discussed before the procedure. Shoulder arthroscopy is most often performed under local anaesthetic. Peripheral nerve blocks are used which cause numbness in the arm and hand. The injection is given at the base of the neck or at the top of the arm. This form of anaesthesia numbs pain for a few hours after the operation. Many surgeons use nerve blocks with sedation or general anaesthesia because it can be quite uncomfortable to remain in one position during the procedure. 

Most arthroscopies take under an hour. However, the duration of each procedure depends on what needs to be fixed. 

Performing the procedure 

Preparing the patient:

During the procedure the patient can be placed in one of two positions: sitting or lying. Each position has its benefits. The doctor chooses the position based on the kind of procedure. 

The procedure

To begin, the surgeon injects fluid into the arm to fill the joint in order to observe all of the shoulder structures with the arthroscope. This allows the surgeon to observe the inside of the arm and all of the damage. 

After establishing the problem, instruments are inserted into the arm to perform the necessary incisions and repairs such as cutting, grasping and suturing.

The incision is closed with either sutures or butterfly closures and is then covered with a bandage. 

Complications and recovery

Most patients do not suffer from any complications after the procedure. However, it is a surgical procedure and there is always some risk. Potential problems may include: infection, excessive bleeding, blood clots, or damage to the blood vessels and nerves.

Postoperative recovery can take between 1-6 months. It is often necessary to wear a sling for 1-2 weeks after the procedure. Sometimes the doctor may recommend taking pain medication if it is necessary. 

Even though the position of the body during sleep does not have a big effect on the healing process, most patients sleep in a partly-reclined position for the first few days after the procedure.

Return to work and sport: it depends on the type of procedure and degree of injury. It usually takes from 1 week to a few months.

Rehabilitation

Rehabilitation plays an important role in regaining full mobility. You can usually start doing exercises in the first week after the procedure. Emphasis is placed on strengthening and stretching exercises.