Arthroscopic Shoulder Surgery

The shoulder is the most mobile joint in the human body. Even though it is not a weight-bearing joint (like the knee or hip joints), there are significant forces that put pressure on the shoulder in doing everyday activities. In sports such as handball, water polo, volleyball or tennis, the pressure on the shoulder joint is substantial what makes this joint very prone to injuries.

According to severity, shoulder injuries range from simple sprains and strains of tendons or ligaments to shoulder dislocations or tendon tears (rotator cuff tendon) what leads to functional disability and impossibility to continue pursuing one’s career in sports. There are also injuries which occur because the body needs to adjust to the requirements of certain sports.

In the last decade, we have witnessed fast developments in shoulder arthroscopy and minimally invasive surgeries thanks to which small surgical procedures can be used to solve large problems. As it is well known, inserting a special optic instrument with a source of light connected to telecamera enables doctors to examine the entire shoulder joint and all its structures. In case there is damage, it can be fixed at the same time. Special instruments make all these procedures possible without having to make large incisions.

In only a few steps, necessary to insert the instrument, even large shoulder injuries can be treated, from unstable shoulder, degenerative and inflammatory problems to shoulder tendon tears, pinched nerve in the shoulder area and alike. After these procedures, postoperative pain is significantly milder, recovery faster and safer, and scars almost invisible.

Shoulder Dislocation (Luxation)

It occurs most frequently when a person falls or in sports with physical contact. The combination of external shoulder rotation in an upright position causes the shoulder to “pop out”, usually forward. The injury is very painful and accompanied by impossibility to move the hand in the shoulder.

Treatment is simple and it consists of repositioning the joint what brings relief but it does not end here. In fact, when a shoulder is dislocated, a very important joint structure called labrum gets injured (this structure is similar to the meniscus in the knee, but with a considerably different function – it enlarges the surface of the joint and prevents the shoulder from slipping out). In a large number of cases, this structure heals up improperly after repositioning which causes repeated dislocations. Therefore, in young and active persons, especially if the dominant arm is in question, we recommend operation already after the first dislocation.
Surgery is carried out arthroscopically, using three 1-2 cm portals, without opening the joint. After releasing the labrum and returning it into its anatomical position, two to four anchors are placed which have extremely tight sutures in its ends. These are then taken through the labrum and shoulder joint capsule using special instruments. The next step is to fix everything to the bone or rather into an anatomical position thus creating a “bumper” which will prevent possible future dislocations.

Another frequent dislocation is a joint injury between the collarbone and shoulder blade (so called acromioclavicular joint). In the majority of cases, when there is a ligament strain of the mentioned joint, treatment consists of resting, using ice and physical therapy, which significantly accelerates recovery. In more severe cases, if acromioclavicular joint ligaments are torn, operation is necessary and it is also carried out arthroscopically.

Damage Caused by Overuse

artroskopski-pristup

Such damage is very frequent in tennis and it is in fact a consequence of functional adjustment of tennis players to the requirements of this sport – wishing to hit the ball as hard as possible (service or smash), athletes increase the range of motion of the shoulder. This leads to an increase in external shoulder rotation but also contracture of the anterior parts of joint capsule. What follows is a gradual damage to the biceps muscle tendon and tearing of its attachment to the bone (SLAP lesion), consequently causing the so called “dead arm syndrome” – severe pain and lack of strength in the final stages of shots which disables the player from throwing the ball or hitting it with a racket. Simultaneously, shoulder tendons get pinched between two bones, which gradually wear off and break, additionally disabling athletes in everyday activities.

The treatment also consists of an operation, arthroscopy, because the damage i.e. the torn tendon can be “sewn” and fixed to the upper arm bone or shoulder blade using special metal or bioabsorbable anchors. The mentioned procedure is also carried out without large incisions, through several small portals, which enables a faster recovery and reduces time spent in hospital (generally, as opposed to shoulder dislocation, recovery is much longer in these kinds of injuries). Therefore, it is exceptionally important to carry out one’s rehabilitation in a specialized centre in cooperation with the orthopaedic surgeon who performed the operation. This contributes to the successfulness of operation and a faster return to sports.

Painful Shoulder Syndrome

This syndrome is one of the most common reasons why patients pay a visit to the doctor’s. The term also used in practice – periarthritis humeroscapularis – is not in fact the most precise one, since it includes several different painful syndromes in the shoulder area. Although certain syndromes result in similar clinical manifestations in terminal phases of illness, they are different based on the cause and place of origin. Thus, they need to be differentiated in order for treatment to be as successful as possible.

Painful shoulder most frequently occurs in men after 40 years of age, especially after doing some physical activity they are not used to. Pain is usually most severe during the night, which causes sleep troubles, while attempts to heat up the shoulder only worsen the pain. It appears suddenly and is accompanied by flashing pain along the outer part of the arm or along the cervical spine on the same side of the body. Active movements in the shoulder only deteriorate it. The so called painful arch is characteristic while raising the arm to about 30 – 70 degrees.

Shoulder contracture is also present (limitation in the range of motion), either because of pain or fast conversion into the so called adhesive capsulitis of the shoulder during which, after an inflammatory and very painful phase, adhesions start growing inside the joint and the joint capsule shrinks. In the final phases of inflammation, shoulder tendon is damaged and active arm movement in the shoulder joint is almost impossible.

Painful shoulder therapy is in its acute phase first and foremost focused on reducing pain. Non-steroidal anti-inflammatory drugs, cold compression and possibly local application of anti-inflammatory prolonged-action medication combined with local anesthetic (DepoMedrol in combination with lidocaine or similar anaesthetic) are used as therapy.

In addition, physical therapy is also useful, such as sonophoresis with non-steroidal anti-inflammatory gel, magnet therapy, usage of different electrical stimulations and laser therapy. Recently, the so called shock wave therapy has emerged and it is intended for treating exactly these kinds of painful syndromes. It consists of applying a short high-energy sound wave which not only speeds up the treatment process but is also able to break calcification which is often present in long lasting problems.

The next main goal of therapy is to maintain the mobility of the shoulder joint. Passive, passive-assisted, and later active kinesitherapy are recommended for this purpose. Swimming pool therapy is also very useful if it enables shoulder movements with less weight bearing. Pendulum and suspension exercises are also applied.

If the mentioned therapy methods are not successful, or when different examinations confirm damage to shoulder tendons, surgical treatment is performed. Such syndromes usually indicate arthroscopic surgery. The most common procedure consists of removing the inflamed bursa arthroscopically using motorized instruments and/or specialized radiofrequency instruments. Bone adhesions are removed if there are any, but this is performed using motorized shavers, similar to those used by dentists, only larger in radius. Inflamed tissue is removed in this way and the access to rotator cuff tendons is enlarged.

In case of shoulder tendon tear, after removing the bursa and widening the tendon area, the torn tendon can be repaired and/or fixed to the upper arm bone using special metal or bioabsorbable anchors.

Frozen Shoulder Syndrome

Arthroscopy can also be performed in case of this syndrome but not in the first three stages. After prolonged rehabilitation, in case it fails, operation is performed. Before the procedure, the shoulder joint needs to be manipulated while the patient is under narcosis in order to achieve the largest possible range of motion (mobilization in narcosis). Afterwards, using the abovementioned motorized instruments, adhesions are removed and the so called capsulotomy i.e. cutting through the shoulder joint capsule is performed in order to achieve the largest possible range of motion in the joint.

Prim. Mladen Miškulin, MD, PhD, specialist in Orthopaedics and Traumatology