Shoulder

Shoulder Arthroscopy

Anatomy

The shoulder is a complex, ball-and-socket joint that rotates through a greater range of motion than any other joint in the body. The shoulder is made up of: the upper arm bone (humerus), shoulder blade (scapula), collarbone (clavicle), and shallow socket (glenoid). The ball, or head of the upper arm, fits into a shallow socket in the shoulder blade. The ends of these bones, where they touch, are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. The glenoid is ringed by the labrum, a strong, fibrous cartilage that forms a gasket around the socket, adding stability and cushioning the joint.

The shoulder joint is surrounded by bands of tissue, called ligaments, to form a capsule that holds the joint together. The undersurface of the shoulder capsule is lined by the synovium, a thin membrane that produces synovial fluid to lubricate the cartilage and eliminate friction. Four tendons surround the shoulder capsule and help keep your arm bone centered in your shoulder socket. This thick tendon material, called the rotator cuff, covers the head of the humerus and attaches it to your shoulder blade. Between the rotator cuff and the bone on top of your shoulder (acromion), a lubricating sac (bursa) helps the rotator cuff tendons glide smoothly during movement.

Normally, these components work together in harmony, but when disrupted by disease or injury the result can be pain, muscle weakness and reduced function.

Description

Arthroscopy is a minimally invasive surgical procedure used by orthopedic surgeons to visualize, diagnose and treat problems inside the joint. Your doctor may recommend shoulder arthroscopy if you have a painful condition that does not respond to nonsurgical treatments such as rest, physical therapy, and medications or injections to reduce inflammation. Shoulder arthroscopy may relieve the painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage, or other soft tissues surrounding the joint. This damage may be the result of an injury, overuse, or age-related wear and tear.

Commonly performed arthroscopic procedures for the shoulder include: rotator cuff repair, bone spur removal, removal or repair of the labrum, repair of ligaments, removal of inflamed tissue or loose cartilage, and repair for recurrent shoulder dislocation. Less common procedures, such as nerve release, fracture repair, and cyst excision can also be performed using an arthroscope, however, complicated procedures such as shoulder replacement still require open surgery with a more extensive incision.

Preparation

Once the decision to have surgery is made, you may be asked to see your primary care physician to be sure you do not have any medical problems that need to be addressed before surgery. Additional tests may be needed, such as blood and urine samples, electrocardiogram (EKG), or chest X-ray. If you have certain health risks, a more extensive evaluation may be required. Be sure to inform your othopaedic surgeon of any medications or supplements you take, as these may need to be stopped prior to surgery.

If your general health is good, your shoulder arthroscopy will most likely be performed on an outpatient basis, which means you will not be required to stay overnight in the hospital. It is very important that you follow all instructions regarding when to stop eating or drinking prior to surgery, and when to arrive at the hospital.

Surgery

Before the operation, you will be evaluated by a member of the anesthesia team. Shoulder arthroscopy is most commonly performed using a combination of regional and general anesthesia. Regional nerve block anesthesia only numbs your shoulder and arm. The numbing medication is injected in the base of your neck or high on your shoulder, where the nerves that control feeling in your shoulder and arm are located. Using a nerve block will also help control your pain for a few hours after surgery is completed. Many surgeons combine nerve blocks with sedation or a light, general anesthetic because patients can become uncomfortable staying in one position for the length of time needed to perform the surgery. The anesthesia team, with your input, will determine the best option for you. Your surgeon will see you before the surgery and sign your shoulder to verify the surgical site. The length of your surgery will depend on what your surgeon finds and what repairs are required.

Once in the operating room, you will be positioned so that your surgeon can easily adjust the arthroscope to have a clear view of the inside of your shoulder. Your forearm may be placed in a holding device to ensure that your arm remains still. Your orthopaedic surgeon will begin by injecting fluid into the shoulder to inflate the joint, making it easier to see all the structures of your shoulder during the procedure. The arthroscope will be inserted into your shoulder through a small puncture (about the size of a buttonhole). Fluid flowing through the arthroscope will help to keep the view clear and control any bleeding.

Images from the arthroscope will be projected onto a monitor, allowing a thorough evaluation of the inside of the your joint. Once the problem has been diagnosed and any necessary treatment identified, your surgeon will insert specialized instruments for tasks such as shaving, cutting, grasping, suture passing and knot tying, as well as a special device often used to anchor stitches into bone. Your incisions may be closed with stitches or small adhesive bandage strips, and then covered with a large, soft bandage.

You will remain in the recovery room for 1 or 2 hours after surgery. During that time, nurses will monitor your responsiveness and recovery from the anesthesia, and provide pain medication, if needed. When you are ready to be discharged, you will be given instructions covering medications, dressing care and other requirements. You will need someone to drive you home and stay with you for at least the first night.

Recovery

Recovery from arthroscopy is often faster than recovery from open surgery, however, your shoulder joint will need weeks or months to recovery completely. You can expect some pain and discomfort for at least a week after surgery. If your surgery was extensive, it may be many weeks before the pain subsides. Ice will help relieve discomfort and swelling, and your doctor may also prescribe pain medicine, if needed.

Although it does not affect how your shoulder heals, lying flat may pull on your shoulder and cause discomfort. Many patients are more comfortable sleeping in a reclining chair or propped up in bed during the first days following the procedure.

Several days after surgery, you should be able to replace your large bandage with simple adhesive bandage strips. Once your wounds stop draining you may shower, but avoid soaking or scrubbing your incisions. A sling or special immobilizer is typically needed to protect your shoulder after surgery. Discuss how long the sling will be required with your orthopaedic surgeon.

Rehabilitation

Rehabilitation plays an important role in getting you back to your daily activities. Your surgeon will develop an exercise program to help you facilitate motion, strength, and return of function to your shoulder. This may include basic exercises to begin at home, or for more advanced surgeries, physical therapy may be prescribed after the first postoperative visit. The physical therapy prescribed will depend on the type and severity of your problem and the surgery required. Your surgeon will tell you when you can return to work, driving and normal daily activities.

Complications

Although most patients experience no complications from shoulder arthroscopy, as with any surgery, there are some risks. These are typically minor and treatable. Potential problems include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves. Your surgeon will discuss possible complications with you prior to your operation.

Outcomes

The time needed for complete recovery varies according to the patient, the condition of the joint, and the extent of damage and repairs required. If your repair was minor, you may not need a sling, your strength may return after a short period of rehabilitation, and you may be able to return to work or school within a few days of the surgery. Most complicated procedures require as long as several months for a full recovery. Although the process may seem slow, following your surgeon's guidelines and rehabilitation plan is vital to a successful outcome.