Shoulder Surgery

Shoulder Arthroscopy

Arthroscopy is a surgical procedure where an instrument called an arthroscope is inserted through a tiny incision in the body. The device is fitted with a camera at the end that will let the surgeon view the area of surgery on a television screen. Shoulder arthroscopy as the name suggests is an arthroscopic procedure performed on the shoulder.

The Rotator Cuff

There is a group of muscles and tendons that hold together the shoulder joint called the rotator cuff. They hold the ball and socket joint in the shoulder and aid in proper movement. However, the tendons can tear due to overuse or accident. This is very common among sports persons as they are involved in rigorous physical activities.

The Anaesthesia

The anaesthesia in arthroscopic surgery depends on the patient and is decided by the anaesthesiologist. Most people are put under general anaesthesia but in some cases regional anaesthesia is also used. People who are put on local anaesthesia are also given medicine to make them very sleepy during the procedure.

Preparation for the Procedure

Your surgeon needs to know your past medical history before he/she can create a surgery plan for you. Be truthful regarding the kind of drugs and supplements that you take regularly. There will be medication as part of the surgery including anaesthetics that will be injected in your body and you don’t want to be in a situation where there is an allergic reaction. The following are two drugs that you should stop taking at least two weeks prior to the surgery:

• Ibuprofen
• Naproxen

You should check whether the brand of medicine you take has these in them. You should also stop taking other drugs and inform the doctor about it. Your doctor can also tell you which drugs are safe to be continued during this period. If there is a medical condition such as heart disease or diabetes for which you are undergoing treatment, first you should meet that doctor and tell him/her about your impending surgery. It goes without saying that you should stop drinking and smoking prior to the surgery. This is because smoking and drinking can slow down the healing of the bone and the surgery wound. In case you get a cold, flue or fever before the surgery, inform your doctor about it. On the day of the surgery, be confident and do not drink or eat anything 6 to 12 hours before the procedure. In case if there is a drug prescribed to you by the surgeon, take that with a little amount of water.

The Procedure

As mentioned before, the procedure involves the use of an arthroscope. In the beginning the surgeon will make one or more incisions in the shoulder and insert the arthroscope through the incision. The surgeon will then inspect the tissues in the joint, the bones, cartilage, tendons and ligaments. More than one incision is made to insert surgical instruments. These instruments are used to repair the damaged tissues. Removing damaged tissue is also possible in this method. To elaborate on the procedure, the surgeon can do any of the following on the shoulder:

• Repairing the Rotator Cuff - In this process, the surgeon will bring the edges of the muscles together. Sometimes rivets known as suture anchors are also used to help with attaching the tendons to the bone. The suture anchors come in either plastic and metal form and need not be removed post surgery.
• Impingement Syndrome Surgery – This is a process where the tissue that has been inflamed or damaged is cleaned out of the area above the shoulder joint. The under side of the bone called acromion can be shaved off and specific ligament called coracoacromial ligament can be cut.
• Shoulder Instability Surgery – The surgeon can repair the torn labrum, which is the rim of the shoulder joint. The surgeon can also repair the ligaments that are attached to this area. There is a form of tear called the Bankart Lesion on the labrum in the lower part of the joint. Yet another lesion that occurs with the labrum and the supportive ligaments is called SLAP, which stands for Superior Labral tear from Anterior to Posterior.

Depending on the kind of tear you have and the complications involved, the surgeon will perform any of the procedures mentioned above. Once he/she has completed the procedure, stitches will be used to close the incisions. Certain surgeons also take pictures for future reference during the surgery.

Type of Problems that Require Arthroscopy

Not all problems can be corrected using arthroscopy. The following are the cases where arthroscopic procedure can be used:

• Instability in the shoulder such as loose joint, slides and dislocation
• Tear or damage in the cartilage ring called labrum
• Rotator cuff tear
• Damage or tear in the biceps tendon
• A spur or inflammation around the rotator cuff
• Damage or inflammation to the lining of the joint
• Existence of loose tissue that requires removal
• Arthritis at the end of the collarbone or clavicle
• To facilitate movement of the shoulder joint or fix shoulder impingement syndrome

Post Surgery

The recovery time post an arthroscopic shoulder surgery can vary from 1 to 6 months and for the first week after the procedure, you may be required to wear a sling. Depending on the extent of the damage and the repair done, the patient may have to wear the sling for an extended period. The doctor will prescribe pain killers to control the pain in and around the wound. It won’t be possible to return to playing sports or involve in heavy physical activity unless the prescribed rest period is over and the surgeon confirms that the wounds have healed 100%. It is not only enough to rest but also involve in certain physiotherapy sessions that are designed to regain motion and strength in the shoulder.

Pros and Cons

Shoulder arthroscopy is considered an alternative to the more open surgery, which exposes the joint. This procedure is less painful and has fewer complications. It also requires the patient to stay for less time in the hospital and the recoveries are fast. The recovery time may extend as much as an open surgery depending on the complication. Though surgery can bring back stability in the shoulder, some people may get an instability after the arthroscopic procedure. Further, though the surgery can relieve pain in the shoulder, some people may not regain all the strength in the joint. The patient should also be ready to switch to an open surgery if the damage is more severe than one that can fixed using a shoulder arthroscope.

Shoulder Arthritis

Arthritis by definition is an inflammation in the joints of a person. Every year millions of people around the world are diagnosed with one type of arthritis or another. Arthritis in the shoulder joint is one that has no cure but fortunately there are many treatment options.

Anatomy of the Shoulder Joint

There are three bones that make up the shoulder joint viz. the collar bone, the shoulder blade and the upper arm bone, technically known as the clavicle, scapula and humerus respectively. The scapula contains a rounded socket called glenoid onto which the head of the humerus fits.

It is curious to know that the shoulder joint itself contains two joints. The first one is where the clavicle meets the tip of the scapula, called acromion. Thus the joint is known as acromioclavicular joint. The other one is where the humerus fits into the glenoid, also known as the glenohumeral joint.

There is a group of 4 tendons that hold the humerus centred in the glenoid. They are collectively called the rotator cuff.

In order for your physician to determine the right type of treatment, he/she needs to know which joint has been actually affected by arthritis and also the type of arthritis that has affected the joint.

Types of Shoulder Joint Arthritis

There are 5 different types of arthritis that can affect your shoulder. They are described as follows:

Rheumatoid Arthritis

This is a chronic disease, which can affect several joints in the whole body. The peculiar aspect of Rheumatoid Arthritis is that it is symmetrical i.e. it affects the same joint on both the sides. The joints in the human body are covered with a lining known as the synovium. Its purpose is to lubricate the joint so that it is easy to move. When a person gets affected by rheumatoid arthritis, the lining swells, creating a stiff and painful joint.

What further aggravates the situation is that this is an autoimmune disorder, i.e. the defences that are supposed to protect the tissues instead resort to damaging them. Thus the cartilage and the ligaments get affected and the bone softens.

Osteoarthritis

Osteoarthritis is a condition where the smooth outer covering of the bone called articular cartilage gets destroyed. It is also known as the wear and tear arthritis because it is caused by the wearing away of the cartilage. The result of this is that the cartilage turns frayed and rough which in turn cause the protective space between the bones to decrease. When the person moves the shoulder joint, the bones start to rub each other causing pain.

This is a condition that is commonly seen among people who are over 50 years of age. Osteoarthritis is more frequent in the acromioclavicular joint compared to the glenohumeral shoulder joint.

Avascular Necrosis

Necrosis as the name suggests involves accumulation of dead cells. When the blood flow to the head of the humerus is disrupted the bone cells of that area start dying. This condition is called Avascular Necrosis and its development can destroy the shoulder joint and cause arthritis.

The collapse of the bone is gradual as dead cells accumulate. Thus Avascular Necrosis is a condition with many stages of development. The gradual collapse of the bone damages the articular cartilage, causing arthritis. In addition to damaging the head of the humerus, it also affects the glenoid socket.

The known causes of Avascular Necrosis include heavy alcohol consumption, high steroid use, traumatic injury and sickle cell anaemia. If no cause can be identified, it is called idiopathic avascular necrosis.

Rotator Cuff Tear Arthropathy

There is a higher chance of developing arthritis if there is a chronic rotator cuff tendon tear. This is because the torn rotator cuff is rendered incapable of holding the head of the humerus in the glenoid, which means the humerus can move up and rub against the acromion. Obviously this will damage the cartilage thereby developing into arthritis. This is the worst case scenario because now the shoulder has a large rotator cuff tear combined with severe pain and weakness caused by arthritis.

Post-traumatic Arthritis

This is just another kind of osteoarthritis, which develops after a traumatic injury such as a fracture or dislocation in the shoulder.

Symptoms of Shoulder Arthritis

Limited range of motion

Another symptom of arthritis is that the shoulder’s motion range will get limited. The patient will find it difficult to do things like lifting the arm to reach for something or to wash the hair. There are also uncanny noises such as clicking, grinding or snapping that can be heard when the shoulder is moved.

Pain

While diagnosing for shoulder arthritis, one must first check for pain, which is the most common symptom. The pain is known to be aggravated when there is activity and have been observed to worsen over time.

Depending on the type of joint affected, the area that pains also varies. For instance, a pain that is centred in the back of the shoulder is indicative of a glenohumeral shoulder joint arthritis. This pain is also intensified when there is a change in the weather, which can be considered a good symptom for arthritis. Some patients have also reported that there is a pain deep in the joint.

If the pain is centred on top of the shoulder, then it is indicative of an acromioclavicular joint arthritis. Unlike the former type, this pain can radiate i.e. it can spread to the side of the neck as well.

In case the pain is spread throughout the shoulder, then there is a fair chance that the patient is suffering from rheumatoid arthritis, which affects both the joints.

As the condition worsens, any type of movement would cause pain and there will be regular pain that makes sleeping very difficult.

Shoulder Examination

The doctor will look into many aspects regarding your condition before suggesting the best treatment. The following are some of them:

• Tenderness to touch
• Weakness in the muscles called atrophy
• Signs of injury to the tendons, ligaments and muscles around the joint
• Extent of passive and active ranges of motion
• Involvement of other joints
• Grating or rough sensation called Crepitus within the joint during movement
• Sense of pain while pressure is applied to the joint

X-Rays

X-ray photography is extensively used in the detection of shoulder arthritis. This is because X-ray images can show details of dense and rare structures in the bone, which helps the physician to distinguish between the types of arthritis that has affected the patient’s shoulder.

X-ray photographs not only show the dense and rare regions of the bone but also the formation of certain bone spurs known as osteophytes. In addition to checking the X-ray image, the doctor may also inject an anaesthetic into the joint and see whether the pain is relieved. If it does, then it might be indicative of arthritis.

Treatment of Shoulder Arthritis

There are both surgical and non-surgical treatments available for shoulder arthritis. The doctor may first recommend the non-surgical one before moving onto the surgical procedure.

Non-Surgical Method

The doctor will first advise you to take rest or vary the activities that you routinely perform. This will be complimented by physiotherapy exercises to improve the shoulder’s range of motion. To reduce pain and inflammation, the physician can prescribe Non-Steroidal Anti-Inflammatory Drugs such as aspirin and ibuprofen. It is also possible to reduce the pain dramatically by injecting corticosteroids into the shoulder.

Icing the shoulder for twenty minutes to half an hour for three times a day can ease the pain and reduce inflammation. In the case of patients suffering from rheumatoid arthritis, drugs such as methotrexate are often prescribed to modify the disease.

Changing the diet is another method to ease the pain. Doctors may ask you to take supplements such as chondroitin sulphate and glucosamine with food. However, there is little medical evidence to support this idea.

Surgical Method

It is obvious that if non-surgical methods fail, then the only other option is surgery. This method is also recommended if the shoulder pain leads to disability. There are many procedures involved in the surgical method. The following are some of them:

Arthroscopy

Arthroscopy is a simple procedure employed to treat cases such as glenohumeral arthritis. An arthroscope, which is a small camera is inserted into a small incision in the shoulder so that the surgeon can see the area on a TV screen. Further incisions can be made to insert more instruments to perform the surgery. In this process, the surgeon will clean the inside of your joint, a process called debriding. The only defect of this procedure is that even though it relieves the pain, it will not eliminate the arthritis and may require further procedures in the future.

Shoulder Joint Replacement

Joint replacement or arthroplasty is a procedure where an entire joint is replaced with an artificial one called prosthesis. This is a recommended method for arthritis that is very advanced in the glenohumeral joint. Conventionally, the total shoulder arthroplasty mimics the normal anatomy of the shoulder. The following are the types of arthrosplasty available for the shoulder:

Hemiarthroplasty

As the name suggests, only the head of the humerus is replaced in this method.

Total Shoulder Arthroplasty

In this procedure, the both the head of the humerus and the glenoid are replaced. The glenoid is fitted with a plastic cup and the humerus is given a metal ball on its top.

Reverse Total Shoulder Arthroplasty

This is the reverse of Total Shoulder Arthroplasty in that the humerus is given the plastic cup while the glenoid is given the metal ball. Some people with cuff tear arthropathy get relief by reverse total shoulder arthroplasty as compared to regular total shoulder arthroplasty.

Resection Arthroplasty

Done arthroscopically, this is perhaps the most commonly used surgical procedure to treat acromioclavicular joint arthritis. The procedure involves removing a small portion at the end of the clavicle so that scar tissues can grow into the void that is created.

Recovery and Complication

Surgery is usually a better treatment for arthritis in the shoulder. It is effective in relieving the pain and also restoring motion in your shoulder. However, your recovery time depends on the kind of surgery performed on you and the severity of your condition.

There is always a risk factor involved in every surgery and shoulder surgeries are no exception. The main issues that arise include infection, blood clots, bleeding or damage to blood vessels or nerves. Before you undergo the surgery, your surgeon will discuss these possibilities with you.

Ongoing Research

Shoulder arthritis is a hot topic of research in the field of medical science. This is because it is still not clear why certain people get arthritis while certain others don’t. This mystery is widely studied by doctors round the globe. A sub-field in this research is the application of joint lubricants shoulders. These lubricants are at present used widely in knee arthritis. Rheumatoid arthritis treatment using new medicines are also under investigation.

In addition, surgical treatments including improvement of shoulder replacement methods are being researched. This line of research includes testing different prosthesis designs for the shoulder. Another sub-field is the usage of biological materials to restore the cartilage of the arthritic shoulder. If successful, this can foster natural healing to a great extend.