Arthroscopy is a method of joint surgery (arthrosis - joint, scopia - visor) that allows you to look inside the joint without having to open it. The arthroscopic procedure is characterized by low invasiveness - the surgeon makes small incisions (8 mm), which are used to insert the camera (arthroscope) and tools into the center of the joint filled with saline. The conventionally defined shoulder arthroscopy most often covers not only the joint, but also the space of the so-called the subacromial bursa outside the joint, the area of the adjacent shoulder-clavicular joint and the tendon of the long head of the biceps muscle. Shoulder arthroscopy is very complicated and should never be performed by young surgeons inexperienced in arthroscopy.
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Structures important for shoulder function
Anatomically speaking, the shoulder complex consists of the proximal epiphysis of the humerus, the clavicle and the scapula. Within the shoulder area, there are joints and functional connections:
The humerus-scapular joint (shoulder joint) - connects the humerus with the scapula,
Shoulder-clavicular joint - connects the collarbone with the scapula,
Scapula that travels along the back of the chest.
The shoulder joint ("shoulder joint") is formed by the head of the humerus and the articular cavity of the scapula complemented by the labrum. The volume of the humeral head is much greater than the cavity in the scapula, thanks to which the shoulder joint is very mobile. At the same time, the shoulder joint is most vulnerable to the uncontrolled displacement of the articular surfaces in relation to each other and is more likely to dislocate than other joints.
The role of the capsule and the ligaments of the shoulder joint that strengthens it is to inhibit the displacement of the humeral head in relation to the acetabulum of the scapula. The correct shape of the labrum is of great importance for the mechanical stability of the shoulder. However, the proper functional stability of the shoulder is provided by the muscles, the tension of which increases the stiffness of the capsulo-ligament system. In addition, the muscles act as dynamic shoulder stabilizers because, as they contract, they steer the forces acting on the shoulder joint in the correct direction. Part of the tendon complex responsible for the active stabilization of the shoulder joint is spatially arranged in such a way that it forms the so-called rotator cuff - these are the tendons of the supraspinatus, infraspinatus, subscapular and rounded minor muscles. These muscles have initial attachments on the scapula and end at the proximal epiphysis of the humerus. The sub-shoulder bursa facilitates easy sliding of the tendons in the sub-shoulder space.
Movement in the shoulder joint allows the arm to be raised to shoulder level. The movement of the arm over 90 degrees is due to the rotation of the scapula and the movement in the sternoclavicular shoulder-clavicular joint. This raises the acetabulum and changes the position of the upper limb so that we are able to reach for objects located high above our head.
Indications for shoulder arthroscopy
The word arthroscopy does not describe the type of surgery - that is, what will be treated during it, but it describes how the surgery is carried out by means of an endoscopy of the joint. The most common arthroscopic diseases and injuries of the shoulder include:
sub-neck tightness,
damage to the rotator cuff, massive calcification of the cone tendons,
labrum damage,
structural shoulder instability,
symptomatic damage to the articular cartilage,
instability of the shoulder-clavicular joint,
the presence of free osteochondral bodies.
Shoulder arthroscopy - types of operations
Arthroscopic treatment of subacromial tightness
Sub-chock space is a condition in which the tendons of the rotator cuff are trapped in the sub-chock space. This leads to chronic irritation of the muscle tendons when making arm movements. The main symptom of sub-shoulder tightness is pain in the shoulder joint, making it difficult to perform overhead activities.
The primary causes of narrowing of the subacromial space include osteoarthritis (osteophytes) and congenital defects in the structure of the bones (e.g. the brachial process or the greater tubercle of the humerus). Another cause of sub-brachial constriction is shoulder instability, which is where the humeral head abnormally moves upward, causing the rotator cuff tendons to be pressed against the shoulder arch. The situation may be worsened by the presence of calcifications within the tendons, as the tendons thicken and need more space to move smoothly in the canal under the brachial process.
The aim of the surgery is to increase the subacromial space by changing the shape of the shoulder process (acromioplasty) and / or removing any bone growths narrowing the subacromial space. If the cause of the tightness is mechanical shoulder instability, the operation will aim to obtain stabilization through the plasticization of the capsule and labrum. Shoulder arthroscopy can also remove any calcifications within the tendons.
Subacromial tightness syndrome with damage to the supraspinatus tendon
Untreated subacromial tightness led to abrasion and complete damage to the supraspinatus tendon. The treatment for such damage is arthroscopic reconstruction. It should be remembered that diagnosed diseases in time and the introduction of appropriate rehabilitation treatment can prevent this type of damage.
Arthroscopic treatment of rotator cuff tendon injury
The tendons of the rotator cuff muscles can be injured as a result of acute trauma or as a result of the accumulation of microtraumas associated with subacromial tightness. The tendon of the supraspinatus muscle, which is responsible for lifting the arm sideways (abduction movement), is most often torn. Symptoms of damage may vary widely in patients. Some patients have a satisfactory range of shoulder motion and no pain after tearing one of the rotator cuff tendons, while others have very severe discomfort and a small range of motion despite minor damage.
Patients in whom surgical repair of the rotator cuff is indicated include:
athletes - if the full efficiency of the shoulder girdle is crucial for the sports discipline practiced,
people who have undergone rehabilitation and other conservative treatment methods, but still experience shoulder pain that hinders everyday functioning,
manual workers performing work related to lifting arms up or carrying heavy loads,
people with severe damage to the rotator cuff, which may lead to serious biomechanical disorders and secondary overload changes in the shoulder.
If there are clear indications for surgical repair of the rotator cuff, an arthroscopic procedure is performed, during which the tendons are stitched in their anatomical position. The surgeon uses special sutures and anchors for this purpose. To speed up the healing process, the operator can make small micro-fractures of the bone to naturally increase the healing potential and tissue fusion. It is also possible to use regenerative medicine methods, e.g. plasma obtained from the patient's own blood.
The time since the injury is not without significance. In the event of tendon damage, the muscles contract and gradually atrophy. After a longer period of time, it is impossible to perform the repair procedure (sewing the tendons).
Shoulder arthroscopy with reconstruction of the rotator cuff
Shoulder arthroscopy with visible arthroscopic anatomy of the shoulder. There is visible damage to the subscapular muscle tendon (SSC), inflammation with damage to the tendon attachment of the long head biceps (LHB) and damage to the supraspinatus tendon (SSP). The film shows the anatomical, complete reconstruction of the rotator cuff tendons, guaranteeing a quick return to full fitness.
Shoulder arthroscopy with reconstruction of the subscapular muscle tendon
Arthroscopic treatment of labrum injuries
Labral lesions often coexist with partial rupture of the rotator cuff and / or damage to the clavicular joint. These types of injuries are typical of an athlete who performs throws and repeated jerky movements of the arm
It is worth emphasizing that in patients with traumatic injuries of the labrum, mechanical instability of the shoulder joint occurs, which may result in habitual dislocation of this joint in the future. Therefore, it is very important to restore the correct position operationally. Sometimes the labrum surgery alone is not sufficient and there is a need to perform additional non-anatomic procedures to improve shoulder stability (techniques with ligation of the articular bag, using the subscapular or bone tendon - translocation of the coracoid process).
Shoulder arthroscopy is aimed at repairing the labrum, i.e. sewing and stabilizing the labrum fragment with special anchors. If the labrum is irreversibly damaged or there is severe bone damage to the joint, or the development of high joint hypermobility, the above-mentioned procedures must be performed - it is not always possible to perform them fully arthroscopically.
The upper part of the labrum connects to the tendon of the biceps muscle, and therefore damage to the tendon of this muscle is often accompanied by simultaneous damage to the labrum. This type of injury is called SLAP (Superior Labrum Anterior Posterior). The so-called tendonesis, i.e. displacement of the tendon attachment from the scapula to the humerus.
Arthroscopic treatment of shoulder instability
Shoulder instability is a tendency for unwanted excessive displacement of the humeral head relative to the acetabulum of the scapula. Patients with shoulder instability report a feeling of jumping and running away of the shoulder, which is accompanied by pain. Under conditions of instability, there is an increased risk of recurrent shoulder dislocations, which can lead to serious sequelae, e.g., damage to the bony acetabular edge and head of the humerus (Hill-Sachs injury) or rupture of the anterior capsule with labral detachment (Bankart injury).
Surgical treatment of shoulder instability includes plastic surgery of the articular capsule and labrum, and sometimes also bone stabilization by cutting and displacing the coracoid process of the scapula to the anterior edge of the acetabulum to prevent anterior dislocation of the humerus. The choice between arthroscopic labelectomy and the need for open surgery depends on the severity of the injury and the experience of the operator. After surgery, physical therapy is required to restore normal muscle function to restore the dynamic stability of the shoulder.
In the case of typical shoulder functional instability resulting from poor posture and imbalance of shoulder girdle muscle tension (without damage to the labrum), rehabilitation is sufficient.
Arthroscopic treatment of the shoulder-clavicular joint
Movement in the acromioclavicular (AC) joint allows the shoulder to be extended, retracted, raised and lowered. Maintaining mobility in the collarbone joints is required to raise the arm above the level of the shoulder joint. The most common cause of joint damage and secondary degenerative changes is a fall on the shoulder. If the lesions fail conservative treatment, arthroscopy is considered.
Shoulder clavicle resection
The indications for the procedure are pain in the AC joint of degenerative origin and / or sub-shoulder tightness caused by the presence of bone outgrowths (osteophytes) on the lower edge of the joint. The procedure consists in cutting the shoulder end of the collarbone up to 5-10mm with osteophytes. After arthroscopy, the pain is reduced and the range of motion in the shoulder joints is improved.
Early surgery for dislocation of the shoulder and collarbone joint
The destabilization of the shoulder-clavicular joint is described by the Rockwood scale. Depending on the degree of damage, it is treated conservatively or surgically. In the early period - up to 3 weeks after the injury, a relatively simple treatment with Kirschner rods is possible, which requires additional guidance in the orthosis after the procedure and care for protruding percutaneous wires for 6 weeks. Another method is to assume the so-called hook plate, which stiffens the connection of the collarbone with the shoulder process while the ligaments heal and does not require the care of protruding rods or the wearing of an orthosis. After 3 months, the titanium hook plate can be removed and the joint remains stable. If the procedure is not performed at an early stage, it will not be possible to restore the stability of the joint with the above-mentioned methods - then more complicated reconstructions with the use of polyester tapes and titanium suspensions (indirectly arthroscopically) or an open procedure with a tendon collection from a different place from the patient will have to be performed.
Reconstruction of the coro-clavicular ligaments
The indication for the procedure is symptomatic old instability of the shoulder-clavicular joint due to dislocation of the shoulder-clavicular joint. The surgeon makes holes in the collarbone and below the underlying coarse process of the scapula, through which he performs a graft taken from the thigh muscles (eg slender muscle) or places an artificial ligament such as LARS or AC Dog Bone - "Arthrex".
Surgical synovectomy of the shoulder joint
The synovial membrane is the inner layer of the joint capsule, the role of which is to produce synovial fluid. Synovial inflammation may occur in the course of rheumatoid arthritis (RA), secondary to fibrosis and post-inflammatory adhesions of the capsule and destruction of the articular cartilage. To relieve pain and improve shoulder mobility, it is sometimes necessary to undergo synovectomy, which involves removing the inflamed synovium. The procedure is performed during periods of RA symptom relief (remission). During arthroscopy, simultaneous removal of the inflamed subacromial bursa, free articular bodies and degenerative-productive changes within the shoulder-clavicular joint can be performed.
Arthroscopic capsulotomy - release of joint capsule adhesions
A disease that disrupts the structure of the capsular-ligament apparatus of the shoulder joint is also obstructive capsular inflammation - the so-called shoulder frozen. Inflammation of the shoulder joint leads to the formation of adhesions, shrinkage of the capsule and severe limitations of the range of motion.
Treatment of a frozen shoulder is difficult and long-lasting - inflammatory changes and tissue remodeling last up to 3 years. In some cases, rehabilitation of the shoulder joint is insufficient - if a satisfactory range of motion is not achieved through rehabilitation within six months, an attempt is made to capsulotomy, i.e. targeted cutting of the joint capsule.
Qualification for arthroscopy of the shoulder joint
Qualification for shoulder surgery is complicated and complex - it must first of all take into account the patient's function and expectations regarding the level of pain, range of motion and fitness after the procedure. The patient must be aware of the sense and the need to undergo rehabilitation after surgery, especially after arthroscopic repair of the rotator cuff . In this case, surgery is only the first step for the patient to regain pre-injury fitness.
Nowadays, diagnostics with the use of shoulder ultrasound and magnetic resonance imaging of the shoulder has eliminated the need for diagnostic arthroscopy of the shoulder, so the orthopedic surgeon can set a specific goal and plan the process of surgical treatment of the shoulder based on imaging tests, clinical tests and symptoms reported by the patient.
Preparation for arthroscopy of the shoulder joint
Two weeks before the procedure, basic tests should be performed: blood count, electrolyte levels, liver tests, chest X-ray and heart ECG. If a patient is being treated for a chronic disease, additional tests are sometimes necessary. Before the procedure, a short visit to the anaesthesiologist takes place, during which the anaesthesiologist confirms the qualification for the procedure and selects the anesthesia. It should be remembered that even short-term infections of the upper respiratory tract or throat disqualify the patient from arthroscopy.
Rehabilitation preparation significantly facilitates the progress of rehabilitation after surgery. A good physiotherapist will safely prepare soft tissues and strengthen selected muscles so that the patient returns to activity as soon as possible after the procedure. In the case of chronic diseases or minor injuries of the shoulder, professional rehabilitation very often (much more often than in the case of other joints) allows to avoid surgical treatment.
Shoulder arthroscopy - the course of the procedure
The procedure is most often performed under general anesthesia, but under certain circumstances the procedure can be performed under anesthesia of the brachial plexus while keeping the patient aware. The patient is placed in a semi-sitting or lying position on his healthy side. The upper limb can be placed on a special lift, thanks to which the surgeon has convenient access to the structures of the shoulder complex.
During the operation, usually 2 or 3 surgical accesses (portals) are performed through which the arthroscope and surgical instruments are inserted. The first posterolateral portal is located in the extension of the posterior edge of the shoulder process, the second on the front surface of the shoulder laterally from the coracoid process of the scapula, and the third on the side of the shoulder. The operator can assess and repair damages to the shoulder structures, e.g. hyaline cartilage, labrum, articular capsule, biceps tendon, rotator cuff tendons, brachial process and its connection with the collarbone and subcapular bursa. The time of arthroscopy is 1 to 3 hours depending on the planned procedures during the operation.
After the repair procedures are performed, the portals are closed with sutures and secured with a dressing. The skin wounds after the treatment are minimal (up to 1 cm) and heal very quickly.
Procedure after shoulder arthroscopy - how to reduce pain after the procedure?
The operated upper limb is placed in a specific way or placed in an orthosis - the procedure depends on the procedures performed during arthroscopy. It is recommended to cool the shoulder area to reduce postoperative tissue swelling and reduce pain. For this purpose, a Game-Ready device can be used, which enables a combination of compression and effective cooling in a form that is comfortable for the patient. The patient can get up and walk on the first 24 hours after shoulder arthroscopy, and the next day he is discharged home. The stitches are removed about 10-14 days after the procedure.
Most patients do not experience any complications from shoulder arthroscopy. In the event of elevated body temperature (above 38.5 ° C), constantly increasing joint swelling and increasing shoulder pain, you should immediately contact your doctor.
Rehabilitation after shoulder arthroscopy
The course and time of rehabilitation after arthroscopy depend on the type of surgery, i.e. what structures have been repaired. The age, level of activity and functional goal determined by the patient prior to surgery should also be taken into account. Due to the multitude of procedures performed during the procedure, there is no single overall plan for rehabilitation after shoulder arthroscopy. The common goal of rehabilitation after shoulder arthroscopy is to restore safe limb patterns in the greatest possible range of motion.
Physiotherapy is an integral part of the treatment process and should begin on the first day after surgery. The time of immobilization of the shoulder in the orthosis varies depending on the type of surgery performed. Until the immobilization is removed, the patient should perform active wrist and finger exercises. An important element is the exercises that mobilize the shoulder blade, as well as exercises for the range of motion in the elbow joint (if the doctor allows them in the early postoperative period). We activate the movements of the shoulder and shoulder joints as soon as possible. If the shoulder is immobilized for too long, it can lead to contractures that are difficult to remove later.
The key to good targeted rehabilitation is the awareness of the biomechanics of the shoulder complex in the physiotherapist. After removing the immobilization of the shoulder joint, the patient usually functions in an unfavorable movement pattern, which consists in lifting and extending the shoulder forward with the arm rotated inwards. Moreover, the head of the humerus tends to move uncontrollably upward relative to the acetabulum of the scapula due to the excessive and premature activation of the deltoid muscle in front of the weakened supraspinatus.
The priority goal of rehabilitation after shoulder arthroscopy is to restore the correct brachio-scapular rhythm, i.e. the harmony of the movements of the shoulder blade and the bones of the shoulder:
The shoulder blade should not start moving earlier than 60-70 degrees, bending or abducting the arm. To this end, the physiotherapist should perform:
manual techniques and exercises aimed at normalizing the tone of the upper trapezius muscle, oblique muscles, levator scapula and pectoral muscles.
exercises that pave the way for the correct activation of the lower trapezius back muscle, which stabilizes the scapula and protects it against too early uncontrolled elevation. The therapy should also take into account the restoration of the correct function of the anterior toothed muscle, which is involved in the dynamic stabilization of the scapula in relation to the chest.
The head of the humerus should be effectively centralized in the acetabulum of the scapula to prevent functional narrowing of the subacromial space. The physiotherapist performs exercises that activate the supraspinatus first, and then the deltoid muscle.
At the beginning, exercises with the support of the hand on the ground (e.g. in a supported kneeling) dominate, which facilitate the activation of appropriate muscles stabilizing the shoulder girdle, and at the same time constitute safe movement patterns for the operated shoulder. Gradually, the exercises involve making movements of the upper limb up to 90 degrees, and then above the shoulder, always maintaining the correct patterns of the shoulder blade.
Sources:
Uszkodzenia barku [w:] Rehabilitacja Ortopedyczna, Brotzman S., Wilk K.; Urban&Partner, Wrocław 2008.
https://www.shoulderdoc.co.uk/article/1234
https://www.arthrex.com/resources/video/OH1G5WyHeUaQGQFQyHihiw/arthroscopic-reconstruction-of-chronic-ac-joint-dislocations
Important information
|
Duration of the procedure (depending on the method) |
1 - 3 hours |
| Basic tests required for the procedure | basic - preparation for surgery tab |
|
Anesthesia |
general or axillary block |
| Hospital stay | 6 - 12 hours |
| The period of significant dysfunction | 2 - 4 weeks |
| The period of limited dysfunction | 4 - 12 weeks |
|
Removal of stitches |
12 - 16 days |
| Change of dressings | every 3 - 4 days |
| Contraindications to the procedure | infection, some damage is old and irreparable |
Frequently asked questions about shoulder arthroscopy
Shoulder arthroscopy is a method of performing a surgical procedure involving the endoscopy of the shoulder joint area. The operator makes minimal incisions through which he introduces a camera (arthroscope) and surgical instruments. Arthroscopy enables effective treatment of many diseases and injuries of the shoulder, e.g. sub-shoulder tightness, rotator cuff injuries or instability of the shoulder and shoulder-clavicular joints. Arthroscopy is a minimally invasive procedure, thanks to which the patient leaves the hospital the very next day after the surgery.
Before qualifying for surgery, shoulder pain should be thoroughly diagnosed by an orthopedist. Clinical tests and imaging tests allow to determine the severity of degenerative changes and / or the extent of shoulder injuries. Surgery is performed if the identified changes hinder sports or professional activity, do not undergo rehabilitation treatment, or a shoulder injury can only be treated surgically. When planning treatment, the doctor also takes into account the patient's expectations regarding the level of shoulder fitness and readiness to undertake rehabilitation after the procedure.
The time of rehabilitation after shoulder arthroscopy depends on the extent of shoulder injuries, the type of procedures performed during arthroscopy and the patient's level of activity. Minor repairs of the shoulder structures are associated with several weeks of rehabilitation, other more extensive treatments require regular participation in rehabilitation for up to several months. It is worth noting that the recovery period is always shorter compared to open shoulder surgery.
