Shoulder arthroscopy is an operative method, which allows the minimally invasive diagnosis and treatment of shoulder injuries and diseases. Operation is conducted under general anesthesia. Similar to arthroscopy of other joints, in shoulder arthroscopy we also introduce the optic endoscope into the joint through a small skin incision. The camera on the endoscope transmits an enlarged picture of the interior of the joint on screen and so allows the surgeon to fully examine all the anatomical structures inside and beside the joint.
Shoulder arthroscopy was, due to high degree of technical complexity of the procedures, well established only in the last decade. Initially, arthroscopic shoulder operations were limited mainly to diagnostic procedures and simpler procedures such as a removal of loose bodies, bone spur removal and interruption of inflamed tendon of the long head of biceps. With the development of arthroscopic techniques and with improvement of instruments and technical equipment, also arise possibilities of implementation of more complex procedures inside the shoulder such as reconstruction of torn rotator cuff tendons, and reconstruction of labrum and joint membranes in various forms of continuous shoulder dislocations. With modern operational techniques and appropriate technological equipment and skills we can now treat most injuries and illnesses of shoulder joint arthroscopically.
Anatomy of the shoulder
Shoulder is an outstanding joint, because it allows the maximum flexibility of all the joints of our locomotor system. This kind of joint functionality is reflected in its complexity, and because of that, possibilities for injury of this joint are many.
Knowing the basic anatomical structure of the shoulder enables understanding the operating principle of this joint and mechanisms, occurrences of injuries, as well as the perception of the complexity of surgical procedure and rehabilitation after injury.
The basic shoulder structure, similar to other joints of locomotor system, is consisted of bones and cartilage surfaces. In shoulder, joint is formed of scapula, humerus and clavicle. In proper conception, shoulder joint consist of three joints – the joint of humerus head and scapula (glenohumeral joint), the joint between acromial process of scapula and final part of the clavicle (acromioclavicular joint) and quasi-joint between the thorax and a scapula (scapulothoracic joint). For a proper function of the shoulder, the motion in all three joints has to be coordinated. Damage or injury of each of the listed joints can lead to disturbed function of the whole shoulder.
Course of shoulder arthroscopy
Shoulder arthroscopy is a surgical procedure that is carried out under general anesthesia. For the implementation of diagnostic shoulder arthroscopy two skin incisions are usually sufficient, each of a length of 0.5-1cm. Through the first, which is located on the back of the shoulder, we lay in the optics, and through the second one, which is in the front, we lay in a probe, with which we examined the interior of the joint. In the case of complex procedures, we do 1-3 additional skin incisions, usually each of them not measuring more than 0.5 cm in length. These additional approaches are needed for introducing instruments, stitches and other surgical implantations in the joint. Similar to knee arthroscopy, shoulder joints are during surgery also filled with sterile saline. It is a solution of NaCl, which flushes the joint, expands it a little and in this way provides good visibility inside the joint.
Shoulder arthroscopy is usually done in two steps. In the first part of the procedure we introduce the arthroscope in the glenohumeral joint, which is the main shoulder joint, where humerus and articular surface of scapula called glenoid are joined. In case of problems associated with instability of the shoulder joint, damage of glenoid labrum (meniscus-like structure that surrounds the articular surface of glenoid scapula), problems related to the tendon of the long head of biceps or partially torn any of the rotator cuff tendons from the inside, are discovered already by examining the inside of the glenohumeral joint. During such diagnostic examination of the joint, we can also detect degenerative changes or injuries on the cartilage surface of the head or humerus or glenoid scapula, loose bodies in the joint, bone defects as a result of repeated dislocations or even a complete rupture of tendons of the rotator cuff. We continue the diagnostic arthroscopy with applying the arthroscope into subacromial bursa. This structure, which is located between the outer surface of rotator cuff and the inferior surface of acromion and it is responsible for smooth scrolling of rotator cuff tendons under the bone surface of acromion in a healthy shoulder. With introduction of optics into subacromial bursa and with its extension with saline solution, we create a space that allows a suitable examination of outer surface of the rotator cuff and inferior surface of acromion.
During shoulder arthroscopy, depending on the type of injury or illness, we perform the planned surgery. That way we can treat conditions of rotator cuff tendon, problems associated with instability and chronic inflammation of the tendon of long head of biceps, chronic instability of the shoulder joint, degenerative changes in the area of acromioclavicular joint, subacromial tightening due to excessive curvature of acromion. These were just few most common situations.
Given the extensiveness and complexity of the procedure, the operation time varies from 20 minutes to two hours. After surgery the patient has to rest for a shorter period of time in the recovery room and on the same day he is released home.
The advantages of arthroscopic shoulder procedures
Arthroscopic surgical techniques allow minimally invasive treatment of injuries and illnesses of joints, and have several advantages over the traditional surgery.
In shoulder joint, arthroscopy allows us a more extensive examination of the whole joint, and shows us numerous anatomical structures that are not even available to analyze in the conventional surgery. A great advantage of arthroscopic procedures on shoulder is also that it enables us to maintain the deltoid muscle. This is the main muscle that covers the entire surface of shoulder joint and assures the main force in moving hands away from the body. Keeping this muscle in arthroscopic surgery is associated with minor pain in postoperative period, no scarring and adhesions, which may otherwise occur between the inferior surface of the deltoid muscle and rotator cuff tendons, the recovery is also more rapid. Arthroscopic surgery on shoulder also have a significantly lower risk of postoperative infection on the surface and inside of the joint, the risk of excessive bleeding and nerve damage, which are near the shoulder joint, is lower. Due to small skin cuts, the cosmetic effect of the operation is also significantly better.
Indications for shoulder arthroscopy
- Chronic subacromial compression
• Rotator cuff tear
• Reccurring shoulder dislocations
• Chronic shoulder instability
• Bicipital tendinitis
• Calcific tendinitis
• Injuries and arthrosis of AC joint
• Labrum injuries
• Adhesive capsulitis
• Unexplained shoulder pain
Recovery after shoulder arthroscopy
Due to minimal invasiveness, recovery from arthroscopic surgery is in many ways much faster and easier than after the conventional one. After these types of operations there is less pain, in some cases the function of the joint is reestablished much faster. The actual recovery time depends on the type ofprocedure performed and is relatively short in simple surgeries, like interruption of inflamed tendon of the long head of biceps, removal of loose bodies or resection of degenerative bone changes on the inferior surface of acromion. The rehabilitation is significantly longer after demanding reconstructive operations such as torn rotator cuff treatment and the operation of chronic instability, where beside the type of surgical procedure, the reconstituted tissue healing time influences on the time of rehabilitation. Rehabilitation after such surgery usually takes 4-6 months. If degenerative changes are already present in the joint or the tissues that have been reconstructed are strongly degeneratively modified and have poor healing potential, then it contributes to a substantial extension of the rehabilitation process and also affects the less favorable end result of such treatment.
Immediately after the operation, it is necessary to cool the operated shoulder with ice several time a day, which reduces swelling and joint pain. On discharge, the patient is prescribed an adequate analgesic therapy while also receiving instructions on permitted activities of operated arm. In the first few days after the surgery, it is generally recommended to rest the arm. After soothing the pain the patient can gradually begin to use his arm at everyday tasks.
Reconstructive procedures such as treating tendon rupture of the rotator cuff and shoulder instability operations are an exception. At the last ones a longer rest period is required and the rehabilitation is slower. At the medical examination after surgery, individualized program of physical therapy, which is adapted to the individual and to the type of surgical procedure performed, is prescribed.