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Arthroscopy Of The Shoulder

The Role Of Arthroscopy

Last updated on:
16/03/2012

Contributing Author: Guy Slowik FRCS

Arthroscopy can be used to diagnose a problem in the shoulder when tests don't give a definite answer as to what's causing the problem. More commonly, however, it is used to treat and correct a number of problems in the shoulder, including:

Shoulder Dislocations And Instability

The shallow ball-and-socket joint of the shoulder (the glenohumeral joint) is the most frequently dislocated major joint in the human body. In most instances, the shoulder dislocates as the upper arm bone (humerus) comes forward out of the joint. Backward dislocation is far less common.

Dislocations are treated by replacing the shoulder back into position and immobilizing it in a sling for a few weeks. This is usually successfully done under mild sedation, but sometimes a general anesthetic with the patient asleep is preferred. Occasionally surgery is required to relocate the joint back into its normal position.

Sometimes a tendency to experience further dislocations may develop, even without much force, following the first dislocation. This is known as an unstable shoulder.

  • The problem usually occurs because the capsule surrounding the joint has been stretched by the dislocation, or part of the labrum (the thickened tissue that surrounds and deepens the socket) has been torn off from the bone, thus making the joint less stable.
  • If non-operative treatment in the form of muscle strengthening exercises fails, surgery is recommended to stabilize the shoulder.
  • Surgery can be done either arthroscopically or by traditional open surgery to repair the damaged tissue.

Either way, the aim is to repair the shoulder damage and restore stability to the shoulder.

Arthroscopy aims to repair the shoulder damage in a dislocation by reattaching the torn labrum to the bone, and by tightening the stretched capsule lining the joint. But arthroscopy is not suitable for all types of shoulder instability.

Torn Rotator Cuff

The rotator cuff is the strong complex of tendons and muscles that helps stabilize the shoulder. One or more of the tendons in the rotator cuff may be torn either by:

  • A single injury (for example, a fall on an outstretched arm)
  • The constant irritation of repetitive overhead arm motions
  • Degenerative damage, due to wear and tear, as we age

In many instances, the reason for the rotator cuff injury is unknown.

A torn rotator cuff will cause pain at the top and outside of the shoulder when you raise or extend your arm. The shoulder may become weak, making it difficult to raise the arm far away from the side.

Depending on the size of the tear, arthroscopic surgery can be used to reattach the torn edge of the rotator tendon to the humerus bone with specialized stitches. Very large tears and complex tears are usually done as an open procedure, or through a combination of open and arthroscopic procedures.

For more information about rotator cuff injury, go to Rotator Cuff Injury.

Impingement Syndrome (Tendinitis And Bursitis)

Repetitive motion - or the normal wear and tear of aging - may cause irritation of:

  • The tendons of the rotator cuff or biceps tendon (tendinitis)
  • The bursa (bursitis), which is a sac that acts as a cushion between the top of the shoulder blade and the rotator cuff, allowing the smooth gliding movements of the rotator cuff tendon.

Impingement syndrome is the first stage of potential rotator cuff problems. It is called impingement syndrome because the rotator cuff tendons are "impinged" - that is, squeezed between the moving head of the upper arm bone and the acromion. This results in inflammation and swelling of the rotator cuff tendons.

Tendinitis and bursitis cause slowly increasing discomfort and pain in the upper shoulder or the upper third of the arm. Sleeping on the shoulder may be painful, and there may be pain when raising the arm away from the body or overhead.

In many cases, tendinitis and bursitis can be improved with rest, ice, and anti-inflammatory drugs such as aspirin or ibuprofen, in combination with physical therapy or with the use of a steroid injection.

If the condition does not respond to these conservative measures, arthroscopic surgery may be used to increase the space for the rotator cuff tendons, to allow them to glide freely, by removing some of the undersurface of the acromion bone and clearing the inflamed bursal tissue.

The biceps tendon, which passes through the shoulder joint, may also become inflamed. This is known as 'biceps tendinitis.'

Osteoarthritis

As we get older, our joints, including the shoulder, may suffer from wear and tear that can cause pain and discomfort. If medication can't control the discomfort, an orthopedic surgeon may suggest arthroscopy to shave and smooth the roughened surfaces of the joint and trim any damage to the rotator cuff.

Clearing out the debris often helps reduce the pain of arthritis. An arthroscopic "clean-out" or "debridement" is a significantly simpler procedure than total shoulder replacement, although total replacement may ultimately be required.

Arthroscopic surgery for osteoarthritis is unfortunately not always reliable; not everyone will benefit from this.

For more information about osteoarthritis, go to Osteoarthritis.

Loose Bodies

Sometimes, a shoulder injury can cause a fragment of cartilage or bone to come loose and float around in the joint. A number of arthritic and other conditions can also cause loose bodies inside the shoulder joint.

Depending on the size of the fragment and whether it is still attached, the orthopedic surgeon may decide to fix it back in place or remove it entirely. This type of procedure can be performed with arthroscopic surgery or traditional surgery, depending on the specific procedure necessary.

Nice To Know

Q. Why is the doctor recommending I have my shoulder repaired through a normal incision rather than arthroscopically?

A. Not all shoulder problems can be properly repaired using an arthroscope. Many surgeons believe that large rotator cuff tears, for example, are better treated by standard shoulder surgery. Similarly, a shoulder that is unstable in all directions will likely require open surgery. Moreover, shoulder arthroscopy is really still in development, and many surgeons are still not confident about the long-term results of certain repairs of shoulder problems with the arthroscope.

Need To Know:

What are the risks of shoulder arthroscopy?

As with any operation, arthroscopy carries a risk of infection, bleeding, and the risks associated with any anesthesia. Arthroscopy, however, has been shown to be safe with few complications. Risks specific to shoulder arthroscopy include:

  • Nerve injury. This is usually temporary and is due to the positioning of the arm during the procedure. Alternative positioning techniques and recognition of this complication by surgeons has now made it a relatively rare complication
  • Stiffness and limitation of motion. Most of the time, the physical therapy prescribed after the procedure will prevent this complication.
  • Re-injury. The shoulder may dislocate again, or the rotator cuff may tear again.
  • Failure to improve. The arthroscopic procedure may not correct the problem.

In the latter three cases, a second surgical procedure may be required.

 

 
 

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From Andrew Maynard - Chair of the University of Michigan Department of Environmental Health Sciences, with help from David Faulkner - 2013 Master of Public Health graduate.