Certain shoulder conditions may require surgery – especially if conservative treatment options have not been successful. For example, a rotator cuff tear often requires the torn tendons to be surgically reattached to the bone in order to once again power the shoulder. Shoulder dislocations may also require surgery to repair the socket and prevent future dislocations. Most shoulder surgeries can be done through an arthroscope using between two and five small incisions, through which your surgeon places their surgical instruments in to make repairs. This type of surgery causes less harm to the healthy tissues and greatly reduces recovery time compared to traditional surgery. Some common shoulder problems that can be treated with arthroscopy include impingement, cartilage damage, rotator cuff tears, labral tears, biceps tendonitis, and arthritis – just to name a few. Often times, multiple shoulder conditions can be addressed at one time with arthroscopic shoulder surgery.
Shoulder arthroscopy is generally an outpatient procedure, which means you do not have to stay overnight in the hospital. For this procedure, you will typically arrive at the facility about an hour and a half before your actual surgery time. Our staff will check you in and will do a brief health check by listening to your heart and lungs and checking your blood pressure, pulse, and temperature before starting an IV to give you fluids and medications. The anesthesia staff will discuss your options for medications during surgery. Often times, a general anesthetic will be used in conjunction with a nerve block; the anesthetic will put you to sleep and the nerve block will numb your arm and shoulder both during and after the surgery. The nerve block can last up to 24 hours after surgery, which helps to manage the initial discomfort caused by the surgery. Your surgery time can vary depending on how much repair needs to be done in the shoulder, but can last anywhere from one to three hours.
Once you are in the operating room and fast asleep, your shoulder gets filled with saline. Saline helps expand your joint, making it easier for your surgeon to move surgical instruments and better see tissues. To be able to see inside of your joint, your surgeon puts an arthroscope into your shoulder, which is a tiny camera hooked up to a large computer screen. This magnifies the structures in your shoulder and allows your surgeon to view it with their own eyes. Once your surgeon can see in the joint, they insert surgical instruments through another incision and are able to repair the damaged tissues. Often times, multiple incisions are made to get to the different areas in your shoulder. While in your shoulder, your surgeon will usually fix any repairable damage they find, even if it was not expected before surgery. Even MRIs can miss damage in your shoulder, but during an arthroscopy, your surgeon can see exactly what is problematic. A Physician Assistant (PA) often helps your surgeon throughout surgery and understands everything that was done during your surgery.
After surgery, your surgeon will talk to your family about what they found while in the operating room and will explain any limitations you will have in using your arm. The degree of your injury and the amount of repair required will determine what type of sling you are placed in after surgery. You may be placed in a simple shoulder sling and be allowed to move your shoulder as tolerated by pain. If a larger repair is needed, you will be placed in a shoulder immobilizer sling which supports your arm at your side. Usually, your surgeon will ask you to just rest and recover for a few days after surgery. After those few days, you may take off the bulky dressing from surgery and will be allowed to shower. As you can imagine, it can be difficult to care for yourself after a shoulder arthroscopy, and you may find you need extra help. Your surgeon will be sure to tell your family if you have any specific restrictions after surgery.
After an arthroscopy, patients can expect to be seen by either their surgeon or a Physician Assistant in 7-14 days. At that time, they will discuss with you what they found during your surgery, what was done, and your recovery process. Sometimes you are able to begin moving your shoulder and returning to activities on your own, as you feel you are able. Other times you may require physical therapy. If you are in an immobilizer shoulder sling, you are often unable to move your surgical arm, other than small circles for six weeks. After that time, you will typically begin physical therapy to regain motion of your shoulder and eventually progress to strengthening exercises. On average, it takes most patients three to four months before they are back to their daily activities; however it can take up to a year before they no longer notice any shoulder pain.
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Impingement and Arthroscopic Decompression
Patients with shoulder impingement, or pinching of the rotator cuff, often cannot alleviate their pain without surgical intervention. The rotator cuff has only a small space to pass through near the top of the shoulder. There can be scar tissue or bone spurs that press down into that small space and cause pinching. If the pinching is not alleviated, it can lead to tearing of the rotator cuff. This is similar to wearing a hole in the knee of a pair of jeans. If you keep kneeling and rubbing the knee of your jeans, the fabric will thin and eventually the fibers of the jeans will break and create a hole. The rotator cuff tendons can catch and rub on bone spurs, initially causing pain and weakness, and progressing to partial or even complete tendon tears.
During an arthroscopic decompression, your surgeon will use surgical instruments to go in the shoulder space and remove any bone spurs and scar tissue. This creates more space for your rotator cuff to pass through. After a simple decompression, you will go home in a shoulder sling and are able to use your arm as tolerated. Your surgeon will tell your family exactly what your restrictions are after surgery. The initial recovery for a decompression is relatively short; however the surface that the spur was removed from can be sore for a few months following surgery as it takes time for your body to develop a new hard covering on the bone. This procedure is typically very helpful for patients and the bone spurs rarely return.
Hard Cartilage Damage and Chondroplasty
The upper arm bone is shaped like a ball to fit neatly into a socket created by the shoulder blade; this is referred to as the glenohumeral joint. These bony surfaces are covered by hard cartilage and should ideally be smooth. If there is a defect or flap in the hard cartilage it can cause your shoulder to have a painful catch or click, which can limit the motion of your shoulder. A damaged hard cartilage flap can catch and damage the remaining healthy tissue in your shoulder. If the defect is relatively small, it can sometimes be polished and smoothed out with gentle motion exercises. If the hard cartilage damage is severe, surgical intervention may be required to remove unstable flaps of tissue.
A shoulder chondroplasty is an arthroscopic procedure to smooth out damaged hard cartilage. Once the problematic area is known, a surgical instrument is used to remove the fraying or flapped hard cartilage and smooth down the remaining tissue. After this procedure you are often placed in a shoulder sling and can begin to move your shoulder as you feel up to it. Your surgeon will tell your family exactly what your restrictions are after surgery.
Rotator Cuff Tears and Debridement vs. Repair
Surrounding the shoulder joint is a group of four muscles that help to rotate the arm and provide additional stability. Together, these muscles form the rotator cuff which is critical for the strength and power of the shoulder joint. The tendons of these muscles can become pinched or torn through daily use, a fall, or an injury. This can be very painful and can cause weakness in your arm. Over time, the rotator cuff can fray little by little and eventually create a partial or complete tear of the tendons. You can injure just one of the rotator cuff tendons or up to all four.
Most rotator cuff tears can be fixed with arthroscopic techniques or a mini open procedure. In the mini open procedure, one of the incisions gets expanded to 3-5 cm in length to better visualize the tissues without the arthroscope. In either case, if your rotator cuff is completely torn and pulled away from where it belongs, your surgeon will use anchors placed into your bone to reattach the torn tendon back to its proper location. The anchors have sutures attached to them, which are similar to a strong thread and are used to sew the tendon tightly back to the bone. The number of anchors and sutures depends on the severity and number of tendon tears. Usually, after a large rotator cuff repair, your tendons need time to heal and you will be placed in an immobilizer shoulder sling for up to six weeks after surgery. This prevents you from putting too much tension on the repair before the tendon heals to the bone, which could cause you to re-tear. If you have only small fraying of your rotator cuff or your tendons are not completely torn, your surgeon may simply debride (clean up) the damaged area. If this is the case, you will likely be placed in a simple shoulder sling and allowed to return to daily activities as tolerated. Your surgeon will tell your family exactly what your restrictions are after surgery. It can take anywhere from two weeks to two months before you return to daily activities following a rotator cuff repair. Often times, it can take six months to a year until your shoulder feels completely normal again.
Labral Repairs and Capsular Shift
Between the ball and socket is the labrum, a flexible rim of soft tissue, which helps increase the stability of the shoulder while allowing a wide range of shoulder motion. When the ball comes out of the socket, the injury is called a dislocation, which can injure the labrum. This can cause pain, popping, and a feeling of instability in your shoulder. The labrum can fray or completely tear causing a flap of tissue to catch within the shoulder joint.
This condition can be treated with an arthroscopy. If the labrum has small fraying, it will be cleaned up and smoothed out. For a completely torn labrum that requires repair, your surgeon will often use anchors made of a bone-like substance to sew your labrum back down to the bone. Over time, your body turns the anchor into your own bone. If you have dislocated your shoulder multiple times, you may have damage to the tissue surrounding the shoulder joint. If this is the case, your surgeon will tighten this tissue surrounding your shoulder and return your shoulder’s stability. The number of anchors and type of sling you are in after surgery will depend on the size and severity of your injury. If only a small repair of your labrum is needed, you will be placed in a simple shoulder sling after surgery and may lift light objects like a pencil, toothbrush, or fork with your surgical arm. If your shoulder requires a large repair, you likely be placed in a shoulder immobilizer sling for six weeks after surgery. Your surgeon will tell your family exactly what your restrictions are after surgery.
Bicipital Tendonitis and Tenodesis/Tenotomy
The bicep muscle runs from the elbow up to the front of the shoulder. It has two attachments within the shoulder. The long head of the biceps attaches to the labrum, a flexible rim of soft tissue that provides a cushion between the upper arm bone and shoulder blade. The short head of the biceps tendon attaches to a bony bump on the front of the shoulder blade called the coracoid process. When the long head of the biceps tendon becomes irritated and inflamed causing tendonitis, it can be very painful or even cause tearing of the tendon at its attachment. Sometimes the pain is hard to control with conservative treatments like oral anti-inflammatory medication, cortisone injections, or physical therapy; therefore, surgical intervention may be necessary.
In cases where surgery is necessary, your surgeon can use the arthroscope to release the long head of the biceps tendon from its attachment on the labrum. Since the short head of the biceps tendon is still attached to the shoulder blade, you will not lose strength or power in your arm. This can provide substantial relief for patients suffering from tendonitis. For the portion of the biceps tendon that was released, it can either be left unattached (tenotomy) causing only a slight bulge in the biceps muscle or it can be re-attached to a lower area of the upper arm bone (tenodesis). After this procedure, you are often placed in a simple shoulder sling and are allowed to lift light objects like a pencil, toothbrush, or fork with your arm. Your surgeon will tell your family exactly what your restrictions are after surgery.
Arthritis of the AC Joint and Distal Clavicle Resection
On the very top of your shoulder, the collarbone comes out to join the top of your shoulder blade to create the acromioclavicular (AC) joint. When the shoulder blade is pulled away from the collarbone, the injury is called a separation. Over time, your AC joint can develop wear-and-tear damage or arthritis. Arthritis can cause pinching of the soft tissue and can be very painful. Sometimes, oral anti-inflammatory medications or cortisone injections can help the pain, but if these treatments do not provide lasting relief, then surgical intervention is considered.
Your surgeon is able to use an arthroscope to visualize the AC joint and clear away the soft tissues. Using a special tool to shave bone, your surgeon removes about a half inch off the end of the collarbone. This provides more space within the AC joint and relieves pain since the bones are no longer rubbing together. If this is the only procedure you have, you are able to go home in a simple shoulder sling and use your arm as you are able. Your surgeon will tell your family exactly what your restrictions are after surgery. The surface the bone was taken from can be sore for a few months following surgery as it takes time for your body to develop a new hard covering on the bone. This procedure is typically very helpful for patients and the problem almost never returns.
Shoulder Arthritis and Total Shoulder Replacement
The upper arm bone is shaped like a ball to fit neatly into a socket created by the shoulder blade; this is referred to as the glenohumeral joint. These bones are covered by a hard cartilage, which provides a cushion between the bones when you move your arm. If the hard cartilage wears away, the bones can rub against each other to cause pain and stiffness. This is called osteoarthritis. If arthritis is limiting your everyday activities and you have not been able to manage your pain with medications, cortisone injections, or physical therapy, then a shoulder replacement might be an option for you.
A shoulder replacement (arthroplasty) is where the entire joint is replaced with metal and plastic. This procedure can be done in an inpatient or outpatient setting depending upon your health, medical history, and insurance. This means you may or may not spend a night in the hospital. The total shoulder replacement surgery involves separating the muscles in the front of your shoulder, the deltoid and pectoralis muscles, in order to access the shoulder in a nerve-free location. The rotator cuff is released to allow access to the shoulder joint. Your surgeon will replace the ball of your upper arm bone with one made out of surgical metal and replace the damaged cartilage of the socket with a surgical plastic insert. This traditional shoulder replacement surgery relies on your rotator cuff to power your shoulder in the same manner that a healthy shoulder functions.
If you have a large rotator cuff tear that is irreparable, then a traditional total shoulder replacement is not an option for you. In this case, you may have the option of replacing just the ball of the upper arm bone with an oversized ball or a reverse total shoulder replacement. In a reverse total shoulder, your surgeon will replace the ball of the upper arm bone with a rectangular plastic insert and the socket with a metal ball. After this type of surgery your shoulder will depend on the deltoid muscles instead of the rotator cuff to power and position the arm. Both surgeries provide you with a substantial reduction in pain.
You can expect to attend physical therapy after surgery, sometimes even starting as early as the next day. Although it can take up to a year, the majority of patients who undergo total shoulder replacement surgery feel much better than they had prior to surgery. You will find that you are able to move your shoulder with greater ease and without pain, making everyday tasks enjoyable again.