Shoulder Arthroscopy

What is it?

Shoulder arthroscopy

Shoulder arthroscopy is a keyhole procedure of the shoulder that can be used as a diagnostic tool or to treat a variety of pathology/conditions within the shoulder accurately. Common reasons for an arthroscopy are:

Diagnosis – when the cause of pain, stiffness or instability remains undetermined, even after clinical examination and investigation (X-rays, Ultrasound scan, MRI). Frequently, this results in demonstration of damage to cartilage, rotator cuff tendon or the biceps tendon, signs of arthritis or evidence of loose bodies (fragments of cartilage) floating around the joint, or inflammation in the sub-acromial space (see sub-acromial impingement).

Labral injury – the labrum is a rim of cartilage that surrounds the glenoid (the socket) of the shoulder joint. It is one of the structures that provides stability to the shoulder joint i.e. stops the humeral head from slipping out of position (subluxation or dislocation). With shoulder dislocation, the labrum may become detached from the glenoid and may require reattachment to stabilise the shoulder (see shoulder dislocation/instability and SLAP lesion).

Biceps tendon injury – the long head of the biceps tendon is found in the shoulder. Inflammation or damage to this tendon can cause pain in the shoulder, which typically radiates down the front of the upper arm. The tendon can rupture; this can be through a traumatic episode or lifting injury or through chronic tendon damage. More commonly, the tendon is partially torn, inflamed or swollen. Pathology of the tendon is also commonly found with rotator cuff tears and SLAP lesions). If non-operative treatment (anti-inflammatory medication, physiotherapy, avoidance of lifting) fails, then surgery may be performed: two main options for treatment of the tendon are to release the tendon from the shoulder allowing it to retract into the upper arm, relieving the discomfort (tenotomy) or releasing the tendon and reattaching it to the humerus just below the shoulder (tenodesis). The latter avoids the risks of biceps weakness, discomfort and the “popeye” appearance but is a more complex procedure.

Articular cartilage injury/damage – this is discrete, well localised damage sustained by the cartilage that lines the surface of ends of the bones that make up the shoulder joint. Naturally, these are extremely smooth surfaces (friction coefficient is almost zero) and thus any disruption of the surface can cause pain and restricted function. The cartilage can become loose resulting in locking of the joint or clicking. Arthroscopy allows assessment of the extent of the damage, stabilisation of the lesion (using a shaver), removal of loose fragments, and if deemed necessary, treatment of the lesion using specialised techniques e.g. microfracture. Mr Patel will discuss the criteria for treatment on an individual basis, in more detail.

Arthritis – this is non-discrete, more diffuse damage to the articular cartilage that occurs as a function of time (wear and tear) rather than a single traumatic or sports injury. Arthroscopy may be used to wash the joint out of loose fragments and “debris” which can offer temporary symptomatic relief. The extent and grade of arthritis can be accurately assessed which can then be discussed along with further pertinent treatment options.

Mr Patel also uses shoulder arthroscopy for a number of reconstructive procedures e.g. anterior stabilisation for shoulder instability, rotator cuff repairs or debridement or for the treatment of adhesive capsulitis or a degenerate acromio-clavicular joint.

Will I need any tests/scans?

It is likely that X-rays and an Ultrasound scan or MRI will be requested for most shoulder injuries. Please see the section Surgery FAQs to see if you will need any other tests e.g. blood tests before your surgery.

How is it done?

The operation is usually carried out under general anaesthetic. Often, the anaesthetist will discuss regional anaesthesia with you; this can be used to carry out the procedure under but also serves as a useful adjunct to post-operative pain relief. Regional anaesthesia for the shoulder involves a technique called inter-scalene block.

Shoulder arthroscopy often utilises multiple portals (small incisions <1cm) around the shoulder (usually 2-5). One allows a fibre-optic camera (arthroscope) to be inserted into the joint and the other portals allow various instruments to be introduced simultaneously under direct vision to treat the varied pathology safely and effectively.

Reattaching detached structures (e.g. rotator cuff tendon or labrum) requires the use of small bone anchors with extremely strong suture attached, which are bio-degradeable. Mr Patel will dicuss with you in detail if any such implants or other devices will be used in your arthroscopy.

At the end of the operation, steri-strips or one stitch is used to close each portal. Waterproof dressings and then a bulky dressing pad are applied to absorb the natural ooze from the joint. The arm is almost always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal.

Can I go home the same day?

More often than not, as with most arthroscopic surgery, this is a day case procedure. Occasionally an overnight stay is advised depending on post-operative comfort levels and time of day of the surgery.

What about after the operation?

You will see a physiotherapist before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises out of the polysling and light stretches, often with assistance (e.g. your other arm or your physiotherapist) and you will be instructed on axillary hygeine. Mr Patel will discuss with you how long you will need to use the polysling and he will ensure you are aware of any mobility restrictions that may apply. This varies between procedures and individuals.

You will be prescribed analgesia to take home and Mr Patel strongly advocates its use to keep pain to a minimum; it should be noted that pain is more difficult to control if allowed to establish itself. Mr Patel recommends the regular application of ice as an adjunct to relieve pain and swelling in the acute post-operative period.

You will see Mr Patel two weeks after surgery for a wound check (and stitch removal) and a physiotherapy program will ensue thereafter which is paramount to the success of the operation. You are likely to have been seeing a physiotherapist before the operation and Mr Patel will liaise with him/her in detail to advise on the post-operative exercise program.

What are the potential complications?

All surgery carries a risk. Specific risks to shoulder arthroscopy are:

Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. Mr Patel also recommends that you take regular analgesia and use ice (see Surgery FAQs) to help minimise post-operative discomfort and facilitate early movements.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Residual symptoms – unfortunately, no guarantees can be offered regarding curing your symptoms, despite the surgeon’s best efforts. In this case, further management and treatment options will be discussed with you.