The use of arthroscopy has revolutionized orthopedic surgery. The shoulder is one of the joints that this method is often used for diagnostic or surgical procedures. During arthroscopy a small camera attached to a fiber optic lens is inserted into the joint to allow the surgeon to examine the inside of the shoulder without requiring a major incision.
This guide will help you understand:
- The anatomy and function of the shoulder
- In which cases arthroscopy is performed
- How is shoulder arthroscopy performed and what to expect postoperatively
The shoulder is composed of three bones: the shoulder blade, the humerus and the clavicle. The shoulder joint consists of a shallow and flat portion of the shoulder blade called the glenoid cavity and the head of the humerus that forms the spherical part of the joint. Both the head of the humerus and the shoulder blade are covered with articular cartilage. The articular cartilage is a smooth, white substance that covers the ends of bones in most joints providing a smooth surface that allows the bones to slide over each other as they move, reducing friction and absorbing vibrations.
The tendons connect the muscles to the bones. The shoulder joint is surrounded by the rotator cuff consisting of four muscle tendons: the supraspinatus muscle, the infraspinatus muscle, the teres minor muscle, and the subscapularis muscle. It connects the humerus to the shoulder blade. The rotator cuff is essential for shoulder stability during movement. When the hand is raised or rotated, the rotator cuff keeps the arm in the glenoid cavity of the shoulder blade. The protrusion at the top of the shoulder blade is called the acromion.
The shoulder joint is surrounded by a waterproof case called an articular capsule. During arthroscopy, sterile saline is injected and the capsule is dilated. The surgeon inserts the arthroscope, so that he can examine the shoulder joint in detail, including: the articular surfaces of the glenoid cavity and the humeral head, the rotator cuff’s tendons, the ligaments and the articular cartilage.
The arthroscope can also be placed in the subacromial space, that is, outside the shoulder joint. From this position, the surgeon can examine the acromion and the lower part of the peripheral end of the clavicle, as well as the joint formed at the point where the clavicle and the acromion meet, the acromioclavicular joint.
In which cases is arthroscopy performed?
Initially, shoulder arthroscopy was used for diagnostic purposes only.
Today it can be utilized in a wide range of different interventions:
- to confirm a diagnosis
- to remove foreign bodies
- in case of rupture or detachment of the articular cartilage
- in case of rupture of the shoulder ligaments, in order to avoid a recurrent dislocation
- in case of rupture of the rotator cuff’s tendons and
- in the treatment of shoulder joint infections
The operation can also be performed outside the joint, in the subacromial capsule:
- to remodel the acromioclavicular joint when suffering from arthritis.
- to washout the subacromial space in case of bursitis.
The goal of the surgeon is to correct or improve the patient’s condition through appropriate surgery. The arthroscope is a tool that helps the surgeon to get a clearer and better image of the affected area. It also offers him the ability to operate by creating much smaller incisions. So we have less tissue damage and, therefore, less healing time is required. But we must remember that the arthroscope is just a tool. The results of a shoulder arthroscopy depend on the severity of the problem, what can be done to surgically correct or improve this problem, and ultimately on the patient’s compliance during recovery.
What do you need to know before surgery?
The patient should discuss with the surgeon and decide whether or not to undergo surgery. The procedure to be followed should be as comprehensible as possible and all patient questions should be answered.
Once the decision is made to undergo surgery, certain procedures should follow. The doctor will recommend some tests to ensure that the patient is in the best possible condition before surgery.
It may also be necessary to arrange a first appointment with the physiotherapist, who will undertake the rehabilitation program, so that the patient can provide some information such as pain level, ability to perform activities, range of motion and shoulder strength. This will give the physiotherapist a clear idea of the problem and prepare the patient for the recovery program, which is about to follow.
The patient is admitted on the day of surgery, usually early in the morning. The patient should not have eaten or drunk anything since midnight on the previous day.
What Happens During a Shoulder Arthroscopy?
Prior to surgery, regional or total anesthesia is administered to the patient. With the method of regional anesthesia when the patient is asleep, a local anesthetic is injected into the area where the shoulder nerves are located and analgesia is provided, both during surgery and for 12-24 hours postoperatively. Finding the right injection site for the anesthetic drug and ensuring nerve safety and integrity is performed using a special device, the neuro-stimulator that informs us about the location of the nerves, so that we can protect them.
This method of anesthesia and analgesia is very successful and fully satisfies almost all patients who evaluate their entire surgical experience as particularly positive.
Then a sterile environment is formed so that the surgeon can work. Around the operating table there is a wide range of tools used during surgery, such as screens, cameras, lights and surgical instruments.
The surgeon begins the operation by making two or three small incisions on the patient’s shoulder. Through these incisions, the arthroscope and other surgical instruments are placed inside the joint in such a way that the nerves and blood vessels of the surrounding area are not injured. Then with a small metal or plastic tube sterile saline is injected, in order to dilate the joint.
The arthroscope is a small metal tube made of optical fibers used by the doctor to examine and operate in the shoulder. It has a diameter of about ½ cm and a length of 15 to 20 cm. The camera and the beam of light are connected to the outer end of the arthroscope through the optical fibers passing through it.
The camera projects the image from the interior of the shoulder joint to a screen next to the surgeon. The surgeon watches the screen (and not the shoulder) as he moves the arthroscope into the joint.
In recent years arthroscopy has evolved a great deal and there are now many specialized tools to perform various surgeries with the help of the arthroscope without major incisions. For example, the fixation of the articular cartilage can be performed by using two or three incisions of only half a centimeter. For more complex procedures, such as repairing a ligament or the rotator cuff, slightly more incisions shall be required.
Once the surgical procedure is complete, the incisions are sutured, the shoulder is bandaged and the patient is transferred to the recovery room.
As with all surgeries, during a shoulder arthroscopy, there is the possibility of complications. Some of the most common complications after a shoulder arthroscopy are:
- Complications of anesthesia
- Damage to equipment
- Slow recovery
Complications of Anesthesia
Most surgeries require some kind of anesthesia. In a very small percentage of patients, a problem may arise, such as a reaction of the body to the medicines used, or complications due to some condition or another problem due to anesthesia. To be sure, the patient should arrange an appointment with the anesthesiologist to provide him with a detailed medical history, to inform him about his/her medication and discuss his/her concerns about the operation.
Thrombophlebitis may occur after each surgery, but most often they occur after a hip or knee surgery. Thrombophlebitis occurs when blood clots form in the arteries of the foot. The foot swells, hurts and is hot. If the clots break down, they can be transferred to the lungs, where they attach to the capillaries, so that part of the lung is not supplied with blood. This is called pulmonary embolism. There are many ways to reduce the risk of thrombophlebitis, but the most effective is for the patient to start moving as soon as possible after surgery. Two other ways of prevention are: special socks that help blood flow to the feet or medication that prevents the formation of clots.
After a shoulder arthroscopy, there may be post-operative infections. This phenomenon is uncommon and occurs in less than 1% of cases. If severe pain, edema, irritation or fever is observed, it should be reported to the surgeon to determine if it is an infection or not.
Infections are of two types: superficial or more severe. A superficial infection can develop on the skin around the incisions. Such an infection does not extend to the joint and is usually treated only with antibiotics. But if the shoulder joint becomes infected, it is a serious complication that will require antibiotics and possibly new surgery to be treated.
Damage to equipment
Many of the tools used by the surgeon to perform an arthroscopy are small and fragile. These tools can break and a piece of them may remain in the shoulder joint. The broken piece is usually easily identified and removed, but this can extend the time of surgery. In most cases there is no damage to the joint.
The same can be the case with surgical material (e.g. sutures, clips, etc.) used to hold the tissue in place during surgery or after arthroscopy. If one of these items breaks, the loose piece can injure other parts inside the joint, particularly the articular cartilage. In this case, a second operation may be needed to remove the piece of equipment broken or to correct the problem.
What happens after surgery?
Shoulder arthroscopy is an operation after which hospitalization is not required and the patient returns home on the same day. In more complex procedures requiring longer incisions or more surgical time, hospitalization may be needed to more effectively and efficiently treat the pain and allow the patient to be properly monitored. In this case, the patient may begin the rehabilitation program in the hospital.
Patients who have undergone more complex reconstructive procedures may need to wear a splint or other orthopedic equipment that will provide support or immobilize the shoulder for several weeks. These aids protect the healing tissue inside the shoulder joint. The patient is able to take off the splint for a few hours a day to do some gentle exercise and bathing.
What will the recovery period be like?
The recovery period depends on the type of surgery the patient has undergone. If the procedure is very simple the patient may not need to follow an intensive physiotherapy program. There are just some simple exercises to do at home as instructed by your doctor or physiotherapist. In general, the more complicated a surgery is the longer and more demanding the physiotherapy program will be. The first few days of the program include exercises that help control pain and edema after surgery.
Nowadays, the arthroscope is used to perform quite complex reconstructive surgeries through very small incisions. It should be noted, however, that even though the incisions are small, it does not mean that the shoulder joint is the same. If the patient has undergone a major reconstructive procedure, the time it will take to fully recover will be several months. The goal of the physiotherapist is to keep the pain under control, improve range of motion and strengthen the shoulder. When the patient’s condition improves sufficiently, he or she will stop frequent visits to the physiotherapist and follow a home exercise program for as long as necessary.