SHOULDER RECONSTRUCTION AND STABILISATION

 

The shoulder is a combination of three bones: the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). The ball-like head of the humerus fits into the cup-like end of the scapula known as the glenoid. This cup or glenoid is commonly referred to as the shoulder socket and is surrounded by a rim of soft tissue called the labrum. In order to maintain shoulder stability, the labrum acts like a bumper and is helped by the glenohumeral ligaments and capsule within the shoulder joint

The head of the humerus may be forced out of the glenoid in a dislocation or can be forced partially out of the glenoid, which is known as a subluxation. Repeated dislocation or subluxation of the humerus out of the glenoid is known as instability. Instability is a weakening of the capsule and ligaments of the shoulder joint, which allows the ball to slip out of the socket, causing pain, frustration and doubt in the shoulder as a stable joint. Dislocations and some subluxations often happen from some sort of injury or trauma. Trauma often involves a high energy impact or may result from a fall onto an outstretched hand. Some patients may also have "loose" shoulders that tend to sublux or even dislocate without trauma.

Repetitive overhead throwing can also cause subtle instability with secondary injury to the rotator cuff. Pain from instability can be from the unstable event or can be from overuse of the rotator cuff in an attempt to stabilize the loose shoulder. This is called instability-induced tendonitis, sometimes also called secondary impingement. Another type of instability is internal impingement, which is when the unstable shoulder rotates excessively (such as in a thrower). The rotator cuff bumps up against the glenoid, and it starts to tear the labrum (the tissue on the rim of the glenoid) and the posterior superior rotator cuff.

 

Both dislocations and subluxations can cause tears of the labrum, ligaments or capsule. They may also cause rotator cuff tears as well as fractures of the shoulder joint. When a traumatic dislocation occurs, and is associated with a tear of the labrum, it is often referred to as a, "Bankart lesion".

Repeated dislocations may cause further tearing of these stabilizing structures and may cause the capsule to stretch out so much that the shoulder remains unstable.

The humerus may be forced out of the glenoid, (a dislocation), or overhead throwing sports may also injure the shoulder joint. Either may cause a SLAP Lesion, which stands for a tear in the Superior Labrum, Anterior to Posterior. In a SLAP Lesion, the labrum is torn from the front to the back. The superior labrum is the attachment for the biceps tendon, the strong muscle in the front of the arm. A sudden pull on this muscle can pull the superior labrum off of the bone.

 

A tear in the Labrum (Bankart Tear) occurs during dislocation

 

The labral tear + surrounding bone damage, causes instability and further dislocation, similar to a golf ball falling of a tee.

History

Patients will commonly complain of symptoms of a loose shoulder joint. They may experience popping or grinding of the shoulder. There is often associated pain with certain positions of the arm. In patients who have a history of multiple dislocations, they may even re-dislocate while sleeping or getting dressed. Sometimes dislocations may be reduced by the patient themselves. This is often painful. More commonly, however, dislocations require a reduction in the emergency room supervised by a physician. Most patients who have had even one dislocation will tell you that it is extremely uncomfortable.

A fall on an extended hand held close to the body presents the greatest risk of a SLAP lesion. Overhead sports, such as baseball, volleyball, swimming and weightlifting also increase the chance of the injury. A SLAP lesion may also occur as the result of an automobile accident. Additionally, those with above-average joint laxity, or looseness of the ligaments, stand at great risk of shoulder instability.

 

Treatment

After an initial dislocation is reduced, most patients are immobilized in a sling for a week or two and then started on a rehabilitation program. Some patients improve after immobilization followed by rehabilitation. One problem that affects younger patients more frequently is recurrence of dislocation. This means that patients will tend to re-dislocate, especially if they suffer their first dislocation between the ages of 15 and 25 years of age. For younger patients, the re-dislocation rate in the Orthopaedic literature ranges from 60-90%.

Patients older than 40 may suffer a rotator cuff tear with a dislocation rather than suffer recurrence of dislocations.

Strong rotator cuff muscles remain the best defence against shoulder dislocation, subluxation, and, thus, instability. Exercises that build up these muscles around the shoulder should be done. Adequate warm-up before activity and avoidance of high-contact sports may help prevent a recurrence of instability.

When non-operative treatment fails, there are many different surgical options to stabilize the shoulder. These treatments include both open and arthroscopic techniques. Recent Orthopaedic literature has shown that arthroscopic techniques can be as successful as open surgery.

The Operation

The operation is performed arthroscopically (key-hole)
A general anaesthetic is usually used with or without a shoulder block (local anesthetic)
3 small stab incision (8mm) are usually required.

The first stage of the procedure involves inspecting the shoulder joint. There is often other pathology in this area which is addressed at this stage. This may include bicep tendon tears, joint inflammation, labral (cartilage) tears and loose bodies.

The labral tear is then defined. The surrounding bone is roughened to provide a "sticky" surface for the repair. Holes are drilled in the bone and anchors inserted. The anchors are attached to sutures "ropes" which are then stitched to the torn tissue.

In some situations the nearby tissue (capsule) is incorporated into the repair. This may restrict external rotation, but may be required to help with the stability of the shoulder.

 

Post-Operative

The dressings will be bulky, but can be removed at day 3. Under these bulky dressings, there will be smaller rectangular dressing which need to be left intact until review.

Wound ooze is common and expected. The operation is performed "under water" using a pressure unit designed to increase the "space" to provide safe instrument insertion. The body will resorb most of this fluid, but the wounds will ooze for the first few days.

The wounds should be kept dry otherwise.

The swelling will resolve over the first few days. A shoulder protocol will outline all the post-operative instructions and limitation.

You will be placed in a sling for 4 weeks.
A full copy of the shoulder protocol is available on this website.

Risks and Complications

All surgery carries risk. Although the operation is minimally invasive and using only 8mm incisions, there are some risks to consider.

  1. Infection: The true infection rate is unknown following this surgery but is not common. Symptoms to consider are feeling unwell, fevers, intense pain and pus from the wound. If this occurs please contact the Rooms or the nearest Emergency Department.

  2. Stiffness: All surgery carries a risk of stiffness. This may also be related to the type and extent of the rotator cuff tear. It is important to carefully follow the shoulder guidelines.

  3. Nerve/Artery Damage: Rare, but reported in the literature. If the patient develops tingling, numbness, lack of movement in the hand of change of colour in the limb, immediately contact the Rooms or the emergency department. NOTE: Some patients are given an anesthetic block which will cause numbness but should wear off by 12 hours.

  4. Re-dislocation and pain: The rate of failure is related to a number of factors. Patients who have dislocated multiple times have a higher rate of failure. Often when dislocation happen, bone is lost due to knocking the humerus on the socket. In some cases a bone-transfer procedure may be required to replace the lost bone.
    Patients with inherent laxity (double jointed) have an increase failure rate.
    Not complying with the post-operative instructions may cause anchor or suture"pull-out"

  5. Blood Clots: This is uncommon

ARTHROSCOPIC ROTATOR CUFF SURGERY

Rotator Cuff Disease

Introduction

The rotator cuff is the group of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff, along with the teres major and the deltoid, make up the six scapulohumeral (those that connect to the humerus and scapula and act on the glenohumeral joint) muscles of the human body.

 

   

 

Function

The rotator cuff muscles are important in shoulder movement and in maintaining glenohumeral joint (shoulder joint) stability. These muscles arise from the scapula and connect to the head of the humerus forming a cuff at the shoulder joint. They hold the head of the humerus in the small and shallow glenoid fossa of the scapula. The glenohumeral joint is often likened to a golf ball (head of the humerus) sitting on a golf tee (glenoid fossa). During abduction of the arm, the rotator cuff compresses the glenohumeral joint, a term known as concavity compression, in order to allow the large deltoid muscle to further elevate the arm. In other words, without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. The anterior and posterior directions of the glenoid fossa are more susceptible to shear force perturbations as the glenoid fossa is not as deep relative to the superior and inferior directions. The rotator cuff's contributions to concavity compression and stability vary according to their stiffness and the direction of the force they apply upon the joint.

Rotator Cuff Tear

The tendons at the ends of the rotator cuff muscles can tear, leading to pain and restricted movement of the arm. A torn rotator cuff can occur following a trauma to the shoulder or it can occur through the "wear and tear" of tendons, most commonly that of the supraspinatus under the acromion. It is an injury frequently sustained by athletes whose duties involve making repetitive throws, such as baseball pitchers, volleyball players (due to their swinging motions), water polo players, shotput throwers (due to using poor technique), swimmers, boxers, kayakers, fast bowlers in cricket, tennis players (due to their service motion), and Wii players. This type of injury also commonly affects conductors due to the swinging motions and other movements used to lead their ensemble. It is commonly associated with motions that require repeated overhead motions or forceful pulling motions.

It commonly occurs due to "impingement" - where the tendons rub against the overlying acromion bone.

Long Term Issues

The tear most often increases in size over time. Although the pain may improve, longer term functional problems usually develop.

Pain is often intermittent but deteriorates over time.

With severe and long standing tears, the humerus migrates skyward causing severe arthritis.

Treatment

1. Non-Operative

Although the tear will most likely increase with time, in the older age groups (suffering from other medical conditions) simple therapeutic modalities may be used to help symptoms.

These include rest, avoidance of aggravating factors (eg. Lifting overhead), and simple analgesics.

Non-steroidal anti-inflammatory drugs can be used with caution. Injection into the area may help the pain temporarily but do not help the tendon repair. Excessive use of steroid injections may be detrimental.

2. Operative

The operation is performed arthroscopically (key-hole).

A general anaesthetic is usually used with or without a shoulder block (local anesthetic) 3 small stab incisions (8mm) are usually required.

The first stage of the procedure involves inspecting the shoulder joint. There is often other pathology in this area which is addressed at this stage. This may include bicep tendon tears, joint inflammation, labral (cartilage) tears and loose bodies.

The arthroscope (telescope) is then placed into the subacromial (rotator cuff area) space.
The inflamed tissue (bursa) is removed. The acromion (overlying bone) is then resected to stop impingement (rubbing of the tendon)
The AC Joint is commonly involved and may be treated.

The tear is then inspected. A number of bone anchors are placed in the humerus bone with stitches (ropes) attached. These are then threaded through the tear so that the tendon is lying against the humerus bone. The bone will need to be roughened to help with the healing.

The Keyhole approach is used to provide better patient outcomes.
It provides better pain relief, higher functional shoulder scores and similar tendon healing rates. The rates of stiffness following surgery are reduced, and most patients will stay in hospital for 1 day, although 50% will be day-patients only.

 

Post-Operative

The dressings will be bulky, but can be removed at day 3. Under these bulky dressings, there will be smaller rectangular dressing which need to be left intact until review.

Wound ooze is common and expected. The operation is performed "under water" using a pressure unit designed to increase the "space" to provide safe instrument insertion. The body will resorb most of this fluid, but the wounds will ooze for the first few days.

The wounds should be kept dry otherwise.

The swelling will resolve over the first few days. A shoulder protocol will outline all the post-operative instructions and limitation.

You will be placed in a sling for 4 weeks.
A full copy of the shoulder protocol is available on this website.

Risks and Complications

All surgery carries risk. Although the operation is minimally invasive and using only 8mm incisions, there are some risks to consider.

  1. Infection: The true infection rate is unknown following this surgery but is not common. Symptoms to consider are feeling unwell, fevers, intense pain and pus from the wound. If this occurs please contact the Rooms or the nearest Emergency Department.

  2. Stiffness: All surgery carries a risk of stiffness. This may also be related to the type and extent of the rotator cuff tear. It is important to carefully follow the shoulder guidelines.

  3. Nerve/Artery Damage: Rare, but reported in the literature. If the patient develops tingling, numbness, lack of movement in the hand of change of colour in the limb, immediately contact the Rooms or the emergency department. NOTE: Some patients are given an anaesthetic block which will cause numbness but should wear off by 12 hours.

  4. Re-tear and pain: The re-tear rates are related to the size of the tear and patient factors. Smoking, diabetes, general medical condition such as cardiovascular and respiratory disease and patients who have an active Workcover or TAC claim are at increased risk.

  5. Blood Clots: This is uncommon

KNEE SURGEON MELBOURNE

The best knee surgeons and sports surgeons have usually obtained a fellowship overseas while studying advanced techniques.

ANTERIOR CRUCIATE LIGAMENT (A.C.L) SURGERY

Historically ACL surgery has been done purely arthroscopically for over 20 years. The operation is usually performed as a day procedure but some patients may stay overnight. The re-rupture rate is approximately 4 per cent and this has many relating factor including age of the patient, activity level and collagen disease.

Prior to the ACL surgery the knee arthroscope is inserted into the joint and a visual inspection is made. Any associated pathology may be addressed at this stage. The formal ACL surgery then begins with obtaining the ACL graft, which is usually the hamstring by hands. The graft is placed in a 4-strand configuration and tied at both ends. Bony tunnels are made in the femur and tibia and the graft inserted usually with a endobutton and a bioabsorbable screw in the tibial surface. The appropriate tension is made during the surgery.

ARTHROSCOPIC KNEE SURGERY

Most sports medicine pathology can be dealt with arthroscopically. The best knee surgeons in Melbourne and throughout the world tend to use purely arthroscopic approaches to deal with ligamentous disruption assuming the disruption is in the joint. Both cartilage and meniscal pathology may be addressed at this stage. Meniscal tears can be either repaired or resected depending the age of the patient and the chance of recovery. In general even with the world best knee surgeons the mensical repair rate is 60 to 70 per cent as the meniscus has a very poor blood supply.

Anterior Cruciate Ligament (A.C.L) Surgery is performed mainly arthroscopically. A very small insertion is used to remove the hamstring for use as the graft but the operation is an arthroscopic procedure. An alternative approach would be to use the patellar tendon again this is arthroscopic but does involve a slightly bigger insertion to obtain the patellar tendon graft. Although the results are very similar my preference is to use the hamstring graft tendon.

SHOULDER SURGERY PAIN

Most patients who will undergo shoulder surgery in Melbourne with an arthroscopic shoulder surgeon will have one of a multitude of anaesthetics. The most common would be a general anaesthesia however the anaesthetist may decide to use a local or general anaesthetic block for postoperative pain. Given that the operation is performed arthroscopically, the pain received form the operation is well controlled with simple analgesics. My experience is that the best shoulder surgeons in Melbourne tend to use highly experienced anaesthetists who specialise in joint surgery. Arthroscopy only involves two to three small insertions in most situations and avoids muscle splitting or muscle in sizing approaches. Patients do experience some pain however mostly due to the local effects of the operation itself or the swelling associated with the fluid entering the joint.

AFTER SHOULDER SURGERY

I reviewed today she is knee replacement 2 weeks after her right shoulder surgery. We planned to do a formal AC joint resection and decompression arthroscopically but upon knee replacements inspection of the knee replacement joint we found a large displaced SLAP tear also. This was repaired with 3 anchors and we then performed the distal clavicle resection and decompression without complication. Today her range of motion is excellent, the wounds have healed and I suspect she will do very well. I have written a letter for a physiotherapist to start stage 2 of activity knee replacement and I will review her in a couple of  weeks. eden raleigh.