ARTHROSCOPIC SURGERY

Arthroscopic surgery, which is commonly referred as keyhole surgery is an important branch of Orthopaedics. During the last decade there has been major advances in this field, especially in Arthroscopic Shoulder Surgery. Many shoulder conditions such as subacromial impingement syndrome, rotator cuff tear, recurrent instability or acromioclavicular joint arthritis are now amenable to arthroscopic treatment with success rates that are equivalent or superior to traditional open procedures. The advantages of arthroscopic surgery over open surgery are:

• Shorter hospital stay
• Smaller scars
• Reduced post-operative pain
• Early return to work

Further information on following common arthroscopic procedures are enclosed:

1. Diagnostic Arthroscopy
2. Arthroscopic Washout & Debridement
3. Arthroscopic Bankart Repair (Shoulder Instability Repair)

4. Arthroscopic Subacromial Decompression
5. Arthroscopic Rotator Cuff Repair
6. Arthroscopic Acromioclavicular Joint Excision


DIAGNOSTIC ARTHROSCOPY

Accurate diagnosis is vital for effective treatment. In most cases this could be achieved after taking a history, clinical examination and appropriate investigations. However, occasionally the diagnosis remains unclear despite these steps. In these instances Diagnostic Arthroscopy could be invaluable in establishing the definitive diagnosis.

Diagnostic arthroscopy could also be a useful prior to open surgery in accurately defining the extent of the problem or the pathology.

Diagnostic arthroscopy is usually carried out as a day case procedure. In general, recovery after this procedure is rapid (<1-2 weeks) and complications are infrequent.

Information derived from diagnostic arthroscopy could on occasions dramatically influence the method of treatment and offer useful information regarding the prognosis.

Shoulder Arthroscopy


Arthroscopic View of the Shoulder

   

ARTHROSCOPIC WASHOUT & DEBRIDEMENT

This simply means wash out of the joint and removal of any loose debris or irregularities within the joint. This procedure is usually carried out for following conditions:

1. Early osteoarthritis.
2. C
ases with torn or unstable intra-articular structures such as torn meniscus, loose oeteochondral fragments, etc.
3. Removal of loose or foreign bodies from the joint

This procedure is usually carried out as a day case. In 60-80% of cases significant improvement in pain or mechanical symptoms are expected following this procedure.

Post-operative recovery in general is rapid (2-6 weeks) and complications are infrequent. Early mobilisation and physiotherapy is encouraged.

 
   

ARTHROSCOPIC BANKART REPAIR (Shoulder Instability Repair)

Most cases of recurrent shoulder instability or dislocation is associated with a Bankart lesion.

Bankart lesion is detachment of the fibro-cartilaginous edge of the shoulder socket (glenoid labrum) away from the bony socket (the glenoid). It is important to note that shoulder ligaments (glenohumeral ligaments) are normally attached to the glenoid labrum and become unstable when a Bankart lesion forms. This lesion creates a potential pocket for the humeral head to displace into during a dislocation. This typically occurs when the arm is taken into the position of abduction and external rotation for example during a throwing action.

In most cases of recurrent shoulder instability, repair of the Bankart lesion restores shoulder stability. My personal preference is arthroscopic repair of this lesion. In general 90% of cases are successfully treated with this procedure. In 10% of cases this type of repair may fail. However, an open repair could be done at a later date.

This procedure is generally carried out using 3 small incisions around the shoulder. Hospital stay is normally for one night only.

The steps involved in this procedure are:

• Mobilisation of the glenoid labrum (Bankart Lesion) and shoulder ligaments.

• Preparation of the edge of the glenoid.

• Insertion of drill holes to the edge of glenoid for placement of bone anchors.

• Passage of sutures through the labrum and glenohumeral ligaments.

• Insertion of anchors into the glenoid and repair of glenoid labrum and glenohumeral ligaments to the edge of the glenoid.

Post-operative recovery involves:

• Use of a shoulder sling for 6 weeks.

• During the first 6 weeks simple activities are allowed, but shoulder elevation above 90° and external rotation beyond 30° is avoided during this period.

• At 6 weeks post operation the sling could be removed and the arm could be mobilised freely. Shoulder strengthening exercises are started at this stage.

• At 12 weeks post operation shoulder stretching exercises are commenced and simple non-contact sports could be started.

• Contact sports are avoided until 9 months post surgery.

The success rate of this procedure is about 80-90%. Serious complications such as infection, stiffness, nerve injury, etc. could occur in 1-2% of cases.

 

Arthroscopic View


Humeral Head Instability



Preparation of Glenoid Bone & Mobilisation of Labrum


Suture Anchor Insertion & Repair of Bankart Lesion






Pre Repair ------ Post Repair

   

ARTHROSCOPIC SUBACROMIAL DECOMPRESSION
This is my preferred method of surgical treatment for subacromial impingement syndrome. This procedure is generally carried out using 3 stab incisions around the shoulder. The procedure entails:

• Release of coracohumeral ligament from anterior acromion.

• Removal of thickened bursal tissue and adhesions.

• Excision of anterior acromial hook.

Post-operative recovery involves:

• Use of a shoulder sling for 2 weeks.

• Immediate early mobilisation of the arm with no restriction in the range of movement.

• Rotator cuff strengthening and shoulder stretching exercises 2-3 weeks post-op.

• At 6 weeks post op unrestricted activity could be commenced.

The success rate of this procedure is about 90%. Serious complications such as infection, stiffness, nerve injury, etc. could happen in 1-2% of cases.

Arthroscopic View



Acromial Lesion



Excision of Acromial Hook & Release of Coracoacromial Ligament



Arthroscopic View of Acromial Excision



ARTHROSCOPIC ROTATOR CUFF REPAIR
This procedure is suitable for small to medium sized rotator cuff tears (less than 2 cm). It is usually carried out using 4 small incisions around the shoulder. Below are some of the steps used during this procedure:

• Mobilisation and preparation of the rotator cuff tear edge.

• Preparation of bone for implantation of the tendon.

• Insertion of suture anchors into bone.

• Passage of suture through the edge of the rotator cuff.

• Knot tying and repair of the rotator cuff down onto the tuberosity.


• Arthroscopic subacromial decompression.

The post-operative rehabilitation following this procedure involves:

• Use of an abduction brace for 6 weeks.

• During the first 6 weeks no active movement of the shoulder is allowed, but passive full range of movement is encouraged under the supervision of a physiotherapist.

• At 6 weeks post surgery the abduction brace is removed and active shoulder movement is commenced. Shoulder stretching exercises are also encouraged at this stage.

• At 12 weeks post surgery rotator cuff strengthening exercises are started and return to full activity is allowed except for contact sports.

• Contact sports are allowed at 9 months post surgery.

Postoperative physiotherapy is an integral part of rotator cuff repair and is vital for a successful outcome.

The success rate of this procedure is about 90%. Serious complications such as infection, stiffness, nerve injury, etc. could happen in 1-2% of cases.

Arthroscopic Rotator Cuff Repair







Post-operative Rehabilitation

Abduction Brace -------- Physiotherapy


ARTHROSCOPIC ACROMIOCLAVICULAR JOINT EXCISION
This is treatment of choice for acromioclavicular joint arthritis that has failed to respond to standard non-operative methods of treatment. This procedure is carried out using 3 small incisions around the shoulder. The steps in this procedure are:

• Diagnostic arthroscopy to rule out or treat other associated lesions.

• Removal of thickened bursal tissue and inferior acromioclavicular joint ligament.

• Excision of outer 1cm of the clavicle and inferior acromial osteophytes.

Post-operative recovery involves:

• Shoulder sling for 2 weeks.

• Immediate active mobilisation of the arm including stretching exercises.

• Rotator cuff strengthening exercises 2-3 weeks post-op.

• Avoiding power movements for 6 weeks.

• At 6 weeks post surgery unrestricted activity could be commenced.

The success rate of this procedure is about 90%. Serious complications such as infection, stiffness, nerve injury, etc. could happen in 1-2% of cases.

Arthroscopic Acromioclavicular joint Excision

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