SHOULDER SURGERY

Shoulder Surgery is a rapidly evolving and expanding branch of orthopaedic surgery. During the last 2 decades we have witnessed dramatic advances in this field. With better understanding of the pathological processes, improvements in operative techniques especially arthroscopic procedures and post-operative rehabilitation programmes most conditions could now be treated with successful outcomes approaching 90%.

Below you would find some information about presentation and treatment of common shoulder conditions.


SUBACROMIAL IMPINGEMENT SYNDROME

This is the most common painful condition of the shoulder. It frequently affects the age groups 40-60 years and in 30% of cases it may also be associated with a rotator cuff tear.

Symptoms include pain and weakness on activity, especially on elevating the arm sideways. The pain is usually localised around the deltoid muscle and may interrupt sleep.

Subacromial impingement syndrome results from abnormal contact between the greater tuberosity and the under surface of the acromion during shoulder abduction. Classically this contact occurs at 60°-120° of shoulder abduction resulting in a painful arc in mid abduction as illustrated in the opposite diagram.

The underlying causes of subacromial impingement syndrome are multifactorial, but rotator cuff dysfunction (weakness) is probably the most likely cause. In a normal shoulder, the coordinated action of the rotator cuff muscles stops any abnormal contact within the subacromial space between the opposing bony surfaces.

Rotator cuff dysfunction is often due to degenerative changes within the rotator cuff muscles and is an age related phenomenon (>40 years). In a minority of cases, rotator cuff dysfunction may follow a painful injury or traumatic tear of the rotator cuff muscles.

Subacromial impingement syndrome is a vicious cycle. The pain associated with this condition increases the rotator cuff weakness (pain inhibition). This then exacerbates the abnormal contact between the apposing bony surfaces within the subacromial space, hence aggravating the impingement pain.

In the long-term subacromial impingement syndrome would result in secondary changes within the subacromial space such as formation of an acromial hook or an inflammatory bursitis, thus further exacerbating the impingement syndrome.

The diagnosis could be confirmed by abolishing the pain using a local anaesthetic injection into the bursa. MRI or shoulder ultrasound is frequently used to confirm the diagnosis and rule out other associated conditions such as a rotator cuff tear.

The treatment for subacromial impingement syndrome is dependant on the severity of the symptoms, age and occupation of the patient as well as whether there is an associated rotator cuff tear.

If this condition is not associated with a rotator cuff tear, the initial treatment consists of a steroid injection into the subacromial bursa to decrease the pain followed by physiotherapy to rehabilitate the weakened rotator cuff muscles. Any residual stiffness in the shoulder should also be addressed with regular stretching exercises. This method of treatment could be successful in up to 70% of cases, although occasionally up to 3 separate injections are necessary to fully resolve the pain.

In cases that fail to improve with injections and physiotherapy, surgical intervention may be required. In these cases arthroscopic subacromial decompression is the treatment of choice and carries a success rate of around 90%. Please use the following link for more information on Arthroscopic Subacromial Decompression.

In cases where the subacromial impingement syndrome is associated with rotator cuff tear, rotator cuff repair may also be necessary as part of the procedure. Depending on the size of the tear, the repair could be achieved using arthroscopic or open techniques.

Regardless of the method of treatment, physiotherapy to strengthen the rotator cuff muscles remains an integral part of the treatment to avoid recurrence of symptoms in the long-term.

 


Subacromial Impingement Syndrome

Abnormal contact between the greater tuberosity and under surface of acromion in mid abduction

Secondary Changes


Impingement Cycle


Subacromial Steroid Injection


Arthroscopic Subacromial Decompression

 


ROTATOR CUFF TEAR
The shoulder joint is broadly surrounded by two layers of muscles. The external muscles such as deltoid, pectoralis major and latissimus dorsi are responsible for power movements. Due to the shallowness of the shoulder socket, if these muscles act unopposed, the shoulder joint becomes severely unstable and this could lead to major problems such as subacromial impingement syndrome, shoulder instability or weakness. Therefore for normal shoulder function, the action of these powerful external muscles are normally counter balanced by more delicate internal muscles known as the rotator cuff.

The rotator cuff muscles consist of supraspinatus superiorly, infraspinatus and teres minor posteriorly and subscapularis anteriorly. The coordinated action of these muscles are responsible for the stability and normal mechanics of the shoulder joint. Damage or weakness of these muscles is known to result in conditions such as subacromial impingement syndrome or instability as outlined before.

Rotator cuff muscles are known to undergo degenerative changes with age. MRI studies have shown partial or full thickness rotator cuff tears in 50% of normal individuals over the age of 65 years. Most rotator cuff tears remain relatively asymptomatic and do not come to the attention of the clinicians. However, in a minority of cases this could lead to pain, weakness or instability necessitating treatment.

The treatment for rotator cuff tear is controversial and depends on a number of factors such as severity of the symptoms, age, occupation and patient expectations as well as the severity of the tear and condition of the torn muscles.

In some cases this condition could be treated conservatively with a combination of steroid injections into the subacromial bursa followed by physiotherapy. This method of treatment is more suitable for the older patient with minimal functional disability as well as patients who wish to avoid surgery due to personal reasons or high surgical risks. The success rate of conservative treatment with steroid injections and physiotherapy is about 30-50%.

For patients who fail to respond to conservative treatment or those in the younger age group (less than 50) surgical repair of the rotator cuff in combination with subacromial decompression gives the best long-term outcome.

Depending on the size of the tear and other technical considerations this could be achieved using arthroscopic or open surgical techniques. Overall, this is a very successful procedure with 90% of patients reporting good or excellent outcome in the long-term. However, this is a major surgical procedure an in 2% of cases complications such as, infection, stiffness, pain, nerve injury, etc could occur.

Rotator cuff repair is a major undertaking and postoperative recovery period is rather prolonged and may take up to 3-6 months. The post-operative rehabilitation following this procedure consists of: -

• Use of a sling and passive shoulder mobilisation for 6 weeks.
• Active mobilisation and stretching exercises between 6-12 weeks post-operatively.

• Strengthening exercises with Theraband as well as return to full activity (except contact sports) at 3 months post-operatively.
• Return to strenuous activity or contact sports at 6 month post-operatively.

Please use the following link for more information on Arthroscopic Rotator Cuff Repair.

 


Rotator Cuff Muscles

Back ------ Side -------Front


Rotator Cuff Tear

Partial Thickness --- Full Thickness

Open Rotator Cuff Repair


Arthroscopic Rotator Cuff Repair





Post-operative Rehabilitation

Physiotherapy

FROZEN SHOULDER
Frozen shoulder generally presents with spontaneous onset of pain and marked stiffness in the shoulder. It normally affects the age group 40-65 years. It is frequently associated with diabetes and ischaemic heart disease, but may also start after a trivial injury to the shoulder.

The pathology in this condition is progressive thickening and fibrosis of the shoulder capsule leading to severe shoulder stiffness. The articular surfaces and the bony anatomy is not affected in frozen and hence shoulder radiographs are normal in this condition.

Frozen shoulder tends to go through 3 separate stages i.e. freezing, frozen and thawing. The freezing stage which usually lasts about 6 months is associated with severe pain, which is worse at nights. During this stage the shoulder gradually stiffens up. In the frozen stage, the pain usually subsides, but the stiffness persists causing functional loss. The frozen stage usually lasts 1-2 years. During the final thawing stage, the shoulder gradually loosens up and function returns to near normal.

As described above in most cases the natural history of this condition is spontaneous resolution within 2-3 years from the onset of symptoms. However, during the active phase, the symptoms and the functional loss could be so severe that intervention may be necessary.

The treatment is dependent on the stage of the disease, the severity of the stiffness and presence of associated medical conditions.

In general if the patient presents early within the freezing stage before significant stiffness has developed, the condition could be resolved with a steroid and local anaesthetic injections into the shoulder joint (glenohumeral joint) combined with intensive physiotherapy.

For patients who have severe stiffness and injections fail, the most effective treatment is manipulation under general anaesthetic with further steroid and local anaesthetic injection into the joint followed by intensive physiotherapy. The manipulation serves to quickly restore the range of movement and the steroid injection and physiotherapy aims to avoid recurrent stiffness. Overall, the success rate of this mode of treatment is about 90%.

In 10% of cases, especially with co-existing conditions such as diabetes or post traumatic stiffness, non-operative treatment may not be effective. In these cases surgical (arthroscopic) release of the shoulder is indicated and carries a 90% success rate.

Limited External Rotation & Normal Radiographs


Anterior Capsular Thickening & Fibrosis


Glenohumeral Steroid Injection

Manipulation Under Anaesthetic


ACROMIOCLAVICULAR JOINT OSTEOARTHRITIS

Degenerative disease of the acromioclavicular joint is extremely common condition and is an age related phenomenon (>40 years). Fortunately in most this is not a painful condition. However, in a small number of cases the degenerative changes (osteoarthritis) within this joint may result in severe shoulder pain.

The pain associated with acromioclavicular joint osteoarthritis is usually felt directly over this joint. It is aggravated by heavy lifting or moving the arm into extremes of range of movement.

This condition classically gives rise to a painful arc in full abduction, which is unlike subacromial impingement syndrome, which the pain is in mid abduction. Full adduction across the chest or reaching for the back pocket is often particularly painful. Symptoms frequently interrupt sleep, especially when turning onto the affected shoulder.

The diagnosis could be confirmed by abolishing the pain using a local anaesthetic injection into this joint. Other conditions such as rotator cuff tear are frequent associations and requires assessment with appropriate investigations such as MRI or shoulder ultrasound.

The treatment is initially a trial of local anaesthetic and steroid injections into this joint. In general 40-50% of patients may respond well to this mode of treatment.

In cases that fail to improve with injections, surgical excision of this joint could be extremely effective in alleviating symptoms with success rate of over 90%.

This joint could be removed using open or arthroscopic techniques. The latter being my personal preference. Please use the following link for more information on Arthroscopic Acromioclavicular Joint Excision.



ACJ Steroid Injection

Outer Clavicle (ACJ) Excision

SHOULDER OSTEOARTHRITIS (GLENOHUMERAL JOINT)

Although uncommon the incidence of osteoarthritis of the shoulder (glenohumeral joint) is increasing due to aging population.

This condition presents with gradual onset of stiffness and pain in the affected shoulder. It is usually seen in the age groups >65 years, but occasionally it is also seen in the younger age groups following complications of recurrent instability or fractures of the shoulder.

In the early stages this condition could be treated with physiotherapy or a steroid injection. For advanced cases however, shoulder replacement may be required.

There are numerous methods of shoulder replacement. For uncomplicated primary cases my preference is a short stem total arthroplasty (Affinis prosthesis).

For complex cases especially when there is associated rotator cuff deficiency, total shoulder replacement with a fixed fulcrum prosthesis such as Delta X-tend or Bayley-Walker would be more appropriate.

The post-operative rehabilitation following this procedure involves:

• Use of a shoulder sling for 6 weeks.

• Strict passive mobilisation of the shoulder for the first 6 weeks under the supervision of a physiotherapist.

• At 6 weeks post surgery, active shoulder movement is commenced and the sling is discarded. At this stage stretching and strengthening exercises are also started.

The success rate of this procedure is about 90% in uncomplicated cases. For complex cases, especially with rotator cuff deficiency results are less favourable. Serious complications such as infection, stiffness, nerve injury, etc. could happen in 1-2% of cases.

Glenohumeral Osteoarthritis

Shoulder Replacement Implants



Affinis --------- Delta Xtend


Shoulder Arthroplasty


RECURRENT SHOULDER INSTABILITY / DISLOCATION

This is a relatively common condition and frequently affects the younger age groups of 16-30 years. In majority of cases the direction of instability or dislocation is anterior (95%) and in minority posterior (5%).

The underlying causes of shoulder instability are complex and different from case to case. In general shoulder instability or dislocation could be classified into 3 major groups i.e.:
• Traumatic (structural)
• Atraumatic (structural)
• Muscle pattern abnormality
The mode of presentation and treatment differs significantly between these 3 major groups.

Traumatic (Structural) Instability is the most common type of shoulder instability (90%). Sporting injuries, major accidents or falls are the most frequent causes. In these cases the first episode of dislocation usually requires reduction under sedation or general anaesthetic in hospital. In 50% of cases the first episode of dislocation could later be complicated by recurrent episodes of instability or dislocation.

As the name implies this type of instability is associated with structural abnormalities such a Bankart lesion or a Hill-Sachs defect. Bankart lesion is detachment of the cartilaginous edge of the glenoid (shoulder socket). This lesion creates a pocket, which in the position of shoulder abduction and external rotation allows abnormal displacement of the humeral head on the glenoid. Hill-Sachs defect is a bony depression fracture in the humeral head that occurs at the time of shoulder dislocation. If this defect is large in size, it could further contribute towards shoulder instability by hinging the humeral head out of the joint when the arm is taken into the position of abduction and external rotation.

The treatment of the first episode of traumatic shoulder dislocation consists of reduction under sedation or general anaesthetic followed by 2-3 weeks of immobilisation in an external rotation brace. The use of this type of brace in preference to other types of slings or braces for first time dislocators has been shown to reduce the incidence of recurrent instability or dislocation in the long-term. For subsequent dislocations early mobilisation without bracing is recommended as specialised bracing is unlikely to decrease the chance of recurrent instability.

The treatment for recurrent traumatic instability or dislocation consists of diagnostic arthroscopy followed by arthroscopic repair as appropriate. As the most commonly encountered abnormality in these cases is a Bankart lesion, arthroscopic Bankart repair is most frequently performed repair procedure. For more detail on this operation please click on the following link: Arthroscopic Bankart Repair

In general 90% of cases are successfully treated with an arthroscopic repair. In 5% of cases this method of treatment may fail and an open repair may be required at a later date.

N.B. In cases with major bony deficiency such as a large bony Bankart defect or Hill-Sachs lesion or in revision cases, a bony repair operation such as a Bristow procedure may be necessary.

Atraumatic (Structural) Instability is the second most common type of shoulder instability (5%). In these cases symptoms start more insidiously. It usually results from repeated micro trauma to the shoulder as seen in throwing athletes (tennis, swimming, volleyball, cricket, etc.). Generalised joint laxity is also a frequent association. A previous history of frank dislocation is generally absent in these cases, but instead the affected individuals complain of less specific symptoms such as sensation of instability, pain on over head activities or dead arm syndrome.

As the name implies this type of instability is also associated with structural abnormalities such as articular surfaces damage, capsular laxity and occasionally a Bankart lesion. Arthroscopic examination of the shoulder is invaluable in distinguishing this type of instability from the muscle pattern abnormality as in the latter no evidence of articular surface damage is observed on shoulder arthroscopy.

The treatment for atraumatic instability is in 2 stages. Initially a programme of specialist physiotherapy and retraining should be tried. If symptoms do not respond to this surgical intervention may be required. The exact operation depends on the abnormalities found. For cases with Bankart lesion, a Bankart repair may suffice. However, in most cases capsular laxity seems to be main problem and this could be addressed with a capsular shift procedure.

In general success rate for treating atraumatic shoulder instability is high (70-80%), but not as high as for treatment of traumatic shoulder instability.

Muscle Pattern Abnormality. Previously this was also referred to as Habitual or Voluntary instability. This type of instability is the least frequent type observed (5%). Trauma is rarely implicated in the onset of symptoms. The condition may initially start as a voluntarily instability (party tricks), but in time becomes habitual as the individual loses the voluntarily control over the episodes of instability or dislocation.

As the name applies this type of instability is not associated with any structural abnormalities. The underlying cause of the instability is inappropriate action or balance between various shoulder muscles. Although the abnormal muscle pattern could be observed clinically, the diagnosis may require confirmation with electromyographic (EMG) studies or arthroscopy. Arthroscopic examination in these cases would reveal normal articular surfaces and helps to distinguish it from other types of shoulder instability.

This is a particularly difficult group of patients to treat. Surgery has almost no role to play in the treatment other than to confirm th
e diagnosis with arthroscopy. The treatment in these cases usually consists of Bio-feedback training and physiotherapy by a specialist in this field. Success rates for this method of treatment is about 60%.

Direction of Dislocation




Instability Classification




Bankart Lesion




Humeral Head Displacement




Hill-Sachs Lesion




External Rotation Brace




Bankart Repair






Bristow Procedure




Articular Surface Damage
Hill-Sachs lesion


Normal ----- Abnormal


Capsular Shift

 
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