Shoulder Arthroscopy. What Is Arthroscopy? What's Wrong With Your Shoulder? The Role Of Arthroscopy. Preparing For Arthroscopy.

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1 Shoulder Arthroscopy What Is Arthroscopy? What's Wrong With Your Shoulder? The Role Of Arthroscopy Preparing For Arthroscopy The Operation What To Expect After Shoulder Arthroscopy How Long Until Full Recovery? Putting It All Together Glossary What Is Arthroscopy? Arthroscopy is a procedure that allows an orthopedic surgeon to see and operate inside a joint using a device called an arthroscope. The arthroscope is inserted into the joint through a tiny incision in the skin. Arthroscopy is both a diagnostic and surgical procedure. An arthroscope is a pen-shaped instrument with a very small video camera attached to the end. Lenses inside the arthroscope transmit an image that is projected onto a television screen. The image can be magnified as much as 30 times, giving the orthopedic surgeon an exceptionally clear view of the inside of a joint. From this view, the surgeon can then operate inside the joint using small instruments inserted through separate tiny incisions. Joint surgery has improved greatly since the arthroscope was introduced. The surgery is less traumatic, healing is faster, scarring is reduced, and recovery is quicker. Only a few tiny scars remain to show that the surgery was ever done.

2 Understanding the Shoulder The shoulder is the most versatile joint in the human body. It has the widest range of motion, which means it can move in more directions than any other joint. The shoulder's versatility enables us to retrieve soup cans from the cupboard, hammer nails, swing golf clubs, roll bowling balls, and perform thousands of other activities. The shoulder's flexibility is due to its unique structure. Like the hip, the main joint of the shoulder is a "ball-and-socket" joint. A "ball" at the top of the upper arm bone (the humerus) fits neatly into a "socket," called the glenoid, which is part of the shoulder blade (scapula). But unlike the hip joint - where the ball sits in a deep, well-protected socket - the shoulder socket is very shallow. The surrounding ligaments, and muscles and tendons that move the shoulder joint, help to keep it stable. Because of this anatomy, the shoulder is the most frequently dislocated major joint in the body. It's also prone to a variety of other injuries and chronic problems that can be painful and hinder a person's ability to perform ordinary tasks. Three bones come together to form the shoulder. These bones are the collarbone (clavicle), the shoulder blade (scapula), and the upper arm bone (humerus). The acromion, a part of the shoulder blade, forms the top of the shoulder. The shoulder is made up of four separate joints. The interrelated action of these four joints allows the complex and extremely wide range of movements of the shoulder.

3 The ball-and-socket joint, or glenohumeral joint, is the main joint of the shoulder. The joint between the acromion (part of the shoulder blade) and the collarbone (the clavicle), is called the AC joint, or acriomio-clavicular joint. Arthritis of the shoulder most commonly affects this particular joint. The junction between the collarbone and breastbone (the sternum), in the front of the chest, is called the sterno-clavicular joint. This joint anchors the shoulder to the chest wall The fourth joint of the shoulder is between the shoulder blade and the back of five of the upper ribs, and is called the scapulo-thoracic joint. This joint provides added movement of the shoulder toward the front and back of the body. The shallow socket of the shoulder is given some extra depth by a structure called the labrum, which is a thickening of tissue that attaches to and surrounds the socket. Damage to this structure from a shoulder dislocation often results in instability of the shoulder. The ball-and-socket joint (glenohumeral joint) is reinforced and assisted in its movement by the rotator cuff, a combination of four tendons and associated muscles. The muscles arise on various parts of the shoulder blade, and their tendons attach to the upper arm bone. (Tendons are stringy tissues that attach muscle to bone.) One of the tendons of the biceps muscle runs through the shoulder joint and further helps to stabilize the joint. The term "rotator cuff" refers to the group of four tendons that attach four shoulder muscles to the bone of the upper arm. Ordinarily, the rotator cuff moves freely in the space between the top of the upper arm and the upper part of the shoulder blade (the acromion), which overhangs the rotator cuff. In some people, for reasons not always known, this space is inadequate to allow the normal smooth gliding movements of the rotator cuff as it moves the arm. So when the arm is raised, the rotator cuff may be squeezed between the two bones. Between the rotator cuff and the bony arch of the acromion lie two fluid-filled sacs called bursae. They protect the rotator cuff and allow smooth movement of the tendons over the bone. Many shoulder problems are caused by injuries to the rotator cuff. If a tendon becomes inflamed or is partially torn, it can cause pain and limit shoulder movement. If a rotator cuff tendon tears completely, the corresponding muscle can no longer properly affect movement of the arm. This type of injury usually causes limitations in shoulder movement as a result of pain and weakness. Nice To Know

4 Q. I don't recall injuring my shoulder. Why is it so painful? A. Shoulder pain arises from the soft tissues (muscles, ligaments, and tendons) more often than from the bones. You need not have injured your shoulder. Pain can be caused by inflammation of the tendons (tendinitis), particularly the rotator cuff tendons and the biceps tendon; a tear of the rotator cuff due to wear and tear; bursitis (which is an inflammation of the bursa, the sac that separates some of the muscle layers and allows the tendons to glide smoothly); or other soft tissue problems as well as arthritis of the joint. Facts About Shoulder Injuries The shoulder is the most flexible joint in the body, but this flexibility also makes it susceptible to instability and injury. According to the American Academy of Orthopedic Surgeons, about six million people each year go to the doctor for shoulder pain, dislocation, or other shoulder problems. Each year, shoulder problems account for about 1.5 million visits to orthopedic surgeons (physicians who specialize in disorders of the bones, muscles, and related structures). Most problems in the shoulder involve the muscles, ligaments, and tendons rather than bones. Shoulder injuries can be caused by sports activities that involve excessive overhead motion (such as swimming, tennis, and pitching). But they also can be the result of everyday activities such as painting, hanging curtains, and gardening. The arthroscope is the most accurate diagnostic tool for examining shoulder problems. Recovery from arthroscopic surgery is generally faster and less painful than

5 recovery from traditional open surgery. --- What's Wrong With Your Shoulder? A number of conditions can cause shoulder pain. Diagnosis of shoulder pain begins with a history and a physical examination to discover: The location and nature of the pain and swelling Muscle strength If there is any limitations of movement Special diagnostic tests can then define the exact nature of the problem. X-rays can show arthritis, a dislocation, and other problems with the bones of the shoulder. Magnetic resonance imaging (MRI) uses strong magnetic fields and radio waves to create a series of cross-sectional images of the joint. These images can provide a detailed map of the injury, particularly one affecting the soft tissues of the joint. For more information about MRI, go to MRI. Arthrography is a technique in which a harmless dye is injected into the shoulder, and then x-ray images are taken. It can identify problems, particularly rotator cuff tears, as the dye passes through the tear. The dye is absorbed safely into the body. It's not as widely used anymore since MRI can clearly show a rotator cuff tear. But an MRI may be enhanced using this technique, so it is still used in selected situations. ---

6 The Role Of Arthroscopy Arthroscopy can be used to diagnose a problem in the shoulder when tests don't give a definite answer as to what's causing the problem. More commonly, however, it is used to treat and correct a number of problems in the shoulder, including: Shoulder dislocations and instability Torn rotator cuff Impingement syndrome (tendinitis and bursitis) Osteoarthritis Loose bodies Shoulder Dislocations And Instability The shallow ball-and-socket joint of the shoulder (the glenohumeral joint) is the most frequently dislocated major joint in the human body. In most instances, the shoulder dislocates as the upper arm bone (humerus) comes forward out of the joint. Backward dislocation is far less common. Dislocations are treated by replacing the shoulder back into position and immobilizing it in a sling for a few weeks. This is usually successfully done under mild sedation, but sometimes a general anesthetic with the patient asleep is preferred. Occasionally surgery is required to relocate the joint back into its normal position. Sometimes a tendency to experience further dislocations may develop, even without much force, following the first dislocation. This is known as an unstable shoulder.

7 The problem usually occurs because the capsule surrounding the joint has been stretched by the dislocation, or part of the labrum (the thickened tissue that surrounds and deepens the socket) has been torn off from the bone, thus making the joint less stable. If non-operative treatment in the form of muscle strengthening exercises fails, surgery is recommended to stabilize the shoulder. Surgery can be done either arthroscopically or by traditional open surgery to repair the damaged tissue. Either way, the aim is to repair the shoulder damage and restore stability to the shoulder. Arthroscopy aims to repair the shoulder damage in a dislocation by reattaching the torn labrum to the bone, and by tightening the stretched capsule lining the joint. But arthroscopy is not suitable for all types of shoulder instability. Torn Rotator Cuff The rotator cuff is the strong complex of tendons and muscles that helps stabilize the shoulder. One or more of the tendons in the rotator cuff may be torn either by: A single injury (for example, a fall on an outstretched arm) The constant irritation of repetitive overhead arm motions Degenerative damage, due to wear and tear, as we age In many instances, the reason for the rotator cuff injury is unknown. A torn rotator cuff will cause pain at the top and outside of the shoulder when you raise or extend your arm. The shoulder may become weak, making it difficult to raise the arm far away from the side. Depending on the size of the tear, arthroscopic surgery can be used to reattach the torn edge of the rotator tendon to the humerus bone with specialized stitches. Very large tears and complex tears are usually done as an open procedure, or through a combination of open and arthroscopic procedures. For more information about rotator cuff injury, go to Rotator Cuff Injury. Impingement Syndrome (Tendinitis And Bursitis) Repetitive motion - or the normal wear and tear of aging - may cause irritation of: The tendons of the rotator cuff or biceps tendon (tendinitis)

8 The bursa (bursitis), which is a sac that acts as a cushion between the top of the shoulder blade and the rotator cuff, allowing the smooth gliding movements of the rotator cuff tendon. Impingement syndrome is the first stage of potential rotator cuff problems. It is called impingement syndrome because the rotator cuff tendons are "impinged" - that is, squeezed between the moving head of the upper arm bone and the acromion. This results in inflammation and swelling of the rotator cuff tendons. Tendinitis and bursitis cause slowly increasing discomfort and pain in the upper shoulder or the upper third of the arm. Sleeping on the shoulder may be painful, and there may be pain when raising the arm away from the body or overhead. In many cases, tendinitis and bursitis can be improved with rest, ice, and antiinflammatory drugs such as aspirin or ibuprofen, in combination with physical therapy or with the use of a steroid injection. If the condition does not respond to these conservative measures, arthroscopic surgery may be used to increase the space for the rotator cuff tendons, to allow them to glide freely, by removing some of the undersurface of the acromion bone and clearing the inflamed bursal tissue. The biceps tendon, which passes through the shoulder joint, may also become inflamed. This is known as 'biceps tendinitis.' Osteoarthritis As we get older, our joints, including the shoulder, may suffer from wear and tear that can cause pain and discomfort. If medication can't control the discomfort, an orthopedic surgeon may suggest arthroscopy to shave and smooth the roughened surfaces of the joint and trim any damage to the rotator cuff. Clearing out the debris often helps reduce the pain of arthritis. An arthroscopic "clean-out" or "debridement" is a significantly simpler procedure than total shoulder replacement, although total replacement may ultimately be required. Arthroscopic surgery for osteoarthritis is unfortunately not always reliable; not everyone will benefit from this. For more information about osteoarthritis, go to Osteoarthritis.

9 Loose Bodies Sometimes, a shoulder injury can cause a fragment of cartilage or bone to come loose and float around in the joint. A number of arthritic and other conditions can also cause loose bodies inside the shoulder joint. Depending on the size of the fragment and whether it is still attached, the orthopedic surgeon may decide to fix it back in place or remove it entirely. This type of procedure can be performed with arthroscopic surgery or traditional surgery, depending on the specific procedure necessary. Nice To Know Q. Why is the doctor recommending I have my shoulder repaired through a normal incision rather than arthroscopically? A. Not all shoulder problems can be properly repaired using an arthroscope. Many surgeons believe that large rotator cuff tears, for example, are better treated by standard shoulder surgery. Similarly, a shoulder that is unstable in all directions will likely require open surgery. Moreover, shoulder arthroscopy is really still in development, and many surgeons are still not confident about the long-term results of certain repairs of shoulder problems with the arthroscope. Need To Know: What are the risks of shoulder arthroscopy? As with any operation, arthroscopy carries a risk of

10 infection, bleeding, and the risks associated with any anesthesia. Arthroscopy, however, has been shown to be safe with few complications. Risks specific to shoulder arthroscopy include: Nerve injury. This is usually temporary and is due to the positioning of the arm during the procedure. Alternative positioning techniques and recognition of this complication by surgeons has now made it a relatively rare complication Stiffness and limitation of motion. Most of the time, the physical therapy prescribed after the procedure will prevent this complication. Re-injury. The shoulder may dislocate again, or the rotator cuff may tear again. Failure to improve. The arthroscopic procedure may not correct the problem. In the latter three cases, a second surgical procedure may be required. --- Preparing For Arthroscopy Arthroscopic surgery is usually done as an outpatient procedure. In most cases, you will return home the same day. If the repair is complicated or if an open surgical incision is required, you may need to stay in the hospital for a day or two. Routine preoperative tests include analyses of blood and urine. Depending on your age, you may require a chest x-ray and EKG (an electrocardiogram, to measure the regularity of the heartbeat). You also will meet the anesthesiologist, who may offer you a choice of anesthesia: General anesthesia. If you choose general anesthesia, you will be asleep during the procedure. A regional anesthetic called an interscalene block. The anesthesiologist will insert a small needle near the base of the neck and inject an anesthetic agent that temporarily numbs the shoulder and arm. If you receive an interscalene block, you will be awake during the procedure. In most cases, you will also receive a mild sedative. You may be able to watch the procedure on the TV monitor.

11 Need To Know Be sure to tell your doctor: If you are allergic to iodine or any other drugs What medications you take About your past medical history About any occurrence of deep vein thrombosis or other blood clotting abnormalities Other steps to take: You should stop taking certain medications (for example, blood thinners such as aspirin) a week or two before the procedure, to cut down on the possibility of bleeding. Your surgeon will discuss with you if this is necessary. You should not eat or drink anything, not even water, beginning at midnight on the day of the procedure.. Ask the surgeon what you should do about any medication that you would normally take during the hours before surgery. --- The Operation After the chosen anesthetic has been administered, the shoulder is thoroughly cleaned, usually with an iodine solution. Two to three tiny incisions, called portals, are made around the shoulder joint, in the back, front, and side of the shoulder. The surgeon usually inserts the arthroscope through a portal at the back of the shoulder (just below the outer bony prominence at the back of the shoulder). Specialized surgical instruments are inserted through the portal in the front of the shoulder.

12 Instruments are frequently switched from portal to portal throughout the procedure. If you are having an acromioplasty for a rotator cuff injury or impingement syndrome, the surgeon will also create a portal at the side of the shoulder to insert additional surgical instruments. In some cases, the surgeon will also make a fourth portal at the top of the shoulder. The arthroscope projects magnified images of the inside of the shoulder onto a television screen. Sterile saline solution is run into the joint through one of the portals. It is necessary to have this fluid in the joint in order to see with the arthroscope. Specialized instruments are inserted into the joint through the portals, and the appropriate procedure is performed. In the case of acromioplasty, the surgeon shaves a small portion of the bone from the underside of the acromion using highly specialized rotating or oscillating burrs. This gives the tendons of the rotator cuff or an irritated bursa more room to move and prevents these tissues from being pinched. If there is an accompanying bursitis, the inflamed bursal tissue may be removed as well. Rotator cuff repair is more involved: The surgeon removes a small portion of the undersurface and front aspect of the acromion to make sure the repaired rotator cuff will have enough room to move freely. The torn rotator cuff tendon is identified and any scar tissue that has built up on the tendon is removed. A small trough is carved at the top of the upper arm bone (humerus) to obtain a small area of bleeding bone that will speed the healing of the tendon to the bone. The torn tendon is reattached to the bone in the trough. This is achieved either using specialized anchor stitches which remain permanently inside the bone (though newer absorbable anchor sutures are now also used), or with regular tough sutures that are placed through tiny holes that have been drilled through the bone. During this operation, the surgeon removes any bone spurs and will release the ligament that contributes to the impingement problem (the coracoacromial ligament). The surgeon may resect the end of the clavicle if there is painful arthritis at the AC joint (acromioclavicular joint ). If a bursa is inflamed, the surgeon will remove it. Shoulder arthroscopy usually takes one to two hours. The length of the procedure will vary depending on the procedure and the extent of the damage within the shoulder.

13 Need To Know Sometimes, the arthroscope will reveal damage that may be better repaired through an open surgical incision. In some cases, the open procedure can be done immediately. This possibility should be discussed with the doctor before the arthroscopy. --- What To Expect After Shoulder Arthroscopy In most cases, you will be able to return home on the day of the procedure. You will need a companion to drive you home, particularly if general anesthesia has been used. In some cases, an overnight hospital stay will be required. Incision care. The portal incisions are so small that they are not always closed with sutures. This will depend on the preference of the surgeon. Dressings are usually light and are kept on for a couple of days. Dressings and wounds should be kept clean and dry. Often, some drainage occurs from the wounds during the first day. This drainage is from the fluid used during the surgery. It is usually light and stops within the first 24 hours. Shoulder immobility. The amount of movement allowed following surgery will depend on the procedure that was done. Your doctor will give you very careful instructions about this. Following rotator cuff repair and repair of an unstable shoulder, certain shoulder movements are not allowed for a period of time. Your shoulder will be held in a sling, a sling and swath, or a brace following the surgery. Ice. Most doctors will recommend that ice be applied to the shoulder to control pain and swelling. Excessive swelling increases pain and may increase scarring, which in turn will tend to cause stiffness in the joint. You should apply ice for at least 20 minutes about three times a day. Ice should not be placed directly onto the skin. Place a moist towel on the skin and apply ice in a plastic bag directly over the towel. Medication will be prescribed for pain. This medication will usually be in the form of pills, but in some cases, when a one or two day hospital stay is required, a patient-controlled anesthesia (PCA) pump will be used. This pump provides pain medication at the push of a button that is connected to a dispensing machine. An intravenous catheter will be left in your arm to allow the medication to enter your bloodstream. PCA is usually continued for one or two days. The total amount of medication dispensed is carefully regulated so you cannot "overdose".

14 Before you leave the hospital, you should have scheduled a visit to see the doctor within one to two weeks of the operation to assure that your wounds are healing properly and all is going well. A visit at approximately three to four weeks will serve to assure progress in therapy. Follow-up visits will then be scheduled at about six weeks and at three and six months. The doctor may obtain new x-rays of the joint at several of these visits. Need To Know When to contact the doctor Complications following arthroscopy are rare. Contact the doctor if: Drainage continues from the wound for more than 24 hours after surgery Redness or foul odor develops around the wounds Pain cannot be controlled by medication Your temperature rises above 101 F Prolonged nausea and vomiting may be a sign of adverse reaction to pain medication. The doctor should be contacted in this case. Physical Therapy Depending on the procedure performed, the doctor may recommend a course of physical therapy to begin immediately after the operation. A series of specific exercises will be prescribed, to be done under the direction of a rehabilitation specialist. Rehabilitation is often the most important part of treatment. Chances of a full recovery increase when the exercises are done faithfully.

15 Some surgical procedures may require that limitations be placed on shoulder motion. In most cases, however, movement should begin early. The pendulum is an exercise often prescribed immediately after the arthroscopic procedure. It is done by leaning sideways and allowing the arm to swing in small circles. This pendulum motion will increase range of motion in the shoulder joint and decrease stiffness. Isometric exercises are exercises in which the muscles are tightened without actually moving the joint. Depending on the procedure, these may be prescribed in the first week or two after the arthroscopic surgery. Passive range of motion exercises are exercises in which someone else moves your shoulder, usually the physical therapist, or you use your other arm to move the side you were operated on. These exercises increase the mobility of the shoulder joint without stressing any of the repaired tissues. Depending on the procedure, these exercises may be started within a few weeks after the arthroscopic surgery. Resistance exercises are exercises in which the shoulder is moved against resistance, usually starting with elastic tubing and progressing to light hand-held weights. They are usually begun at about four to six weeks. --- How Long Until Full Recovery? The time it takes for a return to unlimited activities will depend on: The original problem The procedure that was performed The repair that was made The individual patient Usually, at least six weeks of recovery time are required. In general, activities will be limited and gradually increased until the range-of-motion and strength in the repaired shoulder is equal to that of the other arm. Repair of a rotator cuff tendon or shoulder dislocation usually takes four to six months to heal well enough for a return to full activity. When Can I Return to Work? In some cases, you may be able to return to light work within a few days. Depending on the procedure, heavy labor or contact sports may be limited for

16 about six months, though you will be allowed a lighter type of work. But during this period, you will be continuing the exercise program set by the therapist and your doctor as you continue to strengthen the shoulder. --- Putting It All Together Here is a summary of the important facts and information related to arthroscopy of the shoulder. Arthroscopy is a minimally invasive surgical procedure that can be used to repair injuries to the shoulder with less pain and a shorter recovery time than that required for open surgical repair. It also causes much less scarring. Shoulder arthroscopy is commonly used to diagnose problems inside the shoulder as well as to repair problems of the shoulder. Shoulder problems that can be repaired with arthroscopy include rotator cuff tears and shoulders that dislocate. The procedure also can remove loose bodies and sometimes treat arthritis in the shoulder. Arthroscopy usually does not require an overnight hospital stay, and complications are rare. Physical therapy is the key to a full recovery after shoulder arthroscopy Glossary Here are definitions of medical terms related to arthroscopy of the shoulder. Acromioclavicular joint: The joint between the top of the shoulder blade (acromion) and the collar bone (clavicle). Acromion: An extension of the shoulder blade that forms the highest point of the shoulder. It joins to the collarbone and is attached to the deltoid muscle at the top of the arm and trapezius muscle at the neck and the top of the shoulder. Acromioplasty: A procedure in which a small piece of bone is removed from the undersurface and front of the acromion to allow more room for the rotator cuff muscles.

17 Arthrography: An x-ray technique in which a dye is injected into a joint allowing better visualization of damage to the structures of the joint. Arthroscope: A thin telescope-like instrument containing a fiber-optic light source and a camera. It is about the size of a pencil and transmits magnified images of the inside of the joint to a television monitor. Bursa: A fibrous sac that contains fluid. The bursa acts as a cushion that allows tendons to move smoothly over the bone Clavicle: The collarbone. Glenohumeral joint: The ball-and-socket joint between the arm and the shoulder. Glenoid cavity: The shallow socket in the shoulder blade that receives the ball of the upper-arm bone to form the ball-and-socket glenohumeral joint. Labrum: A thickened firm tissue that surrounds and is firmly attached to the socket of the shoulder joint. It serves to deepen this joint and prevent abnormal motion of the shoulder joint. Ligaments: Elastic fibers that bind joints together and connect bones and cartilage. Magnetic resonance imaging: A diagnostic procedure that uses radio waves and a strong magnetic field to form serial images of the soft tissues of the body. Portal: The small incisions made around the shoulder joint for inserting the arthroscope and surgical instruments. Portal incisions are about the size of a small buttonhole. Rotator cuff: The group of tendons and muscles that attach the bone of the upper arm to the shoulder blade and provide support and mobility to the ball-andsocket joint of the shoulder. Scapula: The shoulder blade. Synovial fluid: A thick clear fluid that looks like the white of an egg and acts as a lubricant for joints, bursae, and tendons. Synovial membrane: The inner layer of the capsule that lines a freely moving joint. It secretes a thick fluid that lubricates the joint but that can accumulate in painful amounts when the joint is injured.

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