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.
|
|
|
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.
|
|
|
|
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
the 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
 |
|
