Providing Quality Orthopaedic Care
Filed under: Shoulder
Arthroscopic surgery, also known as keyhole surgery, involves minimally invasive surgery to the shoulder. Procedures that can be undertaken involve inspection of the joints, decompression of the subacromial space for conditions such as impingement, excision of the distal end of the clavicle for conditions known as AC joint arthritis, repair of the rotator cuff and repair of the labrum (tissue around the socket). Surgery is usually performed for pain or for stabilisation procedures.
The surgery is usually performed under a general anaesthetic often combined with a nerve block known as an interscalene block. A block involves instillation of local anaesthetic around the nerves in the neck which supply the arm, which allows the patient to have a lighter anaesthetic, thus reducing post operative nausea and also stress on the body.
As such the patient is brought into the theatre complex and a nerve block is instilled and the patient is put to sleep at the same time. The patient is then positioned on their side and some traction is placed on the arm in a gentle fashion being careful to protect all the structures and pad the patient appropriately. Traction on the arm opens the joint and allows small holes to be placed in the front and back of the shoulder to allow inspection of the joint surface itself. The level of arthritis can be assessed, the tissues ( labrum ) around the glenoid (socket) can be assessed. If there is a labral tear, it can be repaired using small anchors made of bioabsorbable material implanted into the socket whioch have sutures attached, and these are used to repair any soft tissue that has pulled away from the edge of the socket. This is known as labral repair / Bankart repair or stabilisation procedure.
If the main joint is otherwise intact the subacromial space can then be addressed, during which time the inflamed bursa can be excised through a third incision placed laterally on the arm. Using a small burr, bone that is catching on the tendon can be removed. At the same time, if there is arthritis of the lateral (outside) end of the clavicle leading to problems with the acromioclavicular joint ( AC joint ), a small segment of bone can be removed to stop bone catching on the other area of bone (bone on bone rubbing together ). This is the treatment of osteoarthritis of the AC joint and can be very successful.
If there is a tear of the rotator cuff ( tendons of the muscles surrounding the shoulder ) this can also be repaired totally arthroscopically and in this scenario. This is done by abrading ( roughening ) the top of the greater tuberosity ( the lump on the top and outer end of the shoulder bone) and then one or two small metallic anchors are inserted which have sutures attached to them. These are then used to tie the torn part of the tendon down to the bone. This can be supplemented with a second or third anchor more laterally to help compress the end of the bone down.
Thus through either two, three or four very small 1cm incisions, most surgery can be undertaken on the shoulder in a keyhole or minimally invasive fashion.
This surgery can be very successful. It does have many benefits over an open approach in that there is less blood loss, less risk of infection, the scars are tiny ( and in fact can often not be seen). More importantly there is no damage to the deltoid, which is the muscle over the top of the shoulder, which if undertaken through an open approach, can be damaged.
Surgery undertaken through an arthroscopic approach often results in less pain with a better success rate than many open approaches.
Consequently undertaken for a stabilisation procedure in the case of a shoulder that is dislocating, in the appropriate patient, we would expect a 90% success rate. For impingement or rotator cuff tears, in the appropriate patient the rate can be as high as 95% success.
Another advantage is that in those case not requiring a repair of soft tisssues ( impingement) early mobilisation can begin and in these cases a sling is not required and the patient is encouraged to move as quickly as possible. Whilst such patients should rest for a week after surgery, usually at the eight day period when sutures are removed, the patient is allowed to return to driving.
For those patients who require repair of the soft tissues, a sling is required, however this is worn outside the clothes with particular attention being given to axillary (armpit) care so that the patient can wash and clothing is worn normally. The patient is encouraged to come out of the sling daily to do exercise so they don’t get too stiff but the main hindrance is that in these cases, returning to driving is delayed until the sling is removed. ( The reason a sling is required in these scenarios is to protect the repair of the soft tissues until they heal to the bone, which can take four to six weeks. )
Tear identified at surgery
Whilst all surgery has risks and these need to be taken into account, in general however the risks of arthroscopic surgery is small. The main concerns are several. The first is the risk of the results of surgery, and whilst there is a 90-95% success rate in the average person, in some cases a person may not find they get an improvement and or have full recovery. There is also the risk of the anaesthetic although undertaken as described above is extremely safe.
There is a risk of post operative infection, but with an arthroscopic procedure, as saline is washed through the shoulder in copious amounts, this reduces the risk of infection greater than an open approach. Other risks include a risk of post operative stiffness and physiotherapy is usually required for most patient.
At Glenelg Orthopaedics, Dr Nimon has been committed to arthroscopic surgery for over fifteen years, having trained in Australia and then having gained further experience in the United Kingdom where it was done extensively and travelled to Europe to learn particular techniques. On returning to Australia in 2005 he promoted this extensively and encouraged other orthopaedic consultants to undertake such procedures through the Orthopaedic training program in which he is actively involved
In the following video Dr Gavin Nimon discusses shoulder conditions and shoulder surgery including shoulder arthroscopy. For more information and articles about shoulder conditions and treatment visit our shoulder section, or give us a call 8376 9988.
You be reassured that at Glenelg Orthopaedics you will be in advanced hands when undertaking Arthroscopic (minimally invasive) shoulder surgery.