Common Surgical Procedures

Manipulation Under Anaesthetic

This is commonly used in the treatment of a frozen shoulder. If the stiffness in a shoulder does not respond to intensive physiotherapy and injection of steroid, a manipulation under anaesthetic is usually suggested. Whilst under a general anaesthetic the shoulder is moved through a completed range of motion. This has the effect of breaking down any adhesions within the joint and stretching the ligaments around the shoulder. Subsequent physiotherapy is undertaken during the early days and weeks so as to maintain the range of motion achieved.

The Reason For An Arthroscopy

Arthroscopy is the technique of performing surgery inside the shoulder joint through a telescope without disrupting the surrounding structures. Looking inside the joint with the arthroscope allows the Surgeon to look directly at the tendons, rotator cuff, shoulder labrum, ligaments and the articular surfaces. In some cases it is difficult to be certain of the diagnosis of a labral or rotator cuff tear or the amount of shoulder instability without a close internal inspection. In addition surgery can be undertaken through the arthroscope to remove the labral tear, remove the inflammation around the tendon, to partially remove the overhanging acromium bone, or to remove a loose body from inside the joint. Shoulder arthroscopy is commonly performed as a day case procedure with a rapid recovery and a rapid return of function often within a few days.

Arthroscopy also has the ability to inspect the internal state of the shoulder joint. This is used particularly to inspect the articular surfaces to determine if there are any defects or arthritic changes, the labrum or meniscus of the shoulder to determine any tears of deficiencies, the biceps tendon which may be torn or affected by tendonitis. To the superior aspect of the shoulder joint itself is the rotator cuff tendon originating from the supra spinatus muscle. The under-surface of this can be inspected from inside the shoulder joint itself to determine if there is any tendonitis, partial or complete tearing of the tendon. Subsequently at arthroscopy the space above the rotator cuff tendon and below the bone of the acromium at the top of the shoulder can be inspected. This space contains the sub scapula bursa. Once again this space is inspected at arthroscopy for tears of the rotator cuff or tendonitis. A spur of bone may be seen on the under-surface of the acromial bone. This is commonly present as an over-use or degenerative feature and can be the cause of tendonitis. In addition the distal end of the clavicle can be inspected where it articulates with the acromium and the shoulder. This joint is often affected by arthritic or degenerative changes.

Arthroscopic surgery

Sub Acromial Decompression

Where there is a bone spur on the under-side of the acromium at the top of the shoulder this is commonly associated with rotator cuff tendonitis due to impingement. At arthroscopy of the sub acromial space this spur can be excised with a portion of the acromium itself. This technique is called arthroscopic acromionectomy or sub acromial decompression. Part of this if the acromio-clavicular joint between the acromium itself and the lateral end of the clavicle is arthritic or degenerative then the bony spurs around this joint can be excised. In particularly severe cases the joint itself is sometimes excised.

Rotator Cuff Repair

In cases where the rotator cuff is intact but affected by tendonitis then simple sub acromial decompression and removal of the spur is often sufficient to alleviate patients' symptoms. Where there is a partial thickness tear on the superior or inferior surface then this may be debrided and smoothed over. In more severe cases where there is a tear then this is often repaired. The techniques for repair include some arthroscopic techniques or many open techniques. The nature of the surgery depends upon the extent and nature of the tear. Occasionally in severe degenerative cases where a massive tear is present often in an elderly population then formal repair of the defect is not made as in these cases and often symptomatic relief can be provided by sub acromial decompression without the necessity for repair. Following repair support of the arm in order to protect the repaired rotator cuff tendon is often necessary for a number of weeks. This is often achieved by using an abduction type pillow.

Shoulder Stabilisation

At arthroscopy the stability of the shoulder can be carefully tested under direct vision. Deficiencies of the articular surfaces, labrum of the shoulder itself or laxity of the surrounding ligaments can be assessed. Arthroscopic techniques are available in some cases to undertake repair. These include repair of the labrum itself, shoulder labrum, tightening and repair of the ligaments around the shoulder. These techniques are often used in cases where the history of shoulder instability or dislocation is moderate and there are no other factors which might suggest an open surgical technique would be more suitable.

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