SHOULDER SURGERY

Arthroscopic surgery

          Arthroscopic surgery is one of the most significant advancements in orthopaedic surgery. It was originally developed for use in the knee and became available as a diagnostic tool in the shoulder in the 1970s. I completed an additional fellowship year of training in shoulder surgery and sports medicine after my orthopaedic residency. At that time, in the mid-1990s, shoulder arthroscopy was still considered to be in its infancy. We could make appropriate diagnoses, remove bone spurs and make some basic repairs of a torn labrum using a thumbtack-like device. Over the years, we have developed the ability to treat most all shoulder pathology using the scope. Every shoulder surgery I currently perform is done differently now than how I was trained 20 years ago. The technology continues to advance and keeping abreast of these new changes is important to insure the best possible outcomes for my patients.

            Arthroscopy involves the insertion of a small fiber-optic camera about the size of a pencil into the shoulder through a quarter-inch incision. A flexible, high powered light source is attached to the camera to illuminate the joint. The camera is attached to a high definition monitor viewed by the surgeon at the foot of the operating room table. Saline fluid also enters through the cannula containing the camera. The fluid is under pressure to help distend the joint and compress any small areas of bleeding. The fluid pressure can be adjusted as needed. Several additional small incisions (portals) are created for insertion of working instruments and to allow exchange of the saline fluid. For most labral repairs and removal of bone spurs (called an acromioplasty), only three incisions are needed. There is one in the front of the shoulder, one in the back and one on the side. For rotator cuff repairs or more complex repairs, an additional fourth incision on the top of the shoulder is needed. Plastic cannulas are often inserted through the small incisions to keep fluid from leaking out of the incisions and allow easier passage of the instruments.

 

Arthroscope in the back of the shoulder and working cannulas in the front and side.

I prefer to do the surgery in the beach chair position with the patient sitting upright in a comfortable position. The arm is held by an adaptable arm holder that allows me to place the arm in different positions as necessary. This provides me full access to all sides of the shoulder to work easily. It also is a relaxing position for the patient that does not require general anesthesia.

 

Beach chair position for shoulder surgery

The vast majority of my patients have shoulder surgery utilizing a “nerve block”. Local anesthesia is injected around the nerves at the base of the neck prior to the surgery. An anesthesiologist will perform this procedure under light sedation that is generally well tolerated with minimal discomfort. This will completely numb the shoulder and the arm remains numb for approximately 12 hours after the surgery. The surgery can be performed with the block and “twilight” sedation provided by the anesthesia team through an IV. Most patients are completely asleep (and often snoring) during the procedure but do not have a breathing tube or general anesthesia. This allows them to wake up sooner with less pain and risk of nausea.

Common instruments used in the shoulder are a shaver and an electrocautery device. The shaver is also pencil sized and has a rotating sharp blade on the end. Suction is attached to the device and pulls any loose tissue into the rotating blade. This is useful for smoothing tears or worn area of cartilage. It is also useful for removing an inflamed bursa. The speed of the blade can be increased to allow it to function like a burr and remove bone spurs. An electrocautery device is utilized for cauterizing small bleeders. Using this device combined with the pressurized fluid irrigated through the joint allows good visualization of the joint structures. At higher frequencies, the electrocautery is also used to ablate or remove unwanted tissue. The irrigation fluid in the joint keeps the surrounding structures cool.

Electrocautery (left) and shaver (right) removing a bone spur (acromioplasty)

            Specialty instruments to allow passing sutures and tying knots were developed to allow complex shoulder repairs. These instruments are small enough to pass through small cannulas and have multiple angles to reach difficult locations. Other advancements include high strength sutures made of a braided polyester with a central polyethylene core that are almost unbreakable at normal loads. Anchors made of plastic or absorbable material are small screw-like devices with suture attached to them. They can be inserted in the bone and allow a torn labrum or tendon to be anchored back to the bone.

 

     

 

 

 

 

 

 

 

 

 

 

                      

Birdsbeak suture passers and knot pusher

 

Suture anchors in different sizes. Sutures are different colors to assist with knot tying.

 

Rotator cuff repair. Anchors with attached sutures are placed in the bone and sutures passed through the torn tendon using a suture passer (*) prior to tying.

What to expect with shoulder arthroscopic surgery

            Shoulder arthroscopy is an outpatient surgery. Prior to the surgery, it is important that any underlying medical conditions are maximized. You may be asked to obtain clearance from your medical doctor or cardiologist if you have a history of serious medical conditions such as uncontrolled diabetes, severe hypertension, significant pulmonary problems requiring multiple medications, or have had previous heart surgery or heart attack. Arrangements will be made for any preoperative blood test, chest X-Rays or EKGs. You may continue to take your arthritis medication or anti-inflammatories such as ibuprofen prior to the surgery. You may also continue aspirin but you will be asked to discontinue other blood thinners such as Coumadin, Xarelto, Lovenox, Pradaxa and Plavix. There should be nothing to eat or drink after midnight the night prior to surgery. If your surgery is later in the day, you may be allowed clear liquids for breakfast. You will be called by the surgery center the day prior to the procedure to inform you of the time of the surgery, the time you should arrive for the block, and medications you are allowed to take the morning of surgery.

            Prior to surgery, I like for my patients to be fitted for their shoulder immobilizer and arrangements made for cold therapy after the procedure. The immobilizer will be your friend for almost a month if you are having a repair. It is important that it is as comfortable as possible. Our office attempts to provide the best immobilizer possible for you. Cold therapy after surgery is also important to help with pain. Unfortunately, insurances (except for workman’s compensation) does not cover the cost. There are lower cost items such as refreezable gel icepacks. The best purchase for postoperative comfort is the continuous cold and compression provided by the ice machines with conforming shoulder wraps available in our office.

            On the day of surgery, you will be asked to arrive 1.5 to 2 hours prior to surgery. This allows time to register, talk to the anesthesiologist, placement of an IV and performance of the nerve block. It is important that someone brings you for the surgery and waits there for it to be completed. You are not allowed to drive, take public transportation or have someone drop you off. I will see you prior to surgery and mark the correct shoulder having surgery. You will be asked multiple times the correct side for surgery. My initials on the shoulder are one of the steps to insure there are no mistakes. You and your family will have an opportunity to ask any further questions at that time.

            When the operating room is ready, you will receive some additional relaxing medication through the IV and transported to the operating room on a rolling stretcher. Once in the room, you will be asked to move over to the operating room table and it will be positioned with you sitting upright, like in a beach chair. Once we are sure you are comfortable, additional sedation will be provided by the nurse anesthetist or anesthesiologist who will be with you throughout the surgery. They can make you as sleepy as you desire. Sterile drapes are applied around the shoulder so you will not be able to see anything. We insure your arm is numb prior to the surgery and, if there is any question, general anesthesia can always be performed. However, this is rare. Most surgeries last from 45 to 90 minutes. You will be awakened and transported to the recovery area. Your arm will be in the immobilizer. You will be given something to drink and the nurses will insure your pain is well controlled. You are typically going home within an hour of the surgery completion. I will provide detailed postoperative instructions concerning pain control, showering, bandages, driving, use of the sling, physical therapy, etc. These instructions vary based on the surgery. The nurses will go over them with you prior to your departure. I have included them in this section for your review prior to surgery.

Risks of arthroscopic shoulder surgery

            All surgery has some risks involved. Fortunately, in arthroscopic surgery, those risks are lower than typically seen with open procedures. The overall risk of surgery for arthroscopic shoulder procedures has been reported between 5 and 15%. These numbers are based on large groups of surgeons who were not shoulder specialists. My overall rate of complications is less than 5%. The risk of infection has been noted to be less than 1 in a 100. The most common bacteria causing shoulder infections is the same bacteria that causes acne (Cutibacterium acnes) and is more common in men. Antibiotics are administered prior to surgery and additional steps are also taken during surgery to reduce the risk. The surgical facility where you have your surgery performed is an important factor in preventing infections. I only operate at facilities with a low overall infection rate.

            The most common complication of surgery is shoulder stiffness reported between 2 and 10%. I initiate physical therapy as soon as possible after surgery to reduce this risk and try to reduce the time required in the sling. Working diligently with therapy and home exercises is the best way to avoid this complication. I will make sure you have full shoulder motion at the conclusion of the procedure and maintaining that movement is dependent on your participation afterwards.

            Other, much less common risks, are breakage of the instruments used during the surgery (extremely rare), symptomatic blood clots (less than 1 in 1000, although if you have a risk of clotting, you will be placed on a blood thinner after surgery), fracture during a manipulation (have not seen it occur), bleeding (usually only see bruising, have never seen a transfusion required), nerve damage (rarely see some numbness in the arm from swelling or the nerve block; typically resolves with time), or chondrolysis (a rapid deterioration of the cartilage, also very rare). I do not use pain pumps as the anesthetic in the pump can cause chondrolysis. Absorbable implants have also been associated with this complication and are likewise avoided. Anesthetic risks are always a possibility with surgery. Use of the nerve block reduces the possibility of major problems. Nausea and vomiting can occur and I often prescribe medication to reduce the symptoms. Please notify us prior to surgery if you have had this problem in the past. Urinary retention (cannot urinate) and constipation can also occur from the pain medication. My instructions include some ways to try to avoid this possibility. Other anesthetic risks will be discussed with you by the anesthesiologist prior to surgery.

 

Open Shoulder Surgery

            Most open shoulder surgeries are for shoulder replacement or fracture repair. Rarely, it is required for severe shoulder instability with bone loss (Laterjet procedure) or for augmenting a massive rotator cuff repair. The surgery typically involves a 3 to 4 inch incision over the front of the shoulder with dissection between muscles to reach the shoulder joint. These surgeries are also done utilizing a nerve block administered by an anesthesiologist prior to the procedure. This will keep the arm numb for almost 12 hours. Most of these surgeries are close to 2 hours in length so most patients also have a light general anesthesia to keep them comfortable in a sitting position for that length of time. Many patients spend the night in the hospital but some shoulder replacements and fracture repairs are now being done as an outpatient. The ability to go home the same day depends on the patient’s medical problems and insurance. Healthy patients without Medicare are good candidates for outpatient surgery. Improved techniques in pain control and newer, less invasive surgical techniques allow the option of returning home to a more comfortable environment. At this time, however, Medicare has not allowed this cheaper alternative.

What to expect with open shoulder surgery

            As with arthroscopic surgery, it is important that you are in the best medical condition prior to the surgery. You may need to see your primary care physician or possibly a cardiologist prior to surgery. Even if you have no significant medical problems, we may ask you to be evaluated in our office after preoperative blood tests, chest X-Rays or EKGs have been obtained. My surgical scheduler will coordinate these tests and evaluations for you. For open surgeries, I like for you to discontinue your arthritis medication and anti-inflammatories such as ibuprofen prior to the surgery. You will also be required to discontinue other blood thinners such as aspirin, Coumadin, Xarelto, Lovenox, Pradaxa and Plavix as they would increase your risk of bleeding during surgery. There should be nothing to eat or drink after midnight the night prior to surgery. If your surgery is later in the day, you may be allowed clear liquids for breakfast. You will be called by the surgery center the day prior to the procedure to inform you of the time of the surgery, the time you should arrive for the block, and medications you are allowed to take the morning of surgery.

            As with arthroscopic surgery, I like for my patients preoperatively to be fitted for their shoulder immobilizer and arrangements made for cold therapy after the procedure. You will be in the immobilizer for almost a month and can continue the cold therapy for weeks for pain relief. It is important that it is as comfortable as possible. Our office attempts to provide the best immobilizer possible for you. Cold therapy after surgery is also important to help with pain. Unfortunately, insurances (except for workman’s compensation) does not cover the cost. There are lower cost items such as refreezable gel icepacks. The best purchase for postoperative comfort is the continuous cold and compression provided by the ice machines with conforming shoulder wraps available in our office.

            On the day of surgery, you will be asked to arrive 1.5 to 2 hours prior to surgery. You will be contacted by the hospital the day prior to surgery to tell you the time to arrive. This allows time to register, talk to the anesthesiologist, placement of an IV and performance of the nerve block. I will see you prior to surgery and mark the correct shoulder having surgery. You will be asked multiple times the correct side for surgery. My initials on the shoulder are one of the steps to insure there are no mistakes. You and your family will have an opportunity to ask any further questions at that time.

            When the operating room is ready, you will receive some additional relaxing medication through the IV and transported to the operating room on a rolling stretcher. Once in the room, you will be asked to move over to the operating room table. Most patients do not recall this process because of the sedating medication. After the surgery is completed, I will talk with your family in the waiting room. You will be taken to the recovery area until you are more awake. If you are spending the night, you will be taken to your private room in the Orthopaedic Hospital where a dedicated group of orthopaedic nurses will assume your care. Your family can meet you there. Your arm will be in the shoulder immobilizer and the cold therapy will be started. You will be given something to drink and the nurses will insure your pain is well controlled. The majority of patients are comfortable enough to go home the next day. Physical therapy will see you prior to discharge to make sure you are comfortable getting in and out of bed, ambulating, and doing some simple shoulder exercises. I will provide detailed postoperative instructions concerning pain control, showering, bandages, driving, use of the sling, physical therapy, etc. These instructions vary based on the surgery. Most surgical incisions are covered with a water tight bandage that will allow you to shower and get the shoulder wet. The nurses will go over the instructions with you prior to your departure. I have included them in this section for your review prior to surgery.

Risks of open shoulder surgery

            The risks of surgery for open shoulder surgery are greater than arthroscopic surgery. For primary total shoulder replacements, the complication rate has been reported to be 22%. The most common complication is loosening of the plastic glenoid component. Former reports have stated that 14% of shoulders will have this complication. However, newer anchor peg designs appear to substantially lower this risk. Loosening on the humeral side is noted to be 6% of implants. Again, newer designs that are not cemented in place have lowered this percentage. Instability, or dislocation of the shoulder prosthesis, has been seen in 5% of patients. This risk is often dependent on surgical factors at the time of surgery. In my review of my shoulder replacement patients, this risk is less than 1%. Rotator cuff failure after the replacement has been noted in 3% of shoulder replacements. This is more common in those with rotator cuff problems prior to the replacement. If the rotator cuff tear is large, it may require conversion to a reverse replacement. Injury to a nerve or blood vessel has been noted in 2% of total shoulders. In most cases, the nerve injuries are due to stretching or compression of the nerves during surgery and the neurologic effects resolve over time. It is rare for excessive bleeding to occur that would require a transfusion. Infection occurs in approximately 1% of shoulder replacements. The most common bacteria is the same bacteria that causes acne and is found more commonly on the skin in men. It is a slow growing infection that can only appear as increased pain or early loosening of the prosthesis. Fever, redness and drainage are rarely seen. As with outpatient surgeries, where you have the surgery performed is important. The Orthopaedic Hospital has one of the lowest infection rates in the state.

            The risk of complications are slightly greater with reverse shoulder replacements. Total complication risk is 24%. Since the reverse shoulder requires fixation of the ball on to the scapula with screws, there is an increased risk of fracture or hardware problems from the screws. Instability risk is also slightly greater as there is no rotator cuff to help hold the shoulder in place. Infection risk has been reported to be 4-5 times greater than a primary shoulder replacement. This may due to reverse shoulders often being the second or third surgery on the shoulder.

            Fracture surgery has an additional potential for complications depending on the severity of the fracture. Some fracture patterns have a high likelihood of the blood supply to the humeral head being compromised. If the blood supply is cut off, the head will die (avascular necrosis, AVN) and lead to severe arthritis. For this reason, in many older patients, certain fractures are treated with an initial replacement. Shoulder stiffness is the most common risk with fracture surgery. I tell all patients with a shoulder fracture that they will never regain full movement. Appropriate fracture alignment and early therapy will reduce this risk. Some fractures also have a higher risk of not healing or healing in a poor position. This may cause pain and decreased use of the shoulder.

            Since open shoulder surgery is a larger procedure, there is also an increased risk with anesthesia. This is the reason we often have preoperative medical evaluations by your medical doctor if you have any increased risk factors. I prefer to use a nerve block which decreases the amount of medications required for the surgery. Nausea, vomiting and constipation can occur. If you are susceptible to these problems, appropriate preventive measures can be started. The anesthesiologist will discuss all of the risks with you prior to surgery.

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Tidewater Ortho

901 Enterprise Pkwy, Suite 900

Hampton, Virginia 23666

757-827-2480

Tidewater Ortho

4037 Ironbound Road
Williamsburg, VA 23188
(757) 206-1004

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