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.
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.
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.
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.