Why is surgery required?

The ball and socket joint (known as the glenohumeral joint) of the shoulder is a relatively shallow joint and can become unstable after major trauma. During a fall or a heavy tackle in sport, the structures that usually contribute to its stability can become torn or damaged. In more elderly patients recurrent instability is not usually a problem, but in younger patients, particularly those engaged in contact and overhead sports (rugby, football, tennis) recurrent dislocations can occur and result in significant damage to the joint and its surrounding structures.

X-ray of an acute shoulder dislocation

Which structures are damaged in shoulder instability?

To provide stability, the shoulder relies the labrum (the lip liner made of cartilage which deepens the socket); the joint capsule and ligaments, as well as the co-ordinated action of the muscles around the shoulder. In a traumatic shoulder dislocation, the humeral head (the ball) is usually dislocated anteriorly (to the front), out of the glenoid (socket of the joint). This results in tearing of the labrum and damage to the ligaments.

Labrum and glenohumeral ligaments

This may result in these structures becoming unable to maintain stability of the ball and socket joint of the shoulder, especially in certain arm positions. In some cases, there can also be an injury to the underlying bone of the socket, on its front rim. A fracture can increase the risk of ongoing instability.

Scan showing a fracture of the front and bottom edge (antero-inferior rim) of the glenoid (socket) of the right shoulder (known as a Bony Bankart injury)

Impaction fracture of the humeral head (left shoulder)

What treatments are available for shoulder instability?

The appropriate treatment for shoulder instability is dependent on a number of factors, including the type of instability, the pattern of the structures injured and the anticipated types and levels of activity that the individual wishes to undertake. In a traumatic instability, it may be necessary to repair the damaged structures with either an arthroscopic stabilisation (keyhole surgery) or open procedure.

If the dislocation has occurred without trauma, or with only minor trauma, or if the age and activity levels of the individual make further dislocation unlikely, it may be that the instability can be treated successfully with physiotherapy.

Arthroscopic view of labral damage (left)

Arthroscopic stabilisation (left)

The surgical treatment of shoulder instability involves the repair (usually by way of keyhole surgery) of the damaged tissues, commonly at the front of the shoulder, to help prevent the humeral head from dislocating.

When undergoing surgery, it is advisable to work with a physiotherapist before and after the operation, to maintain a functional range of movement and to rehabilitate to gain confidence in the shoulder.

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Anatomy

The shape of our shoulder ball and socket joint is quite particular in that the socket is flat, and the ball is round. Therefore, the ball relies on 4 tendons that keep it contained in the socket. These tendons are called the rotator cuff tendons. The most commonly affected tendon is the one that lies on the top of the humeral head (the ball) and it is called Supraspinatus.

What does the rotator cuff do?

This when the deltoid muscle attempts to raise your arm by your side or above your head, the Supraspinatus tendon maintains the humeral head (ball) in the socket by pushing it down and into the socket (stabilises it).

The deltoid muscle lifts the arm up whilst the rotator cuff keeps the ball stabilised within the socket.

What happens if the rotator cuff is torn?

When the Suraspinaus (rotator cuff tendon ) is torn then the ball migrates upwards when the deltoid muscle is trying to lift the arm. This is felt as clicking and pain on the side of the shoulder. Sometimes, you feel you need to manipulate your shoulder to get it up (by doing so, you are centering the ball in the socket which means you are trying to subsituting the function of the torn tendon). Once the arm is above your shoulder height it feels easier (less pain) because the ball can position itself in the socket again due to gravity (so it is during the middle of the range of movement that the pain arises).

When the rotator cuff tendon is torn or not working, the humeral head migrates upwards during arm elevation.

Arthroscopic view of a rotator cuff tear

Rotator Cuff Repair

Surgical rotator cuff repair is performed under general anaesthetic with the combination of regional block (this called interscalene block). The surgeon introduces a camera first into the main ball and the socket joint using a small cut at the back of the shoulder and this is done to ensure no other abnormalities are found (this is called diagnostic arthroscopy). After this is done, the camera is then inserted into the subacromial space (that is also done through the same incision and another small cut is made on the side of the shoulder and this is used to pass other instruments that are necessary to perform the repair).

The surgeon places anchors (screws made of metal, plastic or biocomposite material) on the ball and these anchors have strong sutures. The sutures are then passed through the tendon edge which is then pulled down to the ball. Additional anchors are then placed adjacent to the tendon to receive the sutures and the tendon is made snug on the bone (this is called double row repair).

Anchors are placed into the top of the humeral head and sutures are passed through the rotator cuff tendon.

Stitches passed arthroscopically through the rotator cuff.

The sutures are passed over the tendon and into more anchors on the side of the humeral head, fixing the rotator cuff tendon back down onto the bone.

Arthroscopic view of completed tendon repair

After the procedure

When you wake up, your arm will be in a sling that is only required for 4 weeks. Your movements are then restricted to protect the repair, but you will be allowed to move the arm as directed by the surgeon and physiotherapist. After 6 weeks you can drive and move the shoulder in all direction as able, but you should still avoid lifting or loading the shoulder for at least 3 months. It might take a minimum of 3 months before you feel any noticeable improvement from the surgery.

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What are the aims of surgery?

Arthroscopic subacromial decompression aims to address symptoms of impingement in order to restore shoulder function and relieve pain and discomfort.

This is a skeleton model of the left shoulder.
The arrow depicts the subacromial space.

What needs to be done prior to surgery?

The decision to have a subacromial decompression should only be made after thorough discussion with your surgeon. Usually the surgery is offered after non-operative treatments have been tried and offered temporary relief only. You should be satisfied that you have all the information you require in order to make an informed decision and that you are aware of both the potential risks and benefits of the planned procedure.

You should have a physical examination at the time of the initial consultation where the preoperative function of your shoulder is assessed. Investigations such as x-rays, ultrasounds and MRI scans may need to be arranged to confirm the diagnosis and allow your surgeon to plan the procedure. It is important that you fully disclose any health problems you may have had. Some may interfere with surgery, anaesthesia or aftercare. You should inform your surgeon and anaesthetist of previous allergies or reactions to antibiotics, anaesthetics or other medicines and in particular of any problems with prolonged bleeding or excessive bruising. Anti-inflammatories or other drugs which increase bleeding may need to be stopped prior to surgery.

You will need to undergo our preadmission process to ensure you are fit enough to proceed with surgery and to have a tailor made plan to guide you in adjusting to medications you may be on around the time of your surgery.

It is generally advisable to stop smoking to improve your overall health. It also helps to stop smoking around the time of an operation as smoking impairs wound healing.

If you decide to have surgery, your surgeon will ask you to sign a consent form. Read it carefully and raise any questions. It may be necessary for additional procedures to be performed at the time of surgery if the arthroscopic findings vary from the imaging studies.

As you may need help with you daily activities after the operation you should make the necessary arrangements prior to surgery.

What does the operation involve?

The arthroscopic surgical technique involves making several (usually 2 small incisions less that 1cm long around the shoulder so that the subacromial space and rotator cuff tendons can be viewed. The procedure is performed using an arthroscope which is a thin instrument attached to a camera and light source. It allows the operating surgeon to see inside the shoulder joint and perform the procedure while viewing a video monitor.

Soft tissue clearance from the underside of the acromion

The arthroscope is inserted into the subacromial space. Working through other small incisions, the surgeon uses small instruments to remove inflamed tissues. Small burrs are used to remove any bone spurs that may be pressing on the rotator cuff tendons.

Initial bony resection viewed from the back

The incisions are usually closed with stitches that may need to be removed. You will be given specific instructions regarding this.

The details of your anaesthetic will be discussed with the anaesthetist who will be taking care of you alongside the surgeon. This usually happens on the day of surgery.

After surgery, you will be transferred from the operating theatre to the recovery room where nursing staff will monitor your recovery and administer further pain relief if needed.

Completed resection viewed from the side

What happens after the operation?

Your arm may be in a sling or shoulder immobiliser. This is to protect the shoulder, relieve pain and maintain it in the correct position. You will usually be able to go home on the day of surgery but occasionally an overnight stay may be required. You will be unable to drive, so should arrange for someone else to drive you home.

Follow-up will be arranged to review your wounds within the first two weeks. This can be arranged at your local GP surgery or with your surgeon. Stitches (if used) are usually removed at this visit.

What rehabilitation is needed?

While the shoulder is healing some pain and discomfort should be expected. You may need to use pain-killers during this period. It may be difficult to perform some day to-day activities for some weeks following the procedure.

Your physiotherapist will design an exercise program for you. This is important to your recovery should begin shortly after surgery. It starts with gentle exercises that gradually help you regain shoulder movement. In uncomplicated cases the protective sling can be removed 48 hours after surgery. Your surgeon will advise you about a timescale for return to work and resumption of normal activities.

Recovery takes time. It commonly takes take several weeks for strength, comfort and full function of your shoulder to return to normal.

What are the likely outcomes of surgery?

In uncomplicated cases a good outcome in terms of pain relief and improved function can be achieved in around 80% of people.

What complications are associated with the procedure?

As with all surgical procedures there are risks associated with the procedure despite the highest standards of practice. Complications can occur that may have permanent effects. It is not possible to outline every possible side effect or rare complication, however, it is important that you have enough information about the possible complications of the procedure to fully weigh up the benefits and risks of surgery.

Possible complications of surgery include wound infection (treatment with antibiotics may be needed, and a second or third operation may be needed to treat the infection). Pain, discomfort or bleeding from around the incisions may occur. Most scars fade and flatten, but some may become “keloid” and remain raised, itchy, thick and red. Further treatment may be needed to try to improve the scarring.

In unusual cases, pain may not resolve over the long term. Persistent stiffness of the shoulder joint may require additional treatment. Injury to nerves close to the surgical area can occur. This may require further surgery.

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When is surgery required ?

The majority of injuries to the acromioclavicular joint (ACJ), which lies between the outer end of the collar bone (clavicle) and part of the the shoulder blade (scapula) called the acromion, are  sprains. These normally occur after a fall or tackle where the structures that normally control the joints stability are loaded and partially torn. Most sprains although painful will settle with time, applied ice and physiotherapy to rehabilitate the injured area. If these structures are completely disrupted and the joint is rendered unstable, early surgery may be required. In some cases of longstanding instability of the joint reconstructive surgery may be required to restore more normal relationships between the scapula and clavicle.

X-ray of an acute ACJ dislocation

What structures are damaged in ACJ instability ?

The ACJ relies for stability on tough fibres surrounding the joint (capsule) and on two ligaments running between part of the shoulder blade called the coracoid and the clavicle (coronoid and trapezoid). Complete disruption of all three structures will result in instability.

What treatments are available for ACJ instability ?

The appropriate treatment choice is dependant on a number of factors including the degree of instability. How recently the injury occurred, the patterns of structures injured and the anticipated level of activity that the individual wishes to undertake, all have an impact on the appropriate treatment options.

X-Ray following an acute (early) ACJ reconstruction

Most surgeons would agree that with sprains or minor injuries that surgery is inappropriate. Where significant disruption has occurred the options lie between early intervention (preferably within the first 2 weeks) using either open or arthroscopic (keyhole) surgery or an initial non-operative approach and then review to see whether the individual is symptomatic or needs to have a delayed reconstruction.

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What is shoulder arthroscopy ?

Shoulder arthroscopy is keyhole surgery of the shoulder performed through one or more small incisions (known as portals) around the shoulder. The shoulder is filled with pressurised fluid, to help give a good view of the interior of the joint. A 3.5mm diameter telescope is inserted into the shoulder. An digital camera attached to the end allows a high quality image to be transmitted to a video monitor which is viewed by the operating surgeon. Special probes and other tools can be inserted through the second portal, enabling minimally invasive interventional surgery to be performed.

What conditions can be treated by shoulder arthroscopy ?

Shoulder arthroscopy can be used to treat a variety of both traumatic and degenerative conditions both within and around the glenohumeral (shoulder) joint. The use of a telescope allows improved visualisation of disorders within the joint that may not be recognised with traditional ‘open’ techniques’.

In addition to allowing direct assessment of the joint structures it allows for the removal of loose bodies within the shoulder joint. Repairs can be performed to damaged structures in conditions such as shoulder instability, rotator cuff tears and damage to the glenoid labrum (the lip liner to the socket of the ball and socket). By introducing the arthroscope (known as the telescope) and instruments into the subacromial space it is possible to remove spurs that can contribute to shoulder symptoms.

What are the risks of shoulder arthroscopy ?

In most cases shoulder arthroscopy is performed under a general anaesthetic. Although modern anaesthetic techniques reduce risks to a minimum, there are complications associated with this component of the procedure. Surgical risks include a small risk of infection and damage to surrounding nerves and blood vessels. Some scarring is inevitable and its degree will vary from individual to individual. If there is poor mobilisation of the shoulder following surgery, stiffness or a frozen shoulder can occur.

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