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Arthroscopic Shoulder Repair Can Reduce Pain and Speed Recovery

Shoulder arthroscopy is surgery that uses a tiny camera called an arthroscope to examine or repair the tissues inside or around your shoulder joint. The arthroscope is inserted through a small incision (cut) in your skin.

Description

The rotator cuff is a group of muscles and tendons that cover your shoulder joint. These muscles and tendons hold your arm in your ball and socket shoulder joint, and they help you move your shoulder in different directions. The tendons in the rotator cuff can tear when they are overused or injured.

Why the Procedure is Performed

Arthroscopy may be recommended for these shoulder problems:

  • A torn or damaged cartilage ring (labrum) or ligaments
  • Shoulder instability, where the shoulder joint is loose and slides around too much or becomes dislocated (slips out of the ball and socket joint)
  • A torn or damaged biceps tendon
  • A torn rotator cuff
  • A bone spur or inflammation around the rotator cuff
  • Inflammation or damaged lining of the joint. Often this is caused by an illness, such as rheumatoid arthritis.
  • Arthritis of the end of the clavicle (collarbone)
  • Loose tissue need to be removed
  • Shoulder impingement syndrome, to make more room for the shoulder to move around

The advantages of repairing a rotator cuff tear arthroscopically (keyhole surgery) are:

  • Less post-operative pain
  • Less time in hospital (usually can be performed as a day-case operation)
  • Quicker return to work and sports
  • Usually no stitches to remove
  • Less wound complications

However, it is more technically demanding to perform arthroscopically and different skills and equipment are required to those used in open surgery. Dr. Kevin Shaw, Matt Langenderfer, Tim McConnell, Steven Goldfarb , Jon Bell and Mike Lawley at Reconstructive Orthopaedics and Sports Medicine have special expertise in arthroscopic shoulder repair.

Who should consider arthroscopic rotator cuff repair and shoulder surgery?

Arthroscopic or open shoulder surgery is considered for cuff tears when:

  • Pain, weakness, and disability represent a significant problem for the patient, and inhibit his or her ability to perform the activities of daily living, overhead activities, or sporting activities
  • The patient is sufficiently healthy to undergo the procedure
  • The patient understands and accepts the risks and alternatives to the procedure
  • The patient has truly exhausted non-operative treatments, like physical therapy
  • An appropriate and comprehensive diagnostic evaluation has been performed and the nature of the problem is clear
  • The surgeon is experienced and familiar with several techniques and treatments for shoulder injuries, including arthroscopic surgery and open (traditional surgery)
  • The patient is capable and willing to undergo a comprehensive post-operative rehabilitation (physical therapy) program

The Surgical Procedure

Most people receive general anesthesia before this surgery. This means you will be unconscious and unable to feel pain. Or, you may have regional anesthesia. Your arm and shoulder area will be numbed so that you do not feel any pain in this area. If you receive regional anesthesia, you will also be given medicine to make you very sleepy during the operation.

Below is an example of the steps in an arthroscopic cuff repair

Step 1: The tear is viewed via the scope and portals (small holes in the skin) are created for instrument insertion

Step 2: A suture is passed across the long limb of the tear from side to side, using a special instrument, called a suture passer.

Step 3: The suture is tied and the two ends of the tendon brought together. This process is then repeated until the long limb of the tear is repaired.

Step 4: The bone is prepared for the insertion of the suture anchors 

Step 5: The suture anchor is inserted with a long insertor. The insertor is removed, exposing the sutures which are attached to the anchor. Most suture anchors used today are not made of metal, but of a biodegradable material.

Step 6: arthroscopic and cross-sectional views of the suture anchor in the bone, with the sutures arising from it.

Cross-sectional view of the anchor in the bone

Step 7: Suture from anchor pulled through the tendon with a special suture retrieving forceps. The anchor sutures are the passed across the rotator cuff tendon. 

arthroscopic view of the suture being retrieved through the cuff tendon 

Step 8: The sutures are passed through the tendon.

Step 9: The sutures are then tied sequentially

Step 10: Further suture anchors are added, as required depending on the size of tear and steps 5-9 are repeated for each anchor until the tear is fixed to the bone

Final Repair:

Your surgeon may do one or more of these procedures during your surgery:

  • Rotator cuff repair: The edges of the muscles are brought together. The tendon is attached to the bone with sutures. Small rivets (called suture anchors) are often used to help attach the tendon to the bone. The anchors can be made of metal or plastic. They do not need to be removed after surgery.
  • Surgery for impingement syndrome: Damaged or inflamed tissue is cleaned out in the area above the shoulder joint itself. Your surgeon may also cut a specific ligament, called the coracoacromial ligament, and shave off the under part of a bone. This under part of the bone is called the acromion. The spur can be a cause of inflammation and pain in your shoulder. This is called a subacromial decompression
  • Surgery for shoulder instability: If you have a torn labrum, the rim of the shoulder joint that is made out of cartilage, your surgeon will repair it. Ligaments that attach to this area will also be repaired. The Bankart lesion is a tear on the labrum in the lower part of the shoulder joint in the front portion. A SLAP lesion involves the labrum and the ligament on the top part of the shoulder joint.

At the end of the surgery using the arthroscope, your incisions will be closed with stitches and covered with a dressing (bandage). Most surgeons take pictures from the video monitor during the procedure to show you what they found and what repairs they made.

Your surgeon may need to do open surgery if there is a lot of damage. Open surgery means you will have a large incision so that the surgeon can get directly to your bones and tissues. Open surgery is a more invasive and painful operation.

Frequently Asked Questions (FAQ’s) about arthroscopic rotator cuff surgery:

  1. Is my rotator tear "too big" to be fixed using arthroscopy?

    The primary advantage of all-arthroscopic repair is that it allows a surgeon "global" access to the rotator cuff and tear for adequate cuff evaluation, repair and fixation to bone. For this reason, the LARGEST tears are often that require the greatest degree of skill and familiarity with arthroscopic techniques. Surgeons who are facile with arthroscopic techniques actually prefer to prepare and evaluate the cuff using the arthroscope, as this allows better visualization.

  2. Will I recover or "heal" faster after arthroscopic rotator cuff repair?

    Most people feel better faster, but they are not technically healed faster after an arthroscopic repair. All surgeries done to repair the rotator cuff, whether performed through open incisions or using the arthroscope, are designed to replace the rotator cuff to its original site, called the insertion. The sutures placed to hold the cuff would fatigue over time and the repetition of normal shoulder motion if it were not for the fact that the body "heals" the cuff to the repaired position with relatively normal tendon. The rate of the healing process is not affected by the method used to repair the cuff, so the cuff will not "heal" more quickly if a less-invasive, arthroscopic procedure is performed. However, most patients feel better much sooner after an arthroscopic procedure because these procedures do not require the extra healing of the deltoid muscle and longer skin incisions. For this reason, a patient must be disciplined about adhering to a strict postoperative "rest" so that they don’t stress the repair before the body has completed the healing process, which goes on for several weeks and months. Typical healing time for a small tear is 2-3 months. For a large or massive tear it is 6 months.

  3. Are the results as good as with "mini-open" techniques?

    Most of the recent studies show that in the hands of surgeons who are expert in all-arthroscopic rotator cuff repair, the results are comparable to open techniques. Specifically, the best results reported for open repairs are as high as 97% success.1,7,11,142-6,8-10,12,13 Reports of the traditional open fixation tend to demonstrate that the success rates are less favorable for larger tears. Interestingly, the studies of arthroscopic repairs show otherwise: the results do not appear to be significantly worse with larger tear sizes.4 This is probably due to the global access to larger tears with the arthroscopic techniques. Recent articles reported on arthroscopic fixation using the latest instruments and techniques demonstrate 93% to 95% good and excellent results.

Studies have shown that "retear" rates may be higher with arthroscopic techniques, and the durability of these relatively new techniques will be better understood over time. It is interesting that when massive tears deemed "irreparable" by standard techniques are addressed with an arthroscopic technique called margin convergence, the results can be favorable even if the tear can’t be fully repaired to bone.

The results of arthroscopic and open rotator cuff repair procedures are most effective when the patient follows a simple post-operative rehabilitation program. Thus, the patient’s motivation and dedication are important elements of the partnership.

Risks

Risks of shoulder arthroscopy are:

  • Shoulder stiffness
  • Failure of the surgery to relieve symptoms
  • Failure of the repair to heal
  • Weakness of the shoulder
  • Injury to a blood vessel or nerve

Keep in mind, these are the same risks that are present in an open shoulder surgery.

Before the Procedure

Always tell your health care provider what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

Two weeks before surgery you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), and other drugs.

Ask your health care provider which drugs you should still take on the day of your surgery.

If you have diabetes, heart disease, or other medical conditions, your surgeon will ask you to see your doctor who treats you for these conditions.

Tell your health care provider if you have been drinking a lot of alcohol, more than 1 or 2 drinks a day.

If you smoke, try to stop. Ask your health care provider or nurse for help. Smoking can slow down wound and bone healing.

Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

On the day of your surgery:

  • You will usually be asked not to drink or eat anything for 6 - 12 hours before the procedure.
  • Take your drugs your health care provider told you to take with a small sip of water.
  • Your health care provider will tell you when to arrive at the hospital.

After the Procedure

Recovery can take anywhere from 1 to 6 months. You will probably have to wear a sling for the first month. If you had a lot of repair done, you may have to wear the sling longer.

You may take medicine to control your pain.

When you can return to work or play sports will depend on what your surgery involved. It can range from 1 week to several months.

For many procedures, especially if a repair is performed, physical therapy may help you regain motion and strength in your shoulder. The length of therapy will depend on the repair that was done.

Outlook (Prognosis)

Arthroscopy is an alternative to "open" surgery that completely exposes the shoulder joint. Arthroscopy results in less pain and stiffness, fewer complications, shorter (if any) hospital stays, and faster recovery sometimes.

If you had repair done, your body still needs time to heal after arthroscopic surgery, just as you would need time to recover from open surgery. Because of this, your recovery time may still be long.

Surgery to fix a cartilage tear is usually done to make the shoulder more stable. Many people recover fully, and their shoulder stays stable. But some people may still have shoulder instability after arthroscopic repair.

Using arthroscopy for rotator cuff repairs or tendinitis usually relieves the pain, but you may not regain all of your strength.

Kevin Shaw, MD
Reconstructive Orthopaedics & Sports Medicine

References:
Arthroscopic shoulder surgery for the treatment of rotator cuff repairs
Sports Medicine Team

Rotator Cuff Tears: Surgical Treatment Options
OrthoInfo
American Academy of Orthopaedic Sciences

Arthroscopic Rotator Cuff Repair
ShoulderDoc.co.uk

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