Arthroscopy is a minimally invasive surgery on the shoulder joint. With it, the doctor conducts a comprehensive restoration of the shoulder joint, reduces the risk of complications and facilitates the rehabilitation of the patient. Arthroscopy can be performed on various movable joints in the human body, including the shoulder. During surgery, the surgeon receives a picture on the monitor and, according to what he saw, carries out all the manipulations. This type of operation began in 1970. According to the frequency of execution, the procedure is in second place after arthroscopy of the knee joint.
Who is scheduled for surgery?
Damage to the shoulder joint is a common occurrence. It can be explained by the characteristic features of the anatomy of this department and increased motor activity. The contact area of the shoulder head and joint surface is small, in contrast to the range of movements. Shoulder arthroscopy surgery is indicated for:
- subluxation or dislocation of the joint of this department,
- with the development of chondromatosis,
- Tendon injury
- with mobility problems,
- cuff break
- subacromental bursitis,
- post-traumatic arthrosis,
- violation of the condition of the synovial membrane.
Contraindications to the procedure
Repeated surgery is prescribed in case of recurrence of concomitant diseases in the patient or with the development of new symptoms of the disease, as well as if the shoulder completely loses its mobility.
Arthroscopic surgery on the shoulder joint is contraindicated for people with intolerance to anesthesia or bone and fibrous ankylosis. For a while, those who suffer from acute and chronic infections, purulent lesions of the skin of the shoulder will have to forget about the operation. With a decrease in the joint cavity, the decision to conduct surgery will be made by the attending specialist after diagnosing the patient's condition.
The benefits of the procedure
Treatment of the shoulder joint with arthroscopy surgery is performed through several punctures (the incision is not used in this case). Using this technique, the surgeon has many opportunities:
- if the ligamentous apparatus was severely damaged or shifted to the side, the doctor re-fixes it,
- with displacement and any slippery damages: the cartilage lining is cut and repeated fixing is carried out,
- when the ligaments are pinched by bone formations or tendons: the ligaments are neatly truncated and once again fixed in one position, after tissue fusion passes,
- in case of problems with cuff rotation, it is important to visualize the sore spot, as well as reconstruction (truncation and fusion of joint tissues),
- when the position of the joints of the joint of the internal type is changed, restoration is performed by compression, after which bone formations are joined in the joint bag,
- when fragments of cartilage tissue penetrate into the cavity of the articular bag, excess fragments must be eliminated, and sharp ones should be sharpened,
- when ruptured tendons in the shoulder, the specialist performs excision and fusion, in some cases, repeated fixation of the position is required,
- with rheumatoid arthritis, the film is removed from the synovitis bag, which is located in the joint itself.
In case of violations in the cartilage pad, the doctor performs resurfacing, and if bursitis has been determined in the patient, then the joint bag is opened, all thickenings and other extra formations are removed from it, then the organ cavity is treated with antiseptics.
The main advantages of the procedure
Unlike simple open surgery on the shoulder joint, arthroscopy has a large number of advantages. The main ones include:
- minimal risk of injury and other complications during surgery,
- there is a chance to maintain the integrity of the joints,
- after the procedure, no noticeable scars remain on the patient’s body,
- short and painless patient rehabilitation,
- quick restoration of previous joint mobility,
- The risk of complications is minimized.
After surgery on the shoulder joint, recovery lasts for 7 days, and the patient remains in the hospital for only one day. The risk of complications will directly depend on the professionalism of the attending physician: if all the basic rules and rules of the procedure are followed, such a risk is equal to zero.
Arthroscopy allows you to restore the patient’s condition, and with the development of chronic diseases increases the duration of remission. After such an operation, the patient's mobility of the joint is completely restored, and the constant pain syndrome goes away and the patient's condition improves significantly.
The principle of the operation
During the procedure, the surgeon uses an arthroscope - a device in which a small camera is built-in. Such an instrument is inserted into the joint, and on a separate monitor, an image of a many-fold enlarged articular cavity is displayed.
The use of an arthroscope is permitted even in case of loss or instability of the joint. Most often, this method of treatment is considered the only one that helps to consider the condition of the organ fully and determine all the processes taking place inside the cavity.
Most often, during treatment, local anesthesia is used, injecting it. With a reduced pain threshold, other anesthesia methods can be used in the patient. In order for the doctor to gain full access to the joint and be able to restore its mobility, it is important to choose the appropriate posture for the patient’s position.
Usually the patient is laid on a healthy side, the arm with a sore shoulder is raised up and taken to the side through a specialized block system, which sets it in one position. In rare cases, axial traction along two axes is used. With it, the hand is securely fixed immediately in several places through the unit with the load. There is another fixation method - sedentary: with it, the patient is seated in a chair and the body of his body is tilted forward a little, the diseased arm remains hanging over the edge of the table.
The diseased part of the body is treated with antiseptics and labeled: the doctor at the same time indicates the injection sites of the instruments. The first puncture is carried out into the joint cavity using a puncture needle. If the synovial fluid begins to emerge, then a small dose of saline is additionally injected into the joint.
The doctor makes a small longitudinal section and embeds a trocar into it, which passes through an arthroscope. The second incision is made to insert a plastic cannula, with the help of such a device, excess fluid is pumped out of the joint. If necessary, other tools can additionally be used.
What complications can arise?
If the treating specialist performed the procedure correctly and followed the basic norms and rules, and the patient did not neglect the recommendations of the doctor, then complications after surgery should not be expected. But arthroscopy, like any other type of operation, has some risks. During the procedure, the following unpleasant situations may occur:
- cartilage tissue damage,
- vein damage
- the beginning of the inflammatory process,
- impaired functioning of the nerves in the area where the procedure is performed.
Signs of complications
Immediately after surgery, a tumor may form on the operated area of the body; the risk of developing swelling and hematomas is also high. Such negative symptoms do not last long and disappear without a trace after a couple of days, often this does not even require additional treatment.
After the operation, the usual dislocation of the shoulder joint inside it and on the puncture site will continue to persist for some time. But she also leaves on her own. You can reduce the severity of pain in a patient by taking special painkillers.
In order for the patient to recover as soon as possible, it is important to follow a set of measures to restore the body. From the first day after the procedure, it is important to start taking certain medications that will help eliminate inflammation and pain in the joint. While the patient continues to stay in a hospital, a cold compress is regularly applied to the doctor’s shoulder. At each change in the bandage on the shoulder, the surgeon should carefully examine the site for inflammation and other negative signs.
The main thing in the rehabilitation of surgery on the shoulder joint is the performance of special gymnastic exercises. You can begin to perform gymnastics in the first days after the operation. Strict compliance with the instructions of specialists during surgery on the shoulder joint will help speed up the recovery process of the patient.
You can start exercise therapy when the arm is in a fixed state and relaxed as much as possible. When performing the first movements, the joints of the arm on which the operation was performed should be involved. Also, exercises should be performed with a healthy hand. After five days from the moment of immobilization, you can begin to have a minimal effect on the entire shoulder joint.
In the first three weeks after surgery, you can perform the following exercises:
- to squeeze fingers with a special simulator or without it,
- muscle contraction without moving
- bend the wrist joint
- perform accelerated brush movements,
- rhythmically reduce and raise the shoulder blades,
- rotate and raise the forearm.
After surgery, the shoulder should be in a bandage for the next 3 weeks. Eliminate myogenic contracture in the normal condition of the scar is possible only with the help of physical education. The main goal of therapeutic exercises is to stimulate blood circulation to the arm with minimal mobility. In this case, the patient should monitor the sensations of his body: if swelling occurs, and the movement is complicated by pain, then the load should be stopped and an appointment should be made with the doctor who performed the operation.
Types of operation
The main types of surgery in the treatment of the shoulder joint include:
- arthrodesis of the shoulder joint,
- surgery for a habitual dislocation of the shoulder,
- operation with hanging the shoulder.
The doctor will choose the operation based on the patient’s health status and the results of the tests. The cost of surgery on the shoulder joint starts at 50,000 rubles.
Indications and contraindications
Frequent damage to the shoulder joint is due to high mobility and structural features. Arthroscopy is indicated in the following cases:
- chronic tendonitis
- ligament rupture,
- capsulitis - “frozen shoulder”,
- subacromial impingement syndrome,
- post-traumatic arthrosis of the joint,
- instability of the shoulder joint,
- rupture of the rotational cuff,
- habitual dislocation,
- SLAP syndrome
Repeated surgery is sometimes recommended - with a relapse of the disease or with a complete loss of joint mobility.
Contraindication for arthroscopy can serve as purulent-inflammatory processes in the joint, infectious lesions on the skin in the area of the surgical field. Surgical intervention is also contraindicated if it is impossible to apply anesthesia due to allergies or diseases of the heart, kidneys, liver.
Preparation for the operation consists of the following steps:
- consultation of an orthopedic surgeon,
- examination results - MRI, X-ray, ECG,
- test results - OAC, OAM, biochemical tests, HIV tests, hepatitis, RW,
- consultation of an anesthetist,
- Therapist’s opinion.
An important role is played by the position of the body during surgery, which provides convenient access to articular surfaces. Therefore, first, the patient is placed in the most optimal position. There are three positions in total:
- classic - the patient lies on the healthy side of the body, and the operated arm is pulled up and to the side using a system of blocks,
- axial traction on both axes - the arm is fixed in two places and raised through the block with a load,
- “Chaise lounge” - half-sitting, with a hand hanging over the edge of the table.
Then anesthetize the shoulder and arm. An anesthetic is injected into the neck or shoulder, blocking the nerves responsible for sensitivity. Often, regional anesthesia is used in conjunction with sedatives, since the operated person is uncomfortable during the manipulation.
If the operation is performed under general anesthesia, then mask or endotracheal anesthesia is used.
The next stage is the treatment of the surgical field with an antiseptic and marking - the places of introduction of the arthroscope and the projection of the position of the joint. Then, the capsule of the joint is punctured with a puncture needle and the synovial fluid is removed through the catheter. And the surgeon injects saline into the joint cavity - to improve the visibility and dilution of tissues.
An arthroscope is inserted into the joint through another puncture, the surgeon examines the joint, selects tissues for examination and performs the necessary surgical procedures:
- bone implant placement,
- joint capsule strengthening
- ligament fixation
- removal of dead tissue and adhesions,
- strengthening the articular lips and others.
After removing the tools, sutures and a sterile dressing are applied to the skin incisions. The joint is fixed in a certain position with a soft bandage - a shoulder bandage.
The whole procedure takes from one to three hours, depending on the amount of intervention. Hospitalization from one to four days.
Recovery takes much less time than with an open operation. Sutures are removed after 10-14 days, before that they can not be wet. Immobilization of the arm with the help of a bandage is performed for a period of 3-4 weeks. It is not recommended to remove it at night.
Drug therapy in the postoperative period includes:
- antibacterial drugs
- non-steroidal anti-inflammatory,
An important stage of rehabilitation is the exercise therapy complex. Classes can start from the second day, increasing the load every day. In the early days, training is carried out only with healthy joints. From 4–5 days, the operated shoulder can also be used.
1-2 weeks after arthroscopy training is best done under the supervision of a specialist. Severe pain during exercise should be reported to your doctor. Sudden movements are excluded, this can lead to reoperation.
Full recovery takes 3-6 months after the intervention. At this time, it is important to follow the recommendations of the orthopedist, avoiding excessive loads on the joint.
Additionally, the doctor may prescribe physiotherapy and several courses of massage, but not earlier than a month after the operation.
When the operation is performed by an experienced surgeon, and the patient complies with all the prescriptions of specialists, the risk of complications is reduced to zero. But a certain percentage of probability still exists:
- the development of inflammatory processes in the joint capsule,
- damage to blood vessels and nerves,
- bone damage
- swelling and hematomas of the soft tissues of the shoulder.
Urgently need to see a doctor if:
- there is an increase in overall body temperature or locally in the area of the operated joint,
- the sensitivity of fingers, hands is lost,
- severe pain during exercise or at rest.
- high diagnostic accuracy,
- minimally invasive
- low probability of complications
- lack of postoperative scars,
- a relatively short rehabilitation period,
- lack of need for prolonged hospitalization.
Almost the only drawback of the technique is its high cost. There is the possibility of a free operation for the compulsory medical insurance policy, but only if there is a quota and the necessary equipment in a state medical institution.
Sometimes arthroscopy is the only way to completely restore joint mobility - for example, removal of chondromic bodies is possible only with an arthroscope. The recovery process is individual and depends on both the qualifications of the doctor and the diligence of the patient.
The device of the shoulder joint, causes of dislocation
The shoulder joint is a system that connects the upper limb of the human body with the shoulder girdle of the body, namely the shoulder blade.
The spherical head of the humerus, an element that forms the skeleton of the hand, participates in the formation of the joint. The articular cavity is articulated with it - the concave zone of the scapula, which looks like a fossa with a flat bottom. On the edge of the circumference of the fossa is the articular lip formed by cartilage. This element is designed to increase the area of the cavity without limiting the mobility of the head of the joint. In addition, the lip of the joint softens tremors and tremors when moving the head, acting as a shock absorber.
A capsule is attached to the articular cavity between the bone edge of the joint head - it covers the shoulder head and ends on the anatomical neck.
From the base of the coracoid process, a dense bundle of fibers is woven into the articular capsule - it plays the role of an additional ligament of articular surfaces.
Strengthening and maintaining the elements of the joint occurs, for the most part, due to the muscle corset. It would be impractical to connect them together with dense strong ligaments, since the working mobility of the shoulder is achieved precisely due to the free rotation of the joint head in the cavity on the shoulder blade.
Dislocation implies that the normal condition of the joint is broken, and its elements are in places that do not correspond to their usual location. The structural parts of the joint are displaced, shifted or completely leave their intended place (this applies mainly to the articular head).
The main causes of shoulder dislocation of a joint disease, physical activity, strokes, falls, inflammation, unnatural rotation of the limb.
Symptoms and types of dislocations of the shoulder joint
Dislocation of the shoulder in the acute state is quite simple to determine by its manifestations:
- constant pain
- the formation of swelling in the shoulder,
- stiffness of the joint, violation of its motor function,
- loss of sensation with the shoulder and arm,
- if the dislocation is significant, the doctor can feel the deformation of the articular apparatus.
Depending on how the system of elements of the joint is broken, the front, lower and rear dislocation are distinguished.
The first of these is considered the most common. With anterior dislocation, the head of the humerus shifts forward toward the coracoid process or clavicle. The lower dislocation implies a displacement of the head down, because of which a person cannot lower his hand. A person may receive a rear type of injury by falling forward on outstretched arms. In this case, in the articular apparatus there is a separation of the articular lip from the cavity.
What is a common shoulder dislocation
For some people who have experienced this unpleasant injury, the condition becomes normal when, first, after treatment, the articular apparatus returns to normal. The affected person complies with all the requirements of the rehabilitation period, protects the shoulder from stress, and fulfills all the requirements of the doctor. It seems that the trauma is behind, the recovery has come, and you can again return to a normal lifestyle.
However, as soon as a person loads the recovered shoulder with the usual regime of his life, the joint again affects the dislocation.
If the patient develops a pathology called “habitual dislocation of the shoulder”, with any load or sudden movement, he will experience dislocations after a once cured dislocation. The root cause of this condition in most cases is damage to the articular lip, due to which the constituent elements of the joint cannot normally fix in relation to each other.
Treatment methods for habitual dislocation
The doctor who is usually referred to by patients with such an injury is a traumatologist or surgeon. These specialists, having performed the initial examination and questioning of the patient, having determined the state of habitual dislocation, can prescribe treatment regimens that are based on conservative therapy or surgical intervention.
Conservative treatment, most often, is ineffective with the usual dislocation. If their number in the patient did not exceed two or three cases, you can try massage courses in combination with a complex of physiotherapy exercises. During the implementation of this type of treatment, measures must be taken to limit abduction and external rotation in the joint.
If conservative methods do not give a result, and dislocations are repeated, the only effective way to get rid of them is surgical intervention. This method is aimed at eliminating the causes of constantly recurring dislocation, with the condition of maximum preservation of joint mobility. In this way, prevention of relapse of the pathology can be achieved.
The main types of operations on the shoulder joint
Treatment of pathology includes up to 200 varieties of surgical intervention in the articular apparatus. In general, all types of operations with the usual shoulder dislocation can be divided into 4 main groups:
- strengthening the joint capsule,
- plastic interventions on the muscles and tendons,
- osteoplastic procedures with implantation of transplants,
- mixed types of operations.
Indications and preparation for surgery
The appointment of an surgical intervention of this nature is usually preceded by a diagnosis and the number of relapses of dislocation, an examination of the condition of the joint and the degree of its damage. So, the direction of the patient for such an operation is possible subject to several conditions:
- the presence of a confirmed multiple-repeated dislocation of the shoulder joint,
- inefficiencies of conservative treatments.
Accordingly, the indication for surgery is the usual shoulder dislocation - such that it repeats constantly with any type of joint stress.
Preparatory measures include passing some tests that the doctor needs to plan the proper use of anesthesia, as well as to select the technique for the operation. So, the surgeon can refer the patient for a general blood test, coagulation and blood biochemistry.
At the time of the appointment of the operation, the doctor should have the actual results of radiography or MRI of the affected joint on his hands.
Intervention can take place using several types of anesthesia, namely local or general anesthesia, therefore, the day before, for 8-10 hours, the patient needs to refrain from eating food and liquids.
How is the surgical procedure: modern methods of arthroscopy
Joint surgery, if possible, is performed through arthroscopy. Arthroscopy indicates the way the surgeon accesses the surgical field. It eliminates the need for large incisions, respectively, and significant tissue injury. In addition, it more than the classic open operation, takes into account the features of the complex device of the articular apparatus.
The operation process looks like this: the patient is fixed on a couch or in a special chair. It should take the most comfortable position, and to ensure full immobility it is additionally fixed with rollers and belts.
After the introduction of anesthesia, the surgeon processes the surgical field in accordance with the requirements of asepsis. When the anesthesia works, the doctor makes a small incision and through it introduces an arthroscope into the shoulder - a flexible hollow tube with sensitive optics.
In order for the surgeon to have a better view of the field of activity, sterile fluid is pumped into the joint through the tube, due to which it swells somewhat, and it becomes easier to examine. Several small incisions are made to insert instruments and cannulas through them.
Having done the necessary manipulations, the doctor removes the arthroscope and all of his tools, processes incisions, sutures or special patches on them.
Such treatment is based on cutting the tendon of the subscapularis muscle - this way the surgeon achieves mutual muscular balance. In addition, this method makes it possible to strengthen the front-lower section of the capsule. She manages to expose by means of applying a longitudinal excision of the anterior-inner shoulder surface, from the acromial process to the deltoid muscle.
If the patient has external rotation of the shoulder, the section of the subscapularis muscle is made transversely in the area where it is attached to the small tubercle of the humerus. Fascial flap from the thigh is taken in sizes up to 10 centimeters in length and up to 3 centimeters in width. This fascia is first fixed to the capsule in the place of the lower pole zone of the joint depression at one of the ends, and then gradually placed on the capsule from the bottom up and outward in the oblique direction. The fascia is fixed to the capsule along the entire length up to the outer upper edge of the dissected deltoid muscle, after which the free end of the tape is brought under the fascia fascia, and is fixed in the region of the shoulder process of the scapula.
The wound is sutured in layers, and then abduction gypsum is applied to it - in this way it is possible to achieve joint immobilization for the duration of recovery and recovery.
After about a month and a half, the postoperative rehabilitation period ends.
In this case, the capsule is strengthened by moving to the front of the joint head of the long biceps head. The subscapularis muscle is lengthened. This type of surgery is considered minimally invasive, and makes it possible to qualitatively strengthen the articular apparatus by re-fixing the damaged lip of the joint. Using special anchors, a new lip is formed from the joint capsule, after which it is fixed on the bone with anchor fixators. The tears of the biceps muscle or lip identified during the operation must be removed.
In the process, the surgeon lengthens the subscapularis muscle, and moves the tendon of the long head of the biceps brachii muscle to the front surface of the head of the bone. Access for the operation is formed along the groove separating the pectoralis major and deltoid muscles, and they must be torn apart. The deep fascia is subjected to longitudinal excision, after which the short head of the biceps and the beak-brachial are shifted inward.
The inter-tubercle groove is subject to dissection - in this way the tendon part is exposed with the length of the biceps head. With external rotation of the shoulder, it is thrown over the small tubercle inward, and placed in front of the shoulder head. The upper part of the tendon is fixed in the area of the proximal segment of the excised subscapularis muscle, the lower is attached to the small tubercle. The subscapularis muscle is stitched with the implementation of its extension over the used tendon. The wound is sutured, a soft bandage is applied to it. A week later, the doctor removes the stitches, and after this, the patient must gradually begin classes in therapeutic gymnastics.
It is produced to create a thickening in the region of the anterior edge of the articular process. Thus, tendons of the short head of the biceps and the beak-brachial muscle, as well as the outer region of the pectoralis minor, are cut off from the coracoid process. From top to bottom, a tunnel is formed through which the cut off muscles are carried out behind the subscapularis. Then they are fixed in place, strengthening on the coracoid process.
After suturing, a person needs to ensure complete immobilization of the upper limb for 10-12 days.
It is prescribed if the patient has a loss of the bony lobe of the anterior edge of the articular cavity on the scapula. The operation is performed with the movement of the coracoid process and the muscles fixed on it to the front-lower edge of the articular cavity. In this place it is subject to fixation. So it is possible to make up for the missing bone mass in this place. Latarge operation is considered one of the most effective - it is successful in 97-98% of cases.
It is prescribed for the design of the tendon ligament between the shoulder and the acromial process. The incision in this case has an epaulet-like shape - through it, the clavicular-acromial joint and deltoid muscle are exposed. After dissection of the muscle, in the acromial process and the large osseous brachial tubercle, drilling is performed along the channel into which the tendon of the long fibular muscle is held. A tendon is taken about half its length. It is pulled tight, and the ends are stitched. After suturing, it is required to ensure complete rest of the limb for 10-12 days.
Features of the rehabilitation period
Recovery after surgery of any type has one general requirement - rehabilitation at first occurs only if the joint is completely immobilized. In some cases, the very next day, you can gradually move your hand in the hand, elbow and wrist joint.
If the limb must be completely immobilized, a bandage is applied on it that fixes it to the body and does not allow it to move. After about 1-3 weeks, the joint itself gradually returns to motor activity. Full recovery occurs in the period up to three months. All this time, a person needs to engage in special physiotherapy exercises, if necessary, to attend physiotherapy.
For athletes and workers whose activities are associated with intense physical exertion, a return to a normal lifestyle can take up to a year.
If a person is diagnosed and confirmed with the usual dislocation of the shoulder, surgery is the only really effective way to get rid of it. Medicine knows many schemes for the surgical treatment of pathology - some are considered more successful and minimally invasive, others, judging by the reviews of surgeons, are already outdated and are used much less frequently. The type and algorithm of surgical intervention, first of all, depends on the type of injury and the reasons that provoke it.