Shoulder and Arm
Indications and Goals: Shoulder arthroscopy has probably had more advancements than anything in all of orthopaedic sports medicine in the last 10 years. Originally used only for diagnostic assistance, shoulder arthroscopy can be used to address a variety of injuries including instability, superior labral (SLAP) tears, and rotator cuff repair. The advantages of arthroscopy over open procedures include smaller incisions, less pain (allowing outpatient surgery), and quicker rehabilitation.
Procedures and Technique: There are two ways to perform shoulder arthroscopy, beach chair and lateral decubitus. For the beach chair technique, the patient is placed supine in a sitting position, and traction is typically not used. For the lateral decubitus technique, patients are placed on their side with the injured shoulder up and traction (typically 10 to 15 pounds) is used to distract the joint. The arthroscope is introduced from a posterior portal (2 cm distal and 2 cm medial to the posterolateral corner of the acromion) and probing/instrument insertion is done through an anterior superior portal (just anterior to the AC-joint). A variety of additional portals can be made depending upon the procedure. A systematic evaluation of the joint is carried out and all areas in the glenohumeral joint and subacromial space can be evaluated and treated. It is often very helpful to move the arthroscope to different portals (especially the anterior superior portal for glenohumeral visualization and lateral portal for subacromial/rotator cuff visualization). Instruments typically used in shoulder arthroscopy include various motorized shavers and burrs, handheld biters and graspers, and devices used to pass sutures through tissue.
Post-surgical Precautions/Rehabilitation: Depending upon the procedure done, patients are typically placed in a sling and encouraged to do elbow motion and pendulum exercises early. The type of rehabilitation involved following a shoulder arthroscopy depends upon whether or not the tissue was repaired or removed. If the procedure involves removing or debriding tissue without any repair, then acute rehabilitation can focus on pain relief and scar management at the portal sites. Range of motion can begin immediately, with supervision needed based upon the extent of the procedure performed and the confidence in the patient’s/athlete’s compliance. Strengthening exercise can begin within a few days. All exercises can use pain limitations as a guide for progression, but one should be careful not to be overly cautious and end up with adhesive capsulitis. Full active range of motion and functional strength should be restored within a few weeks. If the procedure involved a repair, then care should be taken to avoid placing too much stress on the repaired tissue until adequate and safe healing has occurred. More specific guidelines would depend upon which tissue was involved and the status of the tissue that is being repaired.
Expected Outcomes: The time frame for rehabilitation progression will depend upon the specific tissue that is repaired and the stability of the repair. Numerous procedures can be performed arthroscopically at the glenohumeral joint, thus outcomes will vary based upon the procedure.
Return to Play: This depends upon the procedure. In general, if the procedure does not involve soft tissue repair (e.g., debridement or acromioplasty), then the rehabilitation and return to play is relatively short. For most repairs (labrum, rotator cuff, etc.), return to play is often 4 to 6 months or more.
Carson WG. Arthroscopy of the shoulder: Anatomy and technique. Orthop Rev. 1992;21(2):143-153.
Faber E, Kuiper JI, Burdorf A, Miedema HS, Verhaar JA. Treatment of impingement syndrome: A systematic review of the effects on functional limitations and return to work. J Occup Rehabil. 2006;16(1):7-25.
Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen FA 3rd. Arthroscopic compared with open repairs for recurrent anterior shoulder instability. A systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2007;89(2):244-254. Review.
Mazzocca AD, Cole BJ, Romeo AA. Shoulder: Patient positioning, portal placement, and normal arthroscopic anatomy. In: Miller MD, Cole BJ, eds. Textbook of Arthroscopy. Philadelphia, PA: Saunders; 2004.
Mohtadi NG, Bitar IJ, Sasyniuk TM, Hollinshead RM, Harper WP. Arthroscopic versus open repair for traumatic anterior shoulder instability: A meta-analysis. Arthroscopy. 2005;21(6):652-658.
Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136. Review.
Debridement/Loose Body Removal/Synovectomy
Indications and Goals: This is merely an extension of shoulder arthroscopy, and is indicated for patients with symptomatic foreign or loose bodies in their glenohumeral joint or synovial disease.
Procedure and Technique: Motorized shavers and handheld instruments are used to remove pathologic synovium and loose bodies. For larger loose bodies, it is sometimes necessary to enlarge the portal. Another helpful trick is to bring the object up to the mouth of a large arthroscopic cannula and then pull it out with the cannula, which allows it to follow the path of the cannula. For posttraumatic loose bodies, it is important to do a thorough evaluation of the joint for a donor site and associated pathology.
Post-surgical Precautions/Rehabilitation: There are very little concerns related to postsurgical precautions following these types of procedures. Rehabilitation begins immediately for range of motion and strengthening exercises, guided by a person’s pain tolerance. Return to participation and activity can occur relatively quickly and is often patient-limited.
Expected Outcomes: Outcomes related to arthroscopic debridement or removal of tissue should yield excellent results relatively quickly. Factors influencing the outcomes may include the age and prior activity level of the patient.
Return to Play: Since this procedure does not involve any structural tissue, return to play can be relatively quick—even within a week of the index procedure.
Lunn JV, Castellanos-Rosas J, Walch G. Arthroscopic synovectomy, removal of loose bodies and selective biceps tenodesis for synovial chondromatosis of the shoulder. J Bone Joint Surg Br. 2007;89(10):1329-1335.
Smith AM, Sperling JW, O’Driscoll SW, Cofield RH. Arthroscopic shoulder synovectomy in patients with rheumatoid arthritis. Arthroscopy. 2006;22(1):50-56.
Tokis AV, Andrikoula SI, Chouliaras VT, Vasiliadis HS, Georgoulis AD. Diagnosis and arthroscopic treatment of primary synovial chondromatosis of the shoulder. Arthroscopy. 2007;23(9):1023.e1-1023.e5.
Indications and Goals: Three types of acromial shapes have been described on the basis of their appearance on lateral, or outlet, view—flat, curved, and hooked (I to III, respectively). Hooked acromions are thought to be more likely to result in rotator cuff tears, although this is somewhat controversial. The concept of outlet impingement—where the coracoacromial arch (acromion, coracoid, and coracoacromial ligament) causes pain and eventually rotator cuff tearing—has been challenged recently. Nevertheless, some patients do have subacromial impingement with positive exam findings (pain with passive forward flexion of approximately 120 to 150 degrees [Neer’s sign] and pain with flexion to 90 degrees and internal rotation [Hawkins’ sign]) and may benefit from acromioplasty. This typically also involves resection or recession of the coracoacromial ligament, although many surgeons attempt to preserve this ligament—especially with larger rotator cuff tears because it may prevent “escape” of the proximal humerus anterosuperiorly with massive tears. Surgical indications include pain refractory to cuff rehabilitation and subacromial injections with positive exam and imaging findings.
Procedure and Technique: Acromioplasty is most commonly performed arthroscopically. A shaver and burr is used to flatten the acromion (into a type I acromion). Most surgeons begin with the arthroscope in the posterior portal and, following arthroscopy of the glenohumeral joint, the scope is placed above the supraspinatus tendon into the subacromial space. A mechanical shaver, and sometimes ablater (electrocautery or radiofrequency device), is used to clear off the acromion and identify its borders. The acromioplasty proceeds from lateral to medial. The arthroscope is then moved to the lateral portal and the burr is placed in the posterior portal. Using the posterior acromion as a guide, the remaining acromion is flattened to allow a smooth undersurface (cutting-block technique).
Post-surgical Precautions/Rehabilitation: Since no muscle is taken down and nothing really needs to “heal,” rehabilitation can progress quickly. Early motion is encouraged. Patients/athletes may find horizontal adduction to be painful during the first few weeks postoperatively, and general pain can be used as a guideline for progression. Strengthening exercises can begin as tolerated and full range of motion should be restored within 2 to 3 weeks.
Expected Outcomes: Though some general tenderness may remain in the area for months, full unrestricted range of motion and strength should be restored without complications.
Return to Play: As long as the deltoid origin is not affected, return to play can be within 2 to 3 weeks or as pain is tolerated and function restored to acceptable performance levels.
Barfield LC, Kuhn JE. Arthroscopic versus open acromioplasty: A systematic review. Clin Orthop Relat Res. 2007;455:64-71. Review.
Izquierdo R, Stanwood WG, Bigliani LU. Arthroscopic acromioplasty: History, rationale, and technique. Instr Course Lect. 2004;53: 13-20. Review.
Kesmezacar H, Babacan M, Erginer R, Oğüt T, Cansü E. The value of acromioplasty in the treatment of subacromial impingement syndrome. Acta Orthop Traumatol Turc. 2003;37(suppl 1):35-41. Review.
Distal Clavicle Resection
Indications and Goals: Distal clavicle resection is most commonly indicated in patients with acromioclavicular arthritis (sometimes following low-grade AC separations) and distal clavicle osteolysis (a stress phenomenon commonly seen in weight lifters). Patients typically have localized pain, pain with cross-chest adduction, and radiographic changes (best seen on a Zanca view—10-degree cephalic tilt with soft tissue technique).
Procedure and Technique: The procedure is most commonly performed arthroscopically. It is not uncommon to first perform at least a minimal acromioplasty to appreciate the landmarks for distal clavicle resection. A 70-degree scope can also be helpful to ensure complete resection (the posterior superior portion of the distal clavicle is sometimes missed). The superior acromioclavicular ligament fibers should be preserved to prevent anterior-posterior AC instability. After removing the capsule with a shaver and electrothermal device, the lateral 1 cm of distal clavicle is resected from a portal directly anterior or posterior to the AC-joint. All debris is removed prior to completion of the resection.
Post-surgical Precautions/Rehabilitation: Rehabilitation is similar to acromioplasty. In fact, these procedures are commonly done concurrently. Early motion is encouraged. Patients/athletes may find horizontal adduction to be painful during the first few weeks postoperatively, and general pain can be used as a guideline for progression. Strengthening exercises can begin as tolerated and full range of motion should be restored within 2 to 3 weeks.
Expected Outcomes: Full range of motion and normal restoration of strength should be expected within 1 to 2 months. Return to activities without restrictions should be expected, with the time frame dependent upon the activity requirement.
Return to Play: With appropriate rehabilitation, return to play can be as early as 4 weeks and typically up to 8 weeks, all dependent upon one’s pain tolerance and ability to restore necessary strength and range of motion.
Bigliani LU, Nicholson GP, Flatow EL. Arthroscopic resection of the distal clavicle. Orthop Clin North Am. 1993;24(1):133-141. Review.
Hawkins BJ, Covey DC, Thiel BG. Distal clavicle osteolysis unrelated to trauma, overuse, or metabolic disease. Clin Orthop Relat Res. 2000;(370):208-211. Review.
Kharrazi FD, Busfield BT, Khorshad DS. Acromioclavicular joint reoperation after arthroscopic subacromial decompression with and without concomitant acromioclavicular surgery. Arthroscopy. 2007;23(8):804-808.
Rabalais RD, McCarty E. Surgical treatment of symptomatic acromioclavicular joint problems: A systematic review. Clin Orthop Relat Res. 2007;455:30-37. Review.
Lysis of Adhesions/Manipulation Under Anesthesia
Indications and Goals: This procedure is indicated for adhesive capsulitis (frozen shoulder) that is refractory to rehabilitation and glenohumeral injection(s). Because the process can recur unless immediate postoperative motion is initiated, and the patient is the key to success, we prefer to make an oral “contract” with the patients preoperatively, emphasizing their important role in maintaining their motion.
Procedure and Technique: The patient is positioned in the beach chair position for shoulder arthroscopy. At this point, the arthroscope is detached and used to take preoperative photos of their shoulder motion (forward flexion, abduction, and external rotation). Arthroscopy is then carried out using a smaller sheath, and adhesions (particularly in the rotator interval between the biceps and the subscapularis tendons) are thoroughly removed. The shoulder is then manipulated and remaining adhesions can be felt as they break up. Range of motion pictures are repeated, documenting the improvement in motion and proving to the patients that motion was restored.
Post-surgical Precautions/Rehabilitation: It is critical that the patient maintain his/her motion! A postoperative block and adequate pain medications can be helpful in this process. Although the clinician can be helpful in this process, it is the patient’s responsibility to perform passive range of motion exercises multiple times per day! Range of motion in all directions, and specifically accessory motion such as inferior glenohumeral glides, should begin immediately and preferably under supervision to facilitate improved outcomes and restored range of motion.
Expected Outcomes: Following a manipulation of this kind, the goal is to restore as much range of motion as possible. A reasonable functional goal can be determined at the time of manipulation under anesthesia and should be conveyed to the treating clinician. The most common complication is a recurrence of adhesions as a result of nonaggressive rehabilitation, noncompliance with rehabilitation, or rapid scarring from the trauma of the procedure.
Return to Play: This condition is not commonly seen with younger aged athletes. Return to play can be within 2 to 3 weeks, as long as the athlete maintains his/her motion that was restored during the procedure.
Castellarin G, Ricci M, Vedovi E, Vecchini E, Sembenini P, Marangon A, Vangelista A. Manipulation and arthroscopy under general anesthesia and early rehabilitative treatment for frozen shoulders. Arch Phys Med Rehabil. 2004;85(8):1236-1240.
Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007;89(7):928-932.
Kivimäki J, Pohjolainen T, Malmivaara A, Kannisto M, Guillaume J, Seitsalo S, Nissinen M. Manipulation under anesthesia with home exercises versus home exercises alone in the treatment of frozen shoulder: A randomized, controlled trial with 125 patients. J Shoulder Elbow Surg. 2007;16(6):722-726. Epub 2007 Oct 10.
Loew M, Heichel TO, Lehner B. Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg. 2005;14(1):16-21.
Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder: A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007;89(9):1197-1200.
Indications and Goals: This is an unusual but simple procedure that is often done in conjunction with other arthroscopic procedures in the shoulder. Throwing athletes that develop internal impingement with loss of internal rotation that do not respond to posterior capsular stretching (sleeper-stretches) and other therapy may have thickened posterior capsular tissues. Likewise, patients with long-standing glenohumeral arthritis may have capsular tightness.
Procedure and Technique: This procedure is simply a matter of identifying tight structures and releasing them. The tight capsule, which is most commonly found posteriorly, appears as thickened and shortened tissue. This capsule is divided, usually with electrocautery, from just posterior to the biceps tendon on the superior glenoid rim and continuing inferiorly. The rotator cuff is superficial to the capsule at this point, protecting them during the release as long as the dissection stays adjacent to the glenoid rim. Care should also be taken not to disrupt other normal structures, including the axillary nerve inferiorly.
Post-surgical Precautions/Rehabilitation: With the intent of this procedure to improve shoulder range of motion, supervised rehabilitation should begin immediately and include passive range of motion exercises, with the patient/athlete being encouraged to actively perform range of motion and muscle-strengthening exercises as soon as possible. Typically supervised physical therapy is recommended 5 days a week for the first 2 weeks and accompanied by a home exercise program. For the next 4 weeks, supervised sessions may be reduced to three times a week but the home program is continued daily.
Expected Outcomes: Similar to a manipulation under anesthesia, the goal of capsulotomy is to restore as much motion as possible. A reasonable functional goal can be determined at the time of manipulation under anesthesia and should be conveyed to the treating clinician. Complications primarily consist of a recurrence of adhesions as a result of nonaggressive rehabilitation, noncompliance with rehabilitation, or rapid scarring from the trauma of the procedure.
Return to Play: As long as the patient rehabilitates properly, return to play can be within 2 to 3 weeks or once pre-injury functional strength is restored for required performance levels.
Bach HG, Goldberg BA. Posterior capsular contracture of the shoulder. J Am Acad Orthop Surg. 2006;14(5):265-277. Review.
Bhatia DN, de Beer JF. The axillary pouch portal: A new posterior portal for visualization and instrumentation in the inferior glenohumeral recess. Arthroscopy. 2007;23(11):1241.e1-1241.e5. Epub 2007 Apr 6.
Ticker JB, Beim GM, Warner JP. Recognition and treatment of refractory posterior capsular contracture of the shoulder. Arthroscopy. 2000;16:27-34.
Anterior Bankart Repair/Capsulorrhaphy
Indications and Goals: Traumatic anterior shoulder dislocations almost always result in a Bankart injury (avulsion of the anterior inferior labrum and inferior glenohumeral ligament/capsule from the glenoid). Recurrent atraumatic shoulder instability is usually a result of capsular patholaxity. Surgical indications include symptomatic recurrent instability that has failed rehabilitation (rotator cuff strengthening). Extended rehabilitation (for up to 6 months) has been proven to be beneficial for atraumatic instability, but has not been shown to reduce recurrence for traumatic anterior instability. Bracing has also not been shown to reduce recurrence rates, at least in the United States. In addition, recurrence for traumatic anterior instability is directly related to age—younger patients (18 to 20 years old) may have a recurrence rate of over 80%! This has led many surgeons to consider surgery even for traumatic first-time dislocators. Classic exam findings in anterior instability include a positive apprehension test (abduction and external rotation of the affected arm causes apprehension) and relocation text (a posteriorly directed force relieves this apprehension). The goal for shoulder stabilization procedures is to reduce the recurrence of instability.
Procedures and Techniques: Most anterior instability procedures are now done arthroscopically. The goal is to restore normal anatomy by repairing the Bankart lesion back to bone and to reduce capsular patholaxity (by shifting the Bankart repair laterally and superiorly on the glenoid and creating a bumper pad on the glenoid surface; and [sometimes] reducing capsular volume by plicating [using sutures to make “tucks” of tissue] the capsule of the glenohumeral joint [including the rotator interval [tissue between the subscapularis and biceps]]). A Bankart tear (if present) is mobilized (it often scars down onto the neck of the glenoid medially—an anterior labral periosteal sleeve avulsion [ALPSA]). The glenoid is then prepared (using a shaver or a burr to roughen up the bone and create a bleeding surface). Suture anchors (devices that have sutures imbedded in them that are fixed into bone and are often bioabsorbable) are then placed immediately off the articular surface, and the attached suture is passed through the torn tissue and tied using arthroscopic knots. Plication stitches are added based on the surgeon’s assessment of associated capsular laxity (or for atraumatic instability, may be the only technique utilized). Thermal capsulorrhaphy (heat shrinkage) has been largely abandoned because of high recurrence and morbidity rates. Open procedures use similar techniques, but are done through a deltopectoral approach that usually involves dissecting the subscapularis tendon off of the underlying capsule.
Post-surgical Precautions/Rehabilitation: The patient is immobilized in a sling but encouraged to perform elbow motion and pendulum exercises several times a day. Passive range of motion is initiated but active motion is discouraged the first 4 to 6 weeks. External rotation is delayed until after the first 6 weeks and abductionexternal rotation is discouraged the first 3 months. Closed kinetic chain exercises can begin for proprioception and strength at 6 weeks postoperatively. Return to contact sports is not allowed until 4 to 6 months postoperatively. With an open procedure, additional caution is placed on active and passive external rotation as well as active internal rotation to avoid a strong contraction of the subscapularis muscle and/or strain to the repair. Postoperative subscapularis tendon rupture (excessive external rotation and a positive “lift-off test”) is a well-described but avoidable complication.
Expected Outcomes: The intent of the procedure is to restore joint stability. With restoration of the labrum and tightening of the capsule, this can be successfully accomplished in up to 90% of the cases. Failures are related to recurrent instability and bony defects.
Return to Play: With activities of daily living that do not require excessive forces to the glenohumeral joint, full return to activity is very reasonable within 4 to 6 months after surgery. For throwers who place added stress to the capsule, it may take up to 12 months or longer for a safe return to competition. Complications of recurrent instability have been reported 2 years after surgery suggesting long-term monitoring of patients.
Kartus C, Kartus J, Matis N, Forstner R, Resch H. Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks. A clinical and radiographic study with a seven to ten-year follow-up. J Bone Joint Surg Am. 2007;89(7):1442-1448.
Mohtadi NG, Bitar IJ, Sasyniuk TM, Hollinshead RM, Harper WP. Arthroscopic versus open repair for traumatic anterior shoulder instability: A meta-analysis. Arthroscopy. 2005;21(6):652-658.
Rhee YG, Lim CT, Cho NS. Muscle strength after anterior shoulder stabilization: Arthroscopic versus open Bankart repair. Am J Sports Med. 2007;35(11):1859-1864. Epub 2007 Jul 30.
Thal R, Nofziger M, Bridges M, Kim JJ. Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. 2007;23(4):367-375.
Posterior Bankart Repair/Capsulorrhaphy
Indications and Goals: Posterior instability is less common than anterior instability, but can be associated with certain sports/activities. Football interior linemen can develop posterior instability and labral tears from repetitive stress from blocking. Throwing athletes can also develop posterior laxity. Traumatic injuries are also responsible for some posterior instability, but, unlike traumatic anterior instability, these injuries have a more favorable prognosis with acute reduction and immobilization (in a neutral or externally rotated position). Classic exam findings for posterior instability include increased posterior translation with a load and shift test and a positive jerk test (passive abduction/adduction of the affected arm may reproduce the instability). Again, the goal of these procedures is to restore stability.
Procedures and Technique: Posterior shoulder procedures—both arthroscopic and open—are best performed with the patient in the lateral decubitus position. Standard portals are created and diagnostic arthroscopy is carried out. It is often helpful to switch the scope and instrumentation portals and to view the lesion from the anterior superior portal. An additional posterior (7 o’clock) portal is helpful for anchor placement and suture passage. The technique is similar to anterior Bankart repair and capsulorrhaphy. Open procedures are done through a deltoid-splitting approach with a posterior arthrotomy made in the infraspinatus/teres minor interval.
Post-surgical Precautions/Rehabilitation: Typically, the patient is placed in a neutral or external rotation brace for the first 4 to 6 weeks. Caution is emphasized to maintain this position early on to facilitate optimal healing of the repaired tissue. As one progresses, range of motion should be carefully increased, with no urgency to aggressively push the amount of internal rotation. Upon return to activity, bracing is not necessary and has not been shown to be effective in preventing against posterior shoulder dislocations. Passive forceful stretching into internal rotation and extension should be avoided for 3 months.
Expected Outcomes: The intent of the procedure is to restore joint stability. Again, with proper anatomic repair, success rates of approximately 90% can be expected.
Return to Play: With activities of daily living that do not require excessive forces to the glenohumeral joint, full return to activity is very reasonable within 6 months after surgery. This procedure is not performed as often as the anterior Bankart, yet precautions remain similar and expected outcomes should be similar. The posterior procedure is not as common as the anterior with throwing sport athletes, thus return to play may occur sooner in this case.
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