Shoulder Arthroscopy

Arthroscopy is a type of ‘keyhole’ surgery, which means ‘a small cut’ is made in the body during surgery in order to view the inside of the body parts. Once the cut has been made, an instrument called ‘laparoscope’, which contains a thin telescope, light source, and a mini camera, is inserted through the cut made in the skin. The purpose of using a laparoscope is to provide the doctors with a clear and zoomed in view of the structures inside the body. This process can be used to diagnose many medical conditions and additionally to carry out surgical procedures, for example, removal of dead or damaged tissues inside our body or organs.

According to the National Health System, England, the procedure has various advantages over a major open surgery. These include

• less pain during and after surgery;
• quick healing;
• lower chance of infection after surgery;
• can be performed in a single day and people can return home after it is done;
• it doesn’t need an individual to be bed-ridden for a long period of time.

Some conditions that are routinely treated arthroscopically include:

• Rotator cuff tears  
  Tendons and muscles surrounding the shoulder joint that cause pain and restricted shoulder movement when torn halfway, mostly due to age-related wear and tear as well as an injury.
• Glenohumeral instability
  Pain and difficulty in moving the shoulder due to an unstable shoulder joint.   
• AC joint disease 
  Pain and swelling in the joint due to weakening and wearing out of the cushion like tissue in the shoulder joint.
• Loose bodies
  When the cartilage that sits between the two bones of shoulder joint tears, it results in small pieces of cartilage floating in the joint fluid. These are called loose bodies.
• Sepsis 
  The presence of bacteria and other microbes in the bloodstream and body tissues, which when reaches other body parts may result in multiple organ failure, and in severe cases, death is known as sepsis.
• Osteochondritis dissecans  
  A disorder with unusual jamming and locking of the shoulder joint due to cracks formed in the cushion like tissue and bone because of lack of blood supply in the area.
• Synovitis
  Swelling in a protective sheet surrounding a joint in the body that is present in the shoulder, knee, and wrist. 
• Chondral lesions 
  A tear or injury to the rubber-like tissue joining the bones together. 
• Subacromial impingement
  Swelling in the muscles and similar structures at a small canal in the shoulder joint they particularly pass through, causing pain. 
• Calcific tendinitis
  Hard, bone-like masses collected in the muscles and tendons of the shoulder joint. 

Shoulder arthroscopy has also been used routinely to confirm and treat:

• SLAP lesions
  Tear in the shoulder fibrocartilage.
• Labral tear 
  Tear in the rubbery tissue of the shoulder joint.
• Partial cuff tears 
  Tendons and muscles surrounding the shoulder joint, that cause pain and restricted shoulder movement when torn halfway, perhaps due to age-related wear and tear as well as an acute injury.
• Refractory adhesive capsulitis 
  Also known as frozen shoulder.
• Partial biceps tendon tears
  Torn forearm muscle.
• Multidirectional instability 
  A loose but painless shoulder joint.

Before you go in for surgery, your doctor might discuss the whole procedure and advise a few tests before the surgery is finalised. Here are a few things that your doctor might advise or do before surgery:

• Your doctor may ask a few questions about your medical history, the conditions that you have suffered or are suffering from, the medications that you're taking, and the ones you are allergic to.
• He/she may advise a few investigations, such as blood test, urine test, X-rays, MRI, CT scan, and so on. This will give your surgeon a better idea of the extent of the injury and the technique that could be employed for best results. 
• You will also be informed about the types of numbing agents and techniques that are available. You may either choose to get the numbing agent injected only in the shoulder area or sleep during the entire procedure.
• It is advised not to drink or eat the night before your surgery to prevent vomiting while the surgery is being performed. 
• You may also discuss the cost of shoulder arthroscopy before the surgery is performed. In India, the surgery usually ranges between . 

During the procedure, the surgeon:

• Inserts the arthroscope into your shoulder through a small incision. The scope is connected to a video monitor in the operating room.
• Inspects all the tissues of your shoulder joint and the area above the joint. These tissues include cartilages, bones, tendons, and ligaments.
• Repairs any torn tissues. To do this, your surgeon makes one to three more small cuts and inserts other instruments through them. A tear in a muscle, tendon, or cartilage is fixed and the damaged tissue is removed.

Types and Techniques:

Rotator cuff repair

• The edges of the torn tendon are brought together and it is attached to the bone with stitches.
• 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

• The damaged or swollen tissue is cleaned out in the area above the shoulder joint.
• A ligament called the coracoacromial ligament may be cut.
• A bony growth (spur) on the underside of the bone called acromion may be shaved because often, it causes impingement. This is known as impingement syndrome. The spur can cause swelling and pain in your shoulder.

Surgery for shoulder instability:

• If you have a torn labrum, the cartilage that lines the rim of the shoulder joint, the surgeon will repair it with arthroscopy.  
• Ligaments that attach to this area will also be repaired.

At the end of the surgery, the cuts 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 the repairs that were 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/cut so that the surgeon can get directly to your bones and tissues.

The cost of shoulder arthroscopy ranges from 1-2 lakh INR.

Right after the procedure, you may be taken to a room to recover from the sedation, if used in the procedure. A few things that you may be advised to do after surgery are as follows:

• There is often some pain associated after surgery in the treated joint. This is managed by painkillers, steroids, and swelling-reducing medications.
• You may be visited by a physiotherapist to discuss various light exercises to strengthen the shoulder muscles and joints.
• Depending on the procedure you had, you may need a temporary sling, splint or crutches to support and protect the joint while you recover. In some cases, special pumps or compression bandages are used to help improve blood flow.
• According to National Health Services, the United Kingdom, for recovery, the individual who underwent the surgery should go home accompanied by a caretaker until the effects of sedation wear off, which is usually up to 48 hours.
• Elevation of the joint and application of ice packs are recommended to avoid swelling in your joint. The dressing should be kept as much dry as possible, especially while taking showers. Replace the dressing with a new and dry one immediately if suspected wet. The dressing is usually removed after 5-10 days.
• Non-dissolvable stitches are removed after 1-2 weeks and you might have to come for follow up visits to ensure recovery or manage any suspected complications.
• You may be advised to take one-two weeks off after surgery for recovery.

Once you’re discharged, you have to take special care of yourself and keep in mind a list of things, such as:

• Avoidance of any strenuous or stressful exercises, lifting weights and other such activities.
• Any signs of tenderness, swelling, warmth in the treated area should be reported to your physician or surgeon.
• Keeping the joint at an elevated position to prevent blood clot formation.
• Using compression sleeves to increase blood flow to the surgical areas for faster healing.

Despite the safety of this procedure compared to open surgery, there are potential complications associated before, during and after the procedure. These can be categorised as:

Complications during the procedure

• Blood vessel and nerve injuries
  Although rare, some specific surgical procedures have been shown to have an increased risk of axillary nerve injury (an important shoulder nerve).
• Neurological events
  These are rare but can be devastating; adverse events like neuropraxia (mild injury to a nerve), injury to the cervical plexus, paralysis of the muscles of and surrounding the eye, and fatal venous air embolism (blood vessel blockage due to one or more gas bubbles) have been reported.
• When arthroscopy isn’t the best option for you
  Conducting arthroscopic surgery in conditions that require open surgical intervention may cause relapse and recurrent instability in individuals with conditions like unstable shoulder bones or deficiency in bone repairing hormones. (indicating an open surgery as a more appropriate procedure.
• Your position during surgery
  If you are wrongly positioned before the procedure is carried out, arthroscopy may cause flesh injuries and damage to the nerves, blood vessels and other important structures nearby.

Complications after surgery

• Infection  
  Although rare, the chances of infection increase if the arthroscopic procedure is converted further into open surgery. Typical risk factors for infection following arthroscopic shoulder surgery include obesity, diabetes, smoking, blood vessel diseases, weak immune system, history of prior surgery, and prior joint aspiration or injection. This can be treated by removing the damaged tissue and taking antibiotics. However, the results of the procedure itself may be compromised.
• Clot formation
  They are more common in individuals with genetics that predisposes them to some kind of thrombophilia (quick formation of clots). The risk of developing clots in the leg veins (deep vein thrombosis or DVT) and/or in the lungs (pulmonary embolism or PE) following shoulder arthroscopy depends on age, diabetes, obesity, heritable forms of thrombophilia, and cancer.