Common Surgical Procedures
Manipulation Under Anaesthetic
This is commonly used in the treatment of a frozen shoulder. If the stiffness in a shoulder does
not respond to intensive physiotherapy and injection of steroid, a manipulation under anaesthetic
is usually suggested. Whilst under a general anaesthetic the shoulder is moved through a completed
range of motion. This has the effect of breaking down any adhesions within the joint and stretching
the ligaments around the shoulder. Subsequent physiotherapy is undertaken during the early days
and weeks so as to maintain the range of motion achieved.
The Reason For An Arthroscopy
Arthroscopy is the technique of performing surgery inside the shoulder joint through a telescope
without disrupting the surrounding structures. Looking inside the joint with the arthroscope
allows the Surgeon to look directly at the tendons, rotator cuff, shoulder labrum, ligaments and
the articular surfaces. In some cases it is difficult to be certain of the diagnosis of a labral
or rotator cuff tear or the amount of shoulder instability without a close internal inspection.
In addition surgery can be undertaken through the arthroscope to remove the labral tear, remove
the inflammation around the tendon, to partially remove the overhanging acromium bone, or to
remove a loose body from inside the joint. Shoulder arthroscopy is commonly performed as a day
case procedure with a rapid recovery and a rapid return of function often within a few days.
Arthroscopy also has the ability to inspect the internal state of the shoulder joint. This is
used particularly to inspect the articular surfaces to determine if there are any defects or
arthritic changes, the labrum or meniscus of the shoulder to determine any tears of deficiencies,
the biceps tendon which may be torn or affected by tendonitis. To the superior aspect of the
shoulder joint itself is the rotator cuff tendon originating from the supra spinatus muscle.
The under-surface of this can be inspected from inside the shoulder joint itself to determine if
there is any tendonitis, partial or complete tearing of the tendon. Subsequently at arthroscopy
the space above the rotator cuff tendon and below the bone of the acromium at the top of the
shoulder can be inspected. This space contains the sub scapula bursa. Once again this space is
inspected at arthroscopy for tears of the rotator cuff or tendonitis. A spur of bone may be seen
on the under-surface of the acromial bone. This is commonly present as an over-use or degenerative
feature and can be the cause of tendonitis. In addition the distal end of the clavicle can be
inspected where it articulates with the acromium and the shoulder. This joint is often affected
by arthritic or degenerative changes.
Sub Acromial Decompression
Where there is a bone spur on the under-side of the acromium at the top of the shoulder this
is commonly associated with rotator cuff tendonitis due to impingement. At arthroscopy of the
sub acromial space this spur can be excised with a portion of the acromium itself. This
technique is called arthroscopic acromionectomy or sub acromial decompression. Part of this
if the acromio-clavicular joint between the acromium itself and the lateral end of the clavicle
is arthritic or degenerative then the bony spurs around this joint can be excised. In
particularly severe cases the joint itself is sometimes excised.
Rotator Cuff Repair
In cases where the rotator cuff is intact but affected by tendonitis then simple sub acromial
decompression and removal of the spur is often sufficient to alleviate patients' symptoms.
Where there is a partial thickness tear on the superior or inferior surface then this may be
debrided and smoothed over. In more severe cases where there is a tear then this is often
repaired. The techniques for repair include some arthroscopic techniques or many open
techniques. The nature of the surgery depends upon the extent and nature of the tear.
Occasionally in severe degenerative cases where a massive tear is present often in an elderly
population then formal repair of the defect is not made as in these cases and often symptomatic
relief can be provided by sub acromial decompression without the necessity for repair. Following
repair support of the arm in order to protect the repaired rotator cuff tendon is often
necessary for a number of weeks. This is often achieved by using an abduction type pillow.
At arthroscopy the stability of the shoulder can be carefully tested under direct vision.
Deficiencies of the articular surfaces, labrum of the shoulder itself or laxity of the
surrounding ligaments can be assessed. Arthroscopic techniques are available in some cases
to undertake repair. These include repair of the labrum itself, shoulder labrum, tightening
and repair of the ligaments around the shoulder. These techniques are often used in cases
where the history of shoulder instability or dislocation is moderate and there are no other
factors which might suggest an open surgical technique would be more suitable.