Shoulder arthroscopy is a low-traumatic diagnostic operation, with the help of which it is possible to identify with a high degree of reliability the pathology of bones, ligaments, muscles and tendons in this anatomical zone. Intervention is carried out in cases where the cause of dysfunction, pain syndrome or instability of the shoulder joint is difficult or impossible to determine using other diagnostic methods (MRI, CT, electromyography, etc.). Some pathologies can be eliminated immediately after detection. To correct severe disorders, according to the results of the study, a traditional operation or therapeutic arthroscopy can be prescribed.
Indications and contraindications
Indications for diagnostic shoulder arthroscopy in traumatology and orthopedics are chronic pain, joint instability, suspicion of complete or partial damage to the rotator cuff of the shoulder, traumatic or degenerative damage to the cartilaginous lip. The technique is used for impeachment syndrome (chronic inflammation and bone spurs in the area of the rotator cuff of the shoulder), suspected chondromatosis (the presence of free intra-articular bodies), damage to the long head of the biceps. The operation is contraindicated in general acute infections, severe condition of the patient, infectious changes on the skin in the shoulder joint area.
Methodology of conducting
Shoulder arthroscopy is performed under local anesthesia or general anesthesia. The patient is placed on a healthy side, the sick arm is suspended using a special rack, weights or blocks, carrying out moderate traction along the axis of the limb. Arthroscopy is usually performed from the posterior access. A 0.5 cm skin incision is made by retreating 3 cm from the outer edge and 1-2 cm from the lower surface of the posterior part of the acromion. An arthroscope is inserted through an incision into the joint cavity. Sometimes, to improve the visibility of the joint, 40-50 ml of saline solution is pre-filled. A second incision is made on the anterior surface of the joint for the introduction of special tools and an irrigation cannula. The place of the incision is between the anterolateral edge of the acromion and the beak-shaped process, to the center of the tendon of the long biceps head.
During arthroscopy, the traumatologist consistently examines the biceps tendon, the rotator cuff, other tendons and ligaments of the joint, the articular lip, the head of the shoulder and the inner shell of the joint. Most often, during the study, damage to the articular lip is revealed, including damage to the Bankart, in which the anterior part of the lip is torn off along with the anterior part of the capsule and ligamentous apparatus. The second place in prevalence is occupied by ruptures of the rotator cuff of the shoulder (its supraspinatus portion is torn more often). In some cases, the pathology can be eliminated immediately after detection. Sometimes additional therapeutic arthroscopy or open surgery on the shoulder joint is required for a complete cure. Fixation of the limb after diagnostic arthroscopy is not required. The ability to work is restored within a few days.
When surgery doesn’t help
Any procedure has its own situations when it is powerless. It is not recommended to resort to this method of treatment and diagnosis when:
- fibrous or bony ankylosis;
- the presence of an infected wound;
- purulent-inflammatory processes in the periarticular tissues;
- hepatic, renal, and cardiovascular insufficiency;
- deforming osteoarthritis of stage III-IV.
- In some cases, at the discretion of a specialist, the operation can be performed:
- extensive damage (torn ligaments and joint capsules, violation of joint tightness);
- profuse hemorrhage in the articular cavity.
In cases of ankylosis and arthrosis of the shoulder joint, it is recommended to perform endoprosthetics (replacement of the affected articular surfaces with a prosthesis).
What kind of anesthesia
There are several types and tactics of anesthesia based on the characteristics of damage to the shoulder joint.
- Conduction anesthesia with the help of an interlobular blockade. The injected anesthetic reaches the caudal portion of the cervical plexus (C3, C4), the upper and middle parts of the brachial plexus (C5, C6, C7), the drug reaches the lower trunk later and in much lower concentrations, so the blockade of the median and ulnar nerves most often does not occur. This type of anesthesia is used for osteosynthesis of the clavicle, elimination of habitual shoulder dislocation (HSD), reduction of shoulder dislocation, during operations on the upper third of the shoulder.
- Conduction anesthesia via supraclavicular access. The local anesthetic interacts well with all the trunks of the brachial plexus, but in 80% of cases it does not reach the ulnar nerve. Such anesthesia is indicated during operations on the upper limb, elbow joint. It is used for osteosynthesis of the humerus.
- Endotracheal (inhalation) anesthesia. Such anesthesia plunges the patient into a state of deep drug-induced sleep, close to physiological.
- Combined anesthesia. The most frequent choice of surgeons. Endotracheal anesthesia is used together with the conductor. This makes it possible to potentiate the effectiveness of the methods and increase the analgesic effect after surgery.
Pain and complications of shoulder arthroscopy
If the surgeon complied with all safety standards, and recommendations were followed during the rehabilitation period, complications are usually not observed. However, there are always risks. These include:
- nerve damage or vascular plexus, clots in the area of surgical access;
- skin diseases (eczema, ulcers, psoriasis);
- the inflammatory process in the joint itself;
- cartilage tissues may be damaged, as a result of which complete
- fusion of bone tissues may occur (up to the development of the clinical picture of stage IV arthrosis);
- pains of a different nature in the joint itself and the tissues around it;
- thrombotic complications.
More often than the rest of the complications, there is a postoperative infectious complication. The pathogens are Propionibacterium acnae and Staphylococcus aureus. Such an infection gives a more acute onset, rapid development of a vivid picture of an infectious lesion: swelling and swelling of the joint, local hyperemia (which, without proper treatment, can turn into a generalized form), soreness and limitation of joint mobility.
the pain syndrome almost always accompanies the operated person in the first days after the operation. During this period, it is important to fix the operated limb as much as possible and use any available medications to relieve pain – NSAIDs, glucocorticoids and their intra-articular injections, intra-articular injections of sodium hyaluronate (depending on the severity of pain). The duration of this period is different for each patient, however, most often the condition improves by the end of the first week after arthroscopy.
General principles of rehabilitation
Rehabilitation after arthroscopy is a matter for patient and purposeful patients. The feeling of full recovery will come in six months (~4-6 months). Progressive atrophy of the muscular frame and stagnation can play the greatest danger during the recovery period. To prevent the development of such conditions, it is necessary to engage in therapeutic gymnastics, the purpose of which is to strengthen the shoulder joint and its muscle layers.
The very first movements of the shoulder joint should take place under the supervision of the attending physician. The main goal is to convey to the patient the rules and techniques of performing physical therapy exercises. On day 2, the exercises are performed in three positions: lying on a healthy side, lying on your back and standing. From 3-4 days, classes continue in the physical therapy hall.
From the end of the first week, it is necessary to start using and activating the injured limb. The exercises are aimed at improving local blood supply and preventing hypotrophy of the shoulder muscles.
The patient’s first movements are consecutive active and passive movements with a healthy shoulder. This technique will form a motor stereotype that will help the operated side to perform the exercises correctly. It is important to listen to your own feelings. If pain sensations appear / increase during and after classes– it is necessary to consult with your doctor. As a result of the conversation, the set of exercises can be changed to another one.
Rules for performing gymnastics
To achieve the maximum strengthening effect, certain rules must be followed.
- A systematic approach is required! It is necessary to practice every day, clearly adhering to the prescribed recommendations. There should be no personal preferences. If you feel unwell, the exercises are still performed, at least from the initial sitting position.
- Compliance with safety regulations. Each movement is performed smoothly and progressively. It is important to take into account the capabilities of your body so as not to harm the “sick” joint. If possible, the first two weeks should go to the gym and exercise under the supervision of a specialist.
- Weights and loads increase gradually, in accordance with the recommendations. In case of non-compliance, there is a risk of repeated and irreversible damage to the joint. A new operation will be required.
- Sudden movements and excessive loads are excluded. The shoulder should be in a loyal mode.
Everyone wants to recover sooner in order to return to everyday life. But you should be patient – let the shoulder and muscles gain their necessary conditions.
How are the exercises conducted
Active physical activity is allowed 3-6 weeks after the operation. By this time, the patient can already work with weights, rubber shock absorbers and block simulators.
Physical therapy is conditionally divided into three directions:
- simple actions to maintain muscle tone;
- power active loads affecting the entire shoulder area;
- loads with the use of additional devices (expanders).
- Sports after shoulder arthroscopy
Injuries especially often haunt athletes, especially Olympic sports. The question arises: when and is it really possible to return to the previous level of their condition after arthroscopy of the shoulder joint? Really, with the competent and mandatory implementation of the recommendations of the attending physician and the necessary recovery period.
The average recovery time (subject to continuous rehabilitation, satisfactory condition of the joint before injury) is 6 months. After decompression of the subacromial space: 2-3 months. After reconstructive surgery on the articular lip (including shoulder blades) and acromioplasty: 6 months. After the rotator cuff suture: 8-10 months.
The heavier and higher the load on the shoulder joint in a certain sport, the more carefully it is necessary to restore the muscles and their coordination.