What is Arthroscopic Surgery?

Arthroscopic surgery involves the insertion of a small camera through a minimal incision into the joint, allowing real-time visualization on a monitor. The surgeon then performs the procedure using specialized surgical instruments introduced through one or more small incisions, guided by the monitor display. The surgical instruments utilized in arthroscopic surgery are typically of pen tip size. In addition to the instruments employed in shoulder and knee arthroscopy, the availability of essential devices such as an arthropump (automatically regulating intra-articular fluid pressure), an arthrocare device (utilizing radiofrequency current to precisely remove and coagulate targeted tissues without causing excessive bleeding), and dedicated arthroscopic suture sets is of paramount importance.

Advantages of Arthroscopic Surgery?

  • The structures within the joint, such as the meniscus and cartilage, are non-pain-sensitive tissues. Arthroscopic surgery enables direct access to the joint without causing harm or injury to surrounding tissues, allowing focused interventions solely on the affected tissues. As a result, the post-operative experience is highly comfortable and devoid of discomfort.
  • Arthroscopic surgery provides a magnified and close-up view of intra-articular structures, facilitating superior diagnosis and targeted treatment of pathological tissues.
  • The advantage of arthroscopic surgery lies in its preservation of challenging and pain-sensitive structures, such as muscles and joint capsules responsible for joint mobility. This preservation is particularly crucial in the context of the shoulder. Consequently, post-operative joint movements are pain-free and unencumbered. Furthermore, the absence of surgical incisions and minimal bleeding eliminates the need for extensive wound care, while the risk of infection is significantly reduced when compared to open surgical procedures.

Areas of Use of Arthroscopy in the Shoulder

The utilization of shoulder arthroscopy is extensive, covering various areas:

  • Diagnostic purposes
  • Recurrent instances of shoulder dislocation
  • Tears in the long head of the biceps tendon
  • Shoulder impingement syndrome
  • Osteoarthritis in the acromioclavicular joint
  • Rotator cuff tears
  • Intra-articular cartilage fractures and injuries

Arthroscopic Surgery for Recurrent Shoulder Dislocations

Advantages:

  • Treatment of additional pathologies (such as SLAP tears, loose bodies, etc.) is possible.
  • Reduced pain.
  • Decreased discomfort.
  • Facilitated rehabilitation process.
  • Lower risk of limitations in rotational movements.
  • Minimal scarring.
  • Shorter surgical duration.

Disadvantages:

  • Inability to address dislocations caused by bone deficiency.
  • Surgical technique mastery requires time.
  • Insufficient presence of supporting tissue.
  • Although minimal, there is a slightly increased risk of recurrence

Different arthroscopic surgical methods exist for various types of shoulder dislocations. In the following discussion, we will focus on the treatment techniques employed for classic recurrent traumatic anterior dislocations. The techniques utilized in this context are as follows:

  1. Arthroscopic Bankart repair: The repair of recurrent traumatic anterior shoulder dislocations encompasses various arthroscopic surgical techniques. One such technique involves the reattachment of the labrum, a cartilaginous support structure located in the anterior aspect of the glenoid socket. By accessing the joint through one posterior and two anterior small incisions, the labrum is sutured back to its original position. To secure the labral tissue to the bone, a miniature screw, measuring approximately 3-5 mm, equipped with a thread at its end, is inserted into the bone.

  2. Capsular shifting: In cases where recurrent shoulder dislocations occur due to labral degeneration rather than a tear, or as an adjunct procedure to labrum repair, capsular shifting is performed. The objective is to tighten the lax joint capsule in the anterior-inferior region of the joint that is associated with recurrent dislocations. This tightening process involves suturing the excess capsule tissue, starting from the lower region, and gradually advancing upward. Similar to the Bankart repair, this technique is executed utilizing three portals.

  3. Capsular shrinkage: Another method employed, either independently or in conjunction with Bankart repair, is capsular shrinkage. This procedure involves the arthroscopic application of radiofrequency energy within the joint, resulting in localized heating of the lax capsule. Consequently, the capsule undergoes a process of shrinkage. However, due to the potential complications associated with this technique, it is currently not practiced in accordance with the prevailing international trends within the Istanbul Orthopedic Group.

Postoperative monitoring; Following the surgical intervention, the affected arm is immobilized using a sling for a duration of four weeks. During this period, shoulder pendulum exercises are prescribed thrice daily. On the fifth day, the patient is permitted to take showers. Throughout the sling-wearing phase, regular activities such as eating, computer usage, and writing can be conducted, as long as the shoulder remains stable. Passive and restricted active movements are allowed between the fourth and sixth weeks. From weeks six to ten, the range and intensity of active movements are gradually increased. During this time, patients can resume the majority of their daily tasks, except for elevating the arm beyond shoulder level. By weeks ten to twelve, all movements except for throwing motions are permitted. Full range of motion activities are generally authorized at the twelfth week, while engagement in sports is typically allowed at the six-month mark. Sports involving overhead arm movements, including tennis, basketball, volleyball, and baseball, may be reintroduced after the stipulated six-month period.

Obtaining support from experienced physiotherapists specialized in shoulder rehabilitation throughout this entire process is as crucial as the surgical quality for achieving favorable outcomes.

Arthroscopic Surgery for SLAP Lesion

The biceps brachii muscle consists of two heads, namely the long head and the short head. The long head of the muscle extends into the shoulder joint and attaches to the upper part of the shoulder socket. When the long head of the biceps sustains a tear at its attachment within the joint, it is referred to as a SLAP (Superior Labrum Anterior to Posterior) lesion. In cases of minor tears, the affected areas are cleaned and reattached, allowing for proper healing. However, in more severe tears, the tendon becomes detached from its original position on the socket and requires repositioning at a lower point. For larger tears, similar surgical techniques used for repairing labral tears are applied. The repositioning of the tendon is a complex and technically demanding procedure due to the specific positioning requirements.

SHOULDER IMPINGEMENT SYNDROME – ARTHROSCOPIC SURGERY FOR ROTATOR CUFF TEARS (Subacromial space arthroscopic surgery)

Arthroscopic procedures vary based on the patients’ age and diagnostic conditions.

  1. Bursectomy: The subacromial bursa, which acts as a lubricating sac between the rotator cuff tendons and the acromion, can become inflamed and lead to bursitis. When conservative treatments fail, surgical intervention may be required to remove the bursa. Bursectomy is a minimally invasive procedure performed through a small incision, typically around 1 cm in size. The utilization of Artrocare during the surgery offers substantial advantages, simplifying the procedure and promoting a comfortable postoperative recovery period.

  2. Acromioplasty: Acromioplasty is performed in cases where the acromion, a structural component of the scapula, causes compression of the rotator cuff tendons, leading to restricted shoulder joint movement or discomfort. Following the bursectomy procedure, arthroscopic techniques are employed to address any calcifications and to surgically modify the anterior one-third of the acromion. Additionally, it is often necessary to clean and optimize the articulation between the acromion and the clavicle.

The procedure poses technical difficulties, requiring meticulous attention to the angulation and cleanliness of the surface. The utmost importance lies in achieving optimal surface conditions and ensuring thorough cleaning. It is crucial to exercise caution when considering acromioplasty in individuals below the age of 50, reserving it for exceptional cases, as failure to do so may result in severe complications in subsequent years.

  1. Clavicular joint resection: It is a technically challenging procedure. The precise angulation and cleanliness of the surgical site are of utmost importance. Performing acromioplasty in patients under the age of 50 should be limited to exceptional cases, as it may lead to significant complications in later years.

Postoperative monitoring includes a 2-week period of arm immobilization. During this time, shoulder pendulum exercises are performed thrice daily. Patients are allowed to take showers from the 5th day onwards. While the arm remains immobilized, individuals can engage in activities such as eating, computer usage, and writing, maintaining a stable position for the shoulder. Between weeks 2 and 3, passive and restricted active movements are permitted. Active movements are gradually increased and diversified between weeks 3 and 4. During this phase, patients can perform most of their daily tasks. Full range of motion exercises are initiated between weeks 4 and 6. Sports activities are reintroduced at week 6, with sports involving overhead arm movements, such as tennis, basketball, volleyball, and baseball, being permitted after 8 weeks.

It is essential to seek the expertise of experienced physiotherapists specializing in shoulder rehabilitation throughout the entire process, as their guidance plays a significant role in achieving favorable surgical outcomes.

  1. Rotator cuff tears: Common shoulder condition observed in athletes, young individuals, and the elderly, often resulting from trauma, excessive strain, or degeneration. Early intervention is crucial for successful management. If left untreated for more than two years, rotator cuff tears causing functional impairment can lead to permanent muscular damage and suboptimal outcomes even after appropriate repairs. Initially, arthroscopic bursectomy is performed, followed by acromioplasty in older patients and, if necessary, in younger individuals. Subsequently, the rotator cuff tendon is meticulously sutured to the humeral head, employing specialized screws akin to labrum repairs.

For larger tears, additional portals may be required alongside the conventional 3-4 portals employed in shoulder arthroscopy. However, an alternative approach, known as the “mini-open” technique, is favored by numerous experts worldwide, whereby one of the existing portals is expanded up to 3 cm. Within Istanbul Orthopedic Group, we opt for the arthroscopic mini-open technique instead of performing arthroscopic repair through 5-6 portals.

Massive tears, characterized by their substantial size, necessitate treatment through open surgery.

Postoperative care parallels that of recurrent shoulder dislocations. In this context, intensive physical therapy under the guidance of experienced shoulder physiotherapists assumes paramount significance. Patient compliance remains a crucial factor. Engaging in unauthorized active movements can jeopardize the integrity of the repaired tendon.