Shoulders – Arthroscopic & Replacement

The orthopaedic clinic offers advanced surgical platform

Shoulder injuries interventions

Shoulder injuries can happen suddenly, as in a fall, or from wear and tear from everyday movement and activity. When injury occurs, the shoulders’s ability to function is disrupted, impacting the intricate workings of bones, muscles, ligaments and other structures. Treatments for shoulder problems range from physical therapy to medications to surgery.

Arthroscopy

Arthroscopic Surgery is a procedure that allows surgeons to see, diagnose, and treat problems inside a joint. The procedure, also called an Arthroscopy, requires only small incisions and is guided by a miniature viewing instrument or scope. Before arthroscopy existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the joint to view it and perform surgery. The traditional surgery method carries a higher risk of infection and requires a longer time for recovery. In contrast, arthroscopy is less invasive. It has a decreased risk of infection and shorter recovery period. Today, arthroscopic surgery is one of the most common orthopedic procedures.

WHAT IS A BANKART LESION?

One of the main parts of of the shoulder is the ball-and-socket configuration that allows you to rotate your arm. In a healthy shoulder joint, the ball and socket remain in stable positions, with the ball (humeral head) centered in the shallow socket (glenoid or glenoid cavity).

Reinforcing this stability is the glenoid labrum, a fibrocartilaginous rim that encircles the edge of the glenoid, making its concavity deeper.

Additional ligaments surrounding the joint (some of which are attached to the glenoid labrum) help to hold the humeral head inside its socket. Together, these bones and tissue keep your shoulder in place and stable through a wide range of motion.

Sometimes, however, a sudden shoulder injury or overuse can create a forceful dislocation that tears the cartilage and ligaments of the shoulder When you tear your glenoid labrum below the center anterior (front) of the socket, this is called a Bankart lesion. When the labrum is torn, the cartilage rim around the socket is compromised, allowing the humeral head to slip farther than normal.

Most Bankart lesions are caused by anterior dislocations — when the arm moves too far forward and down, often when the arm is extended to the side. Posterior dislocation (when the arm is forced backwards) can also lead to a tear in the labrum, though less commonly.

If your tear is accompanied by a fracture in the bone of the shoulder blade (scapula) or the shoulder socket (glenoid cavity), this is called a bony, or osseous, Bankart lesion.

An untreated Bankart lesion can lead to chronic shoulder instability — meaning your shoulder may dislocate again in the future, probably in situations involving less force than the original injury.

CAUSES OF BANKART LESIONS

Bankart lesions are frequently the results of collisions, accidents, and sports injuries (either acute injuries or overuse injuries from repetitive arm motions). Though anyone can sustain this injury, young men in their twenties are most susceptible.

Possible causes of shoulder dislocations and lesions:

Car accidentsA sudden blow to the shoulder can knock the ball from its socket, tearing the labrum.

Sports collisionsCrashing into another person with speed and force — for example, during a football or hockey tackle — can shove the shoulder out of alignment or drag the arm forward or backward, leading to dislocations.

Falls from sports Falling and landing on one's shoulder can lead to shoulder dislocations in athletes, especially in sports where falling with height or speed is common, like gymnastics, skating, rollerblading, or skiing.

Falls not from sportsFalling off a ladder or tripping on a crack in the sidewalk can deliver enough force to dislocate the shoulder. Elderly people and those with gait problems can be highly susceptible to these types of falls

Overuse injuriesIn some athletes, overuse of the shoulder can lead to loose ligaments and instability. Swimmers, tennis players, volleyball players, baseball pitchers, gymnasts, and weight lifters are prone to this problem. In addition, non-athletes may develop instability from repeated overhead motions of the arm (for example, swinging a hammer).

Loose ligamentsSome people have a genetic predisposition to loose ligaments throughout the body (e.g., double-jointed individuals). They may find that their shoulders pop out of alignment easily.

Physical abuseDomestic violence, physical bullying, or fighting can involve falls, blows, or sudden wrenching movements that may pull the ball from the socket, damaging surrounding tissue.

Symptoms of bankart lesion

pain, when reaching overhead activity like through ball,combing hair.

Instability and weakness The shoulder may "just hang there," pop out of the joint, or feel too loose.

Limited range of motion. Sudden difficulty moving the shoulder in any direction may indicate a tear.

Unusual noises or sensations in the shoulder. Grinding, catching (not moving fluidly), locking in place, or popping can all be symptoms of torn tissue getting caught in the joint.

Treatment

Non-Surgical Treatment

For older patients, or those who are less active, non-surgical treatment is recommended for a Bankart lesion.

The arm is immobilized in a sling for a few weeks, usually with the arm resting across the front of the body in internal rotation (turned inwards) and a small pillow under the armpit to hold the arm slightly away from the body. This is then followed by intensive physical therapy to regain the strength, stability and mobility of the shoulder.One of the problems with this treatment method is that in this rest position, the glenoid labrum tends to heal in slightly the wrong place, so the socket depth is reduced, making the shoulder more prone to recurrent dislocations.

Surgical Treatment

Bankart repair surgery tends to be the treatment of choice for younger patients with a Bankart lesion, especially those who play sports, as there is a high risk of the shoulder dislocating again. This is because the glenoid labrum tear often fails to heal properly, so doesn’t provide the extra depth to the socket that is needed, reducing the stability and increasing the risk of further dislocation.

A Bankart lesion repair is usually carried out arthroscopically (key hole surgery) under general anaesthesia. The labral tear surgery aims to repair and tighten overstretched and damaged ligaments, joint capsule and cartilage. Suture anchors are placed in the bone and the torn glenoid labrum is reattached to the glenoid fossa. You can usually go home the same day, or the following day after a Bankart repair.

A sling will need to be worn (including when you sleep) to protect the shoulder for the first few weeks and allow it to heal in the correct position. Physical therapy will be started almost immediately to regain strength, stability and movement. You will be given a rehab programme to follow, progressing to more challenging exercises over time. It usually takes around 4-6 months to recover completely from a Bankart repair and be able to return to contact sports.

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles (supraspinatus,infraspinatus,teres minor and subscapularis)that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved. In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

Tears are classified based on extend of tear.

Partial tear This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.

Full-thickness tear This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.

Classification based on location of tear.

Articular side tear

Bursal side tear

Causes for rotator cuff tear

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears. Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.

Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Symptoms

The most common symptoms of a rotator cuff tear include:

Pain at rest and at night, particularly if lying on the affected shoulder Pain when lifting and lowering your arm or with specific movements Weakness when lifting or rotating your arm Crepitus or crackling sensation when moving your shoulder in certain positions Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

Treatment

If you have a rotator cuff tear and you keep using it despite increasing pain, you may cause further damage. A rotator cuff tear can get larger over time, eventually you may develop wear and tear or arthritis of the shoulder joint named “cuff tear arthropathy”,hence forth cuff repair play no Roll, and joint replacement surgery becomes inevitable for restoring the function.

Early treatment can prevent your symptoms from getting worse. It will also get you back to your normal routine that much quicker.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for every person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear you have.

Nonsurgical Treatment

Nonsurgical treatment options may include:

Rest. Limiting overhead activity and sling immobilisation.

Activity modification. Avoid activities that cause shoulder pain.

Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Strengthening exercises and physical therapy. Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.

Steroid injection

PRP injection

Surgical Treatment

Indication for surgical treatment

Your symptoms have lasted 6 to 12 months

You have a large tear (more than 3 cm) and the quality of the surrounding tissue is good

You have significant weakness and loss of function in your shoulder

Your tear was caused by a recent, acute injury

Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). There are a few options for repairing rotator cuff tears

Arthroscopic tendon repair. In this procedure, surgeons insert a tiny camera (arthroscope) and tools through small incisions to reattach the torn tendon to the bone.

Open tendon repair. In some situations, an open tendon repair may be a better option. In these types of surgeries, your surgeon works through a larger incision to reattach the damaged tendon to the bone.

Tendon transfer. If the torn tendon is too damaged to be reattached to the arm bone, surgeons may decide to use a nearby tendon as a replacement.

Shoulder replacement. Massive rotator cuff injuries may require shoulder replacement surgery. To improve the artificial joint's stability, an innovative procedure (reverse shoulder arthroplasty) installs the ball part of the artificial joint onto the shoulder blade and the socket part onto the arm bone.

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. Surrounding the outside edge of the glenoid is a rim of strong, fibrous tissue called the labrum. The labrum helps to deepen the socket and stabilize the shoulder joint. It also serves as an attachment point for many of the ligaments of the shoulder, as well as one of the tendons from the biceps muscle in the arm.

What is SLAP tear?

The term SLAP stands for Superior Labrum Anterior and Posterior. In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and back (posterior) of this attachment point. The biceps tendon can be involved in the injury, as well.

What are the causes for SLAP tear?

Injuries to the superior labrum can be caused by acute trauma or by repetitive shoulder motion. An acute SLAP injury may result from:

A motor vehicle accident

A fall onto an outstretched arm

Forceful pulling on the arm, such as when trying to catch a heavy object

Rapid or forceful movement of the arm when it is above the level of the shoulder

Shoulder dislocation

People who participate in repetitive overhead sports, such as throwing athletes or weightlifters, can experience labrum tears as a result of repeated shoulder motion.

Many SLAP tears, however, are the result of a wearing down of the labrum that occurs slowly over time. In patients over 30 to 40 years of age, tearing or fraying of the superior labrum can be seen as a normal process of aging. This differs from an acute injury in a younger person.

Symptoms

The common symptoms of a SLAP tear are similar to many other shoulder problems. They include:

  • A sensation of locking, popping, catching, or grinding
  • Pain with movement of the shoulder or with holding the shoulder in specific positions
  • Pain with lifting objects, especially overhead
  • Decrease in shoulder strength
  • A feeling that the shoulder is going to "pop out of joint"
  • Decreased range of motion
  • Pitchers may notice a decrease in their throw velocity, or the feeling of having a "dead arm" after pitching

Treatment

Nonsurgical Treatment

In most cases, the initial treatment for a SLAP injury is nonsurgical. Nonsteroidal anti-inflammatory medication. Drugs like ibuprofen and naproxen reduce pain and swelling.

Physical therapy. Specific exercises will restore movement and strengthen your shoulder. Flexibility and range-of-motion exercises will include stretching the shoulder capsule, which is the strong connective tissue that surrounds the joint. Exercises to strengthen the muscles that support your shoulder can relieve pain and prevent further injury. This exercise program can be continued anywhere from 3 to 6 months, and usually involves working with a qualified physical therapist.

Surgical Treatment

Your doctor may recommend surgery if your pain does not improve with nonsurgical methods.

Arthroscopy. The surgical technique most commonly used for treating a SLAP injury is arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery

There are several different types of SLAP tears. Your surgeon will determine how best to treat your SLAP injury once he or she sees it fully during arthroscopic surgery. This may require simply removing the torn part of the labrum, or reattaching the torn part using sutures. Some SLAP injuries do not require repair with sutures; instead, the biceps tendon attachment is released to relieve painful symptoms.

Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.Frozen shoulder most commonly affects people between the ages of 40 and 60, and occurs in women more often than men. In addition, people with diabetes are at an increased risk for developing frozen shoulder.In frozen shoulder, the shoulder capsule thickens and becomes stiff and tight. Thick bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark signs of this condition are severe pain and being unable to move your shoulder -- either on your own or with the help of someone else. It develops in three stages:

Stage 1: Freezing

In the "freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Stage 2: Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Stage 3: Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes. The reason for this is not known. In addition, diabetic patients with frozen shoulder tend to have a greater degree of stiffness that continues for a longer time before "thawing."

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

TREATMENT

Most patients with frozen shoulder gets relief from non surgical treatment like Nsaids and physical therapy also with steroid injection.If frozen shoulder does not respond to conservative treatment surgical option with pericapsular release is the treatment of choice.

Manipulation under anesthesia (MUA) without arthroscopic capsular release is effective but may result in iatrogenic injury,including fracture. Arthroscopic capsular release involves selective release of the capsule, often with electrocautery, in order to minimize the risk of iatrogenic injury as compared with MUA. Secondarily, this may decrease postoperative pain and facilitate early participation in physical therapy.In this procedure which is done arthroscopically,surgeon cuts through the scar tissue that has formed in your shoulder joint capsule to allow free movement of your shoulder.Many patients find that in conjunction with following a physical therapy program, surgical capsular release can offer permanent relief from frozen shoulder.

Subacromial decompression is an operation on your shoulder which treats a condition called shoulder impingement, where you feel pain when you raise your arm. It’s usually done through keyhole surgery (arthroscopy). You might also hear subacromial decompression referred to as ‘acromioplasty’.

What is shoulder impingement?

Shoulder impingement is a common type of shoulder pain. You have a group of muscles called the ‘rotator cuff’ which surround and support your shoulder. The tendons for these muscles lie in a narrow space between the top of your arm bone and the bone at the top of your shoulder blade. Shoulder impingement is the name given to the pain you feel if the tendons within this space become damaged. Doctors aren’t certain why this happens but it may be due to a number of causes, perhaps acting together. These may include:

your tendons becoming swollen or torn from overuse (for instance, doing sports) or ‘wear and tear’ as you get older the shape of the bone at the top of your shoulder blade (the acromion), causing it to rub against your tendons getting bony growths (spurs) on the acromion as you get older

If you have shoulder impingement, you’ll feel pain when you raise your arm. You may have some muscle wasting of the affected arm, and your arm movements may be restricted.

How is subacromial decompression done?

Subacromial decompression is done as a keyhole procedure using an arthroscope.During decompression surgery, a surgeon removes bone tissue to increase the subacromial space, which is located between the shoulder’s ball-and-socket and the bone above it, called the acromion

Decompression surgery can involve one or both of these procedures:

Shaving down the acromion bone in a process called acromioplasty. Shaving down the underside of the acromion relieves shoulder impingement symptoms by reducing pressure on the rotator cuff and bursa.

Removing bone spurs (called osteophytes) that have developed on the shoulder’s bones. These bone spurs can rub uncomfortably against the rotator cuff and/or the subacromial bursa.

The acromioclavicular, or AC, joint is a joint in the shoulder where two bones meet. One of these bones is the collarbone, or clavicle. The second bone is actually part of the shoulder blade (scapula), which is the big bone behind the shoulder that also forms part of the shoulder joint. The portion of the shoulder blade that meets the clavicle is called the acromion. As a result, where the clavicle meets the acromion is called the AC joint.

AC joint serves as a primary link between the axial skeleton and the upper extremity.Like most joints in the body where bones meet, there is cartilage between the two bones, which is the white tissue between bones that allows them to move on each other.The joint has dynamic and static stabilizers and it is movable in all planes so it is not a rigid structure. Its complex ligamentous structure is critical to the normal function of the shoulder girdle.The acromioclavicular and Coracoclavicular ligaments are the static stabilizers whereas the deltoid and trapezoid muscles are the dynamic stabilizers.

What is AC joint injury?

AC joint injury is the separation of the acromioclavicular joint,it means that the ligaments are torn and the collarbone no longer lines up with the acromion.The injury to the AC joint ligament can be graded as mild to severe.

Classification

  • Type I is a sprain injury of the AC ligament; there is no complete tear and both AC and CC ligaments are intact.
  • Type II is a tear of the AC ligament but not of the CC ligaments. A type III injury involves tears of both the AC and CC ligaments, with 25% to 100% displacement of the clavicle compared with that on the contralateral side.
  • In a type IV injury, both the AC and CC ligaments are torn and there is posterior displacement of the distal clavicle into the trapezius fascia.
  • In a Rockwood type V injury, the AC and CC ligaments and both the origin of the deltoid and insertion of the trapezius are torn, causing extreme instability of the AC joint. It is a complex injury where the deltotrapezial fascia is stripped from its attachment and displacement of the clavicle is more than three times the diameter of its distal part. The CC distance is increased to 100% to 300%.
  • Type VI injuries are the result of inferior displacement of the distal clavicle into the subcoracoid position.

Treatment

The traditional literature supports non-operative treatment for grade I and II injuries. Patients with grade IV, V and VI injuries benefit from operative treatment, whereas the treatment of grade III injuries remains a controversial issue.

Many surgical procedures have been described; among these are screws, plates, muscle transfers, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.Anatomical ligament reconstruction using tendon graft can be performed by open and arthroscopic methods. Open surgery requires deltoid detachment from the clavicle and extensive soft-tissue dissection for access to the coracoid process; neurovascular structures are placed at risk because of the suboptimal visibility during tendon transfer around the coracoid.

Recent treatment modalities for AC joint dislocation have focused on either CC ligament reconstruction or CC interval fixation.Many devices such as screws, plates, suture anchors or synthetic tapes have been used as fixation material; however, none of these methods are free of complications such as implant failure or implant migration, bony erosions and fractures of the clavicle, and recurrent dislocation. With the advancement of arthroscopic intervention techniques, the management of AC joint injuries has been shifted from open surgical procedures towards less invasive, arthroscopically-assisted or all-arthroscopic procedures.

The principle advantage of arthroscopy is that it allows the patient early release from the hospital with a shorter rehabilitation period and early return to activity.

Arthroscopy allows a better, greater and clearer visibility around the coracoid, and extensive dissection of the deltotrapezial fascia is not required. This clearer visibility also puts the important neurovascular structures at less risk. The suprascapular nerve and the suprascapular artery are the structures with the closest proximity to any implanted material.Besides, arthroscopy makes it possible to get a straight vision of the inferior aspect of the base of the coracoid – a particularly important anatomical area, especially when placing CC fixation systems.

The superior capsular reconstruction is a novel treatment option for massive, irreparable rotator cuff tears. Treatment goals of such tears are to reduce pain, restore shoulder function and delay the development of advanced cuff tear arthropathy. Current non-prosthetic treatment options include debridement and partial rotator cuff repair, bridging rotator cuff reconstruction with a graft and latissimus dorsi transfer, although each has different factors which limit their clinical applicattion.Superior capsule reconstruction (SCR) is a promising alternative treatment for irreparable posterosuperior rotator cuff tears. It utilizes a graft from the superior glenoid to the greater tuberosity to stabilize the humeral head.

Replacement

Taking hold of life

Brushing your hair. Getting dressed. Carrying groceries. Sleeping through the night. These are just a few of the life basics that can be difficult without full use of your shoulder. Fortunately, there are many ways to treat shoulder pain.One option is shoulder replacement surgery. The shoulder is a ball and socket joint that is made up mainly of two bones. The ball portion of the joint is part of the upper arm bone (humerus). The socket portion is part of the shoulder blade. The ball fits into the socket, allowing the shoulder to move.The ball and socket are covered with a smooth rubber like coating called “cartilage”, The cartilage prevents direct contact between these bones and allows them to move smoothly over each other, without friction or wear on the bone surfaces.Damage to the cartilage will make the shoulder movement painful and this condition is called arthritis.

There are three common conditions that damage the cartilage

Wear and tear osteoarthritis, The problem starts when the cartilage is injured or worn away -which is the definition of the osteoarthritis. The bones grind against each other and that grinding hurts. Eventually, all that friction causes the bones surfaces to deteriorate. Unfortunately, there is no medication or treatment that will make damaged cartilage grow back.

Proximal humerus fracture ,A Proximal humeral fracture is just a medical name for a broken shoulder. (Specifically, it means a fracture of the upper arm at the shoulder joint.) The injury is especially common among older people who suffer from osteoporosis, which causes the bone to become more fragile overtime – making it vulnerable to fractures caused by falls or direct blows, like a car accident.

Rotator cuff arthropathy, Rotator cuff is a group of tendon which stabilizes the shoulder, tear in this tendon causes increase stress on the joint which leads to damage to the cartilage.This condition is termed as rotator cuff arthropathy

Shoulder joint replacement is a technically complex procedure. Although total shoulder arthroplasty (TSA) results are usually successful, a subset of these procedures fail and require a revision procedure. Revision surgery is most often required for aseptic loosening, rotator cuff failure, infection, or instability.

Revision of an anatomic arthroplasty (hemi- or total) to another anatomic arthroplasty has shown variable results, often dependent on the cause for revision or type of implant used.

Common Causes of shoulder arthroplasty failure

Before embarking on a surgical revision of a shoulder arthroplasty it is important to determine the nature of the patient’s problems. The following is a list of the common causes of shoulder arthroplasty failure:

  • Infection
  • Reaction to polyethylene or polymethylmethacrylate
  • Fracture
  • Stiffness
    • Poor rehabilitation
    • Unwanted bone
    • Tuberosity malunion
    • Overstuffing of the joint
  • Instability
    • Anterior
      • Subscapularis deficiency
      • Glenoid component anteversion
      • Tuberosity nonunion
      • Supraspinatus/infraspinatus defect
      • Humeral component anteversion or anterior head offset
      • Insufficient anterior glenoid bone
    • Posterior
      • Glenoid component retroversion
      • Posterior cuff defect
      • Excessive humeral component retroversion or posterior head offset
      • Insufficient posterior glenoid bone
    • Superior
      • Loss of rotator cuff
      • Loss of coracoacromial arch
  • Weakness
    • Reduced muscle strength
    • Subscapularis deficiency
    • Supraspinatus/infraspinatus deficiency
    • Tuberosity nonunion or malunion
    • Deltoid detachment
    • Nerve injury
  • Humeral component
    • Malpositioned
    • Loose
  • Glenoid
    • Bone eroded (hemiarthroplasty)
    • Component malpositioned
    • Component loose

Preparing for Revision Surgery

The history and previous records are reviewed to learn the status of the patient and shoulder prior to the index arthroplasty. What were the details of the reconstruction, including the manufacturer, model, and size of the prostheses? How was the rehabilitation conducted? Is there evidence of infection or allergic reaction? Has there been an intercurrent injury? What is the patient’s status with respect to nutrition, pain, medications, smoking, alcohol, and other concurrent health conditions?

The workup includes a detailed examination of the motion, stability, strength, and smoothness of the shoulder.

EMG’s and nerve conduction studies, CT scans, and expert sonography may be useful in evaluating the nerve function bone and rotator cuff respectively.

Laboratory studies include a CBC sedimentation rate and serum albumin.Radiograph include an anteroposterior view in the plane of the scapula, an axillary view and a full length humeral view.

Partial shoulder replacement, also called shoulder hemiarthroplasty is a surgical procedure during which the upper bone in the arm (humerus) is replaced with a prosthetic metal implant, whereas the other half of the shoulder joint (glenoid or socket) is left intact.

What are the indications for shoulder hemiarthroplasty?

Avascular necrosis of humeral head,Is a condition in which the blood supply to the humeral head (ball) is blocked due to some reasons like excessive alcoholism,corticosteroid use, radiation therapy and sickle cell anaemia.As a result the cells of the head of humerus will start dying.

Tumor,involving the head of humerus will be required to remove surgically and replace with a metal prosthesis.

Trauma,Fracture involving the upper part of humeral bone, particularly “Neer type iv” fracture in which humeral head will be broken in to 4 parts.

Osteoarthritis,Arthritis of the shoulder joint with inadequate glenoid (socket) bone stock.

Goals of shoulder hemiarthroplasty

Goals of hemiarthroplasty include relief of pain, improvement in overhead motion, and improvement in strength with overhead activities.

What Is A Total Shoulder replacement?

In a total shoulder, the arthritic surface of the ball is replaced with a metal ball with a stem that is press fit in the inside of the arm bone (humerus) and the socket is resurfaced with a high density polyethylene component.

After a general or regional anesthetic, this procedure is performed through an incision between the deltoid and the pectoralis major muscles on the front of the shoulder. It includes release of adhesions and contractures and removal of bone spurs that may block range of motion.

How Is The Humeral Component Fixed In The Humerus?

While some surgeons cement the humeral component and others use implants that foster bone ingrowth, we find that these approaches stiffen the bone making it more likely to fracture in a fall on one hand and greatly complicating any revision surgery that may become necessary in the future on the other. We prefer to fix the component by impaction graft- ing the inside of the humerus (using bone harvested from the humeral head that has been removed) until a tight press fit of the implant is achieved.

How Is The Glenoid Component Fixed To The Glenoid Bone?

The bone of the glenoid is precisely shaped with a glenoid reamer and then the glenoid component is secured with a combination of press fitting and ce- menting.

In order for proper healing to occur, the patient must maintain the range of motion achieved at surgery with simple, frequent stretching exercises.

Rehabilitative exercises are started immediately after surgery using continuous passive motion and stretching by the patient.

Attaining and maintaining at least 150 degrees of forward elevation is critical to the success of this procedure. The forward lean and the supine stretch can be helpful in getting there and maintaining this range of motion.

Who Should Consider A Total Shoulder?

Surgery for shoulder arthritis should only be considered when the arthritis is limiting the quality of the patient’s life and after a trial of physical therapy and mild analgesics. Severe arthritis is usually best managed by either a partial or a complete joint replacement. Total shoulder arthroplasty (replacing the surfaces of both the ball and the socket) is usually considered by individuals who want the best chance of a rapid recovery of shoulder comfort and the ability to perform activities of daily living.

Who Should Probably Not Consider A Total Shoulder Replacement?

This procedure is less likely to be successful in individuals with depression, obesity, diabetes, Parkinson’s disease, multiple previous shoulder surgeries, shoulder joint infections, rotator cuff deficiency and severely altered shoulder anatomy.

What Happens After Surgery?

Total shoulder arthroplasty is a major surgical procedure that involves cutting of skin, tendons and bone. The pain from this surgery is managed by the anesthetic and by pain medications. Immediately after surgery, strong medications (such as morphine or Demerol) are often given by injection. Within a day or so, oral pain medications are usually sufficient. The shoulder rehabilitation program is started on the day of surgery. The patient is encouraged to be up and out of bed soon after surgery and to progressively reduce their use of pain medications. Hospital discharge usually takes place on the second or third day after surgery. Patients are to avoid lifting more than one pound, pushing and pulling for six weeks after surgery. Driving is recommended only after the shoulder has regained comfort and the necessary motion and strength. This may take several weeks after surgery. Thus the patient needs to be prepared to have less arm function for the first month or so after surgery than immediately before surgery. For this reason, patients usually require some assistance with self-care, activities of daily living, shopping and driving for approximately six weeks after surgery. Management of these limitations requires advance planning to accomplish the activities of daily living during the period of recovery.

What About Rehabilitation?

Early motion after a total shoulder replacement is critical for achieving optimal shoulder function.

Arthritic shoulders are stiff. Although a major goal of the surgery is to relieve this stiffness by release of scar tissue, it may recur during the recovery process if range of motion exercises are not accomplished immediately. For the first 6 weeks of the recovery phase, the focus of rehabilitation is on maintaining the motion that was recovered at surgery. Strengthening exercises are avoided during the first 6 weeks so as not to stress the tendon repair before it heals back to the bone. Later on, once the shoulder is comfortable and flexible, strengthening exercises and additional activities are started. Some patients prefer to carry out the rehabilitation program themselves. Others prefer to work with a physical therapist who understands the total shoulder program.

When Can Ordinary Daily Activities Be Resumed?

In general, patients are able to perform gentle activities of daily living using the operated arm from two to six weeks after surgery. Walking is strongly encouraged. Driving should wait until the patient can perform the necessary functions comfortably and confidently. Recovery of driving ability may take six weeks if the surgery has been performed on the left shoulder, because of the increased demands on the left shoulder for shifting gears. With the consent of their surgeon, patients can often return to activities such as swimming and golf at six months after their surgery.

Once A Shoulder With A Total Shoulder Procedure Has Successfully Completed The Rehabilitation Program, What Activities Are Permissible?

Once the shoulder has a nearly full range of motion, strength and comfort, we recommend that the shoulder be protected from heavy lifting loads and from impact. Thus we discourage chopping wood, training with heavy weights, vigorous hammering, and recreational activities that subject the shoulder to impact loading.

What Problems Can Complicate A Total Shoulder And How Can They Be Avoided?

Like all surgeries, the total shoulder operation can be complicated by infection, nerve or blood vessel injury, fracture, instability, component loosening, and anesthetic complications. Furthermore, this is a technically exacting procedure and requires an experienced surgeon to optimize the bony, prosthetic and soft tissue anatomy after the procedure. The procedure can fail if the reconstruction is too tight, too loose, improperly aligned, insecurely fixed or if unwanted bone-to-bone contact occurs. The most common cause of failure in the short term is a patient’s inability to maintain the range of motion achieved at surgery during the healing period, which can last up to six months after surgery. The most common long-term problem is wearing or loosening of the glenoid component.

Reverse shoulder arthroplasty

A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic "cup" is fitted into the shoulder socket (glenoid), and a metal "ball" is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.

A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles to move the arm. In a healthy shoulder, the rotator cuff muscles help position and power the arm during range of motion. A conventional replacement device also uses the rotator cuff muscles to function properly. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.

Reverse total shoulder replacement may be recommended if you have:

  • A completely torn rotator cuff that cannot be repaired
  • Cuff tear arthropathy
  • A previous shoulder replacement that was unsuccessful
  • A complex fracture of the shoulder joint
  • A chronic shoulder dislocation
  • A tumor of the shoulder joint

Schedule a visit

Dr. Chirag Thonse is available Monday to Saturday, 06:00 pm to 09:00 pm
at The Orthopaedic Clinic
Also, he is available at Vikram Hospital, Millers Road
(By Appointments only)