Shoulder arthroscopy

Name of the procedure:
shoulder arthroscopy, subacromial decompression, suturing of the rotator cuff, stabilisation surgery

When is surgery indicated?
Shoulder pain caused by narrowing, wear or tear of the tendons under the acromion (impingement syndrome), calcium deposits, instability following shoulder dislocation.

Surgical technique:
Inspection of the shoulder joint following the insertion of a special camera via two to three tiny skin incisions (known as „keyhole surgery“). Damaged sections of tendon can be smoothed, removed or sutured in the same session and the impingement released under the acromion with removal of the inflamed synovial bursa. If the shoulder is unstable, the strained capsule can be reattached or shortened.

Inpatient stay: Brief inpatient stay for 2-3 days, primarily to initiate follow-up treatment

Intensive and protracted follow-up by specialist therapists is required in order to safeguard the operation’s success.

The shoulder joint is the most mobile of the major joints. This mobility, while at the same time providing excellent stability, is essentially guaranteed by the surrounding muscles, tendons, ligaments, synovial bursa and joint capsule, which is where the majority of pathological changes occur. The causes of shoulder conditions are many and varied. Examples include injury, such as shoulder dislocation, strain damage, muscular imbalance and age-related wear and tear.

Impingement syndrome
Shoulder impingement syndrome is the most commonly diagnosed shoulder complaint. It is caused by a narrowing of the gliding space between the head of humerus and the acromion. The tendons of the rotator cuff, which run from the shoulder blade to the side of the humeral head, run through this cavity. On top of the rotator cuff, a large shoulder bursa seals the gliding space between it and the acromion. If there is significant impairment of this cavity (known as the subacromial space), irritation of the shoulder bursa and damage to the rotator cuff can occur. Typical symptoms of impingement syndrome include pain when lifting and lowering the arms to the side, pain on raising the arms above the head, night pain or pain when lying on the shoulder.

A distinction is made between mechanical causes such as bony spur formations on the roof of the subacromial space, anatomical variations of the shoulder height (acromion), acromioclavicular joint wear, calcium deposits in the rotator cuff (calcific tendinitis of the shoulder), thickening of the bursa or a tear in the rotator cuff, and functional causes such as muscular imbalance between the rotator cuff and shoulder girdle muscles (e.g. in power athletes), nerve damage, instability (e.g. in the case of players of sports involving throwing and upper body work) or frozen shoulder.

Wear of the rotator cuff
The rotator cuff is made up of the tendon ends of the four clavicular muscles that emanate from the shoulder blade and surround the humeral head like a cuff. This allows the upper arm to be rotated and lifted in all directions. The rotator cuff also centres the humeral head in the glenoid cavity. Wear and tear or, less commonly, injury can cause a tear or defect in one or more of the rotator cuff tendons. This leads to an imbalance in the rotator cuff with the resultant lack of function and persistent pain. As we age, the frequency of rotator cuff problems increases.

Calcific tendinitis (Tendinosis calcarea)
Calcific tendinitis of the shoulder is caused by calcium deposits in the tendons of the rotator cuff. This causes thickening of the tendons under the acromion, resulting in symptoms similar to those of impingement syndrome. The condition particularly affects middle-aged women and can continue for a protracted period of time. The exact cause of these calcium deposits is not fully understood.

Shoulder instability
The shoulder joint is prone to instability due to the fact that its sole source of stabilisation is the surrounding soft tissue (joint capsule, tendons, ligaments, muscles). Essentially, a distinction is made between accidental (traumatic) and positional (habitual) shoulder instability. Accidental instability typically results from an injury during which the humeral head is dislocated out of the glenoid space. In a process known as shoulder luxation, the labrum of the glenoid cavity is sheared off and the joint capsule is extended or torn. The shoulder usually has to be relocated under mild anaesthetic. The shoulder should then be rested. Depending on the patient’s age and physical activity, there is an increased risk that the shoulder will dislocate again. This can occur even with little force due to the previous damage.
With positional instability, the capsule tendon apparatus is weak, giving the shoulder too much room to move around. This means that, even with only slight force, partial or complete dislocation of the shoulder can occur. Patients are often able to relocate the arm themselves.

When is surgery indicated?
If there is persistent shoulder pain caused by impingement, wear or tear of the tendons under the acromion (impingement syndrome) or calcium deposits which shows no improvement even after intense physiotherapy and treatment with pain relief, surgery is recommended. Surgery is usually also required for new tears of the rotator cuff and attendant injuries following dislocation of the shoulder.

How is the procedure carried out?
Firstly, a "keyhole technique" is used to explore the joint in order to assess the damage. Depending on the findings, small additional incisions are made to smooth, remove or suture damaged pieces of tendon, remove narrowing under the acromion and remove any inflamed bursa or, if the shoulder is unstable, reattach or shorten the extended joint capsule.

If possible, the entire operation is carried out arthroscopically, i.e. using the keyhole technique. This is technically more demanding, but it does offer advantages such as less tissue damage, less pain, a more pleasing cosmetic result and faster recovery. Sometimes, however, the procedure has to be completed via a conventional, somewhat larger incision.

How long will I have to stay in hospital?
The procedure is carried out as part of a brief inpatient stay of 2-3 days, with the main focus being on pain management and the initiation of exercises after the surgery.

What form will the aftercare take?
Immediately after the surgery, patients can expect intensive and prolonged treatment by specialist therapists in order to safeguard the procedure’s success. Depending on the actual operation carried out, each patient will be given their own treatment plan. Aftercare will be organised in consultation with the patient’s physician and is generally carried out as an outpatient.