Arthroscopic Shoulder Surgery
Arthroscopy or Arthroscopic Surgery is commonly known as ‘keyhole surgery”. It involves using a small diameter (4.5 mm or 2.9mm) fibre-optic probe or Arthroscope, inserted through a 10mm incision, to visualize the inside of the shoulder. This allows the surgeon to see the whole of the joint and then, using specialized instruments inserted through additional 10mm incisions, it is possible to undertake an increasing number of surgical procedures.
The shoulder joint is surrounded by several layers of muscles, ligaments and tendons. A traditional Open surgical procedure usually involves cutting through these layers to get access to the inside of the shoulder. These layers then need to be repaired at the end of the procedure. Arthroscopy allows the surgeon to access the shoulder joint and perform surgical procedures with minimal damage to the surrounding layers of muscles.
watch a video of a normal shoulder arthroscopy….
The advantages of Arthroscopy over a more traditional Open procedure are,
- smaller surgical incisions
- initial recovery is usually quicker as the surrounding structures have not been disturbed
- post-operative pain is usually less as the surrounding structures have not been disturbed
- the actual procedure can be undertaken more accurately
- there may be less complications of surgery
Shoulder Arthroscopy
To be able to undertake Shoulder Arthroscopy specialized equipment, instruments and implants are required.
Arthroscope & Visualisation
To visualize the inside of the shoulder requires a long lense & probe, a powerful light source, a video camera and a TV monitor.
- The Arthroscope – the arthroscope is essentially a slim telescope (about 25cm in length) around which it is surrounded by a thin fibre-optic tube. Standard arthroscopes are 4.5mm or 2.9mm in diameter. At one end is the ‘eye-piece’ or video connection and at the ‘patient’ end there is a lens. The lens can be angled at either 300 or 700 to allow a larger field of view as the scope is rotated. A powerful light- cable is attached to the side of the arthroscope to illuminate the joint via the fibre-optics. The arthroscope is usually inserted into the joint through protective sheath that allows for the arthroscope to be taken in and out of the joint
- The Camera & Monitor- the end of the arthroscope is connected to a high resolution HD camera. This is connected by a cable to an HD monitor and computer. The arthroscopic image is then viewed off of the monitor. The camera has focusing and zoom controls and the computer is able to record and store both still and video images of a procedure
- The Arthroscope Sheath & Fluid Control - In order to see inside a joint and to undertake any procedures the joint needs to be ‘opened’ up. This is done by distending the joint with normal saline fluid. The fluid is introduced into the joint through the sheath. This is essentially a metal tube that is 6.5mm in diameter down which the 4.5mm arthroscope is inserted. Through a valve, at the top of the Obturator sleeve, fluid can be introduced down the side of the arthroscope into the joint
- The Pump & Fluid Control - A specialized pump is used to control the pressure and rate of fluid going into the joint. It usually also has a suction control system that is linked to any of the power-instruments that are used. It is then able to adjust the rate of input and output of fluid into the joint and maintain a constant pressure to optimize visualization
- Arthroscopic Stack – the HD Monitor, the central computer, the camera control box, pump, the light source, shaver box and radiofrequency generator are all mounted on a mobile console or stack. This can be easily wheeled in and out of the theatre and can be positioned correctly so that the surgeon can see it
Arthroscope & Visualisation
To visualize the inside of the shoulder requires a long lense & probe, a powerful light source, a video camera and a TV monitor.
- The Arthroscope – the arthroscope is essentially a slim telescope (about 25cm in length) around which it is surrounded by a thin fibre-optic tube. Standard arthroscopes are 4.5mm or 2.9mm in diameter. At one end is the ‘eye-piece’ or video connection and at the ‘patient’ end there is a lens. The lens can be angled at either 300 or 700 to allow a larger field of view as the scope is rotated. A powerful light- cable is attached to the side of the arthroscope to illuminate the joint via the fibre-optics. The arthroscope is usually inserted into the joint through a protective sheath that allows for the arthroscope to be taken in and out of the joint
- The Camera & Monitor- the end of the arthroscope is connected to a high resolution HD camera. This is connected by a cable to an HD monitor and computer. The arthroscopic image is then viewed off of the monitor. The camera has focusing and zoom controls and the computer is able to record and store both still and video images of a procedure
- The Arthroscope Sheath & Fluid Control - In order to see inside a joint and to undertake any procedures the joint needs to be ‘opened’ up. This is done by distending the joint with normal saline fluid. The fluid is introduced into the joint through the sheath. This is essentially a metal tube that is 6.5mm in diameter down which the 4.5mm arthroscope is inserted. Through a valve, at the top of the sleeve, fluid can be introduced down the side of the arthroscope into the joint
- The Pump & Fluid Control - A specialized pump is used to control the pressure and rate of fluid going into the joint. It usually also has a suction control system that is linked to any of the power-instruments that are used. It is then able to adjust the rate of input and output of fluid into the joint and maintain a constant pressure to optimize visualization
- Arthroscopic Stack – the HD Monitor, the central computer, the camera control box, pump, the light source, shaver box and radiofrequency generator are all mounted on a mobile console or stack. This can be easily wheeled in and out of the theatre and can be positioned correctly so that the surgeon can see it clearly whilstoperating
Arthroscopic Instruments
It is possible to undertake a multiple number of procedures arthroscopically but this requires specialized instruments, that are small enough to enter the joint, and implants to undertake various types of fixations and repairs.
Instruments
In order to be able to access the joint and undertake various procedures multiple arthroscopic instruments are used. These include probes, graspers, punches, rasps, elevators and suture cutters. They are all sufficiently slim to access the joint through 5 – 10mm incisions and often have ingenious mechanism to allow them to open, close and cut.
Power Instruments
To arthroscopically remove and debride tissue and to burr away, drill and prepare bone, various power instruments are used. Multiple single use shaver, burr and drill attachments, with varying heads, can be connected to a universal ‘hand-piece’. This ‘hand-piece’ is powered by a variable electric motor that can be controlled by the surgeon. The attachments and ‘hand-piece’ have a central lumen which allows debris to be sucked away as the instrument is working. The amount of suction can also be controlled by the surgeon. The ‘hand-piece’ is connected to a shaver control box on the arthroscopic stack.
Radiofrequency Probes
An arthroscopic radiofrequency probe is used to control bleeding and ablate tissue. These probes are single use and have hand controls for the surgeon. The probe is connected to the radiofrequency generator on the arthroscopic stack and also has a suction lumen.
Implants
Suture-Anchors - are the fundamental fixation devices used in arthroscopic surgery to fix torn ligaments and tendons back down to the bone. Suture-anchors come in varying shapes and sizes, can be made from various materials and can work in different ways. The basic principle is that an implant, with sutures attached to it through an eyelet, can be screwed or inserted into a bone. The implant is sunk flush to the level of the bone. The attached sutures can then be passed through a torn tendon or ligament and then tied, securing the tissues down onto the bone.
Suture-anchor design is constantly evolving and there are multiple different types available, often for specific indications. Anchors can vary by,
- Shape – anchors can be screw-in or interference fit. This may depend on the quality of bone into which they are inserted
- Size – the diameter of an anchor depends on where it is going to be used. As a general rule Glenoid Anchors (used for instability surgery) are between 2.5 – 3mm, whilst Rotator Cuff Anchors are generally bigger, 4.5 – 5.5mm
- Knots or Knotless – traditional anchors have regular sutures that need to be tied by a knot to fix the tissue. Other anchors have various ‘knotless’ systems to secure the sutures. The benefits of knotted or knotless anchors can vary depending on varying situations
- Anchor Material – the first anchors were made out of metal, and Titanium anchors are still used extensively. Other materials have been tried along the way and currently anchors made out of Plastic (PEEK) or a Biocomposite material are also avaialable. I prefer to use Biocomposite anchors, this is a material that is osteo-inductive (encourages bone growth). This means that, over time, the anchor material is resorbed completely by the patient’s own bone. This takes 12 months +, depending on the volume of material in the anchor
- Sutures – suture technology has greatly improved the performance of the sutures used in soft-tissue repair. All of the sutures that we now used are based on a High Molecular Weight Poly-Ethylene (HMWPE) core. This means that the sutures are as strong as wire of the same diameter, preventing suture breakage. Different anchors can have varying numbers of sutures attached to them, usually ranging from 1 to 3
- Suture Tape – suture tape is a ‘broad suture’ that is flat but 2 – 3 mm wide. This can be of some advantage in repairing tendons in certain situation. The broader surface area of the tape can allow a better distribution of forces on to the repaired tendon
- Anchor Configuration – a better understanding of tendon anatomy, how tendons heal and improvements in anchor design have led to new configurations of anchor placement for rotator cuff repairs. Placing anchors in a double-row configuration more accurately re-creates the tendons original insertion.
Interference Screws – are another form of soft-tissue fixation and are particularly useful for fixing tubular shaped tendons, like the Long Head of Biceps, into bone. Interference screws are essentially headless screws with ‘soft’ edges on their threads. They work by drilling an appropriate hole into the bone, pushing the tendon down into the bottom of the socket and then screwing the interference into the tendon within the hole. This provides a very strong fixation and can allow for the tendon to integrate into the cancellous bone.
Like suture-anchors the design and technique by which interference-screws are inserted is constantly evolving. Similarly interference-screws can be made out of varying materials. I prefer to use interference-screws made out of Biocomposite materials for exactly the same reasons as I do for suture-anchors.
Endo-Buttons – are an extremely strong form of fixation that can be used to secure a tendon onto the ‘shaft’ / diaphyseal part of the humerus, clavicle or coracoid process. They are essentially a lozenge shaped metal button, 3-4mm wide and 10-15mm long, with two eyelets. Sutures, that have been secured to a tendon, can be passed through the eyelets. A 4mm drill hole is then made into the hard cortical part of the bone at the desired position of fixation. The ‘loaded’ button can then be ‘posted’ through this hole and ‘flipped’ so that the long flat side of the tendon pulls up against the cortical bone and is secured in place as the sutures, that are passing through the eyelet, are tightened and tied, pulling the tendon into position.
Endo-Button fixation is the strongest type of fixation and something that I use for pectoralis major, sub-pectoral and distal biceps repairs
Orthobiologics – PRP
Orthobiologics is an exciting new development in Orthopaedics. It is the use of natural human cells or tissue to repair or expedite the healing of an injury or a surgical repair.
- Autologous PRP (Platelet Rich Plasma) – Essentially this is the patient’s own blood plasma that has been enriched with platelets, which contain various types of cytokines and growth factors, that can potentially enhance healing.
- A sample of blood is taken from a patient and then spun in a centrifuge
- Using a number of commercially produced syringe systems the concentrated layer of the plasma, that is enriched with platelets, cytokines and growth factors, can be drawn off
- This ‘Platelet Rich Plasma’ concentrate can then be injected back into the patient into an area of injury or site of surgery
- It is postulated that this may help with the patients’ healing
- The use of PRP has expanded to many areas within medicine. However, there is little real scientific evidence that it really has a significant effect on improving healing. The best evidence is in the treatment of refractory Tennis Elbow…. find out more about PRP and Tennis Elbow
- Tendon Grafts – in certain situations where a ligament or tendon has been torn a Tendon Graft can be used to reconstruct it. This is particularly in the case of chronic injuries. Tendon Grafts are sometimes used to reconstruct and stabilise the sternoclavicular joint, the acromioclavicular joint and the elbow. The ‘donor’ tendon can be harvested from the patient (Autograft) or from a cadaver (Allograft)
- Autograft – the most commonly used Autografts are the Hamstring Tendons or Palmaris Longus. Autografts will incorporate and heal well, without the risk of infection or rejection. Harvesting these tendons does not usually lead to a functional deficit for the patient but can result in some donor site morbidity (an incision scar, initial pain and possible infection)
- Allograft – Allograft tendons come from cadavers and have undergone strict screening, denaturing and sterilization processes to avoid transfer of any infection or DNA. Allografts will not incite a rejection reaction. Allografts are expensive and do not have as good a healing potential as Autografts
- Patches – the Rotator Cuff Tendons are broad and relatively thin. There are no other tendons in the body that are this shape and so, in the case of an irreparable rotator cuff tear, no autografts are available. Allograft tendons come from adult cadavers and, as degenerative changes begin to occur at an early age, rotator cuff tendons are not of a sufficient quality to be used.
- To overcome this problem ‘Tissue Patches’, made of a collagen matrix (the essential matrix that forms a rotator cuff tendon), have been developed.
- ‘Tissue Patches’ can be made from Allograft (Human), Xenograft (Animal) or Synthetic tissues.
- I prefer to use Allograft (Human) patches, these are made from dermal tissue (a thick skin Graft).
- As with Allograft tendons they have undergone a strict screening, denaturing and sterilization processes. They are completely safe for human use.
- Augmentation Patch – an augmentation patch is used on top of a rotator cuff repair where the tissue quality is poor. The patch helps to strengthen the repair.
- Interposition Patch – an interposition patch is used to bridge a gap when there is insufficient tendon to actually make a repair.
Orthobiologics – PRP
Orthobiologics is an exciting new development in Orthopaedics. It is the use of natural human cells or tissue to repair or expedite the healing of an injury or a surgical repair.
- Autologous PRP (Platelet Rich Plasma) – Essentiallythis is the patient’s own blood plasma that has been concerntrated with platelets, which contain various types of cytokines and growth factors, that can potentially enhance healing.
- A sample of blood is taken from a patient and then spun in a centrifuge
- Using a number of commercially produced syringe systems the concentrated layer of the plasma, that is enriched with platelets, cytokines and growth factors, can be drawn out of the syringe
- This ‘Platelet Rich Plasma’ concentrate can then be injected back into the patient into an area of injury or site of surgery
- It is postulated that this may help with the patients’ healing
- The use of PRP has expanded to many areas within medicine. However, there is little real scientific evidence that it really has a significant effect on improving healing. The best evidence is in the treatment of refractory Tennis Elbow…. find out more about PRP and Tennis Elbow
- Tendon Grafts – in certain situations, where a ligament or tendon has been torn, a Tendon Graft can be used to reconstruct it. This is particularly in the case of chronic injuries. Tendon Grafts are sometimes used to reconstruct and stabilise the sternoclavicular joint, the acromioclavicular joint and the elbow. The ‘donor’ tendon can be harvested from the patient (Autograft) or from a cadaver (Allograft)
- Autograft – most commonly used Autografts are the Hamstring Tendons or Palmaris Longus Tendon. Autografts will incorporate and heal well, without the risk of infection or rejection. Harvesting these tendons does not usually lead to a functional deficit, but can result in some donor site morbidity (an incision scar, initial pain and possible infection)
- Allograft – Allograft tendons come from cadavers and have undergone strict screening, denaturing and sterilization processes. They are decelluralised to avoid transfer of any infection or DNA. Allografts will not incite a rejection reaction. Allografts are expensive and do not have as good a healing potential as Autografts
- Patches – the Rotator Cuff Tendons are broad and relatively thin. There are no other tendons in the body that are this shape and so, in the case of an irreparable rotator cuff tear, no autografts are available. Allograft tendons come from adult cadavers and, as degenerative changes begin to occur at an early age, rotator cuff tendons are not of a sufficient quality to be used.
- To overcome this problem ‘Tissue Patches’, made of a collagen matrix (the essential matrix that forms a rotator cuff tendon), have been developed.
- ‘Tissue Patches’ can be made from Allograft (Human), Xenograft (Animal) or Synthetic tissues.
- I prefer to use Allograft (Human) patches, these are made from dermal tissue (a thick skin Graft).
- As with Allograft tendons they have undergone strict screening, denaturing, sterilization and decelluralistionprocesses. They are completely safe for human use.
- Augmentation Patch – an augmentation patch is used on top of a rotator cuff repair where the tissue quality is poor. The patch helps to strengthen the repair.
- Interposition Patch – an interposition patch is used to bridge a gap when there is insufficient tendon to actually make a repair.