Treatments

What is the disease?

This is the terminology given to the condition when there is wear and tear of the acromioclavicular joint of the shoulder. As the name describes Acromio clavicular joint is the joint between Acromion (a part of shoulder blade bone) and Clavicle (collar bone). This joint can be easily felt in most of the individuals as it is in the outer edge of the collarbone. To some extent it contributes to the prominence in the front of the shoulder joint.

Arthritis occurring at acromioclavicular joint can be painful and can restrict number of activities and hence reduces the quality of life .As a person becomes older, normal wear and tear, or degeneration, of the cartilage takes place in the joint. There is a loss of cartilage and, over time, the joint can wear out, become larger, and develop spurs (spiny projections from the bone) around the joint.

What causes it?

It is partly related to the stress on the joint over the course of life. The condition is more common in individuals doing lot of overhead activities. Often it can coexist with other shoulder problems such as subacromial bursitis. If there has been an injury to this joint in the past the occurrence of arthritis at a later stage is common. Persons who perform constant overhead lifting, such as is engaged in by weightlifters or construction workers who work overhead, have higher incidence of the disease. Other susceptible individuals are athletes participating in contact sports or engaging in any activity, which may result in a fall on the end of the shoulder. Any blunt force to the shoulder in the course of work, household activities, or accident may cause, over time, arthritis of the acromioclavicular joint.

What are the symptoms/effects?

Similar to arthritis in other joints of the body, there is pain and swelling in the joint as it is used. Overhead activities can be painful. Pain will limit the sports activity and can impair the quality of life.

How is it diagnosed?

A thorough physical examination and investigation such as an X ray will be needed to confirm the diagnosis

What are the Treatment Options?

Initial treatment involves taking adequate painkillers, resting, then when the pain improves to some extent doing physiotherapy exercises to prevent further stiffness and also to regain the lost movement. Injection with a steroid into the joint may be helpful for a short period of time. Occasionally, the injection can give complete relief of pain and there may not be a necessity of further treatment, but often this is not the case and the pain relief usually stays for a short period only. If these measures fail to improve the pain or if the pain recurs then surgery is the treatment. The surgery is done arthroscopically and the procedure is called Arthroscopic excision of Acromioclavicular joint.

We also ensure that the whole team is included in process and that no one is left out during the turnaround. The most crucial part is ensuring some degree of financial stability.

What is Anterior Shoulder Dislocation?

This is the terminology given to those who dislocate the shoulder joint. Some individuals don’t dislocate as such but get an insecure feel of shoulder coming out of the joint anteriorly (front) on performing certain movements.

What causes it?

A severe injury, or trauma, is often the cause of an initial shoulder dislocation. During the injury, usually the shoulder comes out in the front as a result of a forceful manoeuvre that resulted in extreme sideward elevation of the arm combined with the outwards rotation of the arm. (Medically called as Abduction and External rotation). This puts the structures in the anterior aspect of the shoulder joint in extreme stress and when the stress level exceeds their capacity to withstand it gives away and shoulder joint loses the stability and dislocates.

What are the symptoms/effects?

The shoulder is the most moveable joint in our body. This has given an ability for the shoulder joint to perform lot of function above the level of head and also in sporty activities such as throwing, bowling, swimming etc. But the downside of this is that the shoulder can also dislocate. Normally the shoulder dislocation is prevented by ligaments, capsules and muscles surrounding it. But during a sporting injury the ligaments in the front of the shoulder joint can rupture and lead on to dislocation. Often the ruptured ligaments in the front of the shoulder joint does not heal and hence results in recurrent episodes of shoulder dislocation. Sometimes even repetitive activity above the level of the head can strain these ligaments (that is the ligament will elongate and become lax). This can cause subtle anterior shoulder instability but not real dislocation.
Once a shoulder joint dislocates, it loses the stability normally offered by the ligaments, hence it is vulnerable to dislocate repeatedly. Number of pathologies has been identified in recurrent shoulder dislocation. The successful treatment depends on identifying the exact nature of the pathology. The pathologies are described in relation to the structure inside the shoulder joint that got injured while the shoulder dislocated.
The key structures that can be injured while a shoulder dislocates anteriorly (in the front) are:

• Glenoid Labral Attachment Of Inferior Glenohumeral Ligament (Bankart Lesion)
• Humeral Attachment Of Glenohumeral Ligament (HAGL Lesion)
• Any Part Of Anterior Glenoid Labrum
• Anterior Capsule
• Middle Glenohumeral Ligament
• Humeral Head Itself Can Fracture As It Pivots Out Of Glenoid Margin (Hill Sach Lesion)

How is it diagnosed?

Acute dislocation: A Physical examination and investigation will confirm the diagnosis. When the shoulder dislocates the prominence of arm is flattened and any shoulder movements are painful. An X ray will confirm that the shoulder is dislocated.
Recurrent Dislocation: The people who dislocate recurrently are apprehensive to put their arm in extreme sideward elevation and rotating it outwards (Abduction and External rotation). This can be revealed by physical examination. Special tests called Anterior apprehension test and Jobe’s relocation test can almost pinpoint the diagnosis. X ray will be done in order to assess for the presence of an associated fracture of the glenoid margin (Bony Bankart) or a Hill Sach lesion. In order to confirm further, a MR Arthrography of the shoulder joint may be a useful investigation. In MR Arthrography, a contrast dye is injected in the shoulder joint. If there is a tear of the ligament the MR Arthrography will reveal leakage of the injected contrast.

What are the Treatment Options?

Acute dislocation: Initial treatment consists of relocating the shoulder joint in place. This should be performed as an emergency procedure under sedation (injection to make you to sleep). A correct manoeuvre to manipulate the shoulder would relocate the joint. Once the joint is in place, the pain relief is tremendous. A check X ray will confirm that the shoulder is relocated. A rest in sling for 2-3 weeks and then mobilising the shoulder is the usual mode of treatment.
Recurrent Dislocation: The treatment requires surgery. The aim of the surgery is to fix the ruptured structure usually the Bankart lesion. The surgery is called anterior shoulder stabilization surgery. This is usually performed through small stab incisions with the help of arthroscopy. Occasionally, some of the injury character may necessitate an open surgery.

We also ensure that the whole team is included in process and that no one is left out during the turnaround. The most crucial part is ensuring some degree of financial stability.

What is Anterior Shoulder Dislocation?

This is the terminology given to those who dislocate the shoulder joint. Some individuals don’t dislocate as such but get an insecure feel of shoulder coming out of the joint anteriorly (front) on performing certain movements.

What causes it?

A severe injury, or trauma, is often the cause of an initial shoulder dislocation. During the injury, usually the shoulder comes out in the front as a result of a forceful manoeuvre that resulted in extreme sideward elevation of the arm combined with the outwards rotation of the arm. (Medically called as Abduction and External rotation). This puts the structures in the anterior aspect of the shoulder joint in extreme stress and when the stress level exceeds their capacity to withstand it gives away and shoulder joint loses the stability and dislocates.

What are the symptoms/effects?

The shoulder is the most moveable joint in our body. This has given an ability for the shoulder joint to perform lot of function above the level of head and also in sporty activities such as throwing, bowling, swimming etc. But the downside of this is that the shoulder can also dislocate. Normally the shoulder dislocation is prevented by ligaments, capsules and muscles surrounding it. But during a sporting injury the ligaments in the front of the shoulder joint can rupture and lead on to dislocation. Often the ruptured ligaments in the front of the shoulder joint does not heal and hence results in recurrent episodes of shoulder dislocation. Sometimes even repetitive activity above the level of the head can strain these ligaments (that is the ligament will elongate and become lax). This can cause subtle anterior shoulder instability but not real dislocation.
Once a shoulder joint dislocates, it loses the stability normally offered by the ligaments, hence it is vulnerable to dislocate repeatedly. Number of pathologies has been identified in recurrent shoulder dislocation. The successful treatment depends on identifying the exact nature of the pathology. The pathologies are described in relation to the structure inside the shoulder joint that got injured while the shoulder dislocated.
The key structures that can be injured while a shoulder dislocates anteriorly (in the front) are:

• Glenoid Labral Attachment Of Inferior Glenohumeral Ligament (Bankart Lesion)
• Humeral Attachment Of Glenohumeral Ligament (HAGL Lesion)
• Any Part Of Anterior Glenoid Labrum
• Anterior Capsule
• Middle Glenohumeral Ligament
• Humeral Head Itself Can Fracture As It Pivots Out Of Glenoid Margin (Hill Sach Lesion)

How is it diagnosed?

Acute dislocation: A Physical examination and investigation will confirm the diagnosis. When the shoulder dislocates the prominence of arm is flattened and any shoulder movements are painful. An X ray will confirm that the shoulder is dislocated.
Recurrent Dislocation: The people who dislocate recurrently are apprehensive to put their arm in extreme sideward elevation and rotating it outwards (Abduction and External rotation). This can be revealed by physical examination. Special tests called Anterior apprehension test and Jobe’s relocation test can almost pinpoint the diagnosis. X ray will be done in order to assess for the presence of an associated fracture of the glenoid margin (Bony Bankart) or a Hill Sach lesion. In order to confirm further, a MR Arthrography of the shoulder joint may be a useful investigation. In MR Arthrography, a contrast dye is injected in the shoulder joint. If there is a tear of the ligament the MR Arthrography will reveal leakage of the injected contrast.

What are the Treatment Options?

Acute dislocation: Initial treatment consists of relocating the shoulder joint in place. This should be performed as an emergency procedure under sedation (injection to make you to sleep). A correct manoeuvre to manipulate the shoulder would relocate the joint. Once the joint is in place, the pain relief is tremendous. A check X ray will confirm that the shoulder is relocated. A rest in sling for 2-3 weeks and then mobilising the shoulder is the usual mode of treatment.
Recurrent Dislocaiton:The treatment requires surgery. The aim of the surgery is to fix the ruptured structure usually the Bankart lesion. The surgery is called Anterior shoulder stabilisation surgery. This is usually performed through small stab incisions with the help of arthroscope. Occasionally, some of the injury character may necessitate an open surgery.

We also ensure that the whole team is included in process and that no one is left out during the turnaround. The most crucial part is ensuring some degree of financial stability.

What is Arthritis of the Shoulder Joint?

When there is wear and tear in the shoulder joint it is described as arthritis of the shoulder joint. The disease process can be mild to severe. They can lead on to pain and stiffness of the shoulder joint. Hence there is limitation of shoulder function and the quality of life can be affected.
In a normal shoulder, the rounded end of the upper arm bone (head of the humerus) glides against the small dish-like socket (glenoid) in the shoulder blade (scapula). The surface of the joint normally is smooth and shiny and this helps us to perform free movement without much resistance and very low friction. Shoulder is one of the joint in the body that has very high mobility. In arthritis there is loss of this glistening surface of the joint and hence the underlying bone gets exposed. This leads on to pain, clicking, creaking sensation during movement and also reduced range of motion of the shoulder joint.

What causes it?

The common mode people get arthritis in the shoulder joint is part of ageing. Hence this condition is seen in elderly population and this is generally related to the usage of the arm over the course of the life. Previous fracture around the shoulder joint also can predispose to arthritis of the shoulder joint. A group of muscle that surrounds the shoulder joint called rotator cuff muscles if not functioning then that can also predispose to a different type of arthritis called CUFF TEAR ARTHROPATHY.
Inflammatory conditions of the joint such as Rheumatoid Arthritis, gout etc can also result in severe pain of the joint. Rarely sudden lack of blood supply to the humeral head can result in longstanding arthritis.

What are the symptoms/effects?

Patients with arthritis typically describe a deep ache within the shoulder joint. Initially, the pain feels worse with movement and activity, and eases with rest. As the arthritis progresses, the pain may occur even when the shoulder is at rest. Eventually, the pain worsens so that it can disturb the sleep in the night. The patient’s shoulder may make grinding or grating noises when moved. Over the time, shoulder becomes stiff and painful to move. Simple daily activities like reaching into a cupboard, dressing, toileting and washing the opposite arm pit may become increasingly difficult.

How is it diagnosed?

The diagnosis is done by physical examination and investigations such as X ray. Sometimes a CT scan may be needed if we are planning for a total shoulder replacement.

What are the Treatment Options?

Initial treatment starts with taking pain-killing tablets. Gentle exercises to the shoulder will improve the stiffness. This simple measure can be helpful in early stages. An injection into the shoulder joint with a corticosteroid and local anaesthetic can also give short-term pain relief. But if the pain continues and affects the quality of life, disturbs sleep in the night and limits the activities to a considerable extent, then a surgery to replace the shoulder joint.
Total shoulder replacement can dramatically improve the pain, get mobility of the shoulder joint and the quality of life would improve.

What is Biceps Tendon Tear?

The important muscle in the front of upper arm is biceps. It helps in bending and rotating the arm. This muscle has got two attachments in the upper end. One of them goes into the shoulder joint to get attached into the cartilage structure called superior labrum located at the top end of the glenoid (disc like cup) of the shoulder joint. Indirectly, the biceps also confers some stability to the shoulder joint. A tear occurring in the biceps tendon can be partial or complete. If there is a tear in the attachment of the biceps tendon in the shoulder joint it is called as SLAP lesion. The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the glenoid. When the biceps tendon is torn during the injury, the injury could also damage other parts of the shoulder joint such as rotator cuff tendons.

What causes it?

The tear can occur as a result of severe injury or may occur because the tendon has worn. There are certain risk factors that can result in wear of the tendon. Some of the common ones are ageing, smoking, repetitive overhead activities and those who are on steroid medicine.

What are the symptoms/effects?

When it is torn, it can cause a sudden sharp pain in the upper arm, bruising in the upper arm, weakness in the shoulder and elbow.

How is it diagnosed?

By doing physical examination and necessary investigation such as an Ultrasound scan, the diagnosis can be confirmed.

What are the Treatment Options?

The treatment depends on the symptoms. Fortunately, the biceps has two attachments at the shoulder. The other attachment is outside the shoulder joint. Because of this second attachment, many people can still use their biceps even after a complete tear of the other attachment.
In some, it may result in weakness and if that is the main concern, the tendon can be reattached to the bone by a procedure called Arthroscopy assisted biceps tenodesis.

What are Complex Proximal Humerus Fractures?

Proximal humerus is the term given to the upper end of the arm bone. The upper end of the arm bone along with the dish like cup in the shoulder blade bone forms the shoulder joint. If there is a fracture in this part of bone it is called as Proximal humerus fracture or sometimes called as Neck of humerus fracture.
Proximal humerus takes part in forming the shoulder joint and also gives attachment to the important muscle of the shoulder called rotator cuff muscles. The rotator cuff muscles are important in elevating and rotating the arm. Hence a complex fracture occurring in this region can severely affect the function of the shoulder joint.

What causes it?

Fracture occurs after an injury. This can be as a result of fall or a road traffic accident.

What are the symptoms/effects?

Fracture leads on to severe pain, swelling and deformity of the shoulder joint. It is difficult to move the shoulder due to pain.

How is it diagnosed?

A clinical assessment and doing investigation such as X ray will confirm the diagnosis. Sometimes a CT scan of the shoulder will be needed to exactly delineate the complexity of the fracture and also to plan on the appropriate treatment.

What are the Treatment Options?

Initial treatment is to give adequate pain relief by giving painkiller medicines. Resting the arm in a sling will give some comfort. Majority of the fractures occurring in the proximal humerus are simple fractures. If the broken fragments of a fracture are in continuity and the alignment of the upper arm is in acceptable condition, then the treatment for these fracture will be resting on sling until the fracture starts healing. This will be usually a period of 6 – 8 weeks. Then the sling can be taken off and further mobilization can be encouraged.

What is Multidirectional Shoulder Instability?

This is another form of instability whereby shoulder can dislocate either in the front or back or down. Often this is as a result of inherently lax ligaments. The dislocation occurs even without any injury or only with minor injury. Some of them even can dislocate habitually.

What causes it?

In this group of individuals the ligaments are lax by birth. This can be part of other disease conditions like Marfans syndrome or other collagen abnormalities, but it can also occur for no defined cause. This is common in girls as part of their development around puberty due to the hormonal influence. Some of those who can dislocate are also good in gymnastics as their body can bend so easily.

What are the symptoms/effects?

They can have multiple dislocations of the shoulder joint. They can also come with knee cap dislocations or other joint dislocations. Some of the dislocations are painful, and at times they don’t have that much pain and hence they can relocate the joint themselves without attending to see a doctor.

How is it diagnosed?

A thorough physical assessment and investigation such as X ray/MRI as needed will be done.

What are the Treatment Options?

A general strengthening exercises to build up the muscles around the shoulder joint especially the posterior muscles will help to gain more control and confidence over the shoulder joint. A systematic physiotherapy will be useful for that. If the dislocation is painful and does not get better with physiotherapy then a surgery to tighten the capsule of the shoulder joint may be beneficial. The name of the surgery is “Circumferential capsular plication/ Rotator interval closure and Radiofrequency capsulorrhaphy”. The success of this surgery is not as good as a surgery performed for the anterior shoulder instability occurring as a result of trauma. Hence it is only advised if full course of physiotherapy didn’t help.

What is Rotator Cuff Tear?

Detachment or rupture of the rotator cuff muscle from the bone attachment is commonly called as rotator cuff tear. The arm bone is coherently kept in the shoulder socket by the action of the muscles that form the rotator cuff. The function of the rotator cuff muscle is to lift and rotate the arm. It covers the head of the arm bone(humerus) at the shoulder joint and helps to keep the arm bone concentrically articulated with the shoulder blade cup (Glenoid. This also ensures that the shoulder is always well located in the joint. Rupture of the rotator cuff results in loss of normal function of the shoulder joint.

What causes it?

The exact cause of the rotator cuff tear is yet to be identified. It can occur as a result of trauma such as a fall. In this the force involved exceeds the strength of the tendon hence it ruptures. This is the mechanism of tear in an athlete during a forceful throwing activity as part of the involved sports such as cricket, tennis etc.
The other more common mode of tear is due to degeneration. Degeneration is the description given to the wearing of the tendon occurring gradually over a period of time due to the combination of various factors. The common factors that result in degenerative tear are repetitive overhead activities, reducing blood supply to the tendon and also rubbing of tendon by the spur coming from acromion bone which is part of the shoulder blade bone.

What are the symptoms/effects?

The common presenting symptom is pain in the shoulder and reduced ability or inability to lift the arm especially above the level of the head. This is particularly profound when carrying some weight in the hand. The severity of the pain can increase to the level that sometimes it affects the sleep in the night and also sometimes one could also feel a painful creaking sensation while moving the shoulder joint.

How is it diagnosed?

The condition is diagnosed by thorough evaluation of the problem, examining the shoulder for specific clinical tests. The clinical tests involve assessing the shoulder joint for individual muscle function, assessing neck movements and also examining the nerves and blood supply to the arm. After a through assessment, some tests such as X ray, ultrasound scan or an MRI scan may be needed to confirm the diagnosis. The tests that are carried out will give a guidance of how large is the tear and also to assess the quality of the muscle. This will help in giving a guidance on the treatment plan.

What are the Treatment Options?

The initial treatment for this condition is to take adequate painkillers tablets. This can help to alleviate some symptoms. The function of the arm can partially be recovered by physiotherapy exercises. But the torn muscle would not attach by itself, hence the function of the shoulder never reaches normal.
Depending on the age, activity, general health and the type of tear an option to repair Rotator cuff repair by surgery can restore a satisfactory function. Continuing pain, significant weakness and loss of function in the shoulder are the reason why a rotator cuff tear needs repairing. The tears can vary in size and some of the tears are massive and are not repairable. In majority of the cases this repair is done by Arthroscopic surgery. Some times the arthroscopy assisted open rotator cuff repair would be undertaken.

What is Subacromial Bursitis?

Subacromial bursitis is a common problem that occurs in the middle age leading onto painful shoulder. It limits performing activities involving shoulder joint movement and can affect the quality of life significantly. Bursa is the medical term for a lubrication sac. Lubrication sac (Bursa) is present in various locations of the human body where gliding movements are occurring eg. Joint. Subacromial bursa is the name of the lubrication sac that is present underneath a bone called Acromion in the shoulder blade. This bursa is present in a small space between the acromion of the shoulder blade and also the head of the arm bone called humerus. The space is usually around 1-2cm and this space also contains an important rotator cuff tendon called supraspinatus. The function of the tendon is elevating the arm. The normal function of the subacromial bursa is to produce jellylike substance to reduce friction in movement occurring between the shoulder blade bone acromion and the arm bone humerus.
If the lubrication sac underneath the acromion gets inflamed then the condition is called as subacromial bursitis. Inflammation of this bursa leads on to pain in the upper arm, difficulty in lifting the arm due to pain. Initially the pain occurs during overhead activities such as reaching top shelf. But further progression of the condition can lead on to difficulty in daily basic activities such as dressing up, combing hair etc. The pain can also be present in the night and can disturb overnight sleep.

What causes it?

Inflammation of this bursa is commonly seen after the age of mid 30. This is especially common in those who have lots of overhead activities in their life such as in an occupation like painting, plastering etc. It is also common in sports person performing lots of shoulder movements such as cricket, tennis and badminton. Some of them may have curved or hooked shape to their acromion bone. This inherently can reduce the available space between the acromion and the arm bone. This leads on to a tight space under the acromion and predisposes to inflammation as it gets stressed repetitively.

What are the symptoms/effects?

Inherently, when everyone lift the arm to the level of the shoulder joint, the space between the acromion and the arm bone gets narrower, If the bursa that is normally present in this space is inflamed, then the narrowing of the space pinches on the inflamed tissue. Naturally, if the inflamed tissue is pinched it will be experienced as excruciating pain in the upper arm.

How is it diagnosed?

A thorough physical assessment and clinical tests will guide towards diagnosis. X ray of the shoulder will be important to assess the subacromial space.

What are the Treatment Options?

Initial treatment of this condition involves giving anti-inflammatory medicines, steroid injection into the subacromial bursal space and physiotherapy exercises. Often, this can relieve the symptoms temporarily. Occasionally the symptoms can completely improve and patients may return back to their normal life. But majority of the times, the shoulder pain comes back and becomes resistant to all these treatments. In such a situation arthroscopic surgery can be useful and can resolve the pain in more than 85% of the time.

What is Superior Labral Antero Posterior?

SLAP terminology is the abbreviation of the lesion occurring in the Superior Labral Antero Posterior area of the shoulder joint. This can be a cause of pain in the shoulder joint.
Labrum is the cartilage structure surrounding the glenoid rim of the shoulder joint. The glenoid is the dish like cup in the shoulder blade and the head of the arm bone articulates with the glenoid to form the shoulder joint. The glenoid is normally shallow and the fibrocartilagenous structure called labrum is attached around the glenoid to increase its concavity. This confers stability for the shoulder joint. Hence the labrum is located all around the glenoid like a ring. The top part of this ring is called superior labrum. One of the tendon of the biceps muscle gets attached in a broad fashion over the superior labrum. Any lesion occurring from the front of the attachment to the back of the attachment of this biceps tendon on the superior labrum is called Superior Labrum Antero Posterior (SLAP) lesion.

What causes it?

This occurs as a result of injury. A forceful pull of the arm, dislocation of the shoulder joint, falling on an outstretched arm, throwing injury, tackling in spots, weightlifting all can predispose to this. A small lesion occurs initially and if it does not heal, this itself can predispose to further injuries. Extent of tear depends on the severity of the injury. The lesion can vary from simple fraying of the labrum to complete avulsion of the superior labrum with also extension into the front or back of the glenoid.

What are the symptoms/effects?

The features include pain usually with overhead activities, catching, locking or a grinding feel in the shoulder joint, a sense of instability of the shoulder joint, reduced or a painful range of motion and loss of strength of the shoulder joint.

How is it diagnosed?

A thorough history, physical examination with special focus in relation to the SLAP lesion is useful. Some of the special tests whereby putting the biceps in forceful eccentric contraction can reproduce the pain. It is also essential to exclude other conditions that can present in similar way and also to confirm this diagnosis by certain investigations. An X ray of the shoulder joint and a MR Arthrography of the shoulder joint may be useful in confirming the diagnosis. Another better option is by performing arthroscopy of the shoulder joint. In arthroscopy the lesion can be directly visualized and also can be treated at the same time.

What are the Treatment Options?

When the injury occurs, supportive treatment in the form of pain relieving medications, resting in sling should be done. When the acute pain improves to some extent mobilization as pain allows will help to regain some confidence in the shoulder joint. After the acute phase has settled, often there is possibility of recurrent pain and clicking as mentioned above. An arthroscopic surgery may be needed to treat the problem.

Overview of the Surgery

In those who suffer from continuous pain due to Acromioclavicular joint arthritis an Arthroscopic surgery to excise the joint would give a long-term relief.

Steps of Surgery

Arthroscopic surgery is done through two or three tiny incisions of 0.5cm in size around the shoulder joint. Miniature tubular camera is introduced through the small skin incision to visualise the shoulder joint and the space beneath the acromion (subacromial space).
Usually the Acromioclavicular joint is well seen from the subacromial space. A tubular soft tissue shaver and a thin tubular radiofrequency probe are introduced through the skin incision. These instruments clear the adhesions around the joint and this assists in delineating the acromioclavicular joint. Once the joint is well defined a 6mm tubular burr is introduced through the skin incision and 1 depth of the burr (approximately 0.6mm) is excised in either side of the acromioclavicular joint. The wounds will be closed with one stitch for each incision.

Postoperative stage

As this procedure involves shaving the bone, there may be a degree of pain in the shoulder joint after the surgery. But giving a nerve block will control the pain. The nerve block in the shoulder numbs the whole arm and this would facilitate to feel only minimal pain. The block usually lasts for a period of 24 hours. As the intensity of pain is less after 24 hours, thereafter the pain can be controlled with the help of painkiller medicines taken by mouth.

Success

To get back to full function approximate duration could be around 6 weeks to 3 months after the surgery. The success rate is very high.

Complications

The complications include infection, stiffness and frozen shoulder, but the chance is minimal.

Overview of the Surgery

This procedure is recommended in those who fail to respond to conservative treatment measures such as steroid injection into the shoulder joint and physiotherapy. In this procedure the tight capsule (lining of the shoulder joint) and tight muscles are released and shoulder movements are gained.

Steps of Surgery

Arthroscopic capsular release for the frozen shoulder joint is done by two or three tiny incisions of less than 1cm. The stab incisions are done around the shoulder joint. Tiny tubular camera is introduced through this stab incision and the shoulder joint is thoroughly visualized. The lining of the shoulder joint called capsule is usually thick and contracted in this condition. The tight capsule around the socket of the shoulder joint is released with the help of special radio frequency probe. A muscle called subscapularis, which is also tight in this condition, is also released with the help of this radiofrequency probe. This radiofrequency probe generates heat and cuts the tissue in a controlled fashion.
Once the capsule is cut around the socket of the shoulder joint, gentle manipulation of the shoulder joint is performed. This ensues that the full range of motion of the shoulder joint is achieved. Once the surgery is performed, the tiny stab incisions are closed with a small stitch to the skin.

Postoperative stage

The physiotherapist will see in the postoperative ward and will teach the exercises that needs to be performed over the next few weeks in order to preserve the joint motion that were acquired by arthroscopic surgery.

The Success Rates and the Outcomes

The success rate of this surgery is variable, but it is better than other forms of treatment. Complications are minimal. There may be small oozing from the wounds sometimes, but usually the swelling and the oozing settles down in a week or two.

Complications

Infection, chondral damage and axillary nerve damage have been reporting as rare complications

Overview of the Surgery

This procedure is the treatment of choice in those who recurrently dislocate shoulder anteriorly (in the front) as a result damage to the anterior capsulolabral structure.

Steps of Surgery

Arthroscopic surgery is performed through three tiny stab incision of less than 1cm around the shoulder joint. A tubular camera is introduced through one of the stab incision and the joint is visualised. The injuries to the ligaments are delineated and the repair is planned. The retracted ruptured ligament is mobilised so that it can be fixed back to its original position. Often due to the long duration of the pathology the ligaments have lost their normal structure. Special instruments are used to freshen the edges of the bone and also the ligament.
A miniature tubular drill is introduced and a small hole is made into the glenoid bone margin. An absorbable screw with strong fibrewire is anchored into the glenoid margin through the drilled hole. A special miniature device is used to pass the fibre wire through the ligament. The ligament is then approximated to the glenoid labrum and an arthroscopic knot applied to hold the ligament with the glenoid margin tightly. The same procedure is repeated in two or three more places in the glenoid margin so that a tight approximation of the ligament to the glenoid margin is achieved.

Postoperative stage

Immediately after the procedure, a sling will be given to rest the arm. The movements that can put tension on the repaired structures are prevented for duration of 4 – 6 weeks. Further to that the movements are encouraged. A systematic physiotherapy programme will be initiated to get the full function back.

The Success Rates and the Outcomes

The success rate of this surgery is in the range of 90%. The arthroscopic procedure is pretty safe. The pain is minimal as the procedure is done through tiny stab incisions.

Complications

Infection, chondral damage, nerve damage is possible complications but the reported incidences are rare.

Overview of the Surgery

This will be the procedure of choice in those who dislocate the shoulder recurrently as a result of anterior structures damage and also fracture in the back of the humeral head. If there is fracture in the back of the upper arm bone, then it is called as Hill sach lesion. This lesion pivots around the glenoid margin while doing outward rotation movement of the shoulder. Hence dislocation occurs recurrently.
Elective patients may be suitable for an arthroscopic surgery even in the presence of Hillsach defect. In such patients after doing anterior stabilisation surgery as mentioned above, the remplissage procedure helps in preventing further dislocations.

Nature of the procedure

The principle of remplissage surgery is to fill the gap of the hillsach lesion with the rotator cuff muscle. Hence it will act as a physical restraint when the provocative manoeuvres for dislocation are undertaken.

Steps of the Surgery

The procedure is performed as an arthroscopic procedure. Tiny stab incisions of less than 1cm are made around the shoulder joint. Initial anterior shoulder stabilisation is done. Then the camera is focussed on the hill sach lesion. The hill sach lesion can be easily made out as a dent in the back of the head of the arm bone (Posterolateral aspect). The dent is freshened with the help of mini tubular 4.2mm shavers and bone edges are burred with a special burr. Usually over the hill sach lesion one could visualise the infraspinatus muscle (a part of rotator cuff muscle). With a miniature drill two small holes are made in the dent. Absorbable screws with fibre wire are fixed in these holes. The fibrewires attached to these holes are retrieved through the infraspinatus muscle and the knot is applied to fix the infraspinatus muscle to the hill sach lesion.

Postoperative phase

Immediately after the procedure, a sling will be given to rest the arm. The movements that can put tension on the repaired structures are prevented for a duration of 4 – 6 weeks. Further to that the movements are encouraged. A systematic physiotherapy programme will be initiated to get the full function back.

Complications

The arthroscopic procedure is pretty safe. The pain is minimal as the procedure is done through tiny stab incisions. Infection, chondral damage, nerve damage is possible complications but the reported incidences are rare.

Overview

If the shoulder joint is worn leading on to severe pain, an artificial joint can be implanted and this is called Total shoulder replacement. A satisfying function and good pain relief can be achieved after performing total shoulder replacement. If no complications occur, more than 95% of the time a shoulder replacement can last for more than 10-15 years.
The procedure is done for those suffering from advanced arthritis of the shoulder joint. Total shoulder replacements are also performed for fractures of the upper end of arm bone. In fractures, usually it is such a situation that the fixation is not possible as the fracture is complex.

TYPES OF TOTAL SHOULDER REPLACEMENT:

Total Shoulder Replacements are as follows:

• Anatomic Total Shoulder Replacement
• Reverse Polarity Total Shoulder Replacement
• Resurfacing Arthroplasty Of The Shoulder Joint.

The choice of procedure depends on number of factors. A severely destroyed humeral head and glenoid surface with well working rotator cuff muscles would require a Anatomic Total Shoulder Replacement. If the rotator cuff muscles are not functioning and a person has got severely damaged shoulder joint, then Reverse polarity Total Shoulder Replacement will be the correct option. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder blade bone and a plastic socket is attached to the upper arm bone. This gives a biomechanical advantage by changing the centre of the rotation of the shoulder joint and also tensions the arm muscle called deltoid. These factors allow using the deltoid muscle instead of the torn rotator cuff to lift the arm thus facilitating to regain the lost movement.
If the destruction of the humeral head is not severe and hence if adequate bone stock is available, then Resurfacing arthroplasty of the shoulder joint will be the option. The above description gives a general outline. Shoulder replacement surgery is highly technical. Each case is individual. The situation will be carefully evaluated before making any decisions. The correct nature of procedure will be determined after physical examination and performing radiological investigations such as X ray and CT Scan.

Preoperative workup

You will be anaesthetized for the surgery. Hence you would have some blood tests and routine check up by an anesthetist for the surgery. The intensity of the pain in first 24 hours is high. Hence during the surgery you will also have an injection to block the nerve supply of the arm. This block helps to get the whole arm numb and you feel a very little pain after the surgery. A physiotherapist will see you before the surgery and teach you on the exercises that you will have to carry on after the surgery.

Operation

• Access Into The Shoulder Joint Is Performed Through An Incision Of About 10cm From The Front Of The Upper End Of Arm.
• The Gap Between The Arm Muscle Called Deltoid And Chest Muscle Called Pectoralis Major Is Explored And Kept Apart To Have Deeper Access.
• Deeper To That Is Rotator Cuff Muscle Called Subscapularis And Lining Of The Shoulder Joint Called Capsule. Both Are Divided And The Shoulder Joint Will Be Accessed.
• The Humeral Head And The Glenoid Are Prepared And Correct Size Implant Is Fixed In. Stability Of The Joint Is Restored To The Satisfactory Extent
• The Fixation Of The Implant Can Be Achieved By Bone Cement Or With Implants That Have Facility For Bone Growth. This Will Be Determined On The Individual Case Basis Depending On The Condition Of The Bone And The Disease Pathology.
• All The Layers Of The Wound That Are Opened For The Access Are Securely Closed.

Postoperative Stage

An inpatient stay in the ward for 2-3 days may be essential to optimize pain and train for getting range of motion before discharge. An adequate pain relief will be provided, wound will be checked, and an X ray of the shoulder joint will be taken. A physiotherapist will teach the exercises that need to be carried on to get satisfactory function. When discharged, a plan of home exercise programme will be taught.

The Success Rates and the Outcomes

The success of the surgery is very high. It is in the order of 90-95%. Most of the patients are satisfied with pain relief and gain of mobility.

Complications

The complications after the surgery are minimal. Infection, Nerve injury, Dislocation and Fracture are the important complications to think about, but fortunately the incidence of these problems is low.

Rehabilitation Post surgery

A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. A sling will be given for comfort during the first four weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery.
Here are some "do’s and don’ts" for when you return home:

• Don’t Use The Arm To Push Yourself Up In Bed Or From A Chair Because This Requires Forceful Contraction Of Muscles.
• Do Follow The Program Of Home Exercises Prescribed For You. You May Need To Do The Exercises 4 To 5 Times A Day For A Month Or More.
• Don’t Lift Anything Heavier Than A Glass Of Water For The First 6 Weeks After Surgery.
• Don’t Participate In Any Repetitive Heavy Lifting After Your Shoulder Replacement.
• Do Avoid Placing Your Arm In Any Extreme Position, Such As Straight Out To The Side Or Behind Your Body For The First 6 Weeks After Surgery.

Overview of the Surgery

This surgery is performed in those who have weakness as a result of biceps tendon pathology. The objective of the procedure is to reattach the ruptured tendon to the bone with a tenodesis screw. Tenodesis is the medical terminology for attaching a tendon to the bone.

Surgical steps

Arthroscopy of the shoulder joint is done with two or three tiny 0.5cm incision around the shoulder joint. A miniature tubular camera is introduced through these small cuts to visualize the shoulder joint. The biceps tendon is examined, assessed for any abnormality and probed for integrity.
With the help of special arthroscopy needle a stitch is applied through the biceps tendon and the biceps tendon is retrieved through another 2 cm incision over the upper end of the arm bone. The tendon that is retrieved in the upper arm is fixed to the arm bone the help of a clip or a tenodesis screw. The pain is minimal as the surgery is done through a small cut only.
Postop: After surgery, the shoulder may be immobilized temporarily with a sling. Physiotherapist will see and instruct on exercises to carry on. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

Success

Successful surgery can correct muscle deformity and return your arm’s strength and function to near normal.

Complications

The complications with this surgery are very low.

Overview

If the shoulder joint is worn leading on to severe pain, an artificial joint can be implanted and this is called Total shoulder replacement. A satisfying function and good pain relief can be achieved after performing total shoulder replacement. If no complications occur, more than 95% of the time a shoulder replacement can last for more than 10-15 years.
The procedure is done for those suffering from advanced arthritis of the shoulder joint. Total shoulder replacements are also performed for fractures of the upper end of arm bone. In fractures, usually it is such a situation that the fixation is not possible as the fracture is complex.

TYPES OF TOTAL SHOULDER REPLACEMENT:

Total Shoulder Replacements are as follows:

• Anatomic Total Shoulder Replacement
• Reverse Polarity Total Shoulder Replacement
• Resurfacing Arthroplasty Of The Shoulder Joint.

The choice of procedure depends on number of factors. A severely destroyed humeral head and glenoid surface with well working rotator cuff muscles would require a Anatomic Total Shoulder Replacement. If the rotator cuff muscles are not functioning and a person has got severely damaged shoulder joint, then Reverse polarity Total Shoulder Replacement will be the correct option. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder blade bone and a plastic socket is attached to the upper arm bone. This gives a biomechanical advantage by changing the centre of the rotation of the shoulder joint and also tensions the arm muscle called deltoid. These factors allow using the deltoid muscle instead of the torn rotator cuff to lift the arm thus facilitating to regain the lost movement.
If the destruction of the humeral head is not severe and hence if adequate bone stock is available, then Resurfacing arthroplasty of the shoulder joint will be the option. The above description gives a general outline. Shoulder replacement surgery is highly technical. Each case is individual. The situation will be carefully evaluated before making any decisions. The correct nature of procedure will be determined after physical examination and performing radiological investigations such as X ray and CT Scan.

Preoperative workup

You will be anaesthetized for the surgery. Hence you would have some blood tests and routine check up by an anesthetist for the surgery. The intensity of the pain in first 24 hours is high. Hence during the surgery you will also have an injection to block the nerve supply of the arm. This block helps to get the whole arm numb and you feel a very little pain after the surgery. A physiotherapist will see you before the surgery and teach you on the exercises that you will have to carry on after the surgery.

Operation

• Access Into The Shoulder Joint Is Performed Through An Incision Of About 10cm From The Front Of The Upper End Of Arm.
• The Gap Between The Arm Muscle Called Deltoid And Chest Muscle Called Pectoralis Major Is Explored And Kept Apart To Have Deeper Access.
• Deeper To That Is Rotator Cuff Muscle Called Subscapularis And Lining Of The Shoulder Joint Called Capsule. Both Are Divided And The Shoulder Joint Will Be Accessed.
• The Humeral Head And The Glenoid Are Prepared And Correct Size Implant Is Fixed In. Stability Of The Joint Is Restored To The Satisfactory Extent
• The Fixation Of The Implant Can Be Achieved By Bone Cement Or With Implants That Have Facility For Bone Growth. This Will Be Determined On The Individual Case Basis Depending On The Condition Of The Bone And The Disease Pathology.
• All The Layers Of The Wound That Are Opened For The Access Are Securely Closed.

Postoperative Stage

An inpatient stay in the ward for 2-3 days may be essential to optimize pain and train for getting range of motion before discharge. An adequate pain relief will be provided, wound will be checked, and an X ray of the shoulder joint will be taken. A physiotherapist will teach the exercises that need to be carried on to get satisfactory function. When discharged, a plan of home exercise programme will be taught.

The Success Rates and the Outcomes

The success of the surgery is very high. It is in the order of 90-95%. Most of the patients are satisfied with pain relief and gain of mobility.

Complications

The complications after the surgery are minimal. Infection, Nerve injury, Dislocation and Fracture are the important complications to think about, but fortunately the incidence of these problems is low.

Rehabilitation Post surgery

A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. A sling will be given for comfort during the first four weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery.
Here are some "do’s and don’ts" for when you return home:

• Don’t Use The Arm To Push Yourself Up In Bed Or From A Chair Because This Requires Forceful Contraction Of Muscles.
• Do Follow The Program Of Home Exercises Prescribed For You. You May Need To Do The Exercises 4 To 5 Times A Day For A Month Or More.
• Don’t Lift Anything Heavier Than A Glass Of Water For The First 6 Weeks After Surgery.
• Don’t Participate In Any Repetitive Heavy Lifting After Your Shoulder Replacement.
• Do Avoid Placing Your Arm In Any Extreme Position, Such As Straight Out To The Side Or Behind Your Body For The First 6 Weeks After Surgery.

Overview of the Surgery

The surgery is called as Circumferential capsular plication, rotator interval closure and radiofrequency capsulorrhaphy. This is done as an arthroscopic procedure through two or three tiny stab incision.

Steps of the Surgery

Arthroscopic surgery is done after anaesthetising. Two or three tiny stab incision of less than 1cm are made around the shoulder joint. The shoulder joint is thoroughly visualised and the diagnosis of lax capsule in the shoulder joint is confirmed. One could find capsule as a hammock in the front, down and back of the shoulder joint if it is lax.
With the help of a special arthroscopic needle two or three stitches are applied in the anterior (front) capsule of the shoulder joint. Another stitch is applied in the inferior part of the shoulder capsule. Further may be one or two stitch is applied around the posterior aspect of the shoulder capsule.
Rotator interval is a space in the front of the shoulder joint, which is not covered by muscle. This gap is also inherently lax in those who suffer from multidirectional instability; hence this rotator interval is closed with one or two stitches. All these stitches are applied through the arthroscopic stab incisions.
After doing multiple stitches, the capsule is shrunk with the help of radiofrequency probe. The radiofrequency probe emanates radiofrequency waves. This generates heat that is adequate enough to shrink the collagen present in the capsule. The incisions in the skin are closed with small stitches.

Postoperative stage

A sling will be given for comfort for a period of 4 – 6 weeks. The movements are encouraged after 6 weeks to get to full function. A systematic physiotherapy programme will be initiated until the satisfactory function is achieved.

The Success rates and the outcomes

The outcome of this procedure is equivocal. But it is worthwhile trying, if other simple modalities of treatment does not help. The reason the surgery has equivocal outcome is because we cant treat the inherent reason for laxity and it is probably gene mediated and it is a general problem that applies to the whole of the human body.

Complications

The procedure is safe. The rare complications include infection, stiffness, nerve damage and chondral damage.

Overview

Continuing pain, significant weakness and loss of function in the shoulder are the reason why a rotator cuff tear needs repairing. The tears can vary in size and some of the tears are massive and are not repairable. In majority of the cases this repair is done by Arthroscopic surgery. Some times the arthroscopy assisted open rotator cuff repair would be undertaken.

Steps of the Surgery

Arthroscopic surgery is performed by three or four tiny stab incisions of less than 1cm in size. A miniature tubular camera is introduced into the shoulder joint and the joint is thoroughly visualized. The tear in the rotator cuff muscle is confirmed and depending on the size of the tear the repair is planned. Often there may be other pathology along with the rotator cuff tear. This could be fraying at the biceps tendon attachment, labial fraying, partial tear of the biceps tendon or subluxation of the biceps tendon. These are dealt with at the same time.
The camera is introduced into the space beneath the acromion bone(part of the shoulder blade bone). The camera in this space (subacromial space) gives much better appreciation of the size of tear, quality of the muscle and also gives a chance to assess whether the tear can be mobilized to fix it back in its original position.
Two or three cannula will be introduced through the skin incisions into the subacromial space. Two will be used as working portal and one will be used portal for application of knots.

Tear Mobilisation and Foot print preparation:

Initial step is to mobilize the torn rotator cuff tear and with the help of a miniature grasper, the torn tendon is pulled to see whether it comes to its original attachment. The attachment site of this muscle is called as footprint in the upper end of the arm bone. This attachment site is freshened first with shaver and then with a burr.

Converting a larger size tear into a smaller size tear:

Fixing the tear to the footprint:

Once it is done, the muscle is attached to the footprint. This is performed by initially drilling a hole in the footprint with a miniature drill. Then an absorbable screw with fibrewires in its end is introduced into the hole. The fibrewires are passed through the cuff muscle with the help of a special suture passer. Then the rotator cuff muscle is pulled to reach the footprint and can be anchored with another absorbable screw.

Overview of the surgery

This procedure is the treatment of choice in those suffering from subacromial bursitis. If the patient has already tried injection and physiotherapy but did not provide a long lasting relief of pain, then this surgery will improve the condition and can give long-lasting relief of symptoms. The aim is to clear out all the inflamed bursal tissue. Once the bursal excision is done, to prevent further occurrence, the small space between the acromion (part of shoulder blade bone) and the upper end of arm bone is widened. This is done by shaving about 0.5 – 1cm of the shoulder blade bone acromion. Once the space is increased the shoulder movements are passively performed and ensured that there is no more of impingement of tissues in the subacromial space.

Surgical steps

In the past this procedure was done with a large incision in the shoulder joint. Currently it is done through two or three tiny incision of around 0.5cm around the shoulder joint. A tubular camera is first introduced into the shoulder joint to look for any other reason for pain in the shoulder joint. Then the tubular camera is introduced through these small incisions into the space beneath the acromion bone. All inflamed tissue will be excised with the help of 4.2mm wide tubular soft tissue shaver and also with the help of radiofrequency probe. The radiofrequency probe generates heat and can excise the tissue in a controlled fashion. Once the soft tissue clearance is done a special 5mm tubular burr is introduced through the same portal and the acromion bone is excised for a depth of about 0.5 to 1cm. Once the procedure is completed the small skin cuts are closed with one or two stitches.

Postoperative

By doing arthroscopically the space is much better visualized than by doing through a open technique. Because the incision is small and minimal tissue disruption is done during the surgery the postoperative pain is less and the recovery is quick. Usually the shaving of bone heals in about 6 weeks time and the patients will be back to normal function in around 6 weeks to 3 months. The surgery is performed as a day case procedure. Physiotherapist will see you after the surgery and teach you of the exercises that has to be performed to get the function back quickly.

Success

Complications

The complications are rare, but one should be aware that bleeding from the wound, swelling of the shoulder is part of the procedure and these will settle down in few days time. Occasionally infection can occur, and then it needs to be treated as needed. Getting shoulder movement can be an issue in about 10%; usually systematic physiotherapy will resolve the problem. Sometimes, if recalcitrant to physiotherapy manipulation under anaesthetic of the shoulder joint may be needed in order to speed up the rehabilitation.

Overview

Superior labral antero posterior lesion with significant symptoms such as pain, clicking, catching, grinding will necessitate arthroscopic surgery to treat the lesion.

Nature of the procedure

Arthroscopic surgery gives a chance to visualise the shoulder joint thoroughly. The labrum can be seen for obvious tears and can also be probed to identify if there are subtle tears. A dynamic assessment is possible so that the shoulder joint movements are reproduced passively and the hidden presence of any unstable tears can be detected. Some tears can be just fraying then they need debridement. But if the tear is full and if the labrum has avulsed from the glenoid then it needs to be fixed back by stitching the labrum with strong fibrewires and anchoring it to glenoid rim. This gives sound possibility for the lesion to heal.

Steps of the Surgery

The procedure is done under anaesthesia. Two or three tiny incisions are made around the shoulder joint. A tube like arthroscopic camera is introduced into the shoulder joint. Thorough assessment of the labrum all around the ring is performed. The diagnosis of the SLAP lesion will be confirmed. Then the tear is mobilized so that it can be attached back into the glenoid. A miniature drill is introduced to reach the glenoid margin and an absorbable screw with strong fibrewire is anchored to the glenoid margin. The fibrewire is then passed through the labrum and arthroscopic knots are applied to hold the labrum tight to the glenoid margin. Depending on the length of the labral tear there may be a necessity of two or three stitches. The arthrosocopy incisions in the skin will be closed with one or two stitches. There will not be any pain during the procedure as it is done with anaesthesia. Because the arthrosocpic surgery itself is done through tiny incisions the pain after the surgery is minimal.

Postoperative Stage

A sling will be given to rest the arm for 4 weeks. A systematic physiotherapy programme will be implemented with the help of a trained physiotherapist. This will help you to get the pain free range of movements back. To get back to sports level activities it could sometimes take up to 3 to 4 months. The labrum that is reattached takes about 3 – 4 months to heal.

Success

Complications

The complications are minimal. Infection, stiffness, chondral damage are rare possibilities.

Total knee replacement (arthroplasty) has proven to be a very effective surgical treatment of osteoarthritis of the knee for many years. Relatively recently, however, partial knee replacement (also known as unicondylar knee replacement) has emerged as a possible – and viable – option for certain patients.

Figure: Medial compartment osteoarthritis

Overview of surgery

The knee is made up of three compartments: the medial compartment (located on the inside of the knee), the lateral compartment (located on the outside of the knee), and the patellofemoral compartment (located in the front of the knee). In a particular group of osteoarthritis patients, however, the entire knee is not affected by the arthritis. In some patients, only the medial compartment (or, less commonly, only the lateral compartment) may be affected by the disease. For those patients, unicondylar (partial) knee replacement can be considered a treatment option. The term “unicondylar” refers to the replacement of only one section of the smooth bone ends (condyles) – the medial or lateral compartment – as compared to total knee replacement, which involves replacement of all three compartments.

The concept of unicondylar knee replacement entails replacement of the diseased medial or lateral compartment and preservation of the anterior (front) and posterior (rear) cruciate ligaments. In contrast, a standard, posterior stabilized total knee replacement requires the removal of both the anterior and posterior cruciate ligaments, and the implant substitutes for these ligaments.
Since only a part of the joint is replaced in a unicondylar procedure, the surgery often can be performed through a smaller incision and involves less bone and soft tissue dissection, thereby offering potential benefits in the early rehabilitation period. Most studies have shown that a unicondylar knee replacement results in less blood loss and a lower incidence of medical complication. Patients undergoing a unicondylar knee replacement also seem to have a more favorable outcome in regard to certain functions like stair climbing or kneeling. Most studies suggest that patients with a successful unicondylar knee replacement recover range of motion faster and have better overall range of motion compared to patients undergoing total knee replacement.

Figure: A valgus stress view shows an intact lateral compartment in a good candidate for a unicondylar knee replacement The revision rate is higher for unicompartimental knee replacements than for total knee replacement. Based on most studies, a revision of a unicondylar knee replacement will not result in the same functional outcome as in patients that undergo a total knee replacement as their primary procedure. In addition, the revision surgery at times is technically more complex than a primary total knee replacement, especially when bone loss and decreased range of motion are encountered.

The Development of Unicondylar Knee Replacement

The early results of unicondylar knee replacement in the United States in the 1970s and 1980s were discouraging. The first papers reporting the outcome of uni-implants designed in the 1970s often showed a failure rate in the range of 40% at ten years, far below the consistently good results of total knee arthroplasty. Therefore, unicondylar knee arthroplasties never gained popularity in the United States.
Improvements in design have led to the next generation of unicondylar knee replacement implants, which offer better results in selected patients.
In 1998, Dr. Richard Scott and Stuart Kozinn published criteria for the selection of patients for unicondylar knee replacement. At the time, their criteria reflected a selection of patients that would provide a lasting result with a unicondylar knee replacement. Scott and Kozinn considered patients older than 60 years of age suitable candidates because, when compared to younger patients undergoing traditional knee replacement, they typically engage in a diminished level of activity after surgery. Scott and Kozinn also believed that the surgery should be limited to patients weighing under 180 pounds and that, ideally, patients should not be extremely active or perform heavy labor. They also considered patients that have significant pain (at night and at rest) unsuitable candidates since they took these symptoms as evidence of an inflammatory component, which may ultimately result in the progression of arthritis in the other compartments of the knee. Patients with systemic inflammatory arthritis, such as rheumatoid arthritis, were also not considered candidates for this procedure.
In addition to these criteria, patients with a relatively good preoperative range of motion and a minimal amount of deformity were considered to be ideal candidates for a unicondylar knee replacement.

Steps of Surgery

Implant Designs

Today, there are two different concepts for partial knee replacement available for patients in the United States.

Unicondylar Fixed Bearing Knee Replacement:

A Fixed Bearing Knee Replacement Is A Knee Arthroplasty Where The Tibial (Lower Leg) Plastic Insert Is Fixed To The Tibial Bone And Does Not Allow Movement Of The Bearing Surface. Most Implants Today Fall Into This Category.

Mobile Bearing Unicondylar Knee Arthroplasty:

The Concept Of The Mobile Bearing Knee Arthroplasty Is To Have A Fixed Metal Component On The Tibial (Lower Leg) As Well As The Femoral (Upper Leg) Side And Then Have A Mobile Plastic Insert Which Allows For A Mobile Articulation (Low-Friction Contact). The Theoretical Benefit Of A Mobile Bearing Knee Arthroplasty Is A Greater Contact Surface Between The Plastic Insert And The Metal Component Of The Knee Arthroplasty. Larger Contact Surfaces Have Proven To Reduce The Amount Of Linear Wear In The Knee Arthroplasty.

Fixed Bearing Unicondylar Knee Arthroplasty

Fixed bearing knee arthroplasties are currently limited to patients that fulfill the classic criteria established by Scott and Kozinn in 1998. Approximately 6% – 10% of the patients currently considered candidates for total knee arthroplasty are candidates for a fixed bearing knee replacement. Patients can be considered a candidate for a fixed bearing unicondylar knee replacement if they:
Present With Disease Isolated To Only One Compartment
Weigh Less Than 220 Pounds (100 Kilograms)
Do Not Have Significant Deformity (Bow-Legged Or Knock-Knee Deformity Of The Knee)
Are Still Able To Extend The Knee To Within 10 Degrees Of Full Extension (Flexion Contracture Of Less Than 10 Degrees)
Are Able To Bend The Knee More Than 90 Degrees
Have An Average Activity Level And Do Not Have The Goal Of Returning To High Impact Sports Or Heavy Labor

Figure: Example of a fixed bearing unicondylar knee replacement (the images on top represent a preoperative joint; the images on the bottom represent a postoperative joint)

Mobile Bearing Knee Arthroplasty

The current literature suggests that a mobile bearing knee arthroplasty may provide good long term results in younger patients as well as those who engage in higher activity levels. It has also been suggested that patients with an increased body weight might be considered candidates. Patients with mild patellofemoral disease may be considered candidates for the mobile bearing “uni” only if they do not have significant pain in the front of the knee. The success rates and the outcomes

Results

Fixed Bearing Unicondylar Knee Replacement

While the initial results of unicondylar knee replacement published in the 1970s and 1980s were frustrating, these studies focused on early designs for fixed bearing unicondylar knee devices with failure rates at ten years in the range of 30% – 40%. This means that out of ten patients undergoing the procedure, only six to seven had a functioning implant that did not require another surgery ten years after their initial procedure. More recent studies, which focus on new designs for fixed bearing knee arthroplasties, have provided much better long term results, largely because of improvements in implant designs, better material quality, better instrumentation, and more careful selection of appropriate patients. Current ten-year survival rates in specialized centers for fixed bearing unicondylar knee arthroplasty are 90% – 95% at ten years.

Mobile Bearing Knee Arthroplasty

The mobile bearing unicondylar knee arthroplasty, if performed by well-trained surgeons performing high numbers of these surgeries annually, has shown survival rates at ten years of up to 95% at specialized centers. The survival rate of the mobile bearing knee replacement in younger patients has also been relatively high. In a recent study comparing younger and older patients, the overall survival rate for patients under 60 years of age has been 91%, compared to 96% in patients older than 60 years of age. In heavier and older patients with evidence of patellofemoral arthritis, the results have been better with the mobile bearing knee arthroplasty than with other unicondylar knee designs.

Results in the Hand of the General Orthopedic Surgeon

Evaluating the global outcome of unicondylar knee replacements as performed by all orthopedic surgeons by nation, the Swedish and Finnish registries have shown results that are less favorable for unicondylar knee arthroplasty compared to those of total knee arthroplasty, independent of the type of device implanted. In the Finnish registry, the survival rate of unicondylar knee replacements at ten years has been 80%; in the Swedish registry, it has been about 85%. At year ten, unicondylar knee arthroplasties show about a 5% higher revision rate in the hands of a general orthopedic surgeon compared to total knee arthroplasty.

Complications

Unicondylar knee arthroplasty is a surgery that could result in complications during and after the procedure. This type of surgery shares the same possible postsurgical complications as total knee replacement, which include:
Instability Due To Component Position Or Inadequate Ligament Balance Of The Knee
Implant Loosening Over Time
Deep Implant Infection
Deep Venous Thrombosis And Pulmonary Emboli
Nerve Injury
Injury Of The Popliteal Artery
Fracture Of The Bone
Wound Healing Problems
Hematoma
Pain Or Decreased Range Of Motion After Surgery

History

Total hip replacement surgery has evolved over the years into a reliable and effective way to relieve disabling pain and allow patients to resume their active lives. Many of the advances in total hip replacement surgery were pioneered by Sir John Charnley, a British orthopaedist, in the early 1960’s.
Dr. Charnley’s great contributions to this procedure include creating the first low-friction total hip arthroplasty by replacing the arthritic hip joint with a metal ball and polyethylene plastic socket. He fixed the prosthesis to the bone with polymethylmethacralate cement, which acted as a grouting to bond the implant to the native bone. Today, many of his principles form the foundation of modern total hip replacement surgery. Many patients who have had their hip replaced using Dr. Charnley’s technique still have a functioning prosthesis after over 30 years. The surgeons of the Hip and Knee service utilize the surgical techniques of Sir John Charnley as the foundation of modern total hip replacement surgery, along with modern modifications designed to make the implants last longer. Today, approximately 150,000 total hip replacements are performed annually in the United States.

The prosthetic implant

The implant for a total hip replacement is composed of 3 parts: the stem, the ball, and the socket. The stem is made out of metal, usually cobalt-chrome or titanium, and is placed within the native thighbone. The ball is usually made out of polished metal or ceramic, and fits on top of the stem. The socket is usually a combination of a plastic liner and a cobalt-chrome or titanium backing. All together, the components weigh about 1 to 2 lbs. They are fixed to the bone either with bone-in growth surfaces or with cement.

There are alternative materials to metal and plastic, namely ceramic-on-ceramic, and metal-on-metal. Each of these material combinations has advantages and disadvantages; learn more about each of these bearing materials by reading our piece on implant bearing surface materials.

Arthritis of the Hip

Arthritis of the hip is a condition in which there is loss of the articular cartilage of the femoral head and acetabulum. This can be seen on x-ray as a loss of the space between the two ends of bone.
Because of the loss of the gliding surfaces of the bone, people with arthritis may feel as though their hip is stiff and their motion is limited. Sometimes people actually feel a catching or clicking within the hip. Generally, loading the hip joint with activities such as walking long distances, standing for long periods of time, or climbing stairs makes arthritis pain worse. The pain is usually felt in the groin, but also may be felt on the side of the hip, the buttock, and occasionally into the knee.
Arthritis of the hip usually occurs in people as they enter their 60’s-70’s, but this is variable depending upon factors such as weight, activity level, and hip anatomy. Arthritis may be caused by a variety of factors, including simple wear and tear, inflammatory disorders such as lupus or rheumatoid arthritis, infections, and trauma. The end result of all these processes is a loss of the cartilage of the hip joint, leading to bone rubbing against bone.
Another cause of hip arthritis in younger patients is femoroacetabular impingement, in which abnormal anatomy leads to premature cartilage deterioration.

Overview of surgery

Surgery may be the best option to treat hip arthritis. The exact type of surgery depends upon your age, anatomy, and underlying condition. Some examples of surgical options to treat arthritis include an osteotomy, which consists of cutting the bone to realign the joint; total hip replacement, and hip resurfacing.

Hip implant Steps of Surgery

Hip replacement surgery involves cutting away the arthritic bone and inserting a prosthetic joint. Both the arthritic ball and socket are replaced, usually with a metal ball and a plastic socket. The ball is placed upon a stem that is implanted within the femur (thigh bone), with or without cement. The socket is inserted within the native acetabulum after removing the arthritic surface.

Implant in hip Decision to have surgery

People often wonder when and why they should have their hip replaced. This is an individualized question that depends upon a person’s activity level and functional needs. Many people with arthritis live with pain that prevents them from participating in activities that they love, or pain that interferes with their sleep; others are so debilitated that they have difficult putting on their shoes and socks. Total hip replacement offers a solution to the problem of arthritis and is performed with the goal of pain relief and resumption of activity. A consensus statement by the National Institutes of Health stated "total hip replacement (THR) is one of the most successful surgical procedures and provides immediate and substantial improvement in a patient’s pain, mobility, and quality of life. Compared to treatments for other chronic debilitating diseases, THR is highly cost effective"(1994).
A total hip replacement is considered a major operation, and the decision to undergo total hip replacement is not a trivial one. People usually decide to undergo surgery when they feel they can no longer live with the pain of their arthritis.

The prosthetic implant

The implant for a total hip replacement is composed of 3 parts: the stem, the ball, and the socket. The stem is made out of metal, usually cobalt-chrome or titanium, and is placed within the native thighbone. The ball is usually made out of polished metal or ceramic, and fits on top of the stem. The socket is usually a combination of a plastic liner and a cobalt-chrome or titanium backing. All together, the components weigh about 1 to 2 lbs. They are fixed to the bone either with bone-ingrowth surfaces or with cement.
There are alternative materials to metal and plastic, namely ceramic-on-ceramic, and metal-on-metal. Each of these material combinations has advantages and disadvantages; learn more about each of these bearing materials by reading our piece on implant bearing surface materials.

The procedure

The total hip replacement is performed in an operating room with a special laminar airflow system, which helps reduce the chance of infection. Your surgeon will be wearing a "spacesuit", also designed to reduce the chance of infection. The entire surgical team will consist of your surgeon, two to three assistants, and a scrub nurse.
The anesthesia for a total hip replacement is given through an epidural catheter, which is a small tube inserted into the back. This is the same type of anesthesia given to women in labor. You will be made numb from the waist down so that you will not feel anything. The catheter stays in for 1-2 days after the surgery to help with your post-operative pain control. During the course of the operation, you can be as awake or as sleepy as you want to be.
After the epidural block is administered, you will be placed on your side. The incision for a total hip replacement is made along the side of your hip. The incision will measure anywhere from 4 to 10 inches, depending upon your anatomy. It is well-covered by undergarments and is usually not visible when wearing clothes.
The arthritic ball and socket are exposed and removed with power instruments. The bone is prepared to receive the artificial hip joint, and then the prosthesis is inserted. During the closure, two drains may be inserted around the operated area to assist with the evacuation of blood. A combination of staples and/or sutures are used to close the skin.

Your pathway to recovery

The entire operation will take from 1 to 2 hours. Afterwards, you will be brought to the recovery room, where your blood work will be checked, and an x-ray of your new hip will be taken. Most patients can be brought to a regular room within a few hours; others will need to stay overnight in the recovery room, as determined by your surgeon and anesthesiologist. Patients generally stay in the hospital for 3 to 4 days following total hip replacement surgery. Younger, more fit patients may be able to leave within 48 hours of surgery if deemed safe by our doctors and therapists.

History

Total knee replacement surgery was first performed in 1968, and has evolved over the years into a reliable and effective way to relieve disabling pain and allow patients to resume their active lives. Improvements in surgical techniques and implant design and construction have helped make this one of the most successful orthopaedic procedures today. As the population has become older and remained more active, the need for total knee replacement continues to increase. Today, approximately 270,000 total knee replacements are done every year in the United States.
Many of the advancements in knee replacement surgery have taken place at the SPARSH Hospital. Improvements in the surgical technique and the design of new implants are a few of the contributions the surgeons of the Hip and Knee service have made.

Arthritis of the Knee

Arthritis of the knee is a condition in which there is loss of the articular cartilage of the femur, tibia, or patella. This can be seen on x-ray as a loss of the space between the two ends of bone.

X-Ray of an Arthritic Knee

Because of the loss of the gliding surfaces of the bone, people with arthritis may feel as though their knee is stiff and their motion is limited. Sometimes people actually feel a catching or clicking within the knee. Generally, loading the knee joint with activities such as walking long distances, standing for long periods of time, or climbing stairs makes arthritis pain worse. When the arthritis has gotten to be severe, the pain may occur even when sitting or lying down. The pain is usually felt in the inside part of the knee, but also may be felt in the front or back of the knee. As the cartilage is worn away preferentially on one side of the knee joint, people may find their knee will become more knock-kneed or bow-legged.
Arthritis of the knee usually occurs in people as they enter their 60′s-70′s, but this is variable depending upon factors such as weight, activity level, and knee anatomy. Arthritis may be caused by a variety of factors, including simple wear and tear, inflammatory disorders such as lupus or rheumatoid arthritis, infections, and post-traumatic. People who have had prior injury to their knee, damaging the meniscus or cruciate ligament may also develop arthritis. The end result of all these processes is a loss of the cartilage of the knee joint, leading to bone rubbing against bone.

Overview of surgery Operative

If the non-operative methods have failed to make your condition bearable, surgery may be the best option to treat knee arthritis. The exact type of surgery depends upon your age, anatomy, and underlying condition. Some examples of surgical options to treat arthritis include an osteotomy, which consists of cutting the bone to realign the joint; and knee replacement surgery.

Knee replacement implant

An osteotomy is a good alternative if the patient is young and the arthritis is limited to one area of the knee joint. It allows the surgeon to realign the knee to unload the arthritic area and place weightbearing on relatively uninvolved portions of the knee joint. For example, a patient who has begun to become more bow-legged might be realigned to be more knock-kneed in order to redistribute the load across the joint. The advantage of this type of surgery is that the patient’s own knee joint is retained and could potentially provide many years of pain relief without the disadvantages of a prosthetic knee. The disadvantages include a longer rehabilitation course and the possibility that arthritis could develop in the newly aligned knee.

Steps of Surgery

Knee replacement surgery involves cutting away the arthritic bone and inserting a prosthetic joint. All of the arthritic surfaces are replaced, including the femur, tibia, and patella. The arthritic surfaces are removed, and the ends of the bone are replaced with the prosthesis, like capping a tooth. The prosthetic component is generally made of metal and plastic surfaces which are designed to glide smoothly against one another.
The total knee replacement is performed in an operating room with a special laminar airflow system, which helps reduce the chance of infection. Your surgeon will be wearing a "spacesuit", also designed to reduce the chance of infection. The entire surgical team will consist of your surgeon, two to three assistants, and a scrub nurse.
The anesthesia for a total knee replacement is given through an epidural catheter, which is a small tube inserted into the back. This is the same type of anesthesia given to women in labor. You will be made numb from the waist down so that you will not feel anything. The catheter stays in for 1-2 days after the surgery to help with your post-operative pain control. During the course of the operation, you can be as awake or as sleepy as you want to be.
After the epidural block is administered, a tourniquet, or cuff, will be placed around your thigh. The tourniquet will be inflated during surgery to help reduce the loss of blood. The incision for a total knee replacement is made along the front of your knee. The incision will measure anywhere from 4 to 10 inches depending upon your anatomy.
The arthritic surfaces of the femur, tibia, and patella are exposed and removed with power instruments. In so doing, deformities of the knee are corrected, and the knee will appear straighter after surgery. The bone is prepared to receive the artificial knee joint, and then the prosthesis is inserted. During the closure, two drains are inserted around the operated area to assist with evacuation of blood. Staples are used to close the skin.
The entire operation will take from 1 to 2 hours. Afterwards, you will be brought to the recovery room, where your blood work and vital signs will be checked. . Most patients can be brought to a regular room within a few hours; others will need to stay overnight in the recovery room, as determined by your surgeon and anesthesiologist. Patients generally stay in the hospital for 3-4 days following total knee replacement surgery.

Your pathway to recovery

Your return to activity will be guided by your surgeon and therapists. Generally, patients are able to walk as much as they want by 6 weeks post-operatively. Patients are able to resume driving at 6 weeks. At 8 weeks, patients are able to resume playing golf and swimming; at 12 weeks, they may play tennis. Your surgeon will help you decide what activities you may resume.

Your surgery at OUR HOSPITAL Pre-operative Orientation

Most patients will be asked to donate 1 to 2 pints of their own blood in the weeks preceding knee replacement surgery. This helps reduce the need for a blood transfusion from our blood bank. Almost all of the patients will receive the donated blood as a transfusion after surgery. Rarely, an additional transfusion is necessary from our blood bank. The blood from the blood bank is carefully screened to the best of our ability to detect any infectious diseases.
You will be asked to see a medical doctor at SPARSH prior to your surgery. This is a precaution to make certain that you are healthy enough to undergo knee replacement surgery. In the course of this workup, you may be asked to have additional testing to examine your heart and lung function. After your surgery, this medical doctor will see you in the hospital.

Post-operative Course

Immediately after total knee replacement surgery, you will be in the recovery room. Most patients are able to go to a regular room after a few hours, when the sensation returns in your legs. You will be given a pain pump connected to your epidural catheter which will allow you to control when you are given pain medicine. Most people are quite comfortable with the pain pump in place.
On the day of surgery, you may do some of the exercises as instructed by your physical therapist, including quadriceps contractions and moving the feet up and down. Depending on your surgeon’s preference, you may begin bending your new knee right after surgery, or on the first day after surgery. You will be allowed to take some ice chips after surgery to wet your mouth, but drinking liquids or eating may cause you to become nauseated. You will have a catheter in your bladder so that you do not have to worry about urinating. Once you regain the movement in your feet, you may be allowed to sit up, stand, and take a few steps with the assistance of a walker and a therapist.
The first day after surgery will be an active one, designed to help you get more mobile. You will meet our physical therapists, who will instruct you in more exercises to perform while in bed. In the next few days, you will find it easier and easier to move about. You will be freed up from the pain and urinary catheters. Pain medication will be given in the form of tablets. Eventually you will progress to walking with a cane or crutches. On the second day after surgery, if your bowels have shown evidence of recovery, you will be allowed to eat regular food.

Complications

Some of the risks of the surgical procedure include the loss of blood, formation of a clot in your leg, and the chance of infection. The overall incidence of these risks is very small. They should be discussed with your surgeon prior to proceeding with the operation.
Some of the risks of having a prosthetic knee include the chance that the parts may loosen or wear out over time, or the prosthesis may become infected. Again, these issues will be discussed with you by your surgeon.