Arthroscopy of the shoulder joint (synonym: shoulder arthroscopy) is a medical procedure used in both the diagnosis and treatment of various injuries or degenerative changes of joints. Arthroscopy is primarily used in orthopedics and trauma surgery. The arthroscope is a variant of the endoscope that is used exclusively in the therapy and diagnosis of pathological joint changes. Decisive for the function of any arthroscope is the basic principle of its construction. Regardless of where the device is used, every arthroscope consists of an optical system of special rod lenses and a small but powerful light source. Furthermore, flushing devices are often integrated into the arthroscope. Using arthroscopy, it was possible for the first time to perform minimally invasive surgical interventions in the joint area. Diagnostic arthroscopy is of particular importance in surgery and orthopedics because, on the one hand, it can be performed as a stand-alone examination and, on the other hand, it can be used directly as part of peri- and preoperative diagnostics (its use is possible during and before surgery).
Indications (areas of application)
Therapeutic arthroscopy of the shoulder joint:
- Impingement syndrome (English “collision”) – the symptomatology of this syndrome is based on the presence of a constriction of the tendon structure in the shoulder joint.and thus a functional impairment of joint mobility. It is mostly caused by degeneration or entrapment of capsular or tendon material. Degeneration or injury of the rotator cuff is the most common cause. Affected patients can barely lift their arm above shoulder height due to the increasing entrapment of the supraspinatus tendon. The actual impingement occurs subacromially, which is why this is referred to as subacromial syndrome (SAS for short). The elimination of the pathological process, also known as impingement syndrome, is performed by milling off the lower edge of the acromion. Furthermore, the removal of an inflamed bursa can be performed in parallel during the procedure and a clearing of painful calcium deposits are completed.
- Rupture of the rotator cuff – as already described, arthroscopy is almost ideally suited for surgical treatment in the presence of a rupture of the rotator cuff. The rotator cuff is the shoulder joint muscles directly adjacent to the joint capsule, which are usually summarized in the clinic under the term “rotator cuff”, because they embrace the shoulder head like a cuff.
- Therapy of a shoulder joint dislocation – with the help of arthroscopy, there is the possibility of both diagnosing and therapeutically treating a dislocated shoulder joint. The basic principle of this therapeutic measure is the tightening of the joint capsule, so that as a result the stability of the affected joint can be increased. Furthermore, a fixation of the torn joint capsule by means of arthroscopy is possible.
- Frozen shoulder (Syn: Periarthritis humeroscapularis, painful frozen shoulder and Duplay syndrome) – extensive, painful suspension of mobility of the shoulder. Shoulder stiffness can be treated with the use of arthroscope either by capsular splitting or by stretching the capsule.
- Removal of “free joint bodies” – the benefit of arthroscopy of the shoulder joint is both finding and removing the so-called free joint bodies, which can occur due to joint folds and adhesions in the joint area. The exact significance for the development of pain must be clarified individually for each patient. Existing adhesions normally make it much more difficult to perform an examination. Adhesions can be removed during an arthroscopic examination or by separate arthroscopy.
- Removal of hypertrophic synovial villi – the development of hypertrophic synovial villi (enlarged processes of the synovium) represents an adaptive reaction of the synovium. Arthroscopic synovectomy (removal of the synovium) represents a further development of the invasive conventional procedure and is associated with a relatively low risk of subsequent damage.In contrast, conventional non-arthroscopic synovectomy is a non-arthroscopic procedure that is characterized by lengthy and costly follow-up treatment. Intensive physical therapy must follow the conventional procedure. Under certain circumstances, mobilization of the joint is performed under anesthesia during the operation. The further course after arthroscopic synovectomy can therefore be judged to be much better. Normally, the physiological range of motion is almost fully achieved within a few days. An additional advantage of arthroscopic synovial removal is the possible removal of scar strands, which can often form after a bruise or purulent shoulder joint infection.
Contraindications
- Infection – if there is inflammation in the surgical area, arthroscopy cannot be performed under any circumstances.
- Immunosuppressive therapy – treatment with cortisone or other immunosuppressive drugs should be considered an absolute contraindication to performing arthroscopy. The risk of secondary infection is significantly increased by the use of such substances. If there is a non-drug weakening of the immune system, the arthroscopy may also not normally be performed.
- Coagulation disorders – the use of anticoagulant substances or the presence of a pathological coagulation disorder should lead the surgeon either to cancel the planned procedure or to stabilize coagulation by additional measures. With the help of blood tests (coagulation status), it is possible to check the blood clotting characteristics and allow the patient to undergo the procedure.
Before surgery
Arthroscopy of the shoulder joint is a diagnostic or therapeutic procedure, which can be performed under general anesthesia or fully conscious. However, with local anesthesia, there is a risk that reflex muscle twitches may adversely affect the success of the method. Although arthroscopy of the shoulder joint is now a standard procedure, the indication (indication) for its use should only be if there is no improvement in mobility or decrease in pain over a period of at least 12 weeks prior to the therapeutic use of arthroscopy of the shoulder joint. Intensive conservative therapy with targeted physiotherapy by a trained physiotherapist should therefore precede therapeutic arthroscopy. Physical measures such as ultrasound application should be used, and anti-inflammatory drugs (medicinal anti-inflammatory drugs) should be applied (administered) orally (by mouth) or directly by cannula. Examples of antiphlogistic (anti-inflammatory) and analgesic (analgesic) substances include ibuprofen and diclofenac. Thus, it can be stated that no surgical intervention by means of arthroscopy should be performed as long as primary acute pain and movement restrictions exist. Note: For all arthroscopic procedures on the shoulder joint, there is a legal right to an independent second medical opinion. This applies to shoulder joint procedures, provided they can be planned and are not emergency procedures that must be performed promptly.Second opinion physicians are specialists in orthopedics and trauma surgery and in physical and rehabilitative medicine who meet special, procedure-specific qualifications.
The surgical procedure
A few years ago, arthroscopy of the shoulder joint represented the near-optimal diagnostic method for imaging various pathologic processes. In the meantime, the majority of orthopedic surgeons have moved away from the unrestricted use of the procedure in diagnostics, as arthroscopy is an invasive technique that can by no means be considered risk-free. Based on this, arthroscopy of the shoulder joint can be considered dispensable for diagnostics, as other procedures such as magnetic resonance imaging (MRI) and computed tomography (CT) are far gentler for the patient. Nevertheless, there are various issues for which the use of arthroscopy can be considered superior to other procedures.The areas of application of arthroscopy of the shoulder joint are primarily in the preparation, assistance and performance of surgical interventions. The benefits of arthroscopy in surgery should not be underestimated under any circumstances, despite the fact that it is an invasive procedure. The great benefit of arthroscopy in surgery is based in particular on the ease with which the procedure can be performed, since it is an intra-articular procedure and the interior joint space is relatively large. In particular, the size and localization of, among other things, rotator cuff tears can be adequately determined. Structures located outside the joint, however, cannot be visualized by arthroscopy. Of important significance for the performance of arthroscopy is, among other things, that the procedure is used in a fluid environment. To ensure that the shoulder joint is permanently filled with fluid, a roller pump is used to maintain the fluid supply. To prevent nerve damage, the optic is inserted via a dorsal approach (from the dorsal side). At the so-called “soft spot”, the necessary skin incision is made approximately two transverse fingers below the acromion (prominent structure of the shoulder joint). From the access thus created, the arthroscope can now be introduced into the joint. To improve the diagnostic value of the procedure, palpation and inspection of the tissue structures present are performed in parallel during the examination. Special palpation hooks are used for this purpose. Following the diagnostic procedure, it is possible to perform any arthroscopic operations that may be necessary. As a rule, both diagnostic and therapeutic arthroscopy are performed as outpatient procedures. After the procedure has been performed, the patient is observed for another six hours before usually leaving the clinic or an outpatient facility in the evening. Inpatient use of arthroscopy is primarily indicated only for patients who cannot be treated as outpatients for anesthesiological reasons, such as age or reduced general condition. Advantages of arthroscopy of the shoulder joint:
- Arthroscopy makes it possible to combine both diagnosis and necessary surgery during the same procedure.
- As a minimally invasive procedure, there is less surgical stress than in conventional shoulder surgery.
- The procedure is usually possible completely outpatient.
- Due to the small skin incision in the surgical area can be seen less scarring than standard surgery.
- As a result of the reduced rehabilitation period is a shorter incapacity to work.
After surgery
A follow-up examination should be performed within a week to get an overview of the success of the operation and any problems that may have arisen. The period of rest after surgery depends on the arthroscopic procedure on the shoulder. However, as a rule, the healing process can be judged to be far better with this minimally invasive method than with a conventional method.
Possible complications
- Bleeding – unlike arthroscopic knee surgery, bleeding is far more common in shoulder procedures and is a relevant problem of the procedure. However, precise differentiation must be made in the bleeding risks of arthroscopic procedures. In the case of intra-articular shoulder stabilization, the risk of bleeding can be classified as low, since this problem can usually be prevented in the surgical area with the help of the pressure of the irrigation fluid. In contrast, during operations in the subacromial space (outside the joint), even small sources of bleeding significantly limit the overview. This phenomenon is based, among other things, on the fact that easily vulnerable blood vessels run in this area, which are very often damaged when the bursa is removed. To solve this problem, however, can not use the pressure development by the irrigation fluid, because in this surgical area much worse than in the joint, a water pressure exceeding the arterial mean pressure can be built up.
- Swelling – excessive swelling of soft tissues due to wash-in of irrigation fluid can be a significant problem, as unimpeded instrument handling of soft tissues becomes significantly difficult or even impossible due to the increase in volume. In addition, complications such as systemic hypervolemia (increase in the volume of fluid in the bloodstream), compartment syndrome (massive tissue swelling, which can result in amputation in the absence of acute treatment) or even airway obstruction (increasing obstruction of the airways) can occur during shoulder arthroscopy due to the swelling in very long lasting shoulder arthroscopy.
- Embolism – as a result of thrombus (clot) formation, there is a possibility of migration of the thrombus, so that in the worst case, as a result of blockage of a heart supply vessel, myocardial infarction (heart attack) may occur. This can also lead to death. However, due to the short lying time after the procedure is performed, the risk is very low.
- Infection – in the course of arthroscopy, the development of an inflammatory process is possible, but relatively rare. The risk of infection is present even with near-optimal hospital hygiene. The risk of infection is additionally dependent on the duration of lying before the performance of arthroscopy.
