Shoulder arthroscopy is a sterile procedure that allows direct visualization of the shoulder joint to diagnose and treat problems. It is indicated to help diagnose and correct lesions or tears of the cartilage, ligaments and tendons of the shoulder joint.
The word arthroscopy comes from two Greek words, "arthro" (joint) and "skopein" (to look). The term literally means "to look within the joint." In an arthroscopic examination, an orthopaedic surgeon makes a small incision in the patient's skin and then inserts a pencil-sized instrument that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint. The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to determine the amount or type of injury, and then repair or correct the problem, if it is necessary.
Why is arthroscopy necessary?
Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually x-rays. Additional tests such as an MRI, or CT also scan may be needed. Through the arthroscope, a final diagnosis is made which may be more accurate than through "open" surgery or from radiographic studies.
What are the possible complications?
The risk of complications after shoulder arthroscopy is low. However, there is some risk that the following conditions will arise:
·bleeding, ·infection, ·nerve and blood vessel injuries ·a build-up of fluid in the shoulder joint, ·cartilage damage, ·anesthetic complications (including death) ·a tear in joint tissues, and ·loss of limb or function.
What are the advantages?
Most patients have their arthroscopic surgery as outpatients and are home several hours after the surgery. For many people, shoulder arthroscopy provides an alternative to open shoulder surgery. In comparison to open shoulder surgery, shoulder arthroscopy provides:
·better cosmesis, ·shorter recovery time, ·less pain, ·less need for pain medication after surgery, ·less damage to soft tissues at the incision site, ·fewer complications, and ·greater improvement in strength and range of motion of the shoulder after surgery.
In general, what are the results?
With significant tears approximately 50% of patients will have progression of their symptoms without surgery.With surgical intervention, the success rate is upwards of 97% for significant pain relief.Regarding function, approximately 80% of patients with subacute or chronic tears will get 80% or more of their pre-morbid function.With more acute injuries the success rate for functional return can be much higher.
What should I do before shoulder surgery?
Your surgeon may ask you to see your primary care physician for pre-operative surgical clearance. You may be asked to get an ECG, chest x-ray and other laboratory tests a couple of days prior to your scheduled surgery date.
If the surgery involves your dominant arm it presents several problem for you. Strange as it seems, bathroom hygiene is quite difficult with your non-dominant hand and should be practiced. It will be several weeks before you will be able to use your dominant hand normally.
Women have several additional considerations. Most women will want to have a front-closing bra on hand for several weeks after surgery. Additionally, most women will want to have a close shave of the axilla (arm pit) as it will be difficult to do this for several weeks after surgery.
Before having shoulder arthroscopy, you should make sure your doctor knows if you: - any medical conditions not previously disclosed, - have any allergies, - are currently taking any medications, - have any bleeding problems, or - are or might be pregnant.
In addition, your doctor will ask you not to eat or drink anything for 8 hours before surgery. He may ask that you either do or do not take your usual medications. You should not take any aspirin or anti-inflammatory medications (e.g. Advil, Motrin, Ibuprofen, Aleve) for 10 days before your surgery as they inhibit platelet function (blood clotting).
You must arrange for someone to pick you up after surgery and stay with your for the first 24 hours after surgery.
What happens on the day of surgery?
On the day of your shoulder arthroscopy, you will need to:
- wear clothing roomy enough to accommodate the bulky bandage and sling that will be wrapped around your shoulder after the surgery;
- remove all jewelry, and
- go to the bathroom just before surgery.
Before your surgery, you may spend a short period in the preoperative holding area. Nurses will prepare the surgical site and administer any medications that have been ordered. An intravenous line will be started. You will receive fluids and medications intravenously during surgery. This will remain in until you have recovered or until you no longer need intravenous support.
Before any surgery requiring anesthesia a short preoperative exam will be done by an anesthesiologist. During this exam your anesthesiologist will be assessing whether you have any conditions that may affect the course of your anesthesia. During the preoperative interview, your anesthesiologist will ask questions pertaining to any allergies you may have, and medications you may be taking.He or she will also ask about any prior anesthetics that you have had and your reaction to them. Your anesthesiologist will ask about any health conditions you have experienced, any physical symptoms you currently have, and your current lifestyle.
Your anesthesiologist will perform a brief physical exam.This exam will include an assessment of your heart and lungs.He or she will also perform an exam of your airway to assure that you will not have any breathing difficulty during your surgery.
A general anesthetic is usually the anesthesia of choice for a shoulder arthroscopy.It is possible to use other methods.Your anesthesiologist, with your input, will determine the anesthetic that assures the best outcome for your procedure. Regardless of the type of anesthesia, your anesthesiologist will monitor your condition throughout the surgical process.
How is arthroscopy performed?
The length of time shoulder arthroscopy takes varies, depending on what is done during the surgery. Generally, it takes one to two hours for the surgery, depending on the patient and his or her individual situation.
Shoulder arthroscopy is performed under sterile conditions. During surgery you will be placed in the "beach chair" position. This position puts you in a semi-sitting position on the surgical bed. Your head and neck are supported with a cushioned head frame and a pillow will be put under your knees. Padding is used for your ankles and feet, and a cushioned arm board for your non-operative arm.
A small incision is made in the back of your shoulder to introduce the arthroscope. Attached to this is a camera and light source. These, in turn are attached to a T. V. monitor to view and record the findings. The arthroscope is also connected to a pump to precisely monitor the amount and pressure of sterile saline used to irrigate and fill the joint space for better viewing. A second small incision is made in the front of the shoulder to allow passage of arthroscopic instruments. Pictures may be taken and saved for later reference. A third incision may be made to introduce instruments for repair and to correct injuries.
The surgeon will inspect the entire joint first. He will have an assistant to help move, rotate, and reposition the arm for visualization of the entire joint. Surgeons use a motorized "shaving" instrument to shave away torn cartilage, excessive growth and tissues, which may cause friction and pain. Biopsies can be taken. A cautery tool may be used to burn off excess tissue growth. This instrument can also smooth rough surfaces, help with repairs, shrink the capsule of the joint for better stability, and lessen bleeding.
The amount of surgery required and recovery time will depend on the complexity of your problem. Occasionally, during arthroscopy, the surgeon may discover that the injury or disease cannot be treated adequately with arthroscopy alone. The "open" surgery may be performed while you are still anesthetized, or at a later date after you have discussed the findings with your surgeon.
Upon completion of the procedure, the entire joint is irrigated until it is clear of blood and loose particles. The surgeon will inject a long acting local anesthetic into the joint to help with post-operative pain. The surgeon may close the small incisions with stitches or apply steri-strips. The area is covered with a sterile dressing and a sling or KnappSakTM is applied. This brace is very helpful because it allows frequent exercise of the elbow, wrist, and the hand. Additionally, it places the arm in a position that promotes better blood circulation and relieves stress on the repaired tissues.
What happens immediately after surgery?
After your arthroscopy you will go to the post anesthesia care unit (PACU).You will remain there until the effects of your anesthetic have begun to wear off.You will remain in the PACU until you can eat, drink and urinate without difficulty.Specially trained nurses work in the PACU and will monitor your progress and give you verbal and written discharge instructions. Your surgeon or anesthesiologist will discharge you from the PACU to home or your hospital room. However, you will not be able to drive home after surgery and should have someone stay with you overnight.
What is the recovery in the immediate post-operative period?
Ice is applied immediately after surgery and thereafter intermittently for the first 7 days. This reduces swelling and relieves pain. The small puncture wounds take several days to heal. The shoulder dressing is usually kept on for 24 to 48 hours. A smaller, waterproof dressing may be placed by the nurse at this time and left in place until your first postoperative visit, usually 7 days following surgery.
Pumping your hand, moving your wrist and bending and straightening your elbow are encourage as this keeps fluid from building up in your hand and arm.
Although the puncture wounds are small, post-operative pain ranges from little or none to very significant. Your physician will prescribe post-operative pain medication, anti-inflammatory medication and possibly an antibiotic. Instructions and side effects should be reviewed carefully, as some may cause constipation and drowsiness.
During recovery from shoulder arthroscopy, it is normal to feel some mild soreness and a slight grinding sensation for a day or two. However, if you develop:
- pain that is severe or persistent,
- inability to move the shoulder, or
- a fever, or foul smelling drainage
Call your doctor right away. You may have developed a complication that requires medical attention.
You will be able to resume driving after a few days to several weeks following surgery.
During the follow-up visit, the surgeon will inspect your incisions; sutures if present will be removed, if present; and discuss your rehabilitation program.
Your doctor, nurse and physical therapist will instruct you on specific exercises to restore muscle function and strength. They will also instruct you on movements you should avoid. Physical therapy will be ordered for you on an outpatient basis. Most patients are allowed to return to work within a week, depending on the nature of your job.
When can I return to normal activities?
It is not unusual for patients to go back to work or school or resume daily activities within a few days. Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient's arthroscopic surgery is unique to that person. Recovery time will reflect that individuality. It takes several weeks to months for the joint to maximally recover. A specific activity and rehabilitation program will be suggested to speed your recover and protect future joint function.
Following minor arthroscopic procedures, limited sports activities can usually be started by the fourth week.
In general, after major reconstruction it is never less than 3 months and rarely more than 6 months for return to full sporting activities. Professional athletes will require considerably more time than this to return to competitive form.Compliance with gradual resumption of activities is necessary for proper healing and rehabilitation. Vigorous physical activity should not be done without your doctor's permission.
Please feel free to ask any additional questions you may have.
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