Publications / Current Status of Arthroscopic
Shoulder Surgery

Treatment:

1. Conservative, analgesics, anti-inflammatories.
2. Physiotherapy: can play a supportive role and relieve pain but will not change the course of the condition.
3. Manipulation under anaesthesia: of historic importance only.
4. Surgery: Arthroscopic synovectomy and capsulotomy is done in resistant, long-term cases, resulting in rapid return to pain free full function.

Arthroscopic view: Capsulotomy in progress

Osteo-Arthritis of the Gleno-Humeral Joint.

For selected patients (e.g. younger ones) arthroscopic debridement, capsulotomy and osteophytectomy afford pain relief, “buying time” before arthroplasty is done.

Implants for Arthroscopic Repairs:

• Gleno-humeral joint (stabilisation and SLAP)
  
  Polyethylene or absorbable) anchors in most cases- metal anchors are contra-indicated as severe cartilage damage can occur should anchors dislodge or protrude. The “sliding suture” is imperative in arthroscopic knot tying and HPE anchors are superior in this regard. (Our favourites are Tag Rod and ROC).
  
  
• Subacromial space (rotator cuff)
  
  Medially (“footprint anchor”): the Bio-Corkscrew works well due to the excellent suture sliding capability. Laterally metal anchors are used into the hard bone of the tuberosity: Fastin or RC 5.
  
  Sutures – Ethibond II (Braided Sutures) or Panacryl are used as knots “weave” well (monofilament knots tend to have an inherent ‘spring’ recoil).
  
  ‘Tacks’, ‘Plastic screws’, etc, are only of historic importance in our unit.

Ultrasound for diagnosis

• Serves as an extension of the clinical examination. I.e. confirming clinical suspicion of Rotator Cuff Tear.
• Comparative study to contra lateral side is done routinely.
• Bursal full thickness tears or flaps are seen.
• Saline arthrograms (described by the author): fluid leaks to sub-deltoid space, confirming full-thickness tears.
• Post-operatively the integrity of the repaired cuff is monitored.
• Biceps tendon.
• The importance of “dynamic imaging” must be emphasized: ‘creeping’ across the shoulder in an oblique coronal or sagittal plane the rotator cuff tendon is comprehensively and systematically assessed. Small ‘dips’ indicating tears will not readily be missed.
• Guiding of needles into the subacromial space, ACJ, bicipital groove or GHJ for injections.(method described by the author).

Nerve Blocks

• Are commonly used for total analgesia or in conjunction with general anaesthesia. Single shot local anaesthetic blocks or continuous blocks with indwelling catheters deal with post-operative pain.
• Complications of interscalene brachial plexus blocks, especially neuralgia, are rare but severe enough for us to restrict it to selected cases.
• Anatomic research (Du Toit, De Beer, Van Rooyen) on the sensory nerve supply of the shoulder has lead to the development of selective sensory nerve blocks proving to be of great value.

Shoulder Arthroscopy, status in 2010

At the Cape Shoulder Institute we have established arthroscopic surgery for the different indications as follows:

Arthroscopy as the preferred method:

• Acromioplasty and Mumfords.
• Calcific deposit removal.
• Rotator cuff repair.
• PASTA lesions.
• Stabilisation procedures: Bankart, capsular shift.
• Interval plication.
• SLAP repair.
• Capsulotomy.
• Biceps tenodesis.
• Debridement for Gleno-humeral OA.

Arthroscopic repair as definite option:

• Subscapularis repair.

Arthroscopic procedures being researched:

• Weaver-Dunn for AC instability.
• Endoscopic sensory denervation.

Conclusion

Most conditions of the shoulder can be treated successfully with arthroscopy once surgery becomes indicated. Even fractures of the proximal humerus can often be managed using percutaneous pin fixation.

It is evident that the shoulder lends itself to minimally invasive procedures.

References:

1. Gartsman GM. Arthroscopic rotator cuff repair. Clin Orthop 2001;390:95-106.
2. Burkhart SS, De Beer JF. Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted- Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion. Arthroscopy 2000; 7: 677-693.
3. Burkhart SS, De Beer JF, Tehrany AM, Parten PM.Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy 2002; 8: 488-491.
4. Sperber A, Hamberg P, Karlsson J, Sward L, Wredmark T. Comparison of an arthroscopic and an open procedure for posttraumatic instability of the shoulder: a prospective, randomized multicenter study. J Shoulder Elbow Surg 2001;10:105-8.
5. De Beer JF, van Rooyen K, Boezaart AP. Nicky’s knot – a new slipknot for arthroscopic surgery. Arthroscopy 1998;14:109-111.
6. De Beer JF,Van Rooyen K. Arthroscopic Bankart repair – Some Aspects of Suture and Knot Management. Arthroscopy 1999; 15: 660-662.