Instruments and Equipment
Introduction
Arthroscopic Procedure- General Aspects
Arthroscopic Procedures for Impingement Syndrome
Arthroscopic Procedure for Rotator Cuff Tears
Arthroscopic Procedure for Post-Traumatic Recurrent Anterior Shoulder Dislocation
How long dose recovery take after surgery?
Arthroscopic procedures require the use of specific instruments, including arthroscope, video-dedicated system, “pen like” arthroscopic instruments, and motorized power instruments. Sometimes, specific arthroscopic implants are used.
An arthroscope is an optical instrument that allows orthopaedic surgeons to “see” inside a shoulder joint with help of a video-dedicated system. Arthroscopes have changeable diameters, angle of inclinations and fields of view. With an inclined field of view, “hidden” parts of the shoulder joint can still be assessed clearly. Newer arthroscopes can give an increased field of view with a smaller diameter of scope.
The process uses fluid to “distend” the shoulder joint, ensuring a clear view and enough room to work with. A pump system allows precise control over pressure and flow rate.
The video-dedicated system allows a specially designed digital camera that can be mounted onto different arthroscopes. This captures images inside the shoulder joint and displays their images instantly on a monitor. This allows the orthopaedic surgeon to “see” in a more comfortable operating position.
The orthopaedic surgeon can use appropriate pen-like arthroscopic instruments to work inside a distended shoulder joint through small incisions (portals). In addition, there are different instruments that help the orthropaedic surgeons finish the surgery and probes and grasping forceps are examples of basic arthroscopic instruments. A probe acts like an “extension” of the surgeon’s finger, allowing him or her to "feel” inside your shoulder joint. Of course, “seeing” and “feeling” is better than just “seeing” alone. Arthroscopic grasping forceps are also useful to retrieve loose bodies.
Arthroscopic scissors are an example of instruments that cut soft tissue. Different sizes and designs are available.
The arthroscopic motorized burr is an example of a power instrument that removes bone. During acromioplasty, excessive bony spurs can be removed in an efficient way.
Suture anchors are specifically designed arthroscopic implants that allow reattachment of torn soft tissues back onto a prepared bony surface. During arthroscopic rotator cuff repair, torn rotator cuff tendon ends are reattached back onto proximal humerus. During arthroscopic Bankart repair, the detached labrum is reattached back onto the anteroinferior part of the glenoid rim.
Shoulder arthroscopy is a surgical technique allowing an orthopaedic surgeon to see and work inside the shoulder joint through small incisions (portals). The process requires use of appropriate arthroscopes (a rod-lens system), a video-dedicated system, a suitable “pen like” arthroscopic instruments and sometimes specific arthroscopic implants. With recent technical advances, use of arthroscopy in diagnosis and surgical treatment of a variety of shoulder problems has increased dramatically. It should be noted, however, that arthroscopic procedures cannot replace thorough preoperative clinical evaluation and postoperative intensive rehabilitation, which form the key components of good clinical management.
The orthopaedic surgeon together with an anesthetist will decide whether the arthroscopic procedure should be performed under regional or general anesthesia. Arthroscopic shoulder procedures can be performed under either, in beach chair or lateral positions.
After the operation, the small incisions will be taped or stitched, and the shoulder will be bandaged. Because fluid has been used to “distend” the shoulder joint, it is not uncommon to have some retained fluid leaking back through the small incisions (portals) during the early post-operative period. Because the incisions are small in arthroscopic procedures, recovery is usually less painful when compared with open surgery.
During any arthroscopic shoulder surgery, the orthopaedic surgeon may find open procedure to be more suitable and will choose to continue with open techniques.
During surgery, the orthopaedic surgeon can properly assess the subacromial space, rotator cuff tendons and the undersurface of the acromion. Inflamed subacromial bursa and the anteroinferior part of the acromion can be removed to tackle the issue of “outlet impingement”. These procedures are called bursectomy and acromioplasty respectively – because a prominent acromion is thought to cause "impingement" on the cuff tendons and contribute to the pathophysiological changes. Surgical decompression allows the humeral head to move freely in the subacromial space, so that the arm can be lifted without pain.
Other conditions – including acromioclavicular joint (ACJ) arthritis, tearing of the biceps tendon or partial rotator cuff tear – can also be addressed by arthroscopic methods.
During surgery, the orthopaedic surgeon will make a proper assessment of the size, type and location of the tear. A complete tear within the thickest part of the tendon is repaired by suturing two sides of the tendon back together. This is called “Margin Convergence”. If the tendon is torn away from its bony insertion site at the proximal humerus, it is repaired directly back to the bone (greater tuberosity) for healing with use of appropriate arthroscopic suture anchors.
During surgery, the orthopaedic surgeon will make a proper assessment of the detached and retracted anterior glenoid labrum (Bankart lesion), and look for any associated bony defect at the anteroinferior aspect of the glenoid surface. With help of proper arthroscopic instruments, mobilization of the retracted labrum can be achieved. The detached labrum can then be fixed back onto the glenoid rim, thus restoring tension of the stabilizing ligament (inferior glenohumeral ligament). This can help to tighten and stabilize the shoulder joint.
After all arthroscopic procedures are completed, rehabilitation then plays an essential role. The patient’s contribution is key here. Postoperatively, the arm is immobilized, with the duration of immobilization dependent upon the actual conditions. A supervised exercise program will help regain motion and strength of the shoulder joint while, at the same time, avoiding excessive stress to overload the repaired tissue. Usually, the physical therapy program begins with gentle and passive motion and, at appropriate time, advances to active and resistive exercises. The program will be individualized and the orthopaedic surgeon, physiotherapist and occupational therapist will discuss the specific conditions and inform the patient of the appropriate plan. A strong commitment to rehabilitation is essential to achieve a good surgical outcome. The orthopaedic surgeon will assess the final outcome to provide advice on when it is safe to return to overhead work and sports activity.
Dr. YU, Kong-san