The Different Types of Shoulder Surgery

Surgery may be an ideal treatment for many common shoulder problems. While the first step in treatment is seldom a surgical solution, often people do get to a point where surgery becomes the best option to address their shoulder condition. Learn about some of the common surgical procedures performed to address shoulder problems, and if one of these may help you resolve your condition. Some of these surgical procedures are minimally invasive arthroscopic surgeries, while others are more traditional open surgeries. Each procedure has pros, cons, and risks that go along with the treatment. Here you can learn about these issues and concerns.

1
Arthroscopy: Bursitis/Impingement Treatment

shoulder injury
PeopleImages/istockphoto

One of the most common reasons to perform shoulder surgery is for the treatment of inflammation around the rotator cuff. People often use different words to describe this condition. Most physicians will refer to 'impingement syndrome,' a condition that leads to inflammation between the ball of the shoulder and the top of the shoulder blade above. In this space are the rotator cuff tendons and the bursa that cushions the tendons. Other names people may use to describe impingement syndrome include rotator cuff tendonitis and bursitis.

When a shoulder arthroscopy is performed to address impingement syndrome, people call this a subacromial decompression. The acromion is the name of the top of the shoulder blade, and space underneath is where the impingement occurs. Therefore a subacromial decompression is opening up that tight space.

When performing a subacromial decompression, your surgeon may remove the bursa alone, or may also remove some of the undersurfaces of the acromion. The goal is to remove inflammation and create space for the rotator cuff to glide without getting pinched between bone. This surgical procedure may be performed in isolation, or as part of a rotator cuff surgery. While this was done historically as an open surgery, a subacromial decompression is almost always performed as an arthroscopic surgery these days.

2
Arthroscopy: SLAP Repair

A SLAP tear of the shoulder is an injury to the rim of cartilage that encircles and deepens the shoulder socket called the labrum. The SLAP tear occurs at the top of the labrum, called the superior part of the labrum. The name SLAP is from the acronym superior labrum from anterior to posterior. This part of the labrum is important because it is the location of the attachment of the long head of the biceps tendon, and is therefore subjected to unique stresses.

In people who are bothered by a SLAP tear, one option is to repair the labrum. Doing so involves an arthroscopic surgery to repair the torn labrum back to the rim of the shoulder socket. Sutures are attached to the bone of the shoulder socket, and the labrum is tightly repaired back to the bone. If the damage extends into the biceps tendon, and not just the labrum, then other surgical options to address the biceps tendon (see below) may be considered.

3
Arthroscopy: Dislocation Treatment

When a shoulder dislocation injury occurs, something is damaged that allows the ball to come out of the socket of the shoulder joint. Most often, the damage is to one of a few particular structures, and the goal of surgical treatment of a shoulder dislocation is to repair those specific structures.

In young athletes, the injured part of the shoulder joint is called the labrum, and the damage typically occurs to a very specific part of the labrum. To stabilize the shoulder after dislocation, these individuals will undergo a surgical procedure called a Bankart repair. This surgery can be done as an open surgery but is much more commonly performed as an arthroscopic procedure.

In individuals 30 and older, the damage more commonly occurs to the rotator cuff of the shoulder. When this occurs, the typical treatment is a rotator cuff repair, as described below.

There are also some people with generalized laxity of the ligaments of the shoulder leading to a condition called multidirectional instability of the shoulder. These individuals have a shoulder that may come in and out of the socket very easily and need their entire shoulder joint capsule tightened to address their condition.

Lastly, people who have more significant damage to the shoulder, typically resulting from many repeat dislocations, may require a more substantial surgery to keep the ball in the socket. There are a number of different options, but typically these involve moving bone around the shoulder to hold the ball more tightly inside the socket of the joint.

4
Arthroscopy: Frozen Shoulder Treatment

Frozen shoulder is a common shoulder condition. In fact, it is second only to rotator cuff problems as the most common cause of shoulder pain. Unfortunately, frozen shoulder is often misdiagnosed leading to a delay in identification and treatment. The usual treatment of a frozen shoulder can be accomplished with nonsurgical treatments, however, in some rare circumstances, surgical treatment does become an option.

When a frozen shoulder occurs, the capsule that surrounds the shoulder joint becomes tight and contracted. The goal of surgery is to loosen this contracted tissue to allow the shoulder to move more easily. The surgical concept is very straightforward: cut the shoulder capsule all the way around to allow the shoulder to move freely. The difficult part is because the shoulder is so tight, moving around inside the shoulder to cut the capsule safely is a surgical challenge.

The other problem with frozen shoulder surgery is that once the capsule has been cut, the body will want to make new scar tissue. Early, aggressive physical therapy and rehab are essential to keep the shoulder moving normally.

5
Rotator Cuff Repairs

One of the most common surgical procedures for the shoulder is a rotator cuff repair. There are many options to repair a damaged rotator cuff, and each surgeon may have their own preferred techniques. The goal of any rotator cuff repair surgery is to identify the damaged part of the rotator cuff, then clean up and mobilize the surrounding tendon. Once​ the healthy tissue is identified, the goal is to repair the defect in the tendon without excessively stretching the remaining tendon. In most cases, this can be accomplished.

Rotator cuff repairs can be performed several different ways. The traditional way to perform surgery is by making a large incision, detaching the surrounding muscle, and repairing the rotator cuff by directly visualizing the problem. This is called an open rotator cuff repair. A newer option is to perform the surgery arthroscopically. In this technique, only small incisions are used to insert a camera and small instruments. The repair is performed indirectly, by watching on a screen rather than looking directly at the problem.

There is also a hybrid option, called a mini-open rotator cuff repair, that provides some of the advantages of the arthroscopic surgery while still allowing for a direct repair of the tissues. No single option is uniformly better. Some surgeons are more proficient at one type of repair than another, and some tears may be best addressed by one procedure or another.

There are also some circumstances where a repair is not possible. In these cases of very large tears, called massive rotator cuff tears, trying to close the hole in the rotator cuff is not worthwhile as the tissues are too retracted and atrophied. There are options for treatment of this problem, but these tears typically cannot be repaired.

6
Acromioclavicular Joint Problems

The acromioclavicular joint (usually called the AC joint) is the junction of the end of the clavicle (collarbone) and the top of the shoulder blade (the acromion). This joint is an important part of the shoulder joint, although it moves very little relative to the ball and socket of the shoulder.

There are several problems that can occur at the acromioclavicular joint. The first is that it can wear out. Sometimes this occurs as a result of arthritis of AC joint, other times is because of previous trauma to that joint. The AC joint can also wear out as a result of specific activities that cause stress to the joint, such as weightlifting. This condition called distal clavicle osteolysis leads to weakening of the bone around the joint. When these problems occur, the typical treatment is to remove the end of the collarbone to widen the space of the AC joint.

The other common problem that occurs at the AC joint is instability, called a shoulder separation. This occurs usually as a result of an injury to the shoulder region that leads to damage to the ligaments that connect the end of the clavicle to the shoulder blade. Shoulder separations can often be treated nonsurgically, but when surgery is performed, the usual method is to repair or reconstruct the ligaments that support the end of the clavicle.

7
Shoulder Replacements

Shoulder replacement surgery is a treatment option typically reserved for advanced arthritis of the shoulder joint, also can also be used for complex fractures of the shoulder and other problems that cannot be repaired adequately. A typical shoulder replacement will replace the worn out ball and socket shoulder joint with an artificial ball made of metal, and a socket made of plastic. The shoulder implant is designed to function as a normal shoulder.

Sometimes, the entire ball and socket shoulder joint may not need replacement. This may be the case with earlier arthritis or in the case of fractures of the top of the arm bone. In these situations, a partial shoulder replacement may be a reasonable option for treatment of your condition. This procedure, called a hemiarthroplasty, just replaces the ball of the shoulder, and the socket is left alone.

One other option is called a reverse shoulder replacement. This surgery, as it sounds from its name, reverses the location of the ball and socket so that the replaced ball goes where the socket was located, and the replaced socket goes where the ball of the shoulder was. The reason to perform this procedure is that it can provide a mechanical advantage to people who have severe damage to the rotator cuff. This is a great solution for people who have a condition called rotator cuff tear arthropathy, a combination of damage to the shoulder joint cartilage and the rotator cuff.

8
Biceps Tendon Surgery

The biceps tendon is the muscle on the front of your arm. The muscle is connected to bone by tendons, and on the top of the muscle, there are two tendon attachments. One is in front of the shoulder, called the short head of the biceps. The other tendon, called the long head of the biceps, is deep inside the shoulder. This long head of the biceps tendon travels through the rotator cuff, passes inside the shoulder, and attaches to the labrum on the top of the shoulder socket. This complex relationship to the shoulder makes the long head of the biceps tendon a common culprit of shoulder joint problems.

Surgery on the biceps tendon may be performed in isolation, or it may be performed as part of another shoulder surgery such as a rotator cuff repair. There are generally two options if the biceps tendon needs surgery. One is to cut the tendon inside the shoulder and reattach the tendon outside of the joint. The other option is to simply cut the tendon and let it retract down the arm.

There are pros and cons of each option, and both options can have very good results. While many people think just cutting the tendon would lead to reductions in strength and function, there are numerous reports of professional athletes having a tenotomy and returning very quickly to compete in a professional competition!

9
Repair of Fractures Around the Shoulder

Fractures around the shoulder joint can require surgery depending on the severity of the injury and the expectations for the patient. Some of the more common fractures that can occur around the shoulder include:

Determining the best treatment may involve a number of different factors, but surgery is often used for treatment of these injuries.

Risks and Complications of Surgery

All of these aforementioned surgical procedures can be performed safely and effectively, but they are not without risk of possible complications. While complications are unusual after most types of shoulder surgery, they can occur.

Before you have any surgery, you should talk with your surgeon about the possibility of complication and what types of treatments and outcomes can be expected if a complication does occur. In addition, most shoulder surgical treatments are elective—there should be an opportunity to discuss the pros and cons of surgical and nonsurgical treatment with your doctor so you know exactly what you are getting in to.

Source:

Tonino PM, et al. "Complex Shoulder Disorders: Evaluation and Treatment" J Am Acad Orthop Surg March 2009 ; 17:125-136.

Continue Reading