Shoulder arthroscopy is a minimally invasive surgical technique that allows your surgeon to evaluate and, in some cases,treat certain shoulder conditions. During the procedure your surgeon will make small incisions in your shoulder called portals. A tiny camera is then placed in the portals and the interior space of the shoulder can be visualized, proper diagnosis made, and then surgically repaired.
Anatomy of the Shoulder
The shoulder is made up of two joints, the acromioclavicular joint and the glenohumeral joint. The acromioclavicular joint is where the acromion, part of the shoulder blade (scapula) and the collar bone (clavicle) meet. The glenohumeral joint is where the ball (humeral head) and the socket (the glenoid) meet. The rotator cuff connects the humerus to the scapula and is made up of the tendons of four muscles, the supraspinatus, infraspinatus, teres minor and the subscapularis. Tendons attach muscle to bone. Muscles in turn move bones by pulling on the tendons. The muscles of the rotator cuff keep the humerus tightly in the socket. The socket, or the glenoid, is shallow and flat. It is rimmed with soft tissue called the labrum that makes a deeper socket that molds to fit the humeral head. The joint capsule surrounds the shoulder joint. It is a fluid filled sac that lubricates the joint. It is made up of ligaments. Ligaments are soft tissue that holds bone to bone. Shoulder injuries can occur to any part of the shoulder.
Common Conditions that Require Shoulder Arthroscopy
- Rotator Cuff Tears are a common condition where the patient develops pain and limited function as a result of the rotator cuff tendon(s) detaching from their insertion on the bone. This can either occur following an injury (15% of the time) or can occur through regular wear and tear (85% of the time). The rotator cuff is reattached to the bone by using anchors and sutures to hold it in place while your body heals the repair.
- Shoulder impingement/Rotator cuff tendinitis is a condition where the rotator cuff becomes inflamed or abraded. The overlying acromion is shaved down and smoothed down to remove bone spurs and the bursa is debrided to eliminate the source of inflammation.
- Acromioclavicular joint arthritis is arthritis that occurs where the collarbone meets the shoulder blade. This condition can be treated by removing a small wedge of bone from the end of the collar bone. This creates a space between the collar bone and the shoulder blade and helps prevent painful contact or grinding of these bones that occur with certain movements.
- Biceps tendon disease is inflammation, fraying or tearing of the biceps tendon. Half of the biceps muscle actually passes through the ball and socket joint as a thin tendon that glides in a boney groove during shoulder motion. If the tendon is damaged, this can be a significant source of shoulder pain. Biceps problems are more common in patients that also have damage to the rotator cuff tendons. Treatment of this problem involves either releasing the tendon (tenotomy) or reattaching the tendon (tenodesis) to a new spot. Both are effective in treating biceps pain. The decision to perform a tenotomy or tenodesis depends on the age and activity level of the patient and should be discussed with you by your surgeon prior to surgery.
- Shoulder Instability is usually the result of an injury to the shoulder that either tears the soft tissue stabilizers of the shoulder (ligaments and labrum) or breaks part of the bony socket (glenoid). This usually, although not always results from a shoulder dislocation. The damage to the shoulder can vary in severity depending on the nature and chronicity of the injury. During surgery, the shoulder is stabilized by reattaching the labrum and tightening the shoulder capsule.
- Frozen Shoulder is a condition where the patient develops synovitis resulting in a contracture or tightening of the joint capsule, the tissue that makes up the joint space. This contracture restricts motion. To restore mobility the surgeon uses arthroscopy to release the contractures and scar tissue that are present.
Leading Up To Surgery
Depending on the location of your surgery it may be required to have preoperative testing. In some cases, blood work, EKG (heart tracing), or a chest X-ray may be needed. A chest x-ray is only done if you have a lung condition or a history of cigarette smoking. If any of these tests are needed, they will be scheduled for you and will be done during pre-testing when you meet with the anesthesia staff. If it has been some time since you have seen your primary care physician and you have a lot of medical problems, it would be best that you see your medical doctor before your pre-test date.
Medications to STOP prior to surgery (make sure to discuss with Dr. Kirsch)
- Aspirin, enteric-coated, baby, and plain aspirin or any other product containing aspirin. In some cases, we may recommend stopping your aspirin 1 week before surgery. In others cases, low-dose aspirin may be continued based on your medical condition. Please discuss with Dr. Kirsch.
- Coumadin - discuss this with the prescriber as to the best time to stop this medication before surgery.
- Celebrex - stop 1 week prior to surgery.
- Ibuprofen (Advil, Motrin) - stop 1 week prior to surgery
- Naprosyn (Aleve) - stop 1 week prior to surgery
- Plavix - discuss this with the prescriber as to the best time to stop this medication before surgery
- Some over-the-counter herbs can also affect bleeding. These include chondroitin, dan shen, feverfew, garlic tablets, ginger tablets, ginkgo, ginseng, and quilinggao and fish oil. Discuss with Dr. Kirsch if you take any of these medications.
The Day Before Surgery
It is important to make sure you eat a healthy, well balanced diet leading up to your surgery. Make sure you also drink plenty of liquids to make sure you are well hydrated.
Dr. Kirsch recently completed a study which demonstrated that taking Tylenol 1,000 mg every 8 hours the day prior to surgery can improve overall pain control and decrease opioid usage after surgery. Therefore, we recommend that you do this unless you have medical reasons that prevent you from taking Tylenol.
The Night Before Surgery
- Remember that you are to have nothing to eat or drink after midnight the night before surgery. Do not eat or drink anything including gum, mints, or candy, and water or black coffee.
- If you are experiencing any signs of infection such as fever, cold/flu symptoms, diarrhea, skin rash, or open sores, please call the team and your medical doctor as soon as possible.
- Try to get a good night sleep. It is important to be well rested before surgery.
- Bathe or shower the night before or the morning of your surgery. A special wash may have been recommended by pre-screening.
- All nail polish should be removed before your arrival for surgery. Your fingers will be used to accurately monitor your oxygen level during surgery.
- Creams and lotions should not be worn on the day of surgery. A light application of deodorant is allowed.
The Day of Surgery
You will arrive at the hospital approximately two hours before your scheduled surgery time. Procedures are performed on a "to follow" basis. Occasionally, a procedure scheduled ahead of yours may take longer than expected, so there may be some delay before your surgery. Regardless, it is important that you arrive on time. Sometimes an earlier procedure will cancel, and we run ahead of schedule. You should not have anything to eat or drink after midnight the night before surgery. You may be advised to take some of your medications with a sip of water only. The anesthesia staff will discuss this with you at the time of your pre-testing.
Upon arrival to the hospital you will go through a check-in process. At the appropriate time you will be brought into a pre-operative holding area. At this point the nurse will see you, review your records, and an IV will be started. A member of the anesthesia team will meet with you to discuss any anesthesia concerns and anesthetic options. Your surgery will be performed under general anesthesia (you will go to sleep). In addition, the anesthesiologist may recommend a regional nerve block if they think that you are a good candidate. This involves an injection of local anesthetic (numbing medicine) or placement of a catheter near the nerves at the base of the neck. There are several potential advantages of a nerve block. One advantage is that nerve blocks may allow for a significant decrease in the amount of opioid (narcotic) medication needed, which may result in fewer side effects such as nausea, vomiting, itching, drowsiness, constipation, and light- headedness. Nerve blocks generally last for 18-24 hours after surgery. We recommend taking pain medication prior to when your block wears off even though you are not experiencing pain; therefore, you do not fall behind in pain management when the block wears off. The anesthesiologist will discuss the risks of the block and the decision to perform this is a mutual decision between the patient and the anesthesiologist.
You can anticipate that your surgery will last approximately 1 ½ to 2 ½ hours, although this varies depending on the type of shoulder arthroscopy for which you are scheduled. If you have family members with you, they will wait for you in the waiting room. Your doctor will speak with them immediately after your surgical procedure to let them know that you are finished. During your surgery, family members should plan on remaining in or near the waiting area in order to be accessible at the completion of the procedure. Belongings will be stored in a locker in the pre-operative area.
When you wake up from surgery, you will be located in the post-operative recovery room. Unfortunately, family members cannot be present with you at this time as there are many other patients and many nurses in this area. Once you have been stabilized and are comfortable, family members will be invited to sit with you while you continue recovering from surgery. Criteria for discharge include that your pain is under control and that you are eating, drinking, and able to walk to the bathroom with minimal assistance. You will have a dressing on your shoulder and your arm will be immobilized in a sling.
Risks and Complications
The list below includes some of the common possible side effects from this surgery. Fortunately, complications are very rare in your doctor's practice. Please note that this list includes some, but not all, of the possible side effects or complications. Complications may include complications from anesthesia, infection (very rare with arthroscopic procedures), nerve injury (extremely rare), blood vessel injury (extremely rare), bleeding (extremely rare), shoulder stiffness, failure of repair, failure of the anchors or sutures, failure to improve your symptoms as much as you had hoped, a blood clot can form in your arms or legs and very rarely travel to your lungs, complex regional pain syndrome (a painful condition involving the arm).
After surgery your shoulder will be placed in a sling. The sling should be worn as directed by your doctor. The sling is used to limit motion of your shoulder. In some cases where the repair must be carefully protected, your arm may be placed in a sling with a pillow (Ultrasling) that is attached around your waist. It is very important to wear your sling as directed by your doctor after surgery. You may remove your arm from the sling to bend and straighten your elbow and to move your fingers several times a day. You may remove the sling to bathe, dress, and perform elbow range of motion several times a day. In some cases where no soft tissue repairs are performed your surgeon may ask you to discontinue sling use as soon as possible to prevent stiffness of the shoulder.
- Use the sling / brace until your next office visit.
- Remove the sling / brace to allow your arm and elbow to straighten at your side 3-4 times a day for 15-20 minutes at a time. You may move your wrist and fingers either in or out of the sling.
The following is a useful video on how to put on your sling:
We recommend that you eat a light diet the evening of surgery. It is advisable to start with clear liquids after surgery. After any nausea has resolved, you may resume eating a regular diet as soon as you tolerate it.
A prescription for pain medicine will either be provided when you are discharged from the hospital or will be sent to your pharmacy electronically so you can pick it up after surgery. Oral narcotic medication is frequently administered to patients after surgery to help control post-operative pain. It is important to note that although these medications are effective for the treatment of acute pain, use beyond that can be detrimental to your health. It is vital that you discontinue the use of these medications as soon as your pain allows. Specifically, the medication should only be taken as needed as prescribed. The medication is not required for the prescribed time interval.
You will be given the option to purchase a cold pack machine. This machine has a sleeve which is attached to an ice cooler. You place ice and some water in the cooler and plug this into a regular outlet. This circulates cold water through the shoulder sleeve providing relief of pain and swelling after surgery. We do recommend that you put a t-shirt or a thin towel between you and the ice so that it doesn't injure your skin. You should keep ice on the shoulder frequently for the first 48-72 hours after surgery (20 minutes on, 20 minutes off).
- General medication guidelines (ask Dr. Kirsch if you have specific questions):
- Oxycodone 5-10mg (1-2 pills) every 4-6 hours as needed for pain
- Tylenol 650mg every 6 hours or 1,000 mg every 8 hours as needed for pain. (Important to take with Oxycodone)
- Colace 100mg twice a day while on narcotics (can get over the counter)
- Use your medicine liberally over the first 3-5 days, and then you can begin to taper your use. Do not take additional Tylenol if you are taking Percocet, Norco, or Vicodin. It is OK to take Tylenol with the Oxycodone.
- DO NOT take ANY nonsteroidal anti-inflammatory pain medications: Advil, Motrin, Ibuprofen, Aleve, Naproxen, or Naprosyn.
- Resume your home medications
- Colace can be picked up as an over the counter medication. This medication is routinely used as pain medicines can be very constipating. Please take as directed unless you experience loose stools or diarrhea.
- Aspirin has been prescribed to prevent blood clots. This can be picked up as on over the counter medication. Take one 81 mg tablet once a day for 2 weeks. If you take a blood thinner such as Coumadin or Warfarin, take this medication as directed by your medical clearance physician. DO NOT TAKE COUMADIN AND ASPIRIN.
You may remove your dressing 48 hours after surgery if your surgery was performed arthroscopically and you do not have a pain catheter. If you have a pain catheter, this should be removed by a family member 72 hours after surgery along with the shoulder dressing.
Note: You may remove the yellow pieces of gauze (picture on left), however leave the white strips of tape (steri-strips, picture on right) in place.
If you have a clear plastic dressing over your wound, Do NOT remove dressing until follow-up. You may shower directly over this water-proof dressing. You may not get in a hot tub or pool and immerse the incisions underwater for six weeks but you may get in the shower and let the water run over them. Pat the incisions dry afterwards. There is no need to place any ointment over the incisions. Sometimes significant bruising is seen in the front of the shoulder or along the biceps muscle. This is normal and is related to mild internal bleeding after surgery. It is better to keep them dry. If you notice drainage from the incisions, swelling or increased pain 5 days after surgery please call the office. Redness around the incision is very common and should not be a concern unless it is associated with drainage 5 days after surgery, redness spreading away from the incision or fevers.
It is often very difficult to sleep in the week or two following shoulder surgery. The surgery itself may interfere with your sleep-wake cycle. In addition, many patients have increased shoulder pain lying flat on their back. We recommend that you try sleeping in a recliner or in a reclined position in bed. This is often much more comfortable. You may place a pillow between your body and your arm and also behind your elbow in order to move your arm away from your body slightly. This often helps with the pain. You should wear your sling when you sleep.
Operating a motor vehicle may be difficult due to your inability to use your operative arm. If you should have an accident or get pulled over while wearing a sling, the authorities may consider that driving while impaired. The decision to drive is based on your comfort level with driving essentially one-handed. If you need to drive, you should wait at least until you have seen your doctor at the first postoperative visit. You should not drive under any circumstances if you are still taking narcotic pain medication. Once you are out of your sling you may drive once you feel safe operating a vehicle.
The decision to prescribe physical therapy and when to start these activities is made on a case by case basis. This will be discussed with you on your first postoperative visit. It is rare that you surgeon will prescribe therapy before your first postoperative visit. You may be instructed by your surgeon /recovery room nurse to begin gentle range of motion exercises on the day of surgery. These will be self-directed exercises that you start on your own.
- Generally, a follow up appointment has been made for you at the time of surgery. You can call the office to confirm your appointment for 10-14 days after surgery. Notify our office if you have any of the following:
- Fever over 101.5 degrees.
- Excessive blood on your dressing.
- Numbness or tingling in your arm or hand that was not present before surgery and has lasted more than 24 hours.
- Drainage from any incision that last longer than 4 days following surgery.
Do the following exercises while lying on your back unless you were told differently.
**Undo the outer sleeve of your sling.
1. Hand - Bend fingers to make a tight fist, then straighten fingers completely.
2. Wrist - Bend hand downward, then upward.
3. Forearm - Rotate forearm so palm is up, then down.
4. Elbow - Bend, then straighten completely.
NOTE: If you had a biceps tenodesis, you want to use your nonoperative arm to bend your elbow. DO NOT bend your elbow on its own at this stresses the tenodesis repair.
**Exercises 1 - 4 are done actively, 3-4 times a day, 10-15 repetitions.
**Reconnect sling after completing exercises.