Shoulder Surgery

Healing of the rotator cuff needs to occur between the tendon and bone for a repair of a rotator cuff tear to be successful. Immediately following the surgical procedure after the tendon is put back in contact with the bone a small layer of clot forms between the tendon and bone.  

In the first couple of weeks following the surgery specialised cells migrate from the bloodstream into the clot, these cells are called fibroblasts. The role of the fibroblasts is to lay down collagen tissue (collagen is the matrix that is the predominant component of tendons and ligaments in the body). These collagen fibres are initially laid down in a haphazard manner. This laydown of collagen fibres occurs significantly in the first 4-6 weeks following the surgical procedure.

The collagen fibres need to be remodelled from a haphazard collection of fibres into a structure where the fibres run parallel to each other. As this occurs and fibres of the collagen matrix start to be realigned in parallel bundles strength returns to the connection between the tendon and the bone. This remodelling process occurs over a long period of time. However, it is most rapid in the first 4-12 weeks following the initial surgical procedure.

Remodelling occurs for at least 6-12 months following the procedure, but again gradually slows down and the majority is completed by 4-6 months. Strength continues to improve in the connection between the tendon and the bone for at least the first 12 months post-operatively as the remodelling process fine-tunes itself. The remodelling process is improved with light loading across the shoulder and light physiotherapy exercises provide this stimulus to this process.

Post-operative rehabilitation following a rotator cuff tear is complex and requires the input of an experienced physiotherapist. Typically for the first 6 weeks following the surgery the shoulder is immobilised in a sling. Light exercises will be undertaken under the supervision of the physiotherapist. This includes a light range of motion exercises that avoid any pressure being placed on the shoulder or any strain on the rotator cuff tear repair.

After the initial period of immobilisation, the sling will normally be discarded and the exercises for the shoulder will be increased. Light exercises involving active lifting of the arm will be commenced and the initial aim will be to restore the range of motion to the shoulder.

At approximately 12 weeks following the initial surgery light strengthening exercises will generally be started. The aim of the rehabilitation protocol is to have a return to the normal function of the shoulder within 6 months from the time of surgery.

The function will often be regained as early as 3-4 months following the surgical procedure; however, it will normally be 6 months before normal work activities and recreational involvement can be restarted. Normally it will not be possible to return to sports until 6 months following the surgical procedure.

RESULTS OF SURGERY FOR A ROTATOR CUFF REPAIR

‍Repair of the rotator cuff will achieve a good to excellent result in 90-95% of patients. The issues that can affect the success of the surgical repair include thinning and degenerative weakening of the tendon and the size of the tear can be significant.

Larger tears mean that more strain is placed on the sutures to reattach the torn tendon to the bone. Larger tears can also be technically more difficult to repair back to the bone. With time, torn tendons tend to retract away from where they normally attach onto the humerus (upper arm bone) and can eventually become so scarred up that it’s not possible to stretch them back from where they have ruptured from.
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Tendon tears that have been left for a long period of time can result in atrophy or wasting of the muscle to which they attach, and this can be extensive. The final phase of atrophy involves the replacement of the muscle with fatty fibrous tissue and once this occurs the muscle has a very poor chance of functioning again. Long-standing tears can also result in an arthritic change in the shoulder and once arthritis has set in, the rotator cuff tear repair will often not be successful in relieving the symptoms of pain and dysfunction. The significant arthritic change will often be a contra-indication to performing a repair of the rotator cuff.

Patient compliance can also be a factor. The repair is a temporary reattachment of the tendon to the bone and the long-term success of the repair relies on the healing process occurring between the tendon and the bone. If the repair of the tendon is subjected to too much stress, then it can fail as with any mechanical structure.

The repair relies on sutures to reattach the tendon to the bone, these sutures can break if they are put under too much strain, or they can dislodge from the bone or tear through the tendon itself. Close observation of the recommended precautions following surgery is important to prevent failure of the surgical repair.

Normally improvement in pain and function of the shoulder is experienced within6 months following the surgical procedure, occasionally it takes longer.

Symptoms of tendonitis in the shoulder include aching pain down the outer aspect of the arm. Using the arm away from the body can be particularly uncomfortable and can cause deep aching pain. Symptoms of impingement are often prevalent, where the shoulder catches as the arm is lifted away from the body and there is a degree of bursitis in the shoulder.

Tendonitis can be caused by an injury to the rotator cuff tendons. This could occur from repetitive injury, or from an injury such as a fall onto the shoulder.

Tendonitis can also occur with calcium build-up within the tendon. Calcium build-up within the rotator cuff tendons is surprisingly common and, in many cases, it doesn’t cause any problems at all. However, in some patients, they develop an inflammatory reaction to the calcium, which results in calcific tendinitis. An excision of calcium may be performed to help alleviate symptoms.

Treatment for tendonitis can be difficult. Patients with tendonitis as part of bursitis and impingement can often be satisfactorily treated with steroid injections or physiotherapy. If this is unsuccessful in relieving the symptoms, then an arthroscopic acromioplasty and bursectomy may be considered. Patients with pure tendinitis, which is fortunately uncommon, can be quite difficult to treat.

These patients often have a chronic overuse injury to the shoulder and tend to keep re-injuring it, often with seemingly minor events. If patients do not respond to prolonged periods of rest and physiotherapy, steroid injections can be helpful.

Platelet Rich Plasma (PRP) injections may give relief. Arthroscopic surgery to decompress the rotator cuff can also be helpful, however, patients with predominant tendonitis may not respond adequately to surgical treatment.

Shoulders that dislocate following traumatic injuries need to have the damaged and torn structures repaired.

Many patients have only cartilage torn however, some patients have segments of bone broken or worn away from the front of the shoulder. If this is the case, then the shoulder is frequently highly unstable. If a large segment of bone is missing from the front of the shoulder, then it needs to be reconstructed. The best way to do this is with a latarjet procedure. In a latarjet procedure, the coracoid process is transferred from the front of the shoulder joint to the neck of the scapula.

The technique of the arthroscopic latarjet was pioneered by Dr Lafosse from Annecy, France.  It is a complex arthroscopic procedure. This procedure involves transferring the coracoid process from the front of the shoulder to the anterior margin of the glenoid. The procedure was first described as an open operation by Dr M. Latarjet from Lyon, France.

To allow the bone block to be placed on the front of the shoulder joint the subscapularis muscle which runs across the front of the shoulder must be split to allow the bone block to pass through and attached to the glenoid.

My approach to shoulder instability is to perform an arthroscopic bankart repair in those patients in whom there is no bone defect and only a cartilaginous labral defect. In patients whose shoulders have a bony defect, I will normally recommend an arthroscopic latarjet procedure.
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There are advantages and disadvantages of the Arthroscopic Latarjet procedure.Because the bone fixation is so strong with two screws used compared to the anchors utilised in the arthroscopic bankart repair an immobilisation sling is not as necessary in the postoperative period. I ask patients to wear the sling for the first 6weeks following surgery, however, they may come out of the sling if they are at home not using the arm.
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Because the healing is bone to bone in a latarjet the healing occurs much more quickly and securely than the cartilage-to-bone healing of the arthroscopic bankart procedure. This enables patients to return to physical work and sport much earlier than for an arthroscopic bankart repair.
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The disadvantage of the latarjet procedure is that the procedure is more technically difficult and takes longer than the arthroscopic bankart. The potential risk of complications is higher.
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The advantage of the arthroscopic latarjet over the open procedure is the reduced pain and discomfort for patients in the initial post-operative period.Another advantage is that the bone block can be positioned with great accuracy.Being an arthroscopic procedure the risk of complications such as infection is significantly reduced compared to an open procedure.

The original Arthroscopic Latarjet procedure pioneered by Dr Lafosse ablates the anterior capsule and does not include repair of the anterior labrum. It is possible with a modification to the initial exposure to preserve the anterior capsule and labrum allowing repair of the labrum once the coracoid process has been transferred and fixed to the anterior glenoid.
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Dr Cutbush has developed this technique of preserving the anterior labrum and repairing it in all the arthroscopic latarjets that he performs. He currently is undertaking a study to demonstrate the technique’s advantages.

The initial capsular exposure is shown in this video.  A radially directed split is made at the level of the superior margin of the subscapularis. The capsule and labrum are divided at this level to the margin of the glenoid. This tissue is then grasped and taken from the superomedial progressively to the inferolateral.

Biomechanical testing has shown that the sling effect of the conjoined tendon that inserts into the tip of the coracoid process is the most important stabilising structure of the latarjet procedure.

The bone block and the labral repair both contribute to the stability of the reconstructed shoulder to a significant degree.  The effect of the sling is demonstrated in this intra-operative video.

In the Latarjet procedure an osteotomy of the coracoid process is performed and the block is transferred to the front of the glenoid through a split in the subscapularis.

A Physiotherapist will see you the morning after surgery before leaving the hospital. The physiotherapist will give you some exercises to do and will give you a brochure with these exercises outlined. If you have trouble remembering the exercises you can refer to the videos that we have made of the common post-op exercises. in the first 6 weeks after your operation rest is more important than exercise.
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The one activity that I want you to avoid after latarjet surgery is an active biceps contraction as you would if you lift an object towards your head by flexing your elbow. The biceps tendon is attached to the bone block (coracoid) which I have transferred to the front of your shoulder. If you are contracting your biceps too much in the first few weeks after the surgery, it will prevent the bone block from healing to the front of your shoulder or worse still dislodge it or cause it to fracture.
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A CT scan will need to be performed after 6 weeks post-operatively. I will review the CT with you at your 6-week post-operative appointment to confirm bone healing has occurred. If the bone block has healed, then your rehabilitation programme, return to work and sports plans can be upgraded and you will be able to look at going back to work and returning to sports.

The advantages of the arthroscopic procedure area lower complication rate and an easier postoperative recovery in terms of pain and discomfort. Arthroscopic procedures typically have lower complication rates than a similar open operation.

The anatomy can be better visualised at the time of surgery and if the tear is more extensive, particularly if it extends into the posterior part of the shoulder the arthroscopic procedure allows for this to be repaired at the same time.  There are no real advantages of the open Bankart repair over the arthroscopic repair other than the relative simplicity of the procedure over the more technically demanding arthroscopic procedure.

The arthroscopic Bankart repair is performed using bone anchors that are drilled into the Glenoid. The anchors that I am currently using are bio-composite anchors. They have a crystalline structure that is eventually replaced by bone. The bone anchors have sutures attached to them that are then used to tie the torn cartilage (labrum) back to where it has torn off from the anterior Glenoid. 
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At the same time, the shoulder joint capsule that has been stretched by the dislocation is sutured to the anchors further tightening the shoulder. This is termed a capsulolabral Plication.

The arthroscopic Bankart repair is performed under a general anaesthetic, and the surgery takes about an hour. You will be in the operating theatre complex for several hours as you need to be prepared for anaesthesia and then will need to wake up from the anaesthetic. Normally patients stay one night in the hospital. They will discharge from the hospital the next day after seeing the physiotherapist and speaking to Dr Cutbush.

The shoulder may be diagnosed as suffering from impingement because, at this early stage in the disease process, the two conditions appear very similar. After some months of the capsule being inflamed, the shoulder becomes stiff. The stiffness occurs as the capsule thickens and becomes fibrotic as a response to the inflammation of the capsule. At this point, the joint is painful and stiff, which is particularly unpleasant.

Eventually, the condition resolves entirely of its own accord. However, it may take one to two years to resolve, sometimes longer. Due to the common relationship with diabetes, I recommend to patients that if they have a Frozen Shoulder or think they might, they should ask their GP about testing for diabetes. A simple, fasting blood glucose test is usually adequate.

The cause of Frozen Shoulder is unknown, and as such, there is no treatment available to cure Frozen Shoulder. Instead, treatment is aimed at dealing with the symptoms. The main symptoms of a Frozen Shoulder are pain and stiffness.

The pain of a Frozen Shoulder is due to the inflammation of the shoulder joint capsule and tends to be exacerbated by movements that stretch the capsule. For the pain, a cortisone injection placed into the shoulder joint (the glenohumeral joint, not the bursa) can be beneficial in settling down the inflammation and helping ease the pain and discomfort.

The injection contains cortisone and local anaesthetic. The local anaesthetic will ease the shoulder pain for the first few hours after the administration of the dose. This initial relief of the shoulder pain due to the local anaesthetic gives further evidence to support the diagnosis of your shoulder condition being a Frozen Shoulder.

The cortisone works by acting as an anti-inflammatory, helping to resolve the capsulitis that occurs at the beginning of the frozen shoulder condition. Cortisone is a true anti-inflammatory with potent efficacy compared to the more commonly known anti-inflammatory tablets we take, such as aspirin, which have only a weak anti-inflammatory effect.

The cortisone used is usually betamethasone (a fluorinated cortisone molecule) which is a powerful steroid medication. It is also available in tablet form and if taken for some time frequently induces complications such as weakening of the bones, increased susceptibility to infection and weight gain, among other issues. It usually takes at least several weeks to take these cortisone tablets for these complications to develop.

A single cortisone injection into the shoulder joint has a similar dose to a daily cortisone dose taken in tablet form and is unlikely to induce the complications seen with taking the tablet forms over several weeks. Usually, I recommend a single cortisone and local anaesthetic injection into the shoulder joint to start with. Occasionally, patients require more than one injection. However, I don’t recommend more than three cortisone injections into the same location in the shoulder, and I recommend that the injections are given at least a month apart.

Injections into the shoulder joint can introduce bacteria from the skin into the shoulder and in rare cases, infections have occurred following an injection. Some evidence suggests that a cortisone injection into the shoulder joint (the glenohumeral joint) not only greatly helps with the aching pain of a frozen shoulder but also reduces the length of time it takes for the condition to resolve.

Hazleman and co-authors reported in the journal Rheumatology and Physical Medicine in 1972 that patients who receive the injection earlier in the course of the disease recover more quickly.

Dias and co-authors wrote in 2005 in the British Medical Journal (BMJ)that early treatment with a steroid injection into the intra-articular GH joint may reduce synovitis, thus shortening the natural history of the disease.

Sun and co-authors published a systematic review and meta-analysis of 8 randomised controlled trials, totalling 416 patients, in 2016 in the American Journal of Sports Medicine. They concluded that pain scores and passive range of motion were improved in the first 16 weeks and that the effects of a cortisone injection may last up to 26 weeks.

I don’t recommend that patients undergo hydrodilatation when they have a cortisone injection to the glenohumeral joint for Frozen Shoulder. Hydrodilatation is where the local anaesthetic and cortisone are forcibly injected into the shoulder joint to stretch the shoulder capsule.

There is very little evidence to support giving a cortisone injection with Hydrodilatation over administering a cortisone injection on its own. Hydrodilatation is typically painful and, in my experience, too often aggravates the condition.

The stiffness in the affected Shoulder is due to significant thickening, fibrosis and contracture that occurs in the shoulder capsule.The capsule is usually a thin pliable membrane. As the capsule becomes fibrous and contracts the ball of the shoulder joint (the humeral head) becomes tightly held and unable to move in the socket of the shoulder joint (the glenoid) severely restricting the range of motion of the Shoulder.

The stiffness eventually resolves in all patients with Frozen Shoulders. Consequently, the initial recommendation to most patients is to allow it to resolve with time.

‍Surgery is discussed with patients severely affected by stiffness and unable to wait for the Shoulder to resolve on its accord. It often takes several years for the frozen Shoulder to resolve. For some people, that would mean not working or doing their normal activities for that period, which isn’t feasible for most people.

I perform arthroscopic shoulder release surgery for people that have severe stiffness due to Frozen Shoulder. I perform a complete 360° release of the shoulder capsule, releasing the ball of the shoulder joint from the socket so that the shoulder joint can move again. This surgery is effective in restoring motion to the Shoulder. Performing a 360°release of the Shoulder restores 70% to 80% of the range of motion to the shoulder immediately post-op with the remaining range of motion returning as the frozen shoulder condition eventually burns itself out. The original method of releasing a frozen shoulder was to divide only the part of the capsule that was most severely affected. The whole capsule was not released due to concern that a more extensive release might precipitate shoulder instability. Since I first started performing the more extensive 360° release, I have followed every patient I have performed the procedure on as part of an ethics-approved research project. In over 80 patients, I have not seen any complications of the procedure, and I reliably see patients regain about 70 to 80% of their range of motion immediately following the surgery. Out of all the operations I follow as part of my research interests; this operation has the highest patient-reported satisfaction scores.

Dattani and co-authors published a paper in the Bone and Joint Journal in 2013 looking at 100 patients, who had failed non-operative management, treated in the stiffness-predominant phase with an arthroscopic 360° capsular release. They reported highly significant improvement in range of movement at 6 months post-op.

Physiotherapy is a valuable treatment option for shoulder conditions. Following an arthroscopic release, I recommend that patients plan to see their physiotherapist three times a week for the first few weeks. Once the shoulder isn’t tightened up, the frequency of the physiotherapy visits can be reduced. Physiotherapy is most useful in patients with Frozen Shoulders following a surgical release or as the condition is starting to resolve. Physiotherapy is beneficial in helping to maintain a range of motion or to help encourage a range of motion to return. It is not so helpful early during a Frozen Shoulder as it is very easy to aggravate the pain and inflammation with physical exercise or stretching in the initial capsulitis phase.

Diercks and Stevens published a paper in the Journal of Shoulder and Elbow Surgery in 2004 looking at intensive physiotherapy for Frozen Shoulders. They found that intensive physiotherapy in the early stage of Frozen Shoulder appeared to prolong the natural history of the disease from 15 months to 24 months.

‍Manipulation under Anaesthesia (MUA) is where the patient is given a general anaesthetic, and then their shoulder is forced until the capsule tears. This procedure is helpful for patients with Frozen Shoulder, particularly for patients who haven’t developed a severely thickened and fibrous capsule.

However, my concern is that for patients with a severe Frozen Shoulder, this procedure requires a lot of force to get the capsule to tear. Under these conditions, it is difficult to obtain a successful release of the shoulder in all directions, because the tear is uncontrolled. Compared to a clean surgical incision of the capsule performed under direct vision at arthroscopy.

We don’t know what causes a Frozen Shoulder, but treatment is aimed at the symptoms of pain, and stiffness.

For the pain, a cortisone injection into the shoulder joint is very effective in reducing the pain and may speed up the resolution of the condition.

The stiffness will eventually resolve on its own accord. However, it takes several years for this to occur and for some people that would mean that they couldn’t work or do their usual recreational activities and sports.

In people severely affected by Frozen Shoulder, I discuss an arthroscopic release with them. In this surgery, I perform a complete 360° release of the capsule which releases the ball of the shoulder joint (the humeral head) from where the contracted capsule has rigidly held it in the socket of the shoulder joint (the glenoid) unable to move so that movement can occur again.

This reliably restores 70 to 80% of the motion to the shoulder joint immediately with the remaining movement returning as the Frozen Shoulder condition eventually burns itself out. This procedure is safe and has high patient satisfaction rates.

The post-operative recovery from an AC Joint Resection is typically rapid. A sling is not required; however, it can be used to rest the shoulder following the operation for the first few days. Physiotherapy is started immediately after the procedure.Recovery typically occurs within the first six weeks or so following the surgery.

You will normally return for a follow-up at 6weeks postoperatively. A 2-week appointment may be scheduled to check that everything is going well immediately following the surgery.