Types of arthroscopic interventions
Meniscus seam
- Cost: 80,000 - 115,000 rubles.
- Duration: 30-60 minutes
- Hospitalization: 1 day in hospital
More details
The CELT clinic performs arthroscopy of any large joints: knees, elbows, shoulders, hips, ankles, wrists. At the same time, the types of interventions are very diverse.
When pathology is detected in the ankle, wrist, elbow and hip joints, the following operations are performed:
- resection of adhesions;
- joint release;
- resection of exostoses;
- removal of chondromic bodies;
- treatment of intra-articular injuries;
- chondroplasty.
In the knee joints , in addition to the above, the following are also performed:
- resection of the damaged part of the meniscus;
- meniscal suture;
- plastic surgery of cruciate ligaments (anterior, posterior cruciate ligaments);
- plasty of the patellar retinaculum;
- mosaic chondroplasty.
Symptoms
Patients complain of pain in the front or side of the shoulder when lifting or lowering the upper limb.
This disrupts the performance of everyday functions, as discomfort makes it difficult to put on clothes and play sports. The disease gradually progresses, so at the very beginning it can occur unnoticed by the patient. Over time, the pain intensifies and significantly limits the range of motion in the shoulder. It becomes impossible to lie on the injured side, or to place your arm behind your back.
There are three stages during this disease:
1. Swelling and hemorrhage are noted in the shoulder joint. The occurrence of pain during any physical activity is typical. Occurs at a young age. The process is reversible and is treated conservatively. 2. Due to constant mechanical impact, fibrosis and tendonitis develop. This is an irreversible stage, treatment is surgical. 3. It is characterized by degenerative-dystrophic changes with rupture of the rotator cuff and the appearance of bone spurs. Occurs in older people. The stage is irreversible, treatment is surgical.
Impingement syndrome occurs not only in the shoulder, but also in the knee and hip joint. In the latter case, a collision of the femoral neck with the acetabulum occurs due to pathological growth. The causes and process of development of the disease are the same regardless of location.
With hip impingement syndrome, acute pain occurs in the groin area or the outer surface of the thigh when moving the lower limb, especially when squatting and bending. If the patellar fat pad is pinched, pain will appear in the knee area when it flexes and extends.
Shoulder joint and types of arthroscopy
Arthroscopy of the shoulder joint is considered a technically difficult intervention among orthopedic traumatologists. Not all surgeons and clinics undertake it, even in Moscow, but we have extensive experience in this area, so patients with similar pathologies often come to us. Based on the results of diagnostic arthroscopy, we determine the exact location of the pathological focus, determine what treatment tactics the disease requires, and, if necessary, take biological material for laboratory testing.
Currently, we work with almost the full range of arthroscopic surgeries for a wide variety of pathologies of the shoulder joint:
- plastic surgery for injuries localized in the area of attachment of the tendon of the long head of the biceps;
- plastic surgery of various types of tendon ruptures, including chronic rupture injuries;
- removal of calcifications;
- dissection of adhesions;
- decompression of the suprascapular nerve;
- chondroplasty;
- elimination of joint instability/hypermobility;
- plastic labrum;
- osteoplastic surgery.
There are certain indications for arthroscopic interventions on the shoulder joint. To fully diagnose shoulder joint damage, an MRI examination is performed. It is important that the radiology specialists conducting the examination have sufficient experience in conducting examinations for such pathologies. The following are the main pathologies for which surgery is indicated:
- labrum injuries: Bankart injury, slap injury;
- damage or rupture of the rotator cuff;
- impingement syndrome, subacromial bursitis, supraspinatus tendonitis;
- limited mobility of the shoulder joint for no apparent reason;
- various shoulder injuries that are accompanied by tendon rupture.
Labrum injuries: Bankart injury, SLAP injury
Treatment of shoulder instability, Bankart injury
- Cost: 120,000 - 160,000 rubles.
- Duration: 30-90 minutes
- Hospitalization: 1-2 days in hospital
More details
Firm fixation of the labrum and joint capsule to the socket (glenoid) plays a key role in stabilizing the shoulder joint. A tear of the labrum in the anterior region is called a Bankart injury, and a tear in the area of the biceps tendon insertion is called a SLAP injury. There are several types of such damage. These pathologies often cause chronic pain and lead to instability of the shoulder joint or the formation of habitual shoulder dislocation. Only surgery can correct the situation.
The most effective treatment methods:
Arthroscopic refixation of the labrum (in case of Bankart injury, slap injury), tenodesis. The torn section of the articular labrum is fixed to the edge of the glenoid cavity using special anchors - absorbable or titanium.
Habitual shoulder dislocation, shoulder instability
habitual shoulder dislocation , can form . This is a condition in which joint dislocations occur with any minor injury or even sudden movement. The cause may be damage to the capsule and labrum of the joint, or defects in the articular surface of the scapula. Very often, a bone defect known as a Hill-Sachs lesion forms on the back of the humeral head.
The most effective treatment methods:
Arthroscopic stabilization of the shoulder joint. The torn parts of the labrum are fixed using anchors, and the joint capsule is additionally tightened.
Bone grafting (Latarjet operation). A part of the coracoid process, with the muscles attached to it, is transplanted into the defect area on the anterior surface of the glenoid cavity; the displaced fragment is fixed with screws.
Combined operations. Sometimes combined operations are used, when additional fixation of the joint capsule (reimplisage) in the area of the bone defect can be performed (Hill-Sachs).
Damage to the rotator cuff
Around the head of the humerus are several tendons that form the rotator cuff or rotator cuff. The cuff consists of the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis muscles of the shoulder. These muscles provide both stability of the humeral head, pressing it against the glenoid cavity during abduction of the arm (initial phase) and rotation of the shoulder inward and outward. If the rotator cuff tendons (one or more) are damaged, the mechanics of the shoulder joint are disrupted, mobility restrictions occur, and pain occurs. abduction of the hand.
In case of complete tendon rupture, surgical treatment is performed - arthroscopically or minimally invasively.
The most effective treatment methods:
Rotator cuff repair
- Cost: 130,000 - 170,000 rubles.
- Duration: 30-90 minutes
- Hospitalization: 1-2 days in hospital
More details
Plasty of the rotator cuff . Arthroscopic suture or refixation of the rotator cuff tendons . The damaged tendon is isolated, stitched and fixed (refixed) to the attachment point on the head of the humerus using special anchors with a diameter of 2.5-5.5 mm and high-strength threads.
Impingement syndrome, subacromial bursitis, supraspinatus tendonitis
Part of the rotator cuff tendons passes through a narrow space formed by the head of the humerus, the tuberosities of the humerus, the inferior surface of the acromial process of the scapula, the coracoid process and the coracoacromial ligament. This space is called subacromial. This area plays an important role in arm movement, as a decrease in this space causes compression when the arm is abducted, pain and limited mobility. A typical symptom is pain when the arm is abducted 60-120 degrees.
The narrowing of the space may be a consequence of deformation of bone structures, the formation of calcifications, scarring or degenerative changes in the tendons, or bursitis.
The most effective treatment methods:
Subacromial decompression. Using special arthroscopic equipment, altered soft tissues and bursa in the subacromial space are removed; if necessary, marginal resection of the lower surface of the acromial process or the edge of the clavicle is performed.
Development mechanism
Mechanism of development
The shoulder joint is one of the most complex structures of the human musculoskeletal system. The glenoid cavity is formed by the clavicle and the acromion process of the scapula, and contains the head of the humerus.
The spherical shape of the joint provides a significant range of movements of the upper limb in various planes, including rotation (shoulder rotation). Increasing the depth of the glenoid cavity and increasing the stability of the shoulder joint is provided by a lip made of connective tissue localized around the cavity, as well as a cuff formed from the glenohumeral ligaments and muscles that provide rotation of the shoulder (rotators).
Under the acromial process of the scapula there is a muscle located, which is one of the most vulnerable structures of the shoulder. The result of its damage is rotator cuff syndrome or impingement syndrome.
How is shoulder arthroscopy performed?
We perform each intervention on the shoulder joint only according to a specific scheme, which is considered the best option for the patient not only in terms of efficiency, but also comfort. But before the patient receives an appointment for such an intervention, we must study all the examination results available to him and collect the necessary preoperative set of tests.
Arthroscopy is performed under general endotracheal anesthesia.
The following positions are possible for the patient on the operating table:
- Side position. The arm is fixed to the shoulder axis through a special block at an angle with a load of 3-4 kg. The patient himself at this moment is located, lying on his healthy side.
- Beach chair position. The patient is positioned on the operating table in a “semi-sitting” position, while the arm is fixed with a special device that allows the limb to be fixed in any given position.
Once the shoulder joint is fixed in the desired position, the operation begins:
- the skin is treated with a disinfectant;
- Through an incision 5-7 mm long, an arthroscope with a video camera with a diameter of 4.2 mm is inserted into the joint cavity. The joint cavity is filled with saline solution supplied by a pump (for better visualization);
- a second incision is made, and a cannula for a surgical instrument is inserted into it if medical procedures are necessary. If necessary, 1-2 additional arthroscopic ports are installed.
And then everything depends on what results will be obtained during the examination of the joint. Thanks to modern equipment, the surgeon can see the image of the joint on the monitor, assess the condition of tissues, tendons, cartilage and bones and immediately carry out the necessary treatment.
Diagnostics
Diagnostics
Additionally, to identify the disease and differentiate it from other pathological conditions, the Neer impingement test is performed, the essence of which is to inject lidocaine into the subacromial process bursa. If compartment syndrome is present, pain after injection is reduced.
Benefits of Shoulder Arthroscopy
Here are the main advantages of arthroscopy over traditional “open” surgery that patients usually pay attention to:
- the patient is in the inpatient department of a medical institution for a short period of time: a maximum of 3 days, but most often the period is limited to 24 hours;
- During the operation, soft tissues are minimally injured, since incisions only 5-7 mm long are used;
- The cost of arthroscopy is quite adequate and affordable for absolutely all patients.
A more accurate diagnostic examination of the joint simply does not exist in medicine today! Arthroscopy does not allow errors, and at the same time it is possible to immediately carry out the necessary medical manipulations.
Treatment
Treatment depends on the patient's age, activity level, and general health. The goal of treatment is to reduce pain and restore function. The first line of treatment is conservative treatment, which should be followed for at least a year until joint function improves and returns. Surgery should only be considered if the patient does not respond to comprehensive nonoperative treatment.
Conservative treatment consists of rest, reduction of activities that trigger the syndrome, such as movements with the arms above the head, NSAIDs to relieve pain and swelling, physical therapy and injections in the subacromial area. Cortisone is often prescribed for its anti-inflammatory and pain-relieving properties, but should be used with caution and avoided if you have pain due to tendon problems.
There is no convincing evidence that surgery is more effective than conservative treatment. Surgery is indicated only if it is not possible to reduce pain and restore function with a conservative method. Depending on the nature and severity of the injury, certain surgical techniques are used, but there are no clear preferences among them.
Surgery
Surgical repair of torn tissue, especially the supraspinatus muscle, long head of the biceps, or joint capsule. It should be kept in mind that a rotator cuff tear is not an indication for surgery.
- Bursectomy or removal of the subacromial bursa of the shoulder joint.
- Subacromial decompression to increase the subacromial space by removing bone spurs or protrusions on the underside of the acromion or coracoacromial ligament.
- Acromioplasty to increase the subacromial space by removing part of the acromion.
- Arthroscopic acromioplasty is a less invasive procedure than open surgery and also requires less recovery time.
Current research suggests that there is no difference between open surgery and arthroscopic surgery in terms of shoulder function and complications. Open bunionectomy is likely to produce the same clinical outcome as bunionectomy with acromioplasty.
Physical therapy
Case Study of the Shoulder Injury Patient
There is compelling evidence that supervised nonoperative rehabilitation reduces shoulder pain and improves joint function. Unless the patient has a rupture that requires surgical repair, the first line of therapy should be conservative treatment (level of evidence: 4).
Read about the most effective exercises for the subscapularis muscle here.
Physical therapy includes:
- RICE therapy (rest, cold, elevation and compression) – used in the acute phase to reduce pain and swelling.
- Stabilization and postural correction exercises.
- Mobility exercises.
- Exercises to develop strength.
- Stretching, including capsular stretching.
- Manual therapy techniques.
- Acupuncture.
- Electrical stimulation.
- Ultrasound.
- Low-level laser therapy has a positive effect on all symptoms except muscle strength (evidence level 1b).
- Corticosteroid injections in the first 8 weeks.
- High-intensity extracorporeal shock wave therapy is not recommended in the acute phase. High-intensity shockwave therapy is more effective than low-intensity shockwave therapy (level of evidence: 2a).
In the acute period, therapy should be aimed primarily at reducing pain, after which you can move on to strength exercises. This sequence is necessary to avoid injury in the future. Exercise on its own has proven to be effective, but when combined with manual therapy, it can further improve muscle strength. Exercise is the cornerstone of treatment for subacromial impingement, but studies have found no difference between exercise at home and in a clinic (Evidence Level 1b).
Strength training should include (level of evidence 1a):
- Strengthening the rotator cuff: external rotation exercises using expanders, horizontal abduction.
- Strengthening the lower and middle portions of the trapezius muscle (push-ups, unilateral scapular rotations, bilateral external shoulder rotations, unilateral scapular depression).
- Strengthening the lower trapezius muscle is an important part of physical therapy. In patients with subacromial impingement, this portion is weaker than the middle and superior portions of the muscle (LE: 3b).
A specific rehabilitation program that includes eccentric rotator cuff strengthening exercises and eccentric and concentric exercises for the scapular stabilizers has been shown to reduce pain and improve shoulder function (Evidence Level 1b).
Soft tissue mobilization has been shown to be effective in normalizing muscle spasm and other tissue dysfunctions. Joint mobilizations are also effective for SBS to restore range of motion (LE: 3b).
The combination of physical therapy and surgery produces better clinical outcomes than physical therapy alone (level of evidence: 2b).
The movements of the rotator cuff that need to be especially carefully worked on during SBS are internal and external rotation, as well as abduction. It is important to remember that the rotator cuff not only performs a rotation function, but also stabilizes the shoulder joint. Thus, the stronger the rotator cuff muscles, the less pinching. To begin with, it is recommended to perform 10-40 repetitions 3-5 times a week and use additional weights (4-8 kg).
Patients with stage two impingement may require a formal physical therapy program. Isometric stretching can be helpful to restore range of motion. It is also recommended to perform isotonic exercises with a fixed rather than variable weight. Therefore, shoulder exercises in this case are best performed with a stable weight rather than with rubber bands. The emphasis is on repetitions rather than weight, and the exercises use light weights. Sports-specific techniques are sometimes useful, especially to improve movements such as throwing, serving, or swimming movements. In addition, physical therapy techniques such as electrogalvanic stimulation, ultrasound therapy, and transverse friction massage may be helpful (Evidence Level 2b).
Possible contraindications and complications
It is important to note that arthroscopy is not performed for the following concomitant pathologies:
- skin rashes of the pustular type in the shoulder area;
- infectious diseases with localization of the focus in the shoulder joint;
- elevated body temperature, regardless of cause;
- previously diagnosed ankylosis;
- intolerance to painkillers/anesthetics.
Any surgical intervention comes with a risk of complications. But the degree of this risk is important. With the artoscopy method, these are minor complications that can only cause some discomfort to the patient. After joint arthroscopy, swelling and redness of the soft tissues may be observed in the areas where punctures and incisions were made. However, they disappear literally after 3-5 days.
It is extremely rare that deep veins may be damaged during surgery, but this is not dangerous for the patient. We are always able to quickly provide the necessary assistance.
Rehabilitation.
Traumatization of the tissues surrounding the joint during arthroscopy is minimal, due to this, peripheral edema and restriction in movement after surgery are less pronounced and “go away” much faster than after open operations. The likelihood of infectious complications is much lower than with arthrotomy, so antibiotics are prescribed extremely rarely. In the early period, cold is applied to the joint, and if necessary, the patient is prescribed anti-inflammatory painkillers. After the stitches are removed, a course of rehabilitation measures is prescribed for a speedy recovery and to avoid possible complications.
The rehabilitation doctor selects an individual, comfortable and most effective program, which may include:
- Massotherapy.
- Physiotherapy.
- Kinesiotherapy.
- Taping, use of fixatives.
- Mechanotherapy.
If all recommendations are followed, a return to active life and professional sports is possible within 1-2 months.
Return to section: Joint arthroscopy
Recovery period
In the first days after arthroscopy on the shoulder joint, symptomatic therapy and dressings are carried out under the supervision of the attending physician. The limb is fixed using a special orthotic bandage for 3-4 weeks after surgery. At the same time, rehabilitation treatment begins.
The rehabilitation course consists of carrying out a set of rehabilitation measures developed by specialists:
- specialized course of physical therapy for up to 3-4 months;
- use of devices for passive development of movements in the shoulder joint (“Artromot”);
- limiting sports and heavy physical activity for up to 4-6 months.
We perform all the joint manipulations listed in the article in the operating room of the CELT clinic, specially equipped for arthroscopic operations. Arthroscopy is often the only real opportunity to restore joint health, and, therefore, restore quality of life. If problems with the shoulder joints are relevant for you, come for a consultation with the author of the article, an orthopedic traumatologist with extensive experience in arthroscopic operations.
Of course, the best operation is the one that does not need to be done, but even in difficult cases we will try to help you!
Impingement syndrome of the shoulder joint - treatment without surgery
Conservative therapy is prescribed for minor changes in the structures of the shoulder and mild compression of the subacromial muscle. It includes several activities, which include:
- Providing functional rest for the joint.
- The use of non-steroidal anti-inflammatory drugs to reduce the severity of inflammation in tissues.
- Direct injection of glucocorticosteroids (hormonal drugs with a pronounced anti-inflammatory effect) into the area of the acromion process, which is prescribed in a short course no more than once a week.
- Physiotherapeutic procedures, which include magnetic therapy, ozokerite, mud baths, electrophoresis with anti-inflammatory drugs.
- Therapeutic exercise (PT), which is carried out to gradually restore the functional state of the shoulder joint, as well as reduce the degree of compression of the subacromial muscle.
Conservative treatment can be prescribed as monotherapy or to prepare the patient for surgery.