Chapter 7: Arthroscopic surgery
Arthroscopic surgery of the shoulder is still very much in its infancy, but appears to be emerging at a virtually uncontrollable rate. When discussing such a new technique, two basic questions must be asked. The first is 'what can be achieved?' The second, and far more important, is 'what should be achieved?' For the wise surgeon will realize that the mere ability to perform an operation should not be an indication for its use. This chapter aims to answer both of these questions in turn, through a review of current techniques.
At present, arthroscopic surgery of the shoulder can be considered on five planes of increasing complexity, as shown in Table 7.1.
| First generation |
Diagnostic arthroscopy Targeted biopsy Removal of loose bodies Excision of labral tears |
| Second generation |
Diagnostic arthroscopy Targeted biopsy Removal of loose bodies Excision of labral tears |
| Third generation |
Anterior reconstruction Staple Cannulated screw Rivet Suture |
| Fourth generation |
Complex reconstruction SLAP tears Inferior capsular shift Combined intracapsular / extracapsular repair |
| Fifth generation |
Complex reconstruction SLAP tears Inferior capsular shift Combined intracapsular / extracapsular repair |
Second generation surgery
Whereas first generation surgery can be performed with minimal instrumentation, second generation surgery requires powered instruments. Arthroscopic subacromial decompression (ASD) also requires an electrosurgical diathermy apparatus to speed up the procedure and control bleeding, although many surgeons make do without.
Synovectomy
Synovectomy can be performed in rheumatoid arthritis, but is technically difficult due to bleeding and the results are as yet unknown. In Ogilvie Harris' series,3 12 of 15 patients undergoing synovectomy for rheumatoid arthritis had significant benefit at 1-2 years' follow-up.
Shoulder debridement
Osteoarthritis
Debridement can be performed in patients with mild osteoarthritis, a full radius resector being used to clean up the joint generally. In 43 patients in Ogilvie Harris' study,3 13 had mild arthritis and 69 per cent of these did well compared to only 37 per cent of the 30 with severe arthritis.
Cuff tears
Most surgeons would combine debridement of a cuff tear with subacromial decompression, and results of this are given in Chapter 8. The largest series of cuff debridement without decompression was again that of Ogilvie Harris,3 who reported on 174 patients. In those patients with stage 1 impingement (tendonitis), 67 per cent were successful. However, in those patients with stage 2 (partial thickness tear) the results dropped to only 40 per cent successful and, in those with full thickness tears, the results fell even further to only 17 per cent successful results.#
Coracoacromial ligament division
Most surgeons no longer perform coracoacromial ligament division alone, but instead arthroscopic subacromial decompression. Ogilvie Harris3 published his group's results from division alone in 51 patients, 25 of whom had mechanical division and 26 electrocautery division. As only 11 of the 51 patients had a satisfactory outcome, the group concluded that this procedure should be abandoned.
Arthroscopic subacromial decompression (ASD)
This is covered in more detail in Chapter 8.
Third generation surgery
These techniques are discussed in Chapter 9.
Fifth generation surgery
Arthrodesis
Arthrodesis is technically feasible. Here, both the glenoid and humerus are burred down to subchondral bone, and percutaneous screws are placed, backed up with an external fixator. However, the only attempt to this date has been unsuccessful. Such technical feats show a lack of maturity and wisdom on the part of the surgeon.
Rotator cuff repair
Successful rotator cuff repair has been performed, but the patient selection is critical. The technique can only be performed on small rotator cuff tears. The tear is assessed and the edges are debrided. The area where the torn-off cuff should insert is then burred down until there is bleeding from the bone surface. The debrided cuff is then impaled with an arthroscopic staple, which is advanced onto the prepared bed and hammered into the humeral head. At 6 weeks the staple is retrieved arthroscopically and the cuff assessed to see if healing has occurred. If there is impingement at this stage, subacromial decompression can be carried out.
It must be stressed that this is an unproven technique at this stage with no follow up reports in the literature. The wise surgeon will await the results from those centres pioneering these techniques.