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21st Century Shoulder Surgery
Until recently the shoulder had been the forgotten joint. Over the last decade there have been major advances in understanding, diagnosing and treating the many arthritic, traumatic and sports injuries that effect it. In this article we will cover some of the common conditions and what can be done for them.
Frozen Shoulder
 Although this is a very common condition it is misdiagnosed three times out of four, meaning an awful lot of people have it who have been told they don't and vice versa. In fact, the diagnosis is straight forward. The patient cannot move their shoulder and the examiner cannot move it for them. But because arthritis presents in exactly the same way, they must have a normal x-ray to exclude it being that condition.
There are two ways to treat a frozen shoulder. Left alone it will defrost by itself but that can take 18 months on average. The alternative, if the patient wants a rapid return to a pain-free shoulder, is a manipulation under inter-scalene block and general anaesthetic.
There are a few myths about frozen shoulder that we need to explode. Firstly; physiotherapy makes absolutely no difference and, these days, few physios will treat it. It is however, essential after the shoulder has defrosted, whether naturally, or with my helping hand. Secondly; steroid injections may help the pain temporarily but will not cure the condition. Many patients tell me of friends whose frozen shoulder was cured by an injection but I'm afraid that means their initial diagnosis was wrong and they actually had tendonitis!
So, if the patient has limitation in passive movement, especially external rotation, and their x-ray is normal then they have a frozen shoulder.
Dislocation
 The shoulder is a naturally unstable joint consisting of a big ball resting precariously on a smallsocket - rather like a golfball on a golf-tee. Other structures, including the labrum and the rotator cuff, help to hold the humeral head where it's meant to be.
In a traumatic dislocation, the ball shoots forward tearing the labrum off the front of the glenoid leaving a defect that may be a cause of recurrent instability. This is particularly true in the young where the redislocation rate can be 80% and in this group surgical repair is advocated. The decision is less clear cut in the older patient where the redislocation rate drops significantly. For a first time dislocation in a 40 year old the treatment is rehabilitation under the supervision of a sports physiotherapist giving them the chance to recover a normal shoulder without recourse to an operation.
If surgery is required then the shoulder is stabilised arthroscopically reattaching the labrum and retensioning the stretched anterior capsule. This operation - a Bankart Repair - results in a full-range of pain-free movement and confidence in the shoulder.
Some shoulders dislocate or sub-lux without any particular trauma and this can be a difficult condition to treat. Surgery is usually not the answer but rehabilitation using specialist techniques such as bio-feedback should result in the patient regaining control of their shoulder.
Today we do not let patients 'earn' their operation by letting them suffer multiple dislocations. The young ones should be offered the option after one event and the older patient after two.
Rotator Cuff Tendonitis
 The rotator cuff islder upwards, inwards and outwards. They run in a narrow space underneath the acromion so any condition that thickens the tendon or narrows the subacromial space will cause the two to rub or 'impinge' against each other.
The patient may have a structurally normal shoulder and do something abnormal with it - such as paint the ceilings, or have a structurally abnormal shoulder (such as a curved or hooked acromion) in which case norm made up of the tendons that move the shoual activities will cause problems.
The history is of catching pain in certain positions and it is often worse at night. Unlike frozen shoulder, the movements are normal (except putting their hand up behind their back) but are painful. Again, x-rays are essential as they give a good indication as to whether the situation will resolve with physiotherapy and a steroid injection or may require surgery.
A well placed injection into the sub-acromial space can be curative and should be followed up with physiotherapy. If it recurs within a few months then surgery is an option because repeated injections will start to damage the tendon.
Rotator-cuff tendonitis that hasn't settled with conservative measures can be treated with an Arthroscopic Subacromial Decompression. In this procedure more space is created for the inflammed tendon to run in by shaving away bone from the underside of the acromion. It is a very successful operation but it usually takes at least 3 months to recover fully from it. This is a common condition in the middle aged patient but, once diagnosed, can be successfully resolved with physiotherapy and an injection or by an arthroscopic decompression.
Arthritis
 Gleno-humeral arthritis is a much more common condition than was generally thought. Part of the problem is that many elderly patients with a stiff painful shoulder are assumed to have a frozen shoulder when, in fact, the joint is worn out.
Once again the good old-fashioned x-ray tells the story and will show the classic signs of joint-space loss and osteophytes.
Shoulder replacements have evolved dramatically in the last 15 years and now provide consistently good results in relieving pain and recovering function. One of the best available is the uncemented resurfacing implant designed by the UK surgeon Steve Copeland. This simple design accurately resurfaces the worn out humeral head with a smooth metal one in the anatomically correct position.
An arthritic joint can also have an associated massive rotator cuff tear resulting in a very painful and functionally useless shoulder. In this situation a traditional shoulder replacement, whilst helping with pain, will not recover function. This disabling condition - called Cuff Tear Arthritis - can now be successfully treated with a relatively new design that compensates for the absence of the tendons that normally move the joint. I have been using the Reverse Geometry Prosthesis for 4 years with excellent results giving almost miraculous functional recovery to patients who were severely disabled.
 When an elderly patient presents with a stiff and painful knee or hip, the immediate thought is "this is likely to be arthritis." When an elderly patient presents with a stiff and painful shoulder the same thought should come first "this is likely to be arthritis". And a modern shoulder replacement is an excellent treatment.
When the shoulder is doing it's job properly we don't give it a second thought. As soon as it starts to go wrong it rapidly becomes clear just how important it is. Advances in understanding, investigating and treating these conditions, coupled with surgical innovation and new implants means that no-one needs to suffer a painful shoulder. |
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