Shoulder

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Introduction

Shoulder joint replacement, also known as shoulder arthroplasty, is a surgical procedure aimed at alleviating pain and restoring function in shoulders severely affected by arthritis or other degenerative conditions. The shoulder joint, a complex structure comprising the humerus, scapula, and clavicle, is susceptible to wear and tear over time, leading to debilitating conditions that impede daily activities. When conservative treatments fail to provide relief, shoulder joint replacement emerges as a viable option to enhance quality of life and regain mobility.

Common Causes and Treatment

Arthritis, particularly osteoarthritis, stands as one of the leading causes necessitating shoulder joint replacement. Additionally, conditions like rheumatoid arthritis, post-traumatic arthritis resulting from injury, or avascular necrosis, where the blood supply to the bone is compromised, can also lead to significant joint damage. These conditions erode the cartilage that cushions the bones of the shoulder joint, resulting in debilitating pain, stiffness, and restricted range of motion. Conservative treatments such as medication, physical therapy, and injections may provide temporary relief, but when these measures prove ineffective, shoulder joint replacement becomes a consideration.

Surgery and Recovery Post-Surgery

Shoulder joint replacement surgery involves the removal of damaged portions of the shoulder joint and their replacement with artificial components, typically crafted from metal and plastic. This procedure often entails replacing both the humeral head (the ball-shaped top of the upper arm bone) and the glenoid (the socket of the shoulder blade) with prosthetic implants. The surgery aims to recreate the natural structure of the shoulder joint, thereby restoring its function and relieving pain. Post-surgery, patients undergo a period of recovery and rehabilitation, guided by physiotherapy, to regain strength, range of motion, and functionality in the shoulder. While recovery times vary, most patients can expect significant improvement in mobility and pain relief, enabling them to resume daily activities and enjoy an improved quality of life.

Frozen shoulder, medically known as adhesive capsulitis, manifests as stiffness and pain in the shoulder joint, often without a history of injury. This condition can develop following trauma, shoulder surgery, or as a result of certain medical conditions, leading to excessive scar tissue formation and restricted motion. While its exact cause remains unclear, frozen shoulder is linked to various underlying health issues such as diabetes, thyroid disease, heart disease, and Parkinson’s disease. With an incidence rate of 2% in the general population, it predominantly affects individuals aged 40 to 60 years, with a higher prevalence among women than men.

Recognising Symptoms

The hallmark symptom of frozen shoulder is a dull, persistent ache in the shoulder joint, which may radiate towards the elbow and around the shoulder blade (scapula). This discomfort tends to worsen with movement and can be particularly troublesome at rest, often disrupting sleep and affecting daily activities. As the condition progresses, the shoulder gradually becomes stiffer, further limiting its range of motion and exacerbating the pain. These symptoms typically develop over time and may persist for several months or even years if left untreated.

Effective Treatment Approaches

Treating a frozen shoulder typically begins with managing pain and preserving range of motion, often through non-invasive methods. Pain relief measures like regular intake of paracetamol provide a safe starting point, complemented by simple anti-inflammatory medications such as ibuprofen if necessary. For more targeted relief, steroid injections directly into the affected joint can serve as potent anti-inflammatories. Physiotherapy plays a vital role in restoring shoulder movement, employing a regimen of stretching and strength exercises. Applying heat to the shoulder before exercise sessions can help alleviate stiffness and improve joint flexibility. These conservative treatments yield positive outcomes for over 90% of patients, gradually alleviating symptoms and enhancing shoulder function.

Surgery

In rare instances where conservative measures fail to yield improvement, surgical intervention may be considered. Surgical options like manipulation under anesthesia and arthroscopic capsular release are reserved for cases where stiffness persists despite anti-inflammatory medications and physiotherapy. However, it's crucial to avoid surgical interventions during the inflammatory (freezing) stage, as they may exacerbate the condition. These procedures aim to break up scar tissue and release tightness in the joint capsule, facilitating improved shoulder mobility and function. While surgical treatment is uncommon, it can be effective in providing relief for individuals with persistent frozen shoulder symptoms.

Shoulder rotator cuff tears are common injuries involving damage to the group of muscles and tendons that stabilise the shoulder joint. These tears can occur gradually over time due to wear and tear or suddenly from a traumatic injury. Common causes include repetitive overhead motions, aging, degenerative changes, and acute trauma such as a fall or lifting heavy objects. Rotator cuff tears can result in pain, weakness, and limited range of motion in the affected shoulder, impacting daily activities and quality of life.

Treatment Options and Surgical Intervention

Treatment for rotator cuff tears often begins with conservative measures aimed at reducing pain and improving function. Non-surgical approaches may include rest, activity modification, physical therapy to strengthen the surrounding muscles, and anti-inflammatory medications or steroid injections to alleviate pain and inflammation. However, for larger tears or cases where conservative methods fail to provide relief, surgical intervention may be recommended. Surgery typically involves repairing the torn tendon through arthroscopic or open procedures, depending on the severity and location of the tear. During surgery, the surgeon may also address any associated issues, such as bone spurs or inflammation in the shoulder joint.

Post-Surgery Recovery and Rehabilitation

Following rotator cuff repair surgery, a structured rehabilitation program is essential to optimise recovery and restore shoulder function. Initially, patients may wear a sling to protect the repair and limit movement. Physical therapy exercises focus on gradually increasing range of motion, strengthening the shoulder muscles, and improving flexibility. The timeline for recovery varies depending on the extent of the tear, surgical technique, and individual factors. Full recovery may take several months, during which patients are advised to avoid lifting heavy objects or engaging in strenuous activities. With proper rehabilitation and adherence to post-operative guidelines, many individuals can achieve significant improvement in shoulder function and return to their normal activities.

Shoulder arthroscopy is typically conducted under general anaesthesia, allowing for a comprehensive examination and potential repair of the shoulder joint. Through a small incision, a miniature camera is inserted into the joint, enabling visualisation and treatment of shoulder tissues. In cases requiring repair, additional incisions, usually 3-4, may be necessary to facilitate the surgical intervention.

Surgery for Shoulder Impingement

This procedure focuses on addressing impingement-related issues such as inflamed tissue (bursitis) above the rotator cuff tendons and smoothing out any sharp bone spurs that may be causing friction. By alleviating these impingement factors, the aim is to reduce pain and restore optimal shoulder function.

Surgery for AC Joint Arthritis

For individuals with arthritis affecting the acromioclavicular (AC) joint, the arthritic portion of the collarbone is surgically removed. This intervention aims to alleviate pain and discomfort associated with AC joint arthritis, thereby enhancing the patient's overall quality of life.

Surgery for Shoulder Instability

In cases of shoulder instability, the procedure involves reattaching torn cartilage (labrum) to the shoulder socket's edge and tightening stretched ligaments. The primary goal of this surgical intervention is to stabilize the shoulder joint and prevent recurrent dislocations.

Following the completion of the surgical procedure, the incisions are closed with stitches, and appropriate dressings are applied. Patients typically receive post-operative care instructions, including the use of a sling to support the shoulder/arm during the initial recovery phase. Imaging of the procedure may be recorded for review and discussion with the patient once they have recovered from anesthesia.

Anatomy and Mechanism

The shoulder joint, characterised by its shallow ball and socket structure, facilitates an extensive range of motion but is inherently prone to instability. Its stability is reinforced by the labrum, a rim of fibrocartilage that deepens the socket, along with ligaments and rotator cuff muscles. Dislocation occurs when the humerus (ball) slips out of the glenoid (socket), either partially (subluxation) or fully. Following the initial dislocation, tears in the labrum and ligaments increase the risk of recurrent instability, particularly in individuals under 30 years of age.

Treatment of Recurrent Shoulder Instability: Surgical Intervention

For individuals experiencing recurrent shoulder instability after traumatic dislocation, surgical repair of torn labrum and ligaments is a common and effective approach. Keyhole (arthroscopic) surgery is often utilized, boasting high success rates with modern techniques. During the procedure, the torn labrum is reattached to the socket's edge, and ligaments are tightened using suture anchors inserted into the glenoid.

Post-Surgery Recovery 

Recovery following surgical intervention typically involves a one-night hospital stay and six weeks of immobilisation in a sling. Most patients can resume driving after 6 to 8 weeks, with rehabilitation guidelines provided for physiotherapy. Return to sports activities is generally feasible around the six-month mark. Atraumatic shoulder instability, less common than traumatic instability, often requires physiotherapy without surgical intervention, as there is typically no labral tear involved.