I need shoulder surgery. What should I consider and are there alternatives?

Many surgeries have been developed to repair the muscles, connective tissues, or damaged joints that can arise from traumatic or overuse injuries to the shoulder. These are often extremely common injuries that may be helped with physiotherapy or for more chronic conditions may require medical intervention. Although not an exhaustive list, here are some of the most common significant shoulder problems with possible treatment pathways and estimated recovery times. 

Rotator Cuff Repairs

 

The rotator cuff is a group of tendons and muscles in the shoulder that helps you lift and rotate your arm and also keeps the shoulder joint in place. Sometimes these rotator cuff tendons tear or get pinched by the bones surrounding them.

An injury can occur from a sudden fall on the arm, lifting something heavy, or wear and tear over time. You are more likely to cause damage if you have a job where you repeatedly move the arm in a certain way over and over such as a painter, carpenter or athlete.

Other causes of damage to the rotator cuff include slouching or chronically pushing the head forward. As you age, the rotator cuff can be irritated or pinched by calcium deposits in the shoulder area or bone spurs due to arthritis. These rotator cuff injuries can vary and be inflamed from overuse or partially or fully torn.

Home care such as rest and icing, painkillers, and physio should always be considered first when dealing with the rotator cuff but surgery could be the answer if the pain doesn’t go away or improve after six to twelve months. Surgery is also considered if all strength has been lost from the shoulder area and it’s painful to move, if the arms cannot be raised or lift, and if there is a clicking or popping sound. Also if there is an actual tear in the rotator cuff tendon and the patient relies on shoulder strength and activity for either their employment or to participate in sports.

The surgery is designed first and foremost to relieve pain, and then restore function to the shoulder. If surgery is delayed the issue can become more serious and lead to problems such as frozen shoulder or arthritis.

Common types of rotator cuff surgery are- Arthroscopic repair – after making 1/2 cut in the skin, the surgeon will insert a tiny camera called an arthroscope and specialised instruments into the shoulder. This allows the surgeon to see which parts of the rotator cuff is damaged and how to repair them. The surgeon will use the instruments to reattach the tendon to the bone.

Once the tendon is in the right place, the surgeon will attach it with sutures. Often surgeons will use small rivers called suture anchors. These rivets may be made of metal or a material that eventually dissolved. The rivets do not need to be removed. The sutures attach to the rivets, reattaching the tendons to the bone from where it was torn.

Open tendon repair -historically, this was the first technique used to repair the rotator cuff and has been the most traditional form of surgery. If the tear is large and complex, this is the method the surgeon will choose. A large incision is made in the shoulder, then the shoulder muscle is detached so the surgeon has direct access to the tendon. The incision could be 2.5 to 4 inches long for an open repair or 1.5 to 2 inches for a mini open repair. Direct access is needed should the tendon or shoulder need replacing. Both of these surgeries are done under general anaesthesia or a regional block which allows the patient to be awake while the arm and shoulder stay numb.

Open surgery, mini open surgery, or an arthroscopy might be necessary if the surgeon wants to remove calcium deposits or a bone spur. A bone spur is a bony growth that can press on nearby ligaments, nerves or tendons causing severe pain. Bone spurs often develop as people age.

Rotator cuff surgery is major surgery and there are risks involved such as infection, nerve damage and excessive bleeding. In rare occasions, patients may also have an allergic reaction to the anaesthetic or suffer from breathing problems. Patients who smoke, who are over 65, who have larger tears or have shoulders which are already weak will need a longer time period to heal.

The shoulder will still be painful post surgery and in recovery, and will be extremely stiff due to the lack of movement. After surgery it is normal to keep the arm in a sling for 4-6 weeks and wear a shoulder immobiliser strap wrapped around the chest. This protects the shoulder by holding it in its place.

It takes the repaired rotator cuff tendons about 6 weeks to heal to the bone, 3 months to form a relatively strong attachment to the bone, and 6-9 months before the tendon is completely healed to the bone. Most patients will take 9 months before the shoulder feels normal and there will continue to be pain and soreness for several months.

The chances of surgery reducing and eliminating shoulder pain is very good, however surgery may not restore the shoulders full strength. Time and physiotherapy will regain function but there may still be some weakness,stiffness and chronic pain. It will take a few months before sport can be played and other activities that require shoulder strength and a full range of motion can be performed.

Another complication can also arise that not all tendons heal back to the bone after surgery, some do not heal completely and some do not heal at all. Large tendons can have far too much extensive damage to heal.

Once a tendon has failed an attempted surgical repair, the odds are that it will be difficult to repair again and to get it to heal. In some cases, the tear may be small enough after failed surgery to be repaired again, but the larger it is the more unlikely it will be successful. In most cases a second attempt at repairing a tendon will not be successful.

The operation can fail not due to bad surgery or bad aftercare and therapy but that the reality is that the surgery is not perfect and not all tendons will and can heal with surgery.

 

Shoulder Replacements

Shoulder replacements for patients with rotator cuff tears can be successful. Typically shoulder replacements are reserved for patients with torn rotator cuffs who also have arthritis of the shoulder joint. Replacements are not often used for patients who just have a loss of motion alone.

Different types of shoulder replacements are available for patients with arthritis and painful rotator cuff tears. A replacement is needed for severe arthritis or a fracture in the shoulder joint. Each type has its advantages and disadvantages depending on the age of the patient, the activity level and the amount of damage.

Shoulder replacement surgery involves removing damaged areas of the shoulder and replacing it with artificial parts. The procedure is performed to relieve pain and improve mobility.

Conditions leading to shoulder replacements include Osteoarthritis, rheumatoid arthritis, avascular necrosis ( loss of blood to the bone) or a broken shoulder. It is used for patients who are suffering weakness and a loss of motion in the shoulder as well as severe pain even when resting or sleeping or taking medication.

Surgery would be less successful for people with diabetes, depression, obesity, or Parkinson disease.

In the operation, the orthopaedic surgeon will replace the natural bone in the ball and socket of the shoulder joint with a material that could be metal or plastic. It is major surgery which will keep the patient in hospital for several days and will also require physical therapy.

Total Shoulder Replacement – this is the most common type of replacement. It replaces the ball at the top of the humerus with a metal ball which gets attached to the remaining bone. The socket then gets covered with a new plastic surface.

Partial Shoulder Replacement- where only the ball gets replaced

Reverse Shoulder Replacement- this is usually performed when the patient has a torn rotator cuff and also if another shoulder replacement surgery failed. The metal ball is attached to the shoulder bones and a socket is implanted at the top of the arm.

The operation will require a hospital stay of up to 5 days depending on your general health and recovery. The operation will require a local anaesthetic and painkillers. Fine tubes will run out from the wound which drain fluids but these will be removed after a day or two. The patient will be gotten out of bed the next day and physiotherapy will commence as soon as possible.

It usually takes 3 – 6 months to make a full recovery from a shoulder replacement. The arm will be in a sling for up to 4 weeks, especially during the night and it will also take a few weeks before the patient can return to simple everyday tasks like washing and dressing. There will be no heavy lifting or sporting activities for up to 6 months.

There, of course, are side effects and complications that can result from surgery such as continuing discomfort and pain, difficulty in movement,numbness around the scar, swelling fingers and numbness and tingling in the arms and fingers. The shoulder can also suffer from instability and dislocation, infection, loosening of the replacement parts, especially the new socket part of the shoulder and even the fracture of the upper arm bone during or after surgery. There can be damage to the nerves,muscles, and blood vessels. In some cases complications can lead to further shoulder surgery.

There are of course alternatives to surgery- Steroid injections, non steroidal anti inflammatory medicines or physiotherapy. Physio can help towards getting a range of motions back, strengthening the shoulder muscles, improving sitting standing and sleeping positions, learning to carry objects, using ice and heat, and allowing the patient to keep moving and return to regular activities.

Minimally Invasive Regenerative Treatment

There are also alternatives to steroid injections and joint replacement such as minimally invasive regenerative treatment. This can help with both rotator cuff issues and arthritis.

Platelet-Rich Plasma (PRP) therapy is an effective and researched procedure that provides a strong alternative to surgery. It takes advantage of the bloods natural healing properties to both reduce pain and improve joint function. It uses a specially concentrated dosage of platelets prepared from the patients blood to repair damaged cartilage,tendons,ligaments,muscle and bone. Treatment is through an injection – 2-6 injections only at weekly intervals. Patients usually see their symptoms improve within four to six weeks of having the injections. PRP is a safe treatment option, which, because your own blood is used, carries no risk of allergic reaction.

Activated Mesenchymal Pericyte Plasma using Lipogems technology – AMPP combines PRP therapy with lipogems. This is a procedure which uses the bodies own fat cells (adipose) to treat pain and inflammation. The injections are minimally invasive, takes around an hour with only a three hour recovery time.

The AMPP injections can also decrease inflammation and actually stop the progression of arthritis damage and may repair joint cartilage. Following this procedure the patient moves around on the same day and resume normal activities almost immediately.

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