Arthroscopic Shoulder Surgery: Exploring the Latest Techniques and Outcomes

Introduction to Arthroscopic Shoulder Surgery

Orthopedic joint surgery that is performed in a minimally invasive fashion with a small camera and instruments is known as arthroscopic surgery. This term originates from the fact that the procedures are done in the joint (arthro) and with a camera or “scope” (scopic). The most common shoulder operations that are done arthroscopically are those that treat rotator cuff tears and labrum tears, however there are a multitude of other indications and pathologies that can be treated in this minimally invasive way.

The rotator cuff is a group of four muscles whose tendons surround the shoulder joint and provide stability to the shoulder and arm. When a tendon of the rotator cuff frays or tears it is known as a rotator cuff tear, which can be repaired arthroscopically.

The labrum is a structure made of a type of cartilage that surrounds the socket of the joint (the glenoid) and serves as an attachment point of the capsule (ligaments) that surrounds the shoulder joint underneath the rotator cuff. Injuries to the labrum can be a result of a shoulder dislocation or repetitive injuries that occur many times from overhead activities.

The advantage of performing these operations arthroscopically as compared to traditionally open surgery, is that smaller incisions are used and there is less trauma to the larger muscles surrounding the shoulder joint, which allows for less scar tissue, as well as an easier and reduced recovery time. 

Latest Techniques in Arthroscopic Rotator Cuff Surgery

Continued advancements and surgeon experience with arthroscopic techniques have led to the ability to perform a broader range of operations in an arthroscopic manner. When arthroscopic shoulder surgery was first being developed, many surgeons would use the scope to diagnose the condition and then transition to the classic open (larger incision) technique to complete the operation. As surgeons gained more experience, and instruments specific to arthroscopic operations were developed, there was a steady gain in more operations being completed fully arthroscopically. In terms of rotator cuff injuries and repairs, this has led to the evolution of revision rotator cuff repairs, as well as management options for chronic rotator cuff tears that may not be repairable. 

Chronic rotator cuff tears continue to be a challenge for surgeons to manage. A large part of the issue is that after a rotator cuff tendon tears, it is pulled away from the bone where it normally attaches. After being torn for months or longer, the tendon begins to degenerate, and the muscle can begin to atrophy. This atrophy or loss of muscle bulk and quality make the tendon not repairable, or at the very least, decrease the likelihood of the tendon healing back to the bone after being repaired. Because of this, there have been other treatments developed to manage this type of issue. While there is not one treatment option that is the right answer for every patient, there are a myriad of options for patients with this tough to treat problem. 

In cases where the tendon is repairable, but may not have the best quality of tendon, augmenting the repair with a graft can add biologic factors to help the tendon heal to the bone:

• Grafting: Graft options that are available include allograft which is tissue from a cadaver or synthetic scaffolds which give more structure to allow the patient’s own tendon to heal to the bone. 

In cases where the tendon is not able to be repaired to the bone, treatment options are largely based on the patient’s symptoms and other concomitant pathologies. If the patient also has started to develop arthritis, the most reliable treatment is a shoulder replacement. 

In cases where the patient can raise their arm overhead, but has pain when doing so, treatment options to consider are operations that provide a barrier between the bone of the humerus (the arm bone) and the acromion (a part of the shoulder blade).  There are two primary techniques currently used:

• Superior Capsular Reconstruction: In this operation, a cadaver tendon is anchored between the humerus and the top of the glenoid (the socket). Success rates of this operation are variable and are best reserved for a select group of patients. 
• Subacromial Balloon Spacer: This newer option is where a biodegradable product is inflated with saline fluid in the same space between the humerus and the acromion to again create a barrier between the bones. The product is designed to remain in the space for 6 months while the patient strengthens other muscles around the shoulder to stabilize the joint. The product then biodegrades with the goal of maintaining pain relief by the strength of the retrained muscles. This still is an early technology, and long-term outcomes have yet to be borne out.

Latest Techniques in Arthroscopic Instability Surgery

Classic open surgeries for cases of shoulder instability (dislocations) were for a long time considered the gold standard for treatment of this pathology. As mentioned above, advancements in arthroscopic instability surgery have become much more commonplace than many of the classic open options due to smaller incisions and fewer long-term complications.  There are more advanced cases, however, where traditional arthroscopic instability surgery is not enough to fix the pathology. 

After a patient experiences multiple dislocations, they can develop loss of bone from the glenoid (socket) and/or the humeral head (ball). Options to manage this are varied and depend on the specific pathology. In cases where a “dent” is created in the back of the humeral head called a “Hill-Sachs” lesion, there is growing support to fill the defect to keep it from engaging with the socket and levering the joint out of socket. One option to complete this is with a procedure called a “remplissage.”

• Remplissage: which is derived from the French word for “filling”. In this procedure the back tendon of the rotator cuff (the infraspinatus) is repaired into the bony defect to fill the lesion and decrease the risk of engagement. 

In complex cases of glenoid (socket) bone loss, options are based on whether the patient’s own bone is still present, and many can be done in an arthroscopic fashion. In acute cases of instability where the glenoid breaks, and if it is small enough, the piece of bone can be fixed arthroscopically. If the piece is too large to be fixed with standard bone anchors and suture, a screw can be placed arthroscopically to fix the piece of bone.

If the bone loss is large enough and there is not enough native bone to fix, grafting must be performed to make up for the loss of bone. One option for this is a procedure called the Latarjet transfer named after a French shoulder surgeon. 

• Latarjet Transfer: In this operation the coracoid process (a part of the front of the shoulder blade) is sawed off and screwed into the front of the socket. While this operation is classically performed as an open procedure, some very experienced surgeons have developed techniques to perform arthroscopically. 

Another option for severe bone loss is to augment the socket with bone graft from a cadaver. 

• Cadaver Graft: The advantage of this over a Latajet is the ability to replace the lost bone with bone that has cartilage on it (the soft cushion that covers the end of the bones in joints). Again, this is classically done through an open incision, but new arthroscopic techniques are being developed. The largest advantage of performing these operations arthroscopically is to avoid splitting or cutting the front muscle of the rotator cuff known as the subscapularis. By avoiding these, the patient can avoid later complications or issues that are known to occur after surgeries where the subscapularis is manipulated. 

Emerging Technologies

Advancements in surgical techniques utilizing robotic assisted procedures are commonplace in general surgery and gynecologic abdominal procedures. In the realm of orthopedics, robotic assisted surgery is also taking off for knee replacement surgery and developing in hip and shoulder replacement surgery. This technology has not yet garnered significant attention or advancement in arthroscopic shoulder surgery, however opportunities will likely develop in the future.

Three-dimensional surgical planning and transferring these plans to the operating room with the use of robotics and augmented reality headsets is also making gains in open joint replacement surgery, however, it is very much in its infancy for arthroscopic shoulder surgery.  Currently, early research is being done on planning and guidance for the placement of arthroscopic anchoring devices to most efficiently utilize available bone. Time will tell how these technologies develop and are used commonly in arthroscopic shoulder surgery.

Future Directions and Considerations

Future advancements in arthroscopic shoulder surgery will largely be focused on optimizing healing of the tissue that is repaired and limiting disruption to the native structures of the shoulder. Current research is being performed on the possibility of biologic adjuvants such as platelet rich plasma (PRP), which is concentrated plasma (a blood product) with anti-inflammatory and healing factors taken directly from the patient. Additional biologic augmentation with “stem cells” or other healing factors are still very much in the early research and learning phase, however, the hope is that using cells or factors from the patient will aid in healing repaired tissue. 

Finally, pain management after orthopedic surgery and especially arthroscopic surgery has been a hot area of research and advancement in the last decade. With the well-known opioid crisis creating pain and suffering through the struggles of addiction, orthopedic surgeons have taken a serious approach at developing pain management strategies which avoid or limit opioid use. One advancement is the use of regional anesthesia where an entire extremity can be desensitized with a local anesthetic, that can last for up to 24 hours or more, which is usually the time period where the worst post-operative pain exists. 

Multi-modal medication strategies have also been employed where the combination of non-steroidal anti-inflammatories (NSAIDs like Advil (ibuprofen) and Aleve (Naprosyn)) with acetaminophen (Tylenol) help to manage a great deal of post-operative pain. More mild opioids can be used in a limited fashion to help reduce or eliminate the needs for those narcotic medications. Between these efforts by physicians, as well as patient education and the public understanding of the opioid epidemic, great advancements are being made to limit the potential of abuse of these drugs. To see if arthroscopic shoulder surgery is right for you, schedule an appointment with a Rothman specialist today.