Operative Orthopaedics
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Subacromial decompression in impingement
although each shoulder is similar, it is not the same. Namely, the top bone of the so-called the acromion (part of the scapula) can have 3 types or shapes, straight, curved, and curved with a bulge. If you have one of the last two types, it is possible to experience shoulder pain throughout your life. The pain is caused by the collision of the rotator cuff bone and tendon because there is little space between them. Inflammation of these tendons causes pain. The pain is most often felt on the outside of the shoulder (where soldiers put on the regiment band sign). The pain is more intense when raising the arm above the head and when rotating. Later, the pains are present even at rest. The patient cannot sleep on that shoulder. Arthroscopic surgery through several small incisions removes the excess bone on the acromion from the lower side so that the bone is flat. In this way, we increase the space between the bone and tendons of the rotator cuff, which are no longer in contact during movements.
intraoperative presentation of subacromial decompression
- removal of part of the bone and bursa - enlargement of the subacromial space
Calcifying tendinitis and tendon rupture in the shoulder
long-term inflammation of the rotator cuff tendons can lead to degeneration. Inflammation means that the body is repairing the damage. If the damage is constantly repeated, the organism saves energy for repair and gives up on repairing. A kind of scar is formed which we call degeneration. It is a different type of tissue than a tendon. In the case of nerves growing into that scar, pain occurs. Sometimes, instead of a scar, the body begins to deposit calcium. Such calcification has the consistency of toothpaste. It causes pain when it is very large. Then it causes a collision - impingement. Particularly severe pain occurs when the calcification dissolves. Calcification can be removed arthroscopically. It is necessary to remove it completely because the remains can cause severe inflammation and pain. Often, after the removal of large calcium deposits, a rotator cuff tendon defect remains or it ruptures spontaneously, and it is necessary to perform reconstruction (stitching of the tendon).
The hospital stay is one day. A soft orthosis for the shoulder is worn for three weeks and physical rehabilitation is started immediately. Sometimes, on chronis cases, it is not possible to return the tendon to its place in the position of the arm next to the body, but the tendon has to be joined in the position where the arm is away from the body. Then it is necessary to wear a special orthosis for 5 weeks, which maintains the position of the arm away from the body.
calcification in the shoulder rotator tendon X-ray
rupture of the tendon of the supraspinatus muscle MR
Stabilization of the unstable shoulder
falling on the shoulder or on an outstretched arm can result from dislocation of the shoulder joint. Then the head of the upper arm comes out of its socket in the scapula and is positioned in front. It is the so-called anterior luxation.
On this occasion, there is always damage to the stabilizers of the shoulder, namely the ligaments and the labrum.
The labrum is a special type of annular cartilage that is attached to the glenoid. The glenoid is the cup of the shoulder joint. Since the cup is significantly smaller than the head of the humerus, the labrum increases the surface area of the joint and keeps it stable. In case of dislocation, the edge of the labrum separates and it retracts and mosty often heals below the level of the joint of the cup. In that place, it can no longer stabilize the shoulder and that is why each luxation is easier than the previous one. Today, it is recommended to return the labrum to its natural place with arthroscopic surgery, which achieves the stability of the joint, even after the first luxation. The labrum is attached to the rim of the glenoid (cup) with special anchors that are driven into the bone, and the threads attached to the anchors secure the labrum. The next day, the patient can go home immobilized with a soft shoulder orthosis. The orthosis is removed several times a day and exercises are performed.
Stabilization of SLAP lesion
the cartilaginous ring around the cup of the shoulder joint on the upper part is attached to the tendon of the long head of the biceps muscle. Sometimes due to trauma or long-term inflammation, this ring is separated. Pain occurs in the shoulder during some movements. A clear diagnosis can be made by magnetic resonance with the administration of contrast in the joint. By arthroscopic surgery with the use of anchors, the cartilaginous ring and its junction with the tendon can be reattached to the bone in place.
Tenodesis of the tendon of the long head of the biceps
in case of long-term damage to the attachement of the tendon of the long head of the biceps muscle, it is no longer possible to attach it to the original place on top of the cup. Using an anchor with threads, we separate the tendon from its natural grip and place it in a new place at the beginning of the tunnel on the head of the humerus, where the tendon normally passes. On this occasion, it is very important to fasten the string at the appropriate natural length so that it is neither too tense nor relaxed. In this way, the muscle can continue to perform its function.
Partial or total shoulder endoprosthesis
A partial endoprosthesis of the shoulder is implanted after the so-called four-part fracture of the initial part of the upper arm bone. In this fracture, all the main elements of the bone and joint are broken with the displacement of the fragments, since the muscles that attach to the bone are pulled. With this operation, all damaged elements are replaced with an artificial joint. Post-operative rehabilitation begins immediately, in contrast to possible conservative treatment with immobilization, when rehabilitation follows only after the immobilization is removed.
A total endoprosthesis is installed when the joint is completely damaged by arthrosis. Today, the so-called cementless prostheses. Such prostheses are attached to the bone with screws, that is, they are pressed into the bone like a wedge, and later the bone grows into the rough surface of the endoprosthesis, and in this way the prosthesis is permanently fixed.
Total reverse endoprosthesis
In the case when the patient ignores the total rupture of the tendons of the rotator cuff, arthrosis and pain occur over time. In the past, standard endopotheses were implanted in such a shoulder, which successfully solved the problem of pain. However, the patient's dissatisfaction was soon noticed since they did not have the possibility to adequately move the joint due to the lack of function of the tendons of the rotator cuff muscles. That problem was solved with a total reverse endoprosthesis. Such a prosthesis has a different design than a normal shoulder or a standard prosthesis. By installing the semicircular part of the joint in the scapula, and the cup in the initial part of the humerus (meaning the opposite of natural), the center of rotation moves from the middle of the body to the outside. In this way, the deltoid muscle, which is a strong mover of the shoulder (but only after the movements initiated by the rotator cuff muscles under normal conditions), can successfully move the shoulder even without the shoulder rotator.
Osteonecrosis of the lateral part of the clavicle
it occurs in top athletes who use heavy weights in training, eg. weightlifters, judokas. Pain occurs on the front side of the shoulder when practicing the bench press or pushups. With a careful examination, we can feel the place of the strongest pain, which is the outer end of the collarbone. The MR image shows an increase in the signal in that part of the bone, the so-called bone edema. In the X-ray images, there is no change at first, while later the thinning of the bone until the complete disappearance of the outer part is seen.
In operative treatment, we use an approach through two small incisions on the front and back of the acromioclavicular joint. Without damaging the ligaments and joint capsule, the diseased part of the bone is removed with a motorized instrument. Access from the shoulder joint is also possible, but then the lower part of the joint capsule with the ligaments is removed, which we try to avoid.
Dislocation of the acromioclavicular joint
occurs when falling directly on the shoulder or on an outstretched arm. There is pain and swelling of the acromioclavicular joint, and in cases of severe trauma and rupture of ligaments, a large bulge is visible at the joint site. Namely, the outer part of the clavicle protrudes, while the acromion (top part of the scapula) together with the whole arm moves downwards. The AC joint is then dislocated. In the case of a grade 3 injury (then the ligaments that hold the acromioclavicular joint and the clavicle in contact with the scapula in place are injured), we use an arthroscopically assisted operation to repair these ligaments and return the AC joint to its place. We adjust the joint with a special system of tapes or threads, and damaged ligaments can heal with these tapes or threads at the appropriate distance and tension.