FAQs: Shoulder Surgery with the Sports Medicine Center

Preparation

1. What should I do to prepare for the surgery?

Within one month before surgery a few items will need to be completed:

• Make an appointment for a preoperative office visit regarding surgery.
• A history and physical examination will be done.
• Depending upon your age and medical history, you may need to obtain a complete blood count (CBC), electrocardiogram (EKG), or set up an advanced meeting with the anesthesiologist to perform a preoperative assessment.

The day before the surgery, wash the area to be operated several times a day to get it as clean as you can. This decreases the risk of infection. Be careful not to get any scratches, cuts, sunburn, poison ivy, etc. The skin has to be in very good shape to prevent problems. You do not need to shave the area. Check with your doctor's office for your time to report to the Surgical Day Care Unit the next day.

You can have nothing to eat or drink after midnight on the evening before surgery. It is very important to have a completely empty stomach prior to surgery for anesthesia safety reasons. If you have to take medication, you can usually take the medication with a sip of water early in the morning prior to surgery (but later tell the anesthesiologist you have done so). You should discuss with your doctor which medications you should take. If surgery will be done in the afternoon, you can have clear liquids only up to six hours before surgery but no milk or food.

2. Where do I go the day of the surgery?

Report directly to the Surgical Day Care Unit on the third floor of the Wang Ambulatory Care Building at Massachusetts General Hospital, as scheduled (generally two hours prior to the scheduled surgery).

3. What type of anesthetic will I be given?

This depends on the type of shoulder surgery being performed as well as your preference. You may be given a general anesthetic that will enable you to sleep throughout the entire procedure, or you may remain awake after receiving an injection that prevents you from feeling any pain.

Arthroscopy

4. What is arthroscopy?

Arthroscopy is a surgical procedure that orthopaedic surgeons use to visualize, diagnose and treat problems inside of a joint. The word arthroscopy comes from the Greek words, "arthro" (joint) and "skopein" (to look). The term literally means, "to look within the joint". In an arthroscopic examination, your doctor makes a small incision in the patient's skin and inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint. By attaching the arthroscope to a miniature camera, your surgeon is able to see the interior of the joint through this very small incision rather than the large incision needed for conventional "open" surgery. The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing your surgeon to look, for example, throughout the shoulder at cartilage and ligaments. Your doctor can determine the amount and type of injury, and then repair or correct the problem, if it is necessary.

5. Why is arthroscopy necessary?

Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually X-rays. Additional tests such as MRI, or CT scan may also be needed. Through the arthroscope, a final diagnosis is made which may be more accurate than through "open" surgery, X-ray studies, or MRI alone. Disease and injuries can damage bones, cartilage, ligaments, muscles and tendons. Some of the most frequent conditions found during arthroscopic examination of joints are:

• Inflammation
• Synovitis – inflamed lining (synovium) in knee, shoulder, elbow, or ankle
• Injury – acute and chronic
• Shoulder – rotator cuff tears, impingement syndrome, and recurrent dislocations
• Knee – meniscal (cartilage) tears, chondromalacia (wearing or injury to cartilage cushion), and anterior cruciate ligament tears with instability
• Loose bodies of bones and/or cartilage – shoulder, knee, ankle, and elbow

Although the inside of nearly all joints can be viewed with an arthroscope, six joints are most frequently examined with this instrument. These include the knee, elbow, shoulder, ankle, hip and wrist. As advances are made by engineers in electronic technology, and new techniques are developed by orthopaedic surgeons, other joints may be treated more frequently in the future.

6. How is arthroscopy performed?

Arthroscopic surgery, although much easier in terms of recovery than "open" surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal or regional anesthetic, depending on the joint or suspected problem. A small incision (about the size of a buttonhole) will be made to insert the arthroscope. Several other incisions may be made to see other parts of the joint or insert other instruments. When indicated, corrective surgery is performed with specially designed instruments that are inserted into the joint through the accessory incisions.

Initially, arthroscopy was a simple diagnostic tool for planning standard open surgery. With the development of better instruments and surgical techniques, many conditions can be treated arthroscopically. For instance, most tears in the knee can be treated successfully with arthroscopic surgery. Some problems associated with arthritis also can be treated. Several disorders are treated with a combination of arthroscopic and standard surgery:

• Rotator cuff repair
• Repair or resection of torn cartilage from the knee or shoulder
• Reconstruction of the anterior cruciate ligament (ACL) of the knee
• Removal of inflamed lining (synovium) in the knee, shoulder, wrist and ankle
• Repair of torn ligament
• Removal of loose bone or cartilage in the knee, shoulder, elbow, ankle and wrist

After Arthroscopy

7. What happens after arthroscopy?

After arthroscopic surgery, the incisions will be covered with a dressing. You will be moved from the operation room into the recovery room. Some patients need little or no pain medication, although it is not uncommon to have pain if an injury was treated. Before being discharged, you will be given instructions about care for your incisions, what activities you should avoid, and which exercises you should do to aid your recovery. During the follow-up visit, we will inspect your incisions, remove sutures, if present; and discuss your rehabilitation program.

The amount of surgery required and recovery time will depend upon the complexity of your problem. Occasionally, during arthroscopy, you surgeon may discover that the injury or disease cannot be treated adequately with arthroscopy alone. The "open" surgery, if previously agreed, can be performed while you are still anesthetized, or at a later date after you have discussed the findings with your surgeon.

8. What are the possible complications?

Although uncommon, complications do occur occasionally during or following arthroscopy. Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, joint stiffness, damage to blood vessels or nerves, and instrument breakage are the most common complications, but occur in far less than 1 percent of all arthroscopic procedures.

9. What are the advantages?

Although arthroscopic surgery has received a lot of public attention because it is used to treat well-know athletes, it is an extremely valuable tool for all orthopaedic patients and is generally easier on the patient than open surgery. Most patients have their arthroscopic surgery as outpatients and are home several hours after surgery.

Recovery

10. What is the recovery time after arthroscopy?

The small puncture wounds take several days to heal. The operative dressing can usually be removed the morning after the surgery and adhesive strips can be applied to cover the small healing incisions. Although the puncture sounds are small and the pain in the joint that underwent arthroscopy is minimal, it takes several weeks (6-8, sometimes longer) for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recovery and protect your future joint function. It is not unusual for patients to go back to work or school or resume daily activities within a few days. Athletes and others who are in good physical condition may in some case return to athletic activities within a few weeks.

Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient's arthroscopic surgery is unique to that person. Recovery time will reflect that individuality. It is rare that your recovery will be the same as that of a friend of family member who also had "arthroscopic surgery."

Procedures

11. How is a torn rotator cuff repaired?

Most rotator cuff tears can be repaired surgically by reattaching the torn tendon(s) to the humerus. This can be accomplished either arthroscopically or through a formal open procedure. Sutures are attached to the torn tendons. Tiny holes are made in the humerus where the tendons were attached and the sutures are passed through the bone and tied, securing the rotator cuff tendons back to the humerus. The tendons heal back to the bone, reestablishing the normal tendon-to-bone connection. It takes several months for the tendon to heal back to the bone.

Impingement and shoulder bursitis

12. How is impingement or bursitis surgically corrected?

Impingement or shoulder bursitis that does not improve after an extended period of non-operative treatment (including rotator cuff strengthening exercises and anti-inflammatory medication) may require arthroscopic surgery. This involves making small (buttonhole sized) skin incisions about the shoulder in which a specialized small camera and shaver are inserted. The inflamed shoulder bursa and any significant bony projections (spurs) are removed to create enough space for your rotator cuff tendons to move without pain.