Surgical Management of Shoulder Conditions

Adhesive Capsulitis

(Frozen Shoulder) may require surgical intervention to restore function. PTAs can help patients with post-operative education by understanding the structures involved and the expectations for post-operative recovery. Take a moment to review the Animation of Surgery for Adhesive Capsulitis (approximately 20 minutes) to reinforce information from your text book readings.

Glenohumeral Arthroplasty

Surgical techniques can include resurfacing of existing bone, replacement of the humeral head (hemiarthroplasty) or replacement of the humeral head and the glenoid fossa (total shoulder arthroplasty/replacement (TSR)). Traumatic fracture of the humeral head may lead to avascular necrosis and necessitate a TSR to restore arm function.

Choice in surgical procedure will depend on the involvement of articular surfaces and associated soft tissues.

Primary goals for TSR are

  • reduce pain
  • secondary outcomes may be
    • increased shoulder mobility
    • increased shoulder stability
    • restored or increase strength for functional use

Surgical approaches vary with patient condition and surgeon preference. Your text discusses general surgical procedures for a variety of shoulder prostheses. The take home message for the PTA is SURGEONS ESTABLISH ROM LIMITATIONS AND RESTRICTIONS FOR EACH CASE. If you are not sure of the ROM limitations for a post-operative TSR patient, consult with the supervising PT or contact the physician's office for clarification. Err on the side of caution and choose interventions which do not involve GH motion, such as pain management, postural instruction, activity modification, and alternatives for cardiovascular exercise.

In general, TSH without repair of the rotator cuff will have a maximum of 140 degrees of abduction range available. Patients who undergo a rotator cuff repair and TSH average 60 degrees of abduction post-operatively.

Arthrodesis of the Shoulder

Fusion of the shoulder is generally selected when there are no other non-operative or operative approaches which will minimize instability in the shoulder complex. PTAs should understand the significance of post-operative precautions and maintain mobility in distal joints during the recovery phase

Following fusion, ROM is generally limited to the following

  • 15-30 degrees of flexion
  • 15-30 degrees of abduction
  • 35-45 degrees of external rotation

Functional use of the arm is achieved through scapular motion. Consider the muscle origin and insertions at the scapula: what overuse or secondary conditions may evolve with repetitive scapular motions?

Subacromial Decompression

The procedure is also referred to as acromioplasty and can be abbreviated 'SAD' in the medical record. SAD can uses arthoscopic techniques to remove bone spurs in the subacromial area and to remove debris associated with overuse. Surgical decisions to try SAD are based on patient symptoms and previous response to conservative treatment (PT, cortisone, meds, etc. ). Once the surgeon has visualized the RTC tendon during SAD, he/she can assess if a rotator cuff (RTC) repair is indicated.

Video of SAD arthroscopic surgery. Approximately 1.5 minutes

Recovery from SAD is typically 3-6 months. Rehabilitation processes are similar to management of impingement syndromes, with an emphasis on maintaining soft tissue mobility and preventing overuse. Patients may initiate RTC strengthening exercises soon after SAD as long as there has been no surgical repair of the RTC.

Rotator Cuff Tear

RTC tears can be due to repetitive motions or from trauma. Non-surgical and surgical management is largely driven by patient symptoms, surgical approach, and tissue healing times to allow repaired and/or fragile structure to heal. Too much too soon in these patient can result in total loss of RTC function.

Classifications of RTC tear

  • Partial thickness: partial thickness tears can be intraarticular, bursal, or intratendinous

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Major Surgical Approaches

  1. arthroscopic: tendon is repaired with minimal disruption to supporting soft tissue structures; debridement approach is most often used for partial thickness tear
  2. mini-open: deltoid muscle is split to allow surgical access to rotator cuff tendon group
  3. traditional-open: deltoid is detached (taken down); includes a SAD; tendon is typically affixed to bone during repair; may also include a labral reconstruction or capsular tightening (aka capsular shift, capsulorhaphy)

Factors influencing RTC surgical approach include history of chronic impingement, size of RTC tear, associated pathologies in the shoulder, and general medical condition/stability.

 

 

Shoulder Instabilities

Video is approximately 1.5 minutes

  1. Bankhart repair (Tutorial is approximately 1.5 minutes long)
    1. labrum is reattached to glenoid
    2. subscapularis is taken down or split at the humerus
    3. capsulorhaphy: takes up slack in loose capsule
      1. electrotherapy approaches use heat to shrink capsule and tightens capsular structures
  2. SLAP: Superior Labrum Anterior Posterior (Tutorial is approximately 1 minute)
    1. indicated when there is a tear of the superior aspect of the labrum which extends in an anterior-posterior direction
    2. may also include a repair of the long head of the biceps

Special test for SLAP is the O'Briens (Video is approximately 2 minutes)

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  1. Bony block
    1. A bone block can be placed anterior to the GH joint to prevent anterior translation motion and recurrent dislocation. This surgical procedure is performed infrequently.

 

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