Types of Shoulder Surgery

8 Techniques Used to Repair Common Injuries

Surgery may be an ideal treatment for many common shoulder problems, particularly those that fail to respond to conservative therapy. They can range from minimally invasive arthroscopic procedures (in which a scope and surgical instruments are inserted through keyhole incisions in your shoulder) to more traditional ​open surgeries using a scalpel and sutures. Each approach has its pros, cons, limitations, and appropriate uses.

1

Arthroscopy for Impingement Syndrome

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One of the most common reasons for shoulder surgery is the treatment of impingement syndrome. This is a condition in which the tendons of your rotator cuff are intermittently trapped and compressed during movement. This causes progressive damage to the tendons, as well as the cushions inside the joint space (called bursa).

Impingement syndrome can also be described as rotator cuff tendonitis and bursitis. 

The arthroscopic procedure used to correct impingement is known as a subacromial decompression. The aim of the surgery is to increase the space between the rotator cuff and the top of the shoulder (known as the acromion).

When performing subacromial decompression, your surgeon may remove the bursa alone or some of the undersurfaces of the acromion. Doing so creates space for the rotator cuff to glide without getting pinched between bone.

This surgical procedure may be performed in isolation or as part of a rotator cuff surgery. 

2

Arthroscopic SLAP Repair

A SLAP tear is an injury to the rim of cartilage that encircles the shoulder socket (known as the labrum). 

The term SLAP stands for "Superior Labrum Anterior and Posterior." A SLAP tear, therefore, occurs both in front (anterior) and back (posterior) of the labrum. This portion of the labrum is especially important as it serves as the attachment point of the biceps tendon.

Arthroscopic surgery may be used to restore the labrum back to its position at the rim of the shoulder socket. Once repositioned, sutures would secure the bone to the cartilage. If the damage extends into the biceps tendon, additional surgery may be needed.

3

Arthroscopy for Shoulder Dislocation

A shoulder dislocation injury occurs when the ball of the shoulder joint comes out of the socket. 

In young athletes, the damage most commonly occurs at the labrum. To stabilize the shoulder after dislocation, a type of surgery known as a Bankart repair can attach the labrum to the joint capsule to hold the ball in place.

Other cases involved generalized laxity of the shoulder ligaments which can lead to a condition known as multidirectional instability. This can cause the shoulder joint to come in and out of the socket very easily. Surgery would be used to tighten the joint capsule.

Repeated dislocations can lead to severe shoulder damage and require substantial surgery to keep the joint in place. While there are several different ways to achieve this, the procedures typically involve repositioning bone around the shoulder to hold the ball more securely in place.

4

Arthroscopy for Frozen Shoulder

Frozen shoulder is the second-most common cause of shoulder injury next to a rotator cuff tear. While the condition can usually be treated with non-surgical means, there are rare instances in which surgical treatment is required.

When a frozen shoulder occurs, the capsule surrounding the shoulder joint becomes tight and contracted. The goal of surgery is to loosen the contracted tissue to allow the shoulder to move more freely. This is typically done by cutting the capsule all the way around the ball of the shoulder, a technical challenge given that the space inside the joint will be extremely tight.

Another challenge is that once the capsule is cut, the body will want to make new scar tissue. Aggressive physical therapy is essential to restoring the shoulder's full range of motion.

5

Rotator Cuff Repairs

One of the most common surgical procedures for the shoulder is a rotator cuff repair. There are many ways to do this, and most surgeons have their preferred techniques.

The goal of the surgery is to identify the damaged part of the rotator cuff and to clean and reattach any torn or damaged tendons. Once the healthy tissue is found, the surgeon will use different techniques to restore the tendon without excessively stretching the remaining tissues

The traditional approach, called an open rotator cuff repair, involves a surgical incision several inches long to detach the surrounding muscle and repair the rotator cuff directly. A newer technique is performed arthroscopically, usually on smaller injuries.

There is also a hybrid version, called a mini-open rotator cuff repair, which can be used if the damage is extensive. It involves the placement of anchors in the shoulder bone to which the tendons can be securely reattached with sutures.

There may be circumstances when a repair is not possible. Extensive separations, known as massive rotator cuff tears, are difficult to restore as the tissues can retract like a rubber band and experience rapid cell death (atrophy).

6

Acromioclavicular (AC) Joint Repairs

The acromioclavicular joint, commonly known as the AC joint, is the junction of the end of the clavicle (collarbone) and acromion. There are several problems that can occur at the AC joint. 

The first is that it can wear out. This can occur as a result of arthritis, usually at the site of a previous trauma. It can also deteriorate due to a repetitive use injury, such as weightlifting (a condition referred to as distal clavicle osteolysis).

If either of these conditions occurs, open surgery may be performed to remove the end of the collarbone and widen the AC joint space.

Instability can also occur at the AC joint, causing progressive damage to the ligaments that connect the clavicle to the end of the shoulder blade. This can eventually lead to shoulder separation. While shoulder separation can often be treated nonsurgically, severe cases may require surgery to repair or reconstruct ligaments that support the end of the clavicle.

7

Shoulder Replacement

Shoulder replacement surgery is typically reserved for advanced arthritis of the shoulder joint but can also be used for complex fractures and other problems that cannot be repaired with other techniques. 

A typical shoulder replacement will replace the ball and socket joint with an artificial ball made of metal and a socket made of plastic. 

In cases where only the top part of the arm bone (humerus) is broken or the socket of the arthritic shoulder is still intact, a partial replacement, known as hemiarthroplasty, may suffice. Hemiarthroplasty just replaces the ball of the shoulder, leaving the socket untouched.

Another option is the reverse shoulder replacement. As per its name, the surgery reverses the location of the ball and socket so that the replaced ball goes where the socket was, and the replaced socket goes where the ball was. The surgery can provide a mechanical advantage to people who have a condition called rotator cuff tear arthropathy in which both the labrum and rotator cuff are severely damaged.

8

Biceps Tendon Surgery

The bicep is a muscle on the front of your arm. At the top end is a tendon, called the long head of the bicep, that attaches the muscle to the shoulder by traveling through the rotator cuff and affixing itself to the labrum. This complex relationship makes the long head of the biceps a common target for shoulder problems.

Biceps tendon surgery can be performed in isolation or as part of a rotator cuff repair. There are generally two approaches used. One is to sever the tendon connection inside the shoulder joint and reattach it outside of the shoulder joint.

The other, called a tenotomy, simply ​sever the tendon and lets it retract down the arm. While you might assume that doing so will affect the bicep's strength and function, there are numerous professional athletes who have had a tenotomy and returned to their competitive careers, often faster than if they had undergone surgical reattachment.

Risks and Complications

All of these surgical procedures can be performed safely and effectively but are not without their risks. While complications are uncommon, they may include infection, tissue scarring (fibrosis), and sepsis. Proper post-surgical care and rehabilitation can reduce the risk of complications.

Before having any surgery, speak with your surgeon about the risks and benefits of the procedure and the results you can expect. Since most shoulder surgeries are elective, take your time to make an informed choice and seek a second opinion if needed. It is important to manage your expectations and fully understand what is required of you during post-surgical rehabilitation.

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