The treatment of the shoulder joint in our orthopedic clinic OCC Tübingen is carried out using exclusive methods that are not widely spread outside of Germany.
The clinic OCC Tubingen spend: operations on ligaments, tendons of the shoulder, eliminate the effects of sports injuries of the shoulder joint, its inflammation, are struggling with various diseases.
If we consider the shoulder joint as a complex conglomerate, it is formed by bones, cartilage, articular capsule, synovial bags (bursa), muscles and ligaments. In its structure, it is simple, consisting of 2 bones, a complex joint of spherical shape. The components that form it have different structures and functions, but are in strict interaction, designed to protect the joint from injury and ensure its mobility.
The bones of the shoulder joint form a movable joint, the stability of which is provided by the muscles and ligaments.
Such a structure allows for a large amount of movement, but at the same time makes the joint prone to dislocation, sprains and ligament ruptures.
Diseases of the shoulder joint have a different nature. Conventionally, they can be divided into two groups:
- Diseases associated with degenerative changes leading to tissue destruction;
- inflammatory diseases.
The most common diseases of the shoulder joint are:
- Periarthritis is a serious complication of cervical osteochondrosis and is a degenerative lesion of tendons attached to the bone. At first, pain develops at night without a reason. Gradually, the intensity of the pain increases, the patient feels a strong discomfort during movement of the limb, especially when the arm is raised and taken to the side.
- Arthrosis is characterized by the development of dystrophic changes in cartilage, followed by its destruction. Pain syndrome occurs when making any movements. The lack of timely and proper treatment can lead to complete joint immobility.
- Bursitis. As a result of accumulation of unwanted fluid in the synovial bag, there is swelling of the shoulder area, redness of the skin, pain, aggravated by pressure, limited range of motion.
- Myositis is a lesion of muscle tissue and their inflammation. A pain syndrome appears in the muscles of the shoulder, which increases with pressure. Due to the strong tension and weakness of the muscles, the mobility of the joint is lost, swelling and redness are observed.
- The deposition of calcium salts. This process is observed in people over 30 years old. With the deposition of salt pain is felt constantly.
- Dislocation - joint damage and displacement of the bones. There is pain when moving and pressing, there is noticeable deformity, swelling, redness.
- Bruising is characterized by a sharp pain in the joint, edema, and even cyanosis of the skin.
A common symptom of each of the described ailments is pain, the intensity of which increases during movement. In some cases, the mobility of the joint is severely limited.
Diseases of the shoulder joint of inflammatory nature: arthritis, periarthritis, bursitis, osteoarthritis, polyarthritis, capsulitis, require complex treatment - taking medication, physiotherapy, physical therapy, massage.
Drug treatment is assigned to each patient individually, based on the characteristics of the state of his body. Our experts of the clinic OCC Tubingen prescribe patients tablets, injections, ointments. For patients suffering from diseases of the gastrointestinal tract, an excellent solution is electrophoresis, phonophoresis - the introduction of drugs directly into the affected tissue. Two plates are applied to the shoulder joint, under which there is fabric soaked in medicine. Radiation - electric current, ultrasound, moves the drug molecules into the blood, where they are activated.
Physiotherapy is prescribed to patients in combination with drug treatment. With arthritis, polyarthritis, periarthritis, shock wave therapy based on the effects of electric current is often used. During this procedure, the affected vessel is exposed to the healing effect of electrical energy, and the patient feels pleasant warmth spreading all over his body.
Paraffin applications help the patient to get rid of pain, reduce swelling in the shoulder joint. For applications, white melted paraffin wax is used, which is cooled to fifty to sixty degrees before application. Paraffin is applied to the surface of the shoulder with a brush, the patient must suffer a little bit: soon after the application, the burning sensation disappears.
Laser therapy using red (for superficial inflammation), infrared (for deep inflammation) radiation after the first procedure brings relief to the patient: reduces swelling, allows you to move without pain.
Arthroscopy of Shoulder Joint
Arthroscopy is a procedure used by orthopedic surgeons to diagnose and treat the joints from the inside.
If you have arthroscopy of shoulder joint, the surgeon puts a small camera (arthroscope) in your shoulder joint, and it transmits the image on a display. Looking at the image the surgeon operates with surgical instruments.
Since the arthroscope and surgical instruments are too thin, your surgeon can make very small incisions instead of big cuts during a standard open operation. It helps to reduce pain and shortens recovery period.
Arthroscopy of shoulder joint is made since 1970. Diagnostics, treatment and recovery after the surgery has become easier and faster than ever before. Arthroscopy is being constantly improved, because new methods and instruments are introduced.
Your doctor can advise Arthroscopy of shoulder joint, if you experience pain that cannot be relieved without surgical treatment. Non-surgical treatment includes rest, physical therapy, medications and infections that can cause inflammation. Inflammation is normal body reaction to a trauma or a disease. It can trigger swelling, pain and tightness.
- Meniscus seams;
- Plastics of the front crucial ligament;
- Tear of articular lip;
- Damage of rotational ferrule;
- Frozen Shoulder;
- epicondylitis (periostitis).
Traumas, excessive load and wearing because of aging are the main reasons of pain in the shoulder. Arthroscopy of shoulder helps to relieve painful sensations.
Arthroscopy of shoulder includes the following basic manipulations:
- Restoration of movements
- Removal of bone
- Removal or restoration of the upper lip
- Restoration of ligaments
- Removal of inflamed tissue or lose cartilage
- Restoration after recurrent shoulder slip
Least widespread procedures include freeing of nerves, restoration after fractures, and removal of cysts that can also be performed with the help of arthroscopy. Some surgical procedures, such as endoprosthetics of shoulder joint, require an open operation with pretty big cuts. Open operations tend to be riskier and require a longer recovery period.
If you are ready for arthroscopy, you should go through a full medical examination. A doctor will check your health and define the problems that can hinder arthroscopy. Prior to the operation, you should inform the surgeon about the medications you use. Additional tests and analyses can be required. Most probably, you will have to cease taking some medications some time before the operation.
Most often, arthroscopy is performed on an outpatient basis. It means you don’t have to stay overnight in a hospital.
Before the operation, you will need to talk with your anesthesiologist. Arthroscopy of shoulder is usually made with local anesthesia. The numbing agent is injected into the neck or the upper part of shoulder. Blocking of nerves helps to control the pain during several hours after the operation.
Most arthroscopy operations last less than an hour, though, every case is individual.
Positioning and preparation
When you’re in the operating theater, the surgeon will sit you so that to adjust the arthroscope and check the inner part of the shoulder. There are two basic positions for a patient going through shoulder arthroscopy:
- Beach chair. It’s a semisitting position that you typically get when sitting in an armchair with a folding back.
- Transverse decubitus. In this case, a patient lies on his side.
Every position has its own advantages. The surgeons choose the position based on the procedure and individual preparation.
After positioning, the surgeon spreads an antiseptic over the skin of shoulder and will put fixing devices on to immobilize your arm.
First, your surgeon will make an injection of fluid in the shoulder to blow the joint (it helps to see the structures of your shoulder better through an arthroscope). After that, the surgeon will make a small cut in the shoulder for the arthroscope. It will transfer the image on the display for the surgeon to see the inside of your shoulder.
When the problem is clearly defined, the surgeon will insert other small instruments via other cuts. Special instruments are applied for shaving, cutting, clip, sutural pass and stitching. Pretty often, special devices serve to fix stitches in bones.
Your surgeon can close the cuts with stitches or a sterile strip (e.g. a small patch) and will cover it with a big soft bandage.
Recovery after operation
After the operation, a patient stays in his ward for 1-2 hours. Nurses will check patient’s health and administer pain killers.
Although rehabilitation after arthroscopy is faster than after an open operation, it may still take several weeks.
You can experience pain and discomfort during a week after the operation. If you had a serious open operation, you can suffer from pain for several weeks before it subsides. Ice will reduce pain and swelling. Your doctor can administer pain killers, if you need.
Several days after the operation, you can replace the bandage with wrapping. You can start showering when wounds cease emitting wound secretion, don’t scratch them. Most likely, you will need a special sling or an immobilizer to protect your shoulder.
Rehabilitation plays crucial role for getting back to everyday activities. An exercise program will help you to restore powers and light movements. If you had had previous surgical invasion, ask your surgeon to find a physical therapist to control exercise programs for you.
Most patients don’t experience any complications after shoulder arthroscopy. However, as any other operation, it has some risks. As a rule, they are minor and can be easily treated. Potential problems after arthroscopy include infections, excessive bleeding, blood clots and damage of vessels or nerves.
Before the operation, your doctor will discuss possible complications with you.
Since patients have different health, the period of full rehabilitation differs.
If you used to have a minor surgical invasion, you won’t need a sling, and you can recover within short terms. You can get back to work or studying several days after the procedure.
More complicated surgeries require a longer rehabilitation period. Although arthroscopy leaves small cuts, the joint can be significantly damaged inside. Full recovery can take several months.
Endoprosthetics of Shoulder Joint
Shoulder joint is the most mobile joint in human body. It consists of a head of humerus and a glenoid cavity. As all other joints, shoulder joint is surrounded by a glenoid cavity that produces glenoid fluid. It reduces friction in joint, nourishes articular cartilage and stabilizes the joint.
- With resurfacing endoprosthetics of the shoulder joint (resurfacing arthroplasty) only the joint surface (more often the head of the humerus) are changed. The main feature of the resurfacing endoprosthetics is that the damaged parts of the joint cartilage surface are removed without osteotomy. An artificial component of the endoprosthesis is installed on the peeled section of the shoulder bone.
- Unicompartmental endoprosthetics (hemiarthroplasty). In the case of unicompartmental prosthesis, one of the two shoulder joint parts is changed (either the head of the humerus or the glenoid cavity of the scapula).
- Total shoulder joint replacement, with a complete replacement of the adjoining surfaces (both the head of the humerus, and the glenoid cavity of the scapula). There are two types of total shoulder joint replacement: the replacement of only joint surfaces (Partial Resurfacing Arthroplasty - PRA) and the use of prostheses on a stem (Total Shoulder Arthroplasty - TSA).
- Revision shoulder joint arthroplasty is an operation performed to replace the existing endoprosthesis or its component.
There are two types of endoprostheses on a stem:
Anatomical Total Endoprosthesis
This endoprosthesis copies the natural shape, build, and biomechanics of the shoulder joint. The affected joint surfaces are replaced with similar artificial components. A sine qua non for anatomical endoprosthesis is the preservation of the elements of the rotational cuff, which stabilizes the joint pushing the prosthetic head into the glenoid cavity of the scapula, because the surface of the artificial shoulder joint is less than the size of the adjoining surface of the prosthetic head, which, on the one hand, increases the possible amount of motion in the joint and, on the other hand, increases the risk of dislocation of the endoprosthesis head.
Reverse Total Endoprosthesis
The philosophy of this endoprosthesis is in the opposite location of its components. It means that the blade component has a hemispheric form (similar to the humeral head), and the shoulder component has a concave shape. In the case of degenerative changes of the shoulder rotator cuff, its thinning or rupture, gradually progressing arthrosis of the shoulder joint occurs, the shoulder bone gets cranially displaced (upwards, under the acromion) and the joint becomes unstable. This is when this kind of total endoprosthesis is needed.
The stem of the endoprosthesis can be fixed without cement (using the press-fit method, i.e. firm impaction) and with cement (the components are fixed to bone with bone cement). The choice of fixation type depends on a number of factors, such as the quality of the bone, the patient's age, the concurrent conditions, the anticipated activity after the operation and many others, and is made in each case individually.
Endoprostheses of shoulder joint allow restoring the angle and size of head of humerus and a glenoid cavity that are individual in every patient.
Besides, when needed, a worn cartilage in head of humerus can be replaced by an artificial joint. When the damaged cartilage of the head of humerus is replaced, a prosthesis of humerus head is used.
Today, the life cycle of an artificial shoulder joint is about 10-15 years. Besides, it also depends on the level of load, quality of bone tissue, and material and construction of endoprosthesis.
When the results of preliminary research are evaluated, your doctor will evaluate the most suitable type of endoprosthesis and the method of fixation in bone tissue. It depends on patient’s age, quality of bone tissue, severity of arthrosis and degree of damage of rotator cuff.
If arthrosis has mainly damaged the head of humerus, and the glenoid cavity has enough cartilaginous tunic, and there are no considerable deformations, it will be enough to replace only this part of joint with an endoprosthesis.
There are two main types of endoprostheses. In most cases, a prosthesis of a head of humerus is used – all allows restoring the relation of proportions and axes in head of humerus. The core of the prosthesis is tightly fixed in bone pipe of shoulder.
Alternatively, only surface of head of humerus can be worn. In this case, it is closed with a metal “cap”, s0-called superficial prosthesis. In such instance, fixation of endoprosthesis in bone pipe is not appropriate. When a lot of tissue in head of humerus is damaged, a superficial prosthesis is not enough, because it cannot be fixed reliably.
When the cartilaginous tunic is seriously damaged, and there’s pronounced deformation of head of humerus together with glenoid cavity, as a rule, both parts of joint should be replaced. In this cases, a total endoprosthesis of a shoulder joint is required.
Patients with total endoprosthesis of shoulder joint experience less painful sensations and have better mobility of joint compared to patients who have a humerus head prosthesis implanted. However, replacement of glenoid cavity is not possible in case of amphiarthrosis and in patients experiencing considerable load on shoulders and serious loss of bone fluid in the area of cavity.
When rotator cuff is damaged and patient experiences arthrosis, movement of arms can be restricted, so a patient may need a special endorposthesis. Such implant is not suitable for movement of joint within a rotator cuff, and is called an inverse (contrary) endoprosthesis. Head of prosthesis is fixed in the glenoid cavity in a way differing from the one used during fixation of a usual total endoprosthesis of shoulder joint.
Fixation of head of endoprothesis is made with the help of screws without cementation. To fix endoprosthesis of a shoulder joint, a doctor typically uses bone cement. A sliding polyethylene cover is put in the upper part of endoprosthesis to ensure sliding movement around the head.
The success of operation depends on patient, as well. Use the time before shoulder surgery to prepare for it and solve all organizational issues. Visit doctors after the operation, if you feel well: it will help you to get back to normal active life after the operation.
For how long do patients stay in the clinic?
Practice shows that patients usually stay in the hospital for 10-14 days. After that, rehabilitation measures are taken (that can be done in a hospital, or a special rehabilitation clinic).
Stages of surgery
The operation is made while patient is half-sitting. You will feel comfortable, as if you were sitting in a chaise longue.
To open the shoulder joint, a doctor makes a 15-20 cm long cut on the skin above the front part of shoulder. After that, a surgeon removes damaged elements of joint surface of head of humerus and glenoid cavity, worn elements of ligaments and synovial bursa, and inflamed mucous layer of the joint.
With the help of special instruments, damaged elements of cartilage and bone surface of head of humerus and glenoid cavity are prepared for implantation of the new shoulder joint.
Complications rarely occur after implantation of shoulder joint endoprosthesis. However, risks exist after any surgical invasion. These can be bleeding, secondary bleeding, or damage of adjacent nerves. Your doctor will consult you about risks.
Next day after operation, you can stand up and move in your ward and hospital. To reduce pain in the area of wound, you should spend first days after the operation with raised bed-head and take pain killers regularly.
To stop uncontrolled movements of joint, a patient should have his arm fixed with the help of a many-tailed bandage for several weeks. Movement of elbow and hand is allowed after operation. It helps to maintain blood circulation in the operated arm and prevents swelling. Experienced specialists of physical therapy will show the patient suitable exercises that should be performed several times a day.
Movement of the artificial shoulder joint is allowed in 2-3 days after the operation – the surgeon defines to which extent they can be moved. It’s necessary to follow doctor’s instructions to have ligaments and bones grow together correctly.
As a rule, restoration of function of operated shoulder joint relatively to horizontal surface is a pretty long-lasting process. Partial results are reached a year after the operation. Be patient and continue performing exercises for strengthening muscles and stretching joint capsule.