SUBACROMIAL IMPINGEMENT

ANATOMY

The upper part of the shoulder is called the acromion; it is an extension of the scapula. Under the acromion lies the rotator cuff tendons. 4 muscles supraspinatus, infraspinatus, subscapularis and teres major and thus 4 tendons constitute the rotator cuff. The rotator cuff serves to keep the shoulder “in joint” and push the humeral head down when you elevate your arm.

Sub-acromion bursa is a space between the rotator cuff tendons and the acromion. It is filled with fluid and provided lubrication for rotator cuff tendons to glide.

If the space is reduced under acromion the rotator cuff tendons rubs against it due to repetitive movement leading to pain and this condition is known as sub-acromial impingement.

This happens in two main ways:

• A bony spur under the acromial space

• If the rotator cuff tendons are injured, causing local inflammation, subacromial bursa (bursitis).

HOW TO TREAT SUB-ACROMIAL IMPINGEMENT?

Non-operative:

• Analgesia – anti-inflammatories

• Physiotherapy

• Injections – cortisone/hyaluronate

Some patient do not respond to injections despite the fact injection and physiotherapy is known be quite successful initial treatment. However, if this fails, then arthroscopic surgery to increase the space between the acromion and the rotator cuff tendons can be performed: sub-acromial decompression.

WHAT TESTS/SCANS ARE REQUIRED?

X-rays are not normally required as it is soft tissue problem in most cases. Dynamic Ultrasound scan will be requested for sub-acromial impingement. MRI maybe requested if any concomitant intra-articular pathology is suspected.

HOW THE SURGERY IS PERFORMED?

Sub-acromial decompression is performed under general and/or regional anaesthesia. It is an Keyhole procedure (see complete video in UB Media )

Using special keyhole instruments the under surface of acromion is rasped to make space more for the rotator cuff tendons to glide.

I use 2 to 3 stiches to close the wound, the wound is dressed with special dressing pack and Polysling applied.

WHEN CAN I GO HOME?

It’s a day case surgery so most of my patients go home the same day.

WHAT HAPPENS AFTER MY OPERATION?

Physiotherapist will review you before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises and light stretches, you will be instructed on underarmhygiene. You should aim to exercise the shoulder 3-4 times a day.

Sleeping with a pillow under the shoulder is recommended as it can be sore to sleep on the surgical side.

You will receive pain killers to take home although Dr Butt will recommend to minimum use of analgesia once your pain level is reduced. Ice packs application is strongly recommended in the acute post-operative period.

You will see Dr Butt in 2 weeks after surgery and physiotherapist will review you twice a week and can also do home visit if you wish so. The stitches will be removed in 2 weeks

WHAT ARE THE POTENTIAL RISKS?

Shoulder arthroscopy is quite a safe operation but some risks are: Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Residual symptoms – unfortunately, no guarantees can be offered regarding curing your symptoms, despite the surgeon’s best efforts. In this case, further management and treatment options will be discussed with you.

ROTATOR CUFF TEARS

INTRODUCTION

The rotator cuff is a group of 4 muscles namely supra + infraspinatus, Teres minor and Subscapularis . The integrity of the cuff is vital to normal function; any injury may result in pain and/or weakness and restriction of function.

Subacromial impingement can lead to repetitive damage to the undersurface of acromion where tendons lies.

Alternatively, the tendon tissue itself may undergo degenerative change with age, which results in increased vulnerability to injury either through mild injury or overuse The tear of the rotator cuff can be traumatic (e.g , dislocation , accident ) or secondary to ageing process.

Tears can be partial or complete. Complete tears result in tendon retraction away from where the tendon should attach on the humeral head and therefore, complete rotator cuff tears don’t heal spontaneously. Partial tears may become less symptomatic with physiotherapy and analgesia, but also may not heal or even become complete tears if the cause is not removed (i.e. bony spur).

Massive rotator cuff tears are those that have retracted more than 5cm and can be more precisely diagnosed with MRI scanning.

DO I NEED TO HAVE TEAR REPAIRED?

Asymptomatic tear can be left alone.Initially treatment is analgesia, typically anti-inflammatories if tolerated and physiotherapy. Occasionally a cortisone injection may be considered. Multiple steroid injections can be harmful as it can lead to further tendon damage and risk of infection

Failure of non-operative treatment is surgery. Arthroscopic rotator cuff repair is current a gold standard using new high-end technique to repair the tendons. How to Diagnose a Tear

Dynamic Ultrasound scan will be requested for potential rotator cuff tears. MRI maybe requested if any concomitant intra-articular pathology is suspected.

HOW IS IT DONE?

Rotator cuff repair can be done using shoulder arthroscopy. The procedure is carried out under general and/or regional anaesthesia.

It aims to reattach the torn tendon to its bony origin located on the humeral head. It is achieved using bone anchors ( See UB Media complete video of surgery ).

Dr Butt uses minimum portals between 2 to 3 (incisions <1cm) around the shoulder to facilitate the repair. The operation is completed under 40 minutes and wound is closed with stitches and special dressing applied.The arm is always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal.

CAN I GO HOME THE SAME DAY?

Most of the patients go home the same day. Some patients may have to stay overnight if operation is done late or pain management is required

WHAT ABOUT AFTER THE OPERATION?

Physiotherapist will review you before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises and light stretches, you will be instructed on underarm hygiene. You should aim to exercise the shoulder 3-4 times a day. Sleeping with a pillow under the shoulder is recommended. It will be painful to sleep on the side of the operated arm for several weeks.

Depending of type and size of repair Dr Butt will instruct you on exercises and active and passive movement. Polysling or Abduction Brace will be applied depending on type of repair.

Dr Butt will prescribe you pain killers and strongly recommend to stop painkillers as soon as pain level goes down. Ice therapy is strongly advised at least 2-3 times a day.

You will see Dr Butt in 2 weeks after surgery and physiotherapist will review you twice a week and can also do home visit if you wish so. The stitches will be removed in 2 weeks

Dr Butt recommends return to work (sedentary) when you feel comfortable, for manual work between 3-6 months. Driving can resume after 6-8 weeks, as can swimming. Return to freestyle swimming, overhead athletic activity and contact sport is recommended at 3-4 months but is often guided by the strength of the individual.

WHAT ARE THE POTENTIAL COMPLICATIONS?

All surgery carries a risk. Specific risks to arthroscopic rotator cuff repair are:

Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. If there any problem kindly contact Dr Butt PA (Physiotherapist) for urgent advice.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Recurrence – re-tear can and does occur. Good compliance with post-operative rehabilitation will reduce your risk greatly. Contact sports and increasing age carry a higher risk for re-tear. Developing a lump under the wound after surgery. This is caused by a small amount of bleeding under the skin and usually settles after a few weeks.

Infection in the joint which may need treatment.

FROZEN REPLACEMENT SHOULDER

INTRODUCTION

Frozen shoulder is a condition where the shoulder is exquisitely painful and very stiff. Pain is constant and at rest.

Mild trauma or even surgery can trigger frozen shoulder. It is the capsule of the joint that is affected. It becomes inflamed and then contracts. diabetes mellitus, hypercholesterolaemia, heart disease and other medical condition has been shown to be risk factor in developing frozen shoulder

There are typically three stages:

• Increasing pain, gradual loss of movement and pain at night

• Pain settles but shoulder remains very stiff

• Resolution and restoration of movement

The natural history of the condition is that it normally resolves spontaneously but this can be between 1 to 3 years.

HOW TO DIAGNOSE?

Ultrasound scan will be requested for adhesive capsulitis to make the diagnosis

HOW IS IT TREATED?

Initial treatment is analgesia, physiotherapy and cortisone injection

Hydrodilatation is good option to treat frozen shoulder; Dr Butt undertakes procedure under regional anaesthesia or general anaesthesia. The procedure involves injecting large volume saline with local anaesthetic and steroid into the shoulder joint to open up the capsule. You will receive painkillers and undergo supervised physiotherapy for 4 weeks.

Surgery involves shoulder arthroscopy and releasing of the tight capsule using a special radio-frequency probe: arthroscopic capsular release. It is a very accurate way of releasing the contracted capsule and can be very successful, provided physiotherapy is implemented soon after the procedure

CAN I GO HOME THE SAME DAY?

Most of the patients go home the same day. Some patients may have to stay overnight if operation is done late or pain management is required.

RETURN TO WORK?

Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for 4-6 weeks. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.

WHAT ARE THE POTENTIAL RISKS?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The risks of the operation include infection, bleeding, nerve damage and incomplete relief of symptoms

SLAP LESIONS

Introduction

Glenoid has a cartilage rim that lines the periphery, called the labrum.The upper cartilage rim (superior labrum) is where the biceps tendon attaches. Injury to the superior labrum is called a SLAP tear, which stands for Superior Labrum, Anterior to Posterior (front to back). The injury usually occurs after a fall on an outstretched hand, a direct blow on the shoulder or because of repetitive overhead activity, such as throwing sports.

Symptoms

The usual symptom is of shoulder pain, especially after overhead activity or on loading the shoulder such as during gym work. The pain is felt deep within the shoulder and some patients may feel a painful click with certain shoulder movements.

What Investigation is required?

An MRI arthrogram is the best way to detect a potential SLAP tear. This involves having a dye injected into the shoulder joint prior to the MRI scan.

Treatment

Treatment with physiotherapy can be attempted, but most symptomatic SLAP tears fail to settle and require surgery.

Surgery (arthroscopic SLAP repair) is carried out using keyhole (arthroscopic) techniques and involves reattaching the upper part of the labrum to the bone. This is performed using specially designed small anchors placed into the edge of the socket. The anchors have sutures attached that are passed through the torn labrum that are tied securely back to the socket.

What are the risks?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The risks of the operation include infection, bleeding, nerve damage and failure to heal. The shoulder can occasionally get stiff after surgery but this will usually loosen with physiotherapy and time.

What is the recovery after surgery?

The shoulder will be protected in a sling after the operation for a period of 4-6 weeks. During this time you begin a supervised rehabilitation program under the guidance of a physiotherapist. Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will see a therapist prior to discharge from the hospital. You will be given painkillers to take home after surgery. The use of an ice pack on the shoulder may also be helpful for the first few days after surgery. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. There are no sutures to be removed.

When can I return to normal activities?

Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so. You will be unable to drive for 6 weeks until after the sling is removed. Sporting activities is allowed after 3 months.

CALCIFIC (PARTIAL) TENDONITIS

Introduction

Calcific tendonitis occurs when, for no obvious reason, calcium deposits form within the rotator cuff tendons of your shoulder. The build up of pressure can lead to intense shoulder pain that is unbearable. The tissues (bursa) around the deposit also become inflamed.

Symptoms

The pain is typically felt over the shoulder and upper arm. The pain can come over a short period of time and may be very intense. It may be made worse by reaching away from the body or behind the back. It is common to feel pain at night making it difficult to sleep.

What investigations are needed?

An x-ray of your shoulder is needed as this may show the calcium deposit. More detailed scans such as ultrasound or MRI may be required to look at the soft tissues around the shoulder and locate the calcium.

Non-surgical treatment options?

Painkillers and anti-inflammatory medication may help reduce pain. Physiotherapy may help to strengthen the rotator cuff muscles and control symptoms. A steroid injection into the affected area can help reduce inflammation and pain, particularly if the attack is severe.

What does surgery involve?

Surgery (arthroscopic subacromial decompression and excision of the calcific depostits) may be necessary if other treatments fail. This is a keyhole (arthroscopic) procedure, performed under general anaesthetic. A local anaesthetic nerve block is usually given once you are asleep to provide pain relief after surgery. Two or three puncture wounds are made around the shoulder to allow insertion of arthroscopic instruments. An arthroscope (camera) is inserted into the shoulder joint and a thorough inspection is performed to try and locate the calcium which can be released from the tendon and removed. Any inflamed bursa is removed and the space between the tendons and bone opened up by releasing the tight ligament from the bone and removing the bone spur. This allows the tissues to glide more freely and thus prevent the painful rubbing and inflammation.

What is the success?

Overall the operation has a success rate (pain resolved and return of good movement and function) of 85-90%.

What are the risks of surgery?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The risks of the operation include infection, bleeding, nerve damage, stiffness and incomplete relief of symptoms.

What is recovery Period?

You will have a sling to wear for comfort after the surgery that is usually discarded after the initial 2-3 days. You can safely use the shoulder within your comfort zone. Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will see a therapist prior to discharge from the hospital. You will be given painkillers to take home after surgery. The use of an ice pack on the shoulder may also be helpful for the first few days after surgery. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. There are no sutures to be removed. The pain will gradually settle and you will regain the movement in the shoulder over the next few weeks although it can take several months before you fully recover from the surgery.

When can I return to normal activities?

Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for 4-6 weeks. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.

ACROMIOCLAVICULAR JOINT INJURIES

Introduction

The acromio-clavicular (AC) links with the acromion (part of shoulder blade) to form AC joint. The joint is under stress and can develop wear and tear secondary to arthritis or posttraumatic.

Symptoms

Patients experience pain and tenderness at the end of directly over the AC joint. Pain is worse with shoulder across the body and can cause difficulty using the shoulder for everyday activities. Symptoms are usually insidious, without a history of discrete trauma although there may have been an injury in the past.

Diagnosis

Diagnosis is mainly based on clinical examination and X-ray can shownarrowing of the joint and bone spurs around the joint, which are signs of degeneration Non-operative treatment

Painkillers and anti-inflammatory medication may help reduce pain. Physiotherapy may help to strengthen the rotator cuff muscles and control symptoms. A steroid injection into the affected joint can help reduce inflammation and pain although the effects may only be temporary.

Surgical Option

If non-operative treatment fails Dr Butt offers keyhole surgery to make space between the AC joint. The procedure is performed under general anaesthetic usually as a day case. Puncture wounds are made around the shoulder to allow insertion of instruments to perform key hole surgery. The AC joint is located and a burr is used to remove a small portion of the end of the clavicle.

What are the potential risks of surgery?

The risks of the operation include infection, bleeding, nerve damage and incomplete relief of symptoms.

What is the recovery after surgery?

Dr Butt will see you after surgery and explain you about surgery and post-operative regime. You will have a sling to wear for comfort after the surgery that is usually discarded after the initial 2-3 days. You will see Dr Butt Physiotherapist prior to discharge from the hospital. You will be given painkillers to take home after surgery. The use of an ice pack on the shoulder may also be helpful for the first few days after surgery. Dr Butt will see you in 2 weeks when your wound will be inspected and sutures removed.The pain will gradually settle and you will regain the movement in the shoulder over the next few weeks although it can take several months before you fully recover from the surgery. You can return to desk and computer work when you feel comfortable, avoid any heavy lifting or sporting activities for 4-6 weeks.

AC JOINT INJURY

Introduction

AC joint injury usually results from a fall directly onto the shoulder and is common in contact sports such as rugby. Direct impact can lead injury to the ligaments that surround and stabilise the AC joint are damaged. In less severe injuries there may only be a sprain (not tear) of the ligaments and majority of the stabilising ligaments are intact, in complete rupture of ligaments the collar bone can dislocate from its location leading to bump in the shoulder.

Symptoms

Partial rupture of the ligaments (Sprain) can lead to swelling and pain, after a few weeks the acute pain will settle and you will gradually regain motion in the shoulder. In complete rupture the collarbone dislocates and a bump appears. Not all patients get persisting symptoms, but those that do complain of pain and weakness that is particularly noticeable with overhead activities.

Will I need any further investigations?

Diagnosis is usually made on examination, X-ray and in some cases MRI scan is required.

Non-surgical options?

Initial treatment is pain relief, ice therapy, activity modifications and rest. With the guidance of a physiotherapist, range of motion and subsequently strengthening exercises can commence. Most of the time pain is reduced in few weeks and movement is regained. Of those patients that have sustained a complete disruption of the ligaments, there will some that continue to get problems with pain, weakness and failure to return to their pre-injury level.

Surgical Options?

The aim of surgical intervention is bring the clavicle back to its original position. In acute injury ( (under 2-3 weeks) my technique is to perform arthroscopic fixation. In chronic injury Iuse a device called the Lockdown (Surgilig), which is a very strong artificialligament designed to acts as a scaffold to encourage soft tissue in-growth. This is done through minimal incision and ligament is passed under coracoid process and secured with a single screw.

What are the potential risks?

The main risks of the operation include infection, bleeding, nerve damage and failure of the reconstruction. But over all the risk are much less then the benefit achieved

What is the recovery like?

Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. The shoulder is rested in a sling for the initial 2 weeks followed by gently mobilisation as per physiotherapy instruction.

Dr Butt will provide you with clear instruction to follow. You will be given painkillers to take home. Ice pack is highly recommended to reduce swelling. Sutures will come out in 2 weeks. You will see Dr Butt in 2 weeks and then 6 weeks.

When can I return to normal activities?

Depending on nature of your job, you can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for around 3 months. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.

SHOULDER REPLACEMENT DISLOCATIONS

Introduction

The shoulder joint is a ball and socket joint, where the socket is naturally quite shallow. The labrum is a cartilage rim that surrounds the socket to enhance stability of the joint along with capsule and ligaments

Instability results secondary to torn labrum plus capsular structure. A tear in the labrum is commonly described as BANKART LESION. This commonly occurs at the front of the shoulder (3 o’clock to 6 o’clock position), as the majority of shoulder dislocations are when the humeral head dislocates in front (Anteriorly)

Subluxation is abnormal movement of the humeral head within the socket but not frank dislocation. There can be several reasons as to why this occurs and these determine the treatment modality.

First time dislocation in young patients has high risk of recurrence.

There are two main categories:

• Traumatic – a large force is imparted on the shoulder joint that is violent enough to displace the ball out of the socket e.g. rugby tackle, significant fall etc. More often than not, the dislocation needs to be reduced in an A & E department. Bankart lesions are often created by this mechanism of dislocation, which predisposes the shoulder to recurrent dislocations. • Atraumatic – this dislocation occurs as a result of a small force being imparted on the shoulder joint e.g. turning in bed, reaching above head height for an object. Reduction in A & E is not often required. It is common in people who have generalised joint laxity or hypermobility i.e. many joints are lax, especially knees, hands, elbows. A change in the muscles around the shoulder that normally coordinate to keep the shoulder in joint ensues. Loss of muscle interaction in certain positions of the arm occurs causes repeated instability. Because abnormal muscle coordination or patterning is responsible this is often best treated with sustained physiotherapy and re-training of correct muscle patterning.

It should be noted that overlap does exist between these two groups, particularly over time, as some patients may start in the traumatic group but eventually end up in the atraumatic group i.e. continue to dislocate with low energy mechanisms.

Stabilisation procedures aim to prevent further shoulder dislocation; repair of the Bankart lesion and tightening of the capsule is the mainstay of this type of surgery and can be done by shoulder arthroscopy.

Who should have stabilisation surgery

The best method to prevent repeated shoulder dislocation is to strengthen and coordinate the muscles of the rotator cuff and shoulder girdle. This is best supervised by an experienced physiotherapist.

Surgical stabilisation is an option when non-operative management fails. Success of stabilisation surgery is greater in patients with no inherent physiological factors i.e. hypermobility, voluntary dislocations.

Current evidence suggests that patients that sustain their first dislocation traumatically may be at high risk of re-dislocation if they:

Are young active patients (<30yrs) • Intend to continue to participate in athletic overhead activity or contact sports For patients that continue to dislocate over a long period of time, bony damage to the socket may occur (glenoid erosion). X-ray or CT scan can detect this pre-operatively. In the case of confirmed glenoid bone loss, arthroscopic Bankart repair may no longer be a suitable surgical procedure and a bone block stabilisation procedure (Bristow-Latarjet) should be considered. This is open surgery and Mr Patel will discuss the likelihood of this with you at your consultation.

Will I need any tests/scans?

It is likely that X-rays and a CT scan will be requested for shoulder dislocation. A MR arthrogram may also be requested. This is like a standard MRI but prior to the investigation, dye is injected into the joint under local anaesthesia to increase the sensitivity of the scan to demonstrate a Bankart lesion. Please see the section Surgery FAQs to see if you will need any other tests e.g. blood tests before your surgery.

How is it done?

Arthroscopic stabilisation (Bankart repair) is carried out under general and/or regional anaesthesia.

Three portals (incisions <1cm) are made around the shoulder. If a Bankart lesion is present this is reattached to the glenoid rim by using 2-3 small bone anchors (devices that are inserted into bone and have very strong suture attached). If the capusle is excessively loose (also a cause for recurrent dislocation which can occur in isolation with atraumatic dislocations or with a Bankart lesion in traumatic dislocations) this can be tightened (capsular plication) using the same technique. At the end of the operation, steri-strips or one stitch is used to close each portal. Waterproof dressings and then a bulky dressing pad are applied to absorb the natural ooze from the joint. The arm is always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal. The Bristow-Latarjet procedure is an open procedure also carried out under general and/or regional anaesthesia. An incision is made at the front of the shoulder. The coracoid process is transferred to the deficient area of the glenoid with its muscles attached; this replaces the deficient bone and the muscles act as a further dynamic restraint to further dislocation. The coracoid is fixed in place with a screw and washer. The wound is closed with a dissolvable stitch; the area should be kept clean and dry for 2 weeks. A dressing and polysling are then applied.

Can I go home the same day?

More often than not, as with most arthroscopic surgery, this is a day case procedure.

Occasionally an overnight stay is advised depending on post-operative comfort levels and time of day of the surgery.

What about after the operation?

You will see a physiotherapist before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises out of the polysling and light stretches, often with assistance (e.g. your other arm or your physiotherapist) and you will be instructed on axillary hygeine. You should aim to exercise the shoulder 3-4 times a day; although the shoulder will be sore to start, there should be no lasting pain or pain that is not alleviated by the analgesia prescribed to take home. Sleeping with a pillow under the shoulder is recommended. It will be painful to sleep on the side of the operated arm for several weeks. Restrictions of movement: for 6 weeks Mr Patel recommends no combined abduction and external rotation and restriction of forward flexion to shoulder height. These apply to the Bristow-Latarjet procedure also.

You will be prescribed analgesia to take home and Mr Patel strongly advocates its use to keep pain to a minimum; it should be noted that pain is more difficult to control if allowed to establish itself. Mr Patel recommends the regular application of ice as an adjunct to relieve pain and swelling in the acute post-operative period.

You will see Mr Patel two weeks after surgery for a wound check (and stitch removal) and a physiotherapy program will ensue thereafter which is paramount to the success of the operation. You are likely to have been seeing a physiotherapist before the operation and Mr Patel will liaise with him/her in detail to advise on the post-operative exercise program. For this procedure, Mr Patel recommends return to work (sedentary) when you feel able; for manual work this may be 3-4 months. Driving can resume after 6-8 weeks, as can swimming breastroke. Return to freestyle swimming, overhead athletic activity and contact sport is recommended at 3-4 months. These apply to the Bristow-Latarjet procedure also.

What are the potential complications?

All surgery carries a risk. Specific risks to arthroscopic shoulder stabilisation are: Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. Mr Patel also recommends that you take regular analgesia and use ice (see Surgery FAQs) to help minimise post-operative discomfort and facilitate early movements.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered Non-union – this applies to the Bristow-Laterjet procedure. Despite good fixation, very ocassionally the bone transfer does not heal. Re-operation and stimulation may be required in this instance.

Device failure – rarely, the bone anchors used for arthroscopic stabilisation can migrate (move out of position). They will need to be retrieved if this happens as if they are not flush with the glenoid surface or left to float around the joint, they can cause damage to the articular surfaces. The screw used for the Bristow-Latarjet procedure may also migrate; re-operation to revise the fixation will be necessary in this circumstance.

Recurrence – redislocation can and does occur. Good compliance with post-operative rehabilitation will reduce your risk greatly. Contact sports carry a higher risk for redislocation.

ARTHRITIS OF THE SHOULDER

Introduction

Arthritis of the shoulder leads to loss of cartilage lining of the ball and socket, this causes 2 rough surfaces to rub against each other causing pain. Arthritis of the shoulder is less common than arthritis affecting the hip or knee although the symptoms can be very disabling.

Symptoms

Patient feels deep-seated pain and stiffness, which develop over months to years. Patient may feel grinding, locking and catching sensation with loss of joint motion. Pain is made worse with activity and often felt at night making sleeping difficult. Loss of motion in joint may make it difficult to carry out simple activities of daily living.

Diagnosis

X-rays are required to look for wear of the joint space and for the presence of bone spurs (osteophytes). CT scans allow for a more detailed assessment of the joint and are very useful when planning surgery.

Non-operative treatment

Painkillers and anti-inflammatory medication may help reduce pain. Physiotherapy have a role to prevent stiffness but can not be very effective. Cortisone injections into the shoulder joint may provide some temporary relief.

Operative Treatment

When conservative measures fail Total Shoulder Replacement is considered a valuable option to relief pain and improve function of the joint. The typical total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket. Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have arthritis and non-functional rotator cuff. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the rotator cuff to lift the arm.

What is the success of surgery?

Current advances in new technology and experience in shoulder surgery has made total shoulder replacement a reliable operation to relieve symptoms of pain and improve shoulder function.

What are the risks of surgery?

The risks of the operation include infection, bleeding, nerve damage, stiffness and dislocation. The prosthesis may wear down and the components may loosen.

What is the recovery after surgery?

The shoulder is protected in sling for 6 weeks. Supervised physiotherapy programme is initiated. It is essential after the operation to have physiotherapy, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will meet Dr Butt physiotherapist before discharge. It is advised to take regular pain killers as per instruction and ice therapy is essential to reduce swelling. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. Sutures will be removed in 2 weeks.Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so. You will be unable to drive for at least 6 weeks.

REPALCEMENT

Introduction

Arthritis of the shoulder leads to loss of cartilage lining of the ball and socket, this causes 2 rough surfaces to rub against each other causing pain. Arthritis of the shoulder is less common than arthritis affecting the hip or knee although the symptoms can be very disabling.In intact rotator cuff tendons a total shoulder replacement is standard treatment of choice. When a joint replacement is required but there are significant concerns that the rotator cuff is torn or not functional then a reverse shoulder replacement is more appropriate. In reverse total shoulder replacement, the socket and metal ball are placed in opposite side. That means a metal ball is attached to the shoulder bone (Glenoid) and a plastic socket is attached to the proximal humerus.

What does the surgery involve?

You will be admitted to hospital for 2-3 days following surgery. The surgery is performed under general anaesthesia with a local nerve block. The arthritis from the shoulder is removed and replaced with ball and socket prosthesis.

What is the success of surgery?

Current advances in new technology and experience in shoulder surgery has made total shoulder replacement a reliable operation to relieve symptoms of pain and improve shoulder function.

What is the recovery after surgery?

The shoulder is protected in sling for 6 weeks. Supervised physiotherapy programme is initiated. It is essential after the operation to have physiotherapy, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will meet Dr Butt physiotherapist before discharge. It is advised to take regular pain killers as per instruction and ice therapy is essential to reduce swelling. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. Sutures will be removed in 2 weeks.Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so. You will be unable to drive for at least 6 weeks.

What are the potential risks of surgery?

The risks of the operation include infection, bleeding, nerve damage, stiffness and dislocation. The prosthesis may wear down and the components may loosen. pe (camera) and instruments to repair the tendon. Specially designed small anchors are placed into the bone. The anchors have sutures attached that are passed through the torn tendon and tied to secure the tendon back onto the bone. Any inflamed tissue (bursa) and bone spurs are removed with shaving instruments.

What is the success of surgery?

Generally, this is a safe and reliable operation to relieve your symptoms. Overall the operation has a success rate (pain resolved and return of good movement and function) of 85-90 although it can be several months before you get the full benefit from surgery.

What are the potential risks of surgery?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The risks of the operation include infection, bleeding, nerve damage, stiffness and incomplete relief of symptoms. Occasionally despite that the tendon has been repaired back to the bone, it fails to heal and re-tears.

What is the recovery after surgery?

The shoulder will be protected in a sling after the operation for a period of 6 weeks. During this time you begin a supervised rehabilitation programme under the guidance of a physiotherapist. It you have a very large tear repaired, then the rehabilitation is taken more slowly. After 6 weeks you can begin using your arm gently for daily activities which is gradually increased as pain allows. Heavy lifting should be avoided for 4-6months. Physiotherapy is essential after the operation, to encourage good movement, rehabilitate the muscles back to normal function and ensure you are making good progress. You will see a therapist prior to discharge from the hospital. You will be given painkillers to take home after surgery. The use of an ice pack on the shoulder may also be helpful for the first few days after surgery. You will be seen in clinic two weeks after surgery to check the wounds and assess your progress. There are no sutures to be removed.

When can I return to normal activities?

Return to work depends on the nature of the job and your speed of recovery. You can return to desk and computer work when you feel comfortable to do so. You will be unable to drive for at least 6 weeks until after the sling is removed. The timescale for which you can go back to any previous sport or activity will depend on your movement and strength and the particular activity you have in mind.

TENNIS ELBOW

Introduction

Tennis elbow or lateral epicondylitis is common elbow condition. It leads to pain on the side of the elbow where the muscles of the forearm and wrists attach. Golfer’s elbow or medial epicondylitis is a similar less common condition that causes pain on the inner side of the elbow. The condition is caused by repetitive damage to the tendons of forearm and wrists at their attachment site on the bone leading to degeneration.

Symptoms

The pain and tenderness around the outside (tennis elbow) or inside (golfers elbow) of the elbow is aggravated by activities that involve gripping and movements of the wrist. Sometimes the pain is referred further down the forearm.

Diagnosis

Tennis and golfer’s elbow are usually diagnosed on history and examination findings. An x-ray is occasionally needed to rule out bony pathology.

Non-surgical options?

The first line of treatment is splinting and physiotherapy to relieve discomfort in early stages. If early intervention fails Dr Butt offers ultrasound guided steroid injection. Recent evidence has supported injection of platelet-rich plasma (PRP), the patient’s own platelets (blood-clotting cells) are taken from their own blood; the white part is separated from red in a special machine and injected into the diseased tendon

What does surgery involve?

Surgical treatment for tennis elbow can be performed by either open (via a small incision) . Golfer’s elbow surgery is carried out through a small open procedure. Both involve release of the affected muscle/tendon insertions from the bone and removal of the abnormal tissue.

What is the success of surgery?

The surgery is done as day case and generally a safe operation. The success rate is 80-90% although it may take several months to feel the full benefit from the surgery.

What are the potential risks of surgery?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The risks of the operation include infection, bleeding, nerve damage and incomplete relief of symptoms

What is the recovery after surgery?

After completion of surgery you will go home on the same day. The dressing is removed after 48 hours. Dr Butt physiotherapist will meet you and advise on postoperative exercises. You will be seen in clinic two weeks after surgery to check the wound and stitches will come out.

Return to work depends on the nature of the job. You can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for 4-6 weeks. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.

ULNAR NERVE DECOMPRESSION

Introduction

The ulnar nerve is one of the three main nerves in your arm. It travels from your neck down into your hand, and can be constricted in several places along the way, such as beneath the collarbone or at the wrist. The most common place for compression of the nerve is behind the inside part of the elbow. Ulnar nerve compression at the elbow is called “cubital tunnel syndrome.”

Numbness and tingling in the hand and fingers are common symptoms of cubital tunnel syndrome. In most cases, symptoms can be managed with conservative treatments like changes in activities and bracing. If conservative methods do not improve your symptoms, or if the nerve compression is causing muscle weakness or damage in your hand, your doctor may recommend surgery.

Symptoms

Most patients report numbness and tingling in the ring and little fingers, which may be worse with the elbow bent and at night. Pain and achiness on the inner side of the forearm may also be present. More severe cases can result in muscle wasting, weakening of the grip and difficulty with finger coordination.

Will I need any further investigations?

Diagnosis is based on history and clinical examination findings although electrical tests (nerve conduction studies) are often performed to confirm the location and severity of compression. Non-operative option

If your symptoms have just started, it is recommend an anti-inflammatory medicine, such as ibuprofen, to help reduce swelling around the nerve.Although steroids, such as cortisone, are very effective anti-inflammatory medicines, steroid injections are generally not used because there is a risk of damage to the nerve.Bracing or splinting as padded brace or split to wear at night to keep your elbow in a straight position is some time effective.

Surgical option

This short procedure is carried out under general anaesthetic. A small incision is made on the inside of the elbow and the tight tissue is released to relieve the compression of the nerve within the tunnel. Very occasionally, the nerve is found to flip around to the front of the elbow (subluxing nerve) in which case it may be necessary to move (transpose) the nerve to a pocket of tissue in a more forwards position. The wound is closed with absorbable sutures and a dressing and soft bulky bandage applied.

What is the success of surgery?

Generally, this is a safe and reliable operation to relieve your symptoms. However, it is important to be aware that if the nerve has been badly compressed for a long time, recovery will take longer and occasionally may be incomplete. In this situation surgery should at least prevent the problem from getting worse.

What are the potential risks of surgery?

Any surgical procedure carries risks, however every effort is made to minimise these to ensure the best possible outcome from your surgery. The commonest risks of surgery include infection, bleeding, scar tenderness and failure to fully cure the problem.

What is the recovery after surgery?

After completion of surgery you will go home on the same day. The dressing is removed after 48 hours. Dr Butt physiotherapist will meet you and advise on postoperative exercises. You will be seen in clinic two weeks after surgery to check the wound and stitches will come out.

Return to work depends on the nature of the job. You can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for 4-6 weeks. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.

CARPAL TUNNEL SYNDROME

Introduction

Carpal tunnel syndrome causes numbness, tingling, weaknessin your hand due to compression of median nerve on the wrist.

The median nerve and several tendons run from your forearm to the wrist joint under a small tunnel called carpal tunnel. The median nerve controls movement and feeling in your thumb and first three fingers (not your little finger).Pressure on the median nerve causes carpal tunnel syndrome. Illnesses such diabetic mellitus, rheumatoid arthritis and hypothyroidism is a risk factor in developing carpal tunnel syndrome.

Patient complains of pins and needles over thumb, index finger, middle finger, and half of the ring finger.

Diagnosis

Diagnosis is based on detail history and clinical examination. Special test like (Electromyography) is useful tomeasures the tiny electrical discharges produced in muscles. During this test a thin-needle electrode is inserted into specific muscles. The test evaluates the electrical activity of your muscles when they contract and when they’re at rest. This test can determine if muscle damage has occurred and also may be used to rule out other conditions. Nerve conduction study. In a variation of electromyography, two electrodes are taped to your skin. A small shock is passed through the median nerve to see if electrical impulses are slowed in the carpal tunnel. This test may be used to diagnose your condition and rule out other conditions.

Non-operative options?

A wrist splint that holds your wrist still while you sleep can help relieve symptoms of tingling and numbness.Nonsteroidal anti-inflammatory drugs (NSAIDs)such as ibuprofen may help relieve pain as initial treatment.

In some cases Dr Butt may offer injection of steroid into carpal tunnel to relieve your pain.Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve.

Surgical Option

It’s a day case procedure and can be done under local anaesthesia. The goal of carpal tunnel surgery is to relieve pressure on your median nerve by cutting the ligament pressing on the nerve. The surgery is done through a small incision. It’s a day case procedure and can be done under local anaesthesia. The goal of carpal tunnel surgery is to relieve pressure on your median nerve by cutting the ligament pressing on the nerve. The surgery is done through a small incision.

What are potential risks?

Surgery risks may include incomplete release of the ligament, wound infections, scar formation, and nerve or vascular injuries. The final results of endoscopic and open surgery are similar.

What is the recovery after surgery?

After completion of surgery you will go home on the same day. The dressing is removed after 48 hours. Dr Butt physiotherapist will meet you and advise on postoperative exercises. You will be seen in clinic two weeks after surgery to check the wound and stitches will come out.

Return to work depends on the nature of the job. You can return to desk and computer work when you feel comfortable to do so but avoid any manual work, heavy lifting or sporting activities for 4-6 weeks. You may return to driving when you feel safe to control the vehicle, which is usually about 10-14 days after surgery.