Arthroscopy is a procedure that our orthopedic specialists use to inspect, diagnose, and repair problems inside a joint. During arthroscopic shoulder surgery, the surgeon will insert a tiny camera, called an arthroscope, into your shoulder joint area. This small video camera projects images onto a TV screen so the surgeon can guide miniature surgical instruments to repair damage inside the joint.

This common procedure has been performed thousands of times since the 1970s and it has made the diagnosis, treatment, and recovery of shoulder surgery easier and faster. What’s more, this results in less pain for you, the patient, and shortens the length of time it takes for you to recover.

When is Shoulder Arthroscopy Recommended?

If your condition is not responding to nonsurgical treatment, your orthopedic specialist may recommend arthroscopic shoulder surgery. Some causes of shoulder discomfort include inflammation that leads to pain, stiffness, and swelling; injury; overuse; and age-related wear-and-tear.

Some of the most common shoulder arthroscopic procedures include:

• Repair of ligaments
• Rotator cuff repair
• Removal or repair of the labrum
• Bone spur removal
• Removal of inflamed tissue or loose cartilage
• Repair for recurrent shoulder dislocation

What Happens during the Arthroscopic Surgical Procedure?

Your orthopedic specialist will perform this procedure in an operating room or day-surgery room. Once you are there, he will position you so it is easy for him to adjust the arthroscope to have a good look inside the shoulder joint. The most common positions are the beach chair position (you semi-seated in a reclining position) and the lateral decubitus position (you lying on your side).

The surgeon and his team remove all hair from the site and then spread an antiseptic solution on your skin to clean it. The shoulder will be draped with sterile pads and your arm will be in a holding device to keep it still and in place.

To inflate and clean out the joint area, the surgeon will inject fluid into your shoulder. This makes it easier for him to see the structures. He will them make a small buttonhole incision to insert the arthroscope. Once your orthopedic specialist clearly identifies the problem, he will use small instruments to repair it.

These specialized instruments are for tasks such as cutting, grasping, shaving, suturing, and tying. The surgeon will close these incisions when he is finished using stitches or small Band-Aid like structures called Steri-Strips. Then the surgical site will be covered with a soft, large bandage.

What Should I Expect after Shoulder Arthroscopy?

In most instances, you will be able to return home on the day of your surgery. You will need someone to drive you home, especially if general anesthesia was used. For some patients, the orthopedic specialist requires an overnight hospital stay. Here are some of the things you will need to know following your arthroscopic procedure:

Shoulder Immobility: The amount you are allowed to move your shoulder will all depend on what was done during surgery. Your doctor will give you instructions related to this and be sure you follow them closely. Your shoulder will be held in a sling, a swath, or a brace following the procedure.

Incision Care: The small incisions should be kept clean and dry. Dressings are usually light and kept on for a few days. Sometimes, the dressing will drain during the first 24 hours but it usually stops. Call your orthopedic specialist if the dressing is saturated with blood and the bleeding does not stop.

Ice: Most of our orthopedic specialists recommend that ice be used to the shoulder to control your pain and the swelling. Excessive swelling is not common and should be reported to your doctor. Use the ice for at least 20 minutes around three or four times each day. Do not place the ice directly on the skin but rather use a towel or soft cloth place between your skin and the ice bag.

Medications: There will be some medications prescribed for pain, usually in pill form. Your orthopedic specialist will control your pain as he sees necessary.

Hallux Rigidus

Big toe arthritis, also called 1st metatarsophalangeal (MTP) arthritis or hallux rigidus, is a common condition affecting the foot and ankle. It is the most common site for arthritis in the foot. Patients typically develop symptoms between age 30 and 60, and females are more commonly affected than men.

Presentation
Patients typically develop stiffness and decreased range of motion at the big toe, which affects walking, running, and other athletic activities. Some patients develop large bone spurs on the top of the foot, which can cause pain with shoe wear and discomfort when going up on the toes.

Causes
Sometimes trauma (a fracture or crush injury) can lead to this condition, but for most patients there is no specific inciting event. Some patients are more likely than others to develop big toe arthritis, either because of some anatomic abnormality or because of genetic predisposition.

Diagnosis
A clinical exam and x-rays can confirm the diagnosis. Generally, advanced imaging like MRI or CT scan is not required.

Treatment
Non-surgical options include anti-inflammatories, shoe wear modifications, and over-the-counter or custom inserts (orthotics). Physical therapy can be helpful to maintain range of motion. Occasionally cortisone injections into the joint can decrease inflammation for a period of time.

Surgery can be used to treat cases that fail non-operative treatment. Traditionally, a procedure called a cheilectomy can be used to remove bone spurs from the top of the big toe joint. This is recommended for mild to moderate cases of hallux rigidus. This is a joint-sparing procedure. Recovery involves walking in a surgical sandal for about 3-4 weeks after the surgery.

For moderate to severe arthritis, a fusion has until recently been the only proven surgical option. This is a joint-sacrificing procedure, in which the bones on either side of the joint are fused together with screws and possibly a plate.

This reliably addresses pain symptoms but eliminates all motion at the joint. Recovery involves a period of non- or heel- weight bearing followed by fully weight bearing in a surgical sandal for 8 weeks or more after the surgery.

Cartiva

A New Surgical Treatment Option

A new option is Cartiva, which can be an alternative to the aforementioned procedures. Cartiva is an organic polymer engineered to match the properties of human cartilage, which is what wears out as arthritis progresses. Your surgeon implants the polymer into the head of the 1st metatarsal, to act as a new joint surface. This is a joint-sparing procedure which retains, and in many cases increases, range of motion.

Recent literature shows greater than 90% patient satisfaction after 5 years of implantation. Recovery is similar to that of cheilectomy, and involves fully weight bearing in a surgical sandal for about 3-4 weeks after the surgery. If the procedure does not resolve pain, a fusion is still a surgical option for you.

Summary

Hallux rigidus is a common condition that involves pain, swelling, stiffness and decreased range of motion of the big toe. Diagnosis is often straightforward and involves a clinical examination and x-ray. Several non-operative treatments exist, including NSAIDs, shoe wear modifications, shoe inserts, and injections.

When non-operative treatment fails, surgery is an appropriate option. Cartiva may be an appropriate treatment option to avoid fusion of the big toe. Please see a qualified foot and ankle orthopedic surgeon if you believe you may be a candidate.

Mark Reed, MD is a fellowship-trained foot and ankle orthopedic surgeon who has undergone training on the Cartiva procedure and has incorporated it in his practice. Please contact OSS to schedule an appointment for an in-depth evaluation.

What is a Dislocated Elbow?

When the joint surfaces of an elbow are separated, the elbow is dislocated. Elbow dislocations can be complete or partial. In a complete dislocation, the joint surfaces are completely separated (Figure 1a). In a partial dislocation, the joint surfaces are only partly separated. A partial dislocation is also called a subluxation (Figure 2).

The elbow is stable due to bone surfaces, ligaments (which connect bones) and muscles. When an elbow dislocates, all of these can be injured to different degrees. A simple dislocation does not have any major bone injury. A complex dislocation can have severe bone and ligament injuries (Figure 3). In the most severe dislocations, there is injury to the blood vessels and nerves that travel across the elbow. If this happens, there is a risk of losing the arm.

Three bones come together to make up the elbow joint (Figure 4). The humerus bone is in the upper part of the arm and attaches to the two bones of the forearm (ulna and radius). Each of these bones has a very distinct shape. Ligaments connect all three bones together. As muscles contract and relax, two unique motions can occur at the elbow:

• Bending occurs through a hinge joint that allows you to bend and straighten the elbow.
• Rotation occurs though a ball and socket joint that allows the hand to be rotated palm up and palm down.

Injuries and elbow dislocations can affect either of these motions.

Elbow dislocations are uncommon. The most common age for an elbow dislocation is 30 years old.

Mechanism of Injury

Elbow dislocations typically occur when a person falls onto an outstretched hand. When the hand hits the ground, the force is sent to the elbow. Usually there is a turning motion in this force. This can drive and rotate the elbow out of its socket. Elbow dislocations can also happen in car accidents.

When the crash happens, the passengers often reach forward to cushion the impact. The force sent through the arm can dislocate the elbow, just as in a fall.

Diagnosis

When the elbow is dislocated, the deformity of the arm is obvious. X-rays are the best way to confirm that the elbow is dislocated. If the bone detail is difficult to evaluate on an X-ray, sometimes a computer tomography (CT) scan will be done. If it is important to evaluate the ligaments, a magnetic resonance imaging (MRI) can be helpful.

However, the doctor will set the elbow first, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.

Risk Factors and Prevention

Some people are born with greater laxity or looseness in their ligaments. These people are at greater risk for dislocating their elbows. Some people are born with an ulna bone that has a shallow groove for the elbow hinge joint. They have a slightly higher risk for dislocation. Nothing can be done to alter these risk factors.

Symptoms of a Dislocated Elbow

A complete elbow dislocation is extremely painful and very obvious. The arm will look deformed and may have an odd twist at the elbow. Get emergency treatment. It is important to evaluate the circulation of the arm and to check pulses at the wrist after an elbow dislocation.

If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is due to the lack of warm blood getting to the hand. It is also important to check the nerve supply to the hand.

If nerves have been injured during the dislocation, some or all of the hand may be numb and not able to move. Further testing such as an X-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation.

A partial elbow dislocation or subluxation can be harder to detect. Typically it happens after an accident, but because the elbow is only partially dislocated, the bones can spontaneously relocate and the joint may appear fairly normal. There may be pain, however. The elbow will usually move fairly well.

There may be bruising on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can recur on a chronic basis if the ligaments never heal.

Treatment Options: Nonsurgical

The goal of immediate treatment of a dislocated elbow is to put the elbow back in joint. The long term goal is to restore function to the arm. First the alignment of the elbow must be restored. This can usually be done in an emergency department. The patient will receive sedation and pain medications. The act of restoring alignment at the elbow is called a reduction maneuver (Figure 1b). This should be done gently and slowly and usually takes two people to perform.

Simple elbow dislocations are treated with early motion after a short period in a splint or sling. Keeping the elbow immobile for a long time usually results in poor range of motion for the recovered elbow. Physical therapy can be helpful during this period of recovery. Some people will never recover full elbow extension even after a course of therapy.

Fortunately the elbow can work very well even without full motion. Once the elbow’s range of motion improves, the doctor or physical therapist may add a strengthening program. Interval X-rays may be necessary while the elbow recovers. This helps to ensure that the elbow joint remains well aligned.

Treatment Options: Surgical

In a complex elbow dislocation, surgery may be necessary to restore bone alignment and repair ligaments. It can be difficult to reduce the joint and to keep it in line. There is an increased risk for arthritis in the joint if:

• The alignment of the bones is not good.
• The elbow does not track well.
• The elbow continues to dislocate.

After the surgery, the elbow may be protected with an external hinge. This device guards against re-dislocation. If there are associated blood vessel or nerve injuries with the elbow dislocation, multiple surgeries may be necessary. These surgeries repair the blood vessels and nerves in addition to reducing the joint. They also fix the bone and ligament injuries.

Research on the Horizon/What’s New?

Treatment for simple dislocations is usually straightforward and the results are usually good. However, many people with complex dislocations still end up with permanent disability at the elbow. Treatment is evolving to improve results for these people.

The best time to schedule surgery is being evaluated for treatment of complex dislocations. For some patients with complex dislocations, it seems that a slight delay for definitive surgery may improve results by allowing swelling to decrease.

The dislocation still needs to be reduced right away, but then a brace, splint or external fixation frame may rest the elbow for about a week before a specialist surgeon attempts major reconstructive surgery.

Moving the elbow early appears to be good for recovery for both kinds of dislocations. However, early movement with complex dislocations can be difficult. Pain management techniques encourage early movement. Improved therapy and rehabilitation techniques such as continuous motion machines, dynamic splinting (spring-loaded assist devices) and progressive static splinting can improve results.

Late reconstructive surgery can successfully restore motion to some stiff elbows. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement.

Severe arthritis can develop in the elbow. For this condition, newly designed elbow replacement prosthesis can be implanted. The arthritic elbow joint can be replaced with an artificial elbow, similar to joint replacements in the hip or knee. This decreases pain and improves motion.