Anatomy
The shoulder is the most mobile joint in the body. As part of a chain of joints, muscles and ligaments, the shoulder allows the arm to move relative to the upper body. Together, the chain of joints, muscles and ligaments (ligaments) is called the shoulder girdle. It is one of the most complex joints in our body.
The shoulder girdle consists of:
- Sternoclaviculair gewricht: het gewricht tussen het sleutelbeen (clavicula) en het borstbeen (sternum).
- Acromioclaviculair gewricht (AC): het gewricht tussen het sleutelbeen (clavicula) en de bovenzijde van het schouderblad (acromion).
- Scapulothoracaal gewricht: het glijvak (eigenlijk geen echt gewricht) tussen schouderblad (scapula) en borstkas (thorax).
- Glenohumeraal gewricht: het gewricht tussen de kop van bovenarm (humeruskop) en de kom (glenoid). De kom is een onderdeel van het schouderblad.
Muscles
Superficial muscles
- Musculus Deltoideus (monnikskapspier) – Een belangrijke heffer van de arm. Deze loopt van sleutelbeen/schouderblad naar de bovenarm.
- Musculus Pectoralis Major (grote borstspier) – Deze trekt de arm naar binnen en loopt van sleutelbeen en borstbeen naar de bovenarm.
Diepere spieren (rotator cuff)
The rotator cuff is a group of muscles that run from the scapula to the head of the upper arm. These muscles attach with their tendons around the humeral head.
The rotator cuff consists of four muscles:
- Musculus Subscapularis: aan de voorzijde van de humeruskop.
- Musculus Supraspinatus: bovenop de humeruskop.
- Musculus Infraspinatus: boven/achterzijde humeruskop.
- Musculus Teres Minor: achterzijde humeruskop.
The rotator cuff is important for rotational movements in the shoulder. It also plays a major role in stabilizing the shoulder. The rotator cuff ensures that other muscles, such as the Musculus Deltoideus, can do their job properly.
Rotator cuff rupture, torn shoulder tendon
The tendons of the rotator cuff ensure that the shoulder can make rotational movements and that the shoulder joint is stable. For example, the top 2 tendons ensure that, among other things, the head of the upper arm is held against the bowl of the shoulder blade when the arm is raised. However, because of the shape of the scapula, the space the muscles and tendons have to move is not very large. A common shoulder problem is a tear or multiple tears in one or more tendons of the rotator cuff.
The cause may be wear or age of the tendon or trauma, such as a fall. A combination of both causes is also possible. At a relatively young age (from 45 years), this wear and tear of the tendon can already occur. If previous treatment, such as physiotherapy and/or an injection of corticosteroids, has had insufficient results, an arthroscopic cuff repair is the next choice.
The operation
Through keyhole surgery, the torn tendon is sutured back to the bone using bone anchors (a type of plugs with sutures). After the shoulder is covered with sterile drapes, the surgeon makes several small incisions in the shoulder. Through these, the arthroscope (viewing tube) is inserted into the surgical area and the instruments are operated during surgery. With the arthroscope, the orthopedic surgeon first inspects (via images on a monitor) the entire shoulder for any other problems.
Next, the tendon is laid free from the surrounding tissues. After this, the torn tendon is sutured back onto the bone of the upper arm using bone anchors. The sutures allow the tendon to return to its original position as much as possible and allow the tear to heal. If there is not enough space between the roof of the shoulder and the tendon to be repaired, a small piece of the bone of the shoulder roof is removed to make more room.
De ingreep duurt ongeveer 30–45 minuten voor een kleine peesscheur en ongeveer 60 minuten voor een grote peesscheur.
Shoulder instability
An unstable shoulder means that the shoulder capsule is too loose, causing the head of the shoulder to dislocate easily (luxation). If the ball is back in its socket after a luxation, the capsule will generally recover. If, however, a luxation occurs more often, there is a possibility that the joint capsule will no longer recover properly and become too loose.
Shoulder instability can occur after the shoulder has been partially or completely dislocated (the glenoid) as a result of an accident or a severe impact. In the case of a shoulder luxation, in most cases the head will luxate forward out of the bowl of the scapula. After an initial luxation, the shoulder joint can remain unstable due to damage to the shoulder capsule and cartilage ring (the labrum). An unstable shoulder can lead to repeated luxation of the shoulder, even during daily activities.
Bankartrepair
Als de kraakbeenring (het labrum) van de schouderkom (glenoid) is afgescheurd wordt er een Bankartrepair uitgevoerd. Hierbij wordt de kraakbeenring aan het bot van de schouderkom vastgezet met hechtingen en titanium botankertjes (soort schroefjes). Bij voorkeur wordt deze ingreep via een kijkoperatie uitgevoerd. Echter bij patiënten die contactsporten als bv rugby of american football bedrijven zal de orthopedisch chirurg kiezen voor een open procedure. Uit onderzoek blijkt dat de resultaten van de kijkoperatietechniek bij american football en rugbyspelers slechter zijn.
In an arthroscopic procedure, the orthopedic surgeon may immediately retract the capsule (the capsule is then reefed). When reefing, the stretched capsule is loosened from the bone of the shoulder joint and then sutured back in tighter. This causes the capsule to lie tightly around the joint again, making it more stable.
Post-treatment
The hospitalization period for this surgery is 1 to 2 days on average. After surgery your arm will be put in a sling (a kind of sling). The sling prevents you from making (active) movements. These cause too much tension on the shoulder and therefore increase the risk of tearing the stitched tendon or the stitched labrum. It is important that when you wear the sling your hand is higher than your elbow.
You will not be able to fully use the operated shoulder and arm immediately after surgery. Therefore it is advisable to ask someone in your surroundings in advance to help you temporarily with (heavy) housework and shopping. It is also important that you provide clothing that you can easily get on and off, without having to raise the arm. After the operation you have to do many everyday things (such as dressing and undressing, going to the toilet, preparing food) with one hand. It is recommended that you practice this before surgery. It is important to put frequently used items at eye level so you do not have to reach far after surgery.
Revalidatie
Please allow for a rehabilitation period of at least 6 months to 1 year. You will wear the sling for at least 3 weeks and during those weeks you may make some passive (unloaded) movements. After 3 weeks, after a check-up in the hospital, you will gradually start to exercise actively (loaded). If necessary, the physical therapist will explain how to move your shoulder within your pain limits.
Complications
Het risico op complicaties bij dergelijke operaties aan de schouder is gelukkig klein (<1%). Dit kunnen zijn: infectie, bloeding, voorbijgaande zenuwirritatie, verstijving van de schouder en algemene risico’s.
