Shoulder Surgery – what’s it all about?

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By Harry Brownlow, November 2017

Shoulder surgery comes in many forms and is performed for many reasons. The majority of shoulder problems can be treated without the need for surgery. For example, most shoulder pain due to calcific tendonitis or rotator cuff problems can be managed with physiotherapy and cortisone injections. However, if you have a clavicle fracture or shoulder arthritis then the only feasible solution might be an operation.

Nearly all shoulder operations can be performed as daycase procedures. That means going home on the same day. The only times that someone might have to stay in hospital overnight are a) for pain or nausea management: so that we can give strong painkillers (eg shoulder replacement) or to control postoperative sickness, b) if you have nobody to stay with (you must stay with a responsible adult for 24 hours after general anaesthetic), or c) if there are other medical problems which mean it would be safer to monitor progress overnight (eg sleep apnoea).

While it is possible to perform shoulder surgery with the patient awake I prefer that you have a general anaesthetic.

While it is possible to perform shoulder surgery with the patient awake I prefer that you have a general anaesthetic. For several years we used to do shoulder surgery, even big operations, under a block (numbing the arm but keeping you awake). Over time I came to realise that having a block had several major disadvantages; the process of numbing the shoulder requires the injection of local anaesthetic around the major nerves in the base of the neck. This can be a really unpleasant or even frightening experience. And while every precaution is taken there is a small risk of puncturing the lung (pneumothorax) or damaging important nerves permanently.

But the most common problem of using a block is trying to control the pain once the block wears off. Typically it wears off in the middle of the night and I have watched tough rugby players brought to tears by this rebound pain. We have found that by using a general anaesthetic, local anaesthetic infiltration into the wound, and a cocktail of different types of pain killers we can confidently manage pain and know that you will not be pacing the house at midnight! Most shoulder operations are painful for about 2 weeks and may require regular painkilling tablets be taken during this time. However, after that point the pain starts to become more manageable and the patient usually requires none or only a little simple analgesia.

If you have to use a sling for several weeks it will surprise you how adept you become at managing with only one arm.

Depending on the type of shoulder surgery it may be necessary to wear a sling for some time. If you have to use a sling for several weeks it will surprise you how adept you become at managing with only one arm. You would still have use of your hand and some controlled movement is allowed at the shoulder so that you would be able to use a keyboard and cutlery at waist level. The most important aspect of wearing a sling is that it makes it illegal to drive. So, you must have considered this before your operation to think about how you are going to manage your job and activities. If you have surgery for a dislocated shoulder then you will become very frustrated by your sling and there will be a temptation to remove it because, after 2 weeks, you will have no pain and will be feeling good. But the sling is important to limit excessive movement which would pull apart the internal stitches and therefore undo the operation.

In terms of returning to work this is wholly dependent on your particular operation and your particular job. A big operation with 6 weeks in a sling will have a different impact on a manual worker than on someone who can work from home typing on a laptop. This too is something you must have discussed with your surgeon.

Complications of surgery are always a possibility. There is no procedure that has a 100% guarantee of success. The specific risks and complications of shoulder surgery are dependent on both the operation and the patient’s personal circumstances. They need to have been discussed and considered with your surgeon. But thankfully, in general, the risks are smaller for shoulder surgery than for other types of orthopaedic surgery. This is partly because many of our procedures are performed as arthroscopic (keyhole) operations. This involves pumping sterile saline into the shoulder as the operation is being performed and therefore there is very little opportunity for bacteria to settle inside the wound. So the risk of infection is generally low. Additionally, since you can stand up and walk within a few hours of a shoulder operation, there is only a small risk of developing blood clots (DVTs). The commonest complication I encounter is a postoperative frozen shoulder. While this is painful and frustrating it is a temporary hiccup and will get better naturally. An interesting recent study from Australia has shown that people who develop a frozen shoulder after rotator cuff surgery actually did better, in the long run, than those who did not suffer this complication!

I have followed the outcomes of my surgery for years. From almost 5000 operations I have an average success rate of over 90%. So, for those unlucky people who end up having to undergo shoulder surgery, you should be reassured that in the vast majority of people it was a successful process for relieving pain and improving function.