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Two anaesthetics, a vaporiser, a drill and water wings
– what it took it fix my shoulder

Keyhole repairs: Paul Wood’s shoulder pain has now gone

Daily Mail Article - 1st February 2005

The shoulder is the shallowest and most mobile joint in the body – factors which make it prone to dislocation.  Here Paul Wood, 22, who plays rugby for Warrington Wolves and lives in Wigan with his girlfriend, tells ANGELA BROOKS about the injury he suffered, and his surgeon explains the procedure.

THE PATIENT

My shoulder was damaged in November 2003 while I was playing rugby for Great Britian.  I was running with the ball and tackled badly.

My arm was pulled out of its socket and I felt an immense, tearing pain.  I was helped off the pitch and taken straight to see my doctor who said he doubted that I’d broken anything but thought I’d probably done some muscle damage.

He said no-one could be sure until I’d had x-rays and an MRI scan.  I had no shoulder bruising but overnight the pain worsened, so my doctor sent me to see orthopaedic surgeon Mr Lennard Funk.

But by the time I had my first appointment five days later, it hurt less, although any movement was still painful.

I was sent for scans immediately, then Mr Funk carried out a keyhole procedure to loo inside my shoulder joint.  This showed that my shoulder had dislocated – though it had partially gone back into place – tearing the capsule, the shoulder joint lining, at the back.

My shoulder was pretty stiff at that point because I hadn’t been able to use it, but apparently operating on a stiff shoulder is not a good idea because it means a much longer recovery period. 

So Mr Funk started me on physiotherapy to work on the stiffness and tightness, and said he would review the situation later.  If I was still having problems at that stage, he would repair it surgically.

Over the following months, I lived as normal, taking painkillers which made it tolerable, but all the same I was aware that my shoulder was becoming progressively worse.

In September 2004 I went back to see Mr Funk and more scans confirmed my fears.  I had tears in the rim of cartilage around the shoulder socket which helps hold the ball of the joint in place.

Choosing not to have surgery wasn’t really an option.  I knew I’d have to have it done or stop being so active.  Without it, my shoulder wouldn’t have been stable.

So I was admitted to a hospital in Manchester later that month.  I remember being a little worried on my way down to theatre, but nothing too drastic.

I was in a sling for six weeks but after the first three, I could take it off for short while to do exercises.  At three weeks, I couldn’t lift my shoulder or my arm, which was worrying.  But after that, I started to notice gradual improvements.

It wasn’t until the first week in January this year that I started to feel like I was getting back to normal.  And now, for the first time in over a year, I feel good again with no pain at all.

THE SURGEON

MR LENNARD FUNK, consultant orthopaedic surgeon at the Hope Hospital, Manchester says:

The ball and socket joint in the hip is well enclosed whereas the shoulder socket is small and shallow. 

The stability is not provided by bone but by a few structures such as ligaments, a tough rubber-like ring of tissue called the labrum, which encircles the socket, and also by the joint capsule.

That’s why it is so liable to dislocation.

Some people are more inclined towards them, either because they have loose joints, - which is hereditary – or because of their activities and lifestyle.  Dislocations are extremely common in rugby players because of the physically charged nature of the game.

Quite aside from the fact that Paul didn’t want to be out of action by an operation, very few surgeons would have operated on him immediately because his shoulder was very stiff.  This would have compounded the normal stiffness you get post-operatively and this can be extremely hard to overcome.  

When I first examined Paul he simply had a tear in the capsule around the shoulder joint – but when I saw him for review ten months later, he had tears in the rim of tissue around the socket in three places.

The operation was done under general anaesthetic and patients have a regional anaesthetic as well which makes the arm and shoulder numb and will help with pain relief later on.

In theatre the patient is placed in a sitting position with their arm resting at their side.  The first incision I make will be to the side of the most prominent part of the shoulder blade.

Through this tiny 5mm opening – we call it a portal – I insert a tube called a cannula.  Saline solution flows through the tube which expands the joint so we get a better view.  Through this tube we also slip in a tiny fibre-optic camera. 

Then we make another incision at the front of the shoulder in a little recess known as the rotator interval, which is between two tendons.  Through this portal, we can insert probes to manipulate the shoulder structures to properly assess the joint.

What we’re likely to see are tears in the labrum and often a tear in the joint capsule, too – this will almost look like a piece of tissue if you gently pull it apart.

At this stage, I make a second portal in the back of the shoulder.  This is for instruments, but throughout surgery, we alternate the portals to get the best possible views and the best access to the areas we need to repair.

Our first task is to clean up the edges of the tear with a radio-frequency thermal device which vaporises cells.  Then using a filing instrument, we roughen the bone slightly which will make it bleed a little and will help the labrum to stick to it once we reattach it.

With that done, we drill a little hole in the bone and into this we press a sort of V-shaped anchor with a suture – a stitching thread – attached.  By pulling on the suture, the anchor rotates and locks onto the bone.

Now we attach the suture to an instrument similar to a long needle on a stick and push it through the labrum, then tie it down with a knot.  You might need a couple of these anchors and stitches for each tear.  Paul needed six of them for his three tears.

With all the repairs done, I inject a joint fluid replacement solution to replenish the fluid in the shoulder space which will have leaked out in surgery.

The beauty of keyhole surgery is that there are no stitches afterwards.  We just pop little dressings on top of the incisions.

We also use cold compression therapy to help reduce inflammation and swelling.  This means patients leave theatre with a cuff similar to the water wings children wear strapped around their shoulders.  This has a cold water reservoir which allows patients to top it up with chilled water.

Patients were a sling with a strap around the waist for three weeks to keep the arm immobilised and after that they start gentle exercises.  After six weeks the sling comes off and a full physiotherapy programme starts to help strengthen muscles, stabilise the shoulder blade and regain the full range of movement.

Athletes will start specific rehabilitation four weeks later.  For rugby players, it will be a very gentle weight-training programme which will be gradually built up and heavily supervised by the teams’ sports therapists.

Less than 5 per cent of patients will dislocate their shoulder again following this sort of surgery.

I always tell patients I only do a third of the job.  To get a good result, you need the surgeon, the physiotherapist and the patient and if any one of these doesn’t do their job properly, you are not going to get a good result.

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