PROCEDURES & STEROID INJECTIONS
Procedures.
Surgery may be an ideal treatment for many common shoulder problems, particularly those that fail to respond to conservative therapy. They can range from minimally invasive arthroscopic procedures (in which a scope and surgical instruments are inserted through keyhole incisions in your shoulder) to more traditional open surgeries using a scalpel and sutures. Each approach has its pros, cons, limitations, and appropriate uses.
ARTHROSCOPIC PROCEDURES
INSTABILITY REPAIR
- Anterior Bankart
- Posterior Bankart
- Remplisage
- SLAP repair
ROTATOR CUFF REPAIR
- Decompression / Acromioplasty
- Debridement
- Cuff tear repair
- Biceps tenodesis / tenotomy
THORACIC OUTLET SYNDROME: Pectoralis minor tendon release
OPEN SURGICAL PROCEDURES
FRACTURES: Open reduction and fixation
INSTABILITY:
- Laterjet procedure
- Posterior bone block
ROTATOR CUFF:
- Open repair
- Tendon transfer
JOINT REPLACEMENT:
- Proximal humerus fractures
- Arthritis
- End stage rotator-cuff pathology
Steroid Injections.
Steroid or cortisone injections are often used as first line of treatment in chronic shoulder conditions and much less frequent in acute injuries.
WHAT IS A CORTISONE INJECTION?
Cortisone is a hormone normally produced by the body as a response to stress. One of its many functions is that it is a very potent anti inflammatory agent.
The steroid used for cortisone injection is betamethasone (Celestone). This is a powerful synthetic steroid preparation. Celestone consists of a water soluble and fat soluble component. The fat soluble component is slow to release for a long term effect and the water soluble component releases almost immediately for immediate anti inflammatory effect.
INDICATED
As already mentioned, the injections are mostly indicated for chronic shoulder conditions with chronic inflammation as a result. The most common indication could be subacromial bursitis also called rotator cuff syndrome or impingement. It can also be used for AC joint pain, biceps tendinitis and intra articular injection for frozen shoulder and for arthritic conditions.
WHAT SHOULD I EXPECT?
The injection can be described as being uncomfortable, but not extremely painful.
Cortisone is mostly administered associated with a local anaesthetic for immediate pain relief within a few minutes. This pain relief is also an indication that the diagnosis is correct. The pain relief will last approximately three to four hours after which the shoulder will become progressively painful until the next day. Ordinary pain medication, i.e. Myprodol, is usually sufficient for control of this pain.
Should the injection be effective in treatment of the pathology, the pain should subside from the next day, and get progressively better.
A follow up examination will be scheduled 14 days after the injection at which point a discussion would be made regarding the result of the treatment.
HOW MANY INJECTIONS WILL I NEED?
The amount of injections depend on the effectiveness of the injections in relieving the pain and discomfort experienced in the shoulder.
Different scenarios can develop after cortisone injection of the shoulder.
- No pain relief within minutes after the injection usually indicates there might be other pathology than what the injection was indicated for.
- Relief of symptoms for only one to three days after injection after which the pain and discomfort returns to the level as before. This usually indicates that the injections will not be successful in treating the pathology.
- Relief of symptoms for ten to fourteen days after the injection indicates that the injections might be an effective treatment. Under these circumstances the injections will be repeated with fourteen day intervals for three consecutive treatments and that will then be the treatment of choice. It is however important to note that a maximum of three injections can be given in a period of three to six months. (Depending on the symptoms, the surgeon will make a decision on further treatment).
- Relief of symptoms for an extended period after the first injection, this is unfortunately uncommon, but obviously a very good result. No further injections is indicated until symptoms reappear.
HOW LONG WILL THE INJECTIONS LAST?
Depending on the scenarios as mentioned above, the length of time of relief of symptoms is highly variable. In the case of effective relief of symptoms, this effect might last from only a few weeks to several months.
It is however important to remember that the injection only gives relief of symptoms. The original pathology that was the cause of the symptoms is not addressed. Therefore it is unfortunately highly unlikely that steroid injections will give relief permanently.
WHAT ARE THE RISKS OF STEROID INJECTIONS?
Unfortunately all medical procedures involve some risk. However, the complications associated with steroid injections are very rare. The injection is given locally for local effect and fortunately seldom has any systemic effects. Some of the risk associated with steroid injections may be:
- Infection at the injection sight. This is however very uncommon.
- Allergic reactions to the local anaesthetic or steroid preparation.
- In diabetes a slight elevation of the blood glucose levels might be experienced.
- Tendon ruptures due to injection in the shoulder area is very uncommon.
- Development of skin pigmentation or stretch marks over the injection sight might occur in cases where excessive numbers of injections were given.
It is however very important to notify your surgeon of any side effects you might experience after the injection, as this is important in deciding on continuation of the treatment. Furthermore it is also important to note that local cortisone injections will not cause weight gain as is sometimes believed.
INJECTIONS
The injections can be administered by a qualified general practitioner trained in shoulder infiltration techniques.
However, under most circumstances the injections will be administered by die treating shoulder specialist. Depending on the experience of the surgeon, the injections can be given WITH OR WITHOUT ultrasound guidance.
It is however important to remember that it is always preferred that the injection should be done by the TREATING SURGEON. The reasons for these are:
- The results of the injections are highly dependent on the correct diagnosis.
- The results are also very technique dependent.
- Follow up regarding the effectiveness of the treatment is very important for reliable results.