Shoulder

The Eastside Leader in Innovative Solutions

Dr. Santoro is known in the Eastside community for employing minimally invasive shoulder surgery such as arthroscopic rotator cuff and instability/SLAP repair, as well as state of the art shoulder replacement and the latest fracture techniques for the shoulder and upper extremities.

As a team doctor, he sees a wide variety of injuries and routinely performs arthroscopic surgery on the knee, including ACL reconstruction, meniscus repair, cartilage transplantation and patellofemoral reconstruction. He is one of the few Eastside surgeons performing arthroscopic and reconstructive surgery on the elbow and ankle. He also cares for general orthopedic conditions in pediatrics and seniors.

Other specialties include:

  • Shoulder replacements including Reverse TSR
  • Knee replacements with the Depuy system, including the new Rotating Platform (swivel knee)
  • Extensive experience in arthroscopic and open ankle techniques including joint replacement using the Depuy Agility Ankle.
  • Fracture surgery
  • Fluoroscopic injections for arthritis and tendinopathies

Surgical Procedures

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Dislocated Shoulder Surgery

SURGERY FOR THE DISLOCATING SHOULDER

When recurrent episodes of shoulder subluxation or dislocation have lead to chronic functional impairment and an adequate trial of conservative management, including physical therapy and activity modification have failed, then surgical stabilization of the shoulder has been shown to be very affective in eliminating symptoms. Surgical stabilization can be done by way of an open approach, or by way of an arthroscopic approach. There are advocates for both and pros and cons, which will be discussed.

In an open procedure, an incision is made on the anterior or the forward portion of the shoulder for an anterior dislocation and the posterior portion of the shoulder for a posterior dislocation. The goals of treatment are to restore the anatomy and repair the instability. Multiple surgeries have been described for shoulder stabilizations by way of an open approach. In general, a diagnostic arthroscopy should be undertaken prior to any surgical stabilization, to determine the correct diagnosis and the identification of the location of the pathology.

In general, for an anterior dislocation a Bankart lesion, that is a tear of the anterior-inferior corner of the labral tissues plus/minus bony fragment plus/minus laxity in the ligaments should be addressed. An open repair is done by way of a muscle splitting operation and dissection carried down onto the capsular tissues. In general, an incision is made in these capsular tissues and the joint is opened to be evaluated. The degree of laxity and damage is addressed, and in general the labrum is elevated from an inferior position and brought back up onto the glenoid rim. The way in which the labrum and/or ligaments are reattached can be by way of pure sutures passed through, drill holes in the bone, or more commonly used, anchors, which are drilled into the bone and serve as a stabilizing point for sutures to be passed through tissues. In general, these tissues are then advanced up onto the glenoid rim to form a so called buttress, which will then restore the anatomy and give back the labral bumper affect. The so called Bankart repair addresses the primary pathology and is the best procedure for the true primary anterior dislocation.

Historically, many procedures have been done, including just a simple shortening of the muscles, known as a Putti-Platt, and there are a variety of other procedures that have been utilized, but most of these have lead to a failure to address the primary pathology and have long been abandoned.

There are certain centers now, who believe that all chronic instability patients have some loss of bone stalk to the anterior-inferior glenoid, and a transposition of bone by way of either bone graft or a portion of a structure known as the coracoid process may be advanced up onto the glenoid rim to help give both bony and soft tissue stabilization. This procedure is referred to as a Latarjet procedure.

If the primary pathology is posterior, then in like fashion a soft tissue repair of the ligaments and labrum can be addressed in a similar fashion. In some patients with posterior dislocations, a relative tilt of the glenoid known as retroversion may be notable, and bone grafting procedures have been done to address this, in association with a cutting of the glenoid, known as an osteotomy. These are rare.

For patients who have multidirectional laxity, that is instability occurring both anteriorly, posteriorly, and/or inferiorly, then a NEER capsular shift has been shown to be affective in stabilization of the joint.

Most shoulder surgeons prefer now an arthroscopic evaluation of the shoulder, coupled with an arthroscopic repair. Direct visualization of the pathology can be addressed without the need for an open approach, and in similar fashion, the labral tissues plus bone, plus ligament may be advanced up onto the glenoid neck and repaired again using suture anchor technique.

One other pathology that may lead to chronic instability is a Hills Sachs defect. This represents a defect in the posterior aspect of the humeral head and may lead to another stable shoulder, still having ongoing subluxation and/or dislocations, because of the absence of bone. Several techniques have been used to restore the anatomy in this area, including bone grafting of the defect, or a procedure known as a Remplissage, in which the posterior capsular tissues plus rotator cuff may be advanced into the defect and act as one further stabilization point. Arthroscopic techniques can address all pathology within the shoulder joint and are now routinely being used to perform a so called plication; that is a tightening of the ligaments for the multidirectional lax patient. Anterior-inferior, and posterior laxity may be addressed by way of an arthroscopic technique.

TIMING

A dislocated shoulder must be relocated on an emergent basis. Fortunately most shoulder dislocations may be reduced and the patient is not in need of an urgent surgical repair. If the shoulder simply cannot be relocated, then surgical shoulder stabilization becomes an emergent procedure. Often a fracture is associated with this and an open repair is recommended.

For a first time dislocator, it is somewhat controversial to consider a primary shoulder repair. However, certain patients who demand an immediate return to their previous occupation may benefit from early stabilization, especially if they are young, that is less than 20 years of age. Those patients less than 20 have been shown to have a significantly increased chance of recurrent dislocation and primary shoulder stabilization does have its advocates.

RISKS of Dislocated Shoulder Surgery

The risks of either an open or arthroscopic procedure can include infection, anesthetic related issues, temporary or permanent nerve and blood vessel injury, excessive stiffness, recurrence of instability, or hardware problems. Fortunately, these complications are rare.

RECOVERY From Dislocated Shoulder Surgery

Most patients with surgical repair for a dislocating shoulder will benefit from sling immobilization for a period of anywhere from three to six weeks, with gentle range of motion exercises done in the immediate postoperative period.

POSTOPERATIVE

Postoperatively supervised physical therapy is recommended and seems to lead to an increased functional recovery. Depending on the quality of tissue, the stabilization technique utilized, and the occupation or sport that the patient will want to return to, will dictate the ultimate return to function. In general, full range of motion of the shoulder will be appreciated by twelve weeks with gradual return of strength over the ensuing three to six months. Truly most patients will fully recovery by a year, but many patients will have returned to some form of recreational activities as early as three months. The role of bracing postsurgical is not generally a consideration. Some patients may benefit prior to surgery with the use of a SAWA brace or like brace, which can prevent the shoulder from assuming positions which lead to dislocations.

PROS AND CONS OF DISLOCATED SHOULDER SURGERY APPROACH

There are advocates of open procedures who feel that any patient with a chronic dislocation is best served by an open approach, as tissues are felt to often be attenuated and difficult for arthroscopic repair. Training often dictates whether an open or arthroscopic repair is performed.

The pros of an open approach are that an increased tightening may be possible and thus a chance of recurrent dislocation may be somewhat improved. However, this may come at the cost of loss of range of motion.

Arthroscopic techniques in general are less invasive and tend to lead to less stiffness in the shoulder. While anecdotally it seems that patients who have undergone arthroscopic shoulder stabilization improve faster, long term outcomes show that final functional recovery is very similar and results are very similar.

Recurrent dislocations may occur by way of either after an open or arthroscopic repair. The literature tends to show open procedures having a slightly lower recurrent dislocation rate, but an increased loss of motion. For most open approaches, a 5-10% recurrent dislocation rate has been shown in the literature. Arthroscopic techniques, when done correctly, have recurrent dislocation rates very similar to open approaches. The technical understanding and expertise of the shoulder surgeon is often a primary factor in eliminating recurrent dislocations.

SUMMARY

In summary then, open or arthroscopic shoulder reconstructions or repairs have their advocates. Arthroscopic techniques done correctly will give a shoulder that in general, will have a low recurrent dislocation rate and increased flexibility outcome.

Impingement Surgery

Anatomy of Impingement

The acromion is the front edge of your shoulder blade, which sits over and in front of the head of the humerus. When your arm is lifted, the acromion and the surface of the rotator cuff are insulated from each other by the bursa (a fluid-filled sac that aids smooth joint movement).

Injury of Impingement

Impingement pain happens when bone spurs on your acromion and your CA (coracoacromial) ligament press against your rotator cuff. The pressure inflames the bursa that overlies the rotator cuff. A partial tear of your rotator cuff may also cause impingement pain.

Impingement Surgery

Arthroscopic surgery for impingement requires small incisions for the insertion of arthroscope and surgical instruments. A small piece of the CA ligament and the bone spurs on the acromion are removed — which makes more room for the rotator cuff.

Labral Tear Surgery

Anatomy of the Labral Tear

The top of your upper arm bone rests in a shallow socket that’s stabilized by an additional rim of soft, fibrous tissue called a labrum, to which several ligaments attach.

Injury of the Labral Tear

The labrum may be torn above or below the middle of the socket, and tears often occur with other injuries such as dislocations. Often, the result is a destabilized shoulder.

Surgery of the Labral Tear

If the labrum alone is torn, the shoulder may still be stable and the surgeon will remove or repair the torn area and make other corrections. If the tear extends into the biceps tendon or if the tendon is detached, the shoulder is unstable and the surgeon will repair and reattach the tendon with sutures, wires or absorbable tacks. Tears below the middle of the socket are also associated with an unstable shoulder and may require that the labrum be tightened.

PASTA Surgery Frozen Shoulder Surgery

About PASTA Surgery

A distinctive rotator cuff injury, PASTA is common in sports where player contact is part of the play. A sudden hard twist or tug on the arm can result in a Partial Articular Supraspinatus Tendon Avulsion or PASTA tear. With an abrupt pull, the articular — or outer — side of the supraspinatus tendon tears. Since the tear is the result of force, it’s referred to as avulsion.

Arthroscopy is extremely effective in repairing PASTA tears. What’s more, quick and complete recovery is common.

Rotator Cuff Surgery

Anatomy of the Rotator Cuff

This group of 4 muscles and their tendons cover the top of your upper arm bone (humerus), hold it in place and provide stability for your shoulder’s full range of motion.

Injury of the Rotator Cuff

The rotator cuff can tear with a single traumatic injury or after years of use in sports or other activities that require overhead arm extension. Surgery is the only way to improve strength, reattach tendon to bone and keep a tear from getting worse.

Rotator Cuff Surgery

Arthroscopic surgery for a torn rotator cuff is highly effective. A tiny lens, light and set of surgical instruments are inserted through several small incisions. The surgeon operates via a video monitor, suturing (stitching) the tendon onto the bone.

SLAP Tear Surgery

Anatomy of a SLAP Tear

The labrum, a soft, fibrous tissue rim, surrounds the head of your upper arm bone (humerus) where it sits in the socket. With tendons and ligaments anchored to the labrum, the head of the arm bone stays in place and the shoulder joint is secure.

Injury that causes a SLAP Tear

A front-to-back tear in the upper part of the rim of the labrum — superior labral antero-posterior tear — destabilizes the joint, causing pain and catches or clicks during are movement. To regain full range of motion and strength, you’ll probably need surgery.

Surgery SLAP Tear

Most SLAP tears are repaired arthroscopically, where 2 or 3 small incisions and tiny instruments can precisely address the tears. Depending on the severity of the tear, it can be debrided (the torn and fragmented tissue can be trimmed away, leaving a smoother surface) or sutured (stitched back together) and the associated ligaments re-anchored.

Arthroscopy, the minimally invasive surgery, works best with SLAP tears because open surgery doesn’t give the surgeon quite the same access to the tear. You get a better repair — with less pain and stiffness, reduced infection risk, minimal blood loss and a quicker recovery with arthroscopy.

Stabilization Surgery

Anatomy of Shoulder Stabilization

The shoulder is a ball in socket that allows an incredible range of motion. The bony structures include the upper arm bone known as the humerus and/or humeral head and the socket known as the glenoid. In a normal shoulder joint, flexibility and stability are ensured by intact anatomic structures. As described above, the labrum gives static support. The dynamic support for the shoulder is rendered by the ligaments which form the so called capsule. A ligament is the structure that connects one bone to another bone. Surrounding the ligaments are the rotator cuff, which will be discussed later.

Shoulder Stabilization Injury

In the normal shoulder, the labrum, the ligaments, and the rotator cuff and biceps tendon given stability to the shoulder. Stability is defined as maintenance of reduction under physiologic load. When an injury or condition leads to a violation of the labrum, ligaments, or rotator cuff, then the humeral head may be able to be dissociated from the glenoid. A complete dissociation of the humeral head from the labrum is called a dislocation. This is generally produced as a result of a traumatic event. 95% of the time, the shoulder will dislocate in a so called anterior-inferior position; that is the humeral head will rest down and away, forward towards the chest. 5% of the time, the shoulder may dislocate posteriorly. Multiple types of pathology may occur as a result of either an anterior or posterior dislocation.

In a subset of patients who have a generalized hyperlaxity, then the shoulder may shift anteriorly or posteriorly, although, not fully dislocate. This condition is often known as multidirectional instability. When trauma occurs in this group of patients, then a true dislocation can occur.

In certain conditions, which have repetitive trauma, such as throwing or swimming, then the shoulder may sublux, that is, the humeral head will attempt to dislocate, but never fully does so. This leads often to difficulties in diagnosis.

Shoulder Stabilization Surgery

If physical therapy and activity modification is unsuccessful in preventing further dislocations, subluxations, or chronic pain, then surgery may be indicated. The goal of surgery is to render a shoulder that returns back to near full flexibility and stability. This is often very difficult in certain patients.

Several treatments are available, including arthroscopic repair or open repair. Many orthopedists are advocates of one approach relative to another, based on their experience. When surgery is advised and undertaken, the injured structures are repaired, reattached, or tightened. Whether the surgery is done arthroscopically or through a so called open approach, sutures are required to reattach the damaged structures. Most advocate repair back to the glenoid, as this is the primary site of injury.

For those who have multidirectional instability, the classic procedure is a near inferior capsular shift. The tissues are shortened and overlapped and provide a degree of stability that often will lead to improved function. Arthroscopic techniques have also been utilized and appear to be nearly as good as a classic open approach.

Total Shoulder Replacement

Anatomy of Total Shoulder Replacement Surgery

Your shoulder is a ball-and-socket: the rounded end of your upper arm (humerus) sits in the shoulder socket (glenoid). An array of muscles and tendons hold the shoulder together and give it the widest range of motion of any joint.

Injuries That Cause Total Shoulder Replacement Surgery

Osteoarthritis may cause irreparable wear, resulting in bone-on-bone grinding and pain. Severe injuries can make minor repairs impossible. And some rotator cuff damage is so severe that replacement is appropriate.

Total Shoulder Replacement Surgery

In open surgery, your surgeon replaces the damaged ball-and-socket with a plastic socket and polished metal ball attached to a stem. Ball-only replacement is possible with a normal socket and damaged humerus (the decision to do this may be made during surgery).

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BELLEVUE OFFICE

1601 116th AVE NE
Suite 111
Bellevue WA 98004
425-899-4810

KIRKLAND OFFICE

12333 NE 130th Lane
Suite Tan 400
Kirkland, WA 98034
425-899-4810