Tuberoplasty Shoulder: Understanding the Procedure, Indications, and Recovery

What is a Tuberoplasty Shoulder?

Tuberoplasty is a specialized surgical procedure of the shoulder designed to reshape or remove a portion of the greater tuberosity of the humerus, primarily to alleviate subacromial impingement or facilitate rotator cuff repair by creating more space within the joint.

Understanding the Shoulder Joint

To grasp the concept of tuberoplasty, it's essential to understand the basic anatomy of the shoulder. The shoulder is a ball-and-socket joint, comprising three main bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone).

Key anatomical structures relevant to tuberoplasty include:

• Humeral Head: The "ball" portion of the humerus that fits into the glenoid fossa of the scapula.
• Greater Tuberosity: A prominent bony bump on the upper, outer aspect of the humeral head. It serves as the attachment point for three of the four rotator cuff muscles (supraspinatus, infraspinatus, and teres minor).
• Acromion: A bony projection extending from the scapula, forming the roof of the shoulder joint.
• Subacromial Space: The narrow space between the humeral head/greater tuberosity and the acromion. This space houses the rotator cuff tendons and the subacromial bursa.

Subacromial impingement occurs when the rotator cuff tendons become compressed or "pinched" within this subacromial space, often during overhead arm movements. This can lead to pain, inflammation, and eventually, rotator cuff tears. While impingement is commonly caused by a spur or abnormal shape of the acromion (addressed by acromioplasty), it can also be due to an enlarged or abnormally shaped greater tuberosity.

What is Tuberoplasty?

Tuberoplasty, also known as greater tuberosity osteoplasty, is a surgical procedure focused on reshaping or resecting a portion of the greater tuberosity of the humerus. Unlike the more common acromioplasty, which shaves bone from the acromion, tuberoplasty directly addresses the bony prominence on the humeral head.

The goal of tuberoplasty is to increase the clearance between the greater tuberosity and the acromion, thereby reducing impingement, alleviating pain, and improving the range of motion. It is a precise procedure, often performed arthroscopically (minimally invasive), to remove only the necessary amount of bone while preserving the integrity of the rotator cuff tendon attachments.

Why is Tuberoplasty Performed? (Indications)

Tuberoplasty is indicated in specific scenarios where the greater tuberosity is implicated in shoulder pathology. The primary reasons include:

• Primary Greater Tuberosity Impingement: In cases where imaging (MRI, X-ray) reveals an abnormally large or superiorly projecting greater tuberosity that is the primary cause of subacromial impingement, even with a normal acromion.
• Massive, Irreparable Rotator Cuff Tears: When a rotator cuff tear is so extensive that it cannot be fully repaired, the humeral head (and its tuberosity) may migrate superiorly, leading to painful contact with the acromion. Tuberoplasty can help reduce this impingement and improve the remaining shoulder function.
• To Facilitate Rotator Cuff Repair: In some instances, an enlarged greater tuberosity may impede the successful reattachment of a torn rotator cuff tendon or increase the risk of re-tear post-surgery. Reshaping the tuberosity can provide more space and reduce tension on the repair.
• Post-Traumatic Deformity: Following certain fractures of the greater tuberosity, bone healing can result in an enlarged or malformed tuberosity that causes impingement. Tuberoplasty can correct this deformity.

Who is a Candidate for Tuberoplasty?

Candidates for tuberoplasty are typically individuals who:

• Have persistent shoulder pain and limited range of motion due to subacromial impingement.
• Have undergone a thorough diagnostic evaluation, including physical examination and advanced imaging (MRI), which confirms the greater tuberosity as a significant contributor to their impingement.
• Have failed to respond to conservative treatments, such as physical therapy, anti-inflammatory medications, and corticosteroid injections.
• May be undergoing rotator cuff repair where the surgeon identifies the tuberosity as a contributing factor to the tear or a potential impediment to successful repair.
• Are generally in good health and able to undergo surgery and participate in a rigorous rehabilitation program.

The Tuberoplasty Procedure

Tuberoplasty is most commonly performed using arthroscopic techniques, meaning it is a minimally invasive surgery.

1. Anesthesia: The patient receives general anesthesia, often combined with a regional nerve block for post-operative pain control.
2. Incisions: Several small incisions (portals) are made around the shoulder.
3. Visualization: An arthroscope (a small camera) is inserted through one incision to visualize the joint and subacromial space on a monitor.
4. Resection: Specialized arthroscopic instruments, such as motorized burrs, are inserted through other incisions. The surgeon carefully shaves down or reshapes the prominent portion of the greater tuberosity to create sufficient clearance.
5. Concomitant Procedures: Tuberoplasty is often performed in conjunction with other procedures, such as rotator cuff repair, biceps tenodesis, or debridement of the subacromial bursa (bursectomy), depending on the patient's specific pathology.
6. Closure: After ensuring adequate decompression and addressing any other issues, the instruments are removed, and the small incisions are closed with sutures or sterile strips.

Recovery and Rehabilitation

Recovery after tuberoplasty is a critical phase for achieving optimal outcomes. The rehabilitation protocol will vary based on whether other procedures were performed concurrently (e.g., rotator cuff repair requires a more protected recovery).

• Immediate Post-Operative Phase (Days 0-7):

  • Immobilization: The arm is typically immobilized in a sling to protect the surgical site and allow initial healing.
  • Pain Management: Pain medication and ice application are used to control discomfort and swelling.
  • Gentle Movement: Pendulum exercises and passive range of motion (where a therapist or assistant moves the arm) may begin under strict guidance.

• Early Rehabilitation Phase (Weeks 1-6):

  • Protected Mobility: The focus is on gradually increasing passive and active-assisted range of motion, avoiding active lifting or external rotation against resistance.
  • Scapular Stability: Gentle exercises to activate and stabilize the scapular muscles may be introduced.

• Mid-Rehabilitation Phase (Weeks 6-12):

  • Active Range of Motion: The patient progresses to active range of motion exercises, gradually regaining independent movement.
  • Light Strengthening: Isometric exercises and light resistance training (e.g., with elastic bands) for the rotator cuff and periscapular muscles are initiated.

• Late Rehabilitation Phase (Weeks 12+):

  • Progressive Strengthening: The intensity of strengthening exercises increases, incorporating weights and more complex movements.
  • Functional Training: Exercises mimicking daily activities and sport-specific movements are introduced.
  • Return to Activity: Gradual return to full activities, including sports, typically occurs over several months, guided by the physical therapist and surgeon.

Adherence to the prescribed physical therapy program is paramount for regaining strength, flexibility, and function.

Potential Risks and Complications

While generally safe, like any surgical procedure, tuberoplasty carries potential risks, including:

• General Surgical Risks: Infection, bleeding, adverse reaction to anesthesia, blood clots.
• Specific Shoulder Risks:
  • Persistent Pain or Stiffness: Incomplete relief of symptoms or development of shoulder stiffness (arthrofibrosis).
  • Nerve or Blood Vessel Injury: Though rare, damage to nearby nerves or vessels can occur.
  • Re-impingement: Although the goal is to prevent it, re-impingement can theoretically occur if insufficient bone is removed or due to other factors.
  • Rotator Cuff Injury: While designed to help, there's a small risk of iatrogenic (surgery-induced) damage to the rotator cuff.

Outlook and Long-Term Considerations

The long-term outlook following tuberoplasty is generally positive for carefully selected patients. When performed for appropriate indications, it can significantly reduce pain, improve shoulder function, and facilitate rehabilitation, especially when combined with rotator cuff repair.

Success largely depends on:

• Accurate Diagnosis: Identifying the greater tuberosity as the primary source of impingement.
• Skilled Surgical Technique: Precise bone removal without compromising surrounding structures.
• Diligence in Rehabilitation: Consistent adherence to the physical therapy program is crucial for optimal recovery and long-term results.

Regular follow-up with the orthopedic surgeon and physical therapist is important to monitor progress and address any concerns.

Conclusion

Tuberoplasty is a targeted surgical intervention for specific types of shoulder impingement involving the greater tuberosity. While less common than acromioplasty, it serves a vital role in addressing anatomical variations and facilitating the healing and function of the rotator cuff. For individuals experiencing persistent shoulder pain and dysfunction due to confirmed greater tuberosity impingement, consultation with an orthopedic shoulder specialist is recommended to explore if this specialized procedure is the appropriate course of treatment.