News Category: Shoulder

In order to help patients with cuff tear arthropathy, a shoulder injury, many surgeons were settling for partial shoulder replacements, cautioning their patients not to expect full rehabilitation because the surgeons found that the other types of replacements were causing problems. However, researchers began looking into the use of a reverse shoulder prosthesis as a new type of surgery that could offer better results. The reverse procedure literally reverses the ball and socket that are replaced.

Until now, the largest study that looked at reverse arthroplasty (replacement) involved 80 patients with a cuff tear arthropathy, a tear in the part of the shoulder that holds the bones together. Patients had a good response to the surgery, with 96 percent claiming little or no pain at 44 months follow-up. Reverse total replacement has also been performed for other shoulder problems, such as revisions of previous replacements, after tumor removal, and to repair damage from rheumatoid arthritis. The authors of this study wanted to see if the results of this type of surgery were affected by the type of injury that the surgery was meant to correct.

Researchers found 232 patients (average age, 72 years, ranging from 28 to 86 years), who had had this procedure done at one institution between May 1995 and June 2003. The reasons for the surgery included: rotator cuff tears, rheumatoid arthritis, osteoarthritis, fractures, and replacement revisions. Among the 232 patients, 240 procedures were done because 8 patients had both shoulders replaced. The majority of the surgeries (184) were on women.

To evaluate the effectiveness of the surgery, the researchers collected data with x-rays, computed tomography images (CT scans), and range of motion, before and after surgery, as well as Constant scores. The patients were asked to rate their overall experience.

The patients used slings for 1 month after surgery although they were allowed to take them off to do daily activities, as long as there was no lifting. After 1 month, the sling was removed and the patients resumed normal activity to their tolerance. Final data were collected on 191 shoulders in 186 patients. The average Constant score was 22.8 points before the surgery but 59.7 at follow-up. Patient from all shoulder groups showed an average improvement of elevating their arms to 137 degrees after surgery from 86 degrees before surgery.

When the patients were asked to grade their experience, 59.7 percent said that they were very satisfied, 33.3 percent were satisfied, 5.9 percent were uncertain, and 1.1 percent were disappointed.

The patients with cuff tears and primary osteoarthritis seemed to do the best after this surgery than did patients with post-traumatic arthritis and those who were having a replacement revision. Other findings showed that the benefits seemed to be stable after 3 years. When looking at complications, 8 patients in the original group were included, bringing the total number 199 patients for this calculation. The most common complications were dislocation (7.5 percent) and infection (4 percent). Complications such as fractures, hardware breakdown, and others were infrequent.

Those patients who had revision surgeries appeared to have a higher risk than did those patients who were having the surgery for the first time. The total complication rate of 19 percent was lower in this study than in others.

The authors point out that their study was limited because there was no direct comparison between these patients and those who underwent other treatments and follow-up was short, only 2 years. However, the authors conclude that this procedure can be used for patients with cuff tear arthropathy and other shoulder problems, although the approach should be done with caution when these prosthesis are being used for difficult cases.

In this study, one orthopedic surgeon from the University of Florida compared the results of three different operations for the same problem. Each patient had a massive tear of the rotator cuff.

The rotator cuff is a group of four muscles that surround the shoulder. They work together to hold the ball-shaped top of the humerus (upper arm bone) in the shoulder socket. Each muscle of the rotator cuff helps the shoulder move in a different way. A massive tear was defined as two or more tendons with a tear that measured 5 cm or more.

The three surgical procedures used included partial repair, complete repair, and debridement. Debridement is simply removing the frayed edges of a tear and smoothing everything around it.

Each patient was given the same postoperative rehab program. Everyone was followed for at least two years. Results were measured by range of motion and strength.

Overall, the repair patients had the best results. The shoulders were better balanced after surgery. They had better motion and strength. The debridement group had the worst results. The patients got very little pain relief or improvement in function.

This study may be the first one to directly compare all three operations. Most studies look at the results of one type of repair or one type of rotator cuff tear. The authors agree that rotator cuff repairs can be difficult and complex. It’s not always possible to tell who will get good results. They suggest any repair (partial or complete) is better than debridement alone.

Chronic shoulder pain in athletes may be coming from the scapula (shoulder blade). This is most common in overhead athletes. Baseball pitchers or swimmers are affected most often. In this article, Dr. J. D. Kelly, IV from Temple University School of Medicine discusses this particular problem.

Abnormal motion of the scapula is called scapular dyskinesia. Scapular dyskinesia can be observed visually. As the athlete moves his or her arm out to the side and up overhead, the scapula doesn’t glide and tilt smoothly like it should.

Most of the shoulder muscles attach to the scapula. And the shoulder socket is part of the scapula. So scapular dyskinesia affects shoulder motion as well. Athletes report pain, stiffness, and impingement during shoulder movement. Impingement refers to the soft tissue around the shoulder getting pinched during certain movements.

Dr. Kelly reviews the anatomy of the shoulder complex. Special attention is paid to the scapula. He also describes in detail scapular biomechanics (how it moves). Muscle imbalance may occur resulting in scapular dyskinesia.

For example, injury to some other part of the shoulder can cause muscle spasm. Or it can cause reflex inhibition. Reflex inhibition is a way the shoulder has of protecting itself. It does this by keeping the muscles from contracting to limit motion. Pain may be decreased but muscle imbalance leads to scapular dyskinesia.

Surgery can be avoided with a program of stretching, strengthening, and repositioning of the scapula. The author provides a detailed discussion of each aspect of treatment.

He reminds sports medicine health care specialists to look for the cause of scapular dyskinesia above and below the shoulder joint. Ankle sprains, limited back motion, weak hip muscles, or other problems along the kinetic chain can lead to scapular dyskinesia.

The kinetic chain refers to how each part of the body works together smoothly in a sequence from head to toe. For an athlete to throw a ball, there must be a smooth transfer of force from the feet up to the head and neck. Past injuries that have not been rehabilitated fully must be addressed when working with athletes to resolve the problem of scapular dyskinesia.

Small rotator cuff tears (RCTs) can become large tears over time. The four shoulder muscles of the rotator cuff hold the head of the humerus in the shoulder socket. Without this active stabilization, the humeral head moves upward. It starts to rub against the bottom of the acromion. The acromion is the bone that comes from the scapula (shoulder blade) across the top of the shoulder.

The end result is a condition called rotator cuff arthropathy. There is weakness of the rotator cuff, increased wear and tear on the shoulder, and upward migration of the humeral head. In this article, orthopedic surgeons from the University of Southern California review rotator cuff tear arthropathy.

They begin by presenting a summary of the anatomy and biomechanics of the rotator cuff. Results of recent studies explaining RCTs are presented. It appears that there are many factors that can cause RCTs.

Some patients are born with slight anatomical variations that put pressure on the rotator cuff. Age and repetitive use combined together cause wear and tear. Over time, the patient develops painful symptoms, weakness, and decreased shoulder joint motion.

Several theories are offered to explain what actually happens inside the joint with RCT arthropathy. But none of these theories help explain why some people with massive RCTs never develop RCT arthropathy.

Once the exam and X-rays help make the diagnosis, treatment can begin. There is no consensus yet what is the best approach to manage this problem. Conservative care is advised at first. This consists of antiinflammatory drugs and physical therapy.

If nonoperative care fails to relieve symptoms or restore motion, then surgery may be needed. Shoulder replacement is the most common operation. Hemiarthroplasty and reverse ball-and-socket arthroplasty are the two procedures of choice. A hemiarthroplasty just replaces one side of the joint. This is usually the round head with a stem into the upper shaft of the humerus.

Reverse shoulder replacement is a fairly new concept. Instead of a round ball at the end of the humerus that fits into the socket of the scapula (shoulder blade), there is a socket at the end of the humerus. On the other side, a round metal ball is inserted where the shoulder socket normally occurs. The two components still form a ball-and-socket joint but the parts are switched.

The reverse shoulder replacement is gaining in popularity. Patients get pain relief and increased motion. Often, the hemiarthroplasty relieves the pain. But it does nothing to restore normal shoulder motion. Long-term results of this treatment for RCT arthroplasty remain unknown.

Many studies have been done on the treatment of rotator cuff tears (RCTs). Some patients are at risk for retear after repair. Studies show that using a double row of stitches called anchor sutures may be better than a single row of sutures to repair RCTs.

This double-row fixation helps strengthen the anchoring of the tendon to the bone. And it can be done without losing shoulder function. But studies comparing the single-row to double-row repair method are limited.

In this study, 86 adults with a full-thickness rotator cuff tear were included. The tears were all sizes from small to medium, to large, and even massive. The tears were repaired using double-row suture anchors. The operation was done using small incisions and an arthroscope. The authors describe the operation in detail. They include drawings and photos taken with the arthroscope.

The surgeons looked at both patient function and the structural repair to assess the results. An MRI was taken before the surgery and again one year after the operation. A patient exam was performed two years after the procedure.

The retear rate after repair was 40 per cent for the large tears. This compared to about five per cent for the small tears. The overall results showed a better result structurally and functionally after arthroscopic repair compared with open or mini-open surgeries.

The authors suggest patient selection is the key to success with this treatment. Preop MRIs give valuable information before surgery. Shoulders with severe tears and muscle degeneration have worse results. Tendon quality and mobility are important for success using this treatment.

Although the cost of this surgery is higher than the standard open incising operation, the benefits outweigh the costs. Better functional and structural results lead to higher patient satisfaction.

Getting a good X-ray image of the shoulder in a patient who can’t stand or walk just got easier. The new wheelchair axillary view is reported on in this article.

The patient can remain seated in a wheelchair or standard chair. The X-ray cassette is placed on the arm of the wheelchair. The patient’s arm is slightly abducted (moved away from the body). The X-ray beam is positioned just above the shoulder.

This technique has been used successfully since 2002. Shoulder posterior dislocations, fractures, and joint surfaces can be seen with this view. For the trauma patient, it is an easy and comfortable position to assume.

The previously used standard position called the Velpeau axillary view requires patients to stand up and lean back slightly or to lie down. The wheelchair axillary view does not require either of these positions. It can be used with frail older adults, injured patients, or the disabled.

The authors report this view is easy to obtain with good technical quality right in the doctor’s office. Photographs of the patient in position and the X-ray results are provided.

In this study thirty patients with a torn shoulder labrum had an arthroscopic Bankart repair that failed. The results of their second surgery to repair the first are reported. An open Bankart procedure was used to repair the failed arthroscopic repair.

The labrum is a dense fibrocartilage ring that is firmly attached to the bone around the shoulder socket. It provides depth and stability to the joint. When it’s torn, the shoulder can dislocate repeatedly. A Bankart tear means the labrum in the front of the shoulder is damaged.

Surgery to repair this type of injury is usually with an open incision. The results are reliable and hold up long-term. Sometimes stiffness is a problem after an open Bankart procedure. Arthroscopic repair is less invasive and there’s less stiffness afterwards. Some studies report that there are more shoulder instabilities (dislocations) after arthroscopic Bankart repairs.

The patients in this study all had a traumatic event that caused a dislocation after the first operation. The surgeon who performed the repairs on these 30 patients reported some suspected risk factors for their failed surgeries. They did not follow instructions and started to move the shoulder too soon. Immobilization is advised for at least four weeks followed by physical therapy to restore motion.

When the shoulder was opened during the second surgery, the surgeon could see that there weren’t enough tacks or anchors to hold the labrum in place during healing. Improper anchor placement was also noted. These factors may be the reason the repair failed. It’s possible that other patients with these same risk factors have a successful result. More study is needed to find out.

Results were rated as being at least good in 80 per cent of the patients. Loss of motion and limitation in overhead throwing or serving were present in the patients with only fair results. There were no poor results and 100 per cent of the patients said they were satisfied with the outcomes. Most were able to return to their former level of sports activity.

The authors conclude that proper anchor position is important in this surgery. Stiffness after open surgery is not acceptable for athletes. Surgeons will continue to look for ways to improve the arthroscopic technique.

In this article, orthopedic surgeons discuss the evaluation and treatment of five neurologic conditions that can affect athletes. All are seen in players involved in repetitive overhead or throwing activities. They include:

Over the years, many changes have occurred in the treatment of acromioclavicular (AC) separation. In this report, the current management of this condition is reviewed.

AC separation occurs as a result of trauma causing a rupture of the ligaments that hold the clavicle (collarbone) to the acromion. The acromion is a piece of bone that’s part of the shoulder blade. It curves around over the top of the shoulder and attaches to the clavicle to form the AC joint.

A type III complete separation is actually a dislocation of the AC joint. This occurs when the ligaments, joint capsule, and connective tissue are all ruptured. Usually a traumatic accident or sports injury is the cause of the rupture.

To find out how orthopedic surgeons treat this condition, the authors mailed surveys to surgeons treating college and professional athletes. Results were compared to a similar collection of data in 1974, 1992, and 1997.

Thirty years ago, surgery was the preferred treatment for a type III AC separation. Only about 10 per cent of the surgeons reported a nonoperative approach at that time. Today, most surgeons prefer conservative care. An AC immobilizer (sling) is used most often to reduce the dislocation.

A shift in the type of surgery done has also taken place. Many surgeons reconstruct the torn ligament by using a tendon graft. Others choose to repair the damage. Tape, screws, wires, and pins are popular repair methods. Future treatment will likely be influenced by improved graft materials.

The cause of stiffness in shoulder motion called frozen shoulder is slowly unfolding. Thanks to improved technology and lab studies, researchers are now able to examine the affected tissues. Identifying tissue changes at the cellular level may help us prevent and treat frozen shoulder.

In this study, tissue from four patients with frozen shoulder was removed and stained with a special dye. Scientists were able to see that a protein called vimentin was the cause of changes in the anterior (front of the shoulder) capsule. The capsule is a fibrous layer of tissue surrounding the entire shoulder like an envelope.

Staining other sections of the capsule showed that fibroplasia occurs throughout the capsule. Fibroplasia is a term used to describe an excess amount of fibrous or scarlike tissue.

The authors conclude that frozen shoulder is caused by increased levels of vimentin. These changes only occur in the anterior portion of the capsule. It’s the presence of vimentin that causes contracture or tightness. Fibroplasia is a separate process.

Fibroplasia is not the same as contracture. The decreased range of motion associated with frozen shoulder is not caused by fibroplasia. That’s why surgical release of the anterior shoulder capsule is usually enough to restore motion.

Surgical repair of rotator cuff tears (RCTs) is now common. Research to support the best timing and reasons to do the surgery are few and far between. In this study, researchers from the Hospital for Special Surgery in New York City conducted a review of 50 articles published on the topic.

They put together a list of questions they were seeking answers to. For example:

There are at least six ways to describe or classify rotator cuff tears (RCTs). Which one is best? Which one gives the same results no matter who uses it? Finding a reliable way to classify RCTs will help doctors understand and treat this condition.

In this study, a large group of orthopedic surgeons try to find the classification system with the best interobserver agreement. That means everyone using the system comes out with the same (or close) results for each patient.

Arthroscopic videos of 30 patients with partial or full-thickness RCTs were examined by 12 orthopedic surgeons. All 12 were fellowship-trained shoulder surgeons who repair more than 30 RCTs each year.

Each surgeon classified the patients according to size, shape, and depth of the tear. The number of tendons involved and other details were also noted. Analysis of the results showed that experienced shoulder surgeons could identify a partial versus full-thickness RCT.

There was also good agreement about which side of the joint was involved. Depth of tears was not as easy to evaluate. There was poor interobserver agreement for this category. Classification by size (small, medium, large, massive) was fairly subjective. It didn’t take into consideration the size of the patient’s bone or other anatomy.

It is important to find a way to classify RCTs that is precise and consistent. Using arthroscopic video is best when the surgeon can also conduct the study him or herself (as opposed to just watching the video).

The questionnaire used in this study had good interobserver agreement. The next step is to test for accuracy. Both high interobserver agreement and accuracy are needed in finding the best method of RCT classification.

Shoulder instability can cause considerable pain, decrease in motion, and a loss of function. When conservative care fails to help this problem, then surgery may be needed. Open surgical treatment is the standard operation but often leads to shoulder arthritis later.

A newer treatment method using heat to shrink and tighten the loose capsule has also been used. This electrothermal operation is called thermal capsulorrhaphy. Long-term effects of this procedure are unknown. In this study, surgeons present the poor outcome of capsulorrhaphy of one patient.

The patient was a 26-year-old woman with right shoulder pain and a history of chronic shoulder subluxation (partial dislocation). She was treated conservatively but her symptoms didn’t get better or go away. Arthroscopic thermal stabilization was performed.

At first she had a major decrease in her pain and symptoms. The shoulder seemed much more stable. But 18 months later, she started having shoulder pain again. In fact, the pain was severe enough to need narcotics.

X-rays of her shoulder showed severe loss of cartilage throughout the joint. MRI identified bony cysts that weren’t there before her surgery. The shoulder capsule was scarred but not torn or frayed. Conservative cae included steroid injections, pain management, strengthening and once again failed.

Despite shoulder rehab, pain and loss of function continued. A partial shoulder replacement called hemiarthroplasty was done with good results. The authors note that treatment of progressive loss of shoulder cartilage in young, active patients is a challenge. Hemiarthroplasty can provide significant long-term pain relief and improve function.

When large joints like the shoulder are replaced with implants, surgeons try to avoid using cement to hold the implant in place. Cement works well, but problems can develop later. If the implant must be revised or removed for any reason, more bone is lost scraping the remaining cement out.

This is the first study to report the results of using compaction bone-grafting as a fixation method for total shoulder arthroplasty (TSA). Arthroplasty is another word for joint replacement.

Compaction bone-grafting takes the round head of the humerus (upper arm bone) after it is removed and breaks it down into tiny pieces. The pieces are referred to as morselized bone.

The humeral implant is placed down inside the open canal of the humerus. The graft material is put around the implant. The implant is used to tamp or compact the bone in place. The surgeon knows that there is enough bone graft in place when the implant can no longer be pulled out or twisted inside the canal.

Patients with poor bone quality were chosen for this procedure. If the surgeon put the implant down into the bone and could still wiggle it from side to side, compaction bone-grafting was used. Likewise, if the implant slid down into the bone too easily, then this fixation method was applied. Fifty-eight shoulders were treated with compaction bone-grafting.

Results were measured over a five-year period of time. Pain, shoulder comfort, function, and quality of life were used to gauge the success of this method. X-rays were taken to assess the position of the implant and quality of the bone.

Corticosteroid injection (CSI) is used by many physicians in the treatment of rotator cuff tendinitis. The goal is to relieve shoulder pain and improve function. But does it really work?

According to this systematic review of nine other studies, the answer is no. Although CSI may help some patients, the evidence doesn’t support its use for most people. By reviewing and comparing the results of nine other studies, the authors present the best available evidence on the use of CSI.

Studies reviewed included random controlled trials (RCTs), a measure of the highest level of evidence. In RCTs, some patients get the treatment and others do not. Injections were made into the subacromial joint. All patients had rotator cuff disease. Results are compared using the same methods of testing and measuring.

Overall, there was no difference in pain, motion, or function after CSI. Patients who did experience improvement were no better off than those who didn’t when retested three months later.

The authors suggest further study is needed including measuring the accuracy of injections. X-rays or ultrasound could be used to show exactly where the injection goes and to compare the results based on placement of CSI.

In this case report, orthopedic surgeons describe a 28-year old woman with severe shoulder pain. Immediate lab and MRI imaging tests led doctors to consider joint infection called septic arthrosis as a possible cause.

Without the correct treatment right away, septic arthrosis can cause serious joint damage. Urgent arthroscopic exam was scheduled. After draining a milky white fluid from the joint, the surgeon was able to see the problem.

Calcium deposits in the joint had caused an inflammatory response called calcific tendinitis. Usually a patient of this type would develop the more common shoulder bursitis from irritation of the tendon. This was a rare presentation.

The calcium deposits were removed and the joint irrigated. The patient had a good outcome with symptoms improved and no further problems. The authors note that calcific tendinitis usually goes away on its own. Conservative care with physical therapy is often all that’s needed.

However, painful symptoms occur during the resorptive phase. This is when the body starts to absorb the calcium crystals and the joint starts to heal. Since there’s no way to tell how long the symptoms will last, patients often want immediate treatment.

If conservative care isn’t effective, then arthroscopy is considered. In this one case, the minimally invasive procedure was required due to the potential danger of joint infection.

There’s a fine line between normal shoulder motion and shoulder joint give called laxity. Everyone’s shoulder has some give. Too much joint laxity can lead to an unstable shoulder that becomes painful or needs treatment.

Testing for shoulder laxity can be a challenge for the physician. Failure to
identify the correct direction of instability may delay or misdirect treatment. Sometimes a normal laxity pattern is overtreated by mistake.

In this article, orthopedic surgeons from Johns Hopkins University review
tests and measures for shoulder laxity. Biomechanics of the six shoulder motions possible are discussed. They offer guidance as to the clinical usefulness of various shoulder laxity tests. Photos of the more reliable tests are provided.

Patients are more relaxed lying down so most of the tests are performed in this position. With the patient lying on his or her back, the scapula or shoulder blade is also stabilized. This means it is less likely to rotate affecting the results of testing.

The advantages and disadvantages of five tests are reviewed. These include the anterior drawer test, posterior drawer test, load and shift test, sulcus sign, and the Gagney Hyperabduction test. The physician keeps in mind that testing shoulder laxity while the patient is under anesthesia usually results in half a grade more.

The authors conclude by saying that the normal range of shoulder laxity varies greatly from person to person. One shoulder may be more lax than the other.
The physician must distinguish between joint laxity that’s normal and joint
instability.

Being able to move the head of the humerus up over the rim of cartilage around the socket can be a variation of normal. Instability is usually painful and the extra motion presents a problem.

Full shoulder motion relies on normal movement of the scapula (shoulder blade). The scapula has three main motions: internal rotation, upward rotation, and forward tipping. In this study, three dimensional (3-D) analysis of scapular movement was performed on two groups of adults.

Both groups had 17 members. Group 1 had loss of shoulder motion for unknown reasons. Group two had normal motion and no reported shoulder problems. Researchers used a magnetic motion capture system to compare scapular motion between the two groups.

Motion was tested in the standing position. Each person moved the arm through five repetitions of shoulder forward elevation. The results showed that people with impaired shoulder motion had greater scapular upward rotation compared to their other (normal) arm and compared to the normal group.

The authors suggest the increased scapular motion is one way the shoulder compensates or makes up for a loss of shoulder joint motion. Patients having trouble with daily activities because of decreased shoulder motion may benefit from a rehab program to restore normal scapular motion.

In this review article, orthopedic surgeons from the American Sports Medicine Institute in Alabama offer five points to help guide the surgical treatment of SLAP lesions.

SLAP stands for superior labrum anterior posterior tear. The labrum is a thin rim of cartilage around the shoulder socket. A SLAP lesion describes a tear along the superior or top part of the labrum. It starts in the back of the shoulder and comes all the way up and over to the front. The point at which the biceps tendon attaches to the labrum is also torn.

SLAP injuries are most common in overhead athletes. The symptoms are similar to rotator cuff (RC) tendonitis or rotator cuff tear (RCT). Special imaging called magnetic resonance arthrography (MRA) may be used to diagnose the problem. In some cases, arthroscopy is needed to see the tear.

For day-to-day surgical treatment of SLAP lesions, the authors make these suggestions:

Magnetic Resonance Imaging (MRI) is a useful tool when diagnosing some, but not all, shoulder problems. In this review article, the preoperative use of MRI for the shoulder is discussed. MRI scans are most helpful when trying to detect rotator cuff tears, impingement syndrome, and shoulder instability.

Anatomy of the rotator cuff is presented, as knowledge of these sites is needed when viewing shoulder MRIs. Healthy tendons don’t produce a signal on MRI. Partial-thickness rotator cuff tears (RCTs) are seen as high signal intensity. Full-thickness tears show up as bright fluid throughout the entire tendon.

Shoulder pain caused by impingement from variations in anatomy can be determined from an MRI. Impingements refers to pinching of the soft tissues during shoulder motion.

A flattened surface on the acromion where it should be curved or a hooked undersurface can lead to an impingement syndrome. The acromion is an extension of bone from the shoulder blade that curves around over the shoulder to meet at the collarbone.

The authors also review the anatomy and MRI findings for shoulder instability. Because the shoulder has so much free motion, the muscles and tendons around the joint are important in holding the shoulder in place. Any tears in the joint capsule, ligaments, or cartilage can cause shoulder instability. Instability causes pain but can also lead to dislocation.

The MRI doesn’t give the surgeon all the information needed. For example, cartilage tears don’t always show up very well. An arthroscopic exam is needed for that. And the surgeon relies on the arthroscopic evaluation to determine what type of surgery is needed. CT scanning is used when details of the bone surfaces are needed.