News Category: Shoulder

There are several ways to repair a torn rotator cuff in the shoulder. In this study, doctors used cadavers to compare four different arthroscopic repair methods. The results may be very important since the retear rate after RCT repair in humans is at least 50 percent. Some studies report this rate can be as high as 89 percent.

Sutures used to sew the torn tendon back to the bone can be in a single row or a double row. The single row technique was compared to three of the double-row methods. Results were measured by how much of the surface area was restored. Strength of the sutures and strength of the tendon repair were also measures used to judge the results. Since cadavers were used, the researchers could test the strength of the repair to its limits. This means they could apply loads until the repair tore.

The results showed no difference from one method to another. Double-row sutures cover more of the surface. It’s not clear yet if there’s any benefit to this. All methods could withstand loads up to and past 250 N. The authors explain 250 N is the load placed on the tendon repair after surgery with passive motion during early rehab.

The authors suggest using an open repair method (not arthroscopy) when a stronger repair is needed. There’s less suture slippage and a smaller gap formation with open surgery. The open method may give better mechanical performance. In time with better materials and technique, the arthroscopic method of RCT repair may be equal to the open method in all cases.

Many people are familiar with the terms “shoulder separation” or “AC separation” because this is a common injury among athletes. In this injury the ligaments holding the collar bone (just above the shoulder joint) to the acromion of the shoulder blade are torn or damaged.

Many operations have been tried to help repair this problem. None have succeeded 100 percent. Most often AC joint injuries are treated without surgery. In this study surgeons tested a new way to surgically repair an AC separation. They used six cadavers (bodies preserved after death for study) to do the experiment.

First they applied enough force to stress the AC joint to the point of failure. They measured how much force or load was needed to displace the joint. Then they used three different methods of repair and tested the strength of each reconstruction.

Only one repair method had the same tensile strength as the normal AC joint. This was done using a tendon graft from the wrist (flexor carpi radialis tendon or FCR). The graft was used to replace the torn AC ligaments. The most popular repair method used today (modified Weaver-Dunn procedure) was only half as strong as the normal AC joint.

The authors conclude the FCR tendon graft is a better way to repair AC joint separation. This method restores the normal anatomy and provides a stable joint. They say the technique is fairly easy to perform. No screws or wires are used preventing problems that occur with that type of fixation.

Rotator cuff tears (RCTs) are often repaired with surgery. The torn tendon is reattached to the bone and allowed to heal. Too much motion at the site of repair can cause failure of the repair. This is the first study to compare motion at the tendon-bone interface after two different methods of repair.

There are two commonly used ways to hold the tendon in place until healing occurs. This is called fixation. The first is with suture anchors. The second involves threading the suture through a tunnel drilled in the bone. This method is called transosseous suture repair.

Surgeons at Columbia University used cadavers to compare the results of these two fixation methods. First they cut the supraspinatus tendon where it attaches to the shoulder. This simulates a RCT. Then they used one of the two repair operations to fix the rupture. The arm was rotated in and out 10 times while digital photos were taken.

Special imaging software was used to analyze the photos. The researchers were able to show how much motion occurs between the tendon and bone during these motions. They found the transosseous repair had the best fixation. Too much motion can disrupt the healing tissue.

The authors conclude the transosseous suture repair is a stronger fixation method, especially for shoulder internal rotation. They point out they only studied these two approaches. There are many variations on surgery for RCTs. More study is needed to find the best way to repair the torn rotator cuff that enhances healing. Limiting interface motion seems to be a key factor.

Which one gives a better quality-of-life? Doctors from the Fowler Kennedy Sport Medicine Clinic in Ontario, Canada looked at this question from the patient’s point of view.

All patients in the study had osteoarthritis. Conservative treatment had been tried for at least six months before surgery was done to replace the joint. Patients were assessed before the operation and again at three, six, 12, 18, and 24 months later.

Measures used included pain, motion, and quality of life (QOL). QOL included satisfaction with results, symptoms, and lifestyle. The authors report no differences in QOL between the two groups after two years. Patients with hemiarthroplasty (partial shoulder replacement) and patients with total shoulder replacement both had improved QOL.

Most studies report results important to the surgeon. The authors say this study is different because it reports results important to patients.

In this study researchers compared standard MRI (magnetic resonance imaging) findings with MRA (magnetic resonance arthrography) for rotator cuff tears. The goal was to see if MRA gives better information than the regular MRI.

MRA is a newer imaging method. A very weak acid solution is injected into the joint capsule. The fluid acts as a contrast agent to show any tears or damage to the rotator cuff. The MRA takes detailed pictures of the tissues without using X-rays.

All patients in the study had shoulder surgery to repair full thickness rotator cuff tears. Each patient had an MRI and an MRA done before the operation. During the operation, the surgeon recorded the direction, type, and size of the tear.

The MRI findings and MRA findings were compared with the surgical results. MRA findings were more specific and sensitive compared to MRI.

The results of this study suggest MRA is a better tool than MRI for helping surgeons select the best surgical treatment. Knowing the size, shape, and type of rotator cuff tear in advance helps the surgeon plan ahead.

Doctors are trying to find a quick and easy-to-use activity scale for the shoulder. The goal is to use activity to predict what will happen to that patient’s shoulder.

Researchers tested five activities for this rating scale. These included carrying objects that weighed eight pounds or more, using arms overhead, and weight training. Two other measures included swinging motion of the arms and lifting objects that weighed 25 pounds or more.

The scale went through several cycles of patient testing. It turns out the activity scale can’t give a prognosis for patients with shoulder problems. It may be better used to describe shoulder disorders.

The authors say more research is needed to find a reliable and accurate way to predict outcomes of shoulder disorders. For now this tool gives a good measure of shoulder activity. It shows what and how much patients are doing instead of how much trouble they are having with specific tasks.

Everyone’s under the gun to cut costs…including doctors and hospitals. In this study orthopedic surgeons compare the cost of open versus closed Bankart repair for the shoulder.

An equal number of patients were in the open and closed groups. All had repeated shoulder dislocations in the forward (anterior) direction. A Bankart repair refers to repair of a torn labrum. The labrum is a cuff of cartilage in the shoulder joint. When the shoulder pops forward out of the joint it pulls on the cartilage with enough force to tear it.

Open Bankart repairs required an overnight stay for pain control. Closed (arthroscopic) repairs were done on a same-day basis. Patients were sent home with oral pain relievers.

The authors report same-day closed surgery had lower overall costs. Arthroscopic (closed) repairs took less time. Equipment costs were higher though. The number of patients who dislocated a second time was higher in the open repair group.

Arthroscopic repair for recurring shoulder dislocation has some other advantages over open repair. The surgeon can fix anything else inside the joint that’s torn during the same operation. According to these authors, younger, more active patients may do better with the open repair.

Debate about the best treatment for patients with shoulder osteoarthritis is ongoing. Studies comparing a partial with a total shoulder replacement have mixed results. In this article researchers review all the latest studies comparing these two operations and report the results.

Sometimes patients don’t need the entire shoulder joint removed and replaced. Replacing only part or half of a shoulder joint is called a hemiarthroplasty. According to the results of this review, the hemiarthroplasty didn’t do as well as the total shoulder arthroplasty (TSA).

Patients with a TSA had better motion and better function two years after the operation. The authors say long-term studies are needed to see if problems occur with either type of implant. Results to date should be considered preliminary.

Orthopedic surgeons’ treatment of rotator cuff tears (RCTs) varies across the United States. In today’s modern medical world, why can’t surgeons agree on how to treat this problem? The purpose of this study was to find out why surgeons vary in their thinking about RCTs.

Surgeons’ opinions were gathered using a two-page survey. The survey was written and tested by a panel of doctors and researchers. There were surgeons from at least four different regions of the U.S.

Questions were asked about how often and what kind of rotator cuff repairs the surgeons did in the past year. They were asked to guess how many patients were unhappy with the results of the operation.

The surgeons were also asked to read four patient cases. They answered questions about how they might treat each one. Treatment choices included no surgery, cortisone injection, physical therapy, and different kinds of surgery.

The results showed a higher rate of surgery success for surgeons with a high volume of operations. Surgeons in practice the longest preferred the open cuff repair. Surgeons with less experience liked the mini-open or arthroscopic method. Geographic area of the country didn’t seem to make a difference in the surgeons’ answers.

The authors report that overall there was a lot of disagreement among the surgeons for most questions on the survey. There were many reasons suggested by the authors for the differences in opinions.

In this study researchers compared the results of two treatments for chronic shoulder dislocations. All patients had a Bankart lesion, which means the labrum is detached. The labrum is a piece of cartilage along the rim of the shoulder joint that helps deepen the shoulder socket.

The first group of patients had a repair of the labrum. Special biodegradable tissue tacks called Suretac were used to repair the lesion. The second group had the Suretac plus a special heat treatment called thermal capsular shrinkage. In this second treatment, heat was used to shrink the stretched out joint capsule before the labrum was repaired.

Everyone followed the same rehab program after surgery. Results were measured by range of motion, strength, and activity level. Anytime the joint popped out (either part or all of the way) the new instability was also recorded. There were no big differences in outcomes between the two groups.

Patients in both groups had equal motion and went back to work about the same time. Getting full strength back took about six months for everyone. Both groups had patients who had another shoulder dislocation after the surgery.

As a result of this study, surgeons at the University of New South Wales in Australia have changed the way they repair Bankart lesions. They’ve switched to a different anchoring system.

In this study low-energy sound waves of energy were used to treat calcium deposits in the shoulder. Two ways to find the deposits were used and the results compared.

In the first group patients pointed to the area of greatest tenderness. Extracorporeal shock wave therapy (ESWT) was directed to that area. In group 2 a special X-ray unit called fluoroscopy was used to locate the center of the calcium deposit.

In the second group, a computer calculated just the right angle and the best distance to give the most precise shock wave focus. Both groups had pain relief and improved motion. The navigation group had much better results when measured by the disappearance of the calcium deposits.

The authors conclude a navigation system is the best way to find and treat calcium deposits when using ESWT.

Surgery to repair a torn rotator cuff helps improve patients’ quality of life. Less pain and improved function are the two main goals. Does the new mini-open method of doing this surgery help patients meet these goals? Researchers at the University of Alberta in Canada think so.

Patients with a full-thickness tear of the rotator cuff were treated with a mini-open repair. They were followed for up to five years. Success was measured by active shoulder motion, patient satisfaction, and return to work status.

According to this study most of the improvement came in the first six months after surgery. All but one patient was happy with the results a year later. More than three-fourths of the patients returned to work at the same level as before the operation.

The researchers tried to see if there was an effect of age or the size of the tear on the final outcome. Other studies have mixed results. The authors were unable to come to any conclusions in this study about these two factors.

Nitroglycerin (GTN) is used to prevent chest pain from heart disease. It works by relaxing the smooth muscle inside blood vessels. In this study GTN patches were used on patients with shoulder tendon degeneration. They got better results than patients who just did a program of tendon rehab.

Researchers tested the patches in patients with chronic shoulder problems. In one group GTN patches were put over the skin of the painful shoulder. They compared the results to shoulder pain patients who got a placebo patch. The placebo patch didn’t have any medication in it but the patients didn’t know that. Patches in both groups were put on the painful shoulder once each day.

Everyone was given a program of daily exercises for shoulder pain from shoulder tendinopathy, tendon damage from wear and tear (degeneration).

Twice as many patients in the GTN group had pain relief and improved motion compared to the placebo group. The way GTN works is unknown. It may be that the nitric oxide (NO) in the patches causes collagen fibers to grow. The result is tissue remodeling and repair.

The authors concluded that the topical use of NO added to a tendon rehab program can help with chronic shoulder tendinopathy.

Is there a difference in results between arthroscopic and open shoulder repairs? Doctors at the University of Calgary Sport Medicine Centre in Calgary, Canada, asked this question. They did a meta-analysis to find out which treatment method is better.

A meta-analysis means the researchers reviewed many studies on this topic. Studies from around the world over many years were included. Key words were put into a computer, and a search was done. All the studies on the subject were reviewed.

Only articles making a direct comparison between the two treatments were included. The patients in all the studies had more than one shoulder dislocation.

They found the risk of having another shoulder dislocation after surgery was 2.4 times more likely when the operation was done using an arthroscope. Patients also went back to their former activities sooner after an open repair.

The authors offered some conclusions from the results of this meta-analysis. They say it shows that open repair with a skin incision was a better way to do shoulder repairs for shoulder dislocations. They suggest that more trials are needed with the newer methods of arthroscopic surgery.

Impingement is a common cause of shoulder pain in adults. The most common symptom is pain in the upper arm when raising the arm up. Either the bursa or the tendon gets pinched during this movement. The problem develops from wear and tear, degenerative changes with aging, or both.

Physical therapy (PT) is often the recommended treatment. What kind of PT works best remains unknown. In this study a group of therapists from Sweden compared the use of acupuncture with ultrasound for shoulder impingement.

Patients in two groups were treated by PTs twice a week for five weeks. Each patient carried out a home exercise program. Group one also received ultrasound. Group two got acupuncture. Each treatment was done twice a week for five weeks.

The results favored exercise with acupuncture over exercise with ultrasound. Patients in the acupuncture group had less pain, more function, and less disability after 10 sessions. The authors conclude that acupuncture should be considered before ultrasound in the treatment of shoulder impingement.

Orthopedic surgeons at the Cleveland Clinic Foundation in Ohio did this study. They wanted to see how accurate office-based ultrasound studies are in finding rotator cuff tears of the shoulder.

Each patient was examined and X-rayed. Ultrasound (US) and magnetic resonance imaging (MRI) were done before surgery. Results were compared after the operation when the doctor knew for sure what the problem was.

There was no difference between US and MRI. Both were able to find the size and type of rotator cuff tear. The US wasn’t as good as MRI when it came to showing if the tear was partially or fully torn.

The authors conclude that US studies of the shoulder done in the surgeon’s office can help diagnose rotator cuff tears. The surgeon can look at the results of the exam, X-rays, and US to plan the best surgical approach. Failure of the US to show partial versus full tears doesn’t impact the surgery.

The main purpose of this study was to see how much weight patients gained right after shoulder arthroscopy. The second goal was to find out what causes the weight gain.

It all started with a doctor who had shoulder arthroscopy to repair a rotator cuff tendon. The day after surgery he weighed himself. He had gained 15 pounds! There were no other symptoms of any kind. He was worried he might have congestive heart failure. A trip to the emergency room proved it was just fluid from the shoulder surgery.

In this study patients having shoulder arthroscopy were weighed before and after surgery. The same scale was used each time. The same person recorded the weight each time. Patients were weighed without shoes and socks while wearing a hospital gown. After the operation the weight of the sling and bandages was subtracted from the total weight.

It turns out everyone gained some weight. Some patients only gained two pounds. Others gained up to 20 pounds. The average weight gain was 10 pounds. Most of the weight gain was from the fluid pushed into the joint to separate it and give the surgeon room to work.

Some swelling goes away within the first 30 to 45 minutes. The rest of the extra fluid is slowly absorbed by the body over the next few days. Too much fluid retention can lead to nerve damage, difficulty breathing, and skin injury.

The authors warn surgeons to be aware of this possible problem. Shorter surgery time can help reduce the amount of fluid pushed into the joint. It doesn’t seem to matter what size tube is used to send the fluid into the joint.

The debate over open or closed surgery for rotator cuff repair rages on. If anything the differing opinions have become more intense. Some doctors say open surgery is best for small, easily managed tears. This study compares two groups of patients. One group had the open cuff repair. The second group had the first series of arthroscopic repairs done by the surgeon.

Patients in the study had rotator cuff tears of all sizes (small to large). Everyone was followed for at least 15 months and some up to two years. The same surgeon did all the operations. The first 32 patients had the open method of repair. Then the surgeon switched to using the arthroscopic approach for the next 67 patients.

Results in both groups were measured using a pain scale. Patients were asked to report how long it took to become pain free. Everyone was asked if the results of the operation were satisfactory. The closed group had much better pain relief in the first week after surgery. Overall time to reach a pain free period was the same for both groups (about two months).

The authors conclude that arthroscopic surgery is successful for rotator cuff tears of all sizes. Patient reports of decreased pain and increased mobility makes this operation a good choice.

Athletes who throw overhead are at risk for injury to the shoulder. Trauma and overuse are the most common causes. In this study surgeons report on the results of arthroscopic repair of a type II SLAP lesion. Their main interest was in athletic activity after the operation.

SLAP stands for superior labral anterior posterior. It refers to a tear in the labrum of the shoulder joint. The labrum is a fibrous rim of cartilage around the socket of the shoulder. It helps give depth to the shallow opening where the ball-shaped head of the humerus fits.

A Type II SLAP lesion tells the surgeon where the tear is located. The upper (superior) part of the labrum and the biceps tendon are torn. Part of the biceps muscle attaches just above the labrum. A Type II SLAP lesion is unstable. Surgery is needed to repair the damage.

In this study overhead throwing athletes with a Type II SLAP injury were divided into two groups. The first group had a SLAP lesion as a result of overuse. The second group was injured by trauma. All players had an arthroscopic repair with two stitches. One suture was placed at the 11:00 position on the shoulder socket. Another suture went at the 1:00
position.

Ninety percent of the players returned to sports six months after a rehab program. Three fourths were able to play at their preinjury level with only a little discomfort now and then after playing.

The trauma group was more likely to have a complete return to their former level of play. Baseball players were less likely to return to full play compared to other athletes using overhead motions. The authors think the joint capsule might get stretched out over time in the overuse group. Baseball players must be more precise than other overhead athletes. These factors may explain the differences in results between groups of athletes.

Rotator cuff tears of the shoulder aren’t common in children. When they occur, it’s usually because of chronic overuse. Overhead-throwing athletes are at greatest risk. In this report, surgeons present four cases of adolescent rotator cuff tears. All four were athletes between the ages of 12 and 14.

Case 1: A 12-year old boy hurt his shoulder at least twice during different activities. He was involved in many sports such as swimming, football, hockey, weight lifting, and golf. His injuries occurred during skateboarding and baseball. The case was unusual because he had very few positive signs of a rotator cuff tear. CT scan, MRI, and surgery all confirmed a complete tear of the subscapularis tendon.

Case 2: A 14-year old boy injured his shoulder during a wrestling match. Pain and weakness didn’t go away with conservative care. An MRI showed a tear in the subscapularis tendon but the family didn’t want surgery. After a year he finally had surgery because of continued symptoms. The patient was able to return to sports six months after the operation.

Case 3: A 12-year old boy felt something tear in his shoulder after throwing a baseball. Despite normal motion and normal strength in that arm, he couldn’t throw without pain. The MRI was negative so they tried nonoperative therapy. None months later he had arthroscopic surgery. They found a partial tear of the supraspinatus tendon. The bones were still growing in that area so they couldn’t repair the tendon. His sports activities were limited after that.

Case 4: A 14-year old boy tore his supraspinatus tendon during a hockey injury. He had pain and decreased range of motion. He was unable to regain his strength even after two months of physical therapy. At the time of surgery to repair the tear the surgeon saw bone fragments around the edges of the torn tendon. After the operation, his strength came back and he returned to playing hockey.

Rotator cuff tears are uncommon in teenagers. Delays in diagnosis occur because the case doesn’t look like a typical rotator cuff tear. Doctors must look at clues from the history, exam, and imaging studies to make the correct diagnosis. MRIs seem to give the best results over other imaging studies for this problem.