High or Low? What’s the Optimal Dose of Corticosteroid for the Shoulder?

Orthopedic surgeons, primary care physicians, and rheumatologists often use steroid injections into the shoulder to relieve the pain and reduce inflammation in patients with adhesive capsulitis (also known as “frozen shoulder”). But the optimal dose of steroid remains unclear. Current practice is not based on scientific evidence, but rather, experience, cost, and availability of the drug.

In this study from South Korea, surgeons from the Ajou University Medical Center propose that a high-dose corticosteroid would perform better than low dose in terms of reducing pain and restoring function. To test their hypothesis, they set up a randomized, triple-blind, placebo-controlled dose-comparative study. Triple blind means that no one (not the patient, not the person injecting the drug, and not the evaluator) knew who was getting what (drug, drug dose, placebo).

There were 53 total patients divided (randomly) into three groups: low-dose corticosteroid (20 mg triamcinolone acetonide), high-dose steroid (40 mg of the same drug), and placebo (saline injection). The two dosages selected were based on current practice by most physicians. Injections were guided using ultrasound for accurate placement of the drug or placebo. Everyone in all three groups was given a 10-minute follow-up exercise program to do three times daily for 12 weeks.

Outcome measures included pain level, range-of-motion, function, and level of disability. All patients were tested before treatment and again after treatment at regular intervals (one week, three weeks, six weeks, and 12 weeks after injection).

There is much concern about using high-dose corticosteroid drugs because of the potential for negative (adverse) effects. Other studies have shown that higher levels of steroid can cause complications and problems. For example, changes in skin coloration, tendon ruptures, nerve lesions, and loss (atrophy) of tissue have been reported. But too low of a dose might not provide the desired change in symptoms, so determining the optimal dose for this particular problem would be very helpful.

Everyone in the study got better. The two steroid groups had significantly more improvement than the placebo group. But there were no significant differences between the low- and high-dose patients in terms of pain, motion, and function. A few patients experienced some reactions to the drugs (e.g., facial flushing, dizziness) but no one had any infections, skin or soft tissue changes, or other adverse effects.

The authors concluded that a 20-mg dose of steroid injection given early on in the course of adhesive capsulitis is advised. This gives the same benefit as higher dose treatment but with lower risk for local and systemic side effects.

They further commented that this particular drug is a long-acting corticosteroid. Different results might be obtained if using a short-acting steroid. This is also a short-term study and results may change as time goes by. Further follow-up of these patients will be done and outcomes reported at a later date.

Is the Reverse Shoulder Replacement the Answer to Rotator Cuff Deficiency?

For a while now, there has been the notion that poor results of traditional shoulder replacements for patients with severe rotator cuff tears could be improved with a new type of implant. That implant is called a reverse shoulder arthroplasty (more about this in a minute). But as more studies are completed, the clinical perception that the reverse shoulder arthroplasty has better results has come under question.

In this study from New Zealand, results for severely damaged shoulders from massive rotator cuff tears using the reverse shoulder arthroplasty are compared with hemiarthroplasty. Now for a brief description of these two surgical approaches.

The “normal” artificial shoulder was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our normal shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid.

This situation has been compared to placing a ball on a shallow saucer. Without something to hold it in place, the metal ball simply slides around on the saucer. In the shoulder that “something” is the rotator cuff and the muscles that attach to the tendons. Without a rotator cuff to hold the metal ball centered in the plastic socket, the metal quickly wore out the plastic socket and the joint became painful once again.

The answer to this dilemma was to rethink the mechanics of the shoulder joint and design an artificial shoulder that worked differently than the real shoulder joint. The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be.

This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final goal is to have a shoulder that functions better, is less painful, and can last for years without loosening.

With the hemiarthroplasty operation only half of the hip is removed and replaced. (Hemi means half, and arthroplasty means joint replacement.) The hemiarthroplasty replaces only the ball portion of the shoulder joint, not the socket portion.

As this study showed, by comparing 102 patients who received the reverse shoulder arthroplasty with an equal number of patients who received a hemiarthroplasty, results could be compared equally. Items compared included differences in operating times, survivorship of the patient and/or the implant, and revision rates (i.e., second surgeries affecting the implants). In each group, half the patients were women and half were men.

Outcomes were first compared and reported six months after the first surgery. Everyone was followed for at least three years. Some patients were in the study for up to 11 years. They found that reverse shoulder arthroplasty did, indeed, provide better function and results were considered “superior” to that of the hemiarthroplasty.

Healing and recovery seemed to take longer in the hemiarthroplasty group. Younger patients in both groups had the worst function. And patients in the reverse shoulder group had higher rates of complications (e.g., dislocations, infections, ongoing pain, loosening of the socket).

Overall, the results support the use of reverse shoulder arthroplasty (over hemiarthroplasty) primarily for older patients with a degenerative shoulder joint and humeral head collapse from a massive rotator cuff tear. In fact, the authors suggest “use of the reverse shoulder arthroplasty should continue to be restricted to elderly patients.”

Is Obesity a Contraindication to Reverse Total Shoulder Arthroplasty?

Traditional anatomic total shoulder replacements have been shown to aid in reducing pain and improving motion and function in very obese patients. But when compared with adults who are not obese (and who also receive an anatomic total shoulder replacement), results are definitely not as good. The obese patient is more likely to have problems and complications and less likely to be happy with the results.

The “normal” or anatomic shoulder replacement was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our anatomic shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid.

A different type of implant has been developed for use with older adults who need a shoulder replacement but who have a severe tear of the rotator cuff tendons. The four muscles and their tendons that make up the rotator cuff fit around the shoulder joint and help hold the joint stable yet provide full range-of-motion at the same time. This alternate replacement device is called a reverse total shoulder arthroplasty (RTSA).

But without an intact rotator cuff, the implant often loosens and/or the shoulder dislocates. This can be prevented by reversing the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be. This new design provides a much more stable shoulder joint that can function without a rotator cuff. How well does it work with people who have an intact rotator cuff but have a different problem: they are obese.

To find out, the reverse total shoulder arthroplasty (RTSA) was used in three separate groups and results compared in this study. The three groups included 17 obese patients, 36 patients who are overweight, and 23 patients in the normal weight category. The patients were placed in each group according to height and weight using the World Health Organization’s well-known Body Mass Index or BMI measurements.

Patients ranged in age from 51 to 88 years old. Follow-up was started two weeks after surgery and continued at six weeks, three months, one year, and then every two years for up to five years. The study is ongoing but the mid-term results are published here.

Data collected and used to compare results included surgical time, amount of blood loss during the procedure, and length of stay in the hospital. They also compared postoperative complications (type and rate). And, indeed, they found that obese patients were able to regain significant amounts of lost motion but they also had significantly more complications than the other two groups. The obese patients lost more blood during the procedure, but surgical time and length of hospital stay were the same among all three groups.

Complications were greater in the obese group for several reasons. Surgical difficulties occur just due to the amount of adipose tissue (fat) that must be cut through to get to the shoulder joint. Fatty tissues tend to have less blood flow to them (they are said to be poorly vascularized). This lack of blood flow can delay or impair healing.

Many more patients in the obese group also had diabetes, a known factor in decreased circulation and delayed wound healing. And the infection rate of 18 per cent in the obese group was clearly much higher than for the nonobese group who had no (zero per cent) infections.

The authors concluded that obesity is NOT a contraindication to reverse total shoulder replacement. But patients should be warned of the high complication rate, especially for the risk of infection. Of course, they can also expect the same improvements in motion and reductions in pain obtained by nonobese patients. Time will tell if other changes (positive or negative) will occur in the long-term results. This study will continue with additional reports published in the future.

Surgery for Scapular Problems

Without the scapula (shoulder blade), smooth and coordinated motion and function of the arm is compromised. Problems affecting the scapula that can disrupt the motion and rhythm of arm movement include bursitis, snapping scapula, and tumors (benign or malignant) of the bone or nearby soft tissues. Disorders of the scapula are rare and a thorough understanding of the anatomic features of this structure is needed to treat them successfully.

That’s why two orthopedic surgeons wrote this article reviewing the anatomy and physiology of the scapula motion and stability. They go on to discuss the conservative (nonoperative) and surgical management of a specific problem known as snapping scapula syndrome. Details of what they have learned performing arthroscopic surgery on the scapula are provided. They say that complete familiarity with the scapula and surrounding soft tissues (including easily damaged blood vessels and delicate nerves) is essential to avoid unnecessary problems caused by the surgery.

Snapping scapula syndrome is as the name suggests: when the arm moves, some portion of the scapula drags against the rib cage causing a snapping sound and sensation. Pain is often (though not always) a main feature associated with this problem. Patients present with a range of severity from mildly irritating to extreme debilitation. The people affected most often are usually young athletes involved in activities requiring repetitive overhead motion.

An understanding of the knowledge we have about this problem is important because surgery doesn’t always “fix” the problem. That’s why conservative care is recommended first. This approach may include medications and change in activity type/level to reduce inflammation. If these measures don’t help, then one to three steroid injections may be tried.

Physical therapy to address posture and weakness or imbalance in muscle function is a key feature of the nonoperative approach to snapping scapula syndrome. Patients are advised to be patient as the rehabilitation process can take up to six months to be effective. Only when there are tumors or “masses” should surgery be considered sooner.

When six months (or more) of conservative care fails to change the clinical picture, then surgery to remove a portion of the bone and/or inflamed bursae may be advised. The authors take the reader through both open and arthroscopic surgical techniques for snapping scapula syndrome.

Drawings, photos of patient positioning, arthroscopic images, and CT scans are used to illustrate the step-by-step approach described. Special tips are provided to aid the surgeon in avoiding injury to the nerves and blood vessels. Newer portal placements (insertion points for the arthroscope needle) developed for this surgery are described.

Specific surgical tools are recommended (e.g., shielded round burr) when performing scapular resection (removal of part of the scapular bone). And instructions are given to assist the surgeon in avoiding removing muscle fibers along with the bone. The removal of any kind of masses in the area depends on type, size, and location of these tumors. And finally, the authors review the rehabilitation protocols they use and summarize results of surgical management of snapping scapula syndrome from published reports.

In summary, disorders and diseases of the scapula don’t come in neat, tidy packages. There is a wide variation of symptoms and treatment must be tailored to each individual patient. The goal of pain relief and improved (or restored) function may be met with nonoperative care. When surgery is necessary, understanding of the anatomy and careful surgical technique are both very, very important. Patients should be counseled that results reported for surgical treatment of this condition are not always as expected or hoped for.

Healing After Rotator Cuff Tear Not Necessary for Improvement

Adults with very large tears of the rotator cuff (four tendons/muscles surrounding the shoulder) can get pain relief and improved function after surgical repair — even if the tendon doesn’t heal. These are the results of a small study of 15 to 18 patients who were followed over a two to 10 year period of time.

Results were reported two years after the arthroscopic repair in the first study by the same authors of this second study (with the same group of patients). Outcomes were re-measured 10 years after the primary (first) surgery using ultrasound studies and patient self-report of pain, motion, and function. That’s when the surgeons discovered two things.

First, the results were the same at the 10-year post-operative time as compared with results two years after the surgery. That means the patients were able to maintain outcomes without further decline. And second, a failed healing in 17 of the 18 patients didn’t keep them from improving and holding that improvement steady over the years.

X-rays and ultrasound studies done on 11 of the original 18 patients confirmed the continued presence of rotator cuff tears. In a couple of patients, the tear was worse. There was no change in four shoulders and four patients actually had a decrease in the size of the tear. In all 11 cases, the head of the humerus had migrated (moved) up out of the natural resting place where it should be in the shoulder socket.

The bottom-line is that despite evidence of worsening of the soft tissues and shoulder joint, the majority of patients still had improvements with the surgery. Although the unhealed repair allows for continued function, the shoulder is not protected from further degenerative changes.

Other studies have shown that with severe rotator cuff tears, the damaged area fills in with fatty tissue. It’s not clear yet what effect this fatty atrophy will have in the long-run but researchers will continue to study these patients to find out. Osteoarthritic degeneration and function in unhealed shoulder cuff tendons will be the focus of other future studies as well.

Patients with severe or “massive” tears of the rotator cuff tendon should be informed that surgery may fail to create a healing response. But the pain relief offered and improved motion and function may make it worth having the procedure anyway.

According to this study, improvements seem to last for up to a decade (10 years) even when there is evidence of ongoing degeneration of the soft tissues. In older adults who are not in need of full strength and motion, surgical repair of a torn rotator cuff may still be beneficial because healing is not needed for a successful result.

Treatment of Shoulder Instability Using the Bony Bankart Bridge

Each and every day, patients and surgeons face some difficult problems and treatment choices. In this article, surgeons from the Steadman Philippon Research Institute in Colorado explore the use of an all-arthroscopic Bony Bankart Bridge (BBB) surgical technique for chronic shoulder instability.

Here are a few details to help us understand the significance of this treatment procedure. First, chronic shoulder instability means the shoulder continues to dislocate over and over. Pain, fear of movement that might cause another dislocation, and loss of function for daily activities plague these patients. With each dislocation can come further damage to the soft tissues and especially the bony rim around the shoulder socket.

The result can be bony instability of the anterior glenohumeral joint — in other words a shoulder that dislocates forward. Some people report up to 10 or more repeat dislocations. These microtraumas cause the bony rim around the shoulder socket to break away taking with it the attached soft tissues.

Studies have shown that a loss of 20 per cent (or more) of the bony rim significantly increases contact pressure (bone on bone). This type of bone loss also reduces resistance to dislocation. And with this type of bone deficiency, there is a high rate of failure after surgical repair of the soft tissues.

The Bony Bankart Bridge (BBB) addresses the bone loss by reattaching the bone fragment back into its “donor bed” (original place). A special bridging technique using push-lock knotless suture anchors reconstructs the shoulder and restores stability. There is no hardware where the two bony edges meet (where healing takes place). The surgeon also repairs any soft tissue damage to the capsule, labrum, and glenohumeral ligament. Care is taken to avoid tilting the bony piece, which could lead to over- or under-correcting the problem.

The greatest significance of this technique is that it was done completely by arthroscopic techniques. In other words, no open or large incisions were made to give the surgeon access to the area. All-arthroscopic procedures are becoming more common now even for difficult-to-treat problems like this one. The goal of this treatment is to restore the surface area of the shoulder socket and prevent any more dislocations.

How well does it work? And what are the success/failure rates with the all-arthroscopic Bony Bankart Bridge for chronic anterior shoulder instability? This was a small study (only 15 patients) so the total answer to those questions is not available yet. But the results were still important and significant in helping patients with this diagnosis.

Of the 15 patients included, there was only one failed surgery and that was because the person fell and injured the repaired tissue resulting in a shoulder dislocation. For the rest of the patient group, there were improvements in physical function and better mental health because of reduced pain and increased health-related quality of life. Patient satisfaction was 100 per cent. They could sleep better and return to recreational activities. And best of all, there were no reported complications from the surgery.

The authors concluded that this new all-arthroscopic repair for a mild-to-moderate Bankart lesion can restore shoulder stability. Patients experience significant pain relief and return to normal (or near normal) function. The Bony Bankart Bridge technique may help avoid the high failure rates normally associated with this type of bony reconstruction procedure when they are done with an open incision.

Steroid Injections for the Shoulder: Where’s the Evidence?

When shoulder pain from arthritis becomes unbearable and nothing else will touch it, surgeons may recommend steroid injections. Up to one-third of the adult population in America suffers from shoulder disorders at any point in time. So, it’s a problem that affects many people every day.

But in today’s evidence-based medicine, the question comes up: what’s the evidence that injections directly into the shoulder joint (intra-articular) really reduce shoulder pain and stiffness associated with arthritis or adhesive capsulitis (frozen shoulder)?

In this study, researchers from Rush University Medical Center in Chicago, Illinois reviewed the literature from 1948 to 2011 looking for any information, studies, and evidence about the use of shoulder injections. They did not limit their search to articles on just steroid injections but also included hyaluronic acid injections (another form of injection treatment) for shoulder disorders.

We won’t hold you in suspense about the results. They found very few studies and the level of evidence was very weak. In fact, it turns out that current clinical recommendations are all based on expert opinion and consensus (agreement among physicians). Consensus is also based on expert opinion but with experience and case series added in to assist in coming to agreement.

A closer look at the two different injection approaches (steroids versus hyaluronic acid) revealed little scientific evidence to support steroid injections. Steroid injections seem to work better and more consistently for people with adhesive capsulitis compared with shoulder osteoarthritis. Hyaluronic acid injected into the joint may be more effective for both frozen shoulders and arthritis but some high-quality, well-designed studies are needed to provide evidence of this.

Researchers have much to consider when creating future studies in this area. For example, why aren’t there better results with these injections? Is it because of inaccuracy in delivery of the needle (injection) into the shoulder joint? Are results better with more experienced clinicians? Injections are given by many different people — sometimes orthopedic surgeons or primary care physicians but rheumatologists and physician assistants also perform these injections.

Very often, patients are receiving multiple treatments at the same time such as physical therapy and antiinflammatory medications. It’s possible the combination does more harm than good. Or it could be the dosage and specific type of steroid that makes a difference. But what that is for the most effective, optimum results remains unknown.

And finally, the benefits of these kinds of injections must be weighed against the potential adverse side effects. With any injection, there’s the pain of the injection itself — both during and afterwards. Most of the time, this is temporary and only lasts a short time. Joint infection can occur when bacteria is introduced into the joint by the needle pushing through the skin. Anyone with infectious arthritis, a joint replacement implant, or fracture is not a candidate for injection therapy.

With steroid injections, some people have a flare-up reaction that can last several days. Sometimes the protective fat around the joint is lost. It takes the body up to six months to replace or restore this fat. With hyaluronic acid injections, pain and swelling in the joint may get worse instead of better at first. Some people even respond with an acute systemic inflammatory response. It looks like they are developing gout or a blood infection but it’s just a reaction to the injection.

The authors conclude it’s not likely that physicians will stop using steroid (or hyaluronic acid) injections for these two problems. But they are doing so on the basis of very limited evidence. It’s mostly opinion and conjecture and that is not a strong enough recommendation in today’s evidence-based practice.

Guiding Shoulder Injections (Steroid and Hyaluronic Acid) Using Ultrasound

This study from Korea has two unique features. First, it may be the only one so far comparing results of treatment for shoulder adhesive capsulitis between steroid injections and hyaluronic acid. And second, the authors used ultrasound instead of fluoroscopy (real-time X-rays) to guide the injections.

Many adults (mostly women) between the ages of 40 and 60 years of age develop adhesive capsulitis. You may be more familiar with the term “frozen shoulder” to describe this condition that causes shoulder pain and stiffness.

The terms frozen shoulder and adhesive capsulitis are often used interchangeably. In other words, the two terms describe the same painful, stiff condition of the shoulder no matter what causes it. But frozen shoulder and adhesive capsulitis are actually two separate conditions.

A more accurate way to look at this is to refer to true adhesive capsulitis (affecting the joint capsule) as a primary adhesive capsulitis. As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule.

Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis. In either condition, the normally loose parts of the joint capsule stick together. This seriously limits the shoulder’s ability to move, and causes the shoulder to “freeze.”

There are two separate schools of thought regarding treatment for adhesive capsulitis. Some experts suggest a home-based approach because eventually the problem corrects itself. Patients use pain relievers, moist heat, and simple exercises to keep the joint moving. Others recommend direct treatment to make sure patients regain normal motion and function.

Most experts agree that severe painful limitations of motion should be treated by a physical therapist. For patients with persistent pain, pain-relieving medications and steroid injections are commonly used in addition to physical therapy. But steroid injections have some disadvantages and some patients either don’t want them or can’t tolerate them. That’s when hyaluronic injections may be used instead.

Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic. The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements.

Some experts think hyaluronic acid (HA) injected into the shoulder has some additional benefits. They suggest that the HA reduces inflammation of the synovium (lubricating fluid inside the joint). It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal shoulder motion.

The question naturally arises — which works better: steroid or hyaluronic acid injections? To find out, the authors of this study divided 90 patients with adhesive capsulitis into two groups. The first group received a series of three steroid injections (spread out over six weeks’ time) into the shoulder.

The second group was injected with hyaluronic acid with the same frequency (one injection every two weeks for a total of three injections over six weeks’ time). Ultrasound (instead of the usual fluoroscopy) was used to guide the needle into the joint. The main advantage of ultrasound over fluoroscopy is that it doesn’t expose the patient to unnecessary radiation. That is important when using a series of injections with the potential for repeated radiation exposure.

Results were measured using pain intensity, shoulder joint motion, and function. Everyone in both groups was evaluated using these measures before treatment and again two weeks and six weeks after treatment. They didn’t find much difference in outcomes between the two treatment techniques.

Everyone in both groups had less pain, better motion, and improved function. These improvements were observed at the two week follow-up and maintained through the six-week check-up. The only difference was greater passive external shoulder rotation with the hyaluronic acid injections. This might have occurred because the pressure from the hyaluronic acid opened up the joint space, which is needed to increase external rotation.

The authors concluded by saying that hyaluronic acid injections delivered with careful placement using ultrasound may be just as effective as steroid injections. In fact, there may be some added advantages. The patients receiving hyaluronic injection via ultrasound are not exposed to radiation. They are not affected by the potential negative consequences of steroids (e.g., thinning and weakening of the soft tissues, skin color change). They even get some extra rotational motion.

For patients who cannot tolerate steroid injections (or who don’t want them), hyaluronic acid injection may be a good alternative treatment approach. Likewise, patients with other problems that affect the soft tissues such as diabetes, hyaluronic acid injections may be a better choice.

Periprosthetic Fractures Around a Humeral Implant

Anyone who gets a shoulder replacement is told there can be unexpected complications that develop either during or after the surgery. One of those problems may be a humeral fracture around the prosthesis (or implant). The humerus is the upper arm bone. A fracture of the humeral bone next to the implant is called a periprosthetic fracture.

Treatment of these fractures requires surgery either by removing the implant and replacing it or using hardware to hold everything together until healing takes place. This second option is a surgical procedure referred to as open reduction and internal fixation (ORIF).

In this study, two surgeons from the Florida Orthopaedic Institute in Tampa, Florida report on the results of 36 patients. Each one was surgically treated for a humeral shaft fracture after they had a shoulder replacement. The surgeons describe the treatment of these fractures and summarize the results. They also take a look at how valid is the classification system currently in use.

One thing that makes this study unusual is the fact that some of their patients had a reverse shoulder prosthesis. Up until now, only single case reports or small case series have provided any information on humeral fractures associated with reverse shoulder arthroplasty. This study reports on outcomes (bone healing, shoulder motion) after surgical treatment for these patients.

The reverse shoulder prosthesis is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula. In the “normal” artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic and the humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder.

In the reverse shoulder replacement, the ball and the socket are reversed. Patients who have a severely damaged (and irreparable) rotator cuff are the most likely candidates for the reverse arthroplasty. This type of shoulder replacement provides pain relief as well as a stable, functional shoulder.

Of the 36 patients in the study, 35 had complete healing of the fracture and a return of shoulder motion equal to their prefracture level of motion. The group who had the open reduction and internal fixation (ORIF) had good fracture healing without any stem loosening in the follow-up period.

The second group (patients who had the implant removed and replaced) showed X-ray evidence of femoral shaft loosening, which is why they ended up having a revision arthroplasty instead of the ORIF. They were also able to return to their preinjury level of motion and function. In fact, some of these patients were even better than before the fracture developed. BUT there was evidence that the loosening of the stem component was the reason the fracture developed in the first place.

As for the classification process — there was very poor interrater reliability. What does this mean? Orthopedic surgeons rely on X-rays to help them recognize signs of loosening. This is an important piece of information to have when planning surgery. The most commonly used classification system for recognizing periprosthetic humeral fractures was developed by two surgeons: Wright and Cofield.

Using their method, radiologists were able to repeat or reproduce their own conclusions when viewing and then reviewing each patient’s X-rays (called intra-rater reliability. But when the results were compared from one radiologist to the next (inter-rater reliability), there were wide differences of opinion. With such low interobserver reliability, this classification system may not be a good tool to use in diagnosing bone loss and stem loosening as previously thought.

The results of this study can be summarized in three parts:

1) Periprosthetic fractures in the humerus can occur as a result of trauma or previous loosening of the implant inside the bone.

2) Surgery is needed to repair the problem. If the implant is stable, then the fracture can be treated using open reduction and internal fixation (ORIF). This amounts to using metal plates, wires, and screws to hold everything together until the bone heals. Unstable or loose implants can be removed and replaced.

3) The current classification method used to identify implant loosening does not have good inter-rater reliability so should not be depended on to guide treatment.

Mini-Open Rotator Cuff Repair: 15 Years Later

When rotator cuff repairs were first done using the mini-open technique back in 1993, surgeons didn’t really know how the results would turn out years down the road. Now with the data from this study, we have some 15-to 20-year outcomes to judge this technique by.

Seventy-nine (79) patients with shoulder pain, weakness, and impingement from a supraspinatus tendon tear were enrolled between 1993 and 1996. All had a tendon repair (stitching it back to the bone) and a subacromial decompression procedure by the same surgeon.

Subacromial decompression refers to shaving away some of the bone along the acromion to take pressure off the rotator cuff. The acromion is the curved piece of bone that comes from the scapula (shoulder blade) across the top of the shoulder. A mini-open (small incision) approach using an arthroscope was used to perform the surgeries.

Results were assessed using a special patient self-survey called the UCLA score. This simple but reliable tool measures patient satisfaction with the results after rotator cuff surgery based on function, active range of motion, strength, and pain. Everyone in the study completed the survey several times: first two years after surgery, then seven years later, and one final time (between 15 and 20 years).

The 79 patients ranged in ages from 49 to 92 years of age at the end of the study. As might be expected in a long-term study like this, some of the patients dropped out (or were dropped) from the study due to moving, dying, experiencing dementia or other cognitive impairment.

For the 49 patients in the study at the end, slightly more than two-thirds (69 per cent) felt they had good-to-excellent results. If only overall patient satisfaction was used as a measure (i.e., no one was dissatisfied), then 84 per cent thought the results were acceptable. Some patients did experience deterioration over time of the benefits they received and three had to have a reoperation. This is to be expected with an aging adult group.

The authors concluded that the mini-open rotator cuff repair technique does provide satisfactory short-, medium-, and long-term functional results for the majority of patients who have a reparable supraspinatus tendon tear. This is one of the first (and few) studies reporting on long-term outcomes (durability) for this procedure.

Many Things to Consider with Shoulder Rehab

Patients are often sent to physical therapy for strengthening when the shoulder joint is unstable. But physical therapists don’t prescribe the same exercise program for everyone. That’s because there are so many variables to consider.

For example, does the patient have anterior instability (shoulder moves forward in and even out of the socket). Or is there posterior (backward) instability. Sometimes patients have multidirectional instability (unstable in more than one direction). Each one of these situations calls for an individual rehab program.

Then there is the scapula (shoulder blade) to consider. How well does it move? Is it moving in a coordinated rhythm with the shoulder? Scapular control is an important part of glenohumeral (shoulder joint) stability. Muscles must be evaluated for weakness, shortening, length-tension, and ability to generate as well as withstand forces needed for arm movement.

And the therapist mustn’t forget addressing proprioception (joint sense of position) with a physical therapy program. Restoring these aspects of scapular and glenohumeral motion is vital. This concept is especially important for the athlete who depends on his or her arm for accuracy and strength in motion and function (e.g., think about the need for a baseball pitcher to deliver the ball exactly in the strike zone across the home plate).

Another aspect of rehab planning is whether or not the patient has had surgery or is trying to avoid surgery. When surgery is done, the therapist plans treatment that protects the healing tissues. This varies depending on whether the surgeon used an open incision technique or completed the procedure arthroscopically. More muscles are cut into with open surgery so rehab must progress differently than without surgery or with minimally invasive arthroscopic techniques.

Finally, the plan of care is designed by the physical therapist for each specific patient. The therapist uses clinical skill, expertise, experience, and evidence-based information to decide which mode (type) of exercise to use. The same decision-making process is involved in determining a starting point for frequency, duration, and intensity of the exercises. Progressively moving the athlete back toward full function for his or her sport is often the direction therapy goes. This type of conditioning is called a sports specific functional progression.

Physical therapists interested in guidance when planning a rehabilitation program will find this article helpful. The authors provide details for each of the topics presented along with photos of patients performing many of the exercises recommended. Surgeons and physical therapists must work together and maintain close communication. Ongoing changes in surgical technique make it necessary to tweak the postoperative rehab program to get the best results.

More research is needed to verify optimal treatment for shoulder instability whether it’s an anterior, posterior, or multidirectional instability. With all the factors, variables, and considerations the therapist must consider, it’s no wonder one exercise program does not “fit all.”

Shoulder Pain in Spite of Treatment

Pain can be a good thing. For one thing, it is protective. It is a normal response of the body when there is an injury. The body uses pain to protect itself while it is healing. But in time, the healing processes are completed and the pain goes away. That is the normal healing response.

Well, not always. In some people, a persistent pain response gets turned on in the central nervous system and it doesn’t get turned off. The result is chronic pain from this phenomenon we call central hypersensitivity. Pain is felt with even a small touch or input. Pain is felt with lower mechanical pressure than would normally elicit a painful response. And this doesn’t just occur in the arm or leg that’s hurt. The heightened pain response is perceived throughout the body. That’s what we mean by “central” hypersensitivity.

In this study, a group of researchers from Case Western Reserve University School of Medicine carried out part two of a previous study. They examined the pain response of patients with a particular shoulder problem called subacromial impingement syndrome or SIS.

Someone with SIS experiences pain when lifting the arm overhead. The supraspinatus tendon of the rotator cuff gets pinched by the acromion. The acromion is a curved piece of bone coming from the back of the shoulder blade around and over the top of the shoulder.

SIS is caused by different things. Sometimes it’s a previous injury to the rotator cuff. Some people are just experiencing degenerative fraying (wear and tear) of the supraspinatus tendon. In other cases, there is a bursitis (inflamed bursa). Anything that causes the supraspinatus tendon to get pinched or impinged can contribute to the development of SIS.

And as this study showed, once the tissue has healed, the hypersensitivity continues causing persistent pain even after treatment. They proved this by testing pain responses to mechanical pressure applied to the skin.

People with central hypersensitivity clearly had reduced pain thresholds (it took less pressure than normal to cause pain). The reduced pain thresholds were observed at the site of the shoulder problem and in other parts of the arm unaffected by the injury.

And they compared the pain responses of the individuals with SIS to normal controls (people without shoulder problems). As suspected, the patients with SIS had much lower pain thresholds compared with the control subjects. In other words, the patients with SIS felt a painful response when a rubber tip was touched to the skin sooner and with less pressure compared with normal adults. And the sensation caused pain in the SIS group when it was just felt as pressure to the control group.

What can this information do to help these patients? First, it offers reassurance that they are not making this all up in their heads. It’s a real event and it’s something controlled by their nervous system. Second, it may help answer the question which came first: the chronic pain or the central hypersensitivity. And third, by treating the nervous system component of pain (not just the anatomic or biomechanical aspects of the problem), it might be possible to end this problem.

Double Trouble for Overhead Throwing Athletes

Athletes engaged in high-level overhead throwing sports are at risk for shoulder injuries. The constant, repetitive arm motion with force can result in a variety of problems. In this case series, athletes with both a superior labrum anterior-posterior (SLAP) tear and a tear of the infraspinatus rotator cuff muscle are the main feature. Results of surgical treatment for patients with both injuries are compared against baseball players with just the SLAP injury and repair.

This study is important because the road back to recovery after a SLAP injury is hard enough. But with the added infraspinatus injury, return to a preinjury level of play can be even more challenging. Tracking with athletes who have these injuries can aid surgeons in finding the operative technique and rehab program that will provide the best results.

The study included 17 high-level baseball players under the age of 25 years old who had arthroscopic surgery to repair both kinds of shoulder injuries. Suture anchors were used to repair both types of tears (labrum and tendon). An alternate method used for the tendon repair in some of the patients was with a free polydioxanone (PDS) suture.

At the time of the procedure, it was determined that two-thirds of the group had a partial tear of the infraspinatus tendon. The remaining one-third of the players had a full-thickness tear. After surgery, everyone wore a sling with a special (abduction) pillow designed to hold the arm away from the body. Gradual, progressive rehab with a physical therapist was the next step with the goal of returning to their preinjury play.

They were followed for at least two years and results measured using a variety of different tools. The players answered questions from a formal survey about their current playing abilities, ability to return to play, and at what level of participation.

As it turned out, the rate of return to full play was less than hoped for. Although there were no complications after surgery and no one needed a second (revision) operation, only one-third of the group could return to their preinjury level of play. A similar number of players returned to the game but at a lower level or in a different position. They just didn’t have the throwing speed they needed to remain competitive. The last one-third of the group couldn’t get back into the game at all.

Further analysis of the group showed that no one had what was considered an “excellent” result using the Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow (KJOC) questionnaire. Only one player scored high enough to rate a “good” score. The remaining players received a poor to fair result. And a closer look at the data revealed better results for the players whose infraspinatus tendon was repaired using the free PDS suture (compared with those whose repair was done with suture anchors).

The authors review current thoughts and theories about the specific actions of the shoulder, contact points, torsional and shear forces, and joint laxity that might contribute to these injuries. There is an interest and a need to identify the chain of events and possible causes leading to these complex shoulder injuries. A primary goal of future studies should be to use this information to find ways to prevent shoulder problems among these athletes.

In conclusion, high-level overhead throwing athletes with both a rotator cuff tear and labral tear are not likely to regain the precise kinematics (motion) needed to return to their former level of sports participation. The results from this study show that players with both injuries fare much worse than players with only the labral tear.

Loosening of Shoulder Replacements

Shoulder replacements are wonderful inventions. They help restore pain free shoulder and arm motion. Patients are almost always fully satisfied with the results. But from the surgeon’s point-of-view, the results aren’t always 100 per cent acceptable. Complications can occur such as joint infection, dislocation, or nerve injury. Problems with the implant including loosening and subsidence (sinking down into the bone) also occur more often than they would like.

In this study, an orthopedic surgeon from Germany followed 39 of his patients for 10 to 15 years and reported on the long-term results. He used the same third-generation cemented total shoulder replacement in each patient so that results could be compared directly. Pain, shoulder range-of-motion, and X-ray findings were the main measures of outcomes. Third generation refers to the number of times the implant has been redesigned, revised, and improved.

In all cases, pain, range-of-motion and function improved. And along with those results were consistent reports of patient satisfaction. Loosening of the glenoid component (socket side of the implant) occurred in 36 per cent of the group. The author provided a detailed description of the X-ray measurements to diagnose implant loosening. Despite the loosening, the implant remained intact and the patients still had good, pain free motion.

Reasons for the high rate of loosening were explored. Possible risk factors include: the design and shape of the glenoid component, surgical technique (removing too much of the arthritic bone before putting the implant in place), and cementing technique. It is also possible that there are some as yet unknown patient factors.

Younger patients tend to develop loosening more often than older adults, so maybe a higher activity level is part of the picture. And then there is always the possibility that some aspect of the postoperative protocol (either right after surgery or during rehab) that could be a contributing factor. These are all variables that must be evaluated more closely in future studies.

Two-thirds of the group experienced something called cranial migration of the humerus (upper arm). This refers to a gradual change in the position of the humerus upwards toward the top of the shoulder socket. Using X-rays, the condition was classified as mild, moderate, or severe based on how far up the humerus had moved. The problem develops as a result of rotator cuff failure that cannot be corrected surgically.

All in all, even with these reported problems the implant was still intact after 10 years for everyone. No one had to have revision surgery to remove, replace, or repair the loosening or migration. This study demonstrates the long-term satisfactory function patients can have with today’s modern total shoulder replacements. The high rate of loosening still needs to be addressed and corrected in the next generation of implants.

Disappointed with the Results of Your Total Shoulder Replacement?

With more and more older adults having a total shoulder replacement (TSR), it’s expected that more patients will experience unexpected problems. Persistent pain, restricted range of motion, and loss of function can mean a second or revision surgery. An unstable shoulder (one that partially or fully dislocates) will also require further treatment.

In this article, surgeons from Philadelphia bring us up to date on revision total shoulder arthroplasty (shoulder replacement). The results of this second surgery are somewhat dependent on the reason for the failed replacement. Soft tissue problems such as rotator cuff deficiency or capsular adhesions are more difficult to treat than problems with the bone. Infection is another challenging problem that may require removing and replacing some or all of the implant.

Before a second surgery is considered, the surgeon will re-evaluate the patient closely. The reason for the first shoulder replacement (e.g., inflammation, trauma, rotator cuff rupture) is important. The patient’s cognitive and psychologic state are important. Someone who has dementia or Alzheimer’s and cannot follow postoperative directions may not be a good candidate for another surgery even when the shoulder is unstable or painful.

The surgeon’s examination includes assessment of muscle strength, shoulder motion, and nerve function. Clinical tests and imaging studies help pinpoint whether the problem is coming from the prosthetic (implant), soft-tissue structures, bone, or all three. X-rays may not be enough so that more advanced imaging such as MRIs or CT scans could be needed. Basic lab tests are also done to look for any sign of infection.

When after all these tests the cause of the problem is still unknown, then arthroscopic examination may be helpful. Inserting a scope with a tiny TV camera on the end into the joint gives the surgeon a direct view of the shoulder. Loosening of any part of the implant will be seen as well as infection, instability, or component loosening or wear.

The authors provide other surgeons with a flowchart called an algorithm to help when deciding what’s wrong and what to do about it. At the top of the chart is “painful arthroplasty.” Infection workup is first and the chart flows according to whether the test results are positive or negative. If infection is positive, then a determination is made whether this is acute (early onset) or chronic (long-standing problem). Treatment is determined on the basis of this classification.

On the negative side (no infection present), the surgeon must evaluate stiffness versus instability/weakness. In either case, physical therapy is often the next step in treatment with subsequent treatment based on whether there is improvement or not. If the problem cannot be corrected with rehabilitation, then a revision surgery may be necessary.

The decision to perform a revision procedure is not the final decision the surgeon must make. There are many different possibilities including removing just one component of the implant and replacing it, removing the entire implant and replacing it with a reverse shoulder arthroplasty, correction of the soft tissue failures, or perhaps even a do-nothing policy.

Soft tissue deficiencies pose additional challenges depending on which tendon or muscle is torn, worn, or weak and whether or not there are other soft tissue imbalances. In all cases, patients facing a second or revision surgery will be warned that the procedure may not clear up all deficiencies. For example, they may experience pain relief but may not gain any more shoulder motion.

For best results, patients should be evaluated carefully and selected for revision surgery based on a decision-making algorithm. Not all patients can or will benefit from a second procedure. Worst case scenarios include arthrodesis (joint fusion) or even amputation (e.g., in the case of infection that doesn’t respond to treatment).

In summary, orthopedic surgeons and patients facing the possibility of a failed total shoulder replacement will find the information in this article timely and helpful. The reader is taken through the process of evaluation and decision-making step-by-step. Goals of treatment and expectations for each type of problem and solution are reviewed as well.

Freezing the Whole Body to Treat Frozen Shoulder

Research efforts are underway around the world to find effective ways to treat adhesive capsulitis (also known as “frozen shoulder”). Physical therapy is widely accepted as the most beneficial treatment for this problem. In this study from Korea, the use of whole body cryotherapy (WBC) for adhesive capsulitis is investigated.

Whole body cryotherapy refers to spending brief periods of time in a very cold walk-in chamber. The room is kept at -110 to -140 degrees Celsius (that’s -230 down to -284 degrees Fahrenheit). Patients who received the cryotherapy treatment were exposed to four-minutes of cold twice a day, three times a week for a month. There was an elaborate procedure to prevent frostbite, discomfort from the cold, and damage to the lungs from breathing cold air.

For example, a warmer (but still cold) prechamber was entered first for one-minute. Everyone wore a surgical mask and told to avoid holding their breath in order to protect the upper airways. Each person wore a protective hat, triple-layer gloves, dry socks, and shoes. Everyone was monitored by microphone and camera whenever they were in either of the chambers.

In this study, cryotherapy was not the only form of treatment. The patients were actually randomly placed in one of two groups. Everyone in both groups received physical therapy modalities (e.g., ultrasound, electrical stimulation) and manual therapy (joint mobilization) techniques used for adhesive capsulitis. One group also experienced the cryotherapy whereas the second group did not. There was not a control group (patients who did not receive any therapy) as this approach withholds any treatment and is not considered ethical.

Using pain, range-of-motion, and shoulder function as test measures, patients in both groups got better. But the cryotherapy group had more significant improvements in all areas compared to the group who did not receive the cold therapy.

The authors offer several suggestions why whole-body cryotherapy might aid patients with adhesive capsulitis more than just physical therapy modalities and joint mobilization. First, cold has a way of anesthetizing the area, which in turn, reduces pain. With less pain, patients are better able to move the arm and shoulder.

Second, joint mobilization has been shown to improve the flow of synovial fluid in the joint making it easier for the head of the humerus (upper arm bone) to slide and glide inside the shoulder socket.

Mobilization can also break up adhesions and scar tissue. This effect makes it possible for the collagen fibers that make up the joint capsule (soft tissue surrounding the head of the humerus) to line up better. The end result is improved gliding of the capsular fibers during movement. And joint mobilization seems to calm or quiet down cell receptors (called nociceptors) that set up a pain response in the first place.

It has been suggested that cold applied in this way to the whole body increases the release of chemicals in the body such as norepinephrine. Norepinephrine is known to decrease pain messages from the skin in the spinal cord and reduce (or stop) pain (or at least the perception of pain).

This may be the first study to compare physical therapy for adhesive capsulitis using standard mobilization techniques and modalities with whole-body cold (WBC) therapy. Although the results do show a significant improvement for patients who received WBC, there were some limitations to this study.

The authors point out that using a multimodal (many treatments) approach to the problem of adhesive capsulitis does not help sort out what each treatment component does. It is possible that just using one of these techniques would be enough to gain the same results.

The natural history of adhesive capsulitis (what normally happens with this
condition is a gradual improvement over a long period of time (12 to 42 months). Treatment may speed up improvements to less than one-month, which is why efforts are being made to find the best treatment or combinations of treatment approaches. As this study showed, adding whole-body cryotherapy to modalities and mobilization works better than modalities and mobilization alone.

Tendon Pulls Away from Bone After Rotator Cuff Repair

Studies are beginning to show that early on after rotator cuff tendon repair, the tendon retracts or pulls away from the bone. In fact, this study from the well-known Cleveland Clinic reports all rotator cuff repairs pulled away from where they were sutured (stitched in place).

Special marker beads were placed in the repaired tendons of 14 patients. The surgeons used serial low-dose CT scans (repeated at six weeks, 12-weeks, 26-weeks, and one year) to check the position of the anchor beads. Since the beads were inside the tendon, this was a clear representation of the tendon position. Movement of the beads away from the bone signaled tendon retraction.

The surgeons noticed that this retraction did not always mean the tendon would tear. Only about one-third of the group developed an actual recurrent (second) tear in the damaged rotator cuff tendon.

Tendon retraction occurred early after surgery (in the first six to 12 weeks). Those patients who had the most tendon retraction were also the ones who developed a tendon defect. Defect was defined as a full-thickness, fluid-filled gap in the tendon (as seen on CT scan). The authors refer to tendon retraction without defect as a failure with continuity. Retraction and defect did not occur at the same time but rather, retraction developed first that led to the recurrent tendon tear.

Questions that come up from these findings include: 1) Why does this happen? 2) How does this affect the patient’s function? and 3) What can be done about it? The answer to the first question (why) isn’t completely clear.

A couple of clues were uncovered in this study. First, older adults were more likely to experience this tendon retraction/recurrent tear. Tendons that pull through the sutures and repairs that elongate or lengthen in the newly forming tissue during the healing process result in tendon retraction and/or defect.

And second, patients with larger defects to begin with were more likely to develop retraction leading to tendon tear. Both of these factors suggest poor tendon quality at the time of surgery as an important risk factor. These risk factors and findings naturally affect function (question number two) and speculation as to how to prevent it from happening (question number three).

They found that patients who developed a tendon retraction that led to a tendon defect did lose shoulder/arm function but not strength of the scapular (shoulder blade) muscles. Tendon retraction alone (remember: failure with continuity) did not result in loss of function.

Those findings lead to the third question: what to do about this? If tendon retraction doesn’t alter motion or function, does anything have to be done differently? The authors say ‘yes’ because one-third of the group with tendon retraction went on to develop a recurrent tear. By looking at the risk factors (older age, more severe tear) it may be possible to head the problem off at the pass, so-to-speak.

Exactly how to prevent the problem of retraction/recurrence remains unclear. Perhaps reattaching the torn tendon to a different place on the bone might help. There may be other changes in the surgical technique that could help improve the quality of repair. This would have to be studied more closely by comparing results of different suture placement and repair techniques. More study is needed to understand the mechanisms by which tendon retraction occurs in the first place.

The fact that age is a risk factor suggests that biologic characteristics of the damaged tendon are as important as the type of surgical repair. Small tears can be repaired since function is not affected by tendon retraction but medium-to-large tears should be reconstructed. Patient selection for each type of surgery becomes important as well.

And finally, the clear understanding that the problem develops early on leads to the conclusion that activity in the early days and weeks after surgery must be monitored closely. Too much activity, motion, and force on the healing tissue may contribute to tendon retraction and must be prevented. The fact that 80 per cent of all retractions occurred in the first 12 weeks highlights this as a key time period for protection of the healing tissue in all patients.

An Important Mid-Term Follow-up Study on Reverse Shoulder Arthroplasty

Shoulder joint replacement surgery (also called shoulder arthroplasty) can ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery. But, certain patients are not candidates for joint replacement of the shoulder because they lack the muscle function necessary to stabilize the joint. A different type of shoulder replacement, called reverse shoulder replacement or reverse shoulder arthroplasty (RSA), is used instead.

The reverse shoulder arthroplasty (RSA) is used for several different types of problems. This study examines results of patients who had a weak or deficient rotator cuff. The rotator cuff is a group of four muscles that wrap around the shoulder to hold it in the socket. They also help move the shoulder. RSA is an option when the rotator cuff is no longer strong enough or functioning well enough to hold the shoulder in the socket. The RSA provides pain relief as well as a stable functioning shoulder.

There were 75 patients with 76 shoulders included in this study. There were twice as many women as men and all patients were between the ages of 51 and 88 years old. They have been followed yearly by surgeons at the Florida Orthopaedic Institute and Foundation for Orthopaedic Research and Education in Tampa, Florida. The first set of results was published two years after surgery. This report is of the same patients five years after the RSA procedure.

Results were measured in a variety of ways. The patients filled out surveys answering questions about their motion, pain, function, abilities, and disabilities. X-rays were taken to evaluate the implant position, look for any loose screws, and assess the condition of the bone and joint. Implant survival (no loosening, no cracks, no shifting or sinking of the implant) and implant failures were also evaluated. A failure was defined as any time the patient had to have another (revision) surgery.

Analysis of the results showed that the average length of time the implants lasted was 73.5 months (a little more than six years). Almost all implants were still in place and working well at the end of six years. Five patients had to have revision surgery because some part of the implant came loose or the bone graft used was resorbed (broken down and absorbed) by the body.

There was no sign of bone loss around the implant in any of the patients. A new development not seen in the previous study was the presence of scapular notching. This change was seen in about nine per cent of the group. Scapular notching describes a problem that occurs when the medial (inside) edge of the socket (now located at the top of the humerus) bumps up against the lateral (outside) edge of the scapula (shoulder blade) where the new round ball (glenosphere) is located. Loss of shoulder motion occurs from this type of impingement.

The surgeons concluded from this mid-term study of their RSA patients that the shoulders remained stable and the implants durable. The new development of scapular notching is concerning and all patients will continue to be followed for the next five years (total of 10 years since the first RSA surgery).

Revisiting an Old Problem: Hill-Sachs Lesions

All shoulder dislocations cause some amount of bone damage. In the most common type of dislocation, the head of the humerus (upper arm bone) is forced forward and out of the shoulder socket. This is known as an anterior shoulder dislocation.

Even if the shoulder is reduced (head of the humerus is put back in the socket), the soft tissues around the shoulder have been overstretched. If the humeral head hits the rim of the socket with enough force, there can be damage to both areas (the humeral head and the glenoid rim). This type of injury is referred to as a Hill-Sachs lesion.

Studies show that there is always some amount of bone damage with a first-time anterior dislocation. If the defect is moderate-to-severe, the loss of bone results in abnormal shoulder motion (biomechanics). Many patients develop recurrent shoulder instability meaning the shoulder dislocates over and over.

Orthopedic surgeons treating patients with Hill-Sachs lesions and chronic shoulder instability must understand the relationship between these two events. Formulating a successful treatment plan depends on the surgeon’s recognition (and treatment of) any humeral bone loss. That’s why these two surgeons from the University of Michigan are revisiting this problem and reviewing the diagnosis and management of humeral head bone loss in shoulder instability.

They suggest it may not be enough to repair the torn or damaged soft tissues (tendons and ligaments) if there is also a bony defect. The soft tissue repair or reconstructive surgery is more likely to fail if the bony lesion(s) are not addressed as well. They point out that an engaging Hill-Sachs defect (the bone defect catches on the glenoid rim during shoulder motion) must be identified and treated as well.

Using drawings to depict the problems and CT scans and photos of the lesions, these surgeons review all of the reconstructive procedures currently available to treat Hill-Sachs lesions. They provide tables to summarize anatomic and nonanatomic techniques. Pros and cons of each procedure are listed. Postoperative problems and complications are reviewed as well. Special considerations for overhead throwing athletes with this type of injury are also mentioned.

Anatomic repair (putting everything back the way it was meant to be) is always preferred. But a nonanatomic approach (e.g., using bone grafts, removing the humeral head, shoulder replacement) may be necessary in cases where there is more severe damage. The authors describe situations where each type of procedure might be considered. Patient age, activity level, severity of injury, and bone quality are some of the factors that must be evaluated when determining the best plan of care for each individual.

Remplissage Surgical Procedure: Safe and Effective for Repeated Shoulder Dislocations

Athletes who suffer repeated anterior (forward) shoulder dislocations may have two problems going on in the joint: a Bankart lesion and a Hill-Sachs lesion. Unless both problems are recognized and treated, shoulder function may not improve. The authors of this article report on results using two different methods of treating this type of shoulder instability.

To better understand this report, let’s take a quick look at the shoulder and these two injuries. The shoulder joint is a ball-and-socket joint. The socket is fairly shallow. This puts the joint at risk for dislocation. To help deepen the socket, the shoulder joint has a rim of cartilage called a labrum. The labrum forms a cup for the end of the arm bone (humerus) to rest and move inside.

A Bankart lesion is an injury to the labrum caused by forward (anterior) shoulder dislocation. The force of the head of the humerus (upper arm bone) as it dislocates, tears the labrum and the ligaments attached to it. The shoulder joint is unstable when the labrum is torn. There isn’t anything to keep the head of the humerus from slipping forward out of the socket again. Surgery to repair the damage is usually needed.

A Hill-Sachs lesion is an injury that causes damage to the head of the humerus. It also occurs with shoulder dislocation and usually develops after the Bankart lesion occurs. When the shoulder dislocates, the smooth surface of the humerus hits against the bony edge of the socket (called the glenoid). The collision causes a dent in the bone of the humerus. This is also called an impaction fracture.

Treatment is designed to prevent any more dislocations and further damage (and later arthritis) to the surface of the humerus. Reducing pain and improving motion and function are additional goals of surgery. Surgical treatment for each of these problems is slightly different. The Bankart procedure is done to reattach the labrum to the bone. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) must also be stitched back together layer by layer.

In this study, the surgeons used a Remplissage procedure to repair the Hill-Sachs lesion. The word remplissage is French and means “to fill in” or “to fill up.” In the context of this surgery, a portion of the joint capsule and the infraspinatus tendon are moved (transposed) to fill in the hole or “defect” in the bone.

The design of this procedure is to stop the humeral head from banging against the edge of the socket when the arm is rotated and moved away from the body (movements called external rotation and abduction). When pain occurs during this arc of motion for someone who already has a Hill-Sachs lesion, it’s referred to as an engaging Hill-Sachs lesion.

The intention of this study was to compare results in two groups of athletes with both problems: an engaging Hill-Sachs and a Bankart shoulder lesion. One group of 25 athletes had just the Bankart repair. The second group of 25 athletes had a Bankart repair along with the Remplissage procedure. The results were measured by change in shoulder function and whether or not the shoulder dislocated again.

The authors report equal results between the two groups when just looking at improved symptoms (decreased pain, increased motion). But five of the 25 athletes in the Bankart-only group had another shoulder dislocation. That’s a 20 per cent recurrence rate and of course, very distressing to the athlete after having surgery.

In summary, this is the first study to take a look at results of two different surgical treatments for combined Bankart and Hill-Sachs shoulder injuries in athletes. Although the study was small (only 50 patients) and only two surgeons were involved, they say the use of a new approach (the Remplissage Repair) is safe and effective. None of the athletes who had the combined Bankart and Remplissage repairs had any further shoulder dislocations. The Bankart procedure alone for these kinds of shoulder instabilities may not be enough as evidenced by a 20 per cent re-dislocation rate.