Correcting for Bone Deficiency and Deformity in Shoulder Replacement

If you had a perfectly shaped shoulder with good bone stock, you probably wouldn’t need a shoulder replacement. But the long-term effects of osteoarthritis (the number one reason for joint replacement) alter joint shape and biomechanics. And if those changes are not corrected during joint replacement, the chance of implant failure increases dramatically.

Surgeons performing shoulder replacements are often faced with challenging joint deformities. There can be areas of uneven or increased points of joint contact, defects in the bone, and twists or torsions of the bone structures. Poor bone quality can make it difficult for the implant to have the support it needs to function properly and last for a long time.

The authors of this review article help other surgeons appreciate the technical difficulty of correcting shoulder joint deformities. These modifications must be done during shoulder replacement surgery but before inserting the new joint (called a prosthesis or implant).

Eccentric reaming, posterior bone graft, augmented glenoid component, and surgical resurfacing are four surgical techniques described and discussed when facing glenoid bone loss. Glenoid tells us we are specifically dealing with the socket side of the joint.

Let’s take a look at each of these options. First, what is eccentric reaming? It’s a way to restore normal, even contact between the round head of the humerus (upper arm bone) and the glenoid fossa (shoulder socket).

The surgeon uses a shaver to reshape the curvature of the shallow socket and make it the same depth from front to back. Proper reaming is required for the implant to sit inside the socket and move with even contact and force between the two parts of the prosthesis. If there is more than 15 degrees of retroversion (backward twist), then eccentric reaming cannot be used effectively. Anything more than that requires the second treatment option: bone grafting.

When there isn’t enough bone to work with, then the surgeon turns to bone grafting to smooth out uneven wear. There are many advantages to this approach and a few disadvantages. On the positive side, the bone lasts a long time and is considered a permanent solution. The surgeon can use the patient’s own bone by using the removed humeral head.

Using bone graft material also gives the surgeon a chance to restore a more normal joint line. This effect prevents altered joint motion, which could lead to implant failure. On the downside, bone grafts can break down and dissolve or fail to bond with the natural bone. Using bone graft does require a certain skill level on the part of the surgeon to contour the joint properly.

The third solution (augmented glenoid component) refers to the use of plastic liners to help restore a normal joint line and build up areas of thin or deficient bone. Long-term studies to show results with this solution are not yet available.

And finally, the surgeon may turn to the use of joint resurfacing. Shoulder resurfacing that makes it possible to get a “new” shoulder without losing much bone and without replacing the whole thing. Instead the damaged surfaces of the joint are covered with a resurfacing prosthesis or implant.

In addition to saving bone there are many other advantages to the resurfacing technique. For example, the patient’s normal anatomy is preserved. The prosthesis can be fit to the patient instead of the other way around.

The natural angle of the humeral (upper arm) bone is maintained. The cap that fits over the round humeral head has a peg that sets down into a hole drilled in the bone. The bits of bone taken from the hole are used to patch defects under the humeral cup. This means that the joint surface can be smoothed out and no bone is lost.

Joint resurfacing is most likely an option when there is still some joint surface left to work with. At least 60 per cent of the joint surface must be present. The rest can be treated with bone graft or bone graft substitute.

In summary, when choosing from among each of these surgical procedures, the surgeon must evaluate each patient individually to determine all possibilities. Every effort is made to avoid implant loosening or failure for any reason. The surgeon takes into consideration the amount and severity of bone loss and the type of deformities present. Eccentric reaming works well for mild bone loss or minor joint changes. More severe problems may require more extensive surgery (e.g., augmentation, bone graft, or joint resurfacing).

Arthroscopic Release of Adhesive Capsulitis: Results Five Years Later

Gradual, unexplained pain and stiffness of the shoulder that limits motion and function is referred to as idiopathic adhesive capsulitis. Idiopathic means “unknown cause.” The joint capsule (connective tissue surrounding the joint) is thick and tight. The collagen fibers that make up the capsule are packed together more densely than normal.

Treatment ranges from conservative (nonoperative) care with doing nothing, physical therapy, or steroid injections to surgery to release the adhesions. Surgery can be done with a simple manipulation (shoulder is moved through full motion while patient is anesthetized), arthroscopic capsular release, or open incision release.

In this study, one surgeon from the Orthopaedic Research Institute in Australia followed his patients for five or more years to see what kind of long-term results are possible. All patients had idiopathic adhesive capsulitis and were treated with arthroscopic release of the capsule.

The surgeon performed a complete 360-degree release of the capsule (all the way around the shoulder joint). Then a gentle manipulation was performed by moving the arm through its full range-of-motion. The surgeon injected the joint with a numbing agent combined with a steroid (antiinflammatory) medication.

The goal of the injection therapy was post-operative pain relief. Everyone treated with this approach went home on the day of surgery without a sling and with instructions from the physical therapist for the proper exercises to perform.

Results were measured by comparing before and after surgery range-of-motion, pain intensity, activities and function. The ability to reach behind the head and back was measured. Ability to lie on the painful side and sleep at night were also reported and recorded. Current level of sports participation was rated from “none” to hobby, club, or professional play.

All the patients reported immediate pain relief during activity and at night while sleeping. There was at least a 50 per cent improvement in range of motion early on. Functional skills like reaching overhead or behind the back improved steadily from postoperative week 6 through the end of the first year. By the end of the first year, the affected shoulder had motion equal to that of the unaffected shoulder. And there were no complications (e.g., infection, worse symptoms, nerve damage, joint instability).

The author concluded that arthroscopic capsular release for idiopathic adhesive capsulitis is an acceptable, safe, and effective treatment technique. The good-to-excellent results in the short-term were maintained into equally good long-term results. This is the first study to report such results more than two years after the first arthroscopic procedure.

Accuracy of Injections for Shoulder Rotator Cuff Syndrome

Symptoms that suggest a rotator cuff tendinopathy include pain with arm motion overhead, pain at night, and a positive impingement sign (pain during a particular arc of shoulder motion). A common treatment for this problem is a steroid injection into the acromial bursa. The antiinflammatory properties of the steroid medication are designed to reduce swelling and thereby decrease the size of the bursa. An inflamed bursa can be painful but can also take up space in the shoulder causing impingement (pinching) of the rotator cuff tendons.

An orthopedic surgeon performs this as an outpatient procedure in his or her office. First, the skin is numbed with a topical spray. Then the surgeon inserts a long, thin needle into the bursa underneath the acromion bone. The bursa is a fluid-filled sac between the bone and soft tissues. The acromion is the end of the bone from the scapula (shoulder blade) that forms a shelf over the top of the shoulder joint.

This area under the acromion can be reached with the needle from one of three directions: anterior (front), lateral (side), or posterior (back). But the question is: which route is the most accurate? In this study, one orthopedic surgeon injected 75 shoulders using these three pathways.

There were three groups of patients and each group received one of the three types of injection. Patients were randomly assigned to the group they were in. The fluid injected included the steroid medication, a numbing agent, and a dye. The dye was part of the injection so that X-rays taken would show the accuracy of the injection (i.e., did the fluid actually end up inside the bursa?).

This surgeon found that injecting the shoulder from the front and side (anterior and lateral routes) gave better results than injecting from the back (posterior). This was especially true for women. It turns out that the posterior route was the least accurate when injecting the subacromial bursa in females.

One possible reason for this difference between men and women may be the downward-sloping angle of the acromion. Differences in accuracy of the route (anterior, lateral, or posterior) could possibly be because only one physician performed the injections. These results might be different if a group of physicians gave injections and results were compared.

For this particular surgeon who normally used the posterior approach, the results suggested the need to switch to either the anterior or lateral approach, especially for women. When patients fail to get pain relief from a steroid injection for rotator cuff syndrome, it may not be because the injection failed. It could be the injection never reached its intended destination if the surgeon failed to accurately inject the bursa. Pain relief with successful steroid injection is expected to occur within the first hour after injection. A second reason pain relief may not occur is an incorrect diagnosis (the problem may not be a rotator cuff tendinopathy).

The author summarizes by saying that in-office steroid injections for rotator cuff syndrome can be successful. Accuracy is assured when using ultrasound or fluoroscopy (a type of X-ray) but without these tools, the rate of success increases when injecting through the anterior or lateral approaches.

In this study, the success rate when injecting women was highest (91 per cent accurate) when using the lateral route. This was compared with 38 per cent for the posterior route. For men, it didn’t seem to matter; accuracy was fairly equal no matter what direction the injection was delivered.

Encouraging New for Patients with Rheumatoid Arthritis

This study from the Mayo Clinics (Arizona and Minnesota clinics) showed encouraging results for patients with severe shoulder destruction and rotator cuff tears. They successfully replaced the shoulder joints of 19 patients with a reverse shoulder replacement. Early results (after three years) were good but there were some complications.

The mechanics and design of the reverse shoulder replacement are the exact opposite of a traditional shoulder replacement. In the reverse implant, the ball portion of the shoulder is placed where the socket use to be and the socket is where the ball or humeral head occurs naturally in the normal shoulder joint. This new design has made it possible to create a much more stable shoulder joint that can function without a rotator cuff.

The loss of the support and function of the rotator cuff muscle is the key ingredient here. Without this important muscle group, patients with severe rheumatoid arthritis do not do well with the traditional shoulder replacement. But concerns about bone loss and a lack of information on how patients with rheumatoid arthritis would do with this type of implant have kept surgeons from using the reverse shoulder replacement.

That’s why this study is so important. For the first time, we have some early results that support this type of treatment for patients with rheumatoid arthritis affecting the shoulder(s). The 19 patients included men and women between the ages of 58 and 81. Some of the patients (a total of five of the 19) had previous surgery (rotator cuff repairs) that failed.

Results of the reverse procedure were measured using pain levels, shoulder motion, and function of the arm that depended on use of the shoulder. X-rays were used to show position and condition of the implant. X-rays also show the degree of scapular notching.

A notch (opening) in the scapula (shoulder blade) is where an important nerve (the subscapular nerve) passes through. The natural size, shape, and location in the bone can vary. If the ligament across the top of this notch is tight and pressing down on the nerve and/or if the notch is too shallow or too small, the surgeon must make corrections in order to take pressure off the nerve.

Compared with preoperative measurements, the postoperative results were excellent for 12 of the 19 patients. Five others had satisfactory results. Only two had an unsatisfactory outcome. There were a few complications but most were not directly related to the surgery. Falls leading to bone fractures were the biggest postoperative problem but these were not directly related to (or caused by) the shoulder replacement surgery. No one in the study needed revision surgery.

In conclusion, patients with severe shoulder joint destruction from rheumatoid (inflammatory) arthritis are not without some options. According to the early results of this Mayo clinic study, the use of reverse shoulder arthroplasty can benefit these patients. The main indication for the use of reverse shoulder replacements has always been severe rotator cuff damage. It looks like a reverse prosthesis can also successfully reduce pain and significantly improve function previously affected by limited motion. The authors say they will continue using this procedure with their patients when appropriate.

Encouraging New for Patients with Rheumatoid Arthritis

This study from the Mayo Clinics (Arizona and Minnesota clinics) showed encouraging results for patients with severe shoulder destruction and rotator cuff tears. They successfully replaced the shoulder joints of 19 patients with a reverse shoulder replacement. Early results (after three years) were good but there were some complications.

The mechanics and design of the reverse shoulder replacement are the exact opposite of a traditional shoulder replacement. In the reverse implant, the ball portion of the shoulder is placed where the socket use to be and the socket is where the ball or humeral head occurs naturally in the normal shoulder joint. This new design has made it possible to create a much more stable shoulder joint that can function without a rotator cuff.

The loss of the support and function of the rotator cuff muscle is the key ingredient here. Without this important muscle group, patients with severe rheumatoid arthritis do not do well with the traditional shoulder replacement. But concerns about bone loss and a lack of information on how patients with rheumatoid arthritis would do with this type of implant have kept surgeons from using the reverse shoulder replacement.

That’s why this study is so important. For the first time, we have some early results that support this type of treatment for patients with rheumatoid arthritis affecting the shoulder(s). The 19 patients included men and women between the ages of 58 and 81. Some of the patients (a total of five of the 19) had previous surgery (rotator cuff repairs) that failed.

Results of the reverse procedure were measured using pain levels, shoulder motion, and function of the arm that depended on use of the shoulder. X-rays were used to show position and condition of the implant. X-rays also show the degree of scapular notching.

A notch (opening) in the scapula (shoulder blade) is where an important nerve (the subscapular nerve) passes through. The natural size, shape, and location in the bone can vary. If the ligament across the top of this notch is tight and pressing down on the nerve and/or if the notch is too shallow or too small, the surgeon must make corrections in order to take pressure off the nerve.

Compared with preoperative measurements, the postoperative results were excellent for 12 of the 19 patients. Five others had satisfactory results. Only two had an unsatisfactory outcome. There were a few complications but most were not directly related to the surgery. Falls leading to bone fractures were the biggest postoperative problem but these were not directly related to (or caused by) the shoulder replacement surgery. No one in the study needed revision surgery.

In conclusion, patients with severe shoulder joint destruction from rheumatoid (inflammatory) arthritis are not without some options. According to the early results of this Mayo clinic study, the use of reverse shoulder arthroplasty can benefit these patients. The main indication for the use of reverse shoulder replacements has always been severe rotator cuff damage. It looks like a reverse prosthesis can also successfully reduce pain and significantly improve function previously affected by limited motion. The authors say they will continue using this procedure with their patients when appropriate.

Platelet-Rich Fibrin Matrix Has a Negative Effect on Tendon Healing

Surgeons from the Sports Medicine and Shoulder Service at the Hospital for Special Surgery in New York City add a new piece of information about platelet-rich plasma for tendon healing. In their study using this healing method for rotator cuff tears, patients had a worse outcome compared to the control group who had the same surgery but without the use of a platelet-rich fibrin matrix.

Let’s back up a bit and fill you in on what this all means. In the past 10 years, surgeons have started using platelet-rich plasma (PRP) (also known as blood injection therapy) for a wide range of musculoskeletal problems.

Platelet-rich plasma (PRP) refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself. It is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

In this study, the surgeons used a special platelet-rich fibrin matrix (PRFM) they made themselves in the operating room. It is a slight variation from the original platelet-rich plasma (PRP) product first used. The fibrin matrix processes the patient’s plasma in a way that helps keep blood-clotting platelets in the matrix while also slowly releasing cytokines to aid in healing.

Cytokines are signaling molecules used in cellular communication. They are part of the immune system response to injury. They help set up a new blood supply to the area and attract stem cells to the area to help form new tendon. By painting this substance at the tendon-bone interface, the researchers hoped to speed up rotator cuff healing.

Instead, what they found with ultrasound studies and by measuring patients’ motion, strength, and function was that the group who did NOT receive the PRFM got better results. The two groups (with and without the PRFM) had similar outcomes in terms of grip strength and pain after surgery. But the PRFM group had a significantly higher number of tendon defects. This finding indicated the PRFM might have a negative effect on tendon healing.

The original hypothesis in conducting this study was that PRFM would speed up or accelerate rotator cuff tendon healing. It did not. In fact, it seemed to inhibit healing. There were more treatment failures in the PRFM group compared with the control group. Of course, the natural question is, “Why didn’t it work?”

The authors propose three possibilities: 1) the study was fairly small (39 patients in one group, 40 in the other), 2) the study only looked at tendon results with ultrasound 12 weeks out; it is possible that further tendon healing took place much later, and 3) the method used to make the matrix could be improved. They took the patients’ plasma and used it without analyzing exactly how many of each kind of cells (e.g., platelets, growth factors, cytokines, white blood cells) were present.

Although PRFM did not improve rotator cuff tendon healing and was even linked with lower healing rates, further study is needed to understand what happened before either abandoning the technique or using it on other patients.

Evaluation and Causes of Scapular Dyskinesia

The scapula (more often referred to as your “wing bone” or shoulder blade) is a key reason why your shoulder and arm move and glide smoothly and easily. Not only does the scapula give the shoulder muscles a base of operation, it also acts as a moving platform for the shoulder ball-and-socket joint to function properly.

In short, the scapula is a silent partner with the shoulder in moving the arm in any and all directions. Any injury that affects the shoulder is going to also affect the scapula. This connection may not be apparent at first but over time, a condition known as scapular dyskinesia develops. Dyskinesia just means the body part isn’t moving in the normal rhythm or sequence.

This review of the role of the scapula in shoulder injuries with evaluation and treatment of scapular dyskinesia comes from two physicians and an athletic trainer at The Shoulder Center of Kentucky. They provide a detailed description of normal scapular function (motion, coordination, and integration with the arm and trunk). The way in which the scapula contributes to normal shoulder function is also discussed.

In contrast to normal motion, scapular dyskinesia is also described with photos of patients included to help the reader visually understand what is happening. The patient may not feel anything directly wrong with the scapula. Sometimes there is a snapping or grinding sensation as the scapula moves over the ribs. The biggest sign of a scapular problem is what’s called scapular winging. As the patient moves the arm up overhead or forward, the scapula pops out away from the body. Reaching behind the back with the hand on the affected side will also result in excessive winging.

When evaluating someone for this problem, it is necessary to look at all components of the shoulder complex: muscles, joints, bones. The cause of scapular dyskinesia is usually mechanical such as muscle stiffness or shortening, bone fractures, alterations in shoulder joint motion, joint instability, or muscle (strength or timing) imbalances.

Three-dimensional (3-D) motion pictures of patients with scapular dyskinesia show that the altered position of the scapula affects all aspects of upper quadrant movement. Clinical tests to examine the scapular position, alignment, and motion include visual inspection, the scapular assistant and scapular retraction tests, and resisted forward shoulder motion with a three to five-pound weight in each hand.

Treatment depends on a thorough and careful evaluation process to detect all areas of involvement. With this information, researchers can move to the next step of determining the best treatment approach for this problem. Of course, addressing fractures, rotator cuff tears or degeneration and the impingement that comes from rotator cuff disease, and labral tears is the first step. But for complete recovery, it will be important to restore normal alignment and movement of the scapula as well.

Anyone working with athletes, aging adults, or any others with shoulder problems will find the information in this article on the cause and effects of scapular involvement helpful. The detailed discussion of anatomy and evaluation of scapular dyskinesia will benefit physical therapists and athletic trainers working with shoulder impaired patients.

Can Hyaluronic Injections to the Shoulder For Adhesive Capsulitis Improve Treatment Results?

Adhesive capsulitis is a problem of chronic inflammation of the shoulder joint capsule. The shoulder capsule is a covering of connective tissue interconnected with shoulder ligaments and tendons. They all help hold the head of the humerus (upper arm bone) in the shoulder socket.

The inflammatory process causes the capsule to thicken and tighten to the point that the extra fold of capsular tissue needed for full motion overhead gets stuck to itself. There is a loss of normal synovial fluid in the joint.

When this happens, the shoulder can no longer slide and glide smoothly through its full range-of-motion. The capsule loses its ability to stretch. The result is the shoulder gets stuck and becomes stiff and painful. In chronic cases, inflammation is gone but it was the first step that got the process started. Treatment is still directed at the joint capsule.

In this study, the use of hyaluronic acid (HA) injections for this problem is compared with traditional physical therapy. Patients were randomly placed in one of two groups: group one received the HA injections along with physical therapy. Group two only went to physical therapy and did NOT get the injections.

Physical therapy consisted of one-hour sessions, three times a week for 12 weeks. Therapeutic exercise along with the use of heat and electric therapy were provided by the physical therapist. The Hyaluronic Acid (HA) injections were placed directly in the shoulder joint once a week for three weeks. HA has been used successfully in the knee; its use in the shoulder is a relatively new treatment approach.

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. 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.

So, what worked better: PT alone or PT plus hyaluronic acid injections? Neither one was more effective than the other in reducing pain, improving motion, or restoring function. The results were equal between the two groups. If this is the case, then the added expense of the injections may not be needed for this condition.

There were some shortcomings in this study though. So before the recommendation to drop the use of hyaluronic acid for shoulder adhesive capsulitis is made, more research is needed to settle some of the questions left unanswered in this study. For example, they did not compare patients receiving injection only to these other two groups.

Fluoroscopy or ultrasound was not used to guide the injections, so it’s possible more accurate injection technique might make a difference. And different stages of adhesive capsulitis may respond differently to treatment making hyaluronic acid a time-specific treatment. And finally, long term results (six months to several years later) should be investigated.

Current Trends in the SLAP Repair of the Shoulder

SLAP stands for superior labral anterior posterior and refers to a tear of the labrum located around the rim of the acetabulum (shoulder socket). The labrum is a ring of fibrous cartilage around the shoulder socket. It helps support and hold the round head of the humerus (upper arm bone) in the shallow socket.

The superior labrum is located along the top of the socket. It is attached loosely by elastic connective tissue. A force or load through the shoulder that is greater than the tensile strength of the thick connective tissue can cause tearing of the structures.

There are four types of SLAP lesions. The groups are based on severity. Type 1 occurs most often in older adults. Fraying and thinning of the labrum is most common with this type of SLAP lesion. If surgery is called for, the surgeon will shave off any fragments and smooth the remaining edges of the labrum.

The other types describe the extent of injury. For example, in a type 2 SLAP injury, the biceps anchor where the labrum attached is detached. There may be some frayed edges of the labrum as well.

Type 3 is a bucket-handle shaped tear in the labrum but the biceps anchor is not disturbed. Type 4 has a similar bucket-handle shape that extends all the way into the biceps tendon. Sometimes people have more than one type of tear at a time. Surgery is often needed to repair the more severe injuries.

The number of SLAP surgeries being done in the United States is increasing year-by-year. The reason(s) for this are not yet clear. By studying patient characteristics of people having the SLAP repair, this group of surgeons hopes to explain this trend.

Demographic information such as age, sex (male versus female), and geographic location where the surgery took place might shed some light on who, what, where, and why SLAP repairs are being done. This type of study is referred to as a descriptive epidemiology study. It was done by examining the insurance billing records of a national database, which are public but still maintain patient privacy.

Data collected on over 25,500 patients who had an arthroscopic SLAP repair was analyzed for a five-year period of time. There were four major findings:

  • Men have this surgery three times more often than women.
  • There is indeed a rising number of SLAP repairs being done each year with a 105 per cent increase over this short time period.
  • Two age groups seem to be the most likely to need this surgery: between 20 and 29 years old and between 40 and 49. This is a higher number of SLAP repairs in older adults than previously recognized.
  • The West seems to be the place where this procedure is done most often. The second highest geographic location where SLAP repairs are done was in the South.

    What does all this information mean? That’s a good question but the answer is not entirely clear just yet. For example, does the difference in numbers of procedures between men and women suggest men are more active and injured more often? Or do surgeons tend to repair SLAP tears in men more readily than in women (a gender bias)?

    Why are there more older adults having this surgery? It may be because newer repair techniques (e.g., with suture anchors) makes this procedure more successful in that age group than ever before. But other studies have clearly shown that tenotomy (tendon is cut) or tenodesis (stitching tendon back to the bone) procedures have better results than SLAP repairs in patients over 40 — so why are surgeons still performing SLAP repairs on this age group?

    There is also no clear reason why geographical differences exist. In fact, most of the data collected in this study raised more questions than they answered. The authors suggest further comparative studies to find out the “whys” for the “what” they uncovered. Studies are also needed to look at results of treatment for each procedure and with the demographic variables in mind.

  • Controversial Issue in Shoulder Surgery

    Surgeons are grappling with the question of whether a single row of sutures to repair a torn rotator cuff is enough or are the results better with a double row? Some studies have shown that a double row of sutures provides greater stability and biomechanical strength. But similar studies to prove the clinical value (e.g., fewer complications, better shoulder function) are lacking.

    To help solve the debate, surgeons at Boston University School of Medicine conducted a systematic review. This means they searched all previously published articles on this topic to see if there was any consensus or agreement from the studies done so far. They found seven suitable studies to include in their analysis.

    Although they found a trend toward more failures in the single-row group, it wasn’t significant enough to say single-row sutures is an inferior repair method compared with double-row sutures. At this point, you may be wondering what’s the difference in these two surgical techniques?

    Both single-row and double-row suture technique can be done arthroscopically without a wide open incision. Arthroscopic surgery is less invasive and involves less cutting into the soft tissues such as muscles and tendons. The benefit in the end is less scarring, less pain, fewer injuries to important soft tissues such as muscles.

    Double-row sutures brings more of the tendon in contact with the bone. The hope is that more fibers will be recruited in the healing process. This might result in a more stable repair. Double-row sutures also means less stress and force are applied to each individual suture. There is also the potential for less gapping in the soft tissues where they should be smooth and closely reattached to the bone.

    But as this systemic review showed, the retear rate, number of complications, and functional outcomes were not statistically different between the two suture repair techniques. There was a trend toward a higher retear rate among the single-row group. But again, this difference did not reach statistical significance. The mechanically superior double-row fixation simply does not improve the final results.

    The authors concluded that further study of this topic is needed. They suggested that perhaps rotator cuff tear site, size, and quality make a difference and should be included in the analysis.

    Are There Any Benefits of Early Motion After Arthroscopic Rotator Cuff Repair?

    Here’s the drill after arthroscopic rotator cuff repair: you are in an abduction brace for four to five weeks. During that time, you may be given a series of passive exercises to complete. Passive exercise indicates that someone else (family member, physical therapist) is moving the arm for you. The idea is to avoid active muscle contraction that might pull on the healing tissue and disrupt the sutures holding the torn rotator cuff.

    As you start to wean off the brace, active-assisted exercise is prescribed. Active-assisted usually means you use your nonsurgical hand to help guide the operative side through the motions. It can also mean someone helps guide your arm but you are actively using your muscles as well.

    What is the purpose of these exercises? The goal is to prevent postoperative stiffness, muscle atrophy (wasting), and loss of motion. At the same time, movement is designed to restore function. The question arises: is early passive motion exercise really needed after arthroscopic rotator cuff repair?

    With arthroscopic repair, there is much less cutting of the muscles. Healing may (or may not) be disrupted by early motion. Studies with animals actually show a better tendon healing response when the limb is immobilized longer and exercise is delayed. Is it possible the same principle is true for humans?

    A study was done in Korea to verify whether early passive motion exercise is beneficial after arthroscopic shoulder repair. They divided a group of patients who had similar characteristics (age, hand dominance, other medical or health problems) into two groups. All rotator cuff tears were small-to-medium in size.

    Group one started passive shoulder exercises right from day one after the surgery. Group two was not allowed to move the arm until the brace came off four or five weeks later. Patients with small tears were able to remove the brace after four weeks. Anyone with a medium-sized tear wore the brace an extra week. Everyone did active-assisted movements after the brace came off.

    The question then is: did the group who started early passive exercise have a better (or worse) result when compared with the group who waited until the brace was off to begin moving the arm? Using pain, function, and healing (as seen on MRIs and ultrasound studies), they found no difference between the groups.

    On the one hand early passive motion didn’t assist healing. On the other hand, this approach didn’t cause harm by disrupting the healing tissue. The authors propose the idea that early passive motion isn’t required after arthroscopic rotator cuff repair. They point out that their patients all had small-to-medium sized tears.

    The results of this study are consistent with animal studies and a few other similar studies on humans. More study is needed to confirm the idea that early passive motion may not be needed after arthroscopic repair surgery for small-to-medium rotator cuff tears. At the same time, it would be helpful if researchers could verify that a longer period of immobilization could actually improve the rate of healing.

    Pain or Weakness After Rotator Cuff Repair

    Sometimes patients don’t get the expected results after arthroscopic rotator cuff repair. Instead of pain relief, increased shoulder motion, and restored function, they experience persistent pain and/or weakness. Why does this happen and what can be done about it? These are the two questions surgeons from the New York University Hospital for Joint Diseases attempt to answer in this article.

    Arthroscopic repair of the rotator cuff is actually a very reliable technique. Most patients (more than 90 per cent) swear by it and would do it again if they had to make the decision over. But in the remaining few (six to eight per cent), the repaired tendon fails to heal. Or in some cases, the patient reinjures the arm before healing takes place. These cases are called failed rotator cuff syndrome.

    Some of the reasons patients fail to heal include age (65 years old and older), the tear was very large in size, significant muscle atrophy (wasting), and tendon retraction (tendon pulls way back from the bone). A few other factors that hinder healing after rotator cuff tear repair include smoking, diabetes, unwillingness to engage in the rehab program, and failure to follow the physician’s or physical therapist’s guidelines during recovery.

    Treatment for failed rotator cuff syndrome varies depending on the reason(s) why the surgery wasn’t successful in the first place. A three-month trial of physical therapy aided by a home exercise program may be all that’s needed. But if this measure fails to restore motion and strength, then revision surgery is one possibility.

    Revision surgery begins with release of any soft tissue restrictions (scarring, adhesions). If possible, the retracted tendon is brought back to the bone where it was originally attached (a place on the bone called the footprint).

    If there isn’t enough “give” in the tendon, then it is pulled as close as possible and sutured (stitched) to nearby soft tissue. The surgeon must maintain a balance between tendon tension and tendon mobility. Creating a balanced shoulder is important (meaning the muscles all around the joint pull equally, evenly, and in a coordinated fashion to create movement.

    Sometimes patients have a re-tear of the repaired rotator cuff and don’t know it. They either don’t have any pain or the loss of motion and function is mild. That’s when the surgeon has to evaluate and decide if surgery is even needed. The surgeon may decide to follow the patient closely with more of a wait-and-see approach than a surgical one.

    In young, active patients with massive tears, it may not be possible to repair the rotator cuff. In those cases, a tendon transfer can be used to restore motion and function. The tendon harvested for use depends on the location and severity of the rotator cuff tear. For example, with damage to the supraspinatus and subscapularis (front of the shoulder), the tendon to the pectoralis major muscle is used. If the cuff is damaged more toward the back of the shoulder, then the latissimus dorsi tendon is harvested.

    Very large tears with poor tendon healing in older adults may just require a shoulder replacement instead of a revision procedure. There are several options to choose from: a hemiarthroplasty, reverse total shoulder arthroplasty, or traditional total shoulder replacement. The hemiarthroplasty is a partial replacement (only half of the shoulder is replaced). A reverse replacement places the round head needed for motion where the shoulder socket used to be and the shoulder socket where the round head of the humerus (upper arm) is normally located.

    For those who are interested in more details, the authors of this article provide MRI and intraoperative photos of patients with failed rotator cuff syndrome. A separate flow chart for decision-making in treating younger versus older patients is also provided. They also offer their opinions on examination and surgical techniques, factors to consider, and what to expect.

    Detecting Capsule Laxity Important Before Shoulder Surgery

    Shoulder instability can be very complex ranging from painful loss of motion to shoulder dislocation. Surgery to restore a pain free, stable joint requires careful examination by the surgeon. Before a decision can be made what surgical technique should be used, it is important to identify whether the patient has a unidirectional or multidirectional instability.

    A unidirectional instability means the shoulder has too much movement in one direction only. Multidirectional instability refers to a shoulder joint that has too much movement or laxity in several different directions at the same time.

    Most of the time, this type of problem is caused by laxity or looseness of the shoulder capsule or damage to the capsule and labrum. The labrum is an extra rim of cartilage around the shoulder socket designed to give it a little more depth and holding power.

    There is a difference between laxity (looseness of the soft tissues holding the shoulder together) and instability (abnormal increase in capsular volume). When it comes to surgery, the surgeon must understand the difference AND recognize when patients have one or both of these conditions. The surgical procedure selected must specifically address the problem(s).

    Treatment can begin with conservative (nonoperative) care. This consists of a rehab program of rotator cuff strengthening exercises, scapular stabilization, and therapy to restore normal proprioception (joint’s sense of position). A physical therapist will set up and supervise the program. The therapist pays close attention to helping the patient restore normal motor control, strength, endurance, and stability.

    If a nonoperative approach fails to restore shoulder stability, then surgery to correct the capsular laxity may be required. In the case of multidirectional laxity, the surgeon will reduce the excessive volume by “tightening up” the joint. This may involve shifting the capsule and increasing tension on the shoulder ligaments. Sometimes it is best to make an incision or cut straight down the capsule, draw the edges closer together and suture them back together.

    After surgery, shoulder rehab is important. During the first six weeks, the patient wears an immobilizer to protect the healing tissue and does pendulum (Codman) exercises to keep the joint moving without disrupting the incision site. Six weeks after surgery, a rehab program of stretching and strengthening program is started.

    Most of the time, this approach is successful but there are cases where surgery fails to achieve the desired results. Failure is most likely when the surgeon does not address the specific type of capsular laxity present. Other risk factors for a failed stabilization procedure include untreated lesions, stretched ligaments, bone loss, or compression fracture of the shoulder glenoid surface. The glenoid is the shallow shoulder socket.

    A failed result after shoulder stabilization surgery is not the end of the line. Revision surgery can be done to address the ongoing laxity or instability. The decision to perform arthroscopic versus open shoulder surgery depends on the surgeon’s experience and the exact nature of the patient’s problem(s).

    Once again, it is very important that the surgeon re-evaluate the patient and make sure all aspects of the problem have been identified. There are fewer problems after revision stabilization procedures when the patients are young (less than 35 years old), have good bone density, and have not had other previous shoulder surgeries.

    Details of surgical technique described here along with figures depicting the surgical procedures are available in an instructional course lecture. This lecture was sponsored by the American Academy of Orthopaedic Surgeons. The surgeons who wrote the article are from the University of Texas in San Antonio, Texas. They suggest that results after a capsular shift procedure are good to excellent.

    Update on Hill-Sachs Shoulder Lesion

    Traumatic injury to the shoulder with recurrent dislocation can be caused by a Hill-Sachs lesion or defect. This lesion is a fracture of the round head of bone at the top of the humerus (upper arm bone). Usually, this injury occurs when a person has his or her arm cocked back in a ball throwing motion. The shoulder is abducted (moved away from the body) and externally rotated.

    In this position, the head of the humerus moves forward. With enough force and/or load, the forward movement can overcome the strength and restraint of the soft tissues holding the shoulder back. The joint capsule is stretched to the breaking point.

    Once the soft tissues surrounding the shoulder have stretched enough to tear, then the shoulder can dislocate repeatedly. And with every dislocation, the damaged soft tissues give a little more until the shoulder is unstable and no longer stays in the shoulder socket (glenoid fossa). At the same time, the compression against the bone is enough to cause the fracture described as a Hills-Sachs lesion.

    A small lesion or one that is oriented perpendicular (sideways) to the rim of the socket (glenoid rim) can be treated conservatively (without surgery). Rehab under the direction of a physical therapist may be all that is needed. Older adults are also usually directed toward nonoperative treatment. Even with small to mid-size lesions, rehab can be quite lengthy over a period of many months.

    Larger lesions and bony defects that are parallel to the glenoid rim are usually just part of the total picture. In these more extensive injuries, other tissues (e.g., labrum, anterior capsule) are also damaged. Coexisting injuries like his require surgery to stabilize the shoulder and prevent worse shoulder instability.

    Before a treatment plan can be determined, the surgeon takes a complete history, performs a physical examination, and orders imaging studies. X-rays, CT scans, MRIs, and ultrasound studies reveal the full extent of damage including location and direction of the lesion. Imaging studies also help identify the amount of bone loss for both the humeral head and the glenoid fossa.

    Once the decision has been made to do surgery, then the surgeon must figure out the best approach to take. The first decision will be whether to do the surgery arthroscopically or with an open incision. It may be necessary to combine several different procedures in order to treat all the bony and soft tissue problems that are contributing to the shoulder instability.

    Surgical options include bone graft to fill in the bony defect, tissue filling called remplissage, and capsular shift to tighten up the soft tissues. In some cases, a shoulder replacement or resurfacing procedure may be the only way to treat the problem. A newer procedure called disimpaction is being investigated. In this surgery, the fractured bone is lifted up and a layer of bone graft is placed underneath to support it.

    Long-term results with each of these approaches are unknown. There is a great need to identify patients who can benefit from conservative care versus those who need surgery. The role of age and activity level (active versus inactive) in treatment outcomes should be investigated as well.

    In summary, despite the fact that Hill-Sachs compression fracture of the humeral head has been described since 1940, new information and treatment ideas are still forthcoming. Treatment options are expanding as a result of better imaging studies available to examine, describe, and classify these lesions. These are challenging injuries to treat and optimal care is individually determined and carried out for each patient.

    Report on a Rare But Devastating Problem After Arthroscopic Shoulder Surgery

    Imagine you are in your late teens or a young adult in your 20s. You have a simple arthroscopic surgery on your shoulder for a rotator cuff tear or unstable shoulder joint. Three months later, the entire surface of your shoulder joint (called the articular cartilage) is destroyed. Deep shoulder pain with rapid loss of motion (and then function) are the main symptoms of this problem.

    You have a condition called postarthroscopic glenohumeral chondrolysis or PAGCL. Your shoulder has gone from your current age to that of an older adult with osteoarthritis. And all you did was have arthroscopic surgery.

    In this report, surgeons from the well-known Kerlan-Jobe Orthopaedic Clinic in Los Angeles explore this condition. Covering risk factors, causes, and signs and symptoms, the authors provide their own thoughts and recommendations for surgeons. Finding ways to prevent this complete destruction of the shoulder joint is the next step in research for this group.

    The first question is: what went wrong? The second question is: why did this happen? And of course, the third question is: what can be done to prevent this problem in the future? In answer to the “what went wrong” question, studies show that the condition called chondrolysis develops when the chondrocytes (cartilage cells) suddenly stop working. They are no longer able to make new cartilage cells to replace the old or to maintain the healthy state of the joint cartilage.

    The main risk factor is the arthroscopic surgery itself. But many people have arthroscopic shoulder surgery without developing chondrolysis afterwards. There must be other factors at play here. In fact, the authors suggest there is likely a multifactorial etiology. In other words, several or even many risk factors combined together result in postarthroscopic glenohumeral chondrolysis (PAGCL).

    A review of studies with reported cases of PAGCL shows a list of potential risk factors. These etiologic factors include direct trauma to the joint during surgery, shoulder instability before surgery, the use of bioabsorbable sutures and other implants, heating the joint with radiofrequency to shrink the tissues, and the placement of sutures (anchors and knots) on the joint (articular) surface.

    Other possible risk factors being considered and investigated further include family history of early arthritis, patient history of a collagen disorder, and exposure of the joint surface to irrigation solutions or high concentrations of local anesthetics. There could also be some specific risk factor common to young patients that remains elusive (avoids detection).

    X-rays and MRIs clearly show dramatic narrowing of the joint space, erosion or wearing away of the bone surface, and loss of articular cartilage on both sides of the joint (humeral head and shoulder socket). MRI signals also show irregular and patchy areas of bone marrow edema (fluid accumulation or swelling).

    The authors explore the details of potential mechanical, thermal, and chemical causes. Mechanical causes include direct injury to the fragile cartilage when the arthroscopic probe or other surgical instruments come in contact with the cartilage surface.

    As already mentioned, the use and placement of certain types of sutures may contribute to the development of chondrolysis. Loose or prominent sutures/knots rub against the cartilage causing severe wear and tearing. In some patients, the suture material may set off an immune response called a foreign body reaction. The body sets up a massive inflammatory response in an effort to get rid of the sutures or anchors.

    Thermal causes (heating the joint) to stimulate a healing response may actually have the opposite effect of killing the chondrocytes. The use of pain pumps (chemical cause) placed inside the joint may help control postoperative pain but may also contribute to chondrolysis and PAGCL. Anyone with a combined set of risk factors (e.g., foreign-body reaction plus thermal or chemical factor) may be at increased risk for this type of rapid joint destruction.

    Once the various risk factors and potential causes have been identified, the next step is prevention. When the destructive process begins, there is no going back. And without effective treatment, prevention is absolutely essential. The authors make the following recommendations:

  • Surgeons must always be mindful that arthroscopic surgery can injure the joint surface. Care must be taken when inserting the arthroscopic probe or surgical instruments. Gouging and scuffing the joint surface must be avoided.
  • Bioknotless sutures are available and should be used, especially when the sutures must sit right on top of the joint surface.
  • There are also anchors designed to resist pulling out because even a slight pull-out creates suture prominence that can rub against the articular cartilage.
  • Do not use thermal devices such as radiofrequency energy.
  • Avoid bathing the joint with local anesthetics. Infusion of numbing agents to reduce pain can be placed in the subacromial space rather than directly inside the joint.

    The authors conclude that postarthroscopic glenohumeral chondrolysis (PAGCL) is a rare complication of shoulder arthroscopic surgery. But when it happens, the consequences can be devastating. And since the primary age group affected is young adults, every effort should be made to screen for risk factors and avoid anything that might contribute to this condition. Until more is known about the true etiology (cause) of PAGCL, surgeons are advised to follow the recommendations made.

  • Choosing the Best Clinical Tests for Shoulder Impingement Syndrome

    At last count there were at least 20 different clinical tests to test patients with shoulder pain for subacromial impingement syndrome or SIS. And while that may seem like a good thing (so many helpful tests to choose from!), surgeons simply don’t have the time to use each one on every patient with shoulder pain. Not only that, but by the end of all those tests, painful symptoms often get much worse.

    The term impingement tells us something is getting pinched. Subacromial impingement syndrome occurs when the rotator cuff tendons rub against the roof of the shoulder, the acromion. Although SIS is one term, it actually represents a wide range of underlying pathologies. There could be a bursitis, rotator cuff tendinopathy, fracture, calcific tendinitis, or other change in the local anatomy contributing to the problem.

    But before a plan of treatment can be determined, an accurate diagnosis is needed. That’s where all these clinical tests come in. What surgeons, sports physicians, primary care physicians, and physical therapists need is a set of one to three clinical tests for subacromial impingement syndrome that are safe, reliable, and accurate.

    In order to find such a set of accurate clinical tests for SIS, a group of researchers conducted a systematic review and meta-analysis. Systematic review means they carefully and systematically combed through all studies that might have had something to do with the subject. In this case their search found 1,338 articles that might qualify. On closer inspection, only 31 studies could actually be included.

    A meta-analysis means when studies are too small to have much significance, they can be combined with other similar studies to reach statistical importance. They found five tests used and reported on most often in studies conducted around the world. These five tests included the Hawkins-Kennedy test, Neer’s sign, the empty can test, the drop arm test, and the lift-off test.

    Each of these tests is very familiar to physicians and others who examine patients with acute and chronic shoulder pain. These tests may recreate the impingement that is causing painful symptoms or stress weak muscles. Together, they help identify whether the problem is one of impingement, muscle strength/weakness, and whether the rotator cuff is partially or fully torn.

    Athletes with sports injuries as well as adults with non-sports related injuries can be tested using these clinical tests. Each test has its own unique benefits and abilities in diagnosing shoulder problems. Accuracy in testing is essential to providing the best treatment for each shoulder problem.

    After analyzing the data and reviewing the results from the 31 studies included, the authors made a few discoveries. All five of these tests are useful for diagnosing subacromial impingement syndrome. Three of these tests (Hawkins-Kennedy, Neer’s, empty can) were better at ruling out (rather than ruling in) subacromial impingement syndrome (SIS). A negative Neer’s sign is very reliable in showing that SIS is not the problem. When the drop arm and lift-off tests are positive, the likelihood of a SIS is strong.

    The authors make several suggestions from the results of their study. First, they advise us that the Neer’s sign, Hawkins-Kennedy test, and drop-arm test may provide some useful information but by themselves cannot yield an accurate diagnosis. The lift-off arm test is the most informative in confirming a subacromial impingement.

    Other diagnostic test such as MRIs or arthroscopic exam may be needed to get the full picture of severity and underlying cause of the shoulder impingement. With an accurate diagnosis the most appropriate treatment can be prescribed whether that is physical therapy or surgery. In this way, unnecessary surgery can be avoided and overall costs of care reduced.

    Good Results with Joint Resurfacing for Shoulder Arthritis

    Today’s patients with shoulder arthritis are fortunate to have several surgical options. If necessary, a total shoulder replacement can be done. But even better is a procedure called shoulder resurfacing that makes it possible to get a “new” shoulder without losing much bone and without replacing the whole thing. Instead the damaged surfaces of the joint are covered with a resurfacing prosthesis or implant.

    In addition to saving bone there are many other advantages to the resurfacing technique. For example, the patient’s normal anatomy is preserved. The prosthesis can be fit to the patient instead of the other way around.

    The natural angle of the humeral (upper arm) bone is maintained. The cap that fits over the round humeral head has a peg that sets down into a hole drilled in the bone. The bits of bone taken from the hole are used to patch defects under the humeral cup. This means that the joint surface can be smoothed out and no bone is lost.

    Joint resurfacing isn’t possible for everyone. The surgeon must evaluate each patient individually to determine all possibilities. Joint resurfacing is most likely an option when there is still some joint surface left to work with. At least 60 per cent of the joint surface must be present. The rest can be treated with bone graft or bone graft substitute.

    Joint resurfacing can be offered to the patient who has an unstable joint from rotator cuff tears or insufficiency. The main goal of joint resurfacing for deficient rotator cuff disease is pain relief. Improved shoulder motion isn’t a main feature of this surgery without intact muscles to move the arm.

    Anyone with pain, stiffness, and loss of shoulder motion from rheumatoid arthritis or osteoarthritis may be a good candidate. Anyone with shoulder joint infection, too much bone loss or surface erosion, or arm paralysis would not be considered for joint resurfacing.

    Joint resurfacing has been around since the early 1980s. That gives us 30-years of data to examine in order to see how well this technique is working. And in this study, one surgeon from England reviews studies published on this topic along with the results of his 340 patients who had this procedure done.

    The patients in the study ranged in ages from 37 to 89 years old but the average age was 70 years old. The underlying diagnosis was rheumatoid arthritis or osteoarthritis. Follow-up was possible for at least four years and some patients were in the study for as long as 16 years.

    They found that the patients who had the best results had an intact rotator cuff and a diagnosis of osteoarthritis. Overall patient satisfaction was high with 94 per cent of the patients saying their shoulders were “better” or “much better” than before resurfacing.

    The results were compared with a group of patients who had a total shoulder replacement. The surgeon reports equally good results between the two groups with far fewer complications in the joint resurfacing patients. Total shoulder replacement has a greater risk and incidence of infection and bone fractures.

    The surgeon suggested that his method of balancing the soft-tissue around the shoulder prevents erosion of the shoulder socket (glenoid fossa). By releasing some of the soft tissues, the humeral head can be realigned to fit in the center of the socket where it functions best. Glenoid erosion is more likely when there is a soft tissue imbalance remaining after joint resurfacing.

    The author concludes that using a cementless resurfacing prosthesis for advanced arthritis of the shoulder yields very satisfactory results. There are fewer complications than with a total joint replacement. And the basic bone stock has been saved if it becomes necessary to fuse the joint or replace it with a full implant. High rates of patient satisfaction with the joint resurfacing procedure are an added bonus all around.

    Surprising Findings in 3633 Adults with Shoulder Dislocation

    Injuries traumatic enough to dislocate the shoulder can also cause other additional damage to the surrounding soft tissues and bone. Recognizing how often this happens is important in making sure surgeons assess each shoulder carefully for other injuries.

    In order to find out how often associated injuries occur along with traumatic anterior (forward direction) shoulder dislocations, the records of over 3600 patients were reviewed. The researchers looking for this information relied on ultrasound studies to confirm such injuries. The presence and prevalence of nerve damage, fractures, and rotator cuff injuries were reported.

    The most common associated injuries included axillary nerve palsy, brachial plexus injury, detachment of the rotator cuff, and fracture of the greater tuberosity (bony bump on the head of the humerus). Any combination of these injuries was also possible.

    Patients in the study ranged in ages from 13 to 104. Two-thirds of the group was male; the remaining one-third was female. Initial treatment was to reduce the dislocation. This was done by sedating the individual and performing a procedure to put the shoulder back in the socket.

    This type of reduction is called a closed reduction because the patient is conscious during the procedure and surgical incision is not required. For most of the patients in this group, closed reduction was effective. In a small number of cases (24), general anesthesia was required to complete the closed reduction and in three cases, open reduction was needed.

    Patients were followed at regular intervals. Anyone who did not improve had an ultrasound or MRI test done to look for residual soft tissue or bony changes. Motor and sensory testing was done when there were any signs of nerve deficits or nerve palsy.

    As it turned out, there was about 40 per cent of the total group who had more than just an isolated shoulder dislocation. One-third was fractures or rotator cuff tears and the rest were either neurologic injuries or a combination of injuries. Rotator cuff injuries affecting just one tendon were observed in 44 per cent of the group. More than half (55.6 per cent) damaged more than one of the four tendons that make up the rotator cuff.

    Younger patients with sports injuries were more likely to be male and have single nerve lesions. Older patients (60 years old and older) were at greater risk of multiple-nerve injuries. Women who dislocated the shoulder during low-energy falls made up the bulk of this second age group.

    Further analysis of the patients revealed that older women who fall are actually the group at greatest risk for shoulder dislocations and especially dislocation with associated injuries involving nerve damage. Anyone with a rotator cuff tear or greater tuberosity fracture was also at increased risk for nerve deficits.

    In summary, early identification of injuries associated with shoulder dislocation is important when planning treatment and discussing prognosis. Unseen, undiagnosed, and untreated damage to the surrounding cartilage, bone, nerves, muscles, tendons, and other soft tissues can compromise final outcomes. As this study showed, the number of times such associated injuries occurs is much more often than previously suspected.

    Surgeons are advised to carefully examine even what looks like a simple anterior shoulder dislocation. If there has been a force powerful enough to dislocate the shoulder, damage to the nearby areas is also possible. Even low-energy falls when affecting older adults can result in additional injuries.

    On the basis of the findings in this study, routine imaging is recommended for shoulder dislocations in anyone 60 years or older. Patients can be counseled more appropriately about necessary treatment and the possibility of delayed recovery in such cases.

    Low-Dose Steroid Injections Recommended for Shoulder Pain

    In today’s medical world, physicians are moving more and more toward treatment that is evidence-based. For the patient, this means there is reasonable “proof” that the proposed treatment is going to work. Some treatment is easier to study and evaluate than others.

    For example, in this study, surgeons compared the results of using a low dose (20 mg) steroid injection versus high-dose (40 mg) injection for patients with shoulder pain. They included a third (control) group who received a placebo injection. All 90 patients who were divided into these three groups had shoulder pain. They also had loss of motion associated with a diagnosis of subacromial impingement or subacromial impingement syndrome (SIS).

    Subacromial impingement refers to pinching of the soft tissues (bursa, tendons) that pass underneath the acromion (the roof of the shoulder). Although SIS is one term, it actually represents a wide range of underlying pathologies. There could be a bursitis, rotator cuff tendinopathy, fracture, calcific tendinitis, or other change in the local anatomy contributing to the problem.

    There are many factors that add up together to cause subacromial impingement syndrome. Aging with its many degenerative processes isn’t always very kind to the shoulder. Bone spurs form, the rotator cuff and other soft tissues fray and wear thin, and trauma all add to the development of mechanical shoulder pain. Loss of blood supply to the area is another reason why these problems occur.

    No matter what brings on the impingement syndrome, the end result is always the same: shoulder pain with movement. There is also loss of the normal gliding action required for movement of the arm overhead. Treatment often includes steroid injections so it’s important to know whether this approach works and the best way to administer it.

    That’s where this study comes in. Other studies have shown the value of corticosteroid injections as a means of reducing inflammation and reducing pain. With accurate injection into the bursa, success has been reported in up to 83 per cent of patients. Now it’s up to research science to determine the exact dosages that work best.

    The two dosages selected for study (20 mg and 40 mg) are the most commonly used injections. A long-acting medication (triamcinolone acetonide) was used for both. Higher doses have a greater risk of complications but may work faster. Lower doses may not deliver enough medication to make a difference. Everyone in this study received one injection based on the group they were randomly placed in (high-dose, low-dose, placebo).

    The injection was delivered using real-time ultrasound so the surgeon could be accurate in placing the needle right into the bursa. Results were measured on the basis of pain, motion, and perceived disability. Two questionnaires were used to measure outcomes (e.g., Visual Analog Scale, Shoulder Disability Questionnaire).

    Everyone was followed at two-week intervals for eight weeks. At first, they were cautioned against any heavy lifting or exercise. But after two weeks, they were encouraged to start gentle range-of-motion exercises and to remain active. Additional strengthening exercises were added four weeks after the injections.

    They found that the low-dose had just as good of results as the higher dose injections. Effects lasted the full eight weeks in the low-dose group. Complications and negative effects were minimal in both groups. One person experienced dizziness. Another reported facial flushing three days after the injection. But there were no skin or joint infections or changes in skin color where the needle went through.

    The authors concluded that low-dose corticosteroid injection for subacromial impingement is just as effective as high-dose and with fewer side effects. Physicians no longer have to rely on their own experience to determine optimal dosages for their patients.

    It is suggested that the low-dose injection be used as the first injection on a trial basis. Since many patients get up to three injections spaced apart, a low-dose injection could be followed by a higher-dose injection if results of the first injection are not satisfactory.

    To conclude, the authors suggested a few directions for future research in this area. First, it would be helpful to know which shoulder pain patients would benefit the most from steroid injections. For example, do acute patients with early symptoms get the same (more, less?) results compared with patients who have chronic shoulder pain (lasting more than six months). In other words, if there isn’t active ongoing inflammation, should steroid injections even be used at all?

    Next, different doses of steroid need to be evaluated. Just because 20mg gave the same results as 40mg doesn’t mean 20mg is the best (optimal dose) for everyone. Maybe it’s possible to go even lower. Maybe some shoulder problems would respond better at a low-dose while others need a higher-dose injection.

    And finally, although studies show the benefit of exercise for subacromial impingement, there are no studies proving what type is best. And that raises all kinds of additional questions. What is the best timing for exercise following cortisone injections? Does exercise work better with low-dose versus high-dose cortisone shots?

    For now we know there is evidence to suggest the benefit of low-dose over high-dose cortisone injection for subacromial impingement. A treatment plan can be developed around this information. Further refinements can be made as more research is done to answer some of these other questions.

    Tissue Engineering in the Treatment of Massive Rotator Cuff Tears

    Large, full-thickness tears of the rotator cuff can be very challenging for patient and surgeons alike. Loss of motion and loss of strength leads to loss of function for the patient. Finding a way to repair the problem without re-tears and surgical failure is a goal surgeons strive for.

    In this report, the successful use of a regenerative tissue matrix for 24 patients with massive irreparable rotator cuff tears is described. You may be wondering what is a regenerative tissue matrix. This is the use of donor tissue used as a scaffold to help the repair along. It is used when the torn tendon has retracted (pulled back) so far from the bone that it cannot be stretched back and stitched back down.

    By placing graft tissue between the end of the torn tendon and the shoulder bone, the surgeon is able to make a “bridge” and complete the repair. With this donor tissue in place, collagen fibers and blood vessels form to assist healing at the cellular level.

    In fact, if the results of these 24 patients are any indication, this technique is safe and effective without infection or tissue rejection. Patients who previously would not have been candidates for surgery and therefore unable to regain shoulder motion, strength, and function suddenly have a new opportunity for repair and recovery.

    There are some “yes, buts” to consider — meaning not everyone with an inoperable, irreparable rotator cuff tear can have this procedure. The patients in this study were selected very carefully for success. They did not have any shoulder arthritis. The tendon tear had not filled in with fat tissue. And for the most part, they still had fairly good active range of motion despite the rotator cuff damage.

    The use of human dermal allograft (skin harvested from a donor) in this study is not approved by the Food and Drug Administration (FDA) for use as an augmentation procedure of this type. The surgical technique presented in this study is therefore considered “off label.”

    Even so, the technique was successful with good results. Three-fourths of the group had a fully intact repair as shown by ultrasound studies. The rest of the patients had at least a partially repaired rotator cuff. There was no one in the group who ended up with a complete tear after this procedure.

    Everyone was satisfied with their results and said they would do it again if given a second chance. They all reported less pain, more motion, and better overall function. Follow-up was extended over a period of time from 29 to 40 months (two to three and a quarter years).

    The authors concluded that the use of extracellular matrix scaffolds in the repair of massive rotator cuff tears is new and still experimental. But this approach offers hope to those who previously had no opportunity for surgical repair. The successful results of this small study may open doors for future studies to expand the number and types of patients who might benefit from this procedure.

    For surgeons, this mini-open technique is less technically challenging and easier to use. It gives the surgeon a clear view of the area while implanting and suturing the graft. And it can be done without cutting the large deltoid muscle, which helps patients recover faster. Specific details of the surgery are provided including intraoperative and arthroscopic photos to show the placement and suturing of the graft.