Patient Information

Proximal Humerus Fractures

Derek S. Shia, MD

Proximal Humerus Fractures

Proximal humerus fractures are a very common injury that occurs in all populations but is certainly more prevalent in the patient population over the age of 65. It is the third most common fragility fracture after distal radius and hip fractures. The majority of proximal humerus fractures can be treated non-operatively, however there are some fractures that can benefit from operative intervention. The extent of operative intervention can include percutaneous pinning, open reduction internal fixation, and joint replacement depending on various fracture and patient characteristics.

Anatomy

The proximal humeral anatomy consists of four main anatomic structures that are important in understanding xrays when you are interpreting the fracture configuration as well as how a given fracture willhumerus-anatomy-xray.jpg be treated.

The four parts include the humeral head, greater tuberosity, lesser tuberosity and humeral shaft.  Fractures are classified according to which structures are fractured.  The Neer classification is commonly used to describe these fractures and can be categorized into 2-part, 3-part, and 4-part fractures with further differentiation into head splitting fractures and fracture dislocations.  The importance of this classification allows the selection of the optimum treatment and the ability to predict complications including fracture collapse, avascular necrosis and healing.

Treatment

The vast majority of proximal humerus fractures can be successfully treated non-operatively particularly in older patients. The deformity can be well tolerated and the loss of function typically occurs with overhead activities. Most activities of daily living occur at waist level and therefor may be largely unaffected. There are a subset of fracture in younger patients and ones that have significant displacement that may be more amenable to surgery.

Osteoporosis

The need for the diagnosis and treatment of osteoporosis is an important facet of complete musculoskeletal health. Testing for osteoporosis is important but particularly in females over the age of 65 and vitally important in patients that have sustained a fragility fracture. A fragility fracture includes a fracture of the hip, distal radius, humerus or vertebral compression fracture from a low energy injury such as falling from standing height

Testing involves examining the density of various bones in the body and is called a DEXA scan (Dual Emission X-Ray Absorptiometry). This test is usually ordered by your primary care physician and evaluates a patient’s bone density. If you are tested and the bone density is greater than 2.5 standard deviations below normal than a patient is considered osteoporotic.

Treatment for osteoporosis should include the recommended daily doses of calcium and vitamin D but may also involve the need for additional pharmacologic intervention. These medications include bisphosphonates, hormone replacement therapy and calcitonin therapy and can be started in consultation with your primary medical care physician. The goal of these therapies is improve bone density and can reduce the incidence of fragility fracture by as much as 50%.

Physical therapy

This step is very important to regaining functional use of the shoulder and arm and is used in conjuction with operative and non-operative intervention. I generally allow immediate elbow and wrist range of motion. Physical therapy in patients who are treated non-operatively is usually initiated within two weeks from the date of injury. Physical therapy will often begin with pendulum exercises and gentle passive range of motion. This slowly progresses to active and active assist range of motion. The length of time that physical therapy is performed, depend on many patient and fracture characteristics, but complete recovery usually takes 3-6 months.

Surgical intervention

For severely displaced fractures, surgery may be the most reliable way to restore anatomic relationships and allow optimal function of the shoulder. There are a myriad of different techniques for fixing proximal humerus fractures and can vary from percutaneous techniques involving wires to the other extreme involving the total replacement of the shoulder joint. This decision involves many patient factors including the severity of the fracture, age and function of the patient.

Isolated greater tuberosity fractures often occur in younger individuals after a traumatic injury. These fractures need to be closely monitored due to the involvement of the rotator cuff. While many fractures involving the proximal humerus can tolerate displacement, the greater tuberosity, due to the attachment of the rotator cuff, cannot. Displacement more than 5 mm is usually an indication for surgery and often can be accomplished arthroscopically with percutaneous techniques.

Many innovations over the past decade have allowed superior fixation of peri-articular fractures in osteoporotic bone involving the proximal humerus. One of the most important innovations involves the use of locking plate technology. This technology allows the use of a fixed angle construct to help support osteoporotic bone which has a tendency to collapse into a varus deformity. These implants are far superior to older implants that rely on an interference fit between the bone and screw. In patients with osteoporotic bone this interference fit is significantly effected and can lead to early failure of the construct.

humerus-surgical-xray-screws.jpg
humerus-surgical-xray.jpg

New Techniques

Several new techniques have been available over the past few years that can really help patients that have severe fractures. These two techniques include the reverse total shoulder arthroplasty and the use of fibular strut allografts with locking plate technology for patients with severe fractures and osteoporotic bone.

Fibular Strut Allografts

The use of a fibular allograft allows immediate structural augmentation of a patient’s bone stock to allow a more robust and anatomic reconstruction of the proximal humerus. Many patients who have sustained a proximal humerus fracture have osteoporotic bone. When fractures occur in this type of bone even the use of locked plating devises can fail due to the lack of underlying bone support. The use of these allografts provides an immediate structural support and helps to prevent loss of fixation.

This is an example of a four part proximal humerus fracture in a patient with osteoporosis the pre-operative x-ray demonstrates a very typical fracture pattern with the articular surface of the humeral head pointing straight up.

Post-Operative x-rays demonstrate an anatomic reduction with the use of an intra-medullary fibular allograft.

Reverse Total Shoulder Replacement

The reverse total shoulder replacement is performed on severe fractures in patients generally over the age of 65. This has shown in several studies to be superior to reconstruction with a hemiarthroplasty particularly in older patients. Hemiarthroplasty has historically demonstrated good results in terms of pain relief but has been somewhat less predictable in terms of improving function. Most historical studies have only shown forward flexion to about 90 degrees. With newer ingrowth surfaces and attention to the repair and reconstruction of the tuberosities, which control rotator cuff function, these results have shown improvement. The importance of these tuberosities to a good functional outcome is critical.

The reverse total shoulder allows a reconstruction that demonstrates superior functional results to hemiarthroplasty with additional excellent relief of pain.

 

reconstruction-shoulder-xray.jpg
right-humerous-xray.jpg

In summary, proximal humerus fractures are very common and can result in significant morbidity.  The vast majority of these fractures can be treated non-operatively and patients can expect a return to normal function usually with some residual stiffness.  In patients that have more severe fractures there are many available techniques and implants that can allow reconstruction of the shoulder and allow a good return to function without pain.

 

Reverse Total Shoulder Arthroplasty

Reverse Total Shoulder
By Derek S. Shia, M.D.

The reverse total shoulder is a relatively new type of shoulder arthroplasty specifically developed for patients that have a combination of both arthritis and loss of rotator cuff function, also known as rotator cuff arthropathy. Prior to the advent of this prosthesis a good solution was not available for this debilitating shoulder problem. Historically patients with this problem were treated with various non-operative and operative modalities that did not completely address their underlying problem. Often times, treatment was able to achieve some pain relief but did not address the loss of the functional use of the shoulder. The reverse shoulder replacement offers a solution to a problem that prior to its development, was not available. This replacement allows good pain relief but also improves patient’s functionality by allowing restoration of a patient’s ability to raise their arm. Patients may be candidates for this procedure when they have a painful rotator cuff tear that is no longer repairable and have significant loss of shoulder function. The replacement has also been successfully used in severe fractures of the shoulder in older patients, where reconstruction utilizing plates and screws is not possible.

The Rotator Cuff

The rotator cuff is vitally important for normal shoulder function and is comprised of four different muscles. The muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles contribute to two major functions in the shoulder, one is compressing the humeral head on the socket, keeping the joint centered, and the second involves controlling shoulder positioning. The rotator cuff controls the forward elevation as well as internal and external rotation of the shoulder. The loss of rotator cuff function results in weakness, pain, development of arthritis and the inability to functionally use the shoulder. When the function of the rotator cuff is severely compromised the patient may develop a pseudoparalysis, which is an inability of a patient to lift their arm up to 90 degrees.

Rotator cuff tears occur in both young and old patients but are increasingly common as patients become older. Younger patients often report a history of a traumatic event but in older patients rotator cuff tears can occur without an inciting traumatic event. Recent studies have demonstrated an increasing prevalence of rotator cuff tears in patients over the age of 55 even in the absence of trauma. Patients frequently notice progressive shoulder pain and weakness. This often effects their sleep and use of the shoulder.

Patient Presentation

The typical patient presents with a long history of pain as well as a progressive impairment of their shoulder function. Patients are frequently able to perform activities at waist height but find it difficult to impossible to perform many activities above shoulder height.

Radiographic Examination

While the rotator cuff cannot be directly visualized with plain radiographs, secondary changes can be seen. These changes include loss of the normal contour of the greater tuberosity, superior migration of the humeral head, gapping of the glenohumeral joint, and wearing of the acromion from the underlying humeral head.

shoulder-xray.jpg

The image on the left demonstrates a normal shoulder x-ray with the humeral head centered on the glenoid. The image on the right demonstrates superior migration of the humeral head. It has developed arthritis within the glenohumeral joint. In addition, the humeral head can be seen abrading the undersurface of the acromion.

MRI’s of the shoulder frequently demonstrate a massive rotator cuff tear usually involving three or more tendons. MRI’s also commonly demonstrate retraction of the rotator cuff to the level of the socket as well as significant fatty infiltration of the rotator cuff musculature. Fatty infiltration is a common occurrence in chronic rotator cuff tears and is the process where muscle transforms into fat. Unfortunately, this change is not reversible making diagnosis of acute rotator cuff tears that much more important.

rotator-cuff.jpg

Treatment of Rotator Cuff Arthropathy

Treatment of this condition depends on many factors including a patient’s functional level, functional disability, other medical comorbidities, and expectations. Treatments can include both operative and non-operative modalities. The non-operative modalities include physical therapy, pain management, corticosteroid injections, and activity modification. Operative intervention has historically been treated with a humeral head replacement with an enlarged head. This surgery resulted in satisfactory outcomes from patients in regards to some pain relief but offered little in improvement in overall shoulder function. This has lead to the design and implementation of the reverse total shoulder replacement.

Reverse Total Shoulder Implant Design

The reverse total shoulder was FDA improved in 2004 in the United States but has been available for use in Europe for over 15 years. It provides both pain relief and improvement of shoulder function for patients that have a complete loss of their rotator cuff function. This loss of rotator cuff function often results in significant pain as well as an inability to raise one’s shoulder over 90 degrees. The reverse prosthesis works by exchanging the position of the ball and socket portions of the shoulder joint. This design improves two important biomechanical properties of the shoulder. The replacement centralizes and distally translates the center of rotation of the shoulder thereby improving the power that the deltoid muscle can provide and allowing patients to lift their arms again.

reverse-total-shoulder.jpg

The image on the left demonstrates a reverse shoulder replacement, while the image on the right demonstrates an anatomic shoulder replacement.

Post-Operative Protocol

The reverse total shoulder procedure requires surgery at the hospital and typically involves a two day hospitalization. The procedure typically takes two hours to complete and has a low complication rate in primary surgeries. The immediate post-operative regimen includes sling use for the first two weeks followed by night sling use for two weeks. This allows rapid mobilization and allows the patient to achieve early functional recovery.

Reverse in Fracture Surgery

The reverse shoulder replacement has also been used successfully in older patients with severe humerus fractures. Before the advent of the reverse shoulder replacement patients were treated with a hemi-replacement (only the humeral head is replaced). While good pain relief was achieved in these patient’s, this type of replacement required healing of the rotator cuff to the prosthesis in order for it to function properly. Unfortunately, the healing of the rotator cuff is unpredictable in this scenario and frequently leads to significant functional impairment in older patients. The reverse shoulder prosthesis allows reconstruction of severe fractures while improving the functional outcome of the patients that undergo the procedure. The rotator cuff muscles are repaired in a similar technique as used in the hemi-replacement but unlike the hemi-replacement rotator cuff healing is not necessary to regain ability to perform overhead activities.

Summary

The reverse total shoulder is a good option for certain patients with arthritis and underlying rotator cuff tears as well as severe fractures. This design allows for a better functional outcome in comparison to historical treatment options. Short term studies have demonstrated reliable functional recovery as well as reduction in pain. This surgery has provided many patients with difficult problems a good solution, and we await long term studies to further validate these findings.

© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

Rotator Cuff Tears and Repairs

By Derek S. Shia, M.D.

Rotator cuff tears are one of the most common orthopedic problems and effect more than 17 million persons annually in the United States. The rotator cuff is an essential group of four muscles that control shoulder motion and contribute to the concentric reduction of the glenohumeral joint. Rotator cuff tears have a tremendous effect on a patients’ ability to perform athletic activities such as tennis, golf, and softball but can also affect simple activities of daily living such as sleeping, brushing teeth, and combing hair. Not all rotator cuff tears occur due to a traumatic incident and many patients may be living with a painful shoulder as a result of a rotator cuff tear without knowing it. There are various treatment options available to patients depending on their age, activity level, size of tear and the length of time that the tear has been present.

Patient Presentation

There are two principle populations that are effected by rotator cuff tears. The first is young patients that have experienced a significant traumatic event that causes the rotator cuff to tear. The event that causes this is usually a high energy injury and patients complain of an immediate change in their ability to use their arm. The second group of patients is an older population that typically cannot recall a traumatic event. These patients often have an insidious onset of shoulder pain and weakness. They complain of an inability to perform activities above shoulder height such as washing their hair or lifting dishes up to high shelves as well as pain reaching behind themselves. Night pain is also very common and patients commonly seek treatment because they have a difficult time sleeping.

While these two groups make up the majority of patients there is certainly an overlap between these patients groups. Patients that need to be closely evaluated include patients over the age of 45 with a shoulder dislocation as well as patients who fall without radiographic evidence of a fracture but with weakness.

Prevalence of Rotator Cuff Tears

The incidence of rotator cuff tears is very strongly correlated with a patients’ age. Several studies have been recently published investigating this relationship. One of these studies utilized ultrasound to determine the prevalence of rotator cuff tears in 237 asymptomatic individuals. They found that age was strongly correlated with the prevalence of a full thickness rotator cuff tear. None of the patients age 40-49 demonstrated rotator cuff tears, patients who were age 50-59 demonstrated a 10% prevalence of a full thickness rotator cuff tear, patients age 60-69 demonstrated a 20% prevalence and patients older than 70 had a 41% prevalence of a full thickness tear. The importance of this study demonstrated the relationship between age and the likelihood of the presence of a full thickness rotator cuff tear in patients with no complaints of shoulder pain or weakness. In a related study 588 patients who had unilateral shoulder pain had the opposite shoulder examined with ultrasound. This study demonstrated a high incidence of rotator cuff tears in older individuals with 50% of patients over the age of 65 demonstrating a full thickness rotator cuff tear in the opposite shoulder that was asymptomatic.

Natural History of Rotator Cuff Tears

It is important to consider the specific patient in terms of their functional status and also the natural history of untreated rotator cuff tears when contemplating various treatment options. Unfortunately, there is no evidence that rotator cuff tears can spontaneously heal without surgical intervention but depending on the patient and the size of the tear it is possible to make a rotator cuff tear asymptomatic. In a recent study investigating the natural history of non-surgically treated rotator cuff tears that were followed for 5 years, no tears showed any evidence of healing. Of the patients that became symptomatic again after a trial of non-operative management 50% of those patients had an enlargement of the tear. Of the patients that remained asymptomatic over the 5 year period, 20% had an enlargement of their tear. Of the patients whose tear increased, the average increase in size of the tear was 30%.

When considering that rotator cuff tears do not heal without surgical intervention it is important to think about the implications for the patient. When a rotator cuff tear does occur, irreversible changes of the muscle can begin within the first three months after an injury. Without the proper length/tension relationship fatty infiltration will begin in torn rotator cuff muscles. This process results in the replacement of the normal muscle tissue with fat, causing a permanent change in the elastic properties of the muscle tendon unit. This change is irreversible and can affect both a patients’ outcome after surgery and result in a rotator cuff being irreparable at the time of surgery. Various studies have investigated fatty infiltration after a rotator cuff repair and they have found these changes do not reverse even after repair of the tendon.

Physical Exam

The physical exam is one of the most important parts of the patient evaluation and is instrumental in obtaining the correct diagnosis. Inspection of the shoulder should include evaluation of any atrophy along the scapular spine which is often indicative of a chronic rotator cuff tear.

scapular.jpgEvaluation of a patients shoulder range of motion is vitally important in determining the correct diagnosis. Shoulder motion comes both from the glenohumeral joint which is responsible for 2/3 of the overall motion and the scapulothoracic joint which is responsible for the remaining 1/3 of overall shoulder motion. It is important to separate these two motions to detect pathology in the shoulder joint. Scapular kinematics are often abnormal following rotator cuff injuries and can be seen when evaluating the scapula during shoulder range of motion. The assessment of active and passive range of motion is also critical. Loss of both active and passive range of motion is often indicative of an adhesive capsulitis while loss of only active range of motion is often suggestive of rotator cuff pathology.

While there are a multitude of described tests for evaluation of the rotator cuff I have included some of the most common and helpful ones for detecting rotator cuff pathology.

The empty can test helps to evaluate the supraspinatus, the most commonly involved muscle in rotator cuff pathology.

empty-test.jpg

Test of external rotation strength with the shoulders in internal rotation will help evaluate the infraspinatus.

external-rotation-strength-test.jpg

The lift off test will help evaluate the function of the subscapularis.

lift-off-test.jpg

The hornblower test will help evaluate the teres minor and is often only positive in massive rotator cuff tears.

hornblower test.jpg

Evidence of massive rotator cuff tears include a positive drop arm sign, which is the inability for a patient to hold their shoulder in external rotation, a positive hornblower test, as well as a pseudoparalysis of the shoulder when a patient is unable to actively lift their shoulder to 90 degrees.

Imaging

Radiographs are an important modality when examining pathology around the shoulder and can suggest rotator cuff pathology. This xray demonstrates chronic rounding of the greater tuberosity often seen in long standing rotator cuff tears. It also demonstrates superior translation of the humeral head relative to the glenoid and gapping of the glenohumeral joint. Other pathology that can be appreciated by radiographs include both arthritis and calcific tendonitis which can sometimes present similarly to a rotator cuff tear.

 

massive-rotator-cuff-tear.jpgcalcific-tendonitis.jpg

MRI is an integral modality in the evaluation of a rotator cuff tear and adds important information regarding the extent and treatment of the tear. Choices between open and closed MRI’s are a common discussion with patients and are often driven by patient choice, body habitus and difficulty with claustrophobia. While open MRI’s continue to improve, closed MRI’s utilize a larger magnet and provide a clearer picture of all the involved pathology and improves the ability to make an accurate diagnosis.

An MRI can help determine the size of the tear and which tendons are involved, it can demonstrate the amount of retraction of the tendon and the amount of fatty infiltration. All these factors are important for determining the likelihood that a tear is repairable and whether it will heal.

Treatment Options

There are various non-operative treatment options including activity modification, NSAIDS, physical therapy, and corticosteroid injections. The goal of these treatments is to reduce pain, increase range of motion, and improve function. The goals of physical therapy are to strengthen the remaining rotator cuff, improve scapular kinematics that are often abnormal after a rotator cuff tear, and strengthen scapular stabilizers. Physical therapy also works to improve range of motion, and promote functional return to normal activities.

The use of corticosteroid injections for rotator cuff disease is commonly used. The use of corticosteroids has been extensively studied and through multiple studies and meta-analyses have demonstrated limited efficacy in the long term treatment of rotator cuff disease. One benefit that has been shown is an improvement in pain levels in patients in comparison to placebo over the short term.

There are downsides to repeated corticosteroid injections with a theoretical reduction of overall tendon strength. Basic science research have predominated these studies and have even demonstrated increased type III collagen expression after only a single injection. For this reason while a single corticosteroid is often considered, multiple injections should be judiciously utilized. Multiple injections over time are often reserved for patients with limited functional goals and inability to undergo surgical intervention.

Surgical Intervention

Surgical intervention for a repairable tear can be treated arthroscopically in the vast majority of cases. The advantages of an arthroscope versus an open repair includes several things including the ability to fully evaluate and treat any additional intra -articular pathology, preserve the deltoid muscle, and allow full access to the shoulder. Controversy continues to exist regarding the optimal surgical construct for the treatment of rotator cuff tears and whether a single or a double row repair best treats the pathology. A double row repair provides a more anatomic reconstruction of the rotator cuff footprint and may lead to lower rerupture rates in comparison to single row repairs in larger tears. This is currently a hotly debated topic and while basic science studies demonstrate benefits, functional differences have not been demonstrated to be statistically significant between either repair type in clinical studies.

Arthroscopic rotator cuff repair is performed as an outpatient procedure and normally takes between 1- 2 hours depending on the size of the tear and any concomitant pathology that needs to be addressed. The post-operative regimen typically involves a sling for the first 4 weeks. For smaller tears immediate motion is begun and for larger tears there is a period of immobilization. Strengthening is started at 12 weeks with gradual return to normal function. There are very good reported outcomes in the literature following rotator cuff repair with good alleviation of pain and return to functional status.

For certain patients the size and chronicity of their tear may not allow a primary repair. For these patients depending on their age and functional status various treatment options are available. These include tendon transfers including latissiumus dorsi and pectoralis major transfers. These are primarily used in younger patients with painful large chronic tears but with good function. The second treatment option is the reverse total shoulder replacement.

This option is reserved for older patients with a chronic irreparable rotator cuff tear and poor shoulder function. This option through a replacement of the shoulder joint eliminates pain and improves shoulder function.

Factors that Effect Outcomes After Surgery

Several factors have been demonstrated in the literature to negatively affect the functional outcome of patients following rotator cuff repair, these include: smoking, diabetes, patient age, the size of the rotator cuff tear , whether the rotator cuff tear is full thickness or partial thickness, and the degree of fatty infiltration. Some of these factors cannot be controlled but early diagnosis and treatment can avoid some of these pitfalls.

Treatment Algorithm

While no treatment algorithm is without exceptions this is a generalized way to think about rotator cuff tears and their treatment. Partial thickness tears have some risk of enlarging but a trial of non-operative management is indicated to see if a patient will do well without surgery. The second class of patients is the young patient who has a full thickness tear or any patient with an acute tear. In this patient population there is more downside to delaying surgery in that the tear will not heal itself, it may enlarge, and that the rotator cuff may undergo irreversible fatty infiltration. In this patient population surgery is indicated. The third category is elderly patients with a chronic rotator cuff tear. This is another population when waiting will have little impact on the patients’ outcome and non-operative treatment should be attempted.

Summary

Rotator cuff tears are extremely prevalent and have a significant impact on the patients who have them. A careful physical exam, good imaging and understanding of rotator cuff pathology and its natural history are instrumental in obtaining the correct diagnosis and developing the appropriate treatment course for a patient with a rotator cuff tear. While non-operative treatments are commonly utilized initially there are many minimally invasive treatment options available if surgery is necessary and good to excellent results are common following intervention.

© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

Athletic Injuries - Young Adults

Athletic Injuries of the Shoulder and Elbow in the Young Adult
By Derek S. Shia, M.D.

Athletic injuries involving the shoulder and elbow are common problems and range in severity from simple overuse and muscle strains that may require only conservative measures including icing and rest, to fractures and ligament ruptures that can require surgery. As competitive participation in sports continues to be a very important part of life, injuries as a result of repetitive trauma continue to be commonplace. While the shoulder and elbow are separate joints, within the mechanics of throwing and other athletic endeavors these two joints are closely related and pathology in one or the other can affect normal kinematics and result in injury. It is important to recognize overuse injuries early in order to avoid permanent problems.

Injury Prevention

Participation in competitive athletics is a very beneficial endeavor and can be an important outlet for young athletes to help them develop important life skills that are applicable both on and off the field. In the pursuit of winning and producing the next star athlete these benefits can be transcended and unfortunately lead to significant injury. Injuries are not always preventable, however, there are several guidelines and practices that can be implemented to try and reduce the chances that these will occur.

Proper conditioning including core strengthening and stretching are important to overall health of the athlete and forms the basis for injury prevention. Participation in general health and core conditioning can help avoid fatigue, particularly late in games, which can commonly lead to a loss of proper mechanics. The loss of proper mechanics leads to improper loading of the shoulder and elbow and can lead to increased stresses on ligaments, growth plates and tendons. This increased stress can lead to injuries. Learning proper throwing mechanics is extremely important which in conjunction with core conditioning involves improving arm and body position in order to utilize large muscle groups to minimize injuries.

Maintenance of a normal range of motion in athletes through stretching is important particularly of the shoulder. The loss of shoulder motion can lead to abnormal shoulder kinematics and can result is both shoulder and elbow injuries. One particular abnormality that is often seen in throwing athletes is the loss of internal rotation with the shoulder in 90 degrees of abduction. This is a result of compensatory tightness of the posterior capsule of the shoulder and leads to GIRD (Glenohumeral Internal Rotation Deficit). A side to side difference in the range of motion of the shoulder in throwing athletes is very common but as that difference increases above 20 degrees it is considered pathologic. This capsular tightness can lead to internal impingement of the shoulder that over time can develop into rotator cuff and labral tears in the shoulder, as well as injuries around the elbow. Stretching the posterior capsule through several exercises can help to prevent injuries throughout the season. Several studies involving professional athletes from tennis and baseball have demonstrated the importance of these stretches in preventing injuries over the course of the season. Two common stretches that are utilized include the sleeper stretch and the cross arm stretch.

sleeper-stretch.jpgcross-arm-stretch.jpg

The sleeper stretch is performed lying on the patients affected side. The affected arm is brought into 90 degrees of abduction and the arm is stretched in internal rotation. The point of the stretch is to feel the stretch in the posterior aspect of the shoulder, not in the front. The stretch should be performed slowly and should not be painful. The second stretch is performed with the arm adducted across the body. Pressure is applied with the opposite arm on the upper arm. It is important to perform these exercises multiple times per day to achieve maximal effects.

In addition to stretching exercises it is important to keep the rotator cuff musculature in shape through preventive strengthening. Unlike strengthening exercises involving large muscle groups such as the deltoid, pectoralis major, and biceps which can require heavy weights, rotator cuff strengthening usually requires 2-5 lb weights or resistance bands. The rotator cuff is often ignored during weight training for sports and its health and strength is integral for optimal shoulder function. A rotator cuff strengthening program should be incorporated into all conditioning programs but particularly for throwing athletes, swimmers, and overhead athletes.

Pitch Counts and Pitch Types

Pitch counts and types of pitches are important for all pitchers but particularly for younger patients who are skeletally immature (e.g. still growing). In these patients the bones involving the shoulder and elbow joints are not fully mature and are at a higher risk for serious injury than fully grown patients. For this reason it is important to restrict players from throwing certain pitches depending on their age. In addition it is important to take pitch counts into account, depending on the players age pitch counts should be accurately recorded and not exceeded. The little league association in conjuction with orthopedic surgeons have published guidelines regarding pitch types and pitch counts and rest intervals. These guidelines have been published for the protection of the players and are used to ensure that they can avoid overuse injuries. Often athletes can play for multiple teams, select teams, all-stars etc. It is important that information about pitch counts and days of rest are shared between different coaches. Even if an athlete is “needed” for a big game or help with a double header it is important to think about the best interest of the athletes arm, even in professional sports pitchers require rest between starts. The implementation by little league of these rules in 2007 have lead to a significant reduction in injuries and a decrease in the numbers of Tommy John Surgeries performed (reconstruction of the ulnar collateral ligament of the elbow).

Pitchers league age 14 and under must adhere to the following rest requirements:
If a player pitches 66 or more pitches in a day, four (4) calendar days of rest must be observed.
If a player pitches 51 - 65 pitches in a day, three (3) calendar days of rest must be observed.
If a player pitches 36 - 50 pitches in a day, two (2) calendar days of rest must be observed.
If a player pitches 21 - 35 pitches in a day, one (1) calendar day of rest must be observed.
If a player pitches 1-20 pitches in a day, no (0) calendar day of rest is required.


Pitchers league age 15-18 must adhere to the following rest requirements:
If a player pitches 76 or more pitches in a day, four (4) calendar days of rest must be observed.
If a player pitches 61 - 75 pitches in a day, three (3) calendar days of rest must be observed.
If a player pitches 46 - 60 pitches in a day, two (2) calendar days of rest must be observed.
If a player pitches 31 -45 pitches in a day, one (1) calendar day of rest must be observed.
If a player pitches 1-30 pitches in a day, no (0) calendar day of rest is required.

           

Pitch Age
Fastball 8-10
Change-Up 10-13
Curve Ball 14-16
Knuckle Ball 15-18
Slider 16-18
Fork Ball 16-18
Screw Ball 17-19

 

Things to watch out for

Several things are important to watch out for in any throwing athlete including loss of velocity or loss of control. Other signs of fatigue include the loss of proper throwing technique or increasing time between pitches. If these signs are observed then increased rest for the player is required. The loss of range of motion of the elbow with inability to completely extend or flex the elbow is important to watch out for and usually represents underlying pathology in the elbow. Any pain that the player is having while throwing requires immediate cessation of throwing and evaluation by a sports medicine physician.

Evaluation

A thorough history is vitally important including the type of sport the player is engaged in. If the patient is a baseball player it is important to find out the patients position, how many games are played each week, as well as pitch types. It is important to determine when the pain started, was it an acute event with one pitch or hit or has it been gradually worsening. When is the pain occurring: constant, with the early cocking phase of throwing, follow through etc. Are there mechanical symptoms: catching, clicking locking, instability.

Radiographic evaluation of the shoulder and elbow is important part of the initial evaluation of an injury and can demonstrate open growth plates, possible stress fractures, and signs of osteochondral lesions. Many times depending on the symptoms of the patient or due to failure of nonoperative treatment an MRI is ordered. MRI’s can add a lot of information regarding the soft tissue component of an injury. The addition of intra-articular contrast can also be beneficial particularly for detection of labral pathology around the shoulder and ligament pathology around the elbow.

Summary

Sports competition is an important part of many young people’s lives, it is important to encourage participation while attempting to prevent injuries. Through appropriate training, stretching and mechanics as well as following pitching guidelines many injuries can be effectively avoided.

Bankhart Lesion

Derek S. Shia, M.D.

Recurrent instability, ie. multiple dislocations, of the shoulder is typically an indication for surgical intervention. The typical injury of the shoulder is a Bankart lesion, which occurs in over 95% of shoulder dislocations, and is a result of a tear of the anterior inferior labrum of the glenoid. Other types of injuries also commonly occur around the shoulder such as rotator cuff tears but usually happen in patients over the age of 45 years. In the vast majority of the cases, surgery can be performed arthroscopically to address the pathology in the shoulder. This is usually performed with three small incisions about 1 cm in length. Immobilization is required over the first month. Physical therapy is started after surgery and is usually continued for 4 months after surgery and return to play can typically be achieved in  6-9 months.

©excerpt Derek S.Shia, M.D.

Dislocated Shoulder

Derek S. Shia, M.D.

traumatic-shoulder-xray.jpgTraumatic shoulder dislocations are the most commonly occurring large joint dislocations.  As a group, these occur most commonly  in young males and is especially common in contact sports such as football, wrestling, hockey and lacrosse.  The shoulder is a complex joint composed of the ball, humeral head, and the socket, glenoid.  The glenoid has a very shallow concavity unlike other joints, such as the hip, which allows the shoulder to have a tremendous range of motion allowing the arm to be successfully positioned in space. The downside to this freedom of motion is an increased risk of instability.

The shoulder can dislocate in any direction, but the most common is an anterior dislocation. Anterior dislocations occur in 97% of cases. The second most commonly occurring direction is a posterior dislocation.  Anterior dislocation usually occurs with a posterior directed force on the arm when the shoulder is in an abducted and externally rotated position, similar to the position of the arm when cocking back to throw a ball.   For this reason, many overhead athletes may be prone to continued instability despite non-operative management. Posterior dislocations on the other hand, occur with a force directed on the arm when it is flexed and adducted as if trying to scratch your opposite shoulder.

There are two important reasons that x-rays need to be obtained:

  1. It is important to objectively determine whether the shoulder has been relocated and is in the correct position.
  2. It is vitally important to determine whether a fracture has occurred to either the humeral head or glenoid. Fractures of either bone can significantly affect the treatment options and whether surgery will be necessary.

clinical shoulder dislocation.jpgThe shoulder has both static and dynamic restraints that combine to keep the shoulder in a reduced position.  The static restraints when an injury occurs cannot be altered without surgery and include the labrum, glenoid, and ligaments. The dynamic stabilizers of the shoulder include the rotator cuff and the scapular stabilizer muscles. When there is an injury to the static restraints of the shoulder the dynamic stabilizers can be utilized to try and overcome the static restraint limitations to provide a stable shoulder. The use of physical therapy can help optimize the dynamic stabilizers and is the foundation of non operative management surrounding shoulder dislocations.

The acute management of a shoulder dislocation requires prompt recognition of the problem followed by appropriate treatment which results in reduction of the joint. Many times this can occur on the playing field with the assistance of a trained professional. Many techniques have been described to achieve this and patients typically feel significant relief after the reduction has been successfully performed. Delayed reduction can lead to significant problems including nerve and vessel injury so prompt reduction of the shoulder is recommended as soon as a trained professional can be located. 

shoulder-instability.pngAfter reduction has been obtained, it is important to obtain radiographs (xrays) of the shoulder. There are two important reasons that x-rays need to be obtained: 1. It is important to objectively determine whether the shoulder has been relocated and is in the correct position.  2. It is vitally important to determine whether a fracture has occurred to either the humeral head or glenoid. Fractures of either bone can significantly affect the treatment options and whether surgery will be necessary.

Dislocations that occur during an athlete’s season can often be temporized with the ability to return to the field in a relatively short period of time if no fracture or tendon injury is present.  Depending on the athletes sport a brace is sometimes recommended to prevent further instability events.

The difficulty of these braces is that they are typically bulky and do not allow abduction and external rotation.  For an overhead athlete such as a quarterback these braces cannot be worn due to the position necessary to throw a ball.  Non-operative management of athletes that are in season typically involves a short period of immobilization for 7-10 days combined with physical therapy.  Return to play can be instituted after obtaining pain-free range of motion with no objective or subjective feelings of instability. 

The risk of recurrent dislocation is related to several factors including age, activity level, and contact sports.  In patients under the age of 20 there is a >90% chance of recurrent instability. Recurrence rates in patient over the age of 30 falls significantly and is a little less than 30%.

Recurrent instability, ie. multiple dislocations, of the shoulder is typically an indication for surgical intervention. The typical injury of the shoulder is a Bankart lesion, which occurs in over 95% of shoulder dislocations, and is a result of a tear of the anterior inferior labrum of the glenoid. Other types of injuries also commonly occur around the shoulder such as rotator cuff tears but usually happen in patients over the age of 45 years. In the vast majority of the cases, surgery can be performed arthroscopically to address the pathology in the shoulder.

This is usually performed with three small incisions about 1 cm in length. Immobilization is required over the first month. Physical therapy is started after surgery and is usually continued for 4 months after surgery and return to play can typically be achieved in  6-9 months.

Reverse Shoulder Replacement

Reverse Total Shoulder
By Derek S. Shia, M.D.

The reverse total shoulder is a relatively new type of shoulder arthroplasty specifically developed for patients that have a combination of both arthritis and loss of rotator cuff function, also known as rotator cuff arthropathy. Prior to the advent of this prosthesis a good solution was not available for this debilitating shoulder problem. Historically patients with this problem were treated with various non-operative and operative modalities that did not completely address their underlying problem. Often times, treatment was able to achieve some pain relief but did not address the loss of the functional use of the shoulder. The reverse shoulder replacement offers a solution to a problem that prior to its development, was not available. This replacement allows good pain relief but also improves patient’s functionality by allowing restoration of a patient’s ability to raise their arm. Patients may be candidates for this procedure when they have a painful rotator cuff tear that is no longer repairable and have significant loss of shoulder function. The replacement has also been successfully used in severe fractures of the shoulder in older patients, where reconstruction utilizing plates and screws is not possible.

The Rotator Cuff

The rotator cuff is vitally important for normal shoulder function and is comprised of four different muscles. The muscles include the supraspinatus, infraspinatus, teres minor and subscapularis. These muscles contribute to two major functions in the shoulder, one is compressing the humeral head on the socket, keeping the joint centered, and the second involves controlling shoulder positioning. The rotator cuff controls the forward elevation as well as internal and external rotation of the shoulder. The loss of rotator cuff function results in weakness, pain, development of arthritis and the inability to functionally use the shoulder. When the function of the rotator cuff is severely compromised the patient may develop a pseudoparalysis, which is an inability of a patient to lift their arm up to 90 degrees.

Rotator cuff tears occur in both young and old patients but are increasingly common as patients become older. Younger patients often report a history of a traumatic event but in older patients rotator cuff tears can occur without an inciting traumatic event. Recent studies have demonstrated an increasing prevalence of rotator cuff tears in patients over the age of 55 even in the absence of trauma. Patients frequently notice progressive shoulder pain and weakness. This often effects their sleep and use of the shoulder.

Patient Presentation

The typical patient presents with a long history of pain as well as a progressive impairment of their shoulder function. Patients are frequently able to perform activities at waist height but find it difficult to impossible to perform many activities above shoulder height.

Radiographic Examination

While the rotator cuff cannot be directly visualized with plain radiographs, secondary changes can be seen. These changes include loss of the normal contour of the greater tuberosity, superior migration of the humeral head, gapping of the glenohumeral joint, and wearing of the acromion from the underlying humeral head.

shoulder-xray.jpg

The image on the left demonstrates a normal shoulder x-ray with the humeral head centered on the glenoid. The image on the right demonstrates superior migration of the humeral head. It has developed arthritis within the glenohumeral joint. In addition, the humeral head can be seen abrading the undersurface of the acromion.

MRI’s of the shoulder frequently demonstrate a massive rotator cuff tear usually involving three or more tendons. MRI’s also commonly demonstrate retraction of the rotator cuff to the level of the socket as well as significant fatty infiltration of the rotator cuff musculature. Fatty infiltration is a common occurrence in chronic rotator cuff tears and is the process where muscle transforms into fat. Unfortunately, this change is not reversible making diagnosis of acute rotator cuff tears that much more important.

rotator-cuff.jpg

Treatment of Rotator Cuff Arthropathy

Treatment of this condition depends on many factors including a patient’s functional level, functional disability, other medical comorbidities, and expectations. Treatments can include both operative and non-operative modalities. The non-operative modalities include physical therapy, pain management, corticosteroid injections, and activity modification. Operative intervention has historically been treated with a humeral head replacement with an enlarged head. This surgery resulted in satisfactory outcomes from patients in regards to some pain relief but offered little in improvement in overall shoulder function. This has lead to the design and implementation of the reverse total shoulder replacement.

Reverse Total Shoulder Implant Design

The reverse total shoulder was FDA improved in 2004 in the United States but has been available for use in Europe for over 15 years. It provides both pain relief and improvement of shoulder function for patients that have a complete loss of their rotator cuff function. This loss of rotator cuff function often results in significant pain as well as an inability to raise one’s shoulder over 90 degrees. The reverse prosthesis works by exchanging the position of the ball and socket portions of the shoulder joint. This design improves two important biomechanical properties of the shoulder. The replacement centralizes and distally translates the center of rotation of the shoulder thereby improving the power that the deltoid muscle can provide and allowing patients to lift their arms again.

reverse-total-shoulder.jpg

The image on the left demonstrates a reverse shoulder replacement, while the image on the right demonstrates an anatomic shoulder replacement.

Post-Operative Protocol

The reverse total shoulder procedure requires surgery at the hospital and typically involves a two day hospitalization. The procedure typically takes two hours to complete and has a low complication rate in primary surgeries. The immediate post-operative regimen includes sling use for the first two weeks followed by night sling use for two weeks. This allows rapid mobilization and allows the patient to achieve early functional recovery.

Reverse in Fracture Surgery

The reverse shoulder replacement has also been used successfully in older patients with severe humerus fractures. Before the advent of the reverse shoulder replacement patients were treated with a hemi-replacement (only the humeral head is replaced). While good pain relief was achieved in these patient’s, this type of replacement required healing of the rotator cuff to the prosthesis in order for it to function properly. Unfortunately, the healing of the rotator cuff is unpredictable in this scenario and frequently leads to significant functional impairment in older patients. The reverse shoulder prosthesis allows reconstruction of severe fractures while improving the functional outcome of the patients that undergo the procedure. The rotator cuff muscles are repaired in a similar technique as used in the hemi-replacement but unlike the hemi-replacement rotator cuff healing is not necessary to regain ability to perform overhead activities.

Summary

The reverse total shoulder is a good option for certain patients with arthritis and underlying rotator cuff tears as well as severe fractures. This design allows for a better functional outcome in comparison to historical treatment options. Short term studies have demonstrated reliable functional recovery as well as reduction in pain. This surgery has provided many patients with difficult problems a good solution, and we await long term studies to further validate these findings.

© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

Rotator Cuff Tears

By Derek S. Shia, M.D.

Rotator cuff tears are one of the most common orthopedic problems and effect more than 17 million persons annually in the United States. The rotator cuff is an essential group of four muscles that control shoulder motion and contribute to the concentric reduction of the glenohumeral joint. Rotator cuff tears have a tremendous effect on a patients’ ability to perform athletic activities such as tennis, golf, and softball but can also affect simple activities of daily living such as sleeping, brushing teeth, and combing hair. Not all rotator cuff tears occur due to a traumatic incident and many patients may be living with a painful shoulder as a result of a rotator cuff tear without knowing it. There are various treatment options available to patients depending on their age, activity level, size of tear and the length of time that the tear has been present.

Patient Presentation

There are two principle populations that are effected by rotator cuff tears. The first is young patients that have experienced a significant traumatic event that causes the rotator cuff to tear. The event that causes this is usually a high energy injury and patients complain of an immediate change in their ability to use their arm. The second group of patients is an older population that typically cannot recall a traumatic event. These patients often have an insidious onset of shoulder pain and weakness. They complain of an inability to perform activities above shoulder height such as washing their hair or lifting dishes up to high shelves as well as pain reaching behind themselves. Night pain is also very common and patients commonly seek treatment because they have a difficult time sleeping.

While these two groups make up the majority of patients there is certainly an overlap between these patients groups. Patients that need to be closely evaluated include patients over the age of 45 with a shoulder dislocation as well as patients who fall without radiographic evidence of a fracture but with weakness.

Prevalence of Rotator Cuff Tears

The incidence of rotator cuff tears is very strongly correlated with a patients’ age. Several studies have been recently published investigating this relationship. One of these studies utilized ultrasound to determine the prevalence of rotator cuff tears in 237 asymptomatic individuals. They found that age was strongly correlated with the prevalence of a full thickness rotator cuff tear. None of the patients age 40-49 demonstrated rotator cuff tears, patients who were age 50-59 demonstrated a 10% prevalence of a full thickness rotator cuff tear, patients age 60-69 demonstrated a 20% prevalence and patients older than 70 had a 41% prevalence of a full thickness tear. The importance of this study demonstrated the relationship between age and the likelihood of the presence of a full thickness rotator cuff tear in patients with no complaints of shoulder pain or weakness. In a related study 588 patients who had unilateral shoulder pain had the opposite shoulder examined with ultrasound. This study demonstrated a high incidence of rotator cuff tears in older individuals with 50% of patients over the age of 65 demonstrating a full thickness rotator cuff tear in the opposite shoulder that was asymptomatic.

Natural History of Rotator Cuff Tears

It is important to consider the specific patient in terms of their functional status and also the natural history of untreated rotator cuff tears when contemplating various treatment options. Unfortunately, there is no evidence that rotator cuff tears can spontaneously heal without surgical intervention but depending on the patient and the size of the tear it is possible to make a rotator cuff tear asymptomatic. In a recent study investigating the natural history of non-surgically treated rotator cuff tears that were followed for 5 years, no tears showed any evidence of healing. Of the patients that became symptomatic again after a trial of non-operative management 50% of those patients had an enlargement of the tear. Of the patients that remained asymptomatic over the 5 year period, 20% had an enlargement of their tear. Of the patients whose tear increased, the average increase in size of the tear was 30%.

When considering that rotator cuff tears do not heal without surgical intervention it is important to think about the implications for the patient. When a rotator cuff tear does occur, irreversible changes of the muscle can begin within the first three months after an injury. Without the proper length/tension relationship fatty infiltration will begin in torn rotator cuff muscles. This process results in the replacement of the normal muscle tissue with fat, causing a permanent change in the elastic properties of the muscle tendon unit. This change is irreversible and can affect both a patients’ outcome after surgery and result in a rotator cuff being irreparable at the time of surgery. Various studies have investigated fatty infiltration after a rotator cuff repair and they have found these changes do not reverse even after repair of the tendon.

Physical Exam

The physical exam is one of the most important parts of the patient evaluation and is instrumental in obtaining the correct diagnosis. Inspection of the shoulder should include evaluation of any atrophy along the scapular spine which is often indicative of a chronic rotator cuff tear.

scapular.jpgEvaluation of a patients shoulder range of motion is vitally important in determining the correct diagnosis. Shoulder motion comes both from the glenohumeral joint which is responsible for 2/3 of the overall motion and the scapulothoracic joint which is responsible for the remaining 1/3 of overall shoulder motion. It is important to separate these two motions to detect pathology in the shoulder joint. Scapular kinematics are often abnormal following rotator cuff injuries and can be seen when evaluating the scapula during shoulder range of motion. The assessment of active and passive range of motion is also critical. Loss of both active and passive range of motion is often indicative of an adhesive capsulitis while loss of only active range of motion is often suggestive of rotator cuff pathology.

While there are a multitude of described tests for evaluation of the rotator cuff I have included some of the most common and helpful ones for detecting rotator cuff pathology.

The empty can test helps to evaluate the supraspinatus, the most commonly involved muscle in rotator cuff pathology.

empty-test.jpg

Test of external rotation strength with the shoulders in internal rotation will help evaluate the infraspinatus.

external-rotation-strength-test.jpg

The lift off test will help evaluate the function of the subscapularis.

lift-off-test.jpg

The hornblower test will help evaluate the teres minor and is often only positive in massive rotator cuff tears.

hornblower test.jpg

Evidence of massive rotator cuff tears include a positive drop arm sign, which is the inability for a patient to hold their shoulder in external rotation, a positive hornblower test, as well as a pseudoparalysis of the shoulder when a patient is unable to actively lift their shoulder to 90 degrees.

Imaging

Radiographs are an important modality when examining pathology around the shoulder and can suggest rotator cuff pathology. This xray demonstrates chronic rounding of the greater tuberosity often seen in long standing rotator cuff tears. It also demonstrates superior translation of the humeral head relative to the glenoid and gapping of the glenohumeral joint. Other pathology that can be appreciated by radiographs include both arthritis and calcific tendonitis which can sometimes present similarly to a rotator cuff tear.

 

massive-rotator-cuff-tear.jpgcalcific-tendonitis.jpg

MRI is an integral modality in the evaluation of a rotator cuff tear and adds important information regarding the extent and treatment of the tear. Choices between open and closed MRI’s are a common discussion with patients and are often driven by patient choice, body habitus and difficulty with claustrophobia. While open MRI’s continue to improve, closed MRI’s utilize a larger magnet and provide a clearer picture of all the involved pathology and improves the ability to make an accurate diagnosis.

An MRI can help determine the size of the tear and which tendons are involved, it can demonstrate the amount of retraction of the tendon and the amount of fatty infiltration. All these factors are important for determining the likelihood that a tear is repairable and whether it will heal.

Treatment Options

There are various non-operative treatment options including activity modification, NSAIDS, physical therapy, and corticosteroid injections. The goal of these treatments is to reduce pain, increase range of motion, and improve function. The goals of physical therapy are to strengthen the remaining rotator cuff, improve scapular kinematics that are often abnormal after a rotator cuff tear, and strengthen scapular stabilizers. Physical therapy also works to improve range of motion, and promote functional return to normal activities.

The use of corticosteroid injections for rotator cuff disease is commonly used. The use of corticosteroids has been extensively studied and through multiple studies and meta-analyses have demonstrated limited efficacy in the long term treatment of rotator cuff disease. One benefit that has been shown is an improvement in pain levels in patients in comparison to placebo over the short term.

There are downsides to repeated corticosteroid injections with a theoretical reduction of overall tendon strength. Basic science research have predominated these studies and have even demonstrated increased type III collagen expression after only a single injection. For this reason while a single corticosteroid is often considered, multiple injections should be judiciously utilized. Multiple injections over time are often reserved for patients with limited functional goals and inability to undergo surgical intervention.

Surgical Intervention

Surgical intervention for a repairable tear can be treated arthroscopically in the vast majority of cases. The advantages of an arthroscope versus an open repair includes several things including the ability to fully evaluate and treat any additional intra -articular pathology, preserve the deltoid muscle, and allow full access to the shoulder. Controversy continues to exist regarding the optimal surgical construct for the treatment of rotator cuff tears and whether a single or a double row repair best treats the pathology. A double row repair provides a more anatomic reconstruction of the rotator cuff footprint and may lead to lower rerupture rates in comparison to single row repairs in larger tears. This is currently a hotly debated topic and while basic science studies demonstrate benefits, functional differences have not been demonstrated to be statistically significant between either repair type in clinical studies.

Arthroscopic rotator cuff repair is performed as an outpatient procedure and normally takes between 1- 2 hours depending on the size of the tear and any concomitant pathology that needs to be addressed. The post-operative regimen typically involves a sling for the first 4 weeks. For smaller tears immediate motion is begun and for larger tears there is a period of immobilization. Strengthening is started at 12 weeks with gradual return to normal function. There are very good reported outcomes in the literature following rotator cuff repair with good alleviation of pain and return to functional status.

For certain patients the size and chronicity of their tear may not allow a primary repair. For these patients depending on their age and functional status various treatment options are available. These include tendon transfers including latissiumus dorsi and pectoralis major transfers. These are primarily used in younger patients with painful large chronic tears but with good function. The second treatment option is the reverse total shoulder replacement.

This option is reserved for older patients with a chronic irreparable rotator cuff tear and poor shoulder function. This option through a replacement of the shoulder joint eliminates pain and improves shoulder function.

Factors that Effect Outcomes After Surgery

Several factors have been demonstrated in the literature to negatively affect the functional outcome of patients following rotator cuff repair, these include: smoking, diabetes, patient age, the size of the rotator cuff tear , whether the rotator cuff tear is full thickness or partial thickness, and the degree of fatty infiltration. Some of these factors cannot be controlled but early diagnosis and treatment can avoid some of these pitfalls.

Treatment Algorithm

While no treatment algorithm is without exceptions this is a generalized way to think about rotator cuff tears and their treatment. Partial thickness tears have some risk of enlarging but a trial of non-operative management is indicated to see if a patient will do well without surgery. The second class of patients is the young patient who has a full thickness tear or any patient with an acute tear. In this patient population there is more downside to delaying surgery in that the tear will not heal itself, it may enlarge, and that the rotator cuff may undergo irreversible fatty infiltration. In this patient population surgery is indicated. The third category is elderly patients with a chronic rotator cuff tear. This is another population when waiting will have little impact on the patients’ outcome and non-operative treatment should be attempted.

Summary

Rotator cuff tears are extremely prevalent and have a significant impact on the patients who have them. A careful physical exam, good imaging and understanding of rotator cuff pathology and its natural history are instrumental in obtaining the correct diagnosis and developing the appropriate treatment course for a patient with a rotator cuff tear. While non-operative treatments are commonly utilized initially there are many minimally invasive treatment options available if surgery is necessary and good to excellent results are common following intervention.

© 2012 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

Total Shoulder Replacement

Derek S. Shia, MD

 

Total shoulder replacement is the fastest growing joint replacement procedure in the United States.  The number of shoulder replacements performed have increased from 18,000 in 2000 to 45,000 in 2013 and this trend is continuing.  Total shoulder replacement is a reliable procedure that can significantly reduce pain and improve function.  Studies have demonstrated greater than 90 percent good to excellent results in medium to long-term follow up. The longevity of total shoulder replacement is in line with other types of joint replacement surgeries.  The typical shoulder replacement has an annual failure rate of approximately 1% per year resulting in approximately 90% retension at 10 years and 80% retention at 20 years. 

 

 tsr-1.jpgtsr-2.jpg

 

Shoulder Arthritis

While not as common as hip and knee arthritis, shoulder arthritis can still result in significant disability.  Arthritis occurs as the articular cartilage present on the humeral head and glenoid begin to wear away.  This leads to the loss of joint space and the development of osteophytes (bone spurs).  Patients typically experience worsening pain and stiffness.  Pain during the night is also a common result of arthrtis.   Activities of daily living can be impacted, as well as more vigorous activities.  Arthritis can occur from a variety of different causes including inflammatory arthropathy, trauma, and simple wear and tear.

 

Non-operative management of shoulder arthritis can include anti-inflammatories such as advil or alleve, physical therapy to improve range of motion and strength, corticosteroid injections, viscosupplementation injections, such as orthovisc and synvisc, and protein rich plasma injections.

 

Shoulder injections should be performed under image guidance due the difficulties with placing a needle into the intra-articular space.  Accuracy without image guidance has been shown to be 70% while ultrasound guidance improves this to over 92%.  Cortisone injections can decrease inflammation, decrease pain and improve function.  These improvements are usually temporary but with mild disease can often provide relief for long periods of time.

 

Protein rich plasma injections have demonstrated improvement in patients with knee arthritis and can be extrapolated to the shoulder.  An in office procedure is performed for this.  Blood is drawn from a vein, the blood is placed in a centrifuge and spun down.  This provides a supernatent liquid high in growth factors that are then injected into the glenohumeral joint.  In knees significant improvements have been demonstrated in the literature.

 

There are two main types of shoulder replacement.  Anatomic and reverse total shoulder replacements.  Anatomic shoulder replacements are typically performed in patients who have arthritis but a normal and functional rotator cuff.  This involves replacing the ball and socket.   In patients without a functioning rotator cuff, a prosthesis known as, a reverse will typically need to be performed.

 

 tsr-3.jpgtsr-4.jpg

 

Pre-operative planning for surgery will begin with plain radiographs and a CT scan of the shoulder.  This allows detailed 3D analysis of the arthritis and deformity.  Patients with more deformity can have custom guides and implants designed for their specific anatomy.  The production of these typically take 4 weeks to obtain.  Typically shoulder replacement involves replacing both the humeral head (ball) and glenoid (socket).  The humeral component is typically involves a non-cemented stem.  The amount of resection is dependant on several factors including a patients bone quality as well as the amount of deformity that is present.  In younger patients a bone preserving humeral head resurfacing can be performed.

 

Shoulder replacement can occur in both the inpatient and outpatient setting depending on many patient factors including age, health, and complexity of the procedure.  Typically patients undergo surgery, stay overnight and are discharged the next day.  Surgery typically takes 1.5-2 hrs to perform.  Patients usually have an interscalene block and general anesthesia.   The block works to decrease post-operative pain and reduce the amount of general anesthesia used.  This helps to decrease post-operative symptoms such as nausea as well as reduce the risks associated with general anesthesia.

 

Patients use a sling for comfort after the first day and are not required to wear their sling at home.   Lifting of anything in the operative arm is not permitted immediately after surgery to allow healing of the subscapularis muscle which is taken down during the surgery.  Once the subscapularis has healed increasing weight bearing is allowed, typically at three months. 

 

Patients can resume all activities by six months.   Patients are encouraged to return to their pre-operative activity level and resume sports such as golf, tennis, kayaking etc. 

 

 

Superior Capsular Reconstruction

Superior Capsular Reconstruction

By Derek S. Shia, M.D.

Superior Capsular Reconstruction is an arthroscopic procedure that has been developed for patients with massive irreparable rotator cuff tears.  In certain individuals with chronic tears this procedure can be used to improve function and decrease pain in individuals that have failed non-operative management.  Historically patients that fall into this category underwent tendon transfers around the shoulder with higher complications, more morbidity and somewhat less than desired results.  This newer procedure offers an arthroscopic less invasive option.

 

The rotator cuff is made of four individual muscles including the supraspinatus, infraspinatus, subscapularis and teres minor.  Each of these muscles transition into tendons and attach to the proximal humerus.  Rotator cuff tears can occur due to direct trauma such as a fall but can also occur as the result of degenerative changes surrounding the shoulder.

 

 

 

Rotator cuff tears are a common injury and can range in severity from a partial thickness tear of one of the tendons to complete  tears of one or multiple tendons.  The treatment of these injuries will often begin with non-operative management that can consist of a wide variety of different modalities.  Commonly this will consist of physical therapy, activity modification, and anti-inflammatories.  Corticosteroid injections can also be offered to help inflammation and allow more effective physical therapy.

 

After failure of non-operative management surgical options can be considered.  The surgical options available to the patient will frequently depend on multiple factors including age, activity level, size of the rotator cuff tear, the tears chronicity of the tear, and appearance of the rotator cuff on MRI.  The rotator cuff can evaluated with use MRI and will allow provide invaluable information regarding the different treatment options that are available to the patient. 

 

The most common treatment is arthroscopic repair of the rotator cuff.  This involves small incisions around the shoulder and the use of an arthroscope (camera) to visualize the surgery.  This can be performed when the MRI demonstrates a tear without a large amount of retraction and little fatty infiltration of the effected rotator cuff muscle.  Fatty infiltration and retraction are both related to the size and the age of the tear.   Tears that have been present for years often will undergo degeneration where there is transition from normal muscle to muscle that is now containing fat.  The percentage of overall fat is important with less fat being a positive prognostic indicator for a successful repair.   Retraction is another prognostic indicator for a successful primary repair.

 

Some rotator cuff tears cannot be fully fixed at the time of repair.  When this is the case other options are available at the time of surgery.  If a complete repair is not possible a partial repair can be done with a successful outcome.  While a complete repair is desirable some times the entire rotator cuff is not repairable and a partial repair can lead to significant clinical improvement. 

 

Superior capsular reconstruction is utilized in patients where a majority of their rotator cuff is not repairable.  In younger patients this can be a good option to restore function and decrease pain.  In this procedure a cadaver allograft is typically utilized and usually a dermal allograft although other graft materials such as fascia lata can be used successfully.  This procedure is an outpatient procedure performed arthroscopically.

 

This procedure allows arthroscopic placement of the graft attaching it to both the glenoid and the humeral head.  This acts to depress the humeral head and prevents the superior migration that occurs in the rotator cuff deficient shoulder.  This acts to improve the functional rotation of the head.

 

 

 

 

 The early studies with this procedure have demonstrated overall patient satisfaction with the procedure with increase in range of motion, decrease in pain and increase in strength.

 

Rehabilitation for this procedure is slow and requires six weeks in a sling with slow progression of strengthening until 12-16 weeks.   The purpose of the slow rehabilitation is to promote graft healing while minimizing the risk of graft failure. 

 

For patients who also have concomitant arthritis or loss of the subscapularis a reverse total shoulder arthroplasty is one of the few remaining procedures that can restore shoulder function.

 

© 2018 Derek S.Shia, M.D.

Surgical Video- Superior Capsular Reconstruction
Surgical Video – Rotator Cuff Repair