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Summer 2006 Stop Shouldering the PainAdvances in surgical technology and procedures give many who suffer from rotator cuff injuries new options.
When it comes to rotator cuff injuries, pay close attention to the old adage:A stitch in time saves nine. Surgical Department Chair Edward McDevitt, M.D., laughs when he says, “The best way to avoid surgery is don’t get hurt. But if that doesn’t work and you suspect something is wrong, get it checked out immediately, because small tears in the rotator cuff are much easier to deal with than big ones.” The rotator cuff is made up of four muscles and their tendons. These combine to form a “cuff”over the upper end of the arm (head of the humerus).When, through injury, arthritis or overuse, the rotator cuff is torn, it causes pain, loss of mobility and weakness. Because there is little blood in the rotator cuff area, tears are difficult to heal naturally. The injury causes pain, restricted motion, and may result in a “frozen” shoulder. Over time, the tear can get larger. However, most rotator cuff tears can be repaired with great success through minimally invasive and arthroscopic surgeries. These repairs account for more than 50 percent of the shoulder surgeries at AAMC, where last year, more than 650 shoulder surgeries were performed. Minimally invasive and arthroscopic surgeries for small to large tears mean patients are using their arms sooner, with less pain and better results. Massive rotator cuff tears (larger than 5 cm), once considered inoperable, are now being treated with remarkable success using both open and arthroscopic surgeries. Reverse Shoulder ProsthesisFor those with massive tears—about five percent of the patients—AAMC surgeons are offering two new procedures that were unavailable even a few years ago. Upper extremity specialist Jeffrey Gelfand, M.D., said, “In the last year, my colleague, Cyrus Lashgari, M.D., and I have performed a new procedure, reverse shoulder prosthesis, on about 15 patients whose massive rotator cuff tears would have been inoperable five years ago.” Reverse shoulder prosthesis allows for arm motion by increasing the mechanical advantage of the deltoid. During the open surgery, the “ball” and “socket” of the normal shoulder are switched. A metal ball is screwed into the native socket and a plastic socket is cemented onto the top of the humerus after the humeral head is removed. The deltoid is lengthened during the procedure thus giving it more power to elevate the arm. Reverse shoulder prosthesis can give patients increased range of motion and recovery of strength and a reduction or elimination of pain. “Cyrus and I have been very excited with the early results of this procedure at AAMC. We believe this prosthesis provides a treatment option for a large group of patients who previously had no real options,” said Dr. Gelfand. Allograft AugmentationShoulder specialist Charles Ruland, M.D., also is giving hope to patients with formerly irreparable rotator cuff tears. The surgery he performs employs a cadaver allograft that serves as a “scaffolding” to rebuild a new rotator cuff. Dr.Ruland said,“One of the benefits of the allograft is that it can be done arthroscopically, although only a small number of surgeons in the nation are trained to do it. Some surgeons prefer to perform it as an open surgery.” Dr. Ruland is among the small number of surgeons who can perform the surgery arthroscopically. In this surgery, sutures are placed in the edge of the tear in the rotator cuff using arthroscopic suturing instruments. These sutures are then threaded through the graft outside the shoulder and the graft is rolled up so it can fit through a 1 cm portal. “We take a stitch in the rolled up side on the leading edge of the graft, which allows us to pull it to the joint and lay over top of the tendon. Then we pull out the leading stitch and the graft unfolds into position,” he said. Avoiding SurgeryDr. McDevitt said, “Injuries that require surgery are caused by years of wear and tear, traumatic injury, or letting a small problem become a big one. The sooner a patient is treated, the less likely he or she will wind up with a massive tear.” Some of those injuries can be avoided with better sports training. Dr.McDevitt, a former orthopedic surgeon with the U.S. Naval Academy, said, “We’re seeing studies about young baseball players, who develop shoulder instability from too many overhead throws. A young pitcher actually can alter the shape of his shoulders from too much pitching. They may throw faster right now, but later in life they will pay,” he said. As for the more seasoned athlete, Dr. McDevitt said the key is warming up. He said, “There are a lot of weekend warriors out there, and they could avoid a lot of pain by remembering to stretch first. Stretching not only prevents injury but has been proven to help you participate at a higher level.” Older patients who avoided treatment earlier in life, held jobs that involved a lot of overhead work, or are simply prone to developing problems, will probably have an uphill struggle with pain, loss of mobility and weakness. “Getting treated when problems first arise, learning to warm up and exercise properly will go a long way toward avoiding surgery, but when surgery is the best option, at AAMC we have new technology, new procedures and longer lasting prosthetic devices to help,” said Dr.McDevitt.
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