UW Shoulder and Elbow Academy: *

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Friday, January 11, 2013

Revision for failed shoulder replacement

The AAOS recently published: Soft-tissue Management in Revision Total Shoulder Arthroplasty

This provided the impetus to summarize some of the elements of our approach to the shoulder arthroplasty that failed to produce the desired result. We've provided the links below.

Saturday, January 5, 2013

Rotator cuff repair, what matters?

Outcome of single-tendon rotator cuff repair in patients aged older than 65 years.

This is minimum two year followup of 44 out of 58 patients aged older than 65 years with reparable supraspinatus tears. 22 underwent primary open repair via a superolateral approach with detachment of the deltoid, a biceps tenodesis, anterolateral acromioplasty, and a cuff repair using a transosseous technique. 36 patients had an arthroscopic repair with a biceps tenotomy, an anterolateral acromioplasty, and a single-row mattress suture technique. The postoperative rehabilitation included an abduction brace at 45" for 6 weeks with passive range-of-motion exercises initiated on the first postoperative day. Active range of motion with the elbow fully flexed was allowed after 6 weeks and with the elbow extended at 12 weeks. Strengthening exercises were not allowed for 3 months after surgery.

In spite of the dramatic differences in surgical technique, neither the structural nor the clinical results of repair were significantly different between the open and arthroscopic groups. Ultrasonography revealed intact repairs in 31 shoulders. Of the 17 open repairs, 3 had not healed; 5 of 27 arthroscopic repairs had not healed.

The mean Constant score improved for both healed and unhealed repairs; the mean score was better for healed repairs than for nonhealed repairs. Though not statistically significant, dominance, cortisone injection, smoking, and tendon retraction appeared to favor nonhealing as shown in the figure prepared from their data.

In is of interest that these results are virtually identical to those Harryman presented on our open repairs in 1991. In both series there was a one in five chance of a recurrent defect by ultrasound at over two years followup after repair of a single tendon tear. This underscores our observation that the outcome of rotator cuff surgery has more to do with the quality of the tendon and the overall health of the patient than the technique of repair.

It is also of interest that the authors emphasize that easy to discern preoperative factors may be clinically useful predictors of the prognosis for achieving a durable repair. This study shows that carefully selected patients over the age of 65 with single tendon supraspinatus tears can obtain good clinical and anatomical results.

For related posts, see also here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here, and here.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

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Thursday, January 3, 2013

Living well with arthritis

In spite of the many great advances in the medical and surgical management of arthritis, some residual loss of comfort and function may remain. Thus the opportunity is to learn strategies for living well with arthritis.

We have assembled some information that may be useful to patients for managing their arthritis

Lifestyle

College and arthritis

Diet

Family

Fatigue

Frequently asked questions about arthritis

Frequently asked questions about living with arthritis

Joints

Laboratory tests

Pain

Pregnancy

Sex

Stress

Travel

Using joints wisely

Vocational rehabilitation

Work

Exercises

Exercise

Exercise videos

Water exercises

Medications - the good and the bad
Arthritis Foundation Drug Guide
Medications and joint replacement

Unproven remedies

Related conditions
Back Pain
Carpal Tunnel Syndrome
Diabetes
Fibromyalgia

The Arthritis Foundation
The Arthritis Foundation - Washington/Alaska Chapter

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See from which cities our patients come.

See the countries from which our readers come on this post.

Wednesday, January 2, 2013

What is a rotator cuff tear?

The rotator cuff is a group of tendons that surround the ball of the humeral head of the shoulder joint. This is a view of the rotator cuff from inside the joint, showing the humeral head in the center of the healthy shoulder, the biceps tendon upper left, and the tendons of the cuff surrounding the head. If you imagine that you are looking at this anatomy from the shoulder socket (glenoid), you can see how the cuff pulls the humeral head toward the socket providing stability by concavity compression.

A rotator cuff tear is a gap in this complex of tendons, usually occurring near the their attachment to bone and usually occurring in the supraspinatus tendon- the part of the cuff at the upper aspect of the shoulder near the biceps tendon.

Below, we show a series of surgical photographs from the outside of the shoulder looking down on the area of the supraspinatus.

The term 'rotator cuff tear' can refer to anything from a small gap in the tendon as shown below

to a larger tear involving the supraspinatus tendon from an old injury with what appears to be sufficient quality and quantity of tissue for a robust repair

to a long-standing large tear without enough tissue for a repair

to a massive tear of the entire rotator cuff

to tears with deterioration of the joint surface of the humeral head

to full on rotator cuff tear arthropathy without or with collapse of the humeral head and essentially no rotator cuff remaining.

In the mind of many, all rotator cuff tears are the same. This view creates problems when discussing the results of treatment and when deciding on the best management for an individual patient. Publications on the topic tend to lump all rotator cuff tears together. As we've emphasized in previous posts, the best management for a rotator cuff tear depends on many factors, including the size and duration of the tear, the age of the patient and the amount of force that was necessary to cause the tear. We've put together a handout describing some of the different 'faces' of rotator cuff tears.

Our approach to management of rotator cuff tears is shown here.

Stiff shoulder, painful shoulder, frozen shoulder, shoulder arthritis

Shoulder stiffness means that the shoulder is not able to move through its normal range of motion. There are many causes of shoulder stiffness, including shoulder arthritis and frozen shoulder. These two diagnoses can be distinguished by obtaining standardized shoulder x-rays which should be normal in a frozen shoulder but show a narrowed joint space in arthritis.

In deciding if a shoulder is stiff, it is helpful to compare its ability to perform several motions in comparison to the opposite normal shoulder.

Here are the most important motions to compare:

I. Internal and external rotation with the arm at the side (measured in terms of degrees from vertical)

II. Forward elevation (measured in terms of degrees from the horizontal)

III. Internal rotation up the back (measured in terms of the part of the back that can be reached with the thumb).

IV. Cross-body reach (measured as the distance from the elbow to the opposite shoulder).

V. Internal rotation with the arm out to the side (measured as degrees from the vertical).

The last three of these are often the motions limited early on in the process, so checking them may be revealing.

If your shoulder is stiff, check with your doctor to see how it may be best managed.

We have found that whether the stiffness is due to arthritis or to a frozen shoulder, gentle stretching exercises are often helpful.

Here are some other posts on stretching

Forward lean

How to stretch and how not to stretch

Shoulder exercises

Exercise videos

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See the countries from which our readers come on this post.

Tuesday, January 1, 2013

What is arthritis? What is the treatment for shoulder arthritis?

Our joints are normally covered by smooth articular cartilage.

When two normal joint surfaces rub on each other, the friction is less than that of an ice skate on ice.

In most cases, a person's joint cartilage lasts their whole life long.

However, certain conditions can destroy the smooth functioning of the joint. The shoulder can be affected by different types of arthritis.

The traditional dictionary definition of "arthritis" is "inflammation of a joint, usually accompanied by pain, swelling, and stiffness". This definition applies to conditions such as rheumatoid arthritis, psoriatic arthritis, lupus, gout, ankylosing spondylitis, crystal deposition disease, Reiter's, lyme disease, juvenile arthritis, infectious (septic) arthritis, and Sjogren's in which inflammation of the joint lining, or synovium, forms a pannus which invades the articular cartilage normally covering the joint.

Today many of these conditions can be managed with medications before the cartilage is lost.

The more common types of 'arthritis' of the shoulder are not the result of inflammation at all, but rather represent the non-inflammatory loss of cartilage from wear (osteoarthritis (degenerative joint disease)) , injury (post traumatic arthritis), complications of surgery (chondrolysis, post-arthroscopic glenohumeral chondrolysis, capsulorrhaphy arthropathy) or association with rotator cuff loss ( cuff tear arthropathy).

In such cases, the cartilage is destroyed without inflammation, leaving a rough joint surface.

When the shoulder joint reaches this stage, the degree of loss can be seen on x-ray. If symptoms are limiting the quality of life and if gentle exercises are not effective, consideration can be given to a total shoulder replacement or, in selected cases, to a ream and run procedure. In rarer situations a reverse total shoulder or a CTA arthroplasty may be the best choice. The role of surgeon experience is discussed here.

We have posted 67 articles to help individuals with arthritis on our living with arthritis page, including tips on preserving the quality of life. Here are some tips on living well with arthritis.