Ali Narvani Arthoscopy rotator cuff repair review

Mr Ali Narvani comments on Rotator Cuff Tear Review in Arthroscopy

London Shoulder Specialist Mr Ali Narvani and his team had a letter to the editor featured in October’s Arthroscopy, commenting on a recent review of modern literature relating to rotator cuff tears published in the journal earlier this year.

The review, entitled ‘Arthroscopic Superior Capsular Reconstruction for Massive, Irreparable Rotator Cuff Tears: A Systematic Review of Modern Literature’ by Catapano et al, was published by a group of US and Canadian orthopaedic and sports medicine experts in the April 2019 issue.

Mr Narvani’s letter congratulated the study’s authors but highlighted one major limitation they felt had not been acknowledged in the review. A statement that “graft tears did not differ significantly, with combined clinical and/or radiographic retear rates of 3.4% to 33.3% in patients with dermal allografts compared with 4.7% to 36.1% in those with TFL grafts”, did not reflect that magnetic resonance imaging (MRI) was not performed in all patients in the majority of studies.

Mr Ali Narvani and his colleagues agreed that although superior capsular reconstruction provides good short-term clinical outcomes, with similar results between tensor fasciae latae and dermal graft, they felt that the same may not be concluded as far as re-tear rates.

For more advice on rotator cuff repair surgery and to arrange a consultation with Mr Ali Narvani at the London Shoulder Specialists, please call us on 0203 195 2442.

smoking and shoulder surgery risks

Quit It: Smoking Increases Risks After Shoulder Surgery

Shoulder surgery, like any surgery, doesn’t come without its risks. However, in certain patients these risks are elevated. And it seems that smokers are particularly vulnerable to complications after shoulder surgery.

The impact of tobacco use on complications after hip and knee surgery has been well documented, but a recent study in The Bone and Joint Journal has looked at whether smokers are at increased risk of poor medical and surgical outcomes after shoulder arthroplasty.

Here, we’ll look at how smoking increases risks after shoulder surgery and why now is a great time to quit.

What risks do smokers face after surgery?

According to studies, the main risks smokers face after surgery include poor wound healing, infection and less than optimal final outcomes.

The study in The Bone and Joint Journal analysed a total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) that underwent TSA during a five-year study period. Smokers had increased rates of 30- and 90-day readmission, revision within 90 days, infection, wound complications, and instability of the prosthetic joint.

In another study, featuring 235 patients, it was discovered that good results were seen in 84% of non-smokers, yet just 35% in smokers. This shows just how significant the effects of smoking can be. With less than half of smokers experiencing good results, it shows just how significant the risks are.

Smokers have also been found to suffer more pain before and after shoulder surgery. This is because cigarettes have a detrimental impact on the healing of the bone and soft tissue. Infection rates are also higher and there is also an increased risk of surgical revision.

Why does smoking increase shoulder surgery risks?

The reason smoking increases the risks of surgery is because it causes the heart and lungs to not function as well as they should. This can lead to breathing difficulties during and after the procedure.

Smoking is also known to reduce blood flow. This is what slows down the healing process, increasing the risk of infection. It is also known to contribute towards heart disease. This in turn will increase the risk of a heart attack during and after surgery.

Will quitting before the surgery make a difference?

Smokers are always recommended to quit prior to undergoing surgery. Did you know that even if you just quit the day before the surgery, it can still greatly reduce the risks? This is down to the fact that the minute you stop smoking, the body automatically starts to heal itself. All of the harmful chemicals and toxins start to decrease immediately. This improves blood flow, reducing the risk of poor healing.

However, while you can benefit from stopping the day before, the sooner you quit the better the outcome will be. Ideally, you should quit at least a week before the surgery. You’ll also want to avoid smoking during recovery. For this reason, it is the perfect time for smokers to quit for good.

All of the evidence collected through numerous studies, points to smokers having increased risks during and after shoulder surgery. While patients obviously know smoking isn’t good for their health, few realise just how much it increases their risk of recovery. If you need shoulder surgery and you’re a smoker, now is the time to think of quitting for good. If you don’t, you may not receive the best results and you could end up needing a revision surgery.

For more advice on how best to prepare for shoulder surgery, call us on 0203 195 2442.

shoulder surgery waiting lists

British Orthopaedic Association Urges Restarting Orthopaedic Shoulder Surgery

According to data released by NHS England, elective orthopaedic surgery has experienced one of the lowest returns to normal activity in August 2020. Now, the British Orthopaedic Association is urging the restart of orthopaedic surgery.

Here, we will look at why the sector is experiencing a slower return to surgery and the risks delayed treatment presents.

COVID and the impact on shoulder surgery waiting lists

At the moment, orthopaedic surgery comes just ahead of oral surgery at the bottom of the NHS priority list. Only 5 out of 19 surgical sectors are currently back at normal levels. This falls well below the NHS England’s targets.

As a result, a lot of orthopaedic patients are facing significant delays in their treatment. At the end of August 2020, more than 24,000 patients had been waiting for treatment for more than one year. There were also 302,426 patients who had been on the waiting list for 18 weeks.

So, what is the British Orthopaedic Association proposing to do about the current situation? They have put forward a number of arguments for restarting the sector.

The argument for resuming orthopaedic surgery

Due to the ongoing issues caused by delaying treatment, the British Orthopaedic Association is urging the restart of orthopaedic surgery. As the NHS is unlikely to return to pre-coronavirus levels anytime soon, the following arguments are being put forward:

  • A national discussion about how the UK can prioritise and deliver surgery
  • Hip and knee replacements are highly effective and have the lowest cost of QALY of any operation
  • More investment into cold elective orthopaedic centres to combat the backlog
  • Elective surgery continues to take place during a second wave of the virus

These are the main arguments being put forward to tackle the ever-growing issue. A national discussion would help surgeons to come together and explore the options available to safely restart surgeries. The government also needs to realise the cost of delaying treatment, both in terms of patient’s lives and the financial costs passed to the state.

What are the risks of delaying shoulder surgery?

Patients are seeing both their physical and mental health deteriorate as their surgery is delayed. Patients who were already in pain have had to suffer due to the increased waiting times. Many are finding the situation intolerable.

Those with severe arthritis are in danger of losing their independence. As their mobility continues to decline, they are relying more upon others to help them get by. Alongside increased pain and lower independence, it is also causing wider issues. Patients are finding it more difficult to work, and they are relying more upon the state for support and care in their daily lives.

Delaying surgery is having a significant impact on those awaiting orthopaedic surgery. Unless steps are taken now, shoulder surgery waiting lists are only going to get worse and patients will continue to suffer unnecessarily. If you’re interested in discussing self-pay options for shoulder surgery, call us on 0203 195 2442 to speak to one of the team.

rotator cuff repair recovery

Day Case Rotator Cuff Repair Less Risky Than Hospital Stay After Surgery 

A new study has revealed that day case rotator cuff repairs could be less risky than hospital stays after surgery. The results, published within the Arthroscopy journal, could prove useful to patients and surgeons in terms of recovery. 

Here, we’ll look at the new study and its findings, alongside the common risks and complications associated with rotator cuff repair. 

Understanding the study into rotator cuff repair recovery

The new study compared the rate of 90-day post-surgery complications between inpatients and outpatients who had undergone rotator cuff repair. It included 2,812 patients who underwent surgery between 2007 to 2015. Inpatients were considered those who stayed for one or more day in hospital. Outpatients on the other hand, were released the same day.

It discovered that within 90 days, inpatients had a greater incidence of complications than outpatients. In particular, inpatients had greater medical adverse effects, as well as surgical adverse effects. Other risk factors identified included anxiety and depression, alongside a greater Charlson comorbidity index score. 

This isn’t the first study to reveal the potential complications from inpatient care. Hospital stays are considered to be riskier for a variety of reasons, including the increased risk of infection. So, evidence suggests the best course of treatment for rotator cuff repair patients is to undergo the procedure as a day case.

What are the risks and complications of rotator cuff repair?

Whether you undergo rotator cuff repair as an inpatient or outpatient case, there are risks and complications to be aware of. While most repairs see patients experience an increase in shoulder strength, as well as a reduction in pain, the following complications and risks can occur:

  • Anaesthesia complications
  • Damage to blood vessels and nerves
  • Stiffness
  • Infections

As with any type of surgery, there are risks associated with anaesthesia to consider. These include the risk of a blood clot, heart attack or stroke. However, these types of complications are rare. 

Another rare complication is potential damage to the blood vessels and nerves. It is estimated around 1% to 2% of patients experience this complication. Even fewer patients experience an infection, with rates estimated to be 0.16 to 1.9%. 

The most common complication is stiffness, with around 20% of patients experiencing the issue. However, if you do experience stiffness, generally it will go away by itself within six months. 

What factors can impact rotator cuff repair recovery?

There are a number of things that can impact how well patients recover from rotator cuff surgery. The surgical approach used, the quality of tissue, the size of the tear and the rehabilitation method all make a difference to potential complication rates. During your consultation, your London Shoulder Specialist will discuss in full any potential complications.

Overall, the new research suggests patients recover much better and safer when they are treated as a day case. This, alongside a good understanding of the risks and complications, can help patients and surgeons determine the best course of treatment.

shoulder surgery recovery

What to Expect from Your Shoulder Surgery Recovery?

Undergoing shoulder surgery is an effective way to treat numerous shoulder issues. However, it’s important to understand what to expect in terms of recovery.

If you want to experience the best results, it’s crucial to follow the surgeon’s aftercare advice. If you’re not sure what to expect from shoulder surgery recovery, below you’ll discover everything you need to know.

Shoulder surgery recovery: immediately after

After undergoing shoulder surgery, you will typically stay in hospital for 3 hours or so. This is for monitoring purposes, ensuring you are OK to go home. Once you have fully regained consciousness, your surgeon will provide you with aftercare advice.

This will usually include advice on how to manage pain, take care of your wound and control any inflammation which may present. It’s really important that you follow this aftercare advice if you want to experience the best results and limit complications.

Shoulder surgery recovery: keeping the shoulder supported

Many patients may need to keep their shoulder immobilised for a set period of time. This means you will be given a sling to wear. You may be advised to wear it for 1 –2 days or up to 6 weeks depending upon the extent of the surgery carried out.

During this time, you’ll want to wear comfortable clothing and don’t be afraid to ask friends and family for help with daily tasks.

Shoulder surgery recovery: managing pain and discomfort

One of the main side effects of shoulder surgery is pain and discomfort. It’s common to feel some level of pain after surgery, but this can usually be managed with pain relief medication. Your surgeon may prescribe medication for you to keep the pain at bay. They will also advise you on the different pain-relieving methods you can use, such as an ice pack.

Shoulder surgery recovery: issues with sleep

You may experience some issues with sleep for a few weeks after the surgery. You won’t be able to sleep on the shoulder that was operated on. This may mean that you need to sleep differently to usual. The pain can also make it harder to sleep, though pain medication will help.

Shoulder surgery recovery: rehabilitation

Your rehabilitation period will differ depending upon the type of surgery you had. However, it will include some level of physiotherapy. You will also start to introduce daily tasks back into your life, gradually building up the strength in the shoulder.

You may need to have time off work, depending upon the type of job you carry out and the nature of the surgery. If you work in a more physically demanding job role, you may need to take a little longer to recover before going back.

If you participate in contact sports, you unfortunately may be advised to delay your return to play for four to six months, depending on your individual circumstances. This can be difficult for athletes, but it is crucial for the healing process.

The above is a brief guideline on what to expect from shoulder surgery. Your London Shoulder Specialist consultant will be able to give you the best idea of what to expect based upon the actual surgery you have having. Call 0203 195 2442 to arrange your consultation.

frozen shoulder and diabetes

Frozen Shoulder and Diabetes

A new study, published within the Journal of Shoulder and Elbow Surgery, has discovered a link between frozen shoulder and fasting glucose levels. The association between frozen shoulder and diabetes is nothing new, but very little is currently known about the link regarding fasting glucose levels.

Interestingly, a link was discovered in fasting glucose levels of 90-99 mg/dL which are considered to be normoglycemic. Levels below this range haven’t shown any corresponding connection. In fact, fasting glucose levels under 85 mg/dL showed a negative association.

So, there is certainly a link between the shoulder and blood sugar levels. The question is, what is the relationship between frozen shoulder and diabetes?

Frozen shoulder and diabetes

The American Diabetes Association states that around 10% to 20% of those with diabetes, go on to suffer from frozen shoulder at some point in their lives. When you consider the rate is just 2% to 5% in the general population, you can see the increased risk diabetes poses.

Frozen shoulder is otherwise known as adhesive capsulitis and it progresses slowly over time. It occurs as the ball and socket joint of the shoulder starts to lose its mobility.

Eventually, it becomes frozen or immobilised. This means the arm cannot be moved over the head and daily tasks become extremely difficult.

It is thought that the condition can be triggered by high blood sugar levels. These attach to the ligaments and tendons, causing them to become weaker and stiffer. In turn, this causes inflammation. When you combine this with the circulation issues caused by high blood sugar levels, it can worsen the stiffness in the socket.

Generally speaking, the longer a patient lives with diabetes, the bigger the risk there is it will lead to frozen shoulder.

The importance of early treatment

Although it can be challenging to identify the symptoms of frozen shoulder early on, the sooner you can seek treatment, the better. Patients who do have diabetes should take care to control their blood sugar levels. This is the only way to reduce the risk of developing diabetes-related frozen shoulder.

For patients who are experiencing frozen shoulder, treatment includes physiotherapy and anti-inflammatory medications. Steroid injections can also prove useful. However, for those with diabetes these aren’t always suitable as they can lead to high blood sugar levels. In severe cases, surgery may be required to correct the issue.

If you are worried you might be experiencing frozen shoulder, book a consultation with a specialist today. They will be able to diagnose the cause of the condition and recommend the best course of treatment moving forward.

golfers and shoulder surgery

Most Golfers Return to Sport Six Months Post-Shoulder Surgery

Due to the repetitive movements in golf, it isn’t uncommon for golfers to develop shoulder issues. In severe cases, surgery may be required, and this can be a worry for golfers in terms of recovery and time out from the sport. However, a new data review has revealed that most golfers return to sport within six months after shoulder surgery.

Here, we’ll look at what this new golfers and shoulder surgery study revealed and what you can expect if you are due to undergo surgery for the shoulder.

Golfers and shoulder surgery study

The review, entitled ‘Return to Golf After Shoulder Arthroplasty: A Systematic Review”, assessed the return rates of golfers who undergo shoulder surgery. Published in The American Journal of Sports Medicine, there were ten studies included in the review.

A couple of the studies looked at golf performance after the surgery. Three of the studies also addressed return to golf rates for patients who had undergone total shoulder arthroplasty and shoulder hemiarthroplasty. These studies revealed a return to golf rate of 89% to 100% within 5-8 months. An additional two studies also showed 77% and 100% return to golf rates within 5.8 months.

After assessing all of the studies, it was determined that total shoulder arthroplasty resulted in a good return to sport outcomes.  Just one study focused solely on patients who had shoulder hemiarthroplasty and their return rate to golf was 54% within 6.5 months.

Reverse shoulder arthroscopy sees drop in results

Although a total shoulder arthroplasty did show high return to sport rates, a reverse shoulder arthroscopy produces slightly less favourable results. After 5.3 and 6 months, return rates were 50% and 79%. So, this type of surgery does appear to lengthen recovery time for patients.

A reverse shoulder arthroscopy is carried out where a total arthroscopy isn’t ideal. This includes patients who have suffered large rotator cuff tears with the development of complex arthritis. The reason it can take longer for patients to recover from this type of procedure is that it reverses the metal ball and socket. This causes different muscles to be used.

Helping patients understand their options

Recommendations for treatments weren’t able to be provided in the study due to varying patient baseline characteristics and surgical procedures carried out. However, it does allow patients to understand how surgery could impact their chances of returning to the sport.

Generally speaking, a total shoulder arthroscopy does produce high return to golf rates. However, like any surgery, there are risks involved that patients need to be aware of. Golfers need to understand the risks before making a decision, particularly if there is a chance they may not be able to return to the sport. The earlier treatment is provided, the more chance there is the patient will be able to return to golf.

This new golfers and shoulder surgery research does provide hope to patients that they do stand a good chance of returning to sport after their operation. With the right aftercare, golfers could be back to the sport within six months.

To book an appointment with the London Shoulder Specialists, call +44 (0) 203 195 2442.

rotator cuff disease risk factors

UK Study Identifies Risk Factors That Increase Need for Shoulder Surgery

Rotator cuff disease, or trauma to the rotator cuff, is a common complaint and can be caused by an injury, overuse whether due to sporting endeavour or employment, or can occur without any obvious cause.

A new study has helped to identify risk factors that increase the need for shoulder surgery as a result of rotator cuff disease. The population-based cohort study is one of the largest of its kind. Here, we’ll look at what it revealed, and you’ll discover more about rotator cuff injuries.

Understanding the new study

The recent large-scale study included data from 421,894 patients, with 47% being male. Participants were aged between 40-69 and the UK’s Biobank was used for the research. NHS inpatient records were used to identify patients who had undergone surgery for rotator cuff disease.

Hazard ratios were calculated using Multivariate Cox proportional hazards regression. The main risk factors discovered were sex, age, race, BMI, smoking, occupational demands and the Townsend deprivation index.

Interestingly, the study found that every additional 10 years of age contributed to a 55% increase in surgery rates for rotator cuff disease. A high BMI, non-white races and a lower deprivation score also contributed to an increased risk of surgery.

The majority of the risks identified are known to be modifiable. This means the risks can be reduced through healthier lifestyle choices.

The link between depression and rotator cuff tears

Although this new study is one of the largest of its kind, there have been previous smaller studies carried out that are worth referencing. In 2019, a study looked into the link between depression and rotator cuff tears and it produced some surprising results.

Depressive disorders are known to be associated with chronic systemic inflammation. Depression, for example, is associated with chronic diseases such as coronary artery disease and chronic obstructive pulmonary disease. So, how does this link to rotator cuff tears?

Although the underlying mechanism of how depression is associated with rotator cuff tears remains uncertain, it’s thought that inflammation not only plays a role in the onset of tendon injury but also then negatively impacts repair of injured tendons. Furthermore, depression could heighten the sensation of pain associated with rotator cuff disease in those patients suffering from depression.

Further research is needed to determine exactly how the two conditions are associated. However, the evidence so far does support they are connected. Patients with depression are more likely to require surgery for a rotator cuff tear than those without the mental health condition.

What is a rotator cuff tear?

The rotator cuff of the shoulder consists of numerous muscles and tendons which cushion the shoulder joint. It is responsible for keeping the upper arm bone within the shoulder socket. A tear can occur in any of the muscles or tendons surrounding the joint.

Usually, rotator cuff tears are caused by overuse or repetitive motions. However, they can occur as a single injury. They vary in severity and in some cases, surgery may be the only way to repair the injury.

While surgery can be an effective solution to the pain and lack of mobility associated with a rotator cuff tear, there are always risks associated with surgery that need to be considered. The new study suggests that healthier lifestyle choices may reduce the need for surgery. If you suspect you have rotator cuff disease, call 0203 195 2442 to arrange a consultation with the London Shoulder Specialists.

rehab after shoulder replacement

NICE Recommend Rehab Same Day as Shoulder Replacement Surgery

The National Institute for Health and Care Excellence (NICE) that provides guidance, advice and information services for health professionals, has issued new advice for patients undergoing a hip, knee or shoulder replacement. After undergoing surgery, patients should now attend rehab on the same day. This should be provided by an occupational therapist or physiotherapist.

Here, we’ll look at why the new guidance has been supplied and what shoulder replacement surgery involves.

Why is same day rehab recommended?

The new guidelines have been introduced after NICE consulted with the Association of Trauma and Orthopaedic Chartered Physiotherapists (ATOCP). It is known that early rehab can lead to much better outcomes for patients who have undergone joint replacement surgery.

Shoulder replacement surgery can result in a long and painful recovery. So, if patients can minimise the pain and discomfort through same day rehab, it’s a welcome change to the guidelines.

The only potential issue that could cause debate amongst the sector, is that in the small print, initial intervention could be carried out by any member of a therapy team provided they are qualified. Many experts claim the initial rehab should only be carried out by a physiotherapist or occupational therapist.

What does it involve?

The new guidelines mean that patients who undergo shoulder replacement surgery should receive the following rehabilitation therapy:

  • Advice on how to manage daily activities
  • Home exercise programme
  • Ambulation

The guidelines have been designed to be vague enough for clinicians to use their own expertise to decide upon appropriate care for each patient.

Understanding shoulder replacement surgery

Shoulder replacement surgery is carried out to treat a damaged or worn away shoulder joint. This typically occurs due to injury or shoulder arthritis. Either part, or all of the joint will be replaced using artificial parts.

There are different types of shoulder replacement surgery you can undergo. These include reverse, total and partial shoulder replacement. The reverse shoulder replacement tends to be the most common technique used. The standard total shoulder replacement remains the most common. This includes a metal ball being attached to the shoulder blade where the socket was. Then, a new socket is attached to the top of the arm, where the ball was. It basically switches the ball and socket around.

A total shoulder replacement surgery is also common. This technique replaces the ball and socket, but it keeps them in the same position. A partial replacement focuses on just replacing the ball of the shoulder.

Each surgery is designed to help patients improve shoulder motion and eliminate pain. The primary aim is to alleviate pain and hopefully also gain more function and movement The artificial parts used are typically made from metal, plastic, or a mixture of both materials.

Most patients who undergo shoulder replacement surgery are aged 70 or over. Most replacement joints will last at least 10 years before another procedure is required. There is a 10% failure rate at 7 years

The new guidelines issued by NICE ensure patients have the best chance of recovery. Being able to improve results by offering early rehab is going to prove welcome news to both patients and shoulder specialists.

If you think you might need a shoulder replacement, book a consultation with the London Shoulder Specialists today. The earlier treatment is sought, the better the outcome will be.

rotator cuff repair review

Rotator Cuff Repair Reviewed

Published last year in the Annals of the Royal College of Surgeons and now available to the public, is an in-depth analysis of research conducted in the field of rotator cuff repair titled. ‘Degenerative rotator cuff tear, repair or not repair? A review of current evidence’. The goal was to address whether a surgical or non-surgical approach would be better for patients. Among the study’s authors were three members of the London Shoulder Specialists; Mr Ali Narvani, Mr Steven Corbett and Mr Andrew Wallace.

Here, we’ll review the evidence that was revealed and what it means for those suffering from a rotator cuff tear.

Clinical outcomes for non-surgical repairs

In our analysis of research relating to clinical outcomes for non-surgical repairs, we found results were dependent upon the severity of the tear. The review focused on a multicentre study which included 452 patients who had atraumatic rotator cuff tears. They were treated with physiotherapy and reviewed at 6 and 12 weeks. Significant improvements were identified at both the 6- and 12-week review, although after two years, 26% of patients chose to undergo surgery.

It appears non-surgical treatment provides great early results, but patients still often go on to need surgery. Those with large and severe rotator cuff tears experienced the fewest benefits of non-operative treatment. In fact, for older patients with massive tears, the problem simply became worse over time. This is particularly true for patients with tears that affected three or more tendons.

Clinical outcomes for surgical repairs

A lot of studies have been carried out to determine the effectiveness of surgical rotator cuff repair. In one study which involved data from 1600 patients, it showed after six months there was a significant improvement in most patients in overhead motion and pain.

Another looked at surgical repair of full thickness tears. A total of 263 shoulders were included in the study. After five years, 94% of patients didn’t require any further surgery. Most impressively, after 10 years 83% of patients still didn’t require additional surgery.

So, surgical repair does appear to be more effective in the long term. However, it did take six months for patients to experience full improvements. This is slightly longer than the initial outcome for non-surgical treatment.

The role of age in rotator cuff repair results

There were conflicting results in the studies regarding whether age played a role in results. It is widely believed that age does impact the outcome of rotator cuff repair. However, some studies showed that there were no differences between the results experienced in younger age groups and those in older groups.

The only exception here is tendon healing. Evidence suggests that older patients do appear to take longer to heal when tendons are damaged. However, for most rotator cuff repairs, surgery had the same success rate in older patients as it did in younger ones.

The findings of the review confirm that rotator cuff repair surgery does tend to be the best option for patients. However, it does depend upon the size and severity of the tear. For patients experiencing a mild tear, physiotherapy and a non-surgical approach can be effective. However, for more severe and larger tears, surgery is the most effective option.

During the current COVID-19 crisis, all non-urgent / elective surgery bookings and appointments are postponed. These are now restarting though there are some restrictions in a quickly-changing landscape, but the London Shoulder Specialists are still available for consultation if you require more advice on rotator cuff repair. Consultations can be carried out either by telephone or video link and can be arranged by emailing appointments@fortiusclinic.com or by calling 020 3195 2442.