Optimising outcomes from shoulder arthroplasty in York

London Shoulder Specialist member Mr Steven Corbett is attending the British Shoulder and Elbow Society meeting tomorrow on optimising outcomes from shoulder arthroplasty. Held in York, this is the annual meeting of BESS working groups dedicated to driving standardisation in shoulder and elbow arthroplasty, particularly in relation to optimising outcomes for patients.

There will be presentations in implants, procedure techniques, peri-operative care pathways, physiotherapy provision and developing national guidelines for managing joint infections. Mr Corbett is working with colleagues on an approved management care pathway for infected shoulder replacements.

Early Surgical Intervention in Rotator Cuff Tears Produce Long-Term Benefits

A new French study has revealed the benefits of early surgical intervention in isolated rotator cuff tears. According to the study’s findings, if surgery is performed early enough for supraspinatus tears, it helps to improve function and strength, amongst numerous other benefits.

Here, we’ll look at the findings which have been published in The Journal of Bone & Joint Surgery and what it means for patients.

Can the findings be trusted?

The study was conducted by an Orthopaedic Surgery Research Group in France and it followed a total of 511 patients. However, only 288 patients went on to have a follow-up, leading some experts to question the results.

The 511 patients had undergone surgery to repair full thickness supraspinatus tears in 2003. Results of the study were written up at a 10-year follow-up appointment. Out of the 288 patients who did go back for a follow-up, 210 received a magnetic resonance imaging (MRI) scan. This revealed the majority of patients had experienced significant improvement.

The standard Constant score was used to assess shoulder strength, motion, pain and daily activity abilities. In the majority of patients, their score had risen from an average 52 to 78. The scans also revealed around 80% of the tendons had healed, but there was still a minor residual tear found in most cases.

The follow-up also revealed patients who were found to have a build-up of fat in the repaired muscle didn’t heal and recover as well as those who didn’t. Fat build-up within the muscle is a sign of muscle degeneration.

Although the researchers themselves do admit there are limitations of the study due to the fact so many patients didn’t return for a follow-up, they still feel it provides a reliable analysis of how surgery could help to improve the outcome of supraspinatus tears. It’s certainly the longest-term study carried out to assess the benefits of surgery in isolated rotator cuff tears.

What are supraspinatus tears?

There are four major tendons within the rotator cuff of the shoulder, and the supraspinatus is one of them. It is also the most common type of rotator cuff tear patients suffer with. A tear, either partial or full-thickness, can occur because of a trauma, or through repeated micro-traumas.

The majority of full-thickness supraspinatus tears, tend to start out as partial tears and they worsen over time. This backs up the results of the French study in the fact surgery should be carried out early to prevent the condition worsening.

What treatment options are available?

Treatment is decided based upon the severity of the tear. Surgery currently tends to be used as a last resort. Instead, specialists prefer to start out with a physical therapy treatment plan; especially if the tear is only minor. This is because in the past, surgery was known to come with long, often painful recovery times.

However, surgical techniques have advanced and as the French study shows, surgery could be the most effective treatment for early supraspinatus tears. One thing all experts can agree on is the earlier a patient seeks treatment for this type of rotator cuff tear, the better the outcome will be.

Overall, the study’s findings are promising and they do give a good indication of the long-term success rates of early surgery in supraspinatus tears. It also showed the success rate remains the same regardless of whether open or closed surgical techniques are used.

London Shoulder Specialists at the Fortius International Sports Injury Conference

London Shoulder Specialists at FISIC 17This week, the Fortius Clinic hosts FISIC ’17, a multidisciplinary sports conference covering sports injuries ‘from start to finish’. Aimed at orthopaedic surgeons, sports physicians, physiotherapists and other healthcare professionals with an interest in sport, at all levels, it takes place at The Queen Elizabeth II Conference Centre in Westminster, London, on 27th to 28th September.

FISIC ’17 has been awarded 12 CPD points from the BOA, 15 points from the RCP and 12 points from the RCR.

Members of the London Shoulder Specialist team are on the faculty for the event, covering a number of different sessions.

Mr Andrew Wallace is chair of a session on upper limb throwing injuries on Wednesday and one on progression from shoulder instability to stiffness on Thursday. In the Wednesday session, fellow colleague Ms Susan Alexander will cover throwing injuries shoulder pathology in relation to the SLAP and biceps.

Also on Wednesday, two of the LSS team will be presenting on upper limb problems in the cyclist, chaired by Mr Steven Corbett. Mr Andy Richards will be discussing traumatic injuries of the clavicle and, then, Mr Corbett will present on ACJ dislocations. Then, Mr Richards will discuss forearm stiffness in the injured forearm session.

Thursday morning sees a session on sport after arthroplasty, drawing Fortius consultants from all disciplines. Mr Steven Corbett will focus on returning to sport after a total shoulder replacement (TSR).

A key session on the Thursday will focus on football and return to play at an elite level. Mr Andrew Wallace will be discussing contemporary management of shoulder injuries in elite football. He’ll also be reflecting on when to operate on a full thickness tear in the session focusing on the rotator cuff. The role of allograft reconstructions will also be featured in this session, presented by his colleague Mr Ali Narvani.

Two Stryker sponsored workshops on superior capsular reconstruction will also be presented by Mr Ali Narvani.

The shoulder symptoms you shouldn’t ignore

Shoulder problems are extremely common, yet they’re also often ignored. Although some find the issue resolves itself without intervention, the majority of shoulder injuries and conditions will worsen over time.

shoulder symptomsThe impact of musculoskeletal conditions on the economy cannot be underestimated MSKs are one of the primary causes of absenteeism and the UK has one of the highest rates in Europe. Statistics released from the Health and Safety Executive, found that in 2015/16 there were 3,138,000 working days lost due to Work Related Upper Limb Disorders, with workers in the construction industry and skilled trade occupations having significantly higher rates of upper limb disorders.

Here, we’ll look at some of the most common shoulder symptoms you shouldn’t ignore and why it’s important to seek a diagnosis as early as possible.

Common shoulder symptoms to watch out for

Many people underestimate the severity of shoulder symptoms and the effect it can have on their lives. The shoulder is the most mobile joint within the body, making it extremely vulnerable to injury. Symptoms which develop within the shoulder can pinpoint to a number of injuries which is why they need to be checked out as quickly as possible. The most common symptoms to watch out for include:

Pain: The most common shoulder symptom patients experience is pain. Unfortunately, it can link to a wide range of different injuries and conditions, making it difficult to diagnose a specific cause purely from this symptom alone. For example, it could be a sign of a rotator cuff tear, shoulder instability, arthritis or a dislocation.

It is common for patients to put shoulder pain down to overusing the arm, misalignment while sleeping or as a temporary symptom brought on by injury. However, pain in the shoulder should never be ignored, especially if it is severe or brought on due to injury.

Stiffness: Shoulder stiffness is another common symptom often ignored and, like pain, it can be a sign of a more serious issue. Frozen shoulder is a common cause of stiffness within the shoulder joint and it is often mistaken for arthritis. If the condition is behind the stiffness you’re experiencing, you will notice it becoming gradually stiffer and more painful over time.

Stiffness can also be a sign of a dislocated shoulder, a shoulder separation or rotator cuff calcific tendonitis, amongst others.

Swelling: You may notice swelling directly after an injury, or it may develop gradually over time. It can also present itself either on the top of the shoulder or all over. Again, this symptom will typically be accompanied by pain and though it may go down on its own, swelling could pinpoint a more serious injury.

Weakness: If you’re struggling to move the arm or carry out daily tasks due to weakness in the shoulder, this absolutely shouldn’t be ignored. It could be a sign of shoulder impingement, a rotator cuff injury, or shoulder instability.

Locking: This is another potential symptom of shoulder instability. If you notice the joint popping, clicking or locking as you move the arm, you should get it checked out as soon as possible.

The above are the main symptoms to watch out for, but any issues you have with the shoulder should always be looked at by a doctor or a shoulder specialist. If these symptoms relate to a shoulder injury, the earlier you seek treatment the more likely it is to respond to conservative management.

Overall, if you’ve been experiencing pain, stiffness or numbness in the shoulder, it’s important to get it looked at as soon as possible. Never ignore shoulder symptoms, especially if the pain is becoming increasingly worse.

Surgery an effective option for Pectoralis major tendon ruptures

Pectoralis major tendon ruptureNew research presented at the annual meeting of the American Orthopaedic Society for Sports Medicine, has indicated that surgery is an effective option for Pectoralis major tendon ruptures.

Pectoralis major tendon ruptures are one of the less common shoulder injuries, but due to the popularity of strength-based sports, they are starting to be seen more frequently. As they are one of the less-seen shoulder injuries, reviews of the optimal treatment have been limited to small-scale studies.

Here, you’ll discover everything you need to know about Pectoralis major tendon ruptures and why surgery could be the most effective treatment.

Understanding Pectoralis major tendon ruptures

Pectoralis major tendon ruptures are one of the few shoulder injuries to almost exclusively affect men. They can occur at any age from 20 to 50 and are referred to by athletes as ‘pec tears’.

There’s actually four different types of Pectoralis ruptures including:

  • Type 1 – Tendon rupture at the humeral insertion
  • Type 2 – Rupture between the muscle and the tendon at the musculotendinous junction
  • Type 3 – Rupture within the muscle
  • Type 4 – Muscle is torn off the bone of the sternum

Type 1 is the most common Pectoralis major tendon rupture, whereas type 4 is extremely rare. The treatment option recommended will depend upon which type of rupture you’ve experienced and whether it is a partial or full rupture.

What causes a Pectoralis major tendon rupture?

Pectoralis major tendon ruptures are most commonly caused by forceful activities. This could be bench presses, weightlifting, or certain sports such as rugby, wrestling and football.
There’s evidence to suggest steroid use can also increase the risk of developing this type of injury as the steroids weaken the tendons over time. However, you can still develop a rupture even if you’ve never touched steroids.

What are the symptoms of Pectoralis major tendon rupture?

As treatment for Pectoralis major tendon rupture should be sought as soon as possible, it helps to know the symptoms to look out for.

The very first sign of this type of rupture can often be heard, as well as felt, as soon as it occurs. You can literally hear it tear. However, the type of sound will vary depending upon which type of rupture you’ve experienced. If the tendon has ruptured from the bone, the sound is going to be more of a popping noise. If the muscle has ruptured on the other hand, you’ll most likely hear a tearing sound.

There is also likely to be some pretty dark bruising around the area. You’ll experience pain around the tear, but you may also feel pain within the shoulder. This is because the shoulder starts to work harder to compensate for the fact the pectoralis major doesn’t have full strength or motion.

Study reveals surgery is an effective treatment option

The recent study carried out at a multi-centre and multi-surgeon integrated health system, followed 120 patients. Numerous surgical repair procedures were used and, after a final follow-up approximately 71 days after the procedures, a staggering 95 per cent were able to return to their full-time occupation.

There were just three procedures which failed and most procedures carried a very low risk. The procedures with the highest risk of complications were those involving bone tunnels.

Overall, as the study highlights, surgery can be a very effective way to treat Pectoralis major tendon ruptures. However, a full diagnosis will be required to determine which type of rupture the patient has experienced and to determine the best type of procedure that should be performed.

Awake shoulder surgery – it’s not as ‘new’ as you might think!

awake shoulder surgeryRecently, we read with interest a news story featured in the Evening Standard about a “pioneering initiative” known as awake surgery.

Referred to as a groundbreaking treatment option, it highlighted the benefits of patients undergoing shoulder and elbow surgery under new ‘awake’ regional anaesthesia. The newspaper claimed that a shoulder and elbow surgeon at a London hospital was one of the first to offer this innovative technique on upper limb injuries, having carried out 50 of these cases over the last year.

While it’s true that awake surgery does deliver some benefits over surgery carried out under general anaesthetic, there were a couple of significant errors in this news story. This isn’t a new technique and it is used routinely in orthopaedic operations. Our shoulder specialists have been carrying out awake regional anaesthetic procedures for over 15 years, equating to approximately 3,000 cases.

And, for some patients, a general anaesthetic combined with regional anaesthetic techniques to ensure optimal pain relief and earlier mobilisation will always be the preferred option.

Below, you’ll discover everything you need to know about the awake surgery technique, its benefits and the importance of choosing a reliable, highly experienced surgeon.

What is awake shoulder surgery?

Awake shoulder surgery enables the patient to stay awake throughout the procedure. However, most patients choose to be sedated to some degree.

An anaesthetist will inject medication near the nerves surrounding the shoulder and the surrounding area. This will numb the area where the surgery will be performed. It takes approximately 30 minutes for the anaesthesia to be injected and take effect.

The types of awake surgical procedures vary and will be selected based upon the injury being treated.

Benefits of awake shoulder surgery procedures

So, why are awake regional anaesthetic procedures being described as a pioneering technique? Some patients can suffer from side effects from general anaesthesia, such as nausea and dizziness, and, if patients have suffered from these side effects in the past, then these can be mitigated with awake sedation techniques.

In general, though, a general anaesthetic is very safe and well-tolerated and for many patients, shoulder surgery performed under a general anaesthetic augmented with a regional block can be the best option, depending on the patient’s health and fitness and whether major surgery of a much longer duration is required. Both patient and surgical factors will be taken into account in the pre-operative planning stage.

The biggest benefit of awake surgery is a faster recovery time from the anaesthesia, however most shoulder operations are relatively short in duration, hence even with a general anaesthetic combined with a regional block, most patients are able to go home the same day. Whilst some people like to watch their own surgery, for others, this is not so desirable!

The importance of choosing an experienced surgeon

As you can see, there are plenty of excellent benefits that come from undergoing awake regional surgery. However, to enjoy these benefits it’s important to choose an experienced surgeon who has been performing this type of operation for many years and can advise on the best option for you.

New study finds link between higher BMI and poor outcome after shoulder surgery

BMI and shoulder surgery complicationsThe higher your BMI, the more likely you’ll experience a poor result from shoulder surgery. So, how are the two connected and what kind of complications could arise?

Understanding the study

Researchers from the Mayo Clinic, Rochester, Minn, analysed data taken from 4,567 shoulder arthroplasty patients from the years 1970 to 2013. The findings were published in The Journal of Bone and Joint Surgery.

Approximately 43% of patients were diagnosed as obese, which meant their BMI was at least 30. So, the researchers began looking at the correlation between BMI and shoulder surgery complications.

It was discovered that 302 patients experienced complications such as a loose implant and a mechanical failure, which resulted in the need for a revision surgery. A further 62 patients were also required to undergo a separate further operation. Interestingly, it was revealed that patients who were obese at the time of the surgery, had an increased chance of suffering these complications.

Worryingly, the chances of developing these complications increased by 5% for every unit increase in BMI of 35 and over. However, that wasn’t the strongest link found between BMI and shoulder surgery compilations. The study also showed that patients with a BMI of 35 or over, also had an increased risk of wound infections, with each increased BMI unit over 35, adding a 9% increased risk of infection.

It wasn’t all bad news, however. The study showed no link between BMI and an increase in the risk of blood clots – a complication which can be potentially deadly.

BMI also increases functionality risk in shoulder surgery

While the study largely focuses upon an increased BMI and shoulder surgery complications, previous studies have also shown it can have an effect on functionality too.

In 2011, a study revealed that patients undergoing surgery to repair rotator cuff injuries experienced an increased risk of mobility issues. Obese patients were also likely to stay longer in hospital and the shoulder operation also took longer.

Why does your BMI matter?

The theory behind the link between a high BMI and shoulder surgery complications is that the heavier a patient is, the more stress it places upon the implant. So, a high BMI will place additional pressure onto the implant, increasing the likelihood it will fail.

It also increases the chances of developing an infection after surgery. This is thought to be caused by the essentially ‘dead space’ which is left behind by excessive fatty tissues, along with changes to the immune system caused during surgery.

However, although obese patients do tend to experience poorer results, they still report the surgery has made some improvement to the condition.

Overall, what really makes this study stand out, is that it’s the first to actually look at the risks associated with BMI increases of just one increment. Most studies tend to focus more on BMI ranges, which don’t provide an accurate understanding of the increased risks involved.

Will new T20 competition increase pressure on cricketers and increase injury risk?

cricket shoulder injuriesA new T20 competition is set to provide the biggest overhaul in English cricket since the sport was started. The city-based competition is said to be due to launch as early as next year and is designed to rival the Big Bash and IPL.

The proposal submitted by officials of the England & Wales cricket board, has taken months to prepare. If it gets given the go-ahead, new teams will be able to take part in the tournament and the matches will be sold to broadcasters with an estimated one match each week being broadcast on terrestrial TV.

However, could this new tournament increase pressure on cricketers and in turn increase their risk of injury?

Some studies show Twenty20 cricket does not increase injury risk

A study was actually carried out on Australian cricketers who partake in the Twenty20 competition back in 2010. Interestingly, it showed that players taking part in the competition were less likely to develop an injury than those partaking in other types of cricket games.

It measured the injury rate of players based on 1000 days of play. Around 145 injuries occurred in domestic based Twenty20 cricket. When compared to the 219 injuries suffered by those playing in domestic one-day cricket, you quickly see that Twenty20 provides a much lower risk.

Of course, that isn’t to say there is no risk involved. What studies have found is that fast bowlers taking part in Twenty20 cricket are at the biggest risk of developing shoulder-related injuries.

Increased competition puts pressure on fast bowlers

A study has found fast bowlers in cricket are at an increased risk of injury when their workload is increased. So, those taking part in T20 cricket could find themselves susceptible to shoulder injury. During the study, data was collected from a total of 28 fast bowlers. They had bowled for 43 seasons, over a period of six years.

The results of this study are unsurprising. After all, fast bowlers use more strenuous shoulder motions to deliver balls at high speeds. This, combined with a more frequent work schedule is going to increase the likelihood of injury pretty substantially.

If the T20 competition is approved, coaches can decrease the risk of injury by rotating their bowlers. It is also suggested that the rules of the game should be altered to reduce the severity of injuries if they do occur.

Overall, introducing this new competition in England could help to further give the game a boost and increase the amount of money made by teams. There is talk of new grounds being built at sites such as the Olympic Stadium, where fans would be able to purchase tickets for the games. However, it is important for coaches to take the increased risk of injury seriously. Cricketers are renowned for developing shoulder-related injuries and increasing the number of times they play is only set to make the risk even greater.

Living with shoulder instability: management and treatment

shoulder instability treatmentWhatever the cause, successful treatment often relies upon early detection. Here, we’ll look at how shoulder instability is typically managed and treated.

Shoulder instability treatment

There are several treatment options which can be used to treat shoulder instability. Patients who have never suffered a dislocation of the shoulder joint, will typically find physical therapy offers the best course of treatment.

  • Regular physical therapy sessions will focus on strengthening up the girdle; providing stability to the joint. In addition, electrical and ultrasound stimulation, along with massage can also be used to minimise the pain.
  • Placing ice over the affected area twice daily will also help to reduce pain and limit inflammation. In severe cases, the patient may also be given corticosteroid injections to manage the pain and inflammation.
  • If the shoulder has become dislocated, physical therapy alone will not always be enough to repair the problem. Just one dislocation could be treated without the need for surgery, but if multiple dislocations are identified, an arthroscopy may be needed.
  • The arthroscopy can usually be done as an outpatient procedure. It’s minimally invasive and has shown great success in the treatment of shoulder instability.

It’s worth pointing out, treatment can vary depending upon the age of the patient. Below you’ll discover more about age-related treatment options.

Shoulder instability treatment for older patients

The majority of older patients who present with shoulder instability, have developed the condition after a fall or traumatic incident.

If a patient is over the age of 40, treatment will usually be done non-operatively. A sling will need to be worn, ensuring the joint is immobilised for a set time period. This gives it plenty of time to heal. Once it has been rested, usually within a couple of weeks, physiotherapy will be used to help the patient regain motion and strengthen the shoulder joint to prevent future injury.

Interestingly, the re-occurrence rate of shoulder instability in older patients is very low. A full recovery is also expected within three to six months.

Shoulder instability treatment for younger patients

Younger patients are generally more prone to shoulder instability issues; particularly young athletes. In sports which require frequent overarm movements such as tennis, there’s an especially high chance of shoulder instability.

If the shoulder is dislocated, it is likely to end with future instability in the joint. It’s estimated that 80% of young patients who experience a dislocation, go on to experience recurring instability issues.

Treatment will very much depend upon the severity of the instability. If the shoulder has been dislocated fully, it will need to be reset. However, it’s worth noting that this doesn’t treat the actual instability issue.

The instability is most commonly treated with physiotherapy to start. To address the pain, anti-inflammatory medications may also be prescribed. If very little improvement is seen after physiotherapy, surgery may be the only other option.

Overall, shoulder instability can be treated, though the method and recovery period will depend upon several factors, including the age of the patient. As with any shoulder injury, the earlier instability is detected and managed, the easier it will be to treat.

All strenuous physical activities should be stopped until the shoulder is strengthened and the pain is gone.

London Shoulder Specialist Ms Susan Alexander of the Fortius Clinic reiterated in a recent presentation on shoulder instability “the importance of a close working relationship, with good, open and regular communication between surgeon, physiotherapist and general practitioner to optimise the treatment of this complex condition.

Tuning your tennis shoulder

The temperatures have plummeted and rain is predicted so we must be nearing one of the highlights of the British summer: Wimbledon. As the oldest and most prestigious of the Grand Slams looms, it’s that time of year when even amateur tennis enthusiasts dust off their rackets and a great opportunity to highlight one of the most common injuries suffered in the sport and how you can prevent it.

Treating tennis shoulderTennis shoulder is a common, painful injury, which largely occurs due to repetitive overuse of the shoulder. Just like cricket, tennis players use a lot of overhead arm movements; causing the joint and underlying muscles to eventually loosen, tear or – in more severe cases – come away from the socket completely.

Understanding tennis shoulder

The shoulder is by far the most flexible joint within the body. It’s designed to allow a wide range of different movements, while maintaining good stability. However, if you push the joint too far in any direction, it has the possibility to irritate any of the surrounding muscles and tendons.

Out of the entire structure of the shoulder, the rotator cuff tends to be the most susceptible to injury. Some experts argue this is because the rotator cuff isn’t able to adapt quickly enough to any sudden changes. So, with this theory, if you’re just starting out in the world of tennis, you’re at a higher risk of developing shoulder-related injuries.

Even seasoned tennis players are at a high risk of injury. Many take time off during the winter months then, as the weather warms up, returns to their favourite sport. As the shoulder hasn’t been used for months, it’s simply unprepared for the pressure that it’s about to be placed under and injury becomes a high possibility.

Is tennis shoulder preventable?

If you’re looking to return to tennis or take it up for the first time, one of the best pieces of advice is to make sure you’re properly warmed up. This doesn’t just mean doing a series of stretches before playing, it means starting to prepare for the game before the season actually commences.

Proper training will help you expose the shoulder to the movements required within a tennis game, over a gradual period. This alone will make a massive difference to your tennis shoulder risk level. The longer you can prepare the shoulder before you start playing properly, the lower your risk will be.

Right before you play, a proper warm-up will also help. This should ultimately include some of the movements you’ll be performing, such as an overhead serve. You’ll also want to focus on flexibility training of the legs, spine, arms and shoulders.
Similarly, a cool down is just as important as the warm-up. This will also greatly reduce the amount of aching you experience the day after.

Building up your back and shoulder muscles will also help to lower your risk of injury. The more stable and strong you can make the shoulder, the less prone it will be to injury.

Overall, due to how repetitive tennis shoulder movements can be, it’s impossible to completely prevent the risk of injury. However, the above advice will help you minimise your chances of developing tennis shoulder. If you do experience any pain in the shoulder, it’s imperative you get it looked at right away. The earlier you get the problem treated, the easier it will be to rectify.