Could intraoperative fracture during total shoulder replacement have been prevented?

May 26th — admin

We are really bummed as a family. We all encouraged Mom to have a shoulder replacement and then her upper arm broke during the surgery. Is this a fluke? Could it have been prevented?

There are many possible reasons why a bone fracture occurs intraoperatively. Sometimes it’s completely unavoidable. There are some known risk factors such as decreased bone mass (osteopenia or osteoporosis). Shoulder instability from a previous rotator cuff tear can make a difference.

Fractures of this type occur most often during a total shoulder replacement (versus a hemiarthroplasty where only one side of the shoulder joint is removed and replaced). Sometimes the surgeon has trouble getting to the shoulder socket. The angle and force needed may be too much for the brittle bones.

Older women seem to be at increased risk for humeral (upper arm) fractures. They are especially at risk if they also have rheumatoid arthritis or other health issues such as diabetes contributing to delayed or poor healing.

Surgeons must be aware of potential risk factors for fracture. Surgical approach and techniques must be chosen carefully with these risks in mind. Patient position during the operation is important. The elbow should never be used as a lever to get increased shoulder motion when under anesthesia.

Soft tissue release around the shoulder may be needed before moving the arm through its full range of motion. Special care must be taken when reaming out the humeral bone to place the stem of the implant inside. Hand reaming instead of power reaming is advised. The bone should be compressed, rather than removed, in patients who have low bone density.

These are just a few of the many considerations surgeons must include in the surgical process. When many risk factors present at the same time, then the risk of fracture goes up. Even being aware of all the risks doesn’t guarantee complications won’t occur. The surgeon can’t always predict who might develop intraoperative fractures.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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Hair stylist concerned about arthroscopic surgery for shoulder

May 23rd — admin

I need to have surgery on my shoulder because it clicks and hurts whenever I raise my arms over my head. Since I work as a hair dresser, I use this motion all day long. The surgeon I saw wants to put two puncture holes in my shoulder to repair this problem. Should I go through with it? Will the holes cause problems later?

It sounds like your surgeon is suggesting arthroscopic surgery. A long needle with a tiny TV camera on the end is inserted through the skin into the joint. The surgeon can see on a screen what is going on inside the joint.

The scope makes it possible to find and repair damage to the joint capsule, cartilage, and ligaments or tendons in the area. Studies show this type of surgery is very successful. There is no need for a large, open incision. Rehab and recovery is faster because major muscles haven’t been cut through.

The two or three puncture holes needed for placement of the scope usually present no problems. There is a small risk of infection at those sites. Usually, they just fill in with collagen fibers and scar tissue. They may only be visible on close inpsection.

The recovery process does take some time. Depending on what the surgeon has to do, you probably won’t be able to go back to work right away. Most patients are placed in a sling with a pillow under the arm.

You’ll probably see a physical therapist several weeks after the operation. The focus of rehab will be on restoring range of motion, strength, and function. Specific exercises may be prescribed to help you prepare to return to overhead work.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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Pitching arm vulnerable to shoulder instability

May 18th — admin

I’ve been to three orthopedic surgeons now about a problem with my pitching arm. It hurts, clicks, and feels like it’s going to pop out of the socket. No one could figure it out. I finally had an arthroscopic exam that showed a posterior tear of the shoulder capsule. Why was this so hard to diagnose?

Posterior instability as a cause of shoulder pain and/or clicking is an uncommon, but not unheard of, condition. Anterior shoulder problems are much more common. In fact, many pitchers or throwing athletes suffer from an anterior instability. Posterior refers to the back of the shoulder. Anterior refers to the front of the shoulder.

In either case, repetitive microtrauma from the action of overhead throwing is the cause of the problem. During the follow-through phase of pitching, the shoulder is close to the body, flexed, and rotated inwardly. This repetitive motion may put stress along the back of the shoulder.

The shoulder capsule and labrum (rim of cartilage around the shoulder socket) can also get pinched causing pain. This is more likely to occur during the late cocking phase of throwing when the arm is drawn back and externally rotated.

The problem is made worse if the athlete has any natural laxity (looseness) or contracture (tightness) of the soft tissues in this area. Repeated stresses from throwing 100′s of pitches can lead to labral tears or a stretched capsule.

These types of injuries are not easy to diagnose. There can be different directions of instability at the same time causing confusion. Clinical signs and symptoms and results of testing aren’t always consistent for multidirectional injuries. Diagnosis is delayed when there is more than one lesion (and even a combination of problems).

The surgeon will have to sort out the site of damage and resulting structural and biomechanical problems. Even with history, physical exam, and imaging studies, arthroscopy may be the only way to make the final diagnosis.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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What is bursitis? I’ve heard of it and wonder if that’s what’s causing my shoulder pain.

March 16th — admin

What is bursitis? I’ve heard of it and wonder if that’s what’s causing my shoulder pain.

Bursitis is an infection, irritation, or inflammation of a bursa. The bursa is a small fluid-filled sac or cushion. There are many bursae throughout the body. They are found where a muscle or tendon slides across bone. 

Bursae decrease friction between two moving surfaces. With aging, they can become paper thin. Then they no longer provide the necessary cushion. When the two body parts start to rub together, bursitis can occur. Sometimes repetitive motion causes the bursae to become inflamed.

The shoulder is a very complex joint with many moving parts, ligaments, tendons, and muscles. There is a fairly large bursa between the rotator cuff and the head of the humerus (upper arm bone). The rotator cuff is a group of four muscles and tendons that surround the shoulder joint.

An orthopedic surgeon can help diagnose the problem. A careful history and examination may pinpoint the exact cause of your painful symptoms. There is treatment available for bursitis, if that’s what’s causing your pain. 

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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A 54 year old, fell playing ice hockey and now feels a “squishy” sensation in his shoulder. What should he do?

March 3rd — admin

I’m 54-years old and still like to get out on the ice and play broom ball or a little pick up game of ice hockey. Last season, I fell onto my elbow and felt a squishy sensation in my shoulder. Now I can hardly lift my arm up and hold it there without pain and weakness. What should I do?

If you haven’t already seen either your primary care physician or an orthopedic surgeon, that might be your first step. A clinical exam and some imaging tests (X-rays, MRI) will probably help identify the problem.

A traumatic injury through the elbow to the shoulder can cause damage to a number of different structures in the arm. The doctor will make sure there isn’t a fracture that hasn’t healed. The muscles, ligaments, and shoulder capsule will need to be examined.

The most common shoulder injury from this type of fall is a rotator cuff tear. Painful and weak motion suggests a major tear in one or more of the four muscles of the rotator cuff. Painless and weak is more typical when the tendon has ruptured completely.

The rotator cuff covers the shoulder and helps stabilize the head of the humerus (upper arm) in the shoulder joint. Sometimes other injuries accompany a rotator cuff tear. This is impossible to tell without further testing.

Sometimes a specific rehab program can give good results. But in some cases, surgery is needed. Again, a medical exam is needed to know for sure the cause of your symptoms and the best course of action.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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Anthroscopic surgery for a frozen shoulder.

January 17th — admin

Next week I’m going to have arthroscopic surgery for a frozen shoulder. The surgeon has explained everything to me. Just the front part of my shoulder capsule will be cut. I’m wondering if they don’t release the back part, too will I still get my full motion back?

Frozen shoulder also known as adhesive capsulitis is used to describe a loss of shoulder motion caused by changes in the shoulder joint capsule. The capsule is an envelope of connective tissue that surrounds the shoulder joint.

Injury and inflammation can start the process leading to adhesive capsulitis. Painful motion causes the person to stop moving the shoulder, and it gets bound down. It can also occur as a result of other conditions such as diabetes, heart disease, and lung disease.

It was once thought that changes throughout the capsule are what caused the tightness. It is true that with a frozen shoulder, there is fibroplasia throughout the capsule. Fibroplasia refers to the formation of fibrous scar tissue.

But surgeons found that by releasing just the anterior (front) part of the capsule restores shoulder motion. Further research showed that a particular protein called vimentin is what really leads to anterior contracture (tightness) of the capsule.

By releasing the anterior capsular structures, motion is restored throughout the joint for most people. Frozen shoulder can range from loss of external rotation and abduction (moving the arm away from the body) to a complete loss of all motion. More extensive surgery may be needed for more extreme cases.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com. The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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TV method for reducing dislocated shoulder often painful, ineffective

October 1st — admin

Our 14 year old son dislocated his right shoulder after falling off his mountain bike. He had to have anesthesia to put the joint back in place. Can’t they do this without surgery like you see on TV shows like ER or Scrubs?

Not all TV drama is real or accurate. Screen writers do try to research conditions, illnesses, and medical procedures and present them accurately.

In the case of shoulder dislocation, there are several ways to “reduce” or put the joint back in place. The most common method of shoulder reduction after dislocation is the traction counter-traction technique. The doctor pulls on the hand of the dislocated arm.

At the same time, pressure is applied into the armpit in the opposite direction. This method of shoulder reduction is often painful and doesn’t always work.

Using sedation such as general anesthesia relaxes the muscles around the joint. This allows the head of the humerus to slide over the rim of the socket and slip back into the joint.

What you saw on TV could have been the traction-counter traction method of reduction. Another way to do this is an old method called the Milch technique. The Milch method is a safe and easy way to reduce a dislocated shoulder joint. The patient’s arm is moved by the doctor or examiner into a position of 90 degrees of abduction and flexion as if to put the hand behind the head.

The head of the humerus slips back over the rim of the socket and fits back into the joint. No anesthesia and no surgery is required. Because it’s not a recent discovery and because it’s an old method, all doctors today may not know about the use of the Milch method to avoid surgery for shoulder dislocation.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com.The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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Bristow procedure linked to higher rate of arthritis

September 23rd — admin

Thirty years ago I had a special operation called the Bristow for a shoulder dislocation. It seems to have held up pretty good but now I’m getting some arthritis. Is that from the surgery or the dislocation?

Cases of joint arthritis after a traumatic injury are very common. This is true for any joint, not just the shoulder. The type of operation you had is also linked with a higher rate of arthritis afterwards.

The Bristow procedure named after W. Rowley Bristow, MD was used most often back in the 1970s when shoulder repairs were done with an open incision. Today, arthroscopic surgery has replaced open procedures in many cases.

The Bristow procedure transferred the tip of the coracoid process to the front of the shoulder socket. The coracoid process is part of the scapula (shoulder blade) that juts forward toward the front of the shoulder.

The idea was to use this piece of bone to reinforce the shoulder socket. It kept the head of the humerus (upper arm) from popping out of the socket. Usually a piece of muscle was also attached like a sling to help as well.

The Bristow procedure is still used in Europe but has been replaced by other methods now in the U.S. There were concerns about restricted motion and arthritis leading to the development of other methods of surgical repair. The coracoid transfer is still used for some patients. Long-term results have been excellent bringing this method back to the attention of orthopedic surgeons for a second look.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com.The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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What is dead arm syndrome?

September 20th — admin

What is the “dead arm syndrome”? I heard on ESPN that my favorite baseball pitcher is benched for the season with this problem.

Dead arm syndrome starts with repetitive motion and forces on the posterior capsule of the shoulder. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. Four muscles and their tendons make up the rotator cuff. They cover the outside of the shoulder to hold, protect, and move the joint.

Overuse can lead to a build up of tissue around the posterior capsule called hypertrophy. The next step is tightness of the posterior capsule called posterior capsular contracture. This type of problem reduces the amount the shoulder can rotate inwardly — a motion needed by pitchers to throw the ball forward before releasing it.

Over time, with enough force, the player may develop a tear in the labrum. The labrum is a rim of cartilage around the shoulder socket to help hold the head of the humerus (upper arm) in the joint. This condition is called a superior labrum anterior posterior lesion. The final outcome in all these steps is the dead arm phenomenon.

The shoulder is unstable and dislocation may come next. Dead arm syndrome won’t go away on its own with rest — it must be treated. If there’s a SLAP lesion, then surgery is needed to repair the problem. If the injury is caught before a SLAP tear, then physical therapy with stretching and exercise can restore it and return the player to the field.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com.The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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Sharp, aching shoulder pain should be examined

September 15th — admin

I have a sharp, aching pain in the front of my shoulder. I can point to it with one finger. Would an X-ray show what the problem is?

You’ll need to see an orthopedic surgeon to find out for sure. Being able to point to the pain with one finger suggests a local problem in one of the soft tissue structures along the front of the shoulder. This could be a tendinitis or acromioclavicular (AC) joint problem. Shoulder pain can also be referred from one of many other structures including the neck, heart, chest, kidney, or stomach.

The doctor will take a history and examine you first before deciding if X-rays or other imaging studies would offer helpful information. Your symptoms especially when it hurts and how you move help the physician tell what’s wrong. He or she will also palpate (feel) different structures to see what’s hurting.

The AC joint (acromioclavicular) occurs where the outer end of the collarbone meets up with the curved acromion coming around from the shoulder blade. This is a common area of injury and instability with young people and degenerative changes in older folks.

Sometimes an injection of a local numbing agent is helpful. Lidocaine and a steroid mixed together and injected into the AC joint can rule out or verify the joint as the source of pain.

There are many clinical tests the doctor can use to find out what’s wrong. Early diagnosis and treatment may help prevent further problems later.

For more information on this subject, call The Zehr Center for Orthopaedics at 239-596-0100 or visit www.zehrcenter.com.The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.

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