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A Patient’s Guide to Cuff (Rotator) Tear Arthropathy

The rotator cuff is a unique structure in the shoulder that is formed by four tendons. These four tendons attach to four muscles that help keep the shoulder stabilized in the socket (or glenoid) and help rotate the upper arm inward and outward. If the rotator cuff is torn and is not repaired, a type of wear and tear arthritis of the shoulder can develop over time. This condition is sometimes called arthropathy and the term cuff tear arthropathy is used to describe this type of arthritis of the shoulder that develops when the rotator cuff is damaged. If you develop this condition, your shoulder will be painful. Movement and strength of the shoulder will be decreased. Moving the arm away from the body and raising it over your head can be especially difficult.

This guide will help you understand

  • what parts of the shoulder are involved
  • what causes this condition
  • how doctors diagnose the condition
  • what treatment options are available

Anatomy

What parts of the shoulder are involved?

The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle (the collar bone). The roof of the shoulder is formed by a part of the scapula called the acromion. The shoulder joint is also called the glenohumeral joint. One of the bones of the glenohumeral joint is the humerus (the long bone of the upper arm). It has a ball, called the humeral head on the top end. The humeral head fits into a small, shallow cup called the glenoid fossa. It makes up the other part of the glenohumeral joint. The glenoid fossa is part of the shoulder blade. A large ligament runs from the front of the acromion to another part of the shoulder blade called the coracoid process. This ligament is called thecoracoacromial ligament. It adds stability to the front of the shoulder.

The rotator cuff is made up of tough, fibrous tissue. It forms a cuff (or capsule) covering the shoulder joint. There are four tendons that help form the rotator cuff. The muscles that form the tendons are the supraspinatusinfraspinatusteres minor, and subscapularis. These muscles rotate the shoulder outward and inward. Along with another muscle, the deltoid, they also help lift the arm away from the body.

The rotator cuff slides between the humeral head and the acromion as we raise our arm. As this sliding occurs over and over, the rotator cuff tendons will often be pinched as you use the shoulder everyday. This pinching is called impingement. Over time this pinching can lead to damage and weakening of the rotator cuff tendons.

Causes

What causes this condition?

Dr. Charles Neer actually described rotator cuff tear arthropathy (RCTA) in 1977. Today, doctors generally refer to this as simply cuff tear arthropathy. Cuff tear arthropathy is actually a type of wear and tear, or degenerative arthritis of the shoulder that develops over time after the rotator cuff is damaged.

Normally, when the rotator cuff muscles contract, they pull the head of the humerus tightly into the socket of the shoulder. This stabilizes the shoulder and allows the the large deltoid muscle to raise the arm over the head as it rotates the humeral head like a pulley. This motion needs the rotator cuff and deltoid muscles to work together – in balance. When the rotator cuff is torn, the shoulder becomes unbalanced. The deltoid muscle pulls the head of the humerus up into the acromion in a sliding motion. When the top of the humerus hits the underside of the acromion, the deltoid may be able to pull the arm part way up as it levers against the underside of the acromion. But, over time this abnormal sliding motion causes wear and tear on the joint surfaces. Arthritis develops and any motion becomes painful. The shoulder becomes weaker and weaker until you can no longer raise the arm above the head.

Rotator cuff tears are very common. Trauma, such as falls, lifting, and pulling forcefully can also cause a rotator cuff tear. When this happens, it is called an acute tear. Although the rotator cuff can be damaged from a single traumatic injury, damage to the rotator cuff usually occurs gradually. Age can be a factor. As we age, the tendons of the rotator cuff become weaker and more likely to be injured. The blood supply to the tendons diminishes with age. Rotator cuff tears are much more likely to occur after the age of 40.

Certain activities can increase the wear and tear on the rotator cuff. Repetitive overhead activity such as painting, plastering, racquetball, weightlifting, and swimming can cause wear and tear of the rotator cuff.

Surgeons generally will recommend surgery to repair a rotator cuff tear when it occurs. A successful surgical repair of a torn rotator cuff tear can make the development of cuff tear arthropathy much less likely. But, sometimes a rotator cuff tear cannot be repaired. The tissue is simply too damaged and cannot fixed. This is not an uncommon situation in older patients with rotator cuff tears. In other cases, the patient simply elects not to have surgery to repair a rotator cuff tear and chooses to simply live with the discomfort. Over several years, both of these situations can result in the later development of rotator cuff arthropathy.

Symptoms

What does this condition feel like?

The most common symptom of rotator cuff tear arthropathy is pain in and around the shoulder. The pain can also radiate into your neck, arm, even into your wrist or hand. The shoulder can be especially painful when trying to lift the arm, or rotate it outward. The pain is usually worse at night. It can interrupt your sleep, especially if you try to sleep on the affected shoulder. If untreated, the pain can be nearly continuous and can be severe.

Weakness of the shoulder makes it difficult, if not impossible to lift the arm overhead. Often, even starting this motion can be difficult. The tendency is to shrug the shoulder in order to lift the arm part of the way. With time, weakness of the rotator cuff muscles will worsen. Range of motion can be quite limited. You will often find it difficult to do routine things, like reaching behind your back, reaching into a cabinet, or combing your hair. You may notice a crackling or popping sensation. When there is arthritis of the glenohumeral joint, there is often a creaking or grating sound.

Diagnosis

How do doctors diagnose this condition?

Your doctor will want to do a history and physical examination. He will ask you about activities or trauma that could have injured your shoulder. He will want to know the level of your pain, and what limitations you have. A physical examination is done. Range of motion and strength of the shoulder muscles will be evaluated. Your doctor will want to look at your shoulder to see if there is bony deformity, or atrophy (shrinkage) of the muscles. With a complete rotator cuff tear, moving the arm away from the body can be nearly impossible. If your doctor lifts your arm for you, and you cannot hold it up, this is called a positive Drop Arm Test. This usually means the rotator cuff is torn.

Other areas such as the neck may also need evaluation. A pinched nerve in the neck can mimic a rotator cuff tear. A neurological examination to include checking reflexes and sensation may be included. Your doctor may want you to have anelectromyogram (EMG). This checks the function of the muscles of the shoulder. An EMG uses a small needle in the muscle being tested. It measures the electrical activity of the muscle at rest, and when tightened.

Your doctor will request X-rays of your shoulder. X-rays show the shape of the bones and joints. When the rotator cuff is torn, the shoulder will often ride high, meaning that it sits higher in the joint than it should. It can also show how much damage ahs occurred to the joint surfaces.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays to show the muscle, tendons, and ligaments of the shoulder. MRIs will show tears of the rotator cuff tendons. Atrophy of the muscles can also be evaluated with MRI. A computerized tomography (CT) scan shows slices of bone. Like X-rays, it uses radiation. A CT scan can help to more accurately determine the degree of damage of the glenohumeral joint. A CT scan is especially useful to plan surgery if an artificial shoulder replacement is considered for treatment.

Treatment

What treatment options are available?

Nonsurgical Treatment

Conservative care that includes physical therapy, ice, heat, and anti-inflammatories is tried first. The goal of treatment is to reduce pain, and increase range of motion and function. Corticosteroid injection into the shoulder joint is also sometimes helpful. Steroids are very powerful anti-inflammatory medications that can reduce pain temporarily. These injections will not heal the tear but may give pain relief for several weeks to months. If arthritis of the shoulder is advanced, and pain is continuous and severe, surgery may be the best option available.

Surgery

Cuff tear arthropathy is the result of long standing lack of rotator cuff function. In almost all cases, repair of the rotator cuff tear is no longer an option. Surgery for cuff tear arthropathy is done when pain and decreased motion continue after conservative care. The simplest surgical procedure to try and improve the situation is a debridement. During a debridement, the surgeon will surgically remove (debride) any inflammed tissue, bones spurs and loose flaps of tendon tissue that may be catching in the joint and causing pain. This procedure may reduce pain, however, it does not always improve range of motion, strength, or function of the shoulder.

Patients with this type of arthritis would seem to be good candidates for a shoulder replacement, but replacing the shoulder in the typical fashion has not been successful. Replacing the shoulder with a special type of artficial shoulder joint is becoming more popular. This procedure is called a reverse shoulder replacement.

The “normal” artificial shoulder was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our normal shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid. This situation has been compared to placing a ball on a shallow saucer. Without something to hold it in place, the metal ball simply slides around on the saucer. In the shoulder that something is the rotator cuff and the muscles that attach to the tendons. Without a rotator cuff to hold the metal ball centered in the plastic socket, the metal quickly wore out the plastic socket and the joint became painful once again. The answer to this dilemma was to rethink the mechanics of the shoulder joint and design an artificial shoulder that worked differently than the real shoulder joint. The solution was to reverse the socket and the ball, placing the ball portion of the shoulder where the socket use to be and the socket where the ball or humeral head use to be. This new design led to a much more stable shoulder joint that could function without a rotator cuff. The artificial joint itself provided more stability by creating a deeper socket that prevented the ball from sliding up and down as the shoulder was raised. The large deltoid muscle that covers the shoulder could be used to more effectively lift the arm, providing better function of the shoulder. The final result is a shoulder that functions better, is less painful and can last for years without loosening.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Your physical therapist will show you how to use ice or heat to help with pain. You will also be instructed in exercises to strengthen your shoulder girdle as much as possible. Showing you joint protection tips, or motion that you can expect to do safely without causing more harm to your shoulder is also important. The goal is to reduce pain, increase range of motion and function, and prevent further arthritis.

After Surgery

A physical or occupational therapist will see you the day after surgery to begin your rehabilitation program. Therapy treatments will gradually improve the movement in your shoulder. Your therapist will go over your exercises and make sure you are safe getting in and out of bed and moving about in your room.

When you go home, you may get home therapy visits. By visiting your home, your therapist can check to see that you are safe getting around in your home. Treatments will also be done to help improve your range of motion and strength. In some cases, you may require up to three visits at home before beginning outpatient therapy.

Out patient therapy at a facility can often more effective and is often preferred over home physical therapy. The first few outpatient treatments will focus on controlling pain and swelling. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Continue to use your shoulder sling as prescribed.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the shoulder’s strength and function. Finally, a select group of exercises can be used to simulate day-to-day activities, like grooming your hair or getting dressed.

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Should my child have ACL Surgery?

ACL injury in child

ACL Tears in Children

ACL reconstruction surgery is the standard treatment for young, active people who sustain an ACL tear. But what happens when that person is a child? Should ACL surgery be delayed until the child is older, or should ACL reconstruction be performed before skeletal maturity?

Answer: Traditionally, when a child injured his anterior cruciate ligament (ACL), a connection within the knee important for joint stability, surgeons were reluctant to operate and reconstruct the ligament right away for fear of damaging the growth plate. The concern was that before a child has reached skeletal maturity (about 12-13 years old in girls or 14-15 years old in boys) this type of surgery presented a risk of injuring the growth plate. Growth plate problems resulting from ACL surgery could lead to unequal leg lengths or angular deformity. However, recent research shows that the risk of growth plate problems is much less then the risk of permanent knee damage if the ACL is not fixed.

Growth Plates in Children

The growth plates are the part of the bone that grows in length. Most bone growth occurs near to the ends of long bones in these areas called growth plates. Two of the most active growth plates in the body are just above and just below the knee joint. These growth plates contribute to the length of both the thigh bone (femur) and shin bone (tibia).Traditional ACL reconstructive surgery involves making a tunnel in the bone directly in the location of these growth plates. At the time of skeletal maturity, the growth plate closes. Once the growth plate is closed (or nearly closed) the risk of causing a growth disturbance is gone. However, by drilling a hole through an open growth plate, the body may close the growth plate early. This could lead to complete growth plate closure, causing leg length inequality, or partial growth plate closure, causing angular deformity. Angular deformity could in turn lead to knock knees (genu valgus) and bow legs (genu varus), These conditions progressively worsen with further growth and could lead to problems such as joint damage and arthritis.

ACL Tears in Children

Knees that are unstable as a result of ACL tears have a high chance of meniscus tears and cartilage injury. Many surgeons have recommended that ACL surgery in children be delayed until the child has reached skeletal maturity. The hope being that by delaying surgery, you could avoid the potential complications of growth plate injury as a result of ACL surgery.Two factors have lead to more surgeons recommending early ACL surgery, even in children. First, more recent research has evaluated the risk of growth plate injury in comparison to the downside of delaying surgical treatment of the torn ACL. The risk of meniscus tears and cartilage injury was found in a recent study to be higher than the risk of growth disturbances. Second, there are modifications to traditional ACL surgery that allow the growth plate to be minimally affected in children. Furthermore, your doctor may recommend a specific type of graft to help minimize the chance of growth plate injury if surgical treatment is pursued. Therefore, more surgeons are recommending early ACL surgery, even in children.

The bottom line is that the risks of waiting (joint instability, meniscus tears, and cartilage injury) appear to be greater than the risk of growth plate injury for early ACL reconstruction with current surgical approaches. As a result surgeons today are more likely to recommend early ACL reconstruction.

Bunionectomy

Definition of Bunionectomy

A bunionectomy is a surgical procedure to excise or remove a bunion. A bunion is an enlargement of the joint at the base of the big toe and is comprised of bone and soft tissue. It is usually a result of inflammation and irritation from poorly fitting (narrow and tight) shoes in conjuction with an overly mobile first metatarsal joint and over-pronation of the foot. Over time, a painful lump appears at the side of the joint, while the big toe appears to buckle and move sideway towards the second toe. New bone growth can occur in response to the inflammatory process, and a bone spur may develop. Therefore, the development of a bunion may involve soft tissue as well as a hard bone spur. The intense pain makes walking and other activities extremely difficult. Since the involved joint is a significant structure in providing weight-bearing stability, walking on the foot while trying to avoid putting pressure on the painful area can create an unstable gait.

Bunionectomy

 How Bunionectomy surgery done:

Bunions become more common later in life. One reason is that with age the foot spreads and proper alignment is not maintained. In addition, the constant friction of poorly fitting shoes against the big toe joint creates a greater problem over time. Ignoring the problem in its early stages leads to a shifting gait that further aggravates the situation.

Once surgery has been decided on, the extent of the procedure will depend on the degree of deformity that has taken place. There are several different surgical techniques, mostly named after the surgeons who developed them, such as McBride, Chevron, and Keller. The degree and angle of deformity as well as the patient’s age and physical condition play a significant role in the surgeon’s choice of technique, which will determine how much tissue is removed and whether or not bone repositioning will occur. If bone repositioning is done, that part of the surgery is referred to as an osteotomy ( osteo means bone). The type of anesthesia, whether ankle block (the most common, in which the foot is numb but the patient is awake), general, or spinal, will depend on the patient’s condition and the anticipated extent of the surgery. For surgery done on an ambulatory basis, the patient will usually be asked to arrive one to two hours before the surgery and stay for about two to three hours after the procedure. The procedure itself may take about an hour.

The surgeon will make an incision over the swollen area at the first joint of the big toe. The enlarged lump will be removed. The surgeon may need to reposition the alignment of the bones of the big toe. This may require more than one incision. The bone itself may need to be cut. If the joint surfaces have been damaged, the surgeon may hold the bones together with screws, wires, or metal plates. In severe cases, the entire joint may need to be removed and a joint replacement inserted. If pins were used to hold the bones in place during recovery, they will be removed a few weeks later. In some mild cases, it may be sufficient to repair the tendons and ligaments that are pulling the big toe out of alignment. When finished, the surgeon will close the incision with sutures and may apply steri-strips as an added reinforcement. A compression dressing will be wrapped around the surgical wound. This helps to keep the foot in alignment as well as help reduce postoperative swelling.

Diagnosis / Preparation before Bunionectomy Surgery:

Intense pain at the first joint of the big toe is what most commonly brings the patient to the doctor. Loss of toe mobility may also have occurred. Severe deformity of the foot may also make it almost impossible for the patient to fit the affected foot into a shoe. The condition may be in either foot or in both. In addition, there may be a crackling sound in the joint when it moves. Diagnosis of a bunion is based on a physical examination, a detailed history of the patient’s symptoms and their development over time, and x rays to determine the degree of deformity. Other foot disorders such as gout must be ruled out. The patient history should include factors that increase the pain, the patient’s level of physical activity, occupation, amount of time spent on his or her feet, the type of shoe most frequently worn, other health conditions such as diabetes that can affect the body’s ability to heal, a thorough medication history, including home remedies, and any allergies to food, medications, or environmental aspects. The physical exam should include an assessment while standing and walking to judge the degree to which stability and gait have been affected, as well as an assessment while seated or lying down to measure range of motion and anatomical integrity. An examination of the foot itself will check for the presence of unusual calluses, which indicate abnormal patterns of friction. Circulation in the affected foot will be noted by checking the skin color and temperature. A neurological assessment will also be conducted.

Conservative measures are usually the first line of treatment and target dealing with the acute phase of the condition, as well as attempting to stop the progression of the condition to a more serious form. Measures may include:

  • rest and elevation of the affected foot
  • eliminating any additional pressure on the tender area, perhaps by using soft slippers instead of shoes
  • soaking the foot in warm water to improve blood flow
  • use of anti-inflammatory oral medication
  • an injection of a steroidal medication into the area surrounding the joint
  • systematic use of an orthotic, either an over-the-counter product or one specifically molded to the foot
  • the use of a cushioned padding against the joint when wearing a shoe

If these measures prove unsuccessful, or if the condition has worsened to significant foot deformity and altered gait, then a bunionectomy is considered. The doctor may use the term hallux valgus when referring to the bunion. Hallux means big toe and valgus means bent outward. In discussing the surgical option, it is important for the patient to clearly understand the degree of improvement that is realistic following surgery.

X rays to determine the exact angle of displacement of the big toe and potential involvement of the second toe will be taken. The angles of the two toes in relation to each other will be noted to determine the severity of the condition. Studies in both a standing as well as a seated or lying down position will be considered. These will guide the surgeon at the time of the surgery as well. In addition, blood tests, an EKG, and a chest x-ray will most likely be ordered to be sure that no other medical condition has gone undiagnosed that could affect the success of the surgery and the patient’s recovery.

Aftercare Bunionectomy Surgery:

Recovery from a bunionectomy takes place both at the surgical center as well as in the patient’s home. Immediate post-surgical care is provided in the surgical recovery area. The patient’s foot will be monitored for bleeding and excessive swelling; some swelling is considered normal. The patient will need to stay for a few hours in the recovery area before being discharged. This allows time for the anesthesia to wear off. The patient will be monitored for nausea and vomiting, potential aftereffects of the anesthesia, and will be given something light to eat, such as crackers and juice or ginger ale, to see how the food is tolerated. Hospital policy usually requires that the patient have someone drive them home, as there is a safety concern after having undergone anesthesia. In addition, the patient will most likely be on pain medication that could cause drowsiness and impaired thinking.

It is important to contact the surgeon if any of the following occur after discharge from the surgical center:

  • fever
  • chills
  • constant or increased pain at the surgical site
  • redness and a warmth to the touch in the area around the dressing
  • swelling in the calf above the operated foot
  • the dressing has become wet and falls off
  • the dressing is bloody

While the patient can expect to return to normal activities within six to eight weeks after the surgery, the foot is at increased risk for swelling for several months. When the patient can expect to bear weight on the operated foot will depend on the extent of the surgery. The milder the deformity, the less tissue is removed and the sooner the return to normal activity level. During the sixto-eight-week recovery period, a special shoe, boot, or cast may be worn to accommodate the surgical bandage and to help provide stability to the foot.

Expected result of Bunionectomy Surgery:

The expected result will depend on the degree of deformity that has occurred prior to surgery, the patient’s medical condition and age, and the adherence to the recovery regimen prescribed. Some degree of swelling in the foot is normal for up to six months after the surgery. Once wound healing has taken place, the surgeon may recommend exercises or physical therapy to improve foot strength and range of motion. It is important to be realistic about the possible results before consenting to the surgery. Since over-pronation of the foot is not corrected with the surgery, orthotics to help keep the foot/feet in alignment are usually prescribed.

Success rate for Bunionectomy Surgery:

According to the American Orthopaedic Foot & Ankle Society, less than 10% of patients undergoing bunionectomy experience complications, and 90% of patients feel the surgery was successful.

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Total Hip Replacement

Definition of Hip Replacement:

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. Such joint replacement orthopaedic surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage as part of hip fracture treatment. A total hip replacement (total hip arthroplasty) consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is currently the most successful and reliable orthopaedic operationwith 97% of patients reporting improved outcome.

Who is a candidate for Total Hip Replacement?

Total hip replacements are performed most commonly because of progressively worsening severe arthritis in the hip joint. The most common type of arthritis leading to total hip replacement is degenerative arthritis (osteoarthritis) of the hip joint. This type of arthritis is generally seen with aging, congenital abnormality of the hip joint, or prior trauma to the hip joint. Other conditions leading to total hip replacement include bony fractures of the hip joint, rheumatoid arthritis, and death (aseptic necrosis) of the hip bone. Hip bone necrosis can be caused by fracture of the hip, drugs (such as prednisone and prednisolone), alcoholism, and diseases (such as systemic lupus erythematosus).

The progressively intense chronic pain together with impairment of daily function including walking, climbing stairs, and even arising from a sitting position, eventually become reasons to consider a total hip replacement. Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of anti-inflammatory and/or pain medications. A total hip joint replacement is an elective procedure, which means that it is an option selected among other alternatives. It is a decision which is made with an understanding of the potential risks and benefits. A thorough understanding of both the procedure and anticipated outcome is an important part of the decision-making process.

What are preparation needed for the Surgery?

Total hip joint replacement can involve blood loss. Patients planning to undergo total hip replacement often will donate their own (autologous) blood to be banked for transfusion during the surgery. Should blood transfusion be required, the patient will have the advantage of having his or her own blood available, thus minimizing the risks related to blood transfusions. The preoperative evaluation generally includes a review of all medications being taken by the patient. Anti-inflammatory medications, including aspirin, are often discontinued one week prior to surgery because of the effect of these medications on platelet function and blood clotting. They may be reinstituted after surgery. Other preoperative evaluations include complete blood counts, electrolytes (potassium, sodium, chloride, bicarbonate), blood tests for kidney and liver functions, urinalysis, chest X-ray, EKG, and a physical examination. Our physician will determine which of these tests are required, based on your age and medical conditions. Any indications of infection, severe heart or lung disease, or active metabolic disturbances such as uncontrolled diabetes may postpone or defer total hip joint surgery.

What is involved in the rehabilitation process after total hip joint replacement?

After total hip joint replacement surgery, patients often start physical therapy immediately. On the first day after surgery, it is common to begin some minor physical therapy while sitting in a chair. Eventually, rehabilitation incorporates stepping, walking, and climbing. Initially, supportive devices such as a walker or crutches are used. Pain is monitored while exercise takes place. Some degree of discomfort is normal. It is often very gratifying for the patient to notice, even early on, substantial relief from the preoperative pain for which the total hip replacement was performed.

Physical therapy is extremely important in the overall outcome of any joint replacement surgery. The goals of physical therapy are to prevent contractures, improve patient education, and strengthen muscles around the hip joint through controlled exercises. Contractures result from scarring of the tissues around the joint. Contractures do not permit full range of motion and therefore impede mobility of the replaced joint. Patients are instructed not to strain the hip joint with heavy lifting or other unusual activities at home. Specific techniques of body posturing, sitting, and using an elevated toilet seat can be extremely helpful. Patients are instructed not to cross the operated lower extremity across the midline of the body (not crossing the leg over the other leg) because of the risk of dislocating the replaced joint. They are discouraged from bending at the waist and are instructed to use a pillow between the legs when lying on the nonoperated side in order to prevent the operated lower extremity from crossing over the midline. Patients are given home exercise programs to strengthen the muscles around the buttock and thigh. Most patients attend outpatient physical therapy for a period of time while incorporating home exercises regularly into their daily living.

Occupational therapists are also part of the rehabilitation process. These therapists review precautions with the patients related to everyday activities. They also educate the patients about the adaptive equipment that is available and the proper ways to do their “ADLs” or activities of daily living.

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Shoulder Bankart Repair Surgery

What is a Bankart Repair?

The aim of a Bankart repair operation is to restore stability to the shoulder. The operation is suitable for people who have detached the labrum and ligaments at the front of the shoulder as a result of an original violent dislocation. Usually the shoulder has remained unstable and may have dislocated on a number of further occasions.

After the operation you should not suffer further dislocations and have much reduced pain.

bankart_repair1

What does Bankart Repair involve?

Bankart Repair surgery is performed under general anaesthetic and takes around an hour and a half.  Usually the nerves to the whole arm are also numbed with local anaesthetic which lasts for sixteen to twenty-four hours. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth. This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards.

The operation is carried out as a conventional open operation through an incision at the front of the shoulder, or telescopically through a number of small incisions around the shoulder.  The aim is to restore the labrum and ligaments to their original position on the edge of the socket and encouraged to heal there. The first step in the operation is to mobilise and re-position the labrum and ligaments and to create an environment in which healing can occur. Little harpoons or anchors are then inserted into the bone on the edge of the socket, which gain a good grip. Stitches on these anchors are then used to suture the labrum and ligaments back into place. The anchors and sutures then hold everything in the right place while natural healing occurs.

The incisions are closed with stitches and waterproof dressings are applied.

When will I recover?

The operation requires a one night stay in hospital and your stitches will come out at one to two weeks after the surgery. Your arm is placed into a special shoulder-immobilising sling and exercises and physiotherapy start on the day of surgery.  Your physiotherapist will teach you all you need to know for the first couple of weeks before your discharge from hospital.

As a general guideline your sling will be retained for a period of four weeks during which time you will be quite one-handed. At four weeks the sling generally goes and increased exercises and movement are encouraged. Most people can return to driving a car at around six weeks and will have regained good ordinary use of the shoulder by eight to ten weeks.

Physiotherapy and exercises continue for four to six months and sports that do not impose too much stress on the shoulder, such as running, can start again at around eight to ten weeks. Activities such as golf and swimming can be resumed at around three months. Contact sports, such rugby and football and other high demand sports such as surfing and climbing can be reintroduced at six months.

In addition to regular treatment with the physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately all rare.

What risks should I know about?

Bankart Repair is a very successful operation but there are some potential complications you should be aware of even though they are uncommon.

  • Infection can occur although it is rare and infection rates are at 1%.
  • Shoulder dislocation can occur although this risk is minimised by having the operation done very carefully and adhering to the physiotherapy regime.

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Knee Injury – Meniscal Cartilage Tear

The meniscus are cartilage tissue which act like shock absorbers in the knee joint. A meniscus can be torn, commonly after a forceful twisting injury to the knee. Symptoms include knee pain, swelling, and locking of the knee. Some heal by themselves, but an operation to fix, trim or remove the torn meniscus may be advised.

The diagrams below illustrate the knee joint.

Cross-section diagram of a normal joint

The meniscus Each knee joint contains a medial and lateral meniscus (inner and outer meniscus). These are thick rubber-like pads of cartilage tissue. They are C-shaped and become thinner towards the middle of the joint. The menisci cartilages sit on top of, and are in addition to, the usual thin layer of cartilage which covers the top of the tibia. The menisci act like shock absorbers to absorb the impact of the upper leg on the lower leg and also help to improve smooth movement and stability of the knee. When people talk about a cartilage injury to a knee, they usually mean an injury to one of the menisci.

The rest of this leaflet is just about injury to the meniscus.

The knee is commonly injured in sports, especially rugby, football and skiing. You may tear a meniscus by a forceful knee movement whilst you are weight bearing on the same leg. The classical injury is for a footballer to rotate (twist) the knee whilst the foot is still on the ground – for example, whilst dribbling round a defender. Another example is a tennis player who twists to hit a ball hard, but with the foot remaining in the same position. The meniscus may tear fully or partially. How serious the injury is depends on how much is torn and the exact site of the tear.

Meniscal tears may also occur without a sudden severe injury. In some cases a tear develops due to repeated small injuries to the cartilage or to degeneration (wear and tear) of the meniscal cartilage in older people. In severe injuries, other parts of the knee may also be damaged in addition to a meniscal tear. For example, you may also sprain or tear a ligament.

Meniscal cartilage does not heal very well once it is torn. This is mainly because it does not have a good blood supply. The outer edge of each meniscus has some blood vessels, but the area in the centre has no direct blood supply. This means that although some small outer tears may heal in time, larger tears, or a tear in the middle, tend not to heal.

The symptoms of a meniscal injury depend on the type and position of the meniscal tear. Many people have meniscal tears without any knee symptoms, especially if they are due to wear and tear.

  • Knee Pain. The pain is often worse when you straighten the leg. If the pain is mild, you may be able to continue to walk. You may have severe pain if a torn fragment of meniscus catches between the tibia and femur. Sometimes, an injury that you had in the past causes pain months or years later, particularly if you injure the knee again.
  • Swelling. The knee often swells within a day or two of the injury. Many people notice that their knee is slightly swollen for several months if the tear is due to degeneration.
  • Knee function. You may be unable to straighten the knee fully. In severe cases you may not be able to walk without a lot of pain. The knee may lock from time to time if the torn fragment interferes with normal knee movement. Some people notice a clicking or catching feeling when they walk. (A locked knee means that it gets stuck when you bend it and you can’t straighten it without moving the leg with your hands.)

Note: a “clicking joint” (especially without pain) does not usually mean you have a meniscal tear.

For some people, the symptoms of meniscal injury go away on their own after a few weeks. However, for most people the symptoms persist long-term, or flare up from time to time, until the tear is treated.

  • The story and symptoms often suggest a meniscal tear. A doctor will examine the knee. Certain features of the examination may point towards a meniscal tear.
  • Your doctor may sometimes advise an X-ray of the knee. An X-ray will not show cartilage tissue, but it can check for any bone damage which might have also occurred with the injury.
  • The diagnosis can be confirmed by an MRI scan of the knee (see separate leaflet called ‘MRI Scan’ for more detail) or by arthroscopy (keyhole surgery – see below).

When you first injure your knee the initial treatment should follow the PRICE formula: protect, rest, ice, compression (with a bandage) and elevation. This, combined with painkillers, helps to settle the initial pain and swelling. Further treatment may then depend on the size of the tear, the severity of symptoms, how any persisting symptoms are affecting your life, your age, and your general health.

Non-operative treatment

Small tears may heal by themselves in time, usually over about six weeks. Some tears which do not heal do not cause long-term symptoms once the initial pain and swelling subside, or cause only intermittent or mild symptoms. In these cases, surgery may not be needed. You may be advised to have physiotherapy to strengthen the supporting structures of the knee, such as the quadriceps and hamstring muscles.

Surgery

If the tear causes persistent troublesome symptoms then an operation may be advised. Most operations are done by arthroscopy (see below). The types of operations which may be considered include the following:

  • The torn meniscus may be able to be repaired and stitched back into place. However, in many cases this is not possible.
  • In some cases where repair is not possible, a small portion of the meniscus may be trimmed or cut out to even up the surface.
  • Sometimes, the entire meniscus is removed.
  • Meniscal transplants have recently been introduced. The missing meniscal cartilage is replaced with donor tissue, which is screened and sterilised much in the same way as for other donor tissues such as for kidney transplants. These are more commonly performed in America than in the UK.
  • There is a new operation in which collagen meniscal implants are inserted. The implants are made from a natural substance and allow your cells to grow into it so that the missing meniscal tissue regrows. This is not yet available at all hospitals.

Arthroscopy is a procedure to look inside a joint by using an arthroscope. An arthroscope is like a thin telescope with a light source. It is used to light up and magnify the structures inside a joint. Two or three small (less than 1 cm) cuts are made at the front of the knee. The knee joint is filled up with fluid and the arthroscope is introduced into the knee. Probes and specially designed tiny tools and instruments can then be introduced into the knee through the other small cuts. These instruments are used to cut, trim, biopsy, grab, etc, inside the joint. Arthroscopy can be used to diagnose and also to treat meniscal tears. See the separate leaflet called ‘Arthroscopy and Arthroscopic Surgery’ for more details.

Following surgery, you will have physiotherapy to keep the knee joint active (which encourages healing) and to strengthen up the surrounding muscles to give support and strength to the knee.

Get your knee checked by professional knee specialist. Call +65 6471 2744 or Email to: info@boneclinic.com.sg

Arthroscopic Rotator Cuff Repair

Rotator cuff repair leads to good and excellent outcomes in most patients. However, structural failure of the repair occurs in a substantial number of cases and can lead to an unsatisfactory result. Several factors have been implicated, including patient related factors (eg. patient age, tear size) and extrinsic factors (eg, surgeon surgical volume, biomechanical failure). Structural failure requires a detailed patient evaluation to elucidate the cause of persistent symptoms. Function can be maintained despite a recurrent tear; therefore, a recurrent tear alone is not an indication for revision repair. The major indication for revision rotator cuff repair is the persistence clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. Although the outcome is poorer than after primary repair, satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques.

About rotator cuff injuries

Shoulder pain affects around one in five people in the UK and a rotator cuff injury is the most common cause.

Your shoulder joint is a ball and socket joint, formed by the ball-shaped end of your upper arm bone (humerus) and a shallow socket on the edge of your shoulder blade (scapula).

Your rotator cuff is made up of a group of four muscles (the subscapularis, supraspinatus, infraspinatus and teres minor) and their tendons. It plays a crucial role in keeping your shoulder joint stable. Tendons wrap around your shoulder joint, forming a cuff around the ball of your humerus.

On top of your shoulder joint is a bone called the acromion. In the gap between your shoulder joint and acromion is a space that some of your rotator cuff tendons run through. In this space is a fluid-filled pad called the subacromial bursa, which cushions your tendons.

Rotator cuff injury is a general term to describe inflammation (soreness and swelling) or damage to one or more of the muscles or tendons that make up your rotator cuff.

Types of rotator cuff injury

There are a number of conditions that can affect your rotator cuff. The most common are inflammation of your rotator cuff tendons and tearing of your muscles or tendons.

Rotator cuff tendonitis
If the tendons of your rotator cuff become inflamed, this is known as tendonitis. The tendons can become pinched against one of the other structures that make up your shoulder joint. This can be both the cause and the result of tendonitis. Tendonitis most often affects the tendons that run underneath your acromion. When a tendon becomes trapped or squeezed, it’s known as impingement syndrome.

Calcium is sometimes deposited in your rotator cuff tendons if they are inflamed for a long period of time. The tendons become ‘calcified’ and this is called calcific tendonitis.

Your subacromial bursa can also become inflamed – this is called bursitis.

Rotator cuff tear
This is when one or more of the muscles and tendons that make up your rotator cuff become completely or partially torn. It may be a result of trauma, such as a fall, or due to tiny tears in the tendon caused by use and wear over time. It may also be caused by impingement syndrome.

Symptoms of rotator cuff injuries

Symptoms of a rotator cuff injury include:

  • pain and tenderness in your shoulder (this may extend down your arm too), particularly when you raise your arm out to the side, reach behind you or lift or pull a heavy weight
  • pain at night, particularly when you sleep on the affected side
  • a feeling of weakness in your shoulder
  • being unable to move your shoulder as you usually would

Depending on the type of injury you have, the pain may come on gradually (common if you have tendonitis) or you may have sudden twinges of pain (common if you have a tear).

If you have any of these symptoms, contact your GP or a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility).

Causes of rotator cuff injuries

Rotator cuff injuries may occur for a specific reason, for example:

  • lifting or pulling an object that is too heavy for you or lifting it in the wrong way can cause you to strain or tear a rotator cuff tendon or muscle
  • landing on an outstretched hand to break a fall can tear or strain a rotator cuff muscle or tendon

There are some things that increase the likelihood of you getting a rotator cuff injury, including the following.

  • Age – if you’re over 40, you’re at an increased risk of rotator cuff injuries because your tendons start to wear down with age and become more prone to injury.
  • Certain sports, activities and jobs – you’re more likely to have a rotator cuff injury if you do something that involves repetitive overhead motions with your arms. Examples include swimming, weight lifting, playing racquet sports and occupations such as painting, decorating or window cleaning.
  • Musculoskeletal diseases, such as rheumatoid arthritis, can cause your rotator cuff muscles to become weaker making an injury more likely.

Diagnosis of rotator cuff injuries

Your GP or physiotherapist will ask about your symptoms and examine you. He or she may ask about your medical history and any activities that may be causing your condition.

You may be referred for further tests such as an MRI scan, ultrasound scan or X-ray so that your doctor can look at your shoulder in more detail.

Treatment of rotator cuff injuries

Treatment of a rotator cuff injury depends on the type of injury you have and how severe it is.

Self-help

The following measures may help.

  • Rest your shoulder initially, avoiding any movements that cause you pain. Start to do gentle movements as soon as possible to prevent any stiffness in your shoulder.
  • Apply an ice pack or ice wrapped in a towel to your shoulder to reduce swelling and bruising. Don’t apply ice directly to your skin as it can damage your skin. Don’t use ice if you have a skin disorder that makes your skin sensitive. Also, don’t put ice on your left shoulder if you have any known heart problems.
  • Take an over-the-counter anti-inflammatory medicine, such as ibuprofen, to reduce pain and inflammation. Always read the patient information leaflet that comes with your medicine and if you have any questions ask your pharmacist for advice.

Non-surgical treatments

Stretches and strengthening exercises can help build up strength and flexibility in your shoulder. It’s important to get advice from a medical professional, such as a physiotherapist, on which exercises and stretches you should do and how to do them correctly. The exercises will be tailored to your specific injury.

If you have rotator cuff tendonitis, your doctor may recommend an injection of a medicine called a corticosteroid. This is usually only done when other treatments haven’t helped.

You may be able to have extracorporeal shock wave lithotripsy (ESWT) if you have calcific tendonitis. ESWT uses vibrations caused by sound waves to break up the calcium deposits.

Surgery

Rotator cuff injuries can usually be successfully treated without the need for surgery. However, sometimes you may need to have an operation, for example to repair a tear in your rotator cuff or to remove calcium deposits.

Rotator cuff repair surgery is done under general anaesthesia. This means you will be asleep during the operation.

In general, there are two different procedures that may be used to repair a rotator cuff injury: open surgery and shoulder arthroscopy. The type of surgery you have will depend on where your injury is, and if it’s a tear, how big it is and it’s shape.

Open surgery means that your surgeon makes a cut in the skin over your shoulder and repairs your injury through the cut. In an athroscopy, a narrow, flexible, tube-like telescopic camera called an arthroscope is inserted through a small incision in your shoulder and this is used to repair your injury. It’s commonly known as keyhole surgery.

If you have a rotator cuff tear, the two sides of your muscle or tendon will be stitched back together and, if necessary, attached back on to your humerus. Your surgeon may also carry out a procedure called debridement. This means that he or she will remove any damaged tissue, so that the remaining healthy tissue can heal.

If you have impingement syndrome, your surgeon will remove excess bone from the front part of your acromion. This will create more room for your rotator cuff and prevent pinching of the rotator cuff, when you move your arm above your head. This procedure is called subacromial decompression.

Your surgeon will be able to give you advice on which type of surgery you need for your condition.

To schedule for an appointment, call us at +65 6471 2744 or SMS to +65 9235 7641 (24 Hours)

Arthroscopy Acromioplasty

Acromioplasty, also known as subscromial decompression, is an arthroscopic surgical procedure of the acromion, top of the shoulder blade or the part of the shoulder blade extending over the shoulder joint. In the acromioplasty surgery, a small piece of the surface of the acromion that is causing damage to the tendon tissue is removed.

Atrhoscopic acromioplasty is used to treat severe cases of impingement syndrome, a condition resulting from an injury to the rotator cuff muscles and often seen in aging adults. In the impingement syndrome, the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder. Motions such as reaching up behind the back and reaching up overhead to put on a coat or blouse, for example, may cause pain.

In a shoulder arthroscopic acromioplasty, a number of small incisions are made around the shoulder. The surgeon uses an athroscope and video camera to confirm the subacromial impingement. In order to release the pressue on the trapped tendon or bursa and to allow the shoulder joint to move smoothly, the surgeon then removes or shaves a section of bone from the underside of the acromion. If any other injuries such as a rotator cuff tear or slap tear are identifies, then those are also treated at the time of this surgery (e.g. rotator cuff repair).

A dramatic relief in symptoms of impingement syndrome is usually seen soon after the surgery. In some cases, it may take a couple of months for the symptoms to resolve. For complete shoulder recovery and shoulder rehab, the patient must follow through the complete course of physiotherapy.

Microdiscectomy or microdecompression Spine Surgery

In a microdiscectomy or microdecompression spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal.

A microdiscectomy is typically performed for a herniated lumbar disc and is actually more effective for treating leg pain (also known as radiculopathy) than lower back pain.

Impingement on the nerve root (compression) can cause substantial leg pain. While it may take weeks or months for the nerve root to fully heal and any numbness or weakness to get better, patients normally feel relief from leg pain almost immediately after a microdiscectomy spine surgery.

Microdiscectomy

Microdiscectomy

In general, if a patient’s leg pain due to a disc herniation is going to get better, it will do so in about six to twelve weeks. As long as the pain is tolerable and the patient can function adequately, it is usually advisable to postpone back surgery for a short period of time to see if the pain will resolve with non-surgical treatment alone.

If the leg pain does not get better with nonsurgical treatments, then a microdiscectomy surgery is a reasonable option to relieve pressure on the nerve root and speed the healing. Immediate spine surgery is only necessary in cases of bowel/bladder incontinence (cauda equina syndrome) or progressive neurological deficits. It may also be reasonable to consider back surgery acutely if the leg pain is severe.

A microdiscectomy is typically recommended for patients who have:

  • Experienced leg pain for at least six weeks
  • Not found sufficient pain relief with conservative treatment (such as oral steroids, NSAID’s, and physical therapy).

However, after three to six months, the results of the spine surgery are not quite as favorable, so it is not generally advisable to postpone microdiscectomy surgery for a prolonged period of time (more than three to six months).

Microdiscectomy Success Rates

The success rate for microdiscectomy spine surgery is approximately 90% to 95%, although 5% to 10% of patients will develop a recurrent disc herniation at some point in the future.

A recurrent disc herniation may occur directly after back surgery or many years later, although they are most common in the first three months after surgery. If the disc does herniate again, generally a revision microdiscectomy will be just as successful as the first operation. However, after a recurrence, the patient is at higher risk of further recurrences (15% to 20% chance).

 For appointment or enquiry, please call +65 6471 2744 or Email: info@boneclinic.com.sg

Open Reduction Internal Fixation

An open reduction internal fixation (ORIF) refers to a surgical procedure to fix a severe bone fracture, or break. “Open reduction” means surgery is needed to realign the bone fracture into the normal position. “Internal fixation” refers to the steel rods, screws, or plates used to keep the bone fracture stable in order to heal the right way and to help prevent infection.

Open reduction internal fixation can also refer to the surgical repair of a joint, such as a hip or knee replacement.

Open Reduction Internal Fixation (ORIF)

Open Reduction Internal Fixation (ORIF)

The surgical procedure is performed by a doctor who specializes in orthopedics, which is a branch of medicine concerning the musculoskeletal structure of the body. Under general anesthesia, an incision is made at the site of the break or injury, and the fracture is carefully re-aligned or the joint replaced. The hardware is installed, and the incision is closed with staples or stitches. The steel rods, screws, or plates can be permanent, or temporary and removed when healing takes place.

Once the open reduction internal fixation is performed, a cast is usually applied. In the case of an ankle fracture, for instance, the first cast is a non-weight bearing cast, and crutches can be used to help keep weight off the healing bones. Later, when the healing has progressed, this cast will be replaced with one that can bear weight. Eventually, after a period of some weeks, the cast will be removed entirely.

Recovery from a bone fracture after an open reduction internal fixation can be quite painful, and pain management becomes a concern. Commonly, acetaminophen with codeine is prescribed, as research has shown ibuprofen or other non-steroid anti-inflammatory drugs (NSAIDs) may slow down or inhibit the rate of healing. It is important to take the drugs as prescribed to help manage the pain cycle.

Physical therapy is also an important part of the recovery process after an open reductioninternal fixation. Since the part of the body that has been injured is usually held still or immobilized for a long period of time, the muscles, tendons, and ligaments can become weak. Physical therapy helps to restore the strength, range of motion, and endurance of the affected area. It can also help with pain management. Physical therapy can consist of exercises, hot or cold packs, ultrasound, and nerve stimulation, or a combination of treatments.

Complications of ORIF can include infection, swelling, and movement of the installed hardware. The recovery process can take months, because bones grow slowly. Other factors that can affect recovery are the location and severity of the break, the age of the person, and the type of bone broken.

For inquiry or to schedule for an appointment, please call +65 6471 2744 or Email to: info@boneclinic.com.sg