Stephen Franzino, MD
Stitching Up Shoulders
Advances in surgery mean less pain for patients with rotator-cuff tears
By Laura Landro
Whether you've been relatively inactive or fairly athletic, age is the enemy of one of the most important sets of muscles in the body: the group of four known as the rotator cuff that surround the ball of the shoulder joint.
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About 54% of adults older than 60 have a completely or partially torn rotator cuff, compared with just 4% of those between 40 and 60. But tears are most frequently caused by degeneration of the tendon due to age, rather than injury from sports or trauma. Studies show that tears can be managed without surgery in half of patients, mainly through physical therapy, pain medications, and avoiding activities that cause pain.
But one's strength tends not to improve without surgery to reattach tendons to the ball of the shoulder joint. So, the question for many patients who want to have full use of their shoulder is less whether to have surgery than when and how. In a recent review in the Annals of Internal Medicine, researchers noted that patients and doctors struggle with when to stop nonoperative treatment in favor of surgery, but that repairing a tear earlier rather than later may result in better patient outcomes, earlier return to work and lower costs.
The Price of Delay
"Many patients who have a tear figure they can take six months and live with it, but left alone the tear will progress and you can get to the point where it is irreparable," says David Altchek, a surgeon at New York's Hospital for Special Surgery. Dr. Altchek says repairing torn rotator cuffs earlier with a new technique that uses a double row of sutures to fix tendons to bone, rather than a single row, is improving healing rates in his studies.
While some tears may never worsen or need surgery, says Ken Yamaguchi, an orthopedic surgeon at the Washington University School of Medicine in St. Louis, "the older somebody is when they get a repair, the less likely it is for the repair to heal."
The good news is that surgery results in reduced pain and improved function in 80% to 95% of patients. And open surgery with big incisions is being replaced by new, less-invasive techniques known as mini-open and arthroscopic repair, which involve less pain and blood loss, shorter hospital stays and a generally easier rehabilitation period, according to the American Academy of Orthopedic Surgeons.
Ask Your Doctor
The academy, which recently updated its guidelines for rotator-cuff repair, doesn't recommend for or against a specific technique for surgery. Dr. Yamaguchi, vice chairman of a working group that developed the guidelines, says there isn't enough high-quality evidence to recommend any specific technique, a conclusion also reached by the Annals of Internal Medicine researchers. He advises that patients confer with surgeons about their options.
The most common procedure is mini-open repair, which uses a smaller incision than traditional open repair. To remove any bone spurs, a surgeon uses arthroscopic, pencil-size instruments to magnify and illuminate the structures inside the joint. Once that is completed, the surgeon repairs the rotator cuff through the small incision. But some surgeons are now performing the entire operation using the small camera-guided instruments, in what's known as an all-arthroscopic procedure.
There are possible complications with all surgical procedures, of course. An Academy of Orthopedic Surgeons review of about 40 published studies showed that as many as 2% of patients have nerve injuries, while 1% may get an infection at the surgical site. About 6% may have a tendon re-tear, though that doesn't mean a repeat surgery will be needed or that pain and poor function will result.
And as with any surgery, postoperative recovery depends largely on how well patients adhere to their physical-therapy regimens. Initially, that means being extra careful: A repair needs to be protected until the tendon heals strongly to the bone. Patients may be advised to use a sling for the first four to six weeks after surgery and to limit active use of the arm. Therapy usually starts with passive-motion exercises, then range-of-motion exercises continue during the next six to 12 weeks. It can take as long as six months after surgery to return to a functional range of motion and adequate strength.
Eric Taylor, a 62-year-old documentary filmmaker who plays sports like tennis with his right arm, says he was surprised when he began developing pain in his left shoulder. He tried to ease it by doing yoga, but after six months with no relief, he scheduled an MRI. It confirmed that a bone spur digging into a tendon had caused a tear in the left rotator cuff.
He scheduled surgery with Dr. Altchek at the Hospital for Special Surgery last June, but wishes he had acted sooner. Because he waited so long, he says, his surgery required three incisions instead of one. He was surprised at how much work was involved in rehabilitation but has been diligent about his recovery and physical therapy.
Back to playing tennis now, Mr. Taylor says, "When it comes to our own bodies, as baby boomers we've always been active, and we are going to stay active any way we can."
Ms. Landro is an assistant managing editor for The Wall Street Journal and writes the paper's Informed Patient column. She can be reached at email@example.com.
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