What can be done for a failed rotator cuff repair?

Rotator cuff repairs typically produce very good results. Unfortunately, as with any operation, some patients do not have a successful outcome.  Occasionally patients will have an unsuccessful repair that does not heal and continue to have pain after surgery. Sometimes the pain is even worse than before! What can be done for people who have had a failed rotator cuff repair?

These patients are often the most rewarding to treat, and as a shoulder specialist I see many of these individuals for second opinions. Over the past week I have treated three patients with failed rotator cuff repairs who each had very different problems. Together they illustrate the point that each patient is unique, and in order to provide good care we must tailor our treatment to the individual’s problem.

Patient #1: 70 year old man who had a large rotator cuff tear that had been previously repaired and re-tore. He was now in severe pain and could not raise the arm in the air.  His MRI showed a massive rotator cuff tear that could not be fixed. We performed a reverse shoulder replacement, which is a specialized type of shoulder replacement that can be used to treat massive rotator cuff tears in older patients.

 

A reverse shoulder replacement

Patient #2: This active woman had a prior rotator cuff repair one year ago. Unfortunately she continued to have pain and stiffness. We performed an arthroscopic surgery to clean out scar tissue. We found that she had a re-tear of her rotator cuff that we were able to re-fix arthroscopically.

 

Re-tear of rotator cuff. 

Successful revision repair

Patient #3: This young woman had a massive rotator cuff tear. She had a prior arthroscopic surgery by a highly skilled surgeon who found that her tear was not fixable.  She was referred to me for a lattissimus muscle transfer procedures. During this operation a muscle is moved from the back and attached to the shoulder to take the place of the torn rotator cuff. This operation is appropriate for young patient with massive tears that can't be fixed.

These three patients all had a failed rotator cuff repair, but their problems were very different. In order to provide the best possible care we needed to understand their age, activity level, and type of tear.

If you would like a second opinion for a failed rotator cuff repair, please contact

Dr. Carofino at carofinob@atlanticortho.com.

Youth baseball safety guidelines: prevent arm injury

We are all seeing more and more injuries among adolescent baseball players. There is widespread agreement among orthopaedic surgeons that this is caused by kids playing too much baseball without enough rest. Here is a summary of guidelines that have been put forth by baseball medicine experts. Parents and coaches of youth players should familiarize themselves with these issues to help keep our baseball players healthy.

1.     Don’t play baseball year-round. Young players, especially pitchers, should have a period of rest of at least two months each year. During this time they should not be throwing, and instead should focus on other sports and building strength.  For more information onthis topic.

2.     Don’t play through pain. Players should be not throwing if they are having pain. If it hurts to throw, stop playing and rest for a few days and then resume throwing. If it still hurts to throw after a few days of rest seek medical evaluation.  Throwing in spite of pain places athletes at high risk for severe injury.

3.    Know the Pitch Count Guidelines. It is recommended that youth pitchers adhere to a “pitch count”, meaning they should not throw more than a certain number of pitches during a game. There are several good resources from USA baseball,  American Sports Medicine Institute,   Major League Baseball. Coaches and parents should know the pitch count for their athletes and the “days off” recommended between pitching appearances.

4.     Beware of playing on multiple teams during a single season. Many adolescents are playing on multiple teams during a single season. This may include a local recreational league, a travel team, and showcase tournaments. It can become dangerous if a child is pitching on more than one team, because there is often no communication between coaches about how may pitches the child has thrown, and how many days rest he has had. Parents need to be especially cautious in this situation, and help communicate between coaches.

5.     Catchers are at risk also.  After pitchers, catchers have the highest number of youth baseball arm injuries. This actually makes sense, think of how many throws a catcher makes each game. An athlete should probably not play both positions during the same season. If a pitcher is catching during his “days off” from pitching he is not allowing the arm to rest!

6.     Don’t go home and practice after the game. Parents may want to practice with their child after they pitched a game. This should be avoided. Wait until another day and let the arm rest.

7.     Teach proper pitching techniques. Research studies have shown that proper throwing mechanics decrease the risk of arm injury and also improve pitching performance. Here is an article I’ve written on proper throwing mechanics.  

8.     No curveballs until you can shave. This is a statement that Dr. Jim Andrews has put forward. He suggests that we should not teach or allow youth players to throw breaking pitches until after puberty when their bones have matured. Research has shown that a properly thrown curve ball does not place increased stress on the elbow, however many kids do not know how to throw these pitches correctly and can injure themselves with incorrect technique. Furthermore, if our goal is to develop pitchers then coaches should focus on pitch command, emphasizing the fastball and change up. There is no need to have adolescents throwing breaking pitches.

I hope these help ,

Brad Carofino MD. 

Teaching Kids to Pitch with Good Mechanics

Part I: How to properly pitch

Researchers at Kerlan Jobe Clinic in California studied the throwing mechanics of youth baseball pitchers between the ages of nine and eighteen. They were able to identify several characteristics of a proper throwing motion that decrease the likelihood of a pitcher suffering a shoulder or elbow injury. In addition to increasing safety these characteristics also increase the efficiency of the throwing motion, which should lead to better performance. Youth baseball coaches might incorporate this information in their teaching. Pictures are included at the end of the text, If you would like more information on this topic please message me.

1. Lead with the hips: During the early cocking phase of throwing, the pelvis should be leading towards home plate (a) instead the pitcher being upright (b). If the hip is leading towards the plate it sets the pitcher up to drive off with the back leg. This helps to generate power with the legs instead of just throwing with the arm.

2. Elevate the elbow: The elbow should reach its maximum height or elevation by the time the foot strikes the ground. (a) Throwing from a lower elbow position puts more strain on the elbow. (b)

3. The Hand on Top position: When the arm is cocked the hand should be on top of the ball (a), instead of under it (b) By having the hand on top it encourages elbow elevation, when the hand is underneath the elbow may drop down. Some coaches refer to the hand underneath position as a “pie throwing” position and teach pitchers to avoid that posture. Sometimes it can be difficult to teach young kids to throw form a hand on top position if their hands are too small to hold the ball from on top.

4. Front Shoulder Closed. When the foot strikes the ground the front shoulder should be closed and pointing towards home. This allows the pitcher to generate force by uncoiling the body. If the shoulder is open the pitcher has to throw with just the shoulder and elbow which puts more strain on them

Toddler’s Head Attached after “internal decapitation”......not really!

Toddler’s Head Attached after “internal decapitation”......not really!

Over the past few days I’ve had several people ask me if I heard about the “kid who’s head was attached after internal decapitation”. This story from Australia became a mainstream hit after it was presented on the news. However, what happened really isn’t that unusual, but it has become a media sensation because the hospital cleverly coined the phrase “internal decapitation” .

Here is what happened, a two year old was involved in a car accident. He sustained a cervical spine fracture (broke some bones in his neck). From what I have gathered no nerves were severed such as the spinal cord, and the blood vessels going to the brain were not severed either. This does really equal decapitation, in which case both the spinal cord and blood vessels are severed. So in reality, there is nothing about this case that amounts to “internal decapitation”.

The child had a cervical fracture that was treated with surgery and a halo device which is applied to the head temporarily to stabilize the neck. This is a wonderful success by some very capable surgeons. However, these injuries and surgeries occur on a daily basis, more often in adults.

I would say that this news story is more of a triumph of marketing rather than a medical breakthrough.

Thinking about a "resurfacing" shoulder replacement? Think twice!

Are you considering having a “resurfacing” shoulder replacement? Think twice!

I am often contacted by young patients with severe shoulder arthritis that are interested in learning about their shoulder replacement options. Many of these patients have been advised by other orthopaedic surgeons that they should consider a resurfacing shoulder replacement. This is a type of partial shoulder replacement that involves placing a metal cap over the worn-out bone on the ball of the shoulder. Some orthopaedic surgeons advocate this as being “minimally invasive” and of course that sounds great to patients. But here is the problem: Just because a procedure is “less invasive” does not mean that it works well. Unfortunately, that is the case with these resurfacing operations. Recent research studies have shown that these operations are much more likely to lead to a painful shoulder, and much more likely to need to be re-done. 

A recent study found that 10% of resurfacing procedures needed to be re-done within four years. That is a very high number, and a considerable disability for the patients that have to go through a second shoulder replacement in such a short time.

I encourage young patients with severe shoulder arthritis to consider the “Ream and Run” procedure. I believe this operation provides a much better long term result. 

Does Glucosamine Work?

Glucosamine and Chondroitin are common over the counter supplements that are marketed as a treatment for arthritis and joint pains. These can be purchased in pill form in nearly every pharmacy. They are also the active ingredients in the drink “Joint Juice”. These supplements are often marketed as being able to rebuild cartilage, and many patients purchase these supplements for that reason. In a sense, people are led to believe that these pills can turn back time and re-grow the cartilage that is worn away by arthritis. At least once per week a patient asks for my opinion on whether these supplements work. Unfortunately, there is not a simple yes or no answer.

So here we go…….

By way of background, arthritis is a disease where the cartilage is worn away.  Cartilage is essentially the buffer between the bones forming a joint. So, when the cartilage is gone the bones start to grind on each other. Arthritis is an incredibly common problem, which causes pain and stiffness for many people. Wouldn’t it be nice to be able to regrow that cartilage that is worn away?

Cartilage is composed of many things, but one of its main ingredients are glucosamine and chondroitin.  The question is, “Does eating glucosamine and chondroitin cause your body to rebuild cartilage?” Unfortunately, the answer to that is no! The body is more complicated than that. Sadly, we cannot regrow parts by simply eating the ingredients.  If life were that simple, we could all become muscular by eating lots of protein without exercising, or we could regrow dead heart muscle (caused by a heart attack) by eating the proteins found in heart. 

The news is not all bad for these supplements. Although they can’t turn back time, they may be able to ease your pain. Studies have shown that these medications do reduce pain caused by arthritis. Generally speaking they are about as effective as an anti-inflammatory medication such as Ibuprofen.  Unfortunately, they are much more expensive than Ibuprofen.

Here are my take home points:

1.     Glucosamine and Chondroitin may decrease pain caused by arthritis

2.     They are about as effective as Ibuprofen

3.     They cost a lot more

4.     Glucosamine and Chondroitin do not regrow cartilage that is worn away by arthritis