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Six Orthopedic Surgeons Around the World Discuss Challenging Cases

Some shoulder problems are so complex and so difficult, it's not even clear that surgery can help them. This may be the case with massive rotator cuff tears, shoulder instability, adhesive capsulitis (frozen shoulder), revision arthroscopic stabilization surgery, and other tendon injuries.

In this article, six orthopedic surgeons from around the world offer their opinions and expertise for these challenging conditions. Dr. Tonino from the United States, Dr. Gerber from Switzerland, Dr. Itoi from Japan, Dr. Porcellini from Italy, Dr. Sonnabend from New South Wales, and Dr. Walch from France offer insights, patient photos, and ideas for evaluation and treatment of these complex shoulder disorders.

Each patient must be examined and considered on an individual basis. Imaging studies such as MRI and arthroscopic exam help with the decision-making process, but the surgeon can't just rely on the results of those tests to find the optimal treatment for each problem. It's also important to consider why the patient has the problem in the first place.

For example, if there is a chronically dislocating shoulder, is it because a previous stabilization surgery failed? And if so, why did it fail? Were there surgical technical errors or other undetected injuries that affected the outcome? Was there some bony deformity, soft tissue imbalance, or other anatomical reason why this patient didn't get a positive result from the previous surgical treatment?

If surgery is considered (perhaps for a severely frozen shoulder or massive rotator cuff tear), then the surgeon must put on his or her detective hat in making a preoperative assessment. Careful evaluation is needed of pain levels, shoulder motion, strength, and function before deciding on type of repair.

The surgeons say there's no sense in attempting a repair of massive rotator cuff tears when the patient meets any of these three criteria:
  • Unable to hold the shoulder in a position of external rotation
  • Unable to lift the arm up overhead (especially if the shoulder dislocates during this movement)
  • Presence of a second injury involving damage to the deltoid muscle (an important mover and stabilizer of the joint)

    In some cases of irreparable rotator cuff injuries, surgery can be done to improve the patient's situation, even if a complete repair can't be done. The surgeon may decide to débride (carefully scrape) the frayed or torn edges of a tendon and/or muscle, perform a tendon transfer to help substitute function of an irreparable tendon, or try a partial tendon repair with a tendon transfer.

    When it comes to atraumatic shoulder instability (chronically dislocating joint without prior injury), the authors suggest looking at a couple of different things. First, where does the instability occur: is it when the patient is halfway through the motion or at the end of the shoulder joint's range-of-motion?

    This gives the surgeon some idea of how lax (loose) is the joint. Each time the shoulder pops out of the joint, there is microtrauma of the soft tissues that are trying to hold it in place. The capsule and ligaments get stretched a little bit more. Eventually, even just regular motion (something as simple as scratching the nose or touching the hair) can cause a dislocation.

    Second, some time should be taken to examine the position of the scapula (shoulder blade) and see how it moves. Most people don't realize it, but the coordinated motion of shoulder and scapula are really key to normal arm movement. If the natural rhythm and movement of the shoulder-scapular complex are off, the shoulder loses some of its stability.

    At the same time, the surgeon looks to see just what might be causing problems with scapular position or movement. Is there an imbalance between the different groups of shoulder muscles? Are the muscles balanced but weak? Is the head of the humerus (round top of the upper arm bone) centered inside the socket? If not, why not? Is it a problem of muscular imbalance or weakness? Are there anatomical abnormalities such as a shallow, rotated, or tilted socket? Any changes in these factors can increase the risk of instability.

    Once the surgeon has completed all the tests necessary to evaluate every aspect of the shoulder stability, then it's time to figure out what to do. Most experts agree that a good, solid effort at rehab should be attempted before considering surgery. As much as six months should be dedicated to this task.

    A physical therapist provides a supervised program with strengthening exercises, scapular retraining, and proprioceptive activities. Proprioception refers to the joint having a sense of its own position and being able to recognize where it is and respond to any slight changes in movement.

    If the patient fails to improve with conservative (nonoperative) care, then surgery may be the next step. Here again, the surgeon is faced with multiple choices. Which one is best for the patient? How to decide? The authors suggest working with the joint capsule first.

    The joint capsule is a group of tendon fibers wrapped in connective tissue surrounding the joint. When there have been repeated dislocations, this elastic structure gets stretched out. It actually starts to sag, forming an extra pocket of tissue in an anatomical area called the capsular redundancy.

    In the normal shoulder, a certain amount of extra capsular tissue (the capsular redundancy) is needed so that as you raise your arm overhead, the capsule can stretch enough to complete the full movement. But too much stretch leaves the joint more likely to become unstable and the risk of repeated dislocations increases. The surgeon removes some of the extra capsular tissue in a procedure called capsulorrhaphy.

    Next, the authors turned their attention to the patient with a failed arthroscopic shoulder stabilization procedure. This is the patient who has already had one operation to fix the shoulder and keep it from chronically (repeatedly) dislocating. The surgeon must puzzle out just what went wrong the first time.

    Did the suture anchors come loose? Were they placed in the right location? Did the patient reinjure the shoulder after the first surgery causing more ligament damage? Or was there some other ligament instability that went undetected the first time around? This is where MRIs and CT scans can be very helpful. The presence of bone loss or defects contributing to the problem can be seen more clearly with advanced imaging.

    Some patients may simply need another operation. This second procedure is called a revision surgery. The authors outline many situations where revision surgery is the treatment of choice. They also review when the surgeon should choose arthroscopic versus open surgery for the revision shoulder stabilization procedure.

    Some of the factors to consider include condition of the capsule, presence of bone defects, failed implants or other fixation devices, and direction of instability. Most patients should be advised to complete a pre-operative rehab program to regain as much joint motion, scapular function, muscle strength, and stability as possible before surgery.

    Each surgeon offers specific tips on how they position the patient during surgery, surgical techniques used for each procedure, and advise on how to treat other disorders that may be present at the time of the revision surgery. Photos taken during arthroscopic surgery showing different findings and suggestions for ways to prevent unintentional injury to the soft tissue structures are also presented.

    And finally, the authors address the issue of injuries to the subscapularis and long head of the biceps tendons. These two muscles/tendons are important to the movement and stability of the shoulder. The subscapularis is one of the four tendons that make up the shoulder rotator cuff, but the biceps is a separate part of the shoulder complex.

    Often tears of these two tendons occur at the same time. Disruption of one always affects the function of the other. Partial tears or complete ruptures occur as a result of trauma (e.g., falling on the outstretched arm) or from degeneration in older adults. CT scans and MRIs are needed to identify the full extent of the injury before making a treatment decision.

    And here's a case where the surgeon must take into consideration the patient's level of cooperation, compliance, and motivation. The type of surgery done depends on the willingness of the patient to follow the rehab program after surgery. Young, active patients may be good candidates for a tendon transfer when the subscapularis muscle is irreparable. Older, less active or noncompliant patients may be treated with débridement (the surgeon just cleans up the area but doesn't repair the rupture).

    The length and depth of this detailed article show how complex and challenging some shoulder injuries can be. An accurate diagnosis is important. But even with all the information at hand, the surgeon's decision isn't always clear-cut. There are many things to consider when determining the optimal treatment approach.

    And even with a careful evaluation process, the surgery isn't always successful. Sometimes a revision surgery is needed. The surgeon has to go through the steps of examination and evaluation again in charting a new course of action. Success isn't always guaranteed, but results are improved when approached in this way.


    Pietro M. Tonino, MD, MBA, et al. Complex Shoulder Disorders: Evaluation and Treatment. In Journal of the American Academy of Orthopaedic Surgeons. March 2009. Vol. 17. No. 3. Pp. 125-136.

    03/18/2009

    *Disclaimer:* 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.
    All content provided by eORTHOPOD® is a registered trademark of Medical Multimedia Group, L.L.C.. Content is the sole property of Medical Multimedia Group, LLC and used herein by permission.
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