Awake shoulder surgery – it’s not as ‘new’ as you might think!

awake shoulder surgeryRecently, we read with interest a news story featured in the Evening Standard about a “pioneering initiative” known as awake surgery.

Referred to as a groundbreaking treatment option, it highlighted the benefits of patients undergoing shoulder and elbow surgery under new ‘awake’ regional anaesthesia. The newspaper claimed that a shoulder and elbow surgeon at a London hospital was one of the first to offer this innovative technique on upper limb injuries, having carried out 50 of these cases over the last year.

While it’s true that awake surgery does deliver some benefits over surgery carried out under general anaesthetic, there were a couple of significant errors in this news story. This isn’t a new technique and it is used routinely in orthopaedic operations. Our shoulder specialists have been carrying out awake regional anaesthetic procedures for over 15 years, equating to approximately 3,000 cases.

And, for some patients, a general anaesthetic combined with regional anaesthetic techniques to ensure optimal pain relief and earlier mobilisation will always be the preferred option.

Below, you’ll discover everything you need to know about the awake surgery technique, its benefits and the importance of choosing a reliable, highly experienced surgeon.

What is awake shoulder surgery?

Awake shoulder surgery enables the patient to stay awake throughout the procedure. However, most patients choose to be sedated to some degree.

An anaesthetist will inject medication near the nerves surrounding the shoulder and the surrounding area. This will numb the area where the surgery will be performed. It takes approximately 30 minutes for the anaesthesia to be injected and take effect.

The types of awake surgical procedures vary and will be selected based upon the injury being treated.

Benefits of awake shoulder surgery procedures

So, why are awake regional anaesthetic procedures being described as a pioneering technique? Some patients can suffer from side effects from general anaesthesia, such as nausea and dizziness, and, if patients have suffered from these side effects in the past, then these can be mitigated with awake sedation techniques.

In general, though, a general anaesthetic is very safe and well-tolerated and for many patients, shoulder surgery performed under a general anaesthetic augmented with a regional block can be the best option, depending on the patient’s health and fitness and whether major surgery of a much longer duration is required. Both patient and surgical factors will be taken into account in the pre-operative planning stage.

The biggest benefit of awake surgery is a faster recovery time from the anaesthesia, however most shoulder operations are relatively short in duration, hence even with a general anaesthetic combined with a regional block, most patients are able to go home the same day. Whilst some people like to watch their own surgery, for others, this is not so desirable!

The importance of choosing an experienced surgeon

As you can see, there are plenty of excellent benefits that come from undergoing awake regional surgery. However, to enjoy these benefits it’s important to choose an experienced surgeon who has been performing this type of operation for many years and can advise on the best option for you.

New study finds link between higher BMI and poor outcome after shoulder surgery

BMI and shoulder surgery complicationsThe higher your BMI, the more likely you’ll experience a poor result from shoulder surgery. So, how are the two connected and what kind of complications could arise?

Understanding the study

Researchers from the Mayo Clinic, Rochester, Minn, analysed data taken from 4,567 shoulder arthroplasty patients from the years 1970 to 2013. The findings were published in The Journal of Bone and Joint Surgery.

Approximately 43% of patients were diagnosed as obese, which meant their BMI was at least 30. So, the researchers began looking at the correlation between BMI and shoulder surgery complications.

It was discovered that 302 patients experienced complications such as a loose implant and a mechanical failure, which resulted in the need for a revision surgery. A further 62 patients were also required to undergo a separate further operation. Interestingly, it was revealed that patients who were obese at the time of the surgery, had an increased chance of suffering these complications.

Worryingly, the chances of developing these complications increased by 5% for every unit increase in BMI of 35 and over. However, that wasn’t the strongest link found between BMI and shoulder surgery compilations. The study also showed that patients with a BMI of 35 or over, also had an increased risk of wound infections, with each increased BMI unit over 35, adding a 9% increased risk of infection.

It wasn’t all bad news, however. The study showed no link between BMI and an increase in the risk of blood clots – a complication which can be potentially deadly.

BMI also increases functionality risk in shoulder surgery

While the study largely focuses upon an increased BMI and shoulder surgery complications, previous studies have also shown it can have an effect on functionality too.

In 2011, a study revealed that patients undergoing surgery to repair rotator cuff injuries experienced an increased risk of mobility issues. Obese patients were also likely to stay longer in hospital and the shoulder operation also took longer.

Why does your BMI matter?

The theory behind the link between a high BMI and shoulder surgery complications is that the heavier a patient is, the more stress it places upon the implant. So, a high BMI will place additional pressure onto the implant, increasing the likelihood it will fail.

It also increases the chances of developing an infection after surgery. This is thought to be caused by the essentially ‘dead space’ which is left behind by excessive fatty tissues, along with changes to the immune system caused during surgery.

However, although obese patients do tend to experience poorer results, they still report the surgery has made some improvement to the condition.

Overall, what really makes this study stand out, is that it’s the first to actually look at the risks associated with BMI increases of just one increment. Most studies tend to focus more on BMI ranges, which don’t provide an accurate understanding of the increased risks involved.

Will new T20 competition increase pressure on cricketers and increase injury risk?

cricket shoulder injuriesA new T20 competition is set to provide the biggest overhaul in English cricket since the sport was started. The city-based competition is said to be due to launch as early as next year and is designed to rival the Big Bash and IPL.

The proposal submitted by officials of the England & Wales cricket board, has taken months to prepare. If it gets given the go-ahead, new teams will be able to take part in the tournament and the matches will be sold to broadcasters with an estimated one match each week being broadcast on terrestrial TV.

However, could this new tournament increase pressure on cricketers and in turn increase their risk of injury?

Some studies show Twenty20 cricket does not increase injury risk

A study was actually carried out on Australian cricketers who partake in the Twenty20 competition back in 2010. Interestingly, it showed that players taking part in the competition were less likely to develop an injury than those partaking in other types of cricket games.

It measured the injury rate of players based on 1000 days of play. Around 145 injuries occurred in domestic based Twenty20 cricket. When compared to the 219 injuries suffered by those playing in domestic one-day cricket, you quickly see that Twenty20 provides a much lower risk.

Of course, that isn’t to say there is no risk involved. What studies have found is that fast bowlers taking part in Twenty20 cricket are at the biggest risk of developing shoulder-related injuries.

Increased competition puts pressure on fast bowlers

A study has found fast bowlers in cricket are at an increased risk of injury when their workload is increased. So, those taking part in T20 cricket could find themselves susceptible to shoulder injury. During the study, data was collected from a total of 28 fast bowlers. They had bowled for 43 seasons, over a period of six years.

The results of this study are unsurprising. After all, fast bowlers use more strenuous shoulder motions to deliver balls at high speeds. This, combined with a more frequent work schedule is going to increase the likelihood of injury pretty substantially.

If the T20 competition is approved, coaches can decrease the risk of injury by rotating their bowlers. It is also suggested that the rules of the game should be altered to reduce the severity of injuries if they do occur.

Overall, introducing this new competition in England could help to further give the game a boost and increase the amount of money made by teams. There is talk of new grounds being built at sites such as the Olympic Stadium, where fans would be able to purchase tickets for the games. However, it is important for coaches to take the increased risk of injury seriously. Cricketers are renowned for developing shoulder-related injuries and increasing the number of times they play is only set to make the risk even greater.

Living with shoulder instability: management and treatment

shoulder instability treatmentWhatever the cause, successful treatment often relies upon early detection. Here, we’ll look at how shoulder instability is typically managed and treated.

Shoulder instability treatment

There are several treatment options which can be used to treat shoulder instability. Patients who have never suffered a dislocation of the shoulder joint, will typically find physical therapy offers the best course of treatment.

  • Regular physical therapy sessions will focus on strengthening up the girdle; providing stability to the joint. In addition, electrical and ultrasound stimulation, along with massage can also be used to minimise the pain.
  • Placing ice over the affected area twice daily will also help to reduce pain and limit inflammation. In severe cases, the patient may also be given corticosteroid injections to manage the pain and inflammation.
  • If the shoulder has become dislocated, physical therapy alone will not always be enough to repair the problem. Just one dislocation could be treated without the need for surgery, but if multiple dislocations are identified, an arthroscopy may be needed.
  • The arthroscopy can usually be done as an outpatient procedure. It’s minimally invasive and has shown great success in the treatment of shoulder instability.

It’s worth pointing out, treatment can vary depending upon the age of the patient. Below you’ll discover more about age-related treatment options.

Shoulder instability treatment for older patients

The majority of older patients who present with shoulder instability, have developed the condition after a fall or traumatic incident.

If a patient is over the age of 40, treatment will usually be done non-operatively. A sling will need to be worn, ensuring the joint is immobilised for a set time period. This gives it plenty of time to heal. Once it has been rested, usually within a couple of weeks, physiotherapy will be used to help the patient regain motion and strengthen the shoulder joint to prevent future injury.

Interestingly, the re-occurrence rate of shoulder instability in older patients is very low. A full recovery is also expected within three to six months.

Shoulder instability treatment for younger patients

Younger patients are generally more prone to shoulder instability issues; particularly young athletes. In sports which require frequent overarm movements such as tennis, there’s an especially high chance of shoulder instability.

If the shoulder is dislocated, it is likely to end with future instability in the joint. It’s estimated that 80% of young patients who experience a dislocation, go on to experience recurring instability issues.

Treatment will very much depend upon the severity of the instability. If the shoulder has been dislocated fully, it will need to be reset. However, it’s worth noting that this doesn’t treat the actual instability issue.

The instability is most commonly treated with physiotherapy to start. To address the pain, anti-inflammatory medications may also be prescribed. If very little improvement is seen after physiotherapy, surgery may be the only other option.

Overall, shoulder instability can be treated, though the method and recovery period will depend upon several factors, including the age of the patient. As with any shoulder injury, the earlier instability is detected and managed, the easier it will be to treat.

All strenuous physical activities should be stopped until the shoulder is strengthened and the pain is gone.

London Shoulder Specialist Ms Susan Alexander of the Fortius Clinic reiterated in a recent presentation on shoulder instability “the importance of a close working relationship, with good, open and regular communication between surgeon, physiotherapist and general practitioner to optimise the treatment of this complex condition.

Tuning your tennis shoulder

The temperatures have plummeted and rain is predicted so we must be nearing one of the highlights of the British summer: Wimbledon. As the oldest and most prestigious of the Grand Slams looms, it’s that time of year when even amateur tennis enthusiasts dust off their rackets and a great opportunity to highlight one of the most common injuries suffered in the sport and how you can prevent it.

Treating tennis shoulderTennis shoulder is a common, painful injury, which largely occurs due to repetitive overuse of the shoulder. Just like cricket, tennis players use a lot of overhead arm movements; causing the joint and underlying muscles to eventually loosen, tear or – in more severe cases – come away from the socket completely.

Understanding tennis shoulder

The shoulder is by far the most flexible joint within the body. It’s designed to allow a wide range of different movements, while maintaining good stability. However, if you push the joint too far in any direction, it has the possibility to irritate any of the surrounding muscles and tendons.

Out of the entire structure of the shoulder, the rotator cuff tends to be the most susceptible to injury. Some experts argue this is because the rotator cuff isn’t able to adapt quickly enough to any sudden changes. So, with this theory, if you’re just starting out in the world of tennis, you’re at a higher risk of developing shoulder-related injuries.

Even seasoned tennis players are at a high risk of injury. Many take time off during the winter months then, as the weather warms up, returns to their favourite sport. As the shoulder hasn’t been used for months, it’s simply unprepared for the pressure that it’s about to be placed under and injury becomes a high possibility.

Is tennis shoulder preventable?

If you’re looking to return to tennis or take it up for the first time, one of the best pieces of advice is to make sure you’re properly warmed up. This doesn’t just mean doing a series of stretches before playing, it means starting to prepare for the game before the season actually commences.

Proper training will help you expose the shoulder to the movements required within a tennis game, over a gradual period. This alone will make a massive difference to your tennis shoulder risk level. The longer you can prepare the shoulder before you start playing properly, the lower your risk will be.

Right before you play, a proper warm-up will also help. This should ultimately include some of the movements you’ll be performing, such as an overhead serve. You’ll also want to focus on flexibility training of the legs, spine, arms and shoulders.
Similarly, a cool down is just as important as the warm-up. This will also greatly reduce the amount of aching you experience the day after.

Building up your back and shoulder muscles will also help to lower your risk of injury. The more stable and strong you can make the shoulder, the less prone it will be to injury.

Overall, due to how repetitive tennis shoulder movements can be, it’s impossible to completely prevent the risk of injury. However, the above advice will help you minimise your chances of developing tennis shoulder. If you do experience any pain in the shoulder, it’s imperative you get it looked at right away. The earlier you get the problem treated, the easier it will be to rectify.

Age is not a factor in shoulder replacement success

shoulder replacement successA recent study has shown that age may not necessarily be a factor in determining shoulder replacement success. This result has surprised researchers, as up until now, age has always been associated with a decreased chance of success.

What’s more, older patients tend to experience far less complications and gain an increased level of shoulder function after the procedure compared to younger patients.

Understanding the study

The recent study was conducted by the Henry Ford Hospital in Detroit and it followed two different aged patient groups. The first included 262 patients under the age of 65, while the second followed 103 patients who were over 75. Each patient had undergone surgery due to osteoarthritis.

The older group were found to have less function in the shoulder than the younger group before they had surgery. However, once the replacement surgery had been performed, the older group experienced more improvement than the younger group.

While the study determined there was no real link between age and the outcome of shoulder replacement surgery, it was quite a small study. Therefore, more in-depth research would need to be done in order to determine just how factual these results are.

What causes a patient to require shoulder replacement?

Shoulder replacement surgery may not be performed as much as knee and hip replacement surgery, but it’s still surprisingly common. There are numerous things that can lead to a patient requiring this type of surgery including:

Osteoarthritis and rheumatoid arthritisArthritis in the shoulder joint is by far one of the most common causes of shoulder pain; particularly osteoarthritis. This occurs over time and largely affects patients aged 50 or over. The pain results from the cartilage being worn away and the bones then begin to rub against each other. Eventually the joint becomes painful and stiff.

Rotator cuff tear arthropathy – If you have a large rotator cuff tear that’s been there a while, it can lead to rotator cuff arthropathy. Because of the tear, changes can start to appear within the joint, which in turn can lead to damage to the cartilage and arthritis.

Serious fractures – If the bone in the upper arm becomes shattered, it could prove very difficult to have them placed back together. Therefore, a shoulder replacement may be recommended.

Understanding shoulder replacement surgery

Shoulder replacement surgery has proven really successful at eliminating shoulder joint pain. It’s one of the few surgical procedures that has been carried out since the 1950s. However, the techniques and equipment used have certainly improved over time.

While it is an effective treatment option, surgery is only ever considered as a last resort. The first thing patients are usually given to ease the pain is medication and recommended changes in activity. If these initial treatments don’t work, that’s when surgery could be more effective.

The procedure involves removing any damaged sections of the shoulder joint and replacing them with artificial components. The head of the joint alone could simply be removed, or the ball and socket may need to be replaced depending upon the severity of the problem.

Overall, shoulder replacement surgery is common and it does have a high success rate. In the past, patients have been put off due to their age, but this new study proves surgery could actually be more effective in older patients.

London Shoulder Specialist to speak at Sport and Exercise Medicine Symposium

London Shoulder Specialist Ms Susan Alexander is to speak at this month’s One Day International Sport and Exercise Medicine Symposium held in London. Entitled ‘From Pain to Performance’, the conference is widely recognised as one of the leading sport and exercise medicine conferences in the UK and is facilitated by the Society of Sports Therapists.

The Society of Sports Therapists was established in 1990 by Professor Graham Smith to address the increasing demands made on everyone involved in the management and treatment of sports injuries. For the symposium, Professor Smith brings together internationally renowned speakers who work at the cutting edge of musculoskeletal and orthopaedic medicine.

sports and exercise medicine

Alongside colleagues discussing topics such as the management of groin injuries in professional sport to the effects of cryotherapy on muscle reaction time in ankle sprains, Ms Alexander will be speaking on ‘The Problem Shoulder – Referral or Rehab?’.

Could stem cells be used to regrow rotator cuff tendons in the future?

tem cell rotator cuff repairA new discovery made by Uconn Health researchers, could revolutionise the way rotator cuff tears are treated forever. Using stem cells, the researchers found that they could regenerate the tendons, completely repairing the tear without surgery. This exciting discovery provides hope, particularly for athletes, that this common shoulder issue could be treated quickly and almost painlessly.

How would stem cell rotator cuff repair work?

In order to regenerate the tendons, it requires a nano-textured fabric seed complete with stem cells. It is the introduction of the nano-textured fabric along with the stem cells that’s important in the effectiveness of the stem cell rotator cuff repair treatment. Surgeons have already used stem cells occasionally in the past, injecting them in the tear of the rotator cuff. However, on their own, they haven’t proven to be very successful.

The nano-textured fabric seed appears to significantly increase the success of the treatment. With the seeds help, the stem cells found it much easier to attach to the bone. This resulted in regrown tendons that weren’t just repaired, but they were stronger afterwards too. The cell structure appeared to look just like undamaged and natural tissue. This contrasts to current surgical treatment which often leaves an unorganised cell structure, causing the tendons to grow back weaker.

It’s worth noting that this stem cell rotator cuff repair treatment has only been tested on animals. So, human trials would need to be conducted in order to establish whether it presents the same benefits.

Understanding rotator cuff tears

Rotator cuff tears are extremely common, and they’re typically caused by repetitive micro-trauma. That means, they develop over time, whether it be weeks or even years. Once the tendon becomes torn, it causes the shoulder to weaken, which ultimately leads to pain when you try to carry out normal, everyday activities such as brushing your hair.

A lot of the time, torn tendons actually start out by fraying. Then, often after lifting a heavy object, and after a period of time where the damage becomes worse, the tendon finally tears.

Rotator cuff tears are categorised as partial and full-thickness tears. With the partial tear, the tendon becomes damaged, but it doesn’t completely tear. A full-thickness tear on the other hand, occurs when the tendon comes completely away from the bone.

These tears often result in extreme pain, even when the patient is resting, or lying in bed at night. So, the fact these common tears could soon be repaired by stem cells is definitely welcome news for patients. However, until these stem cells can be used as a mainstream treatment, what options do patients have in the meantime?

Current rotator cuff treatment options

There are numerous treatment options available right now, including injections, surgery and physical therapy. The treatment that’s right for you will depend upon the severity of the tear. Surgery tends to be used for the most severe, painful rotator cuff tears, and there’s many different methods that can be used.

If you suspect you have a rotator cuff tear, it’s best to get it diagnosed as soon as possible. The earlier it is detected, the less invasive the treatment will be. For example, a minor tear could repair itself with physiotherapy. So, if you want to avoid surgery, always get your shoulder pain checked out as quickly as possible.

London Shoulder Specialist to speak at ‘The Future of Football Medicine’ conference in Barcelona

Future of Football MedicineThis week, London Shoulder Specialist Mr Andrew Wallace will be attending one of the big events in the international sports medicine calendar. This year’s International Conference on Sports Rehabilitation and Traumatology will focus on ‘The Future of Football Medicine’ and will take place between 13 and 15 May at Camp Nou, the home of FC Barcelona.

With over 2,500 attendees from 90 countries expected, Mr Wallace has been invited to give a lecture on shoulder injuries in footballers. On Sunday, he will be joining other leading sport medicine specialists on a panel focusing on the ‘Future of Sport Surgery: Sparing the Scalpel?’ and reviewing conservative versus surgical options for footballers’ shoulders.

It’s not game over: study finds that majority of shoulder replacement patients return to sports

Shoulder replacement surgery is often considered as a last resort for severe shoulder injuries. However, a new study has shown that the majority of shoulder replacement patients under the age of 55, find they can return to sports, often in as little as seven months.

This proves promising for recreational athletes who worry they’ll never be able to play sports again after the surgery. So, what does shoulder replacement involve and which sports will patients still be able to partake in after the surgery?

Understanding shoulder replacements

A lot like hip and knee replacements, a shoulder replacement involves replacing the damaged components with artificial ones, or more commonly referred to as a prosthesis.

Younger athletes can develop early osteoarthritis due to the repetitive motions performed in various sports. Once the joint develops arthritis, a total shoulder replacement is often required. This involves removing the joint surfaces, and then replacing them with a metal ball which has been highly-polished, that is then attached via a stem, along with a plastic socket.

Once healed, the prosthesis should allow the patient to move the shoulder freely and painlessly; allowing them to get back to the tasks they were unable to perform prior to the surgery. Of course, the results and success of the replacement vary between patients.

However, the study which was published in the World Journal of Orthopaedics, showed in patients under the age of 55, return to sport after shoulder replacement wasn’t only possible, but probable.

Which sports can shoulder replacement patients go back to?

One thing that is worth noting, is that there are limits as to which sports a shoulder replacement patient can go back to. The study questioned 61 patients, and found over 90% were able to return to a high demand sport.

return to sport after shoulder replacementThe exact sports patients returned to included:

  • Fitness sports – 97.2% of patients went back to fitness-related sports
  • Golf – 93.3% of patients went back to playing golf
  • Tennis and swimming – One of the more surprising statistics presented by the study, 87.5% of patients could return to both singles tennis and swimming
  • Basketball – 75% of patients found they could return to basketball
  • Flag football – 66.7% of patients returned to flag football

You’ll notice none of the above sports are contact sports. You may find you cannot return to sports such as rugby, for example, once you’ve undergone a total shoulder replacement.

Why are the results of the study important?

The reason why this study is important to shoulder specialists and young athletes is because it shows a shoulder replacement could be a viable choice for young patients suffering from early osteoarthritis.

It proves the treatment doesn’t eliminate the chances of a return to sport after shoulder replacement. Overall, as with any type of shoulder injury, it is important to seek treatment if you’re experiencing any pain as early as possible. This reduces the risk of the problem getting worse and provides a much more optimistic outcome.