Rotator Cuff Surgery and Risk for Recurrent Tearing

Posted October 9, 2014 by Orthopaedic Specialists

Factors Predicting Rotator Cuff Tears that are at Risk for Recurrence Tearing at the Time of Surgery

Once the rotator cuff is repaired what are the chances of a tear recurring? There have been multiple studies completed to verify risk factors for recurrence of re-tearing of the surgically repaired tendon.

Surgical reconstructed is recommended on symptomatic patients that have full thickness tears and have partial thickness tears that involve over 50% of the tendon. One of the most common postoperative complications in reference to rotator cuff surgery is a recurrent tear.

Even after surgical reconstruction the rotator cuff can re-tear. There have been studies reporting recurrent tear rates from 11 to 94%. What are the risk factors that would indicate a surgically repaired rotator cuff could re-tear? Risk factors that have been identified in prior studies are: large tear size measuring from anterior to posterior in addition to medial and lateral tear size ( retraction distance) , surface area of the tear size, older age of the patient, the existence of fatty replacement of muscle , presence of muscle atrophy and quality of the torn tendon.

The above factors have been reported in smaller sized studies typically under 200 patients. The biggest study to date with the most amount of patients was reported in the May, 2014 issue of the American Journal of Sports Medicine. The study was led by Brian Le MD from the University of South Wales, Sydney, Australia. Their study included 1,000 consecutive patients who it undergone a primary rotator cuff repair by a single surgeon using arthroscopic technique.

Six months after the rotator cuff surgery an ultrasound was completed to assess the repair integrity. The authors found that the most important factor in predicting recurrent tearing of the rotator cuff was the size of the rotator cuff tear at the index surgery. The research team also found a strong relationship between recurrence rates in patients who had poor tissue quality, poor intra operative tendon immobility and had a second surgical procedure performed in the shoulder at the time of the rotator cuff tear.

In addition, the researchers found that a patient’s age at the time of rotator cuff surgery was a strong independent predictor of recurrent tear rates, with increasing age linked to increasing likelihood. When comparing the rotator cuff tear size from side to side versus the distance the tear was retracted, they found that the side to side tear size was more (more…)

Nineteen Key Facts About Anterior Traumatic Shoulder Dislocation

Posted October 2, 2014 by Orthopaedic Specialists

1. Almost half of the people suffering from a shoulder dislocation are between 15 and 29 years of age.

2. Males dislocate their shoulders three times more than females.

3. A quarter of the people who have an anterior shoulder dislocation will require surgical stabilization secondary to persistent instability.

4. Half of the patients who sustain a first episode of shoulder dislocation will most likely experience two more episodes.

5. Moderate to severe osteoarthritis has been reported in 18% of patients with a first time dislocation, and up to 40% of patients who have more than one shoulder dislocation.

6. Recurrence rate following nonsurgical management of traumatic shoulder dislocation ranges from 30% to 67%. This rate increases to 55% up to 82% in young male athletes.

7. The biggest risk factors for recurrent instability after shoulder dislocation includes: young age, athletic activity, male gender, and the presence of a bony Bankart lesion. There are some studies that have concluded that males, that play contact sports, under age 20 are the highest risk for recurrence of anterior shoulder instability after first time this location.

8. Nonsurgical management is the initial treatment of choice for first time dislocators. It is recommended that the athletes be in a sling for up to 1 to 4 weeks. Range of motion is typically started at one week post injury.

9. Stabilizing structures at risk after dislocation: the glenoid labrum, the bony glenoid rim, the anterior capsule and the anterior band of the inferior glenohumeral ligament

10. The shoulder is at risk for dislocation because of its wide range of motion, a shallow glenoid articulating with a nearly spherical humeral head. This makes an inherently unstable configuration relying on other structures to prevent instability, including static structures such as the glenoid labrum, joint capsule, and the glenohumeral ligaments.

11. The glenoid is pear-shaped and measures 5 cm in its position from top to bottom and 2.5 cm and it’s inferior anterior posterior dimension. It is relatively shallow with a concave any measuring 2.5 mm deep.

12. The labrum increases the depth of the glenoid by 2.5–5 mm. The capsule provide the negative hydrostatic pressure between the humeral head and glenoid making it more stable.

13. The anterior inferior rim of the glenoid is important to anterior inferior glenohumeral stability. During an anterior shoulder dislocation, the glenoid rim may have avulsed at the bony attachment of the anterioinferior capsulolabral complex. (more…)

Dancing and ACL Tear

Posted September 29, 2014 by Orthopaedic Specialists

Why do dancers (ballet and modern) have a lower incidence of ACL injury compared to other athletes?

A great study conducted at the Harkness Center for Dance injuries in New York City in conjunction with the Langone Medical Center Hospital for Joint Diseases looked at the biomechanics of landing from a jump between the two groups. It was a two part study published in the American Journal of Sports Medicine in May of 2014. The research group was headed by Dr. Marijeanne Liederbach.

It is documented that poor landing mechanics from a jump such as a rebound can lead to an ACL tear and injury. Poor biomechanics such as an increase in knee abduction, hip adduction, low flexion angle when landing, increase use of quadricep muscles compared to hamstring muscles, and excessive truck tilt results in a higher incidence of ACL injury.

The study looked at 4 groups of athletes: male and female, dancers and team sport athletes. They had the athletes do a single leg drop jump from a 30 cm platform. Joint kinematics and kinetics were compared between groups and genders using multivariate analysis of variance and pair wise t tests.

They found that the male team sport group was similar to both the male and female dancers. They found that the team sport females exhibited poor landing techniques which would place their knee at increased risk of an ACL tear or injury.

The hypothesis from the authors as to the reason the female dancers had excellent landing techniques was that dancers spend hours working on jumping and landing techniques which start at an early age in their training and continue throughout their career.

The second part of the study looked at the 4 groups and what happened to their landing technique when they were fatigued. The study found that the dancers took typically a longer period of time before they became fatigued. Once they did become fatigued they start exhibiting signs of poor landing techniques.

This study shows how it is important to focus on strengthening the muscles around the hip and knee in addition to making sure that the athletes have excellent landing techniques if an ACL tear is going to be prevented. (more…)

Hip Survey

Posted September 26, 2014 by Orthopaedic Specialists

Are you a cyclist who has experienced a hip injury while biking? If yes, please consider participating in a survey Dr. Grossfeld is doing to better understand hip injuries for cyclists. For more info, see: Hip Injury Survey. Thank you for your participation!

Rotator Cuff Pain

Posted September 23, 2014 by Orthopaedic Specialists

Why do rotator cuff tears and rotator cuff tendinitis hurt so much?

As a shoulder specialist, one of the most frustrating situations is trying to control a patient’s pain, when they present with a rotator cuff tear or rotator cuff tendinitis. Rotator cuff pain, after rotator cuff surgery, can be significant. Rotator cuff pain often tends to intensify at night, especially if a person is sleeping on their injured side.

As physicians, we are unsure as to why rotator cuff pathology causes so much rotator cuff pain and have not been very good at controlling it.

High dose pain medications such as Percocet, hydrocodone, or even oral Dilaudid, have been used without great success.

A scientific break through in identification of one of the sources of rotator cuff pain has been identified in a study conducted at the University of Oxford published in the August 2014 American Journal of Sports Medicine. Authors Sarah Franklin PhD et al. looked at the role of glutamate and the glutaminergic system. (more…)

Posterior Shoulder Dislocation

Posted September 15, 2014 by Orthopaedic Specialists

Posterior Dislocations of the Shoulder

There are several types of shoulder dislocations. They are named based on the direction of the dislocation.

The most common type is the anterior dislocation where the shoulder comes out the front. Another type of shoulder dislocation is posterior: this is where the shoulder dislocates out the back.

A posterior shoulder dislocation is rare. Anterior shoulder dislocations occur 15-21 times more often than a posterior shoulder dislocation but the etiology of the posterior dislocations are consistent. We see this in people who have had seizures, high energy trauma such as an auto accident, or have been electrocuted.

The posterior shoulder dislocation gets missed or has a delay in diagnosis up to 79 percent of the time.

The orthopedic doctor should be suspicious of additional injuries associated with a posterior shoulder dislocation. Up to 55 percent of the time there is an associated neck injury and 23 to 42 percent of the time a fracture involving the shoulder bone (greater and lesser tuberosity) occurs at the time of the posterior shoulder dislocation.

If the dislocation is caught early after the injury, a closed reduction can be performed in the emergency department. This is performed with a light anesthetic. (more…)

Knee Surgery Among College Athletes

Posted September 8, 2014 by Orthopaedic Specialists

Effects of knee surgery on a subsequent injury and surgery among NCAA college athletes

Dr. Sharon Hume et al. published a very interesting article in the April 2014 issue of the American Journal of Sports Medicine. She and her colleagues studied 456 Division 1 athletes at UCLA who had a history of an orthopaedic surgery procedure.

They identified a 6.8 fold increased chance of sustaining another knee injury if the athlete had a history of prior knee surgery. There was a staggering 14.4 fold chance that the athletes with a history of a prior knee surgery would end up undergoing another knee surgery.

ACL Reconstruction May Increase Risk Of Additional Knee Surgery for College Athletes

The group of college student athletes that was at extreme risk of an additional knee surgery were the student athletes that had undergone an ACL reconstruction prior to starting their collegiate career.

If a student had an ACL reconstruction before starting college, there was an 892 fold increased risk that they would undergo a second knee surgery during college while playing D-1 sports. There was a 19.6 fold chance that those athletes would experience an additional knee injury.

These research findings suggest that teaching young athletes about ACL injury prevention is more important than ever to reduce the risk of knee injuries (more…)

The Louisville Ironman Experience: From Viewpoint of a Doctor

Posted August 26, 2014 by Orthopaedic Specialists

Dr. Stacie Grossfeld, sports medicine specialist and orthopaedic surgeon in Louisville, Kentucky, interviewed Dr. Brittney Richardson regarding her experience heading a medical team at the 2014 Louisville Ironman. Dr. Richardson is a second year medical resident with the University of Louisville Department of Family Medicine. She is currently doing her orthopedic rotation with Dr. Grossfeld.

2014 Women’s Ironman Winner: Nina Kraft from Germany. Winning her third Louisville Ironman at age 46 in 9:31:19. Dr. Richardson is in the first row right with her team of nurses .

Interview with Dr. Brittney Richardson by Dr. Stacie Grossfeld

Dr. Grossfeld: “Describe what it was like at the Kentucky International Convention Center in Louisville, Kentucky, working the medical treatment area for the 2014 Ironman?”

Dr. Richardson: “It was like a war zone. There were athletes spread out over 200 plus cots in a make shift hospital located in one of the large rooms in the convention center. Many of the athletes were laying down on portable cots hooked up to I.V.s. Athletes were being brought in by medical personnel in wheelchairs and stretchers by the nursing staff and EMS workers. Massage therapists were working on finishers with muscle cramps and spasms.

Dr. Grossfeld: “What was the general appearance of the athletes and how did they compare to other athletes you have taken care of at the end of other endurance races such as the Louisville Marathon and the Triple Crown?”

Dr. Richardson: “I have never seen athletes so sick in appearance at the end of a race. Some of them looked like they were going to die. At times it was scary. We had a full lab at the site so we could draw blood and check electrolytes to help guide in treatment. There was also a full pharmacy present so we could administer drugs. I had four nurses working under me in a pod of eight hospital cots. The beds were always at least 50 percent full during my shift.”

Dr. Grossfeld: “What was the scariest athlete you treated?”

Dr. Richardson : “There was a finisher that was somewhat incoherent. She was having intermittent tremors and had a hard time answering simple questions. Her pupils were dilated and my team thought she might have a seizure. One of the emergency department physicians saw her from across the room and came over to asked me if I needed any help because she looked so bad. I pumped 2 liters of fluids into her and gave her some IV Ativan for her severe muscle spasms. She then perked up. The really critical patients we sent out to one of the local hospitals for more comprehensive treatment.”

Dr. Grossfeld : “What is a catcher?”

Dr. Richardson : “A ‘catcher’ is a healthcare worker that is located at the finish line and they literally catch the athletes that stagger or fall across the finish line. The athletes are completely depleted and cannot walk or even crawl. The catchers were primarily nurses that would transport the finishers into the medical area.”

Dr. Grossfeld: “What were some interesting things you learned from the athletes?”

Dr. Richardson: “It is an amazing commitment to compete in an ironman. I got to spend some time talking to athletes as I was starting their IVs and treating them. It’s not only a 9 month time commitment but a 5 hour a day training schedule. The competitors’ families completely re-work their schedules and routines to allow the athlete to train.” (more…)

Louisville Orthopaedic Specialists Hires Two Certified Physician Assistants

Posted August 25, 2014 by Orthopaedic Specialists

Orthopedic surgeon and sports medicine physician Dr. Stacie Grossfeld and the entire staff at Orthopaedic Specialists in Louisville, Kentucky, are excited to welcome two Certified Physician Assistants to the team, Melissa Edds PA- C and Angel Porter PA-C.

Orthopaedic Specialists hires Melissa Edds

Melissa Edds PA-C will work part-time at Orthopaedic Specialists as a Physician Assistant.

With a combined experience of more than 20 years, Melissa Edds PA-C and Angel Porter PA-C are certified by the National Commission on Certification of Physician Assistants and are licensed to practice in the Commonwealth of Kentucky. While working with Louisville orthopedic surgeon Dr. Stacie Grossfeld at Orthopaedic Specialists, Ms. Edds PA-C and Ms. Porter PA-C will be closely involved in many facets of patient care.

Angel Porter PA-C joins Louisville Orthopedic and Sports Medicine Practice, Orthopaedic Specialists.

Responsibilities for Ms. Edds PA-C and Ms. Porter PA-C will include obtaining medical histories, performing physical exams, and ordering and interpreting lab work and diagnostic studies. They will also be performing certain medical procedures, and helping to educate clients about recommended treatment options. Learn more about our new physician assistants in this press release.

Kentucky State Fair 2014 Kicks Off

Posted August 17, 2014 by Orthopaedic Specialists

The 2014 Kentucky State Fair is happening in Louisville, Kentucky, from August 14 – August 24, 2014. Dr. Grossfeld’s son Adam entered two categories this year (painting and drawing). Find out more about the Kentucky State Fair Daily Schedule including competitions, concerts, horse shows, contests, entertainment options, and more here.