The Wall Street Journal-20080123-The Informed Patient- New Techniques Tackle Rotator-Cuff Injuries
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The Informed Patient: New Techniques Tackle Rotator-Cuff Injuries
When it comes to joint injuries, rotator cuffs are the repeat offenders. Surgery can fix the debilitating shoulder problem, but as many as half of patients retear their rotator cuff, often because of overzealous activity or the weakened quality of their tendon tissue after years of wear and tear.
Now doctors are using a number of new techniques to improve the outcome for rotator-cuff repair, including using double instead of single rows of sutures in the repair. They are also working with new materials -- including those made from the patient's own blood -- that can act as patches or scaffolds to support the repaired rotator cuff while the tissues heal. While new minimally invasive techniques are making the surgery easier on patients, recovery and rehabilitation can still be long and painful. To help, doctors are focusing on getting patients to better adhere to rehabilitation programs, which can take months.
Between three million and four million patients annually see a physician for problems with the rotator cuff, the complex network of muscles and tendons that hold the shoulder in place and enable the arm to rotate. Injuries can be caused by accidents, repetitive use, a bone spur that saws away at muscle, or the aging process. While many pulls and strains can be managed with physical therapy, anti-inflammatory medications or steroid injections, a torn rotator cuff can't heal on its own without surgery. As a result, chances of a more serious tear increases, leaving surgery as the only option. By some estimates the number of tears requiring surgery could more than double over the next several years to 500,000, as active baby boomers push the limits of their aging bodies.
When he first injured his rotator cuff in a ski injury a few years ago, Ron Baron wanted to avoid a recommended surgery, and found relief through physical therapy. But last summer, while testing some home-gym equipment, the 64-year-old New York fund manager felt a sharp twinge in his right shoulder. Later when he tried to hit a tennis ball, he crumpled in pain. After a scan showed that a tear had worsened, he decided to have the procedure last fall so he could maintain his active pursuits.
"There are still patients who say, 'OK, I'll give up golf or tennis rather than have the surgery,'" says David Altchek, the co-chief of Sports Medicine and Shoulder Service at New York's Hospital for Special Surgery who operated on Mr. Baron and has seen the number of rotator-cuff surgeries he performs rise by 20% over the past few years. "But we are in a generational shift where more and more patients are simply not willing to give up their level of activity."
Dr. Altchek was an early pioneer in the use of less-invasive outpatient procedures, which now account for more than 75% of surgeries. Open surgical repair, which may be necessary if the tear is large or complex, requires a big surgical incision under general anesthesia. It also usually requires at least a one- or two-night hospital stay. By contrast, a minimally invasive procedure, known as arthroscopy, requires only three puncture wounds in the skin. Through the tiny incisions, surgeons aided by TV cameras can insert instruments to remove bone spurs, repair tears, and drill tiny holes in bones to reattach tendons that have torn away with sutures and anchors. A partial tear of the tendons may require only a trimming or smoothing procedure known as a debridement.
A complete tear within the thickest part of the tendon has to be repaired by suturing two sides of the tendon back together. If the tendon is torn away from the bone, the surgeon must sew it back using permanent anchors, or rivets, made of plastic or metal that remain in the body.
The minimally invasive surgery can be performed as an outpatient procedure using a local anesthetic that blocks pain to the side of the body being operated on and lasts for several hours after the procedure. Outpatient hospital costs including anesthesia run from $5,000 to $10,000 and the surgeons' fee costs $1,000 to $7,000. Dr. Altchek says his patients rarely encounter resistance from insurance companies, because the surgery can be less expensive than prolonged rehabilitation programs. Insurance typically covers physical therapy, which can last 24 weeks.
But even the minimally invasive surgery includes risks and complications that patients need to consider before consenting to the procedure, including the possibility of infection or nerve injury. While the use of a double row of sutures to stitch tendon to bone is promising, the technique is still being studied. It requires that double the number of holes be drilled into the bone, which may itself be fragile, and double the hardware, increasing the costs.
Some surgeons have used human-cadaver tissue intended for transplantation to patch the surgical repair and reinforce the tendon. And researchers have studied the use of grafts made from pig intestine to help regenerate tissue in the rotator-cuff tendons and avoid retears. But there are questions about the safety of such materials, which can cause inflammation and be rejected by patients' bodies.
To avoid such risks, researchers and medical-device companies are now developing new materials to promote tissue growth and healing that can be safely absorbed by the body. One, under development by Medford, Mass.-based Serica Technologies Inc., uses silk-based implants that can act as a scaffold to support damaged tissues while they heal. "If we could decrease the surgical retear rate we could eliminate the need to do the surgery over again down the road," says Gregory Altman, who developed the silk-based implants and is chief executive of the company. Mr. Altman estimates that of the 30% to 50% of rotator-cuff repairs that fail, 25% become major problems or "chronic massive tears."
At the Hospital for Special Surgery, surgeons are also investigating the use of special clots formed by centrifuging the patient's own blood before surgery to isolate platelets that contain a number of different growth factors. The end result is a product with a chewing- gum-like consistency that is sutured into the site where torn tendons are reattached to bones. Scott Rodeo, who is co-head with Dr. Altchek of the sports medicine and shoulder service, says patients in the study will be evaluated by ultrasound to evaluate whether the tendon- to-bone healing is more effective than in those patients where the blood-clot material isn't used.
But it may be years before such advances are in wide use, if ever. In the meantime, surgeons are focusing on reducing the incidence of retears, in part by better educating patients about the importance of the rehabilitation process. Patients who don't follow the prescribed regimen for physical therapy or exercise too vigorously are at increased risk for re-rupture.
Researchers are also studying the long-term outcomes of rotator- cuff-repair surgery, including patient satisfaction with the procedure over time. In one study at Rush University Medical Center in Chicago, 49 patients who had arthroscopic repair of rotator-cuff tears showed significant improvements two years after the surgery, though 11 had recurrent tears. All but two of the patients said they would have the surgery again. Brian Cole, the surgeon who led the study, notes improvements can occur between the first and second years after surgery, an important consideration for patients who are trying to decide whether to have the procedure.
But patients should be prepared for severe pain directly after surgery. By six months after surgery most patients have regained about 80% of strength, but the experience can vary greatly. Mr. Baron, whose rotator cuff had a single tear one centimeter in length, says he went to work the day after Dr. Altchek performed his surgery. He said that he experienced only moderate pain.
Another patient of Dr. Altchek's, 57-year-old investment banker Garfield Miller had multiple tears in his right shoulder, including injuries from tumbling down a flight of stairs. The night after his surgery "was among the most uncomfortable I'd ever spent in my life," says Mr. Miller. The next morning was just as rough. "I had a moment where if I thought that if I could run into a wall and knock myself out to stop this throbbing pain, I would have done it," he says. After increasing his painkiller dose for a few days, he felt better.
Like most patients after surgery, Mr. Miller kept his arm immobilized in a sling for six weeks and had 24 weeks of physical therapy; he then chose to work with a chiropractor to continue to make improvements. Just over a year after the surgery, Mr. Miller says he is able to serve a tennis ball at full speed without being conscious of his injury, but "in extreme ranges of motion you do still notice weakness in the muscles."
Some studies now show that the longer patients wait to undergo surgery once torn muscles start to deteriorate, the worse the outcome is likely to be. John Green, 66, another patient of Dr. Altchek's, felt he was nearing that point when he had the surgery in early December after years of increasing pain from a fraying cuff and a bone spur. The experience left him unable to enjoy his favorite pastimes, which include tennis and digging in his garden at a retirement home in Ireland. "I really had no choice," he says now. "My arm was never going to get better."
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