Frozen Shoulder

Frozen Shoulder

Dr.Senthil Velan

MBBS, MRCS (Edin), FRCS (Tr & Orth), FEBOT(France), D Orth, Dip SicoT.

Fellowship in Shoulder Elbow Surgery (Bournemouth, UK)

Fellowship in Knee Surgery (Bournemouth, UK)

Consultant Orthopaedic Surgeon.

Apollo Hospitals Ayanambakkam

Apollo Clinic Annanagar, First Med Hospitals.

For Appointments contact 09566222533/nexusortho@yahoo.com

Frozen Shoulder causes Pain and limitations of movements of Shoulder. 2% and 5%of  the general population can be affected by  this condition . It is more common in women than in

men and the age of sufferers tends to be between 40 years and 60 years .In most cases pain in shoulder is the initial symptom and gradually stiffness accompanies it.

In severe cases there is complete restriction of Shoulder movements.

What causes frozen shoulder?

Frozen shoulder happens when the covering of shoulder called capsule becomes thickened.

It is not a true inflammatory condition , and  in most cases there is no obvious causative factor but it can occur secondary to a shoulder injury or shoulder surgery.

It is also more common in persons suffering from

Diabetes

Duypuytrens Contracture- a condition where small lumps of thickened tissue form in the hands and fingers

Other health conditions, such as heart disease and stroke.

When to see a Shoulder Specialist?

You should visit a Shoulder specialist if you have shoulder pain that limits your range of movement.

A diagnosis of frozen shoulder needs to be made early so treatment for the condition can be started quickly to help prevent long-term pain and stiffness developing in your joint.

What investigations will be needed?

In most cases the only investigation required will be a plain X ray of shoulder. But if the Shoulder specialist suspects other pathologies in the shoulder an MRI scan may be required to rule out problems like rotator cuss tear/tendinitis.

Treating frozen shoulder

Some people with frozen shoulder may get better over a period of 18-24 months. In other cases, symptoms can persist for several years.

Studies suggest that about 50% of people with frozen shoulder continue to experience symptoms up to seven years after the condition starts. However, with appropriate treatment it is possible to shorten the period of disability.

The aim of treatment is to keep your joint as mobile and pain free as possible while your shoulder heals. The type of treatment you receive will depend on how severe your frozen shoulder is and how far it has progressed.

Treating frozen shoulder 

A frozen shoulder may get better naturally, but recovery is often slow and may take at least 18-24 months.

The aim of treatment is to keep your shoulder joint as pain free and mobile as possible while your shoulder heals.

Early stage

The first stage of a frozen shoulder is the most painful stage. Therefore, treatment is mainly focused on relieving the pain.

During this stage, your doctor may recommend that you avoid movements that make the pain worse, such as stretching overhead. However, you should not stop moving altogether.

Painkillers

If you are in pain, you may be prescribed painkillers, such as paracetamol or a combination of paracetamol and codeine.

Some painkillers, such as paracetamol, are also available over-the-counter from pharmacies.

If your pain is more severe, your doctor  may recommend or prescribe a non steroidal anti inflammatory medications  (NSAID). As well as easing pain.They are most effective when taken regularly, rather than when symptoms are most painful.

Corticosteroid injections

If you have severe frozen shoulder, painkillers may not be enough to control the pain. If this is the case, it may be possible to have a corticosteroid injection in your shoulder joint.

Corticosteroid are medicines that contain hormones (powerful chemicals that have a wide range of effects on the body). They help reduce pain and inflammation. Corticosteroid may also be given with local anaesthetic (painkilling medication).

Corticosteroid injections can help relieve pain and improve the movement in your shoulder. However, injections will not cure your condition and your symptoms may gradually return.

Corticosteroid injections will not be used after the pain has faded from your shoulder and only the stiffness remains.

Having too many corticosteroid injections may damage your shoulder, so you may only be able to have this type of treatment up to three times. You will need at least 3-4 weeks between injections. 

Later stages

After the initial, painful stage, stiffness is the main symptom of a frozen shoulder. At this time, your doctor may suggest you start shoulder exercises, and you may be referred to a physiotherapist.

Physiotherapy

A physiotherapist can use a number of techniques to help you maintain movement and flexibility in your shoulder. If you are referred to a physiotherapist, you may have treatments such as:

stretching exercises using specific techniques to move the joint in all directions

massage thermotherapy with warm or cold temperature packs

.

Surgery

Surgery for frozen shoulder may be recommended if your symptoms are severe, causing significant problems and other treatments have not worked after a few months.

There are two possible surgical procedures which are explained in more detail below.

Manipulation

You can have your shoulder manipulated (moved) while you are under general anaesthetic  (painkilling medication that puts you to sleep).

During the procedure, your shoulder will be moved in a controlled way and stretched while you are asleep. In addition, you will usually have corticosteroid and local anaesthetic injected into your shoulder joint.

Afterwards, you will usually require physiotherapy to help maintain mobility in your shoulder.

Arthroscopic capsular release

Arthroscopic capsular release is an alternative procedure to manipulation. It is a keyhole or non-invasive surgery. The Shoulder specialist will carry out the procedure after making a small incision that is less than 1 cm (0.4in) long.

The surgeon will use a special probe to open up your contracted shoulder capsule. They will then remove any bands of scar tissue that have formed in your shoulder capsule, which should greatly improve your symptoms.

Arthrosocpic picture of Frozen Shoulder

Arthroscopic release of Tight anterior interval

Arthroscopic release of inferior capsule

Procedure details.

After documenting scapulohumeral range of motion and giving consideration to manipulation under anesthesia, the surgeon establishes a standard posterior portal and performs a diagnostic sequence. The long head of the biceps is inspected, and the rotator interval is defined by the anterior edge of the supraspinatus and the superior border of the subscapularis .

 The rotator interval is typically opened up, and scar tissue is typically released from the undersurface of the subscapularis. This permits translation of the humeral head inferiorly and laterally and allows for complete release of the anterior capsule. Capsular release will then continue along the inferior capsule. The surgeon must be careful while releasing the inferior portion of the capsule, because the axillary nerve courses just inferiorly from medial to lateral in an anterior-to-posterior direction. Posterior capsular release can then be performed by placement of the camera anteriorly and by use of a posterior working portal. 

Instructions after Surgery

As with manipulation, after having arthroscopic capsular release surgery you will need physiotherapy. This will help you regain a full range of movement in your shoulder joint.

The Physiotherapist will see you and inform you of excercises that should be done on a regular basis.

Driving can be resumed in a few days after surgery. Sporting activities involving significant upper body movements can be resumed after two weeks duration.

Shoulder Arthritis

Dr Senthil Velan MBBS,FRCS (Tr &Ortho), FEBOT, Fellow European Board Orthopaedics and Trauma, D.Ortho, Dip SICOT.

Consultant Orthopaedic Surgeon

Apollo Hospitals, Chennai, India

For appointments contact 09566222533/ velansenthil78@yahoo.com

Shoulder arthritis

What is it?

Arthritis is wear and tear of the joint. Osteoarthritis is a slow process that develops over a number of years. With this type of arthritis the joint cartilage gradually becomes thin and roughened. The bone underneath thickens and the bone at the edge grows outwards causing bony spurs (osteophytes).  The joint may swell as the body makes extra fluid to lubricate the joint. The joint may get deformed and there will be gradual loss of movement.

What is its cause?    

The most common cause of osteoarthritis in the body is wear and tear of the joint due

to ageing. This is called ‘primary osteoarthritis’. Fractures or instability of the shoulder can lead to arthritis later in life. This is termed as ‘secondary arthritis’.

In the shoulder a specific of arthritis known as Rotator cuff arthropathy can develop. It occurs in patients with large, long-standing cuff tears which subsequently develop in to arthritis between the humeral head and acromion. The shoulder is a ball (humeral head) and socket (glenoid) joint. It is raised, lowered or rotated by a group of four muscles (supraspinatus, infraspinatus, subscapularis and teres minor), which are called the ‘rotator cuff muscles’. They also help to stabilize the shoulder joint i.e. they try to keep the ball at the centre of the socket. In the presence of a cuff tear, the ball of the shoulder (Humeral head) will become unstable and move upwards towards the acromion(Shown in Figure below). With time this may cause arthritis between the humeral head and the acromion (tip of the shoulder blade).

X ray showing Shoulder Osteoarthritis

                                 

What are the symptoms and how is the condition diagnosed?

The symptoms are of gradually increasing pain and stiffness. With time the symptoms

increase and cause significant functional disability. The patient may complain of

grinding or crunching within the shoulder. In patients with rheumatoid arthritis the shoulder can be damaged at any age. Patients with rheumatoid disease may

have involvement of the other joints in the limb. 

X ray showing Rotator cuff arthropathy

             

What investigations will be needed?

An x-ray of the shoulder is needed. It will confirm the extent and type of arthritis.

A CT scan may be advised to assess loss of bone due to arthritis, to decide

on the right type of replacement. A MR scan may be advised to assess the integrity of

the rotator cuff. 

What is the treatment?

1. Initial management consists of painkillers, anti-inflammatory medication and

activity modification. It is aimed at easing the pain and regaining motion. 

2. If the above measures fail then surgery is considered. The type of surgery that

will depend on the nature and longevity of the symptoms, type and extent of arthritis, age and functional demands of the patient. 

Arthroscopic (keyhole) surgery: A relatively small operation during which a

Telescope is passed into the shoulder through one small incision (½ cm).

Additional 1-2 small stab incisions are used to pass instruments, to allow for

removal of loose bodies, inflammatory tissue and debride any loose cartilage.

Such arthroscopic debridement will provide temporary  relief. 

Shoulder replacement: The eventual solution to an arthritic shoulder is to replace

it. Different types of shoulder replacements can be used, the decision of which is

based on age, functional demands of the patient, extent of arthritis, any bony loss

and presence of a rotator cuff tear. 

Surface replacement: In this type of shoulder replacement, just the humeral head

is replaced. The advantage of this procedure is that it preserves the maximum

amount of bone and minimal soft tissue dissection is needed. If the replacement

fails in the long-term (all replacements will eventually) revision surgery to change

the prosthesis is easier.

Surface Replacement Procedure

Total shoulder arthroplasty: Both the socket (glenoid) and the ball humeral head

are replaced.

Reverse geometry total shoulder replacement: This procedure in which both the

ball and the socket are replaced and reversed, is practiced for rotator cuff

arthropathy. In the presence of a cuff tear, the deltoid is the only functioning

muscle. Reversing the normal shoulder medializes the centre of rotation of the

joint. This maximises the lever arm of the deltoid muscle and helps achieve a

better range of motion of the shoulder.

Reverse Geometry replacement

What happens if it is not treated?

It is possible that with time pain may lessen, but motion between the humeral head

and glenoid will be lost. However most patients will find that their symptoms will

increase with time and they will need further treatment

What is the success of surgical treatment?

Each of the surgical treatments is successful if they have been advised at an

appropriate stage of the disease. More than 90% patients will achieve a significant

improvement in their pain after these procedures. Success rates for regaining the

movement will vary and you may want to discuss this further with your Shoulder

Specialist. The strength in your arm will take longer to improve, and will be dependent  on the amount of pain and stiffness you had prior to the surgery.

What are the complications of surgical treatment?

1. The surgical scar may remain unattractive. An area of numbness can occur around

the scar but this does not cause any problems. 

2. Infection of the wound is possible but usually can be successfully treated with

antibiotics. Very rarely infection may spread into the joint replacement. 

3. Injury to the nerves (axillary) can occur. This may lead to altered sensations and

shoulder / limb weakness.

4. The shoulder replacement may dislocate.  

5. In the long term, the shoulder joint replacement may fail. In this case, the

replacement will need to be revised. It is expected that nearly 85-90% of shoulder

replacements will still be successful after 10 years.  

6. The replacement may fail to relieve the pain totally. 

7. Shoulder stiffness

8. Fracture of the glenoid or humerus

9. Any surgical intervention has the risk of developing complications / setbacks

which are unpredicted. These complications may have the potential to leave the

patient worse than before surgery. 

Is there anything I can do to improve the outcome?

• Keep the wounds dry and clean until they have healed.

• After the operation the therapist will see you to start movements of the shoulder.

It is important to carry out the prescribed exercises regularly, both during the

physiotherapy sessions and at home. It will help to keep the pain levels down with

analgesics so as to keep your shoulder, elbow and hand fingers moving. 

• It is advised against wearing rings on the operated side for 4 to 6 weeks after

surgery. 

When can I do various activities?

Return to work depends on many factors including the nature of the job and hand

dominance. Following shoulder replacement you will be to return to a desk job within

4-6 weeks of the operation and perform reasonable tasks with the limb by that time. 

Manual work is not generally recommended after a shoulder replacement. 

Driving should be possible within 1 or 2 weeks of keyhole surgery, and within 4 to 6

weeks of shoulder replacements. Before driving, do check that you can manage all

controls and start with short journeys.  

Shoulder Instability (Recurrent Dislocation)

Dr Senthil Velan 

MBBS, MRCS(UK) FRCS (Tr &Ortho), FEBOT(France), Fellow European Board Orthopaedics and Trauma., D Ortho,Dip SICOT(Honk Kong).

Consultant Orthopaedic Surgeon

Apollo Hospitals Ayanambakkam , Chennai, India

For appointments and queries contact us on  Ph 9566222533/ nexusortho@yahoo.com

Shoulder dislocation and instability.

What is it?

The shoulder joint is a ball and socket joint. The round end of the upper arm

bone (humerus) fits into the shallow socket (glenoid) on the shoulder blade

(scapula) much like a golf ball rests on a tee. The anatomy of the shoulder

joint makes it the most mobile joint in the body.

While this gives us the ability to move it in many directions it also makes it an easy joint to dislocate.  A complete dislocation means that the ball (humeral head) has come all the way out of the socket. When the ball comes out of the socket incompletely, it is called a partial dislocation or subluxation. When the shoulder dislocates or subluxes repeatedly it is known as shoulder instability. The shoulder joint can dislocate forward, backward  or downward. The most common type is when the shoulder slips forward (anterior).

                                       

What is its cause?

A ring of cartilage surrounds the shallow socket of the shoulder joint (glenoid).

This ring is called the labrum. The glenoid labrum increases the depth of the

socket making the shoulder joint more stable. A tough, but thin elastic tissue

(capsule) further surrounds the shoulder like a bag. The capsule contains a

series of ligaments or bands, which connect the humerus to the glenoid. 

Labrum deepens the glenoid to provide more stability.

                                                    

The most common cause for shoulder dislocation is a forceful injury like falling

on an outstretched hand (sports injuries, falls) or a hard blow to the shoulder

(a cricket injury or a road traffic accident). This is called a traumatic

dislocation.

 X rays showing dislocation of shoulder joint

                                                     

The force that causes this injury can cause the labrum to be torn

from the socket making it shallow. This lesion is known as a Bankart’s lesion

and it can lead to further episodes of subluxation or dislocation. 

Sometimes a relatively minor force may dislocate the shoulder for the first

time and the patient may feel a pop as it reduces by itself. This will occur in

people who have normal but lax joints. This is referred to as an atraumatic

dislocation.

A very small group of patients can dislocate their  shoulders without any

trauma. These type of dislocations / subluxations occur because of abnormal

working of the muscles around the shoulder. Such a condition is referred to as

‘positional instability of the shoulder’.

  

What are the symptoms and how is it diagnosed?

When the shoulder dislocates the first time after an injury, the patient will

immediately complain of pain, deformity and weakness in the shoulder. The

patient may develop bruising and complain of numbness or tingling if any of

the nerves around the shoulder have stretched.  

The symptoms of shoulder instability will range from obvious repeated

dislocations, to just pain with certain activities or shoulder positions. Patients

may complain of clicking or popping of the shoulder, the arm suddenly ‘feeling

dead’ or the shoulder been generally weak. 

MRI Scan of shoulder showing labral injury

                                            

    Arthroscopic picture showing Hill Sachs lesion

                                     .

Will further tests or investigations be needed?

After appropriate clinical assessment, an x-ray of  the shoulder is

recommended. When the shoulder is dislocated the first time an x-ray will

reveal any broken bone.   In some situations after the first injury, or if the first injury progresses to  instability, a MR Arthrogram is advised. A dye is injected into the shoulder  and a magnetic field is used to create cross sectional images of the shoulder.

Sometimes a CT scan may be recommended to assess the bony defects. 

Electrical tests may also be necessary if the patient has tingling, numbness or

an altered sensation, to assess for any nerve damage.

                                       

MR arthrogram  image showing  anterior labral  injury (Bankart  lesion)

                             

What is the treatment?

1. After the first dislocation the shoulder will need to be reduced usually in

the Accident & Emergency department. This will be carried out using a

muscle relaxant, sedative or rarely a general anaesthetic. Following

reduction of the shoulder you will be put in a sling or external brace for a

period of time. Physiotherapy is not always needed but may be advised. 

2. If the patient goes on to develop shoulder instability, further investigations

and treatment may be necessary. Further treatment will depend on the

type of instability and the kind of soft tissue or bony injuries.  

3. Physiotherapy is the initial line of management in  patients who have

developed atraumatic type shoulder instability, due to muscle imbalance or

abnormal patterns of muscle activity. Some of these cases may not

respond to physiotherapy and may need surgical intervention.

4. Surgery is the treatment of choice in patients with traumatic shoulder

instability. These patients will demonstrate soft tissue injuries (Bankart’s

lesion) or bony defects on the MR Arthrogram. Physiotherapy is unlikely to

help in such situations. The aim of surgery is to reconstruct the torn labrum or capsule.

 If there is a bony defect it will have to be filled.

 The surgery is most often done arthroscopically (key hole surgery)

 in our centre although open surgery may be needed depending upon patient factors.

Arthroscopic (keyhole) stabilisation surgery: About 3-4 small incisions of

5mm each are needed. A telescope is passed into the shoulder through

one of these incisions and special surgical instruments are passed through

the other incisions to reconstruct the labrum and capsule. The advantage

of keyhole surgery is that it is less traumatic and so recovery is quicker. It

is usually carried out as a day procedure. Loss of  movement of the

shoulder is rare after arthroscopic repair. 

Picture above showing Labral detachment

Picture  showing completed Arthroscopic(key hole) repair.

Open surgery for bony defects: If there is a significant bone loss, keyhole

surgery is not advised. In such circumstances an open

operation (Laterjet Procedure) is performed. This procedure involves transfer of a small  bone (tip of corocoid process) with its muscle attachments, to the front of the shoulder socket. The transferred bone is fixed with 1or 2 screws.

What happens if it is not treated?

If the first dislocation occurs in an adolescent there is nearly a 100% chance

that the shoulder will dislocate again. Between the ages of 13-18 years there

is nearly a 70% chance the shoulder will dislocate  again. The younger the

person, the higher the chance of re-dislocation.

If the above conditions are not treated it is likely that the symptoms will

persist. It may be that the shoulder will become less troublesome if activities

that cause the problems are stopped. It is possible that an unstable shoulder

may cause arthritis in the long term but there are  no convincing long term

studies that conclude this. 

What is the success of surgical treatment?

Surgical treatment for traumatic shoulder instability, when the shoulder

repeatedly dislocates forward, has a more than 90% success rate. 

What are the complications of surgical treatment?

1. Infection of the wound is possible and can usually be successfully treated

with antibiotics. 

2. Loss of movement is possible especially after open surgery.

3. Damage to the nerve or blood vessels is possible.

4. The operation may fail in about 5-8 % of the patients. 

5. If the repair is too tight, osteoarthritis of the shoulder may result in the

long term. 

6. When bone is transferred to address the bony defects (Latarjet

procedure), the bone may not heal.  

7. Any surgical intervention has the risk of developing complications that are

unpredicted. These complications may have the potential to leave the

patient worse than before surgery.

Is there anything I can do to improve the outcome?

Keep the wounds dry and clean until they have healed.

It is important to remember that during the operation, ligaments were

reconstructed. The shoulder will be protected in a sling after the operation and

the physiotherapist will supervise rehabilitation of the shoulder after the

operation. It is very important that the instructions are followed. 

When can I do various activities?

Return to work depends on many factors including the nature of the job and

hand dominance. Generally you will be able to return to a desk job within 4

weeks of the operation and perform reasonable tasks with the limb within 4-6

weeks. You will be unable to drive for a period of 6-8 weeks and activities like

cricket and  racquet sports are best avoided for at least 3 months. Contact sports

can be resumed after 4-6 months. 

These recommendations will vary from patient to patient.  

SLAP Tear

SLAP Tear (Superior Labral tear from anterior to Posterior) tear.

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

For Appointments and Queries
Contact 9566222533/nexusortho@yahoo.com

What is SLAP Tear ?

The biceps tendon is attached to the superior aspect of the socket of the shoulder by means of a fibrocartilagenous extension. SLAP tear (Superior Labral tear from anterior to Posterior) represents a damage to this area. There are different types of SLAP tears, varying in different grades of severity (7 grades). The tears range from degeneration/fraying to extension to the rest of the glenoid labrum (fibrocartilagenous rim structure of the socket).

Arthroscopic view of SLAP tear

Which group of patients commonly get SLAP tear?

Although any patient can sustain a SLAP tear, sports persons involved especially in  overhead activities frequently develop this lesion. Eg : volleyball players.

What symptoms do you get if you have a SLAP tear?

                        Dull throbbing ache over the shoulder

                        Pain /clicking on certain movement of shoulder(especially with arm across the                     body)

                        Difficulty in carrying on with overhead sporting activities.

                        Pain disturbing the sleep

What are the treatment options?

Most patients require surgical intervention to return back to sports. Although physiotherapy and conditioning excercises play a key role, they are usually supplementary to the surgery.

When is surgery indicated?

When the symptoms are worse to stop activities, confirmation of the diagnosis is done by clinical examination and imaging (MRI arthrogram). When SLAP tear is confirmed on investigation, initial treatment is by analgesics and physiotherapy. When conservative measures fail to improve symptoms, surgery is indicated.

MR Arthrogram showing SLAP tear

What is involved in the surgery?

Surgery is done by arthroscopic method (key hole). The advantage of having key hole surgery is recovery is quicker, better access to the problem area than open surgery and minimal scarring.

The biceps anchor which is detached from the superior aspect of the glenoid (socket) is reattached by suture anchors. 

Arthroscopic SLAP repair being carried out.

Arthroscopic view of final repair using Knotless anchors.

What is the rehab protocol followed?

For the first 4 weeks, arm is rested in a sling allowing only pendulum movements only. This period is for allowing the tissues to heal back on to the bone. After 4 weeks a Specialist shoulder physiotherapist will start muscle strengthening excercises aiming to regain full range of movement.

When can patients resume driving?

Usually by 4-6 weeks

When can patients return to sports after surgery?

It will take 5-6 months before Overhead sporting activities can be resumed at competitive level. 

Calcific Tendinitis of Shoulder

Calcific Tendinitis of Shoulder

Dr.Senthilvelan
Consultant Orthopaedic Surgeon
For Appointments/Queries
Contact 9566222533/nexusortho@yahoo.com



What is calcific tendinitis of the shoulder?

Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimetre size, calcium deposit within the tendons of the rotator cuff. The supraspinatus tendon is most frequently affected. These calcium deposits are usually found in patients at least 30-40 years old, and are more common in diabetics. It accounts for approximately 10% of all consultations for painful shoulder.


What Causes Calcific Tendinitis?

The cause of calcium deposits within the rotator cuff tendon is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.




X rays Showing Calcific Deposit



What do patients complain of ?

Some people may have the calcific deposit incidentally recognised on X-rays.
Some patients have chronic pain in the affected shoulder or radiating downward the upper arm. Especially night pain occurs often. A few people experience sudden an extreme pain in the shoulder, when a calcium deposit is resorbed.

What are the Stages of Calcific Tendinitis?

 Pre calcification Stage

Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.

Calcific Stage

During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky; it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins; this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins--this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.

 Post calcific Stage

This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.



Do all calcium deposits cause problems?
Many calcium deposits are present for years without causing pain. Only when they are large enough to be pinched between the bones when the shoulder is elevated do they cause pain. Smaller deposits may cause pain if they become inflamed, especially when the calcium salts leak from the deposit into the sensitive bursal tissues of the joint lining.


Will calcium deposit damage the shoulder?


Some calcium deposits can cause erosion by destroying a portion of the rotator cuff tendon. However most calcium deposits remain on the outside of the rotator cuff tendon the bursa (the structures that hold the joint fluid) and only cause problems because of the pain caused when they catch during shoulder movement.


Therapy of calcium deposits at the shoulder:

After failed nonoperative treatment calcium deposits can be removed, arthroscopically. If non-operative treatment, like pain medication, injections, acupuncture and so on failed and pain is still the main problem for the patient, the deposits can be removed by an arthroscopic procedure.

Calcium deposits are tracked with a needle during the operative, endoscopic, procedure. If they are found a small cloud of calcium appears and they are removed using surgical instruments like spoons and shavers.



What is involved in arthroscopic surgery to remove calcium deposits?


The procedure is done as outpatient surgery under general anaesthesia. The operation is painless, and only a mild aching sensation is felt for a few days after the operation while the skin puncture sites heal. If the calcium has eroded in a hole in the rotator cuff, then it is necessary to remove a portion of the overhanging bone which will cause a little more discomfort for a few days.

Needling of calcific deposit before arthroscopy

What happens after the removal of a calcium deposit?

The operated arm and shoulder can be used actively, as far as residual pain allows it. A sling or splint is not used. Depending on the kind of work, the patient can return to it after 1 to 6 weeks. (1 week for example for office work or 6 weeks for heavy work ).


What will happen in the future to the operated shoulder / calcium deposit?

Once the calcium clot is removed it won´t come again. There is a higher statistical chance that it might occur on the other shoulder (estimated on 10 to 20%), in the future.


References

1. Uhthoff HK. Anatomopathology of calcifying tendinitis of the cuff. In: Gazielly DF, Gleyze PTT, editors. The cuff. Paris: Elsevier; 1997. p. 144–6.

2. Rotini R, Bungaro P, Antonioli D, Katusic D, Marinelli A. Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience. Chir Organi Mov 2005;90(2):105–12.

3. Costouros JG, Bassi O, Gerber C. Arthroscopic management of calcific tendonitis of the shoulder. Presented at the American academy of orthopaedic surgeons annual meeting,2006. p. 695.

Bone disease in Multiple Myeloma

Bone disease in Multiple Myeloma

Dr.Srinivasan Narayanan

Consultant Haematologist

For appointments /Queries
Contact 956622253/ nexusortho@yahoo.com

What is Multiple Myeloma?

Myeloma is a type of cancer, usually arising in the bone marrow plasma cells producing abnormal proteins. It can affect the bones in up to 80% of the patients with this condition, causing bone pain and weak bones that can lead to fractures. The backbone, ribs, hips, long bones on the arms and legs are the commonly affected areas in this condition.

What are the symptoms and signs?

The most common symptoms of myeloma are unusual tiredness due to anaemia, recurrent infections, high calcium levels, kidney damage, bone pain and fracture of the bone.

Why Myeloma affects the bone?

Cancerous plasma cells produce abnormal substances, which lead to bone destruction by releasing the bone strengthening minerals and preventing new bone formation. This can eventually cause a “Pathological” fracture.

What is a pathological fracture?

Some diseases such as Myeloma, other cancers, infections can weaken the bones, which lead to a fracture of the bone spontaneously or with trivial injury only.

How to diagnose Mutliple Myeloma?

If Multiple myeloma is suspected, blood test to check full blood count, renal functions, calcium and immunoglobulins (abnormal proteins in blood and urine) will be helpful to determine if this is a possibility.

If any of these tests are abnormal, bone marrow biopsy and X-rays (sometimes MRI scans) are done to look for abnormal plasma cells in the marrow and bone diseases respectively, to confirm the diagnosis.

What are the treatment options for Myeloma bone disease?

Chemo/radiotherapy: If bones are affected with myeloma, it suggest active disease requiring treatment with chemotherapy, and this will help to reduce further bone damage. Low dose radiotherapy to the most affected bone is given, which helps to reduce pain.

Bisphosphonates: Bone strengthening medications called ‘Bisphosphonates’ are routinely used to reduce bone pain, prevent further breakdown of the bone and reduces the risk of bone fractures.

Surgery: Long bone fractures or bones ‘at risk’ of fracture should be fixed with surgery and the type of surgery required will depend on the type of fracture, proximity to the joints and the extent of bone disease.

Vertebral fracture causes loss of height and can compromise mobility. Minimally invasive procedures such as “Vertebroplasty” or “Kyphoplasty” are used to regain the lost height, reduce bone pain and maintain the normal bone alignment.

How is Vertebroplasty done:

Vertebroplasty is done under radiological guidance by spinal surgeons. A type of bone cement is injected into the spine to strengthen and stabilise the bone. This helps to reduce bone pain and improve mobility.

How is Kyphoplasty done:

Kyphoplasty is similar to Vertebroplasty, but involves inserting and inflating a balloon in the vertebral bone and then the bone cement is injected.  This also helps to regain the height and the shape of the collapsed vertebrae.

Tunnel placement in Anatomical ACL reconstruction

Tunnel placement in Anatomical ACL reconstruction: (using 4 strand Hamsting tendons)

By Dr. Ravi Kirubanandan,

Consultant Orthopaedic Surgeon

For Appointments and queries contact  09629240084/ nexusortho@yahoo.com

The position of femoral tunnel placement have changed many times in the past decade. Accurate placement of the tunnels appears difficult to achieve. Studies have shown that in more than 50% of patients the tunnels have been poorly placed. The aim of this article is suggest, a reproducible tunnel placement using standard intra-operative landmarks for the use of 4-strand ACL reconstructions. The radiological understanding of the tunnel positions as explained.

Native ACL location:

Centre of the origin as seen on lateral radiographs was located on the femur at a mean of 66% from the anterior edge of Blumensaat’s line (inter- condylar root line). The tibial attachment was located at the junction of the anterior and middle thirds of the tibial plateau.

Knee Arthroscopy - Intra-articular landmarks:

Femoral tunnel:

Identification of the ridge between the AM & PL bundle is the key. The recommended entry point is just posterior to the ridge. But this is difficult to reproduce between surgeons and every other surgery. The new method is using a ruler to measure the AP length of the femoral condyle (visulalisation is done via a 3^rdportal). The mean mid point between the bony margin excluding the articular surface is identified and entry point made with an awl. The height of the entry point from the inferior articular surface is 2mm + ½ of the graft width.

 Tibial tunnel:

The lateral tibial spine and anterior horn of lateral meniscus identifier. 5 mm medial to this juncture of Lateral tibial spine and ant. Horn of lateral meniscus is the marker for the tip aimer jig. The other method is to identify the remenant of ACL stump as a landmark.

Anterior placement of tibial tunnel = Impingement in extension + Cyclops lesion formation

Radiological understanding of Tunnels:

Femoral tunnel:

Lateral view: The position of the femoral tunnel was assessed on the lateral radiographs (Fig. 1). The length of Blumensaat’s line was measured and the points of intersection between it and the anterior and posterior borders of the femoral tunnel were identified. Based on these measurements, the position of the centre of the femoral tunnel was calculated and then expressed as a percentage of the total length of Blumensaat’s line.

AP view: Angle of inclination of the femoral tunnel can be measured in the AP view. Vertical placement of the tunnel leads to increased rotational instability and degenerative radiological changes. This issue was primarily related to the trans-tibial placement of femoral technique.

By placing the tunnel using the anatomical method based on intra-articular landmarks, clearly avoids the placement vertically.

Vertical Femoral tunnel placement = rotational instability and early OA changes

Tibial Tunnel:

Lateral view: Placement of the tibial tunnel was assessed on the lateral radiographs (Fig. 1) as follows: the length of the tibial plateau was determined and the positions of the anterior and posterior borders of the tibial tunnel were identified relative to the anterior edge of the plateau. This allowed the position of the centre of the tunnel to be calculated and then expressed as a proportion of the total length of the tibial plateau.

AP view: Placement of the tibial tunnel was assessed on AP radiographs (Fig. 2) by measuring the total width of the tibial plateau. The distances from the medial edge of the medial tibial plateau to both the medial and lateral borders of the tibial tunnel were measured.

Posterior Tibial tunnel placement = early graft rupture

So what is the ideal radiological positioning of the tunnels ?

Femoral Tunnel : Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel with a mean of 86%  along Blumensaat’s line

Tibial tunnel : with 48% along the tibial plateau.

Recommended radiological position of the tunnels in a) the coronal and b) the sagittal views after reconstruction of the anterior cruciate ligament.

Ref:

1. Pinczewski L, Tashiro S et al; Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament.  J Bone Joint Surg [Br] 2008;90-B:172-9.

2. Pictures – drawn by Author, Dr. Ravi Kirubanandan.