Knee Scope: Medial Meniscectomy

These are some clips from a recent knee arthroscopy. The first clip shows the probing of the medial meniscus tear. The next clip shows the continuation of the medial meniscectomy.

Thanks.

JTM, MD

Arthroscopic Rotator Cuff Repair Pictures

The nice thing about a blog is that I post whatever I want when I have time and energy to do so. This is one of those times. These are some pictures of an arthroscopic cuff repair. The acromioplasty and distal clavicle excision are omitted.

Below are some intraoperative pictures from a recent arthroscopic rotator cuff repair. This first picture reveals the initial debridement of the footprint (attachment) of the rotator cuff. The MRI did not reflect the true extent of the damage to the cuff. The tear was approximately 2 cm from front to back.




The exposed bone is then burred down to bleeding bone.



Here is the anchor inserted into the bone in the greater tuberosity just at the edge of the joint cartilage. The sutures are attached to the bone anchor below. The sutures are then passed through the tendon.


Here I grab the sutures during the repair. I pass the sutures through the small plastic cannulas that pass through the skin.


Below some knots are tied as the first part of the repair. This completes the first row (medial row) of the repair.


Tying knots with a knot pusher below.






Medial row of sutures completed below.



Note the plastic cannula to the left in the below picture.




Sutures from the medial row are then passed through the lateral cannula and are attached to the Versalock suture anchor outside of the shoulder. The anchor is then slid in through the cannula and placed in the correct position on the bone.


Below the first sutures are placed into the bone in the lateral row. Note the closure of the hole in the cuff tear.



Here you see the tiny gap in the repair that I then repaired with another suture. This was passed in a "horizontal mattress" pattern through the tendon. It was then attached to another anchor that was passed into a second Versalock anchor.


Multiple images of the final repair below.











Look, no gaps and a water tight closure.

Thanks.

JM

The Curveball in the Young Pitcher

A biomechanical comparison of forces generated in the curveball, fastball, and change-up pitches has been undertaken by S. Dun et al (Am J Sports Medicine. 2008;36[4]:686-692) to determine the risks of curveball pitches to youthful elbows. There has been a belief that the curveball pitch is harmful, especially to the immature ulnar collateral ligament, more so than, for example, the fastball.

Dun et al observed 29 baseball pitchers, aged 12.5±1.7 years, who threw 5 of each pitch type (ie, fastball, curveball, and change-ups). A three-dimensional motion analytic system was used to measure varus torque, shoulder internal rotation torque, and proximal force at the elbow and shoulder. The greatest force was generated by the fastball, then the curveball, and least the change-up.

The authors concluded that the curveball is not potentially more harmful to the young elbow than the fastball and that the number of pitches thrown carries a stronger risk than the nature of the pitch.

(ORTHOPEDICS 2008; 31:537)

Even young athletes can sustain strain and overuse injuries from too much training and sports. The problem that I commonly see in the office is the case of the young athlete being pushed by the parents. These kids just want to play for fun, but too often there is some well intentioned (read annoying and delusional) mother of father who thinks their son or daughter is the next great thing in their sport. These kids usually give up the sport as soon as they have the nerve and sense of independence that enables them to do so. Those athletes who really excel and go on to professional careers in sports do not need their parents to push them, they need their parents for support. Big difference.

Thanks.

JTM, MD

Our Office

From 1991 to August, 2007, I practiced as a member of Manchester Orthopedic Surgery and Sports Medicine in Manchester, CT. On August 20, 2007, I open my new practice, The Connecticut Center for Orthopedic Surgery, LLC.

I am very proud of my association with my former partners and continue to maintain a great relationship with them. Practices that split up often degenerate into a messy legal fight over assets and patients. I credit my former partners with fostering a friendly and professional evolution of our practices. We continue to refer patients to each other even though my new office is right across the street from the old one.

I continue to hold them in high regard and consider them two of the finest individuals and best orthopedic surgeons I have had the opportunity to know.

Anyway...

When I moved to start my own practice at The Connecticut Center for Orthopedic Surgery, I knew that it would be a representation of me and the kind of practice I could create on my own. Although I am on the active staff of both Hartford Hospital and ECHN Hospital (Manchester Memorial Hospital), I do not work for nor am I employed by any hospital system. In the Wethersfield office, I am in the Hartford Hospital Health care building on the Silas Deane Highway.

It took me 16 years to figure out what I wanted in an office. Because I spend so much time there, I wanted the office to be someplace of which I could be proud and a place I would not mind spending lots of time. I wanted the office to have a "wow factor" for patients. It had to be functional, modern, high tech and it should not seem like a doctor's office. It should be warm and soothing for patients and a place my staff would enjoy working. I gave considerable thought to the materials and design. Although I had help with some of the specifics and selections, I would like to think it it a great representation of what I was trying to achieve.

The outside of the building was designed by the builder.


Once inside the office, you can see the attention I put into the experience of the "office visit". No one really wants to go to the doctor. If I can make the experience a bit more pleasant and soothing, patients can focus on themselves and their problems.

Just inside the front door...


Our reception area and the check in desk...


The main hallway...


Notice the glass door on the left. It's frosted so you can't see through it. The ceiling is definitely one of the best features of the office design.

We have 6 exam rooms...


Each exam room is open and spacious.


In one of the rooms, we have a power exam table that raises and lowers for patients who cannot step up onto a regular exam table.


The sink faucets in the exam rooms and hallway have infrared activation switches. Very cool!

When I selected the x-ray system, I recognized that one of the biggest delays in an office visit is the trip to x-ray. Below is the latest digital x-ray machine. No old fashioned films are produced. No x-ray cassettes required. Images can be provided to patients on paper or CD. These digital images a superior to standard film x-rays in every way.

The image is taken by the C-arm below. The image goes directly to our computer system where it can be modified. The image contrast can be adjusted or the image can be magnified. Specific bone and joint angles can be measured digitally. The amount of displacement of a specific fracture fragment can be measured to a tenth of a millimeter.

All of this technology allows me to compare patient x-rays from one week to the next and measure limb alignment and joint damage from arthritis.


The above x-ray C-arm takes the images which are then sent to the high resolution computer monitors outside of my office seen below.


Here is the checkout desk...


Patients scheduling tests or surgery can do so in a more private area.

Below is my office. A work still in progress...


Physical therapy is available in the practice. We gave considerable thought to the PT space design as well. It is open and spacious. There is also a private room for evaluations or treatments if necessary.


The treadmill is the newest addition to the PT facility.



The office is only part of the reason that I believe we have the best orthopedic office in the area. Our staff has considerable experience in caring for complicated orthopedic patients. They are totally dedicated to to serving our patients. I know that each one takes great personal pride in their job and taking care of our patients.

A beautiful office would not make any difference if I and my staff did not also provide the finest orthopedic care to our patients. I will take an opportunity to brag about my team at The Connecticut Center for Orthopedic Surgery in a future posting. They just have to sit still long enough for me to take some pictures. Needless to say, I am very proud of them and the job they do.

(Note to the CCOS staff: No, this does not mean you can all ask for a raise!)

Thanks.

JTM, MD

Shoulder Trauma

Trauma to the shoulder is common. Injuries range from a separated shoulder resulting from a fall onto the shoulder to a high-speed car accident that fractures the shoulder blade (scapula) or collar bone (clavicle). One thing is certain: everyone injures his or her shoulder at some point in life.

Anatomy

Shoulder Anatomy

The shoulder is made up of three bones:

• Scapula (shoulder blade)
• Clavicle (collar bone)
• Humerus (arm bone)

These bones are joined together by soft tissues (ligaments, tendons, muscles, and joint capsule) to form a platform for the arm to work.

The shoulder is made up of three joints:

• Glenohumeral joint
• Acromioclavicular joint
• Sternoclavicular joint

The shoulder also has one articulation, which is the relationship between the scapula (shoulder blade) and the chest wall.

The main joint of the shoulder is the glenohumeral joint. This joint comprises a ball (the humeral head) on a golf-tee-shaped joint (the glenoid of the scapula).

The bones of the shoulder are covered by several layers of soft tissues.

• The top layer is the deltoid muscle, a muscle just beneath the skin, which gives the shoulder a rounded appearance. The deltoid muscle helps to bring the arm overhead.
• Directly beneath the deltoid muscle is sub-deltoid bursa, a fluid-filled sac, analogous to a water balloon.

Types of Shoulder Injuries

There are many types of shoulder injuries:

• Fractures are broken bones. Fractures commonly involve the clavicle (collar bone), proximal humerus (top of the upper arm bone), and scapula (shoulder blade).
• Dislocations occur when the bones on opposite sides of a joint do not line up. Dislocations can involve any of three different joints.
• A dislocation of the acromioclavicular joint (collar bone joint) is called a "separated shoulder."
• A dislocation of the sternoclavicular joint interrupts the connection between the clavicle and the breastbone (sternum).
• The glenohumeral joint (the ball and socket joint of the shoulder) can be dislocated toward the front (anteriorly) or toward the back (posteriorly).
• Soft-tissue injuries are tears of the ligaments, tendons, muscles, and joint capsule of the shoulder, such as rotator cuff tears and labral tears.

The following discussion will focus on fractures and dislocations.

Cause

Fractures

Fractures of the clavicle or the proximal humerus can be caused by a direct blow to the area from a fall, collision, or motor vehicle accident.

Because the scapula is protected by the chest and surrounding muscles, it is not easily fractured. Therefore, fractures of the scapula are usually caused by high-energy trauma, such as a high speed motor vehicle accident. Scapula fractures are often associated with injuries to the chest.

Shoulder Dislocations

• Anterior dislocations of the shoulder are caused by the arm being forcefully twisted outward (external rotation) when the arm is above the level of the shoulder. These injuries can occur from many different causes, including a fall or a direct blow to the shoulder.
• Posterior dislocations of the shoulder are much less common than anterior dislocations of the shoulder. Posterior dislocations often occur from seizures or electric shocks when the muscles of the front of the shoulder contract and forcefully tighten.

Shoulder Separations

Dislocations of the acromioclavicular joint can be caused by a fall onto the shoulder or from lifting heavy objects. The term "shoulder separation" is not really correct, because the joint injured is actually not the true shoulder joint.

Symptoms of Fractures

Symptoms of fractures about the shoulder are related to the specific type of fracture.

General Findings

• Pain
• Swelling and bruising
• Inability to move the shoulder
• A grinding sensation when the shoulder is moved
• Deformity -- "It does not look right"

Specific Findings: Clavicle Fracture

Fractured clavicle (collarbone)

• Swelling about the middle of the collarbone area
• An area that may have a "bump," which is actually the prominent ends of the fracture under the skin
• Shoulder range of motion is limited, although not as much as with fractures of the proximal humerus

Specific Findings: Proximal Humerus Fracture

Fractured head of the humerus.

• A severely swollen shoulder
• Very limited movement of the shoulder
• Severe pain

Specific Findings: Scapular Fracture

Fracture patterns in the scapula

(Reproduced with permission from Zuckerman JD, Koval KJ, Cuomo F: Fractures of the scapula, in Heckman JD (ed): Instructional Course Lectures 42. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 271-281.)

• Pain
• Swelling
• Severe bruising about the shoulder blade

Specific Findings: Shoulder Separation (Acromioclavicular Joint Separation)

An acromioclavicular joint dislocation with extreme elevation of the clavicle.

(Reproduced with permission from Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:11-18.)

• Pain over the top of the shoulder
• A prominence or bump about the top of the shoulder
• The sensation of something sticking up on the shoulder

Specific Findings: Shoulder Dislocation (Glenohumeral Joint Dislocation)

Shoulder instability

• A prominence about the front of the shoulder
• Inability to move the arm
• An arm rotated outward
• The sensation of a "dead arm"

Diagnosis

Most fractures are diagnosed with X-rays of the area and by physical examination. Sometimes, additional imaging techniques, such as computed tomography, are necessary.

Treatment Options

Clavicle Fractures

Most clavicle fractures can be treated without surgery. Surgery is necessary when there is a compound fracture that has broken through the skin or the bone is severely out of place. Surgery typically involves fixing of the fracture with plates and screws or rods inside the bone.

Proximal Humerus Fractures

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is usually required. Surgery usually involves fixation of the fracture fragments with plates, screws, or pins or it involves shoulder replacement.

Scapula Fractures

Most fractures of the scapula can be treated without surgery. Treatment involves immobilization with a sling or shoulder immobilizer, icing, and pain medications. The patient will be examined for additional injuries.

About 10% to 20% of scapula fractures need surgery. Fractures that need surgery usually have fracture fragments involving the shoulder joint or there is an additional fracture of the clavicle. Surgery involves fixation of the fracture fragments with plates and screws.

Shoulder Separations (Acromioclavicular Joint)

Treatment of shoulder separations is based on the severity of the injury as well as the direction of the separation and the physical requirements of the patient.

Less severe shoulder separations) are usually treated without surgery.

Severe separations in an upward direction or dislocations in the backward or downward directions often require surgery. Surgery involves repair of the ligaments.

Professional athletes and manual laborers are often treated with surgery, but the results are often unpredictable.

Shoulder Dislocations (Glenohumeral Joint)

The initial treatment of a shoulder dislocation involves reducing the dislocation ("putting it back in the socket"). This usually involves treatment in the emergency room.

The patient is given some mild sedation and pain medicine, usually through an intravenous line. Often, the physician will pull on the shoulder until the joint is realigned. Reduction is confirmed on an X-ray and the shoulder is then placed in a sling or special brace.

Additional treatment at a later date is based on the patient's age, evidence of persistent problems with the shoulder going out of place, and the underlying associated soft-tissue injury (either to the rotator cuff or the capsulolabral complex).

Patients who are 25 years of age or younger generally require surgery. Persistent instability (repeat dislocations) of the shoulder usually requires surgery. Surgery involves repair of the torn soft tissues.

Life After a Shoulder Injury

Life after a shoulder fracture, separation, or dislocation can be greatly affected for several weeks or even months. Most shoulder injuries whether treated surgically or nonsurgically require a period of immobilization followed by rehabilitation.

If the injury was not severe, there is fairly rapid improvement and return of function after the first 4 to 6 weeks. Shoulder exercises, usually as part of a supervised physical therapy program, are usually necessary. Exercises decrease stiffness, improve range of motion, and help the patient regain muscle strength.

Some of the information you should discuss with your orthopaedic surgeon includes the following:

• The exact type of your injury
• The severity of the injury
• The treatment plan
• The possible complications
• Whether surgery will be necessary
• When it is expected that you will be maximally improved
• What is the expected outcome will be both in the short term and in the long term

Thanks

JTM, MD


(http://orthoinfo.aaos.org/topic.cfm?topic=A00394)

Shoulder Fractures and Reverse Total Shoulders

Fractures of the proximal humerus are common in my practice and are some of the toughest fractures to treat. There are as many different types of fractures as there are patients. This is the case of an active 75 year old female who sustained this very severely comminuted fracture of the proximal humerus (shoulder). As you can see, the head of the humerus is fractured into many pieces the a large portion of the joint surface of the head compressed downward away from the joint.






Below is the CT scan of the patient.





The above fracture is so severely comminuted (multiple fragments) with displacement of the humeral head, that it cannot be repaired without a shoulder replacement. A replacement is clearly indicated here. In a younger patient, with an intact rotator cuff, we can perform a partial shoulder replacement, preserving the bone attached to the rotator cuff and repairing it around the prosthesis.

This is a diagram of how that would be performed.

The final repair would like like th diagram below. The rotator cuff would cover the top of the prosthesis and, once the bones heal, the cuff will stabilize the joint enabling the patient to lift the arm.

The key to success here is an intact and functional rotator cuff and tuberosities that heal around the prosthesis.
Unfortunately, in some patients, the bone (greater and lesser tuberosities) will not heal, the rotator cuff may be weak or may tear resulting in extremely poor function and pain. The patient may be unable to lift the arm.

The reverse shoulder replacement does not depend on an intact rotator cuff to provide good function. If the deltoid is intact, patients can elevate the arm and have excellent pain relief and function. If necessary, the rotator cuff and tuberosities can be excised and as long as the prosthesis remain securely fixed to the bone, results are often superior to those of hemiarthroplasty. This approach can be appropriate in patients over 70 years.

I usually do not completely excise the entire cuff. I try to preserve the subscapularis and lesser tuberosity and posterior cuff and greater tuberosity. The supraspinatus is excised and the biceps is treated with tenodesis.

This patient had a massive irreparable rotator cuff tear anyway, making the reverse shoulder replacement the only acceptable option for her.



Here, you can see the retained tuberosities healing around the upper part of the prosthesis. She is doing remarkably well with minimal pain and 90 degrees of forward elevation at only 4 weeks after surgery. We are proceeding slowly with therapy to encourage the tuberosities to heal, although, if they never healed, she would still do well.


Thanks,

JTM, MD