Interesting X-rays

Here are some interesting x-rays.  

So one day int he office, an older patient comes in and says she had a left rotator cuff repair by Dr. Kishmeintookus (not his real name, of course) and she has had pain and been unable to move her shoulder since surgery.  Therapy had been causing pain and the therapist did not seem to know why she was not getting better.   I took some simple x-rays and found the following.

The above x-rays show that the metal anchors have pulled out of the bone and are sitting in the joint.  

This points out the importance of having good bone and tendon of one is to consider an arthroscopic rotator cuff repair.  Did the tendon fail to heal and did the anchors pull out due to weak tendon, weak bone, tear size, technique issues, patient compliance or therapy practices?  No way to know.

I suspect that Dr. Kishmeintookus did not really examine the patient and certainly did not x-ray the patient.  If he had he would have found that the patient's rotator cuff repair had failed.  I suspect that she never really had a fixable rotator cuff, since it had been less than a year since her repair. She also had a "pseudoparalytic shoulder".  A "pseudoparalytic shoulder" is a shoulder that appears paralyzed but, in fact, is unable to move due to a massive rotator cuff tear and not true paralysis or nerve injury. 

In an effort to relieve this patient's pain, I took her to surgery to remove the metal anchors arthroscopically.  The cuff was unfixable.  We knew that from the x-rays.  

With the anchors removed, the pain was improved, but she is unable to lift the arm.  The only way to recover function in this case is to perform a reverse shoulder replacement. 

Below are the patient's x-rays of the other shoulder taken at the same visit.  What we see here is that the humeral head (the ball) is not in the center of the glenoid (the socket).  It has moved upward out of the socket as a result of a massive chronic rotator cuff tear.  If there were any cuff that could be fixed, it would not heal and would lead to a poor outcome. 

This is another case that could benefit from a reverse should replacement if she had pain and an impairment that bothered her. The good thing is that this patient does not have any pain in her right shoulder.  She has about 50% of a normal range of motion but has good function.  I would leave well enough alone. 

Thanks,

JTM, MD

How sex influences joint contractures

Why do men get Dupuytren’s contracture and women get adhesive capsulitis?

The myofibroblast is implicated in several superficial (fascial) fibrosing disorders that occur at different ages and are more likely to be found in specific areas of the body depending on the sex of the patient. These conditions have common histopathologic features and are characterized by inflammation, myofibroblast proliferation, and dense scar formation. Men are primarily affected with Dupuytren’s, Ledderhose, and Peyronie’s diseases. Men also have an increased incidence of posttraumatic elbow contracture. Women have a higher incidence of adhesive capsulitis.

Fibrosing disorders in men
Dupuytren’s contracture is reported to be up to nine times more likely to occur in men than in women. This condition consists of nodules and cords that cause contractures of the palmar fascia—most commonly affecting the ring and little fingers. The result is a progressive flexion deformity, preventing the patient from extending the affected digits.

It has been associated with trauma, diabetes, alcoholism, liver disease, and epilepsy therapy with phenytoin. The clinical description of Dupuytren’s uses stages based on the degree of flexion contracture; the histological description uses proliferative, involutional, and residual stages.

Ledderhose disease is the corresponding condition in the plantar fascia of the feet. It is also more common in men through the sixth decade of life.

Peyronie’s disease is contracture of the fascia in the tunica albicans of the penis. It is most commonly acquired at the age of 55. This causes a lump or plaque within the penis and a persistent curvature with erection. Although Peyronie’s disease does not cause impotence, it can cause a change in the erect penis through indentation, diameter, or length. As many as 20 percent of men with Peyronie’s disease have associated Dupuytren’s or Ledderhose disease.

Fibrosing disorders in women
In women, a predilection for the myofibroblast to cause adhesive capsulitis can be found; 70 percent of all cases of adhesive capsulitis occur in women. Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule. The development of adhesive capsulitis has been associated with diabetes mellitus, thyroid dysfunction, Dupuytren’s contractures, autoimmune diseases, and the treatment of breast cancer.

Adhesive capsulitis is characterized by four clinical stages, as well as a three-stage histopathologic progression. Stage 1 is the ‘pre-adhesive’ stage, which is characterized by gradual onset of pain and loss of range of motion. A biopsy will show hypervascular and hypertrophic synovitis with normal capsular tissue. Motion can be restored with an intra-articular injection of local anesthetic and corticosteroid.

Stage 2 is the “freezing” stage, with increasing pain and restriction of motion that cannot be restored under anesthesia. A biopsy taken during this stage of the disease will show hypervascular and hypertrophic synovitis as well as perivascular and capsular scarring, with dense myofibroblast proliferation.

Stage 3 is the “frozen” stage, with pain limited to the end range of motion, and a significant decrease in range of motion. Intra-articular injections of lidocaine are not effective. A biopsy taken during this state will show a thin synovial layer without hypertrophy or hypervascularity, dense scar tissue, and a proliferation of myofibroblasts within the capsular tissue.

Stage 4 is the “thawing” stage, with minimal pain and gradual improvement in range of motion. Without corticosteroid injections or surgery, it can take up to 2 years to completely regain strength and motion.

Does sex make a difference?
Why does the myofibroblast cause contractures in different joints in men than in women? This is unknown at this time, but is yet another example of how the same disease process affects your male and female patients differently.

From AAOS Now
February 2010 Issuehttp://www.aaos.org/news/aaosnow/feb10/clinical6.asp

Thanks.

JTM, MD

Save Your Knees

The American Academy of Orthopedic Surgeons has a website that seems self explanatory.  It is designed and written for patient education.  Check it out here.


Thanks.


JTM, MD