Here are eight trends impacting shoulder surgery and sports medicine that shoulder surgeons should be aware of heading into 2011.
1. Arthroscopic shoulder surgery. Over the past few years, more shoulder surgeons have begun performing arthroscopic shoulder repairs as opposed to the open surgeries. "The trend is to perform procedures in the shoulder that have been traditionally done open arthroscopically," says Jason Rabenold, MD, a shoulder surgeon at Mid County Orthopaedic Surgery and Sports Medicine in St. Louis. "That's a good thing to do as long as you don't violate the principles of open shoulder surgery. You don't want to compromise your repair because you are trying to do it in a less-invasive manner." Surgeons can treat rotator cuff tears, shoulder dislocations, labral tears, AC joint arthritis and proxiamal biceps pathology using arthroscopic techniques.
"A lot of the trends, research and changes have gone towards minimally invasive advanced arthroscopic techniques especially in research for improved outcomes for rotator cuff repair," says Robert J. Nicoletta, MD, director of the division of sports medicine at Cambridge Health Alliance in the Boston area. "I think that more and more patients are becoming educated as to the advances in shoulder arthroscopy and it's becoming the gold standard now to have arthroscopic repairs of rotator cuffs and shoulder instability."
2. Improved equipment for old procedures. Better anchors, sutures and tools for surgeons performing shoulder surgeries have been developed over the past few years, says Lewis Yocum, MD, an orthopedic surgeon at Kerlan-Jobe Orthopaedic Clinic in Los Angeles. "I don't thing there's been many new trends, I think there is more of a refinement on old procedures," he says. Many shoulder surgeons now use high strength sutures and absorbable anchors and can simulate bone construction, says Dr. Nicoletta. "Before, there was a post-op morbidity, long hospital stay and more rehabilitation than patients usually go through now," he says. "The advances in instrumentation have been developed to allow us to repair these tears through two or three small incisions."
3. Bone conserving measures. Instead of performing a total shoulder replacement for young patients, there is a trend toward using more bone conserving measures, says Dr. Rabenold. Some surgeons are shaving off the arthritis and capping it without disturbing the canal when treating arthritis. "There is very little clinically proven advantages to these types of procedures right now," says Dr. Rabenold.
4. Biologic treatments for shoulder injuries. Biologics in shoulder surgery, such as the use of stem cells and platelet-rich plasma injections, have been a popular new source of treatment for athletes at all levels of play. For biologic resurfacing procedures, surgeons sew an allograft from the knee or rolled-up Achilles tendon onto the socket to act as a bumper, says Dr. Rabenold. "That seems to do well but does wear out over five years," he says. "Some people have good results and some people don't. The theory is that it would protect the socket from eroding over time."
Platelet-rich plasma injections have been experimentally used for knee, elbow and shoulder repair, though clinical studies have not yet proven the injection an effective treatment. "PRP is being used in the operating room and in the office for shoulder tendonitis, impingement and rotator cuff injuries," says Dr. Nicoletta. "The research hasn't been brought out in terms of long-term studies. PRP is being used more and more in athletes, especially in the knee." He thinks that biologics is the key to the future of shoulder surgery, especially focusing on cell-based targeted therapies and stem cell use. "We've done about all we can do arthroscopically," he says. "Now we need to focus on cell-based technologies and increasing the healing potential of the tendon."
5. Reverse total shoulder arthroplasty. Reverse total shoulder arthroplasty is now possible because of technology made by several companies and approved by the FDA in the past decade, says Dr. Rabenold. Surgeons use the reverse total shoulder arthroplasty for older patients who have a combination of arthritis and massive rotator cuff tears. "It's reverse because you put the ball in the socket and the socket where the ball used to be," says Dr. Rabenold. "It's not fused together but more constrained than a normal shoulder. The procedure allows the patient to use his or her deltoid muscle to elevate the arm above their head, which makes up for the fact that the rotator cuff is not working."
The reverse total shoulder arthroplasty is usually only performed by shoulder surgeons who have trained in the procedure. "The procedure itself can certainly be learned but you really need to learn the consequences of failure," says Dr. Rabenold. "If you don't spend a lot of time doing shoulder surgery it's harder to perform the procedure with the best long-term outcomes."
6. Shoulder replacement surgery. Patients with osteoarthritis now are more likely receive treatment with total shoulder replacement surgery instead of hemiarthroplasty. "The technology and techniques have improved so that patients are more comfortable that they would benefit from a shoulder replacement if they have arthritis," says Dr. Rabenold. "It's more common now to do a total shoulder replacement for these patients, which means replacing both the humeral aspect and the socket." New data shows that total shoulder replacements could be better than hemiarthroplasty for patients with arthritis.
7. Increased awareness of conservative treatment. Not all shoulder injuries need surgery, says Dr. Yocum, and it will be important for shoulder surgeons to build working relationships with physical therapists and other rehabilitation specialists for referring patients. "There is an increased awareness of what conservative programs can do for mild instabilities," says Dr. Yocum. "There is also a lot of good rehabilitation that happens after surgery. We don't rely on surgery alone. We combine it with physical therapy afterwards."
8. Focus on sports injury prevention. One of the easiest ways to treat sports-related injuries is to prevent them, and several national campaigns have launched over the past few years aimed at preventing injuries in young athletes. The American Orthopaedic Society for Sports Medicine supports STOP Sports Injuries, a campaign that provides educational material for players, coaches, parents and physicians about the proper techniques for preventing injuries. One of the biggest concerns among shoulder surgeons is throwing injuries related to baseball players, especially pitchers, particularly rotator cuff injuries. Dr. Yocum says it's important to remind young patients to take breaks from playing sports and cross train to prevent overuse injuries.
"A lot of the trends, research and changes have gone towards minimally invasive advanced arthroscopic techniques especially in research for improved outcomes for rotator cuff repair," says Robert J. Nicoletta, MD, director of the division of sports medicine at Cambridge Health Alliance in the Boston area. "I think that more and more patients are becoming educated as to the advances in shoulder arthroscopy and it's becoming the gold standard now to have arthroscopic repairs of rotator cuffs and shoulder instability."
2. Improved equipment for old procedures. Better anchors, sutures and tools for surgeons performing shoulder surgeries have been developed over the past few years, says Lewis Yocum, MD, an orthopedic surgeon at Kerlan-Jobe Orthopaedic Clinic in Los Angeles. "I don't thing there's been many new trends, I think there is more of a refinement on old procedures," he says. Many shoulder surgeons now use high strength sutures and absorbable anchors and can simulate bone construction, says Dr. Nicoletta. "Before, there was a post-op morbidity, long hospital stay and more rehabilitation than patients usually go through now," he says. "The advances in instrumentation have been developed to allow us to repair these tears through two or three small incisions."
3. Bone conserving measures. Instead of performing a total shoulder replacement for young patients, there is a trend toward using more bone conserving measures, says Dr. Rabenold. Some surgeons are shaving off the arthritis and capping it without disturbing the canal when treating arthritis. "There is very little clinically proven advantages to these types of procedures right now," says Dr. Rabenold.
4. Biologic treatments for shoulder injuries. Biologics in shoulder surgery, such as the use of stem cells and platelet-rich plasma injections, have been a popular new source of treatment for athletes at all levels of play. For biologic resurfacing procedures, surgeons sew an allograft from the knee or rolled-up Achilles tendon onto the socket to act as a bumper, says Dr. Rabenold. "That seems to do well but does wear out over five years," he says. "Some people have good results and some people don't. The theory is that it would protect the socket from eroding over time."
Platelet-rich plasma injections have been experimentally used for knee, elbow and shoulder repair, though clinical studies have not yet proven the injection an effective treatment. "PRP is being used in the operating room and in the office for shoulder tendonitis, impingement and rotator cuff injuries," says Dr. Nicoletta. "The research hasn't been brought out in terms of long-term studies. PRP is being used more and more in athletes, especially in the knee." He thinks that biologics is the key to the future of shoulder surgery, especially focusing on cell-based targeted therapies and stem cell use. "We've done about all we can do arthroscopically," he says. "Now we need to focus on cell-based technologies and increasing the healing potential of the tendon."
5. Reverse total shoulder arthroplasty. Reverse total shoulder arthroplasty is now possible because of technology made by several companies and approved by the FDA in the past decade, says Dr. Rabenold. Surgeons use the reverse total shoulder arthroplasty for older patients who have a combination of arthritis and massive rotator cuff tears. "It's reverse because you put the ball in the socket and the socket where the ball used to be," says Dr. Rabenold. "It's not fused together but more constrained than a normal shoulder. The procedure allows the patient to use his or her deltoid muscle to elevate the arm above their head, which makes up for the fact that the rotator cuff is not working."
The reverse total shoulder arthroplasty is usually only performed by shoulder surgeons who have trained in the procedure. "The procedure itself can certainly be learned but you really need to learn the consequences of failure," says Dr. Rabenold. "If you don't spend a lot of time doing shoulder surgery it's harder to perform the procedure with the best long-term outcomes."
6. Shoulder replacement surgery. Patients with osteoarthritis now are more likely receive treatment with total shoulder replacement surgery instead of hemiarthroplasty. "The technology and techniques have improved so that patients are more comfortable that they would benefit from a shoulder replacement if they have arthritis," says Dr. Rabenold. "It's more common now to do a total shoulder replacement for these patients, which means replacing both the humeral aspect and the socket." New data shows that total shoulder replacements could be better than hemiarthroplasty for patients with arthritis.
7. Increased awareness of conservative treatment. Not all shoulder injuries need surgery, says Dr. Yocum, and it will be important for shoulder surgeons to build working relationships with physical therapists and other rehabilitation specialists for referring patients. "There is an increased awareness of what conservative programs can do for mild instabilities," says Dr. Yocum. "There is also a lot of good rehabilitation that happens after surgery. We don't rely on surgery alone. We combine it with physical therapy afterwards."
8. Focus on sports injury prevention. One of the easiest ways to treat sports-related injuries is to prevent them, and several national campaigns have launched over the past few years aimed at preventing injuries in young athletes. The American Orthopaedic Society for Sports Medicine supports STOP Sports Injuries, a campaign that provides educational material for players, coaches, parents and physicians about the proper techniques for preventing injuries. One of the biggest concerns among shoulder surgeons is throwing injuries related to baseball players, especially pitchers, particularly rotator cuff injuries. Dr. Yocum says it's important to remind young patients to take breaks from playing sports and cross train to prevent overuse injuries.