Shoulder Instability Surgery- Reliable Results For Most Athletes

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Many young athletes with a shoulder dislocation from sports activity will choose to have shoulder stabilization surgery
  • Modern arthroscopic surgery techniques generally result in extremely stable shoulders for 90% of athletes and high satisfaction

I wrote last week about improvements in ACL surgery over the last 25 years and this week I’d like to explore improved results from another commonly performed sports medicine surgery- stabilization surgery for the dislocating shoulder. The results here mirror those of ACL surgery in many ways.

Many young athletes dislocate a shoulder from trauma, typically a dive with the arm outstretched overhead. This can happen in any sport involving that kind of motion, and any contact sport.

Most surgeries were performed through a large “open” incision 25 years ago, but nowadays can be performed arthroscopically in most cases. For uncomplicated stabilization of shoulders that have had a small number of dislocations from trauma, we should expect 90% of shoulders to remain stable and satisfaction rates upwards of 80% out to about 5 years with current methods, for recreational athletes.

Early Open Surgery Methods- Very Good At Stabilizing, Not So Good At Retaining Motion

Historically, the open surgery was for an unstable shoulder was reported in the early 1900s. A surgeon named “Bankart” first described the essential anatomy of the torn ligament and labrum stabilizing the shoulder in 1923, and for the most part we still generically refer to a shoulder stabilization as a “Bankart repair”.

Over the decades as additional knowledge was gained, modifications to the original procedures were developed. A key component surrounded understanding why surgeries on shoulders with many dislocations tended to do poorly compared to ones with only a few dislocations. While there are many factors, restoring bone loss that resulted from the dislocations was a major advancement.

As it turned out, open stabilization was extremely effective at providing excellent stabilization, with low re-dislocation rates.  But it came at a price. The rehabilitation was difficult and often resulted in permanent motion loss. Some techniques had unacceptably high rates of early arthrits. The end result was that many folks ended up with a stable shoulder but were unhappy about the result.

Arthroscopic Stabilization- Much Better At Retaining Motion With Excellent Stability

 “Arthroscopy” involves small incisions, with the surgeon visualizing and performing repairs through the small incisions. There are numerous advantages over open surgery.  Arthroscopy avoids some complications of open incisions, is generally faster, has minimal blood loss, is more comfortable after surgery, and generally leads to a faster return to sports with excllent joint motion.

And yet, in its earliest years, arthroscopic stabilization had a higher dislocation rate than open surgery. As it has been with ACL reconstruction surgery, arthroscopic shoulder stabilization has improved substantially over the years. Better surgical technique, improved surgical implants, and cutting-edge rehabilitation all play a role.

Measuring the ultimate outcome from arthroscopic shoulder stabilization surgery can involve many factors. Is there another dislocation after surgery? How is the range of motion? What’s the patient’s level of sport activity? How does the patient feel about their result?

If you’re a young athlete with an unstable shoulder, and you have a strong desire to resume a contact or collision sport you’ll likely want to consider shoulder stabilization surgery. Find an experienced shoulder surgeon and have a thorough discussion. You’ll have to work hard on your rehab and be patient but you should generally end up with an excellent result.

Share this:

ACL Reconstruction Is Getting Better All The Time

 

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • ACL surgery has improved substantially over the last 25 years, with stability rates improving from about 80% to about 95%
  • Patients’ own reported outcomes have also improved
  • Reasons for improvements can be traced to better understanding of anatomy, refinements in surgery technique, and advanced rehabilitation

In today’s blog post I’d like to take a look at improved outcomes over the last 25 years from a commonly performed orthopedic sports medicine surgery: ACL reconstruction. We’ve come a long way over this time, with improvements in patient reported outcomes as well as improvements in measured stability of the knee.

Orthopedic surgeons use various objective criteria to assess the stability of the knee. In 1994 when I started my orthopedic practice I typically quoted an 80% success rate in terms of restoring excellent stability to the knee after ACL reconstruction surgery. Today, that number is about 95%.

How the patient who’s had surgery feels about his or her own knee has also improved quite a bit over this time. It’s difficult to find published patient reported outcomes from the early 90s but it’s fair to say that a large percentage of patients weren’t entirely happy with their knees after surgery. Perhaps 40% of people reported difficulties with their knees. Nowadays patient reported outcomes are generally very favorable for about 80% of knees at least two years after surgery.

Improvements In Surgical Technique And Better Understanding Of Anatomy

 Orthopedic scientists didn’t have a good understanding of what the ACL was or what it did prior to the 1970s. But starting in the 1970s there was an understanding that the ACL was an important stabilizer of the knee, and some surgery was performed. Most of those surgeries are what would now be called “extra articular” surgeries, meaning that they didn’t directly repair or rebuild the ACL. Rehabilitation was exceptionally difficult and many surgeries failed.

In the 1980s there was more of an understanding that we had to re-create a new ACL, a surgery that we now call a reconstruction. Tissue was transferred from one place in the knee and used to rebuild and replace the torn ACL. This improved surgical technique resulted in a very substantial improvement in outcomes after surgery.

Further refinements took place in the 2000’s. Most of these refinements were driven by improved understandings in the anatomy of the ACL, and improvements in our ability to more precisely place the tissue graft within the knee joint. ACL fixation techniques also improved, in many cases allowing for a more rapid rehabilitation than was possible previously.

We’ve gained a much better understanding of where exactly to place the graft within the knee joint. To the non-medically trained observer these differences may not seem like much if you were to look at a drawing of the reconstruction, however they have resulted in substantial improvements in stability and patient outcome. These changes are a really big deal from the surgeon’s standpoint.

Future Trends

 We have a much better understanding now of how to best rehabilitate a knee after ACL surgery. Rather than using arbitrary time points to determine readiness for return to sport, there is an increasing understanding of biomechanical and functional landmarks to help make this decision. This should result in lower retear rates after surgery.

Biologic augmentation of the surgery with stem cells or other bioactive agents may lead to enhancements in the quality of the new ACL. And in some instances of a partial ACL tear, there is renewed interest in performing a suture repair of the torn ACL segment and augmenting this with a stem cell treatment.

The newer biologic treatments are very exciting and have the potential to offer further improvements in outcomes. I expect that if I write this article 5 years from now the numbers that I quoted above will be substantially improved.

Share this:

How Does Exercise Actually Make You Better?

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published scientific study shows that blood protein markers fall into specific patterns, and some patterns are associated with regular aerobic exercise
  • The patterns in regular exercisers are different than the patterns found in non-exercisers
  • Studies such as this shed further light into exactly how exercise improves health status and ultimately may lead to improved exercise prescriptions for individuals

I’m sure pretty much everyone knows that exercise is a good thing and makes us fitter and better. The right kind of exercise will make you feel better, look better, and likely add to your healthspan. But the exact mechanisms that lead from exercise to better health are surprisingly hard to pinpoint.

recently published scientific study shows that certain groups of proteins in the body are present in larger quantities in people who exercise regularly, suggesting that the proteins are somehow responsible for actions leading to improved health status. This study did now investigate cause and effect, but it sheds light on a previously poorly understood area. The field of “proteomics”- the study of body proteins and their functions- may lead to exciting discoveries in exercise science.

Researchers at the University of Colorado at Boulder performed the study. The first study group was comprised of 31 healthy young men and women, about half of whom exercised regularly, while the rest did not. They also recruited an additional group of 16 healthy middle-aged and older men, half of whom were physically active and half of whom were sedentary. So this study was a snapshot in time comparison of people who performed regular aerobic exercise vs. those who were physically inactive.

They collected blood samples from the study participants and analyzed for more than 1000 blood proteins. From the analysis they were able to find 10 groups of proteins that they arranged into patterns or modules.

The researchers were able to find 5 specific protein patterns associated with aerobic exercise status in adults, as well as 2 modules that were preserved with aging in regularly exercising men. In the groups of regular exercisers patterns were related to biological pathways involved in wound healing, regulation of cell aging, glucose and insulin response, and inflammation/immune responses. Several of the exercise-related protein patterns were associated with physiological and clinical indicators of healthspan, including diastolic blood pressure, insulin resistance, VO2max, blood vessel function.Logo

This is a unique study that allows us to start digging deeper into the specific processes that take place during exercise and ultimately improve health status. Future studies will need to take a look at cause and effect. How do the protein markers change when taking a sedentary person through a regular exercise program? How do the proteins change from various different types of exercise? Ultimately research studies such as this can lead to improved exercise regimens and personalization of an exercise prescription.

Share this:

Innovations That Will Drive Sports Medicine In 2019

By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • I see three innovations that are currently in use making huge advances in 2019. They are:
  • Increasing use of biologics in sports medicine injury treatment
  • An expanding range of options to treat knee arthritis in active adults
  • A growing role for algorithm based mobile assessments and telemedicine

It’s very easy to get caught up in moonshots, longshots, and fantasy in the world of medicine, but I believe there are three highly innovative technologies that will have an increasingly prominent role and impact sports medicine in 2019.

The first of these is increasing use of biologics in sports medicine injury treatment. Second is the rapidly expanding range of treatment options for active individuals with knee arthritis. And finally, I expect to see an exponential increase in telemedicine and mobile algorithms to provide initial injury guidance.

Let’s have a look at each of these areas.

I recently attended an instructional course on the use of Biologics in orthopedic sports medicine. The course was chaired by my colleagues and Sideline Sports Doc advisors Jason Dragoo M.D.and Brian Cole M.D.The overall theme of the course was that the world of biologic offerings for sports medicine injuries is exploding in terms of the types of treatments we can offer our patients.

In particular, look to see a huge increase in Platelet Rich Plasma (PRP) injections for many types of soft tissue injuries such as chronic tendonitis and muscle injuries. The last year has shown progress with outstanding scientific research into the exact formulations of PRP that work best for different conditions. Not all PRP is created equal; there are critical subtleties especially in the concentration of white blood cells and platelets that go into the different formulations.

Also expect to see a growing number of “stem cell” injections for sports medicine conditions. There is still some debate as to what exactly a stem cell is – which is why I have it in quotes – but current formulations use a person’s own bone marrow or subcutaneous fat, and then purify the tissue for use in the same person. The science lags our experience with PRP but expect to see an expanding role for stem cell treatments, for sure.

New Treatments For Knee Arthritis In Active Individuals

The best way to treat pain and functional limitation for active people in their 40s – 60s remains challenging. Most of these folks have arthritis that’s significant enough to cause them problems but not severe enough to require a total joint replacement. This is where we have an expanding roster of new treatments.

In the last year we’ve seen the approval of an ultra long-lasting cortisone injectable, and increasing evidence that PRP can be effectively used in some types of knee arthritis. The formulations of PRP used in knee arthritis are different than those used in soft tissue problems. Additionally, the stem cell injections mentioned above will likely have a more prominent role in selected cases, and there are also amniotic fluid injections coming into clinical practice.

These technologies will offer new avenues of hope for the huge population of active adults with moderate knee arthritis.

The Move Away From In-Person Initial Advice For Sports Injuries

 This prediction is a bit tough for me, as I’m in a profession that may face some attrition due to the technological advances around us.

In the early 20thcentury doctors routinely made house calls. Those days are long gone. Next to disappear: the initial face to face interactions for many common sports injuries.

At Sideline Sports Doc the algorithm that powers the decision trees in our online courses were developed into a mobile app (Good To Go) that allows an athlete or a parent of an athlete to make an initial triage decision anywhere, in less than 3 minutes. We believe the algorithm can be adapted to any number of conditions.

Outside the realm of sports medicine, I believe care will increasingly be delivered in a hybrid real world-virtual world model. There are multiple companies successfully developing telemedicine networks, artificial intelligence engines, and mobile technologies (including wearables) that have the potential to radically alter the patient-physician interaction.

The time it takes for appointments (including the hassles of traveling to the office, waiting for the appointment, etc.) will drop substantially. The convenience of advice from your home, office, or playing field are compelling.Logo

As I’m trained in the traditional way of orthopedic practice there’s a big part of me that looks at the move away from in-person advice with dread. But when viewed from the patient standpoint I can easily see this becoming a major trend in 2019 and beyond. These innovations, available here and now, are going to be big parts of the sports medicine toolkit in the coming years.

Share this: