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07/Mar/2019

Imagine having pain in your shoulder in every daily activity of your life like washing, wearing clothes, trying to lift an object, drinking tea etc. This is a typical complaint of a frozen shoulder patient. Another big problem is the disturbed sleep due to pain which decreases the quality of life while the patient spends the rest of his day, exhausted and tired.

However some research papers ask a pertinent question that depression and stress may have a part to play in the causation of frozen shoulder. It is not known to what extent does mood depression play a role in causing frozen shoulder or that it even has any role? In the idiopathic type of frozen shoulder, the cause is not known. In others it may be some sort of minor trauma, diabetes, preceding surgery etc. The exact cause is a subject of bewilderment and continues to be researched.

It is understood, though, that some stressor is found in some people which gives rise to this condition. It could be in the form of any minor trauma also. How this condition is related to diabetes or thyroid abnormality is not understood. Diabetics have a 30% association with frozen shoulder. The incidence of bilateral problem is also higher in diabetics and thyroid abnormality.

In this scenario it becomes all the more important to alleviate the pain first and foremost. Since pain interferes with sleep and almost all daily activities, medicines and injections with home based exercise only are the mainstay of treatment.


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07/Mar/2019

Steroids are often spoken of, in a rather dismissive tone, given its bad reputation for causing serious side effects. However, local application of steroids especially local / regional injections of steroid are one of the best blessings of the medicine world. For e.g. local bursitis or inflammation in the shoulder may take days to respond to rest, cold fomentation or medicines, but one local injection of thesteroid in the shoulder gives you instant relief.

In intractable painful conditions of the shoulder, it is even more important to give local steroid injections. The only caution to be used is touse it in the correct site and for the correct indication. For e.g. a sub-acromial bursitis will readily respond to sub-acromial injection, an intra-articular injection may be best used in tendon inflammation. Frozen shoulder responds very well to steroid injections. There are different preferences w.r.t the site of steroid injections is case of a frozen shoulder. However, unequivocally a sub-acromial injection does not seem to work in case of a frozen shoulder. Injecting in the gleno-humeral joint space (a.k.a intra articular) has been a practice with some physicians. But an intra articular injection fails as often as it succeeds. The best outcomes in frozen shoulder are obtained by injecting steroids in the Supra scapular nerve (SSN) space. There are many methods advocated to practice SSN space injection. This injection works to reduce the pain and improves the exercise range of the affected individual.


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07/Mar/2019

Consider this: A Young guy who is troubled by repeated dislocation shoulder treatment – his shoulder gets dislocated while playing sports or even while taking a shower.etc.

An athlete /cricket player /volleyball player who depends on his overhead shoulder movements for their sporting activity which is so essential for his daily life, but repeated shoulder subluxation makes all of the above impossible.An ordinary Mumbai local train commuter, whose shoulder and hands are used extensively to hold on or catch the train, bus etc. for commuting, but cannot do so anymore because his shoulder dislocates each time he tries to use his shoulder.

All these troubled young souls want only one thing- to get shoulder dislocation treatment and get rid of instability- to get on with their normal lives without any fear of impending dislocation. The “Latarjet procedure” in which a part of the coracoid along with the conjoint tendon is transferred to the glenoid, is the best procedure for solving this problem. One might ask – why is it the best? It has a reported recurrence of less than 1 % (yes that’s true!!!). Dr.Gilles Walch in France, who has done more than 2600 latarjet procedures, is the pioneer of this procedure in the modern world..

The best testament which will attest to the fact that latarjet procedure is one of the finest procedure in shoulder surgery is the Xray (see fig 1)of a patient who underwent this procedure 50 years ago by Dr latarjet himself and still has not had any recurrence even after 50 years of follow up- can you beat that?

Shoulder Xray 50 years after Latarjet procedure

There are 4 names to be remembered when we talk of the “latarjet procedure”. Dr Michele Latarjet – who did this procedure for the first time in 1954, Dr. Didier Patte who further improved on this procedure, Dr. Gilles Walch who taught the world how to do this procedure and who has the maximum experience in the current world and lastly Dr. Laurent Lafosse –who was the first surgeon to perform this procedure entirely through Arthroscopy.

Which other treatment for shoulder instability will allow the patient to return to full arm elevation and no feeling of instability as early as 4 weeks after surgery and daily activities after 6 weeks? (see picture figure 2). My personal experience with this procedure, both Arthroscopic and Open Latarjet has been excellent and people have gone back to playing sports at the same pre-injury level as early as 2-3 months. Why would people then offer any other procedure to the patients of recurrent dislocation, if results are all that matters?


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07/Mar/2019

The debate for the best shoulder pain treatment and recurrent dislocated shoulder treatment rests largely between the two procedures in the headline. Bankart repair consists of soft tissue capsulo-labral repair and Latarjet involves osteotomizing (cutting) the vertical half of the coracoid bone and fixing it on anterior glenoid surface. Since I have worked both in France and US, I‘ve had the good fortune of witnessing the debate on both sides very closely. Scientifically it is difficult to prove one is better than the other because of paucity of level 1 evidence. However there are multiple scientific articles that can be cited which speak of the high chance of recurrence after bankart repair. e.g. in JBJS B 2005, Calvo et al says 18 % recurrence after bankart repair, JSES may 2005 Tauber et all analysed 41 cases of recurrence after primary surgery and found highest number of recurrence(60%) occurred after bankart repair(25 cases).

 

There may also be couple of articles, which speak about low recurrence after bankart repair as well. Conferences usually are not the best places where people will frankly admit their failures. But secretly many people have admitted that failures after bankart repair have gone up as the length of follow up has increased. Since, most surgeons in India and many surgeons in western countries also do not keep a regular record, or have long follow ups, it’s hardly believable what any such surgeon would say without hard data. Historically most surgeons will do bankart repair and would stand by it, but will not be able to prove anything because they do not have long follow ups. Failures of bankart start appearing only after 1-2 years so long follow-ups are definitely needed to prove any theory. Proponents of bankart repair ask that since most patients in India are low demand non-athletes, why should we do an extensive procedure like Latarjet? One of the favorite lines of surgeons in US is “Why should you take a bomb where a small gun can work?” However what they would agree is that Latarjet would give better results under all circumstances. In Mumbai since an average person places high stresses on his shoulder on account of his local train, bus travel etc, he can hardly be called low demand.

If “consumer is king” and “patient’s good is the only good to be considered”, Latarjet is the by far the better procedure. The French definitely score ahead here (photo: Dr.Laurent Lafosse, me and other Orthopods in France).


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07/Mar/2019

    Have experienced these symptoms of late?

  • Pain caused by shoulder injury
  • Repeated shoulder dislocations
  • Repeated instances of the shoulder giving out
  • The shoulder persistently starts feeling loose, slipping in and out of the joint

If the answer is yes to any of these factors, consider visiting a shoulder surgeon / specialist. The above mentioned symptoms point to a troubling condition known as recurrent shoulder dislocation.

The shoulder joint in our body gels well with the term ‘feeling out of place’. Able to move in multiple directions, your shoulder can dislocate forward, backward or downward, completely or partially. Though on the other hand, it’s not that fragile too. It requires a strong force, such as a sudden blow to your shoulder, to pull the bones out of place.

But, in some cases, the shoulder acts tough to get in place. When a shoulder dislocation occurs, the ligaments, tendons, and muscles around the shoulder can become loose or torn. These results in a troubling condition called recurrent shoulder dislocation.

    Three common reasons behind this condition are:

  • Shoulder Dislocation:Severe injury, or trauma, often triggers the initial shoulder dislocation. A severe first dislocation can lead to continued dislocations.
  • Repetitive Strain:Repetitive overhead motion can stretch out the shoulder ligaments. This can loosen the ligaments in the shoulder and weaken the shoulder over time. This can result in a painful, unstable shoulder.
  • Treatment:A dislocated shoulder should be reduced to relieve the pain. When the condition becomes chronic and recurs repeatedly, surgery should be considered as the mainstay of treatment. And when it does come down to surgery, the preferred option is arthroscopic labral repair orlatarjetsurgery
  • Key to Recovery:God forbid, if you happen to experience these issues, ensure to follow your doctor’s treatment plan. This entire process may come across as long and tedious. But patience is key here, for your shoulder to get its groove back!

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07/Mar/2019

    Have experienced these symptoms of late?
  • Pain caused by shoulder injury
  • Repeated shoulder dislocations
  • Repeated instances of the shoulder giving out
  • The shoulder persistently starts feeling loose, slipping in and out of the joint

If the answer is yes to any of these factors, consider visiting a shoulder surgeon / specialist. The above mentioned symptoms point to a troubling condition known as recurrent shoulder dislocation.

The shoulder joint in our body gels well with the term ‘feeling out of place’. Able to move in multiple directions, your shoulder can dislocate forward, backward or downward, completely or partially. Though on the other hand, it’s not that fragile too. It requires a strong force, such as a sudden blow to your shoulder, to pull the bones out of place.

But, in some cases, the shoulder acts tough to get in place. When a shoulder dislocation occurs, the ligaments, tendons, and muscles around the shoulder can become loose or torn. These results in a troubling condition called recurrent shoulder dislocation.

    Three common reasons behind this condition are:

  • Shoulder Dislocation:Severe injury, or trauma, often triggers the initial shoulder dislocation. A severe first dislocation can lead to continued dislocations.
  • Repetitive Strain:Repetitive overhead motion can stretch out the shoulder ligaments. This can loosen the ligaments in the shoulder and weaken the shoulder over time. This can result in a painful, unstable shoulder.
  • Treatment:A dislocated shoulder should be reduced to relieve the pain. When the condition becomes chronic and recurs repeatedly, surgery should be considered as the mainstay of treatment. And when it does come down to surgery, the preferred option is arthroscopic labral repair orlatarjetsurgery
  • Key to Recovery:God forbid, if you happen to experience these issues, ensure to follow your doctor’s treatment plan. This entire process may come across as long and tedious. But patience is key here, for your shoulder to get its groove back!

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07/Mar/2019

What are the available options for someone who had a fracture of proximal shoulder, which hasn’t united? One, he has a painful shoulder and 2nd he has limited motion.

Mostly this will be found in old individuals with a poor bone stock, which was a contributory factor to non-union in the first place.

A traditional approach which fails very often would be to attempt refixation with bone grafting. However this may not result in union of the fracture besides giving him a very stiff shoulder.

A reverse shoulder replacement comes as a great rescue in these cases. Paul Grammont innovated the use of reverse shoulder in 1992. Since then reverse shoulder has been used in many rotator cuff arthropathy and irreparable rotator cuff. Its use in non unions of proximal humerus is also very valuable and is now considered as an extended indication. An anatomic replacement has also been tried in these in these unions, but since the greater tuberosity is not anatomical, this also gives very poor results.

There may be an absent subscapularis , a non healed and displaced greater tuberosity. Reverse shoulder prosthesis can still work in the absence of a subscapularis and definitely without a supraspinatus and greater tuberosity. Thus a reverse shoulder replacement is a great option in people above 60 with a failed fixation of proximal humerus fracture. It provides good pain relief and reasonably good return of range of shoulder movements.


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07/Mar/2019

The biggest series of patients from Zurich published in the top ranked journal of orthopaedics (JBJS) proves beyond doubt that Latarjet is clearly the surgery of choice and much more superior to Arthroscopic bankart repair for treatment of anterior recurrent dislocation of shoulder.

People have been arguing back and forth in favor of arthroscopic bankart repair, while secretly accepting it has a high failure rate. The simplicity and the arthroscopy nature of the surgery make it an attractive choice for the treating physician, while at the same time it is prone to high chances of failure.

This biggest series of patients by Prof Gerber who is one of the most respected and top-notched shoulder surgeons of Europe says that arthroscopic bankart repair has a recurrence and failure rate of 30% which is quite unacceptable. Latarjet surgery on the other hand has a very low failure rate of only 3%.

Other advantages of latarjet are that the patient returns to normal activity in as less as 2-3 weeks after the surgery while after bankart repair it may take 6-8 weeks. The authors followed up their patients for a period of 10 years and found that as the follow up increased the failure rate of bankart repair also increased. Follow ups of latarjet surgery, however, did not show this trend and had very few failures on follow up.

My own series of approximately 100 latarjetpatients has shown excellent outcomes with no failures. The surgery also costs much less as compared to bankart repair. It’s actually a French procedure started by Michele Latarjetin 1954 and improved and popularized by Giles Walch from Lyon who is one of the geniuses in the world of shoulder surgery. The surgery involves cutting the coracoid at its base and transferring it along with the conjoint tendon through the subscapularismuscle and fixing it on medial glenoid neck with the help of two malleolar screws. Latarjet is also the treatment of choice in high demand contact athletes as their shoulders face higher stresses during contact sports.


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07/Mar/2019

Most of the minimally displaced proximal humerus fractures in people > 65 years age will unite uneventfully ant the outcomes will be good. However sometimes these fractures are moderately to severely displace and may be accompanied with a head dislocation.

The bone of contention is the highly comminuted and displaced fractures, which pose a significant challenge for the treating physician

Recent literature suggests that in elderly age group, the displaced proximal humerus fractures can also be treated conservatively with outcomes that are comparable to those of a shoulder hemi replacement. What that means it that the average shoulder flexion attained will be around 90-100 degrees in both the scenarios. Sometimes the fractures that are treated non-operatively will not unite. Those fractures will then have to be operated upon and either replaced or fixed with plate etc.

A word of caution with reverse shoulder replacement is that if it fails sometime in the future, the revision is fraught with many complications. Sometimes even a hemi replacement fails and may need to be converted to a reverse shoulder replacement which again has a very high complication rate. So the path to reverse shoulder replacement, although rewarding should be chosen carefully only after giving a good thought to the potential risks ahead


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14/Feb/2019

“Frozen Shoulder” term is a big misnomer.

There is nothing frozen inside or outside the shoulder. In fact it may just be the opposite. The tissues may be inflamed to some extent for some time period.

Codman coined the term “frozen shoulder” in 1934. However, now it is loosely applied to any misunderstood painful condition of the shoulder. Scientifically speaking, frozen shoulder, also known, as adhesive capsulitis is a global restriction of movements of the shoulder, which is diagnosed clinically and with a plain X Ray without the aid of any complex investigation like MRI or CT scan.

The most important role in diagnosing this condition is that of the clinician, since this can only be diagnosed clinically.

The big question is, however, how to best treat it? Surgery? Rest? Exercise? Physiotherapy?

There are equal numbers of patients disappointed by each of the above treatment modalities.

The best way forward is very clear in my mind, after having treated several of frozen shoulders. Exercises done at home with a corticosteroid injection in the shoulder is the best way to treat it. The key point is to never opt for surgery and to remember that the patient has to work hard at the exercises by himself at home without relying on physiotherapy.

Injection of a corticosteroid is one of the key steps in the management of this condition, since the pain in shoulder does not let the patient do a whole lot of exercises. An injection in the shoulder eases the pain and in some cases the pain disappears entirely within 3-4 weeks. The site of injection, however, varies as per the preferences of the treating physician. The latest advancement in the field of pain management is to inject corticosteroid in the area of the Suprascapular Nerve, which eases the pain considerably. This is followed by a set of stretching exercises done at home regularly, which slowly increases the range of motion of the patient’s shoulder.

The onlything to remember here is that these are stretching exercises and NOT theraband or strengthening exercises.



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