labrum tears in the shoulder

Monday, November 6, 2017

There is no such thing as minor surgery. Minor operations are done to other people. Even the most routine procedure may develop complications, because regardless of wat the statistics say, for that one person and that one operation, either all will go 100% according to plan, or it 100% won’t. And for the Indianapolis Colts’ Andrew Luck, he has fallen into the category of not going so well. After undergoing a labrum repair of his throwing shoulder, rehab has been delayed by continuing problems with range of motion, strengthen and pain. The plan that had him playing the first game of the season has been revised and he has been put on the shelf to rest his arm and not throw, perhaps not his expected outcome.

With the advent of increasingly sophisticated technology, surgery has almost become routine but that isn’t necessarily the case. A generation ago, arthroscopy was a new technique and could only be used on the largest joint in the body, the knee. It revolutionized the treatment of torn meniscus (cartilage) and ligaments (like the ACL), not only saving athletes’ careers, but also restoring quality of life to mere mortals as well. It took many years for the tech companies to develop scopes that were tiny enough to work in the tiny confines of the hip, shoulder, elbow, wrist and ankle and because of the tight spaces, there is less room for error. Not only did the tools need to get smaller, but the surgical expertise needed to get better.

Mr. Luck’s injury involves the labrum, a cone of cartilage that extends the depth of the shoulder joint to help with stability. The humeral head, the upper ball joint of the arm, is supposed to rotate inside the shoulder joint, but the glenoid fossa, the bony cup where it rests, is very small and shallow. The cartilage that makes up the labrum is not uniform. The superior or upper part of the labrum is loosely attached to bone and is where the biceps muscle attaches. Repetitive throwing has the potential to stretch the cartilage and make it prone to injury. The inferior or lower part of the labrum has cartilage tightly adhered to bone. The transition point from loose to tight is not the same in everybody. This is important because every shoulder injury is a little different from person to person and it takes the skilled surgeon to put things back the way they belonged.

Shoulder imaging has come a long way from plain x-rays and MRI is the way the surgeon can look inside the joint without having to make the initial cut. By injecting dye in to the shoulder, the anatomy of the shoulder, including the bones, the cartilage, the labrum and the muscles can be mapped. And abnormal things can be found: tears, bone spurs, arthritis and much more. But even with faster and more high tech imaging, there is nothing better than the surgeon looking inside the joint to see what’s going on.

Shoulder arthroscopy is a two-step process. Frist one has to look inside and see what the problem might be and second, the problem has to be fixed. Even if the MRI showed the torn labrum, how the tissue looks and feels will help the surgeon decide how to repair it. Often tissue is sewn back together, sometimes anchors are put it place and rarely, the decision is made to abandon the scope and cut the joint open to be able to deal with what has been found.

SLAP tear = tear of the Superior Labrum from Anterior (front) to Posterior (back)

Surgery is just the beginning in healing and physical therapy and rehab is where the patient’s work begins. There needs to be a balance between allowing the tissue to heal and restarting range of motion so that the shoulder doesn’t get too stiff to move. Then it’s on to strengthening and gradually over months, return to play or work.

Things can get in the way, as they have with Mr. Luck. Recurrent pain with activity may be due to inflammation that will settle with rest, or it may be due to inflammation around the sutures or anchors. Or it may be that the surgeon mistook how tight the tissues needed to be and made too tight of a repair. Another MRI may be helpful…or not. That leaves the decision as to whether the shoulder needs more time to heal, or whether another look inside is the best route to take.

 

For Colts’ fans, the decision to rest their star quarterback for the whole year makes their Sunday football that much less appealing. But Mr. Luck wakes up every day wondering if this is the day the shoulder stats to feel better or whether the surgeon is going to recommend another operation and another 4-6 moths of rehab.

 

There is no such thing as minor surgery. That’s an operation that’s done to other people.

 

 

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internal bleeding and high tech non-surgery

Monday, December 14, 2015

A year ago, Alex Smith of the Kansas City Chiefs fractured his spleen. A month ago, Indianapolis Colts’ quarterback, Andrew Luck, broke his kidney. Last week, San Jose Shark Logan Couture, tore an artery in his thigh.  A generation ago, all three would have undergone major surgery, but technology advances quickly in medicine and has made these disastrous injuries, potentially less disastrous.

ct abdomen

It comes down to being able to look inside the body without having to make an incision. The clinical decision to operate was once  made by a surgeon at the bedside, based upon history, physical exam and the stability of the patient. Exploratory surgery in the stable patient has been replaced with CT scans and angiograms. The ability to stop internal bleeding has become part of the skillset of the interventional radiologist. In trauma situations, the surgeon and radiologist are able to sometimes decrease the need for emergency operations and save some organs, like the spleen and kidney, that only a few years ago had to be removed.

Surgeons like to operate and no doubt that is why they tolerate years of training, to be able to hone skills that lets them cut into the body. In trauma, though, many patients are relatively stable when they present to the emergency department. That means they are awake and have normal vital signs including blood pressure and pulse rate. This gives time to figure out whether what injuries are present and whether a trip to the operating room is needed. All bets are off when the patient is hypotensive (low blood pressure) and seems to be bleeding to death. In this situation, going to the OR emergently seems most prudent, reasonable and the lifesaving thing to do. But if the patient is stable, technology can help look inside the body and sort things out.

In the trauma situation, a FAST scan (Focused Assessment with Sonography in Trauma) can use ultrasound at the bedside to look for blood in the abdomen, chest and surrounding the heart. If the ultrasound shows blood and the patient is unstable, it’s off to surgery as soon as possible. If, however, the patient is stable, a CT scan may be used to look inside the abdomen for injuries to the solid organs like the liver, spleen or kidney. Once upon a time, damage to those organs meant an automatic trip to the OR, but research and experience has shown that the body can heal itself relatively well and damaged organ parts may not need to be removed. With a dye injection that is part of the trauma CT, bleeding arteries can also be identified and instead of rushing to the operating room to tie off a bleeding artery, an interventional radiologist may become the hero of the moment. Threading a catheter though the femoral artery in the groin, the specific bleeding blood vessel can be identified and clotted off, sometimes preventing major surgery.

Spleen injuries are not uncommon, especially if the lower left ribs that protect the organ are damaged. Often the bleeding is contained within the spleen and nothing more needs to be done, other than watch it heal. This is the Alex Smith situation. The diagnosis led to close observation and a few months of healing. The spleen is an important organ that helps filter damaged cells from the blood stream and also plays an important role in the body’s immune system. It is much preferable to have a spleen than not.

For Andrew Luck, he was unlucky enough to fracture his kidney. The kidneys sit in the right and left flank and are protected by the lower ribs and thick back muscles. Still, a blow to the area can damage the kidney by breaking it and causing extensive bleeding. It is better to preserve a kidney instead of having it taken out, and CT can check out the anatomy, injury pattern and risk of bleeding. often, the kidney does fine if it’s left alone. But if needed to be removed, it is fortunate that the kidneys come in pairs and losing one is not necessarily a disaster.

The anatomy of the kidney and the spleen are somewhat similar in that both have segments or poles that have distinct blood supplies. If only part of the organ is damaged and continues to bleed, the radiologist can intervene and control that bleeding and still preserve the rest of the kidney or spleen by the threading technique to find and clot the offending artery.. The organ part without blood supply dies but this is a much better situation than needing to cut into the body. and hack it out. This ability to attack a single blood vessel also saved Logan Couture from having his thigh sliced open to find the bleedig artery in his thigh and tie it off. Instead, the internal bleeding was control in a very high tech way.

Technology has changed how medicine is practiced, especially with the ability to look inside the body. Future generations of physicians and surgeons will look at the care provided in the 21st century as barbaric, yet it’s what we have and it’s better than what we had. The only people who might bemoan the advances are surgeons who marshal their enthusiasm to operate with the understanding that it’s important to pick their patients wisely. In the right situation, the mantra of  “a chance to cut is a chance to cure” has been replaced with “good things come to those who wait”  and “patience is a virtue”.

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