Spero Karas, M.D., an orthopedic surgeon and sports medicine specialist at Emory University School of Medicine in Atlanta, Ga., talks about a new procedure to repair torn rotator cuffs in the shoulder. Tell me about rotator cuff injuries or the kind of shoulder injuries that you are addressing. What causes them and how do you fix them?
Dr. Karas: Rotator cuff injury can be caused by a number of phenomena. Most commonly, it’s an overuse type of injury that is acquired over many years. The rotator cuff tendon will slowly accrue injury that over many years weakens it and causes small partial tears that then can spread or propagate into a larger tear, or a full thickness tear. The rotator cuff tendon itself is anywhere from 12 to 16 millimeters thick. You can actually acquire a pretty good amount of injury through that 12 to 16 millimeters of tendon before you get what we consider a full thickness rotator cuff tear, or one that spans that entire thickness of tendon.
What does the rotator cuff do?
Dr. Karas: The shoulder is a ball and socket joint. What the rotator cuff actually does is it stabilizes the ball in the socket. When the rotator cuff is torn, that ball will tend to ride up out of the socket and then the other shoulder muscles cannot raise the arm effectively, so although a bodybuilder or an athlete would work on focusing on what I call the “beach” muscles — those big muscles that you build up in the weight room — those muscles are basically useless when the rotator cuff is not intact. When the rotator cuff is not functioning, then the shoulder cannot be centered in the ball and socket joint — the glenohumeral joint — and you get an ineffective transfer of power from those big muscles which elevate the shoulder.
If the rotator cuff is torn, what are the options for that patient?
Dr. Karas: It depends. Partial thickness rotator cuff tears are those tears that do not go completely through the tendon. Those can be very effectively managed with physiotherapy, perhaps a cortisone injection, anti-inflammatories and rest from the offending activity. About 80 percent of rotator cuff tears will respond to that management. When you get into a situation with a full thickness rotator cuff tear where there is a hole in the tendon, that is a more serious issue. Those can propagate or get larger over time. I’ve seen relatively small rotator cuff tears turn into large or massive irreparable tears in as little as a year. The important thing to recognize in a rotator cuff injury is there can be a pretty wide spectrum of disease from tendonitis of the tendon to a partial thickness tear of the tendon or to a full thickness tear of the tendon, which could either be small medium or large. The problem is once those tendons give way and once there is a hole in the tendon, then that needs to be fixed. Rotator cuff repair is really quite unique in orthopedic surgery. There are a lot of procedures we do that do not necessarily change the natural history of the disease. If you look at the long term outcomes of ACL reconstruction — even 20 years after an ACL reconstruction — a patient still may end up with arthritis; but an effective rotator cuff repair, one that gets the tendon to heal back down to the bone, actually reverses what we call the natural history of rotator cuff disease, which means the tear over time slowly gets larger, eventually becomes irreparable and then when that head starts to rise up or escape out of what we call the glenohumeral joint, or the ball and socket joint. Then it develops arthritis.
A quality rotator cuff repair in the young to middle ages can actually change the course of a patient later in life and perhaps not only improve function and decrease pain, but also stave off arthritis and more serious procedures like shoulder replacement down the line.
What is the new procedure you are using and what makes it work better?
Dr. Karas: I utilize a procedure called the dual row or double row rotator cuff repair. What the dual row rotator cuff repair does is it reconstructs normal anatomy. Typically, when you approach the rotator cuff injury through an arthroscopic technique, you have to use small rivets or suture anchors in the bone. Those rivets are what basically allows you to repair the rotator cuff back to the bone. Traditional techniques for suture anchor repair employed what was called the single row technique where you put a single anchor or a single row of anchors into the bone where the rotator cuff attaches and reattach that tendon down to the bone. The problem with the single row technique is that it only re-approximates approximately five millimeters of that 12 to 16 millimeter footprint we talked about earlier. In order to improve the strength of the repair, recreate normal anatomy and reconstruct the tendon as it was in its uninjured state, the footprint requires a dual row reconstruction. The concept of dual row or double row repair helps you achieve that by basically matching anatomy as it is in the uninjured state.
In terms of length of the procedure and length of recovery, how does it compare with the traditional arthroscopic procedure?
Dr. Karas: I always say you cannot fool Mother Nature, so regardless of how the rotator cuff is fixed, there is still a natural progression of time where that tendon and bone have to heal together. That actually takes, believe it or not, about a year to get a fully healed bone-tendon construct in the shoulder after rotator cuff repair. It takes about a year and it’s a fairly linear graph. Its 25 percent healed at three months, 50 percent healed at six months, 75 percent healed at nine months and so on until 100 percent healed at 12 months. Regardless of whether you fix a tendon with a dual row or single row construct, ultimate healing takes the same amount of time. What is clearly more advantageous in the dual row construct is that these repairs are stronger so when you test them biomechanically it is more difficult to pull the repair off. Rehab can take place with a little bit more fortitude. You can rehab a little bit stronger, you can move a little bit more aggressively early on. Furthermore, you get a better healing rate with the dual row repair, so the dual or double row repair, that dual fixation point, basically improves the footprint of the tendon onto the bone by a factor of anywhere from 50 to 75 percent. When you look at those repairs long term, especially when you are dealing with larger tears, you see that you actually have improved healing rates when compared to a traditional single row construct.
As I understand, many times people have these tears is because they are over 40 and that tendon is not what it was when they were in their 20s. How do the patients over 40 do in terms of recovery and going back to their regular activity?
Dr. Karas: The results of rotator cuff repair, whether it be done through an open or an arthroscopic technique, are uniformly very, very good. The main impactors in the outcome from rotator cuff repair are age, the size of the tear and if the surgeon was able to get the tear to heal. It’s clearly been shown that patients that have undergone rotator cuff repair do better if, down the road, their tendons have healed. That sounds intuitive, but you would be surprised at how well patients do after rotator cuff repair even when the tendon doesn’t heal. It’s just that those particular patients, if the tendon re-tears, they typically get a recurrence of their symptoms sooner than one would expect. A follow up study showed that the tendon is re-torn. You have to remember that a solid primary rotator cuff repair the first time around puts the patient in a much better situation to have an excellent outcome in terms of healing rates and in terms of long term improvement in symptoms.
In terms of activity, what does this mean for these patients? For the people you were talking about earlier that have had this procedure, what does it mean for them in terms of being able to return to the things that they normally like to do?
Dr. Karas: Clearly, in the smaller tears that are treated with the double row construct, I have a lot of confidence getting these patients up and moving and rehabilitating quicker and more aggressively because there is more confidence in the repair. There is a broader contact area on the bone. Patients with bigger tears, I use the technique almost exclusively because the large tears are the ones that have a higher rate of re-rupture or re-tearing and those patients are clearly the ones that are shown to have a bad outcome. What the double row repair means in terms of how your patients do is, again, a better long term outcome due to a better repair.
How many doctors are doing this procedure besides you? Is it performed all over the country, or are you still one of the only doctors doing this?
Dr. Karas: No, it’s definitely catching on. There is actually a growing number of surgeons who recognize that the dual row construct not only recreates anatomy, but also improves the biomechanics of repair. Quite frankly, some of the studies, as you follow them out, show that it actually improves healing rates in short to intermediate term post-op follow up. Basically to summarize, the dual row rotator cuff repairs are really taking off in terms of surgeons recognizing that it is a more anatomic repair — a stronger repair — and has better healing rates and it’s truly gaining popularity.
Do you do it arthroscopically or is it an open procedure? Does it depend on the patient?
Dr. Karas: It actually does depend on the patient. The percentage of rotator cuff repairs I do arthroscopically are over 95 percent. Today however, I have a patient with a very large tear that was actually what we call an irreparable tear. For an irreparable rotator cuff tear, there is only one way to fix that hole. You can’t fix it back down to the bone. You have to use a graft, and so on those where I’m really trying to get a graft to heal down to the bone, I use the dual row through an open procedure. It’s kind of like golf: You use the club it takes to get you in the hole. It’s almost always a primary arthroscopic repair, but sometimes it has to be performed with an open technique.
Do these people go back to the things that they could do before their injury? Does it give them their range of motion back?
Dr. Karas: Yes. The patient has pain and weakness when using the arm because the tendon is torn and the shoulder is not operating efficiently or effectively. That is why we repair it; we do it to eliminate painful movement and improve the strength in the shoulder. I do not think we can really underestimate the fact that rotator cuff repair, if done effectively and appropriately the first time — if you get a good heal — really does dramatically change the long-term outcome of the patient.
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