Thursday, January 17, 2013

Case Study: Shoulder Injury - Old and New

As an orthopedic surgeon it is my goal to treat injuries by restoring the normal anatomy that has been disrupted. In this case study we will discuss an unusual combination of shoulder injuries which required a unique treatment plan.

In this case, a patient came into the office with a dislocated shoulder. Upon examination, we found remnants of an old injury that left his shoulder anatomy compromised and a new injury that was severely hindering his shoulder function. Many doctors may have opted to only address the new injury, but we knew that the first objective was to restore the patient’s anatomy to normal (fix the old injury) and then address the new injury. 
After thorough evaluation, we discovered scapular dyskinesis (abnormal movement) with winging, a prominent AC joint (the AC joint is the joint where the collarbone and shoulder blade meet) and unstable left shoulder. An MRI further revealed an anterior labral tear and bankart lesion.  The scapular dyskinesis and prominent AC joint were due to the old injury that had not healed properly and likely led to the anterior labral tear and bankart lesion.  In order to give the patient the best chance of full recovery and normal shoulder function, we had to address both injuries. 
We opted for staged surgical procedures.  First, we would need to reconstruct the AC Joint, then 2 months later we would perform a second arthroscopic surgery to repair the bankart lesion and anterior labral tear.  Reconstructing the AC Joint was the first priority.  By performing the reconstruction, we would be restoring the shoulder to its natural anatomy. Restoration of the natural anatomy gives the patient the best chances for a full recovery from the second injury.  By ignoring the old injury (which led to the abnormality of the AC Joint), the chances of a full recovery from the labral tear and bankart lesion would be slim and leave the shoulder more prone to future injury.
Following the surgeries and postoperative physical therapy, we could not be more pleased with the results.  Four months after the second procedure: the scapular winging disappeared, the patient was pain-free, the instability of the shoulder was gone and the patient was able to return to full work duty without any restrictions.  The patient is thrilled with the results.  Following his first injury, he had never returned to “normal”, but now he reports that he is better than ever.  He has complete range of motion in the shoulder and is living pain free. A complete success in our book!


Sunday, January 6, 2013

Ask the Orthopedic Surgeon: What is the meniscus?

I keep hearing of athletes tearing their meniscus.  What exactly is the meniscus and what does it do and what happens if it is torn?

What is the meniscus?
The meniscus is a c-shaped piece of cartilage in the knee that acts as a cushion between thigh bone and shin bone.  The meniscus acts as a shock absorber and keeps the knee stable.  The meniscus also distributes our weight evenly over the knee. The most common causes of a meniscal tear are a sudden twist of the knee or overuse.

What are the symptoms of a torn meniscus?
-        A “pop” may be felt at the time of the injury
-        Pain
-        Stiffness & Swelling
-        Limited range of motion
-        “Locking or Catching”
How is a torn meniscus treated?
Treatment of meniscal tears vary depending on the size, severity and location of the tear.  Tears that are small in size and on the outer edge of the meniscus may not require surgery.  In these cases, the protocol is RICE:  Rest, Ice, Compression and Elevation combined with anti-inflammatory medications (aspirin or ibruprofen). The patient may or may not be required to wear a brace.

If the meniscal tear is moderate to severe, a knee arthroscopy is often needed. Knee arthroscopies are performed through a small incision in the knee.  An orthopedic surgeon then inserts a small camera, which provides a clear view of the knee.  From there, the orthopedic surgeon either repairs the tear or removes the torn portion of the menisci.
Depending on the location of the tear, an orthopedic surgeon decides whether to remove or repair a tear.  The outer layer of the meniscus is often referred to as the ‘red zone’ because it has a good blood supply, which is necessary for healing.  The inner layer is sometimes referred to as the ‘white zone’, which lacks a decent blood supply and makes healing difficult.  If the tear is located in the red zone it is normally repaired, but if it is in the white zone, it is normally fully or partially removed.  Full removal is normally avoided, if possible, as it can leave the patient more prone to osteoarthritis in the future.
For a meniscal repair, the recovery time is about 3 months, with 4-6 weeks on crutches and physical therapy.  A partial menisectomy (removal of the meniscus) has a recovery time of about 6 weeks and only 3 days on crutches.  Physical therapy is needed as well.  In both cases, patients are able to return to full activity. 

If you have an orthopedic question for John Vitolo, MD, please email your question to  John Vitolo, MD is Board Certified in Orthopedic Surgery and Sports Medicine.  Skyview Orthopedic has offices in Sparta and Randolph.

*Picture Source:  American Academy of Orthopedic Surgeons