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Shoulder Return 06/22/2010
Can Shoulder Surgeries Be Combined in Middle-Aged Adults?
When it comes to middle-aged adults with shoulder injuries, surgeons are sometimes left scratching their heads puzzled over what to do. Should a full-thickness (complete rupture) of the rotator cuff be repaired at the same time a SLAP lesion is present?
SLAP refers to the superior labral anterior-posterior
structure around the shoulder joint. Superior anterior-posterior tells us the location of the damage: top of the shoulder socket from front to back. The structure that is torn is the labrum
, a fibrous rim of cartilage around the shoulder socket. It is designed to help hold the round head of the humerus
(upper arm bone) in the joint thus increasing the joint stability.
Another puzzling question is: what's the best way to treat the SLAP lesion? Some studies have shown that surgical results vary depending on the age of the patients. For example, younger age groups (ages 18 to 40) tend to have poor outcomes when SLAP lesions are repaired at the same time as shoulder decompression is done. Decompression removes some of the bone that is pressing on soft tissues around the shoulder.
Older adults (over age 40) don't seem to respond well to surgery for SLAP tears. They get stiff after the recovery period and lose function. Some research has been done to see if a staged
procedure (doing the two repairs separately; first repair the rotator cuff, then later repair the SLAP lesion) might have better results.
In this study, surgeons from Harvard Medical School compared two groups of middle aged adults after surgery for shoulder injuries. The first group had a torn rotator cuff but the labrum was undamaged. The second group had both a rotator cuff tear and a labral tear (SLAP lesion). Surgery for the group with damage to both the rotator cuff and the labrum was done all at one time. This is referred to as a concomitant
There were 34 patients in the group having the concomitant procedure and 28 in the group just having a rotator cuff repair. All patients in both groups had minimal muscle atrophy (wasting) and minimal fatty infiltration (fat filling in the damaged area). Everyone had tried recovery with conservative (nonoperative) care but without success.
One surgeon operated on all patients in both groups. The postoperative care was the same for both groups. Everyone wore a sling with a special pillow under the arm to keep the shoulder positioned slightly away from the body. A physical therapist supervised an intensive rehabilitation program for all 62 patients.
To measure the results and compare outcomes from one group to the other, everyone was tested before and after surgery. The specific tests involved shoulder range-of-motion and function. Information was gathered about patients in both groups and used to analyze differences based on sex, age, type of injury, type of tear, work status, and involvement in sports.
Everyone got better after surgery no matter which procedure they had done. Range-of-motion and function improved significantly in both groups. Almost everyone in both groups was able to return to work and return to sports previously enjoyed. No one was unhappy with the results.
The authors concluded that it is both safe and effective to combine a SLAP repair with a rotator cuff repair in middle-aged adults. The fear that the shoulder will stiffen up too much just isn't a reality. The need for a two-part (staged) procedure isn't there either. The results for the combined (concomitant) surgical group were just as good as for those patients just having a rotator cuff repair. And the authors point out that the average age of patients in this study was 58 years old (older than has been reported in other studies).
There is also some evidence that the aggressive rehab program after surgery might account for the good results. It is possible that early motion is the key to preventing stiffness later. However, intense early range-of-motion programs come with the risk that the repaired soft tissues might re-tear. Future studies are needed to follow patients and perform postoperative imaging studies to see the effect of different types of rehab after surgery.
Brian Forsythe, MD, et al. Concomitant Arthroscopic SLAP and Rotator Cuff Repair. In The Journal of Bone & Joint Surgery. June 2010. Vol. 92-A. No. 6. Pp. 1362-1369.
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