Archive for the ‘Shoulder’ Category

Et tu Shoulder Surgery?

Wednesday, July 28th, 2010

A recent publication by the Agency for Research and Quality that looked at conservative care vs. surgical repair for shoulder rotator cuff tears concluded that surgery provided no measurable benefit. This comes on the heels of other studies showing that orthopedic surgery for meniscus tears may have no benefit over physical therapy, 60% of knee surgery for ACL partial tears likely wasn’t needed, and knee surgery didn’t prevent the development of arthritis. Why all of these studies showing lack of efficacy for these surgeries on knees and shoulders?  Even arthroscopic surgery does a certain amount of damage to get the injured area into a state where it will heal.  In addition, removing parts of a joint (in a shoulder surgery often the end of the collar bone and the ligaments that help stabilize the front of the shoulder joint) can lead to more degeneration of the joint with time.  It’s a bit like repairing a car and having left over parts after the repair and then concluding that you didn’t need those extra parts in the first place.  All the parts are needed and we must be very careful about removing any of them (cutting ligaments, debriding cartilage out of the joint, removing pieces of labrum in a shoulder or meniscus in a knee).  The conclusion?  Orthopedic surgery is a God send for many trauma patients who need to be put back together and can help patients in select circumstances for common sports injuries, but the idea that routine surgery is needed for many problems like meniscus tears, joint arthritis, or torn ligaments, tendons, or muscles, doesn’t appear to be supported by the developing science.  We would advocate using injections in these circumstances (where appropriate and after physical therapy fails to solve the problem) to try to prompt the body to help heal itself.

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Shoulder Arthritis and Rotator Cuff Tears

Friday, January 8th, 2010

JS is a 47 year old male with a 1.5 year history of shoulder pain who due to his arthritis, labral tear, and multiple small tears in his rotator cuff tendon.  He was told he would likely need a shoulder replacement.  In our experience this is a very big surgery with relatively poor clinical outcomes, as most of the patients we’ve seen through the years have had significant pain and disability as a result of shoulder replacement.  We treated his shoulder rotator cuff and shoulder joint by re-injecting his own mesenchymal stem cells into the joint and rotator cuff under x-ray guidance.  The good news is that we appear to have saved him a surgery.  He reported significant improvement and after several rounds of treatment, he wanted to continue.  We requested a repeat MRI to make sure we were on the right track.  Dr. Schultz reviewed that MRI this week and the most striking results are above.  The before picture on top, shows the supraspinatus tendon below the yellow arrows.  The problem is that in November of 2008, the extensive light colored areas in the tendon represent swelling and tears.  The good news is that the after picture below, now shows that the rotator cuff tendon (under the yellow arrows) has much improved dark colored signal on this similar STIR MRI image.  This corresponds with his reported clinical improvement.  In addition, the bone cysts that he had in the head of his humerus, can no longer be found on the follow-up MRI.  He was cleared to continue treatment.

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Big Surgeries, Big Complications

Monday, June 29th, 2009

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Just getting back to blogging after a much needed vacation.  In the last few decades, there has been a big move towards minimally invasive procedures, essentially making smaller and smaller incisions to accomplish the same medical goal.  The reason?  The bigger the surgery, the bigger the potential for complications.  Take the patient I saw this morning for the Regenexx procedure on his ankle.  This gentleman had an ankle arthroscopy to remove a bone spur caused by years of running.  However, he contracted MRSA (a super bacteria that is very hard to kill with antibiotics) during the arthroscopy and then underwent 12 additional surgeries over the next two months.  Because the skin on the outside of his ankle was pretty chewed up, they had to take a skin/muscle graft (flap) from another area and bring it down to the lateral ankle (the large “bump” you see on the outside of the ankle in the picture above).  As a result of the MRSA all cartilage in his ankle was also chewed up and the medial talus also partially collapsed.  While MRSA infections are not common with arthroscopy, I use his case this morning to illustrate a point.  We see many patients in our practice where big surgeries have produced big complications.  A second example is also illustrative.  Last week I met with a patient considering the Regenexx procedure for a labral tear.  She had started with a frozen shoulder (adhesive capsilitis) due to the original shoulder labrum tear.  The help this, arthroscopy was combined with manipulation under anesthesia.  While this MUA procedure can help free up shoulder movement in patients who have very little shoulder range of motion, in her case it tore up the joint capsule leaving an unstable shoulder.  In particular, the damage was to the superior lateral fibers that the shoulder hangs on when it’s at rest at your side.  Without these ligaments, the shoulder becomes grossly unstable, and all of the muscles of the shoulder are in constant “overdrive” spasm, trying to keep the shoulder stable.

The take home message, the advent of regenerative medicine techniques will allow more minimally invasive procedures to be used in more patients.  There will still be a place for bigger surgical procedures and undoubtedly regenerative medicine will be mixed and matched with surgical and non-surgical approaches alike.  However, the ability to perform more procedures through a needle or very small tools, will allow complications rates to fall.  Here’s to the future!

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Surgical Complications and Two Colleagues

Tuesday, May 12th, 2009

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As I have said here before, we have a good number of health care providers as patients. As an example, yesterday I performed a stem cell re-implant on a dentist from Hawaii.  The reason I’ve usually given is that these medical providers know the other side of the big surgical procedure coin.  They have seen the complications of surgical procedures, treated these patients or been involved in treating the complications.  So when it comes time for these medical providers to get a knee replacement or major orthopedic procedure, they go looking for other alternatives.  I’d like to highlight two colleagues who have contacted me in the past week who went through with big orthopedic surgeries and lived to tell the tale (one only barely).  This is not to say that many times big orthopedic procedures don’t change lives for the  better, they do so everyday.  However, the bigger and more invasive the procedure, the bigger the chance for significant complications.

The first is a doctor who had a benign tumor on his spine.  It definitely needed to be taken out.  He scoured our local area for a neurosurgeon who had experience in taking out this particular type of tumor (a tall task).  It was an 11 hour surgery where the surgical site became infected.  He is now on IV antibiotics, had a second surgery where they were forced to remove the hardware and “power wash” the area.  Thank God this wasn’t MRSA, as he likely wouldn’t have lived to tell the tale.  This of course led to protracted inactivity, a deep venous thrombosis, which led to a pulmonary embolus, and finally the placement of a filter in one of his major veins (to catch the little blood clots).  What started as a simple removal of a benign tumor led to him almost loosing his life to surgical complications.  Complications like this are not uncommon in spine surgery, with most studies quoting a 2-5% serious complication rate.

The second story that I’ve heard this past week is another colleague who went in for routine arthroscopic  shoulder surgery for rotator cuff repair.  The surgeon may have speared one of the major nerves of the shoulder with the scope which has led to atrophy in the surrounding shoulder muscles and adhesive capsulitis in the shoulder.  It’s also possible that the traction used to pull on his arm during surgery caused the nerve injury.  He now is forced to leave practice as a chiropractor as he has no strength in the arm.  How often do serious complication occur in shoulder arthroscopy?  Several studies quote about 10%, but reading between the lines, the rate of serious complications is likely lower, about 5%.

Many pundits have written about the possible horrible complications that could befall anybody who tries stem cell therapy.  I have written on this topic in the past. To recap, the safest option for treatment at this point is the patent’s own adult stem cells, as they are used everyday by the body to repair and maintain many tissues.  However, the surgical complications of the procedures that stem cell therapy would replace make any possible complications from the patent’s own adult stem cells look mild.  This is ultimately why we see so many health care providers, they simply weigh both of these things and opt for the much less invasive stem cell treatment.

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Making the Grade…

Friday, May 8th, 2009

Like any procedure, the Regenexx procedure works better in some patients than in others.  We have always provided prospective grading of candidacy.  What does this mean?  It means that we obtain basic information about the patient and ask to review films to determine the severity of their disease.  We compare that severity to our clinical experience with that specific procedure and place the patient in a GOOD, FAIR, or POOR category.  We believe this is an important part of any stem cell based procedure.  What this means practically is that about 1/4 of the patients get put into the GOOD category, 1/2 in the FAIR category, and about 1/4 in the POOR category.  In addition, this stem cell procedure grading is different for each procedure.  As examples:

-For peripheral joints (knee, hip, shoulder, ankle, etc…) the grading depends on severity of the arthritis.  We feel GOOD candidates have a limited amount of cartilage loss or an “OCD”.  FAIR candidates have one compartment cartilage loss (like medial or lateral side) without major bony structural changes and POOR candidates generally have significant structural changes in the bone (huge bone spurs) that cause significant loss of range of motion.

-For ligaments and tendons the grading depends on the integrity of the structure.  GOOD candidates have a partial thickness tear or a small full thickness tear where the tendon or ligament is still intact.  At this point we can’t treat full thickness and retracted tears in ligaments or tendons, so these are placed in a “we can’t treat you” category.  This is because the ends of the tears need to be surgically brought back together before any injection based therapy is likely to help.

-For bone problems (fracture non-union and AVN) our grading is based on the amount of damage.  AVN is graded on a scale (we use ARCO) and stage 1-2 (without structural collapse of the bone) are GOOD candidates, yet stages 3 and above are considered FAIR-POOR candidates (we discourage these patients from trying our non-surgical stem cell treatment).  For fracture non-unions, the fracture site must be stable for the patient to be a GOOD candidate, the fracture site should have all areas in relatively close approximation (we have filled in up to a 1 cm gap), and the fracture within 1-2 yerars old.  Large areas of loss of bone may place you in the FAIR or POOR categories.  In addition, if the fracture has been there many years (more than 1-2), this may also make the procedure much less effective.  The good news is that we have seen healing in smokers and patients that have failed a bone stimulator, patients who are usually notoriously difficult to heal.

-Low back discs are graded on their severity and degree of collapse.  GOOD candidates are patients with at least 75% of disc height preserved, can have a dark disc, have a contained disc bulge or subligamentous herniation (herniated disc where the herniated material hasn’t pushed past the posterior longitudinal ligament). If the disc is collapsed and has lost most of it’s disc height, our procedure is unlikely to help.

There are also other factors outside of disease severity that make up our grading.  These include age vs. sex (male vs. female), number and type of prescription medications, activity level, body mass index, overall physical health, etc…  Even though we prospectively grade candidates for the Regenexx procedure, we have been surprised.  Despite our grading system we have had poor candidates show up from time to time and do well with treatment (the vast majority of these are knee arthritis patients).  In summary, we believe that any valid medical or surgical procedure needs to grade patients up front to let them know their basic candidacy.  In addition, whether or not they are allowed to try to the procedure despite being warned of being a POOR candidate should be directly related to the degree of complications associated with the procedure.  Since we have had no significant stem cell related complications in about 450 patients in the last 4 years and have been surprised in knees, we do allow primarily knee patients to try the procedure even if they are not ideal candidates.  However, we will not see late stage AVN patients, disc patients whose disc has already collapsed, unstable fractures, etc…

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Posted in Ankle, Back/lumbar, Hip, Knee, Ligament/tendon, Medical alternatives, Shoulder, Surgery alternative, Thumb, stem cell | No Comments »

Rotator Cuff Tear Treated with Stem Cells

Monday, January 19th, 2009

Ruth is like many of our patients.  She’s a health care professional who has had the RIGHT rotator cuff treated twice with traditional surgery.  The 3-4 month recovery was difficult, the blue pillow immobilization meant that she couldn’t work as an ER nurse.  Because of the muscle atrophy she likely experienced with the first RIGHT sided rotator cuff surgery, she had a retear of the same rotator cuff a few years later.  The second time she was again off work for several months and loosing income.  Based on her results with her first and second surgeries on the RIGHT, when the LEFT rotator cuff tore while she was transferring a patient, she went searching to see if newer non-surgical alternatives were available.  We treated the LEFT by using her MRI to plan our x-ray guided injections of her own stem cells into the tear.  It’s notable that this time, she remained working and fully active during the procedures.  She has had three injections with excellent relief of pain and return of full range of motion.  Rather than the doctor continuing to tell what happened (this is Dr. Centeno), best to let the patient tell her own story:

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Posted in Medical alternatives, Shoulder, Surgery alternative, stem cell | No Comments »