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What’s New in Shoulder and Elbow Surgery

Dr. Gary Gartsman — Mon, 01 May 2006 14:00:00 GMT

The sources for this annual update on shoulder and elbow surgery were presentations and symposia at meetings of The American Orthopaedic Society for Sports Medicine (Specialty Day, February 26, 2005, Washington, DC), the Arthroscopy Association of North America (Specialty Day, February 26, 2005, Washington, DC; Twenty-fourth Annual Meeting, May 12-15, 2005, Vancouver, British Columbia, Canada; and Twenty-third Fall Course, December 2-4, 2004, Palm Desert, California), the American Academy of Orthopaedic Surgeons (Seventy-second Annual Meeting, February 23-27, 2005, Washington, DC), the Orthopaedic Research Society (Fifty-first Annual Meeting, February 20-23, 2005, Washington, DC), the American Shoulder and Elbow Surgeons (Twenty-first Open Meeting, Specialty Day, February 26, 2005, Washington, DC; and Twenty-first Annual Meeting, September 29-October 2, 2004, New York, NY) and the American Orthopaedic Association (118th Annual Meeting, June 22-25, 2005, Huntington Beach, California).

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1-May-06 9:00 AM

Adhesive Capsulitis

Gary Gartsman — Fri, 17 Jun 2005 21:00:00 GMT

I feel that the cause of your pain is a condition called Adhesive Capsulitis or “Frozen Shoulder.” This is a common shoulder problem that affects thousands of people every year.

We do not know the cause of frozen shoulder. It does not seem to result from an injury. While some people relate the onset of their pain to an injury or illness, many more say the problem began “out of the blue,” without any cause.

Pain may start suddenly or begin slowly. Pain and stiffness in the shoulder increase. Often patients report difficulty with sleep as the shoulder is particularly painful at night. Reaching up to get items off shelves, reaching behind the back to tuck in a shirt or blouse become difficult or impossible.

Adhesive capsulitis is not a disease or aging. Most patients are between the ages of 40 and 60. The condition does not increase as you get older. Let me emphasize that this is a condition, not an injury. Like any condition it has a beginning, a middle and an end. You know the beginning. That is why you came to the office for an examination. The middle occurs as the pain decreases but the stiffness remains. The condition ends as range of motion returns.

Why does adhesive capsulitis occur? Medical science has not found a cause of this process. We know what happens, but not why. Normally the shoulder joint ligaments are folded, like the folds of curtain or fan. When the arm moves upward, the folds expand. When the arm is lowered the folds contract. In frozen shoulder the folds stick to one another. The scar tissue prevents normal shoulder movements and causes pain.

The good news is that most individuals regain excellent use of their shoulder with none or minimal discomfort. The bad news is that this process of healing and recovery can take 1-2 years.

What can be done? Regrettably we have no proven method to speed the natural healing process. Intensive physical therapy, shots, pill, and injections have all been shown to improve the condition but do not improve the condition more quickly than simple exercises that one may do at home.

We will show you the exercises that are beneficial. You cannot break the scar tissue loose. It is too strong. The purpose of these is to gently stretch the shoulder joint and encourage the return of motion. Muscle strengthening exercises help you maintain tone so that when your shoulder motion recovers, the muscles are strong.

You should not be afraid to use your shoulder. Use your shoulder for any and all activities that are not painful, but if pain occurs, stop the activity. Do not try to work through the pain.

I know that this is a frustrating condition as I see hundreds of patients each year with the same problem. Hopefully now that you know why your shoulder is painful and understand what will happen and what you can do about it you will feel more at ease.

Again if you have questions or your condition worsens, please return for another examination or discussion.

17-Jun-05 4:00 PM

Radiographic comparison of pegged and keeled glenoid

Wed, 18 May 2005 22:00:00 GMT

Glenoid loosening is one reason for failure of tota shoulder arthroplasty. Several factors, including radiographic lucency, have been shown to be associated with glenoid loosening. The purpose of this study was to assess the correlation between glenoid design and immediate radiographic lucency in a prospective randomized clinical trial. Total shoulder arthroplasty was performed in 43 patients over a 2-year period. Twenty-three patients were randomized into the keel group and twenty patients into the pegged group. Postoperative radiographs obtained within 6 weeks of surgery were evaluated by 3 raters to determine glenoid lucency. On a scale from 0 (no lucency) to 5 (gross lucency and component loosening), the rate of lucency was 39% (9/23) in the keeled components, which was significantly higher than the rate of 5% (1/20) observed in the pegged components (P = .026). Patient age, gender,and glenoid size did not significantly affect glenoid component lucency (P > .05). The consistency reliability among raters was 0.87,and the intertester reliability was 0.87. Pegged glenoid components have less radiographic lucency when compared with keeled glenoid components in the immediate postoperative period. (J Shoulder Elbow Surg 2005;14:252-257.)

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18-May-05 5:00 PM

The relationship among strength and mobility measures and self-report outcome scores in persons after rotator cuff repair surgery:Impairment measures are not enough

Thu, 31 Mar 2005 13:00:00 GMT

Until recently, few investigators challenged the pre-vailing medical view of health. Medicine perceived health as an observable, biologic fact, and the goal of medical assessment was to objectively evaluate the body’s status. Because patient reports of health status are subjective, they were considered unreliable and unscientific. The use of self-reports to evaluate health and health outcomes, however, has burgeoned in the last 10 to 20 years, as has the authority assigned to patients’ evaluations. Sullivan 14 described this move toward a “new subjective medicine” as a change in medicine’s focus from patients’ bodies to patients’ lives. In the current milieu, self-reported perceptions of health, function, and health-related quality of life (of-ten called patient-centered outcomes) are prominent. These outcomes have authority not in spite of their subjectivity but because of their subjectivity. The inter-est of health policy agents and third-party insurers in health care value and cost-effectiveness may have been at the root of the shift toward patient-centered outcomes.14

31-Mar-05 8:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2005)

Tue, 01 Feb 2005 17:00:00 GMT

Sources

The sources for this annual update on shoulder and elbow surgery were presentations and symposia at meetings of the American Shoulder and Elbow Surgeons (October 8 through 11, 2003, and March 13, 2004), the Arthroscopy Association of North America (November 13 through 16, 2003; March 13, 2004; and April 23 through 25, 2004), the Orthopaedic Re-search Society (March 6 through 9, 2004), the American Academy of Orthopaedic Surgeons (March 9 through 13, 2004), the American Orthopaedic Society for Sports Medi-cine (March 13, 2004), and the American Orthopaedic Asso-ciation (June 23 through 26, 2004).

Shoulder
Rotator Cuff
Basic Science

Zuckerman discussed the early work on cartilage-derived morphogenetic protein-2 (CDMP-2). Rat tendon repairs that had been treated with CDMP-2 were stronger than untreated repairs at four weeks. Dines discussed his initial investigations involving platelet-derived growth factor (PDGF) and insulin-like growth factor-1 (IGF-1). Studies at his laboratory demon-strated that cultured rat fibroblasts could be transduced with the genes from the growth factors and then seeded onto a polymer scaffold and cultured to form tissue-engineered ten-don constructs. Fibroblasts apposed to the tissue engineered constructs containing the IGF gene demonstrated up to a ten-fold stimulation of collagen synthesis compared with con-structs with the gene. The author stated that he hopes that this research can lead to the development of biologically active patches capable of accelerating and modulating rotator cuff repair.

Kikugawa reported on the effects of synovial tissue and growth factors on rotator cuff healing. A supraspinatus ten-don defect was created in forty-eight rats. In half of the rats, the defect was filled with synovial tissue. Compared with the specimens without synovial tissue-filled defects, specimens with filled defects appeared to be more mature, with more-intense staining for TGF-α and increased production of type-I and type-III procollagen. These findings suggest that synovial tissue plays an important role in modulating tendon-healing and that expression of TGF-α may influence the synovial tis-sue in this role.

Sprott investigated the potential for reversal of fatty infiltration following rotator cuff repair in a rabbit model. Fifteen rabbits underwent unilateral detachment of the su-praspinatus tendon from the greater tuberosity. Six weeks following detachment, five rabbits were killed to halt the fatty infiltration process and ten underwent repair of the rotator cuff followed by unrestricted activity. The ten rabbits in the repair group were killed at six months. At six weeks following detachment, significant fatty infiltration was demonstrated (p = 0.001). At six months following repair, the muscle dem-onstrated no further increase in fat (p = 0.03), suggesting that the process of fatty infiltration associated with chronic rotator cuff detachment can be halted, but not reversed, by repair.

Meyer used computerized tomography and both light and electron microscopy to study fatty muscle changes that occur after a rotator cuff tear in a sheep model. Eight sheep underwent unilateral infraspinatus tendon release and delayed repair. Seventy-five weeks after the repair, significant in-creases in muscle retraction and pennation angle as well as significant muscle-fiber shortening (p < 0.0001) were identi-fied. Interstitial fat and fibrous tissue increased from 4% to 46% of the muscle volume. On the basis of geometric model-ing, the authors concluded that the fatty tissue may fill spaces created by the combination of retraction, shortening, and changes in pennation angle. These findings contradict cur-rent thinking that the fatty changes represent primarily a de-generative process.

Bishop evaluated the changes in muscle fatty infiltration and atrophy following rotator cuff repair. Preoperative and postoperative magnetic resonance imaging was used to grade fatty infiltration on a 5-point scale and muscle atrophy on a 4-point scale. Fatty infiltration and muscle atrophy correlated positively with tear size (p < 0.0001, r = 0.712). Moreover, American Shoulder and Elbow Surgeons (ASES) and Constant scores as well as strength measurements correlated inversely with fatty infiltration and muscle atrophy (p < 0.03). Repeat tear was associated with fatty infiltration of the supraspinatus and weakness in forward flexion, and external rotation was most strongly associated with fatty infiltration of the in-fraspinatus. However, pain relief was independent of the de-grees of fatty infiltration and muscle atrophy.

Cohen reported on the inhibitory effects of traditional nonsteroidal anti-inflammatory drugs and cyclooxygenase-2- selective inhibitors on rotator cuff tendon-healing in a rat model. Following rotator cuff detachment and repair, 180 rats were randomly assigned to receive celecoxib, indomethacin, or no drug. Groups of animals were killed at two, four, and eight weeks postoperatively, and the tendons were subjected to bio-mechanical and histologic evaluation. The author found that load to failure was significantly lower in the indomethacin and celecoxib groups compared with the control group at two, four, and eight weeks. In contrast to both treatment groups, the control group exhibited improved collagen maturity and organization at the tendon-insertion site. The results demon-strate that both traditional nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors significantly impair tendon-to-bone healing in the rat rotator cuff.

Tingart evaluated the effect of suture anchor design and bone density on the pullout strength of suture anchors used for rotator cuff repair. The trabecular and cortical bone min-eral density was determined for six regions within the greater tuberosity. Metal screw-type and biodegradable hook-type su-ture anchors were inserted into each region and were cyclically loaded until failure. Metal anchors failed at an average 66% higher load than bioabsorbable anchors did (p < 0.01). For both anchor types, failure loads correlated with bone-mineral density and were significantly higher in the proximal tuberos-ity (p < 0.01).

1-Feb-05 11:00 AM

Development of a Flexilevel Scale for use with computer adaptive testing for assessing shoulder function

randy sarinas — Tue, 01 Feb 2005 14:45:00 GMT

In a 5-year study, a self-report measure of shoulder function—the Flexilevel Scale of Shoulder Function (FLEX-SF)—was developed by use of item response the-ory. A large pool of candidate items (N 68) was developed. A questionnaire that included the 68 items, another scale of shoulder function, and clinical and demographic questions were administered to 400 per-sons with shoulder complaints. Patients’ responses to the 68 items were calibrated by use of Andrich’s rat-ing scale model. Thirty-three items were selected from the pool and subdivided into three overlapping testlets targeting low, medium, and high shoulder function. A table translates raw scores on testlets to a common mathematical metric. The validity and reliability of the FLEX-SF was evaluated in a longitudinal study of 199 patients. The FLEX-SF scores were highly reliable and exhibited excellent validity (including responsiveness). We report on a simulation of a computer-adaptive test of shoulder function. This simulation is based on the developmental items we tested for use in the FLEX-SF. The results indicate that greater measurement effi-ciency can be achieved with a computer-adaptive test format. (J Shoulder Elbow Surg 2005;14:90S-94S.)

1-Feb-05 8:45 AM

Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: A prospective, randomized study of one-year outcomes

Dr. Gary Gartsman — Tue, 31 Aug 2004 14:00:00 GMT

All other aspects of the surgical and postsurgical treatment were identical. We included patients with full-thickness tears limited to the supraspinatus tendon and a type 2 acromion. We excluded patients with prior surgery, those with larger tears involving two or more tendons, those with a type 1 or 3 acromion, those with workers’ compensation claims, and those who had concomitant procedures (labral repair, acromioclavicular joint resection) There were 47 patients in group 1 and 46 in group 2. Minimum follow-up was 1 year (mean, 15.6 3.3 months). We recorded the American Shoulder and Elbow Surgeons (ASES) shoulder scores preoperatively and postoperatively. There was no statistical difference in postoperative ASES scores between group 1 (91.5 10.3) and group 2 (89.2 15.1) (P .392). The change in ASES score over time did not differ between the two groups (61.1 vs 60.2, P .363). In conclusion, within the parameters described above, arthroscopic subacromial decompression does not appear to change the functional outcome after arthroscopic repair of the rotator cuff. (J Shoulder Elbow Surg 2004;13:424–6.)... (download full pdf article)

31-Aug-04 9:00 AM

Outcome Expectancies, Functional Outcomes, and Expectancy Fulfillment for Patients With Shoulder Problems

Wed, 04 Feb 2004 14:00:00 GMT

Methods: Patients (n 199) treated for shoulder problems at one orthopedic surgeon's office completed a baseline survey comprised of measures of outcome expectancies, shoulder function, health status, and demographics. At 1 month, 2 months, and 3 months, patients completed a mailed follow-up survey comprised of all baseline measures except demographic variables. At 3 months, a measure of expectancy fulfillment was added. A general linear modeling approach was used to assess the significance and effect size of 1) outcome expectancies on changes in shoulder function; and (2) outcome expectancies, shoulder function changes, and their interaction on perceptions of expectancy fulfillment. Results: Outcome expectancies significantly predicted changes in shoulder function and accounted for 10% of the variance in functional improvement. The improvement difference between patients with high expectancies compared with those with low expectancies was clinically relevant (4.57 points), as it was greater than the minimal clinically important difference (3.02 points). Outcome... (download full pdf article)

4-Feb-04 8:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2004)

Sun, 04 Jan 2004 15:00:00 GMT

Shoulder Rotator Cuff Basic Science Kelly compared the muscle-firing patterns in both symptomatic and asymptomatic patients who had two-tendon rotator cuff tears. Asymptomatic patients demonstrated increased firing of the intact subscapularis, whereas symptomatic patients continued to rely on torn rotator cuff tendons and scapular muscle substitution, resulting in compromised function. Kalandiak compared the in vivo kinematics of painless shoulders that had massive rotator cuff tears with those of normal shoulders with use of cinefluoroscopy. Only one patient demonstrated normal "ball and socket" kinematics; most demonstrated increased scapulothoracic motion during initial forward elevation. The mean active forward elevation was 129° when performed against no resistance but only 86° when performed against resistance. Rubino studied the progression of fatty infiltration by harvesting the supraspinatus muscle bilaterally at various timeintervals following unilateral surgical detachment of that tendon in a rabbit model. A consistent decrease in muscle weight was noted when detached specimens were compared with intact specimens.

Fatty infiltration was evident as early as six weeks after detachment and increased over time as a percentage of muscle volume (p = 0.002). Schlegel compared the modified Mason-Allen stitch with a horizontal mattress stitch in a sheep model to determine the effect on tendon-healing to bone. Subsequent biomechanical and histological testing demonstrated similar stiffness and loads to failure and normal-appearing tendon-tobone insertions. St. Pierre compared three different suturerepair techniques in a human cadaver model. The modified Mason-Allen and double-mattress techniques had higher ultimate loads to failure than did the single-horizontal-mattress technique when used with suture anchors. Boswell compared bioabsorbable screw-and-washer fixation with various suture-anchor repairs for rotator cuff fixation in a bovine model. The study demonstrated that 5-mm gap formation occurred later in association with the bioabsorbable screw-and-washer method than it did in association with any suture-anchor repair method, including a technique involving the use of single-loaded anchors with modified Mason-Allen sutures. Tasto used a bovine model to demonstrate that the depth of insertion of suture anchors influences their ultimate load strength and mode of failure. Countersunk anchors had greater ultimate load strength to failure than did anchors that were placed proud or level with the cortical surface.

In addition, no sutures in the countersunk-sutureanchor group failed during cyclical loading. Hawkins compared the accuracy of physical examination alone with that of physical examination coupled with magnetic resonance imaging for the diagnosis of rotator cuff tears. Prospective data were collected on 299 patients who underwent rotator cuff surgery, 148 of whom had ancillary magnetic resonance imaging data. The positive predictive values for the diagnosis of a full-thickness tear on physical... (download full pdf article)

4-Jan-04 9:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2003)

Fri, 03 Jan 2003 15:00:00 GMT

Shoulder Rotator Cuff Basic Science Several studies have employed sophisticated animal models to investigate rotator cuff repair and healing. Coleman reported on a chronic rotator cuff injury and repair model involving sheep. Infraspinatus contractile forces and histological findings were evaluated at various times following either immediate or delayed tendon repair. Longer delays to repair led to greater decreases in force and more modest recovery following repair. Muscle biopsies confirmed progressive fatty infiltration that was partially reversed after tendon repair in the group with a six-week delay before repair but not in the group with an eighteen-week delay before repair. This model has important implications regarding the recovery of strength following the repair of chronic rotator cuff tears. Rodeo presented a study on growth factor-enhanced rotator cuff tendon-bone healing in a sheep model.

Histological analysis demonstrated greater new-bone and fibrovascular tissue formation in the treated animals. A substantial increase in attachment strength was noted in the treated animals at twelve weeks. The study demonstrates the ability of a growth factor to influence changes at the tendon-bone interface. MacGilivray evaluated the augmentation of rotator cuff repairs with a bioabsorbable scaffold in a goat model. Biomechanical testing showed no significant improvement in load to failure when a tendon defect was covered with a polylactic acid patch. The inability of the patch to enhance repair strength was thought to result from shielding of the patch from direct load by the repair. Halder used a cadaveric model to identify the characteristics of rotator cuff tears that were responsible for loss of strength. Detachment of one-third and two-thirds of the supraspinatus tendon affected force transmission by the rotator cuff only slightly, while detachment of the whole tendon resulted in greater reductions in force transmission.

Simulated muscle retraction also led to reductions in force transmission. Side-to-side repair of defects involving one third and two thirds of the tendon restored near-normal force transmission. These results echoed the clinical observation that patients with small rotator cuff tears may present without a loss of strength. Furthermore, side-to-side repair of otherwise irreparable defects may help to restore the integrity of the rotator cable. Chronic rotator cuff tears are often accompanied by muscle atrophy, fatty infiltration, and retraction, which may decrease overall muscle volume. Apreleva determined the reliability and validity of magnetic resonance imaging in the assessment of rotator cuff muscle volume in a study of cadaveric shoulders. Magnetic resonance imaging scans were made and the supraspinatus, infraspinatus-teres minor, and subscapularis muscle volumes were then computed with use of three-dimensional image-analysis software. Muscle volumes were confirmed with use of water displacement after dissection. The muscle volumes measured with use of the two methods were found to correlate highly, suggesting that magnetic resonance imaging may hold promise for the preoperative as... (download full pdf article)

3-Jan-03 9:00 AM

Gary Gartsman, MD, Credentials

Tue, 05 Jan 2010 16:38:11 GMT

Download Gary Gartsman, M.D. full cv Certification Board Certified by the American Board of Orthopedic Surgeons July 22, 1983 American Academy of Orthopedic Surgeons January 27, 1985 Current Hospital Appointments Active Staff Texas Orthopedic Hospital Board of Directors (1998-2005) Secretary-Treasurer (1999-2005) Joe W. King Orthopedic Research Institute Board of Directors (1995-) Consultant in Shoulder Surgery The Houston Comets (2003-2005) The Houston Rockets (2003-2005) The Texas State Board of Medical Examiners (1992-) The Houston Astros (1982-1994) The Houston Oilers (1982-1995) The University of Houston (1982-1992) Consultant for Peer Review Journals Clinical Orthopedics & Related Research (1990-2005) The Journal of Orthopedic Trauma (1991-2001) Arthroscopy (1992-2002) The Journal of Shoulder and Elbow Surgery (1992-) The...

About Dr. Gartsman

Tue, 05 Jan 2010 16:34:35 GMT

Download Gary Gartsman, M.D. full cv Gary M. Gartsman, M.D. has practiced with the Fondren Orthopedic Group, L.L.P. in Houston, Texas since January 1982. Since 2002, Dr. Gartsman has held the title of Clinical Professor for the Department of Orthopaedic Surgery at the University of Texas Houston Health Science Center. He is the Fellowship Director of the Shoulder and Elbow Fellowship at the University of Texas Houston Health Science Center. Dr. Gartsman completed his undergraduate education at the University of California at Berkeley in Berkeley, California in 1971. He received his M.D. in 1975 from the University of Chicago Pritzker School of Medicine in Chicago, Illinois, and completed his post-graduate education at The New York Hospital - Cornell Medical Center in New York, New York in General Surgery Residency until June 1977. Other institutions in...

Biceps Tenodesis & Subacromial Decompression

Thu, 21 May 2009 17:40:33 GMT

Surgical Treatment of Rotator Cuff Impingement and Acromio-clavicular Joint Arthritis Why this letter? I think most people find going to see the doctor a difficult and emotional experience that I think is more stressful when potential surgery is a consideration. While many of the things we discussed are simple, you may quickly forget the details. Hopefully, this letter will serve to remind you of our meeting and answer any questions that arise. What is wrong with your shoulder? Your shoulder pain arises from a problem in the biceps tendon and the rotator cuff tendons. A tendon is the thick, cord-like structure that allows muscles to connect to bones. In the shoulder 4 of these tendons are called the rotator cuff. The biceps and rotator cuff tendons have to pass between two bones, the acromion and the humerus. The space is small and normally the tendons just pass through as the arm is raised and rotated. With repeated overuse, a single injury or even just the wear and tear of...

Invited Lectureships

Tue, 20 Jan 2009 22:00:44 GMT

Panther Sports Medicine Symposium
The University of Pittsburgh
Pittsburgh, PA
December 1990

The Hughston Clinic
Columbus, GA
April 1991

33rd Annual Rudolph S. Reich Lecturer
Case Western Reserve University School of Medicine
Cleveland Orthopedic Society
The Cleveland Clinic Foundation
Mt. Sinai Medical Center
April 1998

Recent Advances in Arthroscopic Shoulder Surgery
Villa Anni Cuggiano
Cuggiano, Italy
June 4, 1999

80th Annual Alumni Meeting
The Hospital for Special Surgery
New York, NY
November 2, 2000

10th Corso di Chirugia della Spalla
Milan, Italy

November 6-8, 2000

Weinstein Lectureship
Long Island Jewish – North Shore Medical Center
New York, New York
May 3, 2002

Southern Orthopedic Association
Atlanta, GA
March 11, 2005

Pennsylvania Orthopedic Society
Bahamas
May 5, 2006

86th Annual Alumni Meeting
The Hospital for Special Surgery
New York, NY
November 9, 2006

6th Advanced Course on Shoulder Arthroscopy
Val d’Isere, France
January 21-26, 2007

Anthony F. DePalma Oration
Jefferson Orthopedic Society
Philadelphia, PA
May 4, 2007

VOCA Congress
Utrecht, The Netherlands
October 25, 2008

88th Annual Alumni Meeting
The Hospital for Special Surgery
New York, NY
November 15, 2008

Community Involvement

Tue, 06 Jan 2009 14:45:21 GMT

Dr. Gartsman and his wife, Carol, support several causes and invite you to also
become involved.

Such charities include: