By Steven Meier
The shoulder is one of the most movable joints in the body but also, potentially, the most unstable and prone to injury because of its wide range of motion. Unfortunately, once the shoulder has been injured, there is an increased chance of recurrent injury, tissue degeneration, and reduced function. A shoulder injury can impact all areas of life, with pain that can be local or that radiates to surrounding areas and down the arm. From work and leisure activities, like sports, to daily tasks, like washing dishes or sleeping, shoulder injuries can not only be painful but have a debilitating effect on one’s life.
At Meier Orthopedic Sports and Regenerative Medicine, orthopedic surgeon Steven W. Meier, MD, is a leading expert in shoulder injuries with extensive experience and expertise in regenerative medicine, outpatient shoulder surgery, joint replacement, and non-invasive techniques.
Regenerative medicine is a range of state-of-the-art techniques that harness and boost the body’s natural ability to heal damaged or diseased tissues while also reducing pain and inflammation. Dr. Meier is considered a leading expert on regenerative medicine in Beverly Hills and the U.S., utilizing the most advanced techniques to improve conventional treatments or as alternative treatment options for more invasive surgical procedures. Dr. Meier offers the following types of regenerative medicine:
- Prolotherapy: Also known as proliferative therapy, prolotherapy helps alleviate pain and inflammation in the joints by injecting a dextrose-saline solution that cushions the joint and stimulates the production of collagen and other building blocks that help support cartilage.
- PRP Therapy: Platelet-rich plasma (PRP) therapy is a procedure that utilizes a patient’s blood plasma and other vital growth factors to boost the body’s natural healing process. The PRP is collected from the patient and then injected into the damaged joint or tissues to promote a faster recovery.
- Stem Cell Therapy: Stem cells are the conductors of repair and regeneration for all of the tissues in the human body. Adult mesenchymal stem cells (MSCs), also known as “medicinal signaling cells,” naturally migrate to areas of tissue distress and release chemical signals to direct other specialized cells in the tissue repair process. MSCs also reduce painful inflammation by down-regulating the inflammatory cascade. At Meier Orthopedic Sports and Regenerative Medicine adult stem cells are obtained from the patient’s own bone marrow or fat tissue to be concentrated and then injected into the treatment areas.
Platelet-Rich Plasma to the Shoulder
Surgical Options for Shoulder Injuries
The types of shoulder procedures performed at Meier Orthopedic Sports and Regenerative Medicine include, but are not limited to:
Arthroscopic Shoulder Surgery
Arthroscopic shoulder surgery or simply “arthroscopy” is a minimally-invasive outpatient procedure that requires only a few small incisions in order to treat shoulder injuries and conditions. Arthroscopic procedures are performed by making small access “portals” in the skin and using a fiber optic viewing lens and specialized instruments to perform simple or extensive work on the inside of the joint without making large incisions or cutting any muscle. Arthroscopic techniques offer patients who suffer from shoulder injuries, like rotator cuff tears, a less-invasive option that requires less recovery time and reduced complications and pain compared to more traditional surgical treatments.
Arthroscopic Subacromial Decompression
Arthroscopic shoulder decompression is an outpatient orthopedic procedure that Dr. Meier uses to treat shoulder impingement syndrome for patients that have not had success with non-surgical treatments. The most common types of injuries associated with the shoulder impingement syndrome are bursitis, inflammation, fraying or tearing of the rotator cuff, and bone spur formation in the shoulder. Not only will shoulder impingement syndrome cause pain, but it also limits the range of motion in the joint. Arthroscopic subacromial decompression involves removing inflamed and scarred bursa tissue and shaving down any bony spurs so they no longer impinge on the rotator cuff.
Arthroscopic Distal Clavicle Resection
Arthroscopic distal clavicle resection is an outpatient orthopedic procedure that Dr. Meier uses to treat painful acromioclavicular (AC) joint arthrosis, a condition in which the cartilage that supports the AC joint begins to degenerate. Distal clavicle resection helps relieve pain and restore the range of motion in the shoulder by removing a small portion of the very end of the clavicle or collarbone. This eliminates the painful bone rubbing on bone between the acromion and clavicle, recreating a natural space within which scar tissue will fill in to provide a new cushion.
Arthroscopic Shoulder Instability Surgery
Shoulder instability can be caused by a traumatic injury or due to excessive tissue laxity. Shoulder instability can manifest as recurrent shoulder dislocations or subluxation, which is a partial dislocation. After a traumatic shoulder dislocation, the stabilizing ligaments of the shoulder become torn and/or stretched. Often, these ligaments don’t heal completely, rendering the shoulder unstable and prone to recurrent dislocations or subluxations.
Arthroscopic shoulder stabilization is a very effective procedure that involves repairing the torn ligaments (capsulolabral complex). This is commonly referred to as a “Bankart repair.” Often, if the supportive ligaments are stretched, they are tightened with sutures via a capsular plication or capsulorrhaphy. If the shoulder has been allowed to dislocate many times, there may also be an erosion of the bone of the ball and socket, which correlates with an increased likelihood of recurrent instability and developing post-traumatic arthritis. In cases of severe erosion, bone grafting may be necessary to stabilize the joint. This makes a good argument for performing shoulder stabilization early before the shoulder has dislocated too many times. For advanced cases, though, bone grafting via a Latarjet procedure can increase the incidence of success.
Rotator Cuff Surgery
A rotator cuff is a group of four muscles that are essential to keeping the shoulder joint in place and maintaining a full range of motion. Rotator cuff tears are common and can occur due to injury or chronic degeneration. When a rotator cuff tendon is torn, it can lead to pain, weakness, and reduced functional movement. Depending on the severity of the tear and whether the tear is partial or complete, Dr. Meier may employ a number of therapeutic techniques including physical therapy, regenerative injection therapy, or arthroscopic surgical intervention to repair the torn rotator cuff.
Even with the best surgical techniques, rotator cuff tears are known to heal slowly and, sometimes, incompletely due to a diminished biologic response. The rotator cuff tendons naturally do not have a very rich blood supply and the number of local stem cells in the tissues diminish over time in the presence of a rotator cuff tear. For this reason, Dr. Meier has been combining the use of bone marrow aspirate concentrate (BMAC) containing stem cells and growth factors with arthroscopic rotator cuff repair for enhanced healing. Bone marrow aspirate is obtained from the patient minimally invasively, concentrated, and injected into the rotator cuff repair site. This combination therapy holds great promise as clinical studies have shown significantly improved healing rates when adding BMAC with stems cells and growth factors to rotator cuff repairs.
Superior Capsular Reconstruction
For chronic and severe rotator cuff tears that have deteriorated to the point that they have become irreparable, superior capsular reconstruction (SCR) offers an option of restoring shoulder stability and improving function. Although SCR is a complex procedure that requires great surgical skill, it can be performed minimally invasively using all-arthroscopic techniques. SCR provides a much less invasive and joint-preserving alternative to reverse total shoulder replacement, a procedure that has become highly utilized for massive rotator cuff tears but may be best considered an end-of-the-line treatment when all other options have failed.
One of the major benefits of SCR is that it preserves the integrity of the shoulder joint and burns no bridges for future treatment. SCR involves reconstructing the superior capsular ligament with an acellular dermal graft made of collagen, elastin, and growth factors. Reconstructing the superior capsular ligament reduces superior humeral translation, centering and stabilizing the ball and socket joint to restore a stable fulcrum, allowing the shoulder to generate power for greater movement. The stabilizing effect of the reconstruction may also help to impede the further progression of joint degeneration that often accompanies chronic, irreparable rotator cuff tears. SCR works best with irreparable rotator cuff tears when the joint cartilage is still in good condition. If the condition has progressed to the point where the cartilage is severely worn, though, reverse total shoulder arthroplasty may provide the best option.
AC Joint Separation (Separated Shoulder) Treatment
Acromioclavicular (AC) joint separation, or a “separated shoulder” is a common injury that sometimes requires surgical intervention to reduce pain and restore function. A separation occurs at the AC joint, which connects the clavicle to the scapula and is classified into six types or grades. Depending on the severity of the separation, initial treatment typically includes rest, ice, anti-inflammatory medications, and physical therapy to strengthen the muscles and aid in joint stabilization.
Mild forms of AC joint separation are usually tolerated fairly well but more severe deformities that result from higher energy injuries may lead to chronic pain and weakness in the shoulder due to the disruption of the shoulder girdle mechanics. For these patients, AC joint reconstruction can restore normal alignment for reduction of pain and improved strength.
Read more about AC joint separation treatment.
Shoulder Replacement / Shoulder Arthroplasty
Shoulder replacement surgery is indicated for patients with severe degenerative joint disease, also known as osteoarthritis. The condition causes the cartilage that cushions the shoulder joint to wear away to the point where the bones grind against each other with each movement, causing pain and stiffness. The shoulder replacement procedure involves replacing the rough and deformed joint surfaces with a mechanical ball-and-socket to restore smooth motion, reduce pain, and improve the function of the shoulder.
In a total shoulder arthroplasty, the arthritic ball (humeral head) is replaced with a metal ball that is attached to a stem, which is “press fit” into the shaft of the humerus (upper arm bone). In some cases, the stem is secured in place with cement or by impaction grafting the inside of the humerus using healthy bone tissue collected from the removed humeral head. The plastic socket is affixed to the healthy bone socket with a combination of “press fitting” and cement.
Total shoulder replacement is highly effective for relieving pain and restoring a normal range of motion, allowing the patient to return to daily activities within six to eight weeks. medlineplus.gov has more information about shoulder replacement surgery.
Reverse Total Shoulder Replacement
Reverse total shoulder replacement or arthroplasty provides a unique solution to the challenging problem of severe, irreparable rotator cuff tears in which rotator cuff arthropathy has developed. Rotator cuff arthropathy refers to the advanced stage in a large, chronic rotator cuff tear where the humeral head (or ball) rises up in the socket due to the loss of the stabilizing function of an intact rotator cuff. As a result of the joint slipping out of place in this way, patients experience pain and loss of motion. This imbalance also leads to the joint cartilage wearing away, leading to severe arthritis. For irreparable rotator cuff tears that have not yet progressed to rotator cuff arthropathy, superior capsular reconstruction may be a good option. However, once rotator cuff arthropathy has set in, a reverse total shoulder replacement may be the only effective solution.
In a reverse total shoulder arthroplasty, the diseased joint is replaced with a mechanical joint. A metal ball replaces the socket and a metal and plastic socket replaces the ball, effectively reversing the position of the moving parts in the shoulder joint. The innovative effects of this design alter the mechanics of the joint by leveraging the power of the deltoid muscle, which ends up substituting for the non-functioning rotator cuff. This procedure can alleviate chronic pain and restore power to the shoulder, allowing patients to move their arm more effectively.
Repair of Os Acromiale
An os acromiale is a congenital condition where the acromion (the part of the shoulder blade at the top of the shoulder) does not completely fuse during normal development. This can result in an unstable portion of the acromion, which may lead to shoulder pain and weakness. Many patients with os acromiale may have no symptoms for years until they suffer an injury to the shoulder that destabilizes and loosens the bony separation. The destabilization can result in pain and weakness that persists.
An unstable and symptomatic os acromiale can be repaired with a procedure called “open reduction and fixation” using metallic fixation consisting of pins or screws. A small amount of bone graft may be harvested from the pelvis or tibia and added to the repair site to enhance healing. The goal is to obtain fusion of the separated bony fragment to the remainder of the shoulder blade as nature intended so instead of being separated into two fragments, the scapula becomes one stable structure, relieving the pain and restoring strength and movement.
Contact an Orthopedic Surgery Specialist in Beverly Hills
Whether suffering from shoulder pain caused by injury or a chronic condition, orthopedic specialist Dr. Meier provides each patient with an individualized treatment plan based on your unique needs and long-term goals. His team of experts uses the latest therapeutic techniques including minimally invasive arthroscopic surgery and regenerative medicine treatments to help patients recover from shoulder injuries faster and with less discomfort compared to more invasive surgical treatments.
Contact our Beverly Hills office today to find out why Dr. Meier is known as a leading expert for shoulder injuries.
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