News

New method to repair torn shoulder tendons

The Straits Times (7 June 2012)

The new way, which uses two anchors forming a dual-row repair to hold the tendon against the bone, helps shoulders heal better. Ng Wan Ching reports

The golf swing or baseball pitch can be hell on the shoulder, causing injury to the rotator cuff muscle connecting the shoulder blade to the upper arm bone.

Prevention tips

  1. Do not brush off pain in the shoulder as muscle ache. The pain could be due to more serious injuries of the tendon.
  2. Do not engage in overhead lifting or carrying heavy loads if you are not used to it, especially of you are more than 50 years old.
  3. Warm up your shoulder muscles if you plan to take part in sports with overhead movements such as racquet games and swimming.
  4. Seek your physician's advice if the pain is especially severe after sports or trauma and if the pain persists after a few days.

Source: Associate Professor Denny Lie, a senior consultant at the department of orthopaedic surgery at the Singapore General Hospital

But what is just as damaging and more widespread here is the act of swinging a laundry pole laden with wet clothes out of a window to hang from a bracket. It causes the same injury.

One-third of his female patients who seek treatment for rotator cuff injuries have hurt themselves this way, said Associate Professor Denny Lie, a senior consultant at the department of orthopaedic surgery at the Singapore General Hospital (SGH).

He said the tendons of the shoulder joint can become injured from activities such as carrying heavy bags and lifting loads overhead.

The signs are deep pain in the shoulder, made worse when sleeping on the affected side.

Often, the pain is associated with weakness that affects activities of daily living.

'Women may find it difficult to brush their hair or undo their bra. Men describe difficulties of reaching their back pocket or lifting things overhead,' said Prof Lie.

Patients at the SGH clinic tend to be more than 50 years old. Of these, slightly more are women than men.

Fortunately for patients, the latest development in shoulder surgery, the dual-row repair, is proving to be more effective than single-row repair in getting function back to the shoulder.

Torn tendons are usually repaired with stitches using one or two anchors arranged in a single row.

This can be done through keyhole surgery, where doctors operate using instruments inserted through three small cuts, rather than a large one.

A new development in arthroscopic (keyhole) rotator cuff repair uses two anchors forming the dual-row repair (see graphic). Sutures are threaded through the two anchors and hold the tendon in place against the bone until it heals.

LOWER RISK OF RE-TEARING

Dual-row repairs have been proven to be as strong as single-row repairs in the short term and have lower re-tear rates in the longer term.

At SGH, where it has been used since 2008, a study of 150 patients in 2009 found that patients who had dual-row repairs - for bigger tears in their tendons - recovered as quickly as those with smaller tears (about six weeks). They were also able to return to work and sports in the same amount of time.

After two years, the single-row repair had a 30 per cent higher rate of recurrence than the dual-row repair.

An estimated 250 dual-row repairs are performed each year in SGH alone, where it costs $10,000 to $12,000 for private patients. The cost is similar for single-row repairs.

This technique is now used as the standard of care in most hospitals here.

Surgeons at the National University Hospital started performing the dual-row arthroscopic rotator cuff repair in 2007 and operate on 10 to 15 patients a year.

'We usually only opt for double-row instead of single-row arthroscopic rotator cuff repair for patients with big tears as there is some evidence that the risk of re-tear in the future is lower,' said Dr Tan Chyn Hong, a consultant in the department of orthopaedic surgery.

The same holds for Tan Tock Seng Hospital (TTSH). Adjunct Assistant Professor Lee Keng Thiam, a consultant and deputy head of the department of orthopaedic surgery and head of the sports service there, said the lower re-tear rate of the dual-row repair would eventually result in better long-term recovery.

TTSH, which has been doing dual-row repairs since 2007, does more than 100 each year.

At Changi General Hospital (CGH), it is slightly different. Double row repairs are only done in some patients.

Dr Lim Yi-Jia, consultant orthopaedic surgeon and director of the Shoulder and Elbow Service, said that CGH surgeons have been doing dual-row repair since last year, but only on selected patients.

He said there is currently no evidence that in the long term, double-row repairs have better clinical results than single-row repairs. 'This is partly due to the fact that double-row repair is a relatively new technique. There are some biomechanical benefits to double-row repair, but this has not been shown consistently to translate to superior clinical results,' he said.

He added that his patients who underwent single-row repair have consistently done well, even in patients with massive rotator cuff tears. CGH does about 250 rotator cuff repairs a year.

OVERUSE LED TO INJURY

The new surgery has helped Mr S V Ramamuthi, 62, a senior supervisor at PSA, get back to his normal life.

The exercise enthusiast, who has converted half his bedroom into his gym, works out regularly with weights.

He admitted that, sometimes, when the exercise is pumping him full of 'feel good' endorphins, he gets carried away.

That was what happened in January last year.

He was lifting some dumbbells and kept adding weights to them, until he was lifting 20kg with his right arm.

'It was not all that heavy, but I was doing it repetitively and I did something to my shoulder. I knew something was off and I could not lift weights properly after that,' said the father of two grown-up children.

He could also no longer help his wife with household chores such as hanging poles full of wet clothes outside the kitchen window.

Unable to do his regular exercise, he ended up doing brisk walking, he said.

What was more distressing was the disruption to his normal routine.

'I had to learn how to brush my teeth, shave and do other things with my left hand,' he said.

In February last year, he had his torn rotator cuff repaired with the dual-row method, but he was not patient enough to let it heal.

'I went back to lifting weights too soon. My shoulder became infected and gave me a lot of pain,' he said.

He underwent a second operation in November.

This time, he listened to his physiotherapist and now does no more than lift 3kg per arm each time or 5kg with both arms.

'I agreed with my physiotherapist that, on a scale of one to 10, if I feel pain at level four, I would stop what I was doing,' he said.

wanching@sph.com.sg

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Source: The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.