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Shoulders-relief for rotator cuff tears

BACKGROUND:  The rotator cuff is made up of tendons and muscles in the shoulder.  The tendons and muscles connect the upper arm bone with the shoulder blade and they hold the ball of the upper arm bone in the shoulder socket.  The combination means greater range of motion of any joint in the body.  A rotator cuff injury can include any type of irradiation or damage to the tendons and muscles.  Causes of an injury can include lifting, falling, and repetitive arm activities (usually those that are done overhead like throwing a baseball).  About 50 percent of rotator cuff injuries can heal with self-care or exercise therapy. (Source: www.mayoclinic.com).

SYMPTOMS:  Rotator cuff injury symptoms can include: shoulder weakness, loss of shoulder range of motion, inclination to keep the shoulder inactive, and pain and tenderness in the shoulder.  The most common symptom is pain.  A lot of times it is experienced when a person reaches for a comb, for example.  Lying on the shoulder can also be painful. (Source: www.mayoclinic.com)

INJURY:  The four major muscles, supraspinatus, infraspinatus, teres minor, and subscapularis, and their tendons connect the upper arm bone with the shoulder blade.  A rotator cuff injury, which is common, involves any type of damage or irritation to the muscles or tendons, including: 

  • Tendinitis:  tendons in the rotator cuff can become inflamed due to overuse, especially if you are an athlete.
  • Strain or tear: if tendinitis is left untreated, it can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear.
  • Bursitis: the fluid-filled sac between the shoulder joint and rotator cuff tendons can become inflamed and irritated. (Source:

    www.mayoclinic.com)

NEW TECHNOLOGY:  In the United States, at least ten percent of people over sixty, or close to six million people, will develop a rotator cuff tear.  Usually treatment for rotator cuff injuries involves exercise therapy.  Other treatments can include surgery, steroid injections, and arthroplasty.  Now, the physical therapy program out of Vanderbilt University Medical Center can effectively treat most patients with full-thickness rotator cuff tears and shoulder pain, without the need for surgery.  The study included 396 patients ages 18 to 100 who had atraumatic full-thickness tears that were documented by magnetic resonance imaging and no other abnormality.  Most patients were assigned to a physical therapy program, which included daily postural exercise, active-assisted motion, active training of scapula muscles, and active range of motion, also with anterior and posterior shoulder stretching.  They also performed three weekly rotator cuff and scapula exercises.  The patients returned at six and 12 weeks.  At this point they could decide that treatment was successful and did not need a follow-up, they had improved but would like to continue therapy, or the non-operative treatment had failed and they need arthroscopic rotator cuff repair.  The researchers contacted the patients by phone at one and two years to determine whether they had undergone surgery since their last visit.  At six weeks, the data showed that fewer than 10 percent of patients had decided to go forth with the surgery.  For patients to whom follow-up data was available at the two year mark, only two percent had the surgery.  The finding suggests that pain may be a less suitable indication for rotator cuff repair than is weakness or loss of function.  Researchers hope that future studies will identify risk factors that can predict progression to rotator cuff tears and symptom onset, but also which repaired tears are likely to fail.  (Source: http://www.medscape.com/viewarticle/737461)

Gregory Bashian, MD, Electro-Physiologist at Centennial Medical Center, talks about a new treatment option for atrial fibrillation.

What is atrial fibrillation?

Dr. Bashian: Atrial fibrillation (a-fib) is a common abnormal heart rhythm. Instead of beating in a nice, coordinated fashion, the two upper chambers of the heart are basically quivering, and that has two main implications. First of all, the blood doesn’t move well within those chambers and that can lead to blood clots, which can cause a stroke. Secondly, it tends to make the lower chambers of the heart go very fast, which can cause people to have multiple symptoms including a sensation of palpitations.

Are there a lot of treatment options out there?

Dr. Bashian: Correct. There are many different treatment options for atrial fibrillation. Medications, unfortunately, are not that effective and they certainly carry with them their own set of long-term risks. Catheter-based therapies are very effective in a certain population of a-fib patients, but there is a very large population of patients that are underserved by that catheter treatment; both due to low success rates as well as difficulty actually performing the procedure. In those patients, we found that the hybrid procedure has provided them with a more durable result in one procedure.

What is your role in the hybrid approach? 

Dr. Bashian: So, it is a two-step procedure. During the surgical portion of the procedure performed by my partner, the heart is burned on the outside. I then go in after he has completed his portion, and from the inside of the heart using the traditional, more minimally invasive approaches, I connect the lesion set that he has created and complete it to give us a long-standing isolation of the pulmonary veins, which is really the crux of an a-fib ablation.

So he takes care of the big obvious problems and you go in and get the more detailed?

Dr. Bashian: Exactly. Kind of sharp shoot the gaps of certain places where his catheter cannot get to from the outside of the heart, but mine can from the inside.

This is a pretty new approach, correct?

Dr. Bashian: Correct. In particular, one of the advantages of this particular hybrid approach is that although his is more invasive than the traditional, it is a lot less invasive than other surgical approaches. The two of them work together very well by having him go first and effectively debunk a lot of the atrium, and then I get to see the final isolation.

Can you explain how you burn the atrial tissue?

Dr. Bashian: The atrial tissue is being burned using radiofrequency energy to heat the tissue. The advantage to his ablation is that it is very effective at making full thickness burns that are very contiguous over a large area. The disadvantage is that unfortunately with his approach, he cannot get to all the different parts of the heart; just by the virtue of the cardiac anatomy. So, the two together work nicely because I can get everywhere, but catheter-based procedures tend to use smaller lesions and thus it is much more difficult to create a lesion set that has no gaps in it. 

In both cases, are you using that energy or is it different? 

Dr. Bashian: It is different catheters, but the same type of energy.  

Which candidates are right for this treatment?

Dr. Bashian: So, all a-fib ablation really should be targeted at patients who have symptoms, but within that group of patients there are those that are well treated with catheter-based approaches, meaning they have very high success rates with a very safe procedure. Then there are those that are undertreated or I should say underserved by that procedure. That typically is the patient who has either longer standing persistent atrial fibrillation, meaning their heart has been out of rhythm for an extended period of time despite medications and perhaps even previous catheter-based therapies. We cannot get sinus rhythm in them or people who have more diseased atria, where the atrium itself has actually grown in size and enlarged. Those patients tend to be the ones that we choose to use the hybrid approach on. 

So you said it is not really for people who only experience it once in a while. This is for people who have a-fib all the time, correct?

Dr. Bashian: Correct. For patients who have what we call paroxysmal atrial fibrillation, where their heart is going in and out of rhythm on their own, we know that the vast majority of those patients can get good success rates with a catheter-based procedure alone. Therefore, we do not justify going to the more invasive hybrid approach. In patients in whom the traditional catheter-based approach has a very guarded success rates, it really makes more sense to try the hybrid approach to give them a more durable result.

So, is this an option for people who have had other treatments that failed?

Dr. Bashian: Correct. So, again with the success rates being relatively low on the longer-standing persistent patients, or the patients with larger atria, many of the patients being sent to us have already been to another center and had one or more ablations with a catheter. Those have been unsuccessful and they are really looking for another alternative that is going to have a higher success rate. Those patients will often chose the hybrid approach.

Can people go back into a-fib after having an ablation relatively quickly if it does not work? 

Dr. Bashian: Correct. It can even happen to the patients who the procedure does work on; we call it a “blanking period”. The first several weeks after the procedure, one can go out of rhythm and it does not necessarily mean they have a bad prognosis in terms of success of the procedure, but there are people who have been through multiple ablations and they have had very little in the way of time within normal rhythm.

What is the success rate of this approach? 

Dr. Bashian: It is tough to say because it is still in the earlier portion. It depends on the patient, how much comorbidity they have, and how big their atrium is, but in many patients we are looking at anywhere from 70-90% success rates of staying in rhythm depending on whether they are on or off of drugs. However, it varies.

Are there any negatives to this approach?

Dr. Bashian: This approach, as opposed to the traditional catheter-based, carries with it a slightly longer hospitalization. However, although it is a more open surgical procedure, these patients are walking the night of their surgery and they are usually home within three to five days. So, the added hospital time and slightly more upfront morbidity is the difference between the two procedures, but many patients are happy to take that for a higher success rate or for patients where catheter-based therapy is not even offered to them.

So is the more invasive procedure an older procedure combined with the newer procedure; is that a fair way to sum it up? 

Dr. Bashian: Not really. I guess the way I think about it is there was an open surgical procedure called a Cox Maze procedure that is a much older procedure. Then, almost parallel to that developed a catheter-based approach and then we started doing a combination of the two in a hybrid, but what this particular procedure has in terms of its advantage is that the surgical portion is much less invasive than the traditional portions. The patients are not on cardiopulmonary bypass. They are not undergoing single lung ventilation. There is absolutely no sternotomy. No bones are being broken or cut. I mean, they are literally walking the night of the procedure. So, even the surgical portion of the procedure is much less invasive than traditional surgical or hybrid ablations.

Where does your partner go in through? 

Dr. Bashian: He puts three ports in the abdomen. Two of them are relatively small and then the one that his ablation catheter goes through is a little bit larger and that is central. They are all in the abdomen, laparoscopically. 

FOR MORE INFORMATION, PLEASE CONTACT:

John E. Kuhn, MD

Chief of Shoulder Surgery

Vanderbilt University Medical Center

www.MOONshoulder.com 


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