Kevin Kaplan, MD, an Orthopedic Surgeon, Specializing in Sports Medicine in Jacksonville, Florida, talks about rotator cuff injuries and a new surgical option for patients.
Interview conducted by Ivanhoe Broadcast News in May 2017.
What happens when you have a tear or an injury in the rotator cuff?
Dr. Kaplan: The rotator cuff tendons are a set of four tendons that surround the ball of the ball and socket joint. They are what allow you to move your arm in all different directions; whether it’s over your head or behind your back or in front of you. Those tendons work together to help you coordinate shoulder motion. Through the course of time the tendon will start to wear down and you can tear the tendon away from the bone. You can have a traumatic event, certainly a shoulder dislocation can cause a rotator cuff to tear as well. When a tendon is detached from the bone it becomes either difficult or very painful to do those normal ranges of motion; lifting your arm over your head, putting glass back in the cupboard, putting a plate back after using it. So those are the types of issues people have and the types of pains people have after they tear a rotator cuff.
Normal repairs, this is something that the body heals on its own or when it’s torn away from the bone does there have to be intervention?
Dr. Kaplan: I think a rotator cuff tendon is very much like a rubber band and that’s how I explain it to patients. It’s attached from point A to point B. And when a tendon tears, very much like a rubber band on tension, it will tend to pull back. Tendons don’t have the ability to actually go forward and reattach themselves. Now some tendon tears can be asymptomatic and clinically silent and not need any type of surgery and may just need some physical therapy or a simple injection to get patients back to normal functioning. But if you get an MRI five years down the road that tendon will likely still be torn. So without a surgical fixation, in the instances where conservative management doesn’t work, those are the rotator cuff tears that need to be addressed surgically.
What are your options if traditional surgery just doesn’t seem to be working?
Dr. Kaplan: Traditional surgery if conservative management fails is arthroscopy which is going in through tiny incisions with a camera and using what are called anchors and most of the time we use absorbable anchors that go in to the bone. We attach those anchors with sutures and we put those sutures through the tendon and actually sandwich the tendon down to the bone. Whether or not it’s biologically not possible to heal or if the tendon has degenerated too much then the tendon can actually re-tear off the bone and retract again. Prior to the development of this surgical procedure, which is called a superior capsular reconstruction, our options were very limited with what we could do after a failed rotator cuff repair. Obviously you could go back in and try to re-repair a torn tendon but after a successful repair if that tendon doesn’t attach itself to the bone then doing the same surgery again may not be the best option. In the past we were limited to trying to transfer other tendons from other parts of the body which are very difficult and really don’t offer a functional benefit to patients or perfomring what’s called a reverse total shoulder replacement which is actually removing the old ball and socket and putting in a new ball and socket to try to get better function and relief of pain. That surgical procedure is typically reserved for older patients and we don’t know how long those will last. So, that was why Dr. Mihata in Japan developed what’s called a superior capsular reconstruction. And in fact in Japan he doesn’t have or he didn’t have the option of doing a reverse shoulder replacement so his options were even more limited. So he developed a way to re-create or reconstruct so to speak a new superior capsule to cover over the ball to allow normal function and decrease pain.
How does this procedure work?
Dr. Kaplan: A superior capsular reconstruction utilizes donated tissue to recreate the rotator cuff, in a sense, on top of the ball. Without the top rotator cuff tendon, there is nothing holding the ball centered in the socket. The ball can actually ride up in the socket and it makes it very difficult for you to get your arm over your head so what we utilize is a very thick graft. And we attach that to both the socket and the ball and it acts almost like a reverse trampoline and it keeps the ball centered in the socket while the other muscles around your shoulder then allow you to move.
Tell me a little bit about the surgery, this is something that you can do through keyhole?
Dr. Kaplan: The superior capsular reconstruction is an arthroscopic procedure. We typically have to make a few extra tiny incisions but it’s an arthroscopic procedure and the incisions are small. It’s an outpatient procedure it takes about two hours to perform the procedure and patients go home the same day. It’s very similar in terms of rehabilitation to a regulator cuff repair. The patient is in a sling for about six to eight weeks, starting range of motion after six weeks and strengthening in about ten to twelve weeks.
Can you talk to me a little bit about graft?
Dr. Kaplan: An allograft is a piece of donated tissue. We’ve been using allografts in a lot of different surgical fields, not only orthopedics, for many years. These are safe grafts they are Acellular they have the cells removed from them so the risk of things like rejection or infection are extremely low. We’ve been using allograft tissues for things like ACL reconstructions for many years. The risk of these things going bad inside the body are extremely low, your body will actually incorporate these grafts and become part of your own after the surgical procedure. Part of the superior capsular reconstruction involves attaching the remaining rotator cuff tendons to the graft to help incorporate your own biologic tissue to this graft that we’re putting in.
And even though it is donated tissue there is still no need for anti-rejections drugs or anything like that?
Dr. Kaplan: That’s correct. The risk of things like infections and rejections are low and there’s no need for extra medication after the surgical procedure.
Talk to me a little bit about Mr. Lucas.
Dr. Kaplan: Mr. Lucas was actually one of my first superior capsular reconstructions, in fact, he was referred to me after having failed a rotator cuff repair and I initially told him that there really wasn’t much could be done for him given the retraction on the rotator cuff. I subsequently learned about the superior capsular reconstruction and brought him back in to have a discussion about the repair. He was in such pain with limited function that he said, I’d like to try anything to make this better. I thought he was too young to be a candidate for reverse shoulder replacement and so I indicated him for a superior capsular reconstruction and his results have been fantastic. He’s been one of the biggest advocates I’ve had. In fact, he has met other patients who were nervous about the procedure and was able to talk them through his process and how well he had done with this.
How is he now, how is his arm function?
Dr. Kaplan: Mr. Lucas has near complete range of motion of his shoulder; he has full strength of his shoulder. He’s doing all the activities that he likes to do, like golf and being an active individual. I couldn’t be happier with the way he has done and the way he’s functioned with his reconstruction.
Is there anything I didn’t ask you that you would want people to know about this procedure?
Dr. Kaplan: I think superior capsular reconstruction is an excellent option for those patients that have had issues or a failed rotator cuff repair. I think it’s a new technology and it’s something that a lot of patients may not know about. I want patients to understand that there is an option for them if their rotator cuff repair didn’t heal and they’re still having pain and difficulty with range of motion.
Is there an age restriction on that, I know the reverse replacement is for an older population but is there an age range for the superior capsule reconstruction?
Dr. Kaplan: Most rotator cuff tears happen in patients between the ages of 40 and 70. So that’s typically the type of patient that you would see or indicate for a superior capsular reconstruction.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Kevin Kaplan
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here.
