Shoulder and elbow Surgery

Introduction

The Shoulder and elbow Surgery Unit can host 11 patients, located in 4 rooms with private bathroom. 4 operating sessions are performed weekly and one session of day surgery is performed monthly. The ward doctor is present every day from 7.30 am to 1.30 pm. The ward round is performed twice a week (Monday and Thursday). At least two nurses assist patients in the ward. The senior nurse is present from Monday to Saturday between 7 am and 1 pm.

Clinical practice

The Shoulder and Elbow Surgery Unit was created in 2000, with the aim of focusing attention and energies in pathologies of shoulder and elbow.

Fig. 1: Scheme of a suture in rotators cuff arthroscopy (Anatomical Drawing School, Rizzoli Orthopaedic Institute)

The activity of the ward is almost fully dedicated to the cure of pathologies of shoulder (rotator cuff tears, recurrent dislocation and articular laxity, primitive and secondary osteoarthritis, humeral fractures, scapula and clavicular fractures, acromioclavicular and sternoclavicular dislocations, malunion or nonunion), elbow (fractures and luxations, articular instabilities, arthritis, primitive or post-traumatic stiffness, malunion or nonunion) and forearm (fracture, malunion, instability like Essex-Lopresti syndrome).

Conflict syndromes, cuff ruptures and articular instability of the shoulder are treated by arthroscopy according to the most innovative techniques (with micro-screws and dedicated instruments), with the help of open field surgery in those cases when the best result cannot be guaranteed by arthroscopy. The instruments and devices are the most innovative, like, when possible, full-wire anchors, reabsorbable or radio transparent anchors.

In the same way, elbow arthroscopy is performed for loose bodies removal, in the treatment of arthritic or post-traumatic stiffness, in the treatment of cartilaginous pathologies (as osteochondritis dissecans in young sports people) and in the treatment of some particular intra-articular fractures (radial head, capitulum humeri or coronoid process), siding without substituting open surgery.

Fig. 2: Elbow arthroscopy during intervention

Advanced degenerative-arthritic diseases of shoulder and elbow are treated by prosthetic replacement with the aim of providing pain free movement in elderly patients or in younger patients with severe post-traumatic joint diseases.

In the latest years, articular shoulder and elbow prostheses intensely developed, with always more “anatomic” designs (that is, systems that are similar to the anatomy of the healthy joint).

The continuous research in minimally invasive and new materials development allow us, when indicated, to use implants with short stem or pyrocarbon surfaces, solutions that allow to better respect the patient's anatomy and the osteo-cartilaginous structures of the shoulder, with the aim to speed up the post operative recovery and reduce the possible complications.

Fig. 3: Shoulder arthritis treated with cementless pyrocarbon coated prosthesis

Patients with an irreparable rotator cuff tear (who, until recently, have been severely limited in their activities) can today be treated with the so-called “inverse prosthesis”, which is based on the inversion of the articular surfaces shape.

In the field of prosthetic and reconstructive surgery we use the state of the art technologies and computational pre operative simulations: before the surgery the prosthetic components or the bone grafts are virtually positioned on the diagnostic images of the patient itself, in order to precisely evaluate potential problems occurring during the surgery. This allows to obtain more precision, implants duration and better results.

Fig. 5: Shoulder reverse prosthesis virtually implanted on patient's CT reconstruction

Fig. 6: Pre op computer elaboration of elbow reconstructive surgery with 3D printed systems

Hardware for traumas was also developed (endomedullary systems, more resistant and better contoured titanium plates, which provide an improved strength of the screw-bone and screw-plate interface, plates made of xray-transparent plastic material, fig. 4), up to providing bioreabsorbable screws, useful in some rare articular fracture.

Fig.7: Plastic -transparent plate (improving the rupture visibility) and titanium screws (mounted on the plate as well as on the bone, for a better seal)

In most severe cases, when it is not possible to reduce and fix the elbow intra-articular fracture, a prosthesis substitution (of the joint humeral part) and a synthesis with plates and screws can be necessary, contemporarily, within the same surgical session.

Fig. 8: The metal prosthesis substitutes the articular part that is irreparably ruptured, while the titanium plates allow the reconstruction of the bone fragments around the prosthesis (site of the elbow collateral ligaments)

Nonunions or malunions are often treated with associating metal plates with bone grafts (from donors) and growth factors (platelet gel produced from the patient’s blood), thanks to the presence, within the Institute, of the transfusion service and the Musculoskeletal Tissue Bank.

A special attention is dedicated to an early rehabilitation, with the aid of braces (fig. 6) and dedicated motorized devices, as well as of advanced techniques of continuous loco-regional anesthesia, which allows a painless joint mobilization.

Fig 9: Immobilization tutor: allows a gradual and progressive increase of the movement arch, thanks to the mechanic zip

Watch the movie in streaming (lenght: 25'')

Research activity

Convention poster: "Stiffness and Osteochondritis dissecans", September 2017 From its foundation, the Shoulder and Elbow surgery Unit continuously performs teaching and research activity. It participates to several national and international clinical studies, for example for the ultrasound guided treatment of calcific tendinopathy, the development of new materials for osteosynthesis of shoulder and elbow fractures, for the insertion of shoulder arthroplasty in the Italian register of Orthopedic prosthetic Implant (RIPO). Several patents have been ideated and registered, such as a titanium mini-plate for surgical repair of the rotator cuff, a special postoperative brace for the shoulder, a self-threading titanium screw for a plastic plate.

The Unit has a constant partnership with scientific laboratories to improve arthroscopic suture techniques in rotator cuff repair, for shoulder prosthesis design improvement, and in the field of regenerative medicine for poor quality or massive tears of rotator cuff tendons, for the study and treatment of osteoporosis.

The teaching activity is performed with the continuous organization of courses and conferences on shoulder and elbow pathology, with updates in diagnostic, surgical and rehabilitation state-of-the-art techniques, with the participation of national and international guests. In particular, the “Rizzoli Advanced Elbow Surgery Course”, the “Elbow factors” focused on rehab, both biannual; collaboration with the 1st level master on “upper limb surgery”, organized by the University of Bologna. During these activities, state of the art technologies are used, like the use of 3D educational surgical movies, in order to provide a better visualization of the anatomical structures.

The continuous training of the Unit’s personnel is realized also through the active participation to several national and international courses and conferences, often as speakers or moderators.

Staff

Guerra Enrico, MD

Director

Carbone Giuseppe, MD

MD

Cavallo Marco, MD

MD

Marinelli Alessandro, MD

MD

Ritali Alice, MD

MD

Sessa Andrea, MD

MD

Contacts and Locations

Contacts

Secretary's Office

phone +39-051-6366482
(Mon-Fri, 9 to 10 am)

fax +39-051-6366188
e-mail segreteria.multispec@ior.it

Where are our locations?

Rizzoli Orthopaedic Institute
via G.C.Pupilli, 1
40136 Bologna (Italy)

Diseases and treatments

disease, treatment

Shoulder instability and dislocation

Roberto Rotini, MD; Marco Nigrisoli, MD

What is shoulder instability? Instability is defined as the symptom patients refer when the shoulder slips in its normal position. Shoulder joint instability may be caused by laxity, where it is difficult to keep the shoulder in site for alteration of bone and/or periarticular tissue development. Dislocation of the shoulder is often caused by trauma or microtraumas. An unstable shoulder can dislocate (the femoral head completely comes out of its normal lodging, the glenoid of the scapula), subluxate (partial dislocation of the humeral head) or present with pain in specific positions or movements due to abnormal gliding of the femoral head in during sports or work. When dislocation occurs frequently, even after a long period of time, it is called recurrent dislocation. Why does shoulder dislocation occur? The shoulder joint is a very special joint compared to the others of the human skeleton. The humeral head, approximately hemispheric in shape, loosely rests on a shallow concave vertical surface 3.5 cm high and 2.5 cm wide. This configuration allows the shoulder to have a wide range of motion in the three directions. However it is subjected to gravity therefore during motion joint stability is dependent on the connective tissues: joint capsule and glenoid labrum, ligaments and muscles with their respective tendons. Because of its particular conformation and anatomical distribution the shoulder dislocates more frequently in the antero-inferior direction. In these cases tears occur in bone and cartilage, ligament and tendon depending on the amount of the force and direction of the trauma, number of recurrences and individual resistance of the structures enduring stress. At what age does it most frequently occur? This pathology has a higher incidence in the second and third decades of life, is more frequent in males than in females and is related to the completion of muscle and joint development as well as to the peak of physical and working activity. However, although rarely, dislocations can occur also in other age groups: infants, adults or even elderly. How is diagnosis made? Medical history of the shoulder or of both shoulders, diffused laxity also in other joints (congenital diseases like Marfan’s syndrome generate laxity in all ligaments), the modality (for severe trauma or with no apparent trauma), the frequency, concomitant to specific body movements or positions, are all elements to be considered. At physical examination the patient must assist the orthopaedic surgeon by performing certain movements and specific manoeuvres to help define certain lesions excluding others which may co-exist. Attention must be paid to the fact that frequently the patient automatically tightens muscles and examination becomes difficult. Physical examination of the shoulder before surgery is useful because under anesthesia the muscles in the limb relax and dislocation can be evaluated better. For a sure diagnosis and to program therapy other instrumental examinations may be performed.  Which are the most appropriate instrumental examinations? Standard x-rays are necessary prior to shoulder reduction. Examinations useful to confirm diagnosis and for surgical staging are computerized axial tomography (CT) and magnetic resonance imaging (MRI) scans. CT shows conformation, joint relations and possible proximal humerus and glenoid surface bone damage and more specifically if there are fractures or bone fragments. MRI gives more complete information for connective tissue tears and muscle trophism. In selected cases, to obtain a clearer definition and image of the damaged structures and areas adjacent to the joint both CT and MRI can be performed using contrast dye injected directly in the joint. What treatment options are available? The treatment of choice after a first dislocation is conservative: reduction, orthopaedic bandaging and after about 4 weeks immobilization, progressive mobilization using elastics is started to strengthen the subscapularis (for anterior instability) or the subspinal (for posterior instability) muscles. If instability persists and should dislocations recur surgery may be considered. In the past 20 years surgical techniques for shoulder instability have brought about more precise surgery tailored on the specific tears and on the single patients. The decision as to when reparation surgery of the lesions and reinforcement of the capsule (capsulo-muscular plastic surgery) should be performed is taken together with the surgeon. However, at a certain point it is the same patient who feels the need to intervene on a situation of unease no longer tolerable with an everyday working and social life. The surgical technique chosen depends mainly on: age, frequency of the dislocations or if these are absent, duration of shoulder pain and degree of impediment during sports or working activities, muscle structure, level of weight-bearing during work, sports practiced as professionals or amateurs. It is important to rule out the presence of fractures associated to the dislocation, for this CT or MRI are very useful. Arthroscopy: what advantages? In the past 15 years improvements in arthroscopic techniques (small incisions to access the joint and small instruments controlled by microcameras) have greatly improved results. The advantage of not excising the muscles and the precision in repairing the tears makes this technique suitable for young patients (from 15 to 30 yrs of age), with a limited number of dislocations and with microinstablity. The technique uses “suture anchors” similar to microscrews (in titanium or resorbable polylactic acid) with nonresorbable highly resistant threads that are passed and tied to the joint capsule and to the glenoid labrum to recreate the normal capsular tension. This technique though cannot be used when fractures are present or when the tissue around the capsule is not strong enough. Traditional procedures, are indicated in patients who present simple dislocations, a surgical incision in the front part of the shoulder and the use of various types capsulo-muscular plastic surgery techniques guarantee correct tension.       This surgical procedure is always requires general or combined anesthesia (regional anesthesia with or without deep sedation) and hospitalization for 3 or 4 days. The upper limb is placed in an orthopaedic bandage for 4-5 weeks, then functional  rehabilitation of the shoulder is started, first passive and later active, assisted by a physiotherapist, preferably in water, with complete recovery of joint movement after 6-8 weeks. What happens when the shoulder is not operated? This question is frequently posed especially by patients with an unstable shoulder but with no dislocations and thus less invalidating. Some elderly patients have shoulder lesions without having had any real traumas, but with a history of heavy working activity or episodes of recurrent dislocations in youth always treated conservatively. These are painful lesions and the decrease in strength varying according to the extension of the lesion. In these cases and in this age group positive results of reparation surgery, are uncertain because of the instability present that was never corrected. Edited by Enrico Guerra, MD and Marco Nigrisoli, MD Shoulder and elbow surgery - Istituto Ortopedico Rizzoli, Bologna

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