Transcript Platelet Rich Plasma (PRP)

Regenerative Injection Therapy (RIT)
Rotator Cuff
and
Shoulder Ligament
Platelet Rich Plasma
PRP injection therapy
David L. Harshfield, Jr. M.D. M.S.
Medical Director, College of Integrative Medicine
Little Rock and Fayetteville, Arkansas
Medical Director and Director of Regenerative Medicine- Waterside Medical Centers in Florida
Director of Interventional Radiology and Cellular Medicine- Prime Imaging centers in Dallas, Texas
Chairman- Institutional Review Board, International Cellular Medicine Society
Editor of the AAOM e-journal and Member of the AAOM board of Directors
Shoulder PRP
Shoulder
Rotator Cuff Tear
due to
Ligament Laxity
both treated with
Platelet Rich Plasma
Cuff Tendon
It was believed previously that tendons could not undergo
extracellular matrix (ECM) turnover and that tenocytes were not
capable of repair.
However, it has been shown more recently that throughout the
lifetime of a person, tenocytes in the tendon actively synthesize
ECM components as well as enzymes such as matrix
metalloproteinases (MMPs) that can degrade the matrix
Tendons are therefore capable of healing and recovering from
injuries in a process that is controlled by the tenocytes and their
surrounding extracellular matrix.
However, the healed tendons are thought to never regain the
same mechanical properties as before the injury.
Cuff Tendon
The three main stages of tendon healing are inflammation, repair or
proliferation, and remodeling, which can be further divided into
consolidation and maturation. These stages can overlap with each other.
1. In the first stage, inflammatory cells such as neutrophils are recruited to
the injury site, along with erythrocytes. Monocytes and macrophages are
recruited within the first 24 hours, and phagocytosis of necrotic materials
at the injury site occurs. After the release of vasoactive and chemotactic
factors, angiogenesis and the proliferation of tenocytes are initiated.
Tenocytes then move into the site and start to synthesize collagen III.
The inflammation stage usually lasts for a few days, and the repair or
proliferation stage then begins.
2. In the second (repair or proliferation) stage , which lasts for about six
weeks, the tenocytes are involved in the synthesis of large amounts of
collagen and proteoglycans at the site of injury, and the levels of GAG
and water are high.
3. The third (remodeling) stage begins after about six weeks. The first part
of the remodeling stage is consolidation, which lasts from about six to
ten weeks after the injury. During this time, the synthesis of collagen and
GAG is decreased, and the cellularity is also decreased as the tissue
becomes more fibrous as a result of increased production of collagen I
and the fibrils become aligned in the direction of mechanical stress. The
final maturation stage occurs after ten weeks, and during this time there
is an increase in crosslinking of the collagen fibrils, which causes the
tissue to become stiffer. Gradually, over a time period of about one year,
the tissue will turn from fibrous to scar-like.
Cuff Tendon
Matrix metalloproteinases
•MMPs have a very important role in the degradation and
remodeling of the ECM during the healing process after a tendon
injury.
•Certain MMPs including MMP-1, MMP-2, MMP-8, MMP-13, and
MMP-14 have collagenase activity, meaning that unlike many
other enzymes, they are capable of degrading collagen I fibrils.
•The degradation of the collagen fibrils by MMP-1 along with the
presence of denatured collagen are factors that are believed to
cause weakening of the tendon ECM and an increase in the
potential for another rupture to occur.
•In response to repeated mechanical loading or injury, cytokines
may be released by tenocytes and can induce the release of
MMPs, causing degradation of the ECM and leading to recurring
injury and chronic tendinopathy
Cuff Tendon
While stretching can disrupt healing during the initial
inflammatory phase, it has been shown that controlled
movement of the tendons after about one week following
an acute injury can help to promote the synthesis of
collagen by the tenocytes, leading to increased tensile
strength and diameter of the healed tendons and fewer
adhesions than tendons that are immobilized.
In chronic tendon injuries, mechanical loading has also
been shown to stimulate fibroblast proliferation and
collagen synthesis along with collagen realignment, all of
which promote repair and remodeling.
Cuff Tendon
•Several mechanotransduction mechanisms have been
proposed as reasons for the response of tenocytes to
mechanical force that enable them to alter their gene
expression, protein synthesis, and cell phenotype and
eventually cause changes in tendon structure.
•A major factor is mechanical deformation of the
extracellular matrix, which can affect the actin cytoskeleton
and therefore affect cell shape, motility, and function.
•Mechanical forces can be transmitted by focal adhesion
sites, integrins, and cell-cell junctions.
•Changes in the actin cytoskeleton can activate integrins,
which mediate “outside-in” and “inside-out” signaling
between the cell and the matrix.
•G-proteins, which induce intracellular signaling cascades,
may also be important, and ion channels are activated by
stretching to allow ions such as calcium, sodium, or
potassium to enter the cell.
Co-Guidelines
Regenerative Injection Therapy (RIT)
Buffered 5% Dextrose (D5W)
and/or
Platelet Rich Plasma (PRP)
Interventional Regenerative Orthopedic Medicine (IROM) Practice
6 Co’s of MAXIMIZING EFFECTIVENESS OF RIT
1.
2.
3.
4.
5.
6.
Collaborate with patient’s Primary Care Provider (PCP)
Coordinate with patient’s Chiropractor and/or Manual Therapist to ensure the patient the
dignity of a proper diagnosis.
Collate existing health care records with all prior medical and surgical history with an
updated pharmaceutical history and hormone status.
Correlate prior imaging studies with appropriate up-to-date imaging to arrive at the
correct diagnosis.
Communicate overview of regenerative injection therapy (RIT) in sync with patient’s
understanding of their existing health care regimen (making clear that RIT is ‘in addition
to’, not ‘instead of ’ the patient’s existing and evolving ‘patient specific’ integrative health
care regimen).
Complete patient registry following RIT.
Hilton's law 1863:
• The nerve trunk supplying a joint also supplies the
overlying skin and the muscles that move the joint.
• Buffered Dextrose 5% (D5W) in sterile water in
subcutaneous near nerve injections are predicted to
facilitate the potassium channel and have a TRPV1
antagonist effect blocking neuropathic pain and reducing
neurogenic inflammation, producing cure with repeated
treatments.
• Involves injecting sterile buffered dextrose (neutral pH
sugar solution) around the subcutaneous nerves with only
27-gauge 1/2" needles 1/4" deep blocking neuropathic
pain and reducing neurogenic inflammation, producing
cure with repeated treatments.
Perineural Injection Therapy (PIT)
• Based on the observations and teachings of John Lyftogt
that buffered D5W can alleviate neuropathic pain.
• Another recent revelation is that D5W (5% dextrose water)
obtained in the United States arrives in an acidic form with
a pH ranging from 3 to 6.7.
• TRPV1 pain receptors activate at pH lower than 6.5, thus in
order to optimize perineural injection therapy and maximize
the pain fiber membrane stabilizing effect of the D5W one
must buffer with 8.4% Sodium Bicarbonate to bring the pH
up to neutral (7.2).
• In addition, sterile water in bottles obtained in the U.S. also
are acidic, with a pH 5.5; a fact which must be taken into
consideration when diluting dextrose with sterile water.
Perineural Injection Therapy (PIT)
Dermal plexus and epidermal
ramifications- fat contains more nerves
than any other tissue in the human body.
• Pain is the most common reason for patients to
seek medical attention.
• The current understanding of the primary
cause of pain, is the depolarization (firing) of
unmyelinated pain fibers due to “insufficiency
of energy” (low glucose) in their
neighborhood, which is rapidly calmed by
buffered, neutral pH, 5% Dextrose.
• The 5% buffered dextrose is iso-osmolar (near
identical concentration) and neutral pH (not
acidic) to the nerve cells, thereby repolarizing
(stabilizing) them.
Classification Nociceptors
After Bruce Lynn, NeuroImmune Biology, Vol 8
Neurogenic inflammation in Health and Disease, page 40
Lidocaine prevents exact localization
of neuropathic pain
DRG
Mechano-sensitive
HTM
Aδ, Aβ,C Aδ
Sensory afferent
Classification Nociceptors
After Bruce Lynn, NeuroImmune Biology, Vol 8
Neurogenic inflammation in Health and Disease, page 40
Dextrose in the correct place
Mechano-sensitive
Polymodal C, Aδ
Sensory afferent
blocks neuropathic pain
DRG
Mechano-insensitive
Heat
C
Peptidergic/ TRPV1 pos
Sensory efferent and
Sensory afferent
L
Area of up-regulated TRPV1 receptors with
resultant neuropathic pain (red square)
Mechano-sensitive
HTM
Aδ, Aβ,C Aδ
Sensory afferent
Mechano-insensitive
Silent/Awake –Polymodal
C
Peptidergic /TRPV1 pos
Sensory efferent and
Sensory afferent
D
Area of up-regulated TRPV1 receptors with
resultant neuropathic pain (red square)
•
DEXTROSE selectively blocks
neuropathic pain (analgesic, not
anaesthetic)
•
DEXTROSE is a diagnostic for
neuropathic pain
•
DEXTROSE blocks the release of CGRP
and SP
•
DEXTROSE blocks neurogenic
inflammation by stabilizing the
potassium pump.
Mechano-sensitive
Polymodal C, Aδ
Sensory afferent
Mechano-insensitive
Heat
C
Peptidergic/ TRPV1 pos
Sensory efferent and
Sensory afferent
Mechano-insensitive
Silent/Awake –Polymodal
C
Peptidergic /TRPV1 pos
Sensory efferent and
Sensory afferent
In medicine, we must resist the tendency to confuse
“association” with “causality”. For instance, pain can be
“associated” with physical injury, but pain is not necessarily
“caused” by injury, per se. For instance, ischemic pain of
cardiac disease is not post traumatic in nature, instead being a
consequence of nociceptors in the heart muscle, thus
although decreased with lidocaine is not alleviated by glucose.
But the recent discovery that neuropathic pain is simply
caused by low energy levels in tissues provides the
explanation for the remarkable effectiveness of Lyftogt
Perineural Injection Therapy (Lyftogt P.I.T.)
The peripheral most pain receptors lie just beneath the skin,
thus can be successfully and safely treated utilizing buffered
D5W administered with a ½ inch, 27-gauge needle.
Platelet Rich Plasma (PRP) is a high concentrate of platelets taken from a patient’s blood
stream, having the ability to manage the immune system and reduce pain. The process
involves withdrawing blood from the patient and centrifuging the blood to create a platelet
concentrate (platelet rich plasma- PRP). The platelets are then injected into the area of injury.
There is laboratory evidence for the benefits of PRP for musculoskeletal (MSK) issues. There is
clinical evidence for treating tennis elbow, patellar and Achilles tendinopathies, and osteoarthritis of
the spine and joints, as well. Patients with partial thickness tendon tears often have pain, not severe
enough to undergo surgery but severe enough to limit their activities of daily living. And surgery is
not only associated with poor outcomes, but with a long period of rehabilitation, along with the
risks of surgical intervention.
Platelets are a normal product found in the clotting cascade and inflammatory process of healing.
They produce granules that release growth factors that promote healing. PRP works by increasing
the concentration of platelets, thereby increasing the concentration of growth factors and increasing
healing potential. PRP has an advantage over many tissue engineering products in that it is
autologous.
Prior to the utilization of these PRP matrix grafting protocols our Integrative Medicine group
recommends appropriate first line therapies such as:
1. Relative rest
2. Appropriate bracing and kinesiotaping,
3. Evaluation of core stabilization
4. Reintegration of kinetic chain mechanics
5. Physical/manual therapy—with or without eccentric loading protocol
• PRP has been studied and used for the treatment of tendon injuries, chronic
wounds, ligamentous injuries, cartilage injuries, muscle injuries, and bone
augmentation. The results from in vitro and in vivo studies are much broader
than once thought.
• After determining the appropriate diagnosis and therapy, the physician qualified and
certified in Interventional Regenerative Orthopedic Medicine (IROM) injects the
patient with a derivative of their own blood. Blood is withdrawn from the patient,
placed into a centrifuge machine that spins the whole blood and leaves a layer of
platelet rich plasma (PRP). That plasma is injected back into the patient, generally with
imaging guidance, initiating a physiological response that will induce healing, ease pain
and increase function.
• There are several brands of FDA approved machines which produce various and
different platelet layer concentrations. This approach is similar to Autologous Blood
Injections, however, the platelet rich portion of the blood is separated from the red
blood cells (RBC’s), and only the PRP is injected, which will cause less pain after the
procedure. “Red” PRP, containing red blood cells, can cause a painful but limited post
injection “flare”. For this reason, red cell free preparations are favored.
• PRP can require multiple injections (if a patient doesn't respond immediately) and
often a limitation on activity and training for a period of time (1-2 weeks) after each
injection is recommended. However, physical rehabilitation and/or Chiropractic care is
recommended to resume 12 to 14 days after injection. The treatment course may easily
take up to 6 months, as it takes collagen 6 months to covalently bond and recuperate.
SURGERY
Unnecessary surgeries noted as prevalent issue.
• USA Today (6/18, Eisler, Hansen, 1.71M) reports on what it says
are “tens of thousands” of unnecessary surgeries that are
performed each year.
• USA Today made the assessment after viewing “government
records and medical databases finds.” In fact, “unnecessary surgeries
might account for 10% to 20% of all operations in some specialties,
including a wide range of cardiac procedures.”
• In the last seven years, over “1,000 doctors have made
payments to settle or close malpractice claims in surgical
cases that involved allegations of unnecessary or
inappropriate procedures.”
• Of course, there are also unneeded costs associated with the
surgeries.
SHOULDER
Treatment of shoulder injury with regenerative injection therapy (RIT).
PRP and/or buffered 5% dextrose (D5W) injection therapy should be considered for rotator cuff tears or
tendinopathies before operative intervention, especially where surgical necessity is unclear.
“Traditional” (non-cellular) treatment for torn rotator cuff includes:
 Rest
 Heat or cold to the sore area
 Medicines that reduce pain and swelling
 Electrical stimulation of muscles and nerves
 Ultrasound
 Cortisone injection
 Surgery
Source - NIH: National Institute on Arthritis and Musculoskeletal and Skin Disease
Research shows 57% failure rate in large rotator cuff repairs. Even after surgery, physicians are
exploring a non-surgical alternative in situations where the surgery was not successful, especially for high
performance athletes. In a recent article, researchers noted that even after surgical intervention, residual
defects or “retears” often recur in the tendon. But Platelet-rich plasma therapy has been shown to
enhance the rotator cuff tendon healing. Intratendinous injection of PRP can modify the natural history
of the rotator cuff tendinopathy compared with medical and physical therapies.
Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano
JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective
Open-label Study. Glob Adv Health Med. 2013 Mar; 2 (2):26-31.
48 year old female with MRI revealing “rotator cuff tear” after a motor vehicle collision (MVC).
Supraspinatus modified coronal T2 images:
• Tendon tear involving the insertion of the supraspinatus seen on the
pre-PRP injection image (upper left).
• 4 months later there has been interval “filling in” of the full thickness
defect indicating remodeling and reconstitution of the normal
longitudinal collagenous architecture of the supraspinatus tendon
insertion (upper right image 4 months after US guided PRP
injection into the rotator cuff tear).
Supraspinatus modified sagittal T2 images:
• Amorphous tendon pattern with loss of the normal collagenous architecture prior to PRP
injection (upper left image).
• Interval increase in the amount of fluid signal within the overlying subacromial/subdeltoid
bursa as a consequence of platelet rich plasma (PRP) induced regenerative inflammation.
• Accompanying interval remodeling includes development of smooth, linear hypointense
collagenous bursal and articular surfaces of the supraspinatus tendon.
• Although the possibility of persistent perforation (small focal full thickness tendon defect)
cannot be completely excluded, interval resolution of the large partial thickness tendon
defect without musculotendinous retraction or atrophy of the supraspinatus muscle.
The role of platelet-rich plasma in rotator cuff repair.
Mei-Dan O1, Carmont MR.1Department of Orthopaedic Surgery, Sports Injury
Unit, Meir University Hospital, Kfar Saba, Israel. [email protected]
Abstract
The shoulder is a common source of disability resulting from traumatic and
degenerate tears of the rotator cuff, subacromial impingement, and osteoarthritis.
Nonoperative management has focused on treatment of the predisposing factors,
the use of analgesics and anti-inflammatory medication usually in association with
local anesthetic and steroid injections. Surgical intervention allows debridement of
the degenerate cuff and partial thickness cuff tears, subacromial bursitis, impinging
bone spurs and osteophytes together with rotator cuff repairs. Repairs of
degenerate and torn tissue are often prone to failure due to many intrinsic and
extrinsic factors. It is assumed that some biological therapies might improve
clinical, mechanical, and histologic outcomes. Injections of platelet-rich
plasma (PRP) have led to reduced pain and improved recovery in other
degenerate pathologies areas together with the restoration of function. This study
reviews the current literature on PRP and in particular discusses its relevance in the
treatment of rotator cuff tears.
Sports Med Arthrosc. 2011 Sep; 19 (3):244-50. doi:
10.1097/JSA.0b013e318227b2dc.
Additional Case: 62 year old female with rotator cuff injury
Time lapse MRI’s over 6 months showing decreasing inflammation and return toward normal
longitudinal collagenous architecture of the anterior one third of the supraspinatus tendon
consistent with healing of the initial intermediate to high-grade, partial thickness, insertional and
interstitial tear. Interval remodeling of the bursal surface of the tendon, as well.
Rotator cuff tear and shoulder dysfunction:
• Challenging for the primary care, chiropractic, orthopedic, pain, and sports
medicine physician; especially when accompanied by adhesive capsulitis
and/or compensatory cervicothoracic sprain/strain/dysfunction.
• In addition to x-rays and MRI, we advocate utilizing high resolution
ultrasound not only to diagnose cuff pathology but to guide
regenerative injection therapy. Blind injections are not 100% accurate,
with studies showing that the accuracy is 76% when utilizing the posterior
approach and 69% via anteromedial approaches (Henkus, 2006). And there is
only a 66% correlation between the injector’s confidence in being in the
subacromial bursa and accuracy as confirmed on post-injection MRI
scanning. An accurate injection is associated with pain reduction with VAS
(visual analogue score) and function returning to pre-injury levels at six to
eight weeks in most patients.
• Narido et al. 2004 performed a randomised trial of 41 patients between blind
and ultrasound-guided injections. They showed a significant improvement
of the ultrasound-guided injections compared to the blind injections at
five weeks.
Ultrasound-guided injection of PRP in the supraspinatus tendon (upper left gray scale findings of loss of normal
tendon collagenous architecture) . Needle is shown (upper right image) with arrows and the spread of PRP is visible on
color Doppler.
The top left ultrasound image reveals subscapularis intrasubstance partial thickness tear and tendinosis. Note thickened, disorganize tendon
architecture. 9 months after ultrasound guided PRP injection therapy, the tendon has been remodeled and repaired, and the patient returned
to normal activities of daily life (upper right image).
Shoulder Surgery Side Effects: Common Procedure Is Bad News
About Rotator Cuff Injuries
• The shoulder is amazing and complex ball and socket joint. It is also the
second most mobile joint in the body (C1-2 most mobile). This unique
mobility is possible because the socket portion of the joint is quite
shallow, therefore requiring a group of four tendons called the Rotator
Cuff to hold the ball firmly in the socket upon lifting and rotating your
arm.
• Rotator Cuff tears are the most common injury of the shoulder. They
are also the most difficult to successfully fix surgically. Of the 40,000
Rotator Cuff tear surgeries performed each year, 6 out of 10 fail,
resulting in impaired strength and range of motion or re-tearing. The
reasons for this are simple. Other than trauma, recent studies show that
the reason the tendons tear in the first place is that they are weakened by
a lack of, or inefficient stem cells.
• If we then cut into these tendons, stitch them back together and then
immobilize them for long periods of time creating atrophy, it is illogical
to think that these additional blows to the joint’s regenerative potential
won’t cause problems with healing.
J Shoulder Elbow Surg. 2016 Jan 14. pii: S1058-2746(15)00593-5. doi: 10.1016/j.jse.2015.10.022. [Epub ahead of print]
The effect of coracoacromial ligament excision and acromioplasty on the amount of rotator cuff
force production necessary to restore intact glenohumeral biomechanics.
Budoff JE1, Lin CL2, Hong CK3, Chiang FL4, Su WR5.
Author information
1Department of Orthopaedic Surgery, University of Texas, Houston, TX, USA.
2Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
3Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
4University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA.
5Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Electronic address: [email protected].
Abstract
HYPOTHESIS AND BACKGROUND:
Coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. It is unknown how
much of an increase in rotator cuff force production is required to re-establish intact glenohumeral biomechanics after these surgical
procedures. We hypothesized that, after CAL excision and acromioplasty, an increase in rotator cuff force production would not be necessary
to reproduce the anterosuperior and superior translations of the intact specimens.
METHODS:
Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision,
acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics.
RESULTS:
After CAL excision at 150 and 200 N of loading, an increase in the rotator cuff force by 25% decreased anterosuperior translation to the
point where there was no significant difference from the intact specimen's translation. After acromioplasty (and CAL excision) at 150 and 200
N, an increase in the rotator cuff force of 25% and 30%, respectively, decreased superior translation to the point where there was no
significant difference from the intact specimen's translation.
CONCLUSIONS:
At 150 to 200 N of loading, CAL excision and acromioplasty increase the rotator cuff force required to maintain normal
glenohumeral biomechanics by 25% to 30%.
CLINICAL RELEVANCE:
After a subacromial decompression, the rotator cuff has an increased force production requirement to maintain baseline glenohumeral
mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch.
LEVEL OF EVIDENCE:
Basic Science Study; Biomechanics.
Acromioplasty – Why This Frequent Addition to Rotator Cuff Surgery is Usually a Bad
Idea
• Is Acromioplasty a beneficial addition to rotator cuff surgery and is recovery time
impacted by this addition to shoulder surgery?
• One of the big issues with rotator cuff surgery is the long recovery time spent in an
immobilizer brace.
• Unfortunately, the more procedures a surgeon performs during the surgery (including the
addition of acromioplasty), the longer the recovery time.
Now a new study seems to support the position as it shows that this procedure just
places more stress on the rotator cuff. Why is this important? If you end up with
shoulder rotator cuff surgery, you may forever have an unstable shoulder caused by the
removal of these ligaments without your knowledge. So what are the shoulder-surgery
side effects of acromioplasty?
Why Are Ligaments Important?
• First, a little background. Every joint in your body needs to make sure that its
surfaces are aligned with millimeter precision while you move. To do this, your body
uses two systems. The first system is made up of muscles that actively maintain that
alignment. The second consists of ligaments, which act like duct tape to hold the
joint passively together. Both systems have to work to allow normal and efficient
movement. If you get rid of one of these systems, there will eventually be problems
in the joint as the surfaces undergo too much wear and tear and arthritis sets in.
What Are These Important Shoulder Ligaments?
The shoulder, like every other part of the musculoskeletal system, depends on certain
ligaments for stability. The ligaments in question are the ones that hold the
acromioclavicular (AC) joint, located between the collar bone and shoulder blade,
together. They are called the coracoclavicular (CC) and coracoacromial (CA) ligaments
(see yellow highlighted ligaments to the right)
What Is Acromioplasty?
• The most common shoulder surgery performed in the U.S. today
is a shoulder rotator cuff repair with acromioplasty. The surgery
involves surgically sewing back together the torn rotator cuff,
which makes up the active stability system for the shoulder. Since
surgeons believe that in many patients the rotator cuff tear
happened because of extra pressure placed on the muscle, they
also usually cut the CA ligament to try and give the rotator cuff
more breathing room. This procedure is called an acromioplasty.
• Most patients have no idea that their rotator cuff repair involves
cutting this important stabilizing ligament, as many years later
when their shoulder arthritis brings them to our clinic, they are
surprised to learn that their shoulder was destabilized at the time
of surgery when this structure was cut.
New Research Shows Acromioplasty Is Bad News
• The new study looked at what happens when surgeons cut this critical ligament. The
researchers looked at nine shoulders of cadavers where the forces on various structures
could be measured before and after the ligament was cut. As expected from our
discussion above, when the ligament is no longer able to stabilize the shoulder, the
muscles have to work harder. In this case, after the acromioplasty, they observed extra
forces on the rotator cuff.
• Given that most of these surgeries also involve repairing the rotator cuff, extra tugging
on that muscle because the surgeon cuts a stabilizing muscle is not helpful. In addition,
this likely explains why many of these patients get shoulder arthritis years later. After
acromioplasty, the patient is left with an overloaded rotator cuff that tries to keep up
with the extra stability demands but at some point can’t maintain stability, and eventually
the joint suffers from the extra wear and tear.
• Maybe adding the acromioplasty conveys some sort of other benefit? Nope. Recent
research has shown that in the short run, adding acromioplasty doesn’t help the
outcomes of the rotator cuff repair.
Old Habits Die Hard
If you’re scheduled for a rotator cuff repair or have already had one, it’s highly
likely that an acromioplasty is planned or was already done. Don’t allow your
shoulder to be destabilized because the surgeon is used to cutting this ligament!
In addition, based on our experience, many rotator cuff tears don’t need
surgery at all as they can be helped through a much less invasive and precise
injection of the patient’s own stem cells.
Conclusion
There are no spare parts! For decades orthopedic surgeons have been removing
or cutting critical parts and pieces of the musculoskeletal system without much
scientific justification or much information on the consequences of the surgery.
As our research gets better and better, we’re seeing that these surgeries often do
more harm than good—case in point is acromioplasty. So if your surgeon
wants to cut your CA ligament, find another doctor!
Orthopedics 2.0 – How
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