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Keeping It Together
Paul Favorito of Wellington Orthopaedic & Sports Medicine is using a new technique to stop shoulder dislocations and speed healing.
The shoulder’s a really cool joint, always living on the edge. It’s a fine balance of mobility and stability. Too much movement, people dislocate. Not enough, people are stiff. Athletes, for whatever reason, seem to have a lot of trouble with their shoulders. The things we ask athletes to do—throwing a baseball, serving a tennis ball—we probably weren’t designed to do. That means problems.
There is some soft tissue [in the joint] called the labrum, and it helps stabilize the shoulder. When you dislocate, it pulls off. Sometimes we’d fix it and patients would do great, and other times we’d fix it and patients would dislocate. We had to figure out why.
Imagine a golf ball sitting on a tee. If you take off a quarter of the tee, the golf ball will still sit there, but you’ve got to be really careful. The golf ball can’t move very much. If it does, it will fall off. If you dislocate and knock off a little bit of bone, well, bone is really important. When you lose bone and don’t replace it, people tend to keep dislocating. What we’re trying to do is like robbing Peter to pay Paul. You take bone from the front of the shoulder, cut it, transfer it through a muscle and attach it where the bone is missing. Open Bristow-Latarjet is how it’s traditionally been done.
For the most part, it’s a pretty straightforward procedure. The challenge: Anytime you operate on the shoulder, people can get stiff. Anytime you’re making larger incisions, you’re splitting muscle and there’s natural scar that tends to form. That scar, if it occurs, can limit function afterwards. The arm hurts more. Doing it arthroscopically is a different story. You’re just making little poke holes in the skin, and everything’s done inside. You see things you might not otherwise see. The cameras we use work on an angle, so if I want to look backwards, I just move it. You don’t get as much scarring, and we’ve found that patients are getting really spectacular motion after surgery. Motion so good they go back to their activities quicker.
The first patient I took care of I told, “Look, I’ve never done this before.” But she really wanted it arthroscopically. She’s a competitive ballroom dancer and wanted to make sure she didn’t have big incisions. And she did great. So great that a year later she came back and had the other side done.
These are generally active, younger patients. When you look at everybody who dislocates, the number of people who have a lot of bone loss is pretty small. To me, this is a procedure that should be used in the right setting at the right time. At 50 or older, we start to worry about different problems when you dislocate.
What we’ve got is a new tool in our toolbox, and it’s our job to figure out when to use the new tool. It’s a cool tool to have.
Originally published in the January 2013 issue.