Dr. Anthony Romeo: A Lot to Shoulder: Dr. Romeo's Shoulder Approach
April 01, 2001
A Lot to Shoulder:
Dr. Anthony Romeo's Approach to the Joint
By Tom Keppeler, Shoulder1 Staff
From a mechanical standpoint, the shoulder is an amazing joint. With three bones, a handful of ligaments, and three major sets of muscles, the shoulder articulates through a huge range of motion and is capable of great strength. However, with the abilities of the joints come many possible dangers: muscles can tear, bones can degenerate, and the joint can easily lose function. The necessary combatant in the field, the general in the fight against shoulder pain and poor function, is an orthopedic surgeon. As a "Shoulder Mechanic," an orthopedic surgeon can diagnose the problems of the joint, recommend treatments, and "tune up" the joint with surgery and rehabilitation.
Dr. Anthony Romeo, a standout among shoulder mechanics, has dealt with shoulder woes since his orthopedic residency in 1988. A graduate of the University of Notre Dame, Dr. Romeo earned his medical degree from St. Louis University. He now serves as an assistant professor and a member of the orthopedic surgery staff at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois. Dr. Romeo has attained many awards in his career, including nominations in 1999's Who's Who in Healthcare and 1998's Best Doctors in America and Chicago Magazine's Top Doctors in Chicago lists. He is a fellow of the American Academy of Orthopedic Surgeons and a member of the American Shoulder and Elbow Society, the Arthroscopy Association of North America, the American Orthopaedic Society for Sports Medicine and the American Medical Association. Dr. Romeo has written numerous journal articles and papers, including collaborative efforts with former Shoulder Care Hero Dr. JP Warner and former Knee Care Hero Dr. Brian Cole. Dr. Romeo has immersed himself in the testing and functional design of the European-made Aequalis shoulder replacement system, explained below.
|Although some shoulder injuries are unavoidable, a strength-training program can make your shoulders stronger and, thus, less at-risk. Listen as Dr. Romeo explains how to design a shoulder strength-training program here:|
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Shoulder1: Shoulder instability is something many of our users struggle with. Could you explain what shoulder instability is and what causes it?
Dr. Romeo: Before we talk about shoulder instability, we have to define a couple of terms that we use when talking about whether a shoulder is stable or not. One of the terms is "translation," the movement of the head of the humerus, or upper-arm bone, with respect to the socket, or glenoid. The second term that we use is "laxity," the term used to describe the amount of translation in the shoulder. A patient may have a lot of translation both in the anterior direction, toward the front, or in a posterior direction, toward the back, and we would say that they have a lot of laxity in their shoulder. The final term that we use is "instability," when a patient experiences an unwanted translation of their shoulder joint. It is important to define those terms, because laxity, or looseness of the shoulder, is not the same as instability. As a result, instability is something a patient experiences when they feel their shoulder slip out of place, or translate, more than what is perceived as normal.
Shoulder1: What tends to cause instability?
Dr. Romeo: For most patients, instability is caused by a traumatic event to the shoulder. In other patients, multiple events may challenge the ligaments of the shoulder that cause them to be more loose, causing the patients to experience unwanted translation of the shoulder, and they feel a sensation of instability.
Shoulder1: In the past few years, new procedures have emerged to treat shoulder instability in less-invasive ways. Obviously, with the advent of the endoscope, the surgery now involves less cutting, fewer scars, and, on average, a shorter healing time. But how has shoulder arthroscopy, especially for instability, changed since its inception?
Dr. Romeo: When we deal with instability from a surgical perspective, we have to deal with two major aspects of the soft tissues. One is the labrum, or the lip of the shoulder socket, and the second is the capsule and ligaments of the joint. The early arthroscopic procedures were focused on affixing the torn labrum to the rim of the glenoid, the socket. We developed techniques that included staples and tacks to accomplish this goal. However, these techniques were not successful in doing anything for the ligaments in the shoulder that were stretched or even partially torn at the time patients developed instability. The major advancement in shoulder arthroscopy for instability has been in addressing what is called "capsular laxity," or the looseness of the shoulder joint. We now have essentially three ways in which we reduce the looseness of the shoulder:
- First, we can use sutures. We now have special tools that allow us to pass the sutures through the capsule and then through the labrum or the rim of the socket. We can plicate, or shorten, the capsular tissue.
- Secondly, and even more recently, we can use a thermal device, which heats up the capsule and causes the collagen to shrink. Collagen normally is an extended molecule, and when you apply heat to it, it breaks Hydrogen bonds, and when the bonds are broken, the fibrils of collagen assume their natural configuration, a shortened, less organized pattern. The tissue shrinks as a result. Then, the shoulder heals with shorter ligaments.
- The third way we can address looseness is to close down an area that is known as the "rotator interval." This is the area in the front top part of the shoulder. Closing down this area creates a decreased looseness in both the inferior, or downward, direction and the posterior, or backward, direction. It can also be used to reduce movement in the anterior direction, or toward the front.
The major advancements in shoulder arthroscopy have come about primarily because we do not just perform the labral attachment; we also now have the ability to treat loose ligaments, which was not possible just a few years ago.
Shoulder1: You made a presentation in February at the annual meeting of the American Academy of Orthopedic Surgeons on thermal capsulloraphy, or "thermal shrinkage." Do you think that procedure is the wave of the future for shoulder arthroscopy?
Dr. Romeo: No.
Shoulder1: Why not?
Dr. Romeo: I think that using radio frequency energy to heat up the tissues will be an adjunct to the management of patients with shoulder instability, but it is unlikely to be the primary treatment for the vast majority of patients. The reason why is because many of the factors involved in the final result remain out of the control of the physician and the patient. We are still trying to determine how much energy to apply and exactly where to apply it to make it both effective and free of complications. Then, we have to rely on a healing process that requires a highly compliant patient and a slow rehabilitation for the first four to six weeks. Because of those factors, which remain out of the control of the physician, I think thermal energy will remain an adjunct, whereas sutures will likely remain the primary method for managing instability.
Shoulder1: You mentioned that thermal shrinkage requires a highly compliant patient. What does a patient have to endure after the procedure?
Dr. Romeo: After the thermal shrinkage procedure, the tissue is essentially burnt. If a patient were to try to stretch their arm beyond the constraints that are in place, or if a therapist tried to do the same thing, it would either tear the tissue or completely stretch it. It could even become more flexible than it was before. We know that the healing process of the tissues is such that at two to three weeks, the shoulder is actually at its lowest mechanical strength. We immobilize the patient in a sling and shoulder immobilizer for the first three weeks, and for anterior instability, we keep the patient's hand close to his abdomen so that they do not stretch out the front part of the shoulder. At about three weeks, we can then allow a gentle range of motion that is approximately 50 percent of normal but we will still hold them from progressing onto full range of motion until no less than six weeks. If we have a patient who has a lot of laxity in their shoulder, such as one with instability in multiple directions, we would immobilize them for up to six weeks and not pursue any functional range of motion until 12 weeks.
Shoulder1:Arthroscopic rotator cuff repairs seem to be slow to catch on—in fact, open repair is still considered the "gold standard." However, you repair the cuff arthroscopically. What benefits does arthroscopic cuff repair have?
Dr. Romeo: There are four primary benefits of arthroscopic rotator cuff repair. First, it leads to less pain for the patient, particularly for the first six weeks after surgery. Secondly, there is a decreased incidence of post-surgical stiffness in the shoulder with arthroscopic, as opposed to open, cuff surgery. Third, the surgeon has the ability to fix the tear with very little exposure to the joint. When a surgeon performs open surgery, you essentially have one large surgical approach to handle all the problems of the cuff. In addition, one of the major complications of open rotator cuff surgery is the avulsion, or loss, of the function of the anterior deltoid muscle. With arthroscopic surgery, we avoid that problem entirely by not even touching the deltoid attachment in any way.
For a surgeon such as myself who sees these patients routinely, the ability to manage patients post-operatively is dramatically improved because of the lack of severe pain that many patients experience with open rotator cuff surgery. That is by far the greatest advantage.
Shoulder1: Why has arthroscopic cuff surgery failed to catch on?
Dr. Romeo:Arthroscopic rotator cuff surgery requires an advancement in the technical skills of a surgeon. The most difficult part of the arthroscopic surgery is the repair of the tendon down to the humerus. To perform this technique, the surgeon must be capable of placing suture anchors in the proper position in the humerus, managing the many sutures that may be in the subacromial space at any one time, passing the sutures through the rotator cuff tendon, and then performing arthroscopic knot tying. Each one of these steps requires an advancement over the technical skills required to perform an open rotator cuff repair or a mini-open rotator cuff repair. Since many surgeons are of the opinion that their results following an open or mini-open rotator cuff repair are good to excellent, which is supported by the literature when the patients are followed at two years or more beyond their surgery, they are not motivated to pick up additional surgical skills. Learning the new skills necessary for arthroscopic rotator cuff repair requires the surgeon to handle some early frustration, as well as a decrease in their surgical efficiency. Overall, the less-invasive procedure increases their operating room time to perform a surgery seems to be equal in its outcome to open or mini-open procedures which at the one-to-two year mark. In my opinion, the surgeon should be motivated to move on to arthroscopic cuff surgery if he is performing two or more of these procedures in any one month, as well as if he has a desire to pursue continued expertise in the area of shoulder surgery.
Shoulderl: You have been on two sides of the shoulder replacement procedure, both performing them and assisting in the design of a more modern prosthesis. Could you explain, first, the type of patient who is best suited for an arthroplasty?
Dr. Romeo:The patient who has the best functional outcome following a shoulder arthroplasty are those patients with degenerative arthritis of the glenohumeral joint. These patients have a 95 percent or greater chance of having an intact and functional rotator cuff. Therefore, their problem is entirely related to the deformed architecture of the joint from the arthritis as well as the pain from the arthritis. Once anatomic replacement of the articular surface is performed, the shoulder will go on to develop excellent function because of the quality and integrity of the rotator cuff tendon in the vast majority of patients with osteoarthritis. This is also true for those patients who have avascular necrosis of the shoulder. However many of these patients have underlying medical conditions that lead to the use of oral steroids for the treatment of their problem and therefore have some compromise in the quality of the rotator cuff. Patients with arthritic conditions that affect the rotator cuff, such as rheumatoid arthritis, typically have excellent pain relief and good passive range of motion, but fail to demonstrate the active range of motion and functional gains seen in those patients with an intact rotator cuff, such as those with osteoarthritis.
The indications for treatment that force shoulder replacement surgery include the diagnosis of end stage arthritis that does not respond to conservative measures and creates pain with sleeping at night and interferes with activities of daily living.
Shoulder1: Could you describe your work helping to design the Aequalis prostheses?
Dr. Romeo:In 1991, two French surgeons, Dr. Gilles Walch and Dr. Pascal Boileau, worked in conjunction with Tornier, Inc. from France to develop the first "third generation" shoulder replacement system. This system, the first of its kind, allowed the surgeon to reconstruct the humeral articulating surface to its normal anatomic position. This system did not become available until September of 1996. I was fortunate enough to be the first surgeon in the United States to have the opportunity to use it and, after one or two uses of this shoulder arthroplasty system, I was convinced that the anatomic replacement was clearly the future for patients who are to undergo this type of surgery. However, the initial designs were made only for cemented fixation of the humeral stem. In the United States we have been familiar with using "press-fit," or "non-cemented" fixation of the humerus for the past 15-20 years. Therefore in the collaboration with Dr. Walch and Dr. Boileau, as well as the involvement of the Tornier engineers, I designed he press-fit stem for the Aequalis prosthesis primarily to be used in the United States. This has been available for the past 18 months and is now available on a worldwide basis. I have also recently been involved in the redesign of the glenoid system. We have had some concerns about glenoid fixation, and our new system, includes not only keel fixation—the classical type of glenoid fixation—but also fixation using pegs. In our opinion, both methods if properly implanted will be very affective in stabilizing the glenoid. Therefore, it is more an issue of surgeon choice but there may be situations where the peg system may be more advantageous over a keel system and vice versa. Therefore, there is more flexibility and adaptability to the system with the new glenoid system. Finally, we have recently come out with a new fracture system, which should provide better methods for healing of the fractures that require replacement by a shoulder prosthesis.
Shoulder1:What challenges have you encountered in helping to design the prosthesis?
Dr. Romeo:The initial challenge of the surgical design was to connect the three-dimensional concepts of anatomic reconstruction of the humerus with modern principals of prosthesis fixation. The three-dimensional adaptability of the prosthesis requires that there is a variation with regards to the inclination, or angle, of the head in its relationship to the shaft; a variation in the position of the head with regards to the center of the stem of the offset of the head; as well as a fixed relationship between the head height and radius of curvature. These anatomic principles are critical to obey if an anatomic reconstruction is to be possible. We then had to put together the most modern and advanced thinking on fixation of a prosthetic stem without cement into our design of the stem. In addition, the overall length of the humeral stem had to be taken into consideration. We were able to bring both of these modern concepts together in the new Aequalis press-fit shoulder arthroplasty system. The second major challenge was to convince orthopedic surgeons that anatomic replacement of the humeral articulating surface would provide the best result for shoulder arthroplasty. As remarkable as that may seem, some surgeons believe that the reason why the arthritis occurred is because there was a faulty design of the patient's normal anatomy. This, of course, does make sense, and we are strongly in favor of reproducing the normal anatomy of the articular surface in any reconstruction of any joint, but most particularly the rotator cuff, which relies so heavily on soft tissue envelope for the best function. If the anatomic replacement is not in the normal alignment, soft tissues will not hold up over time and the functional results will be less than ideal.
Shoulder1:When is the product expected to come to market?
Dr. Romeo:The first time that the third generation Tornier Aequalis System was available in the United States was in September of 1996. Currently, both the cemented and press-fit stems are available in the United States and in many parts of the world. The cemented, in fact, is available worldwide and the press-fit stem continues to grow in its worldwide acceptance. We are convinced that we are promoting the correct concepts as we have seen many of the other shoulder systems gradually modifying their current stem design to match the anatomical principles that we have supported. It is clear that emulation remains the most sincere form of flattery and so we expect to continue to see other systems designed with the adaptability that has been present in the Aequalis Prosthesis since 1991 in Europe and in 1996 in the United States.
Shoulder1: Lastly, some shoulder injuries are unavoidable, caused by accidental trauma or degenerative conditions. However, performing certain exercises can keep people's shoulders stronger and, therefore, less at risk. What would you recommend?
Dr. Romeo: Designing a program to help prevent injuries of the shoulders has to take into account both the relationship between the humerus and the scapula and between the scapula and the rest of the body. As a result, we need to think about both areas, including the rotator cuff muscles around the shoulder joint, as well as those muscles that work on the scapula. The programs that we design for the prevention of shoulder injuries includes exercises to stretch the shoulder or maintain its flexibility, as well as strengthen the rotator cuff muscles. The stretching program involves three cardinal movements, including:
- Forward elevation, or raising the arm above the head
- External rotation with the arm away from the side
- Internal rotation, where the hand is brought up from behind the back, as high as possible and reaching across to the opposite shoulder.
The second part involves strengthening the rotator cuff, which adds resistance to the activities of stretching. The other strength-training method we use is abduction, where the arm is brought away from the patient's side, which helps to strengthen the rotator cuff and the deltoid muscle along the top of the shoulder.
As I mentioned, it is also critical that we maintain the stability and mobility of the scapula and the muscles that work on it. Exercises for the scapula include shoulder shrugs, as well as scapular protraction and retraction and other strengthening exercises for the upper back and torso area. A flexible and strong scapula helps to ensure that it is in the right position for our movements, whether they are related to sports or activities, and it also provides a very firm foundation for the activities that we perform with the use of our shoulder.Photo courtesy of Dr. Anthony Romeo.
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Last updated: 01-Apr-01