SURGICAL TREATMENT OF SHOULDER AND ELBOW DISORDERS
The glenohumeral joint has a relatively small contact in between the ball and socket type joint surfaces, allowing an extremely wide range of motion for the upper arm. Due to high mobility a strong and balanced muscular support is required to achieve full function and to prevent joint instability. This delicate rotator cuff structure is vulnerable for injury and tissue degeneration. Consequently, shoulder pain and dysfunction is the second most frequent complaint of all patients with a musculoskeletal disorder.
The elbow on the other hand is complex rotatory and hinge-joint formed by three bones. The structure is vulnerably to injuries eg. dislocations and fractures which may cause long term disability and predispose to joint wear.
RESEARCH AREAS AND AIMS
This research is set out to study the efficacy, effectiveness and safety of surgical treatment of the shoulder and elbow: 1) instability, 2) tendon tear and 3) osteoarthritis and 4) fractures. The ultimate goal is to implement the results into clinical practice and improve the value of patient care.
METHODS
All patients surgically treated for these disorders at Turku University hospital are systematically registered in a comprehensive database with now thousands of patients. This database is utilized in analyses of patient outcome and relating prognostic factors. Both traditional statistical methods and also machine learning algorithms are used for analyses. Patients reported outcome measures are validated in Finnish and used as the primary outcome measures in analyses.
In addition data from Finnish national joint arthroplasty registry together with combined data from Nordic national joint arthroplasty registries (Nordic Arthroplasty Registry Association, NARA and International Society of Arthroplasty Registries (ISAR)) are utilized for analysing risk factors and risk of revision for arthroplasties. Finally, randomized controlled multicenter clinical trials have been meticulously designed and implemented to answer specific clinical research questions.
SPECIFIC STUDY COHORTS
Persistent shoulder instability is a frequent disorder among young adults, especially after an initial traumatic dislocation. This poses a severe handicap on the daily activities and quality of life. A dislocation always disrupts the passive soft-tissue restraints of the glenohumeral joint. There may also be other accompanying lesions, such as an impression fracture of the humeral head, or of the anterior glenoid rim.
Post-traumatic instability of the shoulder is considered a good indication for surgical treatment. The most common operation to treat shoulder instability is an anatomical capsulolabral repair (Bankart operation). Despite a successful operation, patients may still have a considerable risk for re-dislocation. Therefore, more robust and non-anatomic operative techniques, such as Latarjet, have evolved to achieve greater stability of the glenohumeral joint. The Latarjet operation has been reported to yield high success rates in re-stabilizing the joint, potentially outperforming the Bankart repair but high quality comparative evidence is lacking.
The rotator cuff is composed of tendons of the four scapular muscles (subscapularis, supraspinatus, infraspinatus, teres minor) covering the glenohumeral joint. Each functional muscle and tendon contributes to motion and dynamic stability of the joint. Rotator cuff tendon may tear due to trauma and/or degeneration and the risk is significantly increased by patient age. Usually the tear involves the supraspinatus tendon and may be clinically associated with disabling shoulder pain and weakness.
Advocated treatment of rotator cuff tear has generally been surgical re-attachment of the torn tendon. However, with surgical treatment there is a big risk of structural failure and tendon re-tear. Interestingly, despite a re-tear patients may be asymptomatic and patients may also recover sufficiently with conservative treatment only. Therefore, the efficacy and effectiveness of rotator cuff repair is obscure.
Healthy glenohumeral joint surfaces are covered with smooth hyaline cartilage. Traumatic events, shoulder instability, inflammatory diseases and genetic factors may predispose to early wear of the joint and subsequent osteoarthritis with inflamed joint synovia and bony osteophytes. This may cause pain and dysfunction of the shoulder. Operative treatment and total shoulder arthroplasty may be indicated to replace the worn out joint surfaces and to alleviate the symptoms.
Sometimes glenohumeral joint wear is associated with incongruency ie. superior migration of the humeral head in relation to the glenoid joint surface and accompanied with marked loss of strength. This cuff tear arthropathy is due to grossly dysfunctional rotator cuff. In such circumstances a more stable arthroplasty construct may be indicated to alleviate pain, restore the congruency and active range motion. Reverse shoulder arthroplasty may be indicated to treat cuff tear arthropathy and to alleviate the symptoms.
The popularity of shoulder arthroplasty has increased rapidly during the past years, and this trend will most likely continue due to large aging population. Despite generally good results, a shoulder arthroplasty may result in complications and revision of the prosthesis with a potentially catastrophic outcome for the patient. Therefore, understanding the risk of revision and factors related to it, is crucial in clinical decision making and when counceling the patients.
FRACTURES
Proximal humerus fractures comprise the third most common nonvertebral fracture type in the elderly population after the hip and the distal radius fractures. Majority of these fractures can be treated conservatively. However, comminuted and severely displaced fractures in frail patients, pose a persistant clinical problem with various suboptimal treatment options. In cases not amenable to osteosynthesis traditional operative treatment option, hemiarthroplasty, may be prone to complications and revision procedures. Alternatively reverse shoulder arthroplasty yields reportedly good clinical results, and consequently has gained increasing popularity in the treatment of proximal humerus fractures.
To date no consensus exists over treatment strategies of proximal humerus fractures. The popularity of shoulder arthroplasty has increased rapidly during the past years, and this trend will most likely continue due to large aging population. Despite generally good results, a shoulder arthroplasty may result in complications and revision of the prosthesis with a potentially catastrophic outcome for the patient. Therefore, understanding the risk of revision and factors related to it, is crucial in clinical decision making and when counseling the patients.
Olecranon fractures account for approximately 1% of all upper extremity fractures. Olecranon is the most proximal part of one of the two bones in forearm, the ulna. Triceps tendon attaches to olecranon and triceps muscle is the main muscle accounting for extension of elbow joint. The incidence of olecranon fractures seems to be increasing especially in the elderly population. These fractures have typical osteoporotic features such as age-dependent low bone attenuation and low-energy trauma as a cause of injury.
Traditionally displaced olecranon fractures have been treated with osteosynthesis to re-establish the congruency of the elbow joint and to re-attach the triceps tendon. Most frequently used operative methods are tension band wiring or plate fixation. Significant differences between these two methods have not been found concerning patient satisfaction, improvement rate, range of motion (ROM), operation time or blood loss. Both methods achieve adequate union and function but are associated with high rate of re-operations due to operative complications and removal of the prominent metalwork after fracture union.
Recently non-operative treatment has been brought up as a treatment option for elderly patients, in whom the function of the elbow does not significantly limit their activities of daily living. It seems that non-operative treatment could provide similar functional outcome with lower complication burden.
ETHICAL ISSUES
The research is conducted according to the revised declaration of Helsinki by the world medical association and the ICH-guidelines for good clinical practice. Increasing incidence and popularity in certain surgical procedures and lack of evidence provides the ethical base for this research. The methodology has been evaluated by the ethics committee of Varsinais-Suomi Hospital district.
RESEARCH TEAM AND COLLABORATION
Efficient clinical research requires numerous patients and a meticulous execution. Therefore, close collaboration is needed and spread through Finland, Sweden, Norway and Denmark, with over 20 participating clinical centers and over 50 clinical collaborators and researchers. Research plans are comprehensively constructed together with all participating centers. In addition advisory collaborators are consulted frequently Oxford, UK and Sydney, Australia. Communication between participating centers is promoted by regular information bulletins, mobile messaging, information cloud services etc.. Moreover, researcher mobility is strongly supported and visits are made across the research centers.
RESEARCH CAREERS
Clinical research combines a deep understanding of both clinical patient care and scientific methodology. The established widespread collaborative network will allow us to address also other clinical research questions in the future. Clinical research careers are advanced by continuous training, PhD programs, academic positions and interdisciplinary networking involving specialist from eg. orthopedics and traumatology, physiatrics, physiotherapy, biostatistics and applied mathematics. The experience in participating in these trials will enhance the research capabilities of all participants.
DISSEMINATION OF RESULTS
The results are published in high quality peer reviewed journals and communicated in international scientific meetings, courses and congresses. After publishing the results all data regarding the randomized controlled trials will be made open for scrutiny and possible meta-analysis through the website.
PATIENT AND PUBLIC INVOLVEMENT
Shoulder and elbow problems are very common and disabling, and this research will most likely be very interesting to layman audience. The results of this research are communicated through general news media, internet, youtube etc. to reach layman audience. The research attempts to clarify the measures of treatment outcome, the clinical decision making and indications in a fundamental way. The results will also have a potentially substantial societal financial effect and help to guide the healthcare resources in a more effective direction.
FUNDING
We have received substantial grants from eg. Turku University Hospital, Suomen Lääketieteensäätiö, SECEC and Suomen Akatemia.