The Complex Shoulder and Elbow Center continues to provide expert care for the full spectrum of shoulder and elbow conditions. In 2007, Dr. Samer Hasan was recognized for his work by becoming the first and only orthopaedic surgeon in the Greater Cincinnati area, and one of only three in the Commonwealth of Kentucky, admitted into the American Shoulder and Elbow Surgeons. Admission into this society, comprised of the leading national and international orthopaedic surgeons specializing in surgery of the shoulder and elbow, is by nomination only and based on sustained academic and research contributions to the field.
One of the most prevalent trends in shoulder and elbow surgery is toward minimally invasive procedures. Surgeons at the Center currently manage most soft tissue reconstructions, including labrum repairs and rotator cuff repairs, using allarthroscopic methods. The results have been exceptional with a more rapid and comfortable initial recovery and excellent outcomes in terms of return to full function including work and sports. Surgeons at the Center also treat other conditions affecting the shoulder and elbow including arthritis, fractures, nerve compression syndromes and other conditions.
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- Shoulder Instability
Shoulder instability, including dislocations and subluxations, are common injuries, especially among athletes participating in collision sports such as football, rugby, or lacrosse. Anterior shoulder instability, arising when the arm is in a thrower’s position, remains the most common type of shoulder instability, but it is not the only type. One specific condition for which we have seen a great advantage to arthroscopic techniques is posterior instability. This condition is far less frequently encountered than anterior instability and is associated with tears of the posterior labrum. Posterior instability is often seen in weightlifters performing overhead presses and in football linemen who injure their shoulders from repetitive blocking. Since 2003, the Center has carried out over 40 all-arthroscopic posterior labrum repairs with no complications, no re-operations and only one instance of modest residual instability. These surgeries were largely carried out in patients referred to the Center from other physicians and surgeons who encounter these injuries infrequently. Our results show that the technique is vastly superior to open repairs with less morbidity, a lower complication rate, and predictable return to work and sport.
- Rotator Cuff Tears
Rotator cuff strains and tears comprise the most common shoulder condition in patients over age 30. Selecting the proper treatment for a rotator cuff tear requires a thorough integration of history and examination findings as well as the results of radiographs and ancillary studies, such as MRI. However, there is compelling evidence that supports early repair of most full-thickness rotator cuff tears in younger, more active individuals because these tears do not heal on their own and generally enlarge over time. Care must be taken to exclude, pre-operatively, those tears that may not be reparable or worth repairing such as tears arising in tendons that are atrophic or otherwise deficient and tears associated with muscles that have atrophied irreversibly. Most rotator cuff tears, including larger more retracted tears, can be repaired using arthroscopic or arthroscopic-assisted techniques. Dr. Hasan specializes in all arthroscopic rotator cuff repairs. Out of 300 rotator cuff repairs performed since 2005, greater than 240 were repaired entirely using all-arthroscopic techniques. Outcomes following all-arthroscopic repair have been exceptional and complications have been rare. In fact, there have been no infections in this group and only three patients have required subsequent surgery, two of which were for post-surgical scarring and stiffness.
- Shoulder Trauma
Serious traumatic injuries to the shoulder including fractures of the humerus and clavicle and highgrade acromioclavicular (AC) joint separations are seen at the Center. Many fractures of the proximal humerus and clavicle continue to be treated nonoperatively with very good clinical results. However, many markedly displaced, angulated, and shortened fractures benefit from early open surgery to realign and fix the fragments precisely and securely to expedite healing and optimize outcome. Newer “locked” plate and screw constructs provide more stable initial fixation of these fractures, allowing immediate mobilization of the shoulder after surgery.
Another area of interest is the anatomic reconstruction of high grade acromioclavicular (AC) joint separations. Traditionally, these inuries have been managed with soft tissue transfers that do not replicate the normal anatomy of the injured coracoclavicular ligaments. Over the past two years the Center has used allograft hamstring tendon to anatomically reconstruct the injured ligaments. The tendon graft is fixed into the clavicle using bioabsorbable interference screws and reinforced with braided suture to maintain a strong repair while the graft incorporates. Preliminary results have been encouraging.
- Shoulder Replacement for Arthritis
Shoulder arthritis involving the glenohumeral (ball and socket) joint is quite common. Initial treatment is non-operative and mirrors the initial treatment of hip and knee arthritis, but when this treatment fails, shoulder replacement surgery is then considered. Several types of shoulder replacement are currently available including total shoulder replacement, partial shoulder replacement or hemiarthroplasty, humeral head resurfacing, and reverse ball and socket replacement. Over the past five to ten years there has been an explosive growth in the number of shoulder replacements performed for end-stage glenohumeral arthritis. As with hip and knee replacements, and other surgeries such as coronary artery bypass grafting, high volume shoulder replacement surgeons consistently outperform surgeons who perform these procedures infrequently. Not surprisingly, 90 per cent of shoulder replacements performed by high volume surgeons are expected to last for at least 10 years and 85 per cent for 15 years, both of which represent survivorships comparable to that following hip and knee replacement. Over 60 shoulder replacements will be performed in 2007 by surgeons in the Center; this represents a volume that is exceeded by only a handful of institutions nationally. Although complications can and do occur, as with every major surgery, they are largely confined to patients who have had prior shoulder surgery. Many patients at the Center who have bilateral shoulder arthritis go on to request that the opposite arthritic shoulder be replaced as well, often within a few months.
A novel type of shoulder replacement, the reverse ball and socket replacement, has shown great promise for the treatment of a particularly disabling type of arthritis associated with chronic, massive, and irreparable rotator cuff tears. This type of arthritis, termed cuff tear arthropathy, causes not only shoulder pain but also marked loss of strength so that some patients are unable to lift their arm up at all. Cuff tear arthropathy has traditionally been managed with hemiarthroplasty, which often provides adequate pain relief but does not improve active shoulder motion reliably. The reverse ball and socket replacement employs a ball (glenosphere) attached to the glenoid (shoulder socket) and a socket that is attached to the humeral head in order to alter the biomechanics of the shoulder. The result is that larger and stronger muscles, especially the deltoid, are now able to function effectively in order to elevate the arm. The results in certain patients have been truly remarkable. In early 2004 Dr. Hasan became the first surgeon in Greater Cincinnati to perform the reverse ball and socket replacement surgery, as part of a 20-site multi-center study that gained FDA approval for this implant. He continues to perform this surgery in carefully selected patients with this otherwise untenable shoulder condition.
- Elbow Conditions
The most common elbow conditions are overuse injuries such as tennis elbow and golfer’s elbow that usually respond to rest and simple non-operative measures. When these measures fail, surgeries employing incisions as small as two or three centimeters are usually effective. Surgeons at the Center also perform elbow arthroscopy for conditions such as intra-articular loose bodies, osteochondral injuries, and elbow contractures arising after trauma or surgery. Other elbow conditions treated at the Center include biceps tendon injuries, elbow instability and various fractures about the elbow. Although the incidence of biceps tendon tears at the elbow has been estimated at only 0.8 per 100,000 individuals per year, greater than 10 such repairs are performed each year by surgeons at the Center. Finally, surgeons at the Center perform elbow replacement surgery for painful and stiff elbows resulting from rheumatoid arthritis and other inflammatory conditions, and also for certain elbow fractures arising in older adults.