The New Wave in Sports Medicine
Olivia Jamusu was only in the eighth grade when her shoulder started hurting. A talented club volleyball player and swimmer, she had apparently stretched and torn the ligament that holds the head of her humerus bone into the shoulder socket.
The pain grew steadily worse. By her junior year at Notre Dame High School in Sherman Oaks, “I would come home from swim team practice crying,” she says. “That summer, my friends would be going out in the evening after practice, but I would just come home, ice my shoulder, take some Tylenol and go to bed crying.”
She sought the help of doctors, but they simply felt her arm, said it was OK and prescribed physical therapy. Then, last fall, she went to see Dr. Stephen Liu at the UCLA Medical Center.
After taking X-rays and an MRI, he said she needed shoulder surgery and offered her the chance to be one of the first at that center to undergo a newly developed form of a minimally invasive procedure.
The technique, called electrothermal arthroscopy, uses radio frequency energy to shrink the ligament that holds the head of the humerus in the socket. Radio frequency energy employs the same wavelengths used to broadcast radio signals and, when generated next to tissues, causes them to heat up.
It is much less painful than conventional surgery, according to Liu and other surgeons who have used it, and it requires only half the healing time and allows the recipient to retain a greater range of motion in the shoulder joint.
It is particularly popular with professional athletes, for whom complete restoration of function is critical. More than 50 National Football League players, such as Brent Jones of the San Francisco 49ers, have undergone the procedure, as well as many baseball players and swimmers, said Hugh Sharkey of Oratec Interventions in Menlo Park, where the technique was developed. Throughout the country, more than 5,000 people have been treated, he said.
The shoulder has the greatest range of motion, coupled with the least stability, of any joint in the human body. When ligaments are stretched, the shoulder becomes unstable and can dislocate, causing extreme pain and disability.
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About 100,000 Americans undergo surgery for a dislocated shoulder each year, most often as a result of recreational activities. An additional 350,000 could benefit from such repairs because of previous injuries and congenital defects. Many are reluctant, however, because the conventional operation is debilitating.
The conventional surgery requires a three- to five-inch surgical incision that slices through skin, muscle and tendons. The surgeon sews a pleat into the ligament to shorten it, and then tacks it to the shoulder bone.
The surgery requires at least an overnight stay in the hospital, followed by as much as six weeks of immobilization of the arm in a sling. The patient then goes through up to nine months of physical therapy to restore flexibility.
According to Liu, athletes who require use of the shoulder for competition such as swimming, volleyball and baseball have only about a 50% chance of returning to form. Everyday athletes lose 10% to 15% of their flexibility.
In the new procedure, which takes about 1 1/2 hours, a nerve block is injected above the shoulder, which removes feeling from the entire arm for about 12 hours. The patient has the choice of being put to sleep or remaining awake. Small incisions, less than an inch long, are made in the front and back of the shoulder.
A thin viewing tube with a built-in television camera is inserted through the front, and a small tube through which most of the operation is performed through the rear. Watching on a video screen, the surgeon cleans up the bone and ligament, removing ragged edges and roughening it so they will adhere to each other. The free end of the ligament is then stitched to the bone.
The key step involves the use of a small wand that emits radio frequency energy that heats the tissue in much the same manner that a microwave oven heats food. A precise amount of heat causes collagen, a fiber-like protein, within the ligament to contract, in effect shrink-wrapping the ligament around the joint.
The patient leaves the hospital a couple of hours later, still feeling no pain because of the nerve block. Often, an over-the-counter painkiller is all that is needed after the anesthetic has worn off the next day, Liu said. The arm is kept in a sling for 10 days, and then about three months of physical therapy is required. Most patients regain at least 95% of their original range of motion, he said.
“This really gives us a good alternative to the conventional surgery,” said Dr. Lou Yocum of the Kerlan-Jobe Clinic, who has performed the operation on several professional athletes. “The final verdict isn’t in yet with the throwing athlete, but we have had favorable results with volleyball and tennis players.”
The technique can be used in nine of 10 patients who require shoulder surgery, Liu said.
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It is also useful elsewhere in the body. One application is tightening transplanted anterior cruciate ligaments in the knee, which often stretch after they have been implanted. “You can use it anywhere that changing the shape of a ligament, tendon or joint capsule is helpful,” Sharkey said.
Heat from the wand can also be used to kill nerve fibers. That opens the possibility of treating tendinitis (tennis elbow) by killing the problem nerve, or controlling the pain of degenerative disc disease in the back.
The company just received approval for using the wand to clean up herniated discs. “But we’ve had only very limited follow-up with these patients, and we don’t know the long-term prognosis,” Sharkey cautioned.
Jamusu, whose surgery was in October, had her arm in a sling for two months, but took it out each day to exercise it. “It hurt a lot at first, especially if anyone brushed it, but now there is almost no pain at all,” she said.
She started swimming again in January, and now swims two hours a day in practice. She swam in her first meet April 22. Her coach even says that her form has improved, particularly in the butterfly, because she no longer favors her sore shoulder.
“This is absolutely, by far, one of the greatest things I’ve had,” Jamusu said. “Just to do simple things like blow-drying my hair, picking up my backpack, or walking the dog--it doesn’t hurt when he pulls on me, now. It’s been a complete turnaround.”
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New Treatment Procedure
Dislocated shoulders are normally caused by stretching or tearing of the ligaments that hold the head of the humerus nito he shoulder socket. In a new minimally invasive technique, surgeons use three tubes containing a camera and tiny instruments.
1. Surgeons repair tears in the ligaments, if necessary.
2. A special probe that emits radiofrequency energy is used to shrink ligaments so they hold the joint firmly in place.
