Monday, February 2, 2009
His cutting edge offers faster healing
Technique aims to improve shoulder surgery
By Sam McManis
Published: Sunday, Feb. 01, 2009
Think of the innovative shoulder surgery that Sutter Sacramento orthopedic surgeon Alan Hirahara performs, a procedure said to hasten healing for athletes and geriatrics alike, as something akin to sealing a cracked bathtub.
Or, better yet, completing a woodworking project.
“What I’m doing is the same concept as gluing two boards together with nails,” Hirahara says.
Except, of course, that the boards are a patient’s frayed tendons or cartilage, the glue is a viscous fibrin clot made from platelets of the patient’s own blood to enhance healing, and the nails serve as dissolvable anchors.
Now, to extend the metaphor, imagine gluing this board together in a mere slit of a space with an instrument – the arthroscope – no bigger than an average screwdriver.
And as an added degree of difficulty, try doing all that when the surface being worked on is vertical, meaning the “glue” tends to follow gravity and head south.
It is little wonder, then, that shoulder surgery has long proved a challenge for orthopedic surgeons, who say they are seeing more patients with rotator cuff and labrum tears sustained either from manual labor or sports.
In the past, doctors would have had to perform invasive surgery to repair the joint, creating the clot outside the body. A few specialists are trained to sew the tendons back together arthroscopically, which improves recovery, but that procedure heretofore meant not using a fibrin clot – a natural sealant for tissue made from a person’s blood – to bind the tissue back together.
Working without a fibrin clot is like nailing those boards together, sans glue. It can work, but it’s not as secure and could separate again.
But why can’t the clot form internally on its own as a natural part of the inflammation and healing process?
“The first big challenge specific to shoulders is anatomy,” Hirahara says. “The vertical joint makes things fall to the bottom, and most of the things we want to repair are at the top. Blood flows down, so a clot won’t necessarily form. That’s why, in shoulder surgery, you see blue and black (discoloration) running down the arm.”
Another challenge is that joints, when torn from the bone, have poor blood flow to manufacture their own clot. And in older adults, vascularity recedes even further with age.
So what Hirahara has developed is a way to use a fibrin clot with an arthroscope in shoulder surgery. The clot, made of platelets and growth factors called cytokines from the blood, is run through a machine to separate it from denser red blood cells. Then the sticky, globular mass is injected into the shoulder tear as a binding agent and tied with sutures.
“We’ve had a high failure rate with standard techniques,” he says. “You had to create the clot outside the body and thread the clot onto the suture and somehow push that clot into the joint and tie it down. Extremely hard and not feasible.”
Because he knows of no other surgeon using the new technology, called biologics, on shoulder patients, Hirahara embarked on a retrospective study looking at success rates and recovery time of his patients who had procedures with fibrin and without.
The results, which Hirahara will present to the Arthroscopy Association of North America in April, show a steady three-month decrease in healing time for patients receiving the fibrin clot. Not counting workers’ compensation issues, patients in the study group were discharged after 107 days, compared with 150 for the control group.
“As for failure rates, it’s 10 percent in the control group and zero in the (fibrin clot) group,” Hirahara says. “Actually, I just had my first failure today, a weightlifter that may have gone back to training too early, so the percentage is up to 0.7 now. That’s still pretty good.”
Dr. Harold Strauch, medical director of the Sutter Orthopaedic Institute, is cautiously optimistic about the new shoulder procedure.
“The only limitation is, it’s an early investigation of this type of act,” Strauch says. “I always like to watch things for a longer period of time. But so far, the early data will suggest … that it looks favorable in the long term.”
One of Hirahara’s patients is former Sacramento State javelin thrower Ashley Ast, whose bid to qualify for the Olympic trials last spring was dashed because of a partially torn ligaments in her labrum and rotator cuff.
Last July, she underwent biologic surgery. She says she was surprised by the speed of her recovery. Within three weeks, her pain was gone, her range of motion was improving steadily. Now, she’s back training for this spring’s track and field season.
“I couldn’t have asked for it to go better,” Ast says. “I still don’t know what the exact details are of what Dr. Hirahara did in the procedure. I just knew it was supposed to make me heal faster. And it did.”
Athletes are not the only ones who can benefit, Hirahara says. He’s used the biologics procedure on elderly people hurt in falls – or merely the victim of degenerative conditions – and adults injured in auto accidents.
Call The Bee’s Sam McManis, (916) 321-1145. Read his postings on the Sacramento Health & Fitness Blog at sacbee.com/blogs.