April 29, 2016
Story and photo by Gregory Kennedy
EDMONTON — Douglas Gilroyed grew up with the wide open spaces of ranches and farms, and whether riding his horses around his acreage near Westlock or building fences and sheds under the big Alberta sky, he’s not a guy who likes to be confined — whether by geography or by a little thing like a sling after shoulder surgery.
That made this very active retiree the perfect choice to take part in research about the best recovery strategy for patients who undergo rotator cuff repair.
When it comes to rotator cuff repair, local orthopedic surgeons wondered for years why “cheaters” who didn’t wear their slings appeared to enjoy a better quality of life and an improved range of motion sooner than patients who did.
Now the benefits of getting up and at ’em right after surgery have been proven through research, and by Gilroyed himself who, after his surgery, was instructed to do his usual daily activities as long as there was no pain, and to avoid heavy lifting for the first three months.
“I wore the sling home and, after that, I never wore it,” says the 69-year-old, who had surgery on both shoulders. “I keep pretty active. We had lots of work here last year. We put up the fence. Built a shop. I ride horses and look after them. You’ve got to keep busy.”
Gilroyed’s experience reflects the latest thinking that there’s no downside to early mobilization of the shoulder joint after mini-open (small incision) rotator cuff repair surgery — findings which were recently confirmed by a study published in The Bone & Joint Journal.
Local study co-authors include Alberta Health Services (AHS) orthopedic surgeons Dr. Robert Balyk and Dr. David Sheps, both assistant clinical professors in the Division of Orthopedic Surgery in the Faculty of Medicine & Dentistry at the University of Alberta.
“The anecdotal benefits of early active motion led us to question whether strict immobilization was truly required,” says Dr. Balyk, also chief of orthopedics at the Grey Nuns Community Hospital.
“We know these patients are happier if they can move their shoulders sooner because it allows for an earlier return to daily activities. However, we did not know if early mobilization would lead to long-term complications, such as slower healing or a greater number of re-tears.”
Their trial compared outcomes following mini-open rotator cuff repair — a minimally invasive procedure that uses an arthroscope to confirm the presence and reparability of a rotator cuff tear. The surgeon then removes the arthroscope and splits the deltoid muscle through a small incision to repair the tear. Rotator cuff tears become more common in patients over 40 years of age; most patients who undergo the surgery are between 45 and 65.
Conventional rehabilitation following this procedure requires strict immobilization in a sling with no active motion of the shoulder for four to six weeks. However, Dr. Balyk often observed the “cheaters” — those who didn’t wear their slings as instructed — did, indeed, prosper.
“The obvious benefit to early mobilization is that patients can return to activities of daily living and work more quickly,” says Dr. Sheps, who is also facility medical director at the Sturgeon Community Hospital in St. Albert.
“This can also have an economic impact, as patients who undergo mini-open rotator cuff surgery are often of working age, and a quicker return to activity and work may mean an earlier return to productivity.”
In total, 189 patients, recruited by seven regional shoulder surgeons, contributed to the study after undergoing the procedure at the Grey Nuns or the Sturgeon.
Patients were then, at random, given early mobilization or standard rehabilitation. Progress was assessed at six weeks and again at three, six, 12 and 24 months.
At the six-week assessment, patients who began early active motion showed significantly better range of motion than those who wore their slings for six weeks. That difference disappeared at the three-month assessment, as the group that wore their slings caught up to the early mobilization group. No differences between groups were seen at six or 12 months, and by 24 months the final outcomes were the same in both groups.
Early mobilization did not result in any long-term complications, including no differences in healing or re-tear rates — the surgeons’ biggest concern.
“Although the final outcome was the same in both groups, recovery was quicker in the early mobilization group,” says Dr. Sheps. “Since the final outcome was not negatively impacted by early active motion, it may make sense to allow patients to remove their slings sooner.”
The research has garnered attention both in Canada and internationally. At the annual meeting of the American Academy of Orthopedic Surgeons last year in Las Vegas, it was chosen from among hundreds of studies as one of 15 papers most likely to change clinical practice in the next two to three years. A second phase of research is now underway with patients who receive purely arthroscopic rotator cuff repairs — as opposed to the mini-open surgery patients.
“Rotator cuff disease is very common to the population in general,” says orthopedic surgeon Dr. Marty Bouliane, also a study co-author and assistant clinical professor in the Faculty of Medicine & Dentistry at the U of A. “Half of people 70 or older will have a rotator cuff tear.”
Tears can occur as a result of aging, genetics, activity and injury — and many people will have no pain or symptoms at all. Typically, physiotherapy is prescribed to manage the condition. But if rehab fails and pain persists — or in cases of sudden traumatic injury — surgery is performed.
In the AHS Edmonton Zone, more than 1,000 rotator cuff surgeries are performed each year, primarily at Grey Nuns Community Hospital (Covenant Health) in Mill Woods, Sturgeon Community Hospital in St. Albert and Leduc Community Hospital in Leduc.
Funders for this rotator cuff research include M.S.I. Foundation ($50,000); Workers’ Compensation Board – Alberta ($30,000); Arthroscopy Association of North America ($25,000); and Edmonton Civic Employees Charitable Assistance Fund ($10,000).