Duke Shoulder Section Investigating Novel Surgical Therapies

Stemless shoulder replacement, rotator cuff injuries are research targets

Duke Health orthopaedic surgeons are playing a significant role in a national clinical investigation of a stemless reverse shoulder replacement technique that requires significantly less bone resection than traditional shoulder procedures. 

The trial is one of several clinical trials involving the shoulder section surgical team. A study of rotator cuff deterioration is another focus point, and a related investigation explored mental health conditions and outcomes associated with rotator cuff surgery. In addition, other surgeons are participating in a multicenter trial investigating the most effective therapies for shoulder instability. 

The stemless reverse procedure offers total primary shoulder joint replacement and reduces pain while restoring shoulder mobility. Patients with joint dysfunction who continue to experience symptoms after nonoperative therapies are candidates for the procedure. 

The Duke shoulder section is a high-volume orthopaedic surgical team with specialized clinicians who perform complex procedures, including shoulder stabilizing operations, procedures for rotator cuff tears (primary repairs, superior capsule reconstructions, tendon transfers, and reverse shoulder replacements), shoulder replacements for primary osteoarthritis, and repairs of clavicle fractures and acromioclavicular joint separations. 

Illustration of torn rotator cuff
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Stemless reverse shoulder replacement

The fully enrolled trial, which has been underway for two years, is directed by Oke A. Anakwenze, MD, MBA, orthopaedic surgeon and head of the Duke Shoulder Section, and Tally E. Lassiter Jr., MD, MHA, sports medicine orthopaedic surgeon. Anakwenze is the study’s principal investigator. Duke is a leading enroller in this prospective, multicenter, randomized controlled trial.

"This surgical technique can be completed in a shorter operative time with less patient pain,” Anakwenze says. "There’s also less involvement of the humerus. This also allows surgeons to perform this procedure on patients with deformities of the humerus."

Rotator cuff fatty atrophy

Another basic science investigation at Duke is assessing potential solutions for fatty atrophy of the rotator cuff tendon following injury. Fatty degeneration is characterized by atrophy of muscle fibers, fibrosis, and fatty accumulation within and around the muscles. The process is progressive, Anakwenze says, and can lead to failure of rotator cuff repair surgery.

Duke orthopaedic surgeons are studying the properties of rotator cuff injuries to determine why some tears do not heal, says Anakwenze. The team is looking at molecular responses in rotator cuff injuries with the goals of understanding the process that contributes to fatty atrophy, identifying patients at the greatest risk, and understanding how to prevent the process.

Developing a new therapeutic approach to muscle and tendon degeneration, Anakwenze says, could be broadly applied to many musculoskeletal injuries. 

Mental health outcomes and rotator cuff surgery

Jocelyn Ross Wittstein, MD, orthopaedic and sports medicine surgeon, has examined the effects of anxiety and depression on outcomes of rotator cuff repair surgery.

As senior author of a study analyzing mental health and rotator cuff repair, Wittstein reports that patients with anxiety and depression related to their shoulder condition may be ideal candidates for arthroscopic rotator cuff repair because of they benefit most from the procedure.

Patients with shoulder-specific anxiety or depression report lower scores for shoulder function preoperatively, Wittstein says, but, two years after surgery, these same patients reported the most net improvement in shoulder function. Patients with anxiety and depression unrelated to the shoulder condition reported slightly worse outcomes scores before and after the procedure but experienced the same net improvements as patients without depression or anxiety. 

"One important finding from that research was that it’s always important to counsel patients to ensure they understand their overall condition, expected outcomes, and potential benefits of surgery," says Wittstein. 

Women’s orthopaedic health is an emerging focus within the shoulder section because of the effects of the production of estrogen as women age. Fracture risk increases among older women, Wittstein says, while bone density declines. Women also experience more joint stiffness and inflammation as they age, she adds.