Irrepairable tears - and how to fix them!

Irrepairable tears - and how to fix them!

Much is written about the problem of irrepairable rotator cuff tears, particularly with young and active patients. However, what is less clear is what makes a tear irreparable.

As with a car, have a smash and one auto-shop will say it's beyond repair, whereas another might have a way of economically fixing the damage to where you have a usable vehicle again.

Having retorn my rotator cuff in the same shoulder more than once, I have been told by some surgeons that what I have is irreparable, so this motivated me to understand why. Turns out it's not simple.

The classic definition of an irreparable rotator cuff tear is a tear that is large enough that the muscle has actually retracted and can no longer be pulled or stretched close enough to the bone to anchor it back down again. Typically, this means that:
    - The tendon on the end of the muscle is either withered, scarrey or there is little of it there
    - The muscle is weakened and atrophied with fatty infiltration
    - There is a gap of 3cm or more between the remaining tendon ends and their origin on the bone
   
The Boston Shoulder Institute decribe this here: http://bostonshoulderinstitute.com/patient-resources/modules/irreparable-rotator-cuff-tears/

The thinking here is that the tendon is of insufficient quality to effect a repair that would heal - and even if it could be reattached and it did heal, the muscle is unlikely to be able to contract powerfully enough to stabilise the glenohumeral joint. So we leave it alone.

However, what if the patient is 30 years old, has suffered a traumatic injury, torn their rotator cuff to 3cm or more and has been in this condition for long enough for muscle atrophy to begin? Do we wright them off as irreparable? Some surgeons do, but at 30 years of age, options are limited.

The last resort for these kinds of tears is a reverse shoulder replacement in which the ball and socket is switched for a socket and ball and the rotator cuff is done away with - the deltoid does all the work. Given the life span of a replacement like this is about 15 years, this doesn't present a great outlook for our younger, active patient. Reverse shoulder replacements are indicated for the older population of 70 years or more and are not without their own unique issues and complications i.e. they are not well suited to the younger active patient

It is this particular group of patients that may benifit from an allograft (such as GraftJacket) used as an interposition graft.

An interposition graft is one where the graft or patch is used to bridge a gap or hole in the rotator cuff tendon, effectively replacing tendon tissue that is not there anymore. This is in contrast to the augmentation approach which is where the graft is placed over a conventional repair in order to reinforce it and help it heal. The interposition approach is only used when the existing cuff cannot be bought back to it's original footprint on the bone without undue tension, which would cause imbalance in the cuff.

A few surgeons are doing interposition grafts on shoulders in the UK - four of them in Leicester and one in Cambridge. There are a few more doing this in the United States and in other countries, but when looking for a surgeon who is doing this, it is important to ask whether they have performed these repairs using the interposition approach, because not all do; some will only have experience of the augmentation style of graft repair.

Retears - what to do

Given the relatively high incidence of rotator cuff retear among patients of repair surgery, little seems to be written about how you might tell if you've retorn it and what to do. I have seen this article a number of times as it crops up on medical websites and has even been used here in the UK by our NHS as an advice leaflet; however, it seems to contain no information of any use - not to me at least. So, if I may, here are some of my experiences of dealing with retears. I have retorn my repaired rotator cuff more than once and now have an intact repair. Here's how I got there.

What is a Retear?

Simply put, a retear of the rotator cuff is where an attempted repair has failed. You have to have had a tear repaired before you can have a retear, so if you've not had a repair, you can't retear. Sorry if this sounds obvious, but this question has cropped up a couple of times!

Types of retear

Much is written about how the rotator cuff gets torn in the first place (trauma, wear and tear etc), however, much less is written about how tears fail. There are two points at which a repair can fail - pre-healing and post-healing.

Pre-healing: Usually in the first 6-8 weeks from surgery. The repair can fail during this time if the repair construct fails - this includes:
    - Tendon pulls through the suture (the most common cause)
    - Anchor pull-out from bone (rare, but happens)
    - Suture failure (rarer still)
   
Post-healing: Any failure or retear after the 8 week mark is almost definitely due to a failure of the bone-to-tendon healing - includes:
    - Mechanical failure of the healed bone/tendon interface
    - Failure of the bone to heal to the tendon (less common and more likely to result in a pre-healing failure anyway)
   
Causes:
- Using the joint too early
- Bone/tendon have not healed
- Further trauma - e.g. a fall or impact to the joint

Indications of retear:
- A sudden sound (pop/click) in the joint
- Sudden onset of pain
- Return of familiar pain
- Clunking or clicking that is easy to replicate with certain movements.
- Loss of movement

This is to say then, if you've had a rotator cuff repair and you're doing well at three months post-op, then you raise your arm and suddenly feel a click in your shoulder, followed by a return of familiar pain which is accompanied by a repeatable clunk and a loss of movement, then you have probably retorn your rotator cuff. The more of these indications that are present, the more likely a retear.

Red-herrings i.e. things that are very unlikely to indicate a retear on their own:
- Pop or click with no pain - probably just some adhesive scar tissue giving way.
- Sudden onset of pain that comes and goes for a while - probably part of the healing process

Coming to terms with a retear

If you've suffered an injury to your shoulder, undergone a rotator cuff repair and begun the rehab, then the prospect of repeating this experience can be nothing short of harrowing. We all respond differently in these situations: some are optimistic and hope for the best, some are pessimistic and fear the worst. If like me, you are a combination of both of these, you'll want to get answers so you can plan what to do next. The only way to do this is to get it rescanned, either by ultrasound or MRI.

Rescanning after surgery:
Because of the cost of scans, some surgeons don't like to authorise them until many months after surgery, which can be very frustrating if you're worried that you may've retorn your repair. Unfortunately, scans are less reliable after surgery due to residual swelling, fluid and scarring. It is fairly pointless to request a scan prior to three months after surgery as the scan really won't show much and no surgeon will take it seriously. This means, even if you think you retore your shoulder at two weeks post-op, you will have to wait until three-months before an MRI or ultrasound is viable -- sorry about that!

So if you're at 3 months post surgery and your surgeon won't authorise an MRI, what do you do? Well, in my case I got my Osteopath to refer me for an MRI that I paid for myself. In the UK an Osteopath, Chiropractor or your GP/Family Doctor can refer you for a private MRI - only your GP or surgeon can refer you for an MRI on the NHS and they may or may not be willing to do this.

Following your MRI Scan:
When you've had your scan done, my advice is to get hold of a CD of the images and the radiologist report. The images are useless without the report. If the scan was done privately, you should be given a CD of images and the report should be made available to you via the person that referred you for the scan. Get a copy of the report as soon as you can because, as you will see from the following story, you may have to take these to a different surgeon.

My story

Having retorn my repaired rotator cuff more than once, the most typical response I have got from my surgeon when I have first raised this is, no you haven't. Even with an MRI that shows a tear, many surgeons will claim that MRIs after surgery are misleading and you're probably fine. This has happened to me more than once and each time I was proved right and they were proved wrong. The only solution I have found is to go to someone else - no really; for some reason they don't want to accept that their excellent work has somehow failed.

Finding another surgeon:
There really is no straightforward guide to finding the next surgeon. All surgeons are not made equal and each one has their own special thing they do, their own set of preferred methods and their own particular attitude towards your case. This is based on the experience of seeing at least twenty UK shoulder surgeons - a few of whom have gone on to operate on me!

The truth about revision rotator cuff repair:
If you have retorn your cuff, the chances are it will be be harder to repair again. This is because:
    - Your cuff tissue is likely to be of poorer quality
    - The tear is likely to be bigger
    - The presence of anchors in the bone can make the positioning of new anchors more difficult - you can't reuse old anchors.
   
Having seen a number of surgeons and had my cuff repair re-done (revised) more than once, there is one piece of advice that drops out that I would share with anyone looking for a new surgeon and that is:

- If your rotator cuff repair has failed and the surgeon is proposing that they repair it using the same or similar technique as was tried before, then there is no reason to expect a better outcome.

I went through a stage of making sure the next surgeon was the 'best' guy and that his reputation was better so therefore he must be a better surgeon so his repairs must just be better etc. This turned out to be b*llsh*t every single time and I simply ended up suffering the arrogance of some of the UK's biggest rock-star shoulder surgeons; none of whom I'd recommend by the way. Reputation and ability are rarely proportional, in my experience.

Knowing I had limited options, I began researching repair techniques themselves and learning who was doing what. This led me to research the use of allograft patches, in particular a product called GraftJacket. I had a repair with this patch five weeks ago and so far so good. However, finding this surgeon was a long road and whilst I could find plenty of surgeons who had done GraftJacket repairs before, I couldn't find anyone who would do it on me. The reason, it turns out, was because most of these surgeons had done a handful of repairs on a few cases so were unsure if it would help me. I learned this when I went to see one of the first surgeons to do these repairs in the UK, who by this time had between 100 and 200 operations to reflect on. Fortunately for me, he agreed to surgery.

Post surgical pain...and what to do about it.

Hi, week four here and things are still chugging along. I'm still doing passive exercises and I'm still wearing the sling for most of the time. There is still pain which hasn't changed a lot in the last week. Mostly this is due to getting a little bit more range each day so things are changing inside and as I said before, each new thing for the first time hurts a bit - sounds like a song title dunnit?!

 

Causes of Pain following Shoulder Surgery:

Like a lot of folks who have had shoulder surgery, I've spent many moments (too many) trying to figure out what's hurting and why so that I might be able to make it better. So as nothing much has changed with my recovery this week, I thought I'd share some of my ideas and research into these causes of pain. I am not a doctor, by the way. You're mileage may vary, the value of your investment may go down as well as up etc etc.

1. Incisions: These things hurt - even the little arthroscopic ones. Having had both arthroscopic and open surgery - and combinations of the two - my experience is that they all hurt. The medical profession sells us the benefits of arthoscopy (keyhole) as faster recovery, less scarring, but it's more complex than that. Arthroscopy carries lower risk of infection, less blood loss and less risk of the wound opening back up after surgery. Open surgery is typically one large incision whereas with Arthoscopy, between two and five separate incisions are made - that's up to five separate points of pain. The rise in the use of Arthroscopy has meant surgeons can visualise, diagnose and treat many more conditions than they could before - but I would still wager someone with five arthroscopic incisions has more pain than someone with two. Even when the incisions appear to be 'healing nicely' there is still the disruption to the deltoid muscle beneath and this can still cause some pain for two or three months.

How to minimise this pain: Gentle massage of the healed incisions (usually 3 weeks onwards) helps to break down and soften the scar tissue that forms beneath. Do this a couple of times a day for about 6 weeks - remember to wash hands first! Don't massage an incision that is bleeding, weeping or very painful to the touch otherwise you may introduce an infection or cause damage.

Open	Arthroscopic

2. Busa Removal: The soft lubricating sack that sits between the rotator cuff and the deltoid and allows these opposing surfaces to move smoothly against each other. The bursa is nearly always inflamed and scarred when a rotator cuff tear or sub-acromial impingement is present. The surgeon will remove most or all of it during surgery, however it grows back within about three months. I'm sure this hurts, although there is little research to back up this idea. Consider also that the deltoid (with incisions in it) and the rotator cuff (with sutures and anchors it) are now touching without the bursa to keep them apart, so there's bound to be some pain from this in the early stages of rehab.

How to minimise: This is pain that has to be worked through. Begin passive movements as early as you are allowed. Ask your physio about stretches to restore range of motion and stick to the program. Regular movement will encourage the regrowing bursa to find it's way back to where it needs to be.

3. Healing of the Repaired Tendon: Repairing a tendon back down to bone involves passing sutures (stitches) through the tendon that are fixed into the bone either with anchors or holes drilled into the bone. The bone is also abraded down to make it bleed slightly which promotes healing. In some cases, small holes are made in the bone (microfracture) where the tendon fixes down which promotes the release of bone-marrow which also promotes healing. All of this disruption to tissue and bone causes a healing response which results in pain and inflammation. This improves as the tissue and bone heal, but given the slow healing of rotator cuff tendons, this may take many months.

How to minimise: There is little one can do to minimise this pain, other than to follow the recovery protocol set by the surgeon to give the best chance of good healing. Generally this involves immobilisation for 3 to 4 weeks, followed by passive exercises to restore ROM, followed by active movement at around 6 weeks to restore function, with strength rehab beginning at around 10-12 weeks.

4. Capsular Tightness: Beneath the rotator cuff there is a capsule of ligament tissue surrounding the ball and socket joint. This helps stabilise the joint, but it can cause problems if the shoulder is kept immobile for a long time as the capsule can shrink. This results in a tight shoulder that is difficult and painful to mobilise. Some people with limited ROM at three months following surgery are told they have a frozen shoulder. This is because a frozen shoulder is caused by a tight and inflamed capsule, so the cause and symptoms are almost identical. However, even if you are able to coax your ROM back, you will still go through a period of stretching the capsule and this can be quite painful. I've encountered this myself as a deep aching that seems to lessen considerably once full range has been established.

How to minimise: Again, this is pain that has to be worked through. Begin passive movements as early as you are allowed. Regular stretching without undue force is key. Forceful stretching is likely to aggravate this pain and is never recommended prior to ten weeks post-surgery anyway.

5. Scar Tissue and Adhesions: As the soft tissue in the shoulder heals and recovers, it forms scar tissue, much in the same way as an old cut or burn may be visible on your skin. If you are immobile (in a sling) for a long time, the risk of some of these bits of scar sticking together (adhesions) increases. If they are allowed to establish, these adhesions can restrict range of motion - a condition known as captured shoulder; I have had this myself. In captured shoulder the bursa gets stuck to the healing cuff and literally gets dragged around inside the shoulder as you move, becoming inflammed and painful in the process. Adhesions that don't resolve with physiotherapy can be removed during an arthroscopic debridement, which usually works well. However, in the early stages of recovery you will always get a few adhesions which you can hear snapping and popping as they resolve; which is a good thing, as long as they continue to break up.

How to minimise: Pain from adhesions and scar is less obvious and can suddenly onset (and resolve) with certain movements. Very often you can feel adhesions break as you stretch (snap/pop) and they are followed by a sense of relief. Maintaining a good range of ROM as early as possible helps to stay on top of the formation of these bits of adhesive scar.

Brief Article describing Captured Shoulder: https://www.ncbi.nlm.nih.gov/pubmed/8864004


6. Trigger Points: Sometimes called muscle knots, these are painful little points of tension in a muscle or tendon. They can usually be resolved by applying pressure through the skin, either with the sharp point of a finger or by lying on a tennis ball, or better still, a lacrosse ball - but it is best to wait until you're out of the sling before trying this. An operated shoulder can be prone to these knots as the muscles suddenly find themselves unstretched for long periods or when certain muscles have to compensate for others. The infraspinatus muscle in the shoulder can be particularly prone to trigger points as it compensates for a torn or weakened supraspinatus. Sometimes these trigger points can be difficult to treat, especially if they are chronic or in muscles that are difficult to reach through the skin, such as the supraspinatus and the subscapularis. Dry needling or acupuncture is particularly effective at reaching these painful trigger points and I would recommend seeking the help of a chiropractor or osteopath who practises these techniques.

How to minimise: Ask your therapist about treating trigger points with a ball. There are numerous YouTube videos on this, but seek professional advice to avoid hurting yourself and wait until you're out of the sling.

 
In conclusion: I guess the mantra here is 'keep moving'. The longer a shoulder is immobilised, the harder it is to get it moving later. I have read a number of stories of surgeons who insist on keeping some patients immobilised for 8 or 9 weeks following rotator cuff repair. Their reasons for this are usually to do with poor tissue quality found at the time of surgery. However, the pulling and stretching required to get a shoulder moving after 8 weeks of immobilisation exposes a repair of poor quality tissue to even more risk of retear; as has been my own personal experience. Using an allograft to augment such repairs means the patient can mobilise their shoulder earlier with a better chance of a successful rehabilitation. If your surgeon doesn't do this kind of procedure, find one that does.

This post is bought to you by the letter 'P'

Hello again. Today is Wednesday 26th April 2017, three weeks since my rotator cuff repair with GraftJacket. I'm tending to post weekly at the moment as each week I'm permitted to add something else to my list of rehab movements, so that gives me something to write about.

I'm still wearing the sling most of the time, removing it to shower and dress and of course, do my limited exercises. Last week I started doing pendulums, a couple of days ago I added the pulley to my routine, plus I am now able to do some passive movements - so I guess this post is bought to you by the letter 'P'.

P is for:

- Pendulums - I spoke about these in my last post. They are sometimes referred to as Codman exercises, after the surgeon Ernest  Codman who was the first surgeon to perform a repair of the rotator cuff and one of the pioneers of modern methods of outcome monitoring using data gathered from real patients. You can read all about the man and his work here.

 

- Pulley - I cannot recommend an exercise pulley enough for helping to regain range of motion in the early stages. A simple exercise pulley costs little and provides and almost completely passive way to raise and lower the arm through it's main arc of movement. It's not really effective for rotational range, but for abduction (out to the side) and flexion (out to the front), it is highly effective.

- Passive - I am using passive movement to gently push my external and to a lesser extent, my internal rotation. I lie on my back with my elbow at 90degs, rested on a cushion near to my side. I grasp my wrist (or you can use a stick as in the picture) and gently rock it to invoke internal and external rotation of the shoulder. As this is only 3 weeks since surgery, little or no force is used and we stop at pain. Doing this 4 or 5 times a day, I'm seeing small improvements in range each time.

So that's all good stuff. I'm not getting any clicking or unduely painful sensations, although there is still some residual pain from the surgery and it doesn't feel strong nor normal - it's early. However, there are some things we should avoid:

Cross-body movements - stretching the arm accross the body (e.g. scratching the opposite shoulder) is out until at least 6 weeks. This is becasue the supraspinatus (and infraspinatus) is stretched to it's limit by cross-body movement.

Full rotation - whilst I'm getting some rotation back, forcing full external or internal rotation is ill advised as it stretches the deltoid and rotator cuff. Internal rotation is particularly risky early on and I'm waiting until 6 weeks before exploring this to any extent.

A word on progress:
For some people reading this, the progress I'm making may seem fast, to some it may seem slow. If you have had a similar procedure and you are worried about your progress, please do not compare yourself with what you read here as we are all different. I would say the GraftJacket implant allows for a robust-enough repair to begin gentle penulums and to start increasing ROM at 2-3 weeks. Some surgeons still allow this with conventional repairs, especially where a double-row fixation like a speed-bridge has been used, but this is not always the case. It is true that the earlier movement can begin, the less stiffness is likely to persist and the quicker full movement will return. However, you may be kept immobilised by your surgeon for longer and for good reason. Listen to them and follow your protocol, as I am doing.

Incisions, incisions

Today is two weeks and one day from surgery and things are still going ok I guess!

I reported in my last post that the allograft felt pretty comfortable and I wasn't aware of anything scratching or scaping around inside. Not that I would as I'm immoblised in a sling (!!) but I can't say I can feel this thing.

During the last couple of days my rehab plan has permitted me to start some gentle pedulum exercises 3 or 4 times a day. These are simple exercises to mobilise the joint without causing the muscles to fire significantly. The joint feels very smooth with no clicks or bumps and no snapping or popping.

These exercises have felt ok although the first time I did them I did get a few twindges, as one might expect. However, having been though these recoveries before, I am acutely aware that every new thing you do for the first time since surgery HURTS....and can hurt for a while afterwards.

Most of the pain is around the incisions and this makes senese if you consider the healing that's going on around them. I have two arthroscopic and one open incision. They still feel a bit tender and moving the joint feels like it's aggravating the tender tissue around them. Still, this is not a bad thing. staying completely immobile for six weeks would result in adhesions and scar formation that would be even more painful to break up when you first move it, so there's no avoiding the initial pain.

At least that 'old' pain from when my rotator cuff was torn is absent.

What does this thing feel like?

Today is day 7 from surgery and I feel this is probably the first day where I can offer some kind of idea of what the GraftJacket in my shoulder feels like; now that some of the latent pain of the surgical incisions is beginning to abate.

This is not to say I can 'feel' it as such. I don't have a sense that any 'thing' is there - not at the moment anyway - but I do get a sense that the joint feels more solid and connected than it did. It aches, but the pain is very different from what I had before - plus it's changing as it's healing. I've spoken with a few people who've had these kinds of graft operations. Some of them have been out of a sling within a week and encouraged to start using their arm quite quickly. I'm in a sling for six weeks - so what's different here?

My particular operation was perfomed 'fully' open. This means splitting the fibres of the deltoid and detatching some of them from the acromion - like lifting the cylinder head off an engine - to gain access to the medial (inner) portion of the rotator cuff. The deltoid is reattached and closed afterwards and has to heal in the same way the repaired rotator-cuff has to. So, early mobilisation of the joint is not really an option here. Some of the other people I spoke with had this done without deltoid detachment, but my procedure required it because my cuff defect started much further into the medial cuff tendon - where it meets the muscle. So what can I look forward to? Well, I'm hoping that the solidity of the cuff repair means that I will progress more quickly than with a conventional repair, once I'm out of the sling. I can start pendulums at two weeks, passive exercises at three, then fully active from six. Strengenting will probably start after week eight - with conventional cuff repair, this is normally around week twelve. I can't say whether the deltoid detatchment will complicate things - one hopes not, but the human body can be very mysterious!

Day 6

Day 6. A little residual bruising lower down the arm which is, from what I've read, normal and due to blood escaping from the surgery site under gravity. This was open surgery (with arthroscopic examination and debridement first) so to be expected really. Pain has improved somewhat in the last couple of days. Still taking meds at night. Changing these breathable dressings daily, till the weekend (day 10) I reckon. Confined to the sling most of the time. Following a simple daily routine that includes: Change the sling each day after showering - I have two slings and don't remove it for showering. Lie flat on back, loosen sling and flex the elbow with my other hand holding my forearm - about four times a day Gentle shoulder-shrug exercises - 3 or 4 times a day

Surgery Done

Ok, so the procedure was yesterday; Weds 5th April 2017. All seems to have gone to plan. I have a GraftJacket implated in my right shoulder. Sling for the next six weeks.

The surgeon identified a medial tear extending down toward the footprint of the supraspinatus. This has been closed and the GraftJacket applied over the entire tendon, including the margin of the infraspinatus. The GraftJacket is held in place with sutures in bone-tunnels, as opposed to anchors. The procedure was done open with deltoid detatchment and subsequent reattachment - major work.

Pain is under control, but I definitely feel it!! The nerve-block has now worn off and I am taking regualar pain medication including paracetemol, codene and naproxen.

Didn't sleep much in the hospital last night. This is my first night back in my own bed. Should be fun!

I hope to be off the pain meds within the next two days - so tomorrow is Friday and I hope Saturday will be the last day I need them.

What is an Allograft?

In my previous posts, I have mentioned something called an Allograft. It's a piece of donated human skin tissue. It's treated, dried and packaged and is rehydrated at the time of surgery. Think instant freeze-dried skin - no, really.

Who cares? Well, you might do if you've torn your achilles tendon, suffered major skin trauma (like burns) or you have a chronic or massive rotator cuff tear in your shoulder that is difficult to repair. Surgeons have been trialling different tissue grafts for many years. Skin grafts are nothing new, but their applications in tendon repair are newer. Injuries like achilles rupture and rotator-cuff tear - that are always dificult to recover from due to poor healing - are now more readily treatable with the augmentation of the tendon using a tissue graft. Note the word 'augmentation'.

If you're a shoulder patient and you are reading this, then you may be one of the many people with a massive or irrepairable rotator-cuff tear. For you, an 'augmentation' is impossible, because, if your tendon cannot be repaired, the repair cannot be augmented. Fortunately, in recent years, surgeons have been begun to treat these kinds of tears by using an allograft as an 'interposition' graft. This means using the graft to replace the missing tendon tissue, effectively bridging the defect between what is left of the tendon and it's attatchment site on the bone.

There is a big difference between augmentation and interposition grafting, in particular, the surgical complexity and patient eligability. There are many fewer surgeons doing interpositions than there are doing augmentations. In the UK, after a 12 month search to find someone who could do this procedure - including at least six consultations with different surgeons - I discovered the number of surgeons doing interposition allograft surgery in the UK was roughly distributed as follows:

   - London - 0
   - Cambridge - 1
   - Leicester - 4

That's right, no one in London. No one I saw in London knew of anyone doing this kind of operation in London! There maybe others in places like Birmingham, Manchester or Edinburgh, but as I live in the south-east of of the UK, my search did not cover these areas.

Anyway, if you've read this far, you may be interested in this article published by the team from Leicester. It describes the interposition procedure, outcomes and recovery protocol.

Note: if you are from outside the UK, interposition grafts are being performed in the US, Europe and other continents. I would recommend a thorough Google search including the words "Shoulder Allograft Interposition".

Two days until surgey

Today is a Monday and on Wednesday I travel to Leicester for surgery to repair the chronically torn rotator-cuff in my right-shoulder. This should be a repair with an allograft - as mentioned in my first post.

This is not the first rotator-cuff repair I have endured - in fact, it's not my second either. Since 2009, I have endured numerous shoulder operations, some painful but effective, some just painful!

As I write, I am comtemplating another six weeks in a sling, which means:
   - Pain
   - No driving
   - Boredom
   - Lack of sleep
   - Limitation to daily tasks like cooking (which I enjoy) and showering/bathing
   - Little or no exercise, other than walks I must force myself to take
   - No work (see boredom above)

At least the weather's getting better here in the UK - it's the start of spring.

I've spent the last ten days running around like a mad chicken getting "things done". There's nothing like six weeks of being laid up to focus the mind on one's to-do list:
   - Attend to a rat infestation in my loft/attic (great timing there rats)
   - Install a new shower
   - Jet wash the patio
   - Re-seed the lawn
   - Oil the wooden floor and deep-clean the carpets
   - Prepare enough frozen meals for a space mission to Mars!

The thought of having none of these things left to do and not knowing when I will have the energy or enthusiasm for any of them again of kind of scary.





 

Hello,

My name is Nick and I used to do all sorts of crazy things - including Hang Gliding.

I never used to worry about my body letting me down and I enjoyed the stimualtion of an active life, until the age of 36 when I crashed my hang glider and dislocated my right shoulder. That was in 2009.

Now in 2017 I still suffer the effects of that injury, in that my shoulder still casues me a lot of problems - pain, sleep issues, lack of enthusiasm for activity and all of the phycological stress that comes with that.

I have had a number of surgical procedures since 2009, mostly to attempt to repair my reptator cuff tendons that were damaged in the accident. If you don't know what the rotator cuff is, you can read all about it here.

Rotator cuff repair surgery has a bit of an unfortunate reputation in that is is very painful and often fails (retears). This has been my experience! Once a repaired tendon has retorn, it becomes harder to re-repair due to scarring and tissue degradation. There are likely to be many thousands of people in the UK living with irrepairable rotator-cuff repairs that are either too large to repair or have been repaired previously and subesquently retorn. The reality for these people - especially among the younger and more active - is unpleasant to say the least. I am one of them.

This blog is about my attempt to overcome this enormous challenge, against seemingly insurmountable odds. Medical science has kept moving since my accident in 2009 and there is now - in 2017 - a treatment for this group of people in form of an allograft. An allograft is a piece of human derived skin tissue from a donor (cadaver) with all of it's DNA removed to avoid rejection. This can be used to bridge holes, defects and tears in tendons like the rotator cuff (and achilles) to repair and restore function whilst integrating with the host tissue. The name of the allograft product I am to receive is called GraftJacket.