Uncommon Procedures

This is an uncommon shoulder injury seen predominantly in men. It usually occurs during weightlifting although occasionally can happen in football and mixed-martial arts.  It occurs as a sudden pain across the front of the shoulder and chest usually when unsuccessfully trying to bench-press either an unusually heavy weight (“maxing out”) or with a high-intensity to-failure regimen.

These injuries are commonly missed even on MRI, so if you feel you’ve sustained such an injury, it is important to see a specialist quickly. Loss of pectoralis strength will happen on a permanent basis unless these injuries are repaired.  While these injuries can be surgically corrected in chronic situations, the outcomes are generally better if these are repaired within the first 4 weeks.  Surgical repair is performed as an outpatient surgery and requires the use of a sling for the first 4 weeks after surgery.

This is an injury MCO physicians see regularly as they are frequently asked to see these unusual injuries by other surgeons and they have significant expertise in their treatment and repair.

While reverse shoulder replacement is a very successful procedure for patients with irreparable rotator cuff damage, transfers of the Latissimus and Teres Major tendons are classic procedures for this problem and are still occasionally needed when severe rotator cuff disorders occur in patients too young for a shoulder replacement.  Dr. Bak is one of only several surgeons in the state who has performed this procedure and still utilizes it successfully in select patients in place of allograft (donor) tissue or shoulder replacement.  

In some of his most complex patients, Dr. Bak will perform this in conjunction with a shoulder replacement to optimize the performance of the new joint.

This is a novel technique used for more complex cases of shoulder instability or dislocation.  Typical shoulder dislocations cause damage and tearing of the labrum and shoulder ligaments, however, more complex or repeated dislocations can cause “denting” of the humeral head (ball).  If this dent is significant and not treated, shoulder instability can occur again even after a traditional repair.  

Remplissage is an arthroscopic procedure by which a portion of the rotator cuff tendon is shifted into the dent to prevent it from dislocating.  There is no significant difference in pain or recovery with this technique as opposed to a traditional labral repair but there is a significant increase in the success rate of this procedure in the presence of a dent in the humeral head.  It’s imperative that this be recognized and treated at the time of surgery.  Drs. Silas, Bak and Frush have years of experience in evaluating and appropriately treating this type of shoulder instability.

This is a surgical technique pioneered in Europe for severe cases of shoulder instability.  Routine shoulder instability usually involves damage to the soft tissue structures of the shoulder—ligaments and labrum; these injuries can usually be successfully corrected with a routine arthroscopic surgery.  More complex shoulder instability typically comes about due to chronic and repetitive dislocation or severe trauma in which soft tissue and bone are both damaged.  In these situations, addressing only the soft-tissue injury carries a significant risk of failure.  

The recommended treatment for such patients is a bone transplant from the patient’s own scapula to the shoulder socket in addition to repair of the ligaments.  While this is considered a technically difficult procedure, Dr. Bak is highly experienced in Latarjet corrections as well as the more standard soft-tissue repair.  Indeed many surgeons who do not perform this refer these cases to him as he has developed a specialized technique for bone transplant using solid steel screws which are less likely to fail than the hollow screws commonly used in most Latarjet procedures. Dr. Bak is also one of the few surgeons in the country doing these procedures arthroscopically.

Typically, unstable shoulders are a result of a traumatic tear of the labrum off the shoulder socket.  HAGL (Humeral attachment of the glenohumeral ligaments) lesions refer to a rarel pattern of shoulder instability in which the labrum remains attached to the socket and the ligaments actually tear directly under the ball. These types of injuries can be missed by the untrained eye both on MRI and intraoperatively. Failure to recognize this means failure to correct and, ultimately, failed treatment.  

Surgical repair of these injuries is surgically delicate as the primary nerve to the shoulder can be at risk and, therefore, it has been recommended these be repaired through a more traditional, open incision.  Dr. Bak has successfully treated many of these injuries through the open approach and, more recently, through a novel, arthroscopic repair technique in which the nerve is identified and protected during the repair process.  While the repair technique differs dramatically from a standard repair, the recovery and success of this procedure is nearly identical to a standard shoulder instability repair.

For severe cases of shoulder instability in which the socket and/or the ball exhibit severe loss of bone, a transplant is performed to reconstruct that portion of the joint.  This is also a procedure we consider for patients who have been sent to us for a failed Latarjet procedure.  The distal tibia (ankle bone) has been found to have a contour identical to the shoulder socket.   A fresh matched donor tibia is transplanted into the corresponding deficiency of our patient’s glenoid.  

These procedures need to be scheduled within a short window as they require a size-matched donor to be available and these donor grafts have a narrow window in which they may be transplanted.  As such, we take a team approach in which one of our surgeons prepares the graft tissue and uses precision machine cuts to form it perfectly to the patient’s anatomy while Dr. Bak prepares the patient’s shoulder for implantation. 

Dr. Bak has performed multiple glenoid allografts with his modification using solid-core screws to enhance stability and healing. He is one of the few surgeons in the Midwest to have successfully applied this also for the less common posterior shoulder instability.

This procedure uses donor tissue (most commonly human dermis) to substitute for the rotator cuff in a patient with such severe shoulder disease that the rotator cuff is not reconstructable. For some patients, the best option may be a reverse shoulder replacement.  In young patients, the superior capsular reconstruction is an alternative by which donor tissue is used to reconstitute the deficiencies in the rotator cuff.  This is an outpatient procedure, done arthroscopically with a similar recovery process to rotator cuff repair.  Drs. Silas and Bak have extensive experience with this procedure.

The latissimus (“Lat”) is the powerful, large muscle connecting the arm to the thorax and largely responsible for the appearance of shoulder width.  It is uncommonly injured, most frequently seen in our elite pitchers and bodybuiliders.  It is often a neglected diagnosis but common signs are a pop in the upper arm and bruising along the inside of the arm and the upper ribcage.  

Surgical repair is recommended for return to previous level of performance and strength recovery.  This is done via 2 incisions, one in the axilla (armpit) and along the inner arm.  We do this typically as an outpatient procedure and it requires sling immoblilization for 4 wks followed by several months of physical therapy.  Return to high-level weight training requires 4-6 months and return to pitching is a minimum of 6 months after such a repair.

Dr. Bak is one of just several surgeons in the Midwest experienced in treatment of these injuries.

While Dr. Bak and Dr. Silas perform over 90% of the primary shoulder replacements at Ascension Providence, they are also regional experts in painful and dysfunctional shoulder replacements.  They are asked to evaluate and address problems in previously replaced shoulders by many surgeons throughout the state.  These are complex procedures which often require bone graft and customized implants.  

With their extensive experience in primary and revision arthroplasty, Drs. Bak and Silas are adept at identifying the problem you may have with a prosthetic shoulder as well as performing any corrective surgery you may need.

While rare, nerve entrapment at the shoulder is a commonly missed condition which can lead to pain and weakness in the arm. 

Suprascapular nerve entrapment is seen primarily in patients who have had prior surgery but continue to have symptoms in spite of a seemingly structurally intact shoulder.  As we typically perform the nerve exploration and release arthroscopically, minimal immobilization is needed and usually within 4-6 weeks, patients are improving and approaching normal activities.

Less commonly, the axillary or radial nerves can become entrapped between several tendons on the back of the shoulder.  This is known as Quadrilateral Space Syndrome and is mainly seen in male athletes who are involved in throwing sports or contact sports.  A cyst can develop near the bottom of the shoulder due to injury to the labrum and these patients can be successfully treated with arthroscopic decompression of the cyst.  Occasionally these cysts can become quite large and may require a larger incision on the back of the shoulder to adequately correct.

Drs. Bak and Silas see these problems more commonly than the typical orthopedic practice and, as such, we are accustomed to identifying and treating patients who have this rare condition.

This is a rare problem that can be debilitating for patients who experience it.  Often no cause is identified but typically a neurologic condition can affect the muscles that control the shoulder blade’s movement on the chest.  When these scapular stabilizing muscles don’t function appropriately, the shoulder also doesn’t function properly leading to painful loss of motion.  Unfortunately, this is frequently misdiagnosed as a more conventional rotator cuff problem and patients often go years without a proper diagnosis and treatment, often undergoing several surgical procedures that are inevitably unsuccessful.  

An Eden-Lange procedure is performed for patients with lateral winging (typically resulting from prior neck surgery) and pectoralis major transfers are quite successful for medial winging which we typically see in younger patients with a history of trauma.  Dr. Bak is one of the few surgeons in the state experienced in these problems and in their surgical correction.  When properly diagnosed, these problems can be fully corrected.

Traumatic injuries of the Sternoclavicular (SC) Joint can be life-threatening, often requiring emergency treatment.  However, once stabilized, these are often treated nonoperatively.  Surgery around the SC joint has a higher risk of significant complications than elsewhere about the shoulder.  Unfortunately, a small percentage of SC joint injuries can cause ongoing instability in which case an SC joint reconstruction is recommended.  Dr. Bak is one of the few surgeons in the state experienced in this type of procedure.

Chronic arthritis of the SC joint can also occur and likewise typically resolves with nonsurgical treatment.  In patients who continue to have pain, a resection performed on an outpatient basis can eliminate this condition.  Dr. Bak has performed this procedure safely on multiple patients who have subsequently returned to a normal, pain-free lifestyle.

This procedure is performed when a patient has significant pain and deficiency or loss of the meniscus.  Unfortunately, if the meniscus is damaged badly or if it fails to heal after an attempt at surgical repair, it may require removal.  If this is a large portion of your meniscus this can expose the remaining cartilage in your knee to increased stress and place you at increased risk for development of arthritis.  Meniscal transplant is a joint-preservation procedure done to help prevent articular cartilage loss that occurs after large-scale meniscus removal. 

A fresh donor meniscus is size-matched based on preoperative imaging studies such as x-rays, CT scan, or MRI.  Other procedures may be done at the same surgery, such as osteotomy (realignment) or cartilage restoration.  The allograft meniscus is inserted using arthroscopy to assist in visualizing.  It is then sutured into place.  This is a time-consuming, complex procedure performed by only select institutions, and its success may depend on a simultaneous realignment procedure.  Dr. Frush is one of the Midwest’s most experienced surgeons in these techniques.

Athletic knee injuries frequently involve the anterior cruciate ligament (ACL) and, occasionally, the medial collateral ligament (MCL).  Far less common is damage to the posterior cruciate ligament (PCL) and/or lateral collateral ligament (LCL).  In rare situations, damage to these less commonly injured structures can occur in isolation but more typically, these ligaments are damaged as a result of severe trauma involving 3 or 4 of the 4 primary knee ligaments. These can be devastating injuries and are far more complex and require much more rehabilitation than an isolated ACL injury.  

In acute cases, primary repair of these ligaments can be successfully performed, however, if not addressed within the first 2-3 weeks, reconstruction with ligament grafts becomes the preferred method of correction.  There are frequently patient factors, including nerve or blood vessel injury which can be limb-threatening that may require ligament correction to be delayed while focus is placed on saving the leg.

Due to the complexity and potentially limb-threatening nature of these injuries, it is highly recommended that their surgical treatment only be performed by surgeons with high levels of experience and expertise with these problems.  In addition to being a highly-regarded sports physician, Ascension Providence is a Level 2 trauma center and therefore Dr. Frush sees an exceptionally high volume of multi-ligament knee injuries from both athletic injuries and high-energy trauma.  He also sees many of these injuries from other surgeons from around the state who send these patients to him for definitive correction.

The concept of knee preservation iencompasses a wide spectrum of knee procedures focused on alignment correction.  When extremes of abnormal alignment occur in conjunction with wear and tear, arthritis can progressively occur.  Perhaps the most effective way to stop or slow this progression is to realign the knee to a natural position.  This is a technically complex procedure requiring precise planning and execution.  Dr. Frush is Michigan’s highest volume osteotomy surgeon as well as one of the most experienced osteotomy surgeons in the Midwest. He learned alongside Detroit’s renowned sports surgeon, Dr. Robert Teitge who is now retired and has patients from his practice now see Dr. Frush. Alignment procedures are often combined with cartilage restoration (meniscal transplant/repair, cartilage transplant/repair) and ligament reconstruction procedures where necessary.