Re: AC3 Separated Shoulder

Mike Murray

There are several different surgical procedures described for this injury.
It is also appropriate to not treat this injury surgically. Each option has
benefits and risks associated with it. These vary from individual to
individual. In part this is because the amount of deformity produced by a
complete AC separation varies depending on the individual's anatomy and
their tolerance of the problems varies with the demands they make on their
shoulder.. Most orthopedists currently avoid repairing most of these as it
is difficult to show that surgery leads to an improved result compared to
those treated non-surgically. As time goes by, in most people, the size of
the "bump" gets smaller.. Clearly the decision to repair or not is
something that you need to discuss with doctors individually. I would
actually suggest considering getting several opinions before opting for
surgery.

Grade 2 AC separations are not treated surgically. Grade 1 separations are
not treated surgically acutely. Rarely people will have persistent pain at
the AC joint after having a Grade 1 injury. These can be treated by
excising the distal clavicle to obliterate the joint. Personally I would
wait a LONG time before considering this. Maybe a year or so.

Generally all these injuries do well regardless of method of treatment.
There are 2 major concerns. One is development of adhesive capsulitis or
frozen shoulder syndrome. This is a risk after any shoulder injury and the
risk increases with age. This is the primary reason to suggest PT although
to avoid this problem all that needs to be done is range of motion exercises
which can be taught to patients pretty quickly so extended PT is not usually
needed except perhaps in the elderly sedentary patient. This can start
very soon after the injury. There is no reason to wait several weeks. The
second concern is development of impingement syndromes. This actually
probably goes up with surgical treatment. This is a late complication.


--
Mike Murray MD
"JPMM" <jpmm@bigfoot.com> wrote in message
news:4ca95d27.0403290936.71442ce6@posting.google.com...
> I'm 43 and have a AC Type 3 Separated Shoulder. My
> doctor has prescribed rest for several weeks followed by PT. I have a
> considerable hump/bump on my shoulder. Will this go away w/ time or
> reduce in size? Do you typically regain full use of your shoulder?
> What's the recovery period?

Alan Lowich

I agree with most of what you say Doctor but I had a really severe
separation which would not reduce no matter how long I waited.
Although the pain subsided I knew that I needed surgery after reading
Sports surgeon Dr. William Southmayd's book on sports injuries and
writing to him about it. I also consulted Dr. Neer and Dr. Louis
Bigliani both of Columbia Presbyterian Hospital and both agreed that
surgery was in order to return me to my full potential. As Dr.
Southmayd and Dr. Neer agree, a severe AC separation where all the
ligaments are severed and the arm hangs low and the clavical sticks up
like a flagpole surgery is required in their opinion, this is not a
broken collarbone that can be ignored but an injury that cries out for
repair. Fortunately there are more capable sports minded physicians
who can and do return these patients to near full capability today. Dr
Bigliani made the repair in 1986 and thankfully I am still feeling
great with full range of motion and almost full strength. I am
disatisfied and angry with the first orthopedist who did nothing to
heal me and simply told me to live with it and not scar my body. As
you say doctor it pays to listen to your own body and seek several
opinions.

Al



"Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message news:<sNBbc.65046$w54.397507@attbi_s01>...
> There are several different surgical procedures described for this injury.
> It is also appropriate to not treat this injury surgically. Each option has
> benefits and risks associated with it. These vary from individual to
> individual. In part this is because the amount of deformity produced by a
> complete AC separation varies depending on the individual's anatomy and
> their tolerance of the problems varies with the demands they make on their
> shoulder.. Most orthopedists currently avoid repairing most of these as it
> is difficult to show that surgery leads to an improved result compared to
> those treated non-surgically. As time goes by, in most people, the size of
> the "bump" gets smaller.. Clearly the decision to repair or not is
> something that you need to discuss with doctors individually. I would
> actually suggest considering getting several opinions before opting for
> surgery.
>
> Grade 2 AC separations are not treated surgically. Grade 1 separations are
> not treated surgically acutely. Rarely people will have persistent pain at
> the AC joint after having a Grade 1 injury. These can be treated by
> excising the distal clavicle to obliterate the joint. Personally I would
> wait a LONG time before considering this. Maybe a year or so.
>
> Generally all these injuries do well regardless of method of treatment.
> There are 2 major concerns. One is development of adhesive capsulitis or
> frozen shoulder syndrome. This is a risk after any shoulder injury and the
> risk increases with age. This is the primary reason to suggest PT although
> to avoid this problem all that needs to be done is range of motion exercises
> which can be taught to patients pretty quickly so extended PT is not usually
> needed except perhaps in the elderly sedentary patient. This can start
> very soon after the injury. There is no reason to wait several weeks. The
> second concern is development of impingement syndromes. This actually
> probably goes up with surgical treatment. This is a late complication.
>
>
> --
> Mike Murray MD
> "JPMM" <jpmm@bigfoot.com> wrote in message
> news:4ca95d27.0403290936.71442ce6@posting.google.com...
> > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > doctor has prescribed rest for several weeks followed by PT. I have a
> > considerable hump/bump on my shoulder. Will this go away w/ time or
> > reduce in size? Do you typically regain full use of your shoulder?
> > What's the recovery period?

Mike Murray

Just as I said in my note, the consideration to treat this surgically needs
to be individualized. It is not so much a matter of the "severity" of the
injury as we are talking about Grade 3 injuries, i.e. all of the same
severity. It is really more of an issue of the individual's anatomy, the
demands they will make on the shoulder, their individual surgical risks and
cost to the patient. In some individuals a complete AC separation will
leave the end of the clavicle resting several inches above the acromion.
Even these patient may do well from a functional point of view, i.e. they
will be able to move the shoulder normally and have little pain, but the
size of the deformity will lean you towards treating it surgically if only
for cosmetic reasons. In general though most patients will have a resting
position for the clavicle that is only elevated above the acromion a small
amount. In this case non-surgical management makes more sense.
Interestingly, in contrast to the implication of the note below, "capable
sports minded physicians" are probably less likely to treat these surgically
for several reasons; longer healing time, increase risk for subsequent
impingement syndrome, risks of surgery, etc. It has been my experience that
far more of these are treated surgically unnecessarily then are treated
inappropriately non-surgically. Perhaps this has much to do with the fact
that doctors are paid more to do surgery or just the fact that they do
surgery because they like to. I would be wary of any suggestion that surgery
should be considered that was given too rapidly and didn't take into
consideration all the things I have listed in my notes. The surgery does not
need to be done urgently and can be done delayed with no loss.

The bottom line is most can be treated without surgery although some may do
better with surgery. Most will have good results treated either way. A few
will have bad results treated either way. Predicting which method will
produce the best result is difficult and needs to be individualized.
--
Mike Murray MD

"Alan Lowich" <alan.lowich@gte.net> wrote in message
news:980cf357.0404041641.58d68244@posting.google.com...
> I agree with most of what you say Doctor but I had a really severe
> separation which would not reduce no matter how long I waited.
> Although the pain subsided I knew that I needed surgery after reading
> Sports surgeon Dr. William Southmayd's book on sports injuries and
> writing to him about it. I also consulted Dr. Neer and Dr. Louis
> Bigliani both of Columbia Presbyterian Hospital and both agreed that
> surgery was in order to return me to my full potential. As Dr.
> Southmayd and Dr. Neer agree, a severe AC separation where all the
> ligaments are severed and the arm hangs low and the clavical sticks up
> like a flagpole surgery is required in their opinion, this is not a
> broken collarbone that can be ignored but an injury that cries out for
> repair. Fortunately there are more capable sports minded physicians
> who can and do return these patients to near full capability today. Dr
> Bigliani made the repair in 1986 and thankfully I am still feeling
> great with full range of motion and almost full strength. I am
> disatisfied and angry with the first orthopedist who did nothing to
> heal me and simply told me to live with it and not scar my body. As
> you say doctor it pays to listen to your own body and seek several
> opinions.
>
> Al
>
>
>
> "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
news:<sNBbc.65046$w54.397507@attbi_s01>...
> > There are several different surgical procedures described for this
injury.
> > It is also appropriate to not treat this injury surgically. Each option
has
> > benefits and risks associated with it. These vary from individual to
> > individual. In part this is because the amount of deformity produced by
a
> > complete AC separation varies depending on the individual's anatomy and
> > their tolerance of the problems varies with the demands they make on
their
> > shoulder.. Most orthopedists currently avoid repairing most of these as
it
> > is difficult to show that surgery leads to an improved result compared
to
> > those treated non-surgically. As time goes by, in most people, the size
of
> > the "bump" gets smaller.. Clearly the decision to repair or not is
> > something that you need to discuss with doctors individually. I would
> > actually suggest considering getting several opinions before opting for
> > surgery.
> >
> > Grade 2 AC separations are not treated surgically. Grade 1 separations
are
> > not treated surgically acutely. Rarely people will have persistent pain
at
> > the AC joint after having a Grade 1 injury. These can be treated by
> > excising the distal clavicle to obliterate the joint. Personally I
would
> > wait a LONG time before considering this. Maybe a year or so.
> >
> > Generally all these injuries do well regardless of method of treatment.
> > There are 2 major concerns. One is development of adhesive capsulitis
or
> > frozen shoulder syndrome. This is a risk after any shoulder injury and
the
> > risk increases with age. This is the primary reason to suggest PT
although
> > to avoid this problem all that needs to be done is range of motion
exercises
> > which can be taught to patients pretty quickly so extended PT is not
usually
> > needed except perhaps in the elderly sedentary patient. This can start
> > very soon after the injury. There is no reason to wait several weeks.
The
> > second concern is development of impingement syndromes. This actually
> > probably goes up with surgical treatment. This is a late complication.
> >
> >
> > --
> > Mike Murray MD
> > "JPMM" <jpmm@bigfoot.com> wrote in message
> > news:4ca95d27.0403290936.71442ce6@posting.google.com...
> > > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > > doctor has prescribed rest for several weeks followed by PT. I have a
> > > considerable hump/bump on my shoulder. Will this go away w/ time or
> > > reduce in size? Do you typically regain full use of your shoulder?
> > > What's the recovery period?

Alan Lowich

Count me in the camp of Dr William Southmayd who says that in his
opinion all grade 3 separations should be surgically repaired for the
following two reasons:
1) " The shoulder joint is so damaged that it can't repair itself.
Specifically, there is no way for the bones to realign themselves.
The gap is too large"
2) "If you don't have surgery, there is almost 100 percent chance that
your shoulder will lose some mobility. Also the shoulder structure
will be permanently weakened."

Also Dr. Charles Neer and Dr. Louis Bigliani agreed with this opinion.
I realize that there are physicians like yourself who disagree with
this view and I certainly respect that.







Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message news:<Yphcc.195141$po.1012951@attbi_s52>...
> Just as I said in my note, the consideration to treat this surgically needs
> to be individualized. It is not so much a matter of the "severity" of the
> injury as we are talking about Grade 3 injuries, i.e. all of the same
> severity. It is really more of an issue of the individual's anatomy, the
> demands they will make on the shoulder, their individual surgical risks and
> cost to the patient. In some individuals a complete AC separation will
> leave the end of the clavicle resting several inches above the acromion.
> Even these patient may do well from a functional point of view, i.e. they
> will be able to move the shoulder normally and have little pain, but the
> size of the deformity will lean you towards treating it surgically if only
> for cosmetic reasons. In general though most patients will have a resting
> position for the clavicle that is only elevated above the acromion a small
> amount. In this case non-surgical management makes more sense.
> Interestingly, in contrast to the implication of the note below, "capable
> sports minded physicians" are probably less likely to treat these surgically
> for several reasons; longer healing time, increase risk for subsequent
> impingement syndrome, risks of surgery, etc. It has been my experience that
> far more of these are treated surgically unnecessarily then are treated
> inappropriately non-surgically. Perhaps this has much to do with the fact
> that doctors are paid more to do surgery or just the fact that they do
> surgery because they like to. I would be wary of any suggestion that surgery
> should be considered that was given too rapidly and didn't take into
> consideration all the things I have listed in my notes. The surgery does not
> need to be done urgently and can be done delayed with no loss.
>
> The bottom line is most can be treated without surgery although some may do
> better with surgery. Most will have good results treated either way. A few
> will have bad results treated either way. Predicting which method will
> produce the best result is difficult and needs to be individualized.
> --
> Mike Murray MD
>
> "Alan Lowich" <alan.lowich@gte.net> wrote in message
> news:980cf357.0404041641.58d68244@posting.google.com...
> > I agree with most of what you say Doctor but I had a really severe
> > separation which would not reduce no matter how long I waited.
> > Although the pain subsided I knew that I needed surgery after reading
> > Sports surgeon Dr. William Southmayd's book on sports injuries and
> > writing to him about it. I also consulted Dr. Neer and Dr. Louis
> > Bigliani both of Columbia Presbyterian Hospital and both agreed that
> > surgery was in order to return me to my full potential. As Dr.
> > Southmayd and Dr. Neer agree, a severe AC separation where all the
> > ligaments are severed and the arm hangs low and the clavical sticks up
> > like a flagpole surgery is required in their opinion, this is not a
> > broken collarbone that can be ignored but an injury that cries out for
> > repair. Fortunately there are more capable sports minded physicians
> > who can and do return these patients to near full capability today. Dr
> > Bigliani made the repair in 1986 and thankfully I am still feeling
> > great with full range of motion and almost full strength. I am
> > disatisfied and angry with the first orthopedist who did nothing to
> > heal me and simply told me to live with it and not scar my body. As
> > you say doctor it pays to listen to your own body and seek several
> > opinions.
> >
> > Al
> >
> >
> >
> > "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
> news:<sNBbc.65046$w54.397507@attbi_s01>...
> > > There are several different surgical procedures described for this
> injury.
> > > It is also appropriate to not treat this injury surgically. Each option
> has
> > > benefits and risks associated with it. These vary from individual to
> > > individual. In part this is because the amount of deformity produced by
> a
> > > complete AC separation varies depending on the individual's anatomy and
> > > their tolerance of the problems varies with the demands they make on
> their
> > > shoulder.. Most orthopedists currently avoid repairing most of these as
> it
> > > is difficult to show that surgery leads to an improved result compared
> to
> > > those treated non-surgically. As time goes by, in most people, the size
> of
> > > the "bump" gets smaller.. Clearly the decision to repair or not is
> > > something that you need to discuss with doctors individually. I would
> > > actually suggest considering getting several opinions before opting for
> > > surgery.
> > >
> > > Grade 2 AC separations are not treated surgically. Grade 1 separations
> are
> > > not treated surgically acutely. Rarely people will have persistent pain
> at
> > > the AC joint after having a Grade 1 injury. These can be treated by
> > > excising the distal clavicle to obliterate the joint. Personally I
> would
> > > wait a LONG time before considering this. Maybe a year or so.
> > >
> > > Generally all these injuries do well regardless of method of treatment.
> > > There are 2 major concerns. One is development of adhesive capsulitis
> or
> > > frozen shoulder syndrome. This is a risk after any shoulder injury and
> the
> > > risk increases with age. This is the primary reason to suggest PT
> although
> > > to avoid this problem all that needs to be done is range of motion
> exercises
> > > which can be taught to patients pretty quickly so extended PT is not
> usually
> > > needed except perhaps in the elderly sedentary patient. This can start
> > > very soon after the injury. There is no reason to wait several weeks.
> The
> > > second concern is development of impingement syndromes. This actually
> > > probably goes up with surgical treatment. This is a late complication.
> > >
> > >
> > > --
> > > Mike Murray MD
> > > "JPMM" <jpmm@bigfoot.com> wrote in message
> > > news:4ca95d27.0403290936.71442ce6@posting.google.com...
> > > > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > > > doctor has prescribed rest for several weeks followed by PT. I have a
> > > > considerable hump/bump on my shoulder. Will this go away w/ time or
> > > > reduce in size? Do you typically regain full use of your shoulder?
> > > > What's the recovery period?

Mike Murray

"If you don't have surgery, there is almost 100 percent chance that your
shoulder will lose some mobility. Also the shoulder structure will be
permanently weakened."

The above statement is clearly not true. I have seen several patients and
have many bike racing friends who have had Grade 3 AC separations that were
treated non-surgically that have full range of motion and no loss of
strength compared to the contralateral side. The statement does not match
my personal experience. In fact, it also appears to be in contrast to the
group experience as there is literature that has evaluated this question.
The majority of articles indicate that end strength and range of motion does
not vary between the operative and non-operative groups.

A blanket recommendation for surgery also ignores the fact that many
patients treated surgically develop problems secondary to the surgery;
rupture of the repair, painful syndromes related to the implanted materials,
need for subsequent surgery to remove metal, need for subsequent surgery to
resect the distal clavicle due to persistent pain, restricted range of
motion, impingement syndromes, infections, etc.

There have been 2 consensus opinion surveys, for what they are worth. In
1974, Powers and Bach found that most advocated surgical repair. In 1992,
Cox reported that 72.2% favored non-operative, symptomatic management. This
change was prompted by a series of retrospective studies that showed no
outcome differences between operative and non-operative groups. In addition,
the patients treated non-surgically returned to full activity (work or
athletics) sooner than the surgically treated groups. It would appear that
the doctors Mr. Lowich is quoting are hanging on to an idea that many feel
is outdated.

Clearly you can find people on both sides of this issue but the weight of
current opinion falls on the non-operative side for most patients.

Below are some links from a quick internet search on the subject.

http://www.ncbi.nlm.nih.gov/entrez/...t_uids=97363803
http://www.ortho-u.net/l9/61.htm
http://www.worldortho.com/database/...imb/larsen.html
http://ajsm.highwire.org/cgi/content/abstract/29/6/699
http://www.worldortho.com/database/..._limb/taft.html
http://www.worldortho.com/database/..._limb/dias.html
http://www.worldortho.com/database/...b/bjerneld.html
http://www.stoneclinic.com/acjoint2.htm

"Alan Lowich" <alan.lowich@gte.net> wrote in message
news:980cf357.0404051958.7961847@posting.google.com...
> Count me in the camp of Dr William Southmayd who says that in his
> opinion all grade 3 separations should be surgically repaired for the
> following two reasons:
> 1) " The shoulder joint is so damaged that it can't repair itself.
> Specifically, there is no way for the bones to realign themselves.
> The gap is too large"
> 2) "If you don't have surgery, there is almost 100 percent chance that
> your shoulder will lose some mobility. Also the shoulder structure
> will be permanently weakened."
>
> Also Dr. Charles Neer and Dr. Louis Bigliani agreed with this opinion.
> I realize that there are physicians like yourself who disagree with
> this view and I certainly respect that.
>
>
>
>
>
>
>
> Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
news:<Yphcc.195141$po.1012951@attbi_s52>...
> > Just as I said in my note, the consideration to treat this surgically
needs
> > to be individualized. It is not so much a matter of the "severity" of
the
> > injury as we are talking about Grade 3 injuries, i.e. all of the same
> > severity. It is really more of an issue of the individual's anatomy,
the
> > demands they will make on the shoulder, their individual surgical risks
and
> > cost to the patient. In some individuals a complete AC separation will
> > leave the end of the clavicle resting several inches above the acromion.
> > Even these patient may do well from a functional point of view, i.e.
they
> > will be able to move the shoulder normally and have little pain, but the
> > size of the deformity will lean you towards treating it surgically if
only
> > for cosmetic reasons. In general though most patients will have a
resting
> > position for the clavicle that is only elevated above the acromion a
small
> > amount. In this case non-surgical management makes more sense.
> > Interestingly, in contrast to the implication of the note below,
"capable
> > sports minded physicians" are probably less likely to treat these
surgically
> > for several reasons; longer healing time, increase risk for subsequent
> > impingement syndrome, risks of surgery, etc. It has been my experience
that
> > far more of these are treated surgically unnecessarily then are treated
> > inappropriately non-surgically. Perhaps this has much to do with the
fact
> > that doctors are paid more to do surgery or just the fact that they do
> > surgery because they like to. I would be wary of any suggestion that
surgery
> > should be considered that was given too rapidly and didn't take into
> > consideration all the things I have listed in my notes. The surgery does
not
> > need to be done urgently and can be done delayed with no loss.
> >
> > The bottom line is most can be treated without surgery although some may
do
> > better with surgery. Most will have good results treated either way. A
few
> > will have bad results treated either way. Predicting which method will
> > produce the best result is difficult and needs to be individualized.
> > --
> > Mike Murray MD
> >
> > "Alan Lowich" <alan.lowich@gte.net> wrote in message
> > news:980cf357.0404041641.58d68244@posting.google.com...
> > > I agree with most of what you say Doctor but I had a really severe
> > > separation which would not reduce no matter how long I waited.
> > > Although the pain subsided I knew that I needed surgery after reading
> > > Sports surgeon Dr. William Southmayd's book on sports injuries and
> > > writing to him about it. I also consulted Dr. Neer and Dr. Louis
> > > Bigliani both of Columbia Presbyterian Hospital and both agreed that
> > > surgery was in order to return me to my full potential. As Dr.
> > > Southmayd and Dr. Neer agree, a severe AC separation where all the
> > > ligaments are severed and the arm hangs low and the clavical sticks up
> > > like a flagpole surgery is required in their opinion, this is not a
> > > broken collarbone that can be ignored but an injury that cries out for
> > > repair. Fortunately there are more capable sports minded physicians
> > > who can and do return these patients to near full capability today. Dr
> > > Bigliani made the repair in 1986 and thankfully I am still feeling
> > > great with full range of motion and almost full strength. I am
> > > disatisfied and angry with the first orthopedist who did nothing to
> > > heal me and simply told me to live with it and not scar my body. As
> > > you say doctor it pays to listen to your own body and seek several
> > > opinions.
> > >
> > > Al
> > >
> > >
> > >
> > > "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in
message
> > news:<sNBbc.65046$w54.397507@attbi_s01>...
> > > > There are several different surgical procedures described for this
> > injury.
> > > > It is also appropriate to not treat this injury surgically. Each
option
> > has
> > > > benefits and risks associated with it. These vary from individual
to
> > > > individual. In part this is because the amount of deformity
produced by
> > a
> > > > complete AC separation varies depending on the individual's anatomy
and
> > > > their tolerance of the problems varies with the demands they make on
> > their
> > > > shoulder.. Most orthopedists currently avoid repairing most of
these as
> > it
> > > > is difficult to show that surgery leads to an improved result
compared
> > to
> > > > those treated non-surgically. As time goes by, in most people, the
size
> > of
> > > > the "bump" gets smaller.. Clearly the decision to repair or not is
> > > > something that you need to discuss with doctors individually. I
would
> > > > actually suggest considering getting several opinions before opting
for
> > > > surgery.
> > > >
> > > > Grade 2 AC separations are not treated surgically. Grade 1
separations
> > are
> > > > not treated surgically acutely. Rarely people will have persistent
pain
> > at
> > > > the AC joint after having a Grade 1 injury. These can be treated by
> > > > excising the distal clavicle to obliterate the joint. Personally I
> > would
> > > > wait a LONG time before considering this. Maybe a year or so.
> > > >
> > > > Generally all these injuries do well regardless of method of
treatment.
> > > > There are 2 major concerns. One is development of adhesive
capsulitis
> > or
> > > > frozen shoulder syndrome. This is a risk after any shoulder injury
and
> > the
> > > > risk increases with age. This is the primary reason to suggest PT
> > although
> > > > to avoid this problem all that needs to be done is range of motion
> > exercises
> > > > which can be taught to patients pretty quickly so extended PT is not
> > usually
> > > > needed except perhaps in the elderly sedentary patient. This can
start
> > > > very soon after the injury. There is no reason to wait several
weeks.
> > The
> > > > second concern is development of impingement syndromes. This
actually
> > > > probably goes up with surgical treatment. This is a late
complication.
> > > >
> > > >
> > > > --
> > > > Mike Murray MD
> > > > "JPMM" <jpmm@bigfoot.com> wrote in message
> > > > news:4ca95d27.0403290936.71442ce6@posting.google.com...
> > > > > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > > > > doctor has prescribed rest for several weeks followed by PT. I
have a
> > > > > considerable hump/bump on my shoulder. Will this go away w/ time
or
> > > > > reduce in size? Do you typically regain full use of your
shoulder?
> > > > > What's the recovery period?

Alan Lowich

Dr. Murray,

My engineering intuition tells me that a repaired joint has more
structural integrity than a broken joint, maybe I am of the old school
in believing this but I do and respectufully disagree with you.

Al



"Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message news:<kOAcc.82810$w54.479628@attbi_s01>...
> "If you don't have surgery, there is almost 100 percent chance that your
> shoulder will lose some mobility. Also the shoulder structure will be
> permanently weakened."
>
> The above statement is clearly not true. I have seen several patients and
> have many bike racing friends who have had Grade 3 AC separations that were
> treated non-surgically that have full range of motion and no loss of
> strength compared to the contralateral side. The statement does not match
> my personal experience. In fact, it also appears to be in contrast to the
> group experience as there is literature that has evaluated this question.
> The majority of articles indicate that end strength and range of motion does
> not vary between the operative and non-operative groups.
>
> A blanket recommendation for surgery also ignores the fact that many
> patients treated surgically develop problems secondary to the surgery;
> rupture of the repair, painful syndromes related to the implanted materials,
> need for subsequent surgery to remove metal, need for subsequent surgery to
> resect the distal clavicle due to persistent pain, restricted range of
> motion, impingement syndromes, infections, etc.
>
> There have been 2 consensus opinion surveys, for what they are worth. In
> 1974, Powers and Bach found that most advocated surgical repair. In 1992,
> Cox reported that 72.2% favored non-operative, symptomatic management. This
> change was prompted by a series of retrospective studies that showed no
> outcome differences between operative and non-operative groups. In addition,
> the patients treated non-surgically returned to full activity (work or
> athletics) sooner than the surgically treated groups. It would appear that
> the doctors Mr. Lowich is quoting are hanging on to an idea that many feel
> is outdated.
>
> Clearly you can find people on both sides of this issue but the weight of
> current opinion falls on the non-operative side for most patients.
>
> Below are some links from a quick internet search on the subject.
>
> http://www.ncbi.nlm.nih.gov/entrez/...t_uids=97363803
> http://www.ortho-u.net/l9/61.htm
> http://www.worldortho.com/database/...imb/larsen.html
> http://ajsm.highwire.org/cgi/content/abstract/29/6/699
> http://www.worldortho.com/database/..._limb/taft.html
> http://www.worldortho.com/database/..._limb/dias.html
> http://www.worldortho.com/database/...b/bjerneld.html
> http://www.stoneclinic.com/acjoint2.htm
>
> "Alan Lowich" <alan.lowich@gte.net> wrote in message
> news:980cf357.0404051958.7961847@posting.google.com...
> > Count me in the camp of Dr William Southmayd who says that in his
> > opinion all grade 3 separations should be surgically repaired for the
> > following two reasons:
> > 1) " The shoulder joint is so damaged that it can't repair itself.
> > Specifically, there is no way for the bones to realign themselves.
> > The gap is too large"
> > 2) "If you don't have surgery, there is almost 100 percent chance that
> > your shoulder will lose some mobility. Also the shoulder structure
> > will be permanently weakened."
> >
> > Also Dr. Charles Neer and Dr. Louis Bigliani agreed with this opinion.
> > I realize that there are physicians like yourself who disagree with
> > this view and I certainly respect that.
> >
> >
> >
> >
> >
> >
> >
> > Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
> news:<Yphcc.195141$po.1012951@attbi_s52>...
> > > Just as I said in my note, the consideration to treat this surgically
> needs
> > > to be individualized. It is not so much a matter of the "severity" of
> the
> > > injury as we are talking about Grade 3 injuries, i.e. all of the same
> > > severity. It is really more of an issue of the individual's anatomy,
> the
> > > demands they will make on the shoulder, their individual surgical risks
> and
> > > cost to the patient. In some individuals a complete AC separation will
> > > leave the end of the clavicle resting several inches above the acromion.
> > > Even these patient may do well from a functional point of view, i.e.
> they
> > > will be able to move the shoulder normally and have little pain, but the
> > > size of the deformity will lean you towards treating it surgically if
> only
> > > for cosmetic reasons. In general though most patients will have a
> resting
> > > position for the clavicle that is only elevated above the acromion a
> small
> > > amount. In this case non-surgical management makes more sense.
> > > Interestingly, in contrast to the implication of the note below,
> "capable
> > > sports minded physicians" are probably less likely to treat these
> surgically
> > > for several reasons; longer healing time, increase risk for subsequent
> > > impingement syndrome, risks of surgery, etc. It has been my experience
> that
> > > far more of these are treated surgically unnecessarily then are treated
> > > inappropriately non-surgically. Perhaps this has much to do with the
> fact
> > > that doctors are paid more to do surgery or just the fact that they do
> > > surgery because they like to. I would be wary of any suggestion that
> surgery
> > > should be considered that was given too rapidly and didn't take into
> > > consideration all the things I have listed in my notes. The surgery does
> not
> > > need to be done urgently and can be done delayed with no loss.
> > >
> > > The bottom line is most can be treated without surgery although some may
> do
> > > better with surgery. Most will have good results treated either way. A
> few
> > > will have bad results treated either way. Predicting which method will
> > > produce the best result is difficult and needs to be individualized.
> > > --
> > > Mike Murray MD
> > >
> > > "Alan Lowich" <alan.lowich@gte.net> wrote in message
> > > news:980cf357.0404041641.58d68244@posting.google.com...
> > > > I agree with most of what you say Doctor but I had a really severe
> > > > separation which would not reduce no matter how long I waited.
> > > > Although the pain subsided I knew that I needed surgery after reading
> > > > Sports surgeon Dr. William Southmayd's book on sports injuries and
> > > > writing to him about it. I also consulted Dr. Neer and Dr. Louis
> > > > Bigliani both of Columbia Presbyterian Hospital and both agreed that
> > > > surgery was in order to return me to my full potential. As Dr.
> > > > Southmayd and Dr. Neer agree, a severe AC separation where all the
> > > > ligaments are severed and the arm hangs low and the clavical sticks up
> > > > like a flagpole surgery is required in their opinion, this is not a
> > > > broken collarbone that can be ignored but an injury that cries out for
> > > > repair. Fortunately there are more capable sports minded physicians
> > > > who can and do return these patients to near full capability today. Dr
> > > > Bigliani made the repair in 1986 and thankfully I am still feeling
> > > > great with full range of motion and almost full strength. I am
> > > > disatisfied and angry with the first orthopedist who did nothing to
> > > > heal me and simply told me to live with it and not scar my body. As
> > > > you say doctor it pays to listen to your own body and seek several
> > > > opinions.
> > > >
> > > > Al
> > > >
> > > >
> > > >
> > > > "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in
> message
> news:<sNBbc.65046$w54.397507@attbi_s01>...
> > > > > There are several different surgical procedures described for this
> injury.
> > > > > It is also appropriate to not treat this injury surgically. Each
> option
> has
> > > > > benefits and risks associated with it. These vary from individual
> to
> > > > > individual. In part this is because the amount of deformity
> produced by
> a
> > > > > complete AC separation varies depending on the individual's anatomy
> and
> > > > > their tolerance of the problems varies with the demands they make on
> their
> > > > > shoulder.. Most orthopedists currently avoid repairing most of
> these as
> it
> > > > > is difficult to show that surgery leads to an improved result
> compared
> to
> > > > > those treated non-surgically. As time goes by, in most people, the
> size
> of
> > > > > the "bump" gets smaller.. Clearly the decision to repair or not is
> > > > > something that you need to discuss with doctors individually. I
> would
> > > > > actually suggest considering getting several opinions before opting
> for
> > > > > surgery.
> > > > >
> > > > > Grade 2 AC separations are not treated surgically. Grade 1
> separations
> are
> > > > > not treated surgically acutely. Rarely people will have persistent
> pain
> at
> > > > > the AC joint after having a Grade 1 injury. These can be treated by
> > > > > excising the distal clavicle to obliterate the joint. Personally I
> would
> > > > > wait a LONG time before considering this. Maybe a year or so.
> > > > >
> > > > > Generally all these injuries do well regardless of method of
> treatment.
> > > > > There are 2 major concerns. One is development of adhesive
> capsulitis
> or
> > > > > frozen shoulder syndrome. This is a risk after any shoulder injury
> and
> the
> > > > > risk increases with age. This is the primary reason to suggest PT
> although
> > > > > to avoid this problem all that needs to be done is range of motion
> exercises
> > > > > which can be taught to patients pretty quickly so extended PT is not
> usually
> > > > > needed except perhaps in the elderly sedentary patient. This can
> start
> > > > > very soon after the injury. There is no reason to wait several
> weeks.
> The
> > > > > second concern is development of impingement syndromes. This
> actually
> > > > > probably goes up with surgical treatment. This is a late
> complication.
> > > > >
> > > > >
> > > > > --
> > > > > Mike Murray MD
> > > > > "JPMM" <jpmm@bigfoot.com> wrote in message
> > > > > news:4ca95d27.0403290936.71442ce6@posting.google.com...
> > > > > > I'm 43 and have a AC Type 3 Separated Shoulder. My
> > > > > > doctor has prescribed rest for several weeks followed by PT. I
> have a
> > > > > > considerable hump/bump on my shoulder. Will this go away w/ time
> or
> > > > > > reduce in size? Do you typically regain full use of your
> shoulder?
> > > > > > What's the recovery period?

Baird Webel

On 4/6/04 7:16 PM, in article
980cf357.0404061516.56a5ac00@posting.google.com, "Alan Lowich"
<alan.lowich@gte.net> wrote:

> Dr. Murray,
>
> My engineering intuition tells me that a repaired joint has more
> structural integrity than a broken joint, maybe I am of the old school
> in believing this but I do and respectufully disagree with you.
>
> Al
>

So there is nothing in your engineering education and background where your
intuition pointed you in one direction, but upon careful consideration and
study the opposite turned out to be true?

Baird


>
> "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
> news:<kOAcc.82810$w54.479628@attbi_s01>...
>> "If you don't have surgery, there is almost 100 percent chance that your
>> shoulder will lose some mobility. Also the shoulder structure will be
>> permanently weakened."
>>
>> The above statement is clearly not true. I have seen several patients and
>> have many bike racing friends who have had Grade 3 AC separations that were
>> treated non-surgically that have full range of motion and no loss of
>> strength compared to the contralateral side. The statement does not match
>> my personal experience. In fact, it also appears to be in contrast to the
>> group experience as there is literature that has evaluated this question.
>> The majority of articles indicate that end strength and range of motion does
>> not vary between the operative and non-operative groups.
>>
>> A blanket recommendation for surgery also ignores the fact that many
>> patients treated surgically develop problems secondary to the surgery;
>> rupture of the repair, painful syndromes related to the implanted materials,
>> need for subsequent surgery to remove metal, need for subsequent surgery to
>> resect the distal clavicle due to persistent pain, restricted range of
>> motion, impingement syndromes, infections, etc.
>>
>> There have been 2 consensus opinion surveys, for what they are worth. In
>> 1974, Powers and Bach found that most advocated surgical repair. In 1992,
>> Cox reported that 72.2% favored non-operative, symptomatic management. This
>> change was prompted by a series of retrospective studies that showed no
>> outcome differences between operative and non-operative groups. In addition,
>> the patients treated non-surgically returned to full activity (work or
>> athletics) sooner than the surgically treated groups. It would appear that
>> the doctors Mr. Lowich is quoting are hanging on to an idea that many feel
>> is outdated.
>>
>> Clearly you can find people on both sides of this issue but the weight of
>> current opinion falls on the non-operative side for most patients.
>>
>> Below are some links from a quick internet search on the subject.
>>
>> http://www.ncbi.nlm.nih.gov/entrez/...PubMed&dopt=Abs
>> tract&list_uids=97363803
>> http://www.ortho-u.net/l9/61.htm
>> http://www.worldortho.com/database/...imb/larsen.html
>> http://ajsm.highwire.org/cgi/content/abstract/29/6/699
>> http://www.worldortho.com/database/..._limb/taft.html
>> http://www.worldortho.com/database/..._limb/dias.html
>> http://www.worldortho.com/database/...b/bjerneld.html
>> http://www.stoneclinic.com/acjoint2.htm
>>
>> "Alan Lowich" <alan.lowich@gte.net> wrote in message
>> news:980cf357.0404051958.7961847@posting.google.com...
>>> Count me in the camp of Dr William Southmayd who says that in his
>>> opinion all grade 3 separations should be surgically repaired for the
>>> following two reasons:
>>> 1) " The shoulder joint is so damaged that it can't repair itself.
>>> Specifically, there is no way for the bones to realign themselves.
>>> The gap is too large"
>>> 2) "If you don't have surgery, there is almost 100 percent chance that
>>> your shoulder will lose some mobility. Also the shoulder structure
>>> will be permanently weakened."
>>>
>>> Also Dr. Charles Neer and Dr. Louis Bigliani agreed with this opinion.
>>> I realize that there are physicians like yourself who disagree with
>>> this view and I certainly respect that.
>>>
>>>
>>>
>>>
>>>
>>>
>>>
>>> Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in message
>> news:<Yphcc.195141$po.1012951@attbi_s52>...
>>>> Just as I said in my note, the consideration to treat this surgically
>> needs
>>>> to be individualized. It is not so much a matter of the "severity" of
>> the
>>>> injury as we are talking about Grade 3 injuries, i.e. all of the same
>>>> severity. It is really more of an issue of the individual's anatomy,
>> the
>>>> demands they will make on the shoulder, their individual surgical risks
>> and
>>>> cost to the patient. In some individuals a complete AC separation will
>>>> leave the end of the clavicle resting several inches above the acromion.
>>>> Even these patient may do well from a functional point of view, i.e.
>> they
>>>> will be able to move the shoulder normally and have little pain, but the
>>>> size of the deformity will lean you towards treating it surgically if
>> only
>>>> for cosmetic reasons. In general though most patients will have a
>> resting
>>>> position for the clavicle that is only elevated above the acromion a
>> small
>>>> amount. In this case non-surgical management makes more sense.
>>>> Interestingly, in contrast to the implication of the note below,
>> "capable
>>>> sports minded physicians" are probably less likely to treat these
>> surgically
>>>> for several reasons; longer healing time, increase risk for subsequent
>>>> impingement syndrome, risks of surgery, etc. It has been my experience
>> that
>>>> far more of these are treated surgically unnecessarily then are treated
>>>> inappropriately non-surgically. Perhaps this has much to do with the
>> fact
>>>> that doctors are paid more to do surgery or just the fact that they do
>>>> surgery because they like to. I would be wary of any suggestion that
>> surgery
>>>> should be considered that was given too rapidly and didn't take into
>>>> consideration all the things I have listed in my notes. The surgery does
>> not
>>>> need to be done urgently and can be done delayed with no loss.
>>>>
>>>> The bottom line is most can be treated without surgery although some may
>> do
>>>> better with surgery. Most will have good results treated either way. A
>> few
>>>> will have bad results treated either way. Predicting which method will
>>>> produce the best result is difficult and needs to be individualized.
>>>> --
>>>> Mike Murray MD
>>>>
>>>> "Alan Lowich" <alan.lowich@gte.net> wrote in message
>>>> news:980cf357.0404041641.58d68244@posting.google.com...
>>>>> I agree with most of what you say Doctor but I had a really severe
>>>>> separation which would not reduce no matter how long I waited.
>>>>> Although the pain subsided I knew that I needed surgery after reading
>>>>> Sports surgeon Dr. William Southmayd's book on sports injuries and
>>>>> writing to him about it. I also consulted Dr. Neer and Dr. Louis
>>>>> Bigliani both of Columbia Presbyterian Hospital and both agreed that
>>>>> surgery was in order to return me to my full potential. As Dr.
>>>>> Southmayd and Dr. Neer agree, a severe AC separation where all the
>>>>> ligaments are severed and the arm hangs low and the clavical sticks up
>>>>> like a flagpole surgery is required in their opinion, this is not a
>>>>> broken collarbone that can be ignored but an injury that cries out for
>>>>> repair. Fortunately there are more capable sports minded physicians
>>>>> who can and do return these patients to near full capability today. Dr
>>>>> Bigliani made the repair in 1986 and thankfully I am still feeling
>>>>> great with full range of motion and almost full strength. I am
>>>>> disatisfied and angry with the first orthopedist who did nothing to
>>>>> heal me and simply told me to live with it and not scar my body. As
>>>>> you say doctor it pays to listen to your own body and seek several
>>>>> opinions.
>>>>>
>>>>> Al
>>>>>
>>>>>
>>>>>
>>>>> "Mike Murray" <mike.murrayREMOVETHIS@REMOVETHISobra.org> wrote in
>> message
>> news:<sNBbc.65046$w54.397507@attbi_s01>...
>>>>>> There are several different surgical procedures described for this
>> injury.
>>>>>> It is also appropriate to not treat this injury surgically. Each
>> option
>> has
>>>>>> benefits and risks associated with it. These vary from individual
>> to
>>>>>> individual. In part this is because the amount of deformity
>> produced by
>> a
>>>>>> complete AC separation varies depending on the individual's anatomy
>> and
>>>>>> their tolerance of the problems varies with the demands they make on
>> their
>>>>>> shoulder.. Most orthopedists currently avoid repairing most of
>> these as
>> it
>>>>>> is difficult to show that surgery leads to an improved result
>> compared
>> to
>>>>>> those treated non-surgically. As time goes by, in most people, the
>> size
>> of
>>>>>> the "bump" gets smaller.. Clearly the decision to repair or not is
>>>>>> something that you need to discuss with doctors individually. I
>> would
>>>>>> actually suggest considering getting several opinions before opting
>> for
>>>>>> surgery.
>>>>>>
>>>>>> Grade 2 AC separations are not treated surgically. Grade 1
>> separations
>> are
>>>>>> not treated surgically acutely. Rarely people will have persistent
>> pain
>> at
>>>>>> the AC joint after having a Grade 1 injury. These can be treated by
>>>>>> excising the distal clavicle to obliterate the joint. Personally I
>> would
>>>>>> wait a LONG time before considering this. Maybe a year or so.
>>>>>>
>>>>>> Generally all these injuries do well regardless of method of
>> treatment.
>>>>>> There are 2 major concerns. One is development of adhesive
>> capsulitis
>> or
>>>>>> frozen shoulder syndrome. This is a risk after any shoulder injury
>> and
>> the
>>>>>> risk increases with age. This is the primary reason to suggest PT
>> although
>>>>>> to avoid this problem all that needs to be done is range of motion
>> exercises
>>>>>> which can be taught to patients pretty quickly so extended PT is not
>> usually
>>>>>> needed except perhaps in the elderly sedentary patient. This can
>> start
>>>>>> very soon after the injury. There is no reason to wait several
>> weeks.
>> The
>>>>>> second concern is development of impingement syndromes. This
>> actually
>>>>>> probably goes up with surgical treatment. This is a late
>> complication.
>>>>>>
>>>>>>
>>>>>> --
>>>>>> Mike Murray MD
>>>>>> "JPMM" <jpmm@bigfoot.com> wrote in message
>>>>>> news:4ca95d27.0403290936.71442ce6@posting.google.com...
>>>>>>> I'm 43 and have a AC Type 3 Separated Shoulder. My
>>>>>>> doctor has prescribed rest for several weeks followed by PT. I
>> have a
>>>>>>> considerable hump/bump on my shoulder. Will this go away w/ time
>> or
>>>>>>> reduce in size? Do you typically regain full use of your
>> shoulder?
>>>>>>> What's the recovery period?

Shayne Wissler

"Alan Lowich" <alan.lowich@gte.net> wrote in message
news:980cf357.0404061516.56a5ac00@posting.google.com...
> Dr. Murray,
>
> My engineering intuition tells me that a repaired joint has more
> structural integrity than a broken joint, maybe I am of the old school
> in believing this but I do and respectufully disagree with you.

Well the thing your "engineering intuition" is misleading you on is the
wrong notion that we are made of modular parts like a machine. We are not;
surgery causes irreversible damage and scarring to healthy tissue. So there
is a tradeoff between the damage the surgury causes and the benefits it can
potentially create.


Shayne Wissler

Tom Kunich

"Alan Lowich" <alan.lowich@gte.net> wrote in message
news:980cf357.0404061516.56a5ac00@posting.google.com...
> Dr. Murray,
>
> My engineering intuition tells me that a repaired joint has more
> structural integrity than a broken joint, maybe I am of the old school
> in believing this but I do and respectufully disagree with you.

Did you work on the Shuttle?

Point is that as Dr. Murray pointed out, everyone is an individual and in
some cases you'd be right. In MOST of the cases he'd be right. As a person
that has gotten three separations over the years I can tell you that even
pretty extreme one's effectively disappear in time if you are actively using
them.

The real question is are you putting in enough in the way of PT to deal with
your particular case if you aren't one of the few who will require surgery.

And as someone that worked with doctors who use knives, I can tell you that
I'd always avoid them if possible.

Tom Kunich

"Shayne Wissler" <thalesNOSPAM000@yahoo.com> wrote in message
news:ahLcc.206115$Cb.1802703@attbi_s51...
>
> "Alan Lowich" <alan.lowich@gte.net> wrote in message
> news:980cf357.0404061516.56a5ac00@posting.google.com...
> > Dr. Murray,
> >
> > My engineering intuition tells me that a repaired joint has more
> > structural integrity than a broken joint, maybe I am of the old school
> > in believing this but I do and respectufully disagree with you.
>
> Well the thing your "engineering intuition" is misleading you on is the
> wrong notion that we are made of modular parts like a machine. We are not;
> surgery causes irreversible damage and scarring to healthy tissue. So
there
> is a tradeoff between the damage the surgury causes and the benefits it
can
> potentially create.

And there's no way of knowing what the end result is going to be after you
operate. Shortening muscles and ligaments doesn't leave them at the length
you repair them and you can't tell with any certainty what the end result is
going to be. Same with bone structures that require repairs. Doctors do
what their experience tells them is most likely to work. That doesn't mean
it will.

Even a surgery as simple as repair of a separation can end up with the
results nothing like what you hoped. Even doctors with long term experience
are only better on the average then doctors who never did it before.

At least lawyers make a fat living off of the fact that the human body is so
variable in its responses.

Alan Lowich

Following your logic there should be no surgery for fear of a bad
outcome, we should just wait for our broken joints to disappear in
time.


"Tom Kunich" <cyclintom@yahoo.com> wrote in message news:<4WLcc.18058$Dv2.9011@newsread2.news.pas.earthlink.net>...
> "Alan Lowich" <alan.lowich@gte.net> wrote in message
> news:980cf357.0404061516.56a5ac00@posting.google.com...
> > Dr. Murray,
> >
> > My engineering intuition tells me that a repaired joint has more
> > structural integrity than a broken joint, maybe I am of the old school
> > in believing this but I do and respectufully disagree with you.
>
> Did you work on the Shuttle?
>
> Point is that as Dr. Murray pointed out, everyone is an individual and in
> some cases you'd be right. In MOST of the cases he'd be right. As a person
> that has gotten three separations over the years I can tell you that even
> pretty extreme one's effectively disappear in time if you are actively using
> them.
>
> The real question is are you putting in enough in the way of PT to deal with
> your particular case if you aren't one of the few who will require surgery.
>
> And as someone that worked with doctors who use knives, I can tell you that
> I'd always avoid them if possible.

Tom Kunich

"Alan Lowich" <alan.lowich@gte.net> wrote in message
news:980cf357.0404070359.384a9124@posting.google.com...
> Following your logic there should be no surgery for fear of a bad
> outcome, we should just wait for our broken joints to disappear in
> time.

You mean like they always did in the past before they started putting knives
in people with separated shoulders?

Robert Chung

Alan Lowich wrote:
>
> My engineering intuition tells me [...]

Intuition? Good. Data? Better.

Being persuaded by new evidence isn't flip-flopping, it's learning.
Holding to an opinion in the face of overwhelming evidence isn't
consistency, it's stubbornness.

SMMB

"Robert Chung" <me2@privacy.net> a écrit dans le message de :
news:c52sgs$2njogc$1@ID-226327.news.uni-berlin.de...
> Alan Lowich wrote:
> >
> > My engineering intuition tells me [...]
>
> Intuition? Good. Data? Better.
>
> Being persuaded by new evidence isn't flip-flopping, it's learning.
> Holding to an opinion in the face of overwhelming evidence isn't
> consistency, it's stubbornness.
>
Frankly, I think this criticism is unfair, Robert.
Data is not independently valuable, without the application of reasoning.
Reasoning, based on predetermined models, without intuition, advances
nowhere.

To the particular point in the thread, the choices of surgical intervention
or abstention do not lead to plain results. Without surgery, or with it,
the resulting body can't be compared to anything else - bodies seem to be
rather unique.

If one judges success by range of motion, then not cutting is best - you
wouldn't believe how flexible an unattached joint can be ! Presence or
absence of a knob is cosmetic. I am not ready to use that as a valid index
of success leaves me unimpressed. Pain is generally not of concern, except
very early on, as there is not usually nerve damage.

In my own case, I decided on surgery for one shoulder and not for the other.
Different treatments for different presentations. Nearly the same final
results, and I'm getting older, anyway - lots older - so I won't guess
whether there is any natural process influencing.

When the fashion of treatment changes, the data also become skewed. You get
more data, less information. And a good orthopedic sur