Re: AC3 Separated Shoulder

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" <[email hidden]> wrote in message news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

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" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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?

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" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in message

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

There are several different surgical procedures described for this

injury.

Quoted message said:

Quoted message said:

It is also appropriate to not treat this injury surgically. Each option

has

Quoted message said:

Quoted message said:

benefits and risks associated with it. These vary from individual to
individual. In part this is because the amount of deformity produced by

a

Quoted message said:

Quoted message said:

complete AC separation varies depending on the individual's anatomy and
their tolerance of the problems varies with the demands they make on

their

Quoted message said:

Quoted message said:

shoulder.. Most orthopedists currently avoid repairing most of these as

it

Quoted message said:

Quoted message said:

is difficult to show that surgery leads to an improved result compared

to

Quoted message said:

Quoted message said:

those treated non-surgically. As time goes by, in most people, the size

of

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

not treated surgically acutely. Rarely people will have persistent pain

at

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

frozen shoulder syndrome. This is a risk after any shoulder injury and

the

Quoted message said:

Quoted message said:

risk increases with age. This is the primary reason to suggest PT

although

Quoted message said:

Quoted message said:

to avoid this problem all that needs to be done is range of motion

exercises

Quoted message said:

Quoted message said:

which can be taught to patients pretty quickly so extended PT is not

usually

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

second concern is development of impingement syndromes. This actually
probably goes up with surgical treatment. This is a late complication.

--
Mike Murray MD
"JPMM" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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?

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" <[email hidden]> wrote in message news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

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" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in message

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

There are several different surgical procedures described for this

injury.

Quoted message said:

Quoted message said:

It is also appropriate to not treat this injury surgically. Each option

has

Quoted message said:

Quoted message said:

benefits and risks associated with it. These vary from individual to
individual. In part this is because the amount of deformity produced by

a

Quoted message said:

Quoted message said:

complete AC separation varies depending on the individual's anatomy and
their tolerance of the problems varies with the demands they make on

their

Quoted message said:

Quoted message said:

shoulder.. Most orthopedists currently avoid repairing most of these as

it

Quoted message said:

Quoted message said:

is difficult to show that surgery leads to an improved result compared

to

Quoted message said:

Quoted message said:

those treated non-surgically. As time goes by, in most people, the size

of

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

not treated surgically acutely. Rarely people will have persistent pain

at

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

frozen shoulder syndrome. This is a risk after any shoulder injury and

the

Quoted message said:

Quoted message said:

risk increases with age. This is the primary reason to suggest PT

although

Quoted message said:

Quoted message said:

to avoid this problem all that needs to be done is range of motion

exercises

Quoted message said:

Quoted message said:

which can be taught to patients pretty quickly so extended PT is not

usually

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

second concern is development of impingement syndromes. This actually
probably goes up with surgical treatment. This is a late complication.

--
Mike Murray MD
"JPMM" <[email hidden]> wrote in message
news:[email hidden]...
> 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?

"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/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=97363803
http://www.ortho-u.net/l9/61.htm
http://www.worldortho.com/database/abstracts/u_limb/larsen.html
http://ajsm.highwire.org/cgi/content/abstract/29/6/699
http://www.worldortho.com/database/abstracts/u_limb/taft.html
http://www.worldortho.com/database/abstracts/u_limb/dias.html
http://www.worldortho.com/database/abstracts/u_limb/bjerneld.html
http://www.stoneclinic.com/acjoint2.htm

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in message

news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

Quoted message said:

Just as I said in my note, the consideration to treat this surgically

needs

Quoted message said:

Quoted message said:

to be individualized. It is not so much a matter of the "severity" of

the

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

demands they will make on the shoulder, their individual surgical risks

and

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

for cosmetic reasons. In general though most patients will have a

resting

Quoted message said:

Quoted message said:

position for the clavicle that is only elevated above the acromion a

small

Quoted message said:

Quoted message said:

amount. In this case non-surgical management makes more sense.
Interestingly, in contrast to the implication of the note below,

"capable

Quoted message said:

Quoted message said:

sports minded physicians" are probably less likely to treat these

surgically

Quoted message said:

Quoted message said:

for several reasons; longer healing time, increase risk for subsequent
impingement syndrome, risks of surgery, etc. It has been my experience

that

Quoted message said:

Quoted message said:

far more of these are treated surgically unnecessarily then are treated
inappropriately non-surgically. Perhaps this has much to do with the

fact

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

better with surgery. Most will have good results treated either way. A

few

Quoted message said:

Quoted message said:

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" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in

message

Quoted message said:

Quoted message said:

news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

> There are several different surgical procedures described for this

injury.

Quoted message said:

> It is also appropriate to not treat this injury surgically. Each

option

Quoted message said:

Quoted message said:

has

Quoted message said:

> benefits and risks associated with it. These vary from individual

to

Quoted message said:

Quoted message said:

Quoted message said:

> individual. In part this is because the amount of deformity

produced by

Quoted message said:

Quoted message said:

a

Quoted message said:

> complete AC separation varies depending on the individual's anatomy

and

Quoted message said:

Quoted message said:

Quoted message said:

> their tolerance of the problems varies with the demands they make on

their

Quoted message said:

> shoulder.. Most orthopedists currently avoid repairing most of

these as

Quoted message said:

Quoted message said:

it

Quoted message said:

> is difficult to show that surgery leads to an improved result

compared

Quoted message said:

Quoted message said:

to

Quoted message said:

> those treated non-surgically. As time goes by, in most people, the

size

Quoted message said:

Quoted message said:

of

Quoted message said:

> the "bump" gets smaller.. Clearly the decision to repair or not is
> something that you need to discuss with doctors individually. I

would

Quoted message said:

Quoted message said:

Quoted message said:

> actually suggest considering getting several opinions before opting

for

Quoted message said:

Quoted message said:

Quoted message said:

> surgery.
>
> Grade 2 AC separations are not treated surgically. Grade 1

separations

Quoted message said:

Quoted message said:

are

Quoted message said:

> not treated surgically acutely. Rarely people will have persistent

pain

Quoted message said:

Quoted message said:

at

Quoted message said:

> 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

Quoted message said:

> wait a LONG time before considering this. Maybe a year or so.
>
> Generally all these injuries do well regardless of method of

treatment.

Quoted message said:

Quoted message said:

Quoted message said:

> There are 2 major concerns. One is development of adhesive

capsulitis

Quoted message said:

Quoted message said:

or

Quoted message said:

> frozen shoulder syndrome. This is a risk after any shoulder injury

and

Quoted message said:

Quoted message said:

the

Quoted message said:

> risk increases with age. This is the primary reason to suggest PT

although

Quoted message said:

> to avoid this problem all that needs to be done is range of motion

exercises

Quoted message said:

> which can be taught to patients pretty quickly so extended PT is not

usually

Quoted message said:

> needed except perhaps in the elderly sedentary patient. This can

start

Quoted message said:

Quoted message said:

Quoted message said:

> very soon after the injury. There is no reason to wait several

weeks.

Quoted message said:

Quoted message said:

The

Quoted message said:

> second concern is development of impingement syndromes. This

actually

Quoted message said:

Quoted message said:

Quoted message said:

> probably goes up with surgical treatment. This is a late

complication.

Quoted message said:

Quoted message said:

Quoted message said:

>
>
> --
> Mike Murray MD
> "JPMM" <[email hidden]> wrote in message
> news:[email hidden]...
> > 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

Quoted message said:

Quoted message said:

Quoted message said:

> > considerable hump/bump on my shoulder. Will this go away w/ time

or

Quoted message said:

Quoted message said:

Quoted message said:

> > reduce in size? Do you typically regain full use of your

shoulder?

Quoted message said:

Quoted message said:

Quoted message said:

> > What's the recovery period?

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" <[email hidden]> wrote in message news:<kOAcc.82810$w54.479628@attbi_s01>...

Quoted message said:

"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/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=97363803
http://www.ortho-u.net/l9/61.htm
http://www.worldortho.com/database/abstracts/u_limb/larsen.html
http://ajsm.highwire.org/cgi/content/abstract/29/6/699
http://www.worldortho.com/database/abstracts/u_limb/taft.html
http://www.worldortho.com/database/abstracts/u_limb/dias.html
http://www.worldortho.com/database/abstracts/u_limb/bjerneld.html
http://www.stoneclinic.com/acjoint2.htm

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in message

news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

Quoted message said:

Just as I said in my note, the consideration to treat this surgically

needs

Quoted message said:

Quoted message said:

to be individualized. It is not so much a matter of the "severity" of

the

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

demands they will make on the shoulder, their individual surgical risks

and

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

for cosmetic reasons. In general though most patients will have a

resting

Quoted message said:

Quoted message said:

position for the clavicle that is only elevated above the acromion a

small

Quoted message said:

Quoted message said:

amount. In this case non-surgical management makes more sense.
Interestingly, in contrast to the implication of the note below,

"capable

Quoted message said:

Quoted message said:

sports minded physicians" are probably less likely to treat these

surgically

Quoted message said:

Quoted message said:

for several reasons; longer healing time, increase risk for subsequent
impingement syndrome, risks of surgery, etc. It has been my experience

that

Quoted message said:

Quoted message said:

far more of these are treated surgically unnecessarily then are treated
inappropriately non-surgically. Perhaps this has much to do with the

fact

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

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

Quoted message said:

Quoted message said:

better with surgery. Most will have good results treated either way. A

few

Quoted message said:

Quoted message said:

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" <[email hidden]> wrote in message
news:[email hidden]...
> 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" <[email hidden]> wrote in

message
news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

Quoted message said:

> > There are several different surgical procedures described for this

injury.

Quoted message said:

Quoted message said:

> > It is also appropriate to not treat this injury surgically. Each

option
has

Quoted message said:

Quoted message said:

> > benefits and risks associated with it. These vary from individual

to

Quoted message said:

Quoted message said:

> > individual. In part this is because the amount of deformity

produced by
a

Quoted message said:

Quoted message said:

> > complete AC separation varies depending on the individual's anatomy

and

Quoted message said:

Quoted message said:

> > their tolerance of the problems varies with the demands they make on

their

Quoted message said:

Quoted message said:

> > shoulder.. Most orthopedists currently avoid repairing most of

these as
it

Quoted message said:

Quoted message said:

> > is difficult to show that surgery leads to an improved result

compared
to

Quoted message said:

Quoted message said:

> > those treated non-surgically. As time goes by, in most people, the

size
of

Quoted message said:

Quoted message said:

> > the "bump" gets smaller.. Clearly the decision to repair or not is
> > something that you need to discuss with doctors individually. I

would

Quoted message said:

Quoted message said:

> > actually suggest considering getting several opinions before opting

for

Quoted message said:

Quoted message said:

> > surgery.
> >
> > Grade 2 AC separations are not treated surgically. Grade 1

separations
are

Quoted message said:

Quoted message said:

> > not treated surgically acutely. Rarely people will have persistent

pain
at

Quoted message said:

Quoted message said:

> > 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

Quoted message said:

Quoted message said:

> > wait a LONG time before considering this. Maybe a year or so.
> >
> > Generally all these injuries do well regardless of method of

treatment.

Quoted message said:

Quoted message said:

> > There are 2 major concerns. One is development of adhesive

capsulitis
or

Quoted message said:

Quoted message said:

> > frozen shoulder syndrome. This is a risk after any shoulder injury

and
the

Quoted message said:

Quoted message said:

> > risk increases with age. This is the primary reason to suggest PT

although

Quoted message said:

Quoted message said:

> > to avoid this problem all that needs to be done is range of motion

exercises

Quoted message said:

Quoted message said:

> > which can be taught to patients pretty quickly so extended PT is not

usually

Quoted message said:

Quoted message said:

> > needed except perhaps in the elderly sedentary patient. This can

start

Quoted message said:

Quoted message said:

> > very soon after the injury. There is no reason to wait several

weeks.
The

Quoted message said:

Quoted message said:

> > second concern is development of impingement syndromes. This

actually

Quoted message said:

Quoted message said:

> > probably goes up with surgical treatment. This is a late

complication.

Quoted message said:

Quoted message said:

> >
> >
> > --
> > Mike Murray MD
> > "JPMM" <[email hidden]> wrote in message
> > news:[email hidden]...
> > > 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

Quoted message said:

Quoted message said:

> > > considerable hump/bump on my shoulder. Will this go away w/ time

or

Quoted message said:

Quoted message said:

> > > reduce in size? Do you typically regain full use of your

shoulder?

Quoted message said:

Quoted message said:

> > > What's the recovery period?

On 4/6/04 7:16 PM, in article
[email hidden], "Alan Lowich"

Quoted message said:

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

Quoted message said:

"Mike Murray" <[email hidden]> wrote in message
news:<kOAcc.82810$w54.479628@attbi_s01>...

Quoted message said:

"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/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abs
tract&list_uids=97363803
http://www.ortho-u.net/l9/61.htm
http://www.worldortho.com/database/abstracts/u_limb/larsen.html
http://ajsm.highwire.org/cgi/content/abstract/29/6/699
http://www.worldortho.com/database/abstracts/u_limb/taft.html
http://www.worldortho.com/database/abstracts/u_limb/dias.html
http://www.worldortho.com/database/abstracts/u_limb/bjerneld.html
http://www.stoneclinic.com/acjoint2.htm

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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" <[email hidden]> wrote in message

news:<Yphcc.195141$po.1012951@attbi_s52>...

Quoted message said:

> Just as I said in my note, the consideration to treat this surgically

needs

Quoted message said:

> to be individualized. It is not so much a matter of the "severity" of

the

Quoted message said:

> 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

Quoted message said:

> demands they will make on the shoulder, their individual surgical risks

and

Quoted message said:

> 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

Quoted message said:

> 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

Quoted message said:

> for cosmetic reasons. In general though most patients will have a

resting

Quoted message said:

> position for the clavicle that is only elevated above the acromion a

small

Quoted message said:

> amount. In this case non-surgical management makes more sense.
> Interestingly, in contrast to the implication of the note below,

"capable

Quoted message said:

> sports minded physicians" are probably less likely to treat these

surgically

Quoted message said:

> for several reasons; longer healing time, increase risk for subsequent
> impingement syndrome, risks of surgery, etc. It has been my experience

that

Quoted message said:

> far more of these are treated surgically unnecessarily then are treated
> inappropriately non-surgically. Perhaps this has much to do with the

fact

Quoted message said:

> 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

Quoted message said:

> 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

Quoted message said:

> 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

Quoted message said:

> better with surgery. Most will have good results treated either way. A

few

Quoted message said:

> 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" <[email hidden]> wrote in message
> news:[email hidden]...
>> 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" <[email hidden]> wrote in

message
news:<sNBbc.65046$w54.397507@attbi_s01>...

Quoted message said:

>>> There are several different surgical procedures described for this

injury.

Quoted message said:

>>> It is also appropriate to not treat this injury surgically. Each

option
has

Quoted message said:

>>> benefits and risks associated with it. These vary from individual

to

Quoted message said:

>>> individual. In part this is because the amount of deformity

produced by
a

Quoted message said:

>>> complete AC separation varies depending on the individual's anatomy

and

Quoted message said:

>>> their tolerance of the problems varies with the demands they make on

their

Quoted message said:

>>> shoulder.. Most orthopedists currently avoid repairing most of

these as
it

Quoted message said:

>>> is difficult to show that surgery leads to an improved result

compared
to

Quoted message said:

>>> those treated non-surgically. As time goes by, in most people, the

size
of

Quoted message said:

>>> the "bump" gets smaller.. Clearly the decision to repair or not is
>>> something that you need to discuss with doctors individually. I

would

Quoted message said:

>>> actually suggest considering getting several opinions before opting

for

Quoted message said:

>>> surgery.
>>>
>>> Grade 2 AC separations are not treated surgically. Grade 1

separations
are

Quoted message said:

>>> not treated surgically acutely. Rarely people will have persistent

pain
at

Quoted message said:

>>> 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

Quoted message said:

>>> wait a LONG time before considering this. Maybe a year or so.
>>>
>>> Generally all these injuries do well regardless of method of

treatment.

Quoted message said:

>>> There are 2 major concerns. One is development of adhesive

capsulitis
or

Quoted message said:

>>> frozen shoulder syndrome. This is a risk after any shoulder injury

and
the

Quoted message said:

>>> risk increases with age. This is the primary reason to suggest PT

although

Quoted message said:

>>> to avoid this problem all that needs to be done is range of motion

exercises

Quoted message said:

>>> which can be taught to patients pretty quickly so extended PT is not

usually

Quoted message said:

>>> needed except perhaps in the elderly sedentary patient. This can

start

Quoted message said:

>>> very soon after the injury. There is no reason to wait several

weeks.
The

Quoted message said:

>>> second concern is development of impingement syndromes. This

actually

Quoted message said:

>>> probably goes up with surgical treatment. This is a late

complication.

Quoted message said:

>>>
>>>
>>> --
>>> Mike Murray MD
>>> "JPMM" <[email hidden]> wrote in message
>>> news:[email hidden]...
>>>> 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

Quoted message said:

>>>> considerable hump/bump on my shoulder. Will this go away w/ time

or

Quoted message said:

>>>> reduce in size? Do you typically regain full use of your

shoulder?

Quoted message said:

>>>> What's the recovery period?

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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.

"Shayne Wissler" <[email hidden]> wrote in message
news:ahLcc.206115$Cb.1802703@attbi_s51...

Quoted message said:

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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

Quoted message said:

is a tradeoff between the damage the surgury causes and the benefits it

can

Quoted message said:

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.

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" <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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.

"Alan Lowich" <[email hidden]> wrote in message
news:[email hidden]...

Quoted message said:

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?

Alan Lowich said:

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.

"Robert Chung" <[email hidden]> a écrit dans le message de :
news:[email hidden]...

Quoted message said:

Alan Lowich said:

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 surgeon, whom you trust,
and who is open to the patient's objectives and input, is not closed minded.
The two paths are viable, different, and do nothing to diminish the validity
of either one or the other.

Maybe it's like the belief that loose balls, not held in a cage, is a
better/worse technology. Opinions seem to differ greatly, but with a
shoulder, you can't just revise your choice after making the first choice.

When my separations occurred, it was a couple of days before I was on the
bike, again. It's interesting to note, that the weight of the body, leaning
forward, puts the parts in their proper places, really handily. But pulling
on the bars just elongates one side, while the other one works fine :-)
--
Bonne route,

Sandy
Paris FR

Sandy said:

Robert Chung a écrit

Quoted message said:

Alan Lowich said:

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.

[good points snipped]

Right. However, in this case, the data were collected and analysis done
expressly to develop practice guidelines and the conventional therapy
before that was surgical, so one can't say that researchers were starting
tabula rasa in the absence of context, experience, reasoning, or
intuition. In a normative-based field like healthcare it takes a lot to
shift treatment pradigms. Most physicians hate "evidence-based medicine"
because of the unfortunate connotations it carries, and herding cats is
easier than getting them to change their behavior, so when you do see them
change, it means the evidence has to be pretty compelling.

Nonetheless, guidelines are only guidelines; you had surgery on one
shoulder, you didn't on the other, and I'm guessing you thought pretty
deeply about each decision. That's exactly as it should be: the evidence
from the patient in front of you trumps a guideline and a good physician
will always make a treatment decision for an individual patient, not for a
population of potential patients--but that's not what Alan was asserting.
If he had said that on careful weighing of alternatives, in his particular
case, he and his physician opted for a surgical intervention, I wouldn't
have said anything. Rather, he said that his engineering intuition gave
him insight that trumped carefully collected and analyzed evidence, and
that surgery was flatly preferred.

Speaking of subtle, someone (hi there) passed this link on to me:
http://atbash.net/blog/archives/000046.html

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link on to me:
http://atbash.net/blog/archives/000046.html

That was a rather disappointing link.

Ewoud Dronkert said:

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link on to me:
http://atbash.net/blog/archives/000046.html

That was a rather disappointing link.

Try this one:
http://216.239.51.104/search?q=cache:atbash.net/blog/archives/000046.html

In article <[email hidden]>,

Robert Chung said:

Ewoud Dronkert said:

Robert Chung said:

Speaking of subtle, someone (hi there) passed this link on to me:
http://atbash.net/blog/archives/000046.html

That was a rather disappointing link.

Try this one:
http://216.239.51.104/search?q=cache:atbash.net/blog/archives/000046.html

The cached versions of pages often eliminate the images, so I located a
site that still had it up.
http://completewasteoftime.blogs.com/weblog/bagtag-thumb.gif

Subtle?
http://www.thepoorman.net/images/the_war_president_big.jpg

--
tanx,
Howard

Q: Why did the metalhead cross the road?
A: Because he's a gullible moron who'll buy
anything with a skull on it.

remove YOUR SHOES to reply, ok?