Dr. Kazemi

Dr. Namdar (Nami) Kazemi is a shoulder surgeon at Washington Orthopaedic Center. He completed his undergraduate degree at the University of Maryland. Following that he spent one year at the prestigious National Institutes of Health and conducted research studies in the field of biophysics. He then went on to the George Washington University and earned his medical degree. He then completed one year of orthopaedic research and five years of orthopaedic residency training at the University of Cincinnati Medical Center.

For additional training, Dr. Kazemi completed a shoulder and elbow fellowship at the Mt. Sinai Hospital in New York. He trained under world renowned shoulder surgeon, Evan Flatow. His other mentors included internationally recognized surgeons: Leesa Galatz, Brad Parsons and Michael Hausman.

Dr. Kazemi has published more than 14 peer-reviewed articles, 4 book chapters, 12 poster presentations, and has lectured and presented locally and nationally.

Patient Education

PATIENT EDUCATION

Shoulder Arthritis

Shoulder Arthritis

Simply defined, arthritis is inflammation of a joint that could lead to loss of cartilage. All joints in the body, including the shoulder, are covered with cartilage on both sides (ball and the socket in case of the shoulder). With arthritis, the cartilage is lost over time and with bone rubbing on bone, patients will develop pain and stiffness.

There are different types of arthritis:

Osteoarthritis

This is the most common type of arthritis. It is due to wear and tear and develops over time. Normally patients develop osteoarthritis past the age of 50.

Rheumatoid arthritis

This is an inflammatory type of arthritis that is due to rheumatoid disease. All joints in the body are lined with a tissue called synovium. In rheumatoid arthritis, the synovium gets inflamed, which causes pain and destroys the cartilage in the joint. Rheumatoid disease is an autoimmune disorder, which means that the body attacks it’s own tissue (synovium). Nowadays, rheumatoid medications are very effective in treating rheumatoid disease.

Post-traumatic arthritis

This is arthritis that happens as a result of previous trauma to the joint (such as a fracture or a dislocation).

Cuff-tear arthropathy

This is arthritis that develops over time due to lack of rotator cuff tissue. The main function of the rotator cuff tendons is to center the ball on the socket. When this function is not present, the ball tends to ride high on the socket and causes wear of the cartilage, preferentially on the top side of the socket.

Avascular necrosis

Avascular necrosis (AVN) is a condition that occurs when the blood supply of the bone is disrupted. Different causes of AVN include trauma, high dose steroid use, sickle cell anemia, and heavy alcohol consumption. When the structural bone dies in the shoulder, it collapses and causes damage to the overlying cartilage. This usually starts on the ball side and can progress to the arthritis of the socket due to collapse and abnormal shape of the ball.

Diagnosis

Diagnosis of arthritis is generally made on X-ray. Advanced imaging (CT or MRI or sometime both) may be required for preoperative planning in case of surgical management.

Treatment

Treatment options for arthritis of the shoulder are somewhat limited short of surgery. Activity modifications, physical therapy, and injections are the conservative measures that can be considered. Physical therapy should be gentle exercises to improve motion and strength. Aggressive physical therapy exercises can sometimes make this condition worse. In general, you would want to avoid exercises that load the shoulder (push up and bench press for instance) and stick to exercises that distract the shoulder (rowing for example). Injections of cortisone and hyaluronic acid can be considered, but the relief is generally temporary.

For patients who fail conservative care, surgical management can be considered. Anatomic or reverse shoulder replacements are the most common treatment options available.

Complications

The most disastrous complication after shoulder replacement is an infection. This is a rare event with an incidence of less than 1%. However, if it happens, it is a life changing event. Other complications include stiffness, instability, dislocation, peri-prosthetic fractures, and loosening over time. The lifetime of the newer implants is anywhere from 10-20 years.

Rotator Cuff Tears

Rotator cuff tears

Rotator cuff conditions are the most common shoulder ailment seen by an orthopaedic surgeon. In the United States, More than 17 million patients per year have shoulder pain due to a rotator cuff condition. Pain due to rotator cuff pathology generally presents with upper arm pain. Patients generally seek medical attention when the pain disturbs their sleep cycle.

Cause

Rotator cuff tears can either be acute and due to a traumatic event or chronic and due to wear and tear. Chronic rotator cuff tears are more common. There are two different theories behind the etiology of tears. Some believe that tears happen due to “impingement” of the rotator cuff tissue underneath the acromion bone (extrinsic theory). Some authors believe that tears happen over time and due to the inherent deterioration of the biology of the tendon (intrinsic theory).

There is a spectrum of different rotator cuff pathology. From bursitis, to partial tears to complete tears, and at the other end of the spectrum, massive rotator cuff tears.

Diagnosis

Rotator cuff tears are diagnosis based on physical examination and an MRI. The only way that the diagnosis can be 100% confirmed is with an MRI.

Treatment

It is important to understand that the fact that you have a rotator cuff tear on MRI does not necessarily mean that you need surgery. A lot of people have rotator cuff tears in their shoulder and they don’t even know about them. In fact, if you MRI someone over 70 years old with NO SHOULDER PAIN, there is roughly a 40-50% chance that they have a rotator cuff tear.

Treatment strategy is really dependent on patient’s age, comorbid medical conditions, activity level, and the personality of the tear.

For instance, in a young patient with an acute traumatic tear, surgical management is likely indicated. In a patient over the age of 65 with a chronic looking tear on MRI, a more conservative approach is utilized first.

The hallmark of conservative care is physical therapy and strengthening the rotator cuff and other shoulder muscles. Majority of patients get better with a course of physical therapy. In fact, if you look at numbers, about 10% of United States population over the age of 60 have a rotator cuff condition. Based on 2010 US census date, this equates to 5.7 million people. We know that rotator cuff surgery is performed on about 75,000 to 250,000 people per year. So that is roughly about fewer than 5% of patients that would require surgery.
Surgical options include rotator cuff repairs (arthroscopic or open), partial repairs, superior capsular reconstruction, tendon transfers and sometimes even reverse shoulder replacements.

Complications

The most common complication after rotator cuff surgery is stiffness. This is in fact more common after fixing smaller tears as compared to larger tears. The stiffness generally resolves after about 6-12 months.

Another complication is tendon not healing down to bone. Even when everything goes perfect including surgery, rehabilitation, etc…, the tendon may still not heal down to bone. This is more common in older patients (over 65), smokers, and those with diabetes. The caveat is that even if the tear doesn’t heal, it does not necessarily mean that patients are not going to have a good outcome!

If you had weakness before surgery, there is a chance that the affected arm is always going to be a bit weaker than the other arm.

Other complications include the ones with any other surgery: bleeding, infection, nerve damage, and need for additional surgeries.

Clavicle Fractures

Clavicle Fractures (Broken Collarbone)

A clavicle fracture is a broken collarbone. The collarbone is the structure that connects the arm to the body. It is one of the most commonly occurring fractures in the body; accounting for about 5% of all adult fractures. It is generally due to direct impact on the collarbone or due to a fall on an outstretched hand.

The clavicle bone, just like most bones in the body, has several muscles that insert on or originate from its surface. These muscles act as deforming forces on the broken clavicle pieces, hence displacing the fracture.

Diagnosis

Patients with shoulder trauma generally present to the emergency room (ER) after their injury. At that point, an x-ray will be obtained which will make the definitive diagnosis. Additional imaging including a CT scan or an MRI is rarely indicated for clavicle fractures.

Management

Clavicle fractures can be managed either with non-operative treatment or with surgery. Majority of these fracture can be treated without surgery in a sling. The decision to have surgery depends on fracture pattern, age of the patient, activity level, and comorbid conditions.

Non-surgical management generally involves sling immobilization for 6 weeks. Physical therapy (PT) will start at 6 weeks. Back to high demand activities at around 3-4 months. Full recovery takes about 6 months to 1 year.

Surgery if needed should be ideally done within the first 2 weeks. After surgery, patients will be placed in a sling for 6 weeks. PT will start at around 6 weeks. Back to high demand activities at around 5 months. Full recovery takes about 6 months to 1 year.

Surgical options

Surgical options will depend on fracture patterns and surgeons’ preference / comfort with a particular technique. The most common way to fix clavicle (also my preferred technique) is to use plate and screws. Some clavicle fractures can be fixed with a small rod placed inside the bone.

Complications

By far, the most common complication after clavicle fixation is numbness around the incision site. This is due to the fact that there are some very small nerves just deep to the skin that sometimes cannot be protected during surgery. The numbness area generally gets smaller over time, but some numbness may be PERMENANT, but most patients don’t mind it.
The other complication that is fairly common after clavicle fixation is a prominent hardware that may be symptomatic. Because there is not much soft tissue covering the clavicle and hence the plate, once the swelling subsides after surgery, the hardware is usually very obvious and may sometimes become painful (especially with activities such as backpacking). In these cases, the plate can be removed. The earliest I remove a plate is one year after surgery.

Just like any other fracture, other complications include malunion (bone healing in an abnormal position), nonunion (bone not healing), stiffness, periprosthetic fracture (break in the bone right next to the plate), and need for additional surgeries.

There are some major vessels and nerves underneath the clavicle that may be injured during surgery. This is a very rare occurrence, but possible and patients should be aware of that.

Proximal Humerus Fractures

Proximal Humerus Fractures

The humerus bone is the upper arm bone that forms the shoulder joint on one end and the elbow joint on the other. The part of the humerus bone that forms the shoulder joint is called the proximal humerus. Proximal humerus fractures are commonly seen in elderly population with osteoporosis. Often times, they are due to a fall from standing height. It younger individuals, proximal humerus fractures can occur after higher energy trauma such as a motor vehicle accident, ski accident or a high fall.

Diagnosis

Patients with shoulder trauma generally present to the emergency room (ER) after their injury. At that point, an x-ray will be obtained which will make the definitive diagnosis. A cat scan (CT) may or may not be obtained in the ER based on the fracture pattern. A CT is generally required for fractures that may need surgical treatment. Patients will placed in a sling and follow up with an orthopaedic surgeon within the first week.

Management

Proximal humerus fractures can be managed either with non-operative treatment or with surgery. Majority of these fracture can be treated without surgery in a sling. The decision to have surgery depends on fracture pattern, age of the patient, activity level, and comorbid conditions.

Non-surgical management generally involves sling immobilization for 6 weeks. Physical therapy (PT) will start at 3 weeks. Back to high demand activities at around 5 months. Full recovery takes about 6 months to 1 year.

Surgery if needed should be ideally done within the first 2 weeks. After surgery, patients will be placed in a sling for 6 weeks. PT will start at around 10 days. Back to high demand activities at around 5 months. Full recovery takes about 6 months to 1 year.

Surgical options

Surgical options will depend on fracture patterns, patients age and activity level. Options include fixation with small pins, rod fixation, plate and screw fixation or shoulder replacement.

Complications

I think the most common complication after proximal humerus fractures is stiffness. With or without surgery, the affected shoulder may always end up being stiffer than the normal shoulder. A regimented physical therapy protocol will for the most part prevent this from happening

Another complication after proximal humerus fracture is avascular necrosis. This basically means “bone dying due to compromised blood supply”. After a fracture, some of the vessels that provide nutrition and oxygen to the bone can be injured. A lot of times, other small vessels will compensate for this, but sometimes when this compensation is not enough, the bone ends up dying. If you look at the studies, this complication could happen for up to 8 years after an injury. If this happens and if symptomatic (associated with pain or other discomfort), there are surgical options that could address the condition.

The axillary nerve, which provides sensation to the shoulder area and controls the deltoid muscle, is very close to the fracture site. It may sometimes be injured due to the fracture or during surgery. An injury to this nerve during surgery is a very rare occurrence. I always know where the nerve is and hence it is always protected.

Just like any other fracture, other complications include malunion (bone healing in an abnormal position), nonunion (bone not healing), stiffness, periprosthetic fracture (break in the bone right next to the plate), and need for additional surgeries.

Frozen Shoulder

Frozen shoulder

Frozen shoulder (adhesive capsulitis) is a condition that causes the shoulder to become stiff. It is a common shoulder pathology that mostly commonly affects women in their 40’s and 50’s and those with diabetes or thyroid conditions. These particular patients do not necessarily have to have these conditions in order to get frozen shoulder; they are just more prone to get it.

Cause

The cause is unknown. What we do know is that the capsule of the shoulder gets leathery and thick and the volume inside shrinks. That is why the motion becomes limited. Frozen shoulder has a very insidious onset and it is a self-limited condition. That means that even if you don’t do ANYTHING for it, it will go away at some point. However, that may take a long time.

Stages

There are usually three phases: Freezing stage, stiffness stage and a thawing stage.

• Freezing stage: Patients slowly start developing pain in their shoulder and as the pain gets worse, the motions also diminishes. This stage may last from 6 weeks to 9 months!
• Stiffness stage: Patients’ pain may actually improve during this stage, but the stiffness remains. This stage may last from 4-6 months.
• Thawing stage: Shoulder’s motion slowly improves during this stage. Complete recovery (return of motion and strength) may take from 6 months to 2 years!

Diagnosis

Diagnosis of frozen shoulder is generally made by physical examination. An X-ray is usually obtained to rule out other causes of a stiff shoulder.

Treatment

Majority of patients improve with non-surgical management. The hallmark of treatment is physical therapy and sometimes injections. There are different injections that can be used (steroid, saline, etc…), but my preference is a steroid injection. Physical therapy is really a “no pain, no gain” process. The physical therapist will place your shoulder in places that it doesn’t want to go and stretch it.

In patients who do not respond to conservative care, surgical treatment can be considered. Surgery would involve an arthroscopic release of the capsule of the shoulder followed by a manipulation of the joint. There is extensive physical therapy involved immediately after surgery.

Shouder Instability

Shoulder Instability

The shoulder joint is the most mobile joint in the body. Compared to the hip joint (the other ball and socket joint in the body), the shoulder is much shallower. It is often compared to a golf ball on a golf tee. For this reason, the shoulder joint is the most dislocated joint in the body. The most common direction to dislocate a shoulder is in the front. Other possible directions include back, down and in more than one direction.

Cause

By far, the most common cause of shoulder dislocation is a traumatic event such as a fall. Sometimes patients can dislocate without trauma especially if they are young and loose jointed.

Diagnosis

Shoulder instability itself can be diagnosed on physical examination. An X-ray would confirm a dislocation and the direction that the joint is out. The consequences of a dislocation (labral tear, capsular tear, etc…) are generally diagnosed on an MRI.

Treatment

Treatment strategies really depend on patient’s age and how unstable the shoulder is. In a patient younger than 18, there is about an 80% chance of recurrent instability after a first time dislocation (especially if male). For that reason, surgical management is more common in young male patients.

The likelihood of recurrent instability goes down as the patient’s age goes up. Therefore in an older patient (over 30), the first line of treatment is usually physical therapy.

For those who fail conservative treatment or patients with history multiple dislocations, surgical management is certainly an option.

The most common surgery for instability is called an arthroscopic bankart repair. This is when the labrum (bumper around the socket) is repaired and the capsule is made tighter. Other procedures such as an open bankart repair, remplissage procedure, and latarjet can be used for other worse scenarios.

Complications

The most common complication after instability surgery is recurrent instability. Other complications include stiffness, bleeding, infection, nerve damage, and need for additional surgeries.

Anatomic Vs. Reverse?

What is the difference between anatomic and reverse shoulder replacement?

In anatomic shoulder replacement the patient’s anatomy is reproduced with the implant. There are certain situations, however, when an anatomic replacement cannot be performed:

1. The classic scenario is when the rotator cuff is deficient, either because of a tear or bad muscle quality. In these patients, the cuff musculature is not able to center the ball on the socket appropriately. So what happens is that the ball starts rocking (rocking horse phenomenon) on the socket implant and causes loosening of the socket.
2. In certain scenarios when the socket is really worn in the back, an anatomic implant has been shown not to be as durable.
3. Severe fractures of the humeral head sometimes cannot be treated with an anatomic implant.

In the above scenarios and some other situations, a reverse shoulder implant would be a predictable surgical option. Reverse replacement essentially reverses the position of the components (ball and socket). The ball will be placed on the socket and a socket will be placed where a ball would usually be. This changes the biomechanics of the shoulder, changes the center of rotation, and provides a stable fulcrum for the deltoid muscle to move the shoulder in the absence of the rotator cuff muscles.

Active vs. Passive motion

What is the difference between active and passive motion?

The way a joint moves is that a muscle tendon unit pulls on the bone at its insertion site and that causes the joint to move in a specific direction. This is important because most tendon repairs (for instance rotator cuff repairs) are performed at the bone tendon junction. Pulling on that repair construct with motion would compromise the fixation. At the same time, joint motion after surgery is important to prevent stiffness. This is where active and passive motion comes into play.

Active motion is a movement that is performed by the patient himself or herself. What happens during active motion is that the muscle tendon unit would pull on the bone to move the joint. As described above, this could compromise the repair construct. That is why active motion is usually started later on during the rehabilitation process.

Passive motion, on the other hand, is a movement that is entirely performed by a therapist or another person. The patient will not be putting any effort into the motion. This will avoid the pull on the repair construct with active motion and at the same time help with mobility of the joint to prevent post-operative stiffness. That is why passive motion is generally started earlier in the rehabilitation process.

Post Op Protocols