The Two Banditos: SLAP Lesion Shoulder and Labral Tear Hip. Dr. Arno Smit - WROSC Hazelmere Golf and Country Club April 11, 2013
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1 The Two Banditos: SLAP Lesion Shoulder and Labral Tear Hip Dr. Arno Smit - WROSC Hazelmere Golf and Country Club April 11, 2013
2 Hip is the new shoulder Increasing interest in non-arthroplasty hip issues. Clinical concepts advancing based on better imaging, increasing use of arthroscopy. Less acceptance of hip dysfunction. In years past: emphasis on replacement surgery
3 Hip is the new shoulder Analogies between hip and shoulder go back at least to Henry s description of anatomy (2 nd edition 1957) Rough conceptual mapping Rotator cuff shoulder ~ abductors hip Deltoid shoulder ~ Glut max / fascia lata / TFLA Labrum ~ labrum But: glenoid is shallow <-> acetabulum is deep
4 Hip is the new shoulder Hip arthroscopy in 2013 similar in maturity to shoulder arthroscopy in late 1990 s Will catch up very fast Will most likely overshoot and correct
5 Hip is the new shoulder Common focus is femoro-acetabular impingement bump on femoral neck impinging on acetabular rim, leading to labral fraying, delamination of cartilage and subsequent osteoarthritis
6 Hip is the new shoulder Bump or cam deformity as incidental finding
7 Hip is the new shoulder Hip arthroscopy is a rapidly moving field Key opinion leader player is Canadian surgeon Marc Philippon, Vale, Co Has outspoken opinion on function of labrum of hip Sees this as a key structure, maintaining a suction seal Loss of integrity of labrum sets up the hip for future deterioration
8 Shoulder Shoulder arthroscopy is more mature Rate of change is less than in hip arthroscopy Early concepts have already been debated and/or revised Controversy continues unabatedly
9 Pathology vs Normal Variant? Anatomy did not arise from text book Text books arose from anatomy observations Concepts are re-evaluated from time to time - MRI / Ultrasound etc - arthroscopy - anatomy labs
10 Pathology vs Normal Variant Wave of enthusiasm retreat Early knee arthroscopy medial plica Many unnecessary excisions Live and learn!
11 Pathology vs Normal Variant Early shoulder arthroscopy labral non-adherence, mainly anterosuperiorly over-diagnosed as pathologic wide variety of normal variants SLAP lesion disruption of biceps anchor, superior labrum Pathology vs non-pathology not always easy
12 SLAP Tear
13 SLAP tear
14 SLAP tear Sudden force through shoulder can disrupt biceps anchor Pain may fluctuate in severity Role of biceps tendon as pain generator remains under debate Opinion leaders: Dr. S. Snyder Dr. S. Burkhart
15 SLAP tear Treatment: Once conservative treatment failed debridement, repair or tenotomy and tenodesis
16 Pathology vs normal variant Hip arthroscopy: - Labral tear mainly antero-superiorly - Considered pathological - Yet, common finding in asymptomatic hips - Assessment requires judgement
17 Hip - labral tear
18 Hip labral tear Treatment: Once conservative treatment failed debridement or repair, possibly with femoral osteoplasty
19 MRI vs Arthroscopy: Gold standard? MRI arthrogram of hip and shoulder 85-90% accurate against what? Video clips of antero-superior shoulder anatomy poor consensus between orthopaedic surgeons Clinical implications of finding a disruption numerator vs denominator approach
20 Amidst the confusion, they grab the gold Tendency noted to minimize biceps anchor pathology and hip labrum pathology in medical experts retained by ICBC MRI arthrogram portrayed as fishing expedition
21 and tailed it down, all the way to Mexico Liberal, but imprecise, use of statistical terms May cause unnecessary difficulties for personal injury victims / plaintiffs
22 The posse History and clinical exam, X-rays, first Differential diagnosis establishes a priori probability Subsequent imaging or other studies not part of fishing expedition Subsequent findings at surgery and surgical intervention better foundation
23 The crowd Similar issues: tendon tears and tendinopathy rotator cuff, hip abductors, tennis elbow, achilles tendinopathy, etc degenerative joint changes pre-existing, albeit asymptomatic (or less symptomatic) arthritis
24 Discussion Ongoing debate re SLAP and labral lesions Medical probability vs legal probability Pain generator proof of concept acute vs chronic Definite statements are circumspect (!) May see a fair bit of downplaying of findings at MRI or surgery
25 Conclusion SLAP lesions and labral lesions Remain subject of ongoing debate Strong opinion leaders identified Plaintiffs interested to be safeguarded Trivializing injury of the labrum of hip and/or shoulder has been noted and should be recognized as such when applicable
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