Shoulder Update: Instability, Labrum, and Biceps. Brett M. Cascio, MD

Transcription

1 Shoulder Update: Instability, Labrum, and Biceps Brett M. Cascio, MD

2 Disclosures

3 Topics Instability Anterior Posterior MDI SLAP Biceps Shoulder Resurfacing

4 Instability GH joint moves around too much More movement than normal joint laxity Causes irritation of synovium Irritation of biceps Causes tears of labrum and rotator cuff Cartilage and bone damage

5 Instability 3 main types 1 Anterior acute or chronic, subluxation vs dislocation 2 Posterior acute or chronic, subluxation vs dislocation 3 MDI rare 4 th type Luxatio erecta

6 Which type of instability was depicted in Deliverance?

7 Luxatio erecta

8 Anterior GH Instability Acute, dislocation Bankart lesion Chronic, microinstability, subluxation overhead athletes esp. pitchers

9 Acute Anterior GH Dislocation Dislocation - common football injury Arm tackle or QB Arm held down at side, ext rotated Thinner athletes its obvious Thicker athletes Pads, equipment

10 Acute Anterior GH Dislocation Should you reduce on sideline? If you know how My approach: One try on field if appropriate Move to training/locker room

11 Acute Anterior GH Dislocation Reduction methods many Foot in armpit or counter traction hang weights scapula manipulation Lidocaine injection locked Low threshold to go to ER

12 Hippocratic method, circa 400 BC You can do more damage fractures

13 Acute Anterior GH Dislocation QUESTION: In season dislocation return to play?

14 Acute Anterior GH Dislocation conservative treatment In season dislocation return to play When strength and ROM return to normal Minimum 3 weeks Brace limits arm FF and ext rot

15 1st Dislocation to Fix or Not to Fix Military academy data Consider age Consider ability, socioeconomics J Bone Joint Surg Am Apr;90(4): Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. Robinson CM, 75 %

16 Fix what? Bankart 2nd Dislocation Surgery Hill Sach s HAGL Humeral avulsion of glenohumeral lig ALPSA ant labrum periosteal sleeve avulstion

17 Capsulorraphy,, Labrum repair Anterior capsular shift, labrum repair Remplissage? to fill

18 Arthroscopic or Open My preference is arthroscopic for primary and revision if no bone loss or defect

19 Dislocation after Repair, i.e. Revision repair failed stabilization? Bony procedure Latarjet Fill in Hill Sachs with bone or metal

20 Postop Rehab 6 weeks in sling Return to play 3 4 months

21 Chronic Anterior Instability Pitchers peel back phenomenon Internal impingement Really micro instability Subluxations rather than dislocations

22 Pitcher posterior labrum and partial RTC

23 Associated pathology Rotator cuff PASTA lesion partial articular supraspinatus tendon avulsion

24 Chronic Anterior Instability Non-op Controversial surgical treatment in pitchers less is more Arthroscopic Open shift Return to play?

25 Associated pathology - Biceps Biceps irritation 2 major leaguers pitching with biceps tenotomy Elway Superbowls

26 Posterior Instability

27 Posterior Instability Football linemen especially in passing offenses MVA, i.e. dashboard injury

28 Posterior Instability Acute or chronic Usually subluxation, rarely dislocation

29 Acute Posterior Instability Attempt non-op treatment

30 Chronic Posterior Instability Associated with labrum tears and paralabrum cysts

31 Chronic Posterior Instability Failed conservative treatment Arthroscopic is my preference Steep learning curve

32 Postop Posterior Labrum gunslinger Repair Return to play/work 3 to 4 months

33 SLAP Tear

34 SLAP tear Superior Labrum Anterior to Posterior Described in the mid 80s Types

35

36

37 SLAP tear Nonop treatment for most Injection, therapy, activity modification Reason to fix mechanical symptoms fail conservative time off work Paralabrum cyst Suprascapular N.

38 Weakness external rotation

39 SLAP tear - surgery Arthroscopic repair Number of anchors depends on size of tear Knotless versus knotted Rarely occurs with full thickness rotator cuff Watch for bursitis, AC arthrosis Low threshold to add SAD, Mumford (DCE)

40 SLAP tear Trend is to perform biceps tenodesis and just debride slap Why? ADHESIVE CAPSULITIS Rotator cuff interval

41 SLAP tear - surgery I lean toward biceps tenodesis in over 40 y/o Just BT and debride labrum in > 60

42 SLAP tear - surgery

43 SLAP placement of anchor

44 SLAP Repair

45 SLAP PostOP Care MOTION IMMEDIATELY STIFFNESS ADHESIVE CAPSULITIS Sling for 4 weeks Return to work variable

46 MDI Multidirectional instability Overhead athletes Esp females swimmers, volleyball Collagen disorders

47 MDI Therapy, therapy therapy Voluntary subluxors Rarely operate

48 MDI - surgery Arthroscopic my preference Anterior and post capsulorraphy Include tightening/closure of anterior interval

49 6 weeks in sling MDI - postop

50 Biceps Tendon Function 3 joints supinator forearm flexion elbow, shoulder stabilization shoulder Dr. Knight kinesiology blog-spot.com

51 Biceps Tendon pain generator Tenotomy versus tenodesis

52 Biceps Tenodesis Intraarticular Above subscap At subscap Below subscap Sub pec Tying to conjoined tendon

53 Fixation methods Biceps Tenodesis

54 Arthroscopic intra-articular biceps tenodesis with suture anchor: a biomechanical and clinical study Brett Cascio, MD Major, US Army Reserve Director, LCMH Sports Program Assistant Clinical Professor, LSU

55 Disclosures

56 Biceps Tenodesis Methods: IS anchor soft tissue sub pec open bicipital groove open/ats transfer button screw/washer

57 Review of Literature 7 studies Variables: cadaver, sheep, porcine, 5 different types of anchors, diff lengths of screws, subpec, proximal Anchor N Av 206 Highest human: 252 N IS N 246 N Native strength N Proximal rupture of biceps brachii with slingshot displacement into the forearm. A case report Moorman CT. et al. JBJS 1996 Curtis AS and Snyder SJ. Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am Gilcreest EL. The common syndrome of rupture dislocation and elogantion of the long head of the biceps brachii: an analysis of one hundred cases. Surg., Gynec. And Obstet 58: , 1933.

58 Background Cheaper, easier way to do biceps tenodesis Decrease equipment Complications: fracture failure pain

59 Pain, Fracture

60 Intra-articular biceps tenodesis Flex shoulder to 70 deg Use 30 deg scope Subscap repair anchor placement

61 Circumferential, locked stitches

62 Looking for a better way. Intra-articular BT 2010 ICL #106 Snyder Older individuals works well What about younger, higher demand patients?

63 Basic Science and Clinical Study

64 Purpose Purpose: To compare two suture anchor biceps tenodesis fixation techniques: arthroscopic intra-articular and open subpectoral. Type of Study: Biomechanical

65 Materials and Methods Materials: 10 fresh-frozen paired human cadaver shoulders Standard arthroscopic and open equipment 5.5 mm loaded nonabsorbable anchors Loaded to failure with MTS Statistical analysis: paired t test

66 Anchor Placement Intraarticular Locked stitch 1 2 Subpec open Krackow stich

67 N Newtons Table 2. Results Pair Arthroscpic (N) Open subpectoral (N) AVERAGE ± ± 41.6 There was no statistically significant difference

68 Results Mode of failure: consistently suture tearing through the tendon 9/10 One subpec anchor pulled out of the bone.

69 239 BT Clinical Data Consecutive patients work comp, smokers, medicaid, military, legal, revisions min 6 mo f/u (6-24 mo) Age (mean 58, SD 10)

70 Clinical Data Mean Dash: pre 79 (SD 23) post 44 (SD 19) Mean Improvement: 35 (40%) P < correlation between pre-surg Dash and improvement No difference in age, gender, or with or without RTC tear 5 failures (2.1%)

71 Conclusion The tenodesis described provides reliable pain relief and biomechanical, clinical strength tendon quality > fixation, location

72 Total Shoulder Resurfacing Brett M. Cascio, MD, Derek Hinds, MD, Chelsa Patterson, ATC

73 Disclosures

74 Long term results of Total Resurfacing Levy O, Copeland S. surface replacement arthroplasty for osteoarthritis of the shoulder. J Shoulder Elbow Surg May-Jun; 13: Prichett J, Townsley C. Long-term results and patient satisfaction after shoulder resurfacing. J Shoulder Elbow Surg High patient satisfaction Pain, ROM Concern about glenoid

75 Concern #1: Glenoid loosening especially active younger patients Matsen FA 3rd, Lippitt SB. Shoulder surgery: principles and procedures. Philadelphia: Saunders; Principles of glenoid arthroplasty; p 508.

76 Concern #2: Total Resurfacing is technically challenging Intact head Access can be a struggle Weekly Standard

77 Inlay glenoid Rationale Gunther SB et al. Finite element analysis and physiologic testing of a novel, inset glenoid fixation technique. J SES. 2011, 1-9 fixation strength vs. Onlay glenoid 87% displacement stress edge distraction Potentially less wear/loosening

78 Early Success with inlay design -Ross M, Duke P. Early experience in the use of a new glenoid resurfacing technique Shoulder & Elbow Soc Australia Conf Handbook. Nov 4; Session 4: Anand Murthi, MD

79 Inlay glenoid - 2 sizes Small post Cemented

80 Purpose of this study Novel total shoulder resurfacing implant Inlay, load sharing glenoid Anatomically correct resurfacing head

81 Methods IRB approval, Sept 2011 to Dec 2012 Consecutive patients of all ages failed conservative treatment for severe glenohumeral arthritis were identified. Options thoroughly discussed standard deltopectoral approach Humeral head metal w/ screw fixation Inlay glenoid - all poly implant with post and cement fixation. CONSTANT, VAS

82 Results 32 patients, 20 entered into IRB study, 2 bilateral 1 patient refused, 2 dropped from study Average age was 61 (range 43 to 87) 22 men, 10 women Several other previous surgeries/ other diagnoses: 5-1 or more rotator cuff repair 2 - latarjet 1 - prior AC reconstruction 1 - malunion 1 suprascapular nerve/cyst decompr 87 y/o malunion

83 Postop Care Sling 6 weeks then PT No restrictions after 6 weeks Return to labor at approx 12 weeks 6 weeks right, 12 weeks left

84 F/u 3 to 18 months Results Constant scores improved from 40 (33 to 64) to 67 (48 to 92) ROM 116 to 137 deg av. VAS: 6 mo: 7.4 to 1.9 ALL but 2 would have again 1 infection at 3 mo postop loose glenoid 1 revision rotator cuff tear developed pseudoparalysis; converted to Reverse 1 glenoid too soft/ cysts

85 Concerns Coverage, fixation of glenoid How much activity is okay? How long will glenoid last and is it worth it?

86 Conclusions Reliable pain relief Reliable ROM improvement Preserves bone Unanswered questions

87 Thank you