Shoulder Update: Instability, Labrum, and Biceps Brett M. Cascio, MD www.casciosportsmed.com
Disclosures
Topics Instability Anterior Posterior MDI SLAP Biceps Shoulder Resurfacing
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
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
Which type of instability was depicted in Deliverance?
Luxatio erecta
Anterior GH Instability Acute, dislocation Bankart lesion Chronic, microinstability, subluxation overhead athletes esp. pitchers
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
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
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
Hippocratic method, circa 400 BC You can do more damage fractures
Acute Anterior GH Dislocation QUESTION: In season dislocation return to play?
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
1st Dislocation to Fix or Not to Fix Military academy data Consider age Consider ability, socioeconomics J Bone Joint Surg Am. 2008 Apr;90(4):708-21 Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. Robinson CM, 75 %
Fix what? Bankart 2nd Dislocation Surgery Hill Sach s HAGL Humeral avulsion of glenohumeral lig ALPSA ant labrum periosteal sleeve avulstion
Capsulorraphy,, Labrum repair Anterior capsular shift, labrum repair Remplissage? to fill
Arthroscopic or Open My preference is arthroscopic for primary and revision if no bone loss or defect
Dislocation after Repair, i.e. Revision repair failed stabilization? Bony procedure Latarjet Fill in Hill Sachs with bone or metal
Postop Rehab 6 weeks in sling Return to play 3 4 months
Chronic Anterior Instability Pitchers peel back phenomenon Internal impingement Really micro instability Subluxations rather than dislocations
Pitcher posterior labrum and partial RTC
Associated pathology Rotator cuff PASTA lesion partial articular supraspinatus tendon avulsion
Chronic Anterior Instability Non-op Controversial surgical treatment in pitchers less is more Arthroscopic Open shift Return to play?
Associated pathology - Biceps Biceps irritation 2 major leaguers pitching with biceps tenotomy Elway Superbowls
Posterior Instability
Posterior Instability Football linemen especially in passing offenses MVA, i.e. dashboard injury
Posterior Instability Acute or chronic Usually subluxation, rarely dislocation
Acute Posterior Instability Attempt non-op treatment
Chronic Posterior Instability Associated with labrum tears and paralabrum cysts
Chronic Posterior Instability Failed conservative treatment Arthroscopic is my preference Steep learning curve
Postop Posterior Labrum gunslinger Repair Return to play/work 3 to 4 months
SLAP Tear
SLAP tear Superior Labrum Anterior to Posterior Described in the mid 80s Types
SLAP tear Nonop treatment for most Injection, therapy, activity modification Reason to fix mechanical symptoms fail conservative time off work Paralabrum cyst Suprascapular N.
Weakness external rotation
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)
SLAP tear Trend is to perform biceps tenodesis and just debride slap Why? ADHESIVE CAPSULITIS Rotator cuff interval
SLAP tear - surgery I lean toward biceps tenodesis in over 40 y/o Just BT and debride labrum in > 60
SLAP tear - surgery
SLAP placement of anchor
SLAP Repair
SLAP PostOP Care MOTION IMMEDIATELY STIFFNESS ADHESIVE CAPSULITIS Sling for 4 weeks Return to work variable
MDI Multidirectional instability Overhead athletes Esp females swimmers, volleyball Collagen disorders
MDI Therapy, therapy therapy Voluntary subluxors Rarely operate
MDI - surgery Arthroscopic my preference Anterior and post capsulorraphy Include tightening/closure of anterior interval
6 weeks in sling MDI - postop
Biceps Tendon Function 3 joints supinator forearm flexion elbow, shoulder stabilization shoulder Dr. Knight kinesiology blog-spot.com
Biceps Tendon pain generator Tenotomy versus tenodesis
Biceps Tenodesis Intraarticular Above subscap At subscap Below subscap Sub pec Tying to conjoined tendon
Fixation methods Biceps Tenodesis
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
Disclosures
Biceps Tenodesis Methods: IS anchor soft tissue sub pec open bicipital groove open/ats transfer button screw/washer
Review of Literature 7 studies Variables: cadaver, sheep, porcine, 5 different types of anchors, diff lengths of screws, subpec, proximal Anchor 68 561 N Av 206 Highest human: 252 N IS 116 528 N 246 N Native strength 667 890 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. 24 33-43. 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 58:322-340, 1933.
Background Cheaper, easier way to do biceps tenodesis Decrease equipment Complications: fracture failure pain
Pain, Fracture
Intra-articular biceps tenodesis Flex shoulder to 70 deg Use 30 deg scope Subscap repair anchor placement
Circumferential, locked stitches
Looking for a better way. Intra-articular BT 2010 ICL #106 Snyder Older individuals works well What about younger, higher demand patients?
Basic Science and Clinical Study
Purpose Purpose: To compare two suture anchor biceps tenodesis fixation techniques: arthroscopic intra-articular and open subpectoral. Type of Study: Biomechanical
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
Anchor Placement Intraarticular Locked stitch 1 2 Subpec open Krackow stich
N Newtons Table 2. Results Pair Arthroscpic (N) Open subpectoral (N) 1 97.2 196.1 2 210.7 148.1 3 153.2 131.6 4 207.2 213.6 5 193.7 227.3 AVERAGE 172.4 ± 47.8 183.3 ± 41.6 There was no statistically significant difference
Results Mode of failure: consistently suture tearing through the tendon 9/10 One subpec anchor pulled out of the bone.
239 BT 2010-2011 Clinical Data Consecutive patients work comp, smokers, medicaid, military, legal, revisions min 6 mo f/u (6-24 mo) Age 23 84 (mean 58, SD 10)
Clinical Data Mean Dash: pre 79 (SD 23) post 44 (SD 19) Mean Improvement: 35 (40%) P <.0001 0.683 correlation between pre-surg Dash and improvement No difference in age, gender, or with or without RTC tear 5 failures (2.1%)
Conclusion The tenodesis described provides reliable pain relief and biomechanical, clinical strength tendon quality > fixation, location
Total Shoulder Resurfacing Brett M. Cascio, MD, Derek Hinds, MD, Chelsa Patterson, ATC www.casciosportsmed.com
Disclosures
Long term results of Total Resurfacing Levy O, Copeland S. surface replacement arthroplasty for osteoarthritis of the shoulder. J Shoulder Elbow Surg. 2004. May-Jun; 13:266-71 Prichett J, Townsley C. Long-term results and patient satisfaction after shoulder resurfacing. J Shoulder Elbow Surg 2011. 20. 772-777 High patient satisfaction Pain, ROM Concern about glenoid
Concern #1: Glenoid loosening especially active younger patients Matsen FA 3rd, Lippitt SB. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2004. Principles of glenoid arthroplasty; p 508.
Concern #2: Total Resurfacing is technically challenging Intact head Access can be a struggle Weekly Standard
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
Early Success with inlay design -Ross M, Duke P. Early experience in the use of a new glenoid resurfacing technique. 2006 Shoulder & Elbow Soc Australia Conf Handbook. Nov 4; Session 4: 0800 0930. - Anand Murthi, MD
Inlay glenoid - 2 sizes Small post Cemented
Purpose of this study Novel total shoulder resurfacing implant Inlay, load sharing glenoid Anatomically correct resurfacing head
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
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
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
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
Concerns Coverage, fixation of glenoid How much activity is okay? How long will glenoid last and is it worth it?
Conclusions Reliable pain relief Reliable ROM improvement Preserves bone Unanswered questions
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