Degenerative Conditions in the Shouldershoulderandelbow.com.au/images/students/Dr_Trantalis... ·...

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DegenerativeConditionsintheShoulder

Dr JohnTrantalisOrthopaedicSurgeon

W shoulderandelbow.com.au

MyProfile• Dr JohnTrantalis• MBBSUNSW1996• GainedFellowshipinOrthopaedicSurgery2007with:– RoyalAustralasianCollegeofSurgeons– AustralianOrthopaedicAssociation

• Shoulder&ElbowFellowshipinCanadaandSydney2007/08.

TreatmentofLocalizedDisease:LocationLocationLocation!!

PatientHistory1. Painprofile: SOCRATES

– Location– MechanicalPain?e.g shoulder

painworsewithoverheadactivities.

2. FunctionalProfile– Howdoestheproblemeffectthe

patient’sfunctionalactivities

3. JointProfile– MechanicalJointSymptoms:

Clicking,Locking,Instability,Swelling

TreatmentofLocalizedDisease:Examination

1. Look• Wasting,Scars,Posture,etc

2. Feel• Tenderness:Location!!!!!!• Especiallyinshoulder

3. Move• Activemotion• PassiveMotion

4. Specialtests

KeytoShoulderExamination:PassivevsActiveMotion

• ACTIVEMOTION– Patientmovesthejointontheirown

• PASSIVEMOTION– Theexaminermovesthejointforthepatient

• If the joint is stiff:

Ø Both active and passive motion will be restricted

• If all the tendons are torn off…

Ø Only active motion is affected.... Passive preserved.

PASSIVEvs ACTIVEmotion

• Loss of active Motion• Preserved Passive Motion

Ø Massive Cuff Tear

• Loss of Active and Passive Motion

Ø Shoulder Arthritis or Frozen Shoulder

OnlineVideoTutorial:HowtoExamineShoulders

These Video Tutorials can be viewed Online:

Shoulder: shoulderandelbow.com.au

TheShoulderJoint

• GreatROM• VeryShallow

Socket• Mostfrequently

dislocatedjoint

• RotatorCuff

Dr John TrantalisShoulder & Elbow Surgery

ConditionsAffectingtheAdultShoulder

• Age>40y• 85%“RotatorCuffSyndrome”

– RotatorCuffTendonosis andTears– Impingement– LongHeadofBicepsTendonPathology– Acromioclavicular JointPathology

– 10%FrozenShoulder(akaAdhesiveCapsulitis)– 4%Osteoarthritis– 1%other

ConditionsAffectingtheAdultShoulder

• Age<30y– 85%InstabilityofGlenohumeralJoint

• LabralTears

– 15%Other

FunctionoftheShoulderJointinHuman:PositiontheArminSpace

RECENTEVOLUTIONARYCHANGESEXPLAINTHEPATTERNOFDEGENERATIVESHOULDERCONDITIONS

From4legsto2:TheEvolutionoftheShoulderJoint

•Hitchcock JBJS 1948

NOWLET’SFOCUSONTHEACTUALCLINICALCONDITIONS…...

TENDONOSIS:WEARANDTEAROFTENDONSOVERTIME

Tendinosis:LifeExpectancyovertheAges

TheShoulder:Tendonosis

StressFatigueFailure

HowdoesbodyCombatStressFatigue:Regeneration/Healing

RegenerativeCapacityandVascularityofanOrgan

Muscle TendonBone

Tendon:PoorHealingPotential

Tendonosis increaseswithage

DoesTendonosis leadtoTendontears

The Function of the Rotator Cuff

“Effect of Massive Rotator Cuff Tears”

Rotator Cuff

• Supraspinatus• Infraspinatus• Teres Minor• Subscapularis• Integrated Unit

Rotator Cuff Function

• Humeral head depressor / compressor

• RC always co-contracts with the deltoid.

• Deltoid cannot function without the RC

Deltoid contracting alone

Cantilever EFFECT: Co-Contraction of Deltoid and Rotator Cuff

Unbalanced CUFF TEARS: Massive Rotator Cuff Tears

Normal Massive tear: Proximal Humeral Migration

Consequences of a Massive Unbalanced Cuff Tear à Cuff Tear Arthropathy

ROTATORCUFFTENDONOSIS,TEARSANDSUBACROMIALIMPINGEMENET

RCTendonosis andImpingement

AnatomicalChangesContributingtoSubacromialImpingement

Acromial Spurs RC Tendonosis / Thickened Tendon

ImpingementSigns

Neers Hawkins

RotatorCuffTears:Anatomy

• Supraspinatus70%• Infraspinatus30%• Subscapularis20%• Teres Minor5%

RotatorCuffTears:ClinicalPresentation

• Pain– Lateral/Anterior– Wakesuppatientatnight

– Worsewithoverheadactivities

• Examination– Lossofactivemotion– PreservedPassivemotion

RotatorCuffTears:PainwithResistedtestingofmuscles

• Supraspinatus– ForwardElevation

• Infraspinatus/TeresMinor– ExternalRotation

• Subscapularis– InternalRotation

RotatorCuffTears:PainwithResistedTestingofPower

RotatorCuffTears:XRAY/US/MRI

RotatorCuffTears:Non-opTreatment

• Analgesics• ModificationofActivities

• CorticosteroidInjections

• Physiotherapy

RCT’s:SurgicalTreatment

• RepairofRotatorCuff– Open– Arthroscopic

• Longrecovery(6months)butgoodresults

When should a patient with a Rotator Cuff Tear be offered Surgery Semi-Urgently?

MASSIVE CUFF TEARS

– Middle Aged Patient After a Shoulder Dislocation

– Shoulder Injury Leading to Loss of Ability to Lift Arm Above Head

Acute Massive Rotator Cuff Tears

Patient can’t actively lift arm above shoulder level (but passive motion maintained)

Why is this surgery so “urgent”?

Why not trial non-operative management then surgery if this

fails?

What happens to the tendon and muscle after a cuff tear

• Tendon - contracts and shortens

• Muscle belly - Turns into fat

• These changes – Are IRREVERSIBLE– occur rapidly within 12 weeks

Tendon Retraction with Large Cuff Tears

Muscle Wasting and Fatty Infiltration

Significance of these Irreversible Cuff Changes

• Lower the chance of a successful outcome with surgery.

• Early repair of the rotator cuff àstops the progression of the changes

MassiveCuffTearsà CuffTearArthropathy

Clinical Case: 63yo Sign Writer

2 weeks after shoulder

dislocation

Massive Tears fixed early have a much better outcome than chronic massive tears

Acute Massive TearEasy to repair with Low Tension

Chronic Massive TearToo tight / shrunken to allow a repair

Clinical Case: 63yo Sign Writer2 weeks after shoulder dislocation

Double Row Repair

6 months post-op

OSTEOARTHRITISOFTHEGLENOHUMERALJOINT

GlenohumeralOsteoarthritis

• Uncommon– Notaweightbearingjoint

• UsuallyolderPopulation

GlenohumeralOsteoarthritis

• Pain– Anterior– Chronic– Worsewithmovement

• Examination– LossofactiveANDpassivemotion

GlenohumeralOsteoarthritis:Imaging

• XRAY– LossofGlenohumeraljointspace

– Osteophytes• “BeardOsteophyte”

GlenohumeralOsteoarthritis:Treatment

• Non-operative– Analgesics– ModificationofActivities– CorticosteroidInjections

• Operative– ShoulderReplacement

• Half• Total

CuffTearArthropathy oftheShoulder

Unbalanced CUFF TEARS: Massive Rotator Cuff Tears

Normal Massive tear: Proximal Humeral Migration

Consequences of a Massive Unbalanced Cuff Tear à Cuff Tear Arthropathy

CuffTearArthropathy:ClinicalFeatures

• ChronicShoulderpain– Anterior/lateral– Worsewithactivity

• Examination– ReducedActiveMotion– Variablepassivemotion

• XRAYisdiagnostic

“Normal”Osteoarthritis

XRAY Clues for Cuff Tear Arthropathy:“Proximal Migration of Humeral Head

Cuff Tear Arthropathy

- Acromiohumeral distance- Humeroscapular curve

XRAY Clues for Cuff Tear Arthropathy:“Shoulder becomes a Hip Joint”

“Normal”OsteoarthritisCuff Tear Arthropathy

Femoralisation of Humeral HeadAcetabularisation of Acromion / Glenoid

CuffTearArthropathy:Non-OperativeManagement

• Analgesics• ModificationofActivities

• CorticosteroidInjections

• Physiotherapy:– AnteriorDeltoidStrengtheningExercises

CuffTearArthropathy:SurgicalManagement

• Reverse Total Shoulder Replacement

• Good for improving pain AND active motion

WhatisaREVERSEShoulderReplacement?BallandSocketReversed.

Normal Shoulder Standard Shoulder Replacement Reverse Shoulder

Replacement

Can’tdo“Standard”ShoulderReplacement:Glenoidloosens

ReverseTSR:WorksbyLeverMechanism

Acromioclavicular Joint:Anatomy

• SmallFibrocartilaginousJoint

• StabilizedmainlybyCoracoclavicularLigaments

Acromioclavicular Joint:DegenerativeArthritis

• PresentonXrays inalmostallindividuals>50yearsBUT

• Usuallynotsymptomatic

Acromioclavicular Joint:DegenerativeArthritis

• Pain– Superior,directlyoverACjoint

– Worsewithactivitiy

• Examination– TendernessdirectlyoverACjoint

Acromioclavicular JointOA:Exam

Acromioclavicular Joint OA:Imaging

• Xray– NarrowingofACJoint– OsteophytesfromAC

• MRI– ACjt degeneration– Oedema inlateralend

ofclavicle

Acromioclavicular JointOsteoarthritis:Treatment

• Non-operative– Analgesics,– Corticosteroidinjections– ModificationofActivities

• Operative– Excisionsoflateralendofclavicle

• Open• Arthroscopic

LongHeadofBiceps:Anatomy

EvolutionaryAnatomy

• Quadrupeds(e.g horse)– Bicepsonlyhasoneheadproximally– Importantforelevatinglimbafterstance,andlockinglimbinstancephase

– thebicepstendonfitsoverthehumeralheadandlockstheforelimbformingthepassivestayapparatusinstance.

From4legsto2:TheINvolution oftheLongHeadofBiceps

4 legs --------------------------à 2 legs

Anatomical Changes indicate that the role of the biceps tendon in the shoulder is lessening

LongHeadofBicepsTendon

• Tendinitis• Instability• LongitudinalTears/Splits

• Tendinopathy• Rupture(Popeye)

BicepsTendonProblems:History

• Pain– Anterior– Radiatesdownthefrontofthearm

– Worsewithactivity

• Clicking– Withbicepsinstability

BicepsTendonProblems:Examination

• Tenderness– OverBicepsTendonanteriorly

• Painwithresistedforwardelevation

BicepsTendonProblems:Investigation

• XRAY(screeningtest)

• MRI

• Ultrasound:dynamic

BicepsTendonProblems:Treatment

• Non-operative• Analgesics,• Corticosteroidinjections• ModificationofActivities

• Operative• Tenotomy

• Justcutitandletitdrop• Tenodesis

• Attachittothehumerus

KeyPoints

• Increaseinlifeexpectancyiscoincidentwiththemechanicalfailureoftherotatorcuff.

• Tendonosis andCuffTearsaremostlyawearandtearphenomenonoftheshoulder.

Thank You

Lake Louise, Alberta, Canada

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