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FridayGeneralSession

CommonShoulderConditionsforthePrimaryCarePhysician

BenjaminSzerlip,DOOrthopedicSurgeonAustinShoulderInstituteAustin,TexasEducationalObjectivesBycompletingthiseducationalactivity,theparticipantshouldbebetterableto:

1. Listcommonshoulderconditionsseeninpatients.2. Discusshistoryandexamfindingsthatarehighlyindicativeofeachcondition.3. Predictthelikelihoodofresolutionwithconservativecare.4. Determinewhentoorderimagingorrefertoaspecialist.

SpeakerDisclosureDr.Szerliphasdisclosedthathehasnoactualorpotentialconflictofinterestinrelationtothistopic.

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Common Shoulder Problems and Treatment Options

Common Shoulder Problems and Treatment Options

Benjamin W. Szerlip D.O.

Austin Shoulder Institute

Benjamin W. Szerlip D.O.

Austin Shoulder Institute

Speaker DisclosureSpeaker Disclosure

Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.

Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.

Learning ObjectivesLearning Objectives

By completing this educational activity, the participant should be better able to:

1. List common shoulder conditions seen in patients.

2. Discuss history and exam findings that are highly indicative of each condition.

3. Predict the likelihood of resolution with conservative care.

4. Determine when to order imaging or refer to a specialist.

By completing this educational activity, the participant should be better able to:

1. List common shoulder conditions seen in patients.

2. Discuss history and exam findings that are highly indicative of each condition.

3. Predict the likelihood of resolution with conservative care.

4. Determine when to order imaging or refer to a specialist.

OverviewOverview

Anatomy

Why do we have shoulder pain?

What is new today?

What can patients expect?

Anatomy

Why do we have shoulder pain?

What is new today?

What can patients expect?

AcromioclavicularSternoclavicularScapulothoracicGlenohumeral

≠Minimally ConstrainedNot Ball-in-Socket

Balance of Stability & MobilityStatic vs. Dynamic

A coordinated complex ofIntercalated joints…

Normal Anatomy: Static Articular Components

Articular Area ~3X GlenoidUniform Articular Thickness

Approximately Spherical

The Humerus: Surface Area Mismatch

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Anatomy of the HumerusAnatomy of the Humerus

Everyone is Different!!

Everyone is Different!!

Glenoid LabrumGlenoid Labrum

• Extends the articular arc & deepens the glenoid socket

• Does not change the radius of curvature of the glenoid surface

•Reversibly deformable tissue

Williams & Iannotti

Bumper → Conforming to Humeral Head

The Labrum: Essential Stability

Shoulder Joint PainShoulder Joint Pain

Rotator Cuff Impingement, Tendinitis and Tears

Arthritis

Instability/ Labral Tears

AC Joint separation

Fracture

Biceps Tears

Irreparable Rotator Cuff Tears

Rotator Cuff Impingement, Tendinitis and Tears

Arthritis

Instability/ Labral Tears

AC Joint separation

Fracture

Biceps Tears

Irreparable Rotator Cuff Tears

Rotator Cuff Tears -Natural History

Rotator Cuff Tears -Natural History

17 million/year

Prevalence increases with age (>50% in individuals beyond 75 yrs. Old)

Not all tears symptomatic

>50% of previously asymptomatic tears develop symptoms of pain ( 2.8 yrs. f/u)

40% of tears increase in size over 5 yr. f/u

80% of pts. whose tear enlarges develop symptoms

17 million/year

Prevalence increases with age (>50% in individuals beyond 75 yrs. Old)

Not all tears symptomatic

>50% of previously asymptomatic tears develop symptoms of pain ( 2.8 yrs. f/u)

40% of tears increase in size over 5 yr. f/u

80% of pts. whose tear enlarges develop symptoms

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Rotator Cuff - SymptomsRotator Cuff - Symptoms

Pain at night

Weakness

Loss of function

Lateral arm pain

Pain at night

Weakness

Loss of function

Lateral arm pain

Role of MRI in Rotator Cuff TearsRole of MRI in Rotator Cuff Tears

Partial vs. full thickness tears Location of tear Size of tear Muscle atrophy

Ultrasound a useful alternative in experienced hands

Partial vs. full thickness tears Location of tear Size of tear Muscle atrophy

Ultrasound a useful alternative in experienced hands

Rotator Cuff TearWho Needs Surgery?

Rotator Cuff TearWho Needs Surgery?

Younger, more active individuals

Acute, traumatic tears

Higher demand individuals

“Fixable” tears

Persistent symptoms despite non-operative treatment

Younger, more active individuals

Acute, traumatic tears

Higher demand individuals

“Fixable” tears

Persistent symptoms despite non-operative treatment

Rotator Cuff Repair – Best PrognosisRotator Cuff Repair – Best Prognosis

Acute cuff tears

Smaller, more mobile tears

No /minimal muscle atrophy

Younger patient (under 70)

Acute cuff tears

Smaller, more mobile tears

No /minimal muscle atrophy

Younger patient (under 70)

40 yo man falls skiing… can’t raise arm 72 yo woman with gradual weakness and pain

Primary Portals

Accessory Portals

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Identify Tear PatternIdentify Tear Pattern

Crescent U-Shaped L-Shaped

Margin ConvergenceSide-to-Side Repair

Margin ConvergenceSide-to-Side Repair

Results – Rotator Cuff SurgeryResults – Rotator Cuff Surgery

95% pain relief

10% - 26% retear rate (sm.-med. Tears)

20% - 38% retear rate (large tears)

Better long-term function if tendon repair remains intact

Retear Rate not directly related to clinical outcome

95% pain relief

10% - 26% retear rate (sm.-med. Tears)

20% - 38% retear rate (large tears)

Better long-term function if tendon repair remains intact

Retear Rate not directly related to clinical outcome

Arthroscopic Advancements in Rotator Cuff Repair

Arthroscopic Advancements in Rotator Cuff Repair

Bioabsorbable/bone replacing anchors

High strength non-absorbable suture

Suture passing devices

“Double row” fixation (increase surface area of repair)

Surgeon experience/training (video games?)

Bioabsorbable/bone replacing anchors

High strength non-absorbable suture

Suture passing devices

“Double row” fixation (increase surface area of repair)

Surgeon experience/training (video games?)

Shoulder ArthritisShoulder Arthritis

43 million American adults diagnosed

100 different types

OA or “Wear-and-tear arthritis” – most common

Exact causes are unknown

Researchers say genetics may play a role in 40-65 percent of knee osteoarthritis cases

43 million American adults diagnosed

100 different types

OA or “Wear-and-tear arthritis” – most common

Exact causes are unknown

Researchers say genetics may play a role in 40-65 percent of knee osteoarthritis cases

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Osteoarthritis – The Bad NewsOsteoarthritis – The Bad News

Cartilage – the “cushion” – between joints breaks down

Bones begin to erode, bone spurs develop

Symptoms – pain, stiffness, decreased mobility

Disease and symptoms worsen over time

Hips & knees are more common (>1,000,000 replacements/year)

Cartilage – the “cushion” – between joints breaks down

Bones begin to erode, bone spurs develop

Symptoms – pain, stiffness, decreased mobility

Disease and symptoms worsen over time

Hips & knees are more common (>1,000,000 replacements/year)

Osteoarthritis – The Good NewsOsteoarthritis – The Good News

There are things patients can do!

More is known, and more treatments are available, than ever before

Lifestyle changes can help patients feel good, and maintain strength, mobility

Medications to relieve pain

Joint replacement to eliminate pain, restore mobility

There are things patients can do!

More is known, and more treatments are available, than ever before

Lifestyle changes can help patients feel good, and maintain strength, mobility

Medications to relieve pain

Joint replacement to eliminate pain, restore mobility

What do I need to know?What do I need to know?

Hx – Pain level, Night pain, subjective shoulder function (SSF)

Physical exam –restricted motion, intact rotator cuff, nerves working

X-rays – show joint deterioration, bone erosion, excess fluid, bone spurs

DON’T FORGET THE OTHER THINGS!!

Hx – Pain level, Night pain, subjective shoulder function (SSF)

Physical exam –restricted motion, intact rotator cuff, nerves working

X-rays – show joint deterioration, bone erosion, excess fluid, bone spurs

DON’T FORGET THE OTHER THINGS!!

What we know VS what we think we know

What we know VS what we think we know

Arthroplasty

Short press fit stem

Stemless

3D software for pre op planning/ intraoperative guides

Augmented glenoid in TSA/ RSA

Arthroplasty

Short press fit stem

Stemless

3D software for pre op planning/ intraoperative guides

Augmented glenoid in TSA/ RSA

3 Goals Of All Treatments For Osteoarthritis

3 Goals Of All Treatments For Osteoarthritis

1. Control Pain and other symptoms caused by the disease

2. Optimize Function, including the impact of osteoarthritis on mobility and the activities of daily living

3. Educate Patients and families about the disease and treatment options for osteoarthritis

1. Control Pain and other symptoms caused by the disease

2. Optimize Function, including the impact of osteoarthritis on mobility and the activities of daily living

3. Educate Patients and families about the disease and treatment options for osteoarthritis

Temporary ReliefTemporary Relief

Aspirin-Free Pain Relievers

Anti-inflammatory Drugs

Intra-articular Injections

Disease Modifiers

Sleep Aids

Aspirin-Free Pain Relievers

Anti-inflammatory Drugs

Intra-articular Injections

Disease Modifiers

Sleep Aids

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What Makes Someone A Good Surgical Candidate?

What Makes Someone A Good Surgical Candidate?

Everyday activities are difficult

Shoulder pain continues while resting, either day or night

Stiffness limits your ability to move or lift your arm

Little pain relief with non-surgical solutions

Harmful or unpleasant side-effects from medications

Nonoperative treatments no longer work

Everyday activities are difficult

Shoulder pain continues while resting, either day or night

Stiffness limits your ability to move or lift your arm

Little pain relief with non-surgical solutions

Harmful or unpleasant side-effects from medications

Nonoperative treatments no longer work

Surgical SolutionsSurgical Solutions

1. Shoulder Arthroscopy

2. Partial Shoulder Replacement

3. Total Shoulder Replacement

4. Reverse Shoulder Replacement

1. Shoulder Arthroscopy

2. Partial Shoulder Replacement

3. Total Shoulder Replacement

4. Reverse Shoulder Replacement

Shoulder ArthroscopyShoulder Arthroscopy

Joint is viewed using a camera, inserted through a small incision

Other instruments are inserted through additional small incisions

The orthopaedic surgeon can diagnose and treat joint disorders by providing a clear view of the joint.

Allows the surgeon to treat problems other than shoulder arthritis

Joint is viewed using a camera, inserted through a small incision

Other instruments are inserted through additional small incisions

The orthopaedic surgeon can diagnose and treat joint disorders by providing a clear view of the joint.

Allows the surgeon to treat problems other than shoulder arthritis

Why do we Replace the Shoulder?Proximal Humerus Fractures

Why do we Replace the Shoulder?Proximal Humerus Fractures

Reverse for FractureReverse for Fracture Stemless: What we think…Stemless: What we think…

Potential advantages

Canal sparing

Decreased blood loss

Preserve bone

Solution with deformity/ Malunion

Decrease prosthetic fracture

Ease of revision

Marketing to patients

Potential advantages

Canal sparing

Decreased blood loss

Preserve bone

Solution with deformity/ Malunion

Decrease prosthetic fracture

Ease of revision

Marketing to patients

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Total Shoulder ReplacementTotal Shoulder Replacement

The glenoid socket is replaced with a plastic insert that is glued in with bone cement

The humeral head is replaced with a metal prosthesis

The glenoid socket is replaced with a plastic insert that is glued in with bone cement

The humeral head is replaced with a metal prosthesis

Reverse Shoulder ArthroplastyReverse Shoulder Arthroplasty

Technique Modification Critical

Technique Modification Critical

2016

20172015

Shoulder Replacements are SuccessfulShoulder Replacements are Successful

Joint replacement surgery among the most common surgery performed in the US

Shoulder replacements are the 3rd most common

Shoulder replacements have shorter hospitalizations and fewer complications than hip and knee replacements

Joint replacement surgery among the most common surgery performed in the US

Shoulder replacements are the 3rd most common

Shoulder replacements have shorter hospitalizations and fewer complications than hip and knee replacements

Over 60,000 shoulder replacements are performed annually in the U.S.

OsteoarthritisOsteoarthritis Total Shoulder ReplacementTotal Shoulder Replacement

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Too HighToo Large

TOO SMALL A HEAD

TOO SMALL A HEAD

Glenoid Loosening

Poly wearTHE HUMERUS AND GLENOID

ARE MARRIED…..…IN THIS CASE THERE IS

A DIVORCE…

RESULTS

50yo woman: NationalChampion in Horse-jumping 48 yo Former Triathlete

49 yo Electrician(bilateral TSR)

191 Patient 1 yr F/U:

“Are you happy & would youDo it again?” 98.5% Yes

“What percent of normal isYour shoulder?” 97.5%

> 80%; 35% with “normal”

(unpublished: Warner, Millett, Higgins)

Average age = 53yo

I HAVE NO PAIN….AND MY SHOULDER FEELS LIKE A NORMAL SHOULDER

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ComplicationsComplications Infection CATASTROPHIC!!!!!

Diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, remote sites of infection, and previous operations on the shoulder

Infection CATASTROPHIC!!!!!

Diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, remote sites of infection, and previous operations on the shoulder

ComplicationsComplications

Glenoid Wear/Glenoid Loosening 1/3 complications

3rd generation cementation technique

Glenoid Wear/Glenoid Loosening 1/3 complications

3rd generation cementation technique

ComplicationsComplications

Instability 0-29%Anterior – subscapularis tears

Superior – rotator cuff tears

Instability 0-29%Anterior – subscapularis tears

Superior – rotator cuff tears

ComplicationsComplications

Periprosthetic fractures Periprosthetic fractures

ComplicationsComplications

Periprosthetic fractures Periprosthetic fractures

The Reason for Improvement

The Reason for Improvement

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ComplicationsComplications

Rotator Cuff Tears Natural history?

Nonanatomic prostheses?

Stiffness

Bleeding

Nerve damage Rarely Permanent

Mostly Neuropraxias

Rotator Cuff Tears Natural history?

Nonanatomic prostheses?

Stiffness

Bleeding

Nerve damage Rarely Permanent

Mostly Neuropraxias

3D Pre Op Planning and PSI 3D Pre Op Planning and PSI

Improving patient outcomes

Optimizes glenoid bone preservation

Improves Implant accuracy/ selection

No cost/ downside for planning

Real time planning

Patient specific options

Improving patient outcomes

Optimizes glenoid bone preservation

Improves Implant accuracy/ selection

No cost/ downside for planning

Real time planning

Patient specific options

Notes