2/19/2014. Things I love. What s new in shoulder surgery? What s new in medicine? Outline. Focus on problem-based learning for medical school

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1 Things I love What s new in shoulder surgery? Brian Feeley, MD. UCSF Sports Medicine What s new in medicine? Focus on problem-based learning for medical school Outline Shoulder basics Anatomy Differential Diagnosis (What can go wrong) Shoulder history and physical exam What s new in common shoulder problems? Frozen shoulder Impingement Syndrome/Rotator Cuff Tears Shoulder Arthritis Focused recent scientific evidence 1

Goals Understand how the shoulder functions Be able to diagnose

) common shoulder problems Know what state of the art evidence

capabilities Greatest ROM in body Very little inherent stability

2 Goals Understand how the shoulder functions Be able to diagnose and manage (even on your own!) common shoulder problems Know what state of the art evidence shows for treatment of shoulder problems Everyone here should want to be a shoulder surgeon! The Shoulder a complicated joint Shoulder has amazing capabilities Greatest ROM in body Very little inherent stability Dynamic Stabilizers Static Stabilizers Anatomy of the Shoulder Deltoid Origins Anterior, Middle, Posterior Deltoid Tuberosity Innervation: Axillary Nerve 2

Muscle-Tendon-Bone Unit Rotator Cuff (dynamic stabilizers)

Teres Minor Subscapularis Motion and stability Balance

Supraglenoid / superior labral origin Stabilizer when

$(capsule) Surgical neck (fractures) 3 Tuberosities Greater$

3 Muscle-Tendon-Bone Unit Rotator Cuff (dynamic stabilizers) TENDON-ATTACHES MUSCLE TO BONE Suprapinatus Infraspinatus Teres Minor Subscapularis Motion and stability Balance deltoid pull Active and passive restraint Long Head Biceps Supraglenoid / superior labral origin Stabilizer when shoulder rotating AND elbow flexing Glenohumeral joint One-third of a sphere Head-shaft angle 130 Anatomic neck (capsule) Surgical neck (fractures) 3 Tuberosities Greater Lesser Deltoid (static stabilizer) 3

4 Glenoid Fossa (static stabilizer) Glenoid Labrum (static stabilizer) Small, pear-shaped, bony depression Surface area 33% humeral head Overall, bony contact minimal Triangular in cross-section Increases humeral contact area Increases glenoid depth 50% Anchors the capsule Added stability without compromising motion Biceps origin Putting it all together-real time anatomy Biomechanics of the Shoulder 4

Force Couple Concept Superior Migration Rotator cuff tendons

forces create Force Couple Maximize rotation, minimize shear

supraspinatus tendon does not give superior migration Has to

Differential Diagnosis What can go wrong?

Cuff Tears (45%) Shoulder arthritis (15%) Frozen shoulder

5 Force Couple Concept Superior Migration Rotator cuff tendons downward, medial Deltoid muscle upward, outward Opposite forces create Force Couple Maximize rotation, minimize shear Instability Degenerative changes Loss of Force Couple Isolated supraspinatus tendon does not give superior migration Has to have involvement of subscapularis or infraspinatus tendon Differential Diagnosis What can go wrong? Approach to shoulder problems Differential Diagnosis Rotator Cuff Tears (45%) Shoulder arthritis (15%) Frozen shoulder (15%) Biceps problems (15%) Dislocations (5%) Fractures (5%) Bruise (5%) Cervical spine problems (25%) 5

Approach to shoulder problems Differential Diagnosis Rotator Cuff Tears (45%) Shoulder arthritis (15%) Frozen shoulder (15%) Biceps problems (5%) Dislocations (5%) Fractures (5%) Bruise (5%) Cervical

6 Approach to shoulder problems Differential Diagnosis Rotator Cuff Tears (45%) Shoulder arthritis (15%) Frozen shoulder (15%) Biceps problems (5%) Dislocations (5%) Fractures (5%) Bruise (5%) Cervical spine problems (25%) SHOULDER ARTHRITIS Pain all the time, loss of motion Good history + Complete physical exam = Correct diagnosis in 95% of cases 2 steps Patient history Physical examination (Radiographs) (Advanced imaging) HISTORY Key questions to ask 1. Was there an acute injury? 2. Are you losing strength? Physical Examination Visual inspection Palpation Motion Specific testing 3. Are you losing range of motion? 6

Visual Inspection Visual Inspection Remove shirt Systematic Don t let them take off too much

football tackle Skin changes Scars Palpation RANGE OF MOTION Press where it hurts Location

$shoulder Clavicle fracture AC joint arthritis Muscle strain Biceps pathology Arthritis If$

7 Visual Inspection Visual Inspection Remove shirt Systematic Don t let them take off too much clothing Deltoid Supraspinatus Infraspinatus Biceps AC joint Axillary nerve injury after football tackle Skin changes Scars Palpation RANGE OF MOTION Press where it hurts Location Diagnosis ACTIVE ROM PASSIVE ROM Clavicle AC joint Trapezius/Neck Front of shoulder Back of shoulder Clavicle fracture AC joint arthritis Muscle strain Biceps pathology Arthritis If poor think rotator cuff tear If poor think frozen shoulder or shoulder arthritis and STOP THE EXAM 7

8 Rotator Cuff Testing Impingement --Neer s/hawkins tests Muscle Strength --Teres Minor --Infraspinatus --Supraspinatus --Subscapularis Rotator Cuff Impingement Hawkins Test 75% sensitive 49% specific Neer s Test 85% sensitive 44% specific Park, et al. JBJS 2012 Supraspinatus Infraspinatus Jobe s test 90º abduction 30º anterior flexion Internal rotation (palms down) Pain/weakness 30 External rotation strength 0º abduction & 45º ER 53% sensitive/82% spec. (Park, et al. JBJS 12) Infraspinatus 8

Case 1 Key points in the history Physical Examination Was there an acute injury?

9 Common Shoulder Problems Case 1 54 year old woman presents with 4 months of shoulder pain that occurred after taking her jacket off. She now has trouble getting things off high shelves and can t put her belt on. Case 1 Key points in the history Physical Examination Was there an acute injury? Yes, but not really Are you losing strength? No Are you losing range of motion? YES, OH YES! Visual inspection Palpation Motion Specific testing 9

10 Frozen Shoulder=Adhesive Capsulitis Key points in the history and physical No real trauma Pain all the time Limited ROM Causes 2 nd most common cause of shoulder pain in US in patients Mostly unknown Associated with Diabetes, Thyroid Problems Natural History Thickening of capsule with Inflammatory cells and fibrosis 10

6 years 91% return to full/near full function Do Nothing Treatment Injections done

11 JSES 2012 Treatment Options 100 patients, 5 year follow up (no treatment) Average duration of symptoms-1.6 years 91% return to full/near full function Do Nothing Treatment Injections done blindly vs. injections done under ultrasound Patients with less pain at the time of injection More likely to get better after UTZ injection 11

groups got better faster than placebo group No side effects Risks: Can kill cartilage

Orthopaedic Research AJSM 2012 Not Risks: Will not turn you into this: Surgery for

of the Art: Frozen Shoulder 1976: May be auto-immune 2010-2013: Everyone will get better

12 Am J Sports Med 2012 Are steroids safe? 53 patients randomized to steroid (low or high dose) vs placebo Both steroid injection groups got better faster than placebo group No side effects Risks: Can kill cartilage cells Lidocaine and steroid Healthy cartilage Cartilage cells cells After lidocaine UCSF Orthopaedic Research AJSM 2012 Not Risks: Will not turn you into this: Surgery for Adhesive Capsulitis Only for people who fail non-operative 6 months PT, injections State of the Art: Frozen Shoulder 1976: May be auto-immune : Everyone will get better Injections may quicken improvement UTZ injections are more effective Use a low dose steroid Surgery only for those that fail all other treatment 12

Case 2 43 year old male, 6 months of shoulder pain, hurts at night, pain with overhead activity, no weakness. He says that he can t lift at the gym as well.

13 Case 2 43 year old male, 6 months of shoulder pain, hurts at night, pain with overhead activity, no weakness. He says that he can t lift at the gym as well. Case 2 Key points in the history Was there an acute injury? Not really Are you losing strength? Not really Are you losing range of motion? No Impingement of the Shoulder Very common in middle age people Insidious onset of pain Pain with overhead activities Pain at night (can t sleep on that side) Difficulty doing some, but not all ADLs No weakness Impingement Syndrome Mechanism Impingement under acromion with flexion and internal rotation of the shoulder Rotator cuff, subacromial bursa and biceps tendon Lateral view of shoulder 13

Impingement Signs-JAMA 2013 Hawkins test Flex

Positive - reproduce shoulder pain Sens = 88 % Spec

conservative treatment Use it to rule out

specific MRI MRIs almost always will show something

Patient history and physical exam are more

14 Impingement Signs-JAMA 2013 Hawkins test Flex shoulder to 90º Flex elbow to 90º Internally rotate Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 % NPV = 90 % MRI MRI not needed for conservative treatment Use it to rule out significant pathology How good for full thickness tears? 69 to 100 percent sensitive 88 to 100 percent specific MRI MRIs almost always will show something Should be used to augment diagnosis, not make it Patient history and physical exam are more important than MRI findings How good for full thickness tears? 69 to 100 percent sensitive 88 to 100 percent specific Tear 14

15 Treatment of Impingement When to Operate for Impingement? Rest, avoid offending activities Physical therapy (6-12 weeks) Rotator Cuff Strengthening Active/Passive ROM Periscapular exercises Upper extremity proprioception NSAIDS Consider steroid injection Surgery Impingement Mild pain with activity Night pain Moderate pain with activity Wakes pt. up Physical Therapy NSAIDS PT NSAIDS Consider injection Better Not Better Better Home Exercise Program MRI to evaluate for cuff tear Consider injection Home Exercise Program Surgery if not better Rotator cuff surgery in the US Vitale, Levine et al JBJS 2010 Review of NY State Database and ABOS 1996: 5571 acromioplasties=30.0/100k 2006: 19,743 acromioplasties=101.0/100k 1999: 2.6 acromioplasties/abos candidate 2008: 6.3 acromioplasties/abos candidate Outcomes of Impingement Non-operative Cummins, et al. JSES consecutive patients At 2 years, shoulder score % did not require surgery, but 30% still had pain Operative Henkus, et al. JBJS-Br year follow-up 93% good to excellent results 15

Yes Are you losing range of motion? No Rotator Cuff Tears What is a rotator cuff tear?

16 Case 3 56 year old male, 3 months of shoulder pain and weakness after an awkward fall while hiking. Hasn t been able to return to the gym. He has pain at night and lifting things is difficult. Case 3 Key points in the history Was there an acute injury? Yes Are you losing strength? Yes Are you losing range of motion? No Rotator Cuff Tears What is a rotator cuff tear? Impingement Partial Cuff Tear Full Thickness Tear Common condition over age of 60 As high as 40% of patients over 60 will have a tear Increasingly older population.who wants to stay active Loss of attachment of the tendon to bone Can be traumatic or without trauma Usually (but not always) causes shoulder pain and weakness 16

17 In the last 10 years.a lot has happened with rotator cuffs! In the last 10 years. Better recognition/diagnosis of rotator cuff tears Better recognition/diagnosis of rotator cuff tears MRI are better, but there are still limitations Better at fixing rotator cuff tears Better at fixing rotator cuff tears Are we doing too many? How do we fix big tears? Better understanding of the natural history of rotator cuff tears Better understanding of the natural history of rotator cuff tears We understand the tendon well, what about the muscle? Developed strategies to solve cuff tear arthropathy Developed strategies to solve cuff tears arthropathy How good is a reverse? 1 Diagnosis of Rotator Cuff Tears Subscapularis...the other rotator cuff Foad et al, Arthroscopy patients with arthroscopic subscap tear 25/40 the MRI was read as negative (with and without contrast) Waldt et al. Radiology % accurate at SS tears 17

18 Slide 67 1 Need accuracy here for Supra-infra tears Brian Feeley, 3/8/2012

19 2 Subscapularis the other rotator cuff In the last 10 years. Valone et al. (JSES 2014) Better recognition of the rotator cuff tears MRI are better, but there are still limitations 101 Subscapularis tears 8 had undergone previous surgery and missed diagnosis of subscapularis tear Average of 1.4 operations (Range 1-4) MRI showed Subscap tear 75% of time 6/8 had isolated subscap with healed supra tear 2/8 failed initial repair as well All repairs were able to be done arthroscopically with 1-2 anchors Better at fixing rotator cuff tears What is the biomechanically strongest construct? How do we fix big tears? Better understanding of the natural history of rotator cuff tears We understand the tendon well, what about the muscle? Developed strategies to solve cuff tears arthropathy How good is a reverse? Biomechanical progression of rotator cuff repairs Cuff Repair 1980 s Biomechanics (Park, TQ LEE, JSES 2007) Arthroscopic repair Single row 1990 s Gap formation equal 2000 s Double Row Transosseous Better anatomic footprint Stronger repair Better load to failure 18

20 Slide 69 2 Insert picture of repair--jai's article Brian Feeley, 3/8/2012

Arthroscopic Rotator Cuff Repair Rotator cuff surgery in the US

row: 80-90% Healing rates Double Row: 78-92% 3 Iyengar et al.

open repairs Conclusions: Outcomes remain dependent on tear size and

ABOS data pending Are young sports trained switching entirely to

21 Arthroscopic Rotator Cuff Repair Rotator cuff surgery in the US Saridakis, Jones AJSM 2012 Systematic Review Healing rates Single row: 80-90% Healing rates Double Row: 78-92% 3 Iyengar et al. (Arthroscopy 2014) Trends suggest more a/s vs. open repairs Conclusions: Outcomes remain dependent on tear size and muscle quality. No difference in outcome with SR vs DR. ABOS data pending Are young sports trained switching entirely to arthroscopic? How to fix bigger tears Cuff Repair Clinically more anchors is (May be) better for larger (>1 cm) tears AJSM

22 Slide 73 3 put a video or slide show in here need some papers to back this up Brian Feeley, 3/8/2012

In the last 10 years. Asymptomatic rotator cuff tears Better recognition of the rotator cuff tears MRI are better, but there are still limitations Yamaguchi et al.

23 In the last 10 years. Asymptomatic rotator cuff tears Better recognition of the rotator cuff tears MRI are better, but there are still limitations Yamaguchi et al. (JBJS 2006) Better at fixing rotator cuff tears Are we doing too many? How do we fix big tears? Better understanding of the natural history of rotator cuff tears We understand the tendon well, what about the muscle? Developed strategies to solve cuff tears arthropathy How good is a reverse? Patients with symptomatic rotator cuff tears were evaluated by ultrasound on contralateral side 40% had a rotator cuff tear on the asymptomatic side 50% became symptomatic 40% had tear progression Full thickness rotator cuff tears Full thickness rotator cuff tears Maman et al (JBJS 2009) Tear Progression smaller unchanged 2-5mm >5mm Risk factors for progression: Age >60 Fatty infiltration on MRI Larger tear Safran et al. AJSM 2011 Young patients with rotator cuff tears (<60) 50% progressed in 2 year period All had increased symptoms in pain and more weakness 20

progression of FI Case Example Untorn Infraspinatus with grade 3 FI and associated retracted supraspinatus tear Also note atrophic supraspinatus Natural history of fatty

24 What about the muscle? Melis et al (OTSR 2009) 1688 symptomatic tears Fatty infiltration occurred 4 years after onset of symptoms Patient age, side of tear, degree of atrophy correlated with progression of FI Case Example Untorn Infraspinatus with grade 3 FI and associated retracted supraspinatus tear Also note atrophic supraspinatus Natural history of fatty infiltration Older age is significantly associated with increased atrophy fatty infiltration Prevalence of infraspinatus tears is about 1/3 lower compared to supraspinatus But prevalence of FI in the infraspinatus is higher than the supraspinatus! What are the biologic consequences of a rotator cuff tear? Rotator cuff tear 21

25 Gene expression changes after RCT Inhibition of Fatty Infiltration Akt mtor SREBP1 PPARy Adipogenesis FATTY INFILTRATION Natural History: Non Operative Non operative management Rest, activity modification NSAIDS Physical therapy Injections 22

Full Thickness Rotator Cuff Tears Rationale for early treatment of symptomatic rotator cuff tears Smaller tears do better Better muscle quality (no atrophy, no fatty

Improve tendon to bone healing (Appropriate timed delivery of growth factors) Improve muscle biology after rotator cuff repair (regulation of muscle specific pathways) Last

26 Full Thickness Rotator Cuff Tears Rationale for early treatment of symptomatic rotator cuff tears Smaller tears do better Better muscle quality (no atrophy, no fatty infiltration) Lower rate or rerupture Easier rehab Easier for me to do On the Horizon. Improve tendon to bone healing (Appropriate timed delivery of growth factors) Improve muscle biology after rotator cuff repair (regulation of muscle specific pathways) Last case! Understanding Arthritis 75 year old male, 5 year history of gradually progressing pain. No weakness, but can t lift his arm above his head anymore. He has a history of arthritis in his hips and knees, and says this feels similar. What is the most likely diagnosis? 23

Understanding Arthritis Understanding Arthritis Osteoarthritis: Destruction

Articular cartilage Super smooth No nerve endings Few cells No nerve

Arthritis Osteoarthritis: The destruction Understanding Arthritis

// d d / di i /l b / b l b/b i h hh l 24

27 Understanding Arthritis Understanding Arthritis Osteoarthritis: Destruction of the articular cartilage resulting in pain, deformity, and disability Articular cartilage Super smooth No nerve endings Few cells No nerve endings=doesn t sense early damage Few cells=cannot regenerate Understanding Arthritis Osteoarthritis: The destruction of the articular cartilage resulting in pain, deformity, and disability Understanding Arthritis Osteoarthritis: The destruction of the articular cartilage resulting in pain, deformity, and disability Moderate focal arthritis Severe arthritis h // d d / di i /l b / b l b/b i h hh l 24

Diagnosis of Shoulder Arthritis Diagnosis of Shoulder

Exam Limited ROM Xrays Loss of joint space

rotator cuff tears Can help with anatomy of the glenoid

28 Diagnosis of Shoulder Arthritis Diagnosis of Shoulder Arthritis History Chronic all the time pain Toothache Exam Limited ROM Xrays Loss of joint space Osteoarthritis Osteoarthritis Normal Diagnosis of Shoulder Arthritis MRI? Not necessary in PRIMARY OA Useful in cases of suspected rotator cuff tears Can help with anatomy of the glenoid Management of Shoulder Arthritis Shoulder replacement for Primary Arthritis Original total shoulder replacement 25

29 Shoulder Replacement Shoulder replacement without a cuff Question What will happen if you do a shoulder replacement in the setting of a massive rotator cuff tear? 26

How do we fix big tears? Better understanding of the natural history of rotator cuff tears We understand the tendon well, what about the muscle?

30 Big Cuff tears a big problem! In the last 10 years. Better recognition of the rotator cuff tears MRI are better, but there are still limitations Better at fixing rotator cuff tears Are we doing too many? How do we fix big tears? Better understanding of the natural history of rotator cuff tears We understand the tendon well, what about the muscle? Developed strategies to solve cuff tears arthropathy How good is a reverse? Reverse TSA Novel (10 years experience) procedure for chronic massive rotator cuff tears and arthritis Reverse shoulder arthroplasty Early data ( ) concerning for high failure rates 62-80% scapular notching 25% failure rates at 5 years Many catastrophic failures 27

Reverse shoulder arthroplasty Walch et al JBJS 2006 10 year survival of implant 84% 10 year Constant >30=58% A [deterioration] of results began at six years and reflected progressive deterioration of

31 Reverse shoulder arthroplasty Walch et al JBJS year survival of implant 84% 10 year Constant >30=58% A [deterioration] of results began at six years and reflected progressive deterioration of the functional result. Reverse total prosthesis should be reserved for the treatment of very disabling shoulder arthropathy with a massive rotator cuff rupture, and it should be used exclusively in patients over seventy years old with low functional demands. R-TSA The UCSF experience R-TSA The UCSF experience 225 patients 3 infections 3 fractures (all treated non-op) 3 dislocations ASES Forward Flexion Abduction ER 0 Pre-op 6 weeks 6 months >1 year 0 Pre-op 6 weeks 6 months >1 year 28

Notching and R-TSA UCSF (IJSS 2014) Retrospective review of

angle Scapular notching Scapular Notching 7% 3% 0% 29% 61%

patients have no notching or very minor notching only

complicated problem Long term data inconclusive Early

32 Notching and R-TSA UCSF (IJSS 2014) Retrospective review of 4 years experience 2 surgeons 1 implant with low neck-shaft angle Scapular notching Scapular Notching 7% 3% 0% 29% 61% Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Majority (90%) of patients have no notching or very minor notching only Feeley et al IJSS 2014 Base Plate Distance (BPD) Summary * Reverse Shoulder Arthroplasty is a good solution to a complicated problem Long term data inconclusive Early complications still occur No Notching Notching P<0.001, Mann Whitney U test Feeley et al IJSS

Thank you Questions? Questions later? feeleyb@orthosurg.ucsf.

33 Thank you Questions? Questions later? Have a shoulder problem? UCSF Orthopaedic Institute 1500 Owens Drive SF, CA

Survey Results. Survey Results. What we will cover today? An evidence-based approach to rotator cuff disease

Survey Results. Survey Results. What we will cover today? An evidence-based approach to rotator cuff disease Survey Results An evidence-based approach to rotator cuff disease Brian Feeley, MD UCSF Sports Medicine What questions can we answer for you about rotator cuff problems? 1. How to do a good exam (5) 2.