Intern Arthroscopy Course 2015 Shoulder Arthroscopy Cases
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1 Intern Arthroscopy Course 2015 Shoulder Arthroscopy Cases Mary Lloyd Ireland, M.D. University of Kentucky Dept. of Orthopaedic Surgery & Sports Medicine Lexington, KY
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3 Broken screw s/p Bristow procedure
4 Beware prominent hardware in the shoulder. It breaks, erodes cartilage, etc....
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7 Complications How I have managed my own complications If using new equipment, know how to get out of trouble Frustrating to break arthroscopic instruments Be patient! Be honest!
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9 Sutures placed in rotator cuff, arthroscopically-aided with Expressew; tip of needle broke off Search for needle tip not successful Embedded in thick rotator cuff
10 C-Arm View
11 Mini-open rotator cuff repair performed C-Arm used to locate needle tip Informed family of breakage of instrument Post-op xrays taken in office
12 2 week Follow Up
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20 Bankart lesion and capsular insufficiency
21 Preparation of the glenoid, mobilization of capsuloligamentous labral tissue from scapular neck
22 Suture management, 2 anchors with 4 sutures and capsulorraphy sutures inferior and rotator interval
23 Completed stabilization rotator interval closure, re-establishment of anterior capsuloligamentous labral structures
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26 Bicepital Groove Biceps Tendon
27 Operation
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29 Arm position hyper-abduction, IR
30 Physical Exam Weakness on RC testing 3/5 Pain on exam Significant laxity A>P
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34 Thermal Capsular Modification I don t use Is not successful in MDI patient With improved suture-passing devices and anchors, tie instead of fry Improved results in elite professional baseball athletes with suturing has been reported (J. Andrews et. al.)
35 brownjcthermal.mpg
36 Capsular Necrosis Courtesy of Tony Romeo, M.D.
37 Thermal Shrinkage of Bacon Uncooked 90 sec. 30 sec. 120 sec. 60 sec. 150 sec.
38 Thermal on cartilage kills cells Killing is BAD You may get away with it, but
39 Take nothing on its looks. Take everything on evidence. There is no better rule. - Charles Dickens
40 Case 1 Chronic SLAP & Anterior Instability 24 YO Right hand dominant high school pitcher, boxer History of 30 times shoulder slipping out of place in overhead positions PE: anterior apprehension, labral click, pain and weakness in maximum rotation, arm 90 deg. abducted
41 Bucket handle tear, labrum
42 Scope posterior
43 Anterior-inferior glenoid preparation, labral debridement
44 Removal unstable SLAP tissue
45 Mobilization of anterior-inferior capsuloligamentous complex, labral debridement
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47 Osseous raptor x3, 6 sutures
48 Post-repair, arthroscope posterior
49 Arthroscope anterior, debridement degenerative nonrepairable posterior labrum
50 Arthroscope anterior
51 Scope anterior-superior portal, bumper stability reestablished
52 Subscapularis bursa, common location of loose bodies Scope anterior-superior
53 Case 2 Subscapularis Tear & Anterior Instability 49 YO Right-hand dominant white female, homemaker Right shoulder injury swinging basket full of clothes overhead PE: Significant limitation of motion Anterior apprehension Positive O Brien s test Weakness, ER > IR Imaging Studies
54 Scope posterior
55 Sublabral hole
56 Biceps normal, 10% upper subscapularis tear Scope posterior
57 Scope posterior Anterior-superior and anterior portals
58 SLAP labral repair, anchors x2, mattress sutures
59 Scope posterior, s/p subscap debridement
60 Subscapularis Muscle
61 Subscapularis Tears Lift Off (75% tear 5-30) Hand or back Lspine Maximum LR Napoleon (50% tear) Press belly, flexes wrist Bear Hug (Upper tear, most sensitive) Hand on opposite shoulder Elbow forward Examiner pulls hand off shoulder
62 Initial Clinic Visit 46 year-old right-hand dominant male fell onto an outstretched right arm after tripping over his dog. Felt a ripping sensation in his shoulder Went to the emergency room, plain x-rays normal PE next day: Pain diffusely anterior shoulder Weakness, IR > ER
63 Clinical exam: subscapularis tear I was unable to get my wallet out of my back pocket.
64 Subscapularis & Biceps Instability
65 Medially dislocated biceps tendon
66 Subscapularis Footprint 2.5 cm superior-to-inferior 1.5 cm medial-to-lateral Widest superiorly Nevada analogy by Stephen Burkhart, M.D.
67 Bicepital Groove Biceps Tendon
68 Synovitis, partial subscap tear, normal biceps tendon Don t miss subscapularis tears; can be difficult to see at footprint/insertion
69 Biceps Tendon Often associated with: Subscapularis tear Chronic rotator cuff tears Presentation Initial ecchymosis and pain, then feel better Treatment Repair other associated tears Tenodesis vs. tenotomy
70 MRI Scans of the Shoulder Make sure you know the type scanner and radiologist Communicate with radiologist regarding your clinical diagnosis If you can t read the MRI scan, you shouldn t be ordering it
71 MRI Scans I have never seen a normal reading It s a slippery slope to treat based on radiologists reading
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73 CONCLUSIONS Practice makes better, never perfect Practice, practice arthroscopy in the wet lab Practice, practice knot-tying Be ready to face complications in surgery
74 The End... Thank You!
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