6/11/2015. MRI Arthroscopy Correlations: Rotator Cuff. Disclosures. Biomet, Inc Consulting and Speaking. Case #1

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1 6/11/2015 MRI Arthroscopy Correlations: Rotator Cuff Disclosures Biomet, Inc Consulting and Speaking Case #1 1

2 6/11/2015 Case #1 45 y/o RHD male s/p fall from ladder 3mos ago Pain at night and with overhead motions in R shoulder Failed PT PE: Full ROM 4/5 SS, 5/5 ER, Neg Belly Case #1 Case #1 2

3 6/11/2015 Case #1 Case #1 Case #2 3

4 6/11/2015 Case #2 48 y/o RHD female s/p motorcycle accident 4 weeks ago Dislocated R shoulder, reduced in ER Pain and dysfunction PE: FF 110, large shrug 3/5 SS, 4/5 ER, Neg Belly Case #2 Case #2 4

5 6/11/2015 Case #2 Mobilize Tendon Bursal -> Scapular Spine Articular -> Capsule- Labral Junction Carefule to avoid suprascapular nerve. Case #2 Anchors placed at articular margin through percutaneous incision lateral to acromion Case #2 Work away from where you are retrieving sutures 5

6 6/11/2015 Case #2 Case #2 Pearls History and fatty infiltration dictate repairability Adequate mobilization Percutaneous portal for anchor Use penetrator for far posterior Use suturing device for superior Work away from retrieving portal (ie, if retrieving through anterior portal, then pass anterior to posterior) Alternate colors of sutures Case #2 6

7 6/11/2015 Case #3 Case #3 58 RHD male s/p fall down stairs 2 months ago. Pain and dysfunction in R shoulder PE: FF 150, with shrug 4/5 SS, 5/5 ER, Pos Belly Case #3 7

8 6/11/2015 Case #3 Case #3 Case #3 External Rotation, Forward Flexion allows familiar view 8

9 6/11/2015 Case #3 270 degree release of subscapularis Superior base of coracoid Posterior MGHL/capsule Anterior Conjoint to axillary nerve Keep lateral interval tissue intact Case #3 Anterosuperior Tears 9

10 6/11/2015 Case #3 Pearls Arm Position External rotation to pass Internal rotation to tie Forward flexion to see Penetrator for far anterior Maintain Integrity of the Cuff Case #3 Case #4 10

11 6/11/2015 Case #4 72 RHD male with R shoulder pain, no trauma. Good but temporary relief from cortisone 3 months of PT Function OK PE: ROM 170/45/T12 4/5 SS, 4/5 ER, Pos Belly Case #4 Case #4 11

12 6/11/2015 Case #4 Summary Fatty infiltration biggest indicator of ability to repair. Head may be elevated on MRI with acute massive tears -> doesn t mean you can t repair it. Have a methodical system for repair, maintain cuff. If unable to repair, and function is adequate pre-op, then partial, margin convergence repair can be effective at pain relief. Thank You 12

13 6/8/2015 IMAGING OF THE ROTATOR CUFF AND BICEPS LABRUM COMPLEX Gabrielle P. Konin, MD Department of Imaging Hospital for Special Surgery Assistant Professor of Radiology Weill Medical College of Cornell University Financial Disclosures I have nothing to disclose. TENDINOPATHY Tendons are intact Increased signal on short TE Intermediate signal on long TE (not fluid signal) Alteration in tendon size or morphology 1

14 6/8/2015 HADD 60 year-old man with anterior pain for 1 month. No trauma. Intraosseous HADD can have an intense marrow edema pattern and may be confused for tumor or greater tuberosity fracture. IMPINGEMENT SYNDROME Assessment of Secondary Signs Acromial morphology: anterior +/- lateral subacromial spur / slope of acromion CA ligament thickening Tendinopathy Partial Tear Lateral downsloping of the acromion. Tendinosis with bursal fraying and intrasubstance fissuring at critical zone. Synovitis of the subacromial space. 2

15 6/8/2015 IMPINGEMENT SYNDROME Assessment of Secondary Signs AC joint arthrosis Os acromiale Partial Thickness Footprint Tear Partial thickness tendon discontinuity Increased signal intensity on moderate to long TE sequences Bursal vs. articular vs. intrasubstance Intrasubstance / concealed tears - invisible to scope Sept 2014 Nov year old pitcher with intrasubstance footprint tear 3

16 6/8/2015 Sentinel ganglion cyst Sentinel cyst without evidence of tear indicates prior delaminating intrasubstance tear. Interstitial fluid extension between layers of rotator cuff. Typical location is posterior supraspinatus. Partial tear of the subscapularis tendon FULL THICKNESS TEAR Acute tear Failure with continuity 4

17 6/8/2015 FULL THICKNESS RE-TEAR CHRONIC ROTATOR CUFF TEAR Superior migration AH interval (<7mm) Remodeling of acromion Assess tendon quality & degree of retraction for repair *Assess quality of muscle: predictor of outcome Assess articular cartilage CUFF TEAR ARTHROPATHY Chronic rotator cuff tear Anterosuperior migration of humerus Acromial acetabularization Coracoacromial ligament stabilizes progressive superior migration Osteoarthrosis: apron osteophyte, loose bodies Assess glenoid Deltoid dehiscence 5

18 6/8/2015 Classification of SLAP lesions (Snyder et al 1990) I : Labral and biceps fraying, intact anchor II : Labral fraying with stripping of both the labrum and biceps III : Bucket handle tear with displacement and intact biceps anchor IV: Same as III, but with detached biceps anchor Stripping of the labrum and biceps SLAP II 22 year-old NBA player with shoulder pain Chronic stripping of the labrum and biceps anchor 6

19 6/8/ year-old man with pain for 1-2 months Stripping of the anterosuperior labrum with intact anchor and displacement of the labrum into the joint 47 year-old tennis player. Stripping of labrum & biceps anchor w tear extension into biceps 7

20 6/8/ year-old 4 days post diving accident. Near complete detachment of the biceps anchor Thank you 8

21 6/15/2015 MRI : Biceps Chondromalacia? Disclosure Neither I, Stephen J. O Brien, MD, MBA, nor any family member(s), author(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation. The Role of MRI in Diagnosing Biceps Chondromalacia Mary E Shorey BA Samuel A Taylor MD Joshua A Dines MD Hollis Potter MD Joe Nguyen MPH Stephen J O'Brien MD MBA 1

22 6/15/2015 Nothing New Under The Sun... Sisterman - "Biceps Footprint" Castagna - "Chondral Imprints" Kuhn et al - "Humeral Head Abrasions" Appeared that BCM Lesions COULD BE Seen on MRI, Especially COR PD. Normal "Blush" Two Types of BCM 2

23 6/15/2015 Which is the Pain Generator? O'Brien et al- 280 Pts 70% of Pts with Biceps Labral Complex (BLC) Pain had Multiple Sites Of Pain and Pathology Which is the Pain Generator? O'Brien et al- 3 "Pack" 145 Pts prospective "Groove" "Junction" "Deep Inside" Materials and Methods Retrospective Review- 3 Groups - All MRI's at HSS- Pts with OA EXCLUDED. 1)BLC Lesions WithVisible BCM (34pts) 2)BLC Lesions Without Visible BCM (21pts) 3)Control Group Instability Surgery w/o BLC SXS (29pts) Groups 1&2 Age Matched (Mean Age 42). Group 3 (Mean age 29) Digital OR Pictures Only Single Experienced Sports MRI radiologist (HP)- blinded of any clinical data or OR Photos MRI CRITERIA Major 1) Loss of ARTICULAR Cartilage where LHBT traverses 2) Subchondral Signal Change 3) Abnormal Signal in Proximal LHBT Minor 4) Labral Tear 5) Scarring in Rotator Interval 6) Evidence of more global Adhesive Capsulitis Statistical Analysis by Biostatistician 3

24 6/15/2015 Group 1 Cartilage Loss- 85% Subchondral Signal Changes - 64% Pathological Changes Proximal LHBT- 85% Results Group 2 Cartilage Loss- 86% Subchondral Signal Changes - 52% Pathological Changes Proximal LHBT- 81% Group 3 Cartilage Loss- 51% Subchondral Signal Changes - 34% Pathological Changes Proximal LHBT- 44% Results Within the Boundaries of this Analysis (younger) Cohort, Age was not a factor in the presence or absence of a BCM Lesion or the ability of the MRI to Diagnose It. Diagnostic Statistics 4

25 6/15/2015 Biceps Chondromalacia "Medial" 5

26 6/15/2015 Thank you 6

27 MRI / Arthroscopy Correlation: SHOULDER INSTABILITY Stephen F. Brockmeier, MD Sports Medicine & Shoulder Surgery Associate Professor, Orthopaedic Surgery University of Virginia Team Physician, UVA Athletics Cree M. Gaskin, MD Vice-Chair, Radiology Associate Professor, Radiology and Orthopaedic Surgery University of Virginia Charlottesville, VA SFB: Disclosure Consultant: Biomet, MicroAire Medical Education: Biomet, Arthrex Royalties, Springer Publishing Research Grant: Arthrex, Tornier, Biomet Fellowship Support Grant: Arthrex, Depuy Mitek, DJO CMG: Consultant, Depuy Mitek Royalties, Oxford University Press Royalties, Thieme Medical Publishing 1

28 CASE #1 Case #1 19 yo collegiate football player Injured making a tackle Pain / Recurrent subluxation Unable to continue to play Exam: Pain / apprehension in ABER Positive Jobe relocation Rotator cuff exam WNL Positive active compression 2

29 MRI Diagnosis? 3

30 Labral Tear (Bankart) & Chondral Injury NORMAL Sag T2 Fat Sat 4

31 Axial Sag T2 Fat Sat Anterior-Inferior Labrum Generally occurs due to anterior instability SEMANTICS: Bankart - generic term Perthes ALPSA GLAD Artwork of Salvador Beltran. From: Stoller DW. MRI, Arthroscopy, and Surgical Anatomy of the Joints. Lippincott Publishers. 5

32 Perthes Lesion Axial T2 Fat Sat Perthes Lesion Axial T2 Fat Sat 6

33 ALPSA lesion Anterior labroligamentous periosteal sleeve avulsion Periosteum stripped, but not disrupted Displaced when scars down to glenoid Axial T1 ALPSA lesion Axial T1 7

34 ALPSA lesion Axial T1 ALPSA lesion Axial T1 8

35 ALPSA lesion Axial T1 ALPSA lesion Coronal T1 FS 9

36 Coronal T2 FS ALPSA lesion Sag T2 Fat Sat 10

37 ALPSA lesion Sag T2 Fat Sat ALPSA lesion 11

38 GLAD Glenolabral Articular Disruption Ant-inf chondral defect + superficial labral tear Often applied to other glenoid sites Modified artwork of Salvador Beltran. From: Stoller DW. MRI, Arthroscopy, and Surgical Anatomy of the Joints. Lippincott Publishers. GLAD 12

39 Case #1: Arthroscopic Photos Arthroscopic Anterior Stabilization Beach chair vs. lateral 13

40 Arthroscopic Anterior Stabilization Beach chair vs. lateral Low anterior portal Mobilization Stimulate healing response Arthroscopic Anterior Stabilization Beach chair vs. lateral Low anterior portal Mobilization Stimulate healing response Translate tissue medial and superiorly 14

41 Arthroscopic Anterior Stabilization Beach chair vs. lateral Low anterior portal Mobilization Stimulate healing response Translate tissue medial and superiorly 3 anchors, minimum Arthroscopic Anterior Stabilization Beach chair vs. lateral Low anterior portal Mobilization Stimulate healing response Translate tissue medial and superiorly 3 anchors, minimum Bumper?? 15

42 CASE #2 Case #2 29 yo Ortho Resident Former Kickboxer / MMA Many years of recurrent shoulder dislocations (>10) Now comes out with minimal trauma No prior surgeries On exam: Apprehension at 90 & 45 degrees 16

43 Plain Films MRI 17

44 Diagnosis? Evolving Algorithm Epidemiology Clinically relevant bone loss clearly underappreciated Glenoid: 49 86% (recurrent instability) Humeral: % (recurrent instability) Combined: Almost always some combined deficiency Presentation Mechanism (axial load) Acute vs. Chronic Easy to come out; Easy to reduce Instability mid-range Failed prior sx 18

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55 Diagnostic Scope 29

56 Technique Beach chair position Articulated arm positioner Axillary incision No paralysis Postop regional block EUA Diagnostic Scope Technique Subscap split (2/3 rd s down the tendinous portion) Arm in IR for the majority of the case 3/32 nd pin for superior retraction Careful retraction medially No retraction inferiorly 30

57 Technique Intra-op Fluoro 31

58 Technique Postop Films 32

59 CASE #3 Case #3 27 yo male, outdoor enthusiast Posterior shoulder pain 8 months duration Injury bench pressing Exam: Pain with jerk test 33

60 T1 T2 Fat Sat Diagnosis? 34

61 Diagnosis = Posterior Labral Tear w/ Paralabral Cyst Axial T2 FS Sag T2 FS Sag T2 FS Axial T1 FS Companion case: Post. labral tear 35

62 Companion case Axial T2 Fat Sat Suprascapular nerve 36

63 Posterior Labral Tear w/ Paralabral Cyst Cyst Decompression & Labral Repair 37

64 Companion Case: 30 yo laborer, 3 months severe posterior shoulder pain Axial T2 Fat Sat Axial T1 Sagittal T2 fat sat Sagittal T1 Sagittal T2 fat sat 38

65 Cyst Decompression, Post. Labral Repair Additional Companion Case: 19yo D1 Offensive Lineman, Prior Failed AS Posterior Stabilization 39

66 MRI CT SCAN 40

67 CT SCAN CT SCAN 41

68 Arthroscopic Findings OPEN OC ALLOGRAFT 42

69 FRESH DISTAL TIBIA OC ALLOGRAFT OPEN OC ALLOGRAFT 43

70 OPEN OC ALLOGRAFT POSTERIOR DTA 44

71 Post-op Xrays (6 weeks) THANK YOU 45

72 MRI Arthroscopy Correlations in the Throwing Shoulder Seth Gamradt, MD Director of Orthopaedic Athletic Medicine Associate Professor Orthopaedic Surgery and Sports Medicine Keck School of Medicine of USC University of Southern California SUMMARY APPROACH TO SHOULDER PHASES OF THROWING PATHOPHYSIOLOGY MRI CORRELATIONS SLAP PARTIAL THICKNESS RC TEARS GIRD INSTABILITY GENERAL APPROACH TO SHOULDER PATIENT < 30 = INSTABILITY AND LABRAL TEARS IMPINGEMENT AND TENDONITIS 60+ ROTATOR CUFF AND ARTHRITIS THROWER 1

73 Phases of Throwing Stage I Windup Stage II Early cocking Stage III Late cocking Shoulder ER increases from (92N-m of Torque) Stage IV Accleration Internal rotation (80 degrees) and adduction of the humerus with rapid elbow extension Terminates with ball release Stage V - Follow-through Dissipation of excess kinetic energy Eccentric cuff contraction and posterior capsule absorbs 100 percent or more body weight. Wind-up Wind-up 2 2

74 Cocking Late Cocking Late Cocking Early Acceleration 3

75 Ball Release Follow Through Follow Through 2 4

76 WHY DOES THE SHOULDER GET INJURED RAPID KINETIC CHAIN CORE----SHOULDER ELBOW----HAND 7000 DEG/SEC OF ROTATIONAL VELOCITY OF THE SHOULER EX ROT OF UP TO 170 DEG NORMAL ADAPTATIONS ER IR Arc is the same but shifted into ER INCREASE IN HUMERAL RETROVERSION ANTERIOR LAXITY MAKE SURE YOUR TREATMENT DOES NOT RUIN WHAT MAKES THIS SHOULDER GOOD FOR PITCHING! THROWING THEORIES--OLDER BENNETT TRACTION ON POSTERIOR GLENOID NEER SUBACROMIAL IMPINGEMENT JOBE ANTERIOR INSTABILITY 5

77 THROWING THEORIES GIRD GLENOHUMERAL INTERNAL ROTATION DEFICIT INTERNAL IMPINGMENT CUFF/LABBRUM CONTACT IN ABER SCAPULAR DYSKINESIS KINETIC CHAIN WEAKNESS IN LEG/TRUNK REQ 15%-40% INCR IN SHOULDER ROTATIONAL VELOCITY MRI-ARTHROSCOPY CORRELATIONS REHAB SHOULD ALWAYS BE THE FIRST OPTION EXCEPTION IS ACUTE TRAUMA MRI-ARTHROSCOPY CORRELATIONS THROWERS HAVE MRI ABNORMALITIES WITH OR WITHOUT SYMPTOMS LESNIAK ET AL AJSM 2013 CONNOR ET AL AJSM 2003 MINIACI AJSM 2002 MULTIPLE STUDIES SHOW LABRUM AND CUFF ABNORMALITIES IN ASYMPTOMATIC PITCHERS OPERATE ON THE PATIENT NOT THE MRI. 6

78 CASE 1: SLAP 20M CASE 1: SLAP 20M CASE 2: GIRD SLAP--PTRCT 25M 7

79 CASE 2: GIRD SLAP--PTRCT 25M CASE 2: GIRD SLAP--PTRCT 25M CASE 3: PTRCT--REPAIR 20M 8

80 CASE 3: PTRCT--REPAIR 20M CASE 4: INSTABILITY 22M CASE 4: INSTABILITY 22M 9

81 SUMMARY LATE COCKING EARLY ACCELERATION STRESSES SHOULDER AND ELBOW MULTIPLE PATHOPHYSIOLOGIC THEORIES GIRD/INTERNAL IMPINGEMENT PTRCT/SLAP SCAPULA/KINETIC CHAIN MRI ABNORMALITIES COMMON REHAB FIRST IF SURGERY DON T TIGHTEN 10