Christopher A Brown, MD Sports Medicine Orthopedist. Duke Orthopedic Residency Sports Medicine Fellowship Stanford
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1 Christopher A Brown, MD Sports Medicine Orthopedist Duke Orthopedic Residency Sports Medicine Fellowship Stanford
2 Office Geneva Newark Opening Canandaigua and Penfield
3 Topics Of Discussion Shoulder dislocation Traumatic 1 st athlete SLAP Young and old AC joint Rotator cuff No disclosures
4 Primary Traumatic Dislocation Incidence instability high demand population 2.9% 80% anterior Mechanism
5 Primary Traumatic Dislocation Recurrence Highly dependent AGE #1 Contact sports Hyperlaxity Bone loss ANTERIOR POSTERIOR General Consensus < 20 yr 66-97% yr 56-64% >40 yr 0-14%
6 Primary Traumatic Dislocation Long term risk arthropathy Rate Moderate/Severe Arthropathy Multiple Recurrence 40% No Recurrence 18% Hovelius JSES 2009
7 Primary Traumatic Dislocation Evaluation and Management Several advances Imaging Arthroscopy Surgical techniques Functional outcomes scores are good after surgery failure <5%
8 Rationale for surgical stabilization in Young active patient w/ a traumatic 1 st dislocation can be strongly made. High recurrence Compromise athletic performance Long term risk arthropathy
9 A trial of non operative therapy is often done There are still patients who do not have recurrence or modify their activities No consistent way currently to predict who will have recurrence
10 Individualization Understanding WHO a patient is. What his/her goals are What resources athlete has to reach those goals
11 7 question I ask patient 1. Who is the patient? College athlete Manual laborer Office worker Rock climber Time course, return to work, and amount of time that can be devoted to rehabilitation will vary. Can Recurrence be life threatening?
12 7 question I ask patient 2. Present vs. future? High school or College athlete in his junior year looking in the future may differ from a weekend warrior
13 7 question I ask patient 3. What does successful return mean this patient? Office worker vs linebacker will have different answers.
14 7 question I ask patient 4. Is this the dominant or nondominant shoulder? Sometimes this can affect the balance between stability and mobility
15 7 question I ask patient 5. What is the surgical plan? Primary vs revision Open vs arthroscopic Bone loss All can impact rehabilitation program
16 7 question I ask patient 6. What is the patient s postoperative resource and compliance? Elite athlete with daily access to training staff is different that a managed care patient with limited visits.
17 7 question I ask patient 7. How is progress monitored, and how are problems communicated? Individualization requires adaptation through the healing process
18 Stable shoulder functional one Requires a team approach Patient Parents Surgeon Trainer Therapist Coach
19 Limited amount of actual contact when compared to the rehabilitation specialist. We tend not to understand the intricacies Manual therapy Strengthening Protective neuromuscular facilitation Communication and teamwork are key.
20 Protective Mobilization Critical to successful rehabilitation Balance of protecting static restraints repaired but not overprotect A stiff atrophic unresponsive shoulder has a worse prognosis than when the athlete dislocated
21 Keys to a successful rehabilitation program Individualization Protective mobilization Team communication
22 Dislocation Athletic Season 1 st time traumatic MRI-co-exsisting injuries Early PT with in sport bracing
23 Dislocation Athletic Season RTP avg 2 weeks Full ROM, strength, ability to protect If come out again fix Consider repair at end of season 1 st time traumatic
24 Case Labral tear High school Football athlete Dislocated in sectionals Also plays baseball
25 Case Labral tear
26 Post op Brace 4 wks Sleep 6wks ROM 1 st 6 weeks no biceps strengthening 3 mon initiate Throwers 10 program 4 mon interval throwing 5-6 mon RTP
27 Case 2 SLAP and Bankart Personal trainer 8 yrs of shoulder pain and instability Sling 4 weeks
28 Bankart Protocol
29 LatarJet Procedure 1 st described 1954 Recurrent instability Failed Arthroscopic Bone Loss 5% recurrence w/o bone loss vs up to 70% 1 Engaging hills sacs 1 Burkhart 2008 Surgical Techniques
30 Latarjet How it works 1) Replace bone loss 2) Restores articular arc (hills sacs) 3) Conjoined tendon Tether and a sling across the ant inferior capsule
31 Engaging Hill sacs Posterior lateral humeral defect can that lead to continued instability and failed arthroscopic repair
32 Case 3: Latarjet Procedure 18 year old Multiple dislocations Prior failed anterior stabilization Bone loss
33 Post-op Sling 4 weeks PROM below SHOULDER 4-6 weeks AA to AROM above shoulder 6 weeks ROM and joint control 8-12 weeks Strengthening RTP 4-5 months PROTECT SUBSCAP AND DEVELOPING BONEY UNION CONJOIN TENDON
34 SLAP: Historical Perspective Andrews 1985 Identified the superior labrum and biceps tendon complex to be a possible source of pain and dysfunction Snyder 1990 Coined the term SLAP Described lesion as beginning posteriorly and extending anteriorly
35 SLAP Most common symptoms: Pain with overhead activity Mechanical catching, popping, or grinding Mimic multiple pathologies AC joint pain bicipital tendon pathology glenohumeral instability
36 What we know SLAP Biomechanical role Successful repair in young athletes Still problematic overhead athletes Older you get success of repair decreases Worse when done with cuffs
37 SLAP in Older patient Patient s >40 Failed SLAP Preserves biceps function Supination No popeye /cramping Eliminates groove systems MINI SUBPEC BICEPS TENODESIS
38 Biceps Tenodesis Sling 3 weeks Week 1-4 Passive ROM elbow/shoulder Week 5-6 Start active assist to AROM Week 7-9 strengthening phase RTP 3 months
39 WHY I wait 6 weeks
40 Case 3: Body Builder 48 body builder Torn SLAP Subscap Supra
41 The Other Shoulder Separation AC Joint
42 AC joint dislocation: I/II back when comfortable with pad III: week out then back when no strength deficit/full ROM. If not in season consider fixing if dominant arm in throwing athlete or is still sx s with relocation or cross body by 6-8 weeks V: discuss with athlete, fix in season if throwing athlete, otherwise could consider fix post season. Better results if acute though.
43 3-D Deformity Posterior Anterior Acromion Clavicle
44 3 months Post op
45 Sling 6 weeks ok after 3 to remove with hands within eyesight RTP recreational 4 contact 5months
46
47 Rotator Cuff High prevalence in older patients Asymptomatic MRI 54%> 60 years 1 Natural history not transparent 2 51% become symptomatic 39% progress Sher JBJS Yamaguchi 2 JSES 2001
48 Pathogenesis: Intrinsic (codman 1934) Extrinsic (Neer 1972) Traumatic * Evidence suggests both extrinsic & intrinsic play role
49 Presentation Pain: Predominant symptom Troubling at night Overhead activity Stiffness: Painful, limited arc of motion Impingement signs
50 Repair results Re tear rate on MRI 20-39% Most outcome scores significant improvement 1yr Deteriorate with time Intact do better
51 Treatment Challenges Size of Rotator Cuff Tear Number of Tendons Involved Delamination of Tendons Fat Infiltration Chronicity of Rotator Cuff Tear Degree of Tendinous Retraction Quality of Tendons (vascularity)
52 Lack of understanding What factors predict successful non-op tx? Does converting a asymptomatic state allow progression of the tear over time? Is there an optimal interval during the natural history to repair full thickness tear? What factors are associated with repair failure?
53 Non-operative Initially: Rest Activity modifications NSAIDs Physical therapy: Range of motion (regain lost motion from inflammation contractures) Strengthening RTC/periscapular (after motion regained)
54 Operative Indications: Symptoms of sufficient duration and intensity No improvement w/ conservative tx Specific goals/expectations of pt
55 Decisions: Debridement of tear w/wout acromioplasty Mini-open or arthroscopic repair w/wout acromioplasty
56 Double Row Technique Suture Bridge Advantages Larger recreation of the footprint Strength of fixation Disadvantages Tension on the Cuff Medial Row Failure
57 Single Row Advantages Medialization Less Tension on Repair Disadvantages Footprint Reconstitution Strength of Fixation
58 Option for Cuff Arthropathy Reverse Shoulder arthroplasty Indications Psuedoparalysis Cuff arthropathy
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