6/20/2018. What is the dilemma? Management of the Challenging Rotator Cuff Tear. I (and/or my co-authors) have something to disclose.

Transcription

1 Management of the Challenging Rotator Cuff Tear Brian J. Cole, MD, MBA Professor, Vice-Chairman, and Managing Partner Department of Orthopedics Chairman of Surgery, Rush OPH Section Head, Rush Cartilage Restoration Center Team Physician, Chicago White Sox and Bulls I (and/or my co-authors) have something to disclose. Detailed disclosure information is available via: Printed Final Agenda Meeting App Meeting Website or AAOS Orthopaedic Disclosure Program on the AAOS website at What is the dilemma? Arthroscopy, 2017 Roughly 6 million RCTs in the U.S over 65 yo Why? We are rotting from the inside out - Atul Gawande, Being Mortal Non-surgical care is often effective About 300,000 are repaired Satisfaction tied to pre-operative expectations and anatomic integrity.good outcomes pay! Once fixed, we remain surprised that they re-tear 1

2 Case Example 59 yo RHD Male 4 months of R shoulder pain after FOOSH Weakness + HS pain Full A/PROM Given up lifting weights. Treatment SA injection 8 weeks of PT Pain free! Courtesy of Ben Kibler, MD 10 Years Later Insidious onset of pain with activities and sleep Weakness Full PROM 2

3 There are many ways to get it right! What will they do? Limited Options Michael Freehill, MD Large to Massive RCTs Bill Levine, MD The Role of Orthobiologics Brian Waterman, MD Failure of Repair Bill Levine, MD SCR vs RTSA Brian Cole, MD 3rd Annual 2018 Chicago Sports Medicine Symposium World Series of Surgery September 7-September 9, 2018 Chicago, IL 1st Annual AOSSM OLC Biologics/US Course October 12-13, 2018 Chicago, IL 1st Annual AANA Practice Management Course November 8-9, 2018 Chicago, IL 20 th Annual AANA/AOSSM/AAOS SKI COURSE January 30-February 3, 2019 Park City, Utah 3

4 Limited Options: Is there a Role? Tear Pattern Recognition, Debridement and Partial Repair for Rotator Cuff Tears Management of the Challenging Rotator Cuff Tear Michael T. Freehill M.D. Associate Professor of Orthopaedic Surgery University of Michigan VuMedi Webinar June 20, 2018 Disclosures Consultant: Smith and Nephew, Integra Research support: Smith & Nephew Committee member : AAOS, ASES, AOSSM, ISAKOS, AANA Rotator cuff tears: Progression of tear enlargement Muscle degeneration over time

5 Presentation Worsening pain! Worsening function! Something progressed more recently Progression posterior? Subscapularis tear? Unbalanced force couple? One Size Does Not Fit All Individualizing Treatment Pre-operative Factors Age Medical comorbidities Social factors (smoking) Demand Job requirements Recreational activities Fatty infiltration of rotator cuff Previous shoulder surgeries Intra-operative Factors Mobilization of tendon Releases Amount of tendon lateral to musculotendinous junction Bone quality Anchor placement Debridement: Inflammatory factors Substance P Incarcerating debris What could help 2

6 What could help Biceps Tenotomy: RTC repairs not feasible Fatty infiltration Proximal HH migration Tenodesis or tenotomy Reduces pain Improves functional ROM High degree pt satisfaction What could help Suprascapular nerve release: The Case for the Partial Repair Force couple: Subscap <> Infra/Teres minor Centralizes HH Slow superior migration Improved biomechanics Improved compensation Castricini et al. Arth Tech

7 Retrospective n= 24 Excellent 11/24 (46%) Good 5/21 (21%) Fair 7/24 (29%) Poor 1/24 (4%) Satisfactory pain relief= 83% Active elevation 114 o to 154 o Raise arm to 135 o 13 pre-op > 21 post-op 2005 n=73 median f/u 41 months Result/Conclusion: both partial and complete repairs produce equivalent improvements in CS shoulders 2017 Mean f/u 7 years Irreparable supraspinatus but The possibility to repair the infraspinatus and subscapularis, Significant clinical improvement achieved Results reliable regardless of the RCT pattern Female & older pts greater likelihood of lower functional outcomes 4

8 Partial Repair vs Debridement Alone Tricks to the Partial Repair Medializing the Medial Row Avoids undue tension 5

9 Don t miss a subscap tear Convergence sutures Burkhart. Arth 2000 Improved tendon fixation Luggage Tag 6

10 What would you do? Right shoulder pain 72 y/o M, RHD Fall 11/2017 Ongoing limited ROM/weakness w/ AROM Pain anterior and deep Wakes from sleep Slight improvement with PT Reports h/o rotator cuff injury Treated successfully with PT What would you do? Physical Examination FF= 60/145 (160/165) ER= 15/20 (45/50) ABD= 30/145 (155/160) IR= Lumbosacral (T12) Jobes= 3lbs (16lbs) ER= 3/5 (5/5) Subscap x 3= all + Outcome Measures SSV= 50% ASES= 31 Constant= 23 Hamada 2 7

11 Atrophy vs Fatty Infiltration? Options Debridement Biceps tenotomy/tenodesis Partial repair Patch augmentation allograft, xenograft, synthetic Suprascapular nerve release Superior capsular reconstruction Tendon transfer Latissimus, lower trapezius Reverse total shoulder arthroplasty 8

12 Conclusion Benefits of Partial Repair The Force Couple Reconstitution Improved outcomes to debridement alone Possible decreased time for repair Possible decreased chance for Cho Type II tear Cost savings Anchor number Possible case time Pearls for Partial Repair Thorough releases Convergence sutures Picasso Medialization of medial row Decrease tension on repair Luggage tag configuration Improved soft tissue security Thank you 9

13 VuMedi Webinar: Management of the Challenging Rotator Cuff Tear June 20, 2018 My Approach to Large to Massive Rotator Cuff Tears in the Young, Active Patient William N. Levine, MD Frank E. Stinchfield Professor and Chairman NYP/Columbia University Irving Medical Center Department of Orthopedic Surgery New York, NY Disclosure 1. Basic Science Support a. NIH 2. Consultant Zimmer 3. Royalties None 4. Editor in Chief JAAOS 5. Vice President ASES Questions Does patient need surgery? If they do what procedure? How to increase healing? Develop workable algorithm 1

14 Acute Massive Rotator Cuff Tear Acute injury Pain Weakness No prior shoulder pain Evaluation Exam Lag Signs ER IR Hornblower s Evaluation Exam Lag Signs ER IR Hornblower s 2

15 Evaluation Exam Lag Signs ER IR Hornblower s Evaluation Xrays True AP Outlet Axillary Evaluation Xrays True AP Outlet Axillary 3

16 Evaluation Xrays True AP Outlet Axillary Evaluation MRI Size # of tendons Retraction Atrophy (Goutallier) Don t Be Fooled No history of pain No history of problems But 4

17 Treatment Algorithm Arth RCR Treatment Operative Non-op SCR/Balloon? Tendon Transfers Reverse TSA How To Decide? Does pt need surgery? Is it reparable Do you have the tricks to do it? Is there hope for healing? Is It Reparable? Chronicity Size # of tendons Retraction Hamada prox hum migration Goutallier - atrophy 5

18 How to Improve Success? Biomechanical Biologic Biomechanics Single row Double row Transosseous equivalent Literature Review DR>SR Clinical Miyata AJSM 11 DR>SR Radiographic only Tudisco BMC MSK Disorders 13 No Difference Bedi Arthroscopy 13 6

19 Illustrative Case 54 y.o RHD male Acute injury Pain Massive tear Prior arth RCR Physical Examination Well-healed incision AROM: FF 130 ER (arm at side): 30 ER (90 abd): 90 IR L5 Full PROM 3/5 supra 3/5 infra - belly press/lift-off No ER or IR Lag + Hawkins, Neers, Jobe No AC or biceps signs Imaging 7

20 Imaging Beach chair 30 scope Suture passers Scorpion Suture lassos Anchors 4.5mm PEEK FT 4.75mm biocomposite swivel-lock 3 7.0mm cannulae Tool Kit Patient Set-Up Beach chair Head/neck protected Regional anesthesia Pneumatic arm holder 8

21 Patient Set-Up Check trajectory before draping Portals Standard posterior Anterior Anterolateral ASL (subscap) Perc (anchors) Anterolateral Portal Trajectory 9

22 Tear Recognition Footprint Preparation Medial Row Anchor Placement 10

23 Medial Row Suture Passing Anterolateral Row Anchor Posterolateral Row Anchor 11

24 Accessory Posterior Suture Accessory Anterior Suture Final Repair 12

25 Post-Op Rehab No PT x 6 weeks Out of sling POD 1 for elbow/wrist/fingers Full active ROM/ADLs by 3 months Return to sports/higher activities 6 months 6 Pearls for Success 1. Pre-op plan based on MRI evaluation 2. Proper portal position 3. Tear recognition (KEY) 4. Suture management/repair configuration get a routine and stick to it so your team is prepared 5. Have to be expeditious 6. Don t be fooled by acute-on-chronic tears! Thank You! wnl1@columbia.edu 13

26 The Challenging Rotator Cuff Repair: What s the Role of Orthobiologic Adjuncts? Brian R. Waterman, MD Associate Professor, Orthopaedic Surgery Wake Forest Baptist Medical Center Winston Salem, NC Disclosures Wake Forest Baptist Medical Center Disclosures Brian R Waterman, MD AAOS: Board or committee member American Journal of Orthopedics: Editorial or governing board Arthroscopy: Editorial or governing board Arthroscopy Association of North America: Board or committee member Elsevier: Publishing royalties, financial or material support Genzyme/Vericel: Paid presenter or speaker Society of Military Orthopaedic Surgeons: Board or committee member Wake Forest Baptist Medical Center 1

27 Ackowledgements Brian J. Cole, MD, MBA Anthony A. Romeo, MD Nikhil N. Verma, MD Augustus Mazzocca, MD Steven Arnoczky, DVM Wake Forest Baptist Medical Center Age-Related Rotator Cuff Tears Full-thickness Tears 7-40% of the general population Asymptomatic Rotator Cuff Tears 13% of population aged % of population aged % of population aged Jeong et al. JSES Teunis et al. JSES Yamamoto et al. JSES Tempelhof et al. JSES Rotator Cuff Tear & Age: 588 patients U/S Shoulder Pain No cuff tear: avg 48.7 yrs Unilateral tear: avg 58.7 yrs Bilateral tear: avg 67.8 yrs 2

28 Burden of Rotator Cuff Disease Repair associated with cost saving to society of ~$3.4 billion Mather et al. JBJS Am Wake Forest Baptist Medical Center Mochizuki et al. JBJS Am What happens after they are repaired? Structural failure rates after attempt of repair have been reported to range from 20-94% Audenaert E, KSSTA Derwin KA et al. J Shoulder Elbow Surg Galatz LM et al. J Bone Joint Surg Am Harryman et al. J Bone Joint Surg Am Liu SH et al. Arthroscopy Courtesy of Brian Cole, MD Patient Age 408 patient with post-operative evaluation of cuff integrity by CTA or U/S Found age was significantly associated with re-tear rate Wake Forest Baptist Medical Center Chung et al. AJSM 2011 Demonstrated evidence that vascularity of rotator cuff decreases with age All four regions of interest in native human cuff showed decreased blood flow in patients > 40 vs. < 40 years of age Rudzki et al. JSES

29 Integrity of Cuff Repairs Intact cuff = better function 5 year follow-up One tendon tears: 80% intact Two tendon tears: > 50% with defect Most comfortable / satisfied with result Is there a role for biologics to improve healing?! Wake Forest Baptist Medical Center Harryman et al. JBJS Am Mechanical Biological Suture strength Multiple Sutures Suture configuration Suture anchors Double Row Fixation Prepare bone footprint Acromioplasty? Growth Factors Tendon to Bone Healing Maximize Contact Area Anatomic Repair Margin Convergence Interval Slides Pathogenesis of Rotator Cuff Disease Biomechanical Factors Biological Factors Patient Factors Wake Forest Baptist Medical Center 4

30 Stem Cell: Definition Anabolic and anti-catabolic molecules that modify the regenerative process in soft tissue and bone Targets: Cartilage Synovium Mesenchymal Stem Cells (MSCs) Subchondral Bone Tendon Wake Forest Baptist Medical Center 13 Where Do They Come From? d Anz et al. Applications of Biologics in the Treatment of the Rotation Cuff, Meniscsus Cartilage and Osteoarthritis. JAAOS Wake Forest Baptist Medical Center 14 Biologics MSC Strategies HOW? IA INJECTION OR SURGICAL DELIVERY WHAT? CONCENTRATED OR EXPANDED WHERE? From BONE MARROW, ADIPOSE TISSUE, SYNOVIAL TISSUE, PERIPHERAL BLOOD Wake Forest Baptist Medical Center Courtesy of Brian Cole, MD 5

31 Biologics What? CONCENTRATED PROS: minimally manipulated, one-step CONS: heterogeneous composition, small number EXPANDED PROS: higher number Wake Forest Baptist Medical Center CONS: contamination during amplification, regulatory demands Courtesy of Brian Cole, MD Roles of Biologics Stem Cells Medicinal Signaling Cells 1. Recruit other stem cells 2. Secrete bioactive factors Angiogenesis Mitosis Anti-scarring Anti-apoptotic 3. Local modulation Anti-inflammatory Immunomodulatory - Reduce T cell surveillance Bunnell. Stem Cell Res and Therapy, Courtesy of Brian Cole, MD Biologics: Regulations 1997: FDA Title 21, Part 1271 Section 361: Low-Risk HCT/Ps Section 351: High-Risk HCT/Ps 4 criteria Minimal manipulation Homologous use Noncombination products lack of systematic effect Anz et al. Applications of Biologics in the Treatment of the Rotation Cuff, Wake Meniscsus Forest Baptist Cartilage Medical Center and Osteoarthritis. JAAOS

32 Platelet-Rich Plasma (PRP) First utilized in 1990 s Composition Transforming Growth Factor-β (TGFβ) Basic Fibroblast Growth Factor (bfgf) Platelet-Derived Growth Factor (PDGF) Vascular Endothelial Growth Factor (VEGF) Epidermal Growth Factor (EGF) Stimulate neovascularization and accelerate graft integration Boswell et al. Platelet-Rich Plasma: A Milieu of Bioactive Factors. Arthroscopy Misconception: PRP Does not work Biologics such as PRP have no role in shoulder surgery. Evidence Would Suggest PRP may have modest effects on clinical outcome scores, but inconsistent impact on overall retear rates. Despite the limitations of subgroup analysis, small and medium sized tears (<3cm) appear to have lower retear rates or incomplete healing in patients treated with PRP. Future Directions Larger RCTs which are powered to detect differences in complete retear rates of 10% between groups are needed to definitively answer the question All PRP Are NOT Created Equal Direct correlation with peripheral venous blood characteristics Whole blood Platelet count Hematocrit Proprietary processing method Individual variability 7

33 Leukocyte Content: Does It Matter? Leukocyte % ~ GFs, tenocyte profiliferation, collagen synthesis Leukocyte poor PRP promotes collagen synthesis & decreases cytokines linked to matrix degeneration and inflammation Wake Forest Baptist Medical Center 22 Platelet Leukocyte Wake Forest Baptist Medical Center 23 PDGF-AB TGF-B VEGF There is large heterogeneity between PRP separation systems regarding concentrations of platelets, leukocytes, and growth factors in PRP. Wake Forest Baptist Medical Center 24 8

34 Does PRP Influence Rotator Cuff Healing? Wake Forest Baptist Medical Center Courtesy of Anthony Romeo, MD Who is the right patient for this? Not this Patient 9

35 Partial Tear? Wake Forest Baptist Medical Center 28 Irreparable Tear? 29 Irreparable Tear? 30 10

36 Does PRP Influence Rotator Cuff Healing? Healthy Tissue Access to Reparative Cells Availability of Bioactive Factors Synthesis outpaces degradation Wake Forest Baptist Medical Center Courtesy of Steven Arnoczky, DVM Show Me The Data! 32 RCR +/- PRP: No difference in outcome scores PRP+ better healing rates 50% lower risk of failure to heal 65% lower risk in small/medium tears Wake Forest Baptist Medical Center 33 11

37 3193 patients at mo f/u No difference in overall retear rate No difference in PROs (UCLA, Constant, ASES, SST) Subgroup Analysis *Solid PRP > Liquid Tendon-bone interface vs. Over tendon *Small/Medium (NNT 6-14) > Large/Massive Wake Forest Baptist Medical Center RCTs, 1147 patients with arthroscopic RCR PRP rates of incomplete healing All tears (17.2% vs. 30.5%) Small/medium tears (22.4% vs. 38.3%) }P<0.05 Medium/large tears (12.3% vs. 30.5%) Constant scores & VAS Pain (Δ1.4) Wake Forest Baptist Medical Center 35 What about Stem Cells? Source of mesenchymal stem cells (MSCs) derived from iliac crest, proximal humerus, or proximal tibia Increased concentration of MSCs and IL-1 receptor antagonist (IL-1ra) protein vs. PRP Cassano JM et al. Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration. Knee Surg Sports Wake Forest Traumatol Baptist Medical Arthrosc. Center

38 Bone Marrow Aspirate Concentrate Goal: Provide a rich source of progenitor cells to differentiate into mesenchymal connective tissue In vitro and animal model research offers encouraging pre-clinical data for MSCs in RCR Despite safety, clinical efficacy and costeffectiveness remain unclear Courtesy Dr. Gus Mazzocca Is it Safe and Efficient? YES! Where Should We Get the Cells? Iliac Crest Proximal Tibia Proximal Humerus Wake Forest Baptist Medical Center 13

39 Stem Cell Technique Wake Forest Baptist Medical Center Courtesy of Brian Cole, MD 14 consecutive patients with mini-open FTRCR with BMAC 12 mo f/u UCLA: 12±3 31±3.2 MRI: 100% tendon integrity Wake Forest Baptist Medical Center 41 Matched Case-Control Study (LOE II) 45 patients BMAC + SR RCR (Ave MSC: 51K) 45 matched control SR RCR ASIS w MSCs between tendon and bone US and MRI documented Int Ortho % healing (BM-MSC) vs. 44 % (Non BM-MSC) at 10 years Significant improvement in rotator cuff healing rates with local application of BMAC 14

40 Future Directions to Improve Healing Anchoring Systems: Delivery, fixation easier? How much is enough? Improve Biology PRP/Bone Marrow Aspirate Adult Stem Cells Remaining Questions (Biologics): What do we use? When do we need it? How do we get it there? How do we keep it there? ADSCs & Amniotic Products 44 Stromal cells and pericytes comprise 2% of lipoaspirate 500x more pluripotent cells than the volume equivalent BMA May diminish atrophy or fatty replacement after RCR in small animal model 15

41 Cohort Study 35 patients RCR 35 patients RCR + ADSC No 28 mo ROM PROs (Constant, UCLA) MRI re-tear rate 28.5% vs. 14.3% (p<0.001) d d Conclusions Despite wide variability, L-PRP may offer modest short-term patient reported benefits and lower risk of incomplete healing after RCR, particularly with small to medium tears MSCs are safe, easily accessible, and biologically robust, and limited clinical data offers encouraging results with potentially lower retear rates Adipose-derived and amniotic membrane products are emerging technologies with frequent off-label use despite vague FDA regulations Wake Forest Baptist Medical Center 16

42 Thank You! Wake Forest Baptist Medical Center Wake Forest Baptist Medical Center 17

43 Superior Capsular Reconstruction vs Reverse Total Shoulder Arthroplasty How do we decide? Brian J. Cole, MD, MBA Professor, Vice-Chairman, and Managing Partner Department of Orthopedics Chairman of Surgery, Rush OPH Section Head, Rush Cartilage Restoration Center Team Physician, Chicago White Sox and Bulls I (and/or my co-authors) have something to disclose. Detailed disclosure information is available via: Printed Final Agenda Meeting App Meeting Website or AAOS Orthopaedic Disclosure Program on the AAOS website at Managing Expectations Arthroscopy, 2017 Patient satisfaction is the most important quality outcome metric and will affect physician reimbursement Patient satisfaction directly linked to a patient s pre-operative expectations Less Pain and More Function 1

44 AJO, 2017 What do they want? Less Pain More Function Occupation 93.9% 82.7% 17.3% 6.1% Labor Non-Labor Class Prefer Strong Shoulder/Mild Pain Prefer Weak Shoulder/No Pain Overview The Problem The Options Patient Paradigm entering How will of you Humeral choose? Head Source of the Problem 62 M fall onto shoulder C/O weakness and pain 2

45 Massive RCT Options Non-Surgical Debride/Repair Bridge ECM KSST 2016 AJSM 2017 SCR SA Balloon Arthroscopy 2013 AOTS 2017 Tendon Transfer Reverse TSA JBJS 2014 What if it looked like this? SCR vs RTSA Two different options potentially for the same clinical scenario. In common, they at least have an irreparable rotator cuff tear, have failed other treatment options, and are interested and willing to have surgery possibly for a 2 nd or 3 rd time. What does success mean and for whom? Tangible and intangible factors Both options can work and both can fail. Know what each operation can do and match the operation to the patient paradigm. This is the art of medicine and there are no absolutes 3

46 Truly Irreparable RCT Patient Paradigm Physiologic Age Chronologic age Medical co-morbidities What prompted the visit? What are they asking for? What do you feel comfortable doing? Patient tolerances and patience Patient-definition of success or failure SCR Physician-definition of success or failure Cost of the procedure Number and type of prior surgeries Response to prior surgeries Response to non surgical care Treatment fatigue Pain with activities Pain at night Pain location and severity Current pain management AROM/Strength loss and where PROM loss and where Risk tolerance of surgeon and patient Future occupation Future activities Patient expectations Surgeon expectations RTSA Where the surgery will be done Who is paying for it Experience and interests of the surgeon Real and false perceptions Radiographs MRI/CT MRI Based Algorithm Massive Cuff Tear 5 cm² 2 tendons ( Grade 3 Fatty deg.) Repair ± Augmentation ± Bridge Graft Tendon Transfer (Latissimus) (Pectoralis) Reverse Prosthesis ± Latissimus Superior Capsule Reconstruction Mihata T, Arthroscopy 2013 Adapted from A Romeo What is SCR? Cadaveric Study SCR to evaluate superior translation and GH compression forces Proposed Mechanism Prevents superior escape Decreased bony impingement of GT on acromion No change in GH force Improved deltoid function 4

47 SCR Indications Symptomatic Irreparable SS or SS/IS Intact or Reparable Subscapularis Functional Deltoid and Trapezius Minimal to No Glenohumeral Arthritis Hamada Stage 4 0% Success Hamada 4 Hamada Stage 3 33% Success Hamada 3 Hamada Stage 2 69% Success Hamada 2 Hamada Stage 1 82% Success Hamada 1 The larger the pre-operative tear, the lower the rate of success. Subscapularis should be intact or reparable. Pseudoparalysis is not a contraindication. Advanced Goutallier Stages do not preclude a good outcome. 5

48 What can t SCR do? Treat advanced RCA Improve lost PROM Improve strength dramatically that is unrelated to pain SCR Technique Evolution Thicker grafts TOE Laterally 3 Independent Anchors Medially 3 Glenoid Anchors Safe and Effective All 3 Anchor Positions Safe with SSN & Glenoid Fossa Superior Anchor Risk for Glenoid Face Perforation 6

49 What can SCR do? Arthroscopy Shoulder at 2.8 yrs Ave 65 yo Irreparable RCT w Facia Lata Outcomes Increased AHI 4.1 mm Active FE: Active ER: ASES Re-tears Outcomes Arthroscopy, 2018 AJSM 2018 Arthroscopy, 2018 Improved VAS, SST, SANE, ASES RTS possible Improved AFE, AER, AHI 75-90% Satisfaction 15-20% Revision Am J Ortho AOSSM 2017 What is RTSA? Traditionally for patients with rotator cuff arthropathy where conventional arthroplasty fails The socket and head are switched Relies on the deltoid muscle in the absence of the rotator cuff 7

50 Results JBJS 2017 Musculoskeletal Surg, 2017 Excellent results > 65 y.o. with true RC arthropathy, pseudoparalysis less pain, more function and strength But 15-30% complication rate and 7-12% revision rate Black and White When one operation works and the other does not RTSA SCR Irreparable RCT w arthropathy Hamada > 3 Physiologically old Desire for low demand Subscap/Teres out Irreparable RCT w/o arthropaty Hamada < 3 Physiologically young Desire for high demand Intact/repairable Subscap/Teres Black and White When one operation works and the other does not RTSA SCR 8

51 Black and White When one operation works and the other does not RTSA SCR Option 1 Superior Capsular Reconstruction History 58 yo R Shoulder pain Prior massive RCR and never got better Continued pain and weakness Unresponsive to additional non surgical care FE 140, ER 50, Strength 3/5 SS, IS Imaging 9

52 Arthroscopy What was done Option 2 RTSA JSES, % felt that their strength and function were acceptable despite a 25% failure rate

53 Option 2 Reverse Shoulder Arthroplasty 72 yo F s/p B/L massive RCR in 1997 MVA 1 year prior to R shoulder pain Injections and PT Physical Examination Case 7 Imaging 11

54 MRI What was done How she did 12

55 The Grey Zone Why not RTSA for all? Irreparable RCT without arthritis? Prior RCR without arthritis? What if AFE > 90? What if they have pain with normal function? What about patients less than 65? What are the complications? What does it cost? RTSA Massive RCT W/O OA JBJS 2010 Indications: 2 tendon RCT, Hamada < = 3, no OA F/U mean 52 mo ASES 33 75; SST ; VAS 6.3-->1.9 Function ; AFE 53 o 134 o ; AER % Complications Survivorship 92% w/o prior RCR and 87% w prior RCR 13

56 RTSA Failed RCR w/o OA Ave 70 yo Worse ASES, SSV, Pain, FE OJSM 2017 JSES % Complication 5% reoperation In < 90 o ; AFE 56 o to 123 o 93% satisfied In painful shoulders, AFE 146 o 122 o (LOSS OF FE) 27% dissatisfied RTSA Age < 65 Poor Px JSES 2013 Indications: AFE < 90 w intact PROM Improved Constant/SST AFE increase 47 o No improvement in AER 38% Complication 15% Failure JBJS year f/u Constant/SSV improved 39% complications and 10% failure JSES 2015 High pre op SST Complications 20-50% Complication Rate Infected arthroscopy easily treated Infected TSR life-changing 14

57 Implant Cost* SCR $6,700 RTSA $10,400 *Estimated that total cost for RTSA is 15-22K more than SCR Value Based Decision-Making SCR RTSR Rate of Complications Lower Higher Magnitude of complications Lower Higher Cost Lower Higher Conclusions Pain, AROM, weakness, pseudoparalysis can be effectively treated by SCR and RTSA PROM loss and escape difficult to tx with SCR Avoid RTSA if possible for young and prior RCR Can go younger w RTSA w no subscap, escape, > grade 3 change RTSA associated with higher incidence and more severe complications SCR increasing evidence but needs L-T f/u 15

58 3rd Annual 2018 Chicago Sports Medicine Symposium World Series of Surgery September 7-September 9, 2018 Chicago, IL 1st Annual AOSSM OLC Biologics/US Course October 12-13, 2018 Chicago, IL 1st Annual AANA Practice Management Course November 8-9, 2018 Chicago, IL 20 th Annual AANA/AOSSM/AAOS SKI COURSE January 30-February 3, 2019 Park City, Utah 16

59 Case Studies Brian J. Cole, MD, MBA Professor, Vice-Chairman, and Managing Partner Department of Orthopedics Chairman of Surgery, Rush OPH Section Head, Rush Cartilage Restoration Center Team Physician, Chicago White Sox and Bulls I (and/or my co-authors) have something to disclose. Detailed disclosure information is available via: Printed Final Agenda Meeting App Meeting Website or AAOS Orthopaedic Disclosure Program on the AAOS website at History 53 y/o RHD F Works as a nurse CC: L atraumatic shoulder pain Has hs pain Failed prior steroid injection and PT 1

60 Physical Full PROM FF: 150 ER: 55 5/5 subscapularis/infraspinatus 4+/5 supraspinatus + Impingement (Neer, Hawkins) No TTP at biceps or AC joint Radiographs MRI 2

61 What Would You Do? Diagnostic Arthroscopy What Would You Do? 3

62 What was done.should we do anything else? Bio-Inductive Collagen Patch Muscle, Lig, Tendon J, 2013 Arthroscopy Tech, 2015 Arthroscopy Tech, 2016 Surgical Procedure 4

63 Thoughts? JSES, 2017 Preliminary Investigation of a Bio-Inductive Collagen Patch used on Large/Massive Rotator Cuff Tears Savoie et al, AAOS patients large/massive RCR to augment RCR Half revisions U/S Exam w 5-9 mm thickness Improved clinical outcomes Collagen-based Bioinductive Implant for Treatment of Partial Thickness RCT Abigail Campbell MD, Amos Dai BS, John Begly MD, Mark Kramarchuk BS, Soterios Gyftopoulos MD, Laith Jazrawi MD, Robert Meislin MD AAOS Abstract patients PT RCT to augment RCR Reducted pain, improved function in 50% MRI w slight increase thickness Biologics as a surgical adjunct? History 51 yo RHD M Acute R shoulder dx while body surfing Closed reduction under sedation CC: Pain and Weakness 5

64 Physical Radiographs Case 3 MRI Case 3 6

65 What would you do? What was done. Anything else? PRP? BMAC? Adipose? Other? When what how? Early Post-Op? 7

66 The Grey Zone History PMH: DM & HTN 1 year post injury with no prior shoulder problems RCR 4 mo later: Brief relief, but then worsened Primary Complaint: Pain, HS Requires pain Rx Primary Goal: Reduce pain and resume work as school bus driver 56 year old female with right shoulder pain Physical Exam 56 year old female with right shoulder pain 8

67 X-Rays MRI Sagittal MRI Coronal MRI Axial MRI What Would You Do and Why? 9

68 What was done. The Grey Zone History 69 yo RHD male R shoulder pain started 2016 Cannot work as electrician CC: pain and weakness 1 st surgery 5/2016: RCR, biceps tenodesis, SAD and debridement 2 nd surgery 10/2016: MUA 3 rd surgery 2/2017: Arthroscopic debridement The Grey Zone Physical Exam FF 170 with discomfort ER 35 IR to L5 Non-tender AC joint and biceps 4/5 weakness in supraspinatus and infraspinatus No lag signs present Subscapularis intact 10

69 Radiographs What would you do? Sagittal MRI Coronal MRI Axial MRI What Would You Do and Why? 11

70 What was done. 3rd Annual 2018 Chicago Sports Medicine Symposium World Series of Surgery September 7-September 9, 2018 Chicago, IL 1st Annual AOSSM OLC Biologics/US Course October 12-13, 2018 Chicago, IL 1st Annual AANA Practice Management Course November 8-9, 2018 Chicago, IL 20 th Annual AANA/AOSSM/AAOS SKI COURSE January 30-February 3, 2019 Park City, Utah 12