Case 1. Exam. Cases. Shoulder Service

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Karen Young
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1 Cases Friday Afternoon Session Case 1 49 yr male Injury with loss of active elevation and now an internal rotation drop at side Lifting 20 lb bag at time Mild previous infrequent shoulder pain Exam AFE: 60 degrees AER: - 20 degrees 5/5 Belly press 3/5 ER No visible atrophy Dominant R side Occupation- Tradesman 1

2 MRI Obtained Options? RCR Decompress nerve to Teres Minor RCR with Lat Transfer Superior Capsular Reconstruction RTSA with Lat Transfer Open RCR with LT transfer 2

play softball, golf AFE: 90 AER: 40 Weak with ER and Supra testing Options Open RCR Open RCR with ECM augmentation Scope

3 Case 2 49 yr old male Sliding into 2 nd base and felt a pop Immmediate pain and loss of active elevation 3 weeks later, feeling better, better ROM, but weak Primary MD orders MRI Case 2 Works as software rep Non-dominant arm Likes to workout, play softball, golf AFE: 90 AER: 40 Weak with ER and Supra testing Options Open RCR Open RCR with ECM augmentation Scope RCR Scope RCR with ECM Inject and Rehab Partial RCR LHBT tenotomy RTSA Would your thoughts change if this was a female at age 68? 3

4 Initial open view Now what? OR Case 3 Professional baseball outfielder Dominant arm weakness in ER Minimal if any pain Normal MRI in Feb. Visible atrophy of IS on dominant side Physical Exam: Normal Strength: Supra Subscap Deltoid Scapular Rotators 3+/5 ER at side Negative signs of: SLAP, Impingment. LHBT, Instability, Stiffness 4

SLAP elevation and repair What was Performed EMG isolated to SGN notch Neuropathy of IS Only electrical evidence of supra involvement No

5 Next Evaluation Modality? MRI Arthro/MRI EMG Ultrasound Normal MRI in Feb, this MRI is July same year Now What? MRI NO Ganglion NO SLAP lesion NO RCT Minimal Bursa signal Playing EMG--- Options?: Scope Suprascapular nerve decompression But Where? SLAP elevation and repair What was Performed EMG isolated to SGN notch Neuropathy of IS Only electrical evidence of supra involvement No ganglion No SLAP Arthroscopy Spinoglenoid notch suprascapular nerve decompression Arthroscopic suprascapular notch decompression NO: SLAP, labral path, RC path, Bursitis 5

OR Open Decompression at SGN Incision begin

from posterolateral corner of acromion Deltoid

Split fascia over IS muscle Identify scapular

6 OR Open Decompression at SGN Incision begin 3-4 cm. from posterolateral corner of acromion Deltoid split in line with fibers Begin muscle split 4-5 cm. from posterolateral corner Open Decompression Split fascia over IS muscle Identify scapular spine Inferiorly reflect IS Exposes fascial veil off scapular spine Spinoglenoid ligament present in all cases SG Ligament IS 6

Open Decompression Release SG ligament superior to inferior off lateral

bundle: freely movable with freer- DONE Released SGL with NVB showing

3 months Throwing in competition 5 months Leads league in outfield

isolated to the spinoglenoid notch: surgical technique and results of

7 Open Decompression Release SG ligament superior to inferior off lateral scapular spine Carry release inferiorly SGL will unwind and disappear NV bundle: freely movable with freer- DONE Released SGL with NVB showing Progression of Recovery 5 weeks post-op 9 weeks post-op Recovery Throwing 3 months Throwing in competition 5 months Leads league in outfield assists this year Full ER strength Suprascapular nerve entrapment isolated to the spinoglenoid notch: surgical technique and results of open decompression Mall NA, Hammond JE, Lenart BA, Enriquez DJ, Twigg SL,Nicholson GP JSES

Conclusions SSN entrapment at the SGN can be: Isolated entity Associated with ganglion cyst Clinically important in conjunction with RCT SG ligament can be primary causative factor Thus ganglion

8 Conclusions SSN entrapment at the SGN can be: Isolated entity Associated with ganglion cyst Clinically important in conjunction with RCT SG ligament can be primary causative factor Thus ganglion decompression may not eliminate nerve compression GH pathology not common. No SLAPs A ganglion can exist without joint communication Conclusions Operative technique detaches no muscle Combined with open or arthroscopic surgery Consistent and rapid improvement Extremely low morbidity Index of Suspicion Careful physical exam, history, EMG, MRI Thank you! Gregory P. Nicholson, M.D. Rush University Medical Center Chicago, Illinois 8

Case 4 20 yr old college pitcher Pain and loss of velocity Failed Conserative TX Mild loss of IR Impingment type subacromial pain Case 2 Had SA injection with transient relief Shutdown

9 Case 4 20 yr old college pitcher Pain and loss of velocity Failed Conserative TX Mild loss of IR Impingment type subacromial pain Case 2 Had SA injection with transient relief Shutdown for 3 months- pain recur with throwing NO hx or clinical evidence of instability, SLAP type path, or LHBT sx Options MRA? Ultrasound PRP 3 months of Rehab and return to throw EUA and Scope 9

10 Came to OR No GIRD No SLAP LHBT normal Undersurface of RC with footprint exposure Partial RC Tears Articular or Bursal Sided Evaluation of SA space revealed fiber failure on the bursal side also Options?: 20 yr. old Pitcher Completed RCT SAD Returned to throw flat ground at 5 mn Off mound at 8 mn 10

11 ER Strength 2/5 0 3/5 2 (7%) 4/5 9 (35%) 5/5 15 (58%) Results Allimproved at least 1 full grade 81% improved ER strength at 1 week Ganglion: full strength avg. 6 weeks Non-ganglion: full strength avg. 10 wks. Avg. ASES: 87 (60-100) [+28] ER Strength 2/5 0 3/5 2 (7%) 4/5 9 (35%) 5/5 15 (58%) Results Allimproved at least 1 full grade 81% improved ER strength at 1 week Ganglion: full strength avg. 6 weeks Non-ganglion: full strength avg. 10 wks. Avg. ASES: 87 (60-100) [+28] 11

Gregory P. Nicholson, M.D. Disclosures. Indications for Open RCR. Open RC Repairs 2015 and Role of Tendon Transfers. Associate Professor

Gregory P. Nicholson, M.D. Disclosures. Indications for Open RCR. Open RC Repairs 2015 and Role of Tendon Transfers. Associate Professor Open RC Repairs 2015 and Role of Tendon Transfers Gregory P. Nicholson, M.D. Associate Professor Rush University Medical Center Chicago, Illinois Disclosures Research and Educational Support: Tornier,