SHOULDER ANATOMY AND FUNCTION. Disclosure. Case. Learning Objectives MRI. Plan? 3/23/2017 5

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Virgil Nelson
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Editorial or governing board Mid-America Orthopaedic Association, Exhibits Committee: Board or committee member Research and Education Funding: Creighton University 2015 Haddix Grant, 2016-2017 MAOA

1 Disclosure Doc, My Shoulder Keeps me Up at Night! Evaluation and Treatment of Atraumatic Shoulder Pain Matthew F. Dilisio, MD Shoulder and Elbow Surgery, CHI Health Orthopedics Assistant Professor, Creighton University School of Medicine Thursday, March 30, 2017 Matthew F Dilisio, MD Arthroscopy Journal: Editorial or governing board Mid-America Orthopaedic Association, Exhibits Committee: Board or committee member Research and Education Funding: Creighton University 2015 Haddix Grant, MAOA Traveling Fellow 2 Learning Objectives Review anatomy and function of the rotator cuff Review the common culprits of shoulder pain Review how to differentiate various shoulder pathologies through history and exam Review the most up-to-date treatments for shoulder pain Case 48 y/o Electrician 6 Months of shoulder pain and weakness, worse with overhead activity Pain: 7/10 SSV:30% Physical Exam: Full Supple Passive ROM Active-FF: 145* Active ER: 20*, 40* ER lag + Hornblowers -Belly press 4/5 Strength in FE and ER +TTP biceps groove 3 MRI Dx: Massive Posterosuperior Rotator Cuff Tear in 48yo Laborer with Fatty Infiltration SHOULDER ANATOMY AND FUNCTION Plan? 5 6 1

2 Osseous Anatomy of the Shoulder Rotator Cuff Anatomy Subscapularis Subscapular Nerve Supraspinatus Suprascapular Nerve Infraspinatus Suprascapular Nerve Teres Minor Axillary Nerve 7 8 SUPRASPINATUS INSERTS FROM BICEPS GROOVE TO BARE AREA TIGHT TO ARTICULAR SURFACE BLENDS WITH IS ABOVE BARE AREA INFRASPINATUS SECOND LARGEST RC TENDON WRAPS AND INTERDIGITATES WITH POSTERIOR SS TAPERS FROM EDGE OF A.S. SUPERIORLY TO 16 mm AWAY INF. FRAMING THE BARE AREA TERES MINOR SMALLEST RC MUSCLE TENDON UNIT INSERTS FROM 3-5:00 LENGTH 29mm(20-40) WIDTH 20 mm (10-25) SUBSCAPULARIS FOOTPRINT LARGEST OF RC TENDONS COMMA SHAPE FROM 7-11:00 LENGTH 40 mm (35-55) WIDTH 19 mm (15-25) TAPERS TENDON TO MUSCLE 2

3 Biceps and Labrum Glenohumeral Anatomy: Mobility and Stability, Concavity and Compression 13 Allows a stable fulcrum about which the deltoid can elevate the arm. Whiting and Zernicke. Biomechanics of Musculoskeletal Injury, 1998 Lippitt and Matsen. Rotator Cuff Function: The Force Couple The Rotator Cuff Pathoanatomy: a break in the force couple Biomechanics of a Rotator Cuff Tear HISTORY AND EXAM

$fracture/dislocation/significant$ rotator cuff tear Atraumatic

4 History Pain, Stiffness, Weakness Yes, Yes, and Yes Traumatic or Atraumatic Age/Pattern Recognition 18yo: Instability 50yo F, Diabetes: Frozen Shoulder 62yo M: Atraumatic Cuff Tear History Traumatic Rule out fracture/dislocation/significant rotator cuff tear Atraumatic PT/NSAIDs/Injection Exam 1. Location 2. Range-of-Motion 3. Strength Exam #1: Location Location=Anatomy Exam #2: Range of Motion Forward Elevation Internal Rotation External Rotation Exam #3: Strength Forward Elevation Internal Rotation External Rotation

5 Imaging Glenohumeral Arthritis IMAGING 25 Xray/CT MRI: Normal Supraspinatus MRI MRI Labrum

Ultrasound TREATMENT 31 32 Atraumatic Shoulder Pain A Tendon Problem Arthritis Stability Stiffness Instability TREATMENT: TENDON 33 34 Rotator

Pectoralis Major PRP Pecotralis Minor Stem Cells Trapezius Activity Modification Ventral Latismus Rotator Cuff Repair Biologic Graft Open

Partial Thickness Transtendon Reverse Shoulder Arthroplasty Take-Down Glenohumeral Fusion Debridement Resection Arthroplasty Other Arthroscopic

6 Ultrasound TREATMENT Atraumatic Shoulder Pain A Tendon Problem Arthritis Stability Stiffness Instability TREATMENT: TENDON Rotator Cuff Treatment Options Non-Operative Tendon Transfer Physical Therapy Latisimus Modalities Arthroscopic Injections Open Corticosteroid Pectoralis Major PRP Pecotralis Minor Stem Cells Trapezius Activity Modification Ventral Latismus Rotator Cuff Repair Biologic Graft Open Xenograft Arthroscopic Human Dermis Single Row Synthethic Double Row Hemiarthroplasty Full Thickness v. Partial Thickness Transtendon Reverse Shoulder Arthroplasty Take-Down Glenohumeral Fusion Debridement Resection Arthroplasty Other Arthroscopic Options Subacromial Decompression/Acromioplasty Biceps Tenodesis Suprascapular Nerve Decompression Rotator Cuff Debridement Partial Rotator Cuff Repair Treatment 1. PT 2. Inject 3. Surgery

Non-Operative Physical Therapy Injections

Cohort of MRI documented full-thickness,

effective 75% of the time with 2y f/u for

Rotator Cuff Repair Little difference in

relief and restoration of function Healing

7 Non-Operative Physical Therapy Injections NSAIDs Activity Modification Subacromial Injections 2cm medial and inferior to posterolateral tip of acromion Non-Operative Prospective, Multicenter, 2012 Neer Award Winning Paper 452 Patient Cohort of MRI documented full-thickness, ATRAUMATIC RCT 6 Week obligate PT 6 wk, 12 wk, 1y, 2y Conclusion: Nonoperative treatment is effective 75% of the time with 2y f/u for atraumatatic, FT cuff tears Open/Mini-Open Rotator Cuff Repair Little difference in longterm outcome between arthroscopic and open rotator cuff repair Greater risk deltoid complications Infection prolonged recovery aesthetics Arthroscopic Rotator Cuff Repair The most popular method of rotator cuff repair Patient Satisfaction: 80-90% Effective for pain relief and restoration of function Healing rate variable Age-related Easy to address concomitant pathology Healthy supraspinatus tendon 41 7

8 Diagnostic Shoulder Arthroscopy Torn Supraspinatus Tendon 43 Arthroscopic Rotator Cuff Repair 45 Massive Rotator Cuff Repair T1 Sagital MRI image of rotator cuff muscle Arrow: Supraspinatus muscle White=Fat, Dark=Muscle 47 8

9 PALLIATE Other Arthroscopic Treatments Biceps Tenodesis/Tenotomy Partial Repair Rotator Cuff Debridement Subacromial Decompression Suprascapular Nerve Decompression Traction effect Diagnosis Superior shoulder pain SSN injection (CT) EMG RECONSTRUCT Irreparable Cuff Tears: Tendon Transfer Latissimus 1 muscle grade/1 finger Arthroscopic Latissimus Pectoralis Major Partial v. Complete Pectoralis Minor Lower Trapezius Ventral Latismus

10 Tendon Transfers Repair Replace Tendon Grafting/Biologics/Stem Cells/Platelet Rich Plasma Graft Other biologics Xenograft Theoretical benefit Human Dermis and laboratory Synthethic success, but little Should not be used clinical evidence to as bridge, may support efficacy provide biomechanical support (biologic splint) Superior Capsule Reconstruction Superior Capsule Reconstruction TREATMENT: ARTHRITIS Hemiarthroplasty/CTA Heads/Resurfacing Not a great option Has a role in arthritis/cuff Tear Arthropathy For patient that are not candidates for reverse shoulders

11 Total Shoulder Arthroplasty Total Shoulder Arthroplasty with a Rotator Cuff Tear The Subscap Reverse Shoulder Arthroplasty Revolutionized the treatment of rotator cuff deficiency Originally designed for rotator cuff deficient, pseudoparalytic shoulders Arthroplasty, so also cures pain associated with arthritis Expanding indications Biomechanics Recreates a stable fulcrum about which the deltoid can rotate the arm Biomechanics of a Rotator Cuff Tear Reverse Shoulder Arthroplasty Reverse Shoulder Arthroplasty Prerequisites Lower demand patients due to constraint Adequate glenoid bone stock* Deltoid/Axillary Nerve function

12 Physical Therapy Stretch Strengthen/Stabilize TREATMENT: STABILITY (INSTABILITY AND STIFFNESS) Shoulder Dislocations Glenohumeral Instability/Labral Repair Frozen Shoulder/Adhesive Capsulitis What about our patient? BACK TO OUR PATIENT Dx: Massive Posterosuperior Rotator Cuff Tear in 48yo Laborer with Fatty Infiltration 71 Plan? 72 12

2 kg (82%) Pain: 0/10 Left FF-13.9 kg ER-14.

electrician 73 Atraumatic Shoulder Pain A Tendon Problem Arthritis

13 Massive Rotator Cuff Repair 5.5 mos Post-Operative STRENGTH Right FF- 9.6 kg (70%) ER-12.2 kg (82%) Pain: 0/10 Left FF-13.9 kg ER-14.8 kg AROM: FF-160, ABD-160, IR-T12, ER:60 Returns to work as electrician 73 Atraumatic Shoulder Pain A Tendon Problem Arthritis Stability Stiffness Instability Zebras Metastisis Myeloma Lymphoma Primary Sarcoma When to Refer? Immediate Fracture Acute Rotator Cuff Tear in young/active patient Shoulder Dislocation Concern for septic shoulder (rare!!!!!) OK for PT/Inject/Observation Chronic pain Non-traumatic injuries

Shoulder Arthroscopy. Dr. J.J.A.M. van Raaij. NOV Jaarvergadering Den Bosch 25 jan 2018

Shoulder Arthroscopy. Dr. J.J.A.M. van Raaij. NOV Jaarvergadering Den Bosch 25 jan 2018 Shoulder Arthroscopy Dr. J.J.A.M. van Raaij NOV Jaarvergadering Den Bosch 25 jan 2018 No disclosures Disclosure Shoulder Instability Traumatic anterior Traumatic posterior Acquired atraumatic Multidirectional