Common Shoulder Problems and Treatment Options. Benjamin W. Szerlip D.O. Austin Shoulder Institute

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1 Common Shoulder Problems and Treatment Options Benjamin W. Szerlip D.O. Austin Shoulder Institute

2 Speaker Disclosure Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.

3 Learning Objectives By completing this educational activity, the participant should be better able to: 1. List common shoulder conditions seen in patients. 2. Discuss history and exam findings that are highly indicative of each condition. 3. Predict the likelihood of resolution with conservative care. 4. Determine when to order imaging or refer to a specialist.

4 Overview Anatomy Why do we have shoulder pain? What is new today? What can patients expect?

Sternoclavicular Scapulothoracic Glenohumeral Minimally

5 Normal Anatomy: Static Articular Components A coordinated complex of Intercalated joints Acromioclavicular Sternoclavicular Scapulothoracic Glenohumeral Minimally Constrained Not Ball-in-Socket Balance of Stability & Mobility Static vs. Dynamic

6 The Humerus: Surface Area Mismatch Approximately Spherical Articular Area ~3X Glenoid Uniform Articular Thickness

7 Anatomy of the Humerus Everyone is Different!!

8 Glenoid Labrum

9 The Labrum: Essential Stability Extends the articular arc & deepens the glenoid socket Does not change the radius of curvature of the glenoid surface Reversibly deformable tissue Williams & Iannotti Bumper Conforming to Humeral Head

11 Shoulder Joint Pain Rotator Cuff Impingement, Tendinitis and Tears Arthritis Instability/ Labral Tears AC Joint separation Fracture Biceps Tears Irreparable Rotator Cuff Tears

12 Rotator Cuff Tears - Natural History 17 million/year Prevalence increases with age (>50% in individuals beyond 75 yrs. Old) Not all tears symptomatic >50% of previously asymptomatic tears develop symptoms of pain ( 2.8 yrs. f/u) 40% of tears increase in size over 5 yr. f/u 80% of pts. whose tear enlarges develop symptoms

13 Rotator Cuff - Symptoms Pain at night Weakness Loss of function Lateral arm pain

14 Role of MRI in Rotator Cuff Tears Partial vs. full thickness tears Location of tear Size of tear Muscle atrophy Ultrasound a useful alternative in experienced hands

15 Rotator Cuff Tear Who Needs Surgery? Younger, more active individuals Acute, traumatic tears Higher demand individuals Fixable tears Persistent symptoms despite nonoperative treatment

16 Rotator Cuff Repair Best Prognosis Acute cuff tears Smaller, more mobile tears No /minimal muscle atrophy Younger patient (under 70)

17 40 yo man falls skiing can t raise arm 72 yo woman with gradual weakness and pain

18 Accessory Portals Primary Portals

19 Identify Tear Pattern Crescent U-Shaped L-Shaped

20 Margin Convergence Side-to-Side Repair

22 Results Rotator Cuff Surgery 95% pain relief 10% - 26% retear rate (sm.-med. Tears) 20% - 38% retear rate (large tears) Better long-term function if tendon repair remains intact Retear Rate not directly related to clinical outcome

23 Arthroscopic Advancements in Rotator Cuff Repair Bioabsorbable/bone replacing anchors High strength non-absorbable suture Suture passing devices Double row fixation (increase surface area of repair) Surgeon experience/training (video games?)

24 Shoulder Arthritis 43 million American adults diagnosed 100 different types OA or Wear-and-tear arthritis most common Exact causes are unknown Researchers say genetics may play a role in percent of knee osteoarthritis cases

pain, stiffness, decreased mobility Disease and symptoms worsen

25 Osteoarthritis The Bad News Cartilage the cushion between joints breaks down Bones begin to erode, bone spurs develop Symptoms pain, stiffness, decreased mobility Disease and symptoms worsen over time Hips & knees are more common (>1,000,000 replacements/year)

26 Osteoarthritis The Good News There are things patients can do! More is known, and more treatments are available, than ever before Lifestyle changes can help patients feel good, and maintain strength, mobility Medications to relieve pain Joint replacement to eliminate pain, restore mobility

27 What do I need to know? Hx Pain level, Night pain, subjective shoulder function (SSF) Physical exam restricted motion, intact rotator cuff, nerves working X-rays show joint deterioration, bone erosion, excess fluid, bone spurs DON T FORGET THE OTHER THINGS!!

28 What we know VS what we think we know Arthroplasty Short press fit stem Stemless 3D software for pre op planning/ intraoperative guides Augmented glenoid in TSA/ RSA

29 3 Goals Of All Treatments For Osteoarthritis 1. Control Pain and other symptoms caused by the disease 2. Optimize Function, including the impact of osteoarthritis on mobility and the activities of daily living 3. Educate Patients and families about the disease and treatment options for osteoarthritis

30 Temporary Relief Aspirin-Free Pain Relievers Anti-inflammatory Drugs Intra-articular Injections Disease Modifiers Sleep Aids

31 What Makes Someone A Good Surgical Candidate? Everyday activities are difficult Shoulder pain continues while resting, either day or night Stiffness limits your ability to move or lift your arm Little pain relief with non-surgical solutions Harmful or unpleasant side-effects from medications Nonoperative treatments no longer work

32 Surgical Solutions 1. Shoulder Arthroscopy 2. Partial Shoulder Replacement 3. Total Shoulder Replacement 4. Reverse Shoulder Replacement

Shoulder Arthroscopy Joint is viewed using a camera, inserted through a small incision Other instruments are inserted through additional small incisions The

33 Shoulder Arthroscopy Joint is viewed using a camera, inserted through a small incision Other instruments are inserted through additional small incisions The orthopaedic surgeon can diagnose and treat joint disorders by providing a clear view of the joint. Allows the surgeon to treat problems other than shoulder arthritis

34 Why do we Replace the Shoulder? Proximal Humerus Fractures

35 Reverse for Fracture

$Solution with deformity/ Malunion Decrease prosthetic fracture Ease of revision Marketing to$

36 Stemless: What we think Potential advantages Canal sparing Decreased blood loss Preserve bone Solution with deformity/ Malunion Decrease prosthetic fracture Ease of revision Marketing to patients

37 Total Shoulder Replacement The glenoid socket is replaced with a plastic insert that is glued in with bone cement The humeral head is replaced with a metal prosthesis

38 Reverse Shoulder Arthroplasty

39 Technique Modification Critical

40 Shoulder Replacements are Successful Joint replacement surgery among the most common surgery performed in the US Shoulder replacements are the 3rd most common Shoulder replacements have shorter hospitalizations and fewer complications than hip and knee replacements Over 60,000 shoulder replacements are performed annually in the U.S.

41 Osteoarthritis

42 Total Shoulder Replacement

44 Too High Too Large

45 TOO SMALL A HEAD Glenoid Loosening Poly wear

46 THE HUMERUS AND GLENOID ARE MARRIED.. IN THIS CASE THERE IS A DIVORCE

RESULTS (unpublished: Warner, Millett, Higgins) 191

47 RESULTS (unpublished: Warner, Millett, Higgins) 191 Patient 1 yr F/U: Average age = 53yo Are you happy & would you Do it again? 98.5% Yes 49 yo Electrician (bilateral TSR) What percent of normal is Your shoulder? 97.5% > 80%; 35% with normal 50yo woman: National Champion in Horse-jumping 48 yo Former Triathlete

48 I HAVE NO PAIN.AND MY SHOULDER FEELS LIKE A NORMAL SHOULDER

49 Infection Complications CATASTROPHIC!!!!! Diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, remote sites of infection, and previous operations on the shoulder

50 Complications Glenoid Wear/Glenoid Loosening 1/3 complications 3 rd generation cementation technique

51 Complications Instability 0-29% Anterior subscapularis tears Superior rotator cuff tears

52 Periprosthetic fractures Complications

53 Periprosthetic fractures Complications

54 The Reason for Improvement

55 Rotator Cuff Tears Natural history? Nonanatomic prostheses? Stiffness Bleeding Nerve damage Rarely Permanent Mostly Neuropraxias Complications

56 3D Pre Op Planning and PSI Improving patient outcomes Optimizes glenoid bone preservation Improves Implant accuracy/ selection No cost/ downside for planning Real time planning Patient specific options

Shoulder Joint Replacement

Shoulder Joint Replacement Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain. Shoulder replacement surgery was first performed