Common Shoulder Problems and Treatment Options Benjamin W. Szerlip D.O. Austin Shoulder Institute
Speaker Disclosure Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.
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.
Overview Anatomy Why do we have shoulder pain? What is new today? What can patients expect?
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
The Humerus: Surface Area Mismatch Approximately Spherical Articular Area ~3X Glenoid Uniform Articular Thickness
Anatomy of the Humerus Everyone is Different!!
Glenoid Labrum
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
Shoulder Joint Pain Rotator Cuff Impingement, Tendinitis and Tears Arthritis Instability/ Labral Tears AC Joint separation Fracture Biceps Tears Irreparable Rotator Cuff Tears
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
Rotator Cuff - Symptoms Pain at night Weakness Loss of function Lateral arm pain
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
Rotator Cuff Tear Who Needs Surgery? Younger, more active individuals Acute, traumatic tears Higher demand individuals Fixable tears Persistent symptoms despite nonoperative treatment
Rotator Cuff Repair Best Prognosis Acute cuff tears Smaller, more mobile tears No /minimal muscle atrophy Younger patient (under 70)
40 yo man falls skiing can t raise arm 72 yo woman with gradual weakness and pain
Accessory Portals Primary Portals
Identify Tear Pattern Crescent U-Shaped L-Shaped
Margin Convergence Side-to-Side Repair
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
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?)
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 40-65 percent of knee osteoarthritis cases
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)
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
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!!
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
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
Temporary Relief Aspirin-Free Pain Relievers Anti-inflammatory Drugs Intra-articular Injections Disease Modifiers Sleep Aids
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
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 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
Why do we Replace the Shoulder? Proximal Humerus Fractures
Reverse for Fracture
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
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
Reverse Shoulder Arthroplasty
Technique Modification Critical 2015 2016 2017
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.
Osteoarthritis
Total Shoulder Replacement
Too High Too Large
TOO SMALL A HEAD Glenoid Loosening Poly wear
THE HUMERUS AND GLENOID ARE MARRIED.. IN THIS CASE THERE IS A DIVORCE
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
I HAVE NO PAIN.AND MY SHOULDER FEELS LIKE A NORMAL SHOULDER
Infection Complications CATASTROPHIC!!!!! Diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, remote sites of infection, and previous operations on the shoulder
Complications Glenoid Wear/Glenoid Loosening 1/3 complications 3 rd generation cementation technique
Complications Instability 0-29% Anterior subscapularis tears Superior rotator cuff tears
Periprosthetic fractures Complications
Periprosthetic fractures Complications
The Reason for Improvement
Rotator Cuff Tears Natural history? Nonanatomic prostheses? Stiffness Bleeding Nerve damage Rarely Permanent Mostly Neuropraxias Complications
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