Surgical Management of Instability SHOULDER AND ELBOW and ... courses/Dr. Williams Hando… ·...
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Surgical Management of Instability and SLAP Lesions
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 1
Surgical Management of Instability and SLAP Lesions
Gerald R. Williams, MDJohn M. Fenlin, Jr, MD Professor,
The Rothman InstituteSidney Kimmel Medical College,
Department of Orthopaedic SurgeryThomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Conflict of Interest Slide
• Board of Directors– AAOS
• Stipend
• Royalties
• DJO- shoulder arthroplasty
• Depuy: shoulder arthroplasty
• Lippincott, Williams, and Wilkins: shoulder texts
• IMDS/Cleveland Clinic: arthroplasty
• Research: Tornier, Depuy, Synthasome
• Stock Ownership: In-vivo therapeutics, CrossCurrentBusiness Analytics, LLC, OBERD, LLC, Force Therapeutics
Rothman Institute of Orthopaedics at Thomas Jefferson University
Agenda
• Instability• Indications
• Technique
• Results
• SLAP lesions• Indications
• Technique
• Results
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Age
• Number of dislocations
• Ligamentous laxity
• Activity
• Bone deficiency
IndicationsPrognostic factors
Boileau, et. al. JBJS BR
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Operate for instability not pain
• Soft-tissue procedures good for soft-tissue problems
• Soft-tissue stretch must be addressed with more than 5 dislocations
• Bony procedures good for bone pathology
• Seizure disorders controlled (6 months)
IndicationsGeneralizations
Rothman Institute of Orthopaedics at Thomas Jefferson University
Indications
Traumatic AtraumaticMicrotraumatic
TUBS AMBRI
Surgical Management of Instability and SLAP Lesions
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 2
Rothman Institute of Orthopaedics at Thomas Jefferson University
Indications
• Traumatic unidirectional• Anterior
• Posterior
• Traumatic multidirectional
• Involuntary Atraumatic-- very occassionally
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Arthroscopic capsulorrhaphy• +/- Remplissage
• Open Bankart– 3-5 times a year
• Open (arthroscopic) Latarjet• Revisions
• Bipolar bone loss (seizures)
• Open other grafts– allograft, iliac crest
Techniques
Rothman Institute of Orthopaedics at Thomas Jefferson University
Arthroscopic vs. Open
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Arthroscopic equipment and technique have improved considerably
• Still a role for both
• Consider open in revisions or bone loss situations
TechniqueOpen vs. Arthroscopic
Rothman Institute of Orthopaedics at Thomas Jefferson University
Arthroscopic Repair
No labrum, Healed medially
Rothman Institute of Orthopaedics at Thomas Jefferson University
Results(Penn Score)
Surgical Management of Instability and SLAP Lesions
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 3
Rothman Institute of Orthopaedics at Thomas Jefferson University
Open vs. Arthroscopic
• Arthroscopic repair was as effective as open reconstruction for traumatic, recurrent, anterior glenohumeral instability in our study population
• Newer fixation methods provide reliable fixation for experienced shoulder surgeons
• Arthroscopic repair was not associated with greater patient satisfaction
Rothman Institute of Orthopaedics at Thomas Jefferson University
Bone defects Matter
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Age
• SLAP type
• Concomitant pathology
• Injury history
• Desired activity
SLAP RepairPrognostic Factors
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type I SLAP
• Very common
• Can be normal finding
• Debridement
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type II SLAP
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type II SLAP
• Arthroscopic repair
• 1-2 anterior anchors
• 1 posterior anchor-- posterior SLAP• Posterolateral portal (“Port of Wilmington”)
Surgical Management of Instability and SLAP Lesions
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 4
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type II SLAP
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type II Slap
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type III SLAP
Rothman Institute of Orthopaedics at Thomas Jefferson University
Type IV SLAP
Rothman Institute of Orthopaedics at Thomas Jefferson University
Concomitant PathologyInternal Glenoid Impingement
• AIGHL-- checkrein for ABER
• Int. Imp.• AIGHL laxity vs. Posterior capsular
contracture
• Decreased humeral retroversion
Rothman Institute of Orthopaedics at Thomas Jefferson University
Internal Glenoid Impingement
Surgical Management of Instability and SLAP Lesions
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 5
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Good with isolated lesions, young patients
• High incidence of stiffness in older patients
• Decreasing incidence of repair
• Biceps tenodesis vs. SLAP repair
SLAP RepairConclusions
THANK YOU.
Pathophysiology and Surgical Management of Shoulder Arthritis
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 1
Pathophysiology and Surgical Management of Shoulder Arthritis:
Total and Reverse ArthroplastyGerald R. Williams, MD
The John M. Fenlin, Jr., MD Professor of Shoulder and Elbow SurgerySidney Kimmel Medical College
Thomas Jefferson UniversityPhiladelphia, Pennsylvania
Rothman Institute of Orthopaedics at Thomas Jefferson University
Conflict of Interest Slide
• Board of Directors– AAOS
• Stipend
• Royalties
• DJO- shoulder arthroplasty
• Depuy: shoulder arthroplasty
• Lippincott, Williams, and Wilkins: shoulder texts
• IMDS/Cleveland Clinic: arthroplasty
• Research: Tornier, Depuy, Synthasome
• Stock Ownership: In-vivo therapeutics, CrossCurrentBusiness Analytics, LLC, OBERD, LLC, Force Therapeutics
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Pathophysiology
• Arthroplasty background
• Anatomic total shoulder arthroplasty
• Reverse total shoulder arthroplasty
Agenda
Rothman Institute of Orthopaedics at Thomas Jefferson University
Glenohumeral Arthritis
Pathophysiology
Inflammatory Arthritis
Crystalline Arthritis
Post-traumatic Arthritis
Avascular Necrosis
OsteoarthritisRotator cuff
Capsule
Bone
Rothman Institute of Orthopaedics at Thomas Jefferson University
PathophysiologyPrimary Pathology
Cartilage Soft-Tissue
Loss Abnormalities
Osteoarthritis Posttraumatic ArthritisI I
Avascular Necrosis Rheumatoid ArthritisI I
Cuff Tear ArthritisI
Rothman Institute of Orthopaedics at Thomas Jefferson University
Osteoarthritis
Pathophysiology and Surgical Management of Shoulder Arthritis
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 2
Rothman Institute of Orthopaedics at Thomas Jefferson University
CT/MRI
Rothman Institute of Orthopaedics at Thomas Jefferson University
Inflammatory Arthritis
Rothman Institute of Orthopaedics at Thomas Jefferson University
ArthroplastyDecision-making Factors
• Age
• Activity level
• Joint geometry
• Rotator cuff status
• Capsular contracture
Rothman Institute of Orthopaedics at Thomas Jefferson University
Anatomic Shoulder Arthroplasty
Rothman Institute of Orthopaedics at Thomas Jefferson University
Total Shoulder Arthroplasty
Surgical Principles (1970)
• Extended deltopectoral approach• Preserve deltoid
• Soft-tissue balancing• Preserve normal anatomy• Reconstruct joint anatomically
• Tuberosity-Head height• Lateral offset• Version and alignment
• RehabilitationRothman Institute of Orthopaedics at
Thomas Jefferson University
Anatomic Shoulder Arthroplasty
Results
• Neer--Results disease dependent• Neer, Watson, et.al. JBJS, 64A, 1982• Neer, Shoulder Reconstruction, WB
Saunders, 1990• 90% satisfactory results
• Minimum 2 yr follow-up• Approximately 30% glenoid lucent lines• 2/615 revised as of 1988
Pathophysiology and Surgical Management of Shoulder Arthritis
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 3
Rothman Institute of Orthopaedics at Thomas Jefferson University
Anatomic Shoulder Arthroplasty
Results
• Torchia, Cofield, et. al. (JSES, 6, 1997)• 12 year mean follow-up
• 44% glenoid loosening
• 83% good pain relief
• 117 degrees of elevation (related to cuff disease)
• Survivorship: 93% at 10 yrs; 87% at 15 years
Rothman Institute of Orthopaedics at Thomas Jefferson University
Subscapularis Management
Advancement-30 ER < 10
Z-LengtheningAdvancement
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Post-Operative Subscapularis Failure
Moeckel, B. H.; Altchek, D. W.; Warren, R. F.; Wickiewicz, T. L.; and Dines, D. M.: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am, 75(4): 492-7., 1993.
2.9 % Anterior Instability100% subscapularis rupture
Miller, S. L.; Hazrati, Y.; Klepps, S.; Chiang, A.; and Flatow, E. L.: Loss of subscapularis function after total shoulder replacement: A seldom recognized problem. J Shoulder Elbow Surg, 12(1): 29-34, 2003.
67.5% + lift-off or abdominal compression92% Subscapularis dysfunction (tuck in shirt)Did not study relationship to outcome score
Rothman Institute of Orthopaedics at Thomas Jefferson University
Lesser Tuberosity Osteotomy
• Gerber, C.; et.al. : J Bone Joint Surg Am, 87(8): 1739-45, 2005.• 89% negative ACT; 75% normal LOT• Substantially better than historical results with soft-
tissue repair
• Flatow, E. L.; et.al.: J Shoulder Elbow Surg, 17(1): 68-72, 2008.• 60% normal ACT (32.5% previous series-- soft-tissue
repair)• 83.3% no subscapularis dysfunction (tuck in shirt)
Rothman Institute of Orthopaedics at Thomas Jefferson University
Scalise, et. al., JBJS, 92A, 2010 Rothman Institute of Orthopaedics at Thomas Jefferson University
• Tendon-to-tendon repair may be better than peal and equivalent to LTO• Caplan JL, Whitfield B, Neviaser RJ. J
Shoulder Elbow Surg 2009;18:193-6; discussion 7-8.
• LTO to Tendon-to-tendon no difference in subscapularis function, easier glenoid exposure– Levine, et.al.
Other Perspectives
Pathophysiology and Surgical Management of Shoulder Arthritis
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 4
Rothman Institute of Orthopaedics at Thomas Jefferson University
Reverse Total Shoulder Arthroplasty
• Paul Grammont
• 1985
• Dijon, France
Rothman Institute of Orthopaedics at Thomas Jefferson University
Constrained Arthroplasty
Not a new concept
Rothman Institute of Orthopaedics at Thomas Jefferson University
Delta III (Grammont 1987)How is it Different?
• Large sphere, no neck
• Medialized center
• Valgus neck-shaft angle (155 degrees)
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Results
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Werner, Gerber, et.al
• Total complication rate 50%
• Reoperation rate 33%
• Primary cases 18%
• Revisions 39%
• Hematoma most common complication
Rothman Institute of Orthopaedics at Thomas Jefferson University
Early Experience
• Reverse arthroplasty “is a salvage procedure for severe shoulder dysfunction caused by an irreparable rotator cuff tear associated with other glenohumeral lesions.” --Werner CM, Steinmann PA, Gilbart M, Gerber C. J Bone Joint Surg Am 2005;87:1476-86.
• Reverse arthroplasty “should be used exclusively in patients over seventy years old with low functional demands.”—Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. J Bone Joint Surg Am 2006;88:1742-7.
Pathophysiology and Surgical Management of Shoulder Arthritis
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 5
Rothman Institute of Orthopaedics at Thomas Jefferson University
American Experience
• Generally lower complication rate• Benefit of European learning curve
• Still high relative to anatomic implant–similar to when anatomic implant first introduced
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Revision
• CTA
• Malunion/nonunion
• RA
• Tumor
• Osteoarthritis with cuff tear
• Osteoarthritis with intact cuff and bone deformity
• Post-traumatic arthritis
• Cuff tear without arthritis
Expanding Indications
Rothman Institute of Orthopaedics at Thomas Jefferson University
Market Impact
Kim SH, Wise BL, Zhang Y, Szabo RM. J Bone Joint SurgAm 2011;93:2249-54.
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Shoulder arthroplasty has come a long way
• Many more qualified surgeons performing them
• Outcomes have improved and will continue to
• The best operation I do!
Conclusions
THANK YOU.
Rotator Cuff Repair : Who, When, and How
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 1
Rotator Cuff Repair: Who, When, How
Gerald R. Williams, MDJohn M. Fenlin, Jr, MD Professor,
The Rothman InstituteSidney Kimmel Medical College,
Department of Orthopaedic SurgeryThomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Conflict of Interest Slide
• Board of Directors– AAOS
• Stipend
• Royalties
• DJO- shoulder arthroplasty
• Depuy: shoulder arthroplasty
• Lippincott, Williams, and Wilkins: shoulder texts
• IMDS/Cleveland Clinic: arthroplasty
• Research: Tornier, Depuy, Synthasome
• Stock Ownership: In-vivo therapeutics, CrossCurrentBusiness Analytics, LLC, OBERD, LLC, Force Therapeutics
Rothman Institute of Orthopaedics at Thomas Jefferson University
Agenda
• Cuff aging/natural history
• Patient selection– who and when
• Technique of cuff repair-- how
• Results
• Conclusions
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Aging/Natural HistoryAsymptomatic
Sher, et.al., JBJS 77A, 1995
Rothman Institute of Orthopaedics at Thomas Jefferson University
Yamaguchi K. et.al. J Bone Joint Surg 2006:88:1699-1704
Cuff Aging/Natural History
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Cuff Aging/Natural History
Yamaguchi, K., A. M. Tetro, et al. JSES (2001).
Rotator Cuff Repair : Who, When, and How
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 2
Rothman Institute of Orthopaedics at Thomas Jefferson University
• Acuity
• Size
• Patient factors• Age
• Activity
• Smoking history
• DM
• Tissue quality
Patient SelectionPrognostic Factors
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Acuity and Size
(Fenlin, Goutallier, Gerber, others)
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair Principles
Early vs. Late Repair
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0 2 4 6 8 10 12 14 16
Time from Injury (weeks)
Rep
air
Ten
sio
n (
N)
Gimbel, J. A., S. Mehta, Williams, G, et al. (2004). Rothman Institute of Orthopaedics at
Thomas Jefferson University
Cuff Repair Principles
Early vs. Late Repair
Group 13 wks
Group 23-6 wks
Group 36-12 wks
Elevation 168 126 129
Pain relief Satis. Satis. Satis.
• Recommended repair within 3 wks
Bassett, R. W. and R. H. Cofield CORR (1983).
Rothman Institute of Orthopaedics at Thomas Jefferson University
Who?
• Young (< 70)
• Small tear
• Healthy
• Non-smoker
• Active
• Recent injury
• Older (>70)
• Large tear
• Minimal co-morbidities
• Smoker
• Low demand– i.e. may not need it
• No injury
Favorable Unfavorable
Rothman Institute of Orthopaedics at Thomas Jefferson University
When?
• Recent injury
• Large tear (i.e. retraction)
• Weakness
• High demand
• No injury
• Small tear
• Minimal weakness
• Low demand
• Increased age
• Co-morbidities
Early Late
Rotator Cuff Repair : Who, When, and How
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 3
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair TechniquePrinciples (Neer 1972)
• Open superior approach
• Subperiosteal anterior deltoid take-down
• Coracoacromial ligament excision
• Anterior acromioplasty
• Cuff mobilization
• Cuff repair to bone through tunnels
• Early (immediate) passive motionRothman Institute of Orthopaedics at
Thomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Rothman Institute of Orthopaedics at Thomas Jefferson University
Arthroscopic Cuff Repair Technique
• Mobilization• Superficial
• Deep
• Interval slides/releases
Rotator Cuff Repair : Who, When, and How
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 4
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair Principles
acromioplasty No acromioplasty
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair Principles
?Acromioplasty?
• No type 3s, single tendon tears
Gartsman, G. M. and P. O'Connor D JSES (2004).
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair Principles?Acromioplasty?
McCallister W. V. et.al. J Bone Joint Surg2005:87:1278-1283
• No control group
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff Repair Principles?Acromioplasty?
The Jury is still out
Rothman Institute of Orthopaedics at Thomas Jefferson University
ResultsRepair Integrity
• 105 shoulders, avg 5 year f/u• Supraspinatus-- 20% recurrence• Two tendons-- 45% recurrence• Three tendons-- 65% recurrence• Most patients satisfied-- even with
recurrent defect• Function and satisfaction correlated with
integrityHarryman, et.al., JBJS 73A, 1991
Rothman Institute of Orthopaedics at Thomas Jefferson University
Open vs. Arthroscopic Repair
• Less deltoid morbidity
• Less post-operative pain
• Less subacromial scarring
• Better cuff mobilization/visualization
• Better patient acceptance
• Simple sutures• Anchors vs. tunnels• Cuff repair footprint
• Surface area available for healing
• Double row may help
• Technically demanding-- may be volume dependent
Pot. Arthro. Adv. Pot. Arthro. Disadv.
Rotator Cuff Repair : Who, When, and How
SHOULDER AND ELBOW UPDATE 2016
Gerald R. Williams, Jr., MD 5
Rothman Institute of Orthopaedics at Thomas Jefferson University
Post-operative Integrity
Bishop, J., S. Klepps, Flatow, E. et al. JSES (2006).
Rothman Institute of Orthopaedics at Thomas Jefferson University
Post-operative Integrity
Double Row
Lafosse, L., R. Brozska, et al. JBJS (2007).
Rothman Institute of Orthopaedics at Thomas Jefferson University
Cuff RepairConclusions
• Complex event• Right patient
• Right time
• Correct Surgical technique
Rothman Institute of Orthopaedics at Thomas Jefferson University
Acknowledgements
Louis Soslowsky, PhD, Stavros Thomopoulos, PhD, JJ Sarver, J Gimbel, PhD, Cathy Peltz, LM Dourte
THANK YOU.