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Common Shoulder Problems and Treatment Options
Common Shoulder Problems and Treatment Options
Benjamin W. Szerlip D.O.Austin Shoulder Institute Benjamin W. Szerlip D.O.Austin Shoulder Institute
Speaker DisclosureSpeaker Disclosure
Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.
Dr. Szerlip has disclosed that he has no actual or potential conflict of interest in relation to this topic.
Learning ObjectivesLearning 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.
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.
OverviewOverview
AnatomyWhy do we have shoulder pain?What is new today?What can patients expect?
AnatomyWhy do we have shoulder pain?What is new today?What can patients expect?
AcromioclavicularSternoclavicularScapulothoracicGlenohumeral
≠Minimally ConstrainedNot Ball-in-Socket
Balance of Stability & MobilityStatic vs. Dynamic
A coordinated complex ofIntercalated joints…
Normal Anatomy: Static Articular Components
Articular Area ~3X GlenoidUniform Articular Thickness
Approximately Spherical
The Humerus: Surface Area Mismatch
• Extends the articular arc & deepens the glenoid socket• Does not change the radius of curvature of the glenoid surface
•Reversibly deformable tissueWilliams & Iannotti
Bumper → Conforming to Humeral Head
The Labrum: Essential Stability
Shoulder Joint PainShoulder Joint Pain
Rotator Cuff Impingement, Tendinitis and Tears
Arthritis Instability/ Labral Tears AC Joint separation Fracture Biceps Tears Irreparable Rotator Cuff Tears
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
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
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 - SymptomsRotator Cuff - Symptoms
Pain at night Weakness Loss of function Lateral arm pain
Pain at night Weakness Loss of function Lateral arm pain
Role of MRI in Rotator Cuff TearsRole of MRI in Rotator Cuff Tears
Partial vs. full thickness tears Location of tear Size of tearMuscle atrophy
Ultrasound a useful alternative in experienced hands
Partial vs. full thickness tears Location of tear Size of tearMuscle atrophy
Ultrasound a useful alternative in experienced hands
Rotator Cuff TearWho Needs Surgery?
Rotator Cuff TearWho Needs Surgery?
Younger, more active individuals Acute, traumatic tears Higher demand individuals “Fixable” tears Persistent symptoms despite non-
operative treatment
Younger, more active individuals Acute, traumatic tears Higher demand individuals “Fixable” tears Persistent symptoms despite non-
operative treatment
Rotator Cuff Repair – Best PrognosisRotator Cuff Repair – Best Prognosis
Acute cuff tears Smaller, more mobile tears No /minimal muscle atrophy Younger patient (under 70)
Acute cuff tears Smaller, more mobile tears No /minimal muscle atrophy Younger patient (under 70)
Results – Rotator Cuff SurgeryResults – 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
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
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?)
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 ArthritisShoulder 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
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 NewsOsteoarthritis – 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)
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 NewsOsteoarthritis – 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
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?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!!
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
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
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
3 Goals Of All Treatments For Osteoarthritis
1. Control Pain and other symptoms caused by the disease2. Optimize Function, including the impact of osteoarthritis
on mobility and the activities of daily living3. Educate Patients and families about the disease and
treatment options for osteoarthritis
1. Control Pain and other symptoms caused by the disease2. Optimize Function, including the impact of osteoarthritis
on mobility and the activities of daily living3. Educate Patients and families about the disease and
treatment options for osteoarthritis
Temporary ReliefTemporary Relief
Aspirin-Free Pain Relievers Anti-inflammatory Drugs Intra-articular Injections Disease Modifiers Sleep Aids
Aspirin-Free Pain Relievers Anti-inflammatory Drugs Intra-articular Injections Disease Modifiers Sleep Aids
What Makes Someone A Good Surgical Candidate?
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
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 SolutionsSurgical Solutions
1. Shoulder Arthroscopy2. Partial Shoulder Replacement3. Total Shoulder Replacement4. Reverse Shoulder Replacement
1. Shoulder Arthroscopy2. Partial Shoulder Replacement3. Total Shoulder Replacement4. Reverse Shoulder Replacement
Shoulder ArthroscopyShoulder 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
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
Why do we Replace the Shoulder?Proximal Humerus Fractures
Stemless: What we think…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
Potential advantages Canal sparing
Decreased blood loss Preserve bone
Solution with deformity/ Malunion Decrease prosthetic fracture Ease of revision Marketing to patients
Total Shoulder ReplacementTotal 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
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
Shoulder Replacements are SuccessfulShoulder 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
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.
RESULTS
50yo woman: NationalChampion in Horse-jumping 48 yo Former Triathlete
49 yo Electrician(bilateral TSR)
191 Patient 1 yr F/U:
“Are you happy & would youDo it again?” 98.5% Yes
“What percent of normal isYour shoulder?” 97.5%
> 80%; 35% with “normal”
(unpublished: Warner, Millett, Higgins)
Average age = 53yo
ComplicationsComplications Infection CATASTROPHIC!!!!! Diabetes mellitus, rheumatoid arthritis, systemic lupus
erythematosus, remote sites of infection, and previous operations on the shoulder
Infection CATASTROPHIC!!!!! Diabetes mellitus, rheumatoid arthritis, systemic lupus
erythematosus, remote sites of infection, and previous operations on the shoulder
ComplicationsComplications
Glenoid Wear/Glenoid Loosening 1/3 complications 3rd generation cementation
technique
Glenoid Wear/Glenoid Loosening 1/3 complications 3rd generation cementation
technique
ComplicationsComplications
Instability 0-29%Anterior – subscapularis tearsSuperior – rotator cuff tears
Instability 0-29%Anterior – subscapularis tearsSuperior – rotator cuff tears
ComplicationsComplications
Rotator Cuff Tears Natural history? Nonanatomic prostheses?
Stiffness Bleeding Nerve damage Rarely Permanent Mostly Neuropraxias
Rotator Cuff Tears Natural history? Nonanatomic prostheses?
Stiffness Bleeding Nerve damage Rarely Permanent Mostly Neuropraxias
3D Pre Op Planning and PSI 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
Improving patient outcomes Optimizes glenoid bone
preservation Improves Implant accuracy/
selection No cost/ downside for planning Real time planning Patient specific options