2/19/2014

Things I love

What’s new in surgery? Brian Feeley, MD. UCSF Sports Medicine

What’s new in medicine? Outline

Focus on problem-based learning for medical  Shoulder basics  Anatomy school  Differential Diagnosis (What can go wrong)  Shoulder history and physical exam

 What’s new in common shoulder problems?  Frozen shoulder  Impingement Syndrome/ Tears  Shoulder

 Focused recent scientific evidence

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Goals The Shoulder—a complicated joint

 Understand how the shoulder functions  Shoulder has amazing

 Be able to diagnose and manage (even on your own!) capabilities common shoulder problems  Greatest ROM in body  Very little inherent stability  Know what state of the art evidence shows for treatment of shoulder problems  Dynamic Stabilizers

Everyone here should want to be a shoulder surgeon!  Static Stabilizers

Anatomy of the Shoulder Deltoid

 Origins

 Anterior, Middle, Posterior

 Deltoid Tuberosity

 Innervation: Axillary Nerve

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Muscle--Bone Unit Rotator Cuff (dynamic stabilizers)

 Suprapinatus  Infraspinatus  Teres Minor  Subscapularis  Motion and stability  Balance deltoid pull  Active and passive restraint TENDON-ATTACHES MUSCLE TO BONE

Long Head Biceps Glenohumeral joint (static stabilizer)

 Supraglenoid / superior  One-third of a sphere labral origin  Head-shaft angle 130°  Stabilizer when shoulder

rotating AND elbow  Anatomic neck (capsule) flexing  Surgical neck (fractures)  3 Tuberosities  Greater  Lesser  Deltoid

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Glenoid Fossa (static stabilizer) Glenoid Labrum (static stabilizer)

 Triangular in cross-section  Small, pear-shaped, bony depression  Increases humeral contact area  Increases glenoid depth 50%  Surface area 33% humeral head

 Overall, bony contact minimal  Anchors the capsule  Added stability without compromising motion  Biceps origin

Putting it all together-real time anatomy Biomechanics of the Shoulder

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Force Couple Concept Superior Migration

 Rotator cuff  downward,  Loss of Force Couple medial  Isolated supraspinatus  Deltoid muscle  upward, outward tendon does not give  Opposite forces create “Force Couple” superior migration  Maximize rotation, minimize shear  Has to have involvement of  Instability subscapularis or  Degenerative changes infraspinatus tendon

Differential Diagnosis Approach to shoulder problems

What can go wrong? Differential Diagnosis  Rotator Cuff Tears (45%)  (15%)  Frozen shoulder (15%)  Biceps problems (15%)  Dislocations (5%)  Fractures (5%)  Bruise (5%)  Cervical spine problems (25%)

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Approach to shoulder problems Good history + Complete physical exam Differential Diagnosis = Correct diagnosis in 95% of cases  Rotator Cuff Tears (45%)  Shoulder arthritis (15%) 2 steps  Frozen shoulder (15%) SHOULDER ARTHRITIS all the time, loss of •Patient history  Biceps problems (5%) motion  Dislocations (5%) •Physical examination  Fractures (5%) •(Radiographs)  Bruise (5%)  Cervical spine problems (25%) •(Advanced imaging)

HISTORY Physical Examination

Key questions to ask  Visual inspection

1. Was there an acute ?  Palpation

 Motion 2. Are you losing strength?  Specific testing

3. Are you losing range of motion?

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Visual Inspection Visual Inspection

 Don’t let them take off  Remove shirt too much clothing  Systematic  Deltoid  Supraspinatus  Infraspinatus  Biceps  AC joint Axillary nerve injury after football tackle  Skin changes  Scars

Palpation RANGE OF MOTION

Press where it hurts Location Diagnosis ACTIVE ROM PASSIVE ROM

Clavicle fracture AC joint AC joint arthritis If poor—think rotator If poor—think frozen Trapezius/Neck Muscle strain cuff tear shoulder or shoulder

Front of shoulder Biceps pathology arthritis and STOP

Back of shoulder Arthritis THE EXAM

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Rotator Cuff Testing Rotator Cuff Impingement

 Hawkins’ Test Impingement  75% sensitive ’ --Neer s/Hawkins tests  49% specific

Muscle Strength --Teres Minor  Neer’s Test --Infraspinatus  85% sensitive --Supraspinatus  44% specific --Subscapularis Park, et al. JBJS 2012

Supraspinatus Infraspinatus

 Jobe’s test °  90º abduction 30  External rotation strength  30º anterior flexion  Internal rotation (palms  0º abduction & 45º ER down)  Pain/weakness

 53% sensitive/82% spec. Infraspinatus  (Park, et al. JBJS 12)

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Common Shoulder Problems Case 1

54 year old woman presents with 4 months of shoulder pain that occurred after taking her jacket off. She now has trouble getting things off high shelves and can’t put her belt on.

Case 1—Key points in the history Physical Examination

 Was there an acute injury?  Visual inspection

Yes, but not really  Palpation  Are you losing strength?  Motion No  Specific testing  Are you losing range of motion? YES, OH YES!

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Frozen Shoulder=Adhesive Capsulitis Causes

nd  Key points in the history and physical  2 most common cause of shoulder pain in US  No ‘real’ trauma in patients 40-60

 Pain all the time  Mostly unknown  Limited ROM  Associated with Diabetes, Thyroid Problems

Natural History

Thickening of capsule with Inflammatory cells and fibrosis

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JSES 2012 Treatment Options

 100 patients, 5 year follow up (no treatment)  Average duration of symptoms-1.6 years  91% return to full/near full function

Do Nothing Treatment

 Injections done blindly vs. injections done under

 Patients with less pain at the time of injection  More likely to get better after UTZ injection

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Am J Sports Med 2012 Are steroids safe?

 Risks:  Not Risks:  Can kill cartilage cells  Will not turn you into  53 patients randomized to  Lidocaine and steroid this: steroid (low or high dose) vs placebo

 Both steroid injection groups got better faster than placebo group Healthy cartilage Cartilage cells cells After lidocaine  No side effects UCSF Orthopaedic Research AJSM 2012

Surgery for Adhesive Capsulitis State of the Art: Frozen Shoulder

 Only for people who fail non-operative  1976: May be auto-immune

 6 months PT, injections  2010-2013:  Everyone will get better  Injections may quicken improvement  UTZ injections are more effective  Use a low dose steroid  Surgery only for those that fail all other treatment

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Case 2 Case 2—Key points in the history

 43 year old male, 6 months of shoulder pain, hurts at night, pain with overhead activity, no  Was there an acute injury? weakness. He says that he can’t lift at the gym Not really

as well.  Are you losing strength? Not really  Are you losing range of motion? No

Impingement of the Shoulder Impingement Syndrome

Very common in middle age people Mechanism  Impingement under  Insidious onset of pain with flexion and  Pain with overhead activities internal rotation of the  Pain at night (can’t sleep on that side) shoulder

 Difficulty doing some, but not all ADLs  Rotator cuff, subacromial  No weakness bursa and biceps tendon Lateral view of shoulder

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Impingement Signs-JAMA 2013 MRI

Hawkins test  MRI not needed for  Flex shoulder to 90º conservative treatment

 Flex elbow to 90º  Use it to rule out  Internally rotate significant pathology

 Positive - reproduce shoulder pain How good for full thickness tears? Sens = 88 %  69 to 100 percent Spec = 43 % sensitive PPV = 38 %  88 to 100 percent specific NPV = 90 %

MRI

MRIs almost always will show something Tear Should be used to augment diagnosis, not make it How good for full thickness tears? •69 to 100 percent sensitive Patient history and physical exam are •88 to 100 percent specific more important than MRI findings

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Treatment of Impingement When to Operate for Impingement?

Mild pain  Rest, avoid offending activities Physical Better Home with Therapy Exercise activity  Physical therapy (6-12 weeks) NSAIDS Program Night pain  Rotator Cuff Strengthening  Active/Passive ROM  Periscapular exercises MRI to evaluate  Upper extremity proprioception for cuff Surgery if Impingement Not Better tear not better  NSAIDS Consider injection  Consider steroid injection Moderate PT pain with  Surgery activity NSAIDS Home Exercise Wakes pt. Consider up injection Better Program

Rotator cuff surgery in the US Outcomes of Impingement

 Non-operative  Vitale, Levine et al JBJS 2010  Cummins, et al. JSES 2008  Review of NY State Database and ABOS  100 consecutive patients  At 2 years, shoulder score 5695  1996: 5571 acromioplasties=30.0/100K  80% did not require surgery, but 30% still had pain  2006: 19,743 acromioplasties=101.0/100K  Operative  Henkus, et al. JBJS-Br 2009  1999: 2.6 acromioplasties/ABOS candidate  2.6 year follow-up  2008: 6.3 acromioplasties/ABOS candidate  93% good to excellent results

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Case 3 Case 3—Key points in the history

 56 year old male, 3 months of shoulder pain and weakness after an awkward fall while hiking.  Was there an acute injury? Hasn’t been able to return to the gym. He has Yes

pain at night and lifting things is difficult.  Are you losing strength? Yes  Are you losing range of motion? No

Rotator Cuff Tears What is a ?

Common condition over age of 60  As high as 40% of patients over 60 will have a tear  Increasingly older population….who wants to stay active

Full Loss of attachment of the tendon to bone Thickness Partial Cuff Tear  Can be traumatic or without trauma Tear Usually (but not always) causes shoulder pain Impingement and weakness

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In the last 10 years….a lot has happened with rotator cuffs! In the last 10 years….

 Better recognition/diagnosis of rotator cuff tears  Better recognition/diagnosis of rotator cuff tears  MRI are better, but there are still limitations

 Better at fixing rotator cuff tears  Better at fixing rotator cuff tears  Are we doing too many?  How do we fix big tears?

 Better understanding of the natural history of rotator cuff tears  Better understanding of the natural history of rotator cuff tears  We understand the tendon well, what about the muscle?

 Developed strategies to ‘solve’ cuff tears arthropathy  Developed strategies to ‘solve’ cuff tear arthropathy  How good is a reverse?

1 Diagnosis of Rotator Cuff Tears Subscapularis...the other rotator cuff

Foad et al, Arthroscopy 2012  40 patients with arthroscopic subscap tear  25/40 the MRI was read as negative (with and without contrast)

Waldt et al. Radiology 2008 95% accurate at SS tears

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1 Need accuracy here for Supra-infra tears Brian Feeley, 3/8/2012 2/19/2014

2 Subscapularis…the other rotator cuff In the last 10 years….

Valone et al. (JSES 2014)  Better recognition of the rotator cuff tears  MRI are better, but there are still limitations

 101 Subscapularis tears  Better at fixing rotator cuff tears  8 had undergone previous surgery and missed  What is the biomechanically strongest construct? diagnosis of subscapularis tear  How do we fix big tears?  Average of 1.4 operations (Range 1-4)  MRI showed Subscap tear 75% of time  Better understanding of the natural history of rotator cuff tears  6/8 had isolated subscap with healed supra tear  We understand the tendon well, what about the muscle?  2/8 failed initial repair as well  Developed strategies to ‘solve’ cuff tears arthropathy  How good is a reverse?  All repairs were able to be done arthroscopically with 1-2 anchors

Biomechanical progression of rotator cuff repairs Cuff Repair

 Biomechanics (Park, TQ LEE, JSES 2007) • 1980’s

Arthroscopic repair • 1990’s Single row Gap formation equal

• 2000’s Double Row Transosseous

Better anatomic footprint Stronger repair Better load to failure

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2 Insert picture of repair--Jai's article Brian Feeley, 3/8/2012 2/19/2014

Arthroscopic Rotator Cuff Repair Rotator cuff surgery in the US

 Saridakis, Jones AJSM 2012  Iyengar et al. (Arthroscopy  Systematic Review 2014)  Healing rates Single row: 80-90%  Trends suggest more a/s vs.  Healing rates Double Row: 78- 92% open repairs 3

 Conclusions:  ABOS data pending  Are young sports trained switching  Outcomes remain dependent on tear size and muscle quality. No entirely to arthroscopic? difference in outcome with SR vs DR.

How to fix bigger tears Cuff Repair

 Clinically—more anchors is (May be) better for larger (>1 cm) tears

AJSM 2013

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3 put a video or slide show in here

need some papers to back this up Brian Feeley, 3/8/2012 2/19/2014

In the last 10 years…. Asymptomatic rotator cuff tears

 Better recognition of the rotator cuff tears  MRI are better, but there are still limitations Yamaguchi et al. (JBJS 2006)

 Better at fixing rotator cuff tears  Are we doing too many?  How do we fix big tears?  Patients with symptomatic rotator cuff tears were evaluated by ultrasound on contralateral side  Better understanding of the natural history of rotator cuff tears  We understand the tendon well, what about the muscle?  40% had a rotator cuff tear on the asymptomatic side  Developed strategies to ‘solve’ cuff tears arthropathy  How good is a reverse?  50% became symptomatic  40% had tear progression

Full thickness rotator cuff tears Full thickness rotator cuff tears

Maman et al (JBJS 2009)  Risk factors for  Safran et al. AJSM 2011 progression: Tear Progression  Young patients with rotator cuff tears (<60) Age >60 smaller  50% progressed in 2 year period unchanged Fatty infiltration on MRI 2-5mm Larger tear >5mm  All had increased symptoms in pain and more weakness

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What about the muscle? Case Example

 Melis et al (OTSR 2009)  Untorn Infraspinatus with  1688 symptomatic tears grade 3 FI and  Fatty infiltration occurred 4 associated years after onset of symptoms retracted  Patient age, side of tear, degree supraspinatus of atrophy correlated with tear progression of FI  Also note atrophic supraspinatus

What are the biologic consequences of a rotator Natural history of fatty infiltration cuff tear?

 Older age is significantly associated with Rotator cuff increased tear  atrophy  fatty infiltration

 Prevalence of infraspinatus tears is about 1/3 lower compared to supraspinatus  But prevalence of FI in the infraspinatus is higher than the supraspinatus!

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Gene expression changes after RCT Inhibition of Fatty Infiltration

Akt

mTOR

SREBP1

PPARy

Adipogenesis

FATTY INFILTRATION

Natural History: Non Operative Non operative management

 Rest, activity modification

 NSAIDS

 Physical therapy

 Injections

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Full Thickness Rotator Cuff Tears On the Horizon….

Improve tendon to bone healing  Rationale for early treatment of symptomatic rotator (Appropriate timed delivery of growth cuff tears factors)

 Smaller tears do better Improve muscle biology after  Better muscle quality (no atrophy, no fatty infiltration) rotator cuff repair (regulation of muscle specific  Lower rate or rerupture pathways)  Easier rehab  Easier for me to do

Last case! Understanding Arthritis

75 year old male, 5 year history of gradually progressing pain. No weakness, but can’t lift his arm above his head anymore. He has a history of arthritis in his hips and knees, and says this feels similar.

What is the most likely diagnosis?

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Understanding Arthritis Understanding Arthritis

 Articular cartilage  Super smooth  No nerve endings  Few cells Osteoarthritis: Destruction of the articular cartilage resulting in pain,  No nerve endings=doesn’t sense deformity, and disability early damage  Few cells=cannot regenerate

Understanding Arthritis Understanding Arthritis

 Osteoarthritis: The destruction of the articular  Osteoarthritis: The destruction of the articular cartilage resulting in pain, deformity, and disability cartilage resulting in pain, deformity, and disability

Moderate focal arthritis Severe arthritis

h // d d/ dii /lb/b lb/bi h hh l

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Diagnosis of Shoulder Arthritis Diagnosis of Shoulder Arthritis

Osteoarthritis  History Osteoarthritis  Chronic ‘all the time pain’  “”

 Exam  Limited ROM

 Xrays  Loss of joint space

Normal

Diagnosis of Shoulder Arthritis Management of Shoulder Arthritis

MRI?  Shoulder replacement for Primary Arthritis  Not necessary in PRIMARY OA  Useful in cases of suspected rotator cuff tears  Can help with anatomy of the glenoid

Original total shoulder replacement

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Shoulder Replacement

Shoulder replacement without a cuff Question

 What will happen if you do a shoulder replacement in the setting of a massive rotator cuff tear?

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Big Cuff tears—a big problem! In the last 10 years….

 Better recognition of the rotator cuff tears  MRI are better, but there are still limitations

 Better at fixing rotator cuff tears  Are we doing too many?  How do we fix big tears?

 Better understanding of the natural history of rotator cuff tears  We understand the tendon well, what about the muscle?

 Developed strategies to ‘solve’ cuff tears arthropathy  How good is a reverse?

Reverse TSA Reverse shoulder arthroplasty

 Novel (10 years experience) procedure for chronic  Early data (1999-2005) massive rotator cuff tears and arthritis concerning for high failure rates  62-80% scapular notching  25% failure rates at 5 years

 Many catastrophic failures

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Reverse shoulder arthroplasty

 Walch et al JBJS 2006 10 year survival of implant 84% 10 year Constant >30=58%

“A [deterioration] of results began at six years and reflected progressive deterioration of the functional result…. Reverse total prosthesis should be reserved for the treatment of very disabling shoulder arthropathy with a massive rotator cuff rupture, and it should be used exclusively in patients over seventy years old with low functional demands.

R-TSA – The UCSF experience R-TSA – The UCSF experience

 225 patients  3 infections 140

 3 fractures (all treated non-op) 120

 3 dislocations ASES 100 100 80 Forward Flexion 80 60 Abduction 60 40 ER 40 20 20 0 0 Pre-op 6 weeks 6 months >1 year Pre-op 6 weeks 6 months >1 year

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Notching and R-TSA Scapular notching

Scapular Notching UCSF (IJSS 2014) 7% 3% 0%  Retrospective review of 4 years experience  2 surgeons 29% 61%  1 implant with low neck-shaft angle

Grade 0 Grade 1 Grade 2 Grade 3 Grade 4

Majority (90%) of patients have no notching or very minor notching only

Feeley et al IJSS 2014

Base Plate Distance (BPD) Summary

Reverse Shoulder Arthroplasty is a good solution 1.2 * to a complicated problem 1 0.8 Long term data inconclusive 0.6 0.4 Early complications still occur 0.2 0 -0.2 No Notching Notching -0.4 P<0.001, Mann Whitney U test

Feeley et al IJSS 2014

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Thank you

Questions?

Questions later? [email protected]

Have a shoulder problem? UCSF Orthopaedic Institute 1500 Owens Drive SF, CA 94158 415-353-2808

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