Rudolf G. Hoellrich, MD 25th Annual Orthopedics & Sports Medicine Update December 2, 2017 Disclosure Information

 Presenter  Rudolf G. Hoellrich, MD, has nothing to disclose Shoulder Instability: Case 1

 HPI  Physical Exam

 16 year old male football  Normal ROM

player  Normal strength

 Anterior dislocation  Positive anterior shoulder during daily apprehension & doubles relocation test  2 subluxations since then

 Frequent “dead-arm” episodes

 Wants to play next year Imaging studies

 X-rays – instability series • AP • Axillary • Westpoint • Stryker notch

MR arthrogram

 Preferred study for labral pathology

 Bankart lesion is found Treatment Options

 Nonsurgical • Physical therapy • Activity modification • Shoulder Harness • Injection?

 Surgical

 Arthroscopic Bankart repair

 Open Bankart repair Bankart Repair Shoulder Instability: Case 2  HPI  Physical Exam  27 y/o male mill worker  Reveals marked  Traumatic dislocation apprehension and guarding  Approximately 12 instability episodes  Self-limited ROM since  Normal strength and  Reports hx of instability neuro exam in sleep and simple ADLs  Failed PT Shoulder Instability: Case 2

Complex shoulder instability…

 CT scan with 3D reconstruction

 Glenoid and humeral bone loss

 Options? Shoulder Instability: Case 2

 Surgery must address:

 Soft tissue injury

 Bone deficiency

 Surgical options:

 Coracoid transfer

 Iliac crest bone graft

 Osteochondral graft Case 3: Acute rotator cuff injury

 HPI  Physical Exam  49 y/o right-hand  Normal ROM dominant female  + Impingement test  Acute injury lifting  Obvious weakness of compost 6 weeks ago rotator cuff on empty  Pain at night can test  Pain with reaching and repetitive ADLs  Right arms feels “weak” Xrays

 Standard series:

 True AP

 Axillary

 SSOV MR Imaging

 Non-contrast MRI ordered Acute rotator cuff tear

 Recommended treatment:

 Rotator cuff repair

 Alternative options:

 NSAIDs

 Cortisone injection

 PT Case 4: Chronic cuff tear  HPI  Physical Exam  74 y/o male  Popeye deformity  Pain for 3 yrs  Decreased AROM  No specific injury  Subacromial crepitus  Global cuff weakness Imaging

 Xray shows superior migration of humeral head

 MRI shows massive cuff tear with atrophy Chronic cuff tear Non-repairable cuff tear

 Non-op treatment

 NSAIDs

 Cortisone injection

 PT

 Reverse TSA Case 5: low grade AC sprain

 HPI  Physical Exam  19 y/o make  Localized superior snowboarder shoulder pain and  Fall onto shoulder swelling  Normal strength and ROM Treatment

 Rest, ice, NSAIDS

 Sling for comfort

 Activity modification x 6 weeks

 PT program

 Injection? Case 6: High-Grade AC injury

 47 year old female

 Prior grade 3 AC treated non-operatively

 Now has new fall injury

 Marked deformity, pain Grade 5 AC separation High grade AC injury

 Renders the shoulder complex unstable

 Pain

 Weakness

 Impingement

 Deformity AC Reconstruction Questions?