7 Shoulder Pathologies.pdf

Shoulder Pathology A Multifactorial Common Issue Shoulder Referring to PT Shoulder Injuries Incidence Rates Shoulder Injuries Incidence Age and Type Related Instability RC Tears Shoulder Pathology Gleno Humeral Instability RC Tears Arthritis (Gleno-Humeral, AC / SC joints) Capsulitis Ca...

Shoulder Pathology A Multifactorial Common Issue Shoulder Referring to PT Shoulder Injuries Incidence Rates Shoulder Injuries Incidence Age and Type Related Instability RC Tears Shoulder Pathology Gleno Humeral Instability RC Tears Arthritis (Gleno-Humeral, AC / SC joints) Capsulitis Calcific tendonitis Long Head odf the Biceps ... Neurological Dyskenesis ... Pain, Impairment, Disfunction, Poor QoL Gleno-Humeral Instability INTRODUCTION “Glenohumeral Instability Is An Intrinsic Pathological Condition Of The Shoulder, Owing To Its Ample Range Of Mobility That Predisposes This Joint To A Somewhat Limited Degree Of Stability” Shoulder Dislocation Interests 1,7% Of General Population And Represents 40-50% Of All Dislocations. Hovelius L., 1982 Specific at-risk young males have anterior instability at an order of magnitude greater than the general population, with rates as high as 3% per year Owens BD, 2009 Another study found a 14.8% rate of shoulder dislocation among 374 high school rugby athletes Kawasaki T, 2014 Unstable Shoulder: Historical Background • First Report Of Shoulder Dislocation – Humankinds Oldest Book – Edwin Smiths Papyrus (3000 – 2500 BC) • Hussein Reported A Drawing Of Shoulder Reduction Maneuver In Egyptian Tomb In 1200 Bc • Hippocrates (~400 Bc) – Most Detailed Early Description Of Anterior Dislocations From Where We Started Shoulder Dislocation Loss Of Anatomical Reciprocal Position of The Joints Ends Shoulder Instability .. Then Some Tricky Conditions … Shoulder Instability History of Classifications Is the History of Knowledge and Understanding MATSEN et al CLASSIFICATION 1991 Glenohumeral Instability Can Be Classified In 2 Large Groups: • TUBS (Trauma, Unidirectional, Bankarts And Responds To Surgery) • AMBRII (Atraumatic, Multidirectional, Bilateral, Responds To Rehabilitation And Inferior Capsular Shift & Rotator Interval Closure) Matsen, FA; III, Harryman, D.T; 2ND, Sidles, J.A: Mechanics of glenohumeral instability. Clin Sports Med, 1991; 10(4): 783-788. MATSEN et al CLASSIFICATION 1991 STRENGTHS • Easy To Remember And Simple To Apply. • Contained A Management Algorithm Based On The Pathology DRAWBACKS • Represents The Extremes Of A Spectrum. Doesn't Include Minor Instabilities. • No Differentiation Of Voluntary Group And Ambrii. • Oversimplifies A Complex Problem. STANMORE CLASSIFICATION (BAYLEY et al) 2004 The System Has Three Polar Groups With Mutual Transitions: Traumatic Structural a: Acute b: Persistent c: Recurrent Atraumatic structural Recurrent Habitual nonstructural a: Recurrent b: Persistent The diagnosis of each type is made on the basis of careful history taking clinical examination followed by arthroscopy and occasionally electromyography. Angus Lewis, T Kitamura, J.I.L. Bayley. The classification of shoulder instability: new light through old windows! Current Orthopaedics 2004; 18:97-108. 23 Shoulder Instability The Shoulder: Interactive Joint • Balance Between Static And Dynamic Factors Responsible Of Shoulder Stability Is Very Delicate • Malfunction Of Any One May Lead To Overload And Failure Of Its Counterpart With A Consequent GlenoHumeral Instability Shoulder Instability Today Clinical Condition Where The Undesired Translation Of The Humeral Head Over The Glenoid Compromises Function And Comfort Of The Shoulder Laxity Possibility Of The Humeral Head To Be Passively Translated Over The Glenoid Without Compromising Function And Comfort Of The Shoulder INSTABILITY and HYPERLAXITY ARE NOT SYNONYMOUS Shoulder The Most Mobile Joint Of The Human Body – Sophisticated Biomechanics – Balance As The Result Of Dynamic Interaction Of: • • • • • Capsule Labrum Tendons Muscles Bone Shoulder Stability 27 The Most Unstable Joint Of The Body ! 28 Shoulder Instability • Single/Multiple Lesions Lesions – Alterated Biomechanics – Alterated Balance • • • • • • Bone/Cartilage Labrum Capsule/Ligaments Tendons Muscles Unbalance Postural Alteration Instability Shoulder Instability MINOR SHOULDER INSTABILITIES 2007 Defined As Shoulder Pain/Disfunction Secondary To Shoulder Hypermobility That Cannot Be Grouped Under TUBS Or AMBRII. • AIOS (Acquired Instability in Overstressed Shoulder) • AMSI (Atraumatic Minor Shoulder Instability) Castagna A. et al. Minor Shoulder Instability. Arthroscopy 2007; 23(2):211-15 SDSA 1996, Personal Communication Gleno-Humeral Instabilty Condition with Multiple Faces … and Multiple Treatment Options ... Shoulder Instability: What to Do ?? Literature “Arthroscopic Stabilization Using Suture Anchors Seems To Be The Most Effective Technique For Bankart Repair With Similar Rate Of Failure To Open Stabilization” Boileau P. JBJS Br, 2007 “Better results after the Bristow-Latarjet repair than after Bankart repairs done with anchors with respect to postoperative stability and subjective evaluation. Shoulders with original Bankart repair also seemed to be more stable than shoulders repaired with anchors” Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up Hovelius L, Vikerfors O, Olofsson A, Svensson O, Rahme H. . J Shoulder Elbow Surg. 2011 Oct;20(7):1095-101. Aim Past Reduce the Recurrence Rate, also By Reducing ROM PRESENT Reduce the Recurrence Rate without limiting ROM, and allowing return to sport and work activities Treatment Shoulder Instability Treatment WHERE IS THE PROBLEM…. -The Spectrum Of The Pathoanatomic Lesions Encountered Is Broad: Labrum, Capsule, Bone (Glenoid-Humeral Head) -Other Variables Involve The Patients: Sex, Age, Level Of Activity, Number Of Dislocation Deitch J Am J Sports Med 2003 Yiannakopoulos CK Arthroscopy 2007 THE SOLUTION ? ✓SELECTION OF CASES ✓ADDRESS ALL THE PATHOLOGIC LESION Understanding The Unstable Shoulder History and Clinical Exam • Specific Tests • History • Postural Analysis ACTUAL TREATMENTS Open Procedures Open Anatomic Repair ✓Sutures (Bankart)? ✓Soft-tissue Reconstruction? Osseous Glenoid Reconstruction ✓Bristow ✓Latarjet ✓Iliac Crest Autograft (EdenHybbinette) ✓Distal Tibia Allograft Arthroscopic Procedures Arthroscopic Anatomic Repair ✓ Suture Anchors Arthroscopic Capsular Imbrication ✓ Multi-Pleated Capsular Plication? ✓ Posteroinferior Capsular Plication? Arthroscopic Latarjet or Bone Block Targeted Management Of Hill-Sachs Lesions ✓ Humeral Head Or Femoral Head Allograft ✓ Partial Resurfacing Arthroplasty ✓ Hemiarthroplasty ✓ Arthroscopic Remplissage POSSIBLE TREATMENTS IDEAL TRATMENT? 1. Low Rate Of Recurrence 2. Preserved ROM And Function 3. Low Rate Of Complication And Mild Complications BASIC CONCEPT • Most Of «Instability Patients» Are Healthy Subjects • Instability Is Not A Simple «Disease» To Treat…instability Episodes Can Be Considered Life Events →Before Thinking About Surgery You Have To Know The Natural History Of Instability NATURAL HISTORY RECURRENCE RATE 250 First Time Anterior Dislocation Prospectively Evaluated → Recurrence Rate: • 55.7% Within The First 2 Years • 66.8% By The Fifth Year • Higher Rate For Young Patient: 86.6% (15-20 Y.) And 73.8 (20-25 Y.) • In Case Of Recurrence 86.7% Within 2 Years Robinson et al, JBJS, 2006 NATURAL HISTORY DISLOCATION ARTHROPATHY Arthropathy In 257 First-time Anterior Shoulder Dislocations At 25 Years • 26% Patients Had Moderate/Severe OA • “Alcoholic Shoulders” Related To Arthropathy • Moderate/Severe OA Rate: • Shoulders With No Recurrence (17%) < Stabilised Over Time (43%) And Still Recurring (29%) (P<.05) • Operated Shoulders (21 %) = Shoulders With No Recurrence (17%) (P>.05) But < Shoulders Stabilised Over Time (43%) (P<.05) • Primary Dislocation Because Of Traumatic Sports Had The Higher Moderate/Severe OA (37 % Vs 15%) • Shoulders With Severe Arthropathy Had Poorer DASH Scores →Shoulder Dislocation Per Se Is Associated With Arthropathy →It Seems That Stabilising Surgery Prevents The Evolution Of Arthropathy. Hovelius et al, KSSTA, 2016 Managing Soft Tissues in Instability … Inferior Capsule … ... Double Row … ALGORITHM Lesion Patterns • Soft Tissue • Bone Component Role of Glenoid Bone Defect Overall • No Bone Defect – 4% Recurrence • Bone Defect – 67% Recurrence Contact Athlete • No Bone Defect – 6.5% Recurrence • Bone Defect – 89% Recurrence Burkhart SS, De Beer JF Arthroscopy 2000 Size ? Loss Less Than 20 To 25% Timing???? Porcellini 2002: Better Results In Acute Cases Sugaya H JBJS Am 2005: Good Results Also In Chronic Cases Provencher Ajsm 2007: Good Results With Incorporation Of Bony Fragment. 3 Failures On 23 Patients, All In The “Attritional Group” ALGORITHM ? Lesion Patterns - Glenoid 73 Shoulders Underwent Isolated Arthroscopic Bankart Repair • Recurrence Rate: • Glenoid Bone Loss < 20% = 7.3% • Glenoid Bone Loss > 20% = 27.8% • BUT Bone Loss < 13.5% Led To A Clinically Significant Decrease In WOSI Scores Saha et al, AJSM, 2015 50 Intercollegiate Football Players Underwent Primary Arthroscopic Bankart Repair • All Shoulders (N = 3) With Glenoid Bone Loss = 13.5% Experienced Recurrence • None Of Shoulders (N = 47) With 13.5% Glenoid Bone Loss Sustained Recurrence →13.5% As A New Clinical Critical Value? Shin et al, AJSM, 2017 169 Patients With Anterior Glenoid Erosion Underwent Arthroscopic Stabilization • The Optimal Critical Value Of Glenoid Bone Loss Was 17.3% • Surgical Failure: • Glenoid Bone Loss < 17.3% = 3.7% • Glenoid Bone Loss > 17.3% = 42.9% • Better Unction For Glenoid Bone Loss < 17.3% → 17.3% As A New Clinical Critical Value? Dickens et al, AJSM, 2017 ALGORITHM ? Lesion Patterns - Glenoid Which Measurement For Glenoid Bone Loss? • Probabily The APdeficit/APwidth(%) Which Value For Glenoid Bone Loss? • > 20% AP Width→ Latarjet • 13.5-20% AP Width → ? o Attention For Other Risk Factors And Balance o Speaking With Your Patient • < 13.5% AP Width → ARTHROSCOPIC BANKART REPAIR @ Glenoid Augmentation Bone Block Procedure (Latarjet) RC Tears Normal Anatomy Rotator Cuff Tears CLASSIFICATIONS • Partial thickness *Articular side *Bursal side *Intratendinous • Full Thickness • Depth • Size/Shape • Number of tendons • Topography • Retraction Rotator Cuff : Partial Tears Full Thickness Tears SHAPE / SIZE / RETRACTION Rotator Cuff: Rotator Cuff : Full Thickness Tears SHAPE / SIZE / RETRACTION Rotator Cuff : Partial Tears ARTICULAR SIDE Rotator Cuff : Partial Tears ARTICULAR SIDE Rotator Cuff : Partial Tears ARTICULAR SIDE Rotator Cuff : Partial Tears ARTICULAR SIDE Partial Tears P.A.S.T.A. Lesion Rotator Cuff : Partial Articular Supraspinatus Tendon Avulsion (Snyder) Rotator Cuff : Partial Tears INTERNAL IMPINGEMENT (Walch) R.C. Partial Tears INTERNAL IMPINGEMENT Rotator Cuff : Partial Tears BURSAL SIDE Rotator Cuff : Partial Tears BURSAL SIDE Rotator Cuff : Partial Tears BURSAL SIDE Rotator Cuff : Partial Tears BURSAL SIDE Rotator Cuff Partial Thickness Tears INTRATENDINOUS ? Rotator Cuff : Partial Tears INTRATENDINOUS : CALCIUM Full Thickness Tears SHAPE / SIZE / RETRACTION Rotator Cuff: Rotator Cuff : Full Thickness Tears SHAPE / SIZE / RETRACTION Rotator Cuff : Full Thickness Tears SIZE / RETRACTION Rotator Cuff : Full Thickness Tears SIZE / RETRACTION Rotator Cuff : Full Thickness Tears SHAPE Rotator Cuff : Full Thickness Tears SHAPE Rotator Cuff Lesions SUBSCAPULARIS Rotator Cuff Lesions LHB Technical Pearls FLAG TEST Technical Pearls GRASPER TEST GH Arthritis Arthritis (Gleno-Humeral, AC / SC joints) Damaged humeral head and/or glenoid caused by: Primary Secondary – Degenerative – Traumatic – Metabolic – Septic and non septic inflammatory factors – Vascular F.A. Matsen III 1998 GH Arthritis Compared with the weight-bearing joints, glenohumeral arthritis is relatively uncommon. The incidence of GH arthritis is 300 times lower than degenerative joint desease of the knee and 100 times lower than that of the hip The prevalence has been reported to be between 0,1 and 0,4 in different populations Guyette 2002 General clinical presentation • Pain • Loss of mobility and of function • Refractory to rest, medications and esercise Inflammatory artrhitis • • • • • • • • • • Rheumatoid arthritis Pigmented villonodular synovitis Gout and Pseudogout Haemophilia Hyperparathyroidism Acromegaly Chondrocalcinosis Ankylosing spondylitis Psoriasis arthritis Dyalisis arhtropaty Inflammatory artrhitis Soft tissue may be swollen, contracted, weakned or torn Often bilateral Compromission induced by the use of steroids Capsulorraphy arthropathy • Related to surgical treatment for instability • Overtightening of the anterior capsule leads to a posterior glenoid wear and a central humeral head wear • Hardware malpositioning Neurotrophic arthropathy • Associated to syringomelia, diabetes or other cause of joint denervation • Joint cartilage and subcondral bone suffer of the loss of the trophic and protective effects of nerve supply The Problem • • • • • • • • Degenerative Joint Disease Rotator Cuff Tear Arthropathy Capsulorrhaphy Artropathy Infiammatory Arthritis Chondrolysis Avascular Necrosis Post-traumatic Arthritis Neurotropic Arthropathy Different Types Of Arthritis 3 Types Of Shoulder Arthroplasty Humeral Hemiarthroplasty (Hemi) Anatomic Total Shoulder Arthroplasty (TSA) Reverse Total Shoulder Arthroplasty (RSA) Ballmer FT, Lippitt SB, Romeo AA, et al. Total shoulder arthroplasty: Some considerations related to glenoid surface contact. J Shoulder Elbow Surg. 1994;3:299-306 The Shoulder – 2017 Tsvieli Oren, Atoun Ehud and Ofer Levy The Problem Different Pathologies / Different Options • Degenerative Arthropathy • Cta • Rheumatoid Arthritis • Avascolar Necrosis Of The Head • Fractures • Post- Traumatic Arthropathy • • • • • TSA Hemyarthroplasty (HA) Reverse TSA Biologic Resurfacing Of The Glenoid Resurfacing Prosthesis Of The Humeral Head The Topic Anatomic Total Shoulder Arthroplasty (TSA) Reverse Total Shoulder Arthroplasty (RSA) Vs Anatomic Total Shoulder Arthroplasty (TSA) • Rotator Cuff Integrity • Adequate Glenoid Bone Stock For Fixation Neer II CS, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319–37; Rockwood – The Shoulder 5° ed Reverse Total Shoulder Arthroplasty (RSA) Grammont Design Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993;16(1):65–8. Reverse total shoulder arthroplasty: an imaging overview Dong Hyun Lee1 & Yun Sun Choi1 & Hollis G. Potter2 & Yoshimi Endo2 & Thiru Sivakumaran2 & Tae Kang Lim3 & Tong Jin Chun1 Issues Reverse Total Shoulder Arthroplasty (RSA) Medialized Center Of Rotation Instability Wierks C, Skolasky RL, Ji JH, McFarland EG. Reverse total shoulder replacement: intraoperative and early postoperative complications. Clin Orthop Relat Res. 2009;467(1):225–34.) QUESTION Inverted-Bearing Reverse Shoulder Arthroplasty: Clinical and Radiological Results at Mid-Term Follow-Up Castagna A. Borroni M.. Dubini L., Gumina S., Delle Rose G., Ranieri R. JCM, 2022 • What are the clinical results and complications of IB-RSA at longer follow-up? • Does IB-RSA lead to low rate of notching and avoid grades higher than 2? INVERTED BEARING REVERSE SHOULDER ARTHROPLASTY IB-RSA Reverse Shoulder Arthroplasty A. Castagna Clinical History ➢Female, 60 yrs ➢Housewife ➢Right side (dominant) ➢Several yrs of pain , worsening ➢PT and Injections (cortison and Hyaluronic Ac.) ➢VAS 6/10 ➢SSV 20/100 Clinical Exam AROM PROM FF 80 100 ABD 40 50 Fixed scapula Fixed scapula ER1 10 20 IR1 Buttock Buttock Clinical Exam RX 2018 MRI 2018 CT 2018 Beta-Angle = 8° Posterior subluxation >70% Retroversion = - 13° Walch B2 ANESTHESIA Surgery Post-op Avascular necrosis Idiopathic Steroids Dysbaric conditions Transplantation Systemic illness Alcholism … • Uncommon • May occur in debilitated person ICI I IS T IT U T O C L IN IC O H U M A N IT A S Rotator cuff arthropathy Neer 1977 • Irrepairable massive RC tear – HH rise – Instability • HH deformity – Osteoporosis – Subcondral bon ecollapse Treatment ?? Conservative – NSAID – PT Arthroplasty – Hemiarthroplasty – Total Shoulder Arthroplasty Arthroscopy …?? ICI I IS T IT U T O C L IN IC O H U M A N IT A S Arthroscopic role in GH DJD ✓Diagnostic tool ✓Debridement ✓Synovectomy ✓Glenoidoplasty ✓SAD ✓Bursectomy ✓Loose body removal ✓ ✓ ✓ ✓ ✓ ✓ Capsular release LHB tenotomy Ostheophytes removal Microfracture Engineered cartilage (?) Genethic therapy (?) ICI I IS T IT U T O C L IN IC O H U M A N IT A S Diagnostic tool • Iannotti in 1500 shoulder arthroscopies, observed a 5% incidence of previously unrecognized grade 2 to 4 osteochondral lesion • Cofield (’83): “arthroscopy confirmed or modifed the diagnosis or altered the course of treatment in all 8 cases with arthritic desease investigated” ICI I IS T IT U T O C L IN IC O H U M A N IT A S Knee technique Mosaicplasty Osteochondral allograft transplantation Autologous chondrocyte transplantation Not used Debridement Abrasion Chondroplasty Drilling Microfracture Poor experience Debridement Ellman (’93): 18 patients with impingement and OA , mean age 51 yrs. Findings: 7 loose bodies,12 labrum damage and 5 partial RCT. Treatment: debridement of the degenerative tissue, removalm of loose bodies, partial synovectomy, and SAD in only 15 patient. Results: all patients demonstrated improvementICI I in pain witha f.u. of 6 months to 3 years IS T IT U T O C L IN IC O H U M A N IT A S Debridement Richman (’90): 25 patients with early degenerative OA, mean f.u. 34 months. Findings: 7 loose bodies,12 labrum damage and 5 partial RCT. Treatment: debridement of the degenerative tissue ICI I Results: 80% pain relief, 83% improved their ROM, 92% satisfied IS T IT U T O C L IN IC O H U M A N IT A S Debridement Ogilvie-Harris : 54 patients with OA, 3 years f.u.: When degenerative changes were mild, successful outcome occured in 2/3 of cases. For severe involvement, good results were obtained in only 13 of cases. ICI I IS T IT U T O C L IN IC O H U M A N IT A S Debridement The best results were obtained with the removal of osteoarthritic debris and with the debridement of the labrum that was treated like a degenerative tear of the meniscus in the knee ICI I IS T IT U T O C L IN IC O H U M A N IT A S Debridement • Is useful in the evaluation and diagnosis of OA in patients with normal radiographs or only minimal osteoarthritic changes on the radiographs or MR • Debridement has good result in patients with near normal preoperative ROM and concetric GH articulation ICI I IS T IT U T O C L IN IC O H U M A N IT A S Debridement • Patient with an asymmetric glenoid wear and significant humeral head translation has worst results from an isolated debridement • Patient with mild glenoid contracture and posterior subluxation need debridement and capsular release • Patient with advanced OA (grade IV) are not indicated for debridement (Weinstein 2000) ICI I IS T IT U T O C L IN IC O H U M A N IT A S Debridement “conclusions” Short F.U. (3 years) Improvement associated with the debridement of grade 3-4 cartilage lesions will progress Norris in 1997 showed how artrhscopic debridement did not alter the natural history of GH arthritis and only a small percentage of patients obtained any long lasting pain relief ICI I IS T IT U T O C L IN IC O H U M A N IT A S Synovectomy Ogilvie-Harris (’87): 15 pts., 1-2 yrs F.U. , 80% improvement after arthroscopic synovectomy Better results with little or no chondral damage Actually, especially in inflammatory desease, arthroscopic synovectomy is performed routinely ICI I IS T IT U T O C L IN IC O H U M A N IT A S Bursectomy and SAD Simpson and Kelly (1994) :bursectomy and SAD in 24 patients with RA. Pain relief and improved motion in 19 of these patients ICI I IS T IT U T O C L IN IC O H U M A N IT A S Loose bodies removal In chondromatosis and in pigmented synovitis or in RA has been reported the presence of loose bodies that may cause irritation, synovitis and effusion: the treatment is arthoscopic removal ICI I IS T IT U T O C L IN IC O H U M A N IT A S Capsular release • A too tight anterior capsule may lead to a posterior translation of the humeral head with a glenoid erosion ICI I IS T IT U T O C L IN IC O H U M A N IT A S GH Arthritis Arthroscopic treatment Microfractures Rotator cuff arthropathy Warning!! GH Arthritis Arthroscopic treatment LHB tenotomy Glenoidplasty Nevasier reprted results in 29 shoulders undergoing abrasion arthroplasty for isolated GH arthritis: creation of a congruous joint surface was emphasized, without abrading to bleeding, subchondral bone. There were 69% of excellent or good results based on pain relief and patient satisfaction ICI I IS T IT U T O C L IN IC O H U M A N IT A S GH Arthritis Arthroscopic treatment The future …?!? … GH Arthritis Future …? … glenoid resurfacing …!!?? Burhead,JSES,1995 GH Arthritis Arthroscopic treatment …Surface glenoid resurfacing …!!?? Experimental arthroscopic implant of intestine submucosa (Savoie/Castagna) Arthroscopy role in GH OA Conclusion • TSA is the gold standard for treatment of severe symptomatic GH arthritis • In younger patients or in mild form of arthritis • Minimal invasive arthroscopic treatment may have sense in selected and limited goal cases • … technical evolution MUST let us hope for more effective weapons ..! ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Degenerative Arthritis ➢ Deterioration fo the fibrocartilagineus disc ➢ Osteophytes formation ➢ Changes in the acromion and lateral end of the clavicle ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Rheumatoid Arthritis ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Septic Arthritis ➢ Rare ➢ Staphylococcus ➢ Streptococcus ➢ Tuberculosis ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Osteolysis of distal clavicle ➢ Osteoporosis ➢ Osteolysis ➢ Tapering or osteophyte formation ➢ No changes in the acromion ➢ Weigth lifters desease ➢ Pneumatic toolworkers ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Diagnosis ➢ X-Rays (Zanca’s view) ➢ MRI ➢ CT ➢ Bone scan ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Therapy ➢ Rest ➢ NSAIDs ➢ Physiotherapy ➢ Local anestetic + Steroid injections ➢ Surgery ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Surgery Mumford procedure ➢ Resection of 1-2 cm of the lateral end of the clavicle ICI I IS T IT U T O C L IN IC O H U M A N IT A S Painful AC Joint Surgery Arthroscopic Mumford procedure ➢ Resection of 0.5-1 cm of the lateral end of the clavicle Direct superior approach ICI I IS T IT U T O C L IN IC O H U M A N IT A S Subacromial approach Capsulitis Stiff shoulder Condition of severe restriction of active and passive ROM without evidence of intrinsic pathology of the joint Stiff shoulder No consensus of opinion on the degree of stiffness which properly defines a “frozen shoulder” • Freezing (painful) • Frozen (stiffening) • Thawing (stretching) • Self limiting (??, 10% remain stiff for yrs, Ogilvie-Harris) • Spontaneous resolution in 2 yrs • Worse in diabetics • • • • • • Diabetes Trauma Prolonged immobilization Autoimmune disease Calcific tendinitis Phenobarbital treatment • • • • • Female 40-60 yrs old Sedentary more than manual labor General population 2-5 % Diabetics 10-19% • Inflammation - Repair - Scarring • Fibroblastic proliferation=increased production of collagen • Fibrosis and fibroplasia similar to Dupuytren’s desease • • • • • Glenohumeral capsule (majority) Scapulothoracic (1/3) Subacromial A/C Sternoclavicular • Axillary fold redundancy and rotator interval mobility allow full ROM • Loss of active motion with normal passive motion: – RCT – Nerve lesion • Loss of active and passive motion: – Adhesive capsulitis – G/H arthritis – Locked posterior dislocation Frozen shoulder Diagnosis • X-Ray useful for detecting concomitant pathology (i.e. arthritis, calcific tendinitis, locked posterior dislocation) • MRI,CT not necessary usually • Conservative • Manipulation under anesthesia (MUA) • Operative – Open – Arthroscopic • Relieve pain • Restore motion – GET motion – KEEP motion • Restore function • PT , not too aggressive – w/t therapist – home program • Arthroscopic release after 4-6 months (“patient” patient, Rockwood) • • • • • Rarely restores IR Post-surgical stiffness Long lasting recovery Risk of fractures (osteoporosis) Success: 50-90% • • • • • Interscalene block anesthesia Beach-chair better than lateral decubitus Gentle manipulation before Scope posterior (enter with blunt trochar!!) Surgical tools anterior Frozen shoulder Arthroscopic release tecnique Enter the joint …. …. and make a complete assessment • 1) Release of the RI • start release from the superior margin of the subscapularis tendon and retract the elecrocautery back to the supraspinatus/CH ligament area • debride subscapularis bursa • observe increase of mobility • 2) Release of the posterior capsule • • • • switch scope anterior release posterior capsule observe increase of motion IF satisfactory, end intrarticular procedure Frozen shoulder Arthroscopic posterior capsular release • 3) Release of the anterior capsule (in case of unsatisfactory ROM after step 1 and step 2) • switch scope posterior • release anterior capsule • observe increase of motion • 4) Remove subacromial adhesions • • • • scope posterior debride subacromial space debride subdeltoid shelf observe increase of motion Frozen shoulder Arthroscopic release • RI release – safe – “easy” – may reach the goal Frozen shoulder Arthroscopic release • Capsular release – remember nerve proximity !! – sometimes hard to perform Long Head odf the Biceps Neurological Dyskenesis