surgical management of instability shoulder and elbow and ... courses/dr. williams hando… ·...

Surgical Management of Instability and SLAP Lesions

SHOULDER AND ELBOW UPDATE 2016

Gerald R. Williams, Jr., MD 1


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


Agenda

• Instability• Indications

• Technique

• Results

• SLAP lesions• Indications

• Technique

• Results


• Age

• Number of dislocations

• Ligamentous laxity

• Activity

• Bone deficiency

IndicationsPrognostic factors

Boileau, et. al. JBJS BR


• 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


Indications

Traumatic AtraumaticMicrotraumatic

TUBS AMBRI





Indications

• Traumatic unidirectional• Anterior

• Posterior

• Traumatic multidirectional

• Involuntary Atraumatic-- very occassionally


• 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


Arthroscopic vs. Open


• Arthroscopic equipment and technique have improved considerably

• Still a role for both

• Consider open in revisions or bone loss situations

TechniqueOpen vs. Arthroscopic


Arthroscopic Repair

No labrum, Healed medially


Results(Penn Score)





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


Bone defects Matter


• Age

• SLAP type

• Concomitant pathology

• Injury history

• Desired activity

SLAP RepairPrognostic Factors


Type I SLAP

• Very common

• Can be normal finding

• Debridement


Type II SLAP


Type II SLAP

• Arthroscopic repair

• 1-2 anterior anchors

• 1 posterior anchor-- posterior SLAP• Posterolateral portal (“Port of Wilmington”)





Type II SLAP


Type II Slap


Type III SLAP


Type IV SLAP


Concomitant PathologyInternal Glenoid Impingement

• AIGHL-- checkrein for ABER

• Int. Imp.• AIGHL laxity vs. Posterior capsular

contracture

• Decreased humeral retroversion


Internal Glenoid Impingement





• 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



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




• Stipend

• Royalties








• Pathophysiology

• Arthroplasty background

• Anatomic total shoulder arthroplasty

• Reverse total shoulder arthroplasty

Agenda


Glenohumeral Arthritis

Pathophysiology

Inflammatory Arthritis

Crystalline Arthritis

Post-traumatic Arthritis

Avascular Necrosis

OsteoarthritisRotator cuff

Capsule

Bone


PathophysiologyPrimary Pathology

Cartilage Soft-Tissue

Loss Abnormalities

Osteoarthritis Posttraumatic ArthritisI I

Avascular Necrosis Rheumatoid ArthritisI I

Cuff Tear ArthritisI


Osteoarthritis





CT/MRI


Inflammatory Arthritis


ArthroplastyDecision-making Factors

• Age

• Activity level

• Joint geometry

• Rotator cuff status

• Capsular contracture


Anatomic Shoulder Arthroplasty


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


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






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


Subscapularis Management

Advancement-30 ER < 10

Z-LengtheningAdvancement


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


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)


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





Reverse Total Shoulder Arthroplasty

• Paul Grammont

• 1985

• Dijon, France


Constrained Arthroplasty

Not a new concept


Delta III (Grammont 1987)How is it Different?

• Large sphere, no neck

• Medialized center

• Valgus neck-shaft angle (155 degrees)


Results


Werner, Gerber, et.al

• Total complication rate 50%

• Reoperation rate 33%

• Primary cases 18%

• Revisions 39%

• Hematoma most common complication


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.





American Experience

• Generally lower complication rate• Benefit of European learning curve

• Still high relative to anatomic implant–similar to when anatomic implant first introduced


• 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


Market Impact

Kim SH, Wise BL, Zhang Y, Szabo RM. J Bone Joint SurgAm 2011;93:2249-54.


• 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



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




• Stipend

• Royalties








Agenda

• Cuff aging/natural history

• Patient selection– who and when

• Technique of cuff repair-- how

• Results

• Conclusions


Cuff Aging/Natural HistoryAsymptomatic

Sher, et.al., JBJS 77A, 1995


Yamaguchi K. et.al. J Bone Joint Surg 2006:88:1699-1704

Cuff Aging/Natural History


Cuff Aging/Natural History

Yamaguchi, K., A. M. Tetro, et al. JSES (2001).





• Acuity

• Size

• Patient factors• Age

• Activity

• Smoking history

• DM

• Tissue quality

Patient SelectionPrognostic Factors


Acuity and Size

(Fenlin, Goutallier, Gerber, others)


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



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).


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


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





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






Arthroscopic Cuff Repair Technique

• Mobilization• Superficial

• Deep

• Interval slides/releases






acromioplasty No acromioplasty



?Acromioplasty?

• No type 3s, single tendon tears

Gartsman, G. M. and P. O'Connor D JSES (2004).


Cuff Repair Principles?Acromioplasty?

McCallister W. V. et.al. J Bone Joint Surg2005:87:1278-1283

• No control group


Cuff Repair Principles?Acromioplasty?

The Jury is still out


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


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.





Post-operative Integrity

Bishop, J., S. Klepps, Flatow, E. et al. JSES (2006).


Post-operative Integrity

Double Row

Lafosse, L., R. Brozska, et al. JBJS (2007).


Cuff RepairConclusions

• Complex event• Right patient

• Right time

• Correct Surgical technique


Acknowledgements

Louis Soslowsky, PhD, Stavros Thomopoulos, PhD, JJ Sarver, J Gimbel, PhD, Cathy Peltz, LM Dourte

THANK YOU.

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