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Similar to Shoulder Arthritis | Shoulder Instability | South Windsor, Rocky Hill, Glastonbury CT
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Shoulder Arthritis | Shoulder Instability | South Windsor, Rocky Hill, Glastonbury CT
- 1. The Shoulder ______ Arthritis and Instability JAMES T MAZZARA, MD ORTHOPEDIC ASSOCIATES OF HARTFORD, PC MANCHESTER / ROCKY HILL HARTFORD HOSPITAL GLASTONBURY SURGERY CENTER CONNECTICUT JOINT REPLACEMENT INSTITUTE @ ST FRANCIS HOSPITAL ECHN
- 2. Contact Information James T Mazzara, MD Orthopedic Associates of Hartford, PC 29 Haynes Street Manchester, CT 06040 _________________ 150 Enterprise Drive Rocky Hill, CT 06067 860-649-2267 www.HartfordSportsOrthopedics.com
- 3. Age-related Cartilage Changes Older cartilage is less cellular Cartilage cells do not reproduce after growth plates close Chondrocytes only in lower layers Water content decreases
- 4. Age-related Cartilage Changes Proteoglycans change Chondroitin decreases Keratin increases PG chains become shorted and retain less water Decreased PG levels leads to decreased cartilage function
- 5. Grading Cartilage Wear Outerbridge Classification Stage I Soft discolored superficial fibrillation Stage II Fragmentation < 1.3 cm2 Stage III Fragmentation > 1.3 cm2 Stage IV Erosion to subchondral bone (eburnation)
- 7. Osteoarthritis 43 million American adults have doctor-diagnosed arthritis 100 different types Osteoarthritis – “wear-and-tear arthritis” – is the most common Exact causes are unknown Researchers say genetics may play a role in 40-65 percent of knee osteoarthritis cases
- 8. Rotator Cuff
- 9. Full Thickness Tears Loads are concentrated at the margins of the tear Further tearing occurs with smaller loads Partial tears become complete Smaller tears become large Large tears eventually become unfixable
- 10. Progressive Tearing Spacer effect of the cuff is lost Humeral head displaces superiorly Biceps tendon eventually ruptures
- 12. Rotator Cuff Dysfunction A weak or torn rotator cuff results in abnormal shoulder mechanics and abnormal motion that results in pain and further damage.
- 13. Chronic Rotator Cuff Tears Rotator Cuff Tear Arthropathy
- 14. Late Cuff Failure Traction spurs develop in CA ligament Humeral head penetrates through the cuff tear
- 15. Chronic Cuff Failure Humeral head forms a joint with the arch above Secondary joint disease occurs called cuff tear arthropathy
- 16. Radiographs Acromial shape Position of humeral head AC arthritis Calcific tendinitis Glenohumeral arthritis Destructive lesions
- 17. 1 & 2: AP in Scapular Plane 2 Views: IR, ER Calcium deposits Greater tuberosities: excrescences, cysts
- 18. 1 & 2: AP in Scapular Plane 2 Views: IR, ER Calcium deposits Greater tuberosities: excrescences, cysts Moderate osteoarthritis Severe osteoarthritis
- 19. 3: Axillary View Evaluate GH joint & tuberosities Glenoid version Joint space narrowing Os acromiale This is an anatomic variation best seen on this special view
- 20. 4: Outlet View Evaluate subacromial space Acromial shape and thickness
- 21. 5: 30O Caudal Tilt View AP view with a 30O caudal tilt Demonstrates anterior acromial projection spur
- 22. Tendon Imaging MRI 90% accurate in diagnosing complete RC tears 70% accurate in diagnosing partial RC tears These data may vary. It depends on who is reading the MRI. This spur is pushing on the rotator cuff causing “impingement”.
- 23. Bone Imaging CT Scan before shoulder replacement surgery is needed to assess glenoid bone loss
- 24. Nonoperative Treatment Education Realistic expectations Activity modifications Potential occupational changes Physical Therapy Focus on range of motion (Stretching) Increased strength without aggravating pain (Elastic bands) Avoid weight training
- 25. Nonoperative Treatment Medication Nonsteroidal anti-inflammatory (NSAIDS) Potential side effects of gastric, renal, and liver problems, especially in the elderly. Glucosamine/chondroitin sulfate may be anti-inflammatory Turmeric: anti-inflammatory Local Injections with steroid medication may give some temporary relief, but repeated injections are not indicated, and should be avoided. Viscosupplementation (Lubricant injections) Suprascapular Nerve blocks or denervation
- 26. Arthroscopic Debridement Results Depends on the severity of the disease Mild arthritis 2/3 of patients will show some benefits Severe arthritis <1/3 of patients have any long-term benefit Arthroscopic intervention does not alter the natural progression of the disease Current recommendations are that arthroscopy should be seldom recommended for the treatment of established osteoarthritis.
- 27. Arthroscopy for Shoulder Arthritis Images of a focal defect of the humeral head in a shoulder with minimal arthritis. Younger patient. Acute trauma.
- 28. Arthroscopy for Shoulder Arthritis Generalized arthritis on both humeral head and glenoid Early arthritis with only loss of cartilage on glenoid
- 29. Arthroscopy for Arthritis Some patterns of shoulder arthritis are appropriate for debridement to remove loose flaps or cartilage. Microfracture (seen here) can help the arthritic joint for local defects with otherwise good cartilage surfaces. Also called marrow stimulation.
- 30. Shoulder Replacement Arthritis Wear and tear Multiple dislocations Rheumatoid arthritis
- 33. Shoulder Replacement Osteonecrosis / Avascular Necrosis Idiopathic Post Trauma Steroid or Alcohol Use
- 40. Reverse Shoulder Replacement Pseudoparalytic shoulder due to rotator cuff tear and deltoid weakness
- 41. Reverse Shoulder Replacements Reverse shoulder replacements are helpful when treating arthritis associated with irreparable rotator cuff tears in patients unable to lift the arm due to tendon tears.
- 45. Shoulder Instability Shoulder joint is too loose and is able to slide around too much in the socket Dislocation Head of humerus slips completely out of the socket Instability without dislocation Causes pain and apprehension due to excessive motion
- 46. Shoulder Dislocation The shoulder dislocates when the head of the humerus slips completely out of the glenoid (socket). Some shoulders may go back spontaneously while others require medical attention.
- 47. Shoulder Dislocation Shoulder dislocations may result in bone fractures of the glenoid called a Bankart Lesion. Fractures of the humeral head are called Hill-Sachs lesions. When Hill-Sachs lesions are large, the bone can become stuck or engaged on the glenoid.
- 48. Shoulder Dislocation Can lead to fractures and joint damage This degree of glenoid bone loss would require reconstruction with local bone graft. (Laterjet procedure) The fracture on the humeral head will require a tendon transfer (Remplissage) or an osteochondral bone graft using cadaver bone. Bony Bankart Lesion Hill-Sachs Lesion CT Scan of Chronic Dislocation
- 49. Shoulder Dislocation After a dislocation has been reduced, patients wear a sling for comfort then start therapy. Six weeks in a sling and special braces do not seem to help reduce the chances of future dislocations Currently, we recommend that younger first time dislocators consider surgery to repair the damage and reduce the chance of future dislocations. Older patients (21-40 yo) can sometimes be treated without surgery unless there is a second dislocation Patients over 40 yo may initially be treated without surgery unless there is a rotator cuff tear.
- 50. Shoulder Dislocations Torn labrum undergoing arthroscopic repair This shows an arthroscopic labral repair in progress
- 51. Shoulder Dislocations Before repair After repair.
- 52. Shoulder Instability For patients with multidirectional instability (lax ligaments) or those who have had previous surgery that has failed, an open reconstruction may be appropriate to repair the detached cartilage labrum (Bankart repair) and tighten the lax or attenuated ligaments (capsular shift).
- 53. Shoulder Dislocation If the Bankart lesion is small, then it can be repaired. If the Hill-Sachs defect in the humeral head is large and engaging, then a tendon (infraspinatus tendon of the rotator cuff) is attached to the bone defect slightly reducing shoulder mobility but greatly enhancing shoulder stability.
- 54. Shoulder Dislocation When there is significant loss of bone on the glenoid, not soft tissue procedure alone will prevent future instability. In a Laterjet procedure, bone graft is used to replace the deficient glenoid bone restoring shoulder stability. Video animation here https://www.arthrex.com/resources/animation/sjjc6vkEEeCRTQBQVoRHOw/open- latarjet-instrumentation
- 55. Complications of Surgery Always part of pre-op discussion Nerve damage Weakness, numbness Bleeding Infection Tendon rupture Stiffness Continued pain and impairment Stretched repair and recurrent instability
- 56. Thank You Be careful out there.