Glomerular Filtration and determinants of glomerular filtration .pptx
Jonathan Glashow MD - Current advances in orthopedic sports medicine and how they can impact the aging athlete
1. Current Advances in Orthopedic Sports
Medicine and How They Impact the Aging
Athlete
Jonathan L. Glashow, M.D.
Clinical Associate Professor & Co-Chief, Sports
Medicine Service, Dept. of Orthopaedic Surgery,
Mount Sinai Medical Center, New York, NY
Wednesday, October 3, 12
3. When Non-Surgical
treatment is not enough
• How do we get the “Weekend Warrior” back
to play after a major injury such as:
• Knee: ACL, Meniscus
• Shoulder: Rotator cuff tear, Labral Injury
• Articular Cartilage Injury
Wednesday, October 3, 12
4. When Non-Surgical
treatment is not enough
• How do we get the “Weekend Warrior” back
to play after a major injury such as:
• Knee: ACL, Meniscus
• Shoulder: Rotator cuff tear, Labral Injury
• Articular Cartilage Injury
• What are the newest advancements in surgical
techniques and accelerated rehabilitation that:
• Increase Function
• Decrease Pain
• Better Cosmesis
• More rapid return to sports
Wednesday, October 3, 12
5. ARTHROSCOPIC
ACL
RECONSTRUCTION
Wednesday, October 3, 12
6. Natural History:
What Happens when left untreated
Wednesday, October 3, 12
7. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
Wednesday, October 3, 12
8. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*
Wednesday, October 3, 12
9. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*
• with the ACL deficient knee the extensor mechanism
must compensate to try and provide some stability, this
often leads to secondary problems
Wednesday, October 3, 12
10. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*
• with the ACL deficient knee the extensor mechanism
must compensate to try and provide some stability, this
often leads to secondary problems
• chondromalacia
Wednesday, October 3, 12
11. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*
• with the ACL deficient knee the extensor mechanism
must compensate to try and provide some stability, this
often leads to secondary problems
• chondromalacia
• patellar/quad tendonitis
Wednesday, October 3, 12
12. Natural History:
What Happens when left untreated
• the kinematics of the knee change and cause undue
stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*
• with the ACL deficient knee the extensor mechanism
must compensate to try and provide some stability, this
often leads to secondary problems
• chondromalacia
• patellar/quad tendonitis
*Dunn AJSM 2004
Wednesday, October 3, 12
13. How Has ACL reconsturction
Changed?
Wednesday, October 3, 12
14. How Has ACL reconsturction
Changed?
We no Longer use Tools like these
Wednesday, October 3, 12
15. How Has ACL reconsturction
Changed?
We no Longer use Tools like these
Instability
Wednesday, October 3, 12
16. How Has ACL reconsturction
Changed?
We no Longer use Tools like these
Instability Arthritis
Wednesday, October 3, 12
17. How Has ACL reconsturction
Changed?
We no Longer use Tools like these
Instability Arthritis
Advances in technique allow us to recommend
reconstruction in the 50 plus year old to prevent
progression
Wednesday, October 3, 12
18. How Has ACL reconsturction
Changed?
Wednesday, October 3, 12
19. How Has ACL reconsturction
Changed?
• Can be done with a “ NO INCISION”
technique
Wednesday, October 3, 12
20. How Has ACL reconsturction
Changed?
• Can be done with a “ NO INCISION”
technique
• Done on an out patient basis
Wednesday, October 3, 12
21. How Has ACL reconsturction
Changed?
• Can be done with a “ NO INCISION”
technique
• Done on an out patient basis
• Closer to initial injury once swelling is down to
minimize muscle atrophy and “bad habits”
Wednesday, October 3, 12
22. How Has ACL reconsturction
Changed?
• Can be done with a “ NO INCISION”
technique
• Done on an out patient basis
• Closer to initial injury once swelling is down to
minimize muscle atrophy and “bad habits”
• Two separate regional nerve blocks are
performed to reduce the need for general
anesthetics intra op and PO post op
• Femoral nerve block indwelling catheter 72 hours
• High popliteal nerve block
Wednesday, October 3, 12
24. We Begin with Graft
Choice
• Allograft
Wednesday, October 3, 12
25. We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*
Wednesday, October 3, 12
26. We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*
• faster return to
daily activities
Wednesday, October 3, 12
27. We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*
• faster return to
daily activities
• smaller surgical
incisions
Wednesday, October 3, 12
28. We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*
• faster return to
daily activities
• smaller surgical
incisions
• decrease muscle
atrophy
Wednesday, October 3, 12
29. We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*
• faster return to
daily activities
• smaller surgical
incisions
• decrease muscle
atrophy
*Tibial sockets improve cosmesis and decrease morbidity over full tibial
tunnel creation. Preserved tibial cortex allows strong, low profile hybrid
fixation (Walsh et al, AJSM, 37(1): 160-7, 2008).
Wednesday, October 3, 12
30. We Begin with Graft
Choice
• Allograft • Autograft
• no donor site
morbidity*
• faster return to
daily activities
• smaller surgical
incisions
• decrease muscle
atrophy
*Tibial sockets improve cosmesis and decrease morbidity over full tibial
tunnel creation. Preserved tibial cortex allows strong, low profile hybrid
fixation (Walsh et al, AJSM, 37(1): 160-7, 2008).
Wednesday, October 3, 12
31. We Begin with Graft
Choice
• Allograft • Autograft
• no donor site
• your own tissue
morbidity*
• faster return to
daily activities
• smaller surgical
incisions
• decrease muscle
atrophy
*Tibial sockets improve cosmesis and decrease morbidity over full tibial
tunnel creation. Preserved tibial cortex allows strong, low profile hybrid
fixation (Walsh et al, AJSM, 37(1): 160-7, 2008).
Wednesday, October 3, 12
32. We Begin with Graft
Choice
• Allograft • Autograft
• no donor site
• your own tissue
morbidity*
• earlier graft maturity**
• faster return to
daily activities
• smaller surgical
incisions
• decrease muscle
atrophy
*Tibial sockets improve cosmesis and decrease morbidity over full tibial
tunnel creation. Preserved tibial cortex allows strong, low profile hybrid
fixation (Walsh et al, AJSM, 37(1): 160-7, 2008).
Wednesday, October 3, 12
33. We Begin with Graft
Choice
• Allograft • Autograft
• no donor site
• your own tissue
morbidity*
• earlier graft maturity**
• faster return to
daily activities • donor site complications
(fracture, tendon
• smaller surgical
rupture, numbness)
incisions
• decrease muscle
atrophy
*Tibial sockets improve cosmesis and decrease morbidity over full tibial
tunnel creation. Preserved tibial cortex allows strong, low profile hybrid
fixation (Walsh et al, AJSM, 37(1): 160-7, 2008).
Wednesday, October 3, 12
34. We can do Minimally Invasive
drilling from the inside
Wednesday, October 3, 12
35. We can do Minimally Invasive
drilling from the inside
• Traditional drilling of the tibia for
the ACL
Wednesday, October 3, 12
36. We can do Minimally Invasive
drilling from the inside
• Traditional drilling of the tibia for
the ACL
• is a tunnel beginning at the anterior
tibial cortex exiting within the joint
Wednesday, October 3, 12
37. We can do Minimally Invasive
drilling from the inside
• Traditional drilling of the tibia for
the ACL
• is a tunnel beginning at the anterior
tibial cortex exiting within the joint
• can create fractures inside the joint
Wednesday, October 3, 12
38. We can do Minimally Invasive
drilling from the inside
• Traditional drilling of the tibia for
the ACL
• is a tunnel beginning at the anterior
tibial cortex exiting within the joint
• can create fractures inside the joint
• Limits the location of the femoral
placement and requires taking away
more bone
Wednesday, October 3, 12
39. We can do Minimally Invasive
drilling from the inside
• Traditional drilling of the tibia for
the ACL
• is a tunnel beginning at the anterior
tibial cortex exiting within the joint
• can create fractures inside the joint
• Limits the location of the femoral
placement and requires taking away
more bone
• violates the anterior tibial cortex with a
hole 8-10mm in diameter increasing
pain and bleeding
Wednesday, October 3, 12
41. Minimally Invasive Tibial
Drilling Drilling
• Now we make “sockets” instead of tunnels
• Less bone removed equating to less post operative pain
• A cleaner more refined hole is made for the new ACL
Wednesday, October 3, 12
44. Minimally Invasive Femoral
Drilling
• Decreased risk of
cartilage injury
• Placement not
dictated by tibial
tunnel
• more anatomic
• ideal for revision
situations
Wednesday, October 3, 12
46. Repair rather than Remove:
When we can fix the Meniscus
• Location, Location, Location
• blood supply does not penetrate well thus tears further from
the capsule do not heal as well
• Meniscus tissue less cellular w/decreased healing response
after age 40, so repair is augmented using PRP/ACP
• -Mesiha AJSM 2007
•All arthroscopic repair
with no knots
Wednesday, October 3, 12
48. Accelerated Rehab
• Orthobiologics: ACP/PRP, Stem cells
• FWB as tolerated in 48hrs (due to regional
anesthetic blocks)
• Compression ice therapy
• No more use of CPM machine
• early Full range of motion
• Recumbent or upright bike for motion
• Use of a lock/unlock brace for the first 2-3 weeks
when ambulating
Wednesday, October 3, 12
49. Rehabilitation
• Physical therapy beginning within the
first 5 days post operatively, sometimes
day 1
• Portable electrical stim unit to hasten quad
function, used multiple times daily
• Strength training to start at 2 weeks
• Sport specific regiment
• Return to sport is graft dependent
Wednesday, October 3, 12
52. Most common conditions in
the aging athlete
• Weight Lifters
• Impingement, AC joint
• Overhead Athletes
• Labrum, Biceps, Instability
• Contact Athletes
• AC joint, Rotator Cuff, Arthritis
Wednesday, October 3, 12
53. Non Operative Treatment
• Physical Therapy
• Injections
• PRP/ACP, Corticosteriods, IRAP
• Activity modifications
Only Surgery can repair mechanical problems
Wednesday, October 3, 12
54. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
Wednesday, October 3, 12
55. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
Wednesday, October 3, 12
56. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
Wednesday, October 3, 12
57. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
Wednesday, October 3, 12
58. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
• Better visual evaluation of the tear allowing for a more accurate repair
Wednesday, October 3, 12
59. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
• Better visual evaluation of the tear allowing for a more accurate repair
• Can be preformed even on chronic injuries with excellent results*
Wednesday, October 3, 12
60. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
• Better visual evaluation of the tear allowing for a more accurate repair
• Can be preformed even on chronic injuries with excellent results*
• Low complication rate (mini-open**) with a high rate of patient satisfaction
Wednesday, October 3, 12
61. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
• Better visual evaluation of the tear allowing for a more accurate repair
• Can be preformed even on chronic injuries with excellent results*
• Low complication rate (mini-open**) with a high rate of patient satisfaction
*Burkhart SS, Danaceau SM, Arthroscopy. 2001 Nov-Dec;17
Wednesday, October 3, 12
62. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Arthroscopic
• Long acting regional Anesthesia
• Use of smaller portals and cannulas resulting in better cosmesis and
significantly less post operative pain
• Better visual evaluation of the tear allowing for a more accurate repair
• Can be preformed even on chronic injuries with excellent results*
• Low complication rate (mini-open**) with a high rate of patient satisfaction
*Burkhart SS, Danaceau SM, Arthroscopy. 2001 Nov-Dec;17
**Severud EL, Ruotolo C,Arthroscopy2003 Mar;19
Wednesday, October 3, 12
63. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• New repair devices
• Increased number of anchors that are smaller in
diameter
• anchors made of biocomposite materials that morph
into bone as opposed to plastic and metal
• more fixation points
• allows for a larger anchor if needed for weaker bone
• Augmentation utilizing intraoperative PRP/
ACP placement directly into the repair site.
Use of marrow stem cells
Wednesday, October 3, 12
64. Rotator Cuff Tears
• Traumatic vs Chronic
• Timing of repair
• Functional limitations of non-operative
treatment
• Limits of surgery
Wednesday, October 3, 12
65. The Recovery from shoulder
Arthroscopy Begins Intraoperativley
• Double row knotless repair- Suture Bridge
• increased structural repair/healing*
• more reliable and reproducible
• decreases operative time
• More rigid fixation allows for early return to function,
no more 6 weeks sling time
• Saridakis P, Jones G.J Bone Joint Surg Am. 2010 Mar;92(3):732-42.
Wednesday, October 3, 12
69. Instability:
Labral repair
• Patient specific approach
• Non operative treatment often works
• Less ominous than cuff
• Minimally invasive repair with early
mobilization
Wednesday, October 3, 12
70. Biceps Pathology
• The great imitator
• Common source of anterior shoulder
pain
• Variable presentation
• Concomitant injury
• Non surgical treatment often limited
Wednesday, October 3, 12
72. Procedure Specific
Rehabilitation
• Phase I
• Pain management
• Reduce Swelling
• Adapt to daily activities
• Limited sling use
• Home exercises
Wednesday, October 3, 12
73. Procedure Specific
Rehabilitation
• Phase II
• Early passive ROM
• Supervised physical therapy
• Limited aerobic conditioning
Wednesday, October 3, 12
74. Procedure Specific
Rehabilitation
• Phase III
• Must have full PROM
• Emphasis on core
strengthening
• Sports specific conditioning
• Procedure dependent
Wednesday, October 3, 12
75. Articular
Cartilage Injury
Knee Shoulder
Wednesday, October 3, 12
76. Anatomy
• Hyaline Cartilage
• Type II collagen
• Present in all articulating joint
surfaces
• Injury leads to arthritis
Wednesday, October 3, 12
77. Cartilage Injuries
• Untreated articular cartilage injury leads to
early arthritis*
• Biologic restorative options:
• ACI (Autologous Chondrocyte Implantation)
• two procedures where cells are taken from the patient
then grown and implanted back into the defect as
liquid that requires a patch to be sewn over
• can have up to 76% success rate*
• *Zaslav K; Cole B; Brewster R; DeBerardino ,Am J Sports Med . 2009;37:42-55
Wednesday, October 3, 12
78. Cartilage Injuries
• Particulated Juvenile Articular Cartilage Transplant
• single procedure where fresh allograft cartilage is implanted and
"glued" in place
• high cellular activity from the juvenile cartilage
• availability can be difficult as it is a fresh graft
Wednesday, October 3, 12
79. Cartilage Injuries
• Fresh Allograft plug
• Restore bone AND cartilage defect
• needs to be size matched for larger defects and may
take time to obtain
• limited availability
• May require osteotomy
Wednesday, October 3, 12
80. Cartilage Injuries
What is in the pipeline:
• Biocartilage replacement
• Second generation ACI
• Stem cell therapies
• All arthroscopic techniques
Wednesday, October 3, 12
85. Cartilage Injuries
post Operative Care
• Out patient
• Use of long action regional anesthesia
• Non weight bearing 6 weeks (lesions
dependent)
• Early PT
• Bracing
Wednesday, October 3, 12
87. Cartilage Injuries
• High success rate
• Return to active lifestyle
• Restore natural anatomy
• Delay or prevent the need for joint replacement
• Future holds promise for even better techniques
Wednesday, October 3, 12