Jonathan Glashow MD - Current advances in orthopedic sports medicine and how they can impact the aging athlete

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

When Non-Surgical
treatment is not enough


When Non-Surgical

• 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


When Non-Surgical

• 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

ARTHROSCOPIC
ACL
RECONSTRUCTION


Natural History:

What Happens when left untreated


Natural History:


• the kinematics of the knee change and cause undue
stresses


Natural History:


stresses
• if concomitant injury has not already occurred the
patient is at high risk for damaging the meniscus
(medial) and/or articular cartilage*


Natural History:


stresses
• with the ACL deﬁcient knee the extensor mechanism
must compensate to try and provide some stability, this
often leads to secondary problems


Natural History:


stresses
• chondromalacia


Natural History:


stresses
• chondromalacia

• patellar/quad tendonitis


Natural History:


stresses
• chondromalacia

• patellar/quad tendonitis

*Dunn AJSM 2004

How Has ACL reconsturction
Changed?


Changed?

We no Longer use Tools like these


Changed?


Instability


Changed?


Instability Arthritis


Changed?


Instability Arthritis
Advances in technique allow us to recommend
reconstruction in the 50 plus year old to prevent
progression


Changed?
• Can be done with a “ NO INCISION”
technique


Changed?
technique
• Done on an out patient basis


Changed?
technique
• Closer to initial injury once swelling is down to
minimize muscle atrophy and “bad habits”


Changed?
technique
• 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


We Begin with Graft
Choice


We Begin with Graft
Choice
• Allograft


We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*


We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*

• faster return to
daily activities


We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*

daily activities

• smaller surgical
incisions


We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*

daily activities

incisions

• decrease muscle
atrophy


We Begin with Graft
Choice
• Allograft
• no donor site
morbidity*

daily activities

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).


We Begin with Graft
Choice
• Allograft • Autograft
• no donor site
morbidity*

daily activities

incisions

• decrease muscle
atrophy



We Begin with Graft
Choice
• no donor site
• your own tissue
morbidity*

daily activities

incisions

• decrease muscle
atrophy



We Begin with Graft
Choice
• no donor site
• your own tissue
morbidity*
• earlier graft maturity**
daily activities

incisions

• decrease muscle
atrophy



We Begin with Graft
Choice
• no donor site
• your own tissue
morbidity*
• earlier graft maturity**
daily activities • donor site complications
(fracture, tendon
rupture, numbness)
incisions

• decrease muscle
atrophy



We can do Minimally Invasive
drilling from the inside



• Traditional drilling of the tibia for
the ACL



the ACL
• is a tunnel beginning at the anterior
tibial cortex exiting within the joint



the ACL
• can create fractures inside the joint



the ACL
• Limits the location of the femoral
placement and requires taking away
more bone



the ACL
• 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


Minimally Invasive Tibial
Drilling Drilling


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


Minimally Invasive Femoral
Drilling


Drilling

• Decreased risk of
cartilage injury


Drilling

• Decreased risk of
cartilage injury
• Placement not
dictated by tibial
tunnel
• more anatomic

• ideal for revision
situations


Femoral Drilling


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


Accelerated Rehab


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


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


• post op pt


Shoulder Injury
Rotator Cuff Labrum Biceps


Most common conditions in
the aging athlete

• Weight Lifters
• Impingement, AC joint

• Overhead Athletes
• Labrum, Biceps, Instability

• Contact Athletes
• AC joint, Rotator Cuff, Arthritis


Non Operative Treatment

• Physical Therapy
• Injections
• PRP/ACP, Corticosteriods, IRAP

• Activity modiﬁcations

Only Surgery can repair mechanical problems


The Recovery from shoulder
Arthroscopy Begins Intraoperativley



• Arthroscopic



• Arthroscopic
• Long acting regional Anesthesia



• Arthroscopic

• Use of smaller portals and cannulas resulting in better cosmesis and
signiﬁcantly less post operative pain



• Arthroscopic


• Better visual evaluation of the tear allowing for a more accurate repair



• Arthroscopic



• Can be preformed even on chronic injuries with excellent results*



• Arthroscopic




• Low complication rate (mini-open**) with a high rate of patient satisfaction



• Arthroscopic





*Burkhart SS, Danaceau SM, Arthroscopy. 2001 Nov-Dec;17



• Arthroscopic





*Burkhart SS, Danaceau SM, Arthroscopy. 2001 Nov-Dec;17
**Severud EL, Ruotolo C,Arthroscopy2003 Mar;19



• 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


Rotator Cuff Tears

• Traumatic vs Chronic

• Timing of repair

• Functional limitations of non-operative

treatment

• Limits of surgery



• 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.


Rotator Cuff Repair


Instability:
Labral repair

• Dislocating shoulder
• SLAP tear
• Swimmers shoulder
• Biceps pathology


Instability:
Labral repair

• Patient speciﬁc approach
• Non operative treatment often works
• Less ominous than cuff
• Minimally invasive repair with early
mobilization


Biceps Pathology

• The great imitator
• Common source of anterior shoulder
pain
• Variable presentation
• Concomitant injury
• Non surgical treatment often limited


Techniques


Procedure Specific
Rehabilitation

• Phase I
• Pain management

• Reduce Swelling

• Adapt to daily activities

• Limited sling use

• Home exercises


Procedure Specific
Rehabilitation

• Phase II
• Early passive ROM

• Supervised physical therapy

• Limited aerobic conditioning


Procedure Specific
Rehabilitation

• Phase III
• Must have full PROM

• Emphasis on core
strengthening

• Sports speciﬁc conditioning

• Procedure dependent


Articular
Cartilage Injury
Knee Shoulder


Anatomy

• Hyaline Cartilage

• Type II collagen

• Present in all articulating joint
surfaces

• Injury leads to arthritis


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


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


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


Cartilage Injuries

What is in the pipeline:

• Biocartilage replacement

• Second generation ACI

• Stem cell therapies

• All arthroscopic techniques


Knee Injuries


Implantation of Particulated
Juvenile Cartilage


large allograft plug


Biocartilage


Cartilage Injuries
post Operative Care

• Out patient
• Use of long action regional anesthesia
• Non weight bearing 6 weeks (lesions
dependent)
• Early PT
• Bracing


Thank You


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


Jonathan Glashow MD - Current advances in orthopedic sports medicine and how they can impact the aging athlete

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