Shoulder Injuries-unsw 2006 -hand Outs

Advances in the Diagnosis and Management of Shoulder Injuries

Demographics Rotator cuff tear Impingement

George AC Murrell ORTHOPAEDIC RESEARCH INSTITUTE

Instability

St George Hospital Campus University of New South Wales

Frozen shoulder

AUSTRALIA

Paxinos Sign = AC joint

R

L

1

Treatment – AC Joint Pain

Instability

Blair et al, 1996

Gleno-humeral Ligaments

Ligaments with abduction

2

SLAP – Superior Labrum Anterior to Posterior

O’Brien’s Sign = SLAP

13/20

Shoulder Instability

Mechanism of Injury

• Diagnosis • History • Clinical exam

Posterior Dislocation • Forces

Posterior Dislocation • Fitting

3

Load and Shift

Apprehension sign

Relocation sign

Augmentation sign

Non-operative Rx

4

Bankart lesion

Operative Stabilization

5

Frozen shoulder

Cause of restricted joint movement

• 40-60 years •F > M •L > R Lundberg, 1969

Divya/march 01

6

Pathogenesis ?

Natural History

Initiating Event

• Self limiting • Av 2.5 years

Percent improvement

Synovial Proliferation

Pain

Loss of motion

• ?Self limiting

Fibroblast Proliferation

Pain Loss of motion

Capsular Fibrosis

Loss of motion

• 42% loss of ROM at 6 years

Clarke et al, 1975

Manipulation Under Anaesthesia 80 Lee et al Gam et al de Jong et al Fareed et al Hill & Bogumill Placzek et al Ogilve-Harris e Ekelund et al Segmuller et al Pearsall et al

40

0 a An

lg

es

ics e Ex

s c s n n n n id ise io er te atio atio lea rc ero ns l ex di s re n St ids+ iste ds+ mbi nipu lar D roi a o su ro C M p e e St St Ca

Manipulation Under Anaesthesia

Capsular Release

7

*

Forward Flexion

160

M oderate

* M ild

*

*

140

*

*

120 100 80 60 40

N one -1 1

6

12

-10

24

6

12

24

W eeks after Surgery

W eeks after Surgery

Day 1 1 week

+ subscap release + early PT

T7 16

14

+

12 T12 10 L58

6 S54

+ subscap release + PT

80

+

70 External Rotation

Internal Rotation (Vertebral level above S1)

Severity of Night Pain

Severe

60 50

+

+

+

6

12

40 30 20 10

2

0 -1 0 1

6

Weeks after Capsular Release

12

-1 0 1

Weeks after Surgery

8

Need • Understand the pathogenes is

Need • Prevent • Rx early

Rotator cuff tear/Impingement

Function of the Rotator Cuff

Malfunction of the Rotator Cuff

Pain • With overhead activities

9

Pain • At night

r = 0.49

MRI Findings

*** 40

69% supraspinatus

35 30 25 Number of 20 swimmers

tendinosis

15 10 Tendinosis

5 0

No tendinosis Impingement No Impingement

r = 0.35, p = 0.01

Suprapsinatus tendinosis

Supraspinatus tendinosis

1.2 1.0

YES 0.8 0.6 0.4 No 0.2 0.0

5

10

15

20

25

Hours swum per week

30

35

r = 0.34, p = 0.01

1.2 1.0

YES 0.8 0.6 0.4

No 0.2 0.0

0

20

35

40

60

80

100

Kilometres swum per week

10

Apoptosis

Aetiology

• apo-, apart

• Overuse

• ptosis, falling

Programmed cell death

Soslowsky et al, 1999, 2000

Kerr 1972

Apoptosis Percentage of apoptotic cells (%)

40

***

30

20

10

0

RCN

RCT

Uninjured subscapularis

Torn supraspinatus

Negative Control

Age and Rotator Cuff Tears Subjects in Each Group, %

100

Protein Kinases

80

Stress 60

APOPTOSIS 40

20

0 0-19 20-29 30-39 40-49 50-59 60-69 70-79 Tendinopathy

Decade of Age RCTear No Tear

Tendon Degeneration

Tear

11

Subjects: 400 patients with shoulder disability sufficient to warrant arthroscopic examination

Which clinical tests are most predictive for a rotator cuff tear? PIC OF RCT

Lancet, 2001

Examination

Prior to arthroscopy, all patients were given a standard systematic examination of the shoulder

• 23 clinical tests

Arthroscoped

Results

Shoulder Arthroscopy SURGEON’S REPORT v 19 October, 1997

O O

St George Private Hospital St George Public Hospital

SURGEON: Murrell

ASSISTANT: Bryant/Szomor

ANAESTHETIST: Milross

INDICATION FOR OPERATION: ................................................................................... OPERATIONS PERFORMED:

(1)...............................................................................

SHOULDER:

(2)...............................................................................

O

Right

O

Left

ITEM NUMBERS

(3)............................................................................... (4)...............................................................................

FINAL DIAGNOSIS:

1+ O O O O

.................. ..................

2+ O O O O

Right Rotator Cuff

3+ O O O O

Left Rotator Cuff

CUFF Fair Good V.Gd Exc Tissue O O O O Mobility O O O O Repair O O O O O Arthrowand O Oratech O Video O Path Operative Time: ......... min (c) GAC Murrell

SURGEON’S REPORT

Examination Under Anaesthetic ROM Pre-op Post-op Forward Flexion .......... .......... Abduction .......... .......... Internal Rotation .......... .......... External Rotation .......... .......... INSTABILITY 0 Sulcus O Anterior O Posterior O Inferior O

..................

...................................................................................

Only 4 of the 23 clinical tests examined were statistically significant for the diagnosis of rotator cuff tear (at p<0.001)

POST OPERATIVE INSTRUCTIONS O Sling O Cryocuff O Abduction brace O Chalmers/Sullivan to see

Discharge O Today O Tomorrow O F/U: 9 days

Surgeon’s Signature ............................ Date: ....../...../97

12

Drop Arm Sign

1300 900

Drop Arm Sign • If +ve … have tear 100% positive predictive value

Drop Arm Sign • If –ve … can’t rule out a tear

? Sensitivity only 11%

Loss in Power in External Rotation

Loss in Power in Supraspinatus

13

Impingement in ER

or in IR

Summary

Summary

Drop Arm Sign

1300 900

• All positive 98% Rotator Cuff Tear 100% Rotator Cuff Tear

Summary

• 2 positive

> 60 years

98% Rotator Cuff Tear

Summary

• 1 positive Need further imaging

14

Summary Rotator Cuff Tear Size

X

• 0 positive

R/O rotator cuff tear

Size Full Thickness Tears

Size Partial Thickness Tears

R

R

• Clinical examination 0.4

• Clinical examination 0.2

• Ultrasound

0.7

• Ultrasound

0.2

• MRI

0.7

• MRI

0.2

• Arthroscopy

0.9

• Arthroscopy

0.2

• Surgery

• Surgery

1.0 Bryant et al, 2002

1.0 Bryant et al, 2002

Calcific tendonitis

15

Treatment - Impingement

Blair et al, 1996

Treatment

16

Arthroscopic Knotless

Arthroscopic Knotted

Open

N = 49 Mitek RC®

Arthroscopic

N = 53

knotted Mitek Fastin®

Arthroscopic

N = 57

knotless Opus®

Operation Time ***

Operation time (min)

6 months

3 months

6 weeks

2 weeks

Pre-op

100

**

90 80 70 60 50 40 30 20 10 0 Open

Knotted

Knotless

Procedure

Neal Millar

17

External Rotation

Pain with Overhead Activities Very severe

Open RCR Arthroscopic Knotted RCR

+c

Arthroscopic Knotless RCR

+++

80

Severe

+++

*

60

*** Moderate

***

***

***

***

***

External rotation

Pain above head

70

*** Mild

50 40 30 Open RCR 20

Arthroscopic Knotted RCR Arthroscopic Knotless RCR

10

None

0

Pre-op

6 weeks

3 months

Pre-op

6 months

100

*** *** *** ***

120%

Revision

100%

Intact

***

***

80% 60% 40%

***

20% 40

Open RCR Arthroscopic Knotted RCR Arthroscopic Knotless RCR

20 Pre-op

120%

6 weeks

6 months

3 months

**

0% Open

Knotted

Knotless

Procedure

Re-tear

100% Intact 80% Percentage

ASES SCORE

6 months

a,b

Percen tag e

+++ 80

***

3 months

Complications

ASES Score

60

6 w eeks

• Smaller tears • Shorter operative time

60%

(r=0.3, p<0.001)

40% 20%

• Tension band effect

0% Open

Knotted

Knotless

(r=-0.2, p<0.05)

Procedure

18

Summary

Rotator Cuff Tear

Summary O’Brien’s Sign = SLAP

Summary Apprehension sign

Summary

19

Acknowledgements • St George Hospital/South East Health

Contact Details: Prof Murrell Patients

Academic

• Maroubra Day Surgery

Level 2,

Ph 93502827

• NiCox Foundation

4-10 South St

• St George Private Hospital/ Health Care of Australia

• Arthritis Foundation of Australia • National Institutes of Health – USA

[email protected] www.ori.org.au

Kogarah, 2217

• Smith and Nephew Dyonics

Ph 93502088

• Johnson & Johnson

Fax 93502886

www.ori.org.au

20