MANAGING THE SPECTRUM OF ARTHRITIS IN AN ACTIVE POPULATION Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA Tulane Orthopaedic Surgery
COI DISCLOSURES • Royalties: none • Stock/options: none • Consultant: DePuy Mitek; Smith & Nephew; Exactech; Rotation Medical • Institutional Research/Education support: DePuy Mitek; Smith & Nephew Tulane Orthopaedic Surgery
OSTEOARTHRITIS • Significant impairment of ADL – Matsen, et al. – Sperling, et al. Tulane Orthopaedic Surgery
OA: TRADITIONAL MANAGEMENT • Live with it - meds, injections, therapy • Replacement - partial, total, reverse Tulane Orthopaedic Surgery
CURRENT OPTIONS • Live it: - PRP?; HA? Stem cells • Arthroscopic options • Replacement - resurfacing/short/regul ar stem: what about activity level? Tulane Orthopaedic Surgery
ACCEPTED TREATMENT • Age > 60, sedentary lifestyle gets TSA • Age > 70 with RCT : RSP • What about the rest of the population? Tulane Orthopaedic Surgery
OA: SURGERY < 60 • Arthroscopic debridement: mixed results • Replacement: – Rockwood: hemi-arthroplasty – Matsen: Ream and run – TSA is Procedure of choice in “older” patients but unsatisfactory in young patients (Sperling)-is this related to the etiology or the subscapularis? – Usually not compatible with active population (? early glenoid loosening) Tulane Orthopaedic Surgery
WHY DO “YOUNGER” PATIENTS DO WORSE? 1. Not a fair comparison: Etiology different: post traumatic or post surgical 2. Anatomical status of the shoulder is more impaired 3. Activity demands by the patient are different: More longevity is required Tulane Orthopaedic Surgery
“YOUNGER” SOLUTIONS • Think outside the box a little • Try to preserve normal anatomy and reconstruct the abnormal parts • Think long term and utilize “time buying “ philosophy for solutions-means a lot of patient communication: essentially the only lifetime solution would be arthrodesis Tulane Orthopaedic Surgery
REALISTIC OPTIONS: LIVE WITH IT • Supplements: glucosamine, Vit C, Lanny’s Acanthin’s • Oral NSAIDs • Injections : cortisone • PRP, ADSC, BMAC’s Tulane Orthopaedic Surgery
REALISTIC OPTIONS: ACTIVITY MODIFICATION • Best in heavy lifters whom you can convince to “go light” • Temporary fix for most patients Tulane Orthopaedic Surgery
REALISTIC OPTIONS: ARTHROSCOPY • Debridement and microfracture • Capsular release • Remove spurs – Acromion – A/C joint – Coracoid – Humeral “goats beard” Tulane Orthopaedic Surgery
REALISTIC OPTIONS: ARTHROSCOPY Tulane Orthopaedic Surgery
REALISTIC OPTIONS: ARTHROSCOPY • Post op course: start ROM ASAP • Remind the therapist to distract the joint for mobs (they usually load it to mobilize) • Modalities early & often • Remember Aquatics Tulane Orthopaedic Surgery
REALISTIC OPTIONS: RESURFACING • Glenoid - Patches/fascia: flat smooth surface - Lateral meniscus (stress concentrator) • Humeral - SRA vs HHR • Fresh Allografts (Gobezie technique) Tulane Orthopaedic Surgery
OFF LABEL USE • The use of commercial patches to resurface the glenoid is off label: they are not currently indicated for this purpose. Tulane Orthopaedic Surgery
RESURFACING • A “buying time” and activity option • Pain relief neither as good nor as durable as TSA • Activity level can be normal (different than TSA) Tulane Orthopaedic Surgery
OSTEOARTHRITIS: ARTHROSCOPIC GLENOID RESURFACING • Debride and release • Microfracture & decompress • Measure glenoid to size graft • Finish debridement & removal of previous surgical materials Tulane Orthopaedic Surgery
OA: GLENOID RESURFACING Tulane Orthopaedic Surgery
GLENOID RESURFACING: POSTOPERATIVE • Abduction sling 4 weeks • Begin ROM (distract & stretch) • Advance rehab through phases as tolerated Tulane Orthopaedic Surgery
RESULTS: Arthroscopy 2009 (Savoie et al) • 19 / 20 initially satisfied @ 2 years • 15 / 20 satisfied @ 6 years – 5 failures • 2 = pain • 3 = ROM Tulane Orthopaedic Surgery
37 Y/O WELDER: CHONDROLYSIS POST SURGERY • 1 st surgery was a SLAP repair for overuse syndrome • 2 nd surgery=debridem ent of repair • 3 rd surgery=resurfacin g Tulane Orthopaedic Surgery
GLENOID RESURFACING • Activity levels: 2 collegiate football players, 1 softball player, 1 pro water skier. Lots of golfers! • Several power lifters • Jobs: RN, manual laborers Tulane Orthopaedic Surgery
WHAT TO DO WITH THE NON- CONCENTRIC HH • Not a candidate for glenoid resurfacing • Same issues with TSA and high level activity so have to preserve joint to buy time • Try to preserve the subscapularis Tulane Orthopaedic Surgery
HUMERAL HEAD RESURFACING • Arthroscopically assisted, subscapularis- sparing approach – Is this important? • Minimally invasive, rapid rehabilitation • Use when humeral head incongruent: judge on axillary view Tulane Orthopaedic Surgery
SUBSCAPULARIS INSUFFICIENCY • Miller (Flatow) et al :2003 JSES : 66% of post TSA patients had subscap problems and 91% had significant side to side difference • Scheibel et al (Habermier) AJSM in 2006 and 2007: 70% of primary open stabilizations and 91% of revision stabilizations in YOUNG had subscapularis dysfunction and atrophy (MRI) Tulane Orthopaedic Surgery
SUBSCAPULARIS REPAIR MODIFICATIONS • Caplan(Nevaiser): do a better tenotomy repair JSES 2009 • Qureshi (Flatow): do an osteotomy JSES 2008 • Krishnan: Do a novel and better repair: JSES • Defranco (Higgins and Warner) : Lots of techniques –review article JAAOS 20 Tulane Orthopaedic Surgery
SUBSCAPULARIS INSUFFICIENCY: IS IT REAL? • Jackson, Cil, Smith and Steinman: JSES 2010: US evaluation of 15 satisfied TSA patients found that 7 had complete tears of the subscapularis • Remember the old study by Hawk that showed 50% of patients after open subscap takedown had subscapularis dysfunction Tulane Orthopaedic Surgery
SUBSCAPULARIS SPARING APPROACH • “Mini” open delto-pectoral approach • Split and only partially detach lower ½ to ⅓ of subscapularis via lower raphe • Debride head / remove spurs • SRA to match patients on version and alignment • Standard TSA if glenoid deformity not too severe Tulane Orthopaedic Surgery
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POST OP COURSE • Sling x 2 weeks with PROM • Active ER & ext at 2 wks; add IR & flexion at 3 wks • PT progression at 4 weeks • No restriction on post op activities Tulane Orthopaedic Surgery
RESULTS: SUBSCAPULARIS ASSESSMENT • 50 patient series reviewed: 48 / 50 Good/Excellent Results @ 2-5 years (ASES) 2 Fair, 0 poor ( accepted JSES) • No subscap detachments or atrophy via post op MRI/US in 30 pts • All 50 pts had negative belly press, lift off and bear hug on clinical exam Tulane Orthopaedic Surgery
RESULTS: DURABILITY • 120 patient series reviewed at minimum 6 year follow up • Only 3 converted to TSA • 115 of the 120 would do it again • However, only 42% were pain free; most were taking NSAID and some narcotics but most were continuing normal activity Tulane Orthopaedic Surgery
8 Year Follow Up: Bench 325 Lbs. at Age 58 Tulane Orthopaedic Surgery
ACTIVITY: A.A. SRA • Bench press champs in 2 states • 2 UFC fighters • 2 pro water skiers, 1 collegiate cheerleader Tulane Orthopaedic Surgery
TOTAL SHOULDER ARTHROPLASTY • Have started a prospective series of TSA with subscap preserving approach • Seems to be higher satisfaction early but need to wait and see-won’t be publishing for awhile Tulane Orthopaedic Surgery
REVERSE SHOULDER ARTROPLASTY • Miracle result for 70+ year old with pseudoparalysis • Incidence and indications going up exponentially with little follow up • Complications and failure rate are much higher in “young” pts in best of hands • Salvage is problematic Tulane Orthopaedic Surgery
CONCLUSIONS • “Younger” patients with arthritis are becoming more common and demanding better results • Bone and soft tissue (subscap) preservation may be the key to satisfaction • Try to think long term and in stages to buy time and activity without jumping to irreversible options Tulane Orthopaedic Surgery
THANK YOU Tulane Orthopaedic Surgery
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