managing the spectrum of arthritis in an active population


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

  1. 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

  2. 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

  3. OSTEOARTHRITIS • Significant impairment of ADL – Matsen, et al. – Sperling, et al. Tulane Orthopaedic Surgery

  4. OA: TRADITIONAL MANAGEMENT • Live with it - meds, injections, therapy • Replacement - partial, total, reverse Tulane Orthopaedic Surgery

  5. CURRENT OPTIONS • Live it: - PRP?; HA? Stem cells • Arthroscopic options • Replacement - resurfacing/short/regul ar stem: what about activity level? Tulane Orthopaedic Surgery

  6. ACCEPTED TREATMENT • Age > 60, sedentary lifestyle gets TSA • Age > 70 with RCT : RSP • What about the rest of the population? Tulane Orthopaedic Surgery

  7. 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

  8. 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

  9. “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

  10. REALISTIC OPTIONS: LIVE WITH IT • Supplements: glucosamine, Vit C, Lanny’s Acanthin’s • Oral NSAIDs • Injections : cortisone • PRP, ADSC, BMAC’s Tulane Orthopaedic Surgery

  11. REALISTIC OPTIONS: ACTIVITY MODIFICATION • Best in heavy lifters whom you can convince to “go light” • Temporary fix for most patients Tulane Orthopaedic Surgery

  12. REALISTIC OPTIONS: ARTHROSCOPY • Debridement and microfracture • Capsular release • Remove spurs – Acromion – A/C joint – Coracoid – Humeral “goats beard” Tulane Orthopaedic Surgery

  13. REALISTIC OPTIONS: ARTHROSCOPY Tulane Orthopaedic Surgery

  14. 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

  15. REALISTIC OPTIONS: RESURFACING • Glenoid - Patches/fascia: flat smooth surface - Lateral meniscus (stress concentrator) • Humeral - SRA vs HHR • Fresh Allografts (Gobezie technique) Tulane Orthopaedic Surgery

  16. 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

  17. 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

  18. OSTEOARTHRITIS: ARTHROSCOPIC GLENOID RESURFACING • Debride and release • Microfracture & decompress • Measure glenoid to size graft • Finish debridement & removal of previous surgical materials Tulane Orthopaedic Surgery

  19. OA: GLENOID RESURFACING Tulane Orthopaedic Surgery

  20. GLENOID RESURFACING: POSTOPERATIVE • Abduction sling 4 weeks • Begin ROM (distract & stretch) • Advance rehab through phases as tolerated Tulane Orthopaedic Surgery

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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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  34. 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

  35. 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

  36. 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

  37. 8 Year Follow Up: Bench 325 Lbs. at Age 58 Tulane Orthopaedic Surgery

  38. ACTIVITY: A.A. SRA • Bench press champs in 2 states • 2 UFC fighters • 2 pro water skiers, 1 collegiate cheerleader Tulane Orthopaedic Surgery

  39. 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

  40. 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

  41. 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

  42. THANK YOU Tulane Orthopaedic Surgery

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