MANAGING THE SPECTRUM OF ARTHRITIS IN AN ACTIVE POPULATION Felix - - PowerPoint PPT Presentation

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MANAGING THE SPECTRUM OF ARTHRITIS IN AN ACTIVE POPULATION Felix - - PowerPoint PPT Presentation

Aug 07, 2023 821 likes •1.26k views

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

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SLIDE 1

Tulane Orthopaedic Surgery

Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA

MANAGING THE SPECTRUM OF ARTHRITIS IN AN ACTIVE POPULATION

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SLIDE 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

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SLIDE 3

OSTEOARTHRITIS

  • Significant impairment of ADL

– Matsen, et al. – Sperling, et al.

Tulane Orthopaedic Surgery

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SLIDE 4

OA: TRADITIONAL MANAGEMENT

  • Live with it
  • meds, injections,

therapy

  • Replacement
  • partial, total,

reverse

Tulane Orthopaedic Surgery

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SLIDE 5

CURRENT OPTIONS

  • Live it:
  • PRP?; HA? Stem cells
  • Arthroscopic options
  • Replacement
  • resurfacing/short/regul

ar stem: what about activity level?

Tulane Orthopaedic Surgery

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SLIDE 6

ACCEPTED TREATMENT

  • Age > 60, sedentary

lifestyle gets TSA

  • Age > 70 with RCT :

RSP

  • What about the rest
  • f the population?

Tulane Orthopaedic Surgery

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SLIDE 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

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SLIDE 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

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SLIDE 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

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SLIDE 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

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SLIDE 11

REALISTIC OPTIONS: ACTIVITY MODIFICATION

  • Best in heavy lifters whom you can

convince to “go light”

  • Temporary fix for most patients

Tulane Orthopaedic Surgery

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SLIDE 12

REALISTIC OPTIONS: ARTHROSCOPY

  • Debridement and

microfracture

  • Capsular release
  • Remove spurs

– Acromion – A/C joint – Coracoid – Humeral “goats beard”

Tulane Orthopaedic Surgery

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SLIDE 13

REALISTIC OPTIONS: ARTHROSCOPY

Tulane Orthopaedic Surgery

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SLIDE 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 &
  • ften
  • Remember Aquatics

Tulane Orthopaedic Surgery

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SLIDE 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

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SLIDE 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

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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

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SLIDE 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

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SLIDE 19

OA: GLENOID RESURFACING

Tulane Orthopaedic Surgery

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SLIDE 20

GLENOID RESURFACING: POSTOPERATIVE

  • Abduction sling 4 weeks
  • Begin ROM (distract & stretch)
  • Advance rehab through phases as

tolerated

Tulane Orthopaedic Surgery

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SLIDE 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

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SLIDE 22

37 Y/O WELDER: CHONDROLYSIS POST SURGERY

  • 1st surgery was a

SLAP repair for

  • veruse syndrome
  • 2nd

surgery=debridem ent of repair

  • 3rd

surgery=resurfacin g

Tulane Orthopaedic Surgery

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SLIDE 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

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SLIDE 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

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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

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SLIDE 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

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SLIDE 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

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SLIDE 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

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SLIDE 29

SUBSCAPULARIS SPARING APPROACH

  • “Mini” open delto-pectoral approach
  • Split and only partially detach lower ½ to ⅓
  • f 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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SLIDE 30

Tulane Orthopaedic Surgery

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SLIDE 31

Tulane Orthopaedic Surgery

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SLIDE 32

Tulane Orthopaedic Surgery

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SLIDE 33

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

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SLIDE 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

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SLIDE 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

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SLIDE 37

8 Year Follow Up: Bench 325 Lbs. at Age 58

Tulane Orthopaedic Surgery

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SLIDE 38

ACTIVITY: A.A. SRA

  • Bench press champs in 2 states
  • 2 UFC fighters
  • 2 pro water skiers, 1 collegiate cheerleader

Tulane Orthopaedic Surgery

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SLIDE 39

TOTAL SHOULDER ARTHROPLASTY

  • Have started a

prospective series

  • f 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

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SLIDE 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

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SLIDE 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

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SLIDE 42

THANK YOU

Tulane Orthopaedic Surgery