case #1 - 258413772373414384.s3. · pdf filecase #2 pearls history and fatty ... pearls arm...

6/11/2015

1

MRI –Arthroscopy Correlations:Rotator Cuff

Disclosures

Biomet, Inc Consulting and Speaking

Case #1

6/11/2015

2

Case #1 45 y/o RHD male s/p fall

from ladder 3mos ago

Pain at night and with overhead motions in R shoulder

Failed PT

PE:

Full ROM

4/5 SS, 5/5 ER, NegBelly

Case #1

Case #1

6/11/2015

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Case #1

Case #1

Case #2

6/11/2015

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Case #2 48 y/o RHD female s/p

motorcycle accident 4 weeks ago

Dislocated R shoulder, reduced in ER

Pain and dysfunction

PE:

FF 110, large shrug

3/5 SS, 4/5 ER, NegBelly

Case #2

Case #2

6/11/2015

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Mobilize Tendon

Bursal -> Scapular Spine

Articular -> Capsule-Labral Junction

Carefule to avoid suprascapular nerve.

Case #2

Anchors placed at articular margin through percutaneous incision lateral to acromion

Case #2

Work away from where you

are retrieving sutures

Case #2

6/11/2015

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Case #2

Pearls

History and fatty infiltration dictate repairability

Adequate mobilization

Percutaneous portal for anchor

Use penetrator for far posterior

Use suturing device for superior

Work away from retrieving portal (ie, if retrieving through anterior portal, then pass anterior to posterior)

Alternate colors of sutures

Case #2

Case #2

6/11/2015

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Case #3

Case #3 58 RHD male s/p fall

down stairs 2 months ago.

Pain and dysfunction in R shoulder

PE:

FF 150, with shrug

4/5 SS, 5/5 ER, Pos Belly

Case #3

6/11/2015

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Case #3

Case #3

External Rotation, Forward Flexion allows

familiar view

Case #3

6/11/2015

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270 degree release of subscapularis

Superior – base of coracoid

Posterior –MGHL/capsule

Anterior –Conjoint to axillary nerve

Keep lateral interval

tissue intact

Case #3

Case #3

Anterosuperior Tears

6/11/2015

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Pearls

Arm Position

External rotation to pass

Internal rotation to tie

Forward flexion to see

Penetrator for far anterior

Maintain Integrity of the “Cuff ”

Case #3

Case #3

Case #4

6/11/2015

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Case #4 72 RHD male with R

shoulder pain, no trauma.

Good but temporary relief from cortisone

3 months of PT

Function OK

PE:

ROM 170/45/T12

4/5 SS, 4/5 ER, Pos Belly

Case #4

Case #4

6/11/2015

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Case #4

Summary

Fatty infiltration biggest indicator of ability to repair.

Head may be elevated on MRI with acute massive tears -> doesn’t mean you can’t repair it.

Have a methodical system for repair, maintain cuff.

If unable to repair, and function is adequate pre-op, then partial, margin convergence repair can be effective at pain relief.

Thank You

6/8/2015

1

IMAGING OF THE ROTATOR CUFF AND

BICEPS LABRUM COMPLEX

Gabrielle P. Konin, MD

Department of Imaging

Hospital for Special Surgery

Assistant Professor of Radiology

Weill Medical College of Cornell University

Financial Disclosures

I have nothing to disclose.

TENDINOPATHY

• Tendons are intact

• Increased signal on short TE

• Intermediate signal on long TE (not fluid signal)

• Alteration in tendon size or morphology

6/8/2015

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60 year-old man with anterior pain for 1 month. No trauma.

Intraosseous HADD can have an intense marrow edema pattern and may

be confused for tumor or greater tuberosity fracture.

HADD

IMPINGEMENT SYNDROMEAssessment of Secondary Signs

• Acromial morphology: anterior +/- lateral subacromial spur / slope of acromion

• CA ligament thickening

Tendinopathy Partial Tear

Lateral downsloping of the acromion. Tendinosis with bursal fraying

and intrasubstance fissuring at critical zone. Synovitis of the

subacromial space.

6/8/2015

3

IMPINGEMENT SYNDROMEAssessment of Secondary Signs

AC joint arthrosis Os acromiale

• Partial thickness

tendon discontinuity

• Increased signal

intensity on

moderate to long TE

sequences

• Bursal vs. articular

vs. intrasubstance

• Intrasubstance /

concealed tears -

invisible to scope

Partial Thickness Footprint Tear

Sept 2014

Nov 2014

31 year old pitcher with intrasubstance footprint tear

6/8/2015

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Sentinel cyst without evidence of tear indicates prior delaminating

intrasubstance tear. Interstitial fluid extension between layers of

rotator cuff. Typical location is posterior supraspinatus.

Sentinel ganglion cyst

Partial tear of the subscapularis tendon

FULL THICKNESS TEAR

Acute tear Failure with continuity

6/8/2015

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FULL THICKNESS RE-TEAR

CHRONIC ROTATOR CUFF TEAR

• Superior migration – AH interval (<7mm)

• Remodeling of acromion

• Assess tendon quality & degree of retraction for repair

• *Assess quality of muscle: predictor of outcome

• Assess articular cartilage

CUFF TEAR ARTHROPATHY

• Chronic rotator cuff tear

• Anterosuperior migration of humerus

• Acromial “acetabularization”

• Coracoacromial ligament stabilizes progressive superior migration

• Osteoarthrosis: apron osteophyte, loose bodies

• Assess glenoid

• Deltoid dehiscence

6/8/2015

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Classification of SLAP lesions(Snyder et al 1990)

• I : Labral and biceps fraying, intact anchor

• II : Labral fraying with stripping of both the labrum and biceps

• III : Bucket handle tear with displacement and intact biceps anchor

• IV: Same as III, but with detached biceps anchor

Stripping of the labrum and biceps – SLAP II

22 year-old NBA player with shoulder pain

Chronic stripping of the labrum and biceps anchor

6/8/2015

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44 year-old man with pain for 1-2 months

Stripping of the anterosuperior labrum with intact anchor and

displacement of the labrum into the joint

47 year-old tennis player.

Stripping of labrum & biceps anchor w tear extension into biceps

6/8/2015

8

29 year-old 4 days post diving accident.

Near complete detachment of the biceps anchor

Thank you

6/15/2015

1

MRI : “Biceps Chondromalacia?”

Neither I, Stephen J. O’Brien, MD, MBA, nor any family

member(s), author(s), have any relevant financial relationships to be discussed, directly or indirectly,

referred to or illustrated with or without recognition within the presentation.

Disclosure

The Role of MRI in Diagnosing

Biceps Chondromalacia Mary E Shorey BA

Samuel A Taylor MD

Joshua A Dines MD

Hollis Potter MD

Joe Nguyen MPH

Stephen J O'Brien MD MBA

6/15/2015

2

Nothing New Under The Sun.....Sisterman - "Biceps Footprint"

Castagna - "Chondral Imprints"

Kuhn et al - "Humeral Head Abrasions"

Appeared that BCM Lesions COULD

BE Seen on MRI, Especially COR PD .

Normal "Blush"

Two Types of BCM

6/15/2015

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Which is the Pain Generator?O'Brien et al- 280 Pts

70% of Pts with Biceps Labral Complex (BLC)

Pain had Multiple Sites Of Pain and Pathology

Which is the Pain Generator?O'Brien et al- 3 "Pack" 145 Pts prospective

"Groove"

"Junction"

"Deep Inside"

Materials and MethodsRetrospective Review- 3 Groups - All MRI's at HSS- Pts with OA EXCLUDED.

1)BLC Lesions With Visible BCM (34pts)

2)BLC Lesions Without Visible BCM (21pts)

3)Control Group Instability Surgery w/o BLC SXS (29pts)

Groups 1&2 Age Matched (Mean Age 42). Group 3 (Mean age 29)

Digital OR Pictures Only

Single Experienced Sports MRI radiologist (HP)- blinded of any clinical data or OR Photos

MRI CRITERIA

Major

1) Loss of ARTICULAR Cartilage where LHBT traverses

2) Subchondral Signal Change

3) Abnormal Signal in Proximal LHBT

Minor

4) Labral Tear

5) Scarring in Rotator Interval

6) Evidence of more global Adhesive Capsulitis

Statistical Analysis by Biostatistician

6/15/2015

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ResultsGroup 1

Cartilage Loss- 85%

Subchondral Signal Changes - 64%

Pathological Changes Proximal LHBT- 85%

Group 2

Cartilage Loss- 86%



Group 3

Cartilage Loss- 51%



ResultsWithin the Boundaries of this Analysis (younger) Cohort , Age was not a factor in the presence or absence of a BCM Lesion or the ability of the MRI to Diagnose It.

Diagnostic Statistics

6/15/2015

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Biceps Chondromalacia"Medial"

6/15/2015

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Thank you

1

Stephen F. Brockmeier, MDSports Medicine & Shoulder Surgery

Associate Professor, Orthopaedic SurgeryUniversity of Virginia

Team Physician, UVA Athletics

MRI / Arthroscopy Correlation: SHOULDER INSTABILITY

Cree M. Gaskin, MDVice-Chair, Radiology

Associate Professor, Radiology and Orthopaedic SurgeryUniversity of Virginia

Charlottesville, VA

Disclosure

SFB: Consultant: Biomet, MicroAire

Medical Education: Biomet, Arthrex

Royalties, Springer Publishing

Research Grant: Arthrex, Tornier, Biomet

Fellowship Support Grant: Arthrex, DepuyMitek, DJO

CMG: Consultant, Depuy Mitek

Royalties, Oxford University Press

Royalties, Thieme Medical Publishing

2

CASE #1

Case #1

19 yo collegiate football player

Injured making a tackle

Pain / Recurrent subluxation

Unable to continue to play

Exam:

• Pain / apprehension in ABER

• Positive Jobe relocation

• Rotator cuff exam WNL

• Positive active compression

3

MRI

Diagnosis?

4

Labral Tear (Bankart) &

Chondral Injury

NORMAL

Sag T2 Fat Sat

5

Axial

Sag T2 Fat Sat

Anterior-Inferior Labrum

• Generally occurs due to anterior instability

• SEMANTICS:

Bankart - “generic” term

Perthes

ALPSA

GLAD

Artwork of Salvador Beltran. From: Stoller DW. MRI, Arthroscopy, and Surgical Anatomy of the Joints. Lippincott Publishers.

6

Perthes Lesion

Axial T2 Fat Sat

Perthes Lesion

Axial T2 Fat Sat

7

ALPSA lesion

Anterior labroligamentous periosteal sleeve avulsion

Periosteum stripped, but not disrupted

Displaced when scars down to glenoid

Axial T1

ALPSA lesion

Axial T1

8

ALPSA lesion

Axial T1

ALPSA lesion

Axial T1

9

ALPSA lesion

Axial T1

ALPSA lesion

Coronal T1 FS

10

Coronal T2 FS

ALPSA lesion

Sag T2 Fat Sat

11

ALPSA lesion

Sag T2 Fat Sat

ALPSA lesion

12

GLAD Glenolabral Articular Disruption

Ant-inf chondraldefect + superficial labral tear

Often applied to other glenoid sites

Modified artwork of Salvador Beltran. From: Stoller DW. MRI, Arthroscopy, and Surgical

Anatomy of the Joints. Lippincott Publishers.

GLAD

13

Case #1: Arthroscopic Photos

Arthroscopic Anterior Stabilization

Beach chair vs. lateral

14



Low anterior portal

Mobilization

Stimulate healing response



Low anterior portal

Mobilization


Translate tissue medial and superiorly

15



Low anterior portal

Mobilization



3 anchors, minimum



Low anterior portal

Mobilization



3 anchors, minimum

Bumper??

16

CASE #2

Case #2

29 yo Ortho Resident

Former Kickboxer / MMA

Many years of recurrent shoulder dislocations (>10)

Now comes out with minimal trauma

No prior surgeries

On exam:

• Apprehension at 90 & 45 degrees

17

Plain Films

MRI

18

Diagnosis?

Evolving Algorithm…

Epidemiology Clinically relevant bone loss clearly underappreciated

Glenoid: 49 – 86% (recurrent instability) Humeral: 93 – 100% (recurrent instability) Combined: Almost always some combined deficiency

Presentation Mechanism (axial load) Acute vs. Chronic Easy to come out; Easy to reduce Instability mid-range Failed prior sx

29

Diagnostic Scope

30

Technique

• Beach chair position

• Articulated arm positioner

• Axillary incision

• No paralysis

• Postop regional block

• EUA

• Diagnostic Scope

Technique

• Subscap split (2/3rd’s down the tendinous portion)

• Arm in IR for the majority of the case

• 3/32nd pin for superior retraction

• Careful retraction medially

• No retraction inferiorly

31

Technique

Intra-op Fluoro

32

Technique

Postop Films

33

CASE #3

Case #3

27 yo male, outdoor enthusiast

Posterior shoulder pain

8 months duration

Injury bench pressing

Exam:

• Pain with “jerk” test

34

T2 Fat Sat

T1

Diagnosis?

35

Diagnosis = Posterior Labral Tear w/ Paralabral Cyst

Axial T2 FS Sag T2 FS Sag T2 FSAxial T1 FS

Companion case: Post. labral tear

36

Companion case

Axial T2 Fat Sat

Suprascapular nerve

37

Posterior Labral Tear w/ Paralabral Cyst

Cyst Decompression & Labral Repair

38

Axial T2 Fat Sat Axial T1

Companion Case: 30 yo laborer, 3 months severe posterior shoulder pain

Sagittal T2 fat sat

Sagittal T2 fat sat Sagittal T1

39

Cyst Decompression, Post. Labral Repair

Additional Companion Case: 19yo D1 Offensive Lineman, Prior Failed AS Posterior Stabilization

40

MRI

CT SCAN

41

CT SCAN

CT SCAN

42

Arthroscopic Findings

OPEN OC ALLOGRAFT

43

FRESH DISTAL TIBIA OC ALLOGRAFT

OPEN OC ALLOGRAFT

44

OPEN OC ALLOGRAFT

POSTERIOR DTA

45

Post-op Xrays (6 weeks)

THANK YOU

1

Seth Gamradt, MD

Director of Orthopaedic Athletic Medicine

Associate Professor

Orthopaedic Surgery and Sports Medicine

Keck School of Medicine of USC

University of Southern California

MRI—Arthroscopy Correlations

in the Throwing Shoulder

SUMMARY

• APPROACH TO SHOULDER

• PHASES OF THROWING

• PATHOPHYSIOLOGY

• MRI CORRELATIONS

• SLAP

• PARTIAL THICKNESS RC TEARS

• GIRD

• INSTABILITY

GENERAL APPROACH

TO SHOULDER PATIENT

• < 30 = INSTABILITY AND

LABRAL TEARS

• 30-50 IMPINGEMENT AND

TENDONITIS

• 60+ ROTATOR CUFF AND

ARTHRITIS

• THROWER

2

Phases of Throwing

• Stage I – Windup

• Stage II – Early cocking

• Stage III – Late cocking

– Shoulder ER increases from 45-170 (92N-m of Torque)

• Stage IV – Accleration

– Internal rotation (80 degrees) and adduction of the humerus

with rapid elbow extension

– Terminates with ball release

• Stage V - Follow-through

– Dissipation of excess kinetic energy—Eccentric cuff

contraction and posterior capsule absorbs 100 percent or

more body weight.

Wind-up

Wind-up 2

3

Cocking

Late Cocking

Late Cocking

Early Acceleration

4

Ball Release

Follow Through

Follow Through 2

5

WHY DOES THE SHOULDER

GET INJURED

• RAPID KINETIC CHAIN

– CORE----SHOULDER ELBOW----HAND

• 7000 DEG/SEC OF ROTATIONAL VELOCITY

OF THE SHOULER

• EX ROT OF UP TO 170 DEG

NORMAL ADAPTATIONS

ER IR

Arc is the same but shifted into ER

10°

17° INCREASE IN HUMERAL

RETROVERSION

ANTERIOR LAXITY

MAKE SURE YOUR TREATMENT

DOES NOT RUIN WHAT MAKES THIS

SHOULDER GOOD FOR PITCHING!

THROWING THEORIES--OLDER

• BENNETT—TRACTION ON POSTERIOR

GLENOID

• NEER—SUBACROMIAL IMPINGEMENT

• JOBE—ANTERIOR INSTABILITY

6

THROWING THEORIES

• GIRD—GLENOHUMERAL INTERNAL ROTATION DEFICIT

• INTERNAL IMPINGMENT—

– CUFF/LABBRUM CONTACT IN ABER

• SCAPULAR DYSKINESIS

• KINETIC CHAIN

– WEAKNESS IN LEG/TRUNK REQ 15%-40%

INCR IN SHOULDER ROTATIONAL VELOCITY

MRI-ARTHROSCOPY

CORRELATIONS

• REHAB SHOULD ALWAYS BE THE FIRST

OPTION

– EXCEPTION IS ACUTE TRAUMA

MRI-ARTHROSCOPY

CORRELATIONS

• THROWERS HAVE MRI ABNORMALITIES

– WITH OR WITHOUT SYMPTOMS

• LESNIAK ET AL AJSM 2013

• CONNOR ET AL AJSM 2003

• MINIACI AJSM 2002

• MULTIPLE STUDIES SHOW LABRUM AND

CUFF ABNORMALITIES IN ASYMPTOMATIC

PITCHERS

• OPERATE ON THE PATIENT NOT THE MRI.

7

CASE 1: SLAP

20M

CASE 1: SLAP

20M

CASE 2: GIRD—SLAP--PTRCT

25M

8


25M


25M

CASE 3: PTRCT--REPAIR

20M

9

CASE 3: PTRCT--REPAIR

20M

CASE 4: INSTABILITY

22M

CASE 4: INSTABILITY

22M

10

SUMMARY

• LATE COCKING EARLY ACCELERATION

STRESSES SHOULDER AND ELBOW

• MULTIPLE PATHOPHYSIOLOGIC

THEORIES

• GIRD/INTERNAL IMPINGEMENT

• PTRCT/SLAP

• SCAPULA/KINETIC CHAIN

• MRI ABNORMALITIES COMMON

• REHAB FIRST

• IF SURGERY DON’T TIGHTEN

case #1 - 258413772373414384.s3. · pdf filecase #2 pearls history and fatty ... pearls arm...

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