Mark Ganjianpour, M.D.

Soft Tissue AnatomySoft Tissue– Rotator Cuff Tendon– Biceps tendon– Subscapularis– Rotator interval– Bursa– CA ligament– AC ligaments– Labrum/LigamentsPhysical Exam– Essential– Low sensitivity/specificity

Unusual FracturesFloating Shoulder– Disruption ofSuspensory Complex– ORIF ClavicleUnstable Os Acromiale– Pagnani J shoulder and Elbow Surg 2006

Overuse InjuriesImpingementSyndromeTendonitisMyofascial PainSyndromeAC JointInflammationConservative Treatmentfor 3-4 months– Activity Modification (Workrestrictions)– NSAID– Injections– Ergonomic Evaluation– Physical Therapy

Impingement SyndromePrimary– Rotator Cuff andSubacromial space– Age >40– Bone Spur– Respond to SADSecondary– Instability or other causes– Age

Referred Shoulder PainCervical SpineDisc– C3 & C4 nerverootsPancoast Tumor– Non-small Celltumor– Apex of the lung– Chest X-ray

Rotator Cuff AnatomyRotator Cable(Burkhart 1994)– Articular Extensionof coracohumeralligament– Crescent shapearound Codman’s“Critical Zone”HypoVascular– Articular < Bursal

Natural Historyk. Yamaguchi J shoulder Elbow Surgery 20015 year follow upPartial or full thickness rotator cuff tears51% symptomatic50% of patients showed progression ofRotator cuff tearNo patients showed decrease in size orhealing of rotator cuff tear without surgery

50%– Complete & Repair– PASTA RepairFoot Print approx16mmBursal Sided Tear

IndicationsACOEM (page 210-211)– Significant tear– Weakness of armelevation– Younger worker– Fail none operativetreatment for 3 months– Acute full thickness RCtears should be treatednon-operatively with up to86% successEvidence Based Medicine– Age– Symptoms– Size– Activity Level– Available Tissue– Ability to comply with postoperative care/rehab– Acute full thickness RC tearis an indication for surgery

Full Thickness RC TearGoutallier, D etal.; Shoulder and Elbow Surgery 2003Fatty Degeneration– Grades 0-5– Grade 2 and above havesignificant reoperation ratesMuscle AtrophyTendon Retraction/mobilityPreop Range of MotionForce Couple/Subscapintegrity

Tear Pattern

Repair TechniqueSeverud etal, Arthroscopy 2003Arthroscopic VsMini Open– ROM– Pain/Scar– Re-tear Rate (20-80%with both techniques)– Perceived PatientSatisfactionSingle Vs DoubleRow

SLAP TearsFour TypesType I degenerativeGreat variations in Bicepsanchor anatomyMechanism of Injury– Arm abducted/outstretched– Sudden downward motionon the arm (Eccentric)– Peel back mechanism

SLAP TearsKim etal, JBJS 2003SLAP Lesions without other associatedfindings is uncommonOften other lesions are responsible for thesymptomsRecent trends towards less operativetreatment and more rehabSignificant Stiffness and pain with repairof asymptomatic Biceps lesions

Choice of AnchorPark etal, Arthroscopy 2011PLL Anchors are associated with higherfailure of SLAP repairsReoperation rate up to 24%Be aware of using absorbable anchorsaround the glenoidRecommend non-absorbable anchors(PEEK, metal, all suture)

GH DislocationTraumaticFirst Time Vs RecurrentNatural History– 66% recurrence– Younger > OlderFactors to consider– Bankart vs humeral capsular avulsion– Hill Sacs lesion– Glenoid Bone loss– Activity Level/Occupation

Treatment of DislocationsClosed treatment withimmediate external rotationsling (not practical in WCSystem)Recurrent dislocationrequires operative treatment– Repair Bankart lesion– Posterior GH Ligamentbalancing stitches– Engaging Hill Sacs lesion– CT better than MRI toevaluate Glenoid

Glenoid Bone lossBurkhart etal, Arthroscopy 2000High failure rate withGlenoid Boneloss>25%Bone augmentation(Latarjet)

Engaging Hill Sacs LesionRemplissage

Results in WC vs None-WCPatientsHoltby etal, Impact of WC claims on RC relatedpathologies. J shoulder Elbow Surg. 2010.– Injured workers showed statistically significantimprovement 1 year following SAD or RC repairalthough with higher level of disability.Kemp etal, RC tear in WC patients, Occup Med(lond), 2011– Canadian Study concluded that WC patients benefitfrom treatment, but results are inferior

Results in WC vs None-WCPatientsHenn etal, Patients with workers’ compensation claimshave worse outcome after rotator cuff repair. JBJS Am,2008– HSS study concluded that “existence of a workers’compensation claim portends a less robust outcomefollowing rotator cuff repair”.Verma etal, Outcome arthroscopic repair of type IISLAP lesions in WC patients. HSS J. 2007.– WC patients do show improvement, but results areinferior

Results in WC vs None-WCPatientsPark etal, Am J Sports Med. 2011 (RevisionSLAP Repair)Balyk etal, Clin Orthop Relat Res. 2008 (Level IEvidence)Pedowitz, etal, Optimizing the management ofrotator cuff Problems, J Am Acad Orthop Surg.2011– Consenses statement “surgeons can advisepatients that workers’ compensationstatus Correlates with less Favorableoutcomes after rotator cuff surgery”.

ENOUGH is Enough!Patients perception of well being in WCsystemTreat objective findings based on evidencebased MedicineEncourage self responsibility for own wellbeingPatients with longer litigated workers compgenerally have worse outcome

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