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Shoulder Surgery AdvancesLennard Funk
IMPINGEMENT
What is it?
IMPINGEMENT
Neer’s Sign
Causes:• Cuff Dysfunction• Posture & Perfomance• Space Occupying Lesion• Cuff Tears• Calcific Tendonitis• Capsulitis• Instability
Classic Literature:
• Surgery = Rehab = Inject• Inject remote or bursa• Type of Physio not clear• 80% improvement with ASD• Better if good response to inject
Recent Literature:
• Defining causes• Excluding SOL• Dynamic vs Passive
Recent Literature:
• Defining causes• Excluding SOL• Dynamic vs Passive
Scapula Retraction Scapula Assistance
ULTRASOUND IMPINGEMENT
Calcific Deposit
Our data (2012-2014)
• 250 patients; 3 surgeons• SOL excluded on USS +/- MRI• All failed rehab
• 74% had SAI & Rehab• Review at 6wks
• 39% temporary relief• 56% complete relief• 4.8% no relief
• 22% -> ASD• 85% improvement at 3months
INSTABILITY
NOT ALWAYS A DISLOCATION
• Impingement in young• Think Posterior
• More common than you think
Causes:
• Micro-instability• Hypermobile• Repetitive Sports• Minor trauma• Rugby
Diagnosis
1. History2. Impingement3. WPIT4. Kim’s Test5. Kibler Clunk
MODIFIED O’BRIEN’S TEST (MOB)WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
Owen, Mackenzie, Boulter, Funk, 2014
Specificity Sensitivity Notes Reference
Posterior Drawer Test
No data
Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984
Posterior Apprehension
99% 20% Jia et al. JBJSA. 2009
Jerk Test 85% 90% posteroinf. labral tear
Kim et al. AJSM. 2004
Kim Test 95% 80% posteroinf. labral tear
Kim et al. CORR. 1993
MOB/WPIT 25% 83% Muscular Athletes
Owen et al. IJSS. 2014
Posterior Instability Tests
Semogas, Granville-Chapman & Funk, 2014
Glenoid Version
Large Bankart Lesion Bony Bankart Large Hill-Sachs Associated Lesions
Consider Bony Procedure Repair all coexisting lesions
Capsular Laxity Small Bankart Tear Small Hill-Sachs
Address capsular laxity
ROTATOR CUFF TEARS
Rotator Cuff
• Degenerative / Traumatic• Repair or not?
•Predictors• Better results with repair than ASD
NERVE DISORDERS
Presentation
• Young• Athletic • Manual Workers• Disabling
Aetiology
• Neuralgic Amyotrophy• Brachial Neuritis• Parsonage-Turner Syndrome• Viral Neuritis ?
Natural History
Overall recovery was less favourable than usually assumed, with persisting pain and paresis in approximately two-thirds of the patients who were followed for 3 years or more.
Traditional Surgery• Muscle Transfers• Joint Fusion
Neurolysis/ Transfers
• Less Invasive• Assess Nerve• Improved diagnosis• Faster Recovery
Suprascapular Nerve Palsy - Arthroscopic Decompression
Chronic Posterior Shoulder Pain in the Overhead Athlete
‣ Chronic Posterior Pain
‣ Normal EMG & MRI
‣ Exclusion
‣ High index of suspicion
Kevin Plancher
Spinioglenoid Ligament
Long Thoracic Nerve• Neurolysis
Summary:
‣ Spinoglenoid / Suprascapular Notch
‣Always get: EMG & MRI
‣ No cyst = Non-operative initially
‣ Cyst = Surgery
‣ Surgery - train on cadaver
IMAGING
INJECTIONS
Full Time / Part Time
THANK YOU
