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Shoulder Case PresentationsOrthopedic & Sports Medicine Update 2020
Lucas Korcek, MD
Disclosure• I have nothing to disclose.
CASE 1: PASTA injury
PASTA• Partial Articular Supraspinatus
Tendon Avulsion
• Incomplete (partial thickness) rotator cuff tear involving the articular side of the tendon
Presentation• 36F I first evaluated via video conference
technology (VCT) after shoulder injury on a roller coaster last summer
Presentation• 36F I first evaluated via video conference
technology (VCT) after shoulder injury on a roller coaster last summer
• Describes pain in the anterolateral shoulder exacerbated with overhead motion
Presentation• 36F I first evaluated via video conference
technology (VCT) after shoulder injury on a roller coaster last summer
• Describes pain in the anterolateral shoulder exacerbated with overhead motion
• Treatments to date: PT, chiropractor, NSAID
Outside MRI: Rotator cuff tendonosis, mild bursitis
Imaging
Initial Assessment• Subacromial impingement
• Offered reassurance• 6 week course of PT for scapular
stabilization• Follow up in person for exam
Follow up• Not improving/getting worse over several
months/repeated follow ups, physical exam concerning for rotator cuff injury
• Next Step?
Follow up• Not improving/getting worse over several
months/repeated follow ups, physical exam concerning for rotator cuff injury
• New MRI ordered
New Imaging • Partial-thickness articular-sided
rotator cuff tear (PASTA)
New Imaging • Partial-thickness articular-sided
rotator cuff tear (PASTA)
• What now?
Plan: arthroscopy for rotator cuff repair• Indication: partial thickness rotator cuff tear failing conservative
management with worsening serial physical exams and worsening appearance on repeat MRI
Arthroscopic findings: Healthy joint space
Arthroscopic findings:
Arthroscopic findings: Articular-side RC tear
Arthroscopic findings: Intact bursal side RC
Foot print preparation:
Anchor placement:
Sutures passed through RC:
PASTA repaired:
Impingement and Rotator Cuff
Disease Continuum
Impingement and bursitis
Impingement and Rotator CuffDisease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Impingement and Rotator CuffDisease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Massive RC tear
Impingement and Rotator CuffDisease Continuum
Impingement and bursitis
Partial to full-thickness RC tear
Massive RC tear
RC tear arthropathy
Case #2Failed rotator cuff repair
Case 2: Failed rotator cuff repair • Presentation: 65M w/ worsening shoulder pain and weakness
over 6 months w/o known injury
• Failing conservative management (PT, NSAID, activity modification)
Relevant exam findings• Limited active and full passive ROM w/ RC weakness• + Drop sign
Imaging• X-ray:
• Very mild degenerative changes• Humeral head well centered on
glenoid
Imaging• Massive, retracted RC tear
(suprispinatus/infraspinatus)
• Minimal RC muscle atrophy
Options?A: Continue non-op
B: Rotator cuff repair
C: Allograft superior capsule reconstruction (SCR)
D: Reverse total shoulder arthroplasty
Options?A: Continue non-op
B: Rotator cuff repair
C: Allograft superior capsule reconstruction (SCR)
D: Reverse total shoulder arthroplasty
E: Shared decision making with the patient with an involved discussion about his injury and treatment options and associated risks/benefits. Risk factors for failure of repair if attempted (age, non-traumatic tear, retraction) and possible need for revision surgery if repair fails.
Arthroscopic findings: moderate arthritis
Arthroscopic findings: torn/retracted RC
Mobilizing RC for repair
Anchors placed and passing sutures:
RC repaired:
Post op• Did very well for first three months
• Involved in physical altercation return of shoulder symptoms
• Follow up exam concerning for reinjury
• MRI ordered
MRI after injury• RC Re-tear/failure of repair
Options?• A: non-op
• B: revision repair
• C: allograft superior capsule reconstruction
• D: Reverse total shoulder arthroplasty
Options?• A: non-op
• B: revision repair
• C: allograft superior capsule reconstruction
• D: Reverse total shoulder arthroplasty
Reverse total shoulder arthroplastyConsiderations: • Rotator cuff deficiency + arthritis• Massive, retracted tear w/ failed
previous repair attempt• Age ≥ 65 years
Reverse total shoulder arthroplastyPost-op: - Rehabilitated well
- Very satisfied with outcome
- Appreciative of initial attempt at repair (pre-op discussion very important)
Thank you!Questions?