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?