SLAP Tear

SLAP Tear (Superior Labral tear from anterior to Posterior) tear.

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

For Appointments and Queries
Contact 9566222533/nexusortho@yahoo.com

What is SLAP Tear ?

The biceps tendon is attached to the superior aspect of the socket of the shoulder by means of a fibrocartilagenous extension. SLAP tear (Superior Labral tear from anterior to Posterior) represents a damage to this area. There are different types of SLAP tears, varying in different grades of severity (7 grades). The tears range from degeneration/fraying to extension to the rest of the glenoid labrum (fibrocartilagenous rim structure of the socket).

Arthroscopic view of SLAP tear

Which group of patients commonly get SLAP tear?

Although any patient can sustain a SLAP tear, sports persons involved especially in  overhead activities frequently develop this lesion. Eg : volleyball players.

What symptoms do you get if you have a SLAP tear?

                        Dull throbbing ache over the shoulder

                        Pain /clicking on certain movement of shoulder(especially with arm across the                     body)

                        Difficulty in carrying on with overhead sporting activities.

                        Pain disturbing the sleep

What are the treatment options?

Most patients require surgical intervention to return back to sports. Although physiotherapy and conditioning excercises play a key role, they are usually supplementary to the surgery.

When is surgery indicated?

When the symptoms are worse to stop activities, confirmation of the diagnosis is done by clinical examination and imaging (MRI arthrogram). When SLAP tear is confirmed on investigation, initial treatment is by analgesics and physiotherapy. When conservative measures fail to improve symptoms, surgery is indicated.

MR Arthrogram showing SLAP tear

What is involved in the surgery?

Surgery is done by arthroscopic method (key hole). The advantage of having key hole surgery is recovery is quicker, better access to the problem area than open surgery and minimal scarring.

The biceps anchor which is detached from the superior aspect of the glenoid (socket) is reattached by suture anchors. 

Arthroscopic SLAP repair being carried out.

Arthroscopic view of final repair using Knotless anchors.

What is the rehab protocol followed?

For the first 4 weeks, arm is rested in a sling allowing only pendulum movements only. This period is for allowing the tissues to heal back on to the bone. After 4 weeks a Specialist shoulder physiotherapist will start muscle strengthening excercises aiming to regain full range of movement.

When can patients resume driving?

Usually by 4-6 weeks

When can patients return to sports after surgery?

It will take 5-6 months before Overhead sporting activities can be resumed at competitive level. 

Calcific Tendinitis of Shoulder

Calcific Tendinitis of Shoulder

Dr.Senthilvelan
Consultant Orthopaedic Surgeon
For Appointments/Queries
Contact 9566222533/nexusortho@yahoo.com



What is calcific tendinitis of the shoulder?

Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimetre size, calcium deposit within the tendons of the rotator cuff. The supraspinatus tendon is most frequently affected. These calcium deposits are usually found in patients at least 30-40 years old, and are more common in diabetics. It accounts for approximately 10% of all consultations for painful shoulder.


What Causes Calcific Tendinitis?

The cause of calcium deposits within the rotator cuff tendon is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.




X rays Showing Calcific Deposit



What do patients complain of ?

Some people may have the calcific deposit incidentally recognised on X-rays.
Some patients have chronic pain in the affected shoulder or radiating downward the upper arm. Especially night pain occurs often. A few people experience sudden an extreme pain in the shoulder, when a calcium deposit is resorbed.

What are the Stages of Calcific Tendinitis?

 Pre calcification Stage

Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.

Calcific Stage

During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky; it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins; this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins--this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste.

 Post calcific Stage

This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.



Do all calcium deposits cause problems?
Many calcium deposits are present for years without causing pain. Only when they are large enough to be pinched between the bones when the shoulder is elevated do they cause pain. Smaller deposits may cause pain if they become inflamed, especially when the calcium salts leak from the deposit into the sensitive bursal tissues of the joint lining.


Will calcium deposit damage the shoulder?


Some calcium deposits can cause erosion by destroying a portion of the rotator cuff tendon. However most calcium deposits remain on the outside of the rotator cuff tendon the bursa (the structures that hold the joint fluid) and only cause problems because of the pain caused when they catch during shoulder movement.


Therapy of calcium deposits at the shoulder:

After failed nonoperative treatment calcium deposits can be removed, arthroscopically. If non-operative treatment, like pain medication, injections, acupuncture and so on failed and pain is still the main problem for the patient, the deposits can be removed by an arthroscopic procedure.

Calcium deposits are tracked with a needle during the operative, endoscopic, procedure. If they are found a small cloud of calcium appears and they are removed using surgical instruments like spoons and shavers.



What is involved in arthroscopic surgery to remove calcium deposits?


The procedure is done as outpatient surgery under general anaesthesia. The operation is painless, and only a mild aching sensation is felt for a few days after the operation while the skin puncture sites heal. If the calcium has eroded in a hole in the rotator cuff, then it is necessary to remove a portion of the overhanging bone which will cause a little more discomfort for a few days.

Needling of calcific deposit before arthroscopy

What happens after the removal of a calcium deposit?

The operated arm and shoulder can be used actively, as far as residual pain allows it. A sling or splint is not used. Depending on the kind of work, the patient can return to it after 1 to 6 weeks. (1 week for example for office work or 6 weeks for heavy work ).


What will happen in the future to the operated shoulder / calcium deposit?

Once the calcium clot is removed it won´t come again. There is a higher statistical chance that it might occur on the other shoulder (estimated on 10 to 20%), in the future.


References

1. Uhthoff HK. Anatomopathology of calcifying tendinitis of the cuff. In: Gazielly DF, Gleyze PTT, editors. The cuff. Paris: Elsevier; 1997. p. 144–6.

2. Rotini R, Bungaro P, Antonioli D, Katusic D, Marinelli A. Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience. Chir Organi Mov 2005;90(2):105–12.

3. Costouros JG, Bassi O, Gerber C. Arthroscopic management of calcific tendonitis of the shoulder. Presented at the American academy of orthopaedic surgeons annual meeting,2006. p. 695.

Bone disease in Multiple Myeloma

Bone disease in Multiple Myeloma

Dr.Srinivasan Narayanan

Consultant Haematologist

For appointments /Queries
Contact 956622253/ nexusortho@yahoo.com

What is Multiple Myeloma?

Myeloma is a type of cancer, usually arising in the bone marrow plasma cells producing abnormal proteins. It can affect the bones in up to 80% of the patients with this condition, causing bone pain and weak bones that can lead to fractures. The backbone, ribs, hips, long bones on the arms and legs are the commonly affected areas in this condition.

What are the symptoms and signs?

The most common symptoms of myeloma are unusual tiredness due to anaemia, recurrent infections, high calcium levels, kidney damage, bone pain and fracture of the bone.

Why Myeloma affects the bone?

Cancerous plasma cells produce abnormal substances, which lead to bone destruction by releasing the bone strengthening minerals and preventing new bone formation. This can eventually cause a “Pathological” fracture.

What is a pathological fracture?

Some diseases such as Myeloma, other cancers, infections can weaken the bones, which lead to a fracture of the bone spontaneously or with trivial injury only.

How to diagnose Mutliple Myeloma?

If Multiple myeloma is suspected, blood test to check full blood count, renal functions, calcium and immunoglobulins (abnormal proteins in blood and urine) will be helpful to determine if this is a possibility.

If any of these tests are abnormal, bone marrow biopsy and X-rays (sometimes MRI scans) are done to look for abnormal plasma cells in the marrow and bone diseases respectively, to confirm the diagnosis.

What are the treatment options for Myeloma bone disease?

Chemo/radiotherapy: If bones are affected with myeloma, it suggest active disease requiring treatment with chemotherapy, and this will help to reduce further bone damage. Low dose radiotherapy to the most affected bone is given, which helps to reduce pain.

Bisphosphonates: Bone strengthening medications called ‘Bisphosphonates’ are routinely used to reduce bone pain, prevent further breakdown of the bone and reduces the risk of bone fractures.

Surgery: Long bone fractures or bones ‘at risk’ of fracture should be fixed with surgery and the type of surgery required will depend on the type of fracture, proximity to the joints and the extent of bone disease.

Vertebral fracture causes loss of height and can compromise mobility. Minimally invasive procedures such as “Vertebroplasty” or “Kyphoplasty” are used to regain the lost height, reduce bone pain and maintain the normal bone alignment.

How is Vertebroplasty done:

Vertebroplasty is done under radiological guidance by spinal surgeons. A type of bone cement is injected into the spine to strengthen and stabilise the bone. This helps to reduce bone pain and improve mobility.

How is Kyphoplasty done:

Kyphoplasty is similar to Vertebroplasty, but involves inserting and inflating a balloon in the vertebral bone and then the bone cement is injected.  This also helps to regain the height and the shape of the collapsed vertebrae.

Tunnel placement in Anatomical ACL reconstruction

Tunnel placement in Anatomical ACL reconstruction: (using 4 strand Hamsting tendons)

By Dr. Ravi Kirubanandan,

Consultant Orthopaedic Surgeon

For Appointments and queries contact  09629240084/ nexusortho@yahoo.com

The position of femoral tunnel placement have changed many times in the past decade. Accurate placement of the tunnels appears difficult to achieve. Studies have shown that in more than 50% of patients the tunnels have been poorly placed. The aim of this article is suggest, a reproducible tunnel placement using standard intra-operative landmarks for the use of 4-strand ACL reconstructions. The radiological understanding of the tunnel positions as explained.

Native ACL location:

Centre of the origin as seen on lateral radiographs was located on the femur at a mean of 66% from the anterior edge of Blumensaat’s line (inter- condylar root line). The tibial attachment was located at the junction of the anterior and middle thirds of the tibial plateau.

Knee Arthroscopy - Intra-articular landmarks:

Femoral tunnel:

Identification of the ridge between the AM & PL bundle is the key. The recommended entry point is just posterior to the ridge. But this is difficult to reproduce between surgeons and every other surgery. The new method is using a ruler to measure the AP length of the femoral condyle (visulalisation is done via a 3^rdportal). The mean mid point between the bony margin excluding the articular surface is identified and entry point made with an awl. The height of the entry point from the inferior articular surface is 2mm + ½ of the graft width.

 Tibial tunnel:

The lateral tibial spine and anterior horn of lateral meniscus identifier. 5 mm medial to this juncture of Lateral tibial spine and ant. Horn of lateral meniscus is the marker for the tip aimer jig. The other method is to identify the remenant of ACL stump as a landmark.

Anterior placement of tibial tunnel = Impingement in extension + Cyclops lesion formation

Radiological understanding of Tunnels:

Femoral tunnel:

Lateral view: The position of the femoral tunnel was assessed on the lateral radiographs (Fig. 1). The length of Blumensaat’s line was measured and the points of intersection between it and the anterior and posterior borders of the femoral tunnel were identified. Based on these measurements, the position of the centre of the femoral tunnel was calculated and then expressed as a percentage of the total length of Blumensaat’s line.

AP view: Angle of inclination of the femoral tunnel can be measured in the AP view. Vertical placement of the tunnel leads to increased rotational instability and degenerative radiological changes. This issue was primarily related to the trans-tibial placement of femoral technique.

By placing the tunnel using the anatomical method based on intra-articular landmarks, clearly avoids the placement vertically.

Vertical Femoral tunnel placement = rotational instability and early OA changes

Tibial Tunnel:

Lateral view: Placement of the tibial tunnel was assessed on the lateral radiographs (Fig. 1) as follows: the length of the tibial plateau was determined and the positions of the anterior and posterior borders of the tibial tunnel were identified relative to the anterior edge of the plateau. This allowed the position of the centre of the tunnel to be calculated and then expressed as a proportion of the total length of the tibial plateau.

AP view: Placement of the tibial tunnel was assessed on AP radiographs (Fig. 2) by measuring the total width of the tibial plateau. The distances from the medial edge of the medial tibial plateau to both the medial and lateral borders of the tibial tunnel were measured.

Posterior Tibial tunnel placement = early graft rupture

So what is the ideal radiological positioning of the tunnels ?

Femoral Tunnel : Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel with a mean of 86%  along Blumensaat’s line

Tibial tunnel : with 48% along the tibial plateau.

Recommended radiological position of the tunnels in a) the coronal and b) the sagittal views after reconstruction of the anterior cruciate ligament.

Ref:

1. Pinczewski L, Tashiro S et al; Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament.  J Bone Joint Surg [Br] 2008;90-B:172-9.

2. Pictures – drawn by Author, Dr. Ravi Kirubanandan.

Cuff Tear Arthropathy

Cuff Tear Arthropathy

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

For queries Contact 9566222533/nexusortho@yahoo.com

The rotator cuff muscles are:

1. Supraspinatus 2. Infraspinatus 3. Teres Minor 4. Subscapularis

 The tendons of these muscle coalesce to form the rotator cuff. The muscles are inseparable at this level, except for subscapularis which is separate and joined to the rest of the cuff via the rotator interval.

Supraspinatus

Supraspinatus is not only an initiator of abduction, but acts throughout the range of abduction of the shoulder. It has equal abduction power as deltoid. Note that it lies in the scapular plane – i.e. 30 degrees to the coronal plane

Infraspinatus & Teres Minor

These two muscles lies below the scapular spine and are external rotators of the shoulder. Infraspinatus primarily acts with the arm in neutral and Teres Minor is more active with external rotation in 90 degrees of abduction.

Deltoid

The deltoid muscle is the only shoulder elevator if the supraspinatus is torn and dysfunctional. Therefore most rehabilitation is directed towards this muscle. It comprises anterior, middle and posterior portions which are more active depending on the direction of arm elevation.

Force Couples

The rotator cuff muscles work together to contain the glenohumeral joint, which is an inherently unstable joint. As the arm is abducted the resultant joint reaction force is directed towards the Glenoid. This ‘compresses’ the humeral head against the Glenoid and improves the stability of the joint when the arm is abducted and overhead. 

Diagram explaining Force couple of normal shoulder

Diagram explaining Force couple of Cuff tear arthropathy

Cuff Tear Arthropathy

1977 that Charles Neer coined the term “cuff tear arthropathy.” Neer et al.went on to provide the first detailed description of CTA in 1983. CTA encompasses a condition characterized by a massive rotator cuff tear, proximal migration of the humerus resulting in femoralization of the humeral head and acetabularization of the acromion, glenoid erosion, loss of glenohumeral articular cartilage, osteoporosis of the humeral head and eventually humeral head collapse.

Normal xrays on left compared to Cuff tear arthopathy on right.

Radiographic Findings

Radiographs of the shoulder comprise an important step in the diagnosis and evaluation of CTA. Glenohumeral arthritis, osteopenia of the humeral head and superior migration of the humeral head, along with its sequelae, can be seen. Humeral migration leads to changes in the acromion, acromioclavicular joint, coracoid and glenoid. Abnormal contact between the humerus and the acromion can lead to rounding off of the greater tuberosity (femoralization) and concave erosion of the underside of the acromion (acetabularization).

3D CT showing Cuff tear arthropathy

Snapping Scapula Syndrome

Snapping Scapula Syndrome

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

If you have queries
Contact 9566222533/nexusortho@yahoo.com

Anatomy of Scapulothoracic Joint

The scapula is a large, flat, triangular bone that lies along the posterior surface of the thoracic cage between the second and seventh ribs. The scapula is part of the superior shoulder suspensory complex, which provides attachments to the axial skeleton.

The articulation between the scapula and the thoracic cage is one of the most incongruent in the human body. The Scapulothoracic pseudo joint has three layers: superficial, intermediate, and deep layers.

The trapezial bursa lies between the trapezius muscle and the base of the scapular spine and averages 4.3 · 2.7 cm in size. This bursa is particularly important as it provides a smooth surface over which the scapula rotates.

Scapulohumeral rhythm

Scapular control is essential to Scapulohumeral coordination. Posterior tilting is responsible for humeral clearance during the acromio humeral portion of shoulder elevation. Scapular upward rotation and retraction are greatest during abduction, elevation when compared to flexion, elevation. Any disturbance in this rhythm can decrease this Scapulothoracic movement and can be associated with fatigue, impingement, and instability and limits elevation.

Pathophysiology of Snapping Scapula Syndrome

Scapulothoracic motion produces a snapping, grinding or popping sensation. There are many causes to produce crepitus ranging from repetitive forceful shoulder movements producing microtrauma , resulting in a bone spur at the muscular attachment on scapula, to crepitus that can be a end result of bursitis.

3D CT showing decreased Scapulothoracic distance on left side.

Approximately 6% of scapulae demonstrate a hook-shaped prominence, known as

the Luschka tubercle, at their superomedial angle. This tubercle may enlarge and articulate with the thoracic cage, resulting in painful crepitus. However, a clear causal relationship between 

this morphology and the presence of scapulothoracic bursitis has not been demonstrated.

CT scan showing Lushkas Tubercle

 Osteochondroma is the most prevalent benign tumor of the scapula and has been implicated as a common cause of snapping scapula syndrome. Scapulothoracic bursitis may also occur following loss of dynamic control of scapular motion.

Muscle atrophy secondary to nerve injury, trauma, or prior operative treatment can lead to diminished soft-tissue interposition between the scapula and the thoracic cage, resulting in scapulothoracic crepitus and pain.

Management

Non operative management

The majority of patients with scapulothoracic crepitus or bursitis can be managed successfully without operative treatment. Operative management may be considered for patients who

have undergone a prolonged course of nonoperative treatment with little or no improvement.

Arthroscopic Surgery

Arthroscopic surgery for snapping scapula syndrome offers several theoretical advantages over open operative treatment. These include minimizing dissection and preserving muscle attachments, thereby eliminating the need for postoperative immobilization and potentially shortening the rehabilitation period.

Other advantages include an improved cosmetic appearance and potentially decreased hospital stays.

Technique of arthroscopic Surgery

The patient is positioned prone with the arm extended and internally rotated to accentuate the medial border of the scapula. All standard portals are established at least 3 cm

medial to the medial border of the scapula to avoid injuring the dorsal scapular nerve and vessels.

Patient is positioned Prone for Scapulothoracic Bursoscopy

Along the vertical axis, the superior visualization portal is placed just inferior to

the scapular spine to allow access to both the superomedial and the inferomedial angle of the scapula.

Under arthroscopic visualization, the inferior working portal is then created midway between the scapular spine and the inferomedial scapular angle. The instruments are pointed away from the coracoid process to prevent damage to the suprascapular nerve and vessels, which travel just medial to the base of the coracoid.

The visualization and working portals may be interchanged as needed intraoperatively for improved access to the bursal tissues. Portals placed superior to the scapular spine may result in injury to the dorsal scapular nerve and vessels or the spinal accessory nerve, and is avoided.

Intially scapulothorcic  bursectomy is completed,and then subsequently  the arm is moved under direct visualization and if the superomedial angle is deemed prominent a partial scapular resection is  performed.

Before the procedure is completed, the scapulothoracic joint is  examined with the patient under anesthesia to ensure that no impinging structures remain.

An advantage to arthroscopic debridement is that the periosteal sleeve of the rhomboid attachment is maintained, which avoids the need for muscle reattachment and thus eliminates the necessity for postoperative immobilization.

References

1. Snapping Scapula Syndrome  Meredith A. Lazar, Young W. Kwon and Andrew S. Rokito J Bone Joint Surg Am. 2009;91:2251-2262

2.Pearse EO, Bruguera J, Massoud SN, Sforza G, Copeland SA, Levy O.Arthroscopic management of the painful snapping scapula. Arthroscopy. 2006;22:755-61.

3. Pavlik A, Ang K, Coghlan J, Bell S. Arthroscopic treatment of painful snapping

of the scapula by using a new superior portal. Arthroscopy. 2003;19:608-12.

4.Bell SN, van Riet RP. Safe zone for arthroscopic resection of the superomedial scapular border in the treatment of snapping scapula syndrome. J Shoulder Elbow Surg. 2008;17:647-9.

Acromioclavicular joint (AC) Disruption

Dr.Senthilvelan

Consultant Orthopaedic Surgeon

For Appointments and queries Contact 9566222533/nexusortho@yahoo.com

Normal AC joint (The Joint between the end of collar bone and shoulder blade)

The joint between the outer end of the collar bone (clavicle) and shoulder blade (scapula) is called the acromioclavicular joint.

           

X ray of Normal AC joint

This Joint can be injured by falling on point of shoulder with arm by the side. This can result in damage to ligaments around this joint. This can result in prominence of end of collar bone (clavicle) which can be seen or felt as a bump underneath the skin.

Symptoms of AC joint injuries

Symptoms and signs of an acromioclavicular joint injury are pain over the tip of the shoulder and the arm feels             unsupported. There is loss of shoulder movement and prominence of the outer end of the clavicle.

Clinical Picture showing prominent end of clavicle under the skin

X rays Showing AC joint disruption

Treatment of AC joint injuries

Most of these injuries can be managed conservatively in most patients using arm sling, Rest, pain killers, physiotherapy for regaining range of movements in the shoulder. Some of types of AC joint injuries are more complex and require surgery.

Surgical Options

If you remain persistently symptomatic even after having conservative treatment,  surgery would be recommended. Surgery would be done using a synthetic ligament t called Surgilig ^TM.

                                                                        Picture showing Surgilg in position

This ligament allows for tissue ingrowth where the ligaments were torn in your shoulder and help maintain stability. Another advantage is that no other ligament is sacrificed in this repair(unlike other procedures like Weaver Dunn procedure in which coraco acromial ligament is sacrificed)

Post op

Postoperatively the arm is immobilised in a sling for 6 weeks. During this time the patients are allowed to perform pendulum and active assisted exercises. After this time, the patients can use his arm for most everyday living activities. Heavy lifting and resisting exercises are prohibited for a further 6 weeks. After recovery of full range of motion of the shoulder, muscular rehabilitation and sports-specific rehabilitation patients are allowed to return to contact sports. This is usually at three months post-operatively.