We have a session on treating arthritis in the young active patient and Matt Pepe is going to be moderating this with me our panelists Are great thinkers and we're going to extract as much information as we can out of them. They include Glenn Ross Paul Sethi William Pennington and Photios Gemma cares to make Harris job. Yeah. All right. Thank you. All right, so we're gonna get right into it Here's our first case guys. This is the history. This is a 34 year old active male software manager He likes to cycle. He was a former javelin thrower in college and weightlifter He had a history of bilateral posterior shoulder subluxations when he was a kid and had labrum repairs done when he was 17 That was seven years ago, and he comes into clinic today with popping catching and pain in his right shoulder When you examine him, he looks pretty healthy. He doesn't have any real atrophy or deformity He's got pretty good motion. Maybe a little bit of tightness in the posterior capsule, but overall not too bad Normal strength on strength testing no real pain when you translate the humeral head posteriorly But he does have a bit of a labral shear test when you examine his slap lesion He does have a scapula assist test and a scapular attraction test as well And these are his images. So what you can see I'll just kind of go through here Glenn why don't you describe what you see on his x-rays? Sure, well, we got some joint space narrowing certainly some inferior osteophyte formation and Some degree of posterior glenoid where can't quite tell yet, but likely Erring toward at least a b1 if not more. All right And I'm going to show you his MRI I'm going to go through the series of images and then I may ask Paul to comment on what what he sees here So we're working up toward the corpoid here. We're gonna work our way down Here's the next MRI image next one next one and That was the last one. So we'll back up one if I can get there Paul. What do you see on these images? Do you is there anything concerning to you? I mean There's a lot of things that concerning Glenn Glenn at his prescience and noted most of the findings on the x-rays alone Interesting when I hear someone, you know that one tag on this when I hear about someone who had bilateral posterior labral tears as a kid I worry about posterior Version or a hypoplastic glenoid because that's often a precursor to bilateral shoulder injuries and the arthritis here You've got someone with deformity maybe getting into b2. He's got osteophytes He's got a reduced joint space and he's starting to erode the back of his glenoid. So and look he's an arthritic shoulder So William is this we're gonna get to management a little bit, but I think Paul hit it on the head He's first of all, the question is he looks like he's evolving into a b2 glenoid, which we'll talk a little bit about more But William, what would you do to treat his symptoms? Remember his symptoms are kind of popping and catching. He really doesn't have much in the way of instability Well, I think he has symptoms consistent with his arthritis I think I there's definitely the posterior where and some posterior Italic, you know almost micro instabilities and There's some loose bodies within there Obviously for guys like this, I always tell him surgery should be the last option I'm assuming that he's failed if we're talking about what we do surgically for them, but these are people Treat him with therapy treat him with pain reducing modalities, whether it be biologics PRP Or a cortisone injection I still utilize that if that fails At his age giving him reasonable expectations. I think I Have not had the success with the CAM procedure or debridement that Peter has been able to demonstrate but it is reasonable to discuss that but He's definitely going to be on a short list for an arthroplasty type of procedure. He's still pretty young at 37 Fodio so a question for you He had a couple things on his exam that would suggest physical therapy might be helpful. Do you use scapular exams dyskinesis? Positive scapula cyst test. Does that help you predict who might do well with therapy? I probably lean more towards like a like a lidocaine challenge test So what you're doing is moving the acromion out of the way of the rotator cuff and and reducing his impingement So obviously he's getting some impingement. So you're moving the scapula out of the way. He's feeling better So that does indicate that perhaps rotator cuff strengthening program might help him So in my and most of the time what I'm doing is a lot of key challenge test and then coming back examining them Reduces so I just don't find it as reliable and a lot of a lot of these patients tend to be muscular patients They tend to be bench pressers or weightlifters as they as demonstrated the previous talks And so really sort of mobilizing or holding their scapula in place and releasing it So that they can get free a gladiator walk of motion to be challenging. So so I'm more of a an injection guy So let's say you inject it and the injection of lidocaine makes his pain a lot better He's very happy when it's numb, but then that wears off of course and his symptoms come back. How would you guys approach this? Arthroscopically, we'll just go right down Glenn I've had miserable luck with this subset of patients arthroscopically They tend to be in their mid-30s. How long ago was his prior surgery? 17 he's 34. He was 17 when he had it done. So seven 17 years ago, you know So if you look at peter's criteria, you know This would be a very big stretch to bring this patient in under the patients. He's describing I've tried advancing labrum posteriorly at times, but that has a double-edged sword in terms of potentially tightening things as well um, you can certainly try a good debridement or a staging arthroscopy but You know, I have this subgroup has been one of the poorest responders in my Experience and you know, I think they're working their way toward an arthroplasty So here's the real question. We talked about his imaging. We talked about his symptoms. This is an evolving b2 glenoid He's 37. What's this gonna look like when he's 47 Paul? It's gonna be worse and 57 I'm not sure but worse is gonna go with that if I've learned anything on this group of patients whether I'm gonna choose to do An arthroscopic whether I'm gonna choose to do a Riemann run I think that for me the single best predictor is my spider sense It's the patient who is really motivated and sussing out their level of motivation and their interest in proceeding with a certain procedure So, you know the ones who have done Riemann runs on have gone to Madsen's website sort of bought into it and fully get it So the ones who have their arthroscopic have been reasonably like I want this to work for me If if they're not sure if you're like look, this is a 50-50 and they're like, well, I'll try it They're the ones who I had the same experiences as Bill and Glenn I've just been a loser So let's say he does pretty well with physical therapy and he's happy reasonably happy and you explain to him This is a big problem How closely do you follow him because you really don't want this to evolve to a b2 glenoid. That's Unmanageable, right? So William, how closely do you follow him? What do you tell him in the clinic? How you get how often you gonna see him back? Well, I Have a hard time getting any of these patients to come back and to get better and but I definitely counsel them I show them their images on MRI or axillary views of showing that where especially because as has been referenced This gets harder in 10 years, but it's a little bit more reasonable to do in 10 years In 20 years, it gets real hard. And so I really talked to them about Maintenance of their motion and maintenance of their function and don't come in here essentially fused You know come back as you start noticing that stiffness so we can we can monitor you I don't give them a set date as far as come back every every year for an x-ray or anything like that But I really try to Tell them that this is going to be bad. It's going to get bad And I want to get there sooner rather than later when it's a little easier to take care of the deformity Jen can ask so when do you pull the trigger and what point is it? You know, forget about the age Is it you know, he's 60% sublux. He's 70% sublux. When do you say? Hey, look, you're gonna go downhill and what I'm gonna do is not gonna work. It's time Oh, I think 60 so 60% subluxation is too much. I'd say if they're showing, you know, 30 to 50% Man, I think he's probably already there I mean, I would hold off as long as possible and that's if I usually follow these by annually with an MRI But but what is so you're following I'm great But what is exact criteria that you're following when I cannot do it when it's on the verge of? There's two there's two separate tracks of issues One is the degree of his symptoms and in for a guy in his late 30s, you can certainly drag your feet a bit You know, I've put arthroplasties in ten years younger than that. So I'm guilty, you know for that But if his symptoms don't warrant it yet This may be stage one of just a relationship and I would kind of encourage him to stop in every four to six months or So not necessarily for an x-ray a clinical exam just to kind of see where things are But I would tell him that I think that the only thing that's reasonably going to help you at the proper time is an arthroplasty it's some point this glenoid will erode to the point where his risk of Arthroplasty failing goes much higher and so for me in my hands I'll follow these people repeatedly and if I see this is progressing rapidly I'll intervene with an arthroplasty and ream them in the front and not have to do bone grafting or augmentation or reverse or something crazy At a 37 year old last question that I'm going to turn it over to Matt Is there anything you can do now to prevent a b2 glenoid from forming? Run right down the panel if anybody has any comments The reason I brought this case of this because I don't have an answer for this, but you guys are smart So, what do you say? Avoiding his first surgery What well, maybe maybe but we see b2 glenoids in people that never had surgery Is there something that can be done? This guy had RPS, right? So he's recurrently posterior subluxating. So he's he's gonna develop b2 glenoid whether you fix his labrum or not. So I think that you know, it depends what country you live in to maybe right? So I mean there are guys talking about Fixing the critical shoulder angle and if his angles low and and if that predispose him to osteoarthritis And would you do that? When would you pull that trigger? I don't I don't think we know that and so I think that's a huge risk and I think Everybody here would probably agree that you follow this patient clinically until he's at higher risk of subluxation Then just do a well-seated anatomic total shoulder Years ago JP Warner looked at posterior osteotomies of the glenoid and you know, he really didn't end up recommending That intervention based on the data of that time. I don't think that's been revisited for quite some time But I certainly wouldn't go out on a limb and do that I think a well-done arthroplasty would hopefully, you know Bring him into his earlier mid-50s and hopefully technology will continue to evolve and assist him in that Awesome. All right. I want to turn it over to Matt for the second case

panel discussion

shoulder pain

shoulder subluxations

labrum repairs

joint space narrowing