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Surgery or Not Surgery - Case Discussion: Nicholas Colyvas, MD
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Surgery or Not Surgery - Case Discussion: Nicholas Colyvas, MD
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Segment:0 .
NICHOLAS COLYVAS: [MUSIC PLAYS] [APPLAUSE] Thank you. Let's see. Thank you, Colin.
NICHOLAS COLYVAS: Thank you, Anthony and Colin for inviting me to speak today. And there's not going to be much about race cars on this one, I think, but there will be meniscus. OK. So I'm going to, this is going to be mostly a case based review. I'm not going to didactically Just spill out information. You guys are going to have to get involved with your audience response system.
NICHOLAS COLYVAS: So hopefully you've had your coffee. It's just before lunch. You know, we're going to get you all sort of ready for this. I don't have any disclosures that are relevant to this talk. And we're going to start with the knee and we'll see what we get to here but let's go straight ahead with the first question, the first case. So this is a 17 year old, one of my high school star athletes.
NICHOLAS COLYVAS: He's basically supported the basketball and football teams. And unfortunately he sustained a twisting injury to his knee when tackled. His exam when he came in to see me, he was swollen, he did have a stable ligament exam, so that was good. But he did have a distinctly tender lateral joint line and his MC Murray's sign was positive. His X-rays were negative, and his MRI showed this finding here
NICHOLAS COLYVAS: and I don't know how comfortable you are reading and looking at MRI's, but, you know, this is a normal meniscus on the medial side. In the lateral side, there's something missing here as we go through the MRI a little bit more. Here's a piece of his lateral meniscus that's flipped underneath and sort of hanging down there. So the diagnosis here is one of a lateral meniscus tear. It's very clear; history, physical exam, all point to the same thing, MRI.
NICHOLAS COLYVAS: And so now we want to look at what the treatment is here and and I think we've got to take the considerations here. You always into account for any patient, their age and activity level. This guy's a young guy, obviously very active. The type of tear, it's a lateral meniscus. It's flipped under itself and the underlying condition of the knee is good. At 17 years old, he's got no underlying arthritis and doesn't have any other associated injuries.
NICHOLAS COLYVAS: So help me out. What are we going to do for this guy? Physical therapy always a good choice. Anti-inflammatories always a good idea. Cortisone, PRP, stem cells. Well, we know all about that now, don't we? And then what about surgery? You know, usually our last choice.
NICHOLAS COLYVAS: And the results are coming in. OK. We've got some live ones here. 85% of you wanted to help me buy some new race car tires. Get me, get me that surgery. Right? OK. Some of you wanted to start with physical therapy and some conservative treatment.
NICHOLAS COLYVAS: Nobody wanted to do any injections. I like that. I think that that's absolutely appropriate. I think that I would agree more with the 85% here. Why? We've got a young patient. We've got a very structural injury. This is not just a small little tear in the meniscus. It's a big enough tear that this thing has flipped under itself. It is like a pebble in the shoe.
NICHOLAS COLYVAS: If you keep that meniscus there, it's going to continue to break down the cartilage, so although these are typically very good choices, I would say that this is one where we would go almost immediately to surgery to fix that problem, and that's what we did. And he's playing football again and everything's good. OK, let's keep moving.
NICHOLAS COLYVAS: They get a little bit more difficult along the way. So this is a 46-year-old and he came to me and described an injury with his knee that he had had an ACL reconstruction over 10 years ago. So immediately, we all know that ACL reconstructions or ACL injuries in general over 10 years, some of those develop arthritis so we're suspicious OK? And he's got this progressive pain.
NICHOLAS COLYVAS: It's not like he's suddenly twisted his knee, but he doesn't have any instability so this ACL reconstruction obviously worked reasonably well. And when you examine him, he's got a minimal effusion, a stable knee. So his ACL is looking good, but he is tender in the joint lines and his meniscal tests are quite positive. And we obtain an X-ray
NICHOLAS COLYVAS: and I'm not sure how clear you can see it, but just sort of on a first glance here, you look at this X-ray and say, well, you know, it's joint spaces are pretty reasonably maintained. But if you look real carefully, there's a bunch of calcification here and he's got a little bit of arthritis here. So at 46 years old, he's probably got more of an arthritic knee than you'd want for 46. And you get an MRI and it confirms obviously the degenerative changes.
NICHOLAS COLYVAS: But he's also got these horizontal cleavage, sort of degenerative looking menisci. But he's coming to you, of course, today because he got this MRI and he's got tears and they need to be fixed. All right? So diagnosis is degenerative tears basically with some early DJD in the knee. Again, you're going to consider all these things. His age.
NICHOLAS COLYVAS: He's sort of 46. I think that's young. The type of tear; degenerative. He's got some degeneration clearly in his cartilage and associated injuries, nothing really significant. You also have to consider alignment and BMI and all those sort of things but I'm just using these as an example.
NICHOLAS COLYVAS: So. OK, what are we going to do for this guy? Is he a PRP candidate? Unloader brace? What's our, what's our audience response here? OK. Physical therapy is the winner by far. Any physical therapists here in the room?
NICHOLAS COLYVAS: All right. So I would fully agree with that. This this, is a case where physical therapy is probably my first choice. Unloader brace is often times a good choice in this scenario, but he's sort of bilateral. It's not. I mean, it's medial and lateral. It's not really something that we would see an unloader brace being that helpful.
NICHOLAS COLYVAS: If it's all medial or all lateral,
NICHOLAS COLYVAS: I think that would be a good choice. The cortisone and PRP injections, you know, I think that that's something that would be considered if the first line of treatment didn't really kind of work here. And then the surgery, we got about 10% of people talking about that. I'm unconvinced and we'll talk about why. The value of meniscectomy in degenerative knees.
NICHOLAS COLYVAS: I think when I started practice, we were doing a lot of these. This was the classic knee washout. The person's got tears in his meniscus. They need to be taken care of. You need to wash out the knee, you need to smooth over the cartilage surfaces. That was the traditional washout. I think since 2003, and study after study after study. Big randomized controlled studies show that, you know, really there's no significant differences between arthroscopy and conservative management.
NICHOLAS COLYVAS: Understand, though, that some of these patients cross over in these studies. Up to 30% of these patients who start out in the physical therapy group end up getting surgery so it's not that the surgery is absolutely out of the question, but it's just something that I think we've gone further and further away from, and I think that we definitely try conservative management and I'm glad to see that's what most people here are talking about with these types of patients.
NICHOLAS COLYVAS: I think the unloader brace is probably underused. I use it a lot for those patients who have medial or lateral disease predominantly. I put in this little PRP idea here because as we heard just heard from Drew, you know, early osteoarthritis, that might be something we consider. I think we're going away from Visco largely, cortisone on an individual basis.
NICHOLAS COLYVAS: And ultimately, yes, surgery. You might consider that if nothing else is working but this is a tough group because some of them, you know, they're young, they're too young for a knee replacement, but they're having a lot of symptoms so that sort of is my very last choice here. OK, so moving on. 61 year old, we're getting older. This gentleman had no problem with his knee previously. Stepped off a ladder.
NICHOLAS COLYVAS: He twisted the knee and immediately had medial pain. So he comes in to see me and he's got some mild swelling there. He's definitely got some medial joint line tenderness, some meniscus signs. So we're already got a pretty good from the history and physical exam idea. Here's his X-rays, OK? We've got, you know, reasonable maintenance of the joint spaces.
NICHOLAS COLYVAS: I mean, at 61, I wouldn't mind if my X-rays looked like that. If you look at it carefully, there is a bit of narrowing there. And then we get the MRI and there's a subtle little oblique tear on the coronal here, but you can see that meniscus is in place. Cartilage surface looks reasonably good, but there's definitely a tear there. You can see it on the sagittal too.
NICHOLAS COLYVAS: These don't project quite as well, I'm sorry. But here we go. So this is a gentleman, 61 years old, previously active. Look at the type of tear. It's not a flap tear. It's not a bucket handle tear. It's actually a relatively sort of benign tear. You know, could be very stable.
NICHOLAS COLYVAS: Underlying condition of the knee is pretty good and his associated injuries, he doesn't really have any. So physical therapy, conservative treatment for this guy, it is medial sided. You know, an unloaded brace is certainly a reasonable choice. PRP, stem cells, I'm just keep throwing that one in there. I'm not getting very many buyers on that one. And then what about surgery?
NICHOLAS COLYVAS: This guy's, you know, he's got, he's got a tear. He was previously asymptomatic and now he's got symptoms. Probably a pretty easy little tear to take care of. What are we thinking here? And the winner is. Physical Therapy. 20% of you said an unloader brace. No one wants to do the stem cells yet.
NICHOLAS COLYVAS: Drew must be really upset. And surgery. Some of you said. OK, so what did I do? These are all real patients. These are all my patients that I've pulled out of my files. What did I do with this patient? I talked to him quite a bit about the surgery, but I offered him basically both choices, and I think this is the type of patient
NICHOLAS COLYVAS: you can do that. I think that if the patient really aggressively wants to work to getting this sort of, quote unquote, taken care of, surgery is a reasonable choice here. This is a sort of you know, on the borderline. I think most people and certainly if we were talking to our residents and talking to them about their in-training exam, we go with the conservative treatment,
NICHOLAS COLYVAS: OK. And this is what we did. He chose to go conservative treatment and we did an unloader brace and physical therapy and we gave him some time. And at about three or four months, he came back and he said it's a bit better, but it's still a problem. And you know, what else can we do? And I didn't talk about any of that, and I said, let's go ahead and do the surgery.
NICHOLAS COLYVAS: And at the time of surgery, actually, you could see this meniscus was pretty trashed. It actually, it actually probably wasn't going to get better. He did very well after the surgery. But I think it's important to know that there's, you know, these are the patients whose cartilage surface looks beautiful. He's 61 years old, and that looks really good.
NICHOLAS COLYVAS: So you know, he's done well in the short term, probably will do quite well in the long term because most of that meniscus is still in there but this piece was obviously getting in the way and I think the standard approach remains and should remain that this is probably something you want to try at least conservative treatment and if it doesn't work, not all of these tears are ones that you can operate on.
NICHOLAS COLYVAS: Some of them operate on, and they do well. All right. We're sticking with the knee. Now we're kind of moving to something a little different. This is JS. She's one of my patients. She's 63 years old, and she's obviously quite active. She's a skier and March was skiing, had an injury where essentially her left knee collapsed and she went down and she heard multiple pops.
NICHOLAS COLYVAS: So, of course, that's now got you very actively thinking about something. Has something bad has happened in there? She actually got down the hill and we know from, I think some of the previous talks you heard that getting down the hill is quite difficult if you've blown your ACL. But when we listen to the rest of her history, she's had not so much pain, but she's really describing a bit more instability.
NICHOLAS COLYVAS: So when we examine her, she's got a 2B Lachman, her pivot shift is positive so sure enough, she, she must have an ACL tear and her X-rays show very minimal changes as far as her degenerative change in her 63 year, 63-year-old knee. But clearly has an ACL tear and fortunately for her, she doesn't have any meniscal pathology. So our
NICHOLAS COLYVAS: issue here. Our diagnosis here is clearly an ACL tear, but this is an ACL tear in a 63-year-old. But I think you have to consider activity level, what her health is in general and what her symptoms are. Right? Is she having pain or is she having instability? She's having instability.
NICHOLAS COLYVAS: What are we going to do with her? 63 years old. You know, our typical ACL patient is 25. 17, 63 is pretty up there. What's our, what's our, what's our concept here? Any indication for a cortisone injection? Again, PRP. Boy, it's really, really up there, isn't it?
NICHOLAS COLYVAS: OK so we've got virtually none for these, which I think is totally appropriate. Everybody's, everybody's been getting the message. Physical therapy and a brace and surgery. There's quite a few people who want to do surgery on her. That's, you know, that's, that's impressive. This is a sort of a controversial area.
NICHOLAS COLYVAS: The, the, the ACL reconstruction in the patient who's more than 40 years old and this is not a 40-year-old patient, by the way. But the ACL reconstruction in the older patient, I think is something that has to be taken on a case by case basis. I can tell you in the last five years, I've got about 6 over 60-year-old patients and that's probably more than most of my colleagues.
NICHOLAS COLYVAS: It's not a common thing that you will see. Part of that has to do with they do quite well with conservative treatment. A lot of it is because their knees at over 40 years old let's say, have already started to develop some changes that stabilize them. They've already got stiffer knees. They're already developing sort of early arthritis in their knees. So although the studies like these show that these patients can do well with ACL reconstructions, I think it has to be on a case by case basis.
NICHOLAS COLYVAS: Now, this patient I actually started with the physical therapy in ACL brace, and she did come back to me at about six months after that and said, well, this is just not working and we did an ACL reconstruction on her and she's doing great. So I think that this is that older ACL patient, the younger ACL patient, I think is easier to determine what you're going to do unless you read a lot of the European Studies and the European literature where they're quite non-operative for younger patients
NICHOLAS COLYVAS: and in this part of the world, there are younger patients, almost all get ACL reconstructions. But the older patient is one where I think you really have to look at it on a case by case basis. And are there any other orthopedic surgeons in the room? Good. I've got a 73-year-old ACL reconstruction. Just just to let you know, there are just those rare patients that you will do that on. OK, let's keep going.
NICHOLAS COLYVAS: So this is a patient referred to me by Wendy. Is she in here? She's, she's gone. She's there. She's there. OK. 53-year-old. No prior problem in her knee, but she's not a particularly active person. She was getting up from a squat position and she felt this distinct pop in her knee.
NICHOLAS COLYVAS: So any time you see that on the history, obviously you're immediately thinking about some kind of a structural problem. She had pain immediately and then slowly developed some swelling. And she has a history of hypertension and type 2 diabetes. On her physical exam, she's you know, kind of up there, limited range of motion to some degree, although she's got a bit of a bigger knee
NICHOLAS COLYVAS: so maybe she doesn't actually go that much further. Tenderness sort of diffusely on the medial side and posteriorly, but her alignment and her knee stability is pretty good. X-rays. Not a lot of arthritis in here. Doesn't look too bad. But then when you get the MRI and again, if you've looked at a lot of MRI's, you look at this and that medial meniscus is intact, but it kind of looks like a melon seed that's being popped out of the knee.
NICHOLAS COLYVAS: It's kind of being what we call extruded. It's being, it's kind of being pushed out of the knee a little bit there. And when you look at the posterior horn of the lateral meniscus, it comes all the way and attaches, and here there's a pretty clear tear there at the posterior horn. And that's right in the root area so when you get a sagittal, you look at that and that's what's called the ghost sign, that meniscus.
NICHOLAS COLYVAS: This is the normal kind of look of the meniscus, dark black. Here, there's more of a meniscal remnant, a ghost of the meniscus. And on some of them, you can get the axial and you can actually see the meniscus here. This is the medial meniscus. You can see that it's detached there at the root. So this is something that we call a root tear, but essentially it's a meniscus tear in an overweight,
NICHOLAS COLYVAS: older patient. Got some co-morbidities. You know, there's some degeneration in that knee. And the question is, what do we do with this patient? Right. It's physical therapy, medial unloader brace. This is a very sort of aggressive options. You know, three surgeries and one conservative management, notice, no PRP.
NICHOLAS COLYVAS: We finally learned our lesson that PRP is not going to work for any of these. So, you know, this surgeon really wants to get to the OR, but he's not quite sure what he wants to do. So what, what, what? Help us out. What are we going to do for this patient? What is the, what is the audience response on this one?
NICHOLAS COLYVAS: His cortisone right here. I mean, we can probably do some right now. OK, so. Physical therapy, conservative treatment, unloader brace. I always like that. Most of my patients are this age group come in, they walk out with that number one option. Number two, meniscectomy.
NICHOLAS COLYVAS: OK. That's our previously most favorite orthopedic surgery for sports medicine doctors. Meniscus repair in a 50 something year old. A lot of people like that option. And then a partial knee replacement, some people are already going to go to that option. Why did I put all of these here? I mean, these are sort of quite aggressive and this is, you know, pretty straightforward.
NICHOLAS COLYVAS: The story really goes forward a little bit. This is, so obviously we did do some surgery here and I'll go back to conservative treatment. But this is that tear. This is the meniscus coming along and it should go all the way here and actually attach to here. This is a tear at the root OK, and this is another patient of mine just to make it look clearer.
NICHOLAS COLYVAS: But this is the tear here. This, that meniscus should be attached down to right there where the root is and you can see it's ripped off and it's sort of flopping around now. So that meniscus, the meniscus itself isn't torn. This meniscus here looks pretty good. You know, it's in reasonable condition. It's just ripped off the root there.
NICHOLAS COLYVAS: The problem with that is that functionally a total meniscectomy, that is as good as what we used to do when we used to go in. Fortunately, I was never part of this generation but you know, there are still people around that are walking with their quote unquote cartilage removed and you talk to them and they've got a big osteotomy, a big scar where they've had their meniscus removed
NICHOLAS COLYVAS: and that was the treatment in the 60s and the 70s. If you had a meniscus problem, just take it out. You don't need that meniscus. Just take the whole thing out. And this type of tear that we're recognizing more and more, this root tear is essentially the functional equivalent of taking the meniscus out because it no longer is attached to that root and it is now extruded. It's out, you know, out into the soft tissues
NICHOLAS COLYVAS: and it's not providing the same protection. So, you know, there's been a fairly decent amount of biomechanical studies that show that this actually refixing that and repairing that is actually quite helpful and in terms of restoring the biomechanical function of that meniscus and the clinical data is still a bit early. This is a, this is a level three study so it's not a one or two study, but it shows you that same concept where if you take that torn meniscus, that sort of floating here, you tie it back down to where it's supposed to be and you restore that tension on the meniscus.
NICHOLAS COLYVAS: You essentially improve survival of that knee, and though, and fixing it actually doesn't maybe doesn't fully prevent arthritis, but it certainly helps. And this is from that same study. This is the meniscectomy patient where they went through and obviously lost that meniscus and that protective effect and ended up with a total knee. And this is, you know, probably they chose their best one here,
NICHOLAS COLYVAS: but this patient, of course, had a root repair and seven years later, they still have a perfectly good knee so this knee was actually saved. So if I go back to the audience response here. I think that the natural tendency for anyone in this age group with a meniscus tear, absolutely, that would be what I would do.
NICHOLAS COLYVAS: But the reality is that for these patients, we now believe 2018, these should get surgery. These are ones that we should get into the operating room and repair that meniscus. Where it becomes difficult is what about that patient who has fairly severe arthritis at that point? You know, this patient didn't have it too bad, but you know, that patient that's massively overweight or is badly aligned, they're probably not going to get quite the same benefit.
NICHOLAS COLYVAS: But there's still something you want to consider. But a root tear, if you get that report from your radiologist, probably best to go ahead and send that patient to your local surgeon. OK how are we doing on time? We got a little bit more. Let's go ahead and talk about some shoulder stuff. OK. We've switched from the knee. So this is a patient of mine who's a 49 year old, used to be a very active swimmer for the Olympic club, still has sort of retired from competitive swimming, but still really likes to swim twice a week.
NICHOLAS COLYVAS: And he's developed this sort of progressive shoulder pain over about six months, and I see a lot of these type of patients, not acute traumatic injury, but definitely pain that's limiting what he wants to do. His range of motion, he doesn't quite have full range of motion, his impingement tests are positive. Dr. Marr showed you how to do all of those today. His rotator cuff strength
NICHOLAS COLYVAS: if I test him, he definitely has normal strength, but it's painful when he does it. And we did some of the labral tests which we all know are not very definitive, but nonetheless, they weren't definitive in this case either. And he does have a little positive pain with cross arm testing but when you push on his AC joint, it's not that bad. So in my practice, this is not an unusual set of circumstances to find.
NICHOLAS COLYVAS: You get an X-ray and it doesn't really have any arthritis. Nothing very dramatic here. You can't see the AC joint very well on this view, though, you can see that that's a pretty narrowed and tight AC joint here. But the rest of the shoulder X-ray is not very remarkable, and you get an MRI and you show there's definitely a labral tear here. Sub scap is OK.
NICHOLAS COLYVAS: That one doesn't project very well at all but there's some rotator cuff tendinosis and probably a partial articular surface tear here. Not a full thickness tear, not a retracted tear. And his AC joint, true to what we looked at in the X-ray of looks pretty, pretty, pretty bad. And we said he's, you know, he's in his 40s. So the question here from a clinical point of view is, you know, what is the main diagnosis?
NICHOLAS COLYVAS: What are we looking at here? Is this more of a rotator cuff tear or is this more of a labral tear? Is the AC joint the predominant issue here? And with all that in mind, what do we think the next step is? What is everyone going to do with this patient next? Is there something you want to, I did throw PRP in here just to keep it consistent. And I'll tell you, the incidental story is I had a very similar personal issue with my shoulder, similar symptoms
NICHOLAS COLYVAS: and one of the doctors in our office was trying to practice doing PRP injections and I was the guinea pig. And I got better but I don't know if it was that or time or just laying off it, but I'm not recommending it put it this way, and none of you are either. That's good. OK. So physical therapy, cortisone injection surgery. A few of you want to do surgery.
NICHOLAS COLYVAS: That's great. I think I need to know who you are and you can send me these patients. So I think that this is a patient where these two are clearly the first two considerations. And physical therapy would almost 100% be what I would do unless the patient was very aggressively looking for further treatment and maybe to move his treatment forward.
NICHOLAS COLYVAS: But in addition, what I sort of wanted to highlight and talk about with the cortisone injection is that this is not just, and certainly in the shoulder, it's not just a therapeutic tool. It's also a diagnostic tool. Right? I'm not 100% clear. I think that the majority of the problem is the rotator cuff, but I'm not 100% clear with what we have here.
NICHOLAS COLYVAS: Whether or not that AC joint is really a problem, it looks bad but, you know, many people have pretty nasty looking AC joints and they're fine. So the cortisone injection is a way for me to help get some diagnostic information as well. And this patient just got better with physical therapy. Simple as that. We didn't do any surgery. We didn't have to worry about anything.
NICHOLAS COLYVAS: But if he hadn't, I would have gone next to the cortisone injection and try to determine whether there was really. I'd put a subacromial space injection in there. More than likely, that would make him significantly better, we would know that's where the problem was. I think 90% of my patients or more get better in this type of patient, get better with physical therapy and cortisone injections.
NICHOLAS COLYVAS: So this is a very conservative treatment, I don't get excited about the partial rotator cuff tear and all that kind of stuff. Some of the patients do, but I think you just have to be conservative with these type of patients. You know, the rotator cuff tears is they're very, very common. It's an older age group typically, asymptomatic tears in, you know, 30% of seven year olds, seventy year olds, 50% of 80-year-olds
NICHOLAS COLYVAS: so it's very conservative treatment. But one of the things that I think and physical therapy is very effective for rotator cuff tears, but one of the things I think that we want to be careful of is that there are certain variants of rotator cuff tears that we want to be a little bit more careful about. So here's an example. This is a 53-year-old. He's not the world's healthiest patient,
NICHOLAS COLYVAS: and he decided that he would try a hoverboard and I haven't put the rest of the history here because we all know what happened. So in he comes and when we examine him, he's actually a few weeks out and his passive range of motion is good, but he just can't lift his arm up. He's, he's got very limited range of motion in his arm and you test his supraspinatus and infraspinatus and he's very limited.
NICHOLAS COLYVAS: But there's some pain there, he's neurovascularly intact and you get the MRI and here's his MRI and this is the end of the rotator cuff. Instead of attaching here, it's here and there's a nice big gap there. So he has a distinct full thickness, retracted rotator cuff tear. But he's not the healthiest guy and he's a little bit older and what are we going to do with this guy?
NICHOLAS COLYVAS: Sorry, ACL brace. Let's just, that one, that one failed the editing process. I apologize. So just cancel ACL brace. It's physical therapy, cortisone injection, PRP, of course and surgery. Let's see what our collective wisdom is here.
NICHOLAS COLYVAS: OK. Physical therapy. No ACL brace. Surgery. About half of you want to do surgery on this guy. Cortisone injection, A little bit. And somebody wants to try some PRP. Good. Acute rotator cuff tear, it's a different entity to the chronic, slow developing pain. This is someone who didn't have a problem before.
NICHOLAS COLYVAS: Even if their MRI shows some changes if there's clearly been a situation where this guy was lifting and carrying tiles into the bathroom beforehand and now he can't lift his arm up like that, all I would say is get an, get an MRI and just rule out the fact that this is something that is a tear or not, because if it's just pain and you can sometimes get that information with an injection and you can inject those patients
NICHOLAS COLYVAS: and if their function suddenly comes back and they haven't been able to lift because they've just been in pain, then OK, that might be OK. But I would say this is a population that you want to get the MRI early and you want to get them to the orthopedic surgeon early because acute rotator cuff tears usually are better off with surgical treatment than conservative treatment there.
NICHOLAS COLYVAS: The non acute surgical rotator cuff tears are something that we would mostly treat conservatively. Acute ones, we really want to think about doing surgery early. How are we doing on time? I think we're, one more. OK. Colin's really into it. A quick mention. Labral, tears, almost never something to worry about in an older patient group.
NICHOLAS COLYVAS: Yeah. OK. Young, overhead athletes. We can talk about that in more detail, but don't worry about the labral tear on those patients. So let's go back to a younger age group. 26-year-old. At 16 years old, he dislocated his shoulder. Didn't do surgery and did well with physical therapy so he went for 10 years and then had another traumatic fall and dislocated the shoulder again, had to have it reduced in the ER so this was a pretty significant amount of trauma.
NICHOLAS COLYVAS: Now he's doing OK, he's not having a lot of pain. His exam shows he's got a good range of motion. He does have a little bit of weakness but his apprehension and relocation tests are positive and he has some instability in there on testing. This is his X ray, unremarkable as you would expect. Maybe you could read a Hill-Sachs lesion there and the MRI shows he has a Bankart lesion,
NICHOLAS COLYVAS: your classic anterior dislocation sign. The glenoid bone stock is good and he's got a small Hill-Sachs lesion. So this is a sort of a classic anterior dislocation. You know, 90, 90% plus of your patients are going to be anterior dislocations. But, you know, he's kind of young, 26. The injury was traumatic, this is not a voluntary dislocator. He's not having a lot of pain right now, but he hasn't returned to activities and his imaging is not that dramatic.
NICHOLAS COLYVAS: OK. So what are we going to do for this patient? Put another ACL brace. OK. Full disclosure. This was done at 4 in the morning, this morning. I'm surprised that not more, but maybe John corrected some of it before it actually got here. But OK, so. Audience response is. Dada.
NICHOLAS COLYVAS: Whoa, surgery, I like these guys. OK. Why surgery? So actually, I think initially you're going to think about doing some of the physical therapy and all that sort of stuff to maybe get their strength back. This guy was a little bit weaker but the reality is, anyone who has had two dislocations is almost 100% likely to go ahead and have another one
NICHOLAS COLYVAS: and it's going to happen at some point in time unless they somehow dramatically change their activities and everything. This is a patient that's going to dislocate again. We get really good results with arthroscopic Bankart repairs on these patients. So I think the discussion with the patient is, yes, we can do all this again. You probably would do OK with these,
NICHOLAS COLYVAS: you did OK the first time around, although that's unusual, right. 16-year-old who has a primary dislocation. You know, there's some sort of movement in the orthopedic world to fix those patients immediately, to do after one dislocation in the young patient to do an arthroscopic stabilization. But in reality, I think what we do mostly is we give those first time dislocatiors a bit of time, and we physical therapy
NICHOLAS COLYVAS: and if they prove that they've dislocated again, they get another surgery. If you're dislocated more than twice, you're going to dislocate again, it's time to really think about the surgery. So in summary, surgical decisions are not straightforward, but you guys all did really well. I mean, you know, there was a much better than me with the ACL braces.
NICHOLAS COLYVAS: Usually we do conservative treatment and save surgery for later, but really surgery is sometimes necessary on an early basis. Happy holidays to everybody [APPLAUSE] and thank you very much. [VIDEO ENDS]
Segment:0 .
NICHOLAS COLYVAS: [MUSIC PLAYS] [APPLAUSE] Thank you. Let's see. Thank you, Colin.
NICHOLAS COLYVAS: Thank you, Anthony and Colin for inviting me to speak today. And there's not going to be much about race cars on this one, I think, but there will be meniscus. OK. So I'm going to, this is going to be mostly a case based review. I'm not going to didactically Just spill out information. You guys are going to have to get involved with your audience response system.
NICHOLAS COLYVAS: So hopefully you've had your coffee. It's just before lunch. You know, we're going to get you all sort of ready for this. I don't have any disclosures that are relevant to this talk. And we're going to start with the knee and we'll see what we get to here but let's go straight ahead with the first question, the first case. So this is a 17 year old, one of my high school star athletes.
NICHOLAS COLYVAS: He's basically supported the basketball and football teams. And unfortunately he sustained a twisting injury to his knee when tackled. His exam when he came in to see me, he was swollen, he did have a stable ligament exam, so that was good. But he did have a distinctly tender lateral joint line and his MC Murray's sign was positive. His X-rays were negative, and his MRI showed this finding here
NICHOLAS COLYVAS: and I don't know how comfortable you are reading and looking at MRI's, but, you know, this is a normal meniscus on the medial side. In the lateral side, there's something missing here as we go through the MRI a little bit more. Here's a piece of his lateral meniscus that's flipped underneath and sort of hanging down there. So the diagnosis here is one of a lateral meniscus tear. It's very clear; history, physical exam, all point to the same thing, MRI.
NICHOLAS COLYVAS: And so now we want to look at what the treatment is here and and I think we've got to take the considerations here. You always into account for any patient, their age and activity level. This guy's a young guy, obviously very active. The type of tear, it's a lateral meniscus. It's flipped under itself and the underlying condition of the knee is good. At 17 years old, he's got no underlying arthritis and doesn't have any other associated injuries.
NICHOLAS COLYVAS: So help me out. What are we going to do for this guy? Physical therapy always a good choice. Anti-inflammatories always a good idea. Cortisone, PRP, stem cells. Well, we know all about that now, don't we? And then what about surgery? You know, usually our last choice.
NICHOLAS COLYVAS: And the results are coming in. OK. We've got some live ones here. 85% of you wanted to help me buy some new race car tires. Get me, get me that surgery. Right? OK. Some of you wanted to start with physical therapy and some conservative treatment.
NICHOLAS COLYVAS: Nobody wanted to do any injections. I like that. I think that that's absolutely appropriate. I think that I would agree more with the 85% here. Why? We've got a young patient. We've got a very structural injury. This is not just a small little tear in the meniscus. It's a big enough tear that this thing has flipped under itself. It is like a pebble in the shoe.
NICHOLAS COLYVAS: If you keep that meniscus there, it's going to continue to break down the cartilage, so although these are typically very good choices, I would say that this is one where we would go almost immediately to surgery to fix that problem, and that's what we did. And he's playing football again and everything's good. OK, let's keep moving.
NICHOLAS COLYVAS: They get a little bit more difficult along the way. So this is a 46-year-old and he came to me and described an injury with his knee that he had had an ACL reconstruction over 10 years ago. So immediately, we all know that ACL reconstructions or ACL injuries in general over 10 years, some of those develop arthritis so we're suspicious OK? And he's got this progressive pain.
NICHOLAS COLYVAS: It's not like he's suddenly twisted his knee, but he doesn't have any instability so this ACL reconstruction obviously worked reasonably well. And when you examine him, he's got a minimal effusion, a stable knee. So his ACL is looking good, but he is tender in the joint lines and his meniscal tests are quite positive. And we obtain an X-ray
NICHOLAS COLYVAS: and I'm not sure how clear you can see it, but just sort of on a first glance here, you look at this X-ray and say, well, you know, it's joint spaces are pretty reasonably maintained. But if you look real carefully, there's a bunch of calcification here and he's got a little bit of arthritis here. So at 46 years old, he's probably got more of an arthritic knee than you'd want for 46. And you get an MRI and it confirms obviously the degenerative changes.
NICHOLAS COLYVAS: But he's also got these horizontal cleavage, sort of degenerative looking menisci. But he's coming to you, of course, today because he got this MRI and he's got tears and they need to be fixed. All right? So diagnosis is degenerative tears basically with some early DJD in the knee. Again, you're going to consider all these things. His age.
NICHOLAS COLYVAS: He's sort of 46. I think that's young. The type of tear; degenerative. He's got some degeneration clearly in his cartilage and associated injuries, nothing really significant. You also have to consider alignment and BMI and all those sort of things but I'm just using these as an example.
NICHOLAS COLYVAS: So. OK, what are we going to do for this guy? Is he a PRP candidate? Unloader brace? What's our, what's our audience response here? OK. Physical therapy is the winner by far. Any physical therapists here in the room?
NICHOLAS COLYVAS: All right. So I would fully agree with that. This this, is a case where physical therapy is probably my first choice. Unloader brace is often times a good choice in this scenario, but he's sort of bilateral. It's not. I mean, it's medial and lateral. It's not really something that we would see an unloader brace being that helpful.
NICHOLAS COLYVAS: If it's all medial or all lateral,
NICHOLAS COLYVAS: I think that would be a good choice. The cortisone and PRP injections, you know, I think that that's something that would be considered if the first line of treatment didn't really kind of work here. And then the surgery, we got about 10% of people talking about that. I'm unconvinced and we'll talk about why. The value of meniscectomy in degenerative knees.
NICHOLAS COLYVAS: I think when I started practice, we were doing a lot of these. This was the classic knee washout. The person's got tears in his meniscus. They need to be taken care of. You need to wash out the knee, you need to smooth over the cartilage surfaces. That was the traditional washout. I think since 2003, and study after study after study. Big randomized controlled studies show that, you know, really there's no significant differences between arthroscopy and conservative management.
NICHOLAS COLYVAS: Understand, though, that some of these patients cross over in these studies. Up to 30% of these patients who start out in the physical therapy group end up getting surgery so it's not that the surgery is absolutely out of the question, but it's just something that I think we've gone further and further away from, and I think that we definitely try conservative management and I'm glad to see that's what most people here are talking about with these types of patients.
NICHOLAS COLYVAS: I think the unloader brace is probably underused. I use it a lot for those patients who have medial or lateral disease predominantly. I put in this little PRP idea here because as we heard just heard from Drew, you know, early osteoarthritis, that might be something we consider. I think we're going away from Visco largely, cortisone on an individual basis.
NICHOLAS COLYVAS: And ultimately, yes, surgery. You might consider that if nothing else is working but this is a tough group because some of them, you know, they're young, they're too young for a knee replacement, but they're having a lot of symptoms so that sort of is my very last choice here. OK, so moving on. 61 year old, we're getting older. This gentleman had no problem with his knee previously. Stepped off a ladder.
NICHOLAS COLYVAS: He twisted the knee and immediately had medial pain. So he comes in to see me and he's got some mild swelling there. He's definitely got some medial joint line tenderness, some meniscus signs. So we're already got a pretty good from the history and physical exam idea. Here's his X-rays, OK? We've got, you know, reasonable maintenance of the joint spaces.
NICHOLAS COLYVAS: I mean, at 61, I wouldn't mind if my X-rays looked like that. If you look at it carefully, there is a bit of narrowing there. And then we get the MRI and there's a subtle little oblique tear on the coronal here, but you can see that meniscus is in place. Cartilage surface looks reasonably good, but there's definitely a tear there. You can see it on the sagittal too.
NICHOLAS COLYVAS: These don't project quite as well, I'm sorry. But here we go. So this is a gentleman, 61 years old, previously active. Look at the type of tear. It's not a flap tear. It's not a bucket handle tear. It's actually a relatively sort of benign tear. You know, could be very stable.
NICHOLAS COLYVAS: Underlying condition of the knee is pretty good and his associated injuries, he doesn't really have any. So physical therapy, conservative treatment for this guy, it is medial sided. You know, an unloaded brace is certainly a reasonable choice. PRP, stem cells, I'm just keep throwing that one in there. I'm not getting very many buyers on that one. And then what about surgery?
NICHOLAS COLYVAS: This guy's, you know, he's got, he's got a tear. He was previously asymptomatic and now he's got symptoms. Probably a pretty easy little tear to take care of. What are we thinking here? And the winner is. Physical Therapy. 20% of you said an unloader brace. No one wants to do the stem cells yet.
NICHOLAS COLYVAS: Drew must be really upset. And surgery. Some of you said. OK, so what did I do? These are all real patients. These are all my patients that I've pulled out of my files. What did I do with this patient? I talked to him quite a bit about the surgery, but I offered him basically both choices, and I think this is the type of patient
NICHOLAS COLYVAS: you can do that. I think that if the patient really aggressively wants to work to getting this sort of, quote unquote, taken care of, surgery is a reasonable choice here. This is a sort of you know, on the borderline. I think most people and certainly if we were talking to our residents and talking to them about their in-training exam, we go with the conservative treatment,
NICHOLAS COLYVAS: OK. And this is what we did. He chose to go conservative treatment and we did an unloader brace and physical therapy and we gave him some time. And at about three or four months, he came back and he said it's a bit better, but it's still a problem. And you know, what else can we do? And I didn't talk about any of that, and I said, let's go ahead and do the surgery.
NICHOLAS COLYVAS: And at the time of surgery, actually, you could see this meniscus was pretty trashed. It actually, it actually probably wasn't going to get better. He did very well after the surgery. But I think it's important to know that there's, you know, these are the patients whose cartilage surface looks beautiful. He's 61 years old, and that looks really good.
NICHOLAS COLYVAS: So you know, he's done well in the short term, probably will do quite well in the long term because most of that meniscus is still in there but this piece was obviously getting in the way and I think the standard approach remains and should remain that this is probably something you want to try at least conservative treatment and if it doesn't work, not all of these tears are ones that you can operate on.
NICHOLAS COLYVAS: Some of them operate on, and they do well. All right. We're sticking with the knee. Now we're kind of moving to something a little different. This is JS. She's one of my patients. She's 63 years old, and she's obviously quite active. She's a skier and March was skiing, had an injury where essentially her left knee collapsed and she went down and she heard multiple pops.
NICHOLAS COLYVAS: So, of course, that's now got you very actively thinking about something. Has something bad has happened in there? She actually got down the hill and we know from, I think some of the previous talks you heard that getting down the hill is quite difficult if you've blown your ACL. But when we listen to the rest of her history, she's had not so much pain, but she's really describing a bit more instability.
NICHOLAS COLYVAS: So when we examine her, she's got a 2B Lachman, her pivot shift is positive so sure enough, she, she must have an ACL tear and her X-rays show very minimal changes as far as her degenerative change in her 63 year, 63-year-old knee. But clearly has an ACL tear and fortunately for her, she doesn't have any meniscal pathology. So our
NICHOLAS COLYVAS: issue here. Our diagnosis here is clearly an ACL tear, but this is an ACL tear in a 63-year-old. But I think you have to consider activity level, what her health is in general and what her symptoms are. Right? Is she having pain or is she having instability? She's having instability.
NICHOLAS COLYVAS: What are we going to do with her? 63 years old. You know, our typical ACL patient is 25. 17, 63 is pretty up there. What's our, what's our, what's our concept here? Any indication for a cortisone injection? Again, PRP. Boy, it's really, really up there, isn't it?
NICHOLAS COLYVAS: OK so we've got virtually none for these, which I think is totally appropriate. Everybody's, everybody's been getting the message. Physical therapy and a brace and surgery. There's quite a few people who want to do surgery on her. That's, you know, that's, that's impressive. This is a sort of a controversial area.
NICHOLAS COLYVAS: The, the, the ACL reconstruction in the patient who's more than 40 years old and this is not a 40-year-old patient, by the way. But the ACL reconstruction in the older patient, I think is something that has to be taken on a case by case basis. I can tell you in the last five years, I've got about 6 over 60-year-old patients and that's probably more than most of my colleagues.
NICHOLAS COLYVAS: It's not a common thing that you will see. Part of that has to do with they do quite well with conservative treatment. A lot of it is because their knees at over 40 years old let's say, have already started to develop some changes that stabilize them. They've already got stiffer knees. They're already developing sort of early arthritis in their knees. So although the studies like these show that these patients can do well with ACL reconstructions, I think it has to be on a case by case basis.
NICHOLAS COLYVAS: Now, this patient I actually started with the physical therapy in ACL brace, and she did come back to me at about six months after that and said, well, this is just not working and we did an ACL reconstruction on her and she's doing great. So I think that this is that older ACL patient, the younger ACL patient, I think is easier to determine what you're going to do unless you read a lot of the European Studies and the European literature where they're quite non-operative for younger patients
NICHOLAS COLYVAS: and in this part of the world, there are younger patients, almost all get ACL reconstructions. But the older patient is one where I think you really have to look at it on a case by case basis. And are there any other orthopedic surgeons in the room? Good. I've got a 73-year-old ACL reconstruction. Just just to let you know, there are just those rare patients that you will do that on. OK, let's keep going.
NICHOLAS COLYVAS: So this is a patient referred to me by Wendy. Is she in here? She's, she's gone. She's there. She's there. OK. 53-year-old. No prior problem in her knee, but she's not a particularly active person. She was getting up from a squat position and she felt this distinct pop in her knee.
NICHOLAS COLYVAS: So any time you see that on the history, obviously you're immediately thinking about some kind of a structural problem. She had pain immediately and then slowly developed some swelling. And she has a history of hypertension and type 2 diabetes. On her physical exam, she's you know, kind of up there, limited range of motion to some degree, although she's got a bit of a bigger knee
NICHOLAS COLYVAS: so maybe she doesn't actually go that much further. Tenderness sort of diffusely on the medial side and posteriorly, but her alignment and her knee stability is pretty good. X-rays. Not a lot of arthritis in here. Doesn't look too bad. But then when you get the MRI and again, if you've looked at a lot of MRI's, you look at this and that medial meniscus is intact, but it kind of looks like a melon seed that's being popped out of the knee.
NICHOLAS COLYVAS: It's kind of being what we call extruded. It's being, it's kind of being pushed out of the knee a little bit there. And when you look at the posterior horn of the lateral meniscus, it comes all the way and attaches, and here there's a pretty clear tear there at the posterior horn. And that's right in the root area so when you get a sagittal, you look at that and that's what's called the ghost sign, that meniscus.
NICHOLAS COLYVAS: This is the normal kind of look of the meniscus, dark black. Here, there's more of a meniscal remnant, a ghost of the meniscus. And on some of them, you can get the axial and you can actually see the meniscus here. This is the medial meniscus. You can see that it's detached there at the root. So this is something that we call a root tear, but essentially it's a meniscus tear in an overweight,
NICHOLAS COLYVAS: older patient. Got some co-morbidities. You know, there's some degeneration in that knee. And the question is, what do we do with this patient? Right. It's physical therapy, medial unloader brace. This is a very sort of aggressive options. You know, three surgeries and one conservative management, notice, no PRP.
NICHOLAS COLYVAS: We finally learned our lesson that PRP is not going to work for any of these. So, you know, this surgeon really wants to get to the OR, but he's not quite sure what he wants to do. So what, what, what? Help us out. What are we going to do for this patient? What is the, what is the audience response on this one?
NICHOLAS COLYVAS: His cortisone right here. I mean, we can probably do some right now. OK, so. Physical therapy, conservative treatment, unloader brace. I always like that. Most of my patients are this age group come in, they walk out with that number one option. Number two, meniscectomy.
NICHOLAS COLYVAS: OK. That's our previously most favorite orthopedic surgery for sports medicine doctors. Meniscus repair in a 50 something year old. A lot of people like that option. And then a partial knee replacement, some people are already going to go to that option. Why did I put all of these here? I mean, these are sort of quite aggressive and this is, you know, pretty straightforward.
NICHOLAS COLYVAS: The story really goes forward a little bit. This is, so obviously we did do some surgery here and I'll go back to conservative treatment. But this is that tear. This is the meniscus coming along and it should go all the way here and actually attach to here. This is a tear at the root OK, and this is another patient of mine just to make it look clearer.
NICHOLAS COLYVAS: But this is the tear here. This, that meniscus should be attached down to right there where the root is and you can see it's ripped off and it's sort of flopping around now. So that meniscus, the meniscus itself isn't torn. This meniscus here looks pretty good. You know, it's in reasonable condition. It's just ripped off the root there.
NICHOLAS COLYVAS: The problem with that is that functionally a total meniscectomy, that is as good as what we used to do when we used to go in. Fortunately, I was never part of this generation but you know, there are still people around that are walking with their quote unquote cartilage removed and you talk to them and they've got a big osteotomy, a big scar where they've had their meniscus removed
NICHOLAS COLYVAS: and that was the treatment in the 60s and the 70s. If you had a meniscus problem, just take it out. You don't need that meniscus. Just take the whole thing out. And this type of tear that we're recognizing more and more, this root tear is essentially the functional equivalent of taking the meniscus out because it no longer is attached to that root and it is now extruded. It's out, you know, out into the soft tissues
NICHOLAS COLYVAS: and it's not providing the same protection. So, you know, there's been a fairly decent amount of biomechanical studies that show that this actually refixing that and repairing that is actually quite helpful and in terms of restoring the biomechanical function of that meniscus and the clinical data is still a bit early. This is a, this is a level three study so it's not a one or two study, but it shows you that same concept where if you take that torn meniscus, that sort of floating here, you tie it back down to where it's supposed to be and you restore that tension on the meniscus.
NICHOLAS COLYVAS: You essentially improve survival of that knee, and though, and fixing it actually doesn't maybe doesn't fully prevent arthritis, but it certainly helps. And this is from that same study. This is the meniscectomy patient where they went through and obviously lost that meniscus and that protective effect and ended up with a total knee. And this is, you know, probably they chose their best one here,
NICHOLAS COLYVAS: but this patient, of course, had a root repair and seven years later, they still have a perfectly good knee so this knee was actually saved. So if I go back to the audience response here. I think that the natural tendency for anyone in this age group with a meniscus tear, absolutely, that would be what I would do.
NICHOLAS COLYVAS: But the reality is that for these patients, we now believe 2018, these should get surgery. These are ones that we should get into the operating room and repair that meniscus. Where it becomes difficult is what about that patient who has fairly severe arthritis at that point? You know, this patient didn't have it too bad, but you know, that patient that's massively overweight or is badly aligned, they're probably not going to get quite the same benefit.
NICHOLAS COLYVAS: But there's still something you want to consider. But a root tear, if you get that report from your radiologist, probably best to go ahead and send that patient to your local surgeon. OK how are we doing on time? We got a little bit more. Let's go ahead and talk about some shoulder stuff. OK. We've switched from the knee. So this is a patient of mine who's a 49 year old, used to be a very active swimmer for the Olympic club, still has sort of retired from competitive swimming, but still really likes to swim twice a week.
NICHOLAS COLYVAS: And he's developed this sort of progressive shoulder pain over about six months, and I see a lot of these type of patients, not acute traumatic injury, but definitely pain that's limiting what he wants to do. His range of motion, he doesn't quite have full range of motion, his impingement tests are positive. Dr. Marr showed you how to do all of those today. His rotator cuff strength
NICHOLAS COLYVAS: if I test him, he definitely has normal strength, but it's painful when he does it. And we did some of the labral tests which we all know are not very definitive, but nonetheless, they weren't definitive in this case either. And he does have a little positive pain with cross arm testing but when you push on his AC joint, it's not that bad. So in my practice, this is not an unusual set of circumstances to find.
NICHOLAS COLYVAS: You get an X-ray and it doesn't really have any arthritis. Nothing very dramatic here. You can't see the AC joint very well on this view, though, you can see that that's a pretty narrowed and tight AC joint here. But the rest of the shoulder X-ray is not very remarkable, and you get an MRI and you show there's definitely a labral tear here. Sub scap is OK.
NICHOLAS COLYVAS: That one doesn't project very well at all but there's some rotator cuff tendinosis and probably a partial articular surface tear here. Not a full thickness tear, not a retracted tear. And his AC joint, true to what we looked at in the X-ray of looks pretty, pretty, pretty bad. And we said he's, you know, he's in his 40s. So the question here from a clinical point of view is, you know, what is the main diagnosis?
NICHOLAS COLYVAS: What are we looking at here? Is this more of a rotator cuff tear or is this more of a labral tear? Is the AC joint the predominant issue here? And with all that in mind, what do we think the next step is? What is everyone going to do with this patient next? Is there something you want to, I did throw PRP in here just to keep it consistent. And I'll tell you, the incidental story is I had a very similar personal issue with my shoulder, similar symptoms
NICHOLAS COLYVAS: and one of the doctors in our office was trying to practice doing PRP injections and I was the guinea pig. And I got better but I don't know if it was that or time or just laying off it, but I'm not recommending it put it this way, and none of you are either. That's good. OK. So physical therapy, cortisone injection surgery. A few of you want to do surgery.
NICHOLAS COLYVAS: That's great. I think I need to know who you are and you can send me these patients. So I think that this is a patient where these two are clearly the first two considerations. And physical therapy would almost 100% be what I would do unless the patient was very aggressively looking for further treatment and maybe to move his treatment forward.
NICHOLAS COLYVAS: But in addition, what I sort of wanted to highlight and talk about with the cortisone injection is that this is not just, and certainly in the shoulder, it's not just a therapeutic tool. It's also a diagnostic tool. Right? I'm not 100% clear. I think that the majority of the problem is the rotator cuff, but I'm not 100% clear with what we have here.
NICHOLAS COLYVAS: Whether or not that AC joint is really a problem, it looks bad but, you know, many people have pretty nasty looking AC joints and they're fine. So the cortisone injection is a way for me to help get some diagnostic information as well. And this patient just got better with physical therapy. Simple as that. We didn't do any surgery. We didn't have to worry about anything.
NICHOLAS COLYVAS: But if he hadn't, I would have gone next to the cortisone injection and try to determine whether there was really. I'd put a subacromial space injection in there. More than likely, that would make him significantly better, we would know that's where the problem was. I think 90% of my patients or more get better in this type of patient, get better with physical therapy and cortisone injections.
NICHOLAS COLYVAS: So this is a very conservative treatment, I don't get excited about the partial rotator cuff tear and all that kind of stuff. Some of the patients do, but I think you just have to be conservative with these type of patients. You know, the rotator cuff tears is they're very, very common. It's an older age group typically, asymptomatic tears in, you know, 30% of seven year olds, seventy year olds, 50% of 80-year-olds
NICHOLAS COLYVAS: so it's very conservative treatment. But one of the things that I think and physical therapy is very effective for rotator cuff tears, but one of the things I think that we want to be careful of is that there are certain variants of rotator cuff tears that we want to be a little bit more careful about. So here's an example. This is a 53-year-old. He's not the world's healthiest patient,
NICHOLAS COLYVAS: and he decided that he would try a hoverboard and I haven't put the rest of the history here because we all know what happened. So in he comes and when we examine him, he's actually a few weeks out and his passive range of motion is good, but he just can't lift his arm up. He's, he's got very limited range of motion in his arm and you test his supraspinatus and infraspinatus and he's very limited.
NICHOLAS COLYVAS: But there's some pain there, he's neurovascularly intact and you get the MRI and here's his MRI and this is the end of the rotator cuff. Instead of attaching here, it's here and there's a nice big gap there. So he has a distinct full thickness, retracted rotator cuff tear. But he's not the healthiest guy and he's a little bit older and what are we going to do with this guy?
NICHOLAS COLYVAS: Sorry, ACL brace. Let's just, that one, that one failed the editing process. I apologize. So just cancel ACL brace. It's physical therapy, cortisone injection, PRP, of course and surgery. Let's see what our collective wisdom is here.
NICHOLAS COLYVAS: OK. Physical therapy. No ACL brace. Surgery. About half of you want to do surgery on this guy. Cortisone injection, A little bit. And somebody wants to try some PRP. Good. Acute rotator cuff tear, it's a different entity to the chronic, slow developing pain. This is someone who didn't have a problem before.
NICHOLAS COLYVAS: Even if their MRI shows some changes if there's clearly been a situation where this guy was lifting and carrying tiles into the bathroom beforehand and now he can't lift his arm up like that, all I would say is get an, get an MRI and just rule out the fact that this is something that is a tear or not, because if it's just pain and you can sometimes get that information with an injection and you can inject those patients
NICHOLAS COLYVAS: and if their function suddenly comes back and they haven't been able to lift because they've just been in pain, then OK, that might be OK. But I would say this is a population that you want to get the MRI early and you want to get them to the orthopedic surgeon early because acute rotator cuff tears usually are better off with surgical treatment than conservative treatment there.
NICHOLAS COLYVAS: The non acute surgical rotator cuff tears are something that we would mostly treat conservatively. Acute ones, we really want to think about doing surgery early. How are we doing on time? I think we're, one more. OK. Colin's really into it. A quick mention. Labral, tears, almost never something to worry about in an older patient group.
NICHOLAS COLYVAS: Yeah. OK. Young, overhead athletes. We can talk about that in more detail, but don't worry about the labral tear on those patients. So let's go back to a younger age group. 26-year-old. At 16 years old, he dislocated his shoulder. Didn't do surgery and did well with physical therapy so he went for 10 years and then had another traumatic fall and dislocated the shoulder again, had to have it reduced in the ER so this was a pretty significant amount of trauma.
NICHOLAS COLYVAS: Now he's doing OK, he's not having a lot of pain. His exam shows he's got a good range of motion. He does have a little bit of weakness but his apprehension and relocation tests are positive and he has some instability in there on testing. This is his X ray, unremarkable as you would expect. Maybe you could read a Hill-Sachs lesion there and the MRI shows he has a Bankart lesion,
NICHOLAS COLYVAS: your classic anterior dislocation sign. The glenoid bone stock is good and he's got a small Hill-Sachs lesion. So this is a sort of a classic anterior dislocation. You know, 90, 90% plus of your patients are going to be anterior dislocations. But, you know, he's kind of young, 26. The injury was traumatic, this is not a voluntary dislocator. He's not having a lot of pain right now, but he hasn't returned to activities and his imaging is not that dramatic.
NICHOLAS COLYVAS: OK. So what are we going to do for this patient? Put another ACL brace. OK. Full disclosure. This was done at 4 in the morning, this morning. I'm surprised that not more, but maybe John corrected some of it before it actually got here. But OK, so. Audience response is. Dada.
NICHOLAS COLYVAS: Whoa, surgery, I like these guys. OK. Why surgery? So actually, I think initially you're going to think about doing some of the physical therapy and all that sort of stuff to maybe get their strength back. This guy was a little bit weaker but the reality is, anyone who has had two dislocations is almost 100% likely to go ahead and have another one
NICHOLAS COLYVAS: and it's going to happen at some point in time unless they somehow dramatically change their activities and everything. This is a patient that's going to dislocate again. We get really good results with arthroscopic Bankart repairs on these patients. So I think the discussion with the patient is, yes, we can do all this again. You probably would do OK with these,
NICHOLAS COLYVAS: you did OK the first time around, although that's unusual, right. 16-year-old who has a primary dislocation. You know, there's some sort of movement in the orthopedic world to fix those patients immediately, to do after one dislocation in the young patient to do an arthroscopic stabilization. But in reality, I think what we do mostly is we give those first time dislocatiors a bit of time, and we physical therapy
NICHOLAS COLYVAS: and if they prove that they've dislocated again, they get another surgery. If you're dislocated more than twice, you're going to dislocate again, it's time to really think about the surgery. So in summary, surgical decisions are not straightforward, but you guys all did really well. I mean, you know, there was a much better than me with the ACL braces.
NICHOLAS COLYVAS: Usually we do conservative treatment and save surgery for later, but really surgery is sometimes necessary on an early basis. Happy holidays to everybody [APPLAUSE] and thank you very much. [VIDEO ENDS]
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