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Surgery or Not Surgery (Labral Tears) Case Discussion: Nicholas Colyvas, MD
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Surgery or Not Surgery (Labral Tears) Case Discussion: Nicholas Colyvas, MD
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Segment:0 .
NICHOLAS COLYVAS: Thank you, Carlin and thank you to all the members of the team Carlin and the rest of the team for the opportunity to come up here today.
NICHOLAS COLYVAS: Good to see a few familiar faces in the crowd, and I'm hoping that we can make today's talk somewhat fun. It's going to be quite interactive, so get your little clickers out and we'll get started. So first of all, I have no disclosures that are relevant to this particular talk. And our format today is going to be some case reviews. And as Carlin says, hopefully that's going to pull together some of the information that you've been absorbing this last day or two.
NICHOLAS COLYVAS: And you're going to participate and tell me what we're going to do. And the answer is always surgery, because that's we're surgeons right? So everyone is just going to answer surgery and then we'll have a discussion about it. So we'll start out with the knee. And this is a patient of mine, and he actually played for the Mustangs, which was the team that should have beaten Doctor Marr's team and be at the State Championships.
NICHOLAS COLYVAS: They've been before, but we didn't make it this year. And he was their star football player and twisted his knee on the field, came off, came into the office the next day. His exam showed a swollen knee. He was stable. His, his anterior drawer Lachman pivot shifts were all negative, but he clearly had a very distinctively tender lateral joint line and a positive McMurray's. X-rays as we would probably expect were negative.
NICHOLAS COLYVAS: And when we looked at his MRI, there was a clear problem here with the lateral meniscus. The medial meniscus, posterior horn here looks good, but we're missing some lateral meniscus there and on the sagittal, there's a piece of meniscus where it shouldn't really be. It's sort of flipped under and trying to go down the back there. So our diagnosis here pretty clear.
NICHOLAS COLYVAS: This is a lateral meniscus tear. And when we decide what we're going to do for this patient and any of our patients, of course, we're going to look at various factors. And the ones that I typically look at most actively are going to be the patient's age, their physiological age. We talk about physiological age more than chronological age, their activity level. That's both what they're doing and what they want to do.
NICHOLAS COLYVAS: And when we're looking at a meniscus tear specifically, we want to know what type of tear we've seen. This one is a flipped tear of the lateral meniscus. We want to know what the underlying condition of the knee is. Ben Marr talked about those worn out knees. We're going to be a little aggressive, a little less aggressive about treating a badly arthritic knee than we are in a 17-year-old.
NICHOLAS COLYVAS: And what are the associated injuries? While decision is based on not just what that meniscus looks like, but what that ACL looks like, what that MCL looks like. So what is the audience going to tell me to do on this patient? Are we going to do physical therapy and see how he does? Completely shut him down for a while? Stem cells, we heard about, expensive. Maybe that's the right answer
NICHOLAS COLYVAS: or how about surgery? Boom. OK, so the majority of you are helping me out here by recommending surgery. Some of you think that this is something conservative and there may be a place for a conservative treatment in this situation
NICHOLAS COLYVAS: but I think that the real answer here is surgery and the reasoning goes back to our considerations. This is a young patient. He had an acute traumatic injury. It's an unstable tear. It's flipped. It's only going to get in the way. It's mechanical.
NICHOLAS COLYVAS: The underlying condition of the knee is excellent. It's pristine. This is, this is a young patient. He's got a perfect knee other than his meniscus and he has no other associated injuries. He does not have an ACL injury associated with this. So for this kid, we definitely did surgery and he did well. Got back to playing.
NICHOLAS COLYVAS: Repaired that meniscus, long recovery with a repair but got back to playing and everything is fine. OK so let's move on to something a little bit more complicated. 46 year old, still young in my book, had a history of a prior ACL reconstruction, did well 10 years ago. Now's got progressive medial pain, is reasonably active, but not really an athlete of the sort that we just saw and has no significant instability
NICHOLAS COLYVAS: so his ACL did well. He's nice and stable in his knee and he comes in and he's got an effusion there. It's small, but his knee still is stable and he's got tenderness in the medial and the lateral joint lines. His McMurray's and Thessaly's on both sides are positive. So we get an X-ray and you can see there's got a big screw in here and he's got some early arthritis of the notch here.
NICHOLAS COLYVAS: And if we look at the medial and lateral joint lines, they're somewhat preserved. He hasn't fallen into complete arthritis yet, but if you look closely, you'll see there's some chondrocalcinosis in those joint lines. So there's some degeneration and his patellofemoral joint, his knees sort of midway wearing out at this point. It's still like I said, there's still joint space and it looks reasonably good.
NICHOLAS COLYVAS: And we get an MRI and the radiologist's report comes back and says, OK, he's got medial and lateral meniscus tears. So same set of considerations again. What is the patient's age and their activity level? somewhat older patient here and you know, not moderately active, not a high level athlete. The types of tears, these are more degenerative type tears and the underlying condition of the knee, it's got some wear and tear on it and associated injuries.
NICHOLAS COLYVAS: No, his ACL is good. So what are we going to do? Physical therapy. You know, we do use braces quite a bit with patients. We've got a series of injections we can use or of course, we can do surgery. OK, so a small percentage of you wanted me to go straight to surgery.
NICHOLAS COLYVAS: And I think maybe when I came out into practice now that's, you know 20 years ago, anytime we got a radiologist's report that said meniscus tear, lateral medial or both, we were booking that patient for surgery. We were rushing to surgery to do to fix that patient's knee because they had meniscus tears. Those were clearly a problem. Well, we've discovered over time, that actually physical therapy is probably exactly where we want to be
NICHOLAS COLYVAS: for the first choice. An unloaded brace is a good idea in many of these cases, but this is bilateral or at least medial and lateral. So it unloaded really puts you on one side or the other so if it was all medial sided disease, a medial unloaded brace would be a good choice and injections and cortisone in my practice, I think we certainly try with the physical therapy first, then go to the cortisone and move on from there.
NICHOLAS COLYVAS: I think this has changed over time. There may be an older generation of Orthopedic Surgeons in your communities that still operate on these as the first line choice. Sorry, but starting about 10 years ago, studies started to really come out in the bigger journals showing that surgery versus physical therapy for these degenerative tears really has no significant difference
NICHOLAS COLYVAS: and these patients can be well treated with surgery, sorry, with physical therapy. And even if you do sham surgery on these patients, they don't get, as Dr. Marr mentioned, they don't get much better anyway. So we really have shied away from these degenerative tears being surgical things. In my practice, we definitely try conservative management first for these patients.
NICHOLAS COLYVAS: Most of them will get better with physical therapy and/or a combination of injections, activity, modifications, and we have started using some PRP. Again, it's a little bit experimental, but at this time, certainly from a data point of view, but there's a lot of patient demand for it so I think we're becoming more active in using PRP. I think there's going to be a place for it. It's not fully defined and we do end up doing surgery on some of these patients
NICHOLAS COLYVAS: but to make the point clear. Degenerative tears, it's usually a non surgical treatment to start with. OK, so let's keep going. 61-year-old, a little bit older now, this is another knee problem. This gentleman was doing fine, but stepped off a ladder and twisted their knee and now comes in with medial pain. So not all my patients have medial meniscus tears, but a lot of them do.
NICHOLAS COLYVAS: But the examination here shows that some mild swelling, tenderness in the medial joint line and a positive McMurray's and Thessaly test. So we've presented a patient that's very young, straight to surgery, one that is a little older, but, you know, conservative treatment. This patient has X-rays that look like this. So this is a 61 year old, there's good joint space on both these knees.
NICHOLAS COLYVAS: You know, I hope at 61, my knees look like this. And we've got an MRI here and here we have a small tear. It's sort of a oblique tear in the posterior horn here. And it's, you know, out towards where the blood supply is, pretty good in the meniscus. You can see it again on the sagittal. This is not a large tear. There's not a lot big flap component.
NICHOLAS COLYVAS: There's not bucket handle here. But it is an acute tear in an older patient who's actually doing quite well in terms of their physiological condition of the knee. So again, we look at the considerations a bit older, reasonably active. The type of tear is a small. We would consider that probably a stable type tear. The underlying condition of the knee is good and no significant associated injuries.
NICHOLAS COLYVAS: So what are we going to do with this patient? You know, there's a place for physical therapy. We could unload that medial compartment, get that pressure off there. We could use PRP or even stem cells to help that grow or, you know, the ever present option of surgery.
NICHOLAS COLYVAS: OK so people here like physical therapy, and I think that's a very good idea. This is an older patient. It's not an unstable tear with a large bucket handle component. I think this is the type of patient which we would have some consideration for surgery, but lean more towards conservative management. I don't think you could fully criticize the option for surgery here.
NICHOLAS COLYVAS: I think it would be a choice. But in our practice, certainly we are more conservative and go with conservative treatment, which is what this patient underwent, had physical therapy and even got a cortisone injection. A fair amount of time to declare which way this was going to go but he continued to have pain, unable to play his golf and tennis so what do we do next?
NICHOLAS COLYVAS: We've tried the physical therapy. You could always try more an unloaded brace. Again, is not an unreasonable option to try and unload and see if that helps. PRP and stem cells surgery. OK, so surgery. And in fact, that's what we did here. You can see that this is a macerated meniscus.
NICHOLAS COLYVAS: It looks worse than it did on the MRI. Those people who chose surgery in the first place might have been that was the correct choice but I think that we usually want to give these patients a trial of conservative management first. This patient has gone on to do great. And it just points out that even in an older patient, 61, there's still a role for meniscus surgery. There's a lot of bad press about doing meniscus surgery, but it really focuses on those degenerative patients.
NICHOLAS COLYVAS: This is an acute tear. This is a patient whose cartilage surface is in good condition. So this is the type of patient who will do well with the surgery and is very happy after we're done. OK so moving on with our knee series here. This is a 63-year-old patient. Again, I'm going to call this patient relatively young and skiing, fell, heard multiple pops in her knee which always makes you think about ACL's.
NICHOLAS COLYVAS: She was able to ski down with a ACL it's kind of difficult. But once she got down, she was clearly done. And when she came to see me in the office a couple of weeks later, she's got minimal pain. Her swelling, which was immediate, has gone down. She wore a brace. And really her main symptom is instability. So less pain and more instability. And when we talk to her, she's a very active 63-year-old.
NICHOLAS COLYVAS: She loves to hike. She lives up in the mountains and really, really needs to have her knee for all these activities. So physical exam is unremarkable but very clearly when we do a ligament exam, she has a 2B Lachman and a positive pivot shift. So no surprises here when we look at her X rays, she's got a decent looking knee, you know, some narrowing, something you would totally expect for a 63 year old, of course.
NICHOLAS COLYVAS: But she has an ACL tear and the MRI shows us that the meniscus and the other structures are intact. So we go through our considerations again. Older patient, but physiologically actually somewhat younger, right? She's very active, not overweight, good alignment, knees in reasonable condition. Her activity level is high, her general health is good and what are her symptoms?
NICHOLAS COLYVAS: Is she complaining about pain a lot because that's a different set of that's a different algorithm to someone who's complaining about instability. So given what we've talked about, what are we going to suggest for this patient?
NICHOLAS COLYVAS: OK so 29% versus 30%. Pretty close there. But there's a distinct interest in doing ACL surgery overall compared to conservative management. I think this one, you know, everyone's right here. And this brings out some of the difficulty of what we're looking at.
NICHOLAS COLYVAS: So it's obviously difficult when I'm just presenting some select facts to go into what we do on what patient. But, you know, in this patient, you certainly could try physical therapy in an ACL brace. I think that's a reasonable choice. She's very active and so would probably not do as well with this. As someone who said to you, well, you know, I'm 63.
NICHOLAS COLYVAS: I've decided to hang up my boots. I'm not going to do skiing anymore. I just want to play golf and tennis. If that's what they're telling you. I would probably lean heavily towards physical therapy in the ACL brace but as presented, we talked about that she wants to stay active. Her main symptom is not pain, it's instability
NICHOLAS COLYVAS: and so I think surgery is a good choice for her. I put this up here because we really have some strong data now showing that in younger patients and the cutoff for that is probably 30, some people use 35, some use 25. But patients younger than whatever number you want to use don't do as well with allograft. They have a much higher failure rate with allograft. So in younger patients we tend to use autograft. But in older patients like this, it's probably not going to make too much of a difference.
NICHOLAS COLYVAS: And this patient actually underwent an allograft, ACL reconstruction, did well and is back skiing and doing everything she wants to do. And the point here is that we oftentimes think of the older patients and that has that age has gone up to 40 to 50 now and is steadily climbing, but that older patients, we don't tend to want to do ACL reconstruction surgery,
NICHOLAS COLYVAS: there is some definite negatives to doing ACL reconstructions in patients who have arthritis, but in the select patient that is older, that has a younger looking knee that does not have a lot of arthritis, whose main problem isninstability, not pain. It's a good surgery and is something that really yields good enough results good as you would find in a younger patient as well. So this is very clearly a case that really is the guiding principle of all surgery, which is patient selection.
NICHOLAS COLYVAS: If you collect, if you select the right patient and really not are not operating on just everybody that comes in the door, you're going to get good results and have happy patients. OK, so more knees, 53 years old. OK so I guess that used to be called middle aged. I'm still calling that young. Prior injury. No prior injury. Was getting up from a squatting position, felt a distinct pop in the knee and had some swelling and the pain.
NICHOLAS COLYVAS: and this was about a month ago. But this patient is not super healthy, has type 2 diabetes, has hypertension and has, is somewhat overweight. BMI is 30. You examine them, now it's a month later. There's still a mild effusion. The range of motion is a little limited. It's about 125 on the other side, there's some diffuse tenderness, tenderness, medially and posteriorly, but overall, the rest of the knee looks pretty good.
NICHOLAS COLYVAS: Their alignment is good, their stability is good. And this is what their x-rays look like. You know, decent joint space alignment looks reasonable on these films. So what's your next step here in this patient? It's someone who's had an injury. They've got some swelling. It's, you know, subacute. It's a month later.
NICHOLAS COLYVAS: They're not a very active person to start with so what are we going to do next? I mean, very conservative treatment, a little bit more aggressive, more imaging to get you more information. What are we looking at? OK so non-weight bearing, anti-inflammatories, conservative management, throw in some PT as well.
NICHOLAS COLYVAS: Probably the most of you, the injections and as well, most of you. And then imaging, a small section of people would go to imaging and I think that, you know, we've got a patient who's had an injury. It's not a very specific injury. We would all tend to think about conservative management in this case. But the reason I'm obviously showing this case is there's something a little bit different about it.
NICHOLAS COLYVAS: And in this case, we would actually go to an MRI and the MRI shows a medial meniscus tear and I'm going to go back and explain why. But we would go directly to an MRI in this patient. And this is the tear that's shown up on this MRI. You don't see the tear on this coronal image here but what you can see is the medial meniscus and it's sitting a little bit outside of the joint. It's not sitting in the joint where it should be.
NICHOLAS COLYVAS: It's kind of extruded. Right that's what we'd call it, an extruded meniscus. And when you look at the posterior horn of that medial meniscus, there's a gap there where it's supposed to attach right at the root, right? This is the root of the meniscus and there should be an attachment here. So this is a root tear.
NICHOLAS COLYVAS: You can also see on the sagittal that where you should see a thick black triangle, you've got this sort of look to it that's kind of like it should be there. It's like a ghost of what it should be and we actually call this the ghost sign. This is a missing meniscus. And sometimes if you get a good, if you get lucky on your axial cuts, you'll actually see here's your medial meniscus
NICHOLAS COLYVAS: and then there's this gap right here. So this is a variant of a medial meniscus tear that we've recognized in the last 10 years or so is a root tear and prior to that, we had very little understanding of exactly what this meant. So knowing that this is a root tear, what would you recommend here? Are we going to continue with physical therapy?
NICHOLAS COLYVAS: We could put this patient in an unloaded brace or are we going to go straight to surgery? And then what do we do with surgery? Is this a lost case? Are we going to go straight to a knee replacement or is there something else that we can do? All right. So most of you want to repair this, but this is an older patient.
NICHOLAS COLYVAS: You know, some of these patients. I have I have some of these patients whose BMIs are 30, 35. Are there any other Portland orthopedic surgeons in the room? I can admit that I've done a patient whose BMI is 45, so it's not your typical young athlete meniscus repair. And I'll tell you that probably hundreds or maybe even thousands of patients before we recognize what this entity was, got partial meniscectomy, which is an essentially useless surgery for this type of condition.
NICHOLAS COLYVAS: The correct answer, as we're finding out more and more, is actually surgical repair, something called a root repair. In those cases where there is a fair amount of arthritis already, you might consider going straight to a partial knee replacement. If the patient has significant limitations and is really not doing well, fixing that root root fixing that meniscus root in those patients sometimes is just not going to work
NICHOLAS COLYVAS: and you can go to a partial knee replacement. But I think the majority of this would be something we would treat surgically and try and repair and this is what they look like. There's a clear gap here. This is the meniscus coming in here. Should attach right here. You should not see this gap. And this is, again, the tear at surgery. This is the meniscus coming along here.
NICHOLAS COLYVAS: You can see these are older patients. They have some arthritis. That's not a perfect looking intercondylar tibia here, but this is a tear. And what we're really dealing with is once that meniscus root is torn, it's a functional meniscectomy. It's like taking out your meniscus, which is what we used to do in the 50s and 60s is take out the meniscus
NICHOLAS COLYVAS: if it was a problem and we knew that all those patients ended up getting surgery or sorry getting arthritis young. So we now have very good biomechanical data that shows that making that root, fixing that root will actually restore the biomechanics of the knee. The clinical data is coming along and there are studies like this that show that if you do repair that root, this is what that repair looks like.
NICHOLAS COLYVAS: You take stitches down there and you put it through into a tunnel that you get decent results at five years. This is an example of doing a partial meniscectomy for a root repair for a root tear. Here's what it looks like initially when the root tears. This is a few years later that knee is not salvageable. It goes on to a total knee. This is what we're finding in some studies now, seven years later, that that medial meniscus is holding up and still providing the joint with good biomechanics and saving that patient from a knee, knee replacement.
NICHOLAS COLYVAS: So the take home point really going back to our presentation on the initial presentation of this patient is you've got to have a high index of suspicion. These are usually older patients, i.e. the classic would be a 50/55, oftentimes overweight, oftentimes some early degenerative changes in the knee and it's usually a hyperflexion or getting up from a squat or a relatively minimal amount of trauma and a sudden change to a significant, you know, my knee used to ache every now and then, too
NICHOLAS COLYVAS: well, it just really hurt a lot. I felt it pop and there was a lot of swelling. Those patients have a little extra suspicion in your head that they maybe have a root tear and maybe go to an MRI sooner. Certainly your average just sort of my knee started hurting more, you would go with those conservative things but I think we the sooner we get to these, the better. So think about an MRI for those patients. All right.
NICHOLAS COLYVAS: So let's switch to shoulder and look at a couple of things that we see very commonly. 49-year-old, this is a patient who swam competitively in college, still likes to swim, but has had progressive shoulder pain for six months. No specific trauma, but it does limit his swimming. His examination shows a little bit of limitation in his range of motion, impingement tests are positive.
NICHOLAS COLYVAS: Rotator cuff strength is normal, does report some pain with testing. Labral tests are equivocal, these non tender over the AC joint and there's a little bit of pain with the cross arm test. X-rays, joint space, no, not bad at all. AC joint looks a bit narrowed. And your MRI's showing that there is a little there's labral changes here with what the radiologists would report as a labral tear.
NICHOLAS COLYVAS: There's rotator cuff tendinosis not a frank tear, but maybe some partial tears. And here's his AC joint that's got some cysts. It's clearly not happy. So, you know, this is a patient that comes in with shoulder pain, but there's a lot showing up on that MRI report that the radiologist sends you. Are you worried about the rotator, as always right? They can't ever report a normal case.
NICHOLAS COLYVAS: You know, there's a every 54-year-old has at least three pathologies in there, even if they're asymptomatic. So are we worried about this guy's rotator cuff? His labrum, his AC joint? What can we do to figure out what's going on here? What's our next step?
NICHOLAS COLYVAS: OK. Physical therapy, cortisone injection, PRP and surgery. No one wants to go to surgery. Geez so, you know, we're looking at a scenario we see very commonly. There's changes in on the MRI. MRIs are very sensitive, and they are not actually helping us. They're confusing us more than anything else. So I think that this is very clearly one we would all really start with physical therapy.
NICHOLAS COLYVAS: The cortisone injection, I actually think is a good choice. I usually let my patients direct me as to their frustration level with these cases. So I'm really frustrated. I want to get this fixed as soon as possible. What can we do? Well, those ones might lean more to doing an earlier cortisone injection. Others, I usually say, let's do some physical therapy, see how that goes.
NICHOLAS COLYVAS: We can try an injection later. PRP for this particular indication, I think that's an appropriate number. We don't have any data to show that it works for this situation. I think we're going to find that there may be some place for it, but right now I don't think the data supports that and I think surgery is probably aggressive for this situation. You know, we look at rotator cuff tears, a big tear like that.
NICHOLAS COLYVAS: OK that's a structural problem. We probably need to fix that and we'll talk a little bit more about in who. But, you know, cuff tears are very common. They affect the older patients. And, you know, these studies that have been done about asymptomatic patients getting MRI's, showing tears of 51% in the older patients, 30%. These MRIs are really sensitive and they're picking up a lot of pathology that we have to really carefully sift through to be sure that we're actually getting what we want for our patients.
NICHOLAS COLYVAS: And, you know, these traumatic degenerative rotator cuff tears really are sort of a mainstay of what we see in our offices and I think that we really just want to say conservative treatment first for sure. Some of them will end up needing surgery, but certainly not the majority. And, you know, there's been plenty of studies that show that physical therapy is very effective for this.
NICHOLAS COLYVAS: 75% or so of patients will do as well with physical therapy as they do with surgery. So certainly want to consider conservative management for these sort of degenerative, non traumatic type tears. What about this 53-year-old patient? Not very active, does some work remodeling bathrooms so he is actually a laborer of some sort, but decided to try a hoverboard for the first time.
NICHOLAS COLYVAS: Great, great, great orthopedically devised instrument for orthopedic injuries. He's not the super healthy guy. Got a lot, got a lot of issues with high blood pressure and he's a smoker and his examination shows clear weakness in the supraspinatus and infraspinatus. Limited range of motion. He's neurovascularly intact. This is his MRI.
NICHOLAS COLYVAS: OK, so this is his supraspinatus, comes along here, comes to a sudden stop where it's supposed to end, over here on the end plate, and there's a fluid filled gap there. So this is an acute cuff tear in a patient that is otherwise not had a problem in the shoulder before. So what are our choices here? Next steps.
NICHOLAS COLYVAS: All right. So a lot of you want to go to physical therapy on this patient. And I think that, again, talking about rotator cuff tears, that's always a decent option. It might be the type of thing you would consider in this patient if they were very much against surgery or you feel there was a problem with their medical condition that you might want to avoid surgery.
NICHOLAS COLYVAS: But this is a different entity to our degenerative tears. This is a traumatic sudden change from a patient who's able to lift their arms up with no problem to suddenly coming in with this. Hey, you know, something's something's wrong. I've got a broken wing. And these ones, we tend to be far more aggressive surgically. And this is a patient who we would take to surgery. I think that's the correct answer.
NICHOLAS COLYVAS: The results of those patients with acute full thickness tears, especially with retraction that don't get surgery, are not as good as those that get surgery and in fact, the worse the case is, if you have a massive tear where the infraspinatus, the supraspinatus and the sub-scap has been torn off acutely, if you don't get that patient into surgery, they're going to have a significant problem.
NICHOLAS COLYVAS: They're not going to do that well with physical therapy, with surgery, they actually have a very decent chance of getting back most if not all, of their function. So we treat the, we treat the degenerative, non traumatic tears very conservatively. We treat the traumatic, clear, clear new finding tears far more aggressively. The take home is really you know what I've said.
NICHOLAS COLYVAS: They're common. They're very common in older patients and most times not surgical, but acute cuff tears is something we look at very differently kind of like the root tears in the meniscus. Most meniscus treatment is conservative. There are specific areas where we want to be more aggressive early on and that's the acute rotator cuff tear.
NICHOLAS COLYVAS: What about the labrum in this guy? You know, he's, you know, he had changes on his MRI. I don't know how many times I see labral changes on the MRI reports on any patient that's had MRI. It's very frequent. And we I mean, we don't ignore it, but we definitely take it with a pinch of salt when we see labral changes reported on the MRI and even we look at them and we see them and we can see those changes
NICHOLAS COLYVAS: but it's part of the normal degenerative process. If you have that young pitcher that is coming in and they've got an MRI with a labral tear we can talk about, that's a whole separate lesion, the SLAP lesion problem. But if you have like this last patient, that first patient, that first shoulder patient, a 49-year-old that has labral changes, it's seldom that is the problem. So we don't ignore it, but we definitely look for other problems
NICHOLAS COLYVAS: first before we really think that the labrum is the issue. So we've got a little bit more time just going to go. This will be our last case. Instability. 26-year-old dislocated his shoulder 10 years ago. He was 16 when he first dislocated it. And he didn't, didn't have surgery, did well, but then recently had a obviously traumatic injury falling while hiking, landed on an outstretched arm, clearly dislocated his shoulder, got relocated, and he's come back in and he's doing OK quote unquote. Exam.
NICHOLAS COLYVAS: You show he's got good, good range of motion. There is some pain with rotator cuff testing and his instability signs are positive right apprehension and relocation and you can actually physically translate him. This is the X ray, normal looking joint. There's a little lesion down here, but I don't think that that's of any significant relevance. You get an MRI on this patient, find the Bankart lesion, the glenoid bone is in good condition.
NICHOLAS COLYVAS: And there's a small Hill-Sachs lesion, which you could actually see right there. So our considerations. Age. Now, that's age at the time of this dislocation and age, at the time of first dislocation also very important. The nature of the injury was it traumatic or is he able to just pop it in and out by himself? What are the symptoms? Is it instability or is it pain?
NICHOLAS COLYVAS: And what does the imaging show? So what are we going to do for this patient? Put him in a sling and immobilize him for a while. Send him to physical therapy, cortisone injection to help control the pain or do we go straight to surgery on this patient? OK. Surgery. Good number of you pushing for that.
NICHOLAS COLYVAS: Physical therapy, conservative management also a decent number. So what is the main concern here is obviously the re-dislocation risk and we know that if you dislocate in your teens, you have a very high 90% or so likelihood of dislocating again and that surgery is probably a good idea the second time around. This patient dislocated at 16, actually did well and re-dislocated at 26
NICHOLAS COLYVAS: so I actually think there is a place for attempting conservative management here. You know, I couldn't argue with someone who said, we're going to try that first. I think that the data would show that there is still a very high risk for another dislocation. But, you know, a arthroscopic Bankart, not even an open one, does require a lengthy recovery and so you might want to think about a conservative approach in this patient.
NICHOLAS COLYVAS: I think the standard answer would probably be surgery, and that would be correct but this is one where there's a little bit of a grey area. And the reality is that most cases, if it's a young patient, we're looking at conservative management for the first time and then if they recur, if they have another dislocation, we're going to do surgery from them for them. And if we have those patients that are multiple dislocating now what we're doing is far more extensive stabilization procedures.
NICHOLAS COLYVAS: But the take home here is the young patient has a very high dislocation rate so we've got to consider surgery for those and in fact, there are some orthopedists around the country that are actually promoting first time dislocations, surgery right off the bat. And, you know, there's good data behind that so I think that we just need to be a little bit selective as usual.
NICHOLAS COLYVAS: Again, patient selection is everything. I think when we look at surgery, it's not always a straightforward, you know, we have algorithms, but we have to tailor that very well to the patient. Frequently we're going to go with conservative management, but there are some conditions that we are red flags for. Hey, this one will probably do better with surgery. And with that, I was, this was for the wet weather but apparently it's nice and dry today, so that's great.
NICHOLAS COLYVAS: But we're prepared. Thank you to everybody. And I'm happy to answer questions. We're a bit over time. [APPLAUSE] [VIDEO ENDS]
Segment:0 .
NICHOLAS COLYVAS: Thank you, Carlin and thank you to all the members of the team Carlin and the rest of the team for the opportunity to come up here today.
NICHOLAS COLYVAS: Good to see a few familiar faces in the crowd, and I'm hoping that we can make today's talk somewhat fun. It's going to be quite interactive, so get your little clickers out and we'll get started. So first of all, I have no disclosures that are relevant to this particular talk. And our format today is going to be some case reviews. And as Carlin says, hopefully that's going to pull together some of the information that you've been absorbing this last day or two.
NICHOLAS COLYVAS: And you're going to participate and tell me what we're going to do. And the answer is always surgery, because that's we're surgeons right? So everyone is just going to answer surgery and then we'll have a discussion about it. So we'll start out with the knee. And this is a patient of mine, and he actually played for the Mustangs, which was the team that should have beaten Doctor Marr's team and be at the State Championships.
NICHOLAS COLYVAS: They've been before, but we didn't make it this year. And he was their star football player and twisted his knee on the field, came off, came into the office the next day. His exam showed a swollen knee. He was stable. His, his anterior drawer Lachman pivot shifts were all negative, but he clearly had a very distinctively tender lateral joint line and a positive McMurray's. X-rays as we would probably expect were negative.
NICHOLAS COLYVAS: And when we looked at his MRI, there was a clear problem here with the lateral meniscus. The medial meniscus, posterior horn here looks good, but we're missing some lateral meniscus there and on the sagittal, there's a piece of meniscus where it shouldn't really be. It's sort of flipped under and trying to go down the back there. So our diagnosis here pretty clear.
NICHOLAS COLYVAS: This is a lateral meniscus tear. And when we decide what we're going to do for this patient and any of our patients, of course, we're going to look at various factors. And the ones that I typically look at most actively are going to be the patient's age, their physiological age. We talk about physiological age more than chronological age, their activity level. That's both what they're doing and what they want to do.
NICHOLAS COLYVAS: And when we're looking at a meniscus tear specifically, we want to know what type of tear we've seen. This one is a flipped tear of the lateral meniscus. We want to know what the underlying condition of the knee is. Ben Marr talked about those worn out knees. We're going to be a little aggressive, a little less aggressive about treating a badly arthritic knee than we are in a 17-year-old.
NICHOLAS COLYVAS: And what are the associated injuries? While decision is based on not just what that meniscus looks like, but what that ACL looks like, what that MCL looks like. So what is the audience going to tell me to do on this patient? Are we going to do physical therapy and see how he does? Completely shut him down for a while? Stem cells, we heard about, expensive. Maybe that's the right answer
NICHOLAS COLYVAS: or how about surgery? Boom. OK, so the majority of you are helping me out here by recommending surgery. Some of you think that this is something conservative and there may be a place for a conservative treatment in this situation
NICHOLAS COLYVAS: but I think that the real answer here is surgery and the reasoning goes back to our considerations. This is a young patient. He had an acute traumatic injury. It's an unstable tear. It's flipped. It's only going to get in the way. It's mechanical.
NICHOLAS COLYVAS: The underlying condition of the knee is excellent. It's pristine. This is, this is a young patient. He's got a perfect knee other than his meniscus and he has no other associated injuries. He does not have an ACL injury associated with this. So for this kid, we definitely did surgery and he did well. Got back to playing.
NICHOLAS COLYVAS: Repaired that meniscus, long recovery with a repair but got back to playing and everything is fine. OK so let's move on to something a little bit more complicated. 46 year old, still young in my book, had a history of a prior ACL reconstruction, did well 10 years ago. Now's got progressive medial pain, is reasonably active, but not really an athlete of the sort that we just saw and has no significant instability
NICHOLAS COLYVAS: so his ACL did well. He's nice and stable in his knee and he comes in and he's got an effusion there. It's small, but his knee still is stable and he's got tenderness in the medial and the lateral joint lines. His McMurray's and Thessaly's on both sides are positive. So we get an X-ray and you can see there's got a big screw in here and he's got some early arthritis of the notch here.
NICHOLAS COLYVAS: And if we look at the medial and lateral joint lines, they're somewhat preserved. He hasn't fallen into complete arthritis yet, but if you look closely, you'll see there's some chondrocalcinosis in those joint lines. So there's some degeneration and his patellofemoral joint, his knees sort of midway wearing out at this point. It's still like I said, there's still joint space and it looks reasonably good.
NICHOLAS COLYVAS: And we get an MRI and the radiologist's report comes back and says, OK, he's got medial and lateral meniscus tears. So same set of considerations again. What is the patient's age and their activity level? somewhat older patient here and you know, not moderately active, not a high level athlete. The types of tears, these are more degenerative type tears and the underlying condition of the knee, it's got some wear and tear on it and associated injuries.
NICHOLAS COLYVAS: No, his ACL is good. So what are we going to do? Physical therapy. You know, we do use braces quite a bit with patients. We've got a series of injections we can use or of course, we can do surgery. OK, so a small percentage of you wanted me to go straight to surgery.
NICHOLAS COLYVAS: And I think maybe when I came out into practice now that's, you know 20 years ago, anytime we got a radiologist's report that said meniscus tear, lateral medial or both, we were booking that patient for surgery. We were rushing to surgery to do to fix that patient's knee because they had meniscus tears. Those were clearly a problem. Well, we've discovered over time, that actually physical therapy is probably exactly where we want to be
NICHOLAS COLYVAS: for the first choice. An unloaded brace is a good idea in many of these cases, but this is bilateral or at least medial and lateral. So it unloaded really puts you on one side or the other so if it was all medial sided disease, a medial unloaded brace would be a good choice and injections and cortisone in my practice, I think we certainly try with the physical therapy first, then go to the cortisone and move on from there.
NICHOLAS COLYVAS: I think this has changed over time. There may be an older generation of Orthopedic Surgeons in your communities that still operate on these as the first line choice. Sorry, but starting about 10 years ago, studies started to really come out in the bigger journals showing that surgery versus physical therapy for these degenerative tears really has no significant difference
NICHOLAS COLYVAS: and these patients can be well treated with surgery, sorry, with physical therapy. And even if you do sham surgery on these patients, they don't get, as Dr. Marr mentioned, they don't get much better anyway. So we really have shied away from these degenerative tears being surgical things. In my practice, we definitely try conservative management first for these patients.
NICHOLAS COLYVAS: Most of them will get better with physical therapy and/or a combination of injections, activity, modifications, and we have started using some PRP. Again, it's a little bit experimental, but at this time, certainly from a data point of view, but there's a lot of patient demand for it so I think we're becoming more active in using PRP. I think there's going to be a place for it. It's not fully defined and we do end up doing surgery on some of these patients
NICHOLAS COLYVAS: but to make the point clear. Degenerative tears, it's usually a non surgical treatment to start with. OK, so let's keep going. 61-year-old, a little bit older now, this is another knee problem. This gentleman was doing fine, but stepped off a ladder and twisted their knee and now comes in with medial pain. So not all my patients have medial meniscus tears, but a lot of them do.
NICHOLAS COLYVAS: But the examination here shows that some mild swelling, tenderness in the medial joint line and a positive McMurray's and Thessaly test. So we've presented a patient that's very young, straight to surgery, one that is a little older, but, you know, conservative treatment. This patient has X-rays that look like this. So this is a 61 year old, there's good joint space on both these knees.
NICHOLAS COLYVAS: You know, I hope at 61, my knees look like this. And we've got an MRI here and here we have a small tear. It's sort of a oblique tear in the posterior horn here. And it's, you know, out towards where the blood supply is, pretty good in the meniscus. You can see it again on the sagittal. This is not a large tear. There's not a lot big flap component.
NICHOLAS COLYVAS: There's not bucket handle here. But it is an acute tear in an older patient who's actually doing quite well in terms of their physiological condition of the knee. So again, we look at the considerations a bit older, reasonably active. The type of tear is a small. We would consider that probably a stable type tear. The underlying condition of the knee is good and no significant associated injuries.
NICHOLAS COLYVAS: So what are we going to do with this patient? You know, there's a place for physical therapy. We could unload that medial compartment, get that pressure off there. We could use PRP or even stem cells to help that grow or, you know, the ever present option of surgery.
NICHOLAS COLYVAS: OK so people here like physical therapy, and I think that's a very good idea. This is an older patient. It's not an unstable tear with a large bucket handle component. I think this is the type of patient which we would have some consideration for surgery, but lean more towards conservative management. I don't think you could fully criticize the option for surgery here.
NICHOLAS COLYVAS: I think it would be a choice. But in our practice, certainly we are more conservative and go with conservative treatment, which is what this patient underwent, had physical therapy and even got a cortisone injection. A fair amount of time to declare which way this was going to go but he continued to have pain, unable to play his golf and tennis so what do we do next?
NICHOLAS COLYVAS: We've tried the physical therapy. You could always try more an unloaded brace. Again, is not an unreasonable option to try and unload and see if that helps. PRP and stem cells surgery. OK, so surgery. And in fact, that's what we did here. You can see that this is a macerated meniscus.
NICHOLAS COLYVAS: It looks worse than it did on the MRI. Those people who chose surgery in the first place might have been that was the correct choice but I think that we usually want to give these patients a trial of conservative management first. This patient has gone on to do great. And it just points out that even in an older patient, 61, there's still a role for meniscus surgery. There's a lot of bad press about doing meniscus surgery, but it really focuses on those degenerative patients.
NICHOLAS COLYVAS: This is an acute tear. This is a patient whose cartilage surface is in good condition. So this is the type of patient who will do well with the surgery and is very happy after we're done. OK so moving on with our knee series here. This is a 63-year-old patient. Again, I'm going to call this patient relatively young and skiing, fell, heard multiple pops in her knee which always makes you think about ACL's.
NICHOLAS COLYVAS: She was able to ski down with a ACL it's kind of difficult. But once she got down, she was clearly done. And when she came to see me in the office a couple of weeks later, she's got minimal pain. Her swelling, which was immediate, has gone down. She wore a brace. And really her main symptom is instability. So less pain and more instability. And when we talk to her, she's a very active 63-year-old.
NICHOLAS COLYVAS: She loves to hike. She lives up in the mountains and really, really needs to have her knee for all these activities. So physical exam is unremarkable but very clearly when we do a ligament exam, she has a 2B Lachman and a positive pivot shift. So no surprises here when we look at her X rays, she's got a decent looking knee, you know, some narrowing, something you would totally expect for a 63 year old, of course.
NICHOLAS COLYVAS: But she has an ACL tear and the MRI shows us that the meniscus and the other structures are intact. So we go through our considerations again. Older patient, but physiologically actually somewhat younger, right? She's very active, not overweight, good alignment, knees in reasonable condition. Her activity level is high, her general health is good and what are her symptoms?
NICHOLAS COLYVAS: Is she complaining about pain a lot because that's a different set of that's a different algorithm to someone who's complaining about instability. So given what we've talked about, what are we going to suggest for this patient?
NICHOLAS COLYVAS: OK so 29% versus 30%. Pretty close there. But there's a distinct interest in doing ACL surgery overall compared to conservative management. I think this one, you know, everyone's right here. And this brings out some of the difficulty of what we're looking at.
NICHOLAS COLYVAS: So it's obviously difficult when I'm just presenting some select facts to go into what we do on what patient. But, you know, in this patient, you certainly could try physical therapy in an ACL brace. I think that's a reasonable choice. She's very active and so would probably not do as well with this. As someone who said to you, well, you know, I'm 63.
NICHOLAS COLYVAS: I've decided to hang up my boots. I'm not going to do skiing anymore. I just want to play golf and tennis. If that's what they're telling you. I would probably lean heavily towards physical therapy in the ACL brace but as presented, we talked about that she wants to stay active. Her main symptom is not pain, it's instability
NICHOLAS COLYVAS: and so I think surgery is a good choice for her. I put this up here because we really have some strong data now showing that in younger patients and the cutoff for that is probably 30, some people use 35, some use 25. But patients younger than whatever number you want to use don't do as well with allograft. They have a much higher failure rate with allograft. So in younger patients we tend to use autograft. But in older patients like this, it's probably not going to make too much of a difference.
NICHOLAS COLYVAS: And this patient actually underwent an allograft, ACL reconstruction, did well and is back skiing and doing everything she wants to do. And the point here is that we oftentimes think of the older patients and that has that age has gone up to 40 to 50 now and is steadily climbing, but that older patients, we don't tend to want to do ACL reconstruction surgery,
NICHOLAS COLYVAS: there is some definite negatives to doing ACL reconstructions in patients who have arthritis, but in the select patient that is older, that has a younger looking knee that does not have a lot of arthritis, whose main problem isninstability, not pain. It's a good surgery and is something that really yields good enough results good as you would find in a younger patient as well. So this is very clearly a case that really is the guiding principle of all surgery, which is patient selection.
NICHOLAS COLYVAS: If you collect, if you select the right patient and really not are not operating on just everybody that comes in the door, you're going to get good results and have happy patients. OK, so more knees, 53 years old. OK so I guess that used to be called middle aged. I'm still calling that young. Prior injury. No prior injury. Was getting up from a squatting position, felt a distinct pop in the knee and had some swelling and the pain.
NICHOLAS COLYVAS: and this was about a month ago. But this patient is not super healthy, has type 2 diabetes, has hypertension and has, is somewhat overweight. BMI is 30. You examine them, now it's a month later. There's still a mild effusion. The range of motion is a little limited. It's about 125 on the other side, there's some diffuse tenderness, tenderness, medially and posteriorly, but overall, the rest of the knee looks pretty good.
NICHOLAS COLYVAS: Their alignment is good, their stability is good. And this is what their x-rays look like. You know, decent joint space alignment looks reasonable on these films. So what's your next step here in this patient? It's someone who's had an injury. They've got some swelling. It's, you know, subacute. It's a month later.
NICHOLAS COLYVAS: They're not a very active person to start with so what are we going to do next? I mean, very conservative treatment, a little bit more aggressive, more imaging to get you more information. What are we looking at? OK so non-weight bearing, anti-inflammatories, conservative management, throw in some PT as well.
NICHOLAS COLYVAS: Probably the most of you, the injections and as well, most of you. And then imaging, a small section of people would go to imaging and I think that, you know, we've got a patient who's had an injury. It's not a very specific injury. We would all tend to think about conservative management in this case. But the reason I'm obviously showing this case is there's something a little bit different about it.
NICHOLAS COLYVAS: And in this case, we would actually go to an MRI and the MRI shows a medial meniscus tear and I'm going to go back and explain why. But we would go directly to an MRI in this patient. And this is the tear that's shown up on this MRI. You don't see the tear on this coronal image here but what you can see is the medial meniscus and it's sitting a little bit outside of the joint. It's not sitting in the joint where it should be.
NICHOLAS COLYVAS: It's kind of extruded. Right that's what we'd call it, an extruded meniscus. And when you look at the posterior horn of that medial meniscus, there's a gap there where it's supposed to attach right at the root, right? This is the root of the meniscus and there should be an attachment here. So this is a root tear.
NICHOLAS COLYVAS: You can also see on the sagittal that where you should see a thick black triangle, you've got this sort of look to it that's kind of like it should be there. It's like a ghost of what it should be and we actually call this the ghost sign. This is a missing meniscus. And sometimes if you get a good, if you get lucky on your axial cuts, you'll actually see here's your medial meniscus
NICHOLAS COLYVAS: and then there's this gap right here. So this is a variant of a medial meniscus tear that we've recognized in the last 10 years or so is a root tear and prior to that, we had very little understanding of exactly what this meant. So knowing that this is a root tear, what would you recommend here? Are we going to continue with physical therapy?
NICHOLAS COLYVAS: We could put this patient in an unloaded brace or are we going to go straight to surgery? And then what do we do with surgery? Is this a lost case? Are we going to go straight to a knee replacement or is there something else that we can do? All right. So most of you want to repair this, but this is an older patient.
NICHOLAS COLYVAS: You know, some of these patients. I have I have some of these patients whose BMIs are 30, 35. Are there any other Portland orthopedic surgeons in the room? I can admit that I've done a patient whose BMI is 45, so it's not your typical young athlete meniscus repair. And I'll tell you that probably hundreds or maybe even thousands of patients before we recognize what this entity was, got partial meniscectomy, which is an essentially useless surgery for this type of condition.
NICHOLAS COLYVAS: The correct answer, as we're finding out more and more, is actually surgical repair, something called a root repair. In those cases where there is a fair amount of arthritis already, you might consider going straight to a partial knee replacement. If the patient has significant limitations and is really not doing well, fixing that root root fixing that meniscus root in those patients sometimes is just not going to work
NICHOLAS COLYVAS: and you can go to a partial knee replacement. But I think the majority of this would be something we would treat surgically and try and repair and this is what they look like. There's a clear gap here. This is the meniscus coming in here. Should attach right here. You should not see this gap. And this is, again, the tear at surgery. This is the meniscus coming along here.
NICHOLAS COLYVAS: You can see these are older patients. They have some arthritis. That's not a perfect looking intercondylar tibia here, but this is a tear. And what we're really dealing with is once that meniscus root is torn, it's a functional meniscectomy. It's like taking out your meniscus, which is what we used to do in the 50s and 60s is take out the meniscus
NICHOLAS COLYVAS: if it was a problem and we knew that all those patients ended up getting surgery or sorry getting arthritis young. So we now have very good biomechanical data that shows that making that root, fixing that root will actually restore the biomechanics of the knee. The clinical data is coming along and there are studies like this that show that if you do repair that root, this is what that repair looks like.
NICHOLAS COLYVAS: You take stitches down there and you put it through into a tunnel that you get decent results at five years. This is an example of doing a partial meniscectomy for a root repair for a root tear. Here's what it looks like initially when the root tears. This is a few years later that knee is not salvageable. It goes on to a total knee. This is what we're finding in some studies now, seven years later, that that medial meniscus is holding up and still providing the joint with good biomechanics and saving that patient from a knee, knee replacement.
NICHOLAS COLYVAS: So the take home point really going back to our presentation on the initial presentation of this patient is you've got to have a high index of suspicion. These are usually older patients, i.e. the classic would be a 50/55, oftentimes overweight, oftentimes some early degenerative changes in the knee and it's usually a hyperflexion or getting up from a squat or a relatively minimal amount of trauma and a sudden change to a significant, you know, my knee used to ache every now and then, too
NICHOLAS COLYVAS: well, it just really hurt a lot. I felt it pop and there was a lot of swelling. Those patients have a little extra suspicion in your head that they maybe have a root tear and maybe go to an MRI sooner. Certainly your average just sort of my knee started hurting more, you would go with those conservative things but I think we the sooner we get to these, the better. So think about an MRI for those patients. All right.
NICHOLAS COLYVAS: So let's switch to shoulder and look at a couple of things that we see very commonly. 49-year-old, this is a patient who swam competitively in college, still likes to swim, but has had progressive shoulder pain for six months. No specific trauma, but it does limit his swimming. His examination shows a little bit of limitation in his range of motion, impingement tests are positive.
NICHOLAS COLYVAS: Rotator cuff strength is normal, does report some pain with testing. Labral tests are equivocal, these non tender over the AC joint and there's a little bit of pain with the cross arm test. X-rays, joint space, no, not bad at all. AC joint looks a bit narrowed. And your MRI's showing that there is a little there's labral changes here with what the radiologists would report as a labral tear.
NICHOLAS COLYVAS: There's rotator cuff tendinosis not a frank tear, but maybe some partial tears. And here's his AC joint that's got some cysts. It's clearly not happy. So, you know, this is a patient that comes in with shoulder pain, but there's a lot showing up on that MRI report that the radiologist sends you. Are you worried about the rotator, as always right? They can't ever report a normal case.
NICHOLAS COLYVAS: You know, there's a every 54-year-old has at least three pathologies in there, even if they're asymptomatic. So are we worried about this guy's rotator cuff? His labrum, his AC joint? What can we do to figure out what's going on here? What's our next step?
NICHOLAS COLYVAS: OK. Physical therapy, cortisone injection, PRP and surgery. No one wants to go to surgery. Geez so, you know, we're looking at a scenario we see very commonly. There's changes in on the MRI. MRIs are very sensitive, and they are not actually helping us. They're confusing us more than anything else. So I think that this is very clearly one we would all really start with physical therapy.
NICHOLAS COLYVAS: The cortisone injection, I actually think is a good choice. I usually let my patients direct me as to their frustration level with these cases. So I'm really frustrated. I want to get this fixed as soon as possible. What can we do? Well, those ones might lean more to doing an earlier cortisone injection. Others, I usually say, let's do some physical therapy, see how that goes.
NICHOLAS COLYVAS: We can try an injection later. PRP for this particular indication, I think that's an appropriate number. We don't have any data to show that it works for this situation. I think we're going to find that there may be some place for it, but right now I don't think the data supports that and I think surgery is probably aggressive for this situation. You know, we look at rotator cuff tears, a big tear like that.
NICHOLAS COLYVAS: OK that's a structural problem. We probably need to fix that and we'll talk a little bit more about in who. But, you know, cuff tears are very common. They affect the older patients. And, you know, these studies that have been done about asymptomatic patients getting MRI's, showing tears of 51% in the older patients, 30%. These MRIs are really sensitive and they're picking up a lot of pathology that we have to really carefully sift through to be sure that we're actually getting what we want for our patients.
NICHOLAS COLYVAS: And, you know, these traumatic degenerative rotator cuff tears really are sort of a mainstay of what we see in our offices and I think that we really just want to say conservative treatment first for sure. Some of them will end up needing surgery, but certainly not the majority. And, you know, there's been plenty of studies that show that physical therapy is very effective for this.
NICHOLAS COLYVAS: 75% or so of patients will do as well with physical therapy as they do with surgery. So certainly want to consider conservative management for these sort of degenerative, non traumatic type tears. What about this 53-year-old patient? Not very active, does some work remodeling bathrooms so he is actually a laborer of some sort, but decided to try a hoverboard for the first time.
NICHOLAS COLYVAS: Great, great, great orthopedically devised instrument for orthopedic injuries. He's not the super healthy guy. Got a lot, got a lot of issues with high blood pressure and he's a smoker and his examination shows clear weakness in the supraspinatus and infraspinatus. Limited range of motion. He's neurovascularly intact. This is his MRI.
NICHOLAS COLYVAS: OK, so this is his supraspinatus, comes along here, comes to a sudden stop where it's supposed to end, over here on the end plate, and there's a fluid filled gap there. So this is an acute cuff tear in a patient that is otherwise not had a problem in the shoulder before. So what are our choices here? Next steps.
NICHOLAS COLYVAS: All right. So a lot of you want to go to physical therapy on this patient. And I think that, again, talking about rotator cuff tears, that's always a decent option. It might be the type of thing you would consider in this patient if they were very much against surgery or you feel there was a problem with their medical condition that you might want to avoid surgery.
NICHOLAS COLYVAS: But this is a different entity to our degenerative tears. This is a traumatic sudden change from a patient who's able to lift their arms up with no problem to suddenly coming in with this. Hey, you know, something's something's wrong. I've got a broken wing. And these ones, we tend to be far more aggressive surgically. And this is a patient who we would take to surgery. I think that's the correct answer.
NICHOLAS COLYVAS: The results of those patients with acute full thickness tears, especially with retraction that don't get surgery, are not as good as those that get surgery and in fact, the worse the case is, if you have a massive tear where the infraspinatus, the supraspinatus and the sub-scap has been torn off acutely, if you don't get that patient into surgery, they're going to have a significant problem.
NICHOLAS COLYVAS: They're not going to do that well with physical therapy, with surgery, they actually have a very decent chance of getting back most if not all, of their function. So we treat the, we treat the degenerative, non traumatic tears very conservatively. We treat the traumatic, clear, clear new finding tears far more aggressively. The take home is really you know what I've said.
NICHOLAS COLYVAS: They're common. They're very common in older patients and most times not surgical, but acute cuff tears is something we look at very differently kind of like the root tears in the meniscus. Most meniscus treatment is conservative. There are specific areas where we want to be more aggressive early on and that's the acute rotator cuff tear.
NICHOLAS COLYVAS: What about the labrum in this guy? You know, he's, you know, he had changes on his MRI. I don't know how many times I see labral changes on the MRI reports on any patient that's had MRI. It's very frequent. And we I mean, we don't ignore it, but we definitely take it with a pinch of salt when we see labral changes reported on the MRI and even we look at them and we see them and we can see those changes
NICHOLAS COLYVAS: but it's part of the normal degenerative process. If you have that young pitcher that is coming in and they've got an MRI with a labral tear we can talk about, that's a whole separate lesion, the SLAP lesion problem. But if you have like this last patient, that first patient, that first shoulder patient, a 49-year-old that has labral changes, it's seldom that is the problem. So we don't ignore it, but we definitely look for other problems
NICHOLAS COLYVAS: first before we really think that the labrum is the issue. So we've got a little bit more time just going to go. This will be our last case. Instability. 26-year-old dislocated his shoulder 10 years ago. He was 16 when he first dislocated it. And he didn't, didn't have surgery, did well, but then recently had a obviously traumatic injury falling while hiking, landed on an outstretched arm, clearly dislocated his shoulder, got relocated, and he's come back in and he's doing OK quote unquote. Exam.
NICHOLAS COLYVAS: You show he's got good, good range of motion. There is some pain with rotator cuff testing and his instability signs are positive right apprehension and relocation and you can actually physically translate him. This is the X ray, normal looking joint. There's a little lesion down here, but I don't think that that's of any significant relevance. You get an MRI on this patient, find the Bankart lesion, the glenoid bone is in good condition.
NICHOLAS COLYVAS: And there's a small Hill-Sachs lesion, which you could actually see right there. So our considerations. Age. Now, that's age at the time of this dislocation and age, at the time of first dislocation also very important. The nature of the injury was it traumatic or is he able to just pop it in and out by himself? What are the symptoms? Is it instability or is it pain?
NICHOLAS COLYVAS: And what does the imaging show? So what are we going to do for this patient? Put him in a sling and immobilize him for a while. Send him to physical therapy, cortisone injection to help control the pain or do we go straight to surgery on this patient? OK. Surgery. Good number of you pushing for that.
NICHOLAS COLYVAS: Physical therapy, conservative management also a decent number. So what is the main concern here is obviously the re-dislocation risk and we know that if you dislocate in your teens, you have a very high 90% or so likelihood of dislocating again and that surgery is probably a good idea the second time around. This patient dislocated at 16, actually did well and re-dislocated at 26
NICHOLAS COLYVAS: so I actually think there is a place for attempting conservative management here. You know, I couldn't argue with someone who said, we're going to try that first. I think that the data would show that there is still a very high risk for another dislocation. But, you know, a arthroscopic Bankart, not even an open one, does require a lengthy recovery and so you might want to think about a conservative approach in this patient.
NICHOLAS COLYVAS: I think the standard answer would probably be surgery, and that would be correct but this is one where there's a little bit of a grey area. And the reality is that most cases, if it's a young patient, we're looking at conservative management for the first time and then if they recur, if they have another dislocation, we're going to do surgery from them for them. And if we have those patients that are multiple dislocating now what we're doing is far more extensive stabilization procedures.
NICHOLAS COLYVAS: But the take home here is the young patient has a very high dislocation rate so we've got to consider surgery for those and in fact, there are some orthopedists around the country that are actually promoting first time dislocations, surgery right off the bat. And, you know, there's good data behind that so I think that we just need to be a little bit selective as usual.
NICHOLAS COLYVAS: Again, patient selection is everything. I think when we look at surgery, it's not always a straightforward, you know, we have algorithms, but we have to tailor that very well to the patient. Frequently we're going to go with conservative management, but there are some conditions that we are red flags for. Hey, this one will probably do better with surgery. And with that, I was, this was for the wet weather but apparently it's nice and dry today, so that's great.
NICHOLAS COLYVAS: But we're prepared. Thank you to everybody. And I'm happy to answer questions. We're a bit over time. [APPLAUSE] [VIDEO ENDS]
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