Orthopaedic Surgery Sports Medicine

1. Orthopaedic Surgery Sports Medicine Ryan Dobbs, MD Orthopaedic Sports Fellow November 15th, 2005

2. Introduction • Orthopaedic Surgery Sports Medicine • Team Coverage • Athletic Injuries • Surgery of the Shoulder • Surgery of the Knee • Elbow, hip and ankle arthroscopy

3. Purpose of this talk • Exposure to orthopaedic sports medicine • OrthopAedics – We have to get an A in everything. • Three questions • The questions and the answers are found in this talk.

4. ACL Injuries

5. ACL Injuries: Epidemiology • ≈ 100,000 injuries/year • ≈ 1 in 3,000 people in America • > 50,000 ACL reconstructions/year • Majority occur in 15-45 year old group • 1 in 1750 in this age group • 70% occur during sports involvement

6. ACL Injuries: Cost • ≈ 50,000 reconstruction/year • $17,000 per procedure • ≈ $850 Million • Does not account for • Initial care • Conservative care and rehab of nonoperative management • Long term impact of traumatic DJD whether reconstructed or not

7. Anatomy: ACL

8. Anatomy: ACL • Originates lateral aspect of medial tibial spine

9. Anatomy: ACL • Inserts posteriorly on medial aspect of lateral femoral condyle • Passes through the intercondylar notch in a proximal/post/lateral direction

10. ACL Function • Limits anterior displacement of tibia on femur • Works in concert with the PCL • To provide anterior and posterior balance to the knee • Balance of femoral translation and roll back with flexion • ACL and PCL are intracapsular and extrasynovial structures

11. Mechanism of Injury • 70% noncontact • 30% contact • Valgus force most common

12. Mechanism of Injury • 1. Sharp deceleration during or prior to a change in direction (cutting)

13. Mechanism of Injury • 2. Single leg landing off-balance, near full extension, slight valgus, with maximally contracted rectus

14. Presentation of ACL Rupture • Hemarthrosis • Heard or felt a ‘pop’ • Knee ‘gave out’ • Instability since

15. Physical Exam • Effusion

16. Physical Exam • Lachman’s exam

17. Physical Exam • Varus/valgus • Full extension • 30 deg flexion

18. Physical Exam • Posterior Drawer/Sag • Anterior Drawer

19. Physical Exam • Pivot-shift

20. Imaging: Radiographs

21. Imaging: MRI Normal! NOT!

22. Imaging: MRI Empty Wall Sign Bone Bruising

23. ACL Rupture: Management • 1/3 of patients are able to do normal activities without modification • 1/3 of patients modify activities and are able to cope • 1/3 are unable to cope: unstable with daily activities

24. Treatment!ACL Reconstruction • Anatomical reconstruction of ACL by creation of bone tunnels and recreation of stabilizing soft tissue structure • Performed arthroscopically, with a tourniquet, varying techniques

25. Knee Question • The most sensitive physical exam test for anterior cruciate deficiency is: • A) Anterior drawer • B) Posterior drawer • C) Lachman’s test • D) Pivot shift test • E) Wallet biopsy

26. Treatment!ACL Reconstruction Options include bone-tendon-bone and hamstring autografts among others

27. Treatment!ACL Reconstruction • Harvest Hamstrings

28. Treatment!ACL Reconstruction • Drill tunnels

29. Treatment!ACL Reconstruction • Place and stabilize the graft

30. Treatment!ACL Reconstruction • Different methods of fixation utilized

31. Knee Question • The anterior cruciate ligament: • A) Limits posterior translation of the tibia relative to the femur • B) Limits anterior translation of the tibia relative to the femur • C) Limits anterior translation of the tibia relative to the fibula • D) Limits anterior translation of the femur relative to the tibia

32. Shoulder Anatomy

33. Physical Exam • Inspection • Palpation • Sensation • A/R/U/M • Range of Motion • Impingement • Motor function • Deltoid, Biceps, Triceps, WF, WE, IO, Opponens • Internal rotation, external rotation, forward flexion • Suprapinatus, Infraspinatus, Subscapularis

34. Physical Examination Neer Sign Hawkins’ Sign

35. Physical Examination Lift-off test - Subscapularis Belly Press - Subscapularis

36. Physical Exam Abduction/Internal Rotation – Supraspinatus External Rotation - Infraspinatus

37. Bony Anatomy

38. X-ray

39. Muscles of the Rotator Cuff

40. Shoulder Question • The four muscles of the rotator cuff are: • A) Supraspinatus, Infraspinatus, Teres Minor, Subscapularis • B) Supraspinatus, Infraspinatus, Teres Major, Subscapularis • C) Supraspinatus, Infraspinatus, Teres Major, Subspinatus • D) Supraspinatus, Infraspinatus, Teres Minor, Subspinatus

41. Subscapularis Origin: Subscapular fossa Insertion: Lesser tuberosity of the humerus Innervation: Upper and lower subscapular nn.

42. Supraspinatus Origin: Supraspinatus fossa of scapula Insertion: Superior facet on greater tuberosity of humerus Innervation: Suprascapular nerve

43. Supraspinatus muscle

44. Infraspinatus Origin: Infraspinatus fossa of scapula Insertion: Middle facet on greater tuberosity of humerus Innervation: Suprascapular nerve

45. Teres Minor Origin: Superior part of lateral border of scapula Insertion: Inferior facet on greater tuberosity Innervation: Axillary nerve

46. Rotator Cuff Question • Name the only rotator cuff muscle not innervated by the suprascapular nerve: • Supraspinatus • Infraspinatus • Teres Major • Subscapularis

47. Rotator Cuff Tear

48. Rotator Cuff Repair - Open

49. Arthroscopy

50. Rotator Cuff Repair - Arthroscopic