Spire Healthcare Group Plc · LSE:SPI
Spire Healthcare — Investor Presentation (August 2013)
27 slides from Spire Healthcare's investor presentation, August 2013
Slide 1: TP Selvan
TP Selvan MB, LRCS, LRCP, MSc (Orth), FRCS, FRCS Ed (Orth)
Slide 2: Overview
Overview Rotator Cuff Tears Shoulder Instability Frozen Shoulder
Slide 3: Rotator Cuff
Rotator Cuff 4 components Supraspinatus, Infraspinatus, Teres Minor Attached to GT, commonly referred as rotator cuff tears. Elevate, rotate the humerus Run under the acromion, vulnerable to damage Subscapularis Attached to LT, largest and strongest cuff muscle @53% of total cuff str
Slide 4: Rotator Cuff tear
Rotator Cuff tear Several Classifications, commonly used Partial or Full thickness Size of tear Small (<1cm) Medium (1-3cm) Large (>3cm) Massive (>5cm) Side Articular Bursal
Slide 5: Rotator Cuff tears
Rotator Cuff tears Cause Injury-lift or catch a heavy object, FOOSH Overuse, impingement wear and degrade with age liable to rupture Symptoms painful, weak shoulder and decreased ROM Night pain common, often radiating down the arm. Subscap tears more painful as often associated with
Slide 6: Clinical tests for Rotator Cuff
Clinical tests for Rotator Cuff Several tests, Over 100!! described, can be confusing?? Adopt simple approach and common tests Impingement Neers sign, test Hawkin’s-kennedy test Copelands RCT Supraspinatus, Infraspinatus, Teres minor Empty can(Jobes) / Full can test (SS) Ext Rot la
Slide 7: Rotator Cuff tears- Investigations
Rotator Cuff tears- Investigations Ultrasound Scan One stop clinic Accurate, dynamic and cost effective However, operator dependant MRI Scan Expensive and less accessible, Quality of the muscles and fatty infiltration Other intra-articular pathology
Slide 8: Rotator Cuff tears- Investigations
Rotator Cuff tears- Investigations MR arthrography most sensitive and specific technique for diagnosing both FT and PT RCT. US and MRI are comparable in both sensitivity and specificity de Jesus Jo, AJR Am J Roent.2009,a meta-analysis US Scan acceptable sensitivity and specificity. sup
Slide 9: Clinical tests
Clinical tests The use of any single test to make a pathognomonic diagnosis cannot be unequivocally recommended. Support for stressing a comprehensive clinical examination including history and physical examination. Hegedus EJ, Br J Sports Med. 2012 (Syst. Review & Meta-analysis) Insufficien
Slide 10: Rotator Cuff tears
Rotator Cuff tears • Do they progress? (Yamaguchi JSES 2001) 50% tears progress if pts symptomatic & <20% tears if asymptomatic Is age, gender, side or cuff thickness related to symptoms (Yamaguchi JBJS 2006) Av age 48.7=no tear, 58.7=U/L tear, 67.8=B/L tear 50% likelihood of B/L tears > 66y
Slide 11: RCT- Non-operative Rx
RCT- Non-operative Rx 1. Painkillers and anti-inflammatory medications 2. Physiotherapy 3. Cortisone steroid injections Reduces inflammation and control the pain. Avoid repeated steroid injections in the presence of a tendon tear, as this may weaken the tendon further. Outcome following
Slide 12: RCT – Operative Rx
RCT – Operative Rx Single vs. Double row (DeHaan AM AJSM 2012) Single-row repairs did not differ from the double-row repairs in functional outcome scores Trend toward a lower retear rate in DR , although the data did not reach statistical significance All arthroscopic vs. Mini-open repair (v
Slide 13: Partial Thickness RCT
Partial Thickness RCT Articular side (PASTA) or bursal surface O/E Like impingement, strength often reasonable Pre-op diagnosis difficult, MRI inconclusive Beware young patient with PTRCT, other aetiology than impingement Initial conservative Rx appropriate
Slide 14: Partial Thickness RCT
Partial Thickness RCT The "50% rule“(Pedowotz RA ,Arthroscopy 2012) Little scientific information is available to support the 50% rule Significant PT tears need repair, not debridement (Weber OCNA, Arth 1999), (Kartus Arth 2006) 1 in 5 (18%) re-op rate with debridement, progression to FT tea
Slide 15: Massive Cuff Tears
Massive Cuff Tears More common in older people, unusual under 60 years. In patients with cuff degeneration Disabling pain and weakness, pseudo paralysis Marked atrophy and fatty infiltration poor clinical outcomes
Slide 16: Massive Cuff Tears - Rx
Massive Cuff Tears - Rx Non-op Injection Deltoid rehab prog Operative SAD, LHB tenotomy, Debridement SS nerve ablation Tendon transfers (Younger patient with irreparable RCT) Reverse Shoulder Replacement
Slide 17: Shoulder Instability
Shoulder Instability Glenohumeral stabilisers Static restraints Glenohumeral ligaments (below) Glenoid labrum (below) Articular congruity and version Negative intraarticular pressure Dynamic restraints Rotator cuff muscles the primary biomechanical role of the rotator cuff is stabi
Slide 18: Dislocation Categories
Dislocation Categories 1.Traumatic Dislocation A Bankart lesion is the most common injury but other injuries can occur HAGL tear Bony Bankart Hill-Sachs lesion 2. Atraumatic dislocation associated with joint laxity 3. Positional Non-traumatic dislocation 'abnormal muscle patterning' (party tricks
Slide 19: Clinical tests – Instability
Clinical tests – Instability Anterior instability - anterior Apprehension - Jobe Relocation (Fulcrum Test) - anterior Drawer Test - anterior Load and Shift Posterior instability - posterior Apprehension test - posterior Drawer Test - posterior Load and Shift Inferior Laxity - Sulcus Sign
Slide 20: Instability Investigations
Instability Investigations Plain X-ray Initial imaging MR arthrogram Imaging modality of choice to evaluate the labrum Associated ST lesions CT arthrogram Detection of bony injuries like glenoid rim # or HAGL Also capsuloligamentous lesions
Slide 21: Shoulder Instability Rx
Shoulder Instability Rx Non-op Rx What position of immobilisation? ER or IR Liavaag S JBJS(Am) 2011 Immobilization in ER does not reduce the rate of recurrence for patients with first-time traumatic anterior shoulder dislocation Physiotherapy - to train the shoulder muscles to control the
Slide 22: Shoulder Instability Rx
Shoulder Instability Rx Arthroscopic Stabilisation (Bankart Repair) Repairing the over stretched or torn labrum and capsule Latarjet-Bristow Procedure (transfer of the coracoid with it's attached muscles to the deficient area over the front of the glenoid) Success due to the ‘triple effect’
Slide 23: Frozen shoulder
Frozen shoulder Frozen Shoulder is an extremely painful condition Often starts acutely, but may be triggered by a mild injury to the shoulder. Frozen shoulder may be associated with diabetes, high cholestrol, heart disease and Dupuytrens contracture. The capsule and its ligaments becomes inf
Slide 24: Frozen Shoulder-Stages
Frozen Shoulder-Stages Three stages 1)Freezing phase: Pain increases with movement and is often worse at night. Progressive loss of motion with increasing pain. Lasts approx. 2 to 9 months. 2)Frozen phase: Pain begins to diminish, ROMmuch more limited This stage may last 4 to 12 mo
Slide 25: Frozen shoulder Rx
Frozen shoulder Rx Improve over 2-4 years after onset. Painful &stiff shoulder generally require treatment. Rx modalities Physiotherapy Analgesics &Anti-inflammatories Injections - reduce inflammation and provide pain relief Hydrodilatation Procedure MUA & Injection Surgery - Arthros
Slide 26: Frozen Shoulder Capsular Release
Frozen Shoulder Capsular Release Over 80% success and the freedom from pain is quicker than MUA. Diagnose other associated pathologies Capsular release is safer and more effective than MUA for people who have developed a resistant stiff (frozen) shoulder after injury, trauma or fractures, as w
Slide 27: Thank You
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