0:00

<v ->Finally in the last few slides,

0:02

a word or two about cuff-tear arthropathy

0:06

and Milwaukee shoulder.

0:08

Charles Neer, a very famous orthopedic surgeon, indicated

0:11

that in patients who had chronic tears

0:14

of the rotator cuff,

0:15

mal-alignment of the glenohumeral joint,

0:18

produced progressive osteoporosis

0:20

of the glenohumeral joint.

0:23

He called this particular

0:24

sequence of events,

0:26

Cuff-Tear Athropathy.

0:28

And it is the general theory

0:31

that is still accepted by most orthopedic surgeons.

0:35

But along came a famous rheumatologist

0:38

to say that he was wrong.

0:41

This was Daniel McCarty.

0:43

All right,

0:44

who practiced in Milwaukee at the university.

0:47

And he said, wait a minute.

0:48

When you look at these patients

0:50

who have so-called cuff-tear arthropathy,

0:53

and you look carefully

0:54

you will find that there are

0:55

hydroxyapatite crystals present within these joints.

1:00

And it was his belief

1:02

that these crystals led to the release of collagenase,

1:06

which then attacked the rotator cuff.

1:09

And so the rotator cuff abnormalities were in fact

1:12

a secondary phenomenon.

1:15

He pointed out

1:17

in later articles that sometimes the same process involved

1:20

not only the glenohumeral joint,

1:22

but portions of the knee.

1:24

And he emphasized the involvement

1:26

of the lateral femoral-tibial compartment.

1:29

And you know, when you think about it today

1:31

we see examples of what looks like osteoarthrosis early on

1:36

but with incredible rapidity,

1:39

as in this example,

1:41

this looks like not a Milwaukee shoulder,

1:44

but a Milwaukee hip.

1:46

So maybe this is the same sort of process taking place

1:50

in the hip.

1:51

And to in fact, prove that further

1:53

are examples of polyarticular involvement,

1:57

including the shoulder with rapid dissolution.

2:00

So how can cuff-tear arthropathy

2:03

explain involvement

2:05

with rapid deterioration of a hip

2:07

or of a knee as shown in this case?

2:11

This is all in one patient.

2:13

So I think there are probably multiple causes

2:16

for this rapid appearance of joint destruction.

2:20

Be it hydroxyapatite crystal deposition

2:23

in the shoulder,

2:25

be it rotator cuff disruption,

2:28

be it osteonecrosis,

2:30

involving a large segment of the epiphysis,

2:33

or as we'll talk about later in this course,

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be it insufficiency fractures occurring

2:40

in the subchondral bone that explain these areas

2:43

of rapid disruption.

2:46

We're gonna end there with the first lecture.

2:49

And we're gonna turn now to Marcelo sitting in Davos,

2:54

and he is gonna discuss some of the first cases.

2:57

Marcelo?