Shoulder

ACJ

ACJ Arthritis

Aetiology

 

Post-traumatic (type III clavicle fractures)

Idiopathic

 

4 patterns 

 

1. OA with osteophytes 

-  contribute to impingement

 

 Acromioclavicular Arthritis

 

2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)

 

ACJ OsteolysisACj Osteolysis

 

3. RA

 

4. Hyperparathyroidism

 

Symptoms

 

Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm

 

Signs

 

ACJ OA Clinical Photo

 

Tenderness to direct palpation is most reliable sign

- may feel osteophytes

- must compare to ensure other side is not tender (but may have bilateral ACJ OA)

 

Cross body adduction of arm 

- tends to overlap with impingement

 

Diagnosis

 

LA + Cortisone

- inject into joint

- diagnostic / therapeutic

 

DDx

 

Intrinsic

- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis

 

Extrinsic

- Cervical root C4/5

- shoulder tip pain from abdominal pathology

 

Xray

 

Zanca view

- AP 10° cephalic tilt with 50% penetration 

 

ACJ OA Inferior Clavicle Osteophyte

 

Bone Scan

 

Not usually necessary

 

ACJ OA Hot Bone Scan

 

Management

 

Non-operative

 

Most patients respond well

NSAIDs

Activity modification

Steroid injection

 

Operative

 

Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment

 

Aim

 

Resect sufficient distal clavicle to prevent abutment

 

Options

 

1.  Open excision distal clavicle

2.  Arthroscopic resection

 

Open Excision of distal clavicle

 

Post Open ACJ Excision

 

Technique

- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact

 

90% success rate

 

Arthroscopic ACJ Resection

 

Advantage

- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation

 

Results

 

Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

- identified subtle intra-articular changes not seen on MRI  which were treated

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection

 

Technique

 

1.  Identify distal clavivle

- remove bursa and perform SAD

- use electrocautery from lateral portal to identify the distal clavicle (push down on clavicle repetitively)

- clean and identify clavicle anterior and posterior

 

ACJ OA 1ACJ OA 2

 

2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

- must remove full thickness of distal clavicle superiorly / be able to visualise superior AC ligament

- must not leave posterior edge

 

ACJ OA 3 Anterior CannulaACJ OA Debridement 1ACJ OA Debridement 2

 

Post Arthroscopic ACJ resectionSuperior AC Ligament post arthroscopic resection

 

 

 

ACJ Dislocation

Type 3 ACJ Dislocation

Anatomy

 

Synovial joint with hyaline cartilage

 

Has fibrocartilage intra-articular disc

- complete or incomplete

- usually degeneration by 4th decade

 

Clavicle may lie superior to acromion in normal population

 

Acromioclavicular Ligaments

 

ACJ capsule

- strongest superiorly

- horizontal / AP stability

 

Coracoclavicular Ligaments / CCL

 

Primary restraint to superior translation

- primary suspensory ligament of upper limb

 

Trapezoid Ligament (anterolateral)

- anterolateral on coracoid

- inserts trapezoid ridge also anterolateral to conoid

- almost horizontal in sagittal plane

- primary restraint to axial compression

 

Conoid Ligament (posteromedial)

- arises postero-medial to trapezoid

- inverted cone

- inserts conoid tubercle

- apex of posterior clavicular curve

- junction lateral & medial 2/3

- lies vertically

- primary restraint to superior and anterior translation

 

Delto-trapezial fascia

- dynamic stabiliser

 

Motion at ACJ

 

Only small 5-8o

- 40o at SC joint

- motion is at scapulo-thoracic joint rather than ACJ

 

Aetiology

 

Usually direct force onto adducted shoulder joint

- clavicle remains in normal position

- arm falls down

 

Examination

 

Usually clinically obvious

 

Grade 3 ACJGrade 3 ACJ

 

Allman grades I-III 1967 / Rockwood modified 1989 Classification

 

I     ACJ sprain

 

II    ACJ Disrupted & CCL intact / sprained

 

ACJ Dislocation Grade 2

 

III  Rupture ACJ & CCL 

- displaced > 100% of clavicular width

 

Grade 3 ACJ Dislocation

 

IV   Into trapezius

- can be easily missed

- need axillary lateral

 

Type IV ACJ APType IV ACJ Axillary LateralType IV ACJ

 

V     High dislocation > 1 x clavicle width

- disrupted trapezius & deltoid

- end of clavicle subcutaneous

 

ACJ Dislocation Type 5

 

VI    Subcoracoid dislocation

 

X-rays

 

Zanca view

- specific for ACJ

- 10ocephalad, 50% voltage

 

Stress views

- occasionally used

- hold weights in each arm

- bilateral xray

 

Normal 

- 50% overriding clavicle

- 2% under riding

- 29% incongruent

- joint width 0.5-7 mm

 

Management

 

Type I

 

Symptoms 7-10 days

- RICE

- Avoid heavy stress & contact sport till FROM & no pain to palpation

- 2/52

 

Type II

 

Sling 2/52

- avoid heavy lifting, contact sports 8-10/52 to allow ligament healing

- OT if Persistent pain

        

Chronic Symptomatic I & II

- trapped capsular ligament / loose articular cartilage / detached meniscus

- excision outer end clavicle if continued symptoma

 

Acute Type III

 

RCT Operative vs Non-Operative

 

Tamaoki et al Cochrane Database 2010

- meta-analysis of 3 RCT

- operative v non operative

- multiple fixation techniques

- no obvious advantage in operative group

- RCT insufficient to decide merit of operative management

 

Surgical Indications

 

Rockwood

- heavy labourer

- < 25 years undecided on career

- not in athlete (will just destroy repair when next falls)

 

Options

 

1.  Hook plate

- reduction of ACJ

- hook under posterior acromion

- allows CC ligaments to heal

- must be removed

- but can mobilise the shoulder at 4-6 weeks with implant in situ

 

Clavicle Hook Plate

 

Gstettner et al J Should Elbow Surg 2008 

- acute injuries

- hook plate or non operatively, patient choice

- 57 v 30

- hook plate removed after 3 months

- 1 hook plate cut up through acromion (still good result)

- 3 superficial infections

- slightly improved constant scores in surgical group

- similar ROM

- improved pain and power scores

 

Risks

- acromial cut out

- clavicle fracture

 

Clavicle Hook Plate Fracture

 

2.  Reconstruction

 

Chronic Symptomatic Grade III

 

Excision distal clavicle

 

Poor results

- convert long high riding clavicle to short high riding clavicle

 

Reconstruction Options

- Phemister technique

- Weaver Dunn

- CCL augmentation (anchors / tightrope)

- CCL Reconstruction

- combinations

 

1.  Phemister technique

 

Technique

- open reduction of ACJ

- 2 x K wires across ACJ

- suture repair AC and CC ligaments

 

Calvo J Should Elbow Surg 2006

- Phemister v Non operative

- similar rates of deformity (i.e. non anatomic reduction) 

- less radiographic OA in non surgically treated cases

- may be that K wires further damage joint

- similar functional results in each

- recommend non operative treatment

 

2.  Weaver Dunn Reconstruction

 

Concept

- reconstruction of CC ligament with coraco-acromial ligament (CAL)

- CA ligament left attached to coracoid

- excise 1.5 (2.5cm original recommendation) lateral clavicle

- CAL taken off anterior acromion with bone fragment

- transferred from acromion to clavicle end / intra-osseous suture repair

 

Supplement with

- hook plate

- Bosworth Screw

- anchor / sutures

- Lars Ligament / Hamstring / allograft

 

3.  CCL Augmentation

 

Technique

- 5 mm anchor with sutures about clavicle

- tightrope constructs

- Bosworth screw

 

Weaver Dunn with Twinfix AnchorACJ Reconstruction TightropeACJ Reconstruction Tightrope

 

4.  CCL Reconstruction

 

Technique

- pass allograft / autograft / LARS around coracoid

- pass around clavicle and suture or

- can pass through drill holes and secure with screws

- second technique risks clavicle fracture

 

Results

 

Tauber et al J Should Elbow Surg 2007

- 12 revision cases of failed Weaver Dunn

- autogenous ST in figure 8 configuration

- through drill holes in clavicle, around coracoid, then over clavicle

- augmented with Bosworth / TBW removed at 3/12

- 4 weeks immobilised, then ROM to 90o for another 8 weeks

- good results, one clavicle fracture from wire

 

Complications 

- intra-operative fracture coracoid

- failure repair (10 - 20%)

- recurrent deformity common in surgical groups

- clavicle fracture (due to sutures or metal work)

- ACJ OA

- continued pain

- posterior dislocation (due to non intact AC ligament)

- NV damage

 

Type IV, V, VI

 

Most recommend surgery

- hook plate / reconstruction acutely

- reconstruction late

 

Technique Weaver Dunn + Augmentation / Reconstruction

 

Approach

- 45o beach chair

- sabre incision over ACJ

- split fascia transversely along the clavicle and onto acromion

- must skeletalise distal end of clavicle to beyond former insertion of conoid and trapezoid

- expose anterior aspect of acromion

- resect 1 cm of distal clavicle with microsagittal saw

- find the CA ligament which will run from anterior acromion down to coracoid

- often a great deal of scar tissue in this area from injury

- expose the coracoid laterally and carefully medially

- take off anterior 5mm of acromion and carefully peel CAL off the underlying SSC

- will need to release some of CAL from coracoid to get sufficient length

 

Reduction / Reconstruction

- reduce clavicle down with preferred technique

- 5mm anchor / tightrope / allograft / autograft / Lars ligament through drill holes

- cross graft at clavicle so gives front to back stability as well as superior / inferior

- place drill holes through distal clavicle

- use 2 fibre wire to weave through CAL under bony fragment

- secure with intra-osseous sutures

 

Post op

- sling for 6/52

- no contact sports for 6/12

 

Post Weaver Dunn with Lars Ligament

Os Acromiale

Definition 

 

Failure of fusion of adjacent ossification centers

 

Epidemiology

 

Incidence 3%

 

Bilateral in 60%

 

Anatomy

 

4 ossification centers present in acromion

- pre-acromion

- mesoacromion

- metaacromion

- basiacromion

 

The basiacromion fuse to spine of scapula by 12

 

Pre / Meso / Meta appear by 18

- Unite by age 22 - 25

- If un-united = Os Acromiale 

 

Types

 

1.  Meso-Acromion

-  most common

- level with posterior aspect clavicle

 

 Os Acominale XrayOs Acromionale MRI AxialOs Acromionale MRI Sagittal

 

2.  Pre-acromial

- less common

- level with anterior border acromion

 

 Os Acrominale MRI T2

 

3.  Meta-Acomial

- rare

 

X-ray

 

Best seen on axillary lateral

 

Factors favoring diagnosis of os acromiale over fracture 

- bilateral occurrence (Xray other side)

- rounded borders with uniform space

 

MRI

 

Useful investigation

- may show oedema if problematic

 

Os Acromionale MRI 1Os Acromionale MRI 2

 

Bone scan

 

Can be very important

- unlikely to be symptomatic if cold

- may be symptomatic / need addressing if hot

 

Symptomatic Os Acromionale

 

1.  Non union

- painful

- MRI / bone scan shows inflammation

 

2.  Dynamic impingement

- fragment moves with deltoid contraction

- decreases size of SS outlet

- impingement symptoms

 

Os AcromionaleOs Acromionale 3

 

Surgery

 

Indications

- failure of non operative treatment

 

Options

 

1.  Excision

- small fragment / pre-acromion

- risk defunctioning deltoid

- can perform arthroscopically and leave deltoid attachment intact

- open excision with careful reattachment

 

Pagnani JSES 2006

- arthroscopic excision in 11 shoulders of athletes

- all returned to sport at 14 weeks

- no loss of strength detected

 

Os Acromiale Arthroscopic

 

2.  ORIF

- large fragment / mesoacromion

- take down non union

- bone graft / 2 x AP 3.5 mm screws / TBW

- especial care with deltoid reattachment

 

Os Acromionale ORIF 1 Os Acromionale ORIF 2Os Acromionale ORIF 3

 

Risk of nonunion

 

Os Acromionale Nonunion 1Os Acromionale Nonunion 2Os Acromionale Nonunion 3Os Acromionale Nonunion 4

 

Peckettet al JSES 2004

- ORIF in 26 patients

- Union 25/26, 2 fractures

- 30% required removal metalwork

 

3.  Arthroscopic SAD

AVN Shoulder

Shoulder AVN

 

Epidemiology

 

Much less common than hip OA

- usually presents late

 

Aetiology

 

Similar causes as hip (AS IT GRIPS 3C)

 

Alcohol / Steroid / Trauma / Idiopathic

 

Gauchers

 

RA / RTx

 

Sickle Cell 

- commonest cause worldwide

- bilateral

 

Caisons / Chemotherapy

 

Blood Supply

 

Gerber JBJSA 1990

 

1.  Anterior Circumflex Humeral Artery

- primary blood supply

- becomes arcuate artery

- runs lateral aspect bicipital groove

 

2.  Posterior Circumflex Humeral Artery

- collateral circulation

- supplies head when GT / LT fracture

 

3.  Via Rotator Cuff

 

Fracture

 

Wide range of AVN after 4 part fractures

- about 1/3

 

Recent studies to explain this

 

1.   Suggest 2nd anastomotic system 

- via posteromedial branches of PCHA along inferomedial capsule

- blood supply may be further compromised by large exposure in ORIF

 

2.  Creeping substitution

- occurs more extensively in humeral head

 

3.  Rich vascular tissue surrounding humeral head

 

Natural History

 

Variable

- Difficult to predict

- Somewhat related to aetiology

- Sickle cell disease tend not to progress to arthroplasty

- Steroid induced far more likely

 

Less severe than femoral

- non weight bearing

- less conforming joint

- scapulothoracic motion

 

Pathology 

 

Superior head collapse at 90° mark 

- area of peak contact stress in abduction

- ROM Maintained until late

- Glenoid rarely affected

- Soft tissue and SSC rarely contracted

 

Classification / Cruess modification of Ficat-Arlet 

 

Stage 1

- prexray change

- only seen with MRI

 

Stage 2

- sclerotic changes in superior central head

- sphericity maintained

 

Humeral AVN Stage 2Humeral AVN Stage 2 MRI

 

Stage 3 

- "Crescent" Sign

- mild flattening articular surface

 

Shoulder AVN Stage 3

 

Stage 4

- significant humeral collapse with loss integrity joint surface

- loose bodies

 

Shoulder AVN Stage 4Shoulder AVN Stage 4

 

Stage 5

- degeneration extends to involve glenoid

 

AVN Shoulder Xray

 

Symptoms

 

Pain is major problem

- pain before significant loss ROM

- difficulty sleeping

 

MRI

 

Shoulder AVN MRIShoulder AVN MRI Sagittal

 

Management

 

Remove insult

- corticosteroids, alcohol

 

Non Operative

 

Maintain current shoulder ROM / Halt Progression

 

A.  Prevent disuse related stiffness

- passive physio

 

B.  Limit overhead activities

- Joint Reaction Force greatest > 90o

 

C.  Bisphosphonates

 

Operative

 

Core Decompression

 

Decrease intraosseous pressure & increase blood flow

- moderate success mainly in stage 1 or 2

 

Hemiarthroplasty 

 

Usually works well

- glenoid not usually affected

- Soft tissue and subscapularis rarely contracted 

 

Smith et al J Should Elbow Surg 2008

- steroid induced AVN

- survival 92% 10 year

- 2 patients needed revision for painful glenoid arthrosis

- good option

 

TSR

 

Indicated in stage V only

- beware in young patient < 65

 

 

 

Arthrodesis Shoulder

Indications

 

Indications have narrowed

- due to success of shoulder arthroplasty

 

1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Stabilization after resection for neoplastic lesions

 

Contra-Indications

 

Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers (no movement possible)

Charcot arthropathy (low chance union)

 

Advantages

 

Permanent solution

 

Disadvantages

 

Loss of movement at shoulder

Difficulty with activities at head level or behind the back 

Perineal care

Feeding

Loss of movement at other joints 2° prolonged immobilisation

 

Results

 

80-95% patient satisfaction

 

Union rates ~ 95%

 

Aims

 

Rowe 1974 Requisites after Shoulder Arthrodesis

 

1.  Hand should reach face / head / mid-line of the body anteriorly & posteriorly

- thumb to chin

- reach axilla, mouth and belt buckle

- combination of forward flexion and elbow flexion

 

2.  Shoulder be comfortable at rest / scapula should not be prominent

- arm should hang by side with scapula flat against thorax

- no winging

 

Position

 

Rockwood et al JBJS Am April 2001

- Abduction 10-15°

- Flexion 10-15°

- Internal Rotation 45°

 

Issues

1.  Technically difficult to obtain correct position intra-operatively

2.  IR most important to later function

3.  Position in reference to trunk not scapula

4.  Avoid excessive abduction & flexion

- forces the scapula to rotate & wing at rest

- leads to fatigue & discomfort

 

Principles

 

1. Need painless, supple joints above & below

2. Rigidly stabilise congruent vascular cancellous surfaces under compression

3. Bone graft & splint as needed 

 

Options

 

Intra-articular / glenohumeral

 

Extra-articular /  acromio-humeral

 

Combined

 

Principles

 

Approach

 

A.  Posterior

- detach deltoid from spine

- between IS and TM

 

B.  Anterior

- detach deltoid from clavicle

 

Technique

- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- arthrodesis between humeral head and glenoid / acromion

- temporarily fix with steinman pins GHJ and acromion-humerus

- check position / ROM / no winging

- if satisfactory, insert GHJ and acromial-humeral compression screws

- humerus - acromial plate if anterior approach

- humerus - scapular spine plate if posterior approach

 

Complications

 

Early skin breakdown

Loss elbow flexion

Non-union

Mal-union

Painful metalwork

Breakage of metalwork

Suprascapular nerve entrapment

AC joint OA

 

Results

 

Cofield & Briggs JBJS 1979

- 71 fused shoulders

- average 9 year follow up

- 96% union rate

- 75% adequate pain relief

- 70% good functional result

 

 

 

 

Arthroplasty

Hemiarthroplasty Osteoarthritis

Shoulder Anatomical HemiarthroplastyHemiarthroplasty OAShoulder Resurfacing

 

Advantage

 

Fewer complications than TSR

Simpler procedure

Indicated in younger patient

 

Disadvantages

 

Glenoid wear after hemiarthroplasty

- potential for medial migration & progressive glenoid wear

- revision to TSR almost always alleviates symptoms

 

Hemiarthroplasty V TSR for OA

 

Sandow et al J Should Elbow Surg 1999

- study randomized after inspection of glenoid

- less pain with TSR

- high revision rate in Hemiarthroplasty for glenoid wear over time

- had to cease study as TSR results significantly superior

 

Lo et al JBJS Am 2005

- metanalysis

- TSR superior pain relief / active ROM / patient satisfaction

 

Similar in AVN and fracture

 

Less clear for RA

- risk of glenoid component loosening

 

Hemiarthroplasty + Biological Resurfacing

 

Elhassen et al JBJS Am 2009

- 13 patients average age 34

- glenoid resurfacing with achilles allograft

- 10/13 required revision at average 14 months for pain

- all had glenoid wear with no evidence of allograft

 

Indications Hemiarthoplasty

 

1.  Normal glenoid

- AVN / trauma

- replace glenoid later if needed

- simple procedure for elderly

 

2.  Young patient

 

3.  Glenoid insufficient bone stock

 

Clinical Case

 

Patient with OA treated with Hemiarthroplasty

 

Shoulder Hemiarthroplasty for Osteoarthritis AP

 

The patient developed pain 2 years later

Infection was excluded with blood tests

CT and bone scan indicative of glenoid wear

US demonstrated intact rotator cuff

 

CT Shoulder Hemiarthroplasty for OsteoarthritisBone Scan Shoulder Hemiarthroplasty for Osteoarthritis

 

Revision to TSR

- cemented 3 peg glenoid inserted

- modular body removed to access glenoid

- shorter body used to decrease humeral head height

- intra-operative GT Fracture treated with trauma body and sutures

 

Hemiarthroplasty revised to TSR

 

Reverse TSR

Complications

Intraoperative glenoid fracture

 

Avoid by

- careful reaming and drilling osteoporotic bone

 

Management

1.  Rotate metaglene

- use locking screws to stabilise glenoid

2.  PA screws

- cannulated 4.0 mm screws

- inserted percutaneously from posterior

 

Haematomas

 

Great deal of dead space is created

- always use a drain

 

Nerve injuries

 

AXN / MCN

 

Thought to be more prevalent due to increase stretch of plexus compared with TSR

 

TSR Brachial PlexusReverse TSR Plexus Stretch

 

Infection

 

Spacer for Infected Reverse TSR

 

Sabesan et al Clin Orthop Research 2010

- 17 patients treated with 2 stage revision

- 1 recurrence of infection

- 5 dislocations

 

Inferior scapula notching

 

Reverse TSR Notching

 

Cause

- metaglene not placed inferiorly enough

- humeral component impinges on scapular neck in adduction

 

Prevention

 

Inferior tilt / inferior translation / overhand

- place metaglene very inferior

- use eccentric glenoidspheres / overhang inferiorly

- lateralised glenosphere

 

Problem

- may be cause for development of late pain

 

Simovitch et al JBJS Am 2007

- 77 reverse Delta III shoulders

- 44% inferior glenoid notching

- anterior and posterior notching also occurred

- related to height of implantation of glenosphere +++

- less so to the prosthesis-scapular neck angle

- inferior scapula notching related to poorer clinical outcome

 

Loosening

 

Failed Glenoid Reverse TSRReverse TSR Loose Metaglene

 

Dislocation  

 

Dislocated Reverse TSR AP

 

Dislocated Reverse TSRDislocated Reverse TSR Lateral

 

Acromial Stress Fracture

 

Probably due to overtightening

 

Reverse TSR OvertighteningReverse TSR Overtightening 2

 

Xray Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSR 2

 

Reverse TSR Acromial Fracture ORIF

 

Glenosphere loosening from Metaglene

 

Reverse TSR Loose Glenosphere from Metaglene

 

 

Technique

1.  Templating

 

Xray

 

Rotator Cuff Arthropathy

 

AP in plane of scapula

- template glenoid 

- most inferior screw is in thick bone of scapular axillary border

 

AP humerus

- size and fit of diaphyseal and metaphyseal humeral components

 

CT

 

Axial

- assess glenoid bone stock / version

- normally no posterior wear in cuff arthropathy

 

Glenoid Pre Rev TSR Axial CT

 

Coronal

- often superior wear

 

Glenoid Pre Rev TSR Coronal CTGlenoid Pre Rev TSR Coronal CT 2

 

2.  Deltopectoral approach

 

Incision

- long

- need to be able to access clavicle

- make need to perform clavicular osteotomy

 

Approach

- take SSC and capsule off LT and humerus

- often done with osteotomy as per TSR

- identify and protect axillary nerve

- take part of CAL

- remove capsule from inferior humeral neck + any osteophytes

 

3.  Humeral resection using guide

 

Make entry point in humeral head

- hand ream to determine size of stem

- insert stem with cutting block attached

- 0o or 20o (c.f. TSR)

- 155o cut

- plane of cut laterally just below anatomical neck

- usually takes a couple of millimetres of GT

 

4.  Glenoid

 

Remove capsule and labrum

- protect axillary nerve at all times

- mobilise SSC anteriorly

- need to be able to palpate anterior glenoid

- identify axillary border of scapula

- release triceps and capsule inferiorly

- must be able to feel inferior glenoid and spine

 

Good exposure of glenoid is key to reverse TSR

- sandbag behind spine / allows scapula to fall posterior

- tilt bed up on side of operation

- posterior and inferior glenoid retractors

 

Centering Guide wire passed 

- centre of inferior circle of glenoid

- should exit scapula anteriorly about 3cm medial to glenoid

- ensure not too anterior as anterior screws can have little purchase

- ensure inferior screw will be in inferior good bone

- metaglene needs to be positioned low to prevent inferior impingement and dislocation

- wire needs to angle slightly inferior rather than slightly superior

 

Ream

- symmetrically ream

- remove only cartilage, just to subchondral bone

 

Drill central peg hole

 

Insert metaglene

- press fit central peg

- usually only one size

- rotate so superior screw will be in line with base of coracoid

 

Inferior screw

- drill long screw (minimum 35 mm)

- should be in good bone

- is most important screw

- will exit cortex somewhere

- insert locking screw

 

 Reverse TSR APReverse TSR Axillary View

 

Superior locking screw

- feel anterior and posterior edges of coracoid

- aim between

- again will exit cortex

- 25 - 30 mm screw

 

Reverse TSR Coracoid ScrewReverse TSR Axillary

 

Anterior and posterior non locking screws/ not in every design

- are predetermined to be divergent

- get best bite possible

- can use locking or non locking

 

Add glenosphere

- can wait until have done humeral component and trial

- do have option for eccentric glenosphere

- this overhangs inferiorly, preventing notching / impingement / possible dislocation

- otherwise, if happy with position, choose size and screw in place

 

5.  Ream and trial humeral component

 

Set rotation

- is an eccentric option

- ream over trial

- insert stem and metaphyseal component

- add liner (+3, +6, +9)

 

Trial stability

- in full ER will open slightly

- adduct and ensure not dislocating / put hand in armpit

- shuck test - entire shoulder should move first

 

7.  L'Episcopo

 

Consider Latissmus Dorsi transfer

- if no functioning external rotators

- cannot raise hand to mouth

- severe fatty infiltration / tears in IS / Tm

 

Detach LD anteriorly

- pass front to back

- suture via drill holes to the posterior aspect of the humerus

 

LEpiscopo 1LEpiscopo 2

 

8.  Closure SSC / LT

 

Technique

- 5 ticron

- through drill holes in humerus

- pass around stem

 

9.  Rehab

 

Protocol

- 6/52 passive forward flexion

- 6/52 active assist

- at 3-12 begin muscle strengthening

 

 

Theory

Rotator Cuff Arthropathy for Reverse TSR

 

Indications

 

1.  RC arthropathy / > 70 / low functional demand

 

2.  Revision TSR

 

3.  Failed Hemiarthoplasty in proximal humerus fracture

 

Design

 

Reverse TSR Xray

 

In rotator cuff dysfunction

- humeral head superior causing early failure of conventional TSR

 

Professor Paul Grammont

- convex articular surface to glenoid

- concave surface humerus

- shifts centre of rotation medially and distally to glenoid

- improves lever arm of deltoid

 

Limitations of conventional TSR

 

1.  Inability to manage GH translation

 

Fully conforming surfaces

- humeral and glenoid components same radius curvature

- rim loading must occur with any translation

- rocking horse mechanism

 

Non conforming surfaces

- glenoid radius curvature > humeral head

- diminishes contact area

- increases local contact pressure

- risk poly failure

 

2.  Limitation of fixation of poly to glenoid

- subject to shear forces             

 

3.  Limitations of stability

 

Anterior instability

- defects SSC or anterior capsule / glenoid

 

Posterior instability

- posterior glenoid deficiency / dysplasia

- deficient posterior capsule or labrum

 

Superior instability

- deficient SS or CA ligament / acromion

- laxity of deltoid means it cannot function

- pseudoparalysis from antero-superior escape

 

4.  Deltoid dysfunction

- unable to raise / lower / medialise centre of rotation to compensate for deltoid dysfunction

- without risking loosening and failure of the glenoid component

 

Features of Reverse TSR  

 

1.  GH translation

- does not permit GH translation

- due to conforming concavity of humeral component

- full surface contact maintained during range

- nil rim loading

 

2.  Glenoid fixation

- metaglene fixed by locking and non locking screws along with a central press fit HA coated peg

- metal glenosphere fixed by press taper

- no poly to metal fixation issue

- medialisation of centre of rotation decreases the lever arm of forces

- reduces the moments that challenge fixation

 

Reverse TSR AP BiometReverse TSR Lateral

 

3.  Intrinsic stability

- nature of design has increased intrinsic stability

- humeral socket  forms an angle of 155o with humeral shaft

- deltoid force acts to stabilise the joint

- less dependence on soft tissue and CA arch

 

4.  Deltoid dysfunction

- able to lower or lateralise COR

- inherent stability allows prosthesis to work even if only part of deltoid functions

  

Results

 

ROM

 

Cuff et al JBJS Am 2008

- 96 patients with minimum 2 years follow up

- abduction increased from 61 to 110o

- flexion 60 to 120o

- ER from 13 to 30o

 

Complications

 

Wall et al JBJS Am 2007

- 191 shoulders followed for a minimum two years

- worst results in post traumatic arthritis and revision TSR

- 15 cases of dislocation

- 8 cases of infection

 

Survival

 

Guery et al JBJS Am 2006

- calculated 10 year survival rate of 90%

- noted than Constant shoulder scores deteriorated over time

- 60% 10 year survival with Constant score < 30 as an end point

 

Revision Shoulder Arthroplasty

Issues

 

Rule out infection

Assess rotator cuff / bone stock preoperatively

Approach

- difficult / scarring +++

- very difficult to restore any loss of ROM

Removal of prosthesis

Glenoid

- may not be able to revise

Humeral component

- long stem

 

Investigations

 

Rule out infection

- CRP / ESR

- ultrasound or xray guided aspiration

- arthroscopy for fluid and tissue sampling

 

Ultrasound

- good for cuff integrity

- MRI often not useful due to large amount of metal artefact

 

CT scan

- glenoid often deficient posteriorly 

- if ignore will either be unstable posteriorly

- or will expose glenoid to excessive forces, predisposing to failure

 

Implant Removal

 

Glenoid

- often very loose

- easy to remove

 

Revision TSR Loose GlenoidRevision TSR Loose Glenoid

 

Humeral component

- most uncemented stems only proximally coated

- flexible osteotomes

 

Revision TSR

 

Glenoid bone stock restoration

 

1.  Cortical ring allograft

- napkin ring type

- take from calcar of a femoral neck

- cut so is thicker posteriorly to reconstitute the glenoid

- place onto freshened glenoid surface

- use uncemented glenoid

- drill central plug, then superior and inferior screws

 

Problems

- bone can crack, making it unstable

- need long screws with good bite, locking screws preferable

- useful to have available custom made implant with longer central peg

- enables obtain fixation with native glenoid

 

2.  Bulk posterior allograft

 

 Revision Reverse TSR Glenoid Bulk Posterior Allograft

 

Technique

- use femoral head

- reconstitute posterior aspect of glenoid

- fix with 2 x cannulated 4mm screws via stab incisions posteriorly

- need to be able to fix glenoid component with screws still

 

Revision Humeral Component

 

Technique

- often need long stem

- often use cement in revision circumstance

 

Revision TSR Long Stem Cemented Humeral Component

 

Rheumatoid Shoulder

IssuesRheumatoid Shoulder

 

Rotator cuff

- often deficient

 

Bone stock

- often deficient

 

Glenoid

- often posterior version 

 

Management

 

Options

 

1.  TSR

 

Indications

- cuff intact

- sufficient bone stock

 

2. Hemiarthroplasty

 

Indications hemiarthroplasty

- young patient

- rotator cuff not intact, too young for reverse

- insufficient bone stock glenoid

 

Technique if rotator cuff deficient

- CTA head

- over size humeral head / increase valgus

 

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR

 

3.  Reverse TSR

 

Indications

- ruptured cuff (30%)

 

Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects

 

 

 

 

TSR Technique

TSR APTSR Lateral

 

Goal

- head that translates 50% in all directions

- allows 30o ER with arm at side

- stable posteriorly

 

Pre-Op 

- antibiotics

- consider specific Propionobacterium cover

- assess ER pre-operatively

 

Position

 

1.  Beach-chair position

- McConnell head rest

- patient at table edge / removable edge

- shoulder must overhand table

- allows GHJ extension

- need this to insert stem

- 500 ml saline bag between shoulder blades

 

2. T-max table with Spyder attachment

 

Incision / Dissection

 

Extended deltopectoral approach

- coracoid to deltoid insertion 

 

Separate deltoid & pectoralis major

- retracting cephalic vein laterally causes less bleeding

- retracting cephalic medially prevents cephalic avulsion from subclavian vein

- place Cobell retractors under deltoid

 

Deep dissection

- divide clavipectoral fascia on lateral edge conjoint

- elevate conjoint, feel for MCN

- replace medial retractor blade under conjoint tendon

- ER humerus and expose SSC

 

Exposure

- blunt dissect subdeltoid space

- right up to coracoid and clavicle

 

Open Approach Shoulder

 

Dangers

 

1.  Musculocutaneous nerve

 

Branch lateral cord

- penetrates coracobrachialis 3-8 cm distal to coracoid

- beware rare cases higher

- palpate MCN under conjoined tendon

- place finger under tendon and sweep downwards to palpate

 

Average 3 cm

- most common cause of damage = overzealous retraction

- avoid release of conjoined tendon if possible / protects MCN

 

2.  Axillary nerve

 

Terminal branch of posterior cord

- arises inferior to coracoid

- crosses anteroinferior border of subscapularis muscle

- exits quadrangular space with posterior circumflex humeral artery

 

Palpate

- slide finger under conjoint tendon

- run downwards over SSC muscle

- hook finger anterolaterally to feel nerve

- relatively tight cord running posteriorly

- relatively protected with adduction & ER

 

Tug test

- palpate anterior axillary nerve under anterior deltoid

- tug on axillary nerve over SSC

- will feel the nerve moving back and forth

- ensures is intact at end of operation

 

Quadrangular space

- below SSC anteriorly / T minor posteriorly

- inferior is T Major posteriorly

- between long head triceps and SNOH

 

Splits into 2 trunks 

1. Posterior to teres minor & posterior deltoid

- terminates as superior lateral cutaneous nerve

2. Anterior passes to middle then anterior deltoid 

 

Releases / Exposure

 

1.  Coraco-acromial ligament

- place fang retractor on coracoid

- don't divide in full or risk superior escape of humeral component

- take anterior triangle with diathermy

- aids exposure

 

2.  Pect Major insertion

- divide upper 50%

- can release more if needed, but repair at end

- allows ER of humerus

 

Ligate Anterior Circumflex Humeral blood vessels

- 3 sisters

- at inferior SSC tendon

- can tie off with stay sutures

 

Identify rotator interval

 

3.  Identify and release biceps

- divide biceps at insertion with scissors

- perform tenodesis later

 

Feel and palpate supraspinatous / infraspinatous

- ensure that are intact

- otherwise repair / change to reverse TSR

 

4.  Release Lat Dorsi / Teres Major if needed

- ER humerus

- subperiosteal dissection with diathermy

 

5.  Clavicle osteotomy

- if exposure difficult

- revision / large muscular men

- divide fascia to expose clavicle

- anterior 1/3 of clavicle

- from ACJ (don't violate) to anterior curvature of clavicle

- complete with saw / osteotome

- repair with sutures at end of case

 

6.  Can release conjoint tendon if needed

- usually via coracoid osteotomy

- predrill

- secure with screw later

 

SSC options

 

A. Divide SSC tendon

 

Advantage

- easy to do

 

Disadvantage

- tendon - tendon healing less reliable

- need to protect ER post operatively

- high incidence of SSC failure / poor lift off test

 

Technique

- want to leave long

- so don't limit ER when repairing

- insert medial 2.0 vicryl stay sutures

- take vertically right on insertion on LT

- take entire tendon plus capsule

- will repair through drill holes at end of procedure

 

B.  LT Osteotomy

 

Advantages

- bone to bone healing much more reliable

 

Technique

- expose inferior humeral flare

- don't want inferior cut venturing into humeral shaft / is a fracture risk

- release inferiorly

- pass ring handled spike behind the SSC
- IR humerus to neutral

- use oscillating saw

- begin in intertubercular groove

- aim to exit deep rather than shallow

- don't want saw exiting in SSC

- if take cartilage can simply excise with nibblers

- usually small 2 cm oval piece

- place ethibond stay sutures

 

Humeral Osteotomy

 

Release

- soft tissue off inferior neck of humerus

- ER humerus to put tissues on tension

- use osteotome to remove beard osteophytes

- may need to release lat dorsi and teres major tendon

- release capsule anteriorly 12 to at least 6 O'clock from humerus +++

- stay on bone

 

Deliver humeral head

- Extend & ER humerus to dislocate

 

Identify true anatomical neck

- aided by removal of crown osteophytes

- saw blade should exit at superior and inferior edge of articular cartilage

- this is the osteotomy site

 

Cut in planned retroversion

 

Usually 25o of retroversion

- can match to patient's own retroversion

- i.e. osteotomy removes cartilage front and back

- can reduce retroversion if large amount of glenoid retroversion present

 

Varus / valgus 130° to long axis

 

Technique 1

- flex elbow

- use forearm as protractor

- ER forearm 25o

- cut directly posteriorly

 

Technique 2 (Global)

- use jig

- insert humeral reamers (long and straight)

- up to templated size

- attach jig to humeral reamer

- set one part of jig aligned to the forearm as reference

- dial in required retroversion

- set height of desired cut

- pin in situ

 

Use oscillating saw

- insert retractors to protect glenoid / infraspinatous /supraspinatous

- surprisingly small amount of bone removed

 

Remove humeral osteophytes

- anterior crown / often best with osteotome directed superior to inferior

- fully ER head and remove posterior neck osteotophytes

 

Stem

 

Deliver proximal humerus

 

Insert broach

- has fins to ensure correct rotation of prosthesis

- insert trial stem

- also have head caps

- leaving the stem in prevents fractures

- leaving cap on prevents crushing cancellous bone

 

Surface Replacment / No stems

 

May have improved outcome

- recreate anatomy including version

- stem does not dictate head placement

- very difficult to overstuff joint

 

Glenoid Releases

 

Glenoid Releases

 

Very important for the exposure

 

SSC releases

 

Use to be 360o release

- fatty infiltration post operatively was identified on MRI

- thought to be due to denervation anteriorly

 

180o release

- use stay sutures to pull SSC laterally

- posteriorly identify capsule interval

- divide capsule along posterior SSC (MGHL and IGHL)

- completely elevate from anterior glenoid

- superiorly identify CHL and divide

- use finger to free SSC superiorly and posteriorly right along scapula

- should now be able to mobilise SSC freely

 

Divide inferior capsule

- palpate axillary nerve

- place retractor over AXN

- divide capsule along inferior glenoid to 6 o'clock

 

Resect

- biceps insertion

- labrum

- MGHL

 

SSC

- push medially

- protect with sponge

- retract with fang retractor

 

Release anteriorly

 

Release inferiorly

- often more important for reverse TSR

- use cobb to elevate inferior capsule

- divide long head of triceps if needed

 

Continue humeral neck release

- release around neck all the way to posterior

 

Glenoid Exposure

 

TSR Glenoid Exposure 1TSR Glenoid Exposure 2

 

Need a straight shot at the glenoid

 

Humerus

- flexed

- head pushed posteriorly

- IR

 

Retractors

- on posterior lip of glenoid

- retractor displaces head posteriorly

- Fukuda retractor / Fang

 

Allow for stress relaxation to occur

 

Danger: Glenoid Fracture

 

Inferior retractor to protect axillary nerve
- above inferior capsule

- bunny ears / playboy retractor

 

Additional Techniques

- elevate patient's bed / drops arm

- tilt patient ipsilateral side up

 

Assess glenoid

 

Often posterior erosion

- OA may be due to subtle posterior instability

 

Posterior erosion options are

 

1.  Lower anterior rim 

- recreate version

- remove anterior half with reamer

- maximum 10o

 

Problem

- removing bone stock which is limited

- reduce vault and increase risk of vault penetration

- increase risk of difficulty seating glenoid

- medialise glenoid component

- there are no increased poly thicknesses

 

2.  Decrease humeral retroversion

- resect head with arm in < 25o ER

 

3.  Bone graft posteriorly

- use napkin ring femoral neck allograft thicker posteriorly

 

4.  Custom component with post wedge build up

 

Insert Glenoid Component

 

Glenoid options

 

1.  Cemented all poly curved back

- most common, best results

 

A.   Peg v central keel

- pegs may be single or multiple

 

B.  Flat v curved back

- curved backs may seat better

 

C.  Cementing

- trend now to minimize cement behind poly (place only in plug holes)

- this is because can get a very thin film of cement which can crack

- however, demonstrated increased pullout strength with increased cement thickness

 

2.  Uncemented metal back

- secured with screws

- advantage is can be same prosthesis as in reverse

- i.e. can convert later to reverse if failure of cuff

- problem is continued issues with metal / poly interface

- also problems with overstuffing

- higher rate of revision

 

Centre peg crucial

 

Vault is a triangle

- pilot hole critical

- must not penetrate vault

 

Direction

- usually slightly superior in TSR to equator

- if put glenoid too low the humeral head will ride high

- need to match tilt as well as version

 

"Glenoid Centering Point" (Matsen) 

- index finger anterior to glenoid palpates centering point in sulcus 

- bounded by upper & lower crura of scapula & flare of glenoid vault 

- 6-8 cm medial

- wire should exit anteriorly at this point

 

Hypoplasia

- glenoid is sufficient size if can take central peg

 

Technique

- insert guide pin

- gently ream central peg

- check intact cortex with arthroscopy probe

 

Vault blowout

- i.e. any drill hole comes out of vault

- especially important for central peg

- loose pressurisation of cement

 

TSR Central Peg BreachTSR Glenoid Vault Breach

 

Solution

- insert bone graft

- pressurise only intact holes

 

Cement Glenoid

 

TSR Cemented Glenoid APTSR Cemented Glenoid Lateral

 

Remove labrum

- allows sizing and correct orientation of glenoid

 

Trial size

- place trial

- ream central peg where you want it

 

Insert reamer

- take off cartilage

- can eccentrically ream if needed

 

Insert new broach

- ream for other pegs if needed

- three or five

 

Keep holes dry

- insert sponge

 

Insert cement into peg hole

- use syringe

 

Insert Poly

- pressurise

 

Head

 

Overstuffing of joint causes poor ROM

 

1.  Height

- head sits only 3 mm above GT

- too high places excessive stress on RC

 

2.  Size

- small enough to close SSC

- too large a head limits ROM & increases risk of SS and SSC rupture

 

3.  Offset heads

- normal head offset from neck posteriorly and medially

- placing head more anterior than normal increases strain on cuff and glenoid

- i.e. can anteriorly impinge on SSC and cause late rupture

 

Trial

 

Should be able to

A.  Inferiorly sublux head 50% glenoid

B.  Posteriorly sublux head 50% and return to centre

C.  Able to close SSC without impingement on head

D.  Close SSC with arm in ER 30o

E.  Place hand on chest

 

Insert stem

 

A.  Cemented

- don't pressurise

- can crack stem

 

B.  Uncemented

- very good results

 

Posterior Instability

 

1.  Posterior capsule plication

- lamina spreader between stem and glenoid

- place east - west sutures / 3 x horizontal ethibond sutures

 

2.  Place sutures in capsule posteriorly

- run ethibond anteriorly through joint

- tie to conjoint tendon

 

3.  Place arm in ER post operatively

- de-tensions posterior capsule

- allows capsule to scar

- i.e. gunslinger position

- also keeps humeral head forward

 

Closure

 

A. Reattach SSC via drill holes in anterior neck of humerus

- insert sutures prior to cementing stem

- 5 x drill holes

- 4 x 5 ethibond

- place arm in 30o ER

- pass in horizontal mattress suture through SSC edge

 

B.  LT osteotomy

- lateral drill holes in humerus

- suture through drill holes and medial to LT into SSC

- this can tend to lateralise LT, limit ER

- various techniques to avoid this

- can pass sutures about stem

 

Biceps tenodesis

- suture usually

 

TSR0001TSR0002

Total Shoulder Replacement

IndicationsTSR All Poly Glenoid

 

RA 

OA 

AVN 

 

Contra-indications

 

Infection

Charcot

Paralysis of deltoid

Torn rotator cuff

Insufficient glenoid bone stock

 

Requirements

 

1.  Functioning / Repairable rotator cuff

- maintain stability

- maintain centre of joint rotation

- early failure if cuff deficient

 

TSR plus cuff repair

 

2.  Intact Deltoid

 

3.  Resonable glenoid bone stock

- commonly posterior bone loss in OA

- glenoid component must be completely supported by peripheral bone rim or early failure

- beware glenoid hypoplasia

 

Anatomy

 

Glenoid

 

Height

- 35 - 40 mm

 

Width

- approximately 70% glenoids are pear shaped

- remainder elliptical

- upper width average 23 mm

- lower width average 29 mm

 

Shoulder CT Glenoid OvalShoulder Glenoid CT Pear Shaped

 

Inclination

- approximately 4 - 5o superior

 

Version

 

Healthy shoulders

- mean 2o anteversion

- large range

- 14o anteverted to 10o retroverted

 

Pathology

- RC 8o retroversion mean

- OA 15o retroversion mean

- RA 15o degrees retroversion mean

 

Vault

 

Usually triangular

 

Scapula

 

30o anteverted from coronal plane

 

Humeral head

 

Retroversion 30o

 

Design

 

Constraint

 

Highly

- never used

- high failure rates / peri-articular fracture

 

Semi Constrained

- cupped glenoid

 

Unconstrained 

- GE > 90%

- most common design 

 

Stem

- cemented v uncemented

- stems v resurfacing

 

TSR No StemTSR Uncemented StemTSR Cemented Stem

 

Glenoid

- metal backed

- all poly

 

TSR Metal Backed Glenoid

 

Planning

 

AP XR IR & ER 

- Assess head

 

Axillary 

- Assess glenoid

- OA = Posterior bone loss

- RA = Medial bone loss  / protrusio

 

Template

 

1.  Stem

- size

 

2.  Head

- neck osteotomy

- head diameter and depth

 

3. Glenoid size

 

CT

 

1.  Assess bone stock

- sufficent bone in glenoid

- exclude glenoid hypoplasia

 

CT TSR Preop Glenoid CystsTSR Glenoid CT Good Bone StockTSR CT Glenoid Good Bone Stock

 

2.  Assess version / posterior deficiency

 

Measurement

- can be suprisingly inaccurate

 

Hoenecke JBJS 2010

- 2D CT depends on angle CT gantry

- 20% error > 10o

- 3D CT best

 

Normal

- average is 2o anteversion

- up to 15o retroversion can be normal

 

Options for Management Glenoid Version

 

A.  Neutral inclination glenoid

- reduce retroversion of head to 25o

 

TSR Glenoid CT Neutral Inclination

 

B.  0 - 10o retroversion of glenoid

 

Plan

- alter with reaming / 10o change is the maximum

- otherwise can run into difficulty seating glenoid

- reduce retroversion of head further

 

TSR Glenoid CT Mild Retroversion

 

C.  20o + retroversion of glenoid / deficiency

 

Options

- alter up to 100 with reaming

- reduce further the retroversion of head

- glenoid bone augments / augmented poly

- may require primary glenoid osteotomy

 

Glenoid Posterior Deficiency.jpgGlenoid Posterior Version and Deficiency

 

Assess Rotator Cuff

 

MRI

Ultrasound

 

Rehabilitation

 

Neer's 3 Phase shoulder rehabilitation

 

Phase 1 Passive motion in forward flexion & ER

Phase 2 Active Assisted 6-8 weeks 

Phase 3 Advanced muscle strengthening 3/12

 

Results

 

1.  Pain

 

Pain relief good 90%

 

2.  ROM

 

Range of motion variable

- OA with intact cuff = 120° elevation

- Post fracture or huge cuff tear = 40°

 

ROM gain

- OA 77o

- RA 57o

- post trauma 33o

 

3.  Survival

 

Deshmuhk et al J Shoulder Elbow Surg 2005

- 93% survivorship 10 years

- 88% 15 years

- average age 60 years

- mostly Neer II prosthesis

 

Sperling et al J Shoulder Elbow Surg 2004

- patients under 50 having TSR (Neer II)

- 97% 10 years, 84% 20 years

 

Complications

 

1.  Subscapularis Failure

 

Causes

- poor reattachment

- overstuffing anteriorly

- humeral anteversion

- denervation

 

Prevention

- trial ER on table at end

- limit rehab to this

 

Consequences

- decreased ROM

- pain

- instability

 

Salvage

1.  Re-repair - limited success

2.  Pectoralis major transfer

- results poor in shoulder arthroplasty

- Jost et al JBJS Am 2003

3.  Achilles tendon bone allograft

4.  Bristow

5.  Reverse

 

Loosening

 

TSR Loose glenoidGlenoid Component Loosening

 

Rates

- 5-40%

- clinical loosening relatively infrequent

- uncemented > cemented

 

Glenoid lucent lines 

- relatively common 

- ~ 30-96%

- not all are associated with pain

- not all require revision

 

Humeral component

- loosening rare

 

Instability 5%

 

Anterior  

 

Cause

- mal-rotation humeral component most common

- subscapularis rupture

- anterior deltoid dysfunction

- glenoid component loosening

 

TSR Anterior Instability LateralTSR Anterior Instability AP

 

Superior  

 

Cause

- attenuation cuff or frank rupture

- dynamic muscle dysfunction

 

Prevention

- must ensure don't leave humeral head proud

- restore shenton's line

- results in eccentric loading of glenoid component & loosening 

- "rocking horse glenoid"

 

Shoulder Hemiarthroplasty Rotator Cuff FailureTSR Superior Escape

 

Posterior (most common problem) 

 

Cause

- excess retroversion of glenoid or humerus

- posterior glenoid erosion

- ST imbalance

 

TSR Posterior DislocationRevision for Posterior Dislocation TSR Combined Anterior Posterior Approach

 

Management

- may need posterior approach to reduce

- allows posterior capsular plication

- alter component version / increase anteversion

- anterior releases

 

Inferior  

- especially post fracture with shortening of humerus

- important to re-establish humeral length to restore resting tension of cuff & deltoid

- overstuffing of joint

 

Post-op rotator cuff failure

 

Rate

- 2%

 

Cause

- due to head malplacement or malposition

- respond poorly to reconstruction

 

TSR Failed Rotator CUff

 

Management

- revise to reverse TSR

 

Peri-prosthetic Fracture

 

Type

A:  Tip of prosthesis with proximal extension

B:  Fracture at tip only

C:  Fracture distal to tip and extends into distal metaphysis

 

Options Humeral Shaft Fracture

 

A.  Non operative Management

- prothesis stable

- acceptable aligment

 

B.  ORIF

- anterolateral approach and plate

 

C.  Revise to long stem > 2 cortical diameters past fracture

 

TSR Humeral Fracture TSR Humeral Fracture United

 

Results

 

Kumar et al JBJS Am 2004

- 16 patients

- 6 healed after 180 days of non operative treatment

- 5 required operation after 123 days non operative treatment

- recommended all fractures can be treated non operatively

- if well aligned and prosthesis stable

- if not united by 3 months, recommend intervention

 

Infection 1%

 

TSR Infected

 

NV injury

 

AXN / MCN

  

Ectopic Ossification

Arthroscopy

Position

 

1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape

 

Lateral Decubitus Shoulder ArthroscopyShoulder Arthroscopy Lateral DecubitusShoulder Lateral Decubitus Arthrex

 

2.  Beachchair

 

A.  Beachchair table

- pillow under thighs

- arm draped free

- access to posterior shoulder

- head secured to Mayfield head ring

 

B.  Spyder / Tmax

- holds head secure

- good access to posterior shoulder

- hydraulic arm holder elminates need for assistant to hold arm

 

Shoulder Arthroscopy TmaxShoulder Arthroscopy Spyder

 

Portals

 

Shoulder Arthroscopy Portals

 

Posterior Portal

 

Shoulder Arthroscopy Posterior Portals

 

Main portal for arthroscopy

 

A.  Soft spot

- identify posterolateral acromion

- 2 cm medial & 2 cm inferior

- through deltoid

- between infraspinatous and T minor

 

Make stab wound at post portal

- introduce cannula & trocar

- tip towards coracoid process

- distract shoulder joint whilst inserting

- introduce arthroscope

 

B.  Variation

- if mainly performing subacromial / rotator cuff

- move portal lateral and superior

- 1 cm inferior and 1 cm medial to posterolateral acromion

- aims scope over cuff tear which is usually lateral

- increases distance from cuff vertically

- can view larger area

 

Additional portals

 

Anterior Glenohumeral Portals

 

Arthroscopy Anterior PortalShoulder Arthroscopy Portals Anterior

 

Rotator Interval

- biceps, glenoid & humeral head form a triangle with subscapularis in the base

- place anterior portals in this triangle above subscapularis, lateral to coracoid

 

Shoulder Arthroscopy Rotator IntervalRotator Interval

 

A.  Retrograde method

- direct scope into rotator interval

- advance until rests against anterior capsule at superior edge subscapularis

- light transilluminates skin at site of portal

- ensure lateral to coracoid

- remove scope from sheath

- insert Wissinger rod / switching stick through sheath

- make stab incision

- advance rod

- insert cannula over stick

- use portal for probe & instruments

 

B.  Direct / anterograde

- insert 19 gauge spinal needle

- always lateral to coracoid

- pass into rotator interval

- stab incision / switching stick / cannula

 

Anteroinferior portal

- just above SSC

- angle to get to anterior labrum / bankart repair

- 3 - 6 o'clock

 

Shoulder Scope Low Anterior Portal

 

Anterosuperior portal

- high in rotator interval

- in angle between humeral head and biceps

- working portal for suture exchange in stabilisation surgery

- good angle for anchor insertion for SLAP repair

 

Anterosuperior Glenohumeral portal

 

Posterior Portal

 

Technique

- insert switching stitch through camera cannula

- insert camera through anterior cannula

- pass cannula over switching stick

 

Uses

- inspect / probe / repair posterior portal

 

Shoulder Arthroscopy Posterior Portal

 

Posterolateral portal

 

For posterior labral tears

- inferior and lateral to posterior portal

- allows placement of the inferior anchor

 

Shoulder Posterior Portals 1Shoulder Posterior Portals 2

 

Posterior Subacromial Portal

 

Redirect posterior cannular with blunt trochar

- remove camers

- direct it superiorly immediately below acromion once through deltoid

- sweep trochar laterally to break adhesions

 

Lateral Subacromial portal

 

Working portal

- for subacromial decompression / ACJ resection / RC surgery

- 2 - 3 cm lateral to lateral acromion

- 1 - 2 cm posterior to anterior acromion

- usually in line midportion / posterior border of clavicle

- insert needle

- should be above cuff, below acromion

- parallel to acromion

 

Anterosuperiorlateral Portal / Port of Wilminton

 

Shoulder Scope Port WilmingtonShoulder Scope Port Wilmington 2

 

Indication

- SLAP

- passes through supraspinatous

- anterolateral border acromion

- can place more posteriorly to access posterior aspect of SLAP

- in this case will pass through infraspinatous

 

Superior portal Neviaser / Superomedial portal

 

Indication

- access posterior SLAP / decompress suprascapular nerve

- pass through RC / supraspinatous

- 1 cm medial to acromion

- 1 cm posterior to clavicle

 

Fluid

 

A.  Pressure pump

- usually 40 - 50 mmHg

- can temporarily increase if required

 

B.  Adrenaline in bags

- 1 mg in each 3L bag

 

Examination of GHJ

 

Systematic Approach

 

A.  Glenoid medial / Humeral head lateral

- arthritis / chondral damage

 

Arthroscopy Humeral Head OAGlenoid OA Arthroscopy

 

B.  Biceps

- careful examination / probing of insertion

- examination of intra-articular portion for degeneration

- pull extra-articular portion into joint to confirm gliding well

 

Arthroscopy Normal Biceps InsertionArthroscopy Normal Biceps TendonArthroscopy Normal Biceps Tendon 2

 

C.  Labrum

- 360o examination

- anterior / inferior / posterior

 

Arthroscopy Normal Anterior LabrumShoulder Arthroscopy Inferior LabrumShoulder Arthroscopy Posterior Labrum

 

D.  Glenohumeral ligaments

 

Superior

 

Superior Glenohumeral Ligament

 

Middle

- crosses subscapularis vertically

 

MGHL Arthroscopy

 

Inferior / anterior aspect of IGHL

- attachment to labrum between 3 and 6 o'clock

- look down into inferior recess

- see attachment to inferior humerus

- exclude HAGL / exclude loose body

 

Arthroscopy Normal IGHL Humeral InsertionNormal IGHL Glenoid AttachmentShoulder Loose Body

 

E.  Rotator Cuff

 

Subscapularis

- examine insertion

- ER the humerus

 

Arthroscopy Normal SubscapularisSubscapularis Normal Arthroscopy

 

Supraspinatous

- examine underside and insertion

- abduct and ER

- should be no gap between cartilage and insertion

 

Supraspinatous Normal ArthroscopySS normal arthroscopySupraspinatous Tendon Normal Crescent Variant

 

Infraspinatous

- insertion at posterior humerus next to bare area

- Hill Sach's lesion (has cartilage each side c.f. bare area)

 

Shoulder Arthroscopy Infraspinatous Insertion

 

Neurological Complications

 

Uncommon (0.1%)

 

1. Posterior Portal

- if placed inferiorly can damage AXN below Teres minor 

 

2. Anterior Portal

- damages MCN if medial to coracoid

- brachial plexus & axillary artery

Clavicle

Clavicle Fractures

Clavicle Fracture Displaced

Mechanism

 

Usually a direct blow 

- less commonly a fall on the outstretched hand

 

RTA / sporting accidents commonest causes

 

Can be pathological as a result of radionecrosis

- eg following radiotherapy for breast cancer.  

 

Incidence

 

Fractures of the clavicle are common

- 5% of all fractures

- Up to 80% involve the middle third

 

Anatomy

 

Ossification

 

First bone to ossify in 5th week of foetal life

- intramembranous ossification

- medial growth plate accounts for 80% length

- medial physis last to close at 22-25 years

 

Shape

 

The middle third of the clavicle is the junction of two curves

- medial convex anteriorly 

- lateral convex posteriorly  

 

At the junction there is little cancellous bone

- skeletal muscle covers only part of the cortical bone

- the volume of muscle in this region is small

 

The clavicle is secured firmly at each end by stout ligaments and joint capsules

 

Movement

 

It rotates approximately 40o when the scapula is elevated

- most of the rotation occurring after the arm passes the horizontal level 

 

Classification

 

Fractures may be divided into three regions of the clavicle 

 

Medial end

- fifth of the bone

- lying medial to a vertical line drawn upward from the center of the first rib 

- rare

- <5%  

 

Lateral clavicle fracture

- fifth of the clavicle

- lateral to a vertical line drawn upward from the center of the base of the coracoid process

- a point marked by the conoid tuberosity

- approximately 1/3 of all clavicle fractures 

 

Diaphysis 

- intermediate three-fifths between these two areas 

- most common

- 70% of clavicle fractures

 

Clavicle Diaphysis Fracture

 

Examination

 

Examine skin

- ensure skin not threatened by spike of bone

 

Examine AXN

- sensation in deltoid patch

 

Look for scapula winging

- may be an indication for fixation

 

Xray

 

Clavicle Midshaft Displaced

 

Displacement

- the proximal end under the pull of SCM becomes elevated

- the shoulder tends to sag downwards and forwards

- with further displacement there is overlapping and shortening 

- the portions of the clavicle may also be rotated relative to one another

 

Non Operative Management

 

Sling for comfort

- followed by early mobilisation as the pain subsides

 

Figure of 8 bandage 

- these do not effectively reduce the fracture 

 

Complications Non Operative Management

 

1.  Persistent bony spike

- even after normal remodelling

- may require excision

 

2.  Thoracic outlet syndrome

- secondary to hypertrophic non-union of the clavicle

- also due to reduced subclavicular space in a shortened malunion

- late compression of ulna nerve, brachial plexus

- symptoms with overhead activities

 

2.  Non union 

 

Clavicle Non UnionClavicle Nonunion

 

 

Neer (6) 1960 JAMA

- 2235 closed clavicle fractures treated non-operatively

- non union in only 3 (0.1%) 

- his series of 45 fractures treated by open reduction, there was non union in 2 (4%)

 

Rowe Clin Orthop 1968

- nonunion in 0.8% of fractures treated by closed methods

- 3.7 % in those treated by open reduction

 

Robinson et al JBJS Am 2004

- prospective cohort study

- overall non union rate in clavicle fractures of 6.2%

- 4.5% of diaphyseal fractures / 11.5% lateral fractures / 8.3% medial fractures

- factors increasing risk non-union in diaphyseal fractures

- advancing age / female gender / complete displacement / comminution

 

3.  Malunion

 

Clavicle Fracture Shortened and Displaced

 

Hill et al JBJS Br 1997

- studied 52 completely displaced midshaft clavicle fractures

- all treated non operatively

- 8/52 (15%) developed non union

- 16/52 (31%) unsatisfactory (residual pain / brachial plexus symptoms)

- initial shortening of > 20 mm associated with non union and poor outcome

 

McKee et al JBJS Am 2003

- poorer functional outcome

- fractures > 2cm shortening

 

Clavicle Fracture Shortened

 

Canadian Orthopedic Trauma Society JBJS Am 2007

- multicentred RCT of op (62) v non op (49) treatment displaced midshaft clavicles

- 1 year followup

- average time to radiographic union 28 v 16 weeks

- non unions 2/62 v 7/49

- symptomatic malunion 0/62 v 9/49

- better shoulder scores at all times

- in operative group, 3 wound infections, 1 mechanical failure and 5 prominent hardware

 

Operative Management

 

Absolute indications 

 

Skin compromise (open fracture or severe skin tenting)

Neurovascular injury

 

Clavicle Fracture Skin Tenting

 

Open Clavicle Fracture

 

Relative indications

 

Floating shoulder 

Multi-trauma

High risk of non union / malunion

Non union

 

1.  Plate fixation

 

Clavicle PlateClavicle Plate

 

Indications

- fresh fractures of the middle third 

- gross displacement and angulation of the bone 

- shortening of the clavicle that was estimated to exceed 2.5 cm on plain radiographs

 

Results

 

Bostman et al J Trauma 1997

- plate fixation (DCP / Pelvic Recon)

- ORIF in 103 (9.5%) of the total of 1081 patients

- complication rate 23% 

- infection rate was 7.8%

- both patients treated with a 1/3 tubular plate suffered plate breakages

- 10 patients required reoperation for loosening, infection, non union or plate breakage (10%)

 

Technique

 

Lazy beach chair

- square drape

- LA with Adrenalin

 

Transverse incision in Langer’s line

- can make incision inferior to clavicle

- pull it up, keeps wound away from plate

- can identify and protect supraclavicular nerves

- divide platysmus as a layer to repair later

- clean and reduce fracture

- application contoured locking plate

- need 6 cortices each side

 

Complications

- infection

- numbness infraclavicular (tends to reduce in size)

- non union

- hardware failure

- arterial injury

- pneumothorax

 

2.  IM Screw 

 

Clavicle IM Fixation

 

Results

 

Boehme et al 1991 JBJS Am

- 21 patients established symptomatic non union

- intramedullary Hagie pin

- autologous bone grafting

- 20/21 union

- average time to healing of twenty-two weeks (range, twelve to thirty weeks)

- 17 / 21 the screw had to be removed due to development of a tender bursa

 

Technique

 

Open approach to fracture

- 2 - 3 cm

- hand drill medially 

- pass cannulated wire laterally and out through skin

- reduce fracture, retrograde pass wire medially

- drill lateral fragment

- insert cannulated 7.3 mm screw

- needs to be between 80 and 110 mm

- check x-ray to ensure good medial fixation

- BG if non union

 

Post op

- limit ROM above shoulder height for a period

- decreases rotational forces and reduce risk of non union

 

3.  External Fixation 

 

Indications

- open fractures 

- severely displaced fractures with damaged skin

 

Technique

- medial pins are anterior to posterior in an ascending direction to avoid the pleural dome

- lateral pins are superior to inferior in an almost vertical direction 

 

4.  Management Malunion

 

Clavicle Malunion ORIF

 

Results

 

McKee et al JBJS Am 2003

- 15 patients mean age 37 years over 4 year period

- average shortening 2.9 cm

- complaining of pain and fatigueability

- also complaining of symptoms consistent with thoracic outlet syndrome

- many complained of cosmesis

- patients had scapula winging

- osteotomy and DCP (no bone graft required)

- 1 non union

- 8/12 patients with weakness and pain improved

- neurological symptoms eliminated in 7, decreased in 3, unchanged in 1

Lateral Clavicle Fracture

Epidemiology

 

Elderly population

Less common in younger population

 

Lateral 1/3 Neer Classification

 

Type I

 

Lateral Clavicle Fracture Undisplaced

 

Fracture lateral to the CC ligaments

- does not extend into the ACJ

- non displaced

- most common 4:1

 

Type II

 

Lateral Clavicle Fracture

 

2A

- medial to CC ligaments

- CCL ligaments attached to lateral fragment

- medial fragment displaced superiorly

- highest rate of non union

 

2B

- between conoid and trapezoid

- conoid disrupted

- trapezoid remains attached to the lateral fragment

- more stable

 

Type III

 

Involves articular surface ACJ

- ligaments intact

- may present as late degenerative change

 

Type IV

- skeletally immature patient

- paediatric sleeve fracture

- ligaments attached to periosteum

- displacement of proximal fragment

 

Non Operative Management

 

Robinson JBJS Am 2004

- cohort of 100 displaced Type II fractures

- 20% asymptomatic non-union

- 14% of cohort required surgery

- recommended non operative treatment in middle aged / elderly

 

Operative Management

 

Operative Indications 

- Compound / skin compromise

- displaced fracture in young people

- non union

 

Options

 

1.  Dorsal plate / locking wrist plate

 

Lateral Clavicle Plate

 

Case 1

 

Lateral Clavicle ORIFLateral Clavicle ORIF 2

 

The lateral clavice fracture has been cleaned and reduced

- held with K wire across ACJ

- high strength suture around clavicle and coracoid

- locking plate applied, reinforced with IM screw, and high strength tape around coracoid

- advantage: no need to remove hook plate

 

2.  Hook Plate

 

Lateral Clavicle Fracture Hook Plate PreopLateral Clavicle Fracture Hook Plate Post op

 

Halder et al J Should Elbow Surg 2006

- 22 patients treated with hook plate

- very limited ROM (90o flexion) until plates removed at 3-4 months

- 1 disengaged from acromion (should have used acromial screws)

- 1 disengaged from clavicle (should have used 6 not 4 hole plate)

- 1 clavicular fracture at end of plate

- 1 non union, 1 delayed union

- 1 infection

- most complications in patients > 60

 

Hook Plate Disengage

 

3.  Endobutton

 

Robinson et al JBJS Br 2010

- 16 patients under 60 with displaced type 2

- all treated under 3 weeks

- endobutton in coracoid, clavicle reduced, endobutton clavicle

- 1 symptomatic non union

 

Non Union

 

Lateral Clavicle Non unionLateral Clavicle Nonunion ORIF

 

Distal clavicle nonunionDistal Clavicle Nonunion

 

Options

 

1.  Bone graft / ORIF

 

2.  Excise

- open

- arthroscopic

 

Floating Shoulder

Definition

 

Combination of scapular neck fracture and ipsilateral clavicle fracture / CC ligament disruption

 

Imaging

 

Floating Shoulder

 

Floating Shoulder 1Floating Shoulder 2

 

Glenoid Neck Fracture CTClavicle Fracture CT

 

Epidemiology

 

High velocity injuries

- MVA

- MBA

 

Fractures usually of scapular neck

 

Potential Problems

 

Disrupts the suspensory mechanism of the shoulder

- displacement disrupts normal stability of GHJ

- changes biomechanics

- subacromial pain / impingement

 

NHx

 

Little evidence

- concern with displacement of fractures

- weakness of abduction / subacromial pain / poor shoulder function

- risk of non / malunion

 

Used to be recommended surgery for floating shoulder

 

Non operative Management

 

Indication

- undisplaced fractures

 

Edwards et al JBJS Am 2000

- 20 patients with floating shoulder treated non operatively

- 11 with displaced clavicle fractures (>10mm)

- 5 with displaced scapula fracture (>5mm)

- 19/20 united (one had segmental clavicle bone loss from gunshot)

- excellent functional scores

 

Labler J Trauma 2004

- 8 treated non operative, 9 treated operative

- 5 good results in each group

- recommend nonoperative treatment for less displaced fractures
 

Egol et al JBJS Am 2001

- 19 patients with clavicle fracture and displaced fracture glenoid neck

- 12 non operative, 7 operative

- good results in each group

- recommend individualized treatment

 

Operative Management

 

Options

 

1.  ORIF clavicle

 

Minimally displaced glenoid fracture

 

Floating Shoulder Clavicle ORIF

 

2.  ORIF glenoid and clavicle

 

Displaced scapular neck

- > 40o angulation

- > 1cm displacement

- CT useful

 

Leung et al JBJS Br 1993

- 15 patients floating shoulder

- all scapular neck

- ORIF clavicle + glenoid (posterior approach)

- good functional outcome in all patients

 

Note:

- risk of PTX during surgery if rib fracture (secondary to PPV)

- may need chest tube

 

Rib Fracture CT

Frozen Shoulder

Definition 

 

Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 

 

Epidemiology

 

2% incidence

- 40 - 60 years

- Women 2:1

 

Sedentary workers

- Non-dominant limb

 

Bilateral in 10 - 40%

 

Aetiology

 

Primary

- Unknown

- ? Autoimmune theory

 

Associations 

- diabetes - 35% IDDM > 10yrs

- yhyroid disorders

- stroke

- MI

- cardiac surgery

- neurosurgery

- dupuytren's

 

Not Associated with

- OA

- Cuff Pathology

 

Secondary

 

Intrinsic

- post surgery i.e. RC

- trauma i.e. SNOH, stabilisation

- immobilisation

 

Extrinsic

- cervical radiculopathy

- axillary node clearance

- long period immobilisation

 

Classification Neviaser

 

Each lasts 4-8 months

 

1.  Freezing

- painful stage

- capillary proliferation, synovial hypertrophy

- develop capsular adhesions

 

Shoulder Arthroscopy Frozen Shoulder

 

2.  Frozen

- decreasing pain, increasing stiffness

- maturation and development capsular contractures

 

3.  Thawing

- decreasing stiffness

 

Pathology

 

Neviaser described pathology of frozen shoulder 

- contracture of capsuloligamentous structures

- inflammation followed by fibrosis

 

Cellular basis poorly understood

- a dense matrix of type 1 and II collagen

- laid down by fibroblasts and myofibroblasts

 

1° Frozen Shoulder

 

Initial synovitis of unknown cause results in

- intra-articular adhesions

- capsulitis

- obliteration of inferior axillary fold

 

Subsequent development of

- subacromial adhesions

- rotator cuff contracture

 

Eventually spontaneous resolution

 

2° Frozen Shoulder

- much less synovial inflammation

- 2° due to either intrinsic or extrinsic cause

 

Natural History

 

Traditionally thought to be benign & self-limiting

 

Grey 1978

- 24/25 resolved by 2 years 

- Maximum 10 years

 

Most have no significant symptoms or functional restriction

- But not as benign as previously thought

 

Reeves 1975

- 60 % have residual decreased ROM 

- usually limitation ER

- only 6% claimed functional disability

 

Shaffer 1992

- 50% pain or stiffness at mean 7 years

- never more than mild with little functional disability

 

History

 

Insidious onset /  No history of trauma

 

Pain

 

Initially 

- at site of deltoid insertion

- at extremes of motion

 

Becomes more

- diffuse / severe / constant

- interferes with sleep

 

Then begins to decrease

- rest pain disappears

- pain only on movement

 

Stiffness

 

Develops after onset of pain

Difficulty reaching

- overhead

- behind back

 

Examination

 

Muscle atrophy

 

No point tenderness

 

Markedly decreased ROM

- abduction

- ER classically

- limited GH movement, increased ST movement

 

Frozen Shoulder Reduced ER

 

DDx Causes of reduced ER

1. Frozen shoulder

2. OA

3. Unreduced posterior dislocation

 

Pain on forced movement

- most sensitive indicator is pain on forced ER

 

Xray

 

Normal

 

Arthrogram / MRA

 

1. Reduced volume

- <10 ml of contrast can be injected

- normal = 20-30 ml

2. Obliterated axillary capsular recess

3. Thickened capsule

 

Management

 

Goals

- Relieve pain

- Restore range

- Remove secondary cause

 

Non Operative

 

Reassurance as first treatment

 

Careful explanation of 

- nature of disease

- NHx

- reassurance

 

Algorithm

 

Freezing Phase

- directed towards pain relief

- simple Analgesics / NSAID

- sling / ice / TENS

- intra-articular HCLA

- avoid physio as makes it more painful / doesn't increase ROM

 

Frozen Phase

- encourage hand use to avoid RSD

 

Thawing Phase

- gentle ROM & strengthening 

- consider intervention if prolonged / major functional disability

 

HCLA

 

Lorbach et al J Should Elbow Surg 2010

- compared oral corticosteroids to 3 doses of intra-articular corticosteroids

- best ROM and pain relief in intra-articular group although both effective

 

Operative Options

 

1.  MUA

 

Timing

- at least after 6/12

- in late frozen or early thawing  phases

 

Contra-indications 

- osteopenia

- previous fracture or surgery

- history instability

 

Complications

- fractures & dislocations

- cuff tears

- increased inflammation & scarring

 

Technique (Neviaser)

- GA or interscalene block

- confirm diagnosis with MUA (i.e. limited ROM)

 

1.  Abduction first

- gentle, 2 fingers

- sensation of tearing is the axillary fold tearing

 

2.  Rotation second

- must avoid fracture

- IR / ER in abduction

 

3.  HCLA +/- hydrodistension

 

Post-op physio

 

Results

 

Weber Clin Rheum 1995

- average 6 months post diagnosis

- 73% full recovery

- needed 6 weeks off work

 

2.  Hydrostatic Distension

 

Technique

- needle into GHJ under LA

- joint forcefully distended by injection

- 5 ml LA

- 1 ml steroid

- up to 40 ml Saline

- distension till capsular ruptures 

- sudden drop in resistance

- immediate post-op physio

 

Results

 

Rydell Clin Orthop 1992

- 22 patients

- 15 months

- MUA + hydrodistention + steroids

- 91% no or slight pain at 6 weeks

- 83% normal or almost normal ROM

 

Jacobs J Should Elbow Surg 2009

- 53 patients randomised to either MUA or steroid hydrodistention

- 2 year follow up

- no difference in two group

 

Quraishi et al JBJS Br 2007

- randomised trial of MUA v hydrodistention

- improved ROM in both groups

- more patients satisfaction and better shoulder scores in hydrodistention

 

3.  Open Release

 

Ozaki et al 1989 JBJS Am 1989

- one of first papers

- open release CH ligament and RC interval

- mean of 10 months post diagnosis

- MUA as part of procedure

- 94% relief of pain and complete ROM

 

Segmuller et al J Should Elbow Surg 1995

- released inferior and middle GH ligaments

- 24 patients

- 88% satisfied

- 76% normal function

 

4.  Arthroscopic release

 

Diagnosis

- +++ synovitis

- very tight shoulder to arthroscope

- capsule very thick

- very limited ROM

 

Arthroscopy Frozen Shoulder Synovitis

 

Technique

 

1.  Release rotator interval

- remove all tissue in between biceps and SSC

 

Frozen Shoulder Interval Release 1Frozen Shoulder Interval Release 2

 

2.  Release anterior IGHL

- from 3 o'clock down to 5 o'oclock

- leave labrum intact / anterior to labrum

- release inferior capsule with scissors / 6 o'clock

 

Frozen Shoulder MGHL ReleaseFrozen Shoulder IGHL ReleaseFrozen Shoulder Release IGHL Complete

 

Frozen Shoulder Inferior Release with scissors

 

3.  Mobilise SSC

- release adhesions on posterior and superior aspect

- some advocate release of intra-articular tendinous portion

 

4.  Release posterior IGHL

- place camera in anterior portal

- posterior to posterior labrum

- complete inferior release

 

Frozen Shoulder Posterior Capsule ReleaseFrozen Shoulder Posterior Release CompleteFrozen Shoulder Complete Inferior Release

 

5.  MUA with abduction

- remove instruments and camera

- tears inferior aspect of capsule

 

6.  Injection of HCLA

 

Results

 

Ogilvie-Harris et al Clin Orthop 1995

- MUA v arthroscopic release in 40 patients

- better outcomes in arthroscopic release at 2 and 5 years

- excellent in 15/20 arthroscopic

- excellent in 7/18 MUA

 

 

 

Glenoid & Scapula Fractures

Glenoid Fractures

 

Indications for Surgery

 

ORIF

- > 5mm step

- > 1/4 glenoid rim and displaced

 

Ideberg Classification Intra Articular Fracture

 

Type I

 

Fractures of the Glenoid rim

I A anterior 

I B posterior

 

Differentiate from small bony Bankart

- ORIF if > 1/4th or > 10 mm displaced (Neer)

 

Case 1

 

Glenoid Rim Fracture 1Glenoid Rim Fracture 2Glenoid Rim Fracture 2Glenoid Rim ORIF

 

Case 2

 

Glenoid FractureGlenoid Fracture CTGlenoid Fracture CT 2Glenoid ORIF

 

Case 3

 

Scapular fracture intraarticular glenoid axialScapula ORIF APScapula ORIF Lateral

 

Case 4

 

Glenoid Frac APGlenoid Frac AxialGlenoid Fracture CT

 

Type II

 

Transverse fracture through glenoid fossa

- inferior triangular fragment 

- exits lateral border scapula

 

Glenoid FractureGlenoid ORIF

 

Scapula Fracture XrayScapula Fracture Intra articular CT SagittalScapula Fracture Intra articular Glenoid Coronal CT

 

Glenoid Fracture 1Glenoid Fracture 2Glenoid Fracture 3

 

Type III

 

Oblique fracture through the glenoid    

- exiting through superior border of the scapula

- associated with AC fracture or ACJ dislocation

- includes the Coracoid

 

Type IV

 

Similar to II, larger superior fragment

- horizontal

- exiting thru the medial border of the blade

 

Type V

 

Combination

- Va =IV+II

- Vb=IV+III

- Vc=IV+III+II

 

Type VI

 

Extensive comminution

 

Glenoid Malunion

 

Case 1

- untreated glenoid rim fracture

- patient with chronic instability

- treated with glenoid osteotomy

 

Glenoid Fracture Malunion CTGlenoid Osteotomy APGlenoid Osteotomy Lateral

 

Scapular Fractures

 

A.  Body

 

Often don't need ORIF
- well splinted by fascia / haematoma

- can treat non operatively

 

Scapula Body FractureScapular Body Fracture CT

 

Scapular Blade Fracture CTScapular Blade Fracture CT 2

 

Indications for surgery

- > 45 degrees of angulation of body

 

Scapular Body /> 45 degrees

 

B.  Neck

 

Indications for surgery

- > 450 angulation

- > 10 mm displaced (i.e. medial displacement

 

Case 1

- > 1 cm medial displacement

- ORIF via posterior / modified Judet approach

 

Scapula Neck FractureGlenoid Neck Fracture

 

Scapula ORIFScapula ORIF 3

 

Case 2

 

Glenoid DisplacementGlenoid Displacement CT

 

Glenoid ORIF 1Glenoid ORIF 2

 

C.  Spine

 

Scapula Blade Fracture CTScapula Spine Fracture

 

 

D.  Acromion

 

Spine scapula fracture

 

E.  Coracoid

 

Coracoid Fracture 1Coracoid Fracture 2

 

Coracoid Fracture CT 1Coracoid Fracture CT 2Coracoid Fracture CT 3Coracoid Fracture CT 4

 

Combined Glenoid and Scapula Fractures

 

Case 1

- displaced glenoid fracture and neck fracture

- ORIF both through posterior / Judet approach

 

Glenoid Scapular FractureComplex Scapular Fracture CT 1Complex Scapular Fracture CT2Complex Scapular ORIF

 

 

 

 

Humeral Shaft Fracture

 

Non operative Mangement

 

Indications

 

< 20o sagittal

< 30o coronal

< 3 cm of shortening

 

Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral

 

Options

 

1.  Vietnam Cast / hanging cast

2.  Functional bracing 3/52

 

Functional Humerus Brace

 

Results

 

United Humeral Fracture LateralUnited Humeral Fracture

 

Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative group nonunion 20% and 12% malunion

- operative group nonunion 8% v 1%

- no increased time to union or radial nerve palsy in operative group

 

Operative Managment

 

Indications

 

Absolute

- compound fracture

- radial nerve palsy post reduction

- failure to obtain / maintain acceptable reduction

- displaced Holstein Lewis with radial nerve palsy

 

Relative

- multi-trauma

- floating elbow

- obese (very difficult to splint)

- pathological fracture - won't heal

- segmental fracture

- bilateral humeral fractures

- brachial plexus injury - allows early rehab

 

Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral

 

Options

- antegrade IM Nail

- retrograde IM Nail

- ORIF with plate

 

Indications Plate vs Nail

 

Chapman et al J Orthop Trauma

- RCT antegrade nail v plate 84 patients

- union rates similar in each - 90%

- shoulder discomfort and decreased ROM with nail

- decreased elbow ROM with plate especially distal third

 

1.  Antegrade Humeral Nail

 

Humeral Nail APHumeral Nail Lateral

 

Relative indications

- segmental fracture - need very long plate

- impending pathological fracture

 

Technique

 

Set up

- lazy beach chair

- need to get II of shoulder and distal forearm

- patient relatively supine to ensure ease of AP distal locking

 

Anterolateral approach shoulder

- longitudinal split SS

- entry point at medial aspect GT

- entry with K wire or awl

- check down IM canal of humerus with II

- most nails have mild valgus proximal angulation

- increase diameter proximally with hand reamers

 

Pass guide wire

- can do closed

- can perform mini open to blunt dissect and protect radial nerve

 

Minimal reaming

 

Pass nail

- bury enough to protect cuff

- need to consider hardware removal

 

Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon

 

Distal AP locking screw

 

Careful repair of rotator cuff

 

Results

 

Cox et al J Orthop Trauma 2000

- 37 patients treated with antegrade nail

- 4 non unions and 4 delayed unions (>4 months)

- 6 patients had poor shoulder function (4 due to stiffness, 2 due to pain)

 

Complications

 

Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

- still incidence of shoulder pain

 

Humerus Prominent IM Nail

 

2.  Retrograde IM Nail

 

Relative indication

- distal 1/3 humeral fracture

- avoids shoulder pain

 

Technique

 

Set up

- Patient prone

- arm on table, need to flex elbow

 

Entry dorsal

- 3cm above Olecranon fossae

- gentle reaming to prevent blow-out

 

Distal locking with butterfly construct and screws

 

Proximal locking

- some have extendable hook

 

Complications

 

Distal blow out

- difficult problem

 

Nail removal

- not easy procedure

 

Results

 

Cheng et al J Trauma 2008

- RCT of antegrade v retrograde IMN

- similar union rates (>90%)

- longer time to perform retrograde IMN

- longer time to recover shoulder function in antegrade group

 

3.  Plate Osteosynthesis

 

Humeral Plate LateralHumeral Plate Long AP

 

Indications

- nerve injury requiring exploratation

 

Approaches

1.  Proximal 2/3

- anterior or anterolateral

2.  Distal 1/3

- posterior

 

Technique

 

A.  Anterior Approach Humerus

 

Sterile tourniquet

 

Incision lateral aspect of biceps

- incise deep fascia

 

Proximally

- retract deltoid laterally and biceps medially

 

Identify plane between biceps and brachialis

- protect MCN between the two

- identify and split brachialis in midline

 

Internervous plane

- radial nerve lateral brachialis

- MCN medial brachialis

 

Distal extension

- between brachialis and BR in distal 1/4

- find and protect radial nerve

 

4.5 mm DCP

- minimum 6 cortices above and below

 

B.  Anterolateral approach

 

Allows more distal plating

 

Utilise interval between triceps and brachialis

- identify and protect radial nerve distally between brachialis and BR

- extend proximally into deltopectoral groove

 

C.  Posterior Approach

 

Humerus ORIF Posterior Approach

 

Position

- lateral approach

- arm over bolster

 

Sterile tourniquet if needed

 

Midline incision

- interval between long and lateral heads

- Split medial head of triceps

- identify radial nerve proximally 

 

Radial Nerve Injury

 

Incidence

 

4% incidence of radial nerve injury

 

Associated with Holstein Lewis fracture

 

Holstein - Lewis JBJS Am  1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach

 

Holstein Lewis

 

Incidence of laceration / entrapment

 

Noaman et al Microsurgery 2008

- operative exploration of 36 patients with radial nerve palsy

- entrapped in fracture site in 9 and lacerated in 8

- 9 epineural repairs and 5 nerve grafts

- neurolyis in remainder

 

Recovery

 

Average time to see recovery is 7 weeks

Average time to full recovery 15 weeks

Longest time to see recovery 7 months to 1 year

 

NHx

 

Sarmiento JBJS Am 2000

- 922 fractures managed in brace, 620 followed, no MUA

- radial nerve palsy in 11% / 101

- 1 radial nerve didn't recover

 

Pollock & Drake et al JBJS Am 1963

- 24 humeral shaft fractures with radial palsy (14/24 distal third)

- 9 of these were complete motor and sensory (8/9 distal third)

- treatment immobilisation or traction

- all had complete recovery

 

Options

 

1.  Explore + ORIF

- easy to make this decision if fracture requires operative management

 

2.  Manage non operative

- if no recovery tendon transfer

Instability

Anterior

Acute Anterior Dislocation

EpidemiologyAnterior Shoulder Dislocation

 

Most common form of shoulder instability

- young males 

- M:F = 2:1

 

Aetiology

 

Indirect ER and abduction moment on arm

- disruption of anterior stabilisers

 

History

 

Initial injury

- severe pain in shoulder

- ± transient paraesthesia / dead arm syndrome

 

History of dislocations

 

Examination

 

Very painful & tender shoulder

- significant muscle spasm

- arm held across abdomen

 

Hollow under acromion

- fullness in anterior shoulder

 

Axillary nerve palsy

- important to exclude

- look for parasthesis in badge area

- 20 years = 5% --> 90% recover

- 80 years = 90% --> 10% recover

 

Left Deltoid Wasting

 

Musculocutaneous Injury + Rotator Cuff Tear

 

Musculocutaneous nerve injuryMusculocutaneous Nerve Injury 2Supraspinatous Infraspinatous Wasting

 

Diagnostic Dilemma

 

Patient with history traumatic dislocation / wasting of shoulder / loss ROM

1.  Wasting deltoid (AXN)

2.  Wasting SS, not IS (RC tear)

3.  Wasting SS & IS (SSN injury or massive tear)

4.  Wasted deltoid + SS/IS (upper trunk brachial plexus or AXN palsy with RC tear)

 

Axillary nerve palsy with Massive Rotator Cuff Tear

 

Xray

 

True AP

- dislocation

- fracture GT

- bony bankart

 

Shoulder Dislocation Greater Tuberosity FractureAnterior Shoulder Dislocation AP

 

AP in IR

- Hill Sachs lesion

 

Scapular Lateral

- dislocation

- humeral head should be in centre of Y

 

Anterior Shoulder Dislocation0002Shoulder Anterior Dislocation Scapula Lateral

 

Axillary Lateral

- dislocation

- Hill Sachs

 

Shoulder Fracture DislocationAnterior Shoulder Dislocation Axillary LateralShoulder Hill Sachs Axillary Lateral

 

Garth

- aim beam caudally

- bony bankart

 

Bony Bankart Xray

 

Classification

 

According to direction seen on xrays

1. Subcoracoid / most common

2. Subglenoid

3. Intrathoracic

 

Management

 

Reduction

 

ASAP

- appropriate analgesia & muscle relaxation / conscious sedation

- atraumatic closed reduction performed

- if unsuccessful, may require GA

- rarely need open reduction

 

Post-reduction xray

- confirm reduction

- rule out associated fracture

 

Shoulder Post Dislocation Check Reduction

 

Techniques

 

1.  Stimpson

- patient prone

- arm hanging over side of bed

- weight applied to wrist

- give mild sedation

- not appropriate if obese / sleep apnea etc

 

Stimpson Method

 

2.  Harvard / Traction & Countertraction method

- patient supine

- traction with abduction

- countertraction via sheet around axilla

- similar to Hippocratic but no foot in the axilla

 

3.  Kocher

- externally rotate and maximally abduct arm

- relocate via adduction

- nil IR til located to avoid humeral fracture

 

4.  Hippocrates

- foot in arm pit

- apply longitudinal traction 

 

Immobilisation

 

No effect on re-dislocation rate

- no sport for 6/52 reduces dislocation rate

 

Protocol

- sling for comfort

- avoid provocation 6/52

- no sport until painless FROM

 

ER brace

 

Theoretical

- tightens SSC
- reduces bankart lesion into anatomical location whilst healing

- may reduce redislocation rates

- problems with compliance as is uncomfortable and in young population

 

Itoi et al JBJS Am 2007

- RCT ER brace v sling 198 patients 3 weeks duration

- relative risk reduction 38%

- 26% recurrence v 42% (p < 0.03)

- particularly beneficial if < 30

 

Finestone et al JBJS Br 2009

- RCT 51 patients

- no difference

 

Rehabilitation

 

Start with ROM exercises

- pendulum / active Assisted / active

 

Progress to shoulder strengthening

 

Prognosis

 

1. Age at first dislocation

 

Increased in young

- the majority of recurrences occur within 2 years of the first traumatic dislocation

 

Classic paper Rowe CORR '61

- < 20    90% redislocation

- 20-30  60% redislocation

- 30-40   30% redislocation

- > 40     10% redislocation

 

McLaughlin and MacLellan 1967 

- 95% traumatic dislocations in teenagers recurred

 

Simonet and Cofield 1982 

- overall incidence of recurrence 33% over 4 years

- 66% in patients < 20 years

- 17% in patients 20 - 40 years

 

2. Trauma of First Dislocation

 

Decreased incidence of re-dislocation with 

- severe trauma

- associated fracture (usually LT / GT)

 

3. Activity

 

Re-dislocation more common in athletes

- 80% in athletes

- 30% in non-athletes

 

4. Rehabilitation

 

Activity restriction & effective muscle strengthening reduces re-dislocation

- overall re-dislocation rate 25% at 3 years in Army

- need strict adherence with program

 

Indications Operative Management in Acute Dislocation

 

1.  Rotator cuff tear

2.  Displaced GT fracture

3.  Large glenoid rim fracture

4.  ? Athlete

 

Rotator cuff tear

 

Diagnosis

 

Important not to miss

- high incidence in patients > 40

- suspect if pain or decreased ROM

- MRI

 

Incidence

 

Berbig et al J Should Elbow Surg 1999

- prospect ultrasound on 167 patients with dislocation

- full thickness tears in 31.7%

- only acute tears in patients younger than 60

- control group had no FT tears in patients younger than 60

 

Management Options

 

A.  Repair RC / leave Bankart

B.  Repair RC and Bankart

 

Voos et al Am J Sports Med 2007

- retrospective review of arthroscopic repair of RC and labrum

- average age 47, 16 patients

- good or excellent results in > 90%

 

2.  Displaced GT Fracture

 

Indications

- > 5 mm displacement

 

Management

- ORIF

- screw + suture repair

- screw alone in young patient

 

Shoulder Dislocation Non Displaced GT FractureGT ORIF

 

3.  Large Glenoid Rim Fracture

 

Indications

- > 25 - 30% and displaced

 

Management

- open or arthroscopic

- fix with 1 or 2 cannulated screws

 

Glenoid Rim FractureGlenoid Rim Fracture CTGlenoid Rim ORIF

 

4.  Acute dislocation in professional athlete

 

Robinson et al JBJS Am 2008

- prospective randomised control trial arthroscopic surgery in first time dislocators

- 88 patients under 35, arthroscopic stabilisation v arthroscopic lavage

- reduced risk of recurrence by 80%

- patient satisfaction and shoulder scores significantly improved

 

Kirkley et al Arthroscopy 2005

- RCT of 40 patients for arthroscopic stabilisation v immobilisation

- 3 recurrences in surgical group, 9 in non surgical group

- small improvement in shoulder scores in operative group

 

Jakobsen et al Arthroscopy 2007

- RCT 76 patients

- arthroscopy to diagnose labral injury

- either open repair or non operative

- 74% unsatisfactory results at 8 years in non operative group

- 75% good results in operative group (1 redislocation)

Anterior Instability

Epidemiology

 

Traumatic initial cause in 95%

 

M:F 2:1

 

Age of initial dislocation inversely related to recurrence rate

- patients younger than 20 have a redislocation rate of 90%

- between 20 - 40 years, redislocation rate of 60%

- patients > 40 years have a 10% rate of dislocation but a higher rate of cuff tears (up to 40% in patients > 60yrs)

 

Anatomy & Stability

 

1. Passive Stabilisers

 

Glenoid labrum 

- significant deepening by 50%

- labrum attaches capsule / ligaments / biceps

 

Negative intra-articular joint pressure

 

Joint fluid adhesion/ cohesion

 

Capsule 

- attaches to SNOH

 

Coracoacromial arch

- prevents superior displacement

 

Coracohumeral ligament

- attaches base of coracoid

- to lesser and greater tuberosity 

- passess through rotator interval between SS and SSC

- static restraint to anteroinferior translation in the adducted shoulder

 

Capsulo-ligamentous structures

 

1.  IGHL

 

Most important

- resists anterior translation in abduction and ER

- anterior & posterior band with sling between

- anteror band limits ER at abduction > 90°

 

Origin

- anterior band glenoid 3 o'clock

- posterior band 9 o'clock

 

Insertion

- inferior anatomical neck / head

 

Arthroscopy Normal IGHL Humeral AttachmentIGHL

 

2.  MGHL

 

MGHL in Buford Complex

 

Action

- behind SSC

- 2° restraint anterior translation

- limits ER at 45° Abduction

- present in 60% population

 

Origin

- supraglenoid tubercle below SGHL

 

Insertion

- medial to LT

 

3.  SGHL

 

SGHL

 

Action

- adjacent to biceps tendon

- prevents inferior subluxation 

- functions only in adduction

- no function in decreasing anterior translation

- present 50% population

 

Origin

- supraglenoid Tubercle 

 

Insertion

- LT

 

2. Dynamic Stabilisers

 

Rotator Cuff

- SSC resists anterior translation

- compresses head into glenoid socket

 

LH Biceps

 

Deltoid 

- especially when arm is elevated 90o

 

Scapular Rotators 

- move glenoid into stable position

 

Pathology

 

No essential pathological lesion responsible for every recurrent subluxation or dislocation

 

Thomas and Matsen Aetiology Classification

 

AMBRII 

- Atraumatic, Multidirectional, Bilateral

- Rehabilitation, Inferior capsular shift, closure rotator Interval

 

TUBS 

- Traumatic, Unidirectional, Bankart, Surgery

 

1.  Labrum / Ligament / Capsule

 

A.  Bankart lesion

 

Pathology

- described in 1938 

- humeral head forced through capsule

- humeral head tears fibrocartilaginous labrum from almost entire anterior 1/2 of glenoid rim 

- is an IGHL avulsion

- usually between 3 and 6 o'clock

 

MRA

- see detachment of anterior labrum

 

Anterior Bankart Lesion MRIShoulder MRI Anterior Bankart

 

Arthroscopy

 

Anterior bankart lesion ArthroscopyArthroscopy Soft Tissue Bankart

 

Incidence

- present in 85% traumatic recurrent dislocations 

- may be associated with avulsion fracture of glenoid rim / bony bankart

 

B.  Excessive Capsular laxity 

 

Incidence

- may be present alone or with Bankart lesion

- 30% have both

- 85% previous failed surgical procedures

 

Causes

- congenital collagen deficiency / MDI

- plastic deformation of capsuloligamentous complex

- single macro-traumatic event or repetitive micro-traumatic events

 

C. Capsular Tears

 

Capsular Tear 1Capsular Tear 2Capsular Tear 3

 

Capsular Repair 1Capsular Repair 2

 

D.  HAGL

 

Definition

- avulsion of IGHL from anterior humeral neck

- Humeral Avulsion of Glenohumeral Ligament

 

Incidence

- 2 - 10%

 

Associations

- can be in combination with anterior bankart (Floating IGHL)

- association with subscapularis tear

 

Xray

- may see bony avulsion

 

MRA

- enlarged inferior  pouch

- discontinuity of IGHL / J sign

 

MRI Normal Humeral IGHL InsertionMRI HAGL J Sign

 

Arthroscopy

- will see exposed subscapularis muscle

 

Arthroscopy HAGL Normal Humeral attachment IGLH

 

Management

 

A.  Open Repair

- take down SSC

- repair via bone anchors to inferior neck

- can cause limitation ER

 

B.  Arthroscopic repair

- 70o scope and 5 o'clock portal

 

E.  Bankart Variations

 

ALPSA

- anterior labrum periosteal sleeve avulsion

- labral-ligamentous structures shifted medially

- roll up under the periosteum

 

Perthes Lesion

- stripping of the scapular periosteum medially

- labrum may or may not be attached

 

Perthes Lesion MRI 1Perthes Lesion MRI 2Perthes Lesion MRI 3

 

GLAD

- glenoid labrum articular disruption

- damage to the glenoid cartilage

- labrum undisplaced

 

Shoulder GLAD

 

F.  Muscle

 

Cuff Tears

- Present as pain or weakness 

- > 40 years = 30%

- > 60 years > 80% 

 

Increased Rotator Interval

- between SS and SSC

- tends to open up with AMBRI

 

2.  Bony

 

A.  Bony Bankart

 

Xray

- AP

- Garth (aim beam caudally)

 

Bony bankart XrayShoulder Garth ViewBony Bankart

 

Importance

- large bony bankart increases risk of failure of soft tissue bankart repair

 

Diagnosis

- may need CT to decide the size best

 

Burkhart and De Beer Arthroscopy 2000

- described the inverted pear appearance

- loss of bone antero-inferior

 

Small

 

CT Sagittal Small Bony Bankart

 

Large

 

CT Axial Large Bony BankartCT Axial Large Bony BankartLarge Bony Bankart

 

Size calculation

 

Bony Bankart Size CalculationGlenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 1

 

Lo Parten and Burkhart, Arthroscopy 2004

- calculation of percentage bone loss arthroscopically

 

1.  Inferior glenoid is nearly a perfect circle

- centre is the bare area of the glenoid

- measure anterior radius v posterior radius at this level

 

2.  Calculate the diameter of the inferior circle

- twice the posterior radius

 

3.  Calculate the difference between anterior and posterior radius

 

The average diameter is 24 mm

- hence 12 mm posterior and 12 mm anterior

- if lose 8 mm anteriorly

- 12 mm posterior and 4 mm anterior

- calculation is 8/24 = 30%

 

Risks

 

25% loss and above poor prognostically

- means approximately 7.5 mm anterior bone loss

< 4mm anterior to bare area

- > 30%

- likely not amenable to soft tissue bankart repair alone

 

Acute Bankart Repair

 

Sugaya et al JBJS Am 2005

- demonstrated union of fragment with arthroscopic restoration

- must mobilise fragment, restore anatomically

- otherwise bony procedure

 

Decision Making

 

A.  Small fragment < 15%

- arthroscopic bankart repair

- can attempt to include fragment

 

B.  Intermediate 15 - 25%

 

C.  > 25%

- must restore glenoid rim

- acute restoration of bony frament or

- bony procedure / Latarjet / Bristow

 

B.  Hills Sachs Lesion 

 

Definition

- lesion posterior aspect of head

- where head engages on anterior glenoid

 

Xray

- AP with IR

- Garth view

 

Hill Sachs XrayLarge Hill Sachs Xray

 

Arthroscopy

- cartilage each side of lesion

- this differentiates it from the normal bare area next to infraspinatous

 

Arthroscopy Hill Sachs LesionLarge Hill Sachs

 

Issue

- large lesion can contribute to dislocation

- head engages defect in external rotation & abduction

 

Large Hill Sachs MRICT Hill Sachs

 

Dynamic CT

Dynamic CT 1Dynamic CT 2Dynamic CT 3

 

Management options for engaging Hill Sachs

 

1.  Posterior capsular advancement / Remplissage

2.  Humeral head allograft

3.  Anterior Bony Procedure / Latarjet / Bristow

- Hill Sach's lesion unable to engage on anterior glenoid rim

4.  Humeral osteotomy

 

Remplissage

 

Theory

- described by Wolf Arthroscopy 2008

- advance IS into Hill Sachs lesion

- makes lesion extracapsular

 

Technique

- perform arthroscopic transtendinous advancement of IS and capsule into defect

- tie knots from subacromial space

 

Results

 

Zhu et al Am J Sports Med 2011

- 8.2% failure in 42 cases

 

Humeral head allograft

 

Humeral Head Allograft APHumeral Head Allograft Lateral.jpg

 

Technique

- anterior deltopectoral approach

- ER shoulder

- debride base of Hill Sachs

- secure allograft with 2 x screws

 

Issue

- late resorption of graft with recurrent instability

 

Humeral Head Allograft Resorption

 

Humeral Head Osteotomy

 

Weber et al JBJS Am 1984

- series of 180 patients

- very low risk of recurrence

 

C.  Abnormal Version 

 

Glenoid or Head

- rarely a cause

Arthroscopic Bony Bankart Repair

Case 1: Acute Presentation

 

Bony Bankart Xray

 

Bony Bankart Fixation 1Bony Bankart Fixation 2Bony Bankart Fixation 3

 

Bony Bankart Fixation 4Bony Bankart Fixation 5Bony Bankart Fixation 6

 

Bony Bankart Fixation 7

 

Arthroscopic Stabilisation

Labral Repair

Arthroscopic Shoulder Stabilisation

 

 

1.  EUA

 

Compare both shoulders

- ROM

- anterior and posterior draw

- load and shift

- sulcus sign

 

2.  Labral Assessment

 

A.  Above equator

 

Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability

 

Beware normal variations in this area

 

Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types

 

1.  Sublabral foramen

 

Arthroscopy Anterior Sublabral ForamenShoulder Sublabral foramen

 

2.  Sublabral foramen with cord like MGHL

 

Buford Complex

 

3.  Absence of AS labrum with cord like MGHL

- Buford complex

 

Buford Complex

 

B.  Below equator 

 

Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)

 

Anterior Bankart LesionShoulder Anterior Bankart

 

C.  Exclude HAGL

 

Assess anterior IGHL attachment to humeral neck

 

Normal IGHL Humeral Attachment

 

D.  Posterior Labrum

 

Always assess

- place camera through anterior portal

 

Arthroscopy Posterior Labral Tear

 

3.  Bony Assessment

 

A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?

 

Shoulder Anterior Glenoid DeficiencyGlenoid Bone Loss

 

Glenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 2

 

Solution

- anterior bony procedure

 

B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

- only a problem if engages with head centred and ER < 30 - 40o

 

Hill Sachs ArthroscopyHill Sachs Lesion SuperiorShoulder Engaging Hill Sachs

 

Solution

 

1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid

 

2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular

 

3.  Humeral head allograft

 

4.  Humeral head osteotomy

 

Technique Anterior Bankart Repair

 

Labral Repair

 

Set up

 

Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg

 

Portals

 

Shoulder Portals Labral Repair

 

A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work

 

B.  Anteroinferior Portal (AI)

- for anchor placement

- rotator interval just above SSC
- 1 cm lateral to glenoid

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal

 

Shoulder Scope Anteroinferior Portal

 

Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula

 

Shoulder Arthroscopy Anterosuperior PortalShoulder Stabilisation 2 Anterior PortalsRotator Interval 2 cannulas

 

Problem

- can make rotator interval very crowded

- repair can be done through single portal

 

Mobilise labrum

 

Shoulder Scope Bankart RaspShoulder Stabilisation Labral Mobilisation

 

Labral mobiliser / rasp / scissors

- labral tear can be obvious, but may have partially healed or healed medially

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view

 

Shoulder Arthoscopy Bankart MobilisationShoulder Scope Bankart Mobilisation

 

Bony Fragments

- important to recognise

 

Options

 

1.  Incorporate in repair

- pass sutures medially to bony fragments

 

2.  Remove / debride

 

Shoulder Arthroscopy Bony Bankart

 

Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs

 

Shoulder Stabilisation Anterior Labral MobilisationShoulder Stabilisation Anterior Labral Mobilisation 2

 

Labral Repair

 

Anchors

- 2.3 or 3.2 mm bioabsorbably anchors

 

Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point

 

Arthroscopy Bankart Anchor Drill GuideInferior Glenoid Anchor

 

Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

- suture passer with loop / single nylon in anterior to posterior direction

- retrieve through portal

- retrieve suture posterior to anterior through portal

 

Shoulder Bankart Repair Suture PasserShoulder Instability inferior Suture passage

 

Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect

 

Arthroscopy Anterior Bankart Repair

 

Remaining anchors

- 5 mm apart

- beware lysis and risk of anterior glenoid / postage stamp fracture

- up to glenoid equator

- usually three in total

 

Shoulder Bankart RepairShoulder Scope Bankart Repair 2

 

Additional Issues / Continued Instability

 

Capsular Shift

- take bite of capsule with suture passer, then labrum

 

Shoulder Instability Capsular Plication

 

SLAP

- contributes to inferior instability

- requires repair

 

Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30o ER

- do away from glenoid on humeral side or will make patient very stiff

- SGHL to MGHL

- must do last

 

Results

 

Primary Arthroscopic Stabilisation

 

Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

- identified patients < 25 / ligamentous laxity / Hill Sachs > 250mm3 high risk

 

Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability

 

Arthroscopic v Open Bankart Repair

 

Bottoni et al Am J Sports Med 2006

- RCT open v arthroscopic, 2 - 3 year follow up

- 2 failures in open group v 1 failure in arthroscopic group

- open took significantly longer and was associated with decreased ER

 

Revision of Failed Arthroscopic Stabilisation

 

Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

- redislocation in 3 shoulders all with engaging Hill Sachs and ligamentous laxity

 

Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence

HAGL

DefinitionHAGL Arthroscopy

 

Humeral Avulsion of Glenohumeral Ligament

 

Incidence

 

Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%

 

Bhatia KSSTA 2012

- 10% incidence of HAGL

 

Bigliani et al J Ortho Research 1992

- cadaveric dislocations

- 25% HAGL

 

Why the difference with cadavers

- ? differences in tissue

- HAGL lesions heal / don't always cause instability

 

Type

 

Bony avulsions (BHAGL)

 

Soft tissue

- humeral

- humeral and bankart (floating)

- posterior / Reverse HAGL

 

Pathology

 

Pouliart J Should Elbow Surg 2006

- cadaveric study

- extensive capsular injury +/- SSC required for HAGL to cause instability

 

MRA

 

Normal

 

Shoulder MRI Normal Humeral IGHL InsertionMRI Normal IGHL

 

Abnormal

- J sign

 

HAGL MRI

 

Arthroscopy

 

Normal

 

Normal Humeral Attachment IGHL

 

Abnormal

 

HAGL

 

Management

 

1.  HAGL

 

Open Technique

 

Detach lower half SSC

- L Shaped tenotomy

- repair IGHL to surgical NOH

 

Arthroscopic Technique

 

Burkhart

- 70o scope

- 5 o'clock portal through SSC with arm adducted

- danger to MCN if arm abducted at all with insertion 5 o'clock portal

- ensure good angle to proximal humerus with needle, for insertion of anchors

- may use suture passers from posterior portal

 

HAGL 1HAGL 2HAGL 3

 

2.  Bankart + HAGL (Floating)

 

Options

- arthroscopic repair both

- open repair both

- arthroscopic repair bankart, open HAGL

- arthroscopic repair bankart, leave HAGL

 

Kim et al Arthroscopy Supplement 2006

- all arthroscopic, 8 good results

 

Rhee et al J Should Elbow Surg 2007

- 4 floating HAGL, open treatment

- loss 15o ER
- elected to leave humeral side in volleyballer for risk of loss of ER

 

Bhatia KSSTA 2012

- subscap sparing approach in 7 patients

- good outcome

 

Latarjet / Bristow

Bristow

 

Concept

 

Non-anatomical bony block 

- transfer of coracoid process through subscapularis

- dynamic anteroinferior musculotendinous sling

- provides subscapularis tenodesis

- preventing lower portion from displacing proximally as arm abducted

- when shoulder in vulnerable position abduction and ER

 

BristowBristow CT

 

Indications

 

1.  Contact Sportsman

- sportsman who will return to dislocating action and loss of ER not a problem

- football, basketball

 

2.  Large bony bankart

- > 25 - 30%

 

Large Bony Bankart CT0001Large Bony Bankart CT0002

 

3.  Poor soft tissue

- multiple dislocations

- anterior labrum very poor quality

 

4.  Revision surgery

- i.e. failed arthroscopic or open soft tissue bankart

 

Problems

 

1.  Loss of ER 12-20°

- problem if throwing athlete

- subscapularis is relatively shortened 

 

2.  Screw problems 2-14%

 

3.  Instability 1-20%

- does not address bankart pathology

- difficult to revise with scarring in abnormal positions 

 

4.  Injury MCN

 

Technique

 

Hovelius

- correct positioning of transferred coracoid process critical to success 

- must be near but not over anterior glenoid rim

 

Good results can be correlated with

 

1. Coracoid process < 5 mm medial to glenoid rim

2. Coracoid positioned inferior to transverse equator of glenoid

3. Bony union develops between coracoid & scapula

4. Fixation screw purchases posterior glenoid cortex

5. Screw does not penetrate articular surface

 

Latarjet

 

Difference from Bristow

 

Transfers larger fragment

- allows 2 x screw fixation of coracoid to neck of scapula

 

Latarjet APLatarjet Lateral

 

Indications

- large > 20-25% bony Bankart

- revision surgery

- contact athlete

 

CT Large Bony Bankart

 

Contra-indication

- ? throwing athlete

- can lose considerable ER

 

Technique

 

Approach

 

Deltopectoral approach

- divide clavipectoral fascia at lateral edge of conjoint

 

Coracoid

 

Identify coracoid

- use fang retractor on superior surface to identify entire coracoid

- strip Coracoacromial ligament off lateral coracoid

- take pectoralis minor off medially

 

Divide coracoid

- 3 cm long

- use 90o oscillating blade on microsagittal saw 100

- medial to lateral

 

Prepare coracoid

- release conjoint for length, identify and protect MCN

- pect minor surface will be placed onto glenoid

- remove cortex with burr

- opposite side clear soft tissue with diathermy

- hold coracoid with Kocher forceps

- make 2 indentations with small burr where 2 x drill holes will be

- stops drill spinning off, ensures drill holes are sufficiently far apart

- 2 x 2.5 mm drill holes, tap, countersink

 

Deep Approach

 

SSC

- identify 3 sisters inferiorly

 

A.  Divide muscle transversely at inferior 1/3 of SSC

- at muscle is easier to take off capsule

- also want to be inferior

- do so by inserting scissors and opening blades vertical

- use sponge to separate from capsule

- insert fang superiorly / blunt homan medially for view

 

B.  Take down superior half of SSC

- repair later

 

Capsule

- feel joint line

- 2 x stay sutures 2 ethibond superiorly and inferiorly

- these must be medially over glenoid

- then divide capsule vertically with knife medial to stay sutures

- want maximum amount of capsule length to repair to anterior glenoid

- this prevents IR contracture

 

Dissect capsule from SSC

- inferiorly

- medially

- will have a free medial edge to repair to anterior edge glenoid

- may be easier to do this after osteotomy coracoid

- use scissors to dissect capsule superiorly

- beware inferiorly as AXN here

 

Exposure

- remove retractorr

- insert fukuda to expose humeral head, joint, glenoid

- again use fang / blunt homan superiorly and medially for exposure

 

ORIF Bone Block

 

Bone block

- clear glenoid 3 - 6 o'clock

- need medial area to place bone

- can use burr

- place bone on glenoid using Kockers to hold

- 2 x drill bits, leave first one insitu

- bone must not overhang medially

- bicortical, tap, typically 30 - 40 mm partially threaded cancellous

 

Latarjet Scapular LateralLatarjet Axillary LateralLatarjet AP

 

Capsule repair

 

Remove Fucuda

- find capsue with stay sutures

- insert 2 x 3 mm absorbable anchors 3 and 5 o'clock

- pass in mattress formation through capsule

- can use Depuy Mitek Suture grasper

- pass this through capsule lateral to medial, grasp suture

- tie capsule down, ensure knot goes down past bone block to glenoid

 

Results

 

Burkhart et al Arthroscopy 2007

- 102 procedures for patients with the inverted pear glenoid +/- engaging Hill Sachs

- 4.7% recurrence rate

- 5o loss or ER

 

Boileau et al Arthroscopy 2010

- arthroscopic Latarjet

- 6/47 had to be converted to open

- no recurrence of instability at 16 months

- 1 bony block fracture and  7 migrations

- potentially dangerous and difficult procedure

 

Complications

 

Failure of fixation

Non union of coracoid

Dislocation

 

Failed Latarjet APFailed Latarjet Lateral

 

 

 

Open Bankart Repair

Aim

 

Repair of the anterior capsule & avulsed labrum to anterior glenoid 

- anatomic repair

 

Usually combined with a capsular shift

 

Contraindications

 

Bony bankart > 25% glenoid

 

Technique

 

Position

- beach chair position

- arm free

- Mayfield head ring / Spyder and Tmax

 

Incision

 

Can perform axillary incision

- in axillary fold

- mobilise skin to gain view

- more cosmetic scar

- more difficult visualisation

 

Axilary Incision 1Axillary Incision 2

 

Superficial dissection

- deltopectoral approach

- cephalic vein lateral with deltoid

- divide clavipectoral fascia

- mobilise lateral aspect conjoint tendon

- insert shoulder retractor deep to conjoint

- expose subscapularis with three sisters inferiorly

 

Increase exposure

- +/- partially detach conjoint tendon from coracoid

- ± partially release P major tendon (1.5 cm) from humerus

- can take of tip of coracoid (predrill for lateral repair)

 

Deep Dissection Options

 

Note:

Always leave inferior 1/4 of SSC

- protects AXN

 

L shaped incision in SSC / Capsulotomy 

Technique

 

Mark lower 3/4 of SSC

- ER shoulder

- use knife to divide muscle belly transversely

- expose capsule underneach

- use Cobb / dissecting scissors

- pass artery forcep up between capsule and SSC to rotator interval

- open interval further by spreading forceps

- tagging sutures in SSC medially (artery clips)

- divide SSC tendon vertically down onto forcep protecting capsule

- carefully elevate SSC from capsule medially using Cobb

 

Separate vertical incision in capsule

- right on humeral insertion

- superior and inferior

- stay on articular margin at all times

- can release down past 6 o'clock if wish to perform capsular shift

- usually don't perform horizontal / T shaped capsulotomy if repairing labrum

- T shaped capsulotomy used for MDI

 

Repair

- insert Fukuda retractor to expose joint

- displaces head posteriorly, exposes labrum

- inspect for pathology: labral detachment / loose bodies / loose capsule

- labrum mobilised

- bony glenoid roughened to bleeding surface

- suture anchors at 3, 4 & 5.30 

- sutures passed through labrum and capsule

 

Capsular plication / shift as required

- always repair with arm ER 30o to prevent loss of ER

- check ER with arm adducted and abducted

- need 50% of normal ER / other side

 

Tie medial labral / capsular sutures

- recheck ER as above

 

Subscapularis repaired / close rotator interval if shoulder still loose

 

Post-op

- shoulder immobiliser for 6/52 with pendulars

- no ER

- elbow & hand exercises

- ROM exercises at 6/52 (passive, active assist, active)

- muscle strengthening at 3/12

- return to sport at 6/12

 

Results

 

Rowe et al JBJS Am 1978

- classic quoted paper

- 5 recurrences in 145 patient(3.5%)

 

Flatow et al Orthopedics 2006

- 41 open stabilisations followed for average 6 years

- one recurrence

- average loss of ER 4o

 

 

 

 

Other Surgical Techniques

Putti-Platt

 

Concept

 

Plication subscapularis & capsule

 

Problems

 

Loss ER 

Secondary OA if ER < 0°

 

Contraindication

 

MDI

- will force head out posteriorly

 

Technique

 

Divide SSC 2.5cm from insertion 

- may divide capsule in same plane

- re-attach lateral flap to convenient medial soft tissue eg under surface of capsule

- double breast medial muscle over lateral stump

- limit ER to neutral

 

Results

 

Kiss et al J Should Elbow Surg 1998

- 70 Putti platts assessed clinically and with xray at average 9 years

- 11% redislocation rate

- 29% moderate and with 1 severe OA

- 11% pain at rest

- average loss of ER 23o

- 83% fully satisfied

 

Magnusson-Stack

 

Concept

 

Lateral advancement of SSC and capsule

- transfer of subscapularis from LT 

- across bicipital groove to GT

- Magnusson recommended distal transfer as well to allow subscapular sling

 

Bone Block Procedure

 

Concept

 

Transfer of bone graft to anterior glenoid rim

- Eden-Hybinette & Oudart procedures

 

Problem

 

Worse results than Putti-Platt with high incidence OA >10%

 

Osteotomy Humeral Head / Glenoid

 

No evidence to support either in most circumstances

- Glenoid neck osteotomy high rate of serious complications

 

Indication

- malunion post fracture

 

Glenoid MalunionGlenoid Osteotomy

 

 

 

 

Remplissage

 

Indications

 

Engaging Hill Sachs

 

Engaging Hill SachsEngaging Hill Sachs

 

Engaging Hill Sachs 1Engaging Hill Sachs 2

 

Technique

 

Tips

1.  Insert Hill Sachs anchors before performing bankart repair

- may be easier to do with humeral head subluxed over glenoid

- increases room to more

2.  May be best to clear subacromial space before inserting Hill Sachs anchors

 

Posterior portal glenohumeral jont

- camera anterior portal

- debride Hill Sachs

 

Hill Sachs DebridementRemplissage Anchors 1Remplissage Anchor 2

 

Insert 2 x anchors

- insert both via posterior portal

- leave one set of sutures out through portal

- separate stab incision posteriorly to retrieve other set of sutures into subacromial space

- use bird beaks or suture runner

 

Remplissage Anchors

 

Subacromial tying

- tip:  may be best to do this before passing anchors into Hill Sachs defect

- redirect posterior portal into subacromial space

- camera via lateral subacromial portal

- debride posterior subacromial space carefully to find sutures

- may want to place suture savers over sutures

 

Subacromial sutures

 

Knots

- separate with birds beak

- tie these knots (white) directly

 

Remplissage Subacromial Space

 

Knots / double pulley

- tie two limbs of separate anchors together

- use other limbs to oppose knots to tissue

- then tie other limbs

 

Remplissage Double PulleyRemplissage Subacromial Knots

 

Camera back into glenohumeral joint

- check capsule tied down into defect

 

Shoulder Post Remplissage

Revision Stabilisation

Causes for failure

 

1.  Patient factors

 

A.  Recurrent Trauma

- contact athletes higher risk

 

B.  MDI / Ligamentous Laxity / Voluntary dislocaters

 

C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow

 

2.  Surgeon Factors

 

A.  Unrecognised bony defect

- large bony bankart

- large engaging Hill Sachs

 

B.  Non Anatomical repair

 

C.  Poor sutures / poor knots / insufficient anchors

 

D. Unaddressed capsular laxity / Laxity RC interval / poor anterior labrum

 

E.  Posterior capsular tear / incorrect diagnosis / MDI

 

Management

 

Identify cause of recurrent instability

 

History

- traumatic or atraumatic

 

Examination

- MDI

 

CT

- large Hill Sachs

- large Bony Bankart

 

MRI

- assess anchor position

- reassess labral repair / integrity

 

Rehabilitation

 

Long period non operative

- best results if muscle control  and strength are optimal

 

Revision Options

 

1.  Revision arthroscopic stabilisation

 

Indications

- no bony defect

- poorly done original surgery

- traumatic redislocation

 

Technique

- repair labrum

- capsular plication

- +/- rotator interval closure

 

2.  Open stabilisation

 

Indications

- as above

 

3.  Laterjet

 

Indications

- bony defect

- large Hill Sachs

 

Results of revision surgery in those without bony defects

 

Arthroscopic revision post failed arthroscopic stabilisation

 

Franchesci et al Am J Sports Med 2008

- revision labral repair / capsular plication +/- rotator interval closure

- 1 failure

 

Arthroscopic revision post failed open stabilisation

 

Boileau et al Arthroscopy 2009

- 22 cases post Latarjet and open Bankart

- arthroscopic labral reattachment / capsular plication +/- rotator interval closure

- 1 recurrent subluxation and 2 with positive apprehension

 

Open revision

 

Levine et al Am J Sports Med 2000

- 49 shoulders treated with capsular shift +/- Bankart repair if needed

- all patients who had a traumatic redislocation had a good result

- only 67% of patients with atraumatic recurrent instability had a good results

 

Cases

 

Case 1

 

Recurrence of instability without trauma

- anchors very high

- into glenoid face

- MRI suggests remaining inferior bankart

- no bony deficiency, no HAGL

 

Failed Open Stabilisation APFailed Open Stabilisation LateralFailed Open Stabilisation CT AxialFailed Open Stabilisation CT Sagittal

 

Failed Open Stabilisation MRIFailed Open Stabilisation MRI 2

 

Case 2

 

Recurrent instability

- non recognised bony defect

- revised with Latarjet

 

Revison Shoulder Stabilisation CT Bony DefectRevision Shoulder Stabilisation Bony Defect 2Revision Stabilisation with Latarjet

 

 

 

 

 

Locked Glenohumeral Dislocation

Definition

 

A GH dislocation which has been missed for a significant period of time

- time period is arbitary

- > 3-6 weeks

 

Pathology

 

Humerus soft and osteoporotic

Significant soft tissue contractures

 

1.  Anterior / subcoracoid dislocation

 

Beware

- scarring to NV structures

- RC tears including SSC, especially > 40

- anterior glenoid wear / can have significant bone loss

- large engaging Hill Sachs / humeral head defects

 

2.  Posterior dislocation

- posterior glenoid wear

- reverse Hill Sach's / large anteromedial defects

 

Epidemiology

 

Anterior 41%

 

Posterior 59%

 

Aetiology

 

Multi trauma

Seizures

Poor patient mental function

 

History

 

Limitation ROM

History multi trauma / seizures

Previous treatment

- often have had inadequate X-rays

- extensive physiotherapy / injections

 

Examination

 

Usually some asymmetry

 

Some reduction ROM

 

Palpate humeral head anteriorly / posteriorly

 

X-rays

 

Scapular AP view

Scapular lateral

Axillary lateral

 

CT

 

Aids diagnosis and preoperative planning

 

Management

 

Non Operative

 

Indications

- elderly 

- minimal functional limitation

- significant medical issues

 

Only operate if significant clinical problems

- anterior more difficult than posterior to solve

 

Operative

 

Closed reduction

 

Issues

 

1.  Timing 

- has been successful up to 6-8 weeks

- most successful outcomes in literature < 4 weeks

 

2.  Humeral head impression

- if this is locked on glenoid, closed reduction is contraindicated

 

3.  May be unstable afterwards

- need further open procedure

- need careful postoperative monitoring

- regular xray surveillance

 

Chronic Anterior Dislocation

 

1.  Large Humeral Head Defect

 

Hill Sach's

- posterolateral defect

- manage according to size

 

Defect < 40%

 

A.  Elevate and Bone graft defect

- < 4 weeks in young patient

- adequate bone, salvageable cartilage

- posterior approach

- split deltoid / L shaped Infraspinatous tenotomy

 

B. Advance Infraspinatous +/- GT

- posterior approach

- < 20% IS alone

- if larger must also take GT

 

Defect > 40%

 

A.  Allograft

- young patient

- pre-op CT to estimate humeral head size

- appropriate sized femoral / humeral head

 

B.  Prosthesis

- often significant OA with long standing dislocation

- anterior glenoid deficiency

- older patient

- increase retroversion of humeral component

- may need to address anterior glenoid deficiency

 

2.  Glenoid Deficiencies

 

Indicated when > 20-25% anterior glenoid eroded

 

Bristow / Latarjet

 

Glenoid Reconstruction

- humeral head

- iliac crest

 

Glenoid Reconstruction Humeral HeadGlenoid Reconstruction

 

3.  Soft tissue deficiencies 

 

Always combine with anterior labral repair +/- inferior capsular shift

 

4.  Rotator cuff tears

 

Significant issue

- if massive cuff tear, may lead to chronic instability

- very difficult to treat

 

CASE 1

 

50 year old, missed locked anterior dislocation one year

- head severely mis-shapen

- missing 50% glenoid

- massive rotator cuff tear

 

Treatment

- open reduction

- shoulder hemiarthroplasty / humeral head used to bone graft glenoid / rotator cuff repair

- unfortunately rotator cuff repair failed, and developed recurrent instability

- option: Reverse TSR / fusion

 

Locked Anterior 1Locked anterior 2Locked Anterior 3

 

Locked anterior MRI 1Locked anterior MRI 2Locked anterior MRI 3

 

Locked anterior surgery 1Locked anterior surgery 2Locked anterior surgery 3

 

CASE 2

 

26 year old female

- ligamentous laxity, but no previous shoulder problems

- traumatic anterior shoulder dislocation

- leading to recurrent anterior subluxation

- had an arthroscopic anterior and posterior capsular plication

- shoulder now permanently dislocated anteriorly

- options: open posterior capsular release and latarjet / or fusion

 

Chronic anterior dislocation 1Chronic anterior dislocation 2Chronic anterior dislocation 3

 

Locked anterior 1Locked anterior 2Locked anterior 3

 

Chronic Posterior Dislocations

 

Approach

 

Standard DP approach

- manage SSC depending on operative plan for humeral head defect

- open capsule

- remove any fibrous tissue in glenoid

- use lever to reduce humeral head

- usually can ignore posterior capsular detachments

 

Manage humeral head / glenoid defects

 

See Posterior Shoulder Instability

 

1.  Humeral Head defects

 

Posterior dislocation

- anteromedial

 

Defects < 40%

 

A.  Disimpaction and bone graft

- < 4 weeks, young patient

- articular cartilage must be salvageable

- via anterior approach

 

B.  McLaughlin

- < 20%, SSC only

- < 40% transfer SSC + LT into defect

- secure with 2 x cancellous screws

 

Defects > 40%

 

A. Allograft

- young patient

 

B.  Hemiarthroplasty / TSR

 

2.  Posterior Glenoid Deficiency

 

May need posterior bone graft

 

Luxatio Erecta

Epidemiology

 

Rare, inferior shoulder dislocation

 

Aetiology

 

Forced abduction injury

 

Pathology

 

Shoulder is hyperabducted

- humeral shaft abuts the acromion

- humeral head is levered inferiorly

- tears inferior capusle

 

Head becomes locked inferior to glenoid

 

May button hole through inferior capsule

- becomes irreducible

- need open reduction

 

Has tear rotator cuff / GT fracture

 

Associations

 

Tear RC

GT fracture

AXN palsy

Thrombosis axillary artery

 

Clinical Presentation

 

Patient has shoulder abducted

- has elbow flexed

- elbow resting on head

 

Reduction

 

Conscious sedation

- increased abduction initially

- then adduct

 

Post Reduction

 

MRI

- assess RC / biceps

 

AXN

- usually recovers

 

 

 

 

Multidirectional Instability

DefinitionMDI Shoulder

 

Instability in at least 2 planes

- postero-inferior

- antero-inferior

- antero-postero-inferior

 

Epidemiology

 

Recognised as a common problem 

- often misdiagnosed

 

Most patients athletic

- average age 24 years (15 - 54 years)

 

Aetiology

 

1.  Inherent ligament laxity > 50%

 

2.  Repetitive overuse with capsular stretch 

- microtrauma

 

3.  Macro-trauma < 50%

 

Pathology

 

Collagen abnormality

 

Increased joint volume 

- 2° enlarged inferior axillary capsular pouch

- patulous anterior and posterior

 

Often attenuated, broad rotator interval

 

History

 

Often bilateral

 

Instability of other joints

 

Feeling of shoulder "slipping down" while carrying heavy loads

- inferior instability

 

Often recurrent subluxation with minimal trauma

- sleeping

 

Shoulder pain

- fatigue 

- impingement type pain with overhead activities

 

Examination

 

Ligamentous laxity 75%

 

Inferior instability

- Sulcus Sign +

 

Shoulder Sulcus Sign

 

Anterior instability

- anterior draw

- anterior load and shift

- anterior apprehension, positive Jobe's relocation

 

Posterior instability

- posterior draw

- posterior load and shift

- posterior apprehension / jerk test

 

Xray

 

Traction xray

- patient standing with 5-10 kg in each hand

- Shows inferior subluxation of head

 

DDx of Inferior displacement of head

 

Torn superior rotator cuff

Suprascapular nerve palsy

Deltoid atony eg CVA

Deltoid / axillary nerve palsy

 

Management

 

Non-operative

 

Mainstay of treatment

- operative results poor

 

Physiotherapy

 

Minimum 12/12

- initial shoulder strengthening

- strengthen 3 parts of deltoid, cuff & scapular stabilisers

- specific programme with rope & pulleys

- combined with education program

- ~ 90 % success

 

Operative

 

Principles

- never operate on voluntary dislocator

- MDI surgery less successful than surgery for unidirectional instability

- cannot perform isolated anterior surgery

- bristow procedures etc fail as capsule remains redundant 

- anterior surgery may displace head posteriorly

 

MDI with traumatic anterior bankart

- new symptomatic instability on a background of ligamentous laxity / MDI

- MRA diagnosis of anterior bankart

- is reasonable to operate on patient with new traumatic anterior instability with labral tear

- issue is whether to combine with capsular shift

 

Options for MDI

 

1. Neer and Foster inferior capsular shift

2. Arthroscopic capsular plication

 

1.  Open Inferior Capsular Shift ~ Neer & Foster 1980

 

Principle 

- detach capsule from neck of humerus

- shift capsule superiorly to obliterate the inferior pouch

- decrease joint volume

 

Technique

 

EUA

- to confirm diagnosis

 

Deltopectoral Approach / Axillary fold

 

SSC

- must divide SSC separate to capsule

- need to leave capsule intact

- make horizontal incision in inferior border of SSC

- at muscular aspect

- insert curved artery forcep between SSC and capsule

- will exit at rotator interval

- insert medial stay sutures x 2 (use different colour to differentiate from capsular sutures)

- make vertical incision on artery forcep to avoid injury to capsule

 

T shape capsulotomy of capsule

- vertical component on humeral insertion

- transverse component to midpoint glenoid

- mark with pen first

- make vertical component on articular margin

- place inferior and superior stay sutures

- make horizontal incision

- creates superior and inferior capsular flaps

 

Inspect joint

- ensure no loose bodies

- repair bankart lesion if needed

 

Inferior capsular flap

- must sharp dissect capsule off inferiorly around humeral head

- protect AXN at all times

- do so by following articular margin around

- ER shoulder +++

- must get past 6 o'clock into posterior aspect

- check that traction on interior flap reduces inferior capsular pouch

 

Superior advancement inferior capsular flap

- tension on flap aimed at eliminating inferior pouch

- must reduce posterior capsular redundancy

- multiple 0 pull off stay sutures through flap and into remnant humeral tissue

- +/- anchors

- begin inferiorly, care with AXN

- cut and clip each sutures

- then tie all sutures togther at end

 

Check ER

- arm adducted, check ER 45o

- arm abducted to 90o, check ER 45o

 

Superior flap sutured down over inferior flap

- again multiple 0 pull off sutures

- tie

- check ER as above

 

Check not too tight

- can dislocated posteriorly

 

Closure of RI

- check ER as above

 

Subscapularis tendon brought over & reattached to normal location

- check ER as above

 

Post op

- Arm immobilised in sling 6/52

- No sport for 9/12 

 

Results

 

Bigliani et al JBJS Am 2000

- 52 shoulders with open inferior capsular shift

- approach posterior or anterior depending on greatest instability

- 96% remained stable at average 61 months

- 60% excellent and 30% good results

- 70% athletes able to return to sport at same level

 

Ogilvie-Harris Br J Sports Med 2002

- contact athletes

- antero-inferior capsular shift in 37 with 3 recurrences (8%)

- posterior-inferior capsular shift in 16 with 2 recurrences (1 anterior / 1 posterior)(12%)

- 80% return to sport in antero-inferior capsular shift

- 75% return to sport in postero-inferior capsular shift

- only 17% return to sport if bilateral procedures

 

2.  Arthroscopic

 

Technique

 

EUA

 

Posterior portal very high

- just under supraspinatous

- will need to tie inferior posterior sutures

 

Anterior portal

 

Anterior plication

- use shaver to create capsular stimulation

- don't remove or resect capsule

- 3 x sutures 1 PDS
- inferior suture first

- take bite of anterior inferior capsule with suture passer

- advance suture passer

- then pass separately through anterior labrum at a more superior level

- tie

- repeat x 2

 

MDI Anterior Capsular PlicationMDI Anterior Capsular Plication 2MDI Anterior Capsular Plication 3

 

MDI 2 bites anterior capsuleMDI 3 x anterior capsular sutures

 

Posterior plication

- camera inserted via anterior portal

- insert posterior cannula

- repeat inferior posterior sutures x 3

 

MDI Posterior capsular plication

 

May suture rotator interval if needed

 

Results

 

Baker et al Am J Sports Med 2009

- 43 patients average age 19 years

- 86% return to sport

 

3.  Thermal Capsular Shrinkage

 

Recognised as poor procedure

 

Results

 

Miniaci et al JBJS Am 2003

- 19 patients with MDI

- 9 recurrent instability

- 4 had parasthesia in AXN, one had deltoid weakness, all resolved

- worse results in posteroinferior compared with anteroinferior

 

 

 

Posterior

Posterior Dislocation

Chronic Posterior Dislocation APChronic Posterior Dislocation Lateral

 

Epidemiology

 

Rare 

- 2% of acute dislocations

 

Often missed

- < 1/ 52 25%

- < 6/52 25%

- < 6/12 25%

- > 6/12 25%

 

Aetiology

 

Usually secondary major trauma

- MVA

- Seizures

- ECT

- Electrocution

- Alcohol-related injuries

 

Examination

 

Loss of ER

 

Arm kept IR

- Hold arm across chest 

 

Beware of young patient with arm across chest & limited ROM

- don't think frozen shoulder only

 

AP Xray

  

1.  Light-bulb sign 

- globular head 2° IR

 

Posterior Shoulder Dislocation Light Bulb Sign

 

2.  Vacant Glenoid Cavity

- > 6 mm space between humeral head and anterior rim of glenoid

 

Posterior Shoulder Dislocation AP Non Concentric GHJ

 

Axillary Xray

 

Diagnostic

- humeral head posterior to glenoid

 

Look for reverse Hill- Sachs

 

Posterior Shoulder Dislocation Axillary Lateral

 

Scapular lateral

 

Can be missed if any obliquity to Xray

- centre of the humeral head must be centred on the Y / Mercedes

- Y is formed by coracoid anteriorly / scapular spine posteriorly / scapula body inferiorly

 

Posterior Shoulder Dislocation LateralPosterior Shoulder Dislocation Scapula Lateral

 

CT scan

 

A.  Confirms dislocation

 

Posterior Shoulder Dislocation Sagittal CTPosterior Shoulder Dislocation CT 1Posterior Shoulder Dislocation CT 2

 

B.  Quantifies humeral head defect 

- very important to decide management if locked / chronic / unstable

 

Humeral Head Defect

 

Quantification

- measured as a percentage of the articular surface

  

Case 1

 

CT Chronic Posterior Humeral Head DefectPosterior Shoulder Dislocation Anterior Hill Sachs

 

Case 2

 

Posterior Shoulder Dislocation Head Defect 1Posterior Shoulder Dislocaton Head Defect QuantificationPosterior Shoulder Dislocation CT

  

MRI

 

Chronic Posterior Shoulder Dislocation MRI AxialChronic Posterior Shoulder Dislocation MRI Sagittal

 

Management

 

Closed reduction

 

Beware

- injury more than 6 /52 ago

- large posterolateral defect locked on glenoid rim

- > 40% defect (will be unstable)

 

Technique

 

Consent for

- open reduction

- +/- bone grafting

- +/- McLaughlin procedure

 

GA

- arm adducted

- arm flexed to 90o

- increasing IR first to unlock head

- traction

 

Unstable closed reduction 

- may have to use gun slinger cast

- arm abducted 90o and ER

 

Post Reduction

 

Assess anterior Hill Sachs

 

Posterior Shoulder Dislocation Post Reduction Anterior Hill SachsReverse Hill Sach's

 

Open reduction

 

Indication

- failure closed reduction

- inability to maintain reduction in gunslinger

- chronic posterior dislocation

 

Technique

 

1.  Anterior deltopectoral approach

- reduce humeral head

 

2.  Address instability / manage anterior humeral head defect

 

Humeral head Defect Management

 

1.  HS < 25% 

 

Options

- treat non operatively if stable

- may be able to elevate and bone graft acutely in young patient

- +/- posterior labral repair

 

Reverse Hill Sachs less than 25 percent

 

2.  HS > 25%

 

Options

- transfer SSC +/- LT

- osteochondral allograft young patient

- hemicap / resurfacing older patient

 

Reverse Hill Sachs Defect greater than 25%

 

3.  HS > 40%

 

Options

- hemiarthroplasty / TSR (older patient)

- osteochondral allograft (younger patient)

 

Reverse Hill Sachs greater than 40 percent

 

SSC +/- LT transfers

 

Options

 

SSC transfer / McLaughlin

- makes defect extra-articular

 

SSC + LT / Neer modification

 

Indications

- best for small defects = 25%

- young patient

 

Problem

- may weaken IR

 

Osteochondral Reconstruction

 

Shoulder McLaughlin APShoulder McLaughlin Lateral

 

Reverse Hill Sachs AllograftReverse Hill Sachs Allograft 2

 

Results

 

Diklic et al JBJS Br 2010

- 13 patients with anteromedial defects between 25 and 50%

- all chronic / missed injuries

- open reduction

- SSC divided 1 cm from insertion, separated from capsule

- posterior labral repair / posterior plication if required

- femoral allograft inserted and fixed screws

- ER brace post op

- 9 patients pain free, 1 developed AVN, other 2 mild pain

 

Hemiarthroplasty / TSR

 

Indication

- older patient

- humeral defect > 40%

 

Issues

- may get recurrent posterior instability

- may have posteror glenoid bone defect

 

Technique

- anterior SSC Z lenthening

- posterior capsular plication +/- advancement IS / Tm

- glenoid poly insertion if posterior glenoid wear

- decreasing humeral head retroversion to 20o

- gunslinger post op for 6 weeks

 

Results

 

Sperling et al J Should Elbow Surg 2004

- 12 patients, average age 55 years, average 26 months since dislocation

- mix of hemiarthroplasty and TSR depending on state of glenoid

- some posterior plications performed

- 2 patients had recurrent posterior instability

- one patient had advancement of IS / Tm and posterior capsular plication

- one hemi was revised to TSR with plication

Posterior Instability

Definition

 

Patients usually complain of subluxation rather than dislocation

- rarely requires reduction

 

Different entity to acute posterior dislocation usually

 

Epidemiology

 

Rare

 

Aetiology

 

1.  Ligamentous laxity > 50%

- commonly associated with MDI

- posterior only 20%

- posterior & inferior 20%

- posterior / inferior & anterior 60%

 

2.  Trauma

 

A.  Repetitive microtrauma 

- common

 

B.  Macro-trauma 

- uncommon

- seizures

- electrocution

- ECT

- alcohol related injuries

- MVA

 

Pathogenesis

 

1.  Capsulo- ligamentous

 

A.  Reverse Bankart lesion 

- uncommon

- detached posterior labrum < 10%

 

B.  Capsular laxity

- much more common

 

C.  Posterior IGHL avulsion

- reverse HAGL

 

2.  Bony

 

A.  Humeral Head Defects  

- reverse Hill-Sachs lesion 

- defect in Ant humeral head

- seen in traumatic dislocations / chronic posterior dislocation

- can make humerus unstable

- compared with anterior Hill-Sachs which rarely does

 

CT Humeral Head Defect

 

B.  Posterior glenoid deficiency

- seen in traumatic / chronic dislocations

 

Posterior Glenoid DeficiencyPosterior Glenoid Deficiency Sagittal

 

C.  Humeral head / glenoid retroversion

 

Shoulder Posterior Instability Glenoid Retroversion

 

History

 

Must exclude voluntary dislocator

 

History of ligamentous laxity / other problems

 

Examination

 

Must assess for

- MDI / Ligamentous Laxity

- voluntary dislocator

 

Tender posterior joint line 

- fairly specific for OA rather than instability

 

ROM

- loss of ER (in locked posterior dislocation)

 

Ligamentous laxity

 

Sulcus sign

- indicates MDI

 

Anterior apprehension

- indicates MDI

 

Posterior stress test 

- supine

- adduct, forward flex and IR arm

- posterior force

- apprehension test

 

Load and Shift / Posterior Drawer

 

Altchek Grading

 

Grade 0       No translation

Grade 1+     Up to glenoid rim

Grade 2+     Beyond rim with spontaneous reduction

Grade 3+     Translation beyond rim without spontaneous reduction

 

CT

 

1.  Define extent of Hill Sach's lesion

 

2.  Glenoid bone defect

 

3.  Glenoid version

 

Posterior Instability Glenoid Retroversion

 

MRI

 

Posterior bankart lesion

 

Shoulder MRI Posterior Labral Tear

 

Posterior labral cysts

 

Shoulder Posterior Labral Tear with Cysts0001Shoulder Posterior Labral Tear with Cysts0002Shoulder Posterior Labral Tear with Cysts0003

 

Management

 

Non-operative

 

Not infrequently little functional problems

 

Prolonged initial physical treatment for all patients

- minimum 12 months

- treat similar to MDI patients

- Matson & Rockwood 80-90% success rate

 

Operative

 

Indications

- failed non-operative management

- moderate to severe disability

 

Contra-Indications

- MDI

- voluntary dislocator

- ligamentous laxity

- minimal functional impairment

 

Pathology

 

1.  Posterior Bankart lesion

 

Options

- arthroscopic / open reconstruction

 

Posterior Labral Tear

 

Failure / Bony Block Revison

- posterior approach

- detach infraspinatous

- expose capsule

- divide capsule medial to glenoid

- take 2 cm long x 1 cm thick iliac crest

- secure to glenoid with 2 x small fragment screws

- reattach capsule lateral to bony block

 

Failed Posterior Arthroscopic Shoulder Stabilisation0001Failed Posterior Arthroscopic Shoulder Stabilisation0002Shoulder Posterior Bony Block0001Shoulder Posterior Bony Block0002

 

2.  Capsular laxity

 

Options

- posterior capsular shift arthroscopic or open

- reverse Putti-Platt

 

Open capsular plication

 

Bigliani and Flatow July 1995

- 35 patients

- If primary operation 23 of 24 successful

- 89% stable at 5 yrs

 

Reverse Putti-Platt

 

Technique

- posterior approach

- posterior imbrication of IS & Tm 

- combine with posterior capsule imbrication

- shorten tendon 1cm = 20°

- limit IR to 20o

 

3.  Humeral Head Defect

 

Humeral Head Anterior Hill Sachs CT

 

1.  HS < 25% 

- leave

 

2.  HS > 25%

- transfer SSC + LT (McLaughlin)

- OC allograft

 

3.  HS > 40%

- hemiarthroplasty / TSR (older patient)

- OC allograft (younger patient)

 

4.  Posterior Glenoid Defects

 

Option

- posterior glenoid bone graft

 

Posterior Glenoid Bone BlockPosterior Bone Block CT

 

Results

 

Meuffels etal JBJS Br 2010

- 18 year follow up of 11 patients treated with posterior bone block

- 36% had had recurrent dislocation

- half would not have the surgery again

- all had evidence of OA

 

5.  Retroverted Glenoid Version / Static Posterir Shoulder Subluxation

 

Issue

- posterior shoulder subluxation > 65%

- shoulder OA

- young age

- glenoid osteotomy

 

Static Posterior Shoulder SubluxationGlenoid Retroversion SPSSSPSS MRISPSS Calculation

 

Option

- posterior opening wedge glenoid osteotomy

- rarely indicated & technically hard

 

Indication

- congenital retroversion of glenoid > 30o

 

Technique

- only 5 mm medial to glenoid rim otherwise injure SS nerve

- must prevent penetration of glenoid

 

Complications

- anterior impingement of subscapularis on coracoid causing pain

- anterior subluxation of humeral head

Surgical Techniques

1.  Arthroscopic Posterior Bankart Repair +/- Capsular Plication

 

Posterior Labral TearPosteior Labral Repair

 

Technique

 

Posterior Portal

- make slightly inferior and lateral compare to normal

- inspect joint

- place anterior portal +/- ASL portal

 

Remove cameral and place thorough anterior portal

- place 8 mm cannula through posterior cameral portal (over switching stick)

 

Often need second portal lateral and inferior to place inferior anchor

- can use simple stab incision here

 

Assess labrum and capsule

- repair posterior bankart

- plicate redundant / patulous capsule

 

Results

 

Kim et al JBJS Am 2003

- 27 patients with unidirectional posterior instability

- all with labral injuries, most with capsular laxity

- all had arthroscopic posterior labral repair and capsular shift

- only one recurrence

 

Pennington Arthroscopy 2010

- 28 athletes with pure posterior labral pathology

- 93% return to sport

 

Bradley et al Am J Sports Med 2006

- 91 athletes with 100 shoulders with unilateral posterior instability

- variations of suture anchor labral repair / anchor capsulolabral repair / capsular plication sutures

- 30% posterior labral tear, 43% patulous capsule with no labral pathology

- remainder combination injuries including partial labral tears

- 8% failure rate, all with capsular laxity

- patients had evidence of chondrolabral retroversion

 

2.  Open Posterior Capsular shift 

 

Open Technique

 

Position

- lateral

 

Incision

- vertical incision

- posterior axillary fold

 

Shoulder Posterior Approach

 

Superficial dissection

- split deltoid to expose infraspintous

- elevate IS off capusle

- L shaped incision infraspinatous after tagging sutures medial

- T shaped capsulotomy of capsule for posterior shift (vertical limb on humeral insertion)

 

Dangers

- no more than 1.5cm medial to glenoid to protech SS nerve

- axillary nerve through quadrangular space below Tm

 

Procedure

- labral detachment reattached if present

- graft glenoid with bone from spine / iliac crest if defect

- inferior capsule shifted superiorly

- reinforced with superior limb of capsule

- may augment with IS tensioning

 

 

 

 

Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2

 

Technique

 

1. Establish portals

 

A.  Posterior portal for viewing

 

B.  Anterior portal

- need to keep low and away from biceps, otherwise difficult to get around biceps

- for suture passage, if in combination with bankart repair often use AI portal instead of AS

 

SLAP repair anterior portal

 

C.  Anterosuperolateral portal / Wilminton for insertion of anchors

- insert spinal needle first

- anterolateral border acromion

- needs to be close to acromion to get angle over humeral head

- check with needle

- need best angle to insert anchors to anterior and posterior aspect of biceps

- passes through supraspinatous

- use knife to cut in line with fibres

- insert portal

 

SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals

 

2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone

 

Shoulder SLAP Preparation Base

 

3.  Anchors

 

Drill and insert via Wilminton portal

Usually 3 anchors is a minimum

 

Technique

- insert anchor

- suture through each cannula

- limb through W portal will be the suture limb that is passed

- suture passer through anterior portal (right angled for left shoulder)

 

SLAP Anchor InsertionShoulder SLAP Repair Suture Management

 

Anterior anchor

- best to pass the suture passer above the biceps to get good bite

- retrieve sutures and tie from port of Wilmington

 

SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2

 

SLAP Anchor 1SLAP Tie anterior anchor

 

Posterior 2 anchors

- pass suture passer under biceps

 

SLAP Vertical MattressSLAP Second Anchor

 

SLAP third anchorSLAP 3 anchor repair

 

Can suture Portal of Wilminton if desired

 

Portal WilmingtonWilminton Repair 1Wilminton Repair 3

 

4.  Dfficult posterior anchors

 

Camera through anterior / anterosuperiorlateral portal

 

A.  Place anchor through posterior portal

- does not always give good angle

 

SLAP repair posterior portal

 

B.  Trans infraspinatous Portal

 

SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair

 

Biceps Tenodesis

Options

 

Arthroscopic

- intra-articular

- suprapectoral

 

Open

- suprapectoral

- subpectoral

 

A.  Arthroscopic Intra-articular

 

Biceps Tenodesis Intra articular

 

Concept

- suture biceps to superior capsule using figure 8 no 2 non absorbable

 

Technique

- anterior portal + portal of Wilmington

- debride capsule and biceps with shaver so will heal

- use curved suture passer with no 1 PDS

- suture shuttle no 2 fibre wire

- divide 90% biceps insertion so will rupture in time

- allows healing of biceps to capsule

 

Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture

 

Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut

 

Attempt Figure 8 Suture Configuration

 

Biceps Tenodesis Step 1Biceps Tenodesis Step 2

 

B.  Arthroscopic Suprapectoral Technique

 

1.  Secure Biceps Tendon - allows tensioning and prevents losing tendon

 

A.  Birds Beak Passer with 2 ethibond loop

- pass loop through intact tendon at entry through RC interval

- retrieve loop out through portal and lock

- this gives strong hold on tendon

 

B.  Pass 18 G spinal needle through biceps tendon

- thread 1 PDS or nylon

- retrieve both suture ends via portal in rotator interval

- secure with half hitches

- pass 1 loop of PDS about entire tendon and tie again

 

Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon

 

2.  Resect tendon with electrocautery at insertion

 

Arthroscopy Biceps Tenotomy

 

3.  Make portal over biceps interval into subacromial space

- release biceps tendon with electrocautery or arthroscopic scissors

 

4.  Secure tendon

- make drill hole

- insert tendon

- secure with biotenodesis screw

- multiple techniques with specifically designed equipment

 

C.  Open Technique for Intact Biceps

 

1.  Divide biceps arthroscopically

- may wish to place stay suture first to avoid retraction

- biceps normally has vinculae preventing complete retraction into arm

 

2.  Suprapectoral

- deltoid split

- between anterior and middle parts

- find biceps in groove

- pull out of wound and whip stitch with heavy suture

- drill appropriate size tunnel for fixation screw

- multiple biceps tenodesis devices

- push the tendon into the hole, then fixate with screw

 

3.  Subpectoral

- medial incision in arm

- below inferior edge of pectoralis major

- find biceps tendon

- whip stitch

- pass through drill holes / secure with screw / secure with anchor

 

Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis

 

D.  Open Technique for Ruptured LHB / Popeye in young patient

 

1.  Locate biceps

 

Options

 

A.  Suprapectoral

- best to make deltopectoral approach

- biceps may be futher retracted

 

B.  Subpectoral approach

 

2.  Fixation

SLAP lesion

DefinitionMRI SLAP Tear

 

Superior labrum anterior & posterior

 

Injury to superior part of glenoid labrum involving region of biceps tendon insertion

 

Epidemiology

 

2 groups

 

1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability

 

2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis

 

Aetiology

 

Three mechanisms

 

1.  Compression force applied to GHJ

- FOOSH

- commonest

- arm in abduction & forward flexion

- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression

 

2.  Traction on Arm

- sudden pull on arm

- grab while falling

 

3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading

 

History

 

Pain with overhead activities

 

Catching or popping with overhead activities

 

Acute trauma

 

Mimics impingement

 

Examination

 

Speed's Test 

Yergason's Test

 

O'Brien's test

 

Causes impingement of biceps on anterosuperior labrum

 

1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain

 

2.  Relieved when same again but with ER

- i.e. no pain with thumbs up

 

McMurray's Shoulder test

 

Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click

 

MRA

 

See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant

 

MRI Slap with SS tearMRI Anterior Bankart

 

Supralabral ganglion cyst

- associated with posterior SLAP tears

 

Normal Arthroscopy

 

Normal Biceps Insertion

 

Arthroscopic Classification Snyder

 

Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 

 

Arthroscopy Meniscoid Biceps Insertion

 

Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   

 

Subtypes

- anterior

- posterior

- anterior and posterior

 

SLAP arthroscopyShoulder Scope SLAP Type 2

 

Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid

 

Shoulder Scope Type 3 SLAP

 

Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear

 

Type 4 SLAP Tear extends partially into bicepsSLAP Type 4

 

Type 5 - 7 added by Gartsman

 

Type 5
- SLAP 2 with anterior bankart extension

 

Type 6

- SLAP 2 with free flap of meniscal tissue

 

Type 7

- Slap 2 with anterior bankart extension and into MGHL

 

Normal Variations of the Superior Labrum

 

The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair

 

Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion

 

Davidson et al Am J Sports Medicine 2004

- described normal variations

 

1.  Triangular

 

2.  Bumper

- lump of fibrous tissue

 

3.  Meniscoid

- labrum extends down over glenoid face

 

Management

 

Non Operative

 

Trial

- physio

- HCLA

 

Operative

 

Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy

 

Options

 

1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy

 

Issues

 

1.  Older patient with RC tear and SLAP

 

Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group

 

2.  Repair v Tenodesis Type II SLAP

 

Boileau et al Am J Sports Med May 2009

- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)

- repair group 40% satisified, 20% returned to previous level of sport

- tenodesis patients 93% satisified, 87% return to previous level of sport

 

Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

- this was higher (92%) if athlete described a discrete traumatic event

 

3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist

 

MRI SLAPMRI Anterior Bankart

 

Management Algorithm

 

Type 1

 

Debride labrum

 

Type 2

 

A.  Arthroscopic repair

 

B.  Tenotomy / tenodesis

 

Type 3

 

Debride bucket handle labrum

 

Type 4

 

Remove labral flap

 

Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis

 

Types 5 - 7

- associated with instability

- repair as per treatment of instability

Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps

 

LHB primary function is humeral head depressor

 

Also accelerate / decelerate arm in overhead sports

 

Problems

 

Biceps problems usually occur with other pathology 

- rotator cuff / instability

 

3 main problems

 

1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture

 

Rupture

- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps

 

2.  Instability

 

Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament

 

Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear

 

Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears

 

3.  Disorders of the origin (SLAP)

 

4.  Hourglass Biceps

 

Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis

 

Anatomy

 

Origin 

- from postero-superior labrum and supraglenoid tubercule

 

Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament

 

Examination 

 

Tenderness over biceps tendon crucial

 

Rupture

- Popeye appearance

 

Popeye Sign BicepsPopeye Biceps

 

Speed's

- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness

 

Yergason's

- elbow flexed and pronated

- resist supination

- pain over LHB

 

O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up

 

MRI

 

Normal

 

MRI Enlocated Biceps Tendon

 

Tendonitis

 

Biceps Tendonitis MRI

 

Tendonosis / thickening

 

Biceps Tendinosis MRI

 

Medial Subluxation

 

Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC

 

Arthroscopy 

 

Normal

 

Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit

 

Mild Tendonopathy

 

Biceps Tendonopathy Grade 2 Arthroscopy

 

Moderate Tendonopathy

 

Shoulder Biceps Moderate Tendonopathy

 

Severe Tendonopathy

 

Biceps Tendonopathy ArhroscopyBiceps Tear near complete

 

Dislocated Biceps in Presence of complete SSC Rupture

 

Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon

 

Management

 

1.  Tendonitis

 

Non Operative

 

As per rotator cuff / impingement

- HCLA

- physio

 

Surgical Options

 

1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament

 

2.  Tendon Fraying / Tendinosis / Rupture

 

Grade tendon integrity

 

I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture

 

Management Strategy

 

I & II

- SAD & debride tendon 

 

III & IV

- SAD & biceps tenodesis / tenotomy

 

Tenotomy v Tenodesis

 

Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another

 

Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores

 

Tenotomy

 

Popeye deformity

 

Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men

 

Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis

 

Strength

 

Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength

 

Tenodesis

 

Indications

- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)

 

Issues

- screw prominence / pain

- failure of fixation

 

Options

- arthroscopic

- open

- see techniques

 

Arthroscopic

 

Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral

 

Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony

 

Open

 

Suprapectoral or subpectoral

 

Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury

 

3.  Subluxation

 

Issues

 

Usually medial from SSC tear

- must manage LHB or SSC repair will fail

 

Options

 

1.  Tenodesis / Tenotomy + SSC repair

 

2.  Stabilisation + SSC repair

 

Issue

- can get stenosed painful tendon  

 

Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US

 

 

 

 

 

 

Miscellaneous

Axillary Nerve Lesions

Anatomy

 

Terminal branch of the posterior cord

- lateral to radial nerve

- behind axillary artery

- runs over inferolateral border of SSC

- enters quadrangular space

 

Quadrangular space

- SSC superiorly anterior

- T major inferior

- T minor superiorly posterior

- long head triceps and humerus

 

Divides into anterior and posterior branches

 

Axillary Nerve Sagittal MRI 1Axillary Nerve Sagittal MRI 2

 

Anterior branch

- curves around SNOH

- deep to deltoid

- 4-7 cm inferior to corner acromion

- supplies anterior and middle portions deltoid

 

Posterior branch

- supplies T minor and posterior deltoid

- sensory branch

 

3 distinct fascicles

- T minor

- deltoid (supero-lateral)

- superior lateral cutaneous branch

 

Aetiology

 

1.  Traumatic

2.  Iatrogenic

3.  Quadrilateral Space Syndrome

4.  Brachial Neuritis

5.  SOL

 

1.  Traumatic

 

A. Shoulder Dislocation

- 10-20% incidence post dislocation

 

Blom et al Acta Chir Scand 1970

- 9 complete and 15 partial lesions

- all recovered within 1 - 2 years

 

Gumina JBJS Br 1997

- high rate in elderly > 40 (50%)

- all recovered by 3 years

- high rate of RC (20%)

 

B. Proximal Humeral fracture

 

C. Brachial Plexus injury

- rarely isolated

- in conjunction with other injuries

- upper trunk

 

D.  Blunt trauma to deltoid

 

2.  Surgery

 

A.  Deltoid-Splitting approach

- lies 5cm lateral to anterolateral corner of acromion

 

B.  Deltopectoral approach

- undue care at inferior level of SSC

 

3. Quadrilateral space syndrome

 

Mechanism

- Compression in position ER and abduction

 

Symptoms

- get pain and paraesthesia in shoulder 

- can have chronic dull ache

 

Signs

- usually no deltoid atrophy or sensory changes

 

Investigation

 

EMG

- normal

 

Angiogram

- shows compression of posterior humeral circumflex artery with less than 60o abduction

 

MRI

- may shows changes in deltoid and Tm

 

Mangement

- usually just observation

- occasionally need to decompress scar tissue or fibrous band

 

4.  Parsonage-Turner Syndrome

 

Brachial neuritis

- spontaneous development severe shoulder pain

- then develop loss of motor function

- usually also LTN, SS nerve, but occasionally isolated

 

Management

- can treat with steroids

- usually good prognosis

 

5.  Nerve compression from mass effect

 

Cause

- aneurysm, tumour

 

History

 

No history trauma

- suspect mass effect / quadrilateral space syndrome / brachial neuritis

 

Pain then loss of function

- suspect brachial neuritis

 

History dislocation

 

Examination

 

Deltoid Wasting

 

Wasting Deltoid

 

Weakness of shoulder abduction

 

Numbness in Regimental patch 

- variable

 

DDx

 

1.  Upper trunk injury / root injury (C5/6)

- will also have injuries to

 

A.  SS nerve

- IS / SS

- remember dislocation may cause RC tear

 

B.  Subscapularis

 

C.  Biceps

 

2.  Posterior cord injury

- will also have injuries to

 

A.  Radial nerve

- triceps, WE, FE, thumb extension

 

B.  Thoracodorsal

- Lat Dorsi

 

C.  Upper and lower subscapular

- SSC

 

NCS / EMG

 

Diagnose higher lesion

- reference point for recovery

 

MRI

 

Mass lesions

Atrophy of T minor

Assess RC 

 

Operative Management

 

Indications

- no clinical or NCS / EMG sign of recovery at 6/12

- open wounds / stab wounds

 

Timing

 

Best results 

- reinnervation must occur before one year

- otherwise get degeneration of NMJ

- i.e. surgery must occur by 9 months

 

Options

 

No muscle transfer for deltoid

- nerve repair

- neurolysis

- nerve grafting

- nerve transfer

 

1.  Neurolysis

 

Indications

- if nerve intact but encased in scar or compressed by fibrous bands

 

Technique

- identify nerve

- use nerve stimulator intra-operatively

- stimulation of nerve will cause muscle contraction if intact

- uncommon

 

2.  Neurorrhaphy 

 

Indication

- laceration

 

Technique

- direct repair of laceration

- if in first few weeks

 

3.  Nerve grafting

 

Indications

- neuroma usually at or in quadrilateral space

 

2 Incision Technique

 

Sural nerve graft

- anastomose anteriorly, then pass through

- anastomose posteriorly

 

Lateral decubitus

- access anterior and posterior shoulder

- allows sural nerve harvest

 

Deltopectoral approach

- release half or all of P major (leave cuff for repair)

- must release conjoint tendon and P minor

- do so 1cm from origin

- expose axillary, radial and MCN

- use nerve stimulator to ensure nerve not working

- identify and protect axillary artery and vein

- if deltoid active, neurolysis

 

Identify neuroma

- if deep

- posterior approach to shoulder

 

Posterior vertical incision

- lateral border acromion to posterior axillary crease

- mobilise inferior border deltoid superiorly

- find nerve as exits quadrilateral space

- identify deltoid fascicle using nerve stimulator

 

Results

 

Allnot Int Orthop 1991

- 23/25 isolated sural nerve grafting achieved M4 or M5 strength

 

4.  Neurotisation / Nerve transfer

 

Concept

- use branch of radial nerve

- transfer into motor branch axillary

- single incision

 

Technique

- posterior longitudinal approach to arm

- find AXN under wasted deltoid, exiting above T Major

- identify anterior branch of AXN going into muscle

- ensure not branch to T minor or sensory branch

- develop interval between long and lateral heads

- find radial nerve in groove between medial and lateral heads

- will be exiting below T Major between long and humerus

- harvest branch to long or medial head triceps

- long may be better as has two sources nerve supply and less functional impairment

- check with nerve stimulator

- repair with 9.0 nylon under microscope

 

Results

 

Leechavengvongs et al J Hand Surg Am 2003

- all 7 patients had M4 power

- 5 excellent and 2 good results

- no demonstrable loss of elbow extension power

Constant Shoulder Score

 

Subjective Assessment 35 points

 

Pain

 

ADLS

- work

- recreation

- sleep

 

Ability to work at specific level

- waist

- chest

- neck

- head

- above head

 

Objective Assessment 65 points

 

Flexion

 

Abduction

 

ER

 

IR

 

Strength

Pectoralis Major Rupture

Aetiology

 

Usually related to sporting activities including weight lifting

- bench press most common 

- higher risk with steroid use

 

Epidemiology

 

Peak age 20 - 40

 

Often unrecognised

 

Classification

 

Site

- intra-muscular

- MT junction

- tendon avulsion

- 2:1 tendon avulsions compared with musculotendinous junction

 

Partial or complete

 

Sternal / clavicular heads or both

 

Anatomy

 

Clavicular head

- medial clavicle and upper sternum

- inserts at lowermost aspect of biciptial groove

 

Sternal head

- sternum, aponeurosis external oblique and costal cartilages of first 6 ribs

- inserts at uppermost aspect of bicipital groove

 

Insertion

 

2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa

 

Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head

 

Nerve supply

 

Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head

 

Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor

 

Actions

- powerful adductor, flexor and internal rotator

 

History

 

Usually recall incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising

- only later when it settles is the cosmetic and functional deficiency apparent

 

Acute Pectoralis Major Tear

 

Examination

 

Asymmetry chest wall

 

Pectoralis Major RupturePectoralis Major Tear Chronic

 

Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction

 

Pectoralis Ruture Palpable Cord

 

Resisted adduction is weak

- hand on hip

- feel tendon insertion

 

MRI

 

Useful in the acute setting

 

Will also identify site of rupture and amount of retraction

 

Management

 

Non Operative

 

Indications

- partial tears

- muscle belly tears

- elderly

 

Operative

 

Results

 

Pochini et al Am J Sports Med 2010

- 10 operative cases (70% excellent, 20% good, 10% poor)

- 10 non operative (20% good, 50% fair, 40% poor)

- strength in non operative group 50% of other arm

 

Timing

 

Chronic ruptures

- best to repair within 8 weeks

- have been successful repairs from 3 months up to 13 years

 

Chronic

- may wish to have allograft / achilles tendon available

- especially needed if tendon has retracted beyond nipple line

 

Technique

 

Deltopectoral approach / axillary fold incision

 

Anterior lamina fibres of clavicular head are usually intact

- pectoral fascia also usually intact

- blunt dissection medially under clavicular head to find sternal head

 

Repair

 

1.  Make trough in bone lateral to biceps tendon with burr

- Krackow suture in tendon with no 5 non absorbable

- repair through drill holes

- +/- suture anchors

- + / - direct suture of MT junction

 

Pectoralis Major Repair 1Pectoralis Major Repair 2Pectoralis Major Repair 3

 

2.  Foot print technique

- roughen area of insertion lateral to LHB / osteotome

- insert 3 double loaded anchors in V formation ( 2 lateral and one medial)

- pass through tendon and suture down

 

3.  Allograft reconstruction

- fascia lata / tendo achilles

- pass graft through pec major

- double over and insert into bone tunnel

 

Post op

- sling 6 weeks

- ROM 6 weeks

- strengthening at 3/12

 

Complications

 

Infection

- higher than normal risk due to proximity to axilla

 

Humerus fracture

- case report with bone trough

 

LHB rupture

- case report

 

Re-rupture

- most common

- up to 7%

 

 

 

 

 

 

Shoulder Xrays

AP Shoulder

 

Technique

- in plane of thorax

- oblique of GHJ

 

Shoulder AP Xray

 

AP in plane of scapula

 

Grashey

- angle 45o lateral

- allows estimation of glenohumeral space

 

AP Plane Scapula

 

AP IR / ER

 

Demonstrates Hill Sach's and other humeral head morphology

 

Scapular lateral

 

Patient erect

- affected shoulder against plate

- rotate other shoulder 45o out of way

- beam aimed along spine of scapula

 

Scapular LateralScapula Lateral Posterior Shoulder Dislocation

 

Axillary lateral

 

Patient seated

- arm abducted

- plate under axilla

- beam angled down towards shoulder

 

Axillary Lateral XrayAxillary Lateral Posterior Subluxation

 

Supraspinatous outlet view

 

For acromial morphology and impingement

 

Similar to scapular lateral

- tilt beam caudal 10o

 

Supraspinatous Outlet View

 

West Point View

 

Variation axillary lateral

- tangential view anterior / inferior glenoid 

- for bony bankart

 

Patient prone with arm hanging off bed

- plate superior to shoulder

- camera 25° cephalad to horizontal / 25° to long axis body

 

Westpoint view Hill Sachs

 

Garth View / Apical Oblique

 

True AP with 45o caudal tilt

- to show anterior / inferior capsule 

- bony bankhart / Hill Sachs

- standing with plate behind joint

- 45° caudal tilt / 45° in coronal

 

Garth XrayShoulder Garth View

 

Stryker Notch view

 

Patient supine with cassette posterior to shoulder

- hand on head, elbow straight up

- beam 10o cephalic aiming at corocoid

 

Demonstrates Hill-Sach's

 

Stryker Notch View Hill Sachs

 

Zanca view

 

ACJ

 

Patient erect with cassette behind shoulder

- aim beam at ACJ 10 - 15o cephalic

- half strength to not overexpose ACJ

 

Zanca View

 

Serendipity view

 

SCJ

 

Technique

- prone with cassette under chest

- aim beam 40o cephalic

 

Sternoclavicular Joint Xray 1Sternoclavicular Joint Xrays 2

 

 

 

 

 

Sternoclavicular Pathology

 

Condensing Osteitis

 

Epidemiology

- seen in women over 40

 

Xray

- sclerotic and overgrown

 

Condensing Osteitis Xray

 

CT

 

Condensing Osteitis CT 2Condensing Osteitis CT

 

NHx

 

Sng Ann Acad Med Sing 2004

- follow up of 9 patients mean 34 months

- pain reduced over time

 

Management

 

Refractory

Will resolve with time

 

Options

- HCLA injection

- excision

 

Friedrich's Disease

 

Very rare condition seen in young adults

- AVN of sternal end of clavicle / occasionally lateral end

- pain and swelling

- ESR may be raised

- irregular sclerotic appearance on xray

- rarely requires excision

 

Sternoclavicular Hyperostosis

 

Bilateral condition

- ossification of sternoclavicular ligaments

- may lead to solid ossification with restriction of shoulder motion

- associated with pustules and elevated Alk Phos

 

Osteoarthritis

 

Sternoclavicular OA

 

SCJ OA MRI 1SCJ OA MRI 2

 

Options

 

1.  Intra-articular cortisone

2.  Fusion

 

 

Suprascapular Nerve

Anatomy

 

C5, 6 from Upper trunk

 

Posterior triangle

- arises upper trunk and passes backward through posterior triangle

- under belly of omohyoid

- deep to trapezius to the suprascapular notch

 

Suprascapular Ganglion Coronal MRI

 

Runs through suprascapular notch

- under superior transverse scapular ligament

- suprascapular artery and vein run over this ligament

- supplies SS 1 cm after passing under ligament

- give articular branch to the shoulder

 

Suprascapular Nerve Sagittal MRI 1Suprascapular Nerve Sagittal MRI 2

 

Passes around lateral border spinous process / Spinoglenoid notch

- under spinoglenoid ligament

- inferior transverse scapular ligament

- supplies IS

 

Motor

-  supplies supraspinatus & infraspinatus

 

Sensory

- ACJ, GHJ

- CA and CH ligaments

 

Sites of Compression / Injury

 

Suprascapular notch

- weakness wasting SS & IS

 

Causes

- trauma most common / driect blow / clavicle or scapula fracture

- iatrogenic / excessive rotator cuff release

- athletes / repetitive overhead motion

 

Spinoglenoid notch

- weakness wasting IS

 

Causes

- spinoglenoid cyst associated with superior labral tear / horizontal cleavage / acts as one way valve

- posterior approach to shoulder - > 1 cm medial to glenoid neck

- posterior shoulder OA causing a cyst

 

History

 

Pain at back of shoulder

Weakness

 

Examination

 

Weakness

 

Atrophy SS/IS

 

Atrophy of IS alone

 

DDx

 

Rotator Cuff tear

 

MRI 

 

1.  Spinoglenoid cyst / labral tear

- may be better seen with MRA

 

Spinoglenoid cyst Coronal MRISpinoglenoid Cyst Sagittal MRISpinoglenoid Cyst MRI Axial

 

2.  Atrophy of SS / IS

 

Spinoglenoid Cyst Infraspinatous Fatty Atrophy

 

3.  Exclude cuff tear

 

EMG 

 

Demonstrate denervation SS/IS or IS alone

 

HCLA

 

Inject SS nerve at suprascapular notch

 

Management

 

Non Operative

 

Reasonable if no ganglion cyst

- a neuropraxia which usually resolves

- avoid overhead activities if possible

- 6 - 9 months

 

Operative

 

Spinoglenoid Cyst

 

1.  Secondary to superior labral tear

 

Majority of cases

  

A.  Cyst Decompression + Arthroscopic labral repair

 

Technique

- identify horizontal cleavage tear

- decompress throught tear

- repair labrum

 

Posterior Labral Tear Cyst 1Posterior Labral Tear Cyst 2Posterior Labral Tear Cyst 3

 

Posterior Labral Tear 1Posterior Labral Repair 2Posterior Labral Tear 3

 

Piatt et al J Should Elbow Surg 2002

- excellent results

 

B.  Arthroscopic Labral Repair without cyst decompression

 

Schroder et al JBJS Am 2008

- 42 patients

- posterior labral repair without cyst decompression

- cyst resolved in 88% on MRI and smaller in remainder

- all patients satisfied with outcome

 

2.  Spinoglenoid Cyst without labral tear

 

Options to decompress cyst

- ultrasound drainage / not always effective but may be worth a try intially

- posterior approach

- arthroscopic glenohumeral approach / posterior capsulotomy

- subacromial approach / between supraspinatous and infraspinatous

 

Results

 

Werner et al Arthroscopy 2007

- posterior capsulotomy above IGHL with decompression of cyst with shaver

 

Posterior Shoulder Capsulotomy to decompress cyst

 

Ghodadra et al Arthroscopy 2009

- subacromial space

- identify spine of scapula

- dissect between infraspinatous and supraspinatous

- accessory posterior portal, retract IS and nerve

- decompress with shaver

 

Shoulder Subacromial Space Spinous ProcessSubacromial Spinous Process 1

 

Suprascapular Notch Impingement

 

Decompression / Division of Suprascapular ligament 

 

Indication

- weakness atrophy of SS and IS without cuff tear

- massive irreparable cuff tear with intractable pain

 

Options

- open

- arthroscopic

 

Results

 

Lafosse et al Arthroscopy 2007

- 10 patients with clinical and EMG evidence of suprascapular nerve compression

- no complications

- good clinical outcome in all patients

 

Open Technique

- incision along spine of scapular

- sharply elevate trapezius off spine off scapula

- SS reflected inferiorly to expose notch

- preserve superior NV bundle

- suprascapular artery lies above ligament, (branch of Subclavian Artery)

- divide ligament

 

Arthroscopic Technique

 

Standard posterior portal

- subacromial portal to debride cuff and identify base of coracoid as landmark

- find coracoid by following CAL to it

- feel hard bony prominence

 

Anterolateral working portal

- need to be able to work lateral to medial along anterior aspect of humeral head

 

Dissection

- clear space medial to coracoid along subscapularis

- identify the conoid ligament attaching to the base of the coronoid

- medial to this is fatty area with THL

 

SSN Release CoracoidSSN Release Coracoid and CHL

 

Suprascapular portal / accessory Nevasier

- 7cm from posterior edge of acromion

- insert blunt instruments posteriorly from suprascapular portal

- pass under clavicle

- elevates supraspinous muscle

- use blunt trochar to dissect area

 

Anatomy

- will usually see the artery passing over the top of the THL 

- be careful as this runs from subclavian

- can get torrential bleeding

 

Conoid Ligament  SSA over THLSuprascapular artery and transverse scapula ligament

 

Identify transverse ligament

- identify SSN passing under

- divide TSL with scissors from posterior ACJ portal

- whilst retracting SS artery with probe from SSN portal

 

SSN release Divided THLSSN Release Divided TSL

Thoracic Outlet Syndrome

Definition

 

Symptoms & signs due to compression of brachial plexus & /or subclavian vessels at root of neck

 

Epidemiology

 

80% 30-50 years 

 

F:M = 2:1 

 

Incidence

 

Uncommon

 

Anatomy

 

Thoracic Outlet forms communication at root of neck 

- for passage of nerves and vessels from mediastinum to axilla 

- vein is anterior to Scalenus Anterior

 

Boundaries

 

Anterior:  Scalaneus Anterior

Posterior: Scalaneus Medius

Floor:      First Rib

Roof:       Prevertebral fascia & clavicle

 

Aetiology

 

Bony / muscular / ligamentous compression of neurovascular bundle at Thoracic Outlet

 

Bony

 

1.  Cervical Rib

- 5 / 1000 

- only 10% of cervical ribs are symptomatic

- 10% of TOS have cervical rib

 

Varies from 

- enlarged TP 

- complete developed with cartilage uniting it to cartilage of 1st thoracic rib 

 

2.  1st Thoracic Rib

-  abnormal curve 

-  increased size or shape

 

3.  Clavicle

-  posterior fracture callus 

-  abnormal shape / malunion

 

Musculo-ligamentous

 

Most important cause

 

1.  Fibrous Band

 

Cervical rib joined to 1st rib by congenital fibrous band 

-  elevates lower part of brachial plexus 

-  makes it more susceptible to scissor compression by clavicle from above 

-  9 variants recognised

 

2.  Scalenus Muscles

 

Abnormal insertion 

Decreased size of cleft between S Anterior & S Medius

 

Other

 

Trauma

- Precipitates condition in 2/3

 

Posture

- shoulder sags with middle age 

- hyperabduction in sleep

- scapular winging secondary to trapezius palsy

 

Occupational

- hyperabduction of shoulders (painters, welders) 

- pressure (backpacks, soldiers)

 

Classification

 

1. Neurogenic

 

Compression of brachial plexus alone 

-  usually lower trunk C8,T1

-  most common 95%

 

2. Vascular

 

Compression of subclavian blood vessels alone 

- usually vein obstruction 

- occasionally arterial insufficiency 

- rare 2%

 

3. Combined

 

Compression of both nerves & vessels 

- rare 3%

 

Symptoms

 

2° compression of Plexus > Vessels

 

Pain

-  intermittent

-  suprascapular area and neck

-  may be whole arm

-  more common medial arm & ulnar forearm 

-  radiates to neck 

 

Worse after activity

- overhead

- carrying heavy weight

 

Paraesthesia

- C8 & T1 (mainly ulnar nerve distribution)

- may be whole arm

 

Weakness

- most noticeable is grip

 

Venous

- duskiness & cyanosis of hand 

 

Arterial

- cold, pale hand & forearm

- Raynaud's 

 

Signs

 

Pain from percussion or constant thumb pressure in supraclavicular region over plexus

 

Listen for bruit / compare arm BP

 

Sensation

-  decreased in C8 / T1 distribution

 

Power

-  decreased especially grip strength

 

1. Elevated Arm Stress Test (EAST)

- shoulder abducted 90° & ER 

- elbows at 90° 

- hands clasped / unclasped for 3min

- positive if symptoms reproduced or arms drop 2° pain & weakness

 

2.  Adson Manoeuvre

- head toward side tested, neck extended

- arm by side

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

3.  Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm abducted and ER

- breath in

- loss of pulse or reproduction of symptoms

- highly sensitive

 

Xray neck / CXR

 

Cervical rib

Clavicle fracture

 

CT 

 

MRI

 

May show fibrous band 

- exclude cord pathology

 

Angiogram

 

Must do with arms abducted and by side

- will show compression of subclavian vein

 

NCS

-  unhelpful as symptoms intermittent 

-  stimulus cannot be placed proximal to site of compression or irritation 

-  exclude CTS / cubital tunnel Syndrome

 

DDx

 

Cervical Disc (C8/T1) / spinal cord lesion

Ulna nerve entrapment

Shoulder pathology

Pancoast tumour

MS

 

Management

 

Non-operative

 

Explanation & reassurance

- shoulder girdle exercises 

- posture improvement 

- analgesia

 

Operative

 

 

Indications

 

10% of patients

- intolerable pain 

- significant loss of function

- significant arterial or venous symptoms

 

Options

 

Resection of cervical rib

Scalenectomy 

Resection first rib

Clavicular osteotomy

 

Complications

 

Chest

- pneumothorax 

- empyema 

 

Nerve injury 

- phrenic nerve 

- T1 

 

Vessel injury 

 

Recurrence of symptoms

 

 

Throwing Athlete

Throwing

 

Wind-up

- cocking

- ER up to 180o in pitcher

 

Acceleration

- large scapular muscles 

- acceleration - 7000o/sec

- rotatory acceleration similar to car tyre at 130 kph

 

Control and deceleration

- fragile cuff & glenohumeral ligament complex 

 

Anatomy

 

Pitchers have increased ER range, but corresponding decreased IR range

- have increased humeral head retroversion

- probably from adaptations of growth plate whilst young

- "little leaguer's shoulder" may be part of this

 

They have a "normal" abnormality

 

Treatment of posterior capsular stretching in athletes is debatable

- limited IR is normal state

 

Problems / Spectrum

 

1.  Subtle anterior instability / Posterior capsular contracture

- internal impingement

 

2.  SLAP

 

3.  Posterior instability

 

4.  RC injuries

 

Internal Impingement Posterior / Superior Glenoid

 

Definition

 

Described by Davidson 1997

- throwing athletes

- impingement in ER and abduction

- classic 90 / 90 position

- posterior aspect of SS impinges on posterosuperior rim of glenoid 

 

Pathology

 

Posterosuperior labrum is damaged

 

Cause

 

Argument whether posterior capsule tightness or anterior instability

- can be either

 

Symptoms

 

Usually posterior shoulder pain

 

Examination

 

Careful comparison of shoulders

- normal to have increased ER / decreased IR

 

EUA

- load and shift examination of instability very important

- need to examine shoulder in 90 / 90 position

- i.e. 90o ER and 90o abduction

- this is the throwing position

- look carefully for anterior instability

 

Diagnosis

 

Xray

 

Bennett's Lesion

 

MRI

- damaged posterosuperior labrum

- partial cuff tears

 

Arthroscopy

- place arthroscope anteriorly

- ER arm in 90o abducted position

- see posterior cuff impinge exactly on damaged area of labrum

 

Management

 

A.  Posterior capsule tight and thickened

- feel / confirm thickening with probe

- careful release at edge of labrum

 

B.  Shoulder unstable anteriorly in EUA

- may see anteroinferior labral injury

- may simple be redundant tissue

- anterior labral injury (careful repair with sutures)

- capsule stretched (advance part of capsule to glenoid rim to tighten)

 

NB Must be very careful

- cannot afford to lose ER in throwing athlete

 

Partial Thickness Tears Cuff

 

Pathology

 

Articular sided

- more posterior than in elderly

- at the SS / IS interval

- consistent with internal impingement

 

Associations

 

SLAP

Posterior capsular contracture

 

Aetiology

 

1.  Repetitive trauma from massive eccentric forces in SS and IS during deceleration in throwing

 

2.  Internal impingement from anterior subluxation / posterior tightness with posterior glenoid impingement and microtrauma

 

Non Operative

 

1.  ROM / posterior capsular stretches

- decrease inflammation

- NSAIDS

2.  Balanced RC exercises

 

Operative

 

Debridement is mainstay

- acromioplasty and repair rarely indicated

- some major league pitchers have full thickness tears

- repair initially may end career

 

Little Leaguer's Shoulder

 

Clinical

 

Present with painful shoulder

 

Xray

 

Physeal widening

 

Pathology

 

Chronic SH 1 growth plate

 

Management

 

Rest

 

 

 

 

Winged Scapula

 

Classification

 

Primary

 

Due to scapulothoracic articulation disorder

 

1.  Neurological Origin

 

A.  Spinal Accessory Nerve / Trapezius palsy

B.  Long Thoracic Nerve /  Serratus Anterior palsy

C.  Dorsal Scapular Nerve / Rhomboids palsy (rare)

 

2.  Osseous Origin

 

Osteochondromas (tangential x-rays, CT useful)

Fracture malunions

 

3.  Soft Tissue Origin

 

Muscular Origin

- traumatic ruptures of Serratus Anterior

- iatrogenic during thoracotomy

 

Secondary

 

Due to GHJ articulation disorders

A.  Erb's palsy

B.  Deltoid fibrosis

C.  Painful conditions i.e. RC tear, fracture, impingement

 

Voluntary

 

Rare

 

Trapezius Winging / Spinal Accessory Nerve

 

Anatomy

 

C3, 4

-  supplies Sternocleidomastoid

-  then runs in posterior triangle of neck to supply Trapezius (Upper 1/2)

 

Aetiology

 

Stab wounds to neck

Operations on posterior triangle (Lymph node biopsy)

Traction injuries

 

History

 

Pain

- will attempt to compensate by using levator scapulae

- can lead to disabling pain and spasm

- pain can also be from secondary effects (impingement / radiculopathy / Brachial plexus traction)

 

Examination

 

Shoulder depressed

- scapula translated lateral 

- inferior angles rotated laterally

 

Trapezius wasting

- unable to shrug shoulders

- weakness with protraction

 

Non operative management

 

Reasonable for a time for traction injury

- physio

- wait 6 - 12 weeks

 

Operative

 

1.  Neurorrhaphy

- direct repair for open laceration

 

2.  Nerve Graft

 

3.  Levator scapulae and Rhomboid transfer

- Eden-Lange procedure

- most common

 

Technique

- L. Scapulae to medial acromion

- R. minor upper 1/3

- R. major middle 1/3

 

4.  Scapulothoracic Fusion

- reasonable pain relief

- poor function

- high complication rate

 

Serratus Anterior winging / Long Thoracic Nerve

 

Anatomy

 

C 5, 6, 7 from Roots

- runs down posterior axillary wall

- deep to fascia

- posterior to midaxillary line

- supplies Serratus Anterior

 

Action

- boxer's muscle

- protracts scapula

 

Origin

- fleshy slips

- upper 8 or 9 ribs

 

Insert

- costal aspect medial margin

 

Aetiology

 

Surgery

- shoulder or neck operations

- 1st rib resection

- mastectomy

 

Carrying loads on shoulder

 

Trauma

 

Repetitive microtrauma - swimming

 

Examination

 

Winging of scapula

- scapula medial

 

Management

 

1.  Nerve Transfer 

- TDN to LTN

 

2.  Stabilisation of scapula / Marmor-Bechtol transfer

- transferring sternocostal head Pectoralis major to inferior corner scapula

- require fascia lata extension

 

 

 

 

 

Osteoarthritis

EpidemiologyShoulder OA

 

Usually 50-60 years old

 

Aetiology

 

1° uncommon

 

2° most common

- AVN

- trauma

- cuff arthropathy (Neer)

- instability

 

Pathology

 

Cuff & biceps intact as rule

- rare to have OA and rotator cuff pathology

 

Inferior osteophytes 

- beard

 

Retroversion of glenoid 

- posterior wear

 

Posterior subluxation not uncommon

 

Shoulder OA Posterior Subluxation

 

Tight anterior capsule & subscapularis

- limitation of ER

 

Post traumatic

- always soft tissue contracture

- limitation of ER

- CH ligament and rotator interval contracted

- malunion of tuberosities leads to impingement and offset of normal cuff action

- non-union results in extensive shortening of cuff

- scarring about axillary nerve

 

Signs

 

Global painful restriction of range of movement 

- due to incongruity of joint surfaces

- crepitus

- limitation of ER

 

DDx Limitation ER

 

Frozen Shoulder

Chronic posterior dislocation

Arthrodesis = Lack of ER

Post septic arthritis

 

X-ray

 

Shoulder OAShoulder OA Xray

 

Typical changes of OA

1. Teardrop osteophytes on inferior head & glenoid

2. Osteochondral loose bodies

 

Shoulder Loose Body

 

DDx

- cuff arthopathy - proximal migration of head & subacromial sclerosis

 

Arthroscopy

 

Shoulder OA GlenoidShoulder OA Debridement

 

Management

 

Non-operative

 

Education & Reassurance

- Analgesia

- NSAID

- Physio

ROM

Strengthening

 

Operative

 

1.  Arthroscopic Debridement

 

Concept

- if patient has acromial spur and acromioclavicular pathology

- may benefit from debridement

- concept of limited goals

 

Technique

 

A.  Glenohumeral joint

- deal with biceps tendon pathology if present (tenotomy / tenodesis)

- synovectomy

 

Shoulder OA Synovitis

 

B.  Subacromial space

- acromioplasty

- CA ligament left intact

- ACJ resection

 

C.  Removal beard osteophyte

- additional option

- may improve ROM

- risk of axillary nerve injury

 

2.  Arthrodesis

 

Indication

- may be considered in young active patient

 

Issues

- good pain relief but limitation movement

- difficult to perform

- rarely done in the modern age

 

3.  Excision Arthroplasty

 

Issue

- good pain relief but main problem is flail arm

 

4.  Arthroplasty

 

Options

- hemiarthroplasty (young patient or insufficient glenoid bone stock)

- TSR

 

 

Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture

 

>65

- third most common fracture after hip and distal radius

 

Anatomy

 

Neck shaft angle

- 130o

 

Head retroverted

- 20o relative to shaft

 

Anatomical neck

- junction of head and metaphysis

 

Surgical neck

- junction of diaphysis and metaphysis

 

Blood supply 

 

Gerber JBJS Am 1990 December

Anatomical cadaver study

 

1.  Anterior humeral circumflex

 

Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis

 

Nearly always disrupted in fractures

 

2.  Posterior Humeral circumflex

 

Small contribution posterior head

- allows head to survive with both tuberosities fractured

 

3.  RC

- supplies blood to tuberosities in fractures

 

Neer Classification 1970

 

Displaced 

-  any fragment > 1cm or > 45o

 

Number of displaced fragments

- 2 part (head/shaft, GT, LT)

- 3 part (head/shaft/GT, head/shaft/LT)

- 4 part (head/shaft/GT/LT)

 

Fracture / dislocation

 

Shoulder Fracture DislocationProximal Humerus Fracture DislocationShoulder Fracture Dislocation AnteriorPosterior Shoulder Fracture Dislocation

 

Head splitting fracture

 

SNOH Head Split CTProximal Humerus Head Split CT

 

Anatomical Neck Fracture

 

Humerus Anatomical Neck Fracture

 

AVN

 

SNOH AVN

 

In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- increases with amount of displacement

 

Rates AVN

 

4 part fracture 30%

 

3 part fracture 15%

 

Hertel Radiographic criteria

 

Hertel et al J Should Elbow Surg 2004

 

2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm

 

97% positive predictive of ischaemia if both factors present

 

Aetiology

 

FOOSH

- mostly elderly patients with osteoporotic

 

Young 

- high energy MVA

 

Deforming Forces

 

2 part fracture

- P. major displaces shaft medially

- head internally rotated by SSC

 

SNOH Fracture Displaced

 

GT fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor

 

Displaced Greater Tuberosity Fracture APDisplaced Greater Tuberosity Fracture LateralShoulder CT Displaced GT Fracture

 

LT fracture

- medially by SSC

 

Lesser Tuberosity FractureLesser Tuberosity Fracture 2

 

X-rays

 

AP / Scapula Lateral / Axillary lateral

 

CT 

 

Indication

- delineate no of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF / in elderly

 

Surgical Neck of Humerus CT 4 Part CoronalSurgical Neck of Humerus CT 4 Part SagittalSNOH CT 3 Parts

 

Associated Injuries

 

Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid

 

Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand

 

Management

 

Non operative 

 

Indications

- undisplaced

- elderly

 

NHx

 

85% are undisplaced and do not require surgery

 

Technique

 

Sling for 2/52 then mobilise

 

Results

 

Koval et al JBJS Am 1997

- 104 patients minimally displaced fracture as per Neer

- < 1cm displacement and <45o

- 90% no pain, 77% good or excellent result

- ROM approximately 90% of the other side

- 10% moderate pain and 10% poor result

- poor function and ROM associated with phyio started > 14 days after injury

- poor function associated with pre-existing cuff problems

 

Olerudet al JSES 2011

- RCT nonop v hemiarthroplasty for displaced 4 part

- 55 patients, average age 77

- 2 year follow up

- significant advantage of hemiarthroplasty

 

Operative Management

 

1.  2 Part Fractures

 

A.  SNOH

 

Indications

- >1 cm or > 45o

 

Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP

 

Options

- percutaneous wires / screws

- intra-osseous sutures

- proximal humeral nail

- locking plate

 

B.  GT 

 

Issues

- > 5mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step

 

Displaced Greater Tuberosity Fracture LateralCT Coronal Greater Tuberosity FractureCT GT Fracture Sagittal

 

Technique

- deltoid splitting approach

- young patient can ORIF with screw

- in elderly insert Mason Allen no 2 suture in cuff and tie over screw

- repair rotator cuff

 

 ORIF Greater Tuberosity Fracture

 

Consequences Nonoperative Treatment

 

SNOH MalunionSNOH Malunion 2

 

C. LT Fractures

 

Soft tissue washer and screw

 

LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF

 

LT ORIFLT ORIF

 

2.  3 & 4 Part fractures

 

A.  ORIF with plate

 

SNOH Plate

 

Indications

- need sufficient bone quality

- always attempt in young

 

Results

 

Moonot et al JBJS Br 2007

- 32 patients with 3 or 4 part treated with Philos plate

- 31 of 32 united

- 27/32 (86%) excellent or satisfatory results

- 5/32 (16%) poor results

- 1 patient AVN and non union

 

Yang et al J Orthop Trauma 2010

- 64 patients treated with proximal humeral plate

- screw penetration into joint most common complication 5/64

- deep wound infection 2/64

- AVN 2/64

- 3 fixation failures requiring revision

- half good and half moderate shoulder scores, few excellent or poor

- all complications in 4 part fractures

- tuberosity malunion associated with poor outcome

 

B.  IM Nail

 

Results

 

Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions

 

C.  Hemiarthroplasty

 

Shoulder Trauma HemiarthroplastyShoulder Trauma Hemiarthroplasty

 

Indications

- unreconstructable

- elderly

- 4 part fractures

- head splitting fractures

- anatomical neck

- head impression > 40% articular surface

 

Proximal Humerus Unreconstructable

 

Problem

- only good ROM if tuberosities heal

 

Timing

- best to do in first three weeks

- whilst GT / LT still easy to mobilise

 

Results

 

ROM often poor

- better if anatomical union tuberosities

- early ROM gives better results (<2/52)

- rarely > 90o

 

SNOH Hemi 1SNOH Hemi 2

 

Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100o

- 16% moderate or severe pain

 

Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty

 

D.  Reverse total shoulder

 

Indication

- elderly patient

- poor cuff

- poor chance of tuberosity healing

 

Problems

- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding

 

Results

 

Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90o v 60o) and abduction (90o v 53o) better in reverse

- rotation better in hemiarthroplasty

 

ORIF Locking Plate

 

SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CT

 

Proximal Humerus 4 Part Head Splitting ORIF APProximal Humeral 4 Part Head Splitting ORIF Lateral

 

Technique

 

Set up

- GA, IV ABx, lazy beach chair

- mark anatomy

- II (patient either in middle of radiolucent table or remove lateral aspect shoulder table) 

 

Deltopectoral approach 

- cephalic usually taken lateral

- take part of pec major off to facilitate exposure

- Hawkins Bell retractor (shoulder charnley retractor) / non pointed double gelpies 

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractor deep to tendon

 

Dangers

- protect MCN under conjoint, minimal retraction

- find and protect the axillary nerve on inferior border of SSC, sweep finger inferiorly

 

Deep dissection

- clear sup deltoid bursa

- must elevate deltoid from head

- place a homan retractor over head to elevate deltoid

 

Identify structures

- remove callous

- reduce head onto shaft

- head is displaced posteriorly

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check for head splitting fractures

 

Find tuberosities

- secure with Mason Allen

- no 5 non absorbable

 

Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check II now to avoid having plate too high

- must not leave head in varus

 

SNOH ORIF

 

Fixation

- to prevent cutout must have head out of varus

- long inferomedial screws / kickstand screws

- similar concepts to NOF (don't want screws high in the head)

 

Closure over drain

 

Rehab

- sling 6/52 with pendulars

- ROM 6/52

 

Complications

 

Non-union

- uncommon

- associated with AVN

 

Malunion

 

SNOH Malunion

 

Cutout

- medial support very important

- must avoid varus malreduction

 

Plate impingement

- need to ensure place plate low on the head

 

Screw perforation of humeral head

- most common complication

 

AVN

- fortunately uncommon

 

Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral

 

SNOH ORIF AVN

 

Vascular Injury

 

Axillary / MCN / Brachial Plexus

 

OA

- from signficant deformity

- TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy

 

Hemiarthroplasty

 

Proximal Humerus 4 Part Fracture In Elderly

 

Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2TSR Post OA

 

 

Technique

 

Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height

 

Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades

 

Deltopectoral approach

 

Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities

 

Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation

 

Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities

 

Need retroversion of 30o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30o

 

Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets

 

Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture

 

Place on head with 12/14 taper

 

Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole

 

Biceps tenodesis

 

Close over drain, rehab as above

 

Complications

 

Malunion / Non union tuberosities

 

Causes

- increased in women

- increased with initial malposition

- excessive height or retroversion of humeral head

 

Incidence

- 4-50%

 

Heterotropic ossification

- 10%

 

Glenoid degeneration

- 8% at 3 years

 

Prosthetic loosening

- 3-6%

 

Nerve injury

- AXN, MCN

 

Infection

- 1-2%

 

Stiffness

- need realistic goals

- aim to achieve function at shoulder height

Rheumatoid Arthritis

EpidemiologyRheumatoid Shoulder

 

Females

 

2/3 involved

- ACJ arthritis

- subacromial bursitis / rotator cuff pathology

- GHJ less commonly

 

Pathology

 

1.  ACJ 

- erosive arthritis

- joint expands with severe involvement

- ACJ capsular destruction / instability / impingement

 

2.  Subacromial Bursa

- becomes inflamed & thickened

- rupture of LH of biceps / cuff rupture

- rotator cuff arthropathy

 

3.  GHJ

- develop marked soft tissue inflammation

- 2° laxity capsule & folds of synovium

- followed by severe cartilage & bone erosion

 

Neer described 3 types RA shoulder

- Wet = Synovitic with soft tissue pathology

- Dry = Articular Surface Erosion

- Resorptive = Severe Bony Erosion

 

History

 

Shoulder pain & swelling with flares of RA

- gradually decreasing ROM

- functional impairment

 

Cuff Tendonosis 

- pain with overhead activity

 

Examination

 

Deformity 

- muscle wasting

- humeral medialisation 2° bone loss in glenoid cavity with humeral protrusion

- effusion with swelling

 

Cuff rupture 

- loss of abduction

 

Biceps rupture / popeye

 

Painful arc

 

Xray

 

Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions

 

Rheumatoid Shoulder Erosions

 

Symmetric Arthritis

 

Protrusio

- medialisation of humeral head

- can erode anteriorly or posterior

- inferior glenoid preserved

 

Rheumatoid Shoulder 2

 

Superior migration due to cuff rupture

 

Arthritis mutilans

 

Arthritis Mutilans RA

 

US / MRI / Arthrogram

 

30% have cuff tear

 

Rheumatoid Shoulder Arthrogram Cuff Tear

 

CT

 

Assess glenoid stock

 

Rheumatoid Shoulder CT

 

Aspiration

 

RA

- 20 000 WBC / ml

- 60-70% neutrophils

 

Sepsis

- > 100 000 WBC / ml

- > 75% neutrophils

 

DDx

 

Septic arthritis

 

Gout

- sodium urate

 

Pseudogout

- calcium pyrophosphate

 

Milwaukee Shoulder

- calcium hydroxyapatite crystals

 

RC arthropathy

 

OA - beard osteophytes

 

Management

 

General

- Medical treatment

- HCLA injections

 

ACJ

 

Excision of outer 1/3 of clavicle

 

Subacromial Bursa

 

SAD

Bursectomy

 

GHJ

 

1.  Arthroscopic Synovectomy 

 

Indications

- mild arthritis / cuff intact

 

Technique

- synovectomy

- via anterior and posterior portals

- removal loose bodies

- biceps tenotomy

- bursectomy / ACJ resection if necessary

- minimal acromioplasty especially if cuff tear as must preserve CA ligament

 

Rheumatoid Shoulder Arthroscopy Rheumatoid Shoulder Post Debridement

 

Rheumatoid Shoulder Arthroscopy 2Rheumatoid Shoulder Arthroscopy 3

 

Cofield et al Arthroscopy 2006

- 16 shoulders followed up for 5 years

- 13/16 good pain relief

- some mild improvement in ROM

- arthritis tended to progress over time

 

2.  Hemiarthroplasty / TSR

 

Indications hemiarthroplasty

- young patient

- glenoid not involved / unusual

 

Indications TSR

- sufficient bone stock glenoid

- glenoid often deficient centrally and superior

- intact RC
 

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR

 

4.  Reverse TSR

 

Indications

- ruptured cuff (30%)

 

Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects

 

5.  Arthrodesis

- indicated for severe bone loss

- problem is actual or potential involvement of other joints

 

6.  Excision arthroplasty

- salvage procedure

Rotator Cuff

Calcific Tendonitis

Definition

 

Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia

 

Supraspinatous CalciumSupaspinatous Large Deposits

 

Aetiology

 

2 groups of patients

 

1.  Degenerate Calcification

 

Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller

 

These patients do not have calcific tendonitis

- older patient group

- different histology

 

2.  Calcific Tendonitis

 

Cause

 

Reactive Hypoxic Calcification Theory

 

Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium

 

Codman proposed cuff hypoxia as the causative factor

 

Classification

 

1.  Pre-Calcific stage

 

Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia

 

2. Calcific Stage

 

A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

- crystals may be in the form of phosphates / carbonates / oxalates / hydroxyapatite

 

B. Resting Stage

- fibrocartilage surrounds deposits

 

C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma

 

3. Post-Calcific Stage

 

Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I

 

Epidemiology

 

Accounts for 10% all consultations for painful shoulder

 

Peak 40 years

- diabetes

- F > M 

 

SS most common tendon

- IS less common

- SSC rare

 

Asymptomatic patients can have cuff calcium on xray

 

Clinical Presentation

 

Usually acute pain

- Resorption Stage

- background of absent to mild chronic pain of the Formative Stage

 

Patients may present to ED

- severe pain

 

DDx infection

 

DDx

 

Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD

IHD

 

X-ray

 

Calcific Tendonitis APCalcific Tendonits Lateral

 

Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size

 

ER AP Xray

- shows SSC

 

Subscapularis CalciumSubscapularis Calcium Lateral

 

IR AP Xray

- shows IS & Tm

 

Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak

 

Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density

 

MRI 

 

Low signal on T1 

Oedema on T2

 

Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2

 

US 

- more sensitive than Xray ~100%

 

Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous

 

Bloods

 

Check serum glucose / uric acid & iron

 

Management

 

Non operative Management

 

Options

 

1.  NSAIDS

- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration

 

Extracorporeal shock wave therapy

 

Extracorporeal Shock Wave Machine

 

Peters Skeletal Radiol 2004

- RCT

- 90 patients

- treatment group complete resolution in 86%, reduction in size in 13.4%

- control group 0 disappeared completely, 9% partial reduction

- significant reduction in pain and improvement in function at 4 weeks

- no adverse affects

 

Effectiveness directly related to energy

- 0.44 mJ/mm3

 

Needle aspiration and irrigation

 

Aim

- drain a substantial portion of the calcium

- stimulate resorption of remainder

 

Indications

- resorption phase (soft, toothpaste material)

 

Contraindications

- small deposits

- formative phase (hard, chalky material)

 

Technique

- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive

 

Complications

- very painful for first 2-3 days

 

Results

 

Aina et al Radiology 2001

- excellent results in 74%

 

Serafini et al Radiology 2009

- non randomised controlled trial

- patients treated better at 1 month / 3 months and 1 year

- no difference long term

 

Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone

 

Operative Management

 

Indications

- severe disabling symptoms > 6 months

- failure of needling / ECSW

 

Issues

 

Acromioplasty

- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement

 

Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

- SAD much longer time to return to non painful shoulder activity

 

Options

 

Open

Arthroscopic and mini open

Arthroscopic

 

Arthroscopic Technique

 

Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit

 

Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon

 

Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness

 

May need to remove entire diseased section and repair

 

Calcific Tendonitis Arthroscopy 1Calcific Tendonitis Arthroscopy 2Calcific Tendonitis Arthroscopy 3Calcific Tendonitis Arthroscopy 4

 

Complications

 

Secondary stiffness

 

Pain

- secondary to calcium deposits

- careful shoulder washout at the end of the case

 

 

Cuff Tear Arthropathy

DefinitionRotator Cuff Arthropathy

 

Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch

 

History

 

Neer

- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases

 

Aetiology

 

Crystal induced arthropathy

- hydroxyapatite-mineral phase in altered capsule, synovium or degenerate articular cartilage

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally

 

Cuff tear theory

- loss of cuff leads to mechanical and nutritional alterations in shoulder

- due to loss of closed joint space and altered range of motion

 

Incidence

 

4% of massive cuff tears go on to arthroplasty

 

Theory

- tears with unbalanced force couplet go on to arthropathy 

- massive tear that are balanced & / or above equator don't go onto to arthropathy

 

Epidemiology

 

Women > men

60% bilateral

 

Symptoms

 

Recurrent swelling

Loss of Motion

Night pain

 

Xray

 

1.  Superior migration of head 

- defined as AHI / acromiohumeral interval of 7mm or less

 

Humeral Head Superior Migration

 

2.  Collapse of proximal head articular surface 

 

3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity

 

4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification

 

Acromial Acetabularisation

 

CT

 

RC Arthropathy CT

 

DDx

 

GH OA 

- no superior migration

- beard osteophytes

 

Management

 

Non-Operative

 

Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia

 

Operative Management

 

1.  Acromioplasty & tendon debridement 

 

Not indicated with superior migration

- can consider biceps tenotomy if still intact

 

2.  Arthrodesis

 

Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid

 

3.  TSR 

 

Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 

 

4.  Hemiarthroplasty

 

Indications

- < 70

- intact CA arch

- anterior deltoid muscle

 

Technique

- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape

 

Results

 

Rockwood

- 18 of 21 satisfactory

- good pain relief

- ROM often not improved

 

Neer 

- concept of limited goals category

- 20° of ER and 90° of forward elevation

 

Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency

 

5.  CTA Humeral Head

 

Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER

 

CTA HemiarthroplastyCTA Head APCTA Head 2

 

6.  Reverse TSR

 

Indications

- > 70

- functioning deltoid

 

Concept

- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder

 

 

 

 

Impingement

Arthroscopic Acromioplasty

Technique

 

Position

- beach chair / lateral

- water pump, adrenaline in bags

- block pre-op useful as easier to control BP

- often inject the SAD with combination of LA with A prior to scope

 

Posterior portal

- 2 cm inferior, 1 cm medial

- soft spot between IS and Tm

 

Enter subacromial space

- sweep to clear adhesion

- saline on pump at 30 - 40 - 50

- keep BP  100 - 110

- can increase pump pressure to 60 - 80 if needed in short bursts

 

Midlateral portal

- spinal needle

- 3cm distal to anterior acromion

- midpoint clavicle

- slightly lower to aim up

 

Bursectomy

- with shaver

 

Arthroscopic Bursectomy

 

Electrocautery / Shaver

- clear periosteum / coracoacomial Ligament off acromion

- avoid deltoid as bleeders

- beware thoroaco-acromial artery in CA ligament medial and inferior to acromion

- spinal needle ACJ to mark medial limits

- need to see anterior and lateral acromion

 

Arthroscopy Type 3 AcromionShoulder Scope Large Acromial Spur

 

Acromioplasty

- 5.5mm burr

- multiple techiques

- 5mm deep resection at midpoint clavicle

- taper anteriorly

- must ensure lateral edge is cleared

 

Arthroscopy Post AcromioplastyArthroscopy Cleared Subacromial Space

 

Residual Lateral Acromial Spur

 

 

 

 

Impingement

DefinitionLateral Acromial Spur

 

Painful impingement of rotator cuff

- on anterior 1/3 of Acromion, CA ligament & ACJ

- causes tendinosis of the RC

 

Anatomy Subacromial Space

 

1.  Roof / CA Arch

- acromion

- CA ligament

- coracoid process

- ACJ is superior & posterior to CA ligament

 

2.  Floor 

- GT & superior aspect head

- rotator cuff

 

Aetiology

 

Controversial

- extrinsic and intrinsic theories

 

1.  Extrinsic / Extra-tendinous / Bursal sided tears

 

CA arch impinges on RC

- true impingement syndrome

- causes tendinosis of the cuff

 

Factors

 

A.  Subtle GH Instability

- relationship poorly understood

- respond poorly to acromioplasty

- alteration in dynamics of shoulder

 

B.  Internal Impingement Posterior / Superior Glenoid

 

Described by Davidson 1997

- throwing athletes

- impinge in abduction & ER

- SS impinges on posterosuperior rim of glenoid 

- normally humeral head translates posterior in glenoid 

- this may be lost with instability or laxity of throwing athlete

- alternatively may be caused by posterior capsular tightness

 

See Miscellaneous/Throwing Athlete

 

C. Degeneration ACJ

 

OA Spurs

 

D.  Acromion Morphology

 

Neer = impingement on anteroinferior acromion 

 

E.  Os Acromiale

- mesoacromion most common

- hypermobile unfused epiphysis

- tilts anteriorly

- 1-15% normal population

- increased incidence with impingement

 

F.  CA Ligament Spurs 

 

Develop calcium in tendon

 

G.  CA Ligament Impingement

- common

- "Snapping shoulder"

- in flexion & IR

- SS & Biceps impinge on it

- Neer recommends division

 

H.  Coracoid Impingement

- less common

- subscapularis impingement between coracoid and LT

- may be exacerbated by anterior instability

- more medial pain with arm flexed, adducted and IR

- find SSC partial tears on arthroscopy

 

Coracoid Impingement Lateral Coracoid

 

2.  Intrinsic / Intra-tendinous / Articular sided tears

 

2° to bursal thickening or intrinsic problem in cuff

- ? Now thought to be most common

 

Factors

 

1. Muscle Fatigue

- overloaded weak muscles

- eccentric tension load

- associated with proximal humeral migration

 

2. Shoulder Overuse

- soft tissue inflammation

- repetitive microtrauma

- athletes / manual labourers

 

3. Degenerative Tendinopathy

- 1° intrinsic degeneration of RC

- ? hypovascularity

- increasing incidence with age

 

Pathology

 

Impingement Zone 

- centered on supraspinatus tendon insertion

- Codman's "Critical Zone" 1cm from insertion

- zone of hypoperfusion

 

Neer's Pathological Classification

 

Stage I

- reversible

- oedema & haemorrhage

- < 25 years

 

Stage II

- irreversible change

- fibrosis & tendinitis

- 25-40 years

 

Subdivided by Gartsman

- Stage IIA = No tear

- Stage IIB = Partial thickness tears

 

Stage III

- > 40 years

- chronic

- partial & full thickness tears

 

Acromial Morphology

 

Bigliani / Assess on Supraspinatous Outlet View / Scapula Lateral

 

Type I:  Flat

- 20% of normal population

 

Type 1 AcromionType 1 Acromion

 

Type II:  Curved

- 40% of normal population

 

Type 2 Acromion

 

Type III:  Hooked

- 40% of normal population

- 80% of RC tears

 

Type 3 AcromionAcromion Type 3Acromial Spur Type 3

 

Cadaver study

- 30% of all cadavers had a full thickness cuff tear

- 75% type III & 25% type II & 3% type I

 

Morphology does change with age

- Spur more common > 50 years

- ? 2° event to cuff process

- most hooks appear to be acquired & lie in CA ligament 

 

Symptoms

 

Painful arc

 

Weakness overhead

 

If < 40 years look for instability

 

Examination

 

Painful Arc

- 70-120°

- > 120° - ACJ OA / terminal phase pain

 

IR

- limitation of IR may suggest posterior capsular tightness

 

Neer Impingement Sign

- stabilize scapula from behind patient

- passively elevate arm in scapula plane

- pain between 70-120°

 

Hawkins Modification

- IR humerus at 90° flex

 

Neer Impingement Test 

- LA in SAD

- abolish pain & test for cuff tear / weakness

 

Always

- anterior apprehension / Jobes relocation (young patient)

- ACJ assessment

- biceps assessment

- NVI

- C spine

 

X-ray

 

AP view (True AP)

- acromio-humeral interval:  Normal 1-1.5 cm, < 0.7cm abnormal

- sclerosis greater tuberosity / acromion

- lateral Acromion spur

- OA ACJ

 

Acromial Spur AP

 

Axillary Lateral

- os acromion

- bone scan to exclude symptomatic hypermobility

 

Os Acomionale Axillary Lateral Xray

 

Supraspinatus Outlet View

- Acromion morphology / calcification Coraco-Acromial Ligament

- scapula lateral variant

- plate on affected shoulder, other turned out of way 

- 10° caudal

 

Scapular Lateral for Acromial Morphology

 

Zanca view

- ACJ

- half voltage / centred on ACJ / 10o cephalad

 

US

 

Diagnose

- dynamic impingement

- bursitis

 

Shoulder Ultrasound Bursitis

 

MRI

 

Sensitive

- assess acromial morphology

- look for tendinosis / tears

 

MRI Type 3 Acromion

 

Management

 

Non Operative

 

HCLA injection 

 

Goals

- decreases pain & inflammation

- diagnostic

 

Alvarez et al Am J Sports Med 2005

- RCT HCLA v LA in RC tendonosis

- no clinical difference between the two groups

 

Cuff Rehabilitation

 

Rockwood 3 Stages of Physio

 

1. Decrease Inflammation / Increase ROM

- rest

- gentle ROM 

- posterior capsular stretches

- scapula & trunk stabilisers

- modify activities

- NSAIDS

 

2. Cuff Stabilisation and Balancing

- strengthen humeral depressors

- work on SSC and IS

- takes load off SS

- theraband / IR / ER exercises

- avoid abduction drills

 

3. Deltoid strengthening

- task specific exercises

 

Operative Management

 

Acromioplasty

 

Theory

 

Believe primary problem is extrinsic impingement

- abnormal acromial morphology on outlet view

- spurs in CA ligament

 

Results

 

Ketola et al JBJS Br 2009

- RCT of patients with impingement

- treated with exercise program or acromioplasty + exercise program

- no difference between the two groups

 

Henkus et al JBJS Br 2009

- RCT of bursectomy alone v bursectomy + acromioplasty

- no difference between the two groups

 

Open v Arthroscopic Acromioplasty

 

Results

 

Sachhs JBJS 1997

- open v arthroscopic

- open longer return to work & in hospital stay

- results similar

 

Davis et al Am J Sports Med 2010

- meta-analysis of open v arthroscopic acromioplasty

- no significant difference in outcome

- longer return to work and inpatient stays

Open Acromioplasty

Described by Neer / modified by Rockwood

 

Two Step Acromioplasty

 

1.  Anterior acromioplasty

- resect anterior acromion back to ACJ

- prevent impingement in flexion

 

2.  Resect anteroinferior acromion 

 

Technique

 

Position

- beach chair 

- mark anatomy

- limb draped free

 

Incision 

- along anterolateral border acromion

- curve into anterolateral incision

 

Superficial Dissection 

- expose deltoid to ACJ

- find fibrous raphe at anterolateral corner acromion 

- marks anterior & middle parts of deltoid

- split raphe 3cm, ensure protect underlying cuff

- bursa is now exposed, separate subdeltoid space

 

Deep Dissection

- detach deltoid from anterior acromion to ACJ 

- release CA ligament 

- place retractor under acromion to protect cuff

- tablespoon, Langerhan's retractor turned on side

 

2 stage acromion resection with microsagittal saw

- anterior acromion level with ACJ

- antero-inferior acromion

- ensure surface smooth

 

Resect distal 2cm clavicle if OA

- < 4% of patients

- only if pain referable to ACJ 

- confirmed by LA preoperatively

 

Bursectomy

- inspect cuff & repair defects

- abduct & rotate humerus

- biceps tenodesis if > 50% torn

 

Closure

- ? repair CA ligament

- reattach Deltoid No. 2 ethibond intraosseous sutures

 

Post Op

- rendulum exercises & passive flex

- sling for comfort

- no active abduction for 6/52 to protect deltoid

 

 

 

RC Tears

Arthoscopic Supraspinatous Repair

 

Large Supraspinatous TearSS tear arthroscopy GHJSS tear arthroscopy

 

Advantages

 

Improved cosmesis

Shorter hospital stay / less immediate post operative pain

Deltoid not detached

Ability to evaluate and treat coexisting intra-articular pathology i.e. biceps

 

Disadvantage

 

No quicker to rehab or return to activities 

- limiting factor is healing of tendon to bone

- healing rates not as high especially for large to massive tears

- steep learning curve / longer surgery

 

Issues

 

1.  Footprint

- 25 x 15 mm

- healing zone

- the greater the extent a repair covers, the greater the chance for tendon bone healing

 

2.  Suture technique

 

Note:  Most common means of failure is suture cutout

 

A.  Open transosseous

 

Technique

- performed in open surgery

- captures a wide section of cuff footpring

- very secure repair with uniform compression between cuff and bone

 

B.  Single row repair

 

Technique

- anchors placed in line laterally at insertion

 

C.  Double row repair

 

Technique

- medial anchor row at articular margin

- lateral anchor row at lateral footprint

 

Kim et al Am J Sports Med 2006

- biomechanical study

- more successful at restoring footprint

- less gap formation

- increased load to failure

 

D.  Transosseous equivalent / suture bridge

 

Technique

- biomechanically replicate tradional open transosseous

- sutures crossed as below in double row

- aiming to increase contact between cuff and footprint

 

Arthroscopic Suture Bridge Cuff Repair

 

Siskoksy et al AAOS 2007

- biomechanical study suture bridge v double row

- bridge higher load to failure

- no difference in gap formation

 

Results 

 

Outcome arthroscopic

 

Lafosse et al AA Should Elbow Surgeons 2006

- 105 patients treated with double row

- 11.45 structural failure on CT / MRI

 

Sugaya et al JBJS Am 2007

- prospective study 106 FT

- arthroscopic double row

- MRI follow up

- 17% retear

- 5 % small to medium

- 40% large and massive

 

Arthrocopy v mini-open

 

Kim et al Arthroscopy 2003

- arthroscopy v mini open

- similar outcomes in each group

- poor outcome related to size of tear, not method of repair

 

Verma et al Arthroscopy 2006

- arthroscopy v mini open

- US review

- 24% retear mini-open

- 25% retear arthroscopic

- no difference in outcome

 

Bishop et al AAOS 2004

- mini open v arthroscopic

- MRI review

- tears < 3 cm: 26% retear mini open, 16% arthroscopic

- tears > 3m: 38% v 76%

- do larger tears do better with open surgery?

 

Morse et al Am J Sports Med 2008

- meta-analysis of arthroscopic v open

- no difference in outcome or complications

 

Single v Double Row

 

Francheschi et al Am J Sports Med 2007

- RCT single v double row

- 60 patient

- no difference functional outcome

- improved cuff appearance on MRI

 

Burks et al Am J Sports Med 2009

- RCT single row v double row

- 20 in each group

- 1 retear in each group

- no difference in MRI appearance or clinical outcome

 

Cost

 

Churchill et al J Should Elbow Surg

- arthroscopic took average 10 minutes longer / cost $1000 dollars more

- even at high volume centres

 

Arthroscopic Supraspinatous Repair

 

Technique

 

Position

- lateral decubitus with arm traction 10 lb or

- beachchair in Tmax / Spyder (can depress arm and ER to aid visualisation)

- water pump

- useful to have adrenalin in bags

- stable BP 110 (interscalene block can help)

- inject LA with A into subacromial space and prospective portals

 

Portals

 

Posterior Portal

- make more superior and lateral

- awkward for GHJ arthroscopy

- good visualisation in subacromial space

- will put camera over and high above tear

 

Lateral portal

- standard position

- insert large 8 mm cannula (will need to pass sutures)

- perform bursectomy +++ for visulisation

- bursa posteriorly and medially often bleeds

- perform SAD

- control bleeding with electrocautery and temporary increases in pump pressure

 

Anterior portal

- smaller 6 mm

- for suture shuttling

 

Preparation

 

Prepare insertion

- debride tendon edges

- debride footprint to punctate bleeding

 

Arthroscopic Cuff TearArthroscopic Cuff Prepare InsertionArthroscopic Cuff Prepared Footprint

 

Assess tendon mobilisation / tear geometry

- perform releases if needed

- as per open surgery

- above and below tendon 1 cm medial to glenoid

- release coracohumeral ligament

 

Repair

 

Large U shaped tendon

- insert margin convergence sutures

- put camera in lateral portal

- insert posterior cannula over switching stick

- anterior and posterior bird beaks

 

Arthroscopic Cuff Repair Margin Convergance 1Arthroscopic Cuff Repair Margin Convergance 2

 

Place medial row anchors

- anterior first

- insert 18 G spinal needle and ensure good angle

- just medial to articular cartilage

- stab incision

- insert 5 mm anchor

 

RCR arthroscopic Spinal NeedleRCR Arthroscopic TapRCR Arthroscopic AnchorRCR Arthroscopic Anchor 2

 

Pass sutures in lateral margin cuff

- camera posterior

- elite / scorpion / concept suture passer via lateral portal

- pass sutures through cuff anterior to posterior

- retrieve sutures through anterior portal

- retrieve via anterior portal

 

Suture PassageSuture Retrieval

 

Repeat with posterior anchors

 

Large Cuff Repair 1Large Cuff Repair 2Large Cuff Repair 3

 

Tie sutures

- posterior to anterior / anterior to posterior

 

Double row

- either pass second lateral row of anchors or

- use foot print anchors, retrieve previous sutures

- can make suture bridge configuration

- check repair via lateral portal

 

Arthroscopic Supraspinatous RepairArthroscopic Cuff Suture Bridge RepairArthrscopic Cuff Repair

 

 

Background

Definition

 

Full thickness tear (FTT)

- variable amount retraction from insertion

 

Rotator Cuff Tear Large

 

Partial thickness tear (PTT)

- incomplete

- bursal or articular sided

 

Articular sided tearBursal Tear

 

Epidemiology

 

Older patients

- average age 60

- uncommon < 40

- cadavers  30%

 

Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years

 

Anatomy

 

Blood Supply

 

Proximal from muscle belly

- suprascapular artery

- subscapular artery

 

Distal from bone

- branch of anterior circumflex humeral

 

Vessels more abundant on bursal side than articular side

 

NHx

 

1.  Healing

- full thickness tears don't heal because of presence of synovial fluid

 

2.  Progression

- tears do not necessarily extend

 

3.  OA

- 5% FTT go on to cuff arthropathy if untreated

 

Pathogenesis

 

Chronic Tears

- 95% 

- abnormal tendon

 

Acute tears

- trauma 

- 5% 

- normal tendon

 

Pathology

 

No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia

 

Involvement

- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn

 

Classification

 

1.  Size 

 

Cofield

- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm

 

2.  Extent

 

Partial Thickness

 

Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium

 

A.  Intra-tendinous

- in tendon

- no communication with bursa / joint

 

Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis

 

B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly

 

Supraspinatous articular sided tear

 

C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement

 

Full Thickness

 

One tendon 

- supraspinatus only

 

Multiple Tendons 

- more likely OA if multiple tendons involved

 

3.  Topography

 

Sagittal Plane

 

Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons

 

Coronal Plane

 

A. Minimal retraction

- close to insertion

 

Supraspinatous Tear Minimal Retraction

 

B. Moderate retraction

- humeral head

 

Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2

 

C.  Significant retraction

- at glenoid

 

Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1

 

History

 

Pain

 

Weakness

- 2° to tear

- can be limited by pain

- can use LA to differentiate

 

History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon

 

Chronic Tear 95%

-  long history impingement

-  no history of injury

 

Examination

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Wasting

- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears

 

Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear

 

Supraspinatus

 

1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate

 

2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o

 

3.  Shoulder hiking

- usually means massive cuff tear

 

Shoulder Hiking

 

Infraspinatus

 

1.  Resisted ER

 

2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags

 

3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor

 

Involvement of IS can often indicate a large or massive tear

 

Subscapularis

 

1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test

 

2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly

 

3. Increased ER compared with other arm

 

Subscapularis tear increased ER

 

HCLA

 

Improves pain and allows physio

 

Diagnostic

- ensures pain from shoulder pathology

 

Xray

 

Views as for impingement

- assess acromion / GHJ OA / high riding head

 

Ultrasound

 

Advantages

- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery

 

Disadvantage

- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)

 

Evidence

 

O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable

 

Normal

 

Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal

 

Tears

 

Shoulder Ultrasound Supraspinatous Tear

 

Arthrogram

 

Arthrogram Intact RC

 

MRI

 

Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 

 

Shoulder MRI Supraspinatous Fatty Infiltration

 

Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space

 

For more MRI see

- massive tears

- partial thickness tears

- full thickness tear

 

Arthroscopy

 

Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space

 

Management Guidelines

 

1. Repair all acute full thickness tears

 

2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain

 

3. Observe chronic tears with no disability

- especially in elderly

 

Non-operative Management

 

As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears

 

 

 

Full Thickness Tears

Surgical Options

 

1.  Open antero-lateral approach 

 

Large / Massive Cuff Tear

 

2.  Deltopectoral approach

 

Large Subscapularis tear

 

3.  Arthroscopic Assisted Mini-open

 

Indication

- Small / Moderate Cuff Tear < 3cm

- no retraction

 

Technique

- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split

 

Advantage

- avoids deltoid detachment from acromion

- small scar

- still have to immobilise shoulder for 6/52 to protect cuff tear

 

4.  Arthroscopic repair

 

SAD

 

Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not

 

Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs

 

Biceps / SLAP

 

Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group

 

Morphology

 

4 types of cuff tears

 

1.  Cresent shaped

- simple lateral repair

 

Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped

 

2.  U shaped

- larger

- need margin convergence, then lateral repair

 

Supraspinatous Tear U shaped

 

3.  L shaped

 

Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly

 

4.  Massive

 

Rotator cuff retracted to glenoid

 

1.  Open Rotator Cuff Repair

 

Indications

- large to massive tear

 

Concept

- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures

 

Advantage

- reliable

- good results in terms of tendon healing and outcome

 

Disadvantage

- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

- miss any intra-articular pathology if don't perform arthroscopy

- ? management of biceps

 

Technique

 

Position

- lazy beachchair

 

Incision

- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid

 

Approach

- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

- must not extend incision > 5 cm from acromion or risk damaging anterior AXN

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery

 

Acromioplasty

- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure

 

Bursectomy

 

Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint

 

Techiques to mobiise retracted SS tendon

 

1.  Release CHL (runs from coracoid to free edge SS / into rotator interval)

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

4.  Release above glenoid 1.5cm (beware suprascapular nerve)

5.  Interval slide - divide between SS and IS posteriorly, rotator interval anteriorly

6.  Medialise insertion - take away some of articular cartilage

7.  Repair SSC and IS for restoration of force couplet (if SS irrepairable)

 

Repair Options

 

1.  Direct suture of tendon

- margin convergence

 

2.  Suture of tendon to bone

 

A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across

 

Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral

 

B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors

 

C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)

 

3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head

 

Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow

 

Closure

- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery

 

Large - Massive Tear 

 

Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above

 

Post op

 

Must protect deltoid repair

- passive ROM 6/52, hand and elbow exercises, sling

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12

 

Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM

 

2.  Arthroscopic SAD + Mini open Rotator Cuff Repair

 

Concept

- perform subacromial decompression with arthroscope

- no need to detach deltoid

- made 2 - 5 cm deltoid split directly over tear and repair

 

Indication

- moderate size tear up to 3 cm

 

Technique

- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above

 

Results

 

Open v Mini-open

 

Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years

 

Tear integrity

 

Papadopolous et al J Should Elbow Surg 2011

- ultrasound evaluation of tears at 3 years in 37 mini-open patients

- 48% intact in patients who tended to have smaller original tears and be 15 years younger

- most patients had satisfactory outcome

 

Complications

 

Rerupture

- up to 50%

- increased in older patients with larger tears

 

Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head

 

Shoulder High RIding Humersu

 

Infection

 

Pain

- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)

 

Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture

 

Stiffness

 

Deltoid avulsion

 

Axillary nerve injury

 

Acromial fracture

 

RC Tear / Anchor Pullout

 

Rotator Cuff Anchor Pull Out

 

Massive Tears

DefinitionsMassive RC Tear High Riding Humeral Head MRI

 

Massive tear 

 

1.  > 5cm 

- retracted to humerus / glenoid margin

 

2.  At least 2 complete tendons

- lose SS / IS or SS / SC

 

Classification

 

Antero-Superior

- SS + SSC

 

Postero-Superior defects

- SS + IS
- more common

 

Pathogenesis

 

Cuff works to compress / depress head in glenoid while deltoid acts as prime mover

- ff still have intact force couple often good function

 

Plan is to reproduce force couple 

- if tear is below equator of head 

- get uncoupling of cuff force couple

- lose cuff depressor effect & acts as head elevator

 

Integrity of coracoacromial arch integral component of repair

- acts as check rein to proximal migration 

 

Presentation

 

Massive SS / IS wasting + rupture LHB

- weakness

- reduced active ROM

- atrophy

 

Shoulder Hiking due to massive cuff tearSupraspinatous and Infraspinatous wasting

 

2 classic signs

 

1.  ER lag sign

 

2.  Hornblowers

- 100% sensitive, 93% specific

 

Both indicate infraspinatous is torn which is usually a sign of a massive PS tear

 

DDx

 

Suprascapular nerve palsy

Brachial plexus injury

Cervical stenosis

 

X-ray

 

Reduced acromiohumeral space

- < 7 mm RC tear

- < 5 mm massive tear

 

Rotator cuff OA

- acetabularisation

 

Decreased Acromioclavicular DistanceShoulder Massive Rotator Cuff Tear CTMassive Rotator Cuff Tear

 

MRI

 

1.  Level of retraction

- past coracoid irreparable

 

MRI Supraspinatous Retracted to Glenoid Margin

 

2.  Quantify fatty infiltration Goutallier

 

Parasagittal MRI T1

- atrophy and fatty replacement in SS / IS fossa

 

0 - no fat

1 - minimal fat

2 - more muscle than fat

 

Supraspinatous fatty infiltration grade 2

 

3 - fat equal muscle

 

MRI Fatty Infiltration Supraspinatous Infraspinatous

 

4 - more fat than muscle

 

Grade 4 Fatty Atrophy

 

3 & 4 have poor prognosis

- poor functional improvement with repair

- high incidence of retear

 

3.  Atrophy

 

Also poor prognosis

 

MRI Supraspinatous Atrophy

 

Management

 

Non Operative

 

Physio /  HCLA

- improvement in 50-85%

 

Operative

 

Options

 

A.  Primary repair / Debridement

1.  Mobilisation and repair

2.  Partial repair

3.  Decompression and debride

4.  Suprascapular nerve release

 

B.  Salvage

1.  Local tendon transfer - SSC

2.  Distant tendon transfer - P. major / Lat dorsi

3.  Allograft

4.  Synthetic Graft

5.  Arthroplasty

 

Repair / Debridement

 

1.  Rotator Cuff Mobilisation and repair

 

Technique of mobilisation

- release coracohumeral ligament

- anterior slide (between SS and SSC)

- posterior slide (between SS and IS)

- release above glenoid 1 cm

- medialise insertion

- transosseous repair

 

Results

 

Bigliani et al J Should Elbow Surg 1992

- 61 patients massive cuff tears followed up 7 years

- open repair

- 50% excellent and 30% good

 

2.  Partial repair

 

Theory

- restore balanced force couplet

- SSC + partial SS / IS repair

- act in conjuction to depress humeral head

- allow deltoid to work

 

Massive Cuff TearMassive Cuff Tear Partial Repair 1Massive Cuff Tear Partial Repair 2

 

Massive Cuff Repair Partial Repair 3Massive Cuff Tear Partial Repair 4Massive Cuff Tear Partial Repair 5

 

Results

 

Rhee et al Am J Sports Med 2008

- partial repair with interposition of biceps tendon to bridge gap

- MRI of 14 / 16 cases done arthroscopically

- complete healing in 60%

 

3. Decompress & debride alone

 

Concept

- doesn't restore power

- aiming for pain relief in elderly population

 

Technique

- maintain Coracoacromial arch to prevent humeral head escape

- don't perfrom SAD to preserve CA ligament

- debride cuff edges

- debride GT / tuberoplasty to decrease impingement

- biceps tenotomy / tenodesis

 

Results

 

Boileau et al JBJS Am 2007

- demonstrated good results with tenotomy or tenodesis

- 61 patients with irreparable tears

 

Liem et al Arthroscopy 2008

- 31 patients average age 70

- debridement cuff edges + biceps tenotomy

- no SAD

- reasonable results

 

Walch et al Arthroscopy 2005

- arthroscopic tenotomy in 307 irreparable RC tears

- 87% satisfied with results

 

4.  Suprascapular nerve release

 

Theory

- retraction of cuff tethers / impinges SSN

- release of nerve arthroscopically relieves pain

 

Technique

- arthroscopic release

- see miscellaneous/suprascapular nerve for technique

 

Salvage

 

Indications for tendon transfer / Graft

 

Young patient with poor function

- failed primary repair

- significant weakness

- good deltoid function

- CA arch intact / no superior escape

- good ROM

- either posterosuperior or anterosuperior defect

 

1.  Subscapularis Transfer

 

Disadvantage

- may lose humeral depressor effect

- lose abduction with deltoid

 

Technique

- release upper 1/3 tendon from capsule

 

Results

 

Karas et al JBJS Am 1996

- 20 patients

- good results in 17

 

2.  P.  Major Transfer

 

Indication

- functional deficit from SSC tear

 

Technique

- deltopectoral approach

- use sternal head rerouted under clavicular head for better line of pull

 

Results

 

Jost et al JBJS Am 2003

- reasonable results in isolated SSC

- less so with combined SS and SSC (doesn't recommend)

 

3.  Lat Dorsii Transfer

 

Indications

- IS / SS tear

 

Technique

 

Lateral Decubitus position

- arm over mayo table

 

Standard deltoid splitting open approach to subacromial space

- acromioplasty - minimal, preserve CA arch

- ACJ excision if needed

- tag cuff edges medially with sutures to augment repair

- place lateral anchors / sutures

 

L shaped incision

- inferior margin deltoid, lateral aspect of latissimus dorsi

- arm forward flexed to 90 degrees and IR

- infraspinatous usually very wasted

- identify T major

- find L dorsi below T major, develop interval between the two

- identify tendon insertion on humerus, often have to release T major tendon from it

- place homan over humeral head

- release tendon from insertion / keep long

- is usually thin / 3 cm wide / 5 cm long

- suture each margin with strong suture, leave limbs long to pass tendon

- release muscle belly for length / above and below / must identify and preserve pedicle

- tunnel tendon under deltoid & acromion

- suture anchors repair to GT + subscapularis + medial cuff remnant

- repair with arm in abduction and ER

- maintain in abduction and external rotation splint for 6/52

 

LDTT exposureLDTT intervalLDTT find tendon

 

LDTT homanLDTT tendonLDTT tendon suture

 

LDTT ReleaseLDTT humeral headLDTT repair

 

Pre op Lat Dorsi TransferPost Op Lat Dorsi TransferLat Dorsi Transfer Lateral

 

Results

 

Miniacci JBJS Am 1999

- 14 / 17 good results regarding pain relief and ROM

 

Tauber et al JBJS Am 2010

- compared patients with tendon transfer to those with tendon + bone block

- significantly improved results in bone block

- 4/22 reruptured on MRI in tendon v 0/20 in bone block group

 

4.  Allograft

 

Results

 

Moore et al Am J Sports Med 2006

- 28 patients average age 59

- patella tendon or achilles

- sewn to tendon medially

- bone block laterally or sutured

- 15 repeat MRI - all complete failure of graft

- 1 infection and 1 allograft rejection

- similar functional results to debridement alone

- not recommended by authors

 

5.  Synthetic Allograft

 

Results

 

Nada et al JBJS Br 2010

- dacron graft for massive cuff tears in 17 patients

- sutured medially, tied through bony tunnels laterally

- 90% satisfaction

- 15/17 intact on MRI

- 1 rupture, 1 deep infection

 

6. Arthroplasty

 

CTA Hemiarthroplasty / Reverse TSR

- salvage in patients > 65 years

 

Partial Thickness Tears

Clinical

 

Pain & Stiffness

- often more pain than FT tears

 

Bursal side tears more painful than articular

 

Articular side more common

 

May see in young patient overhead throwing

 

Examination

 

Painful arc

 

Impingement signs

 

No weakness

- function good

- cable system intact

 

Classification

 

Articular sided more common than bursal

 

Ellman

- A (articular)

- B (Bursal)

 

Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed

 

Incidence

 

Sher et al JBJS Am 1995

- 19 - 39 years - 4% PT , no FT

- > 60 years - 26% PT, 28% FT

 

NHx

 

Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT

 

MRI

 

Articular Sided

 

Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear

 

Bursal Sided

 

Arthroscopy

 

Articular side

 

Minor

 

Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear

 

Major

- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage

 

PASAT Arthroscopy 1PASTA Arthroscopy 2

 

Bursal Sided

 

Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear

 

Management

 

Non Operative

 

Physio / HCLA

 

Operative

 

Indications

 

1.  Failure of non operative treatment (6-12 months)

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth

 

Options

 

1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT

 

1.  Acromioplasty + debridement

 

Indications

- < 50% tears

 

Shoulder Scope PASTA Debridement

 

Results

 

Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years

 

Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair

 

Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT

 

Conclusions

- bursal sided tears tend to do more poorly than articular sided

- repair > 50% especially in young patients

 

2.  Acromioplasty and repair

 

May be done open / arthroscopically / arthroscopically + mini open

 

Options

A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open

 

A.  Convert to FT and repair

 

Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction

 

B.  Articular sided / transtendinous PASTA repair

 

Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation

 

Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair

 

C.  Bursal sided

- can repair top layer of tear only

 

Technique Transtendinous Arthroscopic PASTA Repair 

 

Advantage

- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness

 

Technique

 

Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal

 

Shoulder Partial Articular Supraspinatous Tear PASTA

 

Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint

 

A.  Pass bird beak suture passers through cuff to retrieve sutures

 

B.  Pass 20G spinal needle and pass down 0 nylon, retrieve via anterior portal

- tie to thread, and pass suture back through tendon

- do so each time for each thread in horizontal mattress pattern

 

Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled

 

Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ

 

Shoulder PASTA Repair Sutures in Subacromial SpaceShoulder PASTA Repair Knots Tied Subacromial Space

 

Post op

- can range aggressively

- the repair is protected by the intact portion of the tendon

- prevents stiffness

 

Technique Open Articular PT Tears

 

Arthroscopy

- put spinal needle through torn portion

- pass suture through to mark tendon

 

Open approach over needle entry

- identify tear by suture

- convert to FT and repair

 

Technique Arthroscopic Bursal Sided Tear

 

Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion

 

Insert anchor

- pass sutures through top layer of torn tendon

- tie down

 

Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair

Revision Cuff Tears

Incidence

 

Variable

- may be up to 50% retear over time

- many asymptomatic

 

MRI

 

Shoulder MRI Failed Rotator Cuff RepairShoulder MRI Failed RC Repair 2

 

Options

 

1.  Debride / Biceps tenotomy or tenodesis

 

2.  Revision cuff repair

- open

- arthroscopic

 

Revision Rotator Cuff 1Revision Rotator Cuff Repair 2

 

3.  Tendon transfer

 

 

 

 

 

 

Subscapularis Arthroscopic Repair

Technique

- extra-articular

 

Portals

- posterior portal very lateral so can see anterior aspect subacromial space

- port of Wilminton at anterolateral acromion to access SSC

- anterior portal in normal position, slightly more lateral so becomes working portal

 

SSC Repair Portals 1SSC Repair Portals 2

 

GHJ

- identify tendon

- work through portal Wilmington

- grasp, forms comma sign

- perform biceps tenodesis

- tag SSC with fibrewire

 

SSC tornSSC comma sign

 

Subacromial space

- place standard lateral portal as well

- total bursectomy plus acromioplasty

- use tagging sutures to identify SSC

- release as necessary

- may need long posterior cannula to see anteriorly

- may need to move camera to lateral portal to see around corner anteriorly

- can use 70 degree scope

 

SSC Tagging Suture Subacromial SpaceSSC Debridement Anterior Subacromial

 

Prepare footprint

- debride

- insert anchors (retract port of Wilminton into subacromial space)

- pass sutures with suture passer

- tie

 

SSC Debride FootprintSSC First AnchorSSC Suture Passage

 

SSC Second AnchorSSC Repair

 

 

 

 

Subscapularis Tears

AnatomySSC Longitudinal Tear

 

Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus

 

Action

- IR (with T major, P major, Lat Dorsi)

- part of force couplet depressing humeral head

 

Incidence

 

Can be isolated event

 

More commonly seen with SS tears (2% in MRI study)

- anterosuperior tears

 

Associations

- HAGL

- biceps subluxation

- coracoid impingement

 

MOI

 

Trauma

- hyperextension and ER

 

Degenerative

 

Examination

 

Pain anterior shoulder

 

Increased ER

 

Lift off test

 

Belly Press

- elbow falls posteriorly to harvest post deltoid

 

MRI

 

Subscapularis Tear MRISubscapularis FT Tear MRI Glenoid RetractionMRI Retracted Subscapularis TearMRI SSC tear minimal retraction

 

Arthroscopy

 

Complete absence of SSC

 

Subscapularis Retracted Tear Arthroscopy

 

Comma Sign

 

SSC tornSSC Comma Sign

 

Medially Subluxed Biceps

 

Medially Subluxed Biceps

 

Management

 

Operative Indications

 

Degenerative

- failure of 6/12 non operative

 

Trauma

- fix acutely

 

Options

1.  Debridement

2.  Open Repair

3.  Arthroscopic Repair

 

Debridement

 

Results

 

Edwards et al Arthroscopy 2006

- 11 patients with SSC tears

- debridement

- tenotomy in 9 with dislocating / unstable biceps

- 9/11 good results

 

Open Repair

 

Technique

 

Deltopectoral approach

- preserve axillary nerve inferiorly

- mobilise SSC

- subscapular nerves on anterior surface medial to glenoid rim

- tenodesis LHB

- suture anchor repair to lesser tuberosity

 

Results

 

Barti et al Am J Sports Med 2010

- 30 traumatic tears, patient average age 43

- associated biceps subluxation and HAGL's seen

- repair structurally intact in 93%

- 20% still unable to perform lift off / belly press tests

- these patients had higher degree of fatty infiltration preoperatively

 

Arthroscopic Repair

 

Intra-articular technique

- camera in GHJ

- anterosuperior portal

- mobilise tendon front and back

- must remove adhesions

- roughen insertion point on LT / gentle with burr as bone is soft

- insert twinfix anchors x 2 via stab incision

- pass birdsbeak suture passer through portal and through SSC

- retrieve 3 sutures through tendon

- retrieve 4th suture over top of SSC

 

Extra-articular Technique

- see article

 

Results

 

Lafosse et al JBJS Am 2007

- isolated repair in 17 patients

- 15 intact repairs and 2 partial reruptures on CT arthrogram

- good outcomes

 

Late reconstruction

 

P. major transfer

 

Results

 

Jost et al JBJS Am 2003

- good results in isolated SSC tears

- results poor in shoulder arthroplasty

 

Sternoclavicular Dislocations

EpidemiologySCJ Anterior DIslocation

 

Extremely uncommon

Stability provided by joint capsule /costoclavicular & interclavicular ligaments 

 

Recurrent instability uncommon

 

Many apparent dislocations in adolescents may be growth plate injuries 

-will remodel without treatment

 

If OA from chronic dislocation may resect SCJ

 

Types

 

Anterior & posterior 

 

Posterior

- more serious injury

- least common

 

Diagnosis 

- difficult on physical examination

- radiographs often are non diagnostic

- most consistent diagnostic modality = CT

 

Anterior 

 

SCJ CT Anterior DislocationSternoclavicular Anterior Dislocation

 

Usually managed non-operatively

- with activity modification and reassurance

 

MUA 

- often will redislocate

 

Open reduction

- need to stabilise

- can use strip PL to stabilise

- uncertain if any benefit 

 

Posterior 

 

CT Posterior SCJ Dislocation

 

May require treatment because of proximity of major neurovascular structures and airway 

 

1.  Closed reduction

- performed under GA in operating room 

- chest surgeon available

- potential vascular / airway catastrophe associated with injuries to the mediastinum

- thorough vascular exam pre-operatively

 

2.  Assess stability

 

Successful closed reduction usually stable

- avoid internal fixation because of likelihood of hardware migration

- possible injury to the mediastinal structures

 

Closed reduction unsuccessful

- open reduction is indicated

- can stabilize with PL graft / intra-osseous sutures

 

SCJ Open ReductionSCJ Reduction 2SCJ Suture Fixation