Shoulder

Question 1

contraindications to TSA?

Answer 1

<div>irreparable cuff</div>

RC arthropathy<div>poor glenoid bone stock</div><div>deltoid dysfunction</div><div>brachial plexus palsy</div><div>active infection</div>

Question 2

Appropriate Balancing for TSA?

Answer 2

40-50-60<div>40deg ER in Adduction (with reducible subscap)<div>50% posterior sublux</div><div>60 deg IR in Abduction</div></div>

Question 3

Correct humeral height for a hemi for PHF

Answer 3

Pect major is 5.6cm distal to top of HH and 4.2cm distal to GT<div>GT should reduce tension-free</div><div>HTD (head to tuberosity) should be 10mm</div><div>intra-op fluoro/contralateral side</div>

Question 4

landmarks for hemi positioning for PHF

Answer 4

Height: sup border of pect 5.2cm<div>Version: 20 deg retro</div><div>tuberosities: anatomic, tension free, 5-10mm below top of HH</div>

Question 5

Shoulder X-rays and their uses?

Answer 5

“<div>Garth view: HS and Bankart</div><div>West-point axillary: Glenoid/Bankart</div><div>Stryker notch: HS</div><div><img></img><br></br></div><div><div><br></br></div><div><br></br></div></div>”

Question 6

RFs for recurrent instability post arthroscopic capsulolabral repair?

Answer 6

Patient Factors<div>- <b>Age < 28years</b></div><div><b>- </b>Age at surgery<20</div><div>- immobilization < 4 weeks</div><div>- Ligamentous laxity</div><div>- Contact/overhead/competitive sports</div><div><br></br></div><div>Anatomic Factors</div><div>-H-S > 250mm3</div><div>- HS visible on ER A/P Xray</div><div>- Glenoid bone loss > 15%</div><div>- Glenoid loss of contour on AP x-ray</div><div><br></br></div>

Question 7

ISIS score

Answer 7

Shoulder instability recurrence (total = 10)<div><6 = 10%</div><div>>6 = 70% -> undergo open procedure</div><div><br></br></div><div>Age<20 = 2</div><div>Hyperlaxity = 1<br></br></div><div>competitive sport = 2</div><div>Contact sport = 1</div><div>HS on ER AP X-ray = 2</div><div>Glenoid abN on AP Xray = 2</div>

Question 8

Surgical Management of HS lesion?

Answer 8

<div>Glenoid augmentation</div>

Capsular Shift<div>HH augmentation (auto or allograft)</div><div>Remplissage (posterior capsulodesis and infraspinatus tenodesis)</div><div>Humeroplasty (subchondral disimpaction + graft)</div><div><br></br></div><div>Historic: Rotational HH Osteotomy, PuttiPlat (subscap tightening)</div>

Question 9

Frozen Shoulder: Assx conditions, NHx, Tx

Answer 9

“Assx conditions: thyroid, DM, CVA, Malignancy, breast ca ca, dupuytren’s<div><br></br></div><div>NHx:gradual resolution with mild treatment</div><div><br></br></div><div>Tx:</div><div>-nonop: steroids</div><div>-op: MUA (95% happy at 6/12) and release of anterior capsule and RI</div>”

Question 10

Poor PX factors for RC failure?

Answer 10

<u>Patient Factors</u><div>Age>65</div><div>female</div><div>smoker</div><div>decreased BMD</div><div>longer duration of symptoms</div><div><b>inability to FF>100 deg (or weakness in FF)</b></div><div>inability to comply with post-op rehab</div><div><br></br></div><div><u>Tear characteristics</u></div><div>Massive tear >5cm</div><div>Fullthickness</div><div>>1 tendon</div><div>Atrophy/fatty infiltration (Goutallier grade 3/4)</div><div>Degree of muscle retraction (>2.5cm - to level of glenoid)</div><div>Hooked acromion (type III)</div><div><br></br></div><div><b><br></br></b></div><div><br></br></div>

Question 11

“JAAOS 2018 - Changes in thrower’s shoulder?”

Answer 11

“<div> <div> <div><img></img></div> </div></div>”

Question 12

<div>RC 2012 -5 components of the SSSC</div>

Answer 12

“glenoid<div>coracoid</div><div>CC lig</div><div>clavicle</div><div>AC ligament</div><div>Acromion</div><div><br></br></div><div><img></img><br></br></div>”

Question 13

<div>SC joint anterior dislocation. Best treatment?</div>

<ol> <li>Closed reduction and figure of eight brace</li> <li>Open reduction and suture fixation</li> <li>Do nothing</li> <li>K wire fixation</li></ol>

Answer 13

“<div>ANSWER: A (but C is reasonable)</div> <ul> <li>2011</li> <li>JAAOS 2011 - Management of Traumatic Sternoclavicular Joint Injuries</li> <ul> <li>"”Closed reduction is the current treatment of choice, although there is still some controversy regarding management because good long-term results have been reported with nonsurgical management””</li> <li>Patient under sedation, pressure on medial clavicle, immobilization with figure of eight brace x 6 weeks</li> <li>Most unstable after reduction, but if they do stay there is better cosmesis</li> <ul> <li>Do not recommend open reduction</li> </ul> </ul></ul>”

Question 14

<div>COTS Trial - Op vs Non-Op for AC joint injuries?</div>

Answer 14

<ul> <li>Types 3, 5 mainly</li><li>Better Constant scores and return to work with Non-op at 6 weeks, 12 weeks and 6 months</li> <ul> <li>Equalize at 1-2 years</li> </ul></ul>

Question 15

nerves at risk during Lat Dorsi Transfer (not a RC Q)

Answer 15

“-radial nerve (sits anterior and medial to tendon insertion)<div>-axillary (superior to tendon, distance is greatest in ER)</div><div><br></br></div><div><img></img><br></br></div>”

Question 16

Principle of Pc Major tendon transfer? (Not a RC Q)

Answer 16

“partial or complete transfer of tendon UNDERNEATH conjoint tendon (improves vector) but SUPERFICIAL to MCN<div><img></img><br></br></div>”

Question 17

Fusion of GH? Not a RC Q yet

Answer 17

“<ul> <li>Fusion position: 30-30-30</li><li>Saber Incision: from spine of scapula to anterior acromion and down anterior aspect of humeral shaft</li> <ul> <li>Deltoid detached from anterior acromion and split distally, Rotator cuff resected</li> <li>Decorticate head, glenoid and underside of acromion</li> <li>Lag screws from plate, through head and into glenoid for compression</li> <li>Attempt fusion of acromion, glenoid and humeral head</li> <ul> <li>bone graft</li> </ul> <li>10 hole 4.5mm pelvic recon plate</li> <li>Fusion position is 30-30-30 (maybe 20 abduction)</li> <ul> <li>Feeding position: 30 deg flex, 30 deg IR, 30 deg abd</li> </ul> </ul> <li><img></img></li></ul>”

Question 18

Biceps pulley components?

Answer 18

“intertubercular groove<div>CHL</div><div>SGHL</div><div>Subscap</div><div>Supra</div><div><br></br></div><div><img></img> <div></div> <img></img><br></br></div>”

Question 19

Approach to Anterior shoulder instability

Answer 19

“<img></img>”

Question 20

COR HH vs Humeral canal in TSA?

Answer 20

“<div>COR is offset posterior and medially</div><div><br></br></div>Humeral canal is ANTEROLATERAL to COR of HH<div><br></br></div><div><img></img><br></br></div>”

Question 21

Comma Sign? How to treat?

Answer 21

<div> <div> <div>At arthroscopy, a chronic subscapularis tear can be </div> <div>identified by the comma sign, which represents an avulsed SGHL.</div> <div><br></br></div><div>Surgical treatment, either open or arthroscopic, is generally indicated; in chronic cases, a pectoralis transfer is occasionally required.<br></br></div> </div> </div>

Question 22

Subcoracoid Impingement?

Answer 22

<div> <div> <div> <ol> <li><div>Subcoracoid impingementis defined as impingement of thesubscapularisbetweenthecoracoidandlesser tuberosity<br></br></div></li><li> <div>Patients with long or excessively laterally placed coracoid processes may have impingement of this process on the proximal humerus with forward flexion (120 to 130 degrees) and internal rotation of the arm. </div> <div>2. It may occur after surgery that causes posterior capsular tightness and loss of internal rotation. </div> <div>3. Local anesthetic injection should relieve these symptoms. 4. CT performed with the arms crossed on the chest is helpful </div> <div>in evaluating this problem.<br></br> 5. A distance of less than 7 mm between the humerus and coracoid process is considered abnormal.</div></li><li><div><div> <div> <div> <div> <div>Treatment of chronic symptoms involves resection of the lateral aspect of the coracoid process and reattachment of the conjoined tendon to the remaining coracoid. </div> <div>Arthroscopic coracoplasty has also been successful in treat- ing this condition without detachment of the conjoined muscle group.</div> </div> </div> </div></div></div></li></ol></div></div></div>

Question 23

Predictors of failure of non-op tx for RC tears?

Answer 23

<ul> <li>Dunn WR, MOON Consortium (JSES 2016) Predictors of failure of non-operative treatment of chronic, symptomatic, full-thickness rotator cuff tears</li> <ul> <li>433 patients at 1 year (94% follow up)</li> <li>20% had surgery</li> <ul> <li>Underwent surgery early in follow up period (median 120 days)</li> </ul> <li><b><i>Patient expectations about the effectiveness of rehabilitation the most significant predictor of failure of rehab</i></b></li> <li><b><i>Other predictors --> higher level of activity, non-smoker</i></b></li> </ul></ul>

Question 24

Goutallier Classification?

Answer 24

<div> <div><br></br></div><div><br></br></div><div>Stage</div> <div>Rotator Cuff Fat Content</div> <div>0</div> <div>Normal muscle, no fatty streak</div> <div>1</div> <div>Some fatty streaks in muscle</div> <div>2</div> <div>Fatty infiltration present, but more muscle than fat</div> <div>3</div> <div>Fat = muscle</div> <div>4</div> <div>Fat > muscle</div> <br></br></div>

<div>Goutallier evaluated 220 open RCT with transosseous tunnels. 36% re-tear rate. All shoulders with > class 2 infiltration had re-tears<br></br></div>

Question 25

Hamada classification?

Answer 25

“<div>Can do lat transfer if Stage 1, 2 - otherwise likely RTSA</div><div><br></br></div><img></img>”

Question 26

TOS: sites of compression, presentation, P/E?

Answer 26

“<img></img><br></br><div><br></br></div><div><ul> <li>Soft tissue (70%)</li> <ul> <li>Scalenus minimus (accessory muscle)</li> <ul> <li>10-50% of patients with TOS</li> <li>Cervical TP to first rib between subclavian artery and T1 root</li> <li>43% in one study had anomalous scalene insertion</li> </ul> <li>10% subclavius tendon anomalies</li> <li>Hypertrophy of scalene musculature</li> <li>Congenital anomalous ligaments or bands</li> <li>Trauma/scarring</li></ul></ul> <ul> <li>Osseous Anomalies (30%)</li> <ul> <li>Cervical ribs (8.5%)</li> <li>Prominent C7 transverse process</li> <li>Exostoses</li> <li>Tumor</li> <li>Fracture callus</li> </ul><li><u>P/E</u></li><li>Wright –> decrease in pulse with arm hyper-abduction and ER with head opposite side (RC EXAM)</li> <ul> <li>Decrease in pulse with 7% normal population</li> </ul> <li>Adson —> extension with head towards affected side + deep breathe</li> <ul> <li>51% normal people have diminished pulse</li> <li>Sensitive, not specific</li> </ul> <li>Roos –> arms 90o abduction, elbows 90o plus hand open and closed for 3 minutes</li> <ul> <li>TOS if replication of symptoms</li> <li>Most sensitive test according to Green’s</li> </ul><li><u>Presentations</u></li><li>Neurogenic (compression of brachial plexus)</li> <ul> <li>90% of cases</li> <li>Lower and combined plexus is more common (85-90%)</li> </ul><li>Vascular (arterial or venous)</li> <ul> <li>3-5% venous</li><li><1% arterial</li> </ul><li><br></br></li></ul></div>”

Question 27

<div> <div> <div>Most important anatomic restraint for anteroposterior translation in SC injury?</div> </div> </div>

Answer 27

The posterior capsule.<br></br><div><br></br></div><div>Treatment Principles</div><div><div> <div> <div> <div> <ol> <li> <div>Anterior dislocation should be first treated with acute closed reduction. </div> </li> <li> <div>Failures of reductions and chronic dislocations are treated conservatively. </div> </li> <li> <div>Posterior dislocation should be treated with closed reduc- tion and open reduction if necessary, particularly with compression of the posterior structures. Consultation with a cardiothoracic surgeon may be appropriate. </div> </li> <li> <div>The use of hardware should be avoided whenever possible</div> </li> </ol> </div> </div> </div></div></div>

Question 28

Adv/Disadv to positioning in shoulder surgery

Answer 28

“<img></img>”

Question 29

Scapular Winging - etiologies, tx?

Answer 29

“<img></img><br></br><div><br></br></div><div>-Lateral winging - Eden Lange transfer: lateralization of levator scapula and Rhomboid major</div><div>-Medial Winging - Split Pect Major with ITB fascial augment to infeior scapula</div><div><br></br></div><div><img></img><br></br></div><div><br></br></div><div><br></br></div>”

Question 30

WOSI and WORC Scores?

Answer 30

<ul> <li>Western Ontario Rotator Cuff Index (WORC)</li> <ul> <li>Domains: (VAS scores)</li> <ul> <li>Pain and physical symptoms</li> <li>Sports and recreation</li> <li>Work function</li> <li>Social function</li> <li>Emotional function</li> </ul> <li>Validated in wide variety of populations</li><li>PRO</li></ul></ul>

<ul><li>Western Ontario Shoulder Instability Index (WOSI)</li> <ul> <li>Four Domains:</li> <ul> <li>Physical Symptoms</li> <li>Sports, recreation and work</li> <li>Lifestyle</li> <li>Emotions</li> </ul> </ul></ul>