Shoulder Flashcards
What are the intrinsic causes of shoulder pain?
[JAAOS 2015;23:492-500]

What are the extrinsic causes of shoulder pain?
[JAAOS 2015;23:492-500]

What are the advantages and disadvantages of lateral decubitus and beach chair positions for arthroscopic or open shoulder surgery?
[JAAOS 2015;23:18-28]
- Lateral Decubitus
- Advantages
- Traction increases space in the glenohumeral joint and subacromial space
- Traction accentuates labral tears
- Operating room table and/or patient’s head not in the way of posterior and superior shoulder
- Cautery bubbles move laterally out of view
- No increased risk of hypotension/bradycardia
- Better cerebral perfusion
- Disadvantages
- Nonanatomic orientation (ie, glenoid is parallel to the floor)
- Must reach around arm for anterior portal
- May need to reposition and redrape to convert to open procedure
- Not ideal for patients who cannot tolerate regional anesthesia
- Traction can cause neurovascular and soft-tissue injury
- Increased risk of injury to axillary and musculocutaneous nerves when placing anteroinferior portal
- Beach Chair
- Advantages
- Upright, anatomic position
- Ease of examination under anesthesia and ability to stabilize the scapula
- Arm not in the way of anterior portal
- No need to reposition or redrape to convert to open procedure
- Can use regional anesthesia with sedation
- Mobility of surgical arm and ability to set up arm holder to the operating room table
- Disadvantages
- Potential mechanical blocks (eg, the head) to the use of arthroscope in posterior or superior portals
- Increased risk of hypotension/bradycardia causing cardiovascular complications (ie, cerebral ischemia)
- Cautery bubbles obscure view in the subacromial space
- Fluid can fog camera if there is a leak in the attachment or in certain cameras
- Theoretically increased risk of air embolus
- Expensive equipment if using beach-chair attachment with or without mechanical arm holder
What is the normal glenoid inclination (tilt)?
[J Am Acad Orthop Surg 2015;23:317-326]
Glenoid inclination/tilt = the slope of the glenoid face in the superior-inferior direction relative to a line drawn perpendicular to the tangent of the medial scapular border
- Average of 2.2° of inferior tilt to 4.2° of superior tilt (range of -12-15.8°)
?B-angle
- Angle between glenoid face line along scapular spine
- Inclination angle is 90 - Bangle
What is the normal glenoid version?
[J Am Acad Orthop Surg 2015;23:317-326]
Glenoid version = the angle between the glenoid surface and a line drawn perpendicular to the axis of the scapular spine
- Average of 2° of retroversion (range of 12° anteversion to 14° retroversion)
What is the glenoid vault?
[J Am Acad Orthop Surg 2015;23:317-326]
It is the triangular bone extending from the glenoid articular surface to the body of the scapula (serves as the bony support for the glenoid component in shoulder arthroplasty)
How is glenoid version measured?
[The Open Orthopaedics Journal, 2017, 11, (Suppl-6, M4) 1115-1125]
Friedman method
- Friedman line drawn from the medial scapular border to the center of the glenoid on CT
- A line perpendicular to the Friedman line is drawn from the anterior edge of the glenoid
- A line drawn from the anterior to posterior edge of the glenoid
- If the posterior edge of the glenoid is anterior = anteverted
- If the posterior edge of the glenoid is posterior = retroverted
Walch classification of glenoid morphology associated with primary glenohumeral OA
[JAAOS 2012;20:604-613]
- Type A – concentric wear with no subluxation (59%)
- Subtype A1 – minor
- Subtype A2 – major
- Line connects anterior/posterior glenoid rims and transects humeral head (HH)
- Type B – posterior humeral subluxation with asymmetric wear of the posterior glenoid rim (32%)
- Subtype B1 – posterior joint space narrowing but no posterior erosion
- Subtype B2 – posterior erosion and biconcave appearance
- Subtype B3 - monoconcave, posterior wear, at least HH subluxation >70% OR retroversion >15%
- Type C – dysplastic glenoid with glenoid retroversion >25°and posterior humeral head subluxation (9%)
- Type D - Glenoid anteversion or anterior HH subluxation

What imaging modality is needed to evaluate glenoid morphology?
[JAAOS 2012;20:604-613]
CT with 3D recon – assess version, bone stock, vault anatomy
In a B2 glenoid what does each concavity represent?
[Curr Rev Musculoskelet Med. 2016 Mar; 9(1): 30–39.]
- Anterior concavity = paleo glenoid (native glenoid)
- Posterior concavity = neoglenoid

What are the complications associated with TSA from most to least frequent?
[JBJS 2017;99:256-69]
- Component loosening (glenoid > humeral)
- Glenoid wear
- Instability
- Rotator cuff tear
- Periprosthetic fracture
- Neural injury
- Infection
- Hematoma
- Deltoid injury
- VTE
What is the most common long-term complication of TSA?
[JAAOS 2015;23:317-326]
Glenoid loosening (24% of all TSA complications)
What factors contribute to glenoid loosening?
[JAAOS 2012;20:604-613]
- Altered joint reaction forces
- Component malposition
- Insufficient bony support (native glenoid)
What are the indications, absolute and relative contraindications for glenoid resurfacing in TSA?
[JAAOS 2015;23:317-326]
Indications
- Painful glenoid degeneration
- Adequate glenoid bone stock
- Intact rotator cuff
Absolute contraindications
- Active shoulder infection
- Neuroarthropathy
- Paralysis of shoulder muscles
Relative contraindications
- Age <50
- High functional demand
- Significant bone loss
- Rotator cuff dysfunction
What is the rocking horse phenomenon?
[JAAOS 2015;23:317-326]
The mechanism by which the glenoid component loosens overtime
- Occurs when the component is edge loaded causing compression on one side and distraction on the other resulting in the breakdown at the bone implant interface
What factors lead to or worsen the rocking horse phenomenon?
[JAAOS 2015;23:317-326]
- Glenohumeral instability
- Rotator cuff dysfunction
- Glenoid malposition in retroversion or superior inclination
What are revision options for glenoid component failure?
[JAAOS 2015;23:317-326]
- Component reimplantation in one or two stages
- Glenoid removal without reimplantation
- Isolated glenoid bone grafting
- Reverse TSA
New What are causes of anterior instability in TSA?
- component malposition (anteversion)
- anterior glenoid deficiency
- surgical deltoid takedown
- axillary nerve injury
- failure of subscapularis repair
new - What are causes of superior instability in TSA?
rotator cuff deficiency
New - what are causes of posterior instability in TSA?
- posterior glenoid deficiency
- component malposition (retroversion)
- posterior capsular redundancy
What are surgical options for advanced glenoid deformity in TSA?
[JAAOS 2015;23:317-326]
- Downsizing glenoid component
- Slight undercorrection and implantation in retroversion
- Bone grafting (native osteotomized humeral head)
- Nonprosthetic resurfacing
- “ream-and-run” (ream glenoid without implanting glenoid component)
- Soft tissue interposition
- Augmented implants
- Reverse TSA
What are the principles for glenoid component implantation?
[JAAOS 2015;23:317-326]
- Adequate glenoid exposure and visualization (through soft tissue releases and optimal retractor placement)
- Recognition and correction of deformity
- Preserve bone stock and subchondral bone avoiding perforation of the glenoid vault
- Proper implant sizing
- Proper implantation of prosthesis with cement pressurization and full seating of the component in appropriate position
What are treatment options for management of glenoid retroversion and posterior glenoid bone loss in TSA?
[JBJS 2015;97:251-9][JSES (2013) 22, 1298-1308]
- <15° = Eccentric reaming
- 15-25° = augmented glenoid components
- >25° = glenoid bone grafts
- Elderly, sedentary patients = reverse TSA
What are the advantages and disadvantages of eccentric reaming for management of posterior glenoid bone loss?
[JBJS 2015;97:251-9]
Advantages
- Technically simple
- Quick
Disadvantages
- Reduction of subchondral bone
- Medialization of joint line
- Risk of poly peg cortical perforation













