Shoulder - RC Q's

Question 1

RC 2013 - Pt factors that predict poor RC healing postop?

Answer 1

Age>65 years<div>Female sex</div><div>Smoking</div><div>Decreased BMD<br></br></div>

Question 2

RC 2013 - CPx factors that predict poor RC healing post-op

Answer 2

Duration of symptoms<div>*Inability to elevate >100 deg (MCQ2014,2016)</div><div>Weak elevation and external rotation<br></br></div>

Question 3

RC 2011 - Types of SLAP Tears

Answer 3

“1- labral fraying<div>2- detached sup labrum/biceps anchor</div><div>3-bucket handle sup labrum (intact biceps)</div><div>4 -bucket handle with extension into biceps</div><div><br></br></div><div><img></img><br></br></div><div><img></img><br></br></div><div><ul> <li>RFs for failure after SLAP II repair</li> <ul> <li>(Frank, 2013) Retrospective Analysis of Arthroscopic Superior Labrum Anterior to Posterior Repair: Prognostic Factors Associated with Failure</li> <ul> <li>Age<20</li> <li>Age>40</li> <li>Overhead athletes</li> <li>Others: smokers, EtOH use, labourers, DM</li> </ul> </ul></ul></div>”

Question 4

RC 2015, 2010 - Mechanisms for SLAP tear

Answer 4

Traction to arm<div>Direct Compression/blow</div><div>Repetitive Overhead throwing (peel-back)</div>

Question 5

RC 2017 - Strategies for TSA in B2 Glenoid?

Answer 5

Eccentric Reaming<div>Posterior Bone Graft (use HH)</div><div>Glenoid component augment</div><div>Downsive Glenoid component</div><div>Implant in retroversion</div>

Question 6

<div>RC 2015, 13, 10 - What are 3 mechanisms of injury for a SLAP tear?</div>

Answer 6

Forceful traction to arm<div>Direct blow/compression</div><div>Repetitive overhead throwing</div>

Question 7

<div>RC 2015 - Rate of return to play at same level following SLAP repair:</div>

<ol> <li>5%</li> <li>20%</li> <li>50%</li> <li>80%</li></ol>

Answer 7

D.<div><ul> <li>Brockmeier SF (JBJS 2009) Outcomes after arthroscopic repair of type II SLAP lesions</li> <ul> <li>47 patients at 2 years following arthroscopic SLAP repair with suture anchors</li> <li>Return to sport (same level) = 74%</li> </ul> <li>Neuman BJ (AJSM 2011) Results of arthroscopic repair of type II SLAP in overhead athletes</li> <ul> <li>30 patients at 3.5 years</li> <li>84% return to preinjury level of function</li> </ul></ul></div>

Question 8

<div>RC 2015, 14, 12, 10 - Acute posterior shoulder dislocation with large anterior humeral bone defect- What are the most appropriate surgical treatment options</div>

Answer 8

HS <20%<div>-Posterior labral repair (Bankart) -open or arthroscopic</div><div>-Modified McLaughlin: Transposition of LT (Neer mod) and subscap tendon (original) into reverse HS defect</div><div><br></br></div><div>HS 20-40%</div><div>-Disimpaction (must be <3 weeks old)</div><div>-McLaughlin - isolated subscap transfer into defect</div><div>-Modified McLaughlin - subscap transfer with LT Osteochondral allograft (i.e. from cadaver humeral head usually)</div><div><br></br></div><div>HS >40%</div><div>- Hemiarthroplasty/TSA - May need bankart repair if unstable</div><div>- Humeral head re-surfacing</div><div>- Rotationplasty (historical)</div>

Question 9

<div><div>RC 2013 - Flexion, Adduction and internal rotation of the shoulder. Which structure is primarily responsible for posterior stability?</div> <ul> <li>A) Superior Glenohumeral and Coracohumeral</li> <li>B) Middle glenohumeral</li> <li>C) Teres minor and infraspinatus</li> <li>D) Posterior inferior glenohumeral ligament and posterior labrum</li></ul></div>

Answer 9

<div>Answer: D</div>

<div><br></br></div>

Question 10

<div>RC 2008 - Posterior shoulder instability. All are true EXCEPT</div>

<ol> <li>Dislocation is more common than subluxation</li> <li>Non operative treatment is usually satisfactory</li> <li>Posterior Bankart is unusual</li> <li>Commonly associated with multidirectional subluxation</li></ol>

Answer 10

“<div>A</div><div><u><br></br></u></div><div><u>posterior instability:</u></div><div>Assx with MDI</div><div>Posterior bankart less common<br></br></div>Non-op is satisfactory, but surgery is helpful<div>Glenoid osteotomy - not indicated</div><div><br></br></div><div><b>-subluxation is more common than dislocation</b></div><div><b>-Pt’s can’t voluntarily d/l (also an MCQ)<br></br></b><div><br></br></div></div>”

Question 11

RC 2017, 2013 List 4 Stabilizers of AC joint?

Answer 11

<ul> <li>Static Stabilizers:</li> <ul> <li>Joint capsule</li> <li>AC ligaments</li> <li>CC Ligaments</li> <ul> <li>Conoid ligament (medial)</li> <li>Trapezoid ligament (lateral)</li> </ul> </ul> <li>Dynamic Stabilizers:</li> <ul> <li>Anterior deltoid muscle</li> <li>Trapezius through fascial insertion on acromion</li> </ul></ul>

Question 12

<div>RC 2017 What are the four glenohumeral ligaments?</div>

Answer 12

“SGHL MGHL IGHL CHL <div><img></img></div>”

Question 13

<div>RC 2014 All the following are components of the rotator cuff interval EXCEPT?</div>

<ol> <li>CHL</li> <li>SGHL</li> <li>Glenohumeral joint capsule</li> <li>Short head of biceps tendon</li></ol>

Answer 13

“4. - its the LHB tendon!<div><ul> <li>Rotator interval is the area of the capsule between the supraspinatus and subscapularis, includes the…</li> <ul> <li>SGHL</li> <li>Coracohumeral ligament</li> <li>Long head of biceps</li> </ul> <li>Contracture common in adhesive capsulitis, should release if treating arthroscopically</li></ul><div><br></br></div><div><img></img><br></br></div></div>”

Question 14

<div>RC 2015 - What is a static restraint of the GH joint?</div>

<div> a. CH ligament</div>

<div> b. CA ligament</div>

<div> c. biceps</div>

<div> d. negative intra-articular pressure</div>

Answer 14

D<div><ul> <li>Static restraints</li> <ul> <li>glenohumeral ligaments(below)</li> <li>glenoid labrum(below)</li> <li>articular congruity and version</li> <li>negative intraarticular pressure</li> <li>if release head will sublux inferiorly</li> </ul> <li>Dynamic restraints</li> <ul> <li>rotator cuff muscles</li> <li>rotator interval</li> <li>biceps long head</li> <li>periscapular muscles</li> </ul></ul></div>

Question 15

<div>RC 2015 - what is true?</div>

<ol> <li>West point view is best for imaging a Hill-Sachs lesions</li> <li>Garth view is good for Hill-Sachs and Bankart lesions</li> <li>Xray is sufficient for assessing glenoid bone stock</li> <li>MRI is best for assessing glenoid bone loss</li></ol>

Answer 15

“ANSWER: 2 (is true)<div>The rest are false</div><div>-West point AXILLARY - looks for bankart</div><div>-styker notch - looks for HS lesions</div><div>-garth - both</div><div><img></img><br></br></div><div><img></img><br></br></div>”

Question 16

<div>RC 2016, 2011 - List the boundaries of the Quadrangular space. List TWO contents of the Quadrangular space</div>

Answer 16

“<ul> <li>Borders: Medial border of humerus, Long head of triceps, Teres Major, Teres Minor</li> <li>Contents: Axillary Nerve, Posterior Circumflex humeral artery</li> <li><img></img></li></ul>”

Question 17

<div>RC 2012 - All of the following make up the quadrangular space except?</div>

<ol> <li>Humerus</li> <li>Teres major</li> <li>Infraspinatus</li> <li>Long head of triceps</li></ol>

Answer 17

“3.<div><br></br></div><div>note: triangular Space = circumflex Scapular artery<br></br><div><br></br></div><div><img></img><br></br></div></div>”

Question 18

<div>RC 2015 - List 5 nerves coming off the posterior cord of the brachial plexus</div>

Answer 18

“<ul><li>Radial</li><li>Axillary</li><li>Thoracodorsal (lat dorsi)</li><li>Upper subscapularis</li><li>Lower subscapularis</li></ul><div><img></img><br></br></div>”

Question 19

<div>RC 2016 - Name the 2 muscles innervated by the lower subscapular nerve</div>

Answer 19

“<div>Subscapularis</div><div>Teres Major</div><div><br></br></div><div><img></img><br></br></div>”

Question 20

<div>RC 2018 Based on the best current evidence, what is the main blood supply to the humeral head?</div>

<div>a.Posterior humeral circumflex artery</div>

<div>b.Anterior humeral circumflex artery</div>

<div>c.Circumflex scapular artery</div>

<div>d.Profunda brachii</div>

Answer 20

A - PHCx 64%

Question 21

<div>RC 2008 What is a cause of poor outcomes for shoulder hemiarthroplasty?</div>

<ol> <li>Rotator Cuff Tear</li> <li>Non concentric wear on glenoid</li> <li>Eburnated bone on glenoid</li> <li>Circumferential capsular release</li></ol>

Answer 21

B.<div><br></br></div><div><div>86% satisfaction with concentric shoulders, 63% with non-concentric glenoids</div></div>

Question 22

RC ORAL - Walch classification?

Answer 22

“<div><img></img></div> <div></div> Walch Classification: <div>A1 - Minor erosion</div> <div>A2 - Central Erosions</div> <div>B1 - Posterior subluxation</div> <div>B2 - Biconcave glenoid, posterior wear</div> <div>C - Glenoid retroversion > 25 deg</div><div><br></br></div><div>Note: can only eccentrically ream <15 deg</div><div>Techniques to deal with retroverted glenoid:</div><div><ul> <li>Exposure</li> <li>Eccentric reaming</li> <li>Posterior bone grafting using humeral head autograft</li> <li>Glenoid component augmentation</li> <li>Downsizing glenoid component</li> <li>Implantation in slight retroversion</li></ul></div>”

Question 23

<div>RC 2017 What are four surgical considerations in doing an anatomic total shoulder arthroplasty in a patient with a B2 glenoid?</div>

Answer 23

B2 = biconcave<div><br></br></div><div>-exposure</div><div>-eccentric reaming</div><div>-bone graft (HH or allograft)</div><div>-glenoid augment</div><div>-glenoid downsizing</div><div>-implantation in slight retroversion</div><div><br></br></div><div>JAAOS 2015</div><div><br></br></div>

Question 24

<div>RC 2017 Glenoid component in anatomic total shoulder with the lowest failure rate:</div>

<div>A. Cemented keeled glenoid</div>

<div>B. Cemented pegged glenoid</div>

<div>C. Metal Backed Component</div>

<div>D. Porous ingrowth component</div>

<div></div>

<div><br></br></div>

Answer 24

Answer B<br></br><div><br></br></div><div>(technically they are equivalent at 7 years from a 2017 study)</div>

Question 25

<div>RC 2015 What is a cause of glenoid loosening in total shoulder arthroplasty in rotator cuff arthropathy?</div>

<div> a. superior eccentric wear</div>

<div> b. concentric wear</div>

<div> c. posterior eccentric wear</div>

Answer 25

Answer A<div><br></br></div><div>rocking horse phenomenon</div>

Question 26

<div>RC 2011 - Most common cause of anterior shoulder instability after TSA?</div>

<ol> <li>humeral anteversion</li> <li>glenoid anteversion</li> <li>subscap repair failure</li> <li>Posterior capsule not released</li></ol>

Answer 26

C<div><br></br></div><div><div>Anterior instability is associated with humeral component malpositioning, anterior glenoid deficiency, anterior deltoid muscle dysfunction, failure of the subscapularis tendon and anterior aspect of the capsule</div></div>

Question 27

<div>RC 2018 What prosthetic factor has the MOST impact on decreasing the rate of scapular notching in a Grammont-style reverse total shoulder arthroplasty? (question very similar to that seen on Orthobullets)</div>

<div>a.Inferior tilt of the glenoid component</div>

<div>b.Inferior positioning of the glenoid component</div>

<div>c.Use of a cemented humeral component</div>

<div>d.Use of locking screws in the glenoid component</div>

Answer 27

B<div><br></br></div><div>tilt is important, but inferior position more important</div>

Question 28

<div>RC 2017 Regarding RTSA and anterior instability, all are associated except:</div>

<ol> <li>Risk with subscap deficiency</li> <li>Risk with BMI >30</li> <li>Risk with posterior cuff (infraspinatus, teres minor) insufficiency</li> <li>Risk with chronic dislocations prior to surgery</li></ol>

Answer 28

C. JW agrees.

Question 29

<div>RC 2017 - 75 yo F with pseudoparalysis and massive cuff tear. No arthritis. Which will give her the most reliable function?</div>

<ol> <li>Reverse total shoulder arthroplasty</li> <li>Rotator Cuff Repair</li> <li>Hemi</li> <li>Physio</li></ol>

Answer 29

B<div><ul> <li>Pseudoparalysis</li> <ul> <li>Inability to raise arm above shoulder level, with preserved deltoid firing</li> <ul> <li>Uncoupling of glenoid and HH</li> </ul> <li>Can reverse pseudoparalysis with a RC repair in absence of GH OA (ie do not have to do a RTSA)</li> <ul> <li>Denard, P. J., Burkhart, S. S. (2015). Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis.The American Journal of Sports Medicine,43(10), 2373–2378.</li> </ul> </ul></ul><div><br></br></div></div>

Question 30

<div>RC 2016 What are 3 local biologic or anatomic features predictive of non-healing after rotator cuff repair?</div>

Answer 30

<ul> <li>Tear size</li> <ul> <li>full thickness</li> <li>involvement of >1 tendon</li> </ul> <li>Atrophy/fatty infiltration (Goutallier grade 3 or 4)</li> <li>Degree of muscle retraction (>2.5cm, i.e. lateral tendon at level of glenoid)</li> <li>Severely hooked acromion (type III)</li></ul>

Question 31

<div>RC 2013 Excluding medical co-morbidities, what are 4 patient factors (not tear characteristics) that predict poor rotator cuff healing post operatively? (2013)</div>

Answer 31

<ul> <li>Patient Factors:</li> <ul> <li>Age>65 years</li> <li>Female sex</li> <li>Smoking</li> <li>Decreased BMD</li> </ul> <li>Clinical Presentation</li> <ul> <li>Duration of symptoms</li> <li><b>Inability to elevate >100 deg</b></li> <li>Weak elevation and external rotation</li> </ul></ul>

Question 32

<div>RC 2008, 2014, 2016 What predicts poor outcome following rotator cuff tear? </div>

<ol> <li>Pain with resisted external rotation </li> <li>Acromiohumeral distance of 1cm</li> <li>Small tear size</li> <li>Weakness in forward elevation</li></ol>

Answer 32

Answer: D

Question 33

<div>RC 2015 - Benefit of double-row repair for rotator cuff tear:</div>

<ol> <li>Better in large tears</li> <li>No difference in biomechanical outcomes</li> <li>No difference in clinical outcomes</li> <li>No difference in costs</li></ol>

Answer 33

“C<div><ul><li>Arthroscopy 2011 - Single row repair versus double-row repair of full-thickness rotator cuff tears</li> <ul> <li>Meta-analysis</li> <li>"”Despite the fact that double-row repair shows a significantly higher rate of tendon healing and greater external rotation than does single-row repair, there is no significant improvement in shoulder function, muscle strength, forward flexion, internal rotation, patient satisfaction, or return to work.</li> </ul></ul></div>”

Question 34

<div>RC 2014, 2015 What are 3 ways in which a Laterjet procedure through a split subscapularis stabilizes the glenohumeral joint?</div>

Answer 34

<ul> <li>JAAOS 2009 - Glenoid Bone Deficiency</li> <ul> <li>Increased glenoid bone stock</li> <li>Capsulolabral repair (may be augmented by attachments of the released coracoacromial ligaments to the labrum)</li> <li>Dynamic sling via transfer of conjoined tendon</li> </ul></ul>

Question 35

<div>RC 2015, 2017 What is not a risk factor for redislocation following Bankart repair:</div>

<ol> <li>Contact sport</li> <li>Hill Sachs visible on external rotation x ray</li> <li>Age >40yrs</li> <li>Ligamentous hyperlaxity</li></ol>

Answer 35

<div>ANSWER: C</div>

<div><br></br></div>

<div><ul> <li>JAAOS 2014 - Anterior Glenohumeral Instability</li> <li>Patient Factors</li> <ul> <li>Ligamentous laxity</li> <li>Immobilization <4 weeks</li> <li><28 years old</li> <li>Contact, overhead, competitive sports</li> <li>Age at surgery < 20</li> </ul> <li>Anatomic Factors</li> <ul> <li>Hill-Sachs > 250mm3</li> <li>Glenoid bone loss > 15%</li> <li>Hill-Sachs visible on ER A/P radiograph</li> <li>Glenoid loss of contour on AP radiograph</li> </ul></ul></div>

Question 36

<div>RC 2016 - What is true about recurrent traumatic shoulder dislocation? </div>

<ol> <li>Females have more recurrent traumatic shoulder dislocation </li> <li>More likely if Glenoid fracture </li> <li>? </li> <li>?</li></ol>

Answer 36

<div>ANSWER: B</div>

Question 37

<div>RC 2012, 2014 - Regarding a Hill-Sachs lesion following anterior shoulder dislocation, which of the following is true?</div>

<ol> <li>Located in the posterolateral aspect of the humeral head</li> <li>Is the most common cause of recurrent dislocation</li> <li>Best seen on AP view </li> <li>Best seen on the AP view with the humerus in maximal external rotation</li></ol>

Answer 37

A<div>The Hill-Sachs lesion: diagnosis, classification, and management. JAAOS. 2012<div><ul> <ul> <li>“The Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.”</li> <li>Stryker notch view is most specific for evaluating a Hill-Sachs lesion - adduction and internal rotation view brings posterolateral aspect of humeral head into view</li> <li>Lesions <20% of humeral head are of no clinical significance; lesions >40% are nearly always clinically significant and can result in recurrent anterior instability - basis of classification system (Flatow & Warner)</li> <li>Consider all GH anatomy when planning treatment - small HS lesions can be clinically significant in the setting of large glenoid bone loss</li> <li>Address primary problem prior to addressing HS lesion = Bankart or glenoid bone loss</li> <li>Surgical options for HS lesions include auto/allograft, soft tissue filling (remplissage), disimpaction, hemiarthroplasty/resurfacing</li> </ul></ul></div></div>

Question 38

<div>RC 2013 - Patient with a Hill Sachs lesion. All of the following are choices for surgical treatment, except: </div>

<ol> <li>Lesser Tuberosity transfer into defect</li> <li>Infraspinatus transfer into the defect</li> <li>Allograft humeral head to fill the defect</li> <li>Remplissage</li></ol>

Answer 38

A<div><ul> <li>Surgical management:</li> <ul> <li>Capsular Shift</li> <li>Glenoid bone augmentation</li> <li>Humeral head bone augmentation</li> <ul> <li>Autograft, fresh or frozen allograft or synthetic</li> </ul> <li>Tissue Filling (Replissage)</li> <ul> <li>Connolly procedure - open procedure involving transfer of the infraspinatus and portion of GT into defect</li> <li>Remplissage:</li> <ul> <li>Converted to extra-articular defect with soft-tissue coverage</li> <li>Arthroscopic posterior capsulodesis and infraspinatus tenodesis with fixation to the surface of the Hill sachs defect</li> </ul> </ul> <li>Disimpaction</li> <li>Resurfacing/Prosthesis</li> </ul> <li>Posterior Instability:</li> <ul> <li>McLaughlin = open transfer of the subscap tendon and LT to fill humeral head defect</li> </ul></ul></div>

Question 39

“<div>RC 2015 - The following are true regarding shoulder imaging, except:</div> <div>Jer: I think this question is supposed to read: ‘what is true’</div> <ol> <li>West point view is best for imaging a Hill-Sachs lesions</li> <li>Garth view is good for Hill-Sachs and Bankart lesions</li> <li>Xray is sufficient for assessing glenoid bone stock</li> <li>MRI is best for assessing glenoid bone loss</li></ol>”

Answer 39

B<div><ul> <li>A: West point (modified axillary) is best for Glenoid, Stryker Notch View best for Hill-Sachs lesion</li> <li>C: glenoid bone stock –>CT</li> <li>D: bone loss –> CT</li></ul></div>

Question 40

<div>RC 2012 - 18 year-old female presents to you complaining of her shoulder going “in and out” when swimming or playing volleyball. Never had a traumatic dislocation. Which of the following is the best option for treatment of her instability?</div>

<ol> <li>Bankart repair </li> <li>Magnuson-Stack procedure </li> <li>Inferior capsular shift</li> <li>Putti-Platt procedure</li></ol>

Answer 40

C<div><ul><li>JAAOS - Management of Multidirectional Instability of the Shoulder</li> <ul> <li>Reconstructive techniques include glenoid osteotomy, labral augmentation, capsuloligamentous reconstruction</li> <li>Open Inferior Capsular Shift</li> </ul></ul></div>

Question 41

<div>RC 2015, 14, 12, 10 Acute posterior shoulder dislocation with large anterior humeral bone defect- What are the most appropriate surgical treatment options?</div>

Answer 41

<ul> <li>Reverse HS<20%</li><li>Posterior labral repair (Bankart) - open or arthroscopic</li><li>Modified McLaughlin</li></ul>

<ul><li>Reverse HS 20-40%</li> <ul> <li>Disimpaction (must be <3 weeks old)</li> <li>McLaughlin - isolated subscap transfer into defect</li> <li>Modified McLaughlin - subscap transfer with LT</li> <li>Osteochondral allograft (i.e. from cadaver humeral head usually)</li> </ul> <li>Reverse HS >40%</li> <ul> <li>Hemiarthroplasty/TSA</li> <li>Humeral head re-surfacing</li> <li>Rotationplasty (historical)</li> </ul></ul>

Question 42

<div>RC 2013 - Flexion, Adduction and internal rotation of the shoulder. Which structure is primarily responsible for posterior stability?</div>

<ul> <li>A) Superior Glenohumeral and Coracohumeral</li> <li>B) Middle glenohumeral</li> <li>C) Teres minor and infraspinatus</li> <li>D) Posterior inferior glenohumeral ligament and posterior labrum</li></ul>

Answer 42

“<div>ANSWER: D</div> <ul> <li>2013</li> <li>Jerk test evaluates posterior band of IGHL and posterior labrum and simulates this position </li> </ul> <div></div> <div>JBJS Current Concepts Review 2015 - Posterior Instability</div> <ul> <li>The posterior band of the IGHL is the most important stabilizer in adduction, flexion and internal rotation</li></ul><div><br></br></div><div><div>Jerk test evaluates posterior band of IGHL and posterior labrum and simulates this position<div></div><div><img></img></div></div>think arm position: flex, add, IR…<div>posterior band of IGHL</div></div>”

Question 43

<div>RC 2008 - Mechanism of injury for posterior shoulder dislocation</div>

<ol> <li>Abduction, ER</li> <li>Abduction, IR</li> <li>Elevation, ER</li> <li>Elevation, IR</li></ol>

Answer 43

<div>ANSWER: D</div>

Question 44

<div>RC 2013 - Which of the following is true about atraumatic SC joint arthritis</div>

<ol> <li>Common joint involved with RA</li> <li>Elderly people get atraumatic anterior SC dislocations without generalized ligamentous laxity</li> <li>Freidrich’s avascular necrosis produces irregularity and curving of the medial clavicle</li></ol>

Answer 44

“<div>ANSWER: C</div><ul> <li>JAAOS 2005 - Atraumatic Disorders of the SC Joint</li> <ul> <li>Rheumatoid arthritis has variable involvement, one study estimated 30%</li> <li>Spontaneous anterior subluxation generally occurs in teens or twenties in patients with ligamentous laxity</li> <li>Freidrich’s Disease</li> <ul> <li>Aseptic osteonecrosis of the medial clavicle</li> <li>Discomfort, swelling and crepitus of SC joint</li> </ul> </ul></ul>”

Question 45

<div>RC 2011 - Patient with hand pustules, acne, pain and swelling at SC joint. What is the diagnosis?</div>

<ol> <li>condensing osteitis</li> <li>friedrich’s</li> <li>sternal hyperostosis</li> <li>infection</li></ol>

Answer 45

“3<div><ul> <li>2011</li> <li>JAAOS 2005 - Atraumatic Disorders of the Clavicle</li> <ul> <li>Sternocostoclavicular Hyperostosis</li> <ul> <li>Rare disorder of soft-tissue ossification and hyperostosis between clavicles</li> <li>Associated with severe acne and palmoplantar pustulosis</li> <li>Synovitis and osteitis can also be present</li> <li>Hyperostosis of the sternum, clavicles, upper ribs with ossification of the costoclavicular, costosternal, and intercostal ligaments</li> <li>Japanese males in 4-6th decade</li> </ul> </ul> </ul> <div></div> <div></div> <div><img></img></div></div><div><br></br></div>”

Question 46

“<div>RC 2010 - Thoracic outlet syndrome, which is false?</div> <ol> <li>Vascular cause accounts for 5%</li> <li>Adson’s is sensitive but not very specific</li> <li>Can be tested my abducting arm and internally rotating shoulder</li> <li>Cervical rib is most common X ray finding</li> </ol> <div></div>”

Answer 46

“C<div><br></br></div><div><div>Wright test is symptoms with abduction an EXTERNAL rotation</div></div><div><img></img><br></br></div>”

Question 47

<div>RC 2008 - Thoracic outlet, all of the following except</div>

<ol> <li>50% vascular</li> <li>Occurs in females more often </li> <li>Can present with C8-T1 nerve symptoms</li> <li>First event can present with thrombosis</li></ol>

Answer 47

A<div><ul> <li>Vascular causes rare (3-5% venous, <1% arterial)</li> <li>Females are more common</li> <li>Neurogenic (90%)</li> <ul> <li>Lower and combined plexus presentation is more common (85-90%)</li> </ul> <li>Arterial cases –> can develop and aneurysm, thrombosis and limb threatening ischemia</li></ul></div>

Question 48

<div>RC 2017, 2014 - What are 4 stabilizers of the AC joint?</div>

Answer 48

<ul> <li>Static Stabilizers:</li> <ul> <li>Joint capsule</li> <li>AC ligaments</li> <li>CC Ligaments</li> <ul> <li>Conoid ligament (medial)</li> <li>Trapezoid ligament (lateral)</li> </ul> </ul> <li>Dynamic Stabilizers:</li> <ul> <li>Anterior deltoid muscle</li> <li>Trapezius through fascial insertion on acromion</li> </ul></ul>

Question 49

<div>RC EXAM - What is the best view for AC joint?</div>

<ol> <li>Zanca view</li> <li>Stryker notch </li> <li>AP shoulder </li> <li>Oblique View</li> <li>Outlet coracoid view</li></ol>

Answer 49

A. Zanca View - 10-15 deg cephalic tilt (to clear scapular spine)

Question 50

<div>RC 2017 - What is weightlifters shoulder? What is the etiology?</div>

Answer 50

<div>JAAOS 1999</div>

Distal clavicle osteolysis caused by repetitive microtrauma and osteopenia<div><br></br></div><div>steroids, resection (no more than 1 cm)</div>

Question 51

<div>RC 2012, 2010 - All of the following are true in patients with Adhesive Capsulitis, except ?</div>

<ol> <li>Associated with thyroid disease </li> <li>Relief with corticosteroid injection</li> <li>Favorable natural history for resolution</li> <li>Impingement test will be positive</li></ol>

Answer 51

“D<div><ul><ul> </ul> <li><div> <div> <div> <div>essential lesion involves the coracohumeral ligament and the rotator interval capsule</div> </div> </div></div></li><li>Transient pain relief with corticosteroid injections</li> <li>Natural resolution of symptoms with mild treatment/physio</li><li>surgical tx: MUA, capsular release (rotator interval)</li><li>Associated Conditions:</li><ul><li>Cardiovascular disease</li><li>Thyroid dysfunction/ACTH deficiency</li><li>Breast cancer treatment</li><li>Risk factors –> CVA, MI, DM</li><ul><li>DM has worse prognosis</li></ul><li>Minor trauma to limb</li><li>Heart Disease, cardiac surgery</li><li>Parkinsonism</li><li>Malignancy</li><li>Hyperlipidemia</li><li>Drugs –> MMP inhibitors (glaucoma), antiretroviral, pneumococcal/influenza vaccine, fluoroquinolones</li><li>Dupuytren’s contracture</li></ul></ul></div>”

Question 52

<div>RC 2018, 2016, 2013 - What is the best indication for non-operative treatment of a Pec Major injury?</div>

<ol> <li>If the intimal fascia is intact and attached to the medial antebrachial fascia</li> <li>Proximal tear in the muscle </li> <li>No cosmetic deformity when the muscle is at rest</li> <li>Inferior tear of the tendon because of the spiral orientation</li></ol>

Answer 52

B.<div><ul> <li>Orthobullets: Indications for Non-op treatment</li> <ul> <li>may be indicated for partial ruptures</li> <li>tears in themuscle or musculotendinous junction</li> <li>low-demand patients</li> </ul> <li>JAAOS – Pectoralis Major Tears</li> <ul> <li>Investing fascia is continuous with brachium and medial antebrachiam septum. can often be confused for an intact tendon on palpation (not option A)</li> <li>Indications for repair:</li> <ul> <li>Complete tears, myotendinous junction, tendon tears</li> </ul> </ul> <li>ElMaraghy AW (JSES 2011)</li> <ul> <li>Supports non-operative management of proximal muscle tears</li> </ul> <li>Also, two people wrote in to JAAOS after that Pec Major tendon article was published to say they treat all their muscle tears (not avulsions) non-op, including in power lifters, and they have good results</li></ul></div>

Question 53

<div>RC 2011 - Most common location of suprascapular nerve compression</div>

<ol> <li>suprascapular notch</li> <li>spinoglenoid notch</li> <li>quadrilateral space</li> <li>between scalene muscles</li></ol>

Answer 53

“A<div><div>The most common site is suprascapular notch, where it is compressed by a thickened or ossified transverse scapular ligament.</div></div><div>spinoglenoid notch may be more common in overhead athletes</div><div><img></img><br></br></div>”

Question 54

<div>RC 2015 - Dude with 3 weeks of shoulder pain; no history of trauma. Complains of pain at night and progressive weakness for the last week. MRI is normal except for diffuse edema in the infra and supraspinatus muscles</div>

<div>(1) Dx?</div>

<div>(2) What test helps to determine this?</div>

Answer 54

(1) Parsonage Turner Syndrome = brachial plexus neuritis =<b>neuralgic amyotrophy</b><div>(2) EMG</div><div><ul> <li>Acute denervation with PSW and fibrillations at 3-4 weeks</li> <li>May see chronic denervation at 3-4 months</li></ul><div>Note: MR can see high signal in plexus and muscles on T2 early</div></div><div><br></br><div><br></br></div></div>

Question 55

<div>RC 2018 - Which of the following nerve(s) can cause scapular winging?</div>

<ol> <li>Long thoracic</li> <li>Dorsal scapular</li> <li>Spinal accessory</li> <li>All of the above</li></ol>

Answer 55

“D.<div><div></div> Medial –> seratus anterior palsy (LTN)</div><div>Lateral –> trapezius palsy (Spinal Accessory CN XI) and Rhomboids, levator scapulae (Dorsal scapular nerve)<br></br></div><div><img></img><br></br></div>”

Question 56

<div>RC 2008 Young swimmer with shoulder pain. All are likely reasons except:</div>

<ol> <li>Muscle imbalance</li> <li>Subacromial impingement</li> <li>Multidirectional instability</li> <li>Hypovascularity of the supraspinatus</li></ol>

Answer 56

D<div>DDx:</div><div><ul> <li>Subacromial Impingement</li> <ul> <li>Occurs with hand entry (contact between posterior GT and posterosuperior glenoid)</li> <li>Narrow subacromial space (shoulder abducted and IR)</li> </ul> <li>Hyperlaxity:</li> <ul> <li>20% of swimmers hyperlax</li> <li>Unequal capsular stretching leads to micro-instability</li> </ul> <li>Scapular Dyskinesis</li> <ul> <li>Scapulothoracic muscle imbalance</li> <li>Scapular pronation stretches anterior capsule</li> <li>Peri-scapular muscles are used throughout stroke –> tendency to become fatigued</li> <ul> <li>But pectoralis major/minor not fatigued</li> </ul> </ul> <li>GIRD</li> <ul> <li>Tight posterior capsule</li> <li>GIRD >25o more likely to be symptomatic</li> </ul> <li>Labral Damage</li> <ul> <li>Anterior capsular laxity, instability</li> <li>Race diving may contribute to this</li> </ul> <li>Os Acromiale</li> <ul> <li>uncommon</li> </ul> <li>Suprascapular Neuropathy</li> <ul> <li>Secondary to scapular dyskinesis and infraspinatus hyper-contraction</li> </ul></ul></div>

Question 57

<div>RC 2018 Which is true about axillary nerve course</div>

<div>a. Posterior branch of axillary nerve supplies motor to teres minor but no sensory</div>

<div>b.Courses posterior to the subscap</div>

<div>c.Courses medial to the long head of triceps</div>

<div>d.Abduction brings the axillary nerve further away from the inferior aspect of the glenoid</div>

Answer 57

D<div><br></br></div><div><div>A- false. posterior nerve splits into branch to teres minor and superolateral brachial cutaneous nerve</div> <div>B-false. Courses anterior to subscap, and posterior to axilllary artery</div> <div>C-false. Courses lateral to LHT</div> <div>D- true. arm abduction to 90° decreases the distance between acromion and nerve by 30%</div></div>

Question 58

RC 2018 - List two steps in Laterjet that put nerves at risk the most?

Answer 58

<ul> <li>JSES 2018 Complications and Contraindications to Latarjet</li> <ul> <li>MOST are traction injuries of the SHORTEST nerves (MCN, axillary)</li></ul></ul>

<ul> <li>1% risk of nerve injury</li> <ul> <li><u>Corocoid harvest and placement</u></li> <ul> <li>Dissection around coracoid</li> <ul> <li>Always stay lateral to tendon</li> <li>Usually do not need to expose MSC or Ax nn. </li> </ul> <li>Osteotomy of corocaoid</li> <ul> <li>Put a chandler inferior and medial to coracoid</li> </ul> </ul> </ul> <ul> <li><u>Glenoid exposure</u></li> </ul></ul>

Question 59

RC 2018 - List 4 complications of Latarjet?

Answer 59

<u>Short-term</u><div>-nerve injury</div><div>-fracture</div><div>-non-union</div><div>-stiffness</div><div>-hardware prominence</div><div><br></br></div><div><u>Longterm</u></div><div>-recurrence of instability</div><div>-OA progression</div><div><br></br></div><div>ALWAYS: -infection,bleeding</div>

Question 60

RC 2018 Excluding active infection, list 3 contraindications to using a latissimus dorsi tendon transfer in the setting of a failed rotator cuff repair.

Answer 60

<ul> <li>Absolute</li> <ul> <li>Subscap dysfunction</li> <li>Advanced age</li> <li>Hamada Stage >2</li> <li>Compromised CA arch</li> <li>Anterosuperior escape</li> <li>Deltoid def</li> <li>Nerve injury</li> <li>Inability to comply with rehab</li> </ul> <li>Relative</li> <ul> <li>Partial subscap tear</li> <li>Fatty degen of teres minor</li> <li>AHI <7</li> <li>Moderate OA</li> <li>Pseudoaralysis</li> </ul></ul>

Question 61

<div>RC 2009 Posterior shoulder dislocation; all are true, except:</div>

<ol> <li>Pts can voluntarily dislocate their own shoulder</li> <li>Glenoid osteotomy is no longer indicated</li> <li>Surgery is often helpful</li> <li>Subluxation is more common than dislocation</li></ol>

Answer 61

“A.<div><br></br></div><div><div>Assx with MDI</div><div>Posterior bankart less common<br></br></div>Non-op is satisfactory, but surgery is helpful<div>Glenoid osteotomy - not indicated</div><div><br></br></div><div><b>-subluxation is more common than dislocation</b></div><div><b>-Pt’s can’t voluntarily d/l (also an MCQ)<br></br></b></div></div><div><b><br></br></b></div>”

Question 62

<div>RC 2018 - Which is true about axillary nerve course</div>

<div>a.Posterior branch of axillary nerve supplies motor to teres minor but no sensory</div>

<div>b.Courses posterior to the subscap</div>

<div>c.Courses medial to the long head of triceps</div>

<div>d.Abduction brings the axillary nerve further away from the inferior aspect of the glenoid</div>

Answer 62

D.<div><div>A- false. posterior nerve splits into branch to teres minor and superolateral brachial cutaneous nerve</div> <div>B-false. Courses anterior to subscap, and posterior to axilllary artery</div> <div>C-false. Courses lateral to LHT</div> <div>D- true. arm abduction to 90° decreases the distance between acromion and nerve by 30%</div></div>

Question 63

<div>RC 2015 - What is a static restraint of the GH joint?</div>

<div> a. CH ligament</div>

<div> b. CA ligament</div>

<div> c. biceps</div>

<div> d. negative intra-articular pressure</div>

Answer 63

D.<div><ul> <li>Pagnani MJ (JSES 1994) Stabilizers of the glenohumeral joint</li> <ul> <li>The coracohumeral ligament appeared to have no significant suspensory role</li> </ul><li>Static restraints</li> <ul> <li>glenohumeral ligaments - techincally CHL in this</li> <li>glenoid labrum</li> <li>articular congruity and version</li> <li><b>negative intraarticular pressure</b></li> <li>if release head will sublux inferiorly</li> </ul> <li>Dynamic restraints</li> <ul> <li>rotator cuff muscles</li> <li>rotator interval</li> <li>biceps long head</li> <li>periscapular muscles</li> </ul></ul></div><div><br></br></div>

Question 64

RC 2012 - 5 components of the SSSC

Answer 64

“<ul> <li>Glenoid</li> <li>Coracoid</li> <li>Coracoclavicular ligament</li> <li>Distal Clavicle</li> <li>Acromioclavicular ligament</li> <li>Acromion</li> </ul> <div></div> <div><img></img></div>”

Question 65

RC 2016 -All of the following medications for osteoporosis are anti-resorptive, except: <div>a. Risedronate</div> <div>b. Alendronate</div> <div>c. Denosumab</div> <div>d. Teraperitide</div>

Answer 65

D.<div><br></br></div><div><div>· <i>JAAOS 2004 – Parathyroid Hormone</i></div> <div> “approved antiresorptive treatments include the bisphosphonates alendronate and risendronate, raloxifene ( a selective estrogen receptor modulator) and calcitonin”</div> <div> “Unlike antiresorptive medications that reduce bone resorption, parathyroid hormone is an anabolic agent that enhances osteoblastic bone formation”</div></div>

Question 66

RC 2016 - What is true about tendon transfers for massive rotator cuff tears? <ol> <li>Pectoralis major transfer can be used for subscapularis deficiency </li> <li>A latissimus dorsi transfer is indicated for supraspinatus, infraspinatus and subscapularis deficiency </li> <li>When doing a pec major transfer, it should pass above the conjoint tendon </li> <li>?</li></ol>

Answer 66

“A.<div><br></br></div><div><div></div> <div>ANSWER: A</div> <ul> <li>2016</li> <li>JAAOS - Tendon Transfers for Irreparable Rotator Cuff Tears</li> <ul> <li>Latissimus for irreparable posterosuperior tears –> wouldn’t reach subscap</li> <li>Subcoracoid pectoralis major transfer better approximately the force vector originally provided by the subscap</li> <li>The pec major tendon gets transferred under the conjoined tendon for the transfer. If there is not enough space under the conjoined tendon, only a partial pec major tendon transfer can be done. The location of musculocutaneous nerve must be known because the pec major tendon should lie superficial to it (i.e. in a tunnel between the deep musc n. and the superficial conjoined tendon)</li> <li><img></img></li> </ul></ul></div>”

Question 67

<div>RC 2008 During an extensive rotator cuff repair, the subscapularis is released using the following releases EXCEPT</div>

<ol> <li>Superior margin released from coracoid</li> <li>Posterior surface is released from anterior capsule, superior glenoid neck, plexus</li> <li>Inferior border released from axillary nerve and circumflex vessels</li> <li>Anterior surface released from conjoint tendon</li></ol>

Answer 67

“<div>recall…</div><div><br></br></div><div>DO NOT release inferiorly</div><div><br></br></div><div>Based on Lo’s talk: you release sup, ant and post, but NOT inferior…</div> <div></div> <div>ANSWER: C</div><ul> <ul> <li>360o release</li> <ul> <li>Superior margin from coracoid</li> <li>Posterior surface from anterior capsule and scapular neck</li> <li>Inferior border from axillary nerve and circumflex vessels</li> <li>Anterior surface from conjoined tendon</li> </ul> </ul></ul>”

Question 68

<div>RC 2011 - List the 4 types of SLAP tears</div>

Answer 68

“<div><img></img><br></br></div><ul> <li>Labral fraying</li> <li>Fraying with detached biceps tendon anchor</li> <li>Bucket handle tear, intact biceps tendon anchor</li> <li>Bucket hand with detached biceps anchor (bucket extends up biceps)</li></ul><div><img></img><br></br></div><div><br></br></div>”

Question 69

RC 2011 - SC joint anterior dislocation. Best treatment? <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 69

“A (or C)<div><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><li>CR Technique</li> <ul> <li>Sedation or local or general anestheia</li> <li>Supine with 3 inch pad between shoulders</li> <li>Direct pressure on medial clavicle in posterior direction</li> <li>Immobilize in figure of 8 or Velpeau sling for 6 weeks</li> </ul></ul></div>”

Question 70

<div>RC 2014, 2008 - Which of the following is associated with thoracic outlet syndrome?</div>

<ol> <li>Positive Watson’s test</li> <li>Obesity</li> <li>Compression between anterior scalene and SCM</li> <li>Elevation of scapula</li></ol>

Answer 70

B.

Question 71

<div>RC 2014, 2016 - What is not true about internal impingement of the shoulder in a throwing athlete?</div>

<ol> <li>Results in full-thickness RC tear</li> <li>Treatment with sleeper stretches</li> <li>Tight posterior capsule</li> <li>Associated with mild shoulder instability</li></ol>

Answer 71

“A.<div><ul> <li>JAAOS 2007 - Understanding Shoulder and Elbow Injuries in Baseball</li> <ul> <li>Internal impingement has been through to have the following etiologies contributing: traction on biceps tendon, laxity of anterior band of IGHL caused by excessive external rotation stretch, posterior capsular tightness and scapular dyskinesia</li></ul></ul> <ul> <li>JAAOS - Posterior Capsular Contracture of the Shoulder:</li> <ul> <li>Non-operative treatment includes sleeper stretches</li> <li>Micro-instability is associated</li></ul></ul> <ul> <li>OKU Shoulder and Elbow:</li> <ul> <li>Regardless of their etiology, injuries to the throwing shoulder share many final sequelae, including <b>superior labrum anterior to posterior (SLAP) tears, proximal biceps pathology, partial thickness rotator cuff tears, and scapular dyskinesia</b></li> <li>"”Full thickness tears are uncommon, but partial thickness articular sided tears are almost ubiquitous in throwing athletes””</li> </ul></ul></div>”

Question 72

<div>RC 2017 - What is true about the definition of medial vs lateral scapular winging</div>

<ol> <li>Determined by position of superomedial border</li> <li>Determined by movement of inferior tip</li> <li>Determined by direction of movement by coracoid</li> <li>….</li></ol>

Answer 72

“A. JAAOS def’n<div><ul> <li>Scapular winging: anatomical review, diagnosis and treatments. Curr Rev Musculoskelet Med (2008) 1:1–11</li> </ul> <div><img></img></div> <div></div> <div>Orthobullets</div> <div>Two types based on direction of top-medial corner of scapula </div> <ol> <li>Medial winging = serratus anterior(long thoracic nerve)</li> <li>Lateral winging = trapezius (CN XI - spinal accessory nerve)</li></ol></div>”

Question 73

RC 2015 - Injury to which nerve is least likely to result in scapular winging? <div> a. Upper trunk (C5/C6)</div> <div> b. Nerve to subscapularis</div> <div> c. Long thoracic</div> <div> d. Spinal accessory</div>

Answer 73

B.<div><br></br></div><div><ul> <li>Primary - dysfunction to serratus anterior, trapezius, rhomboids, levator</li> <li>Secondary - intra-articular glenohumeral </li> <li>Long thoracic (C5-C7) = serratus anterior = medial winging</li> <li>Spinal accessory = trapezius = lateral winging</li></ul></div>

Question 74

RC 2016, 2012 - Patient has shoulder injury 1 month ago. Has weakness of shoulder abduction, numbness over shoulder radicular arm pain, and scapular winging. What is his injury? <ol> <li>Superior trunk</li> <li>C6 root</li> <li>Posterior cord</li> <li>?</li></ol>

Answer 74

B.<div><div>Scapular winging = long thoracic nerve, therefore must be at least root</div></div>

Question 75

<div>RC 2010 - Which patient will present with the sensation of instability</div>

<ol> <li>Suprascapular nerve palsy</li> <li>Rotator cuff tear</li> <li>Long thoracic nerve palsy</li></ol>

Answer 75

C.<div><br></br></div><div><div>For patients ultimately diagnosed with scapular winging, initial presentations and diagnoses included rotator cuff disorders (20%), glenohumeral instability (8%), peripheral nerve disorders (6%), cervical spine disease (6%), acromioclavicular disorders (6%), thoracic outlet syndrome (4%), and unknown or unspecified (41%).</div></div>

Question 76

<div>RC 2018 - In RTSA for fracture, healing of the tuberosities helps with what motion?</div>

<ol> <li>External Rotation</li> <li>Adduction</li> <li>Abduction</li> <li>Internal rotation</li></ol>

Answer 76

“A.<div><br></br></div><div><div><a>J Orthop Trauma.</a>2019</div> <div>Effect of Tuberosity Healing on Clinical Outcomes in Elderly Patients Treated With a Reverse Shoulder Arthroplasty for 3- and 4-Part Proximal HumerusFractures.</div> <div><br></br></div> <div>Greater tuberosity healing significantly influences ER and ER-type activities.</div></div>”

Question 77

“<div style="">RC 2018 - Regarding radiotherapy in spine metastasis, which is true</div><div> a. Radiotherapy is always effective</div><div> b. Radiotherapy is never effective</div><div> c. Radiotherapy following surgery is not useful</div><div> d. Radiotherapy before surgery has increased complications</div><br></br><div><div style="">RC 2018 - In a patient with metastatic spine lesion in the c-spine, symptomatic. What’s true?</div><div> a. radiotherapy alone is same as with surgery </div><div> b. Surgery followed by radiotherapy have better outcome</div><div> c. no role for radiotherapy</div><div> d. Radiotherapy alone is better</div><br></br></div>”

Answer 77

top: D; bottom: B<div><br></br></div><div><div>-FACT: surgery then radiation is best treatment</div><div><div><b>Thus, if surgery is considered, it is best performed before radiotherapy treatment is administered.</b></div><div><b>Preoperative radiotherapy and/or neurologic deficit place patients at higher risk of surgical complications.</b></div></div><br></br><div>- JAAOS 2015: Management of Metastatic Cervical Spine Tumors </div><div> • Radiosensitive tumors such small cell lung cancer, multiple myeloma, and lymphoma can be treated without surgery as long as no signs of neurologic deterioration or gross instability are present. </div><div> • Preoperative radiation therapy has been associated with wound complications and infections. </div><div> • Postoperative radiation can contribute to pseudarthrosis by inhibiting the development a fusion mass. </div><div> • Postoperative radiation can also contribute to dysphagia by causing scarring of the pharyngeal soft tissues.</div><br></br><div>- JAAOS 2011: Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management </div><div> • Patchell et al sparked renewed enthusiasm in surgery as first-line treatment of metastatic disease. In their prospective randomized multicenter trial, outcomes with decompressive surgery followed by radiotherapy were shown to be superior to those following radiotherapy alone. In this study, 50 patients were treated with surgery followed by radiotherapy, and 51 were treated with radiotherapy alone. Average survival was 126 days with surgical treatment plus radiotherapy versus 100 days with radiotherapy alone (P = 0.033). Neurologic function, which was assessed using the ASIA and Frankel scales, was maintained for an average of 566 days in the surgical group compared with an average of 72 days in the radiotherapy-only group (P = 0.001 and P = 0.0006, respectively). </div><div> • Notably, patients in the study by Patchell et al who were first treated with radiotherapy and who then crossed over to the surgical treatment arm had inferior clinical outcomes. <b>Thus, if surgery is considered, it is best performed before radiotherapy treatment is administered. </b></div><div><b>Preoperative radiotherapy and/or neurologic deficit place patients at higher risk of surgical complications.</b></div><br></br></div>

Question 78

RC 2016 -<b>What is the main disadvantage of using absorbable suture anchors for rotator cuff repair?</b> <div><b>a. </b><b>Infection </b></div> <div><b>b. </b><b>Reduced pull-out strength </b></div> <div><b>c. </b><b>Biological reaction </b></div> <div><b>d. </b><b>Modulus of elasticity?</b></div> <div></div>

Answer 78

“C<div><br></br></div><div><div>· Comparisons of the mechanical strength of bio absorbable and metal anchors have yielded mixed results; some studies report inferior biomechanical characteristics, whereas others report equivalent profiles””</div> <div>· ““additional evidence of inflammatory response to bio absorbable anchors, which may lead to bone osteolysis, chondral damage and significant morbidity has also been reported””</div></div>”

Question 79

What is true about double row rotator cuff repair vs. single row (RC 2019)?<div>A. Double row has better clinical outcomes</div><div>B. Double row has better healing</div><div>C. Double row has better (sooner?) ROM</div><div>D. Double row is mechanically superior and recreates footprint</div>

Answer 79

“<div><span>Answer: D</span></div><br></br><div><span>Ref: Wall LB, et al. Double-row vs single-row RCR: A review of the biomechanical evidence. JSES 2009</span></div><ul><li><div><span>The current literature reveals that the biomechanical properties of a double-row rotator cuff repair are superior to a single-row repair.</span></div></li></ul><br></br><div><span>Ref: Buess E Arthroscopy 2005, Verma NN Arthroscopy 2006</span></div><ul><li><div>Similar results with arthroscopic, mini-open and open repairs</div></li><li><div>Double row techniques:</div></li><ul><li><div>Medial row at articular margin</div></li><li><div>Lateral row is at lateral aspect of footprint</div></li></ul></ul><ul><li><div><span>Recreates more anatomic footprint</span></div></li></ul><ul><li><div>Repaired tendons are histologically and biomechanically inferior to normal enthesis</div></li><li><div>Supraspinatus footprint is 25mm A/P and 14.7 mm M/L</div></li></ul>”

Question 80

“<span>All of the following result in “limited instability” (i.e MADE MORE STABLE) reverse total shoulder instability, all are true except? (RC 2019)</span><div><span><br></br></span></div><div><span>A. Superior tilt of glenosphere by 10-15 degrees</span></div><div><span>B. Lateralization of the humerus</span></div><div><span>C. Limited humeral lengthening</span></div><div><span>D. Inferior translation of glenoid component</span></div>”

Answer 80

“Answer: A<div><br></br></div><div><ul><li><div>Dislocation increased risk with:</div></li><ul><li><div>Irreparable subscapularis (strongest risk)</div></li><li><div>Proximal humeral bone loss</div></li><li><div>Failed prior arthroplasty</div></li><li><div>Proximal humeral nonunion</div></li><li><div>Fixed glenohumeral dislocation pre-op</div></li><li><div><span>Not</span><span> related to condition of rotator cuff</span><br></br><br></br></div></li></ul></ul><div><span>REF: Char et al. </span><span>Instability in Reverse Total Shoulder Arthroplasty. </span><span>JAAOS Sept 2018</span></div><ul><li><div>A<span> larger glenosphere</span> diameter allows for an increase in abduction ROM, but data on its effect on stability are limited.</div></li><li><div>Various studies have suggested that <span>eccentric positioning on the </span><span>inferior</span><span> aspect of the glenoid</span>, creating an overhang, may reduce the incidence of adduction impingement and allows for approximately 11° to 39° of additional adduction.</div></li><ul><li><div>In a computer modelling study, inferior eccentric positioning was the <span>most important factor </span>preventing adduction impingement, and it has been shown to increase stability by 17%.</div></li></ul><li><div>Gutiérrez et al evaluated the stability of the glenosphere based on the abduction angle and concluded that an <span>inferior tilt </span>of 15° resulted in the <span>highest compressive forces</span> compared with 0° and 15° of superior tilt.</div></li><li><div>In a cadaver study, lateralizing the glenoid resulted in a stepwise increase in forces required for anterior dislocation in 5-, 10-, and 15-mm lateral offsets but at a cost of increased deltoid forces required for abduction, with a potential risk for acromial stress fractures and deltoid pain.</div></li><ul><li><div>Boileau et al. reported a 6% dislocation rate in 45 patients using a medialized COR and no dislocation in 42 patients using bony increased-offset rTSA Biomechanical and clinical data support improved stability with glenosphere lateralization.</div></li></ul><li><div>Lädermann et al. have shown improved active elevation with lengthening and a correlation between shortening and an increased dislocation risk.</div></li></ul></div>”