Sports - Upper Extremity Flashcards
1
Q
What is the rotator interval of the shoulder?
[DeLee & Drez’s, 2015]
A
- Triangular space formed by:
- Supraspinatus
- Subscapularis
- Glenoid
- Contents
- Coracohumeral ligament
- Superior glenohumeral ligament
- Joint capsule
2
Q
What is the critical shoulder angle (CSA)?
[JBJS REVIEWS 2018;6(8):e1]
A
- CSA is the angle between the plane of the glenoid fossa (the line from the inferior edge of the glenoid to the superior edge of the glenoid) and a line drawn from the inferior edge of the glenoid to the lateral edge of the acromion on a true anteroposterior (Grashey) shoulder radiograph
* Accounts for contributions from both glenoid inclination and lateral acromial length - Normal = 30-35°
- <30 = increased risk for GH arthritis
- Decreased CSA (<30°) increases compressive forces across the glenohumeral joint
- >35 = increased risk for rotator cuff tear
- Increased CSA (>35°) is thought to alter deltoid vectors, which results in increased superior shear forces on the rotator cuff muscles
3
Q
What is the epidemiology of rotator cuff tears?
[Clin Sports Med 31 (2012) 589–604]
A
- Full thickness tear is present in 25% of patients in their 60s and 50% of patients in their 80s
- 50% of patients >65 with a symptomatic full thickness tear will have an asymptomatic full thickness tear on the contralateral side
- 50% of asymptomatic tears develop symptoms in 2-3 years
- 50% of symptomatic tears increase in size
4
Q
What are the indications for surgery for rotator cuff tears? (Sports Med Arthrosc Rev 2018;26:129-133]
new
A
- Persistent pain despite nonoperative treatment (4-6 months)
- Options
- Decompression with arthroscopic acromioplasty +/- debridement
- Indication - impingement, low grade partial articular sided tear
- Rotator cuff repair
- Indication - symptomatic full-thickness tears, acute bursal-sided partial thickness tears that involve >25% of tendon thickness and partial articular sided tears involving >50% of tendon thickness
- Decompression with arthroscopic acromioplasty +/- debridement
5
Q
What is the primary function of the rotator cuff? [Operative Techniques in Orthopaedics, Vol 12, No 3, 2002: pp 140-155/
new
A
- The primary function of the rotator cuff is to balance the force couples about the glenohumeral joint
- Transverse plane force couple = subscapularis and posterior rotator cuff (infraspinatus, teres
minor) - Coronal plane force couple = deltoid and inferior rotator cuff (infraspinatus, teres minor,
subscap)
- Transverse plane force couple = subscapularis and posterior rotator cuff (infraspinatus, teres
- The primary goal of rotator cuff repair is to balance force couples
6
Q
Where is the ‘bare area’ located in the proximal humerus?
[J Am Acad Orthop Surg 2014;22:521-534]
A
- It is the triangular area between the humeral head articular surface and the medial margin of the posterior cuff insertion
- The superior apex of the triangle is where the supraspinatus and infraspinatus fibres converge
7
Q
Where does the rotator cuff re-tear or failure of healing occur?
[JAAOS 2017;25:e261-e271]
A
Tendon-bone interface
8
Q
Although adequate pain relief and patient satisfaction can be achieved in the absence of tendon healing following RTC repair, what are the benefits of tendon healing?
[JAAOS 2017;25:e261-e271]
A
- Higher strength
- Increased function
- Higher outcome scores
9
Q
What risk factors are associated with lower tendon-bone RTC healing following repair?
[JAAOS 2017;25:e261-e271]
A
- Increased age
- Osteoporosis (independent of age)
- Chronic rotator cuff tear
- Muscle atrophy
- Fatty degeneration
- Larger size
- Tobacco use
- Low initial fixation strength
- Larger gap
- High tension repair
10
Q
what is the goal of partial Rc repair when complete repair is not feasible in massive RC tears
A
balance the force couples about the GH joint (restores equilibirum, stability and function)
11
Q
what is the anatomy and function of the native GH superior capsule
new
A
- superior capsule lies between the rotator cuff and the joint space on the undersurface of supra and infra tendons
- attaches medially to the superior glenoid and laterally to the GT
- functions as a static stability to superior translation of the humeral head
- becomes disrupted with RC tears and loses its function
12
Q
what are the mechanisms by which superior capsular reconstruction is believed to work in the setting of massive RC tears
A
- soft tissue spacer (prevents contact between the humeral head and the undersurface of the acromion)
- trampoline effect (graft physically holds the humeral head inferiorly to improve acromiohumeral clearance)
- restores RC force couples
13
Q
what are the indications for superior capsular reconstruction?
new
A
- massive irreparable supraspinatus and/or infraspinatus tear
- minimal to no arthritis
- functioning deltoid
- not suitable for rTSA (young, active)
14
Q
what are graft choices recommended for arthroscopic superior capsular reconstruction
new
A
- fascia lata autograft (6-8mm thickness)
- dermal allograft (≥ 3mm thickness)
15
Q
how is the graft secured in an arthroscopic superior capsular reconstruction
new
A
- secured by multiple anchors medially at the superior glenoid rim and laterally at the GT
- posterior margin convergence between the superior capsule graft and infra or teres minor is also recommended (important for the RC force couple and ER)
16
Q
What are the classification systems used to describe RTC tears?
[J Am Acad Orthop Surg 2014;22:521-534]
A
- DeOrio and Cofield - rotator cuff tear size
- Measurement based on “length of the greatest diameter of the tear” (i.e. AP or ML)
- Small =0-1 cm
- Medium =1-3cm
- Large =3-5cm
- e. Massive =>5cm
- Patte classification – D**egree of retraction
- Stage 1 = lateral margin of cuff close to footprint area
- Stage 2 = lateral margin of cuff at level of humeral head
- Stage 3 = lateral margin of cuff at level of glenoid
- Goutallier Staging System – Fatty infiltration
- Stage 0 - normal muscle
- Stage 1 - some fatty streaks
- Stage 2 - amount of muscle is greater than fatty streaks (<50% fat)
- Stage 3 - amount of muscle is equal to fatty streaks (50% fat)
- Stage 4 - amount of muscle is less than fatty streaks (>50% fat)
- Thomazeau classification – Muscle atrophy
- Stage 1 - normal or slight atrophy
- Occupation ratio = 0.6-1
- Stage 2 - moderate atrophy
- Occupation ratio = 0.4-0.6
- Stage 3 - severe atrophy
- Occupation ratio = <0.4
- Ellman classification – Degree of partial thickness tear
- Grade 1 - tear <3mm in depth
- Grade 2 - tear 3-6mm in depth
- Does not exceed 50% of tendon thickness
- Grade 3 - tear >6mm in depth
- Involves > 50% of tendon thickness
- Snyder classification – Tear type
- Type A - Articular sided partial tear
- Type B - Bursal sided partial tear
- Type C - Complete tear
17
Q
What is the classification of rotator cuff tear shape proposed by Davidson and Burkhart; Describe repair of each shape?
[J Am Acad Orthop Surg 2014;22:521-534]
A
- Crescent-shaped
- Most common
- Excellent medial-lateral mobility allowing tension-free repair back to GT
- U-shape and V-shape
- Apex of tear extends farther medial toward glenoid
- Medial-lateral mobility is limited, anterior-posterior mobility is adequate
- Repair by “margin convergence”
- Suture free margins together converting tear into a smaller crescent tear
- L-shape and reverse L-shape
- Have both a transverse and longitudinal component
- L-shape tears propagate along the interval between the supraspinatus and infraspinatus
- Reverse L-shape tears propagate through the rotator interval
- One edge is more mobile than the other
- Repair by technique similar to “margin convergence”
4. Massive, contracted, immobile - L-shaped or U-shaped
- Immobile in both AP and ML direction
- Interval slide technique to enhance mobility
- Anterior interval slide
- Incise the superior margin of the rotator interval and the CHL at the corocoid base
- Posterior interval slide
- Incise the interval between supraspinatus and infraspinatus towards the scapular spine
- ***Suprascapular nerve at risk
- Anterior interval slide
- Management options [JSES 2015; 24, 1493-1505]
- Nonoperative management
- Arthroscopic debridement with biceps tenotomy or tenodesis
- Complete repair
- Partial repair
- Patch augmentation
- Superior capsular reconstruction
- Tendon transfer
- Reverse total shoulder arthroplasty
18
Q
What angle should a suture anchor be inserted to increase an anchors resistance to pullout?
A
45 degrees (the Deadman Angle)
19
Q
What is the definition of a ‘massive’ RTC tear?
[International Orthopaedics (2015) 39:2403–2414]
A
Various definitions exist:
- >5cm tear in either the A-P or M-L direction (Cofield)
- Complete tears of at least 2 RTC tendons (Gerber)
- Coronal length and sagittal width ≥2cm on MRI (Donaldson)
20
Q
What is the classification of massive rotator cuffs based on location?
[J Am Acad Orthop Surg 2013;21:492-501]
A
- Posterosuperior
* Involving the supraspinatus, infraspinatus, and possibly teres minor - Anterosuperior
* Involving the subscapularis and supraspinatus
21
Q
What factors should be considered when determining if a RTC tear is repairable or irreparable?
[J Am Acad Orthop Surg 2013;21:492-501]
A
- Size
- Retraction
- Fatty infiltration and atrophy
* Goutallier stage 3-4 = generally considered irreparable - Acromiohumeral distance
* <7mm = generally considered irreparable - Static vs. dynamic superior migration
* Static migration = generally considered irreparable
22
Q
What tendon transfers can be considered for irreparable RTC tears?
[J Am Acad Orthop Surg 2013;21:492-501]
A
- Latissimus dorsi for irreparable posterosuperior tears
- Pectoralis major for irreparable anterosuperior tears
23
Q
What is the classification system for fatty infiltration on CT/MRI?
[J Am Acad Orthop Surg 2013;21:492-501]
A
Goutallier Staging System
- Stage 0 - normal muscle
- Stage 1 - some fatty streaks
- Stage 2 - amount of muscle is greater than fatty streaks (<50% fat)
- Stage 3 - amount of muscle is equal to fatty streaks (50% fat)
- Stage 4 - amount of muscle is less than fatty streaks (>50% fat)
***Note – fatty infiltration is not reversible
24
Q
What factors contribute to retear rates after repair of massive RTC tears?
[J Shoulder Elbow Surg (2015) 24, 1493-1505]
A
- Increased fatty infiltration
- Decreased acromiohumeral space
- Smoking
- Size of the rotator cuff tear
- Increased tension on the repair
25
What are the indications for surgery for rotator cuff tears?
[Sports Med Arthrosc Rev 2018;26:129–133]
1. Persistent pain despite nonoperative treatment (4-6 months)
2. Options:
* Decompression with arthroscopic acromioplasty +/- debridement
* Indication
* Impingement
* Low grade partial articular sided tear
* Rotator cuff repair
* Indication
* Symptomatic full-thickness tears
* Acute bursal-sided partial thickness tears that involve \>25% of tendon thickness
* Partial articular-sided tears involving \>50% of tendon thickness
26
What patient factor predispose to developing calcific tendinitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
1. Female
2. Age (30-60)
3. Right shoulder \> left shoulder
4. Endocrine disorders
* Hypothyroidism
* Diabetes
* ?estrogen/menstrual disorders
4. Tendon overuse
27
Where are the calcific deposits most commonly found in calcific tendonitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
1. 5-2 cm from the insertion in the hypovascular zone of the superior cuff
* Most common tendon involved is the supraspinatus
28
Describe the pathogenesis of calcific tendinitis of the RTC and the three main stages described by Uhthoff and Loehr
[J Am Acad Orthop Surg 2014;22:707-717]
1. Calcific tendinitis of the RTC has a different pathogenesis than insertional RTC calcific tendinitis and calcific tendinitis at other sites (eg. Achilles, patellar tendon) which are degenerative
2. Calcific tendinitis of the RTC is an active, cell-mediated process (rather than degenerative)
3. Three main stages
* Precalcific stage
* Fibrocartilage metaplasia of the tendon in hypovascular zone
* Calcific stage
* Formative phase
* Calcific deposits form
* Resting phase
* Dormant
* Resorptive phase
* Calcific deposits replaced by fibroblasts and granulation tissue
* Most painful
* Postcalcific stage
29
What are the two commonly used radiographic classification systems for calcific tendonitis of the RTC?
[J Am Acad Orthop Surg 2014;22:707-717]
1. Gartner and Heyer
* Type I
* Well circumscribed, dense
* Type II
* Soft contour/dense or sharp/transparent
* Type III
* Translucent and cloudy appearance without clear circumscription
2. Mole et al (French Society of Arthroscopy)
* Type A
* Dense, homogenous, sharp contours
* Type B
* Dense, segmented, sharp contours
* Type C
* Heterogeneous, soft contours
* Type D
* Dystrophic calcifications at the insertion of the rotator cuff tendons
30
What are the radiographic features of cuff tear arthropathy?
[AAOS comprehensive review 2, 2014]
1. Superior humeral head migration
* Decreased acromiohumeral space
2. Acetabularization of the acromion
3. Femoralization of the humeral head
* Rounding of the GT
4. Eccentric superior glenoid wear
5. Osteopenia
6. Snowcap sign
* Subarticular sclerosis
7. Absence of the typical peripheral osteophytes
* Lack inferior and medial humeral head osteophytes
31
Describe ‘pseudoparalysis’ of the shoulder
[J Bone Joint Surg Am. 2012;94:e34(1-11)]
1. Defined as inability to actively elevate the arm in the presence of free PROM and in the absence of a neurologic lesion
2. Occurs as a result of superior migration of the humeral head due to unopposed deltoid contraction in the presence of a rotator cuff tear (loss of the inferior directed force)
32
What is the management of rotator cuff arthropathy?
[J Shoulder Elbow Surg (2009) 18, 484-494]
1. First line = nonoperative
* Physical therapy
* Injections
* Activity modification
2. Second line = surgery
* Shoulder arthrodesis
* Indication:
* Significant anterior deltoid deficiency
* Multiple previous surgeries
* Arthroscopic debridement
* Indication:
* Multiple medical co-morbidities
* High risk patient
* Hemiarthroplasty (typically CTA prosthesis)
* Indication:
* Intact deltoid
* Intact CA ligament
* FF \>90
* ER \>30
* rTSA
* Indication
* Intact deltoid
* Incompetent CA ligament
* Elderly, low demand
33
What is the blood supply to the glenoid labrum?
1. Suprascapular artery
2. Circumflex scapular artery
3. Posterior humeral circumflex artery
34
What are the 3 most common anatomic variants of the superior labrum?
[DeLee & Drez’s, 2015][AJSM 2012;41(2):444]
1. Buford complex
* Combination of an absent anterosuperior labrum with an associated “cordlike” middle glenohumeral ligament that attaches to the superior labrum near the base of the biceps tendon
2. Sublabral recess
* Potential space located under the biceps anchor and the anterosuperior portion of the labrum
3. Sublabral foramen
* Groove between the normal anterosuperior labrum and the anterior cartilaginous border of the glenoid rim
35
What is the classification system for SLAP tears?
[AJSM 2013;41(2):444]
1. Snyder classification – 4 types
* Type I
* Fraying and degeneration of the free edge of the superior labrum with an intact biceps anchor
* Type II
* Detachment of the superior labrum with detachment of the biceps anchor from the supraglenoid tubercle
* Morgan subclassification
* Anterior
* Predominant anterior detachment of the superior labrum–biceps tendon anchor
* Posterior
* Predominant posterior detachment of the superior labrum–biceps tendon anchor
* Anterior and posterior
* Combined anterior and posterior detachment of the superior labrum–biceps tendon anchor
* Type III
* Bucket handle tear of the superior labrum with an intact biceps anchor
* Type IV
* Bucket handle tear of the superior labrum with extension into the biceps tendon root
2. Maffet modification of Snyder classification
* Type V
* Anteroinferior capsulolabral separation (Bankhart lesion) + Type II tear
* Type VI
* Unstable labral flap + Type II tear
* Type VII
* Type II tear with extension into the capsule inferior to the MGHL
3. Moderresi modification
* Type VIII
* Type II tear with a posterior labral extension as far as the 6-o’clock position
* Type IX
* Type II tear with circumferential extension
* Type X
* Type II tear with a posteroinferior labral disruption (reverse Bankhart)
36
What is the most common type of labral tear based on Snyder’s original publication?
[J Am Acad Orthop Surg 2014;22:554-565]
Type II lesions were most common (55%)
* Followed by:
* Type I (21%)
* Type IV (10%)
* Type III (9%)
37
What is the general approach to treatment of each type of SLAP lesion?
[Knee Surg Sports Traumatol Arthrosc (2016) 24:447–455]
1. Nonoperative management is first line for all
2. Failure of nonoperative management can consider surgery
* Type I = debridement
* Type II = repair or biceps tenotomy/tenodesis
* Consider tenodesis for overhead athletes
* Consider tenotomy or tenodesis for age \>40
* Type III = debridement of bucket handle
* Repair labrum if necessary
* Type IV = debridement if there is \<50% of biceps tendon involved (repair labrum if necessary) OR tenotomy/tenodesis if there is \>50% of biceps tendon involved (repair/debride labrum if necessary)
* Type V = Bankart repair and labral repair
* Type VI = debride unstable flap and repair labrum
* Type VII = repair
38
What is the definition of a failed SLAP repair?
[J Am Acad Orthop Surg 2014;22:554-565]
Postoperative pain and/or stiffness (not associated with concomitant pathology) that does not resolve with nonsurgical measures
* A failed repair is characterized by symptoms that either never resolve or resolve postoperatively and return at a later date
39
What is the treatment algorithm for surgical management of failed SLAP repair?
[J Am Acad Orthop Surg 2014;22:554-565]
1. First line = nonoperative
2. Second line = surgery
* Revision SLAP Repair if:
* Patient \<30
* Overhead athlete
* No biceps pathology
* Diagnostic arthroscopy and biceps tenodesis if:
* Patient \>30
* Female
* Biceps pathology
* Cosmesis
* Diagnostic arthroscopy and biceps tenotomy if:
* Patient \>50
* Preoperative stiffness
* Poor tendon quality
40
Describe the impingement involved in subcoracoid impingement
[J Am Acad Orthop Surg 2011;19:191-197]
The subscapularis tendon or LHBT becomes impinged between the coracoid and lesser tuberosity of the humerus
41
What is the provocative shoulder position that causes subcoracoid impingement?
[J Am Acad Orthop Surg 2011;19:191-197]
Flexion, horizontal adduction, internal rotation
42
What factors/conditions can lead to primary or secondary subcoracoid impingement?
[J Am Acad Orthop Surg 2011;19:191-197]
1. Idiopathic
* Congenitally elongated or curved coracoid
* Calcification of the subscapularis tendon
* Ganglion cyst
2. Traumatic
* Fracture of humeral head and neck
* Malunion of coracoid or glenoid fracture
* Displaced scapular neck fracture
3. Anterior glenohumeral instability
4. Iatrogenic
43
What is internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
Condition characterized by repetitive or excessive contact between the greater tuberosity of the humerus and the posterosuperior glenoid when the arm is abducted and externally rotated leading to impingement of the adjacent rotator cuff (articular side of posterior supraspinatus and/or anterior infraspinatus) and labrum
44
What are the cardinal lesions of internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
1. Articular-sided rotator cuff tears
2. Posterosuperior labral lesions
45
What are the five structures at risk with internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
1. Posterosuperior labrum
2. Rotator cuff (articular surface)
3. Greater tuberosity
4. Posterosuperior glenoid
5. IGHL complex
46
What factors/pathologies contribute to the development of internal impingement?
[AJSM 2009; 37(5): 1024]
1. Anterior shoulder instability (attenuation of the AIGHL)
2. GIRD (GH internal rotation deficit)
3. SICK scapula
* Scapular malposition
* Inferior medial border prominence
* Coracoid pain and malposition
* dysKinesis of scapular movement
4. High glenoid anteversion
5. Low humeral head retroversion
47
What are four radiographic features associated with internal impingement of the shoulder?
[AJSM 2009; 37(5): 1024]
1. Exostosis of the posteroinferior glenoid rim
* AKA Bennett lesion
* Due to repetitive traction from the PIGHL and posterior capsule
2. Sclerotic changes of the greater tuberosity
3. Posterior humeral head osteochondral lesions or cystic “geodes”
4. Rounding of the posterior glenoid rim
48
What are the phases of throwing?
1. Wind up
2. Early cocking
3. Late cocking
4. Acceleration
5. Deceleration
6. Follow through
49
What is the critical point in the throwing cycle that injuries occur?
Transition between late cocking and acceleration phase
50
What anatomical structures are at risk during the late cocking phase of throwing?
1. Anterior capsule stretching
2. Coracohumeral ligament stretching
3. Internal impingement
* Posterosuperior rotator cuff
* Posterosuperior glenoid labrum
4. Biceps anchor
51
What is the muscle activity about the shoulder during late cocking and acceleration phases of throwing?
1. Late cocking
* Concentric contraction = infraspinatus, teres minor
* Eccentric contraction = pec major, lat dorsi, subscapularis
* Minimal supraspinatus activity
2. Acceleration
* Concentric contraction = pec major, lat dorsi, subscapularis
* Eccentric contraction = teres minor \> infraspinatus
52
What anatomical structures are at risk during the deceleration phase of throwing?
1. Posterior capsule stretch
2. Posterior rotator cuff stretch
53
What are the most important dynamic stabilizers of the thrower’s shoulder?
1. Rotator cuff
2. Long head of biceps
54
What are the common adaptive changes to the thrower’s shoulder?
1. Increased proximal humeral retroversion
* Normal = 33° dominant, 29°nondominant
* Throwers = 36.6°
2. Thickening of the PIGHL and posterior capsule
3. Attenuation of the AIGHL and anterior capsule
4. Sclerosis of the posterosuperior glenoid rim
5. Cystic changes in the posterolateral humeral head
6. Altered scapular position and motion
7. Alterations in total arc of motion
* At ≥25° loss of total arc GIRD is considered symptomatic
8. Alterations in kinematics
55
In the presence of a tight posterior inferior capsule which direction does the GH joint center of rotation shift (in thrower's shoulder)?
GH center of rotation shifts posterior and superior
56
What are the 3 groups of injuries seen in the thrower’s shoulder?
Group 1
* Internal impingement
* Pinching of the posterolateral rotator cuff and the labrum between the posterolateral portion of the greater tuberosity and the posterosuperior glenoid
* Presentation:
* Pain with abduction and ER
* Pathology:
* Rotator cuff injury at junction of supraspinatus and infraspinatus
* Tendinitis, tendinosis or partial articular supraspinatus tendon avulsion (PASTA)
* Posterosuperior labral injury
* Cystic changes in posterolateral tuberosity
* SLAP lesion with peel back of labrum posteriorly (not anteriorly)
* Tight posteroinferior capsule
Group 2
* Internal impingement + acquired secondary anterior instability
* Repetitive microtrauma to anterior structures results in stretching of AIGHL and anterior capsule leading to symptomatic instability
* Presentation:
* Deep anterior pain with late cocking and acceleration, 2+ anterior translation
* Pathology
* Anterior labral tears
* PASTA
Group 3
* Primary anterior or multidirectional instability
* Presentation:
* Extremity fatigue (“dead arm”) – instability as the rotator cuff fatigues
* Positive anterior apprehension, relocation, sulcus sign
57
What is the nonoperative management of thrower's shoulder?
1. All should trial nonop (90% respond)
2. Posterior capsular stretching (GIRD)
3. Scapular stabilization (address SICK scapula)
4. Rotator cuff strengthening
5. Address kinetic chain
58
What is the surgical management of thrower's shoulder?
Group 1 (Internal Impingement)
* Type I SLAP = debride
* Type II SLAP = repair
* Limit anchors to posterior to avoid limiting ER
* Partial thickness RCT \<50% = debride
Group 2 (Internal Impingement + 2o anterior instability)
* As group 1
* Drive through sign present = Plication of AIGHL
* Include ≥20% of anterior capsule in plication
Group 3 (1o Anterior instability or MDI)
* Instability = capsular shift
* So-called 270° repair involving the rotator interval and the anterior and posterior bands of the inferior glenohumeral ligament
59
What is the criteria for return to play following an in-season acute anterior shoulder instability event?
[J Am Acad Orthop Surg 2012;20:518-526]
1. Symmetric pain-free shoulder ROM and strength
2. Ability to perform sport specific skills
3. Absence of subjective or objective instability
60
What is the nonsurgical management of an acute in-season shoulder instability event?
[J Am Acad Orthop Surg 2012;20:518-526]
Week 1
* Simple sling use
* Shoulder adducted and internally rotated
* Cryotherapy
* Gentle ROM exercises
Week 2-3
* Dynamic stabilizer and periscapular strengthening
* Progress to supervised sport-specific training once strength and ROM are symmetric
Week 4
* Return to sport once able to perform sport specific skills
* Consider brace if sport permits
61
What are the indications for nonoperative management of acute traumatic shoulder instability?
[J Am Acad Orthop Surg 2012;20:518-526]
1. Injury characteristics
* Initial shoulder dislocation
* Osseous defects of the glenoid \<25%
* Osseous defects of the humeral head \<25%
* Absence of fracture or soft-tissue injury that requires surgery
2. Player- and sport-specific characteristics
* Athlete desires return to sport in season
* Nonoverhead or nonthrowing athlete
* Athlete plays a noncontact sport
* Athlete can complete sport-specific drills without instability
62
What are the indications for early in-season surgery for anterior shoulder instability?
[J Am Acad Orthop Surg 2012;20:518-526]
1. Absolute Indications
* Associated Injury
* \>50% rotator cuff tear
* Glenoid osseous defect \>25%
* Humeral head articular surface osseous defect \>25%
* Proximal humerus fracture requiring surgery
* Irreducible dislocation
* Interposed tissue or nonconcentric reduction
* Failed trial of rehabilitation
* Inability to tolerate shoulder restrictions
* Inability to perform sport-specific drills without instability
2. Relative Indications
* \>2 shoulder dislocations during the season
* Overhead or throwing athletes
* Contact sport athletes
* Injury near the end of the season
* Age \<20 years
63
How do you manage bone loss in shoulder instability?
## Footnote
Hill-Sachs
Reverse Hill-Sachs
Anterior Glenoid
Posterior Glenoid
Hill Sachs Lesion
* \<20% = Soft tissue Bankhart OR glenoid bone augmentation
* 20-40% = Remplissage OR disimpaction/bone graft
* \>40% = Osteochondral allograft (young) OR prosthesis (old)
Reverse Hill Sachs
* \<20% - McLaughlin procedure OR soft tissue Bankhart repair
* 20-40% - Modified McLaughlin procedure OR disimpaction/bone graft OR osteochondral allograft
* \>40% - Osteochondral allograft (young) OR prosthesis (old)
Anterior Glenoid
* \<10% = Soft tissue Bankhart
* 10-20% = Soft tissue Bankhart +/- glenoid bone augmentation
* \>20% = Glenoid bone augmentation (Latarjet, ICBG, distal tibial allograft) OR ORIF if acute bony bankhart
Posterior Glenoid
* \<10% = Soft tissue Bankhart repair
* 10-20% = Soft tissue Bankhart repair +/- glenoid bone augmentation
* \>20% = Glenoid bone augmentation (ICBG or distal tibial allograft) OR ORIF if acute bony
64
What is the Hill Sachs lesion?
[J Am Acad Orthop Surg 2012;20:242-252]
A compression fracture of the posterosuperolateral humeral head
* Occurs in association with anterior instability or dislocation of the GH joint
65
What is an engaging Hill Sachs lesion?
[J Am Acad Orthop Surg 2012;20:242-252]
1. Occurs when the humeral head defect engages the rim of the glenoid while the shoulder is in a position of athletic function
2. In an engaging lesion, the long axis of the humeral head defect is oriented parallel to the anterior glenoid rim and thus engages with it when the shoulder is in abduction and external rotation
66
What is a reverse Hill Sachs lesion?
[J Am Acad Orthop Surg 2012;20:242-252]
A compression fracture of the anterosuperomedial humeral head that occurs in association with a posterior shoulder dislocation
* Typically more extensive articular cartilage damage compared to Hill Sachs lesion proper
67
What is the dedicated radiographic view best suited for evaluating for a Hill Sachs lesion?
[J Am Acad Orthop Surg 2012;20:242-252]
Stryker notch view
* Patient supine
* Cassette under affected shoulder
* Palm of hand on affected side placed on top of head with fingers pointing posterior
* Elbow points straight up
* Beam is centred over coracoid and angled 10 deg cephalad
68
What factors should be considered when determining if the Hill Sachs lesion is clinically significant?
1. Size
2. Engaging/nonengaging
3. Location
4. Orientation of lesion
5. Extent of concomitant glenoid bone loss
69
Historically, what size of Hill Sachs lesion is clinically significant (as % of humeral head articular surface)?
[J Am Acad Orthop Surg 2012;20:242-252]
\<20% = rarely clinically significant
20-40% = depends on factors described
* Size
* Engaging/nonengaging
* Location
* Orientation of lesion
* Extent of concomitant glenoid bone loss
\>40% = almost always clinically significant
70
What is the ‘glenoid track’ and what is an ‘on-track lesion’ and an ‘off-track’ lesion?
[J Shoulder Elbow Surg 2007;16:649-656][Clinics in Orthopedic Surgery 2015;7:425-429]
1. The glenoid track is a zone of contact between the glenoid and the humeral head that extends from inferomedial to superolateral portion of the humeral head as the arm elevates from 0-60° of abduction with maximum external rotation and horizontal extension
* The width of the glenoid track is determined by the width of the glenoid
* Thus bone loss narrows the glenoid track
* The width of the glenoid track is 84% of the width of the glenoid (in the absence of bone loss)
2. An ‘on-track lesion’ describes a Hill Sachs lesion that remains within the glenoid track through abduction ROM and does not engage
3. An ‘off-track lesion’ describes a Hill Sachs lesion where the medial margin travels outside the glenoid track and engages on the anterior glenoid rim
\*\*\*Note: The location of the Hill Sachs lesion AND the width of the glenoid determine engagement
* Rather than size or depth of the Hill Sachs lesion alone
71
What are the surgical options available to address Hill Sachs lesions?
[J Am Acad Orthop Surg 2012;20:242-252]
1. Capsular shift
2. Glenoid bone augmentation
* Coracoid transfer or iliac crest bone grafting
* Prevent engagement of the Hill Sachs defect
3. Humeral head bone augmentation
4. Tissue filling (remplissage)
* Surgical technique in which a bony intra-articular defect is converted to an extra-articular defect with soft-tissue coverage, with the goal of preventing engagement
* Indication:
* Moderate to large Hill-Sachs defects associated with glenoid defects of \<20% to 25%
5. Disimpaction (i.e. Humeroplasty)
* Involves elevating the impaction fracture and supporting it with bone graft
* Indication:
* Acute lesions \<3 weeks old and with \<40% involvement of the articular surface
6. Resurfacing and prosthesis replacement
* Indication:
* Older or less active patients with defects involving \>40% of the articular surface and/or significant articular cartilage degeneration
\*\*\*Note: Most clinically significant Hill-Sachs injuries may be successfully managed by addressing the primary instability problem, that is, labral tear and/or glenoid bone loss
* Thus, glenoid-side techniques are usually adequate
* However, several surgical techniques manage the Hill-Sachs lesion directly.
72
What are the surgical options available to address a reverse Hill Sachs lesion?
1. Modified McLaughlin procedure
* Involves an open transfer of the subscapularis tendon and lesser tuberosity to fill the humeral head defect
2. Fresh osteoarticular allograft
3. Prosthetic reconstruction for large lesions (\>40%)
73
What is the frequency of glenoid defects following anterior shoulder dislocation?
[JAAOS 2018;26:e207-e218]
20% first time dislocation
* Up to 90% of recurrent dislocations
74
Where are glenoid rim defects typically located?
[JAAOS 2018;26:e207-e218]
Centered around the 3-o’clock position and oriented parallel to the superior-inferior axis of the glenoid
75
What is the dedicated radiographic view best suited for evaluating glenoid bone loss?
[J Am Acad Orthop Surg 2009;17:482-493]
West Point
* Patient prone
* Affected shoulder on a pad raised approx 8cm
* Head and neck turned away from involved side
* Cassette is held against the superior aspect of the shoulder
* Beam is centred on the axilla and angled 25 degrees from midline and 25 degrees downward from horizontal
76
What are two methods to assess amount of glenoid bone loss?
[JAAOS 2018;26:e207-e218]
Based on CT 3D reconstruction with humeral head subtraction
* Surface area = best fits circle
* Width
77
What size of glenoid bone defect is significant?
[JAAOS 2018;26:e207-e218]
1. Biomechanical studies = 21-30%
2. Clinical studies = as low as 13.5%
78
What are the treatment options for glenoid bone loss?
[JAAOS 2018;26:e207-e218]
1. Arthroscopic or open bony Bankhart repair
2. Coracoid transfer
* Open vs. arthroscopic
* Bristow vs. Latarjet
3. Autograft iliac crest
* Tricortical vs. bicortical
* Open vs. arthroscopic fixation
4. Allograft
* Glenoid
* Distal tibia
79
What is the algorithm for management of glenoid bone loss?
[JAAOS 2018;26:e207-e218]
1. Glenoid bone loss \>25%
* Acute fragment present = fragment repair (ORIF)
* No acute fragment present = glenoid bone graft
2. Glenoid bone loss \<25%
* If high risk patient or off-track humeral lesion:
* Consider glenoid bone graft if bone loss 13.5-25%
* If not high risk patient or off-track humeral lesion:
* Soft tissue procedure or nonsurgical treatment
80
What are high risk patient factors for recurrent shoulder?
[JAAOS 2018;26:e207-e218]
1. Young age
2. Male sex
3. Failed previous soft-tissue procedures
4. Competitive athletic activity
5. Hyperlaxity
81
What is the optimal position for the coracoid transfer in a Latarjet procedure?
[Arthrosc Tech. 2017 Jun; 6(3): e791–e799]
Anterior inferior between the 3-and 5-o’clock position flush with the glenoid articular surface
* Lateralization = degenerative changes
* Medialization = graft resorption and lack of stability
82
Describe the Latarjet procedure?
[Arthrosc Tech. 2017 Jun; 6(3): e791–e799.]
1. Beach chair position
2. Standard deltopectoral approach
3. Identify and harvest the coracoid process
* Protect the musculocutaneous nerve and axillary nerve throughout
* Expose from tip to CC insertion at the base
* Transect the coracoacromial ligament 1cm from the coracoid insertion
* Pectoralis minor is released
* Perform a medial-to-lateral osteotomy at the base just anterior to the CC ligaments
* Ensure a graft of ~2.5cm is harvested
4. Prepare the coracoid graft
* Preserve the CA ligament stump and conjoint tendon – debride the remaining soft tissue
* Decorticate the undersurface
* Two drill holes are made in the graft ~1cm apart
5. Prepare the glenoid
* A subscapularis split is performed at the superior 2/3 and inferior 1/3 junction
* L-shaped capsulotomy is performed
* The anterior-inferior glenoid neck is exposed and prepared with a burr
6. Coracoid transfer
* The graft is positioned with the longitudinal axis superior/inferior on the glenoid neck (tip inferior), flush with the articular surface between the 3-and 5-o’clock position
* The graft is fixed by two 3.5mm cortical screws or 4.0 cancellous screws in lag fashion
7. Closure
* Capsule is repaired with incorporation of the CA ligament
* Subscapularis split is closed
83
Describe the key points for an arthroscopic Bankhart repair?
1. Diagnostic arthroscopy
2. Posterior portal and two anterior working portals
3. Glenoid preparation
* Capsulolabral complex is mobilized off the glenoid neck with an elevator
* The glenoid rim and neck are prepared with a burr
4. Anchor placement
* A minimum of 3 anchors are placed
* Located on the glenoid face
* All below the 3-o’clock position
* Angled 45° relative to the glenoid rim
5. Capsulolabral plication
* A curved suture passer is used to pierce the capsule just distal to the anchor
* Sutures are tied from inferior to superior with each suture creating a capsular shift superiorly
* Result is decreased capsular volume and a capsulolabral “bumper”
84
What mechanisms are commonly associated with posterior shoulder dislocations?
[JAAOS 2014;22:145-152]
1. Seizures and Electrocution
* Pectoralis major and latissimus dorsi overpower the external rotators
2. High energy trauma
* Shoulder flexed, adducted and internally rotated
85
In what percentage of patients is the diagnosis of posterior GH joint dislocation missed or delayed? [JAAOS 2014;22:145-152]
79%
86
What ligaments are responsible for providing resistance to posterior translation?
[JAAOS 2014;22:145-152]
1. Coracohumeral ligament and superior glenohumeral ligament
* Limit posterior translation when shoulder is flexed, adducted and internally rotated
2. Posterior band of the inferior glenohumeral ligament
* Limits posterior translation when shoulder is abducted
87
What muscle provides the greatest dynamic resistance to posterior humeral translation?
[JAAOS 2014;22:145-152]
Subscapularis
88
What is the clinical presentation of acute posterior GH joint dislocation?
[JAAOS 2014;22:145-152]
1. Shoulder is internally rotated
2. Corocoid is prominent
3. Posterior axilla is full
4. Block to external rotation
89
What are indirect radiographic signs of posterior GH dislocation?
[JAAOS 2014;22:145-152]
1. Lightbulb sign
* Fixed internal rotation of the humeral head which takes on a rounded appearance
2. Trough line
* On AP two parallel lines in the superomedial aspect of the humeral head represent a reverse Hill Sachs
* Medial line is the subchondral bone and the lateral line is the margin of the compression fracture
3. Loss of the half moon sign
* Normally on AP there is a “half-moon” overlap between the humeral head and the glenoid
90
What is the imaging modality of choice for quantifying the humeral head bone defect?
[JAAOS 2014;22:145-152]
CT
91
What are the associated injuries with a posterior GH joint dislocation?
[JAAOS 2014;22:145-152]
1. Bony
* Fracture of neck, LT or GT (in decreasing order)
* Reverse Hill-Sachs
2. Soft tissue
* Rotator cuff tears
* Posterior labral tears
* Reverse Bankhart
* Periosteal sleeve avulsions
* Posterosuperior tears
* Avulsed capsule
* Long head of biceps tendon tear
3. Nerve
* Axillary nerve palsy (rare)
92
What are the treatment options for posterior GH joint dislocations?
[JAAOS 2014;22:145-152]
1. Supervised neglect
* Indication:
* Elderly low demand patient where pain is minimal and anterior elevation activities are sufficient for ADLs
2. Isolated closed reduction
* Indication:
* Reverse Hill-Sachs ≤20% that is stable after reduction
3. Isolated open reduction
* Indication:
* Unsuccessful closed reduction
* Technique:
* Anterior approach (deltopectoral)
* Open rotator interval and insert finger to aid in reduction
* If unsuccessful perform formal arthrotomy
4. McLaughlin procedure
* Indication:
* Reverse Hill-Sachs lesion ≤20% with persistent instability following reduction
* Technique:
* Subscapularis is lifted off the LT and transposed into the defect or left intact and sutured into the bed of the defect
5. Modified McLaughlin procedure
* Indication:
* Reverse Hill-Sachs lesion 20-40%
* Technique:
* LT osteotomy is transferred into the defect after joint reduction
6. Anterior approach, disimpaction and bone grafting
* Indication:
* Reverse Hills-Sachs lesion 20-40%
* Technique:
* Fracture is disimpacted and iliac crest bone graft is inserted subchondral for support
7. Posterior Open Bankhart repair
* Indication:
* Irreducible posterior GH dislocation or persistent instability after closed reduction with reverse Hill-Sachs ≤20%
* Technique:
* Judet incision with access to the joint either through an infraspinatus tenotomy or between infraspinatus and teres minor
8. Arthroscopic Posterior Bankhart repair
* Indication:
* Reverse Hill-Sachs lesion ≤20% with persistent instability following reduction
9. Hemiarthroplasty
* Indication:
* Reverse Hill-Sachs \>40% in patients aged \>55 or are not good candidates for graft incorporation
93
What position is the shoulder braced following any type of treatment pf posterior GH dislocation?
[JAAOS 2014;22:145-152]
20°of external rotation and abduction for 4 weeks
94
What are risk factors for posterior GH joint dislocation recurrence?
[JAAOS 2014;22:145-152]
1. Young age (\<40)
2. Seizure
3. Large reverse Hill-Sachs lesion (\>1.5cm3)
95
What is the difference between posterior glenohumeral joint acute dislocation and instability?
[JAAOS 2017;25:610-623]
1. Acute dislocation is a single traumatic event
2. Instability is most commonly due to repetitive microtrauma
96
What are the different etiologies of posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Acute trauma
* Posterior-inferior dislocation or subluxation
2. Repetitive microtrauma
* Most common etiology of recurrent posterior shoulder instability
* Eg. bench press, swimming, football linemen blocking
3. Insidious onset
* Least common etiology
* Predisposition in patients with generalized ligamentous laxity
4. Voluntary
* Voluntary position:
* Instability defined by subluxation in a provocative position (usually flexion and IR)
* Voluntary muscular:
* Instability occurs with arm in adducted position (habitual)
97
What are the static and dynamic stabilizers resisting posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Posterior labrum
2. Posterior capsule
3. Glenoid and humeral head
4. Rotator interval (SGHL, CHL, MGHL, LHBT)
5. Rotator cuff
98
What is the most common presenting symptom in patients with posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Deep pain in posterior shoulder joint
2. Often associated with worsening athletic performance and endurance
99
What physical examination maneuvers can be performed for posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Kim test
2. Jerk test
3. Posterior stress test
4. Load and shift
5. Sulcus sign
100
What is the management of posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Nonoperative
* Atraumatic posterior shoulder instability
2. Operative
* Traumatic posterior shoulder instability
* Failure of nonoperative management
101
Based on bone loss, what is the operative management of posterior GH joint instability?
[JAAOS 2017;25:610-623]
1. Posterior glenoid bone loss \<10%:
* Arthroscopic labral repair with posterior-inferior capsule plication as needed
2. Posterior glenoid bone loss 10-20%:
* As above +/- bone augmentation
3. Posterior glenoid bone loss \>20%:
* Arthroscopic or open posterior-inferior glenoid bone augmentation with ICBG or distal tibial allograft
102
What is the postoperative management after stability of posterior GH instability?
[JAAOS 2017;25:610-623]
1. Sling with 30° abduction pillow and shoulder in neutral rotation for 6 weeks
2. During the 6 weeks start pendulum and limited passive ROM
3. After 6 weeks discontinue sling and start AROM
4. Return to full activities at 4-6 months
103
What is the definition of MDI of the shoulder?
[Sports Med Arthrosc Rev 2018;26:113–119]
Symptomatic subluxation or dislocation of the glenohumeral joint occurring in \>1 direction
104
What is the etiology MDI of the shoulder?
[Sports Med Arthrosc Rev 2018;26:113–119]
1. Generalized ligamentous laxity
* With or without congenital disorders (Ehlers-Danlos, Marfans, etc.)
2. Repetitive microtrauma
* Repetitive overhead activities (eg. swimmers, weightlifters, gymnasts, etc)
105
What is the common anatomical finding in MDI of the shoulder?
[Sports Med Arthrosc Rev 2018;26:113–119]
Patulous inferior capsule
106
What are the physical exam tests for MDI of the shoulder?
[Sports Med Arthrosc Rev 2018;26:113–119]
1. Load and shift
* Patient supine, axial load applied then humerus translated anterior and posterior
* Grade 1
* Humeral head translation to the glenoid rim
* Grade 2
* Humeral head translation over the glenoid rim with spontaneous reduction
* Grade 3
* Humeral head subluxation over the glenoid rim requiring manual reduction
2. Sulcus sign
* Grade 1 - acromiohumeral distance \<1 cm
* Grade 2 - 1 to 2 cm
* Grade 3 - \>2 cm
3. Anterior apprehension test
4. Apprehension-relocation test
5. Posterior jerk test
* Performed with the arm in flexion, adduction, and internal rotation
* Axial force is applied to the humerus, which can cause a posterior subluxation or “clunk” of the humeral head over the glenoid rim
107
What is the management of MDI of the shoulder?
[Sports Med Arthrosc Rev 2018;26:113–119]
1. Nonoperative
* First line
* Comprehensive rotator cuff and scapular stabilization rehab (6 months)
2. Operative
* Indicated after failure of nonoperative
* Open inferior capsular shift
* Deltopectoral approach
* T-capsulotomy
* Inferior flap is shifted superiorly and superior flap inferiorly
* Arthroscopic inferior capsular shift
* Anterior inferior and posterior inferior capsular plications are made to reduce the capsular volume
108
What is the innervation of the AC joint?
[J Am Acad Orthop Surg 2009;17:207-219]
1. Suprascapular nerve
2. Lateral pectoral nerve
3. Axillary nerve
109
How much does the distal clavicle rotate relative to the acromion?
[J Am Acad Orthop Surg 2009;17:207-219]
5-8 degrees
110
What are the static and dynamic stabilizers of the AC joint?
[J Am Acad Orthop Surg 2009;17:207-219][JAAOS 2018;00:1-9]
1. AC joint capsule
2. AC ligaments
* Anterior, posterior, superior and inferior ligaments
* Function – anterior and posterior stability
3. Coracoclavicular ligaments
* Conoid ligament (medial)
* 35mm from lateral clavicle to center of conoid ligament
* Ratio of 0.24 with respect to clavicular length
* Trapezoid ligament (lateral)
* 26mm from lateral clavicle to center of trapezoid ligament
* Ratio of 0.17 with respect to clavicular length
* Function – superior stability
4. Anterior deltoid and trapezius
111
What is the normal distance between the coracoid and clavicle (CC interspace)?
[J Am Acad Orthop Surg 2009;17:207-219]
1. 1 - 1.3cm
* Rockwood classification traditionally based on the CC distance
112
Describe the Rockwood Classification of AC joint injuries?
[J Am Acad Orthop Surg 2009;17:207-219]
Type I
* Radiographic CC distance = normal
* AC ligament = sprained
* CC ligament = intact
Type II
* Radiographic CC distance = \<25% increase
* AC ligament = disrupted
* CC ligament = sprained
Type III
* Radiographic CC distance = 25-100% increase
* AC ligament = disrupted
* CC ligament = disrupted
Type IV
* Radiographic CC distance = increased
* AC and CC ligaments = disrupted
* Posterior clavicle displacement
* AC joint not reducible
Type V
* Radiographic CC distance = 100-300% increased
* AC and CC ligaments = disrupted
* AC joint not reducible
Type VI
* Radiographic CC distance = decreased
* AC ligament = disrupted
* CC ligament = intact
* AC joint not reducible
* Subcoracoid clavicle displacement
113
What radiographs should be included when evaluating the AC joint?
[J Am Acad Orthop Surg 2009;17:207-219]
1. AP shoulder
2. Axillary
3. Zanca views (15 degree tilt)
\*\*\*Ideally with unaffected shoulder views for comparison
114
What is the maneuver to assess for reducible AC joint?
[JAAOS 2018;00:1-9]
1. Superior directed force on the elbow, shoulder or scapula
2. Inferior directed force on the clavicle
115
What types of AC joint injuries should be managed nonoperatively and by what means?
[J Am Acad Orthop Surg 2009;17:207-219] [JAAOS 2018;00:1-9]
1. Types
* Type I
* Type II
* Type III
* Nonop vs Op
* No difference in strength, pain, overhead activities, AC arthritis
* Quicker recovery with faster return to work/sport with nonop but worse cosmetic result
* Type V with \<2cm AC joint separation
* Controversial, nonop return to work/ADLS with lower PROMs
* \*\*\*COTS trial (2015) – for III/IV/V, nonop get better faster with fewer complications
2. 1-2 weeks of immobilization followed by progressive ROM and strengthening
* Avoid contact sports and heavy lifting for 2-3 months (until symptoms resolve)
116
What are the indications for surgery in AC joint injuries?
[J Am Acad Orthop Surg 2009;17:207-219] [JAAOS 2018;00:1-9]
1. Failure of nonoperative management (all types)
2. Type III
* ≥2cm of AC displacement
* Young patients
* High shoulder demanding job or sport
* Chronic symptoms of instability and pain
* \*\*\*Nonop vs Op
* No difference in strength, pain, overhead activities, AC arthritis
* Quicker recovery with faster return to work/sport with nonop but worse cosmetic result
3. Type IV
4. Type V \>2cm AC joint displacement
* With nonop treatment, can return to work/ADLs but may have lower PROMs
5. Type VI
6. Medial-lateral instability
* Demonstrated by overriding of the clavicle and acromion on cross arm AP radiograph
7. Open injury
8. Associated neurological deficits
117
What complications can follow nonoperative treatment of AC joint injuries?
[J Am Acad Orthop Surg 2009;17:207-219]
1. AC joint arthrosis
2. Instability
3. Distal clavicle osteolysis
118
What are the 3 categories of surgical techniques for AC Joint Injuries?
[JAAOS 2018;00:1-9]
1. AC fixation
2. CC fixation
3. Ligament reconstruction
119
What is the difference in management of acute vs. chronic AC joint injuries?
[JAAOS 2018;00:1-9]
Acute
* Joint reduction is maintained to allow native ligaments to heal
* Stabilize joint via repair or reconstruction
Chronic
* High grade – requires ligament reconstruction
* Reconstruction preferred because soft tissues don’t allow for repair
* Low grade – distal clavicle excision
120
What surgical techniques are available for management of AC joint injuries?
[J Am Acad Orthop Surg 2009;17:207-219] [JAAOS 2018;00:1-9]
1. Distal clavicle excision (5mm)
* In isolation for failed nonop Type I and II
* Combined with other procedures if chronic AC separation is not reducible
2. Hook plate
3. Bosworth CC screw +/- ligament reconstruction
4. Synthetic (suture) loops +/- ligament reconstruction
5. Weaver-Dunn ligament reconstruction
* CA ligament transfer from acromion to distal clavicle
* Sabre incision
* Distal clavicle excision
* CA ligament released from acromion
* With or without bone block
* Clavicle is reduced and stabilized with suture/tape around coracoid base
* CA ligament is passed into the canal of the distal clavicle and fixed with nonabsorbable suture passed through drill holes and tied over a bone bridge
6. Ligament reconstruction with semitendinosus autograft or tibialis anterior allograft
* Anatomic reconstruction of the conoid and trapezoid ligament
* +/- reconstruction of posterosuperior AC capsule
**\*\*\*No single technique has been shown to be superior**
* Anatomic reconstrucitons biomechanically superior to nonanatomic recons, but ↑risk of clavicle/coracoid fracture
121
What complications are associated with CC ligament reconstruction?
[JAAOS 2018;00:1-9]
1. Loss of reduction (early or late)
* Up to 53%
2. Clavicle fracture
* Up to 18%
3. Coracoid fracture
* Up to 20%
4. Infection
* Up to 6%
5. Total complication rates
* Up to 53%
122
what are the components of the lateral collateral ligament of the elbow
1. lateral ulnar collateral ligament
* inserts on the supinator crest
2. radial collateral liagement
* inserts on the annular ligament
3. annular ligament
* inserts on the supinator crest
4. accessory lateral collateral ligament
* inserts on the supinator crest
123
What is the primary ligament injured that leads to PLRI of the elbow?
[AJSM 2013; 42(2): 485]
Lateral ulnar collateral ligament (LUCL)
avulses off lateral epicondyle typically
124
Describe the resulting posterolateral rotatory instability of the elbow following LUCL injury
[AJSM 2013; 42(2): 485]
Transient external rotatory subluxation of the ulna on the humerus with posterior and valgus displacement
* Secondarily the radiocapitellar joint subluxes or dislocates (while the radioulnar joint remains intact)
125
What is the mechanism of injury of LUCL and resulting PLRI?
[AJSM 2013; 42(2): 485]
FOOSH injury with:
* Axial compression
* Supination
* Valgus
126
What is the staging of PLRI based on degree of capsuloligamentous disruption?
[AJSM 2013; 42(2): 485]
3 stages that correspond to ligament disruption (described by O’Driscoll):
* Stage 1
* Subluxation of the elbow in a posterolateral direction
* Stage 2
* Subluxation of the elbow joint with the coronoid perched underneath the trochlea
* Stage 3
* Complete dislocation with the coronoid resting behind the trochlea
* Stage 3a
* Includes the posterior band of the MCL tear
* Stage 3b
* Includes the anterior and posterior bands of the MCL tear
Circle of Horii
* Stage 1 – LUCL disrupted
* Stage 2 – remaining LCL and anterior/posterior capsule
* Stage 3a – posterior MCL
* Stage 3b – complete MCL
127
What are the components of medial UCL of the elbow
- anterior bundle
- most important for stability (resists valgus), inserts on sublime tubercle (anteromedial facet of coronoid)
- posterior bundle
- transverse bundle
128
What is the presentation of UCL injuries in throwing athletes?
[JAAOS 2014;22:315-325]
1. Vague medial elbow pain
2. Decreased pitching velocity and accuracy
3. Pain in late cocking and acceleration phases
129
What are the physical examination tests that should be performed for a UCL injury of the elbow?
[JAAOS 2014;22:315-325]
1. GIRD
2. Scapular dyskinesia
3. Lack of terminal elbow extension
4. Ulnar nerve
* Tinel sign
5. Valgus stress test with 30° flexion
* Positive = \>2mm gapping compared to contralateral elbow
6. Milking maneuver
* Shoulder 90°, elbow 90°, forearm supinated, examiner pulls thumb creating valgus force
* Positive = pain
7. Moving valgus stress test
* Shoulder 90°, elbow taken from full flexion to 30° with valgus force applied to elbow
* Positive = max pain between 70 and 120°
130
What imaging should be obtained to assess a UCL injury of the elbow?
[JAAOS 2014;22:315-325] [JBJS 2017;99:76-86]
1. Radiographs
* AP
* Lateral
* Bilateral stress views
2. MRA
* MRA more accurate than MRI
* T-sign is seen when a pathologic amount of dye leaks down along the sublime tubercle but is contained under the superficial fibers of a partially torn UCL.
131
What are preventative strategies to avoid UCL injuries in pitchers?
[JAAOS 2014;22:315-325] [JBJS 2017;99:76-86]
1. Limit pitching to 100 innings in a calendar year
2. Do not pitch for multiple teams
3. Do not pitch all year (3 month rest period advised)
4. No pitching on consecutive days
5. No pitching in a game or practice after being removed from a game
6. No breaking pitches (curveballs/sliders) until puberty
7. Proper pitching mechanics and year round conditioning should be stressed
8. Avoid pitching while fatigued
132
What is the initial management of UCL in throwing athletes?
[JBJS 2017;99:76-86]
1. Nonoperative
* All patients should be treated initially nonoperatively
2. Protocol
* 3 month cessation of throwing
* Followed by progressive strengthening and throwing mechanics analysis
* Graduated throwing program
* Return to play when pain free and graduated throwing program completed
133
What are the indications for surgery for UCL injuries in throwing atheletes?
[JBJS 2017;99:76-86]
1. Failure of nonoperative treatment
2. Desire to return to sport
3. Medial instability or full thickness UCL tear on MRI
4. Willing to comply with rehabilitation
134
What is the role of UCL ligament repair in throwing atheletes?
[JBJS 2017;99:76-86]
1. UCL reconstruction is the gold standard
2. UCL repair can be considered in proximal or distal UCL tears in the acute phase
135
What are the two main approaches to UCL reconstruction in throwing athletes?
[JAAOS 2016;24:135-149]
1. Figure-of-8 technique
* Jobe/modified Jobe technique
2. Docking technique
136
Describe the classic Jobe UCL reconstruction
[JAAOS 2016;24:135-149]
1. Graft source
* Ipsilateral palmaris longus
* Contralateral gracilis if absent PL
2. Approach
* Flexor-pronator mass detachment
3. Ulnar nerve management
* Submuscular transposition
4. Ulnar fixation
* Anterior and posterior tunnels drilled relative to sublime tubercle
5. Humeral fixation
* ‘Y-pattern’ tunnel in medial epicondyle
6. Graft fixation
* Figure-of-8 passage
* Tensioned and sutured to self
137
What are the modifications to the Jobe UCL reconstruction?
[JAAOS 2016;24:135-149]
1. Flexor-pronator split (instead of detachment)
2. Flexor-pronator elevation (instead of detachment)
3. Subcutaneous ulnar nerve transposition (not submuscular)
* Using slip of medial intermuscular septum as a sling
4. Ulnar nerve transposition only if preoperative symptoms or subluxation
138
Describe the docking technique for UCL reconstruction in throwing athletes
[JAAOS 2016;24:135-149]
1. Graft source
* Same as Jobe (Ipsilateral PL, contralateral gracilis)
2. Approach
* Flexor-pronator split or elevation
3. Ulnar fixation
* Same as Jobe (Drill holes in sublime tubercle)
4. Humeral fixation
* Single anterior tunnel in medial epicondyle
* Two small tunnels from superior on the medial epicondyle to the single anterior tunnel
* Posterior limb is passed into the humeral tunnel and tensioned
* The anterior limb length is estimated, cut, then passed into humeral tunnel
* Sutures tied over bone bridge
139
How might the graft length determine which UCL reconstuction procedure is performed in a throwing athelete?
[JAAOS 2016;24:135-149]
1. Graft length ≥15cm = modified Jobe
2. Graft length \<15cm = docking technique
140
What are the alternative techniques for UCL reconstruction in a throwing athelete?
[JAAOS 2016;24:135-149]
1. Hybrid technique
* Ulnar tunnel = same as Jobe (Drill holes in sublime tubercle)
* Humeral fixation is with 2 suture anchors
2. DANE TJ
* Humeral tunnel = same as docking (Single anterior tunnel)
* Ulnar fixation = single tunnel with interference screw
141
what is the underlying histopathology in lateral epicondylitis
tendinosis (degenerative condition) rather than tendinitis (inflammation)
142
what are the histological findings in lateral epicondylitis
- angiofibroblastic hyperplasia
- characterized by dense populations of fibroblasts, vacular hyperplasia and disorganized collagen
143
what tendon is most commonly implicated in lateral epicondylitis
ECRB
144
P/E tests for lateral epicondylitis
- maudsley test
- resisted middle finger extension
- resisted wrist extension with elbow in full extension and pronation
- postitive - pain at lateral elbow
- chair test
- patient lifts a chair with the shoulder forward-flexed, elbow extended and forearm pronated
- positive - pain at lateral elbow
145
DDx for lateral epicondylitis
cervical radiculopathy, PIN entrapment, OCD of capitellum, anconeus inflammation and edema, PLRI of elbow, radiocapitellar arthritis
146
recommended management of lateral epicondylitis
1. first line - nonop
1. most resolve without surgery
1. 80% resolve in 6 months and 90% resolve after 1 year
2. consider - rest, eccentric exercises, couterforce braces, NSAIDs, prp injection, perc radiofrequency thermal treatment, ESWT, low level laser, botox
2. second line - operative
1. open surgery
1. involves direct lateral approach, debridement of degenerated ECRB tendon +/- tendon repair, +/- tendon lengthening, +/- drilling or decortication of the epicondyle to stimulate blood flow
2. arthroscopic surgery
1. debridement and release of ECRP from inside out
147
what is valgus extension overload
- describes collection of injuries in the medial, lateral and posterior aspects of the overhead thrower’s elbow
- occurs as a consequence of the large valgus loads and rapid elbow extension during the throwing motion
148
what are the mechanics by which the pathology develops in valgus extension overload
1. medially - repetitive near-tensile failure loads result in microtrauma to the anterior band of the UCL - male lead to ligament attenuation of failure
2. lateral - overload of the radiocapitellar joint in compression occurs due to the large forces and valgus instability
3. posterior - combined balgus and forceful extension cause posteromedial impingement between the olecranon and olecranon fossa and trochlea
149
what are pathologies that develop as a resultof the repetitive trauma in valgus extension overload
- posterior
- posteromedial olecranon osteophytes
- kissing lesions - chondromalacia of the olecranon fossa and posteromedial throchlea
- loose bodies
- transverse proximal olecranon process stress fracture
- lateral
- chondromalacia
- chondral/osteochondral fracture
- osteophytes
- loose bodies
- medial
- ucl attenuation or tear
- medial epicondylitis/apophysitis, ulnar neuritis
150
what are the common presenting symptoms of valgus extension overload in over head thrower’s
1. decreased performance (velocity, control, fatigue)
2. elbow pain
3. locking/catching (loose bodies)
4. ulnar nerve symptoms 9neuritis, subluxation)
151
what are the special tests to perform in the evaluation of valgus extension overload
- extension impingement test
- elbow is snapped into terminal extension
- simultaneous application of valgus stress often increases the pain, whereas varus stress decreases the pain
- positive - pain in the posterior compartment
- arm bar test
- patient’s shoulder at 90° of FF, full IR, with the patient’s hand placed on the examiner’s shoulder
- examiner pulls down on the olecranon, simulating forced extension
- positive - pain
152
what are nonop and op indications in the management of valgus extension overload
- first line - nonop
- second line - surgical treatment is indicated for the patients who have persistent symptoms despite nonsurgical treatment a desire to return to the same level of competition
153
what is the recommended surgical procedure for valgus extension overload syndrome
1. open or arthroscopic
1. posteromedial olecranon osteophyte resection (limited to osteophyte only)
2. removal of loose bodies
3. +/- open UCL reconstruction
