Upper Extremity

Question 1

What is the Walch classifciation of shoulder OA

Answer 1

• Type A: Concentric wear, no subluxation, well centered
  
  • A1 minor erosion
  • A2 deeper central erosion
• Type B: Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
  
  • B1 narrowing of posterior joint space, subchondral sclerosis, osteophytes
  • B2 posterior wear, biconcave glenoid
• Type C: Glenoid retroversion of more than 25 degrees (dysplastic in origin) and posterior subluxation of humerus

Question 2

What imaging do you want for primary OA

Answer 2

• Radiographs
  
  • AP/true AP
  • • subchondral sclerosis
      
      • osteophytes at inferior aspect of humeral head - “goat’s beard”
      • look for superior migration of head to indicate cuff deficiency
      • look for evidence of previous surgery (staples)
      • look for medialization that occurs in inflammatory arthritis (RA = concentric wear)
        
        • osetopenia, margican erosions, cysts
  • Can use IR and ER also to look at the osteophystes and template the size of the canal
  • Axillary
    
    • posterior glenoid wear
    • posterior humeral head subluxation
    • Version of the glenoid
      
      • draw a line along the scapula
      • humeral head is used as neutral
      • then calculate the difference between glenoid and humeral head
• CT
  
  • indicated in inflammatory arthritis if large bony defects are present on radiographs
  • Need to quantify the amount of posterior glenoid wear
• MRI
  
  • may be indicated to evaluate rotator cuff tendon

Question 3

What are the indications and contraindications for a total shoudler arthroplasty

Answer 3

• indications
  
  • unresponsive to nonoperative treatment
  • progressive pain
  • decreased ROM
  • inability to perform activities of daily living
• contraindications
  
  • deltoid dysfunction
  • insufficient glenoid stock
  • rotator cuff arthropathy
• outcomes
  
  • literature shows decreased rate of revision surgery when compared to hemiarthroplasty

Question 4

What’s your differntial for a stiff shoulder

Answer 4

• Adhesive capsulitis
  
  • pain with limited ROM
• spondyloarthropathy/gout
• RA
  
  • most common inflammatory affecting the shoulder
  • central glenoid wear with periarticular erosions and cysts
• posterior shoulder dislocation
• Primary OA/RCA
• Secondary OA
  
  • previous surgery
• AVN shoulder
• Tumor

Question 5

Mechanisms of RC tears

Answer 5

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• Overhead throwing athletes
  
  • partial thickness rotator cuff tears are associated with internal impingement
  • deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears
• Mechanisms include
  
  • chronic degenerative tear
    
    • usually seen in older patients
    • usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may extend anteriorly to involve the superior margin of subscapularis tendon in larger tears
  • acute avulsion injuries
    
    • acute subscapularis tears seen in younger patients following a fall
    • acute SIT tears seen in patients > 40 yrs with a shoulder dislocation
    • full thickness rotator cuff tears need to be repaired in throwing athletes
  • iatrogenic injuries
    
    • due to failure of surgical repair
    • often seen in repair failure of the subscapularis tendon following open anterior shoulder surgery.

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Question 6

How do you characterize an RC tear

Answer 6

• PASTA vs compete
  
  • 14mm, can characterize whether bursal or articular
• Size<!--StartFragment-->
  
  • Small 0-1
  • Moderate - 1-3
  • Large 3-5
  • Massive > 5
• Shape
  
  • U, cresent, L, Massive
• Degree of retraction
• Goutillier Fatty infiltration<!--StartFragment-->
  
  • 0 - Normal
  • 1 - Some fatty streaks
  • 2 - More muscle than fat
  • 3 - Equal amounts fat and muscle
  • 4 - More fat than muscle
• Fuchs Muscle atropy
  <!--EndFragment--><!--StartFragment-->
  
  • Mild (0.6-1 occupancy; grade 1) - at the tangent line
  • Moderate (0.4-0.6 occupancy; grade 2) - just below
  • Severe (<0.4 occupancy; grade 3) - very minimal
  • Also know as a negative tangent sign
    
    • Zanettic tangent line
• <!--EndFragment-->​Characterize the subsap
• <!--EndFragment-->​Characterize the biceps

Question 7

What is the anatomy and biomechanics of the RC

Answer 7

<!--StartFragment-->

• rotator interval
  
  • capsule, SGHL, and the coracohumeral ligament
• rotator crescent
  
  • ​ thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions.
• rotator cable
  
  • thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons.<!--EndFragment--><!--StartFragment-->
• t**he primary function of the rotator cuff is to provide dynamic stability by balancing the force couples about the glenohumeral joint in both the coronal and transverse plane. **
• coronal plane
  
  • ​the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions to balance the superior moment created by the deltoid
  • The rotator cuff pulls the humerus down, while the deltoid pulls it up
  • If you loose the rotator cuff, when you try to abduct, you will just pull the humerus up and not be able to abduct
• transverse plane
  
  • the anterior cuff (subscapularis) functions to balance the posterior moment created by the posterior cuff (infraspinatus and teres minor)
  • this maintains a stable fulcrum for glenohumeral motion.
  • When you have a subscapularis tear, you can no longer pull the humeral head anteriorly
• You fire the deltoid and the posterior cuff, the humeral head migrates up but is not able to fully flex
• This is called - pseudoparalysis
• the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes.

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Question 8

What are the JAAOS recommendations for cuff tears

Answer 8

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• *There is no role in treating asymptomatic tears
• *There is no good or bad evidence for specific exercise programs or non-op treatments
• *There is no good indications for acute vs chronic treatment
• *open and arthroscopic are equivocal
• *should not use porcine intestine for repair
• *no evidence for abduction pillow vs standard sling
• *no conclusive evidence when to start rehab

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Question 9

Treatment considerations for RC Tear? What is your pre-op work-up?

Answer 9

activity and age of patient
mechanism of tear (degenerative or traumatic avulsion)
characteristics of tear (size, retraction, muscle atrophy)
partial thickness tears vs. complete tear
articular sided (PASTA lesion) vs. bursal sided

• History
  
  • ​where is the pain, excaerbating factors
  • assocaited weakness, neck pain, radiculopathy
  • previous trauma, previous treatment
  • function, activity, vocation
  • PMHx, smoker, drinker
• Physical
  
  • ​Look - shoulder assymetry, previous scars, swelling, atrophy, winging
  • Feel - palpate for location of pain
  • Move
    
    • ​AROM FF, AB, ER, IR
      
      • assess for winging
    • PROM
  • ​RC tests
    
    • ​jobe, ER, ER lag or excess ER, IR, Lift off, belly press, horn blowers
  • Bicipital Irritaiton - speeds, yeargons
  • Impingement - hawkins, neer
    
    • Internal impingement
• ​​XR
  
  • ​True AP, lateral, Ax
  • Supraspinatous outlet
  • IR, ER, Stryker Notch
• ​U/S
  
  • ​dynamic, cheap
• ​MRI
  
  • ​much more sensitive to show you all the pathology

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Question 10

Treatment options for RC tear

Answer 10

<!--StartFragment-->

• **physical therapy, NSAIDS, and subacromial corticosteroid injections **
  
  • Cortisone injections have not been shown to be beneficial
  • indications
    
    • first line of treatment for most tears
    • grade 1 & 2 partial tears can be managed with therapy
    • Massive tears retracted past the glenoid
  • technique
    
    • physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening
    • subacromial injections if impingement thought to be major cause of symptoms
• ******The repair is based more on whether the cuff will heal, not whether you can repair it. **
• **arthroscopic or open rotator cuff repair **
  
  • indications
    
    • bursal-sided tears >3 mm
    • articular sided supraspinat tears >7mm
  • Intra-op
    
    • Look for the comma sign associated with a subscap tear
      
      • Will also see a bear LT with subsap retracted anteriorly
    • Fix the subscap first if torn
    • Do your biceps tenotomy/tenodesis
      
      • >50%, signficant symptoms
      • lipstick=inflammed
      • medial subluxation
    • Then debride the bursa, bone and trephanate the GT
    • Perform double row repair
  • Postoperative
    
    • rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity, which is believed to take 8-12 weeks
    • postop with limited passive ROM (no active ROM)
  • Outcomes
    
    • Worker’s Compensation patients report worse outcomes
    • higher postop disability and lower patient satisfaction
  • Acrominal Decompression
    
    • _​_only if they have a T3 acromion
• **Augmentation Procedure - **massive cuff tears
  
  • Latissimus Dorsi transfer: best for irreparable posterosuperior tears with intact subscapularis
    
    • More indicated in young workers
    • Has the most excursion
  • Contraindication
    
    • Subscap tear
      
      • can stage it, and do the subscap first

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Question 11

Procedures to faciliate RC repair

Answer 11

Marginal convergence

Anterior or posterior interval slide

Question 12

When would you consider operative treatment for proximal biceps tear

Answer 12

• indications
  
  • >50% tears
  • Medial subluxation with or without cuff tear
  • Type II or IV SLAP lesion
  • “lipstick” or inflammed tendon during diagnostic arthroscopy
    
    • Needs to be done with a dry joint because the pressure can wash out the appearance
• technique
  
  • Beachchair, spider
  • Posterior portal, anterior portal - diagnostic scope
    
    • Stress the biceps - internal rotation will displace the tendon medially
    • Pull the biceps into the joint to assess for tendonitis
  • Tenotomy
    
    • Release the tendon
    • Make sure there is no fraying so it doesn’t get caught
    • No rehab required
  • Tenodesis
    
    • Intra-articular/arthroscopic
      
      • Clear the bicipital groove of debris
      • Suture anchor at the entrance of the sheath
    • Open subpectoral
      
      • Anterior incision just inferior to the pec
      • Release the delto-pec fascia and elevate the pec to identify the bicipital groove
      • Debride the groove and place a suture anchor at the top of the groove
      • Non-absorbable suture krachow threw the tendon with one as a post
    • Rehab - as per tendon, no active elbow flexion or supnation for 6 weeks
    • Sling 3-4 weeks, building on shoulder ROM
• Complications
  
  • Pop-eye
  • Continued pain
  • Infection
  • Proximal humerus fracture

Question 13

Complications of biceps tenodesis

Answer 13

<!--StartFragment-->

Pop-eye
Continued pain
Infection
Proximal humerus fracture

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Question 14

Biceps tenodesis vs tenotomy

Answer 14

Outcomes and complications are similar

may have decrease cramping and improve cosmesis with tenodesis

Question 15

Factors associated with cuff re-tear

Answer 15

<!--StartFragment-->

The patient

> 65
Diabetes
Smoking
Non-compliance with PT

The tear

Massive tear
Moderate/severe atrophy
>50% fatty infiltration
>2.5 cm retraction after mobilization or medial to glenoid on pre-op MRI

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Question 16

What are your options for a re-torn RC

Answer 16

<!--StartFragment-->

• Partial repair - only if you think it might heal and the shoulder is balanced
  
  • • younger
  • no pesudoparalysis
  • no medical issues
• Hemiarthroplasty - intact coracohumeral arch and no pseudoparalysis
• RTSA - older patient with pseudoparalysis

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Question 17

Complications associated with RC repair

Answer 17

• Recurrence
  
  • patient age >65 years is a risk factor for non-healing of rotator cuff repair
• Deltoid detachment
  
  • complication seen with open approach
• AC pain
• Axillary nerve injury
• Suprascapular nerve injury
  
  • may occur with aggressive mobilization of supraspinatus during repair
• **Infection **
  
  • less than 1% incidence
  • Usually common skin flora: staph aureus, strep, p.acnes
  • Propionoibacterium acnes is the most commonly implicated organism in delayed or indolent cases
• Stiffness
  
  • Physical therapy and guided early range of motion exercises are not shown to reduce stiffness one-year post-operatively

Question 18

Management of massive rotator cuff repair

Answer 18

1. Arthroscopic, tension free repair
   
   • interval slide
   • marginal repair
   • assess the pattern of the tear
   • Extensive release and debridement with double row fixation
2. Debridement, assess for other pathology
3. Assess the biceps

Question 19

Work-up for stiff elbow

Answer 19

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• Symptoms
  
  • may or may not be painful
  • unable to perform activities of daily living
  • loss of elbow flexion and extension 30-130
  • locking, catching
  • previous trauma, surgeries
  • PMHx, smoker
• Physical exam
  
  • inspection
    
    • examine the skin around the elbow
    • scars from previous surgeries
    • inflammation
  • range of motion
    
    • measure elbow flexion/extension, pronation/supination
  • neurological
    
    • assess ulnar nerve function
      
      • position and function<!--EndFragment--><!--StartFragment-->
• Radiographs
  
  • serial radiographs
    
    • if heterotopic ossification is noted
  • findings
    
    • dependent on pathology causing stiffness/contractures
    • Loose bodies, old fracture, OA, HO…
• CT scan
  
  • indications
    
    • loose bodies in joint
    • non-unions
    • joint incongruity
    • abnormal bony anatomy
• MRI
  
  • rarely indicated

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Question 20

Differential diagnosis for stiff elbow

Answer 20

<!--StartFragment-->

• intrinsic causes
  
  • joint incongruity
  • synovitis
  • loose bodies
  • intra-articular fractures
  • osteochondritis dissecans
  • post-traumatic arthritis
• extrinsic causes
  
  • formation of eschar following a burn
  • heterotopic ossification
  • adhesions/contraction of the capsule
  • myositis ossificans
  • ligament contractures

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Question 21

Options for treatment of elbow stiffness

Answer 21

• NSAIDs, therapy with active and passive range of motion exercises
  
  • indications
    
    • first line of treatment in most cases
    • contractures <40 degrees
    • Should be attempted for 3-4 months prior to surgical treatment
• Operative
  
  • Want to restore function to 30-130
• Arthroscpic treatment
  
  • Contraindications to arthroscopic treatment
    
    • Extensive scarring, burning
    • Severe flexion contracture
    • Bridging HO
  • Relative
    
    • Ulnar nerve tranposition
      
      • Must be done for patients with < 90 deg ROM
    • Lack of pronation/supnation (must be addressed open)
• Open capsular release
  
  • indications
    
    • extrinsic capsular contractures
    • patients with arthritis
    • Restrictions in sup/pro
  • Ulnar nerve must be transposed if flexion <90 deg
• distraction interpositional arthroplasty
  
  • intrinsic contractures with diffuse arthritis in high demand younger patients
• total elbow arthroplasty
  
  • intrinsic contractures with diffuse arthritis in low demand elderly patients
  • outcomes
    
    • high failure rate in young, active patients
    • permanent 5-lb lifting restriction
• musculocutaneous neurectomy
  
  • neurogenic contractures with a flexion deformity of less than 90 degrees
• Nerve transposition
  
  • if > 30 deg will be acheived
  • if < 90 deg of flexion

Question 22

What are the portals for elbow arthroscopy?

Answer 22

• Proximal anterolateral
  
  • 2cm proximal, 1cm anterior to lateral epicondyle
  • Radial n.
• Distal anterolateral
  
  • 1 cm anterior and 1-3cm distal to lateral epicondyle
  • 1st portal for supine position
  • See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa
  • Radial and lateral antebrachial cutaneous
• Direct lateral (or midlateral)
  
  • “soft spot” portal (in triangle formed by olecranon, radial head, epicondyle)
  • Initial site for joint distension before scope is inserted, viewing posterior compartment (capitellum, radial head, radioulnar articulation)
  • relatively safe, lateral antebrachial cutaneous nerve
• Anteromedial
  
  • 2 cm anterior and 2cm distal to medial epicondyle.
  • Place under direct visualization.
  • medial antebrachial cutaneous and median
• Proximal medial (or superomedial)
  
  • 2cm proximal to medial epicondyle, anterior to intermuscular septum
  • viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea
  • ulnar and median
• Straight posterior (transtriceps)
  
  • 3cm proximal to olecranon, triceps midline (musculotend. junction)
  • Elbow partially extended, good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment
  • posterior antebrachial cutaneous and ulnar nerve
• Posterolateral
  
  • 2-3 cm proximal to olecranon and just lateral to triceps
  • center of anconeus triangle
  • Elbow 20-30deg flexion (to relax triceps)
  • Best access to posterior compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures
  • posterior antebrachial cutaneous and medial brachial cutaneous and ulnar

Question 23

Indications and contraindications to elbow arthroscopy

Answer 23

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• Indications
  
  • loose body removal
  • osteophyte debridement
  • synovectomy
  • capsular releases for stiffness
  • osteochondritis dissecans of capitellum
  • lateral epicondylitis
• Contraindications
  
  • prior trauma
  • surgical scarring
  • previous ulnar nerve transposition
    
    • ulnar nerve subluxation is not a contraindication, but it should be identified prior to surgery
• Advantages
  
  • improved articular visualization
  • decreased postoperative pain
  • faster postoperative recovery
• Disadvantages
  
  • technically demanding
  • high risk of damage to neurovascular structures due to proximity to the joint

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Question 24

Complications of elbow arthroscopy

Answer 24

<!--StartFragment-->

• Nerve palsy (1-5%)
  
  • greatest risks for nerve palsy
    
    • underlying rheumatoid arthritis
    • elbow contracture
  • nerves
    
    • transient ulnar nerve palsy (most common)
    • radial nerve palsy (second most common)
  • mechanism
    
    • direct injury
      
      • trocars and instrumentation
      • failure to use blunt dissection (neuromas)
    • indirect injury
      
      • compartment syndrome (aggressive distension, fluid extravasation)
      • local anesthesia extravasation (transient)
• Joint ankylosis/ heterotopic ossification
  
  • less than open surgery
  • minimize bleeding
• **Infection **
• Persistent drainage
  
  • ​close portals with suture

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Question 25

Describe you approach to elbow arthroscopy

Answer 25

• Lateral decutibus position on a beanbag and an axiallary roll
• Saddle bolster under arm with tourniequtte
• Mark out the ulnar nerve (assess whether it subluxes), and boney prominences
• Inflate the joint with 20 mL of saline in the lateral soft spot
• anteromedial portal is created first with sharp incision through the skin and blunt disection
• anterolateral is the working portal and is created under direct visualization
• use any adjunct portals you might need to removes osteophytes, loose bodies; may need to release capsule to gain ROM
• then go posterior via posteolateral portal and one central to clean the pathology at the back
• post-op
  
  • brachial plexus block PRN
  • CPM machine if needed
  • early ROM
  • indomethecin 25mg TID

Question 26

Common etiology

Answer 26

• Can be seen in
  
  • association with dominant hand
  • men to women 4:1
  • middle aged laborers
  • MUCL or ligamentous insufficiency
• Etiologies
  
  • rheumatoid arthritis
    
    • most prevalent form with 50% of patients affected
    • causes progressive bone resorption and osteopenia
  • post-traumatic arthritis
    
    • second most common form
  • primary arthritis
    
    • rare
    • common in middle-aged male laborers
  • history of osteochondritis dissecans

Question 27

Work-up for patient with progressive pain in their elbow, generalized, worse with activity. Fracture as a child.

Answer 27

• History
  
  • progressive pain
  • loss of terminal extension or flexion
  • painful locking of elbow
  • Will progress from pain at end-arc to pain through-out ROM
  • History of trauma, throwing/sports/labour, instability
  • PMHx - RA, OCD
• Physical exam
  
  • loss of elbow range of motion
  • ligamentous incompetence can be seen
    
    • especially in rheumatoid arthritis
  • ulnar neuropathy present in up to 50% of patients
• Radiographs
  
  • elbow joint space narrowing
    
    • Usually have more preserved anatomy than seen with other joints
  • osteophytes - most prominent finding
    
    • coronoid process and fossa
  • especially in olecranon tip and posteromedial olecranon fossa
  • loose bodies
• CT scan
  
  • can help better define osteophytes and loose bodies
  • Especially shelf osteophytes in the olecranon fossa, radial fossa and coronoid fossa
  • Can help you see osteophytes around the ulnar nerve

Question 28

Options for treatment

Answer 28

Elbow OA

• NSAIDS, cortisone injections, resting splints, and activity modification
  
  • indications
    
    • mild to moderate symptoms
    • < 15 deg of motion loss
• Arthroscopic or open debridement and capsular release
  
  • indications
    
    • mild disease with bone spurs
    • mechanical block to motion
    • preferred in patients with >90 degrees of motion
  • technique
    
    • removal of osteophytes and loose bodies
    • often combined with soft tissue release
    • Radial head is only resected if it is causing severely limited ROM
  • Outcomes
    
    • Improved with symptoms < 1 yr
    • Arthroscopy = better pain relief
    • Open = better gain in ROM
• ulnohumeral distraction interposition arthroplasty
  
  • indications
    
    • young high demand patients
      
      • Who don’t want to comply with TEA restrictions
  • technique
    
    • Posterior approach
    • Minimal debridement of articular surface
    • can use
      
      • autogenous tensor fascia lata
      • achilles tendon allograft
    • patients with severely limited preoperative motion (extension > 60 degrees and flexion of < 100 degrees are at risk for ulnar nerve dysfunction postoperatively
      
      • should undergo a concomitant ulnar nerve decompression
    • Hinged external fixation is used to allow immediate ROM
    • Removed after 4 weeks
  • Outcomes
    
    • Better outcomes with TEA, especially for post-traumatic
• olecranon fossa debridement (Outerbridge-Kashiwagi procedure)
  
  • indications
    
    • younger patients with decreased ROM
  • technique
    
    • Posterio-medial approach, identify the ulnar nerve
    • burr hole through olecranon fossa
    • removes osteophytes and arthritic bone anteriorly threw the hole
    • increases range of motion
    • be sure to decompress the ulnar nerve if there is an extension contracture preoperatively
• total elbow arthroplasty
  
  • indications
    
    • older patients >65 years with severe elbow arthritis
    • complex distal humerus fracture in elderly with poor bone stock
  • Semi-constrained
    
    • Most commonly used
    • Linked so that they don’t dislocated with some strain that is taken by the soft tissue/ligaments
  • Convertible
    
    • Can be converted to linked if becomes unstable
    • Can be converted to unlinked once some rehab has been done
  • unconstrained TEA
    
    • used with competent elbow ligaments and adequate bone stock
    • Can have problems with instability, maltracking, subulxation
  • constrained TEA
    
    • used with incompetent elbow ligaments
  • Either triceps sparing or bryan-morrey apparoch
  • Immobilized in extension for 48 hrs
    
    • Start early active ROM
    • If triceps has been detached then avoid active extension for 6 weeks
  • Complications
    
    • Instabiltiy
    • Infection
    • Fracture
    • HO
    • Ulnar nerve neruopraxia

Question 29

Technique for open debridement elbow

Answer 29

• Painful OA with loss of 30-130 degree of motion
• Lateral decubitus with a bolster under the arm
• Lateral column approach
  
  • ECRB and BR
  • elevate off the anteiror humerus and the capsule
  • remove the lateral portion of the capsule
  • then elevate the triceps off posteriorly
  • open the posterior capsule and debride the olecranon fossa and the olecranon
• Medial approach
  
  • transpose the ulnar nerve
    
    • >30 deg release
    • <90 deg of flexion
  • can release the posterior bundle of the MCL to help get more flexion
• Post-op
  
  • splint for comfort with early ROM

Question 30

Technique for TEA

Answer 30

total elbow arthroplasty

indications

older patients >65 years with severe elbow arthritis
complex distal humerus fracture in elderly with poor bone stock

Semi-constrained

Most commonly used
Linked so that they don’t dislocated with some strain that is taken by the soft tissue/ligaments

Convertible

Can be converted to linked if becomes unstable
Can be converted to unlinked once some rehab has been done

unconstrained TEA

used with competent elbow ligaments and adequate bone stock
Can have problems with instability, maltracking, subulxation

constrained TEA

used with incompetent elbow ligaments

Either triceps sparing or bryan-morrey apparoch
Immobilized in extension for 48 hrs

Start early active ROM
If triceps has been detached then avoid active extension for 6 weeks

Complications

Instabiltiy
Infection
Fracture
HO
Ulnar nerve neruopraxia

Question 31

Compare one-incision to two-incision technique for distal biceps rutpure

Answer 31

• Anterior one-incision technique
  
  • technique
    
    • transverse incision made over antecubital fossa
    • interval between brachioradialis laterally and the pronator teres medially
    • supinate forearm expose tuberosity and protect PIN
  • complications
    
    • injury to the lateral antebrachial cutaneous nerve is most common
    • injury to radial nerve is most severe
    • synostosis and resulting loss of pronation/supination
      
      • avoid exposing periosteum of ulna
      • avoid dissection between the radius and ulna
    • heterotopic ossification
  • postoperative
    
    • immobilize in 110° of flexion and moderate supination
• Two-incision technique (Boyd-Anderson)
  
  • recommended by most
  • technique
    
    • uses smaller anterior incision over antecubital fossa and a second posterolateral elbow incision
    • anterior dissection is same as single incision described above
    • after radial tuberosity exposed, blunt hemostat passed along medial border towards dorsolateral proximal forearm
    • hemostat pierces aconeus and tents skin indicating where posterolateral incision should be made
    • tendon is passed between radius and ulna and attached to radial tuberosity
    • regain more flexion
  • complications
    
    • lateral antebrachial cutaneous nerve is most common less common
    • by using two incisions you avoid deep dissection in the antecubital fossa and minimize risk to the radial nerve
    • synostosis and HO are more common

Question 32

What is the functional loss following distal biceps rupture

Answer 32

will lose 40-50% supination
will lose ~30% flexion
will lose 15% grip strength

Non-operative for elderly or for someone who doesn’t need strength

Question 33

Describe the anatomy of the distal biceps

Answer 33

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• Biceps inserts on radial tuberosity
  
  • 21 mm total
  • long head more for supnation
    
    • Proximal and radial
  • Short head more for flexion
    
    • Distal and ulnar
    • Lacertus originates from the short head
• Complete vs Partial
  
  • Parital usually occurs on the radial side
• Intersubstance transection
• Mechanism of tear
  
  • eccentric contraction at 90 deg flexion

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Question 34

Work up for distal biceps rupture

Answer 34

• **History **
  
  • patient often hears a pop
• **Symptoms **
  
  • pain in antecubital fossa
• **Physical exam **
  
  • inspection and palpation
  • popeye deformity (muscle bulges appearing more prominent)
  • for distal rupture, may be referred to as a “reverse” popeye
  • palpable defect
  • hook test
    
    • With a partial tear or no tear (strain) the examiner will be able to get their finger under the tendon near the insertion.
  • tenderness at biceps insertion
  • neuromuscular
    
    • loss of supination/flexion strength
    • lose more supination than flexion, up to 50%
  • challenge is to distinguish between complete tear and partial tear.
    
    • biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they have a very similar clinical picture)
• **Radiographs **
  
  • usually normal
• **MRI is important to distinguish between **
  
  • complete tear vs. partial tear
  • muscle substance vs. tendon tear
  • degree of retraction

Question 35

Recommendations for youth pitchers

Answer 35

• No breaking pitches (curveball, sliders) until puberty (approximately age 13 y)
• Proper pitching mechanics in youth and year-round physical conditioning should be stressed.
• Discourage youth from pitching for more than one team in a season.
• Three-month rest period per year from overhead throwing activities
• No pitching in a game or practice after being removed from pitching in a game.

Question 36

What are the restraints to the shoulder

Answer 36

• SGHL
  
  • restraint to inferior translation at 0° degrees of abduction (neutral rotation)
• MGHL
  
  • resist anterior and posterior translation in the midrange of abduction (~45°) in ER
• IGHL
  
  • posterior band IGHL
    
    • most important restraint to posterior subluxation at 90° flexion and IR
    • tightness leads to internal impingement and increased shear forces on superior labrum (linked to SLAP lesions)
  • anterior band IGHL
    
    • primary restraint to anterior/inferior translation 90° abduction and maximum ER (late cocking phase of throwing)
      
      • anchors into anterior labrum
      • forms weak link that predisposes to Bankart lesions
  • superior band IGHL
    
    • most important static stabilizer about the joint
    • 100% increased strain on superior band of IGHL in presence of a SLAP lesion
• Coracohumeral ligament (CHL)
  
  • limits posterior translation with shoulder in flexion,adduction, and internal rotation
  • limits inferior translation and external rotation at adducted position

Question 37

What are complications associated with distal biceps repair

Answer 37

• LACN most commonly
• PIN and superficial radial nerve
  
  • two incision technique was supposed to reduce this, but now with smaller anterior incision it is low with both
• synosteosis
• HO

Question 38

What are the phases of RC calcific tendonosis

Answer 38

• Formative - chronic pain with deposition
• Resting - less painful
• Resorptive - acutely painful, mimics infection

Question 39

What are the options for treatment of calcific tendonosis

Answer 39

• PT
  
  • to maintain joint mobility
  • always do this first
• intrabursal cortisone injection
  
  • during formative phase
• Needle lavage
  
  • resorptive phase
  • offered by author after 3 months - injection of bupivicane, 3-5 passes with 18 guage
• Extracorpeal shock-wave
  
  • sill a lot of research necessary
• Surgery - arthroscopic vs miniopen decompression

Question 40

Indications for surgery in RC calcific tendonitis

Answer 40

• progression of symptoms - following 6 months of trial of PT the USNL
• interference with ADLs
• refractory to nonoperative treatment
• rarely indicated during resorptive phase

Question 41

What are the characteristics of thoracic outlet syndrome

Answer 41

• clavicle, first rib, subclavius muscle, costoclavicular ligament, and anterior scalene muscle
  
  • junction of lower trunk and first rib
• Brachial plexus and subclavian vessels travel between anterior and middle scalene
  
  • more often neuro compression occurs
  • rarely vascular compression occurs; this requires heparinizaiton and surgical treatment
• Physical
  
  • Wright
    
    • abduction and external rotation with the neck rotated away leads to loss of pulse and reproduction of symptoms
  • Adson
    
    • extension of the arm with the neck extended and turned towards the affected side may result in loss of radial pulse or reproduction of symptoms with inhaling
  • Roos
    
    • hands repeatedly opened and closed while holding them overhead for 1 minute can reproduce symptoms
• CXR
  
  • most common finding is a cervical rib
  • assess for pancoast tumor

Question 42

What is the treatment of thoracic outlet syndrome

Answer 42

• neurologic decompression
  
  • indications
    
    • neurogenic etiology
    • nonoperative modalities have failed
    • progressive and severe neurologic deficits and pain
  • technique: address site of compression
    
    • repair clavicle malunion
    • transaxillary first rib resection (90% good to excellent results)
    • scalene takedown
    • pectoralis minor tenotomy
    • release of fibromuscular anomalous bands
• vascular reconstruction (open or interventionally)
  
  • indications
    
    • subclavian aneurysm present
    • persistent insufficient vascularity

Question 43

Conditions associated with adhesive capsulitis

Answer 43

diabetes

thyroid disorders (autoimmune etiology)
previous surgery (lung and breast)
prolonged immobilization
extended hospitalization

Question 44

Stages of adhesive capsulitis

Answer 44

• Clinical Stages
  
  • Painful
    
    • Gradual onset of diffuse pain (6 wks to 9 mos)
  • Stiff
    
    • Decreased ROM affecting activities of daily living (4 to 9 mos or more)
  • Thawing
    
    • Gradual return of motion (5 to 26 mos)
• Arthroscopic Stages
  
  • Stage 1
    
    • Patchy, fibrinous synovitis
  • Stage 2
    
    • Capsular contraction and fibrinous adhesions
  • Stage 3
    
    • Increasing contraction, synovitis resolving
  • Stage 4
    
    • Severe contraction

Question 45

Treatment options for adhesive capsulitis

Answer 45

• Pain in all ROM, limited PROM
• XR may show associated calcification or hardware
• MR arthrogram may show loss of the axillary recess
• NSAIDs, physical therapy, and intra-articular steroid injections
  
  • physical therapy
    
    • program of gentle, pain-free stretching and moist heat
    • should be supervised and last for 3-6 months
    • results
      
      • successful in vast majority although patience is required
  • most common complication is decreased range of motion compared to contralateral extremity
• manipulation under anesthesia (MUA)
  
  • indications
    
    • failure to improve with therapy and NSAIDs
  • surgical techniques
    
    • may be combined with arthroscopic surgical release
• arthroscopic surgical release
  
  • indications
    
    • only after extensive therapy has failed ( 3-6 months)
  • technique
    
    • arthroscopic rotator interval release will increase ER
      
      • superior glenohumeral and coracohumeral ligaments
    • arthroscopic posterior capsular release will increase IR

Question 46

What are the characteristic of a SLAP lesion

Answer 46

• helps to maintain the stability of the joint
  
  • strains the IGHL without it
• Buford complex is a normal anatomical variant
• Pathoanatomy
  
  • forceful traction
  • repetative throwing
  • direct compression
• Physical exam
  
  • no specific exam is useful
  • O’briens, yeargson and speed can be helpful
  • assess the cuff
  • Assess for associated spinoglenoid compression

Question 47

Staging of AVN of the shoulder

Answer 47

Stage I Normal x-ray. Changes on MRI
Stage II Sclerosis (wedged, mottled), osteopenia
Stage III Crescent sign indicating a subchondral fracture
Stage IV Flattening and collapse
Stage V Degenerative changes extend to glenoid

Question 48

Algorythm for shoulder OA

Answer 48

• In a young patient, arthroscopic debridement can be used as a temporizing measure to improve ROM
  
  • more to release the capsule and the rotator interval than debride the osteophytes
• >50
  
  • good glenoid bone
    
    • TSA
  • Inadequate glenoid bone
    
    • stemmed or unstemed hemiarthroplasty
• < 50; manual labourer
  
  • resurfacing
  • stemmed hemiarthroplasty
  • biological resurfacing
• Stage II/III AVN
  
  • stemmed hemiarthroplasty
• proximal humerus malunion
  
  • TSA with resurfacing and glenoid resurfacing

Question 49

Indications and contraindications to shoulder hemiarthroplasty

Answer 49

• Indications
  
  • primary arthritis
    
    • rotator cuff is deficient
    • glenoid bone stock is inadequate
    • risk of glenoid loosening is high
    • young patients
    • active laborers
  • rotator cuff arthropathy
    
    • hemiarthroplasty > rTSA if able to achieve forward flexion > 90 degrees
  • osteonecrosis without glenoid involvement
  • proximal humerus fractures
    
    • three-part fractures with poor bone quality
    • four-part fractures
    • head-splitting fractures
    • fracture with significant destruction of the articular surface
• Contraindications
  
  • infection
  • neuropathic joint
  • unmotivated patient
  • coracoacromial ligament deficiency

Question 50

Surgical considerations for shoulder hemiarthroplasty

Answer 50

• Approach
  
  • deltopectoral approach
• Shaft preparation and prosthesis placement
  
  • humeral head resection
    
    • start osteotomy at medial insertion line of supraspinatus
  • determine retroversion, implant height and head size
    
    • 30° of retroversion is ideal as reference from the fin to the biceps
      
      • inappropriate version will lead to instability
    • implant height
      
      • greater tuberosity should be
        
        • 3-5 mm below top of humerus
        • 10 mm below articular surface of humeral head
      • distance from top of prosthesis head to upper border of pectoralis major should be 56mm
    • head size
      
      • radiograph of contralateral shoulder
      • measuring size of native head removed earlier in procedure
    • using too large of a head may “overstuff” joint
• Fixation
  
  • cemented prosthesis
    
    • standard of care
    • provides better quality of life, range of motion, and strength compared to uncemented humeral component
• Tuberosity reduction
  
  • tuberosity migration is one of the most common causes of failure for fractures treated with hemiarthroplasty
  • technique
    
    • strict attention to securing the tuberosities to each other and to the shaft
    • autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates
    • tuberosity reduction must be anatomic or it may lead to a deficit in rotation

Question 51

Deltopectoral Appraoch

Answer 51

• Beachchair at 45 deg
• Prep both anterior and posterior
• 12cm incision from coracoid to the deltoid insertion
• find the cephalic vein and retract laterally
• incise the clavipectoral fascia and retract the deltoid laterally
• Identify the pec major inferiorly, and the conjoint tendon superiorly, be aware of the musculocutaneus nerve
• Identify the superior and inferior margins of the subscap, be aware of the axillary nerve along the inferior margin
• Release the subscap leaving some tendon to sew back to

Question 52

Rehab post shoulder resurfacing

Answer 52

• Early passive motion until fracture has healed
• duration usually 6-8 weeks
• Strengthening exercises begin once tuberosity has fully healed

Question 53

Complications of a shoulder hemiarthoplasty

Answer 53

• Progressive glenoid arthrosis
  
  • increased risk with
    
    • young patients
    • active patient
  • treatment
    
    • conversion to total shoulder arthroplasty
• Tuberosity displacement/malunion
  
  • one of the most common complications of shoulder hemiarthroplasty when used to treat fracture
  • treatment
    
    • repositioning of the tuberosity with bone grafting
• Joint overstuffing
  
  • may lead to
    
    • stiffness
    • accelerated arthritis of glenoid
• Subcutaneous (anterosuperior) escape
  
  • occurs when both rotator cuff and coracoacromial arch are deficient

Question 54

Anatomical requirements for successful TSA

Answer 54

• rotator cuff intact and functional
  
  • due to proximal migration
  • do rTSA or hemi
  • an isolated supraspinatus tear without retraction can proceed with TSA
  • incidence of full thickness rotator cuff tears in patients getting a TSA is 5% to 10%
    
    • if positive impingement signs on exam, order a pre-operative MRI
• glenoid bone stock and version
  
  • if glenoid is eroded down to coracoid process then glenoid resurfacing is contraindicated

Question 55

How to measure glenoid bone loss

Answer 55

Defect length – measure the length of the fragment
Width:length = normal = 0.7

W:H
Lower ratio = greater bone loss

• *Inverted pear**
• *Glenoid index**

Maximum width compared to contralateral width

Glenoid ratio

d/r
distance to center of deficiency over radius of glenoid

Perfect Circle

draw a circe and estimate the percent lost from the circle

Pico method
3D is gold standard

Question 56

Outcomes of TSA

Answer 56

• pain relief most predictive benefit (more predictable than hemiarthroplasty)
• reliable range of motion
• good survival at 10 years (93%)
• good longevity with cemented and press-fit humeral components
• worse results for post-capsulorrhaphy arthropathy

Question 57

Technical aspects of TSA

Answer 57

• Deltopectoral
  
  • detach the subscapularis and capsule from anterior humerus
  • dislocate shoulder anteriorly
  • may require release of the upper half of the pectoralis tendon
  • Complications
    
    • axillary nerve damage is the most common complication
    • axillary nerve and posterior humeral circumflex artery pass beneath the glenohumeral joint in the quadrilateral space
• Capsule
  
  • anterior capsule contracture (passive ER < 40°)
    
    • treatment
      
      • anterior release and Z-lengthening
  • posterior capsule stretching
    
    • treatment
      
      • volume-reducing procedure (plication of posterior capsule)
• Glenoid deficiency and retroversion
  
  • Goal is a 5-10 retroversion
  • Options
    
    • single stage
    • two stages with reaming and grafting
    • ream and run
  • glenoid deficiency
    
    • autograft (head or iliac crest)
    • metal augments
    • eccentric ream (10 deg)
• Glenoid component - all poly pegged, cemented
  
  • convex superior to flat
  • recreate neutral version
  • peg design is biomechanically superior to keel design
  • polyethylene-backed components superior to metal-backed components
  • uncemented glenoid has a lower rate of loosening
  • conforming vs. nonconforming
    
    • both have advantages and neither is superior
    • conforming is more stable but leads to rim stress and radiolucencies
    • nonconforming leads to increased polyethylene wear
• Humeral stem fixation
  
  • cemented stem or uncemented porous-coated implants
  • ream on hand to prevent notching and fractures
  • 9mm lateral to center of humeral head will ensure proper trajectory and decreased risk of fracture
  • position of humeral stem should be 25-45° of retroversion
    
    • if position of glenoid retroversion is required, then the humeral stem should be less retroverted to avoid posterior dislocation
  • causes of increase joint reaction forces and tension on the RC
    
    • valgus positioning
    • avoid overstuffing
    • the top of the humeral head should be 5 to 8 mm superior to the top of the greater tuberosity
• intraoperative humerus fracture
  
  • prevention
    
    • _​_gentle positioning
    • higher risk with revision cases and osteopenic bone
    • hand ream
  • greater tuberosity fracture
    
    • if minimally displaced, insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture
  • humeral shaft fracture
    
    • remove prosthesis and add longer stem with cement and reinforce with cerclage wiring
      
      • bypass 2-3 cortical diameters
    • can cement the distal end
    • use allograft strut if there is severe osteopenia
    • if you don’t have a stem long enough you can fix it without passing the stem, just make sure you don’t have a stress riser
• Closure
  
  • ​drill 3 holes
  • then use bone tunnel fixation with a small plate to prevent cutout threw the cuff

Question 58

Complications of TSA

Answer 58

• Glenoid loosening
  
  • most common cause of TSA failure (30% of primary OA revisions)
  • risk factors
    
    • insufficient glenoid bone stock
    • rotator cuff deficiency
    • 2.9% reoperation rate for loosening (28% with revision)
  • radiographic lines - progression (not presence) correlates with symptoms
• Humeral stem loosening
  
  • more common in RA and osteonecrosis
  • rule out infection
• Subscapularis repair failure
• Malposition of components
• Improper soft tissue balancing
  
  • failure due to undiagnosed presence of rotator cuff tears
• Iatrogenic rotator cuff injury
  
  • can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion
• Stiffness
• Infection
  
  • early infection (<6 weeks) can be treated with open irrigation and debridement
  • late infection (>6 weeks) should be treated by explant and staged reimplantation after IV antibiotic course
  • Propionibacterium acnes (P. acnes)
    
    • high bacterial burden around the shoulder
    • common cause of indolent infections and implant failures
• Neurologic injury
  
  • axillary nerve is most commonly injured
  • musculocutaneous nerve can be injured by retractor placement under conjoint tendon

Question 59

Management of the glenoid in TSA

Answer 59

• wear to the coracoid means not enough bone to do the glenoid
• 3D CT to assess bone stalk of the glenoid
  
  • draw a line from the sapula, use the articular surface as neutral and determine the differnece of the glenoid
  • a dysplastic glenoid (type C), the humeral head is concentric in the glenoid;
• use a centralized guide wire into the scapula to ensure correct version
• eccentric reaming
  
  • can safely address 10 deg of version
• bone graft - technically demanding and not reproducible
  
  • insufficient bone stalk
  • corrections > 15 deg
  • deficiency after eccentric reaming
  • Risks - nonunion, dislodgement
• Metal augments
• For the dysplastic glenoid
  
  • the posterior structures are hyperplastic
  • there is no posterior subluxation as there is with a biconcave glenoid
  • safe to correct only slightly or leave them where they are or they will loose internal rotation

Question 60

Definition of PPJI as defined by the MSK infection society

Answer 60

• Major criteria
  
  • Draining sinus tract
  • Identical organisms isolated by culture from at least 2 separate tissue or fluid samples
• Minor criteria
  
  • Elevated serum erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) concentration
  • Elevated synovial white blood cell count
  • Elevated synovial neutrophil percentage (PMN%)
  • Presence of purulence in affected joint
  • A single positive culture of tissue or fluid
  • >5 neutrophils per high-power field in 5 high-power fields of tissue histology

Question 61

Diagnosis of infected TSA

Answer 61

• Have a high suspicion
• Common organisms
  
  • P. Acnes
  • S. Aureus
  • Staph epideridus
• Blood work - elevated ESR, CRP
• May or may not be evidence on XR
• Bone scan is not useful
• Image guided joint aspiration
  
  • ask to hold cultures for 21 days
  • no good recommendations for elevated WBC and PMN
• Intra-operative
  
  • increased risk with cloudy fluid and membrane formation
  • send synovial tissue and fluid cultures
  • Fresh frozen section: > 5 neutrophils in 5 high powered feild
• Ways to increase chance of finding infection
  
  • don’t give antibiotics before OR
  • multiple deep cultures
  • hold cultures for 21 days
  • implant sonification and culture
  • PCR of synovial fluid

Question 62

Management of confirmed TSA infection

Answer 62

• Risk factors
  
  • low immunity in joints, high nutrients in synovial fluid
  • sebaceous glands
  • close proximity to axilla
  • medial and patient factors
• ID Consult
  
  • ​Start IV antibiotics
    
    • PenG
    • then Vanco is second choice
• Debridement with hardware retention and antibiotic suppression
  
  • only if recognized < 3 weeks
  • 50% failure ratae
• Single stage prosthesis exchange
  
  • ​Not in favour, but there have been good results
• Two-stage prosthesis exchange
  
  • implant extraction
    
    • humeral split osteotomy
    • cortical window
    • fix with circlage wires
  • ​prefabricated spacer, or make a spacer out of a stimen pin and a chest tube
  • can be used to bridge fracture as well
  • then convert to TSA if possible or rTSA if there has been severe supeiror bone loss and comprimise of the RC, or a hemiarthroplasty due to increased risk of re-infection with total
  • IV antibiotics, antibiotic holiday when ESR/CRP normalize, if remain low then perform second stage
• Arthrodesis or resection arthroplasty
  
  • ​severely deficient bone
  • very poor results compare to prosthesis reimplantation with no imporvement in recurrence

Question 63

Classification of periprosthetic humerus fracture

Answer 63

• Wright and coland
  
  • ​A - above the prosthesis
  • B - at the tip of the prosthesis
  • C - below the prosthesis

Question 64

Options for treatment of periprosthetic humerus fractures

Answer 64

• Non-operative
  
  • C type fracture that can be maintained in a sugar tong
  • medical co-morbidities, active infection
• Components
  
  • fracture displacement
  • location
  • stability of humeral component
    
    • > 2mm lucency around the stem
    • change in stem position
• ORIF - plates, circlage wires
  
  • stable component
  • displaced fracture
  • B type fracture
  • Nonunion of previous C type fracture treated non-op
    
    • agument with allograft strut
    • iliac crest graft in the nonunion site
• Revision long stem
  
  • stem subsidence
  • cemented or uncemented ok
  • pass fracture by 2 cortical diameters
  • augment with plates, screws and circlage wires
• Be very cogniscent of the radial nerve at all times

Question 65

Post-op rehab TSA

Answer 65

• sling for comfort
• start PROM but limit ER to neutral and FF to 100deg
• increase to AAROM and increase PROM at 6 weeks
• active use of the shoulder isn’t started until 12 weeks

Question 66

Approach to glenoid loosening

Answer 66

• assess instability and issues with soft tissues
• if you just replace the component it will probably get loose again
• take it out
  
  • ream
  • graft
  • rTSA
    
    • solves the problem of soft tissue balancing and instability
    • technically demanding and high rate of complications

Question 67

Assessment of failed TSA

Answer 67

• History
  
  • indication for index procedure
  • complicance with post-op rehab
  • history of RC tear
  • pain free period
  • instability, clunking, stiffness, signs of infection
  • numbness or other neurologial deficiet
• Physical
  
  • scars, atrophy of deltoid or RC
  • palpate boney prominences
  • PROM, AROM
  • assess RC function
  • full neurovascular exam
• Studies
  
  • ESR, CRP
  • aspiration - keep for 21 days
  • Plain XR - AP, lateral, Axillary
  • CT - assess glenoid, version of the humerus, loosening of components
  • EMG if concerns
  • MRI with modified sequences
• Indications for revision
  
  • Goals
    
    • primarily pain control
    • function, strength are secondary
  • infection
  • malpositioning
  • loosening
  • adhesions
  • contractures

Question 68

Management of failed TSA

Answer 68

• Always rule out infection
• Glenoid loosening
  
  • removal of glenoid
  • structural iliac crest graft
  • the later can revise to TSA or rTSA
• Stiffness
  
  • try PT for at least 6 months
  • Open threw deltopec
    
    • release deltoid adhesions being careful of axillary nerve, release pec
    • biceps release
    • release the subscap - can consider medial transfer or Z-lengthening
    • capsule release with arm in 60 abduction and 30 ER
  • assess components for overstuffing
  • Post-op
    
    • limt ER for subscap repair
    • supervised PT program
    • consider scalene block for adequate pain control to encourage ROM
• Unstable arthroplasty
  
  • humeral head should translate < 50% in any direction
  • ​Imablance in soft tissue stabilizers
    
    • tight anterior capsule can be relased, capsule, subscap, pec major
    • posterior capsulorraphy
  • ​Rotator cuff deficieny
    
    • _​_more common in RA
    • will cause superior migration, early loosening, decrease in function and pain
    • treated with
      
      • expectant managment (usually fails)
      • surgical repair
      • latissiumus dorsi transfer
      • revision to rTSA
  • subscapularis failure
    
    • _​_should be fixed early
    • if you can’t repair it
      
      • pec major transfer
      • allograft
• Neurological injury
  
  • usually axillary, less commonly MC
    
    • more common in rTSA
  • ​invovle peripheral nerve surgery
  • EMG at 6 weeks and 3 months
  • PT and ROM

Question 69

Classification of TSA infection

Answer 69

Type I:

Positive cultures at time of revision surgery—directed culture-specific antibiotic treatment for an undetermined period of time

Type II:

Acute infection within 30 days after surgery—surgical debridement and irrigation with retention of prosthetic components

Type III:

Acute hematogenous infection more than 30 days after surgery—either surgical debridement and irrigation with retention of implants versus explantation and two-stage revision arthroplasty

Type IV:

Chronic infection—surgical debridement and irrigation, antibiotic spacer placement, IV antibiotics for at least
8 weeks, and staged reimplantation of components after negative intraoperative cultures

Question 70

Indications and contraindications to shoulder arthrodesis

Answer 70

• Indications
  
  • stabilization of paralytic disorders
  • brachial plexus palsy
  • irreparable deltoid and rotator cuff deficiency with arthropathy
  • salvage of a failed total shoulder arthroplasty
  • reconstruction after tumor resection
  • painful ankylosis after chronic infection
  • recurrent shoulder instability which has failed previous repair attempts
  • paralytic disorders in infancy
• Contraindications
  
  • ipsilateral elbow arthrodesis
  • contralateral shoulder arthrodesis
  • lack of functional scapulothoracic motion
  • trapezius, levator scapulae, or serratus anterior paralysis
  • Charcot arthropathy
  • elderly patients
  • progressive neurologic disease

Question 71

Surigcal technique of shoulder arthrodesis

Answer 71

• Approach
  
  • S-shaped skin incision beginning over the scapular spine, traversing anteriorly over the acromion, and extending down the anterolateral aspect of the arm
• Fusion position
  
  • think “30°-30°-30°”
• Technique
  
  • rotator cuff is resected from the proximal humerus and the biceps tendon is tenotomize
  • glenoid and humeral head articular surfaces and the undersurface of the acromion are decorticated
  • arm is placed into the position of fusion (30°-30°-30°)
  • a 10-hole, 4.5 mm pelvic reconstruction plate is contoured along the spine of the scapula, over the acromion, and down the shaft of the humerus
  • compression screws are placed through the plate across the glenohumeral articular surface into the glenoid fossa
  • the plate is anchored to the scapular spine with a screw into the base of the coracoid
• Postoperative care
  
  • a thermoplastic orthosis is applied the day after surgery and is maintained for 6 weeks
  • at 6 weeks, may transition to a sling if there are no radiographic signs of loosening
  • at 3 months, mobilization exercises and thoracoscapular strengthening are commenced if no radiographic signs of loosening are present
  • expected recovery period is 6-12 months

Question 72

Classification of SLAP lesions

Answer 72

• Type I
  
  • Labral and biceps fraying, anchor intact
  • 11%
• Type II
  
  • Labral fraying with detached biceps tendon anchor
  • 41%
• Type III
  
  • Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear)
  • 33%
• Type IV
  
  • Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)
  • 15%
• Type V
  
  • SLAP lesion and anterior labral tear (Bankart lesion)
• Type VI
  
  • Superior flap tear
• Type VII
  
  • SLAP lesion with capsular injury

Question 73

physical exam and imaging for SLAP lesion

Answer 73

• Physical
  
  • may see infraspinatous wasting
  • weankness in ER
  • yeargson, speed, O’brien
• Imaging
  
  • MRI or MRarthrogram
  • will see SLAP lesion with spinoglenoid cyst
• Arthrscopy
  
  • can assess with peel-back test

Question 74

Rehabilitation following SLAP repair

Answer 74

• week 1-4
  
  • sling with passive forward elevation. Avoid extremes of abduction and external rotation
  • passive and active assisted flexion in the scapular plane
• week 4-6
  
  • progress to active ROM, isometrics
• week 6-12
  
  • functional exercise and light strengthening
• week 12+
  
  • advance strength and ROM, sport-specifics
  • typical return to sport around 6 months