SURGICAL SHOULDER SOLUTIONS
| Technical Tips and Pearls for Instability Surgery— Brian J. Cole, MD, Assistant Professor, Department
of Orthopedics, Rush University Medical Center, Chicago
|
| Spectrum of labral pathology: from atraumatic (laxity problems or capsular and plastic deformations over time) to clear-
cut traumatic instability; careful evaluation critical
|
| Lesions to look for: lesions coming off humeral side; humeral avulsion; labile, chronic pathology scarred down medially
|
| Decision making: mechanism of injury—some patients recall macrotraumatic event; many injuries evolve over time and
have more subtle findings; physical examination; radiography—look for bony deficits; may include computed tomography
(CT) or magnetic resonance imaging (MRI); first-time dislocators—whether patient in or out of activity; degree
of risk; gold standard—findings on examination or anesthesia; findings on arthroscopy
|
| Open vs arthroscopic surgery: identical goals; define pathology; establish biology; make anatomic repair; provide secure
fixation; pathology that cannot be addressed arthroscopically—bone deficits >25% to 30%, especially on glenoid
side
|
| Instrumentation: passing sutures—most difficult step during instability or rotator cuff work; devices with small sharp
tips give most versatility; some new devices allow less dependence on portal placement but require “shuttling” technology;
suture anchors—variety available; speaker prefers bioabsorbable anchors because pullout no longer problematic
(metal anchors may lead to arthropathy in short time); knotless anchors obviate need to tie knots and provide additional
fixation and security of multiple loops; multiple suture strands pass through labral tissue, allowing it to be interposed with
interference fit against anchor; titration of capsular plication, but this may limit usefulness; knots—learn one knot very
well; nonsliding preferred; obtain secured locked knot
|
| Interscalene block: patients can help themselves off and on bed; less postoperative nausea and vomiting from narcosis effect;
occasionally combined with anesthesia
|
| Patient positioning: beach-chair position for straightforward anterior or anteroinferior (AI) instability; lateral decubitus
position better if any posterior component or dealing with multidirectional instability (MDI)
|
| Examination under anesthesia: decides what will be done in surgery; examination—various positions of rotation and
stress to glenohumeral joint (GHJ) indicate pathology at arthroscopy; portal placement—anterior, superior, and posterior
standard; allow access to most of GHJ; place AI portal just above or through subscapularis; can place anchors percutaneously
and not use portals if necessary to get more inferior; speaker recommends 2 portals anteriorly to prevent suture
entanglement; posteroinferior (PI) portal allows access around curvature of humeral head and onto glenoid posteroinferiorly
|
| Repair sequence: standard—if including PI band to add balance to capsular plication, start with PI repair; follow with AI
repair; if necessary, rotator interval repair; MDI—start with posterior component of repair; anterior component; rotator
interval as needed; superior labrum anterior to posterior (SLAP) tears and Bankart lesions—repair Bankart first;
follow with superior labral repair; traumatic instability with traumatic cuff tear—Bankart first
|
| Thermal repair: associated with new complications, eg, young people with MDI treated with radiofrequency, who develop
rapid chondrolysis in <1 yr
|
| Contemporary rehabilitation: requires rotator cuff, deltoid, and scapular stabilizers in postoperative course
|
| Results of adopting principles: recurrence rates of 4% to 10%; excluding bone loss, especially on glenoid side, relative
contraindications fall into ideal category for patients with glenohumeral instability
|
| Evaluation and Treatment of Partial-Thickness Cuff Tears —Wesley M. Nottage, MD, Clinical
Professor of Orthopedics, University of California, Irvine, School of Medicine
|
| Recognize condition leading to cuff failure: patient’s age; mechanism of onset; location of lesion in cuff; associated
physical and/or arthroscopic findings
|
| Location: articular side—most common; typically, area of early failure; can be associated with microinstability; possibly
due to abrasion against glenoid rather than degeneration or early cuff failure; superior labrum, anterior cuff (SLAC) lesion;
posterior rim (internal impingement); tensile failure; bursal side—almost always from functional weakening, then
secondary abrasion against arch; complex tears—combination of locations
|
| Source of pain: uneven lines of pull due to degenerative areas that do not carry load; mechanical abrasion against acromion
or labrum; secondary bursitis or synovitis; catching of flaps or edges of tear against acromion or labrum
|
| Rotator cuff: normally changes with age; supraspinatus attachment develops cable and crescent configuration; area of load
(cable) hypertrophy and area spared load (crescent) atrophy; bursa more resistant to tension than articular layer; intratendinous
tears—develop between superficial and deep layers due to shear within tendon; do not heal
|
| Magnetic resonance imaging: helps identify articular-side partial-thickness cuff tears; traditionally considered unhelpful;
abduction and external rotation (ABER) view with contrast valuable
|
| Classification: normal cuff thickness 10 to 12 mm; grade 1, <3 mm; grade 2, 3 to 6 mm; grade 3, >6 mm
|
| Articular-side tears: do not commonly demonstrate healing; 52% enlarge and 28% progress to full-thickness tears;
management—Weber compared debridement and decompression alone to that plus mini-open repair; found mini-open
repair group had better University of California, Los Angeles (UCLA) scores; key points—not related to acromial morphology
or degenerative changes in arch; decompression alone not beneficial; depth—measurement of exposed bone
good estimate of extent of tendon loss and degree of tear; if lesion exposes >7 mm of bone lateral to articular margin, it
involves ≥50% of articular portion of rotator cuff and tendon substance; microinstability lesions—30% associated with
rotator cuff pathology; location specific (front or back, not central); fraying more than cuff defect; treatment options—
convert to complete tear and repair; side-to-side repair (anteroposterior [AP] sutures); anchor through cuff (partial articular-side
supraspinatus tendon avulsions [PASTA] repair); abrading bone and leaving tear; options controversial (subacromial
decompression [SAD]; addressing ligamentous deficiencies, eg, SLAC or SLAP lesion, microinstability); key
guidelines—identify location and clinical situation; ensure no microinstability; measure defect after debridement (if >7
mm, defect >50% and good basis for repair); debridement of diseased cuff tissue important for pain relief; SAD not
proven necessary
|
| Bursal-side tears: indicated by ballooning on articular side; associated with degenerative changes in 100% of cases; decompression
alone inadequate; must deal with tendon failure (29% vs 3% on articular side); significant tear—mobile
flap of trapped tissue; >7 mm (>50%) deep into substance of cuff; multiple splits or tears involving >2 cm2 (>50%) of
cuff substance; management—prepare for repair (more than one third “unexpected”); can debride and decompress if
very small; repair or take down and repair if significant; poorly viable tendon tissue does not demonstrate healing
|
| Results of arthroscopic repair: 91% good or excellent by UCLA standards; no difference by repair technique, tear size,
or postoperative stiffness
|
| Treatment guidelines: articular—evaluate joint and bursal sides; repair necessary only if >50% after debridement; evaluate
for associated SLAP and SLAC lesions; bursal—consider decompression or debridement if superficial scuffing
present; take down and repair if large mobile flap present
|
| How to Control Pain and Increase Patient Satisfaction —F. Alan Barber, MD, Plano Orthopedic and
Sports Medicine Center, Plano, Texas
|
| Postoperative pain: constant and aching; exacerbated by activity; self-limiting; progressively improves over short time;
peak—on first postoperative day; if reduced, patient experiences less pain over subsequent days; goals—pain reduced
or eliminated at peak; minimal side effects; inexpensive; reassures family and patient; earlier rehabilitation program; successful
pain control—improves clinical outcomes; reduces problems that accompany increased pain
|
| Preoperative methods: preoperative counseling—increases confidence in surgeon; increases understanding of procedure,
decreasing postoperative anxiety (increased anxiety increases pain); rested state—zolpidem (Ambien) day before
and days after surgery gives patients good night’s sleep, and they perceive less pain
|
| Preemptive methods: interscalene block—difficult; expensive; requires experience; takes time; risks (inadvertent epidural,
subarachnoid, or vertebral artery injection; phrenic nerve or recurrent laryngeal, vagus, or cervical sympathetic
block; pneumothorax; incomplete block; rebound pain); 3% complication rate; suprascapular block—nerve provides
sensation to shoulder and acromioclavicular (AC) joint; compares well to interscalene block; effective for outpatient arthroscopy
and inpatient shoulder surgery; local infiltration—speaker infiltrates entire portal tract with lidocaine (Xylocaine)
or bupivacaine (Marcaine) with epinephrine; numbs area before incision; joint inflation—using same solution
after scope inserted
|
| Intraoperative methods: reduce operative time—less pain; arthroscopy takes less time than open procedures; minimal
invasion—less pain and stress; injection into joint—at end of case; bupivacaine provides 12 hr of pain relief; morphine
binds to pain receptors and more effective than bupivacaine for long-term pain relief
|
| Postoperative medications: short-acting narcotics; long-acting narcotics; nonsteroidal anti-inflammatory drugs (NSAIDs)
slow tendon healing and bone fusion; constant infusion pumps effective, but Medicare does not pay for devices
|
| Physical methods: cold therapy—reduces pain and swelling; speaker prefers continuous-flow cold device over crushed
ice, frozen peas, or gel packs, but no Medicare reimbursement; other physical methods—bracing; physical therapy;
transcutaneous electrical nerve stimulation (TENS)
|
| Speaker’s regimen: preoperative—extensive counseling; gain patient’s trust; Ambien; preemptive—suprascapular
nerve block; local infiltration; joint inflation; intraoperative—quick procedure; morphine injection at end of case;
postoperative—oral narcotics; Ambien; infusion pump; physical—continuous-flow cold device; physical therapy
|
| Repairing Rotator Cuff Tears That Cross the Interval —Jeffrey S. Abrams, MD, Associate Director,
Princeton Orthopaedic and Rehabilitation Associates, Princeton, New Jersey
|
| Tears: also known as anterosuperior rotator cuff tears; less common, so less experience fixing them and less literature; biceps
involved 30% of time; results of repairs do not match those for other tears; MRI helpful
|
| Different from posterior cuff tears: tear protected along rotator interval by ligament; as tear goes from supraspinatus, extends
posteriorly toward infraspinatus as it gets larger; seen in younger patients; trauma often part of etiology; more difficult
to visualize (speaker believes easier with arthroscopy than open method)
|
| Anatomy of tear: head destabilized; must consider impingement (subcoracoid and subacromial); biceps normal, subluxed, or
torn
|
| Conclusions: tears mostly crescent shaped, therefore entire sheet of tissue containing subscapularis, supraspinatus, and portions
of pulley system included; anatomy not well visualized through single portal; be comfortable placing scope laterally
and anteriorly to visualize greater and lesser tuberosities; biceps involved in 30% of cases; keep connection intact until able
to understand location of subscapularis relative to supraspinatus; subacromial or subcoracoid decompression for visualization
only; goal to restabilize humeral head to avoid anterior-superior escape (often devastating to shoulder movement)
|
| biologic Glenoid Resurfacing: Technique and Results —Felix H. Savoie, MD, Staff, Mississippi
Sports Medicine and Orthopaedic Center, Jackson
|
| Osteoarthritic shoulder: significant impairment of activities of daily living (ADL); can be secondary to instability repair,
trauma, or rotator cuff tear
|
| Nonoperative treatments: medication—hyaluronic acid derivatives (eg, Hyalgan, Synvisc); anti-inflammatory drugs;
prednisone; glucosamine; chondroitin; physical therapy—not helpful; expensive
|
| Surgery: arthroscopic debridement—mixed results; remove spurs (use caution with spur on humerus); repair impingements
or tears; synovectomy or abrasion repair in GHJ; drilling; rim lesions (vs panarticular lesion); shoulder
replacement—treatment of choice for failed arthritic shoulder
|
| Resurfacing glenoid: without replacing glenohumeral head; arthroscopic interposition graft; diagnostic scope; debridement
and synovectomy; glenoid abrasion and smoothing; humeral smoothing and microfracture; graft—allograft; small
intestine submucosa (SISM) patch; graft jacket; suture
|
| Postoperative management: abduction sling for 1 wk; gentle range of motion (ROM) exercises; advance through rehabilitation
phases as tolerated
|
| Results: study—20 patients 15 to 65 yr of age; 5 had chondrolysis after other types of index operations, 12 had degenerative
changes, 5 younger with posttraumatic changes, and 10 had osteoarthritis (OA); average flexion improved from 90º
to 150º, abduction 70º to 120º, visual analog scale (VAS) 8 to 2, and patients with significant pain from 10 to 0; MRI—2
to 5 mm of joint space maintained 1 yr out; satisfaction—17 of 20 patients “very satisfied”; failures relate primarily to
squaring of humeral head
|
| Summary: for osteoarthritic shoulder, start with nonoperative treatment; shoulder replacement definitive, final option; interposition
grafting reasonable intermediate step
|
Educational Objectives
| The purpose of this program is to educate the listener about surgical management of conditions of the shoulder. After hearing
and assimilating this program, the clinician will be better able to:
|
 | 1. Update instability surgery techniques.
|
| 2. Expand skill in evaluating and treating partial-thickness cuff tears.
|
| 3. Improve pain control and increase patient satisfaction after shoulder surgery.
|
| 4. Compare anterosuperior rotator cuff tears to posterior cuff tears.
|
| 5. Discuss techniques for and results of glenoid resurfacing.
|
Discussed on This Program
Bupivacaine HCl [Marcaine HCl, others]
Chondroitin (chondroitin sulfate)
Epinephrine (many trade names)
Glucosamine sulfate
Hyaluronic acid derivatives [Hyalgan, Supartz, Synvisc, Orthovisc]
Lidocaine HCl [Xylocaine, others]
Mepivacaine HCl (many trade names)
Morphine sulfate (many trade names)
Prednisone (many trade names)
Zolpidem tartrate [Ambien]
Suggested Reading
Baechler MF, Kim DH: Patient positioning for shoulder arthroscopy based on variability in lateral acromion morphology.
Arthroscopy 18:547, 2002; Baumgarten KM et al: Glenoid resurfacing in shoulder arthroplasty: indications and contraindications.
Instr Course Lect 53:3, 2004; Bennett WF: Subscapularis, medial, and lateral head coracohumeral ligament insertion
anatomy. Arthroscopic appearance and incidence of "hidden" rotator interval lesions. Arthroscopy 17:173, 2001;
Gartsman GM et al: Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis.
J Bone Joint Surg Am 82:26, 2000; Ito Y et al: Computerized assessment of Bankart lesions under tension with magnetic
resonance arthrography. J Shoulder Elbow Surg 14:247, 2005; Lee SY, Lee JK: Horizontal component of partial-thickness
tears of rotator cuff: imaging characteristics and comparison of ABER view with oblique coronal view at MR arthrography
initial results. Radiology 224:470, 2002; Scranton PE Jr et al: Bone suture anchor fixation in the lower extremity:
a review of insertion principles and a comparative biomechanical evaluation. Foot Ankle Int 26:516, 2005; Singelyn FJ et
al: Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and
interscalene brachial plexus block. Anesth Analg 99:589, 2004; Warner JJ et al: Diagnosis and treatment of anterosuperior
rotator cuff tears. J Shoulder Elbow Surg 10:37, 2001
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Abrams is a consultant for ConMed Linvatec and Arthrocare Corporation, receives royalties from ConMed Linvatec,
and owns stock in Arthrocare Corporation; Dr. Nottage is a consultant for Arthrotek, Inc.
Drs. Cole, Nottage, Barber, and Abrams were recorded at the 22nd Annual Arthroscopy/Arthroplasty/Fractures, held
June 22-25, 2005 in La Jolla, California and sponsored by San Diego Shoulder. Dr. Savoie was recorded at Shoulder
Surgery Controversies 2005, held October 20-22, 2005, in Newport Beach, California, and sponsored by the University
of California, Irvine, School of Medicine and The Sports Clinic Orthopaedic Medical Associates, Inc. The Audio-Digest
Foundation thanks the speakers and sponsors for their cooperation in the production of this program.
|
