ADVANCES IN SHOULDER SURGERY
From San Diego Shoulder’s Arthroscopy/Arthroplasty/Fractures
| SURGICAL EXPOSURE FOR SHOULDER ARTHROPLASTY: CORNERSTONE OF A GOOD
OUTCOME —David S. Bailie, MD, Vice President, The Orthopedic Clinic Association, Scottsdale, AZ
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| Good result in shoulder arthroplasty: pain relief; ability to perform activities of daily living; increased
range of motion; ability to engage in recreational activities; return to sports; different for individual patients;
evaluate for each patient
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| Nonsurgical factors: age (relative; eg, athletic 75-yr-old patient); muscle conditioning (rotator cuff strength;
scapular stabilizers; duration and severity of disease process); medical status and overall health; patient motivation
and compliance
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| Surgical factors: surgeon experience (laboratory training; confidence around neurovascular structures); implant
(anatomic); technique (exposure; implant postioning)
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| Key factors in exposure: room set-up; assistant (1 sufficient); surgeon comfort level; approach; patient placement
(shoulder and arm move freely)
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| Deltopectoral approach: advantages—true internervous plane; no deltoid protection needed postoperatively;
can be extended if necessary; disadvantages—difficult glenoid exposure (in muscular patients); excessive
traction on deltoid; incision—≤2 cm from coracoid (6-8 cm distally); cephalic vein laterally; conjoined tendon
retracted medially; extend as needed; results—1% to 4% axillary nerve injury (usually from overzealous
retraction); minimize retraction time; better exposure for proximal humerus (eg, fractures, tumors)
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| Anterosuperior approach: advantages—direct exposure of glenoid; easy to repair rotator cuff at same time;
avoids cephalic vein; avoids excessive traction on deltoid; disadvantages—requires subperiosteally detaching
deltoid from acromion (healing risk); cannot access proximal humerus fractures; axillary nerve at higher risk;
surgical procedure—beach-chair position; incision starts just behind acromioclavicular (AC) joint; subacromial
decompression (stop at bursal reflection; nerve just behind acromion); release subscapularis; avoid active
elevations for 3 to 4 wk to allow deltoid healing
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| Subscapularis tendon: contracted (lost external rotation); forces humeral head posteriorly (erodes glenoid);
limited excursion; must be released 360°; step 1—locate rotator interval; circumflex vessels (ligate if implant
stemmed; preserve if resurfacing); identify interval between capsule and subscapularis (cut just above
vessels; place blunt retractor); step 2—incise from interval, 1 cm laterally to myotendinous junction (save
lateral tissue for repair; no need for Z-lengthening); do not separate capsule from subscapularis; place 3 sutures
(top, middle, and bottom of tendon); step 3 (anterior release)—release coracohumeral ligament from coracoid;
blunt finger release beneath coracoid (avoid nerve); check subscapular bursa for loose bodies; step 4
(inferior release)—tension subscapular tendon; with suction tip, take Bovie to glenoid; step 5 (posterior
release)—from inferior release through superior glenohumeral ligament just off labrum; “if you don’t have a
bouncing subscap, you’ve got to do more work”; inferior capsular release—externally rotate humerus; cut
from anteroinferior to posteroinferior; remove osteophytes as you go; use retractor to keep tension on capsule;
release along humeral neck; expose humerus—patient hand points toward anesthesia; need to see entire
humeral head; glenoid—3 retractors (posterior, anterior, and superior)
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| Goals of shoulder arthroplasty: near-full motion; no pain; full strength over time; return to all desired activities;
longer implant survival
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| HUMERAL HEAD REPLACEMENT FOR PROXIMAL HUMERUS FRACTURES (THE JIGSAW PUZZLE
METHOD) —Evan L. Flatow, MD, Lasker Professor and Interim Chair, Leni and Peter May Department of
Orthopaedic Surgery, Mt. Sinai Medical Center, New York, NY
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| Jigsaw puzzle method: for determining height of prosthesis; application limited, eg, 4-part fracture with
head separated several centimeters; requires determining proper height; hold trial at that height while securing
implant
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| Basic approach: select anatomic head; reconstruct fractured humerus; judge height by setting prosthetic head
to same position; utilize local anatomy to calculate height
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| Precise reconstruction: possible with fracture in shoulder not arthritic and deformed; can determine curvature
and thickness, looking for cartilage line; even with missing or extra pieces, possible to figure location of anatomic
head within fractured shoulder; calcar gap usually 5 to 7 mm (looking at calcar line also effective in assessing
height); small error possible, but not 2- to 3-cm error; employing anatomic head enables good
reconstruction of height and location for tuberosities
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| Obtaining measurement: several ways possible; from top of head to landmark, spike, metaphyseal flare, or
pectoralis insertion (≈5.2 cm); provides redundancy, comparing measurements to check accuracy
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| Speaker’s system: small sponges placed around shaft to hold height provisionally; clamps of varying thickness
on prosthesis used to judge height; retroversion pins provide retroversion to forearm (overly retroverting
prosthesis places undue tension on greater tuberosity when arm in sling or across chest)
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| HEMIARTHROPLASTY FOR PROXIMAL HUMERUS FRACTURES: GETTING IT RIGHT —Joseph D.
Zuckerman, MD, Walter H.L. Thompson Professor and Chair, Department of Orthopedic Surgery, New York
University School of Medicine, NYU Hospital for Joint Diseases, New York, NY
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| Indications: 4-part fractures; fracture-dislocations; select 3-part fractures (particularly elderly with osteoporosis);
irreparable head-splitting fractures
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| Preoperative evaluation: standard trauma series x-rays; computed tomography (CT) may not be helpful
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| Basic principles: deltopectoral approach preserving deltoid; restoration of proper height and version; secure
tuberosity fixation, allowing early motion
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| Surgical technique: positioning—beach chair; allow full adduction and extension of humerus; approach—
preserve origin and insertion of deltoid; mobilize spaces; preserve coracoacromial ligament; exposure—
identify biceps tendon (helps locate lesser and greater tuberosity); identify and tag tuberosities (with sutures
through tendon, not bone); mobilize tuberosities to locate articular segment; inspect glenoid; expose humeral
shaft by adducting humerus and extending arm; prepare humeral shaft with sequential broaching (speaker cements
implants in fractures); place sutures through shaft before implantation
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| Assessing height and version: speaker uses Dr. Flatow’s technique; intraoperative jig useful during learning
curve; forearm used as guide for assessing version (20°-40° standard range)
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| Anatomic fracture stem: offset anterolateral fin lines up with bicipital groove (anatomic landmark between
tuberosities)
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| Tuberosity fixation: horizontal fixation to stem; vertical fixation to shaft; close rotator interval; finish with
cerclage suture; cancellous bone graft from head under tuberosities
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| Complications: component malposition (avoid with cementing); infection; tuberosity malunion, nonunion, resorption;
instability; neurologic injury
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| MISTAKES, PITFALLS, AND ERRORS WITH BANKART REPAIR —Robert H. Bell, MD, Chief, Shoulder
Section, SummaCare and Crystal Clinic, Akron, OH
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| Errors in diagnosis: “3 Ds” key (direction; degree; disability); examine both shoulders to assess degree of
laxity; correlate findings in office with those under anesthesia
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| Technical errors: most procedures that start poorly end poorly; avoiding errors requires—good staff (physician
assistant; cannot rely on residents); double traction for anterior instability; basic set of instruments; proper
portal placement
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 | Anchor placement: speaker prefers absorbable devices around glenoid; absorbable tacks now more durable;
key factors—position of insertion; depth of insertion; place at apex of glenoid; assess stability immediately
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| Capsular mobilization and tensioning: obligate capsular laxity accompanies chronic instability; arthroscopic
Bankart repair alone may not address laxity; may require capsular plication; Liberator knife useful in executing
procedure
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| Other considerations: capsular avulsion—invisible on magnetic resonance imaging (MRI); becomes apparent
when capsule distended; rotator interval closure—applicable in multidirectional and posterior instability
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| Bony deficiencies: with Hill-Sachs lesions, consider allograft, osteotomy, infraspinatus tenodesis; with glenoid,
extracapsular-type reconstruction
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| Patient compliance and rehabilitation: not always possible to identify noncompliant patient at outset; determine
patient expectations; educate patient about limitations and potential problems
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| MY PLICATION TECHNIQUE FOR MULTIDIRECTIONAL SHOULDER INSTABILITY —Jeffrey S.
Abrams, MD, Attending Surgeon, University Medical Center at Princeton, Princeton, NJ
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| Multidirectional instability: diagnosis depends on symptoms; patients present with pain resulting from inferior,
anterior, and/or posterior subluxation
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| Evaluation: get to know patient (begin rehabilitation program); try to understand symptomatic directions;
onset—traumatic event; multidirectional or atraumatic event, eg, overuse in swimmers; frequency of symptoms;
outcome of previous physical therapy; load-and-shift test— in operating room, helps center humeral head and
translate anteriorly, directly toward sulcus, or posteriorly; in supine position, can compare with opposite shoulder;
other considerations—presence of thickened scar suggests collagen disease implicated in failed repair; note
degree of external rotation when patient sitting with elbow at side (90° indicates multidirectional laxity)
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| Intraoperative findings: what appears to be humeral avulsion of glenohumeral ligament (HAGL) lesion at inferior
quadrant where capsule attaches to humeral head (at 6 o’clock) probably result of repetitive inferior
subluxations; treatment not advised
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| Surgical procedure: lateral decubitus position—facilitates surgery in humeral head and inferior pouch;
portals—posterior, slightly lateral to glenoid; anterior, just in front of acromion; capsular plication—
tensioning monofilament suture placed through capsule and adjacent inferior labrum; suturing continues, first
in most symptomatic direction, then in less symptomatic; capsular shift—grasp capsule adjacent to first stitch;
place stitch through full thickness of capsule; move inferior capsule up face of glenoid before making second
puncture and bringing in braided suture; interval closure—avoid using tendon; instead, use capsular interval;
close with superior and coracohumeral ligament; conclusion—humeral head well centered; remains centered
when arm taken out of traction and rotated
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| Postoperative care: allow time for tensioned ligament to heal correctly; continue sling 5 to 6 wk; exercises—
emphasize scapular stabilization and mid-range motion
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| Final comments: less tensioning needed in patients from 20 to 25 yr of age and older; consider sport and activities
patient trying to resume; able to reduce inferior pouch with sutures in front and back for balance; arthroscopy
allows visualization of result
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Educational Objectives
| The goal of this program is to educate the listener about advances in shoulder surgery. After hearing and assimilating
this program, the orthopaedic surgeon will be better able to:
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| 1. Obtain a surgical exposure conducive to successful shoulder arthroplasty.
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| 2. Employ the jigsaw puzzle method during humeral head replacement for proximal humerus fractures.
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| 3. Perform hemiarthroplasty in the surgical management of proximal humerus fractures.
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| 4. Avoid potential technical errors in executing Bankart repairs.
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| 5. Execute capsular plication during arthroscopic therapy for multidirectional shoulder instability.
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Suggested Reading
Abrams JS et al: Recent advances in the evaluation and treatment of shoulder instability: anterior, posterior,
and multidirectional. Arthroscopy 18:1, 2002; Abrams JS: Arthroscopic repair of posterior instability and reverse
humeral glenohumeral ligament avulsion lesions. Orthop Clin North Am 34:475, 2003; Abrams JS: Innovations
in arthroscopic surgery of the shoulder: advances in arthroscopic shoulder stabilization. Arthroscopy 19
Suppl 1:106, 2003; Alberta FG et al: Arthroscopic anteroinferior suture plication resulting in decreased glenohumeral
translation and external rotation. Study of a cadaver model. J Bone Joint Surg Am 88:179, 2006; Bell
RH et al: The management of significant glenoid deficiency in total shoulder arthroplasty. J Shoulder Elbow
Surg 9:248, 2000; Cuellar R et al: Exploration of glenohumeral instability under anesthesia: the shoulder jerk
test. Arthroscopy 21:672, 2005; Gartsman GM et al: Arthroscopic treatment of multidirectional glenohumeral
instability: 2- to 5-year follow-up. Arthroscopy 17:236, 2001; Hewitt M et al: Arthroscopic management of
multidirectional instability: pancapsular plication. Orthop Clin North Am 34:549, 2003; Keller J et al: Glenoid
replacement in total shoulder arthroplasty. Orthopedics 29:221, 2006; Neer CS 2nd: Displaced proximal humeral
fractures. Part I. Classification and evaluation. By Charles S. Neer, I, 1970. Clin Orthop Relat Res:3, 1987;
Neer CS 2nd: Displaced proximal humeral fractures. Part II. Treatment of three-part and four-part displacement.
J Bone Joint Surg Am 52:1090, 1970; Stableforth PG: Four-part fractures of the neck of the humerus. J
Bone Joint Surg Br 66:104, 1984; Sugaya H et al: Arthroscopic repair of glenoid fractures using suture anchors.
Arthroscopy 21:635, 2005.
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. Bailie—Plus Orthopedics; Biomet (consultant); Dr. Flatow—Zimmer
(royalties; academic support); Dr. Zuckerman—Exactech, Inc (design surgeon; royalties); Dr. Bell—Stryker
Orthopaedics; ArthroCare; Dr. Abrams—ConMed; Linvatec; ArthroCare Medical Wright Medical (consultant);
ConMed; Linvatec (royalties); AthroCare Medical (stock).
The speakers were recorded at Arthroscopy/Arthroplasty/Fractures, sponsored by San Diego Shoulder, June 21-24,
2006, in San Diego, CA. The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation
in the production of this program.
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