Shoulder ReconstructionShoulder Reconstruction

Department of Orthopaedic, CKUHDepartment of Orthopaedic, CKUH

Sen-Jen LeeSen-Jen Lee

Reference: Orthopaedic Knowledge Update 6Reference: Orthopaedic Knowledge Update 6

Muscular Function and Anatomy of the Muscular Function and Anatomy of the Glenohumeral JointGlenohumeral Joint

Static stabilizer:Static stabilizer: Capsuloligamentous structuresCapsuloligamentous structures

• Superior, middle, and inferior GH ligamentsSuperior, middle, and inferior GH ligaments

Dynamic stabilizer:Dynamic stabilizer: Rotator cuff musclesRotator cuff muscles

• Center the humeral head in the glenoid fossaCenter the humeral head in the glenoid fossa• Long head of the biceps tendonLong head of the biceps tendon

Proprioceptive mechanismsProprioceptive mechanisms Ruffini receptors and pacinian corpusclesRuffini receptors and pacinian corpuscles Ligamentomuscular reflex arcsLigamentomuscular reflex arcs

AnatomyAnatomy

Arthroscopy of the ShoulderArthroscopy of the Shoulder

As a diagnostic tool As a diagnostic tool Arthroscopic subacromial decompressionArthroscopic subacromial decompression For treating frozen shoulder and rotator cuff For treating frozen shoulder and rotator cuff

tearstears For treating superior labral tears (SLAP lesions)For treating superior labral tears (SLAP lesions) For treating dislocating or subluxating For treating dislocating or subluxating

shouldersshoulders

Rotator Cuff DiseaseRotator Cuff Disease

EtiologyEtiology Mechanical impingementMechanical impingement Compression of the supraspinatus tendon between the acroCompression of the supraspinatus tendon between the acro

mion and the greater tuberositymion and the greater tuberosity Intrinsic degenerative processes within the aging tendonIntrinsic degenerative processes within the aging tendon

Tendon inflammation, tendon and bursal fibrosis, Tendon inflammation, tendon and bursal fibrosis, tendon tears (partial- or full-thickness), and cuff ttendon tears (partial- or full-thickness), and cuff tear arthropathyear arthropathy

Acromial morphologyAcromial morphology Flat, curved, or hooked Flat, curved, or hooked

Rotator Cuff DiseaseRotator Cuff Disease

In a biomechanical studyIn a biomechanical study The acromial undersurface and rotator cuff were in closest prThe acromial undersurface and rotator cuff were in closest pr

oximity between 60° and 120° of elevationoximity between 60° and 120° of elevation Contact was consistently centered on the supraspinatus inseContact was consistently centered on the supraspinatus inse

rtionrtion

Intrinsic histological and mechanical properties Intrinsic histological and mechanical properties The bursal-side layer: tendon bundles The bursal-side layer: tendon bundles The joint-side layer: a complex of tendon, ligament, and joint The joint-side layer: a complex of tendon, ligament, and joint

capsulecapsule The strain-to-yield point and ultimate failure stressThe strain-to-yield point and ultimate failure stress

• Bursal-side layer were twice as great as those of the joint-Bursal-side layer were twice as great as those of the joint-side layerside layer

Impingement SyndromeImpingement Syndrome

Common cause of shoulder painCommon cause of shoulder pain Clinical diagnosisClinical diagnosis

History and physical examinationHistory and physical examination

RadiographsRadiographs Supraspinatus outlet view:Supraspinatus outlet view:

• Subacromial spurs and the morphology of the acromionSubacromial spurs and the morphology of the acromion

Functional impingement Functional impingement instability instability Internal impingementInternal impingement

Impingement of the undersurface of the rotator cuff on the Impingement of the undersurface of the rotator cuff on the posterior glenoid rimposterior glenoid rim

Pathogenesis of Rotator Cuff LesionPathogenesis of Rotator Cuff Lesion

Intrinsic

10 Impingement-Outlet Stenosis

20 Impingement-Instability

10 Degeneration-Insubstance tears-Aging-Avascularity

Extrinsic

Overuse

Rotator Cuff Injuries

Tendinitis / Tendinosis

Three Stages of Impingement LesionsThree Stages of Impingement Lesions

Stage I: edema and hemorrhageStage I: edema and hemorrhage Reversible lesion, < 25 years oldReversible lesion, < 25 years old

Stage II: fibrosis and tendinitisStage II: fibrosis and tendinitis Recurrent pain with activity, 25 - 40 years old.Recurrent pain with activity, 25 - 40 years old.

Stage III: tears of the rotator cuff, biceps rStage III: tears of the rotator cuff, biceps ruptures, and bone changesuptures, and bone changes Progressive disability, > 40 years old.Progressive disability, > 40 years old.

Neer C.S ii, 1983Neer C.S ii, 1983

Impingement SyndromeImpingement Syndrome

Extrinsic FactorsExtrinsic Factors 95 % of RCT are initiated by impingement wear rather than c95 % of RCT are initiated by impingement wear rather than c

irculatory impairment or trauma.irculatory impairment or trauma. Shape and slope of the acromion.Shape and slope of the acromion. Impingement wear, then “acute extension” of a tear.Impingement wear, then “acute extension” of a tear.

Neer II, JBJS,1972 & Cli.Orthop, 1983Neer II, JBJS,1972 & Cli.Orthop, 1983

Intrinsic FactorsIntrinsic Factors Partial articular-sided tears wPartial articular-sided tears w

ith normal acromial morpholoith normal acromial morphologygy

Cuff degeneration (aging and Cuff degeneration (aging and trauma) trauma) RCT RCT

Ozaki et al: JBJS, 1988 Ozaki et al: JBJS, 1988

(A study in cadaver(A study in cadaver))

Inflammation Inflammation Angioblastic Angioblastic hyperplasia hyperplasia fibrosis, calcifi fibrosis, calcification, RCT.cation, RCT. Nirschl et al: Instr. Course Lect. 1989Nirschl et al: Instr. Course Lect. 1989

Diagnosis of Impingement Syndrome: Diagnosis of Impingement Syndrome: Hx, PEHx, PE

RCT: sensitivity:RCT: sensitivity: 91%91% specificity: 75 %specificity: 75 %

Elevation Ext. R Int. R.

Neer imp.sign Hawkin imp. sign Painful arc

Imping. Test Supraspinatus test

Lift-off testSpeed’s test

Image Study of the Rotator CuffImage Study of the Rotator Cuff

X-ray: scapular AP/LatX-ray: scapular AP/Lat ArthrogramArthrogram MRIMRI UltrasonogramUltrasonogram

Ultrasonogram of the Shoulder(I)Ultrasonogram of the Shoulder(I)

High resolution, real-time equipment High resolution, real-time equipment A 7.5 MHz linear array transducerA 7.5 MHz linear array transducer

ATL’s high definition imaging (HDI) 5000 (NCKU)ATL’s high definition imaging (HDI) 5000 (NCKU)

Rotator Cuff TearRotator Cuff Tear

Impingement SyndromeImpingement Syndrome Nonsurgical Treatment Nonsurgical Treatment

Corticosteroid injections Corticosteroid injections • Better pain relief and greater increases in active motioBetter pain relief and greater increases in active motio

nn• No more than 2 subacromial cortisone injections No more than 2 subacromial cortisone injections • Be avoided in patients with rotator cuff tearBe avoided in patients with rotator cuff tear

Anti-inflammatory medications and physical theAnti-inflammatory medications and physical therapy rapy

• 67% satisfactory results 67% satisfactory results

Impingement SyndromeImpingement Syndrome Surgical Treatment Surgical Treatment

Open acromioplasty Open acromioplasty More excellent resultsMore excellent results

Arthroscopic acromioplastyArthroscopic acromioplasty Reduced early perioperative morbidityReduced early perioperative morbidity Easier rehabilitationEasier rehabilitation Decreased hospitalization timeDecreased hospitalization time Ability to detect and treat concomitant glenohumeral pathAbility to detect and treat concomitant glenohumeral path

ologyology Better preservation of the deltoid originBetter preservation of the deltoid origin A smaller surgical scarA smaller surgical scar

Impingement SyndromeImpingement Syndrome

Failure of arthroscopic acromioplastyFailure of arthroscopic acromioplasty Improper diagnosisImproper diagnosis Inadequate bone removalInadequate bone removal Technical errors Technical errors

• Overaggressive bone removal leading to deltoid injury or in rare Overaggressive bone removal leading to deltoid injury or in rare cases to acromial fracturecases to acromial fracture

Partial-thickness TearsPartial-thickness Tears

Partial-thickness tearsPartial-thickness tears Magnetic resonance imaging (MRI) and arthroscopyMagnetic resonance imaging (MRI) and arthroscopy Arthroscopic debridement and acromioplastyArthroscopic debridement and acromioplasty

Recent study: Recent study: (>50% thickness of the tendon )(>50% thickness of the tendon )

15/32 good results in arthroscopic debridement and 15/32 good results in arthroscopic debridement and acromioplasty acromioplasty

31/33 excellent or good results in arthroscopic 31/33 excellent or good results in arthroscopic acromioplasty and mini-open repairacromioplasty and mini-open repair

Full-thickness TearsFull-thickness Tears

Symptomatic full-thickness rotator cuff tears Symptomatic full-thickness rotator cuff tears Anterior acromioplasty and rotator cuff repair Anterior acromioplasty and rotator cuff repair

Factors in decision-making Factors in decision-making Severity and duration of symptomsSeverity and duration of symptoms Functional limitationsFunctional limitations Patient demands and expectationsPatient demands and expectations Tear size, and tear locationTear size, and tear location

Factors affect the results of rotator cuff repairFactors affect the results of rotator cuff repair Surgical techniqueSurgical technique The extent of damage to the cuffThe extent of damage to the cuff Postoperative rehabilitation Postoperative rehabilitation

Treatments of Full-thickness TearsTreatments of Full-thickness Tears

Arthroscopically assisted or mini-open repair Arthroscopically assisted or mini-open repair Massive rotator cuff tears Massive rotator cuff tears

Surgical options Surgical options • Subacromial decompression and debridementSubacromial decompression and debridement• Mobilization and repair of existing local tendonsMobilization and repair of existing local tendons• Transfer of a distant tendon (latissimus dorsi, teres major, or Transfer of a distant tendon (latissimus dorsi, teres major, or

trapezius)trapezius)• Reconstruction using grafts or synthetic materialsReconstruction using grafts or synthetic materials

Surgical OptionsSurgical Options

Arthroscopic procedure:Arthroscopic procedure:

Open procedure:Open procedure:

Prosthetic ArthroplastyProsthetic Arthroplasty

Indications and resultsIndications and results For osteoarthritic patientFor osteoarthritic patient

• Excellent results in most patientsExcellent results in most patients• Implant survivorship was 97% at 5 years and 93% at 8 Implant survivorship was 97% at 5 years and 93% at 8

yearsyears For RA and other inflammatory arthropathies For RA and other inflammatory arthropathies For rotator cuff tear arthropathyFor rotator cuff tear arthropathy For neurogenic shoulder arthroplasty For neurogenic shoulder arthroplasty For arthritis after previous instability surgeryFor arthritis after previous instability surgery For young active patients with severe glenoid arthrosisFor young active patients with severe glenoid arthrosis For proximal humeral comminuted fractureFor proximal humeral comminuted fracture

Prosthetic ArthroplastyProsthetic Arthroplasty

Challenge: Challenge: Relieving pain (strength, Relieving pain (strength,

smoothness, mobility, stasmoothness, mobility, stability)bility)

Relative "stuffing" of the Relative "stuffing" of the glenohumeral joint glenohumeral joint

Critical factor: soft-tissue Critical factor: soft-tissue balancebalance

Complications Complications Glenoid and humeral looseGlenoid and humeral loose

ningning Component instabilityComponent instability Rotator cuff tearsRotator cuff tears Periprosthetic fracturesPeriprosthetic fractures InfectionInfection Nerve injuriesNerve injuries Implant dissociationImplant dissociation Deltoid dysfunctionDeltoid dysfunction

Glenohumeral ArthrodesisGlenohumeral Arthrodesis

Salvage procedureSalvage procedure IndicationIndication

GH destruction, instability, GH destruction, instability, pain, and/or a flail pain, and/or a flail

Neurologic problems (such Neurologic problems (such as BPI)as BPI)

TumorsTumors InfectionInfection

Fusion postureFusion posture Flexion (< 15° )Flexion (< 15° ) Abduction (< 15° ) Abduction (< 15° ) Internal rotation (40°< < 60Internal rotation (40°< < 60

° )° )

Adhesive CapsulitisAdhesive Capsulitis

Frozen shoulderFrozen shoulder(a poorly defined syndrome)(a poorly defined syndrome)

Both active and passive shoulder motion is lost (because Both active and passive shoulder motion is lost (because of soft-tissue contracture)of soft-tissue contracture)

Adhesive capsulitis Adhesive capsulitis Idiopathic loss of shoulder motionIdiopathic loss of shoulder motion Thickening and contracture of the joint capsuleThickening and contracture of the joint capsule A fibrosing rather than an inflammatory oneA fibrosing rather than an inflammatory one

TreatmentsTreatments Physical therapy with stretching exercisesPhysical therapy with stretching exercises Manipulation under anesthesia Manipulation under anesthesia Arthroscopic capsular release Arthroscopic capsular release Open release Open release

Long Thoracic Nerve PalsyLong Thoracic Nerve Palsy Weakness of the serratus anterior muscleWeakness of the serratus anterior muscle Clinically: Clinically:

Periscapular pain, Periscapular pain, Winging of the scapula Winging of the scapula Difficulty elevating the arm above shoulder levelDifficulty elevating the arm above shoulder level

Causes Causes Blunt trauma or stretching of the nerve Blunt trauma or stretching of the nerve Viral infectionViral infection Iatrogenic trauma (during a mastectomy ) Iatrogenic trauma (during a mastectomy )

For symptomatic patientsFor symptomatic patients Pectoralis major transfer Pectoralis major transfer