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Shoulder Reconstruction

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Presentation on theme: "Shoulder Reconstruction"— Presentation transcript:

1 Shoulder Reconstruction
Department of Orthopaedic, CKUH Sen-Jen Lee Reference: Orthopaedic Knowledge Update 6

2 Muscular Function and Anatomy of the Glenohumeral Joint
Static stabilizer: Capsuloligamentous structures Superior, middle, and inferior GH ligaments Dynamic stabilizer: Rotator cuff muscles Center the humeral head in the glenoid fossa Long head of the biceps tendon Proprioceptive mechanisms Ruffini receptors and pacinian corpuscles Ligamentomuscular reflex arcs

3 Anatomy


5 Arthroscopy of the Shoulder
As a diagnostic tool Arthroscopic subacromial decompression For treating frozen shoulder and rotator cuff tears For treating superior labral tears (SLAP lesions) For treating dislocating or subluxating shoulders


7 Rotator Cuff Disease Etiology
Mechanical impingement Compression of the supraspinatus tendon between the acromion and the greater tuberosity Intrinsic degenerative processes within the aging tendon Tendon inflammation, tendon and bursal fibrosis, tendon tears (partial- or full-thickness), and cuff tear arthropathy Acromial morphology Flat, curved, or hooked

8 Rotator Cuff Disease In a biomechanical study
The acromial undersurface and rotator cuff were in closest proximity between 60° and 120° of elevation Contact was consistently centered on the supraspinatus insertion Intrinsic histological and mechanical properties The bursal-side layer: tendon bundles The joint-side layer: a complex of tendon, ligament, and joint capsule The strain-to-yield point and ultimate failure stress Bursal-side layer were twice as great as those of the joint-side layer

9 Impingement Syndrome Common cause of shoulder pain Clinical diagnosis
History and physical examination Radiographs Supraspinatus outlet view: Subacromial spurs and the morphology of the acromion Functional impingement instability Internal impingement Impingement of the undersurface of the rotator cuff on the posterior glenoid rim

10 Pathogenesis of Rotator Cuff Lesion
Overuse 10 Impingement -Outlet Stenosis 20 Impingement -Instability 10 Degeneration -Insubstance tears -Aging -Avascularity Extrinsic Intrinsic Rotator Cuff Injuries Tendinitis / Tendinosis

11 Three Stages of Impingement Lesions
Stage I: edema and hemorrhage Reversible lesion, < 25 years old Stage II: fibrosis and tendinitis Recurrent pain with activity, years old. Stage III: tears of the rotator cuff, biceps ruptures, and bone changes Progressive disability, > 40 years old. Neer C.S ii, 1983

12 Impingement Syndrome

13 Extrinsic Factors 95 % of RCT are initiated by impingement wear rather than circulatory impairment or trauma. Shape and slope of the acromion. Impingement wear, then “acute extension” of a tear. Neer II, JBJS,1972 & Cli.Orthop, 1983

14 Intrinsic Factors Partial articular-sided tears with normal acromial morphology Cuff degeneration (aging and trauma)  RCT Ozaki et al: JBJS, 1988 (A study in cadaver) Inflammation  Angioblastic hyperplasia  fibrosis, calcification, RCT. Nirschl et al: Instr. Course Lect. 1989

15 Diagnosis of Impingement Syndrome: Hx, PE
RCT: sensitivity: 91% specificity: 75 % Ext. R Int. R. Elevation

16 Neer imp.sign Hawkin imp. sign Painful arc Imping. Test Supraspinatus test

17 Speed’s test Lift-off test

18 Image Study of the Rotator Cuff
X-ray: scapular AP/Lat Arthrogram MRI Ultrasonogram

19 Ultrasonogram of the Shoulder(I)
High resolution, real-time equipment A 7.5 MHz linear array transducer ATL’s high definition imaging (HDI) 5000 (NCKU)

20 Rotator Cuff Tear

21 Impingement Syndrome Nonsurgical Treatment
Corticosteroid injections Better pain relief and greater increases in active motion No more than 2 subacromial cortisone injections Be avoided in patients with rotator cuff tear Anti-inflammatory medications and physical therapy 67% satisfactory results

22 Impingement Syndrome Surgical Treatment
Open acromioplasty More excellent results Arthroscopic acromioplasty Reduced early perioperative morbidity Easier rehabilitation Decreased hospitalization time Ability to detect and treat concomitant glenohumeral pathology Better preservation of the deltoid origin A smaller surgical scar

23 Impingement Syndrome Failure of arthroscopic acromioplasty
Improper diagnosis Inadequate bone removal Technical errors Overaggressive bone removal leading to deltoid injury or in rare cases to acromial fracture

24 Partial-thickness Tears
Magnetic resonance imaging (MRI) and arthroscopy Arthroscopic debridement and acromioplasty Recent study: (>50% thickness of the tendon ) 15/32 good results in arthroscopic debridement and acromioplasty 31/33 excellent or good results in arthroscopic acromioplasty and mini-open repair

25 Full-thickness Tears Symptomatic full-thickness rotator cuff tears
Anterior acromioplasty and rotator cuff repair Factors in decision-making Severity and duration of symptoms Functional limitations Patient demands and expectations Tear size, and tear location Factors affect the results of rotator cuff repair Surgical technique The extent of damage to the cuff Postoperative rehabilitation

26 Treatments of Full-thickness Tears
Arthroscopically assisted or mini-open repair Massive rotator cuff tears Surgical options Subacromial decompression and debridement Mobilization and repair of existing local tendons Transfer of a distant tendon (latissimus dorsi, teres major, or trapezius) Reconstruction using grafts or synthetic materials

27 Surgical Options Open procedure: Arthroscopic procedure:

28 Prosthetic Arthroplasty
Indications and results For osteoarthritic patient Excellent results in most patients Implant survivorship was 97% at 5 years and 93% at 8 years For RA and other inflammatory arthropathies For rotator cuff tear arthropathy For neurogenic shoulder arthroplasty For arthritis after previous instability surgery For young active patients with severe glenoid arthrosis For proximal humeral comminuted fracture

29 Prosthetic Arthroplasty
Challenge: Relieving pain (strength, smoothness, mobility, stability) Relative "stuffing" of the glenohumeral joint Critical factor: soft-tissue balance Complications Glenoid and humeral loosening Component instability Rotator cuff tears Periprosthetic fractures Infection Nerve injuries Implant dissociation Deltoid dysfunction

30 Glenohumeral Arthrodesis
Fusion posture Flexion (< 15° ) Abduction (< 15° ) Internal rotation (40°< < 60° ) Salvage procedure Indication GH destruction, instability, pain, and/or a flail Neurologic problems (such as BPI) Tumors Infection

31 Adhesive Capsulitis Frozen shoulder(a poorly defined syndrome)
Both active and passive shoulder motion is lost (because of soft-tissue contracture) Adhesive capsulitis Idiopathic loss of shoulder motion Thickening and contracture of the joint capsule A fibrosing rather than an inflammatory one Treatments Physical therapy with stretching exercises Manipulation under anesthesia Arthroscopic capsular release Open release

32 Long Thoracic Nerve Palsy
Weakness of the serratus anterior muscle Clinically: Periscapular pain, Winging of the scapula Difficulty elevating the arm above shoulder level Causes Blunt trauma or stretching of the nerve Viral infection Iatrogenic trauma (during a mastectomy ) For symptomatic patients Pectoralis major transfer

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