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

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

Anatomy

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

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

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

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

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

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

Impingement Syndrome

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

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

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

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

Speed’s test Lift-off test

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

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)

Rotator Cuff Tear

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

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

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

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

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

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

Surgical Options Open procedure: Arthroscopic procedure:

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

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

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

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

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