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