contraindications to TSA?
<div>irreparable cuff</div>
RC arthropathy<div>poor glenoid bone stock</div><div>deltoid dysfunction</div><div>brachial plexus palsy</div><div>active infection</div>
Appropriate Balancing for TSA?
40-50-60<div>40deg ER in Adduction (with reducible subscap)<div>50% posterior sublux</div><div>60 deg IR in Abduction</div></div>
Correct humeral height for a hemi for PHF
Pect major is 5.6cm distal to top of HH and 4.2cm distal to GT<div>GT should reduce tension-free</div><div>HTD (head to tuberosity) should be 10mm</div><div>intra-op fluoro/contralateral side</div>
landmarks for hemi positioning for PHF
Height: sup border of pect 5.2cm<div>Version: 20 deg retro</div><div>tuberosities: anatomic, tension free, 5-10mm below top of HH</div>
Shoulder X-rays and their uses?
“<div>Garth view: HS and Bankart</div><div>West-point axillary: Glenoid/Bankart</div><div>Stryker notch: HS</div><div><img></img><br></br></div><div><div><br></br></div><div><br></br></div></div>”
RFs for recurrent instability post arthroscopic capsulolabral repair?
Patient Factors<div>- <b>Age < 28years</b></div><div><b>- </b>Age at surgery<20</div><div>- immobilization < 4 weeks</div><div>- Ligamentous laxity</div><div>- Contact/overhead/competitive sports</div><div><br></br></div><div>Anatomic Factors</div><div>-H-S > 250mm3</div><div>- HS visible on ER A/P Xray</div><div>- Glenoid bone loss > 15%</div><div>- Glenoid loss of contour on AP x-ray</div><div><br></br></div>
ISIS score
Shoulder instability recurrence (total = 10)<div><6 = 10%</div><div>>6 = 70% -> undergo open procedure</div><div><br></br></div><div>Age<20 = 2</div><div>Hyperlaxity = 1<br></br></div><div>competitive sport = 2</div><div>Contact sport = 1</div><div>HS on ER AP X-ray = 2</div><div>Glenoid abN on AP Xray = 2</div>
Surgical Management of HS lesion?
<div>Glenoid augmentation</div>
Capsular Shift<div>HH augmentation (auto or allograft)</div><div>Remplissage (posterior capsulodesis and infraspinatus tenodesis)</div><div>Humeroplasty (subchondral disimpaction + graft)</div><div><br></br></div><div>Historic: Rotational HH Osteotomy, PuttiPlat (subscap tightening)</div>
Frozen Shoulder: Assx conditions, NHx, Tx
“Assx conditions: thyroid, DM, CVA, Malignancy, breast ca ca, dupuytren’s<div><br></br></div><div>NHx:gradual resolution with mild treatment</div><div><br></br></div><div>Tx:</div><div>-nonop: steroids</div><div>-op: MUA (95% happy at 6/12) and release of anterior capsule and RI</div>”
Poor PX factors for RC failure?
<u>Patient Factors</u><div>Age>65</div><div>female</div><div>smoker</div><div>decreased BMD</div><div>longer duration of symptoms</div><div><b>inability to FF>100 deg (or weakness in FF)</b></div><div>inability to comply with post-op rehab</div><div><br></br></div><div><u>Tear characteristics</u></div><div>Massive tear >5cm</div><div>Fullthickness</div><div>>1 tendon</div><div>Atrophy/fatty infiltration (Goutallier grade 3/4)</div><div>Degree of muscle retraction (>2.5cm - to level of glenoid)</div><div>Hooked acromion (type III)</div><div><br></br></div><div><b><br></br></b></div><div><br></br></div>
“JAAOS 2018 - Changes in thrower’s shoulder?”
“<div> <div> <div><img></img></div> </div></div>”
<div>RC 2012 -5 components of the SSSC</div>
“glenoid<div>coracoid</div><div>CC lig</div><div>clavicle</div><div>AC ligament</div><div>Acromion</div><div><br></br></div><div><img></img><br></br></div>”
<div>SC joint anterior dislocation. Best treatment?</div>
<ol> <li>Closed reduction and figure of eight brace</li> <li>Open reduction and suture fixation</li> <li>Do nothing</li> <li>K wire fixation</li></ol>
“<div>ANSWER: A (but C is reasonable)</div> <ul> <li>2011</li> <li>JAAOS 2011 - Management of Traumatic Sternoclavicular Joint Injuries</li> <ul> <li>"”Closed reduction is the current treatment of choice, although there is still some controversy regarding management because good long-term results have been reported with nonsurgical management””</li> <li>Patient under sedation, pressure on medial clavicle, immobilization with figure of eight brace x 6 weeks</li> <li>Most unstable after reduction, but if they do stay there is better cosmesis</li> <ul> <li>Do not recommend open reduction</li> </ul> </ul></ul>”
<div>COTS Trial - Op vs Non-Op for AC joint injuries?</div>
<ul> <li>Types 3, 5 mainly</li><li>Better Constant scores and return to work with Non-op at 6 weeks, 12 weeks and 6 months</li> <ul> <li>Equalize at 1-2 years</li> </ul></ul>
nerves at risk during Lat Dorsi Transfer (not a RC Q)
“-radial nerve (sits anterior and medial to tendon insertion)<div>-axillary (superior to tendon, distance is greatest in ER)</div><div><br></br></div><div><img></img><br></br></div>”
Principle of Pc Major tendon transfer? (Not a RC Q)
“partial or complete transfer of tendon UNDERNEATH conjoint tendon (improves vector) but SUPERFICIAL to MCN<div><img></img><br></br></div>”
Fusion of GH? Not a RC Q yet
“<ul> <li>Fusion position: 30-30-30</li><li>Saber Incision: from spine of scapula to anterior acromion and down anterior aspect of humeral shaft</li> <ul> <li>Deltoid detached from anterior acromion and split distally, Rotator cuff resected</li> <li>Decorticate head, glenoid and underside of acromion</li> <li>Lag screws from plate, through head and into glenoid for compression</li> <li>Attempt fusion of acromion, glenoid and humeral head</li> <ul> <li>bone graft</li> </ul> <li>10 hole 4.5mm pelvic recon plate</li> <li>Fusion position is 30-30-30 (maybe 20 abduction)</li> <ul> <li>Feeding position: 30 deg flex, 30 deg IR, 30 deg abd</li> </ul> </ul> <li><img></img></li></ul>”
Biceps pulley components?
“intertubercular groove<div>CHL</div><div>SGHL</div><div>Subscap</div><div>Supra</div><div><br></br></div><div><img></img> <div></div> <img></img><br></br></div>”
Approach to Anterior shoulder instability
“<img></img>”
COR HH vs Humeral canal in TSA?
“<div>COR is offset posterior and medially</div><div><br></br></div>Humeral canal is ANTEROLATERAL to COR of HH<div><br></br></div><div><img></img><br></br></div>”
Comma Sign? How to treat?
<div> <div> <div>At arthroscopy, a chronic subscapularis tear can be </div> <div>identified by the comma sign, which represents an avulsed SGHL.</div> <div><br></br></div><div>Surgical treatment, either open or arthroscopic, is generally indicated; in chronic cases, a pectoralis transfer is occasionally required.<br></br></div> </div> </div>
Subcoracoid Impingement?
<div> <div> <div> <ol> <li><div>Subcoracoid impingementis defined as impingement of thesubscapularisbetweenthecoracoidandlesser tuberosity<br></br></div></li><li> <div>Patients with long or excessively laterally placed coracoid processes may have impingement of this process on the proximal humerus with forward flexion (120 to 130 degrees) and internal rotation of the arm. </div> <div>2. It may occur after surgery that causes posterior capsular tightness and loss of internal rotation. </div> <div>3. Local anesthetic injection should relieve these symptoms. 4. CT performed with the arms crossed on the chest is helpful </div> <div>in evaluating this problem.<br></br> 5. A distance of less than 7 mm between the humerus and coracoid process is considered abnormal.</div></li><li><div><div> <div> <div> <div> <div>Treatment of chronic symptoms involves resection of the lateral aspect of the coracoid process and reattachment of the conjoined tendon to the remaining coracoid. </div> <div>Arthroscopic coracoplasty has also been successful in treat- ing this condition without detachment of the conjoined muscle group.</div> </div> </div> </div></div></div></li></ol></div></div></div>
Predictors of failure of non-op tx for RC tears?
<ul> <li>Dunn WR, MOON Consortium (JSES 2016) Predictors of failure of non-operative treatment of chronic, symptomatic, full-thickness rotator cuff tears</li> <ul> <li>433 patients at 1 year (94% follow up)</li> <li>20% had surgery</li> <ul> <li>Underwent surgery early in follow up period (median 120 days)</li> </ul> <li><b><i>Patient expectations about the effectiveness of rehabilitation the most significant predictor of failure of rehab</i></b></li> <li><b><i>Other predictors --> higher level of activity, non-smoker</i></b></li> </ul></ul>
Goutallier Classification?
<div> <div><br></br></div><div><br></br></div><div>Stage</div> <div>Rotator Cuff Fat Content</div> <div>0</div> <div>Normal muscle, no fatty streak</div> <div>1</div> <div>Some fatty streaks in muscle</div> <div>2</div> <div>Fatty infiltration present, but more muscle than fat</div> <div>3</div> <div>Fat = muscle</div> <div>4</div> <div>Fat > muscle</div> <br></br></div>
<div>Goutallier evaluated 220 open RCT with transosseous tunnels. 36% re-tear rate. All shoulders with > class 2 infiltration had re-tears<br></br></div>
- Soft tissue (70%)
- Scalenus minimus (accessory muscle)
- 10-50% of patients with TOS
- Cervical TP to first rib between subclavian artery and T1 root
- 43% in one study had anomalous scalene insertion
- 10% subclavius tendon anomalies
- Hypertrophy of scalene musculature
- Congenital anomalous ligaments or bands
- Trauma/scarring
- Osseous Anomalies (30%)
- Cervical ribs (8.5%)
- Prominent C7 transverse process
- Exostoses
- Tumor
- Fracture callus
- P/E
- Wright --> decrease in pulse with arm hyper-abduction and ER with head opposite side (RC EXAM)
- Decrease in pulse with 7% normal population
- Adson ---> extension with head towards affected side + deep breathe
- 51% normal people have diminished pulse
- Sensitive, not specific
- Roos --> arms 90o abduction, elbows 90o plus hand open and closed for 3 minutes
- TOS if replication of symptoms
- Most sensitive test according to Green's
- Presentations
- Neurogenic (compression of brachial plexus)
- 90% of cases
- Lower and combined plexus is more common (85-90%)
- Vascular (arterial or venous)
- 3-5% venous
- <1% arterial
- Anterior dislocation should be first treated with acute closed reduction.
- Failures of reductions and chronic dislocations are treated conservatively.
- Posterior dislocation should be treated with closed reduc- tion and open reduction if necessary, particularly with compression of the posterior structures. Consultation with a cardiothoracic surgeon may be appropriate.
- The use of hardware should be avoided whenever possible
- Western Ontario Rotator Cuff Index (WORC)
- Domains: (VAS scores)
- Pain and physical symptoms
- Sports and recreation
- Work function
- Social function
- Emotional function
- Validated in wide variety of populations
- PRO
- Western Ontario Shoulder Instability Index (WOSI)
- Four Domains:
- Physical Symptoms
- Sports, recreation and work
- Lifestyle
- Emotions
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Tumor75
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Tumor - RC Q's92
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Trauma - RC Q's176
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Trauma118
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Sports - RC Q's55
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Sports28
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Spine - RC Q's117
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Spine83
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Shoulder - RC Q's80
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Shoulder30
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Peds - RC Q's273
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Peds78
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JAAOS2018131
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JAAOS 201853
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H&W - RC Q's127
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H&W68
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F&A - RC Qs81
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F&A44
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FLUFF41
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Elbow - RC Q's38
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Elbow42
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Diseases7
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Basic Science91
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ATLS7
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Arthroplasty - RC Q's102
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Arthroplasty85
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2021 Exam173
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2020 Q's2
