HIGH-YIELD SHOULDER & ELBOW TOPICS

Dragomir Mijic, DO 1. Rotator Cuff Tears

 Epidemiology  Rotator cuff repair

 age >60: 28% have full-thickness tear  acute or chronic full-thickness tears

 age >70: 65% have full-thickness tear  bursal-sided tears >3 mm (>25%) in depth  Risk factors: age, smoking, hypercholesterolemia, family history  partial articular-side tears>50%.

 Acute SIT tears: > 40 with shoulder  PASTA with >7mm of exposed bony dislocation footprint between the articular surface and intact tendon  late cocking/early represents significant (>50%) cuff acceleration>internal tear impingement>PASTA  rate-limiting step for recovery is  MRI biologic healing of RTC tendon to Overview of Physical Exam of Rotator Cuff  sagittal images: muscle atrophy greater tuberosity: 8-12 weeks Cuff Muscle Special Tests Supraspinatus o Drop arm test  medial biceps subluxation: subscap  WC: higher postop disability and o Pain with Jobe test tear lower satisfaction Infraspinatus o ER lag sign Teres minor o Hornblowers  tangent sign: line between spine and Subscapularis o Excessive passive ER coracoid: SS grade III atrophy o Belly press o Lift off o IR lag sign  55% of asymptomatic pt 60+ will have RCT on MRI https://www.orthobullets.com/shoulder-and-elbow/3043/rotator-cuff-tears https://www.pagepress.org/journals/index.php/rr/article/view/rr.2010.e1/1907 Rotator Cuff Tears

 Tendon Transfers  Complications

 Pectoralis (subscap)  Repair Failure

 under the conjoined tendon  failure of cuff tendon healing and suture pullout from tissue  Latissimus Dorsi (post/sup RC)  Risk Factors  Thoracodorsal N. (C6-C8)  age >65  young laborer  large tear >5cm  brace in 45º abd and 30º ext rotation  muscle atrophy  radial nerve at risk (3cm medial to tendon insertion on humerus)  DM, tobacco

 Lower Trapezius (post/sup RC)  tear retraction medial to glenoid

 Spinal Accessory N. (CN XI)  Infection (<1%)

 requires Achilles tendon allograft for  P. acnes (delayed or indolent cases) increased excursion  Pneumothorax

 due to regional anesthesia

 smokers/COPD due to hyperinflated lungs 2. Traumatic Anterior Shoulder Instability (TUBS)

 Traumatic Unilateral Dislocations with  Axillary Nerve a Bankart Lesion Requiring Surgery  Transient Neuropraxia (5%)  recurrence rate corelates with age at dislocation (90% recurrence if <20)  Rotator Cuff Tears  80% of TUBS patients > 60  Hill-Sachs defect is "on track" and will NOT "engage" if width of HS defect < glenoid articular track width  Anterior static shoulder stability  Associated Injuries  Anterior band of IGHL: (main  HAGL restraint) arm in 90° of abd and ext rot  in patients slightly older than Bankart  MGHL: 45° of abduction and external rotation  associated with high recurrence rate if missed and not repaired  SGHL: static restraint with arm at the side  indication for open repair

 Bony Bankart

 "critical bone loss" 13.5-25%

 require bony procedure to restore stability https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590004/ Traumatic Anterior Shoulder Instability (TUBS)

 Surgical Management ➢ Putti-Platt & Magnuson-Stack (historic)

 Arthroscopic Bankart +/- capsular shift  loss of external rotation>posterior glenoid loading>post capsulorrhaphy  relative indications arthropathy  first time dislocation with bankart lesion in  Complications athlete younger than 25  recurrence  > one dislocation after non-op treatment  unrecognized bone loss  <20% glenoid bone loss  less than 3 anchors  Latarjet  <20, lig laxity, contact sports,  > 20-25% bone loss ("inverted pear") male  increase glenoid track, sling effect, CA lig  seizure disorder capsule recon  Nerve Injury  Remplissage  Axillary and  "off track" engaging Hill-Sachs defect >25-40% Musculocutaneous  post capsule and infraspinatus sutured into the Hill-Sachs lesion 3. Posterior Shoulder Instability & Dislocation

 Mechanism  Provocative Tests

 Trauma  Jerk Test

 Microtrauma  arm in 90º abd, int rot, elbow bent, apply axial force and add arm to  lineman, weightlifters, overhead forward flexed position athletes  "clunk" positive for post subluxation  flexed, adducted, internally rotated arm position  97% sensitive for post labral tear when combined with Kim Test  Seizure and electric shock  Kim Test  Anatomy  pt. seated, arm at 90º abd, flex  posterior band of IGHL (restraint in shoulder to 45º forward flexion while internal rotation) applying axial load on the elbow and  subscapularis (dynamic restraint in post-inf force on upper humerus external rotation) (pain=positive test)

 SGHL & Coracohumeral ligament  Imaging

 primary static stabilizer to post  AP (lightbulb sign) translation with arm in flexion,  Axillary adduction, and internal rotation https://jetem.org/posterior-shoulder-dislocation/  Velpeau https://www.orthobullets.com/shoulder-and-elbow/3038/shoulder-imaging Posterior Shoulder Instability & Dislocation

 Treatment  Hemiarthroplasty  reduction and immobilization in  chronic dislocation >6 months external rotation for 4-6 wks  >40% reverse Hill Sachs  Posterior Labral Repair  Complications  in cases of recurrent instability despite PT course  Stiffness

 Negative Beighton Score (0-3)  Recurrence

 Posterior capsular shift and rotator  DJD BEIGHTON SCORE interval closure

 Positive Beighton Score (4-9)

 Open Reduction

 <6 moths chronic dislocation

 Reverse Hill Sachs <40%

 McLaughlin (subscap transfer)

 Modified McLaughlin (lesser tuberosity transfer)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946643/ 4. Multidirectional Shoulder Instability (MDI)

 Overview:  Treatment

 AMBRI: Atraumatic, multidirectional, bilateral,  Dynamic Stabilization PT rehabilitation, inferior capsular shift  3-6 month regimen  microtrauma or generalized ligamentous laxity (ED/Marfan)  vast majority of patients  dynamic stabilizer strengthening/closed  Hallmark Findings of MDI kinetic chain exercises  patulous inferior capsule on MRI (IGHL anterior and posterior bands)  Operative  inferior capsular shift superiorly  Physical Exam  plication of redundant capsule  instability in 2 or more planes to be defined as MDI  rotator interval closure (results in decrease  Sulcus Sign (> 2+) in ROM in ext rot with the arm at the side)  apprehension/relocation test  address labral pathology  ant/post load and shift (2+ or more)  Complications  +Neer and +Hawkins in pt. < 20  Recurrence  Breighton's criteria > 4/9 5. Glenohumeral Internal Rotation Deficit (GIRD)

 Overview  Presentation

 overhead athletes (pitchers)  Altered GH ROM

 during late cocking/early acceleration phase  GIRD < external rotation gain (ERG)=normal kinematics  tightening of posterior capsule with anterosuperior HH translation in flexion,  GIRD > (ERG)=deranged kinematics posteroinferior capsular tightness leads to posterosuperior translation of HH in ABER  Treatment  rest from throwing + PT (sleeper stretch) x 6  associated with internal impingement: GT > postsup glenoid > posterosuperior RC months (90%)  Posterior capsular release  articular sided partial RC tears

 SLAP lesions ("peel-back mechanism) during late cocking due to postsup HH translation and change in biceps vector force

https://mikereinold.com/gird-glenohumeral-internal-rotation-deficit/ 6. SLAP Lesion  Treatment

 Nonop: rotator cuff strengthening,  Overview scapular dyskinesia, GERD

 overhead athletes/GIRD/FOOSH  OP: controversial

 SLAP lesion > increased strain on  Debridement anterior band of IGHL > instability  Repair vs Tenodesis/Tenotomy  Biceps attachment to labrum is posterior  Type II: traditionally repaired to 12 o'clock position (50 lab/50 tub) la in overhead athletes  Antero-superior labrum > poorest blood  Tenotomy/Tenodesis >40 supply  Decompress any cysts  Anatomic Variant > Buford complex  Peel back test: 90 ext rot/abd https://www.orthobullets.co  Presentation: mechanical symptoms m/shoulder-and-  Rehab elbow/3053/slap-lesion  Exam: O'Brien's Test, Crank Test, Speed's  week 1-4: passive and active assisted  Imaging flexion in the scapular plane (avoid  MRI arthrogram: T2 signal intensity biceps exercises, extremes of between the superior labrum, abduction and external rotation) lateral to glenoid rim, and posterior  Complications: to the biceps> paralabral cyst  Stiffness, suprascapular nerve injury, SLAP repair failure (>36) 7. Adhesive Capsulitis

 Overview  Arthroscopic Release

 40-60, females, DM, tyroid  Rotator Interval Release

 Fibroblastic proliferation > TYPE III  from area just anterior to biceps collagen > essential lesion tendon to superior edge of (coracohumeral ligament and rotator subscapularis interval)  Coracohumeral ligament release  external rotation deficit (most common finding)  Posterior capsular release > increase IR and cross body adduction  loss of axillary recess on MRI  Complications  Treatment  Residual Stiffness  PT/HEP (GENTLE to point of pain stretching), cortisone, NSAIDS  Axillary Nerve (inferior capsular release)  Brachial plexopathy, proximal humerus  MUE fractures, GH dislocation, rotator cuff  Arthroscopy (>3 months conservative) tears (MUA)

 capsular, rotator interval, subacromial

 assess and document pre and post procedure ROM 8. Suprascapular Neuropathy

 Overview

 C5-C6 superior trunk  Spinoglenoid notch

 Suprascapular Notch  infraspinatus weakness ONLY

 supra and infraspinatus weakness  posterior labral tear CYST

 labral tear ganglion cyst  spinoglenoid ligament

 deep diffuse posterolateral  spinoglenoid notch ganglion shoulder pain, pain with palpation  traction injury (volleyball players) of the suprascapular notch, posterior scapula atrophy  normal supraspinatus strength with infraspinatus atrophy  MRI + EMG/NVC  posterior shoulder capsule  PT trial if no structural lesion on MRI stretching  Surgical nerve decompression at SS  arthroscopic cyst decompression notch if MRI positive and labral repair

 spinoglenoid ligament release 9. Total Shoulder Arthroplasty

 Contraindications  Glenoid

 insufficient glenoid bone stock  Walch Classification: A1, A2, B1, B2, B3, C, D

 rotator cuff arthropathy  Peg design superior to keel

 isolated supraspinatus tear without  Retroversion: partial correction or augmented glenoid retraction is an acceptable component condition to proceed with TSA  Humeral component  incidence of full thickness rotator  Press Fit or Cemented cuff tears in patients getting a TSA is 5% to 10%  25-45 degrees of retroversion

 deltoid dysfunction  Avoid overstuffing

 irreparable rotator cuff  top of the humeral head should be 5 to 8 mm superior to the top of the greater tuberosity  "rocking horse" phenomenon

 active infection

 brachial plexus palsy

https://www.researchgate.net/figure/Modified-Walch-classification-Notes- A1Centered-humeral-head-with-minor-erosion-A2_fig2_323361294 Total Shoulder Arthroplasty

 Complications  Neurologic injury

 Glenoid component loosening  axillary nerve is most commonly injured

 most common cause of TSA failure  musculocutaneous nerve can be injured by retractor placement under  insufficient glenoid bone stock conjoint tendon  rotator cuff deficiency  Rehabilitation  Subscpularis Failure  Limit passive external rotation and  anterior instability pushing out of chair due to risk of tear and pull-off of subscapularis  Infection  treatment of subscapularis pull-off  P. acnes is early exploration and repair of tendon  most common cause of indolent infections and  Outcomes implant failures  good survival at 10 years (93%)  1-2% after primary TSA

 anaerobic culture bottles, keep for 10-14days (mean time to detection 6 days) 10. Reverse Shoulder Arthroplasty

 Contraindications  irreparable subscapularis

 Axillary nerve palsy/deltoid deficiency  fixed glenohumeral dislocation preop  Biomechanics  failed prior arthroplasty  Increase in deltoid moment arm  proximal humeral nonunion  Distalization and medialization of center of rotation  Scapular notching

 Loss of external rotation  Grammont design, superiorly placed glenoid component,  latissimus, teres major, or lower insufficient inferior tilt trapezius transfer  Sirveaux Classification of Scapular  Complications Notching  Dislocation  Grade 1: Scapular Pillar  2-3.4%  Grade 2: Inferior Screw  proximal humeral bone loss  Grade 3: Beyond inferior  deltoid disfunction, loss of deltoid screw wrapping  Grade 4: Central post

http://shoulderarthritis.blogspot.com/2017/04/scapular-notching-is-it-about-notch-or.html 11. Total Elbow Arthroplasty

 Indications  Design

 RA (Larsen 3-5)  Semiconstrained or Linked components  longest survivorship  Cooonrad-Moorey  90% at 15 years  "sloppy hinge", anterior flange  Advanced primary OA  best results of all designs  Fracture (>70, unreconstructible)  5-10 lbs lifelong lifting limitation  Contraindications  Complications  Charcot, infection  Infection (8%)  Olecranon osteotomy (relative)  staph epi (encapsulating)  Patient younger than 65 (relative)  Aseptic Loosening (6%)

 Bushing Wear

 Ulnar Neuropathy

 Triceps Insufficiency

https://www.orthobullets.com/shoulder-and- elbow/3084/elbow-arthritis 12. Medial UCL Injury (Valgus Instability)

 Overview  Imaging

 Elbow dislocation  MR-arthrogram ("T-sign")

 Repetitive valgus stress during late cocking  Treatment and early acceleration > microtrauma to  PT (1st line treatment) anterior band of UCL > rupture  6 week throwing holiday  Anatomy  Flexor pronator strengthening  Anterior oblique: main valgus stabilizer, medial epicondyle to sublime tubercle,  Improvement of throwing isometric mechanics

 Posterior oblique: tighter in flexion, not  Operative isometric  MCL anterior band ligament recon  PE  multiple techniques (palmaris,  Milking Maneuver gracilis, or allograft)

 Moving Valgus Stress Test (70-120º)  Complications

 100% sensitive, 75% specific  Ulnar Nerve, MABC, fracture, stiffness 13. Distal Biceps Avulsion

 Overview  Operative Treatment

 men, 40, dominant arm, eccentric load  Single Incision: LABCN, PIN, superficial Radial Nerve (3-6months)  anabolics, tobacco, mechanical impingement (during pronosupination)  Double Incision: HO, synostosis

 Long Head: supination, proximal  Fixation Options insertion, apex of tuberosity  Native biceps force to rupture = 200N  Short Head: flexion, distal insertion  suture button (400N) > suture anchor  Rupture: 50% supination, 30% flexion (380N) > bone tunnel (310N) > interference screw (230N)  MRI: elbow flexion, shoulder abduction, forearm supination  combination technique (suture button + interference screw) stronger than single  Olecranon osteotomy (relative) technique  Patient younger than 65 (relative)  Delayed repair  Partial Tears: radial fibers on tuberosity  Repair in hyperflexion

 Achilles allograft ❖ Nicholson, Gregory P. Orthopaedic Knowledge Update: Shoulder and Elbow 4. American Academy of Orthopaedic Surgeons, 2013.

❖ Miller, Mark D., and Stephen R. Thompson. Miller's Review of Orthopaedics. Elsevier, 2016.

❖ Shoulder & Elbow High-Yield Topics.” Orthobullets, www.orthobullets.com/topic/dashboard?id=3&specialty=3&expandLeftMenu=true