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1

What is the Walch classifciation of shoulder OA

  • Type A: Concentric wear, no subluxation, well centered
    • A1 minor erosion
    • A2 deeper central erosion
  • Type B:  Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
    • B1 narrowing of posterior joint space, subchondral sclerosis, osteophytes
    • B2 posterior wear, biconcave glenoid 
  • Type C: Glenoid retroversion of more than 25 degrees (dysplastic in origin) and posterior subluxation of humerus

2

What imaging do you want for primary OA

 

  • Radiographs
    • AP/true AP
      • subchondral sclerosis
      • osteophytes at inferior aspect of humeral head - "goat's beard"
      • look for superior migration of head to indicate cuff deficiency
      • look for evidence of previous surgery (staples)
      • look for medialization that occurs in inflammatory arthritis (RA = concentric wear)
        • osetopenia, margican erosions, cysts
    • Can use IR and ER also to look at the osteophystes and template the size of the canal
    • Axillary
      • posterior glenoid wear  
      • posterior humeral head subluxation
      • Version of the glenoid
        • draw a line along the scapula
        • humeral head is used as neutral
        • then calculate the difference between glenoid and humeral head
  • CT 
    • indicated in inflammatory arthritis if large bony defects are present on radiographs
    • Need to quantify the amount of posterior glenoid wear
  • MRI
    • may be indicated to evaluate rotator cuff tendon

 

3

What are the indications and contraindications for a total shoudler arthroplasty

  • indications
    • unresponsive to nonoperative treatment 
    • progressive pain
    • decreased ROM
    • inability to perform activities of daily living
  • contraindications
    • deltoid dysfunction
    • insufficient glenoid stock
    • rotator cuff arthropathy
  • outcomes
    • literature shows decreased rate of revision surgery when compared to hemiarthroplasty  

4

What's your differntial for a stiff shoulder

  • Adhesive capsulitis
    • pain with limited ROM
  • spondyloarthropathy/gout
  • RA
    • most common inflammatory affecting the shoulder
    • central glenoid wear with periarticular erosions and cysts
  • posterior shoulder dislocation
  • Primary OA/RCA
  • Secondary OA
    • previous surgery
  • AVN shoulder
  • Tumor

5

Mechanisms of RC tears

  • Overhead throwing athletes
    • partial thickness rotator cuff tears are associated with internal impingement
    • deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears 
  • Mechanisms include
    • chronic degenerative tear
      • usually seen in older patients
      • usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may extend anteriorly to involve the superior margin of subscapularis tendon in larger tears
    • acute avulsion injuries
      • acute subscapularis tears seen in younger patients following a fall
      • acute SIT tears seen in patients > 40 yrs with a shoulder dislocation 
      • full thickness rotator cuff tears need to be repaired in throwing athletes 
    • iatrogenic injuries
      • due to failure of surgical repair
      • often seen in repair failure of the subscapularis tendon following open anterior shoulder surgery.
  •  

6

How do you characterize an RC tear

 

  • PASTA vs compete
    • 14mm, can characterize whether bursal or articular
  • Size
    • Small 0-1
    • Moderate -  1-3
    • Large 3-5
    • Massive > 5
  • Shape
    • U, cresent, L, Massive
  • Degree of retraction
  • Goutillier Fatty infiltration
    • 0 - Normal
    • 1 - Some fatty streaks
    • 2 - More muscle than fat
    • 3 - Equal amounts fat and muscle
    • 4 - More fat than muscle
  • Fuchs Muscle atropy
    • Mild (0.6-1 occupancy; grade 1) - at the tangent line
    • Moderate (0.4-0.6 occupancy; grade 2) -  just below
    • Severe (<0.4 occupancy; grade 3) - very minimal
    • Also know as a negative tangent sign
      • Zanettic tangent line
  • ​Characterize the subsap
  • ​Characterize the biceps

7

What is the anatomy and biomechanics of the RC

  • rotator interval
    • capsule, SGHL, and the coracohumeral ligament 
  • rotator crescent
    •  thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions.
  • rotator cable
    • thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons.
  • the primary function of the rotator cuff is to provide dynamic stability by balancing the force couples about the glenohumeral joint in both the coronal and transverse plane. 
  • coronal plane
    • the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions to balance the superior moment created by the deltoid
    • The rotator cuff pulls the humerus down, while the deltoid pulls it up
    • If you loose the rotator cuff, when you try to abduct, you will just pull the humerus up and not be able to abduct
  • transverse plane
    • the anterior cuff (subscapularis) functions to balance the posterior moment created by the posterior cuff (infraspinatus and teres minor)
    • this maintains a stable fulcrum for glenohumeral motion.
    • When you have a subscapularis tear, you can no longer pull the humeral head anteriorly
  • You fire the deltoid and the posterior cuff, the humeral head migrates up but is not able to fully flex
  • This is called - pseudoparalysis
  • the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes. 

8

What are the JAAOS recommendations for cuff tears

  • *There is no role in treating asymptomatic tears
  • *There is no good or bad evidence for specific exercise programs or non-op treatments
  • *There is no good indications for acute vs chronic treatment
  • *open and arthroscopic are equivocal
  • *should not use porcine intestine for repair
  • *no evidence for abduction pillow vs standard sling
  • *no conclusive evidence when to start rehab

9

Treatment considerations for RC Tear?  What is your pre-op work-up?

activity and age of patient
mechanism of tear (degenerative or traumatic avulsion)
characteristics of tear (size, retraction, muscle atrophy)
partial thickness tears vs. complete tear
articular sided (PASTA lesion) vs. bursal sided 

  • History
    • where is the pain, excaerbating factors
    • assocaited weakness, neck pain, radiculopathy
    • previous trauma, previous treatment
    • function, activity, vocation
    • PMHx, smoker, drinker
  • Physical
    • ​Look - shoulder assymetry, previous scars, swelling, atrophy, winging
    • Feel - palpate for location of pain
    • Move
      • ​AROM FF, AB, ER, IR
        • assess for winging
      • PROM
    • ​RC tests
      • ​jobe, ER, ER lag or excess ER, IR, Lift off, belly press, horn blowers
    • Bicipital Irritaiton - speeds, yeargons
    • Impingement - hawkins, neer
      • Internal impingement
  • ​​XR
    • ​True AP, lateral, Ax
    • Supraspinatous outlet
    • IR, ER, Stryker Notch
  • ​U/S
    • ​dynamic, cheap
  • ​MRI
    • much more sensitive to show you all the pathology

10

Treatment options for RC tear

  • physical therapy, NSAIDS, and subacromial corticosteroid injections 
    • Cortisone injections have not been shown to be beneficial
    • indications
      • first line of treatment for most tears
      • grade 1 & 2 partial tears can be managed with therapy
      • Massive tears retracted past the glenoid
    • technique
      • physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening
      • subacromial injections if impingement thought to be major cause of symptoms
  • ****The repair is based more on whether the cuff will heal, not whether you can repair it. 
  • arthroscopic or open rotator cuff repair  
    • indications
      • bursal-sided tears >3 mm 
      • articular sided supraspinat tears >7mm 
    • Intra-op
      • Look for the comma sign associated with a subscap tear
        • Will also see a bear LT with subsap retracted anteriorly
      • Fix the subscap first if torn
      • Do your biceps tenotomy/tenodesis
        • >50%, signficant symptoms
        • lipstick=inflammed
        • medial subluxation
      • Then debride the bursa, bone and trephanate the GT
      • Perform double row repair
    • Postoperative
      • rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity, which is believed to take 8-12 weeks
      • postop with limited passive ROM (no active ROM)
    • Outcomes
      • Worker's Compensation patients report worse outcomes
      • higher postop disability and lower patient satisfaction 
    • Acrominal Decompression
      • only if they have a T3 acromion
  • Augmentation Procedure - massive cuff tears
    • Latissimus Dorsi transfer: best for irreparable posterosuperior tears with intact subscapularis 
      • More indicated in young workers
      • Has the most excursion
    • Contraindication
      • Subscap tear
        • can stage it, and do the subscap first

11

Procedures to faciliate RC repair

Marginal convergence

Anterior or posterior interval slide

12

When would you consider operative treatment for proximal biceps tear

  • indications
    • >50% tears
    • Medial subluxation with or without cuff tear
    • Type II or IV SLAP lesion
    • "lipstick" or inflammed tendon during diagnostic arthroscopy
      • Needs to be done with a dry joint because the pressure can wash out the appearance
  • technique
    • Beachchair, spider
    • Posterior portal, anterior portal - diagnostic scope
      • Stress the biceps - internal rotation will displace the tendon medially
      • Pull the biceps into the joint to assess for tendonitis
    • Tenotomy
      • Release the tendon
      • Make sure there is no fraying so it doesn't get caught
      • No rehab required
    • Tenodesis
      • Intra-articular/arthroscopic
        • Clear the bicipital groove of debris
        • Suture anchor at the entrance of the sheath
      • Open subpectoral
        • Anterior incision just inferior to the pec
        • Release the delto-pec fascia and elevate the pec to identify the bicipital groove
        • Debride the groove and place a suture anchor at the top of the groove
        • Non-absorbable suture krachow threw the tendon with one as a post
      • Rehab - as per tendon, no active elbow flexion or supnation for 6 weeks
      • Sling 3-4 weeks, building on shoulder ROM
  • Complications
    • Pop-eye
    • Continued pain
    • Infection
    • Proximal humerus fracture

13

Complications of biceps tenodesis

Pop-eye
Continued pain
Infection
Proximal humerus fracture

14

Biceps tenodesis vs tenotomy

Outcomes and complications are similar

may have decrease cramping and improve cosmesis with  tenodesis

15

Factors associated with cuff re-tear

The patient

> 65
Diabetes
Smoking
Non-compliance with PT

The tear

Massive tear
Moderate/severe atrophy
>50% fatty infiltration
>2.5 cm retraction after mobilization or medial to glenoid on pre-op MRI

16

What are your options for a re-torn RC

  • Partial repair - only if you think it might heal and the shoulder is balanced
    • younger
    • no pesudoparalysis
    • no medical issues
  • Hemiarthroplasty - intact coracohumeral arch and no pseudoparalysis
  • RTSA - older patient with pseudoparalysis

17

Complications associated with RC repair

  • Recurrence
    • patient age >65 years is a risk factor for non-healing of rotator cuff repair 
  • Deltoid detachment
    • complication seen with open approach
  • AC pain
  • Axillary nerve injury
  • Suprascapular nerve injury
    • may occur with aggressive mobilization of supraspinatus during repair
  • Infection 
    • less than 1% incidence
    • Usually common skin flora: staph aureus, strep, p.acnes 
    • Propionoibacterium acnes is the most commonly implicated organism in delayed or indolent cases 
  • Stiffness
    • Physical therapy and guided early range of motion exercises are not shown to reduce stiffness one-year post-operatively

18

Management of massive rotator cuff repair

  1. Arthroscopic, tension free repair
    • interval slide
    • marginal repair
    • assess the pattern of the tear
    • Extensive release and debridement with double row fixation
  2. Debridement, assess for other pathology
  3. Assess the biceps

19

Work-up for stiff elbow

  • Symptoms
    • may or may not be painful
    • unable to perform activities of daily living
    • loss of elbow flexion and extension 30-130
    • locking, catching
    • previous trauma, surgeries
    • PMHx, smoker
  • Physical exam
    • inspection
      • examine the skin around the elbow
      • scars from previous surgeries
      • inflammation
    • range of motion
      • measure elbow flexion/extension, pronation/supination
    • neurological 
      • assess ulnar nerve function
        • position and function
  • Radiographs
    • serial radiographs
      • if heterotopic ossification is noted 
    • findings
      • dependent on pathology causing stiffness/contractures
      • Loose bodies, old fracture, OA, HO…
  • CT scan  
    • indications
      • loose bodies in joint
      • non-unions
      • joint incongruity 
      • abnormal bony anatomy  
  • MRI
    • rarely indicated

20

Differential diagnosis for stiff elbow

  • intrinsic causes
    • joint incongruity
    • synovitis
    • loose bodies
    • intra-articular fractures
    • osteochondritis dissecans
    • post-traumatic arthritis
  • extrinsic causes
    • formation of eschar following a burn
    • heterotopic ossification
    • adhesions/contraction of the capsule
    • myositis ossificans
    • ligament contractures

21

Options for treatment of elbow stiffness

  • NSAIDs, therapy with active and passive range of motion exercises
    • indications
      • first line of treatment in most cases
      • contractures <40 degrees
      • Should be attempted for 3-4 months prior to surgical treatment
  • Operative
    • Want to restore function to 30-130
  • Arthroscpic treatment
    • Contraindications to arthroscopic treatment
      • Extensive scarring, burning
      • Severe flexion contracture
      • Bridging HO
    • Relative
      • Ulnar nerve tranposition
        • Must be done for patients with < 90 deg ROM
      • Lack of pronation/supnation (must be addressed open)
  • Open capsular release
    • indications
      • extrinsic capsular contractures
      • patients with arthritis
      • Restrictions in sup/pro
    • Ulnar nerve must be transposed if flexion <90 deg
  •  distraction interpositional arthroplasty 
    • intrinsic contractures with diffuse arthritis in high demand younger patients
  • total elbow arthroplasty
    • intrinsic contractures with diffuse arthritis in low demand elderly patients
    • outcomes
      • high failure rate in young, active patients
      • permanent 5-lb lifting restriction 
  • musculocutaneous neurectomy
    • neurogenic contractures with a flexion deformity of less than 90 degrees
  • Nerve transposition
    • if > 30 deg will be acheived
    • if < 90 deg of flexion 

22

What are the portals for elbow arthroscopy?

  • Proximal anterolateral   
    • 2cm proximal, 1cm anterior to lateral epicondyle  
    • Radial n.
  • Distal anterolateral   
    • 1 cm anterior and 1-3cm distal to lateral epicondyle
    • 1st portal for supine position
    • See radial head, medial side of elbow, coronoid, trochlea, brachialis insertion, coronoid fossa
    • Radial and lateral antebrachial cutaneous
  • Direct lateral (or midlateral)     
    • "soft spot" portal (in triangle formed by olecranon, radial head, epicondyle)
    • Initial site for joint distension before scope is inserted, viewing posterior compartment (capitellum, radial head, radioulnar articulation)
    • relatively safe, lateral antebrachial cutaneous nerve 
  • Anteromedial   
    • 2 cm anterior and 2cm distal to medial epicondyle. 
    • Place under direct visualization.
    • medial antebrachial cutaneous and median 
  • Proximal medial (or superomedial)     
    • 2cm proximal to medial epicondyle, anterior to intermuscular septum
    • viewing entire anterior compartment, radial head, capitellum, coronoid, trochlea
    • ulnar and median 
  • Straight posterior (transtriceps)   
    • 3cm proximal to olecranon, triceps midline (musculotend. junction)
    • Elbow partially extended, good for removing impinging olecranon osteophytes and loose bodies from posteromedial compartment
    • posterior antebrachial cutaneous and ulnar nerve
  • Posterolateral   
    • 2-3 cm proximal to olecranon and just lateral to triceps
    • center of anconeus triangle
    • Elbow 20-30deg flexion (to relax triceps)
    • Best access to posterior compartment, radiocapitellar joint (debridement of OCD capitellum), olecranon fossa and posterior structures
    • posterior antebrachial cutaneous and medial brachial cutaneous and ulnar

23

Indications and contraindications to elbow arthroscopy

  • Indications
    • loose body removal 
    • osteophyte debridement
    • synovectomy
    • capsular releases for stiffness
    • osteochondritis dissecans of capitellum
    • lateral epicondylitis
  • Contraindications
    • prior trauma
    • surgical scarring
    • previous ulnar nerve transposition
      • ulnar nerve subluxation is not a contraindication, but it should be identified prior to surgery
  • Advantages
    • improved articular visualization
    • decreased postoperative pain
    • faster postoperative recovery
  • Disadvantages
    • technically demanding
    • high risk of damage to neurovascular structures due to proximity to the joint
  •  

24

Complications of elbow arthroscopy

  • Nerve palsy (1-5%)
    • greatest risks for nerve palsy
      • underlying rheumatoid arthritis
      • elbow contracture
    • nerves
      • transient ulnar nerve palsy (most common)  
      • radial nerve palsy (second most common)
    • mechanism
      • direct injury
        • trocars and instrumentation
        • failure to use blunt dissection (neuromas)
      • indirect injury
        • compartment syndrome (aggressive distension, fluid extravasation)
        • local anesthesia extravasation (transient)
  • Joint ankylosis/ heterotopic ossification
    • less than open surgery
    • minimize bleeding
  • Infection 
  • Persistent drainage
    • close portals with suture

25

Describe you approach to elbow arthroscopy

  • Lateral decutibus position on a beanbag and an axiallary roll
  • Saddle bolster under arm with tourniequtte
  • Mark out the ulnar nerve (assess whether it subluxes), and boney prominences
  • Inflate the joint with 20 mL of saline in the lateral soft spot
  • anteromedial portal is created first with sharp incision through the skin and blunt disection
  • anterolateral is the working portal and is created under direct visualization
  • use any adjunct portals you might need to removes osteophytes, loose bodies; may need to release capsule to gain ROM
  • then go posterior via posteolateral portal and one central to clean the pathology at the back
  • post-op
    • brachial plexus block PRN
    • CPM machine if needed
    • early ROM
    • indomethecin 25mg TID

26

Common etiology

  • Can be seen in
    • association with dominant hand
    • men to women 4:1
    • middle aged laborers
    • MUCL or ligamentous insufficiency
  • Etiologies
    • rheumatoid arthritis
      • most prevalent form with 50% of patients affected
      • causes progressive bone resorption and osteopenia
    • post-traumatic arthritis
      • second most common form
    • primary arthritis
      • rare
      • common in middle-aged male laborers
    • history of osteochondritis dissecans

27

Work-up for patient with progressive pain in their elbow, generalized, worse with activity.  Fracture as a child.  

  • History
    • progressive pain
    • loss of terminal extension or flexion
    • painful locking of elbow
    • Will progress from pain at end-arc to pain through-out ROM
    • History of trauma, throwing/sports/labour, instability
    • PMHx - RA, OCD
  • Physical exam
    • loss of elbow range of motion
    • ligamentous incompetence can be seen
      • especially in rheumatoid arthritis
    • ulnar neuropathy present in up to 50% of patients
  • Radiographs 
    • elbow joint space narrowing 
      • Usually have more preserved anatomy than seen with other joints
    • osteophytes  - most prominent finding
      • coronoid process and fossa
    • especially in olecranon tip and posteromedial olecranon fossa
    • loose bodies
  • CT scan 
    • can help better define osteophytes and loose bodies
    • Especially shelf osteophytes in the olecranon fossa, radial fossa and coronoid fossa
    • Can help you see osteophytes around the ulnar nerve

28

Options for treatment

Elbow OA

  • NSAIDS, cortisone injections, resting splints, and activity modification
    • indications
      • mild to moderate symptoms
      • < 15 deg of motion loss
  • Arthroscopic or open debridement and capsular release
    • indications
      • mild disease with bone spurs
      • mechanical block to motion
      • preferred in patients with >90 degrees of motion
    • technique
      • removal of osteophytes and loose bodies
      • often combined with soft tissue release
      • Radial head is only resected if it is causing severely limited ROM
    • Outcomes
      • Improved with symptoms < 1 yr
      • Arthroscopy = better pain relief
      • Open = better gain in ROM
  • ulnohumeral distraction interposition arthroplasty
    • indications
      • young high demand patients
        • Who don't want to comply with TEA restrictions
    • technique
      • Posterior approach
      • Minimal debridement of articular surface
      • can use
        • autogenous tensor fascia lata
        • achilles tendon allograft
      • patients with severely limited preoperative motion (extension > 60 degrees and flexion of < 100 degrees are at risk for ulnar nerve dysfunction postoperatively
        • should undergo a concomitant ulnar nerve decompression
      • Hinged external fixation is used to allow immediate ROM
      • Removed after  4 weeks
    • Outcomes
      • Better outcomes with TEA, especially for post-traumatic
  • olecranon fossa debridement (Outerbridge-Kashiwagi procedure)
    • indications
      • younger patients with decreased ROM
    • technique
      • Posterio-medial approach, identify the ulnar nerve
      • burr hole through olecranon fossa
      • removes osteophytes and arthritic bone anteriorly threw the hole
      • increases range of motion
      • be sure to decompress the ulnar nerve if there is an extension contracture preoperatively
  • total elbow arthroplasty
    • indications
      • older patients >65 years with severe elbow arthritis
      • complex distal humerus fracture in elderly with poor bone stock
    • Semi-constrained
      • Most commonly used
      • Linked so that they don't dislocated with some strain that is taken by the soft tissue/ligaments
    • Convertible
      • Can be converted to linked if becomes unstable
      • Can be converted to unlinked once some rehab has been done
    • unconstrained TEA  
      • used with competent elbow ligaments and adequate bone stock
      • Can have problems with instability, maltracking, subulxation
    • constrained TEA  
      • used with incompetent elbow ligaments
    • Either triceps sparing or bryan-morrey apparoch
    • Immobilized in extension for 48 hrs
      • Start early active ROM
      • If triceps has been detached then avoid active extension for 6 weeks
    • Complications
      • Instabiltiy
      • Infection
      • Fracture
      • HO
      • Ulnar nerve neruopraxia

 

29

Technique for open debridement elbow

  • Painful OA with loss of 30-130 degree of motion
  • Lateral decubitus with a bolster under the arm
  • Lateral column approach
    • ECRB and BR
    • elevate off the anteiror humerus and the capsule
    • remove the lateral portion of the capsule
    • then elevate the triceps off posteriorly
    • open the posterior capsule and debride the olecranon fossa and the olecranon
  • Medial approach
    • transpose the ulnar nerve
      • >30 deg release
      • <90 deg of flexion
    • can release the posterior bundle of the MCL to help get more flexion
  • Post-op
    • splint for comfort with early ROM

30

Technique for TEA

total elbow arthroplasty

indications

older patients >65 years with severe elbow arthritis
complex distal humerus fracture in elderly with poor bone stock

Semi-constrained

Most commonly used
Linked so that they don't dislocated with some strain that is taken by the soft tissue/ligaments

Convertible

Can be converted to linked if becomes unstable
Can be converted to unlinked once some rehab has been done

unconstrained TEA  

used with competent elbow ligaments and adequate bone stock
Can have problems with instability, maltracking, subulxation

constrained TEA  

used with incompetent elbow ligaments

Either triceps sparing or bryan-morrey apparoch
Immobilized in extension for 48 hrs

Start early active ROM
If triceps has been detached then avoid active extension for 6 weeks

Complications

Instabiltiy
Infection
Fracture
HO
Ulnar nerve neruopraxia