Shoulder Reconstruction - National Cheng Kung University
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Transcript Shoulder Reconstruction - National Cheng Kung University
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
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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 jointside 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
Rotator Cuff Injuries
Tendinitis / Tendinosis
Intrinsic
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
Elevation
RCT: sensitivity: 91%
specificity: 75 %
Ext. R
Int. R.
Neer imp.sign
Imping. Test
Hawkin imp. sign
Painful arc
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
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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
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
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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
Salvage procedure
Indication
GH destruction, instability,
pain, and/or a flail
Neurologic problems (such
as BPI)
Tumors
Infection
Fusion posture
Flexion (< 15° )
Abduction (< 15° )
Internal rotation (40°< <
60° )
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