Orthopedic Upper Extrem Review | Dr Hutaif General Orth -...

Elbow joint aspiration

MRI scan

Splint for 2 weeks and repeat examination

Sedimentation rate and C-reactive protein level DISCUSSION…The best way to make the diagnosis is to aspirate the fluid from the joint and send it to the laboratory for a cell count and crystal search. This will allow for the diagnosis of an infection, gout, or pseudogout. An MRI scan will confirm the examination finding of an effusion, but it will not reveal the cause of an inflammatory effusion. If the patient has chronic gout, an MRI scan or ultrasound can aid in diagnosis if gout tophi are seen. A splint will help relieve the pain from the effusion and the effusion may resolve on its own, but it will not contribute to a diagnosis. Sedimentation rate and C-reactive protein level will help to rule out an infection, but they are not as diagnostic as an aspiration.

Revision rTSA

Conversion to hemiarthroplasty

Continued observation

Infection work-up with screening labs and joint aspiration **DISCUSSION..** Based upon the patient’s clinical examination and symptoms, continued observation is appropriate. The remaining options are not indicated. The radiograph reveals scapular notching, one of the more common complications specific to rTSA. Notching is caused by repeated contact between the humeral component and/or humerus and the inferior pillar of the scapular neck. Generation of particulate debris from this interaction can result in osteolysis with the potential for screw and base plate failure. The overall incidence of notching has been reported to be between 51% and 96%. This nearly ubiquitous finding has been attributed to implant positioning, altered glenoid and humeral anatomy, and duration of implantation. Recent studies that indicate increased lateral offset, increased glenosphere size, and inferior positioning of the base plate may reduce the incidence of scapular notching.

Open reduction internal fixation with transosseous sutures

Arthroscopic fixation using a suture bridge technique

Nonsurgical treatment with early passive range of motion

Nonsurgical treatment with sling immobilization for 4 weeks DISCUSSION..Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women older than age 60. Greater tuberosity fractures that are displaced less than 5 mm in the general population and less than 3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range of motion is important to avoid the complication of stiffness.

Brief period of immobilization and reinitiation of therapy

Open posterior capsular shift with labral repair

Arthroscopic capsulolabral repair with subscapularis and lesser tuberosity transfer

Resurfacing arthroplasty with labral repair DISCUSSION..Posterior glenohumeral dislocations are much less common than anterior glenohumeral dislocations, with a prevalence of 1.1 per 100,000 per year. There is a bimodal distribution with a peak in young men (2.4 men to 1 woman) and a second peak in elderly people with a more equivalent gender ratio. Posterior dislocations most commonly result from trauma, with the remainder of events secondary to seizure activity. According to Robinson and associates, age younger than 40 years, dislocation during a seizure, and a large Hill-Sachs lesion were all predictive of recurrent instability. Concomitant injuries associated with posterior shoulder dislocations include capsulolabral tears, fractures, and rotator cuff tears. Imaging studies in this patient indicate a reverse Hill-Sachs lesion with a corresponding posterior labral tear. Because of his persistent mechanical symptoms, continued immobilization and therapy is not appropriate. An open capsular shift with labral repair alone would not address symptoms related to an engaging Hill-Sachs lesion. Based upon the patient’s age, activity level, and percentage of humeral head involvement, a resurfacing arthroplasty is not recommended. Historically, the Zuckerman procedure, lesser tuberosity transfer, has been used to address symptomatic reverse Hill-Sachs lesions (20% to 40% humeral head involvement) associated with posterior shoulder dislocations. Modifications of this technique such as arthroscopic transfer of the subscapularis tendon without posterior capsulorrhaphy have proven beneficial.

Disorganized collagen fibers with mucoid degeneration

Disorganized collagen fibers and acute inflammatory

Normal tendon fibers infiltrated with capillary proliferation

Normal tendon fibers infiltrated with acute inflammatory cells DISCUSSION..This patient has impingement syndrome based on the history and examination. The best way to confirm the diagnosis is by performing a subacromial injection with lidocaine, which is also called a Neer impingement test. If the pain is relieved, the patient’s pain is coming from the subacromial space. An MRI scan would not confirm the diagnosis of impingement, although it can aid in diagnosis of other causes of anterior shoulder pain such as a rotator cuff tear. This patient has normal rotator cuff strength, so that diagnosis is less likely. A radiograph can show acromial morphology, which would support the diagnosis of impingement, but it does not rule out impingement if the radiograph findings are normal. Ultrasound would not support the diagnosis of impingement, but, like an MRI scan, it can reveal pathologies other than impingement. The MRI scan shows a supraspinatus tendon with changes consistent with tendinopathy, which is defined by disorganized collagen fibers with mucoid degeneration on the microscopic level. Although there are always exceptions, most tendinopathy occurs without inflammatory cells or capillary proliferation.

Suboptimal graft placement

Pain before surgery

Progression of osteoarthritis

Previous surgical treatment DISCUSSION…Recurrent glenohumeral instability with anteroinferior glenoid bone loss is best treated with a coracoid transfer. Schmid and associates reported on 49 patients with these lesions and recurrent instability who underwent coracoid transfer procedures. Good and excellent outcomes were reported in 88% of patients, and there were no instances of recurrent instability. With anteroinferior glenoid bone loss, capsular procedures—whether open or arthroscopic—are unlikely to provide stability. Remplissage is a procedure designed to address Hill-Sachs lesions rather than glenoid defects. The absolute indications to treat Hill-Sachs lesions surgically include a lesion associated with a humeral head fracture, a lesion involving more than 30% of the humeral head with chronic instability, and reverse Hill-Sachs lesions involving more than 20% of the articular surface with symptoms of posterior instability. Lesions involving 20% to 35% with or without engagement on examination are relative indications, as are lesions exceeding 10% that do not remain centered in the glenoid following arthroscopic stabilization. In Schmid and associates’ series of coracoid transfers for recurrent instability and anterior glenoid deficiency, patients who reported pain before surgery were 20 times more likely to have pain after surgery that compromised the functional outcome. Optimal graft placement correlated with better functional outcomes and less progression of arthrosis, but not with pain. Consequently, poor graft position, arthritis progression, and prior surgical treatment are not as consistently predictive of pain after surgery.

MRI scan

Cortisone injection therapy with continued physical therapy (PT)

Closed manipulation under anesthesia

Arthroscopic release with manipulation under anesthesia DISCUSSION..Based upon the duration of symptoms and clinical presentation, this patient would benefit from cortisone injection therapy and continued PT. Adhesive capsulitis is most commonly an idiopathic process that results in joint pain and loss of motion from capsular contracture. It affects approximately 2% to 5% of the general population. The process typically affects middle-age women. There are secondary causes such as previous trauma and fractures as well as associated medical conditions such as diabetes, stroke, and cardiac and thyroid disease. Debate remains as to whether there is a genetic predisposition for the development of adhesive capsulitis despite increased frequency noted in twin studies. Although the underlying etiology and pathophysiology are not well understood, the consensus is that synovial inflammation and capsular fibrosis result in pain and joint volume loss. It is hypothesized that in patients with diabetes, an increased rate of glycosylation and cross-linking of the shoulder capsule raises the incidence of frozen shoulder. For this patient, history reveals a short course of symptoms that did not improve with nonsurgical modalities. Clinically, the patient has reduced passive range of motion, particularly with external and internal rotation and forward elevation. Radiographs are usually obtained to exclude other causes of shoulder pain such as glenohumeral arthrosis, malignancy, calcific tendonitis, impingement, and acromioclavicular degeneration. If pain and stiffness persist beyond 6 months, closed manipulation may be an option. Complications associated with this modality may include humerus fracture, dislocation, hematoma, rotator cuff and labral tears, and brachial plexus injury. Some surgeons advocate arthroscopic capsular release to allow for examination of concomitant pathology and controlled release of capsular tissue, with the potential for reduced required force when performing the manipulation portion of the procedure. This modality may be appropriate after an initial treatment with PT. Controversy remains as to whether posterior capsular release should be performed routinely because studies have shown outcomes to be similar with anterior and combined approaches. Therapy should be initiated early after intervention, with some surgeons advocating admission to the hospital with inpatient therapy for pain management and compliance.

early mobilization only.

surgical repair or reconstruction of the lateral collateral ligament (LCL) and the medial collateral ligament (MCL).

active range of motion in a hinged brace with a range of 30 degrees to 120 degrees.

application of a hinged external fixator with early mobilization. DISCUSSION…This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the MCL is intact and the LCL is disrupted or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction, application of a hinged external fixator may be considered.

Inferior glenohumeral ligament

Acromioclavicular (AC) ligaments

Coracoclavicular ligaments

Coracoacromial ligament DISCUSSION..The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened and there is marked fracture displacement. It is clear that the coracoclavicular ligaments must also be torn. The inferior glenohumeral ligament is important to glenohumeral joint stability, but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects 2 parts of the scapula (coracoids and acromion) and is part of the arch that supports the rotator cuff.

Radial head resection

Casting in 90 degrees of flexion for 3 weeks, followed by reassessment of elbow stability

Repair of the annular ligament

Revision open reduction and internal fixation of the ulnar fracture DISCUSSION…This case is a variant of a type I Monteggia fracture according to the Bado classification with a segmental ulna fracture. In some cases, the radial head subluxation can be subtle, and missing this would lead to a poor outcome. In this case, the anterior radial head dislocation is obvious, but the segmental nature of the ulna fracture makes anatomic reduction difficult. The radial head usually spontaneously reduces once the ulna is anatomically reduced, and no surgical treatment to the lateral side is required. When this is not the case, a lateral approach and incision of the annular ligament may be required for reduction. If an open reduction of the radial head is unsuccessful, the problem is almost always residual malalignment of the ulna. Therefore, casting and annular ligament repair will not improve reduction. A radial head resection would eliminate the nonconcentric contact between radial head and capitellum, but would not be an appropriate treatment for this young patient who has an acute, correctable fracture deformity.

Sling immobilization with continued observation

Open reduction and plate fixation

Open reduction, plate fixation, and application of an external bone stimulator

External fixation DISCUSSION..Midshaft clavicle fractures are relatively common and account for 3% to 10% of all adult fractures. Historical studies regarding nonsurgical treatment of displaced clavicle fractures indicated a low nonunion rate approaching 1%. Contemporary studies, however, suggest that the nonunion rate is much higher, reaching 15% to 20% with corresponding loss of shoulder strength and residual deficits at 6 months from date of injury. A recent meta-analysis by McKee and associates comparing nonsurgical treatment with a sling and surgical treatment with plate fixation concluded that initial fixation of displaced midshaft clavicle fractures demonstrated a positive effect on pain reduction at 3 weeks and improved Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 6 weeks and 3 months after surgery. The choice of fixation remains a matter of debate because both plate and pin fixation have been used to achieve clavicle union. Intramedullary fixation of clavicle fractures historically has demonstrated an increased risk for pin tract infections and hardware removal attributable to local irritation from the implant. External bone stimulator use has not proven beneficial in effecting a reduction of nonunion rates. The most common complications noted with surgical intervention included local hardware irritation and wound infection.

Bushing wear

Infection

Aseptic component loosening

Component fracture DISCUSSION..TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (fewer than 10% of patients), and usually occurs more than 10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure, but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at intermediate-term followup.

intrasurgical traction on the musculocutaneous nerve.

residual interscalene blockade.

ulnar neuropathy after sling use.

sensory axillary nerve palsy from his dislocation. DISCUSSION..Several studies have demonstrated the equivalency of arthroscopic Bankart repair to open surgery, but most studies have also demonstrated increased recurrence rates in patients who participate in collision sports such as rugby. Revision surgery with arthroscopy is unlikely to be durable, and in patients who have large glenoid defects, a coracoid process transfer (Latarjet or Bristow) is the preferred surgical treatment. Arthroplasty would not be indicated in a young and active patient.

Gender

Age

Sport

Bone loss DISCUSSION…Nonsurgical treatment for a first-time traumatic dislocation may not be effective in a young, athletic patient; moreover, a Bankart lesion may be present in 70% of all traumatic subluxations. A period of immobilization in external rotation may decrease the risk for recurrence, but only if the patient is placed in a brace immediately and complies with the treatment. Return to play may be possible after 2 weeks of immobilization, provided the patient undergoes appropriate range of motion, cuff strengthening, and scapular stabilization exercises. Among athletes in 1 study, 80% were able to finish the season, but 40% experienced episodes of subluxation or recurrent dislocation prior to the end of the season. The rate of recurrence after arthroscopic stabilization should be lower than 10% and may be equivalent to open repair for most patients. Bone loss remains the primary indication for open procedures, as coracoid transfers or other bone-grafting operations may be needed to reconstruct the glenoid if more than 20% of its surface area is missing. Furthermore, collision athletes may fare better with open surgery than arthroscopic options. Bone loss remains the most significant factor for recurrence across many studies. Glenoid bone loss may be present in 20% of primary dislocations and 70% of recurrent dislocations. Age younger than 30 has a high correlation with recurrence. Although men may be almost twice as likely as women to have a recurrent dislocation, age seems to be the most reliable patient-related risk factor for recurrence. Thermal capsulorrhaphy has not proven to be effective and carries a high risk for complication. More recent studies have found equal recurrence rates between open and arthroscopic Bankart repair, with a greater loss of motion in patients who underwent open repair. Longitudinal studies have demonstrated that 40% to 50% are likely to develop arthritis after a shoulder dislocation; however, recurrent dislocation seems to be the most important factor for early development of arthritis, while age younger than 25 may be protective. Postcapsulorrhaphy arthropathy may be more associated with open repairs or those that severely limit external rotation.

Physical therapy

CT scan

Arthroscopic capsular release

Arthroscopic Bankart repair DISCUSSION..The patient has a posterior glenohumeral dislocation, as evidenced by the overlap on the initial radiograph. While posterior dislocations are rare, they can be overlooked. A CT scan will accurately show the lesion prior to a trip to the operating room. If a simple closed reduction is performed acutely and the arm is stable after the reduction, no further intervention may be needed and treatment can be successful with a 2-week period of immobilization for defects involving less than 30% of the humeral head. However, in this scenario, open reduction is likely and stabilization may require a modified McLaughlin procedure or other intervention to fill in the humeral defect. Younger male patients, those with a large humeral head defect, and those with seizure disorder may be at highest risk for recurrence. For treatment of chronic posterior dislocations, it may be necessary to perform shoulder arthroplasty to restore stability. Stiffness is attributable to articular incongruity; therefore, physical therapy and capsular release are inappropriate.

be at increased risk for infection compared to patients without a Worker’s Compensation claim.

have significant functional improvement after rotator cuff repair that is less robust than that of patients without a Worker’s Compensation claim.

have pain relief that is equivalent to that of patients without a Worker’s Compensation claim.

return to work without restrictions within a 3-month time frame. DISCUSSION..Many factors have been associated with less-than-favorable outcomes following rotator cuff repair such as tear size, age at time of intervention, gender, fatty degeneration of rotator cuff musculature, and Worker’s Compensation status. Henn and associates performed a prospective study regarding rotator cuff repairs in a cohort of 125 patients to assess the factors that may affect outcome as measured with the Simple Shoulder Test (SST), Disabilities of the Arm, Shoulder, and Hand (DASH), Short Form-36 (SF-36), and Visual Analog Pain Scale (VAS). When confounding factors were controlled, Worker’s Compensation status was an independent predictor of poorer DASH scores. With the use of historical controls, Bhatia and associates concluded that the vast majority (89%) of workers who underwent an arthroscopic rotator cuff repair returned to their preoperative level of work at a mean time of 7.6 months. There was a trend toward decreased return to full duty with increased work demands before surgery (light, medium, and heavy duty), but this result did reach statistical significance. Alcohol consumption (more than 6 drinks per week) was the only factor to demonstrate an association with postoperative restricted work duty and increased rotator cuff repair failure. There is no evidence to support increased infection rates for rotator cuff repair in Worker’s Compensation patients.

Scratching the opposite shoulder

Pushing off an ipsilateral chair armrest to assist in standing up

Tying shoelaces on the contralateral foot

Brushing hair DISCUSSION…Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder implanted with the deltopectoral approach; dislocation of the prosthesis is exceedingly rare if the superior approach is employed. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation, such as pushing out of a chair. The other positions described do not involve extension of the shoulder.

median nerve as it crosses the surgical field 6 cm proximal to the medial epicondyle.

medial antebrachial cutaneous nerve as it crosses the field 3 cm distal to the medial epicondyle.

anterior antebrachial cutaneous nerve as it crosses the field at the medial epicondyle.

posterior antebrachial cutaneous nerve that crosses the field 2 cm distal to the medial epicondyle. DISCUSSION..The medial antebrachial cutaneous and medial brachial cutaneous are nerves that can be injured during ulnar nerve decompression at the elbow. The medial antebrachial cutaneous nerve crosses the surgical field at an average of 3.1 cm distal to the medial epicondyle. The medial brachial cutaneous nerve crosses the field 7 cm proximal to the medial epicondyle and arborizes into 2 to 3 terminal branches. Because the surgical approach involves dissection on the medial side, the posterior antebrachial cutaneous nerve is distant from the exposure. Although the median nerve potentially can be located in the deep dissection of a submuscular transposition, it is considered distant to an in situ decompression.

gravity.

the trapezius.

the biceps.

the pectoralis minor. DISCUSSION…Open reduction and internal fixation with a plate and screw construct have been demonstrated to reduce nonunion rate and improve outcomes compared to sling immobilization for displaced clavicle fractures. Neurovascular injury and infection risk increase, however, with surgery. In the upright position, the weight of the extremity inferiorly displaces the lateral segment.

Elbow flexion

Thumb interphalangeal (IP) extension

Index proximal IP flexion

Index metacarpophalangeal (MCP) abduction DISCUSSION..The most distal locking screw in this intramedullary nail construct was placed from anterior to posterior, passing through the distal portion of the biceps and brachialis muscle bellies. The median nerve, along with the brachial artery, is at risk as it lies between these 2 muscles. Malrotation of the nail, producing a more anteromedial starting point for the screw, can lead to a path that intersects with the nerve. Blunt dissection and soft-tissue protection is warranted with this screw placement. Median nerve injury would affect innervations of the flexor digitorum superficialis and profundus to the index finger (among other motors). Although the dissection violates the muscle belly of these 2 elbow flexors, measurable weakness is not typically seen. The radial nerve has already provided function to triceps (elbow extension) proximal to this level and lies sufficiently lateral to be more of a concern with a lateral screw placement (thumb IP extension). The ulnar nerve (index MCP abduction) is further medial at this level and would be at considerably lower risk than the median.

recurrence rate is reduced with 4 weeks of immobilization instead of 2 weeks of immobilization.

age at the time of injury is the most consistent risk factor for recurrent instability.

a majority of patients in this age group will elect to have surgery for recurrent instability.

after an in-season return to sports, his likelihood of choosing surgery after the season is 25%. DISCUSSION..In a study by Sachs and associates, age younger than 25 years at the time of presentation was found to be the strongest predictor of recurrent instability. In this age group (20-to 29-year-olds), only 14% elected to proceed with surgery. After an in-season return to sports, about 50% of patients in this same study chose to proceed with surgery after completing the season. Immobilization in a sling for longer than 2 weeks has no effect on future instability.

5 degrees

10 degrees

15 degrees

20 degrees DISCUSSION..Posterior glenoid wear is the most common pattern seen in typical glenohumeral arthritis. Central wear can also be seen, but it is less common and anterior wear is least common. TSA is the gold standard for surgical treatment of glenohumeral osteoarthritis. Multiple comparative studies between hemiarthroplasty and total shoulder arthroplasty demonstrate advantages of TSA regarding pain relief and most functional parameters. Shoulder hemiarthroplasty with meniscal interposition has been described for young patients with glenohumeral arthritis, but outcomes at intermediate-term followup have been inferior to those of TSA. Reverse TSA is contraindicated in patients with an intact rotator cuff. Proprionobacterium acnes and Staphylococcus species are the most common pathogens causing deep infection after TSA. In a recent long-term follow-up study of total shoulder infections, male gender and younger patient age were significantly associated with a higher infection risk. Other comorbidities and indications for TSA were not predictive. Posterior glenoid wear results in increased retroversion and erosion of the bony vault, which can compromise component fixation. Iannotti and associates reported on 13 patients with varying degrees of glenoid deformity. At 20 degrees of retroversion, optimal glenoid component placement after eccentric reaming was associated with glenoid vault perforation.

Open reduction internal fixation (ORIF) with parallel plates

ORIF with orthogonal plates and iliac crest bone grafting

Total elbow arthroplasty (TEA)

Closed reduction and percutaneous pinning DISCUSSION..TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF to TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared to ORIF. TEA was also likely to result in a lower resurgical rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA vs ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of followup. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population.

Implantation of the glenoid component in 10 degrees of retroversion

Hemiarthroplasty

Eccentric reaming of glenoid

Posterior glenoid bone graft DISCUSSION..Total shoulder arthroplasty (TSA) is superior to hemiarthroplasty for primary osteoarthritis. The most common complication of TSA is glenoid loosening and malposition, which are common causes of glenoid failure. Glenoid malposition decreases the glenohumeral contact area and subsequently increases contact pressures. Altering the stem version to accommodate glenoid retroversion does not appropriately address soft-tissue balancing. A retroversion of less than 12 degrees to 15 degrees can be corrected with eccentric reaming without excessively compromising glenoid bone stock and risking glenoid vault penetration by the glenoid component. Posterior glenoid bone grafting may be considered for glenoid retroversion exceeding 15 degrees.

Decreased strength in forward elevation

Increased external rotation

Cosmetic deformity

Earlier fatigability with pronation DISCUSSION..Patients with subluxation of the biceps tendon and full-thickness tears of the subscapularis require treatment of the biceps tendon. Studies have shown there is increased likelihood for cosmetic “Popeye” deformity after tenotomy when compared to tenodesis, but there is little or no functional deficit associated with tenotomy. In other studies, there have been findings of supination strength reduction in patients with tenotomy compared to those with tenodesis.

loss of elbow extensor power.

implant dislocation.

implant malposition.

development of heterotopic ossification. DISCUSSION..Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies, transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach used for elbow arthroplasty.

Capsular reinforcement by the coracoacromial ligament

Dynamic sling created by the conjoint tendon

Increased glenoid depth

Subscapularis tenodesis DISCUSSION…Because bone loss is likely the biggest risk factor for this patient’s recurrence, a CT arthrogram will provide the most accurate representation of the defect. An arthrogram enhances the ability to evaluate the capsule and ligamentous attachments that may have a role in recurrent instability. Collision athletes may have a lower recurrence rate with open surgery. The Latarjet coracoid transfer achieves its primary stability through the increased glenoid surface area that the bone block provides.

Posterior capsular stretching

Arthroscopic subacromial decompression

Diagnostic acromioclavicular (AC) joint injection

MRI scan DISCUSSION…This patient’s examination is consistent with posterior capsular tightness, which can mimic impingement. Four weeks of posterior capsular stretches will likely improve motion and pain. Surgical treatment should be considered only after failure of a dedicated stretching program. An AC joint injection would help differentiate this condition from AC joint arthritis, but in light of the radiographic findings, arthritis is unlikely. An MRI scan likely will not change the initial treatment at this point.

Ulnar collateral ligament

Pronator teres

Ligament of Struthers

Lateral collateral ligament DISCUSSION…The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure vs injury. In older pitchers, the ulnar collateral ligament fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an ulnar collateral ligament injury and/or bony injury.

Continued physical therapy

Open capsular shift

Arthroscopic capsulolabral shift

Thermal capsulorrhaphy DISCUSSION..In this scenario, the patient has already failed therapy. An MRI scan did not indicate recurrent injury to the labrum. The open capsular shift procedure initially popularized by Neer and modified by Wirth and Rockwood allows surgeons to reduce joint volume by imbricating the patulous inferior capsule through an anterior axillary-based incision. Through this anterior approach, concomitant injuries such as a humeral avulsion of the glenohumeral ligament, Bankart lesions, and subscapularis tears may be addressed. Multidirectional instability (MDI) of the shoulder is defined as symptomatic instability in more than 1 direction. Both dynamic (rotator cuff, periscapular muscles) and static stabilizers (glenoid, labrum, and joint capsule) impart stability to the glenohumeral joint. In this patient, the examination may indicate a positive sulcus sign, increased humeral head translation in more than 1 direction with the load-and-shift test, and generalized hyperlaxity such as elbow, knee, and metacarpophalangeal joint hyperextension. Radiographs may infrequently reveal glenoid dysplasia and bone loss. MRI arthrogram imaging may demonstrate a redundant capsule without specific injury to the labral complex. Initial management of MDI involves therapy with a focus on rotator cuff and periscapular muscle strengthening. Arthroscopic capsulorrhaphy may be a viable option but is not indicated in this scenario based upon lack of injury to the labrum. As with the open capsular shift, care must be taken when performing an arthroscopic plication to avoid overreduction and subsequent shoulder stiffness. Thermal caspulorrhaphy has been abandoned as a treatment option because of high failure rate (60%) and risk for chondrolysis and axillary nerve injury.

TEA

Distal humeral replacement arthroplasty

Arthroscopic release with debridement

Soft-tissue interposition arthroplasty DISCUSSION..The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

physical therapy and nonsteroidal anti-inflammatory medications.

open biopsy of the lesion for permanent section.

manipulation under anesthesia.

shoulder arthroscopy. DISCUSSION..Calcific tendinitis of the shoulder is a deposition of calcium carbonate apatite crystals into the structure of the rotator cuff tendon. The crystalline form appears to progress throughout the clinical disease process, demonstrating increasing matured stoichiometric apatite deposition during the resorptive phase. MRI can be difficult to interpret because the signal of the calcific lesion is frequently similar to that seen in normal supraspinatus tendon. Plain radiographs remain the gold standard for diagnosis. Ultrasound can be a useful ancillary study to determine the location and size of the lesion. Primary management of calcific tendinitis starts with nonsurgical treatment including physiotherapy and injections, if indicated. Mixed results have been reported with extracorporeal shock wave therapy. Surgical removal with repair of the tendon in larger lesions remains the definitive treatment when nonsurgical modalities fail. Subacromial decompression may improve pain relief in patients who require surgery; however, patients with decompression may take longer to fully recover.

Strengthening in physical therapy

Anterior labral repair

Posterior labral repair

Coracoid transfer DISCUSSION..The MRI scan shows a posterior labral tear, which is contributing to his posterior instability. If a patient does not improve after 8 weeks of physical therapy, the therapy likely will not correct his or her instability. Activities that involve internal rotation of the shoulder and adduction will put the shoulder at most risk for posterior dislocation or subluxation. The patient elevates his risk when he pushes fire hoses into the truck repetitively, which further supports the diagnosis of posterior instability attributable to a posterior labral tear. An anterior labral repair or a coracoid transfer would not treat posterior instability.

Acute avulsion of the medial epicondyle attributable to valgus stress

Chronic weakening of the ulnar collateral ligament attributable to chronic tension forces

Chronic compressive forces on the medial epicondyle leading to fragmentation

Chronic tension forces of valgus overload on the medial epicondyle leading to physeal separation DISCUSSION..The medial epicondyle ossification center is first seen at 5 to 6 years of age and is the last to fuse at age 15 to 16. The capitellum first appears at age 1 to 2. The radial epicondylar epiphysis appears at 2 to 4 years. The trochlea appears at age 8 to 10; the olecranon appears at approximately age 10. The lateral epicondylar epiphysis is the last to appear at age 12. Repetitive tensile stress on the medial epicondyle is caused by the flexor-pronator mass and the ulnar collateral ligament. This chronic valgus microtrauma eventually can lead to apophysitis and/or stress fracture. In the skeletally immature athlete, tension across the medial elbow produces a physeal injury rather than a ligamentous injury. Based upon the history, this is a repetitive overuse injury and not an acute injury.

Elbow splint at 40 degrees at night for 6 weeks

Electromyography (EMG)

Exploration of the ulnar nerve and transposition

Observation DISCUSSION..This patient has an early postsurgical ulnar nerve palsy. The causes of this injury are laceration of the nerve during surgery, entrapment of the nerve in the fracture or hardware, or traction injury during surgery. If the orthopaedic surgeon is sure that the nerve was not lacerated at the end of the case or entrapped in the hardware, then the nerve is probably intact and will recover. Observation is the best treatment in this case because the nerve was checked before wound closure. Elbow splinting has not been shown to help with postsurgical nerve recovery. EMG findings may not be accurate this early in the injury.

The patient’s age

The patient’s gender

Work-related injury

Acute nature of the tear DISCUSSION…Several studies have demonstrated that patients with work-related injuries do not do as well as those whose injuries are not work-related after repair of the rotator cuff. This patient’s age and gender are not negative prognostic indicators. The acute nature of the tear does not lead to an inferior outcome.

Diagnostic shoulder arthroscopy with labral repair

Diagnostic shoulder arthroscopy with open capsular shift

Diagnostic shoulder arthroscopy with coracoid transfer

Diagnostic shoulder arthroscopy with thermal capsulorrhaphy DISCUSSION…If nonsurgical treatment has failed in the revision setting, the amount of bone loss should be quantified. The current standard for quantification of glenoid bone loss is CT scan with or without digital subtraction of the humeral head. An initial diagnostic arthroscopy may permit calculation of glenoid bone loss. The glenoid bare-spot method popularized by Lo and associates provides a reliable estimate of bone loss. Percentage of bone loss is calculated by subtracting the distance from the anterior rim to the bare spot from the posterior rim-bare spot distance divided by twice the posterior rim-bare spot distance. The critical limits of glenoid bone loss are based on a combination of cadaveric and clinical reports. Nonsurgical management may still be a reasonable choice with less than 20% glenoid bone loss in low-demand individuals, patients with high surgical risk secondary to medical comorbidities, and voluntary dislocators. When addressing recurrent anterior instability of the shoulder, it is imperative to assess both soft-tissue and bone injury. Particular attention must be paid to glenoid and humeral head deficiencies. Patient-specific demands should be considered when discussing treatment options. In a high-demand patient such as this contact athlete, surgical treatment is appropriate. In general, if glenoid bone loss is less than 15%, a soft-tissue stabilization procedure may be all that is necessary. In those with 15% to 25% bone loss, arthroscopic stabilization with bone fragment incorporation may be performed if local bone is available. In the setting of a high-demand patient with no local bone for repair, coracoid transfer, iliac crest bone autograft, or distal tibial allograft is appropriate. With more than 25% bone loss, the glenoid deficiency must be addressed. In this scenario, the athlete demonstrates more than 25% bone loss involving the anteroinferior glenoid. This deficiency must be addressed to restore stability to the glenohumeral joint. In a high-demand patient (contact athlete), augmentation with iliac crest bone graft, distal tibial allograft, or a coracoid transfer procedure is appropriate if local bone is not available.

Midsubstance tear of the lateral ulnar collateral ligament

Proximal avulsion of the ulnar collateral ligament

Proximal avulsion of the lateral ulnar collateral ligament

Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle DISCUSSION..Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

include postsurgical elbow continuous passive motion (CPM).

perform the surgery open.

decompress the ulnar nerve.

release the anterior band of the medial collateral ligament. DISCUSSION..The patient is exhibiting signs of ulnar neuropathy. The surgeon should be sure to decompress and possibly transpose the ulnar nerve, if unstable, to prevent worsening neuropathy after surgery. CPM has not been shown to be of benefit after contracture release. Equal success rates have been shown for open and arthroscopic contracture releases. The anterior band of the medial collateral ligament is important to maintain valgus stability of the elbow. The posterior band can be released to improve flexion without increasing concern for elbow instability.

an MRI of the shoulder.

a physical therapy referral for rotator cuff strengthening and proprioceptive exercise.

a home stretching program and corticosteroid injection.

arthroscopic glenohumeral capsular release. DISCUSSION..This patient has idiopathic adhesive glenohumeral stiffness. Most patients with this condition are women between 40 and 60 years of age with no specific mechanism of onset. Patients typically develop pain, at which point the disease is marked by significant inflammation. This patient is likely in the second stage of the disease, marked by inflammation and early fibrosis of the joint capsule, leading to joint stiffness. Associated conditions include diabetes mellitus and hypothyroidism, although there is no explainable cause for most cases. The most appropriate treatment step at this stage is an intra-articular glenohumeral corticosteroid injection, most often in conjunction with either a supervised or home-based capsular stretching program. Physical therapy that prioritizes toward rotator cuff strengthening is more appropriate for patients with isolated subacromial impingement syndrome and may worsen symptoms in patients with stiff shoulders. An MRI scan likely would not alter initial treatment for patients who are stiff at presentation. Arthroscopic glenohumeral capsular release is reserved for those patients who fail initial attempts at nonsurgical management and remain functionally limited.

Closed reduction with immobilization

Closed reduction with percutaneous pinning

Open reduction, bicolumnar fixation with plate and screws

Open reduction, bicolumnar fixation with Kirschner wires DISCUSSION..The radiographs and CT scans indicate a comminuted and displaced intra-articular fracture of the distal humerus. Rigid internal fixation with bicolumnar orthogonal or parallel plating is the treatment of choice for most fractures of the distal humerus that involve the joint surface. Closed reduction and variations thereof will not yield a stable environment for healing. To achieve adequate exposure for fixation, a chevron olecranon osteotomy is the preferred approach. Disadvantages associated with this approach include complications such as nonunion of the osteotomy site and intra-articular adhesions. Prominent hardware may need to be removed during a secondary procedure, and intraoperative conversion to an elbow arthroplasty may be limited. The most common complications after open reduction and internal fixation include elbow stiffness, nonunion (2%-10%), and ulnar neuropathy (0%-12%).

Glenohumeral arthritis

Bone graft absorption

Anterior ligament attenuation

Rotator cuff tear DISCUSSION..The CT scan shows bone loss exceeding 20% on the anterior glenoid, which is the most likely reason the arthroscopic Bankart repair failed. One study showed that using 3 or fewer anchors increases risk for failure; 4 anchors were used in this patient, so that is not the likely cause of failure. The patient returned to full activity 6 months after surgery, which is the usual time needed to regain full strength in the shoulder and ensure complete labrum healing. Suture configuration has not been shown to affect failure rates. The patient did not have signs of multidirectional instability such as a sulcus sign on examination, instability without a labral tear, or excessive translation of the humeral head posteriorly on examination. This patient has recurrent instability due to glenoid bone loss, so the procedure of choice would need to restore the anterior bone to the glenoid. The coracoid transfer procedure uses the coracoid for bone restoration, but iliac crest bone graft would be appropriate as well. An open Bankart repair, arthroscopic capsular plication, or a revision arthroscopic repair are all soft-tissue procedures, which do not correct the bone loss. Braces may work to allow a patient to finish a season before having surgery, but will not allow a return to activities of daily living without instability. The most common complication of the coracoid transfer is a loss of external rotation. The rate of recurrent instability is low. Most patients regain all of their internal rotation. The technique for the coracoid transfer splits the subscapularis muscle, so a tear of the muscle is rare. Axillary or musculocutaneous nerve palsies are rare after this procedure, but can occur if the nerves are not protected and mobilized during the dissection of the conjoint tendon. The most common long-term complication is early arthritis of the glenohumeral joint. Most cases of arthritis are asymptomatic and appear on follow-up radiographs. The graft rarely absorbs, and tears of the rotator cuff are uncommon with this procedure and infection is rare. Anterior ligament attenuation is uncommon, and some surgeons do not even repair the anterior labrum or capsule because this can lead to a loss of external rotation after surgery.

loss of sensation on the ulnar side of the index finger.

weakness with thumb extension.

weakness with elbow flexion.

weakness with finger abduction. DISCUSSION..Ulnar nerve lesions manifest with weakness in the finger abductor muscles. There will be loss of interossei muscle function as well as the third and fourth lumbricals. Extensor pollicis longus function is based on the posterior interosseous nerve (radial), not the ulnar. The index finger has sensation from the median nerve distribution. Elbow flexion strength is not dependent on the ulnar nerve.

Open reduction and internal fixation (ORIF)

Cast treatment for 4 weeks followed by static splinting

Percutaneous pinning

Total elbow arthroplasty (TEA) DISCUSSION...Advantages of TEA for fracture in elderly patients include preservation of the extensor mechanism, early mobilization, and avoiding complications of fixation; however, there are lifetime activity limitations and risk for loosening over time. Reoperation rates may be lower, functional outcomes improved, and results more predictable for TEA than ORIF in elderly populations. Cast treatment leads to unacceptable rates of stiffness and disability. Percutaneous fixation does not provide rigid enough fixation in the adult population.

Reassurance and a review of his rehabilitation program with an emphasis on deltoid strengthening

Open repair of the subscapularis tendon

Latissimus dorsi tendon transfer

Revision to reverse TSA DISCUSSION..This patient had a fall approximately 2½ months following a TSA. He now has poor active elevation but good passive motion and external rotation exceeding that of the contralateral shoulder. Rupture of the subscapularis tendon, which would have been released and repaired intrasurgically, would be the primary concern in this scenario. In the native shoulder treated surgically for instability, subscapularis failure can produce pain, weakness of abdominal press and lumbar pushoff, apprehension, and frank instability. Further delay in treatment of the tendon failure with therapy is not indicated because this will lead to further muscle atrophy and adhesions to the scapula and overlying brachial plexus. Augmentation or replacement with a transfer of the superior portion of the pectoralis major muscle is sometimes required. Transfer of the pectoralis minor muscle is also described. However, latissimus dorsi transfer is described for irreparable supraspinatus deficiency. Revision to a reverse TSA can be considered as a salvage of a persistently unstable shoulder, but will not be the primary treatment for this shoulder if radiograph findings are normal.

Radial head replacement to restore radiocapitellar contact

Radial head excision because there is no risk for posterolateral instability

Percutaneous fixation to avoid the risk for stiffness after surgery

Allograft reconstruction to prevent capitellar erosion DISCUSSION..Prosthetic replacement is an appropriate option in cases of a nonreconstructable fracture to restore the radiocapitellar contact. Most complex fractures are associated with instability; therefore, it is advisable to consider open reduction and internal fixation or radial head replacement when the injury involves a dislocation or fracture of the ulna. Simple radial head excision may be a viable option for a comminuted fracture without instability or associated ulnar fracture. When the radial head is replaced, caution must be exercised to avoid overstuffing the joint because this can lead to stiffness from impingement, capitellar erosion, loss of flexion, or synovitis.

implant fracture. 2- suture anchor dislodgement.

scapular notching. 4- acromial fracture. DISCUSSION..The patient has anterior superior instability. This condition is caused by a combination of rotator cuff insufficiency and loss of coracoacromial arch integrity. The only known way to restore shoulder function in this scenario is to implant a rTSA. The device works by converting the translational force of the deltoid into a rotational force, resulting in restoration of forward elevation of the shoulder. Performing a rotator cuff repair or arthroscopic debridement will not address this biomechanical problem. TSA will also not change this biomechanical problem. The poor motion and function are not a result of synovitis or pain because an injection with local anesthetic has eliminated the pain and serves as a useful test to determine if rTSA is the only viable solution. If the patient can achieve near-normal function with a local anesthetic challenge, rTSA is overtreatment. Scapular notching is a long-term concern for implant longevity because it represents bone loss under the baseplate of the glenoid component. This loss of support can lead to catastrophic failure of the device. Implant fracture, acromial fracture, and dislodgement of suture anchors are not likely to be asymptomatic in a non-Charcot joint.

Aseptic loosening of a linked implant

Instability of an unlinked implant

Triceps rupture

Wound dehiscence DISCUSSION..Patients with elbow osteoarthritis tend to be active and are often involved in manual occupations that place greater demands on a total elbow implant. Such patients are most often treated with nonprosthetic options because of concerns about prosthetic longevity. As a result, few cases of primary osteoarthritis are included in published studies. However, complications such as stem fracture and aseptic loosening appear to be more common in this population than in any other subgroup, including revision patients. The poor soft-tissue quality associated with rheumatoid arthritis leads to a high-risk ligamentous attenuation and is a general contraindication to use of an unlinked implant. The same poor soft tissue leads to a higher rate of triceps insufficiency and wound dehiscence.

Resumption of sling immobilization

Open reduction and internal fixation

Application of a bone stimulator and rest from exacerbating activities

Application of a figure-of-8 brace      DISCUSSION..The radiographs reveal an atrophic nonunion of the midshaft of the clavicle. The treatment of acute, displaced midshaft clavicle fractures in adults continues to evolve, with several reports advocating early surgical intervention. Although many fractures heal, symptomatic delayed unions or nonunions occur and may eventually require treatment. In this case, further sling immobilization or use of a figure-of-8 brace is unlikely to lead to fracture consolidation at 8 months after the injury. Although use of an electrical bone stimulator may be attractive, there is no conclusive data suggesting its efficacy in promoting healing of a displaced clavicular nonunion. Most authors advocate treatment with open reduction internal plate fixation. Controversy exists as to the need for allograft or autograft bone augmentation.

This is an experimental procedure.

You have no financial relationship with the implant company.

There will be an implant company representative in the room.

The hospital will lose money because of the cost of the implant. DISCUSSION..Current recommendations from the American Orthopaedic Association Orthopaedic Institute of Medicine are that the patient be notified if an industry representative is going to be present in the operating room. This surgery is not experimental for this indication, and Medicare currently covers the surgery for patients with appropriate indications. Court cases have demonstrated that surgeon-related factors can be litigated (such as surgeon experience), but there are no current requirements to disclose this. Surgeons are not required to disclose cost and compensation information to their patients.

Subacromial injection

Referral to pain management

Arthroscopic removal of a calcium deposit

Arthroscopic subacromial decompression       DISCUSSION…The radiographs show a calcium deposit in the supraspinatus tendon. The MRI scan shows a small black signal in the supraspinatus tendon without a tear of the tendon. These findings are consistent with calcific tendonitis. A subacromial injection will help distinguish between the pain from the calcific tendonitis and the chronic fibromyalgia. Pain management is an option after an injection is done for diagnostic purposes. Surgery should not be considered until the diagnosis is confirmed because it will not be successful if the shoulder pain is attributable to the patient’s fibromyalgia.