Essentials of Orthopedic Surgery, third edition / 08-The Shoulder

Surgical Treatment

In the absence of a RC tear, most surgeons recommend a subacromial decompression performed either open or arthroscopically. This procedure involves removing the inflamed subacromial bursa and shaving the undersurface of the acromion (acromioplasty) to create more room in the subacromial space for the rotator cuff. Patients who have reparable RC tears are treated with primary repair, and most surgeons perform an acromioplasty. Care should be taken to preserve the CA ligament in patients with large tears and multiple tendon tears to prevent superior migration of the humeral head. There are a variety of options for patients with irreparable tears, including arthroscopic debridement, partial tendon repair, and tendon transfers. Patients with irreparable RC tears and arthropathy may be candidates for shoulder arthroplasty with a humeral head replacement. If biceps tendon pathology is found at the time of surgery, either tenodesis or tenolysis can be performed. Patients who are noted to have AC joint arthropathy and pain before surgery may benefit from a distal clavicle resection. Recovery from RC surgery can take from 4 to 6 months. The goal of early (4–6 weeks) postoperative physical therapy is recovery of passive shoulder motion. Restoration of strength and function is the goal of subsequent postoperative therapy. Failure of the patient to adhere to postoperative physical therapy can result in a poor outcome.

Osteoarthritis

Degenerative or osteoarthritis occurs in the glenohumeral joint but is less common than in the hip or knee joints. Osteoarthritis of the glenohumeral joint has the same pathophysiology as in other joints with progressive articular cartilage destruction.

History

Patients with early osteoarthritis may have a clinical syndrome that is virtually indistinguishable from impingement syndrome. In patients with advanced osteoarthritis, pain is more likely to be chronic, occur at rest, and be resistant to standard analgesics and antiinflammatory medications. In addition, loss of shoulder motion is a common complaint.

Examination

Patients with early osteoarthritis (OA) may examine similarly to those with impingement syndrome. In more-advanced OA, generalized disuse atrophy of the shoulder girdle may be noticeable. In general, active motion is decreased in all planes but loss of external rotation is often the most dramatic. Passive motion is similarly decreased.

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FIGURE 8-8. All the classic findings of osteoarthritis are present in this true AP X-ray of the glenohumeral joint, including joint space narrowing, subchondral sclerosis, osteophyte formation, and subchondral cyst formation.

Differential Diagnosis

Adhesive capsulitis and inflammatory arthropathy can have similar presentations. The examiner must have a high index of suspicion for locked posterior shoulder dislocations in older patients who are poor historians as a result of dementia or stroke.

Radiographs

A standard shoulder series is recommended. Joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cyst formation are classic findings in osteoarthritis and are best seen on the AP and axillary view (Fig. 8-8). In the glenohumeral joint, inferior humeral osteophytes predominate. Often, eccentric posterior glenoid wear is present. MRI scans are generally not used in the evaluation of OA. A CT scan to assess the glenoid for eccentric wear or bone loss is common during preoperative evaluation for shoulder arthroplasty.

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respect to motion and pain relief has been demonstrated with TSA relative to HHR. Total shoulder arthroplasty introduces the risk of glenoid-sided prosthetic loosening and wear, which may require revision surgery. Humeral head replacement can fail as a result of inadequate pain relief.

Miscellaneous Arthropathy

A variety of other disease processes can lead to glenohumeral joint destruction. Inflammatory arthropathy such as rheumatoid arthritis can lead to joint destruction as a result of synovial disease. Although the clinical presentation may be similar to osteoarthritis with pain and loss of motion, there are some important differences. In particular, rheumatoid arthritis can result in rotator cuff deficiency and incompetence. In these patients, total shoulder arthroplasty is contraindicated because glenoid loosening in the setting of rotator cuff deficiency is a common problem. Progressive bony destruction of the humeral head and glenoid can result from rheumatoid arthritis, making prosthetic arthroplasty difficult if not impossible. Avascular necrosis can occur as a result of trauma, corticosteroid use, alcoholism, and other less common etiologies. Avascular necrosis of the humeral head can lead to pain and loss of motion in the glenohumeral joint. Humeral head replacement is an option for patients with humeral head collapse and chronic pain. Total shoulder arthroplasty is indicated when secondary destruction of the glenoid is present. Charcot or neuropathic arthropathy is typically a painless condition that results in severe joint destruction. Charcot arthropathy in the glenohumeral joint is commonly related to a cervical spine syrinx. There are no reliable surgical options for Charcot arthropathy.

Adhesive Capsulitis

Adhesive capsulitis, or frozen shoulder, is a painful condition in which the synovial lining of the glenohumeral joint is inflamed. Adhesive capsulitis is a clinical diagnosis in which examination reveals an equal loss of active and passive motion. Primary adhesive capsulitis is idiopathic, meaning that no trigger can be identified; it occurs in middle-aged persons and is associated with diabetes. Secondary adhesive capsulitis implies that a trigger or cause of the disease process can be identified. Trauma, surgery, and concomitant shoulder girdle pathology may result in secondary adhesive capsulitis.

History

The patient reports an insidious onset of shoulder pain. Pain often occurs during rotational movements such as reaching behind the back, putting on a coat, or fastening a bra. Often the patient may recall a minor event that

precipitated the condition. It is important to obtain a past medical and surgical history to identify possible risk factors. Insulin-dependent diabetes is a strong risk factor for adhesive capsulitis.

Examination

In the absence of prior trauma or surgery to the shoulder girdle, the inspection and palpation portions of the examination are usually unremarkable.

Active motion can be extremely limited in all planes of motion, and passive motion is similarly restricted. The patient often experiences pain at the end range of motion (active or passive).

Differential Diagnosis

Early adhesive capsulitis can mimic impingement. Subtle losses of internal and external rotation in abduction may be the only clues to differentiate between the two diagnoses. Unrecognized trauma (locked posterior shoulder dislocations) and glenohumeral joint arthropathy can mimic adhesive capsulitis.

Radiographs

A standard shoulder series is useful in excluding other diagnoses; however, there are no radiographic findings for adhesive capsulitis. Further studies are generally not indicated unless additional pathology is suspected.

Treatment

Once the diagnosis is made, education of the patient is paramount. In general, the treatment of adhesive capsulitis is twofold: treatment of the synovial inflammation and restoration of motion. Antiinflammatory medications can be used, but a corticosteroid injection into the glenohumeral joint space is more efficient and effective for treating the synovial inflammation. The patient must start a stretching program to regain motion in all planes. Initially, supervised physical therapy is helpful, but the patient must independently perform a battery of home stretching exercises daily. A gradual restoration of motion is the anticipated course. In patients who fail to respond to nonoperative treatment over the course of 3 to 6 months, surgery may be a reasonable option. Historically, patients with diabetes have a higher failure rate of nonoperative treatment compared to patients without risk factors. Additionally, patients with secondary adhesive capsulitis from trauma or prior shoulder surgery often fail to respond fully to nonoperative treatment.

Manipulation of the shoulder under anesthesia was once the preferred treatment and continues to be a reasonable option. Proximal humerus

History

In the resorptive phase, the patient may present with an acute onset of severe shoulder pain. In the formative phase, the patient may present with more chronic symptoms that mimic impingement syndrome.

Examination

Acute bursitis in the resorptive phase may lead to fullness of the anterosuperior shoulder, but otherwise the inspection is typically unremarkable. There may be tenderness at the rotator cuff insertion corresponding to the calcium deposition. There may be a loss of active motion secondary to pain, but passive motion, although painful, is generally preserved. Impingement signs are often positive.

Differential Diagnosis

The differential diagnosis includes rotator cuff disease and adhesive capsulitis. Referred pain from cardiac origin or other visceral organs and radicular pain from the cervical spine should be considered.

Radiographs

The appearance of calcific tendonitis on radiographs varies depending on the phase of the disease. In the formative phase, the calcium deposit is usually well circumscribed and easily identified. In the resorptive phase, the deposit may appear fluffy and less well defined. In addition to the standard shoulder series, internal and external rotational views (AP) can be helpful for identifying more subtle deposits. Additional studies are not usually indicated.

Treatment

Treatment generally involves pain management. Noninvasive treatment options include antiinflammatory medications and extracorporeal shock wave therapy. More-invasive options include corticosteroid injections and lavage therapy. Surgical treatment is a last resort and involves arthroscopic debridement of the calcium deposit.

Multidirectional Instability

Shoulder instability is a complex problem with a spectrum of pathology ranging from atraumatic multidirectional shoulder instability to traumatic, unidirectional shoulder dislocations. Multidirectional instability (MDI) generally refers to shoulder pain and disability caused by excessive laxity of the static shoulder stabilizers (capsule and glenohumeral ligaments).

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History

In the overhead athlete (pitchers, swimmers, and volleyball players), MDI can present with activity-related pain, scapular winging, and occasionally with neurologic symptoms down the arm. Other patients may present with shoulder subluxations and dislocations that may easily reduce on their own but are a significant source of disability and distress to the patient.

Examination

Scapular winging may be noticeable on inspection during range of motion and strength testing. The active and passive ranges of motion are often excessive compared to the average shoulder. Additionally, the patient may exhibit generalized ligamentous laxity at other joints. The sulcus sign (hollowing of the subacromial region with downward traction on the arm) may be noticeable and indicative of shoulder laxity. Provocative shoulder testing such as the apprehension test may produce pain rather than apprehension. This pain is often related to secondary rotator cuff irritation. Other patients may have true apprehension. Load-and-shift testing often reveals subluxation or dislocation in multiple directions.

Differential Diagnosis

The differential diagnosis includes rotator cuff disease, labral pathology, and peripheral nerve injury in the setting of scapular winging.

Radiographs

The standard radiographs are typically unremarkable, although bony abnormalities such as glenoid hypoplasia can be identified. Patients who have had previous traumatic anterior shoulder dislocation may have a posterosuperior impression fracture of the humeral head (Hill–Sachs lesion) or a bony deficiency of the anteroinferior glenoid rim (bony Bankart lesion). An MRI arthrogram can be useful to exclude labral injury (Bankart lesion) and document the patulous capsule.

Treatment

The mainstay of treatment for MDI is rehabilitation. Physical therapy is focused on strengthening the dynamic stabilizers of the shoulder girdle, including the rotator cuff and scapular stabilizers. More-specialized therapy can be prescribed for athletes and is based on their specific sport and needs. Patients who fail rehabilitation may be candidates for surgical treatment. In most cases, rehabilitation should be continued for at least 6 to 12 months. Surgical treatment involves decreasing the volume of the shoulder joint by surgically altering the capsule (capsulorraphy). Surgery may be

performed by arthroscopic or open methods. Arthroscopic methods tend to preserve motion better and may be preferable in athletes who would not tolerate minor losses of motion. Open surgical treatments historically have had lower rates of recurrent instability. Criticisms of open procedures such as the inferior capsular shift include loss of motion and potential subscapularis deficiency.

Summary

The shoulder is a complex structure that provides tremendous versatility and power to the upper extremity. The majority of painful shoulder girdle conditions are readily diagnosed with a thorough history and physical examination. Successful treatment of shoulder girdle problems is often accomplished by following a relatively simple algorithm of rest, activity modification, nonsteroidal antiinflammatory drug therapy, and physical therapy. More-invasive treatment options such as arthroscopic and open surgery are highly effective in appropriately selected patients.

Suggested Readings

Norris TR. Orthopaedic Knowledge Update: Shoulder and Elbow, 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2002.

Rockwood CA, Matsen F, Wirth M. The Shoulder, 3rd ed. Philadephia: Saunders, 2004.

Questions

Note: Answers are provided at the end of the book before the index.

8-1. Which of these articulations is not a true diarthrodial joint?

a.Sternoclavicular

b.Acromioclavicular

c.Scapulothoracic

d.Glenohumeral

e.Hip joint

8-2. The primary, passive restraint to anterior displacement of the humeral head when the shoulder is abducted and externally rotated to 90 degrees is the:

a.Coracohumeral ligament

b.Anterior band of the inferior glenohumeral ligament complex

c.Superior glenohumeral ligament

d.Long head of the biceps tendon

e.Posterior band of the inferior glenohumeral ligament complex

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8-3. Which of the following radiographic findings is not a hallmark of glenohumeral osteoarthritis?

a.Central erosion of the glenoid

b.Osteophyte of the inferior humeral head

c.Subchondral sclerosis

d.Joint space narrowing

e.Subchondral cysts

8-4. Which of these peripheral nerves does not exit from the brachial plexus?

a.Long thoracic nerve

b.Thoracodorsal nerve

c.Axillary nerve

d.Suprascapular nerve

e.Spinal accessory nerve

8-5. The rotator cuff includes all the following muscles except:

a.Supraspinatus

b.Teres minor

c.Deltoid

d.Subscapularis

e.Infraspinatus

8-6. What is the most common origin of shoulder pain that does not originate within the shoulder girdle?

a.The cervical spine

b.The heart

c.The gallbladder

d.The lungs

e.The thoracic spine

8-7. Which of the following procedures is not an option for the treatment of glenohumeral osteoarthritis?

a.Total shoulder arthroplasty

b.Humeral head replacement

c.Arthroscopic debridement

d.Arthroscopic labral repair

e.Fusion

8-8. What is the best noninvasive study to evaluate the integrity of the rotator cuff tendons?

a.Computerized tomography scan

b.Plain AP radiograph in the plane of the scapula

c.Electromyography study

d.Magnetic resonance imaging arthrogram

e.Magnetic resonance imaging scan

8-9. All the following are treatment options for adhesive capsulitis except:

a.Arthroscopic rotator cuff repair

b.Arthroscopic adhesiolysis