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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
•
•

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
•
•
•

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
•
•
•
•
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



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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