Reverse shoulder replacement for cuff tear "repair" arthropathy

In the case below it is demonstrated that surgical exposure for a reverse shoulder replacement after failed rotator cuff repair in the elderly can be difficult. The patient is in her 70s and has stiffness to the shoulder, a high riding humeral head with shoulder arthritis and a surgical field altered due to scar tissue formation from a previous deltopectoral approach that was used for repair of the rotator cuff. The rotator cuff repair was performed 7 years ago by another surgeon. During surgery it was found that the prior surgeon detached the anterior fibers of the deltoid from the acromion (deltoid take down) and re-attached those after the repair. The partially scarred deltoid made the exposure of the glenoid a difficult task. In this case the release of the inferior capsule and removal of bone from the anterior aspect of the proximal humerus allowed for insertion of a baseplate and glenosphere. The patient had significant relief of pain a few days after her surgery.

High riding humeral head. Anchors from prior rotator cuff repair. Arthritis of glenohumeral joint

Axillary view

Exposure of the humeral head

Exposure of the glenoid

implantation of the baseplate

implanation of the glenosphere

Postoperative shoulder xray after implantation of the reverse total shoulder prosthesis

Shoulder replacement for postinfectious destructive arthritis

This is a healthy patient in her seventies who presented in our office with right shoulder pain and loss of motion. She had active forward elevation of the shoulder to 20 degrees. She has a history of septic shoulder arthritis which was treated elsewhere 3 years ago with irrigation and debridement and 6 weeks of IV antibiotics via a PICC line. At the time of presentation she had no signs of infection, she had no recurrent infection over the past 43 years and her lab work (WBC, CRP, ESR) was normal. The patient had problems sleeping at night and pain with any motion of the shoulder. Her radiographs were indicative of severe joint destruction, loss of bone stock at the glenoid and humeral head and severe medialization/erosion of the glenoid.

A CT scan demonstrated the severity of the joint destruction.

During surgery we found that the glenoid did not have enough bone stock for insertion of a glenosphere for a reverse shoulder replacement and the rotator cuff (supraspinatus) muscle was torn. The subscapularis was present but was atrophic.

We elected to proceed with a hemiarthroplasty with a large size humeral head to avoid instability and provide some pain relief. Cultures were obtained at the time of surgery that will be held for 3 weeks to look for p. acnes and the patient was placed on oral Augmentin for 3 weeks until cultures finalize.

The post-operative XR shows restoration of the acromion index as described before 

(Association of a Large Lateral Extension of the Acromion with Rotator Cuff Tears

Richard W. Nyffeler, MD, Dipl.Ing. ETH; Clément M.L. Werner, MD; Atul Sukthankar,MD; Marius R. Schmid, MD; Christian Gerber, MD

J Bone Joint Surg Am, 2006 Apr;88(4):800-805.

This case illustrates the complexity involved in the treatment of shoulder arthritis that is associated with (1) loss of soft tissue balance-rotator cuff (2) loss of glenoid bone stock.

Although some surgeons would have suggested bone grafting of the glenoid and implantation of a reverse shoulder prothesis we elected not to proceed with this approach due to the (1) high chance of absorption of the bone graft at the glenoid (2) history of infection increasing the chances of failure of the bone graft (3) early loosening of the glenosphere in shoulders with hypoplastic, dysplastic or atrophic glenoids.

"Bone spurs" and shoulder replacement surgery

There has been a significant debate about the role of osteophytes (bone spurs) in the pathogenesis of shoulder pain or joint pain. There is nowdays enough evidence to support that "bone spurs" do not always cause shoulder pain. For example, foot and ankle surgeons believe that the calcaneal bone spurs that are seen in the plantar ligaments of the foot (spring ligaments) are traction spurs and are not sources of pain. In addition, recent studies show that rotator cuff repair with or without acromioplasty (removal of bone spurs from acromion) have the same outcome in shoulder function and pain relief.

The following case is an example of a similar clinical condition. This patient is in her seventies and presented with symptoms of pain and popping of the glenohumeral joint of the left shoulder. On radiographs of the shoulder, as seen below, there is a large anterior inferior acromial spur and a significant size spur at the footprint of the rotator cuff.

During surgery we found that the acromial spur was not eroding into the rotator cuff muscles and for this reason was left intact. The rotator cuff footprint bone spur was within the intact supraspinatus fibers and for this reason was left intact to avoid damage to rotator cuff from potential surgical removal. As it is well known one of the main reasons of failure of the total shoulder arthroplasty is rotator cuff denegeration and tearing. Removing the footprint "bone spur" would have caused damage to the rotator cuff and failure of the glenoid component in the long run.

The patient was seen in the office at 3 years postoperatively. She had no pain and active forward elevation of the shoulder to 170 degrees. Xrays are shown below

Although this is a case report (Level 5 of evidence) it highlights the need to think twice before saying to patients that "bone spurs in the shoulder = shoulder pain". Generalization and false analogy are common mistakes performed by scientists and physicians including myself.

Hippocrates was the first to introduce the concept of 'physis' and to transform hieratic or theocratic medicine into rational medicine. Correct use of new scientific knowledge, individualized management with a Hippocratic holistic approach and compassionate sympathy for the patient who suffers, should be considered in the years to come for maintaining the level of medical profession.

Surgical treatment of "multidirectional" shoulder instability.

This patient is in his 20s and presented to the office with multidirectional shoulder instability. He reported more 100 dislocations that they started since high school and were not painful at the beginning and without hx of trauma. He has generalized laxity and reports no recent trauma. At the time of evaluation he did not have a sulcus sign but had a positive Jerk's and negative apprehension test. The patient reported that the pain is a new problem and his past recent dislocations were painless. Currently, the dislocations are associated with severe pain and no neurologic deficits.

His shoulder would dislocate easily posteriorly and inferiorly as you can see on the XRs below that were taken in the office. 

His MRI demonstrated a posterior labrum tear and unfortunately was not ordered with intra-articular contrast by his PCP and thus information about laxity of the inferior capsule was not available.

Due to the significant pain and the failure of his 4 months of PT to provide relief we elected to proceed with arthroscopic reverse Bankart repair and possible arthroscopic capsular shift. On exam in the operating room and under anesthesia he had a +3 posterior load and shift test. Postoperative images after his repair as shown below. 

Symptomatic posterior inferior instability is an indication of multidirectional instability and those cases have either recurrent or persistent labral pathology or patulous capsules with occult multi-directional instability primarily manifesting in the posterior direction. 

There have been cases of a painful multidirectional instability that have no associated shoulder pathology other than patulous capsules. Although some authors report on performing a 180-270 deg repair it seems more appropriate to address the lesion/ first without extensive use of anchors and by repaing only the detached labrum. We will follow him closely hoping that this procedure will solve this difficult problem.

How does the brain can cause "shoulder pain". The importance of history taking

This is an interesting case that was seen in the office. This patient was referred to "the shoulder surgeon" for shoulder pain. The patient reported pain to bilateral shoulders and occasional numbness and tingling to bilateral arms associated with headaches. She did not report the headaches. She was asked specifically for those as she thought that these are two problems - headache and shoulder pain-are not related. She had no neurologic deficits.

We thought at the first visit that the patient had signs of cervical radiculopathy a common cause of "shoulder pain", numbness and tingling and headaches. XRs of the cervical spine were negative.

We advised her for 4 weeks of physical therapy but she did not improve. For this reason we obtained an MRI of the c spine which at our surprise demonstrated an arachnoid cyst in the cerebellar area. After discussing the case with a neurosurgeon these cysts are benign but can explain the headaches and some neurologic symptoms.

We learn every day!

Shoulder hemi-arthroplasty for humeral head avascular necrosis

The following case is a middle aged patient with shoulder pain for several years. The radiographic evaluation of the shoulder demonstrated post-collapse avascular necrosis of the humeral head. The cause of his disease was alcohol abuse. While some surgeons believe that a "minimallly invasive" procedure is appropriate for the treatment of this condition we avoid the use of such procedures because:
(1) mini caps have the problem of loosening and do not prevent further progression of the disease

(2) shoulder resurfacing implants result in early loosening and revision to hemi-arthroplasties.

The longevity of a hemi-arthroplasty is approximately 10 years before glenoid wear becomes an issue. At that point a conversion of the hemi-arthroplasty to a total shoulder replacement can be offered extending the longevity to an additional 10-15 years.  Preop/postop radiographs and intraoperative images are shown below

Severe loss of cartilage from AVN

Type I-II-III-IV pediatric supracondylar humerus fractures

The majority of pediatric supracondylar humerus fractures are extension type injuries. Fixation of these fractures requires attention to detail and avoidance of use of medial pinning when possible. Use of medial pins runs the risk of injury to the ulnar nerve and there is no additional biomechanical stability by adding medial pins. Gartland classified these fractures in 3 types based on the displacement and treatment method.

Gartland Classificaiton
Type I	Nondisplaced, beware of subtle medial comminution leading to cubitus varus
Type II	Displaced, posterior cortex intact
Type III	Completely displaced
*Type IV	Complete periosteal disruption with instability in flexion and extension

Type I fractures can be treated in a long arm cast or with pinning. Some orthopaedic surgeons prefer pinning of the non displaced  Type I fractures in an attempt to avoid lost to followup cases, avoid frequent visits to the office and radiation exposure. Currently, both methods of treatment are acceptable as long as a close weekly followup is scheduled for the patients that receive conservative Rx in a cast without pinning. If the fracture displaces then pinning is required. 

The case below is a 4 year old patient who presented with elevation of the fat pad on the lateral view due to a non displaced supracondylar humerus fracture. She was treated in a long arm cast for 6 weeks and healed without complications.

The following case is a 3 year old patient who presented with a Type II supracondylar humerus fracture that was treated with 2 lateral pins. The fracture healed without complications at 6 weeks.

The last case is a 4 year old patient who presented with a Type III supracondylar humerus fracture and was treated with lateral pinning only. The patient had the pins removed at 3 weeks and received long arm cast immobilization for a total of 6 weeks. Xrays show a healed fracture at 6 weeks.

XRs 6 months after show healed fracture. XRs are shown below at 6 months after surgery.

During fixation of these fractures it is ideal to have tricortical fixation by penetrating the coronoid fossa with the pins as demonstrated in the picture below.

This method of fixation provides better biomechanical and rotational control of the fracture. It is important to take into consideration the 3 column theory and private stability to the three columns of the distal humerus.

In addition, after the placement of the pins the stability of the fixation must be tested with "live" fluoroscopic evaluation of the fracture with flexion and extension of the joint.

The AAOS published practice guidelines for the treatment of these fractures that can be found by a clicking here