OU Shoulder and Elbow OITE

Review
September 27, 2017
Betsy M. Nolan MD

CONFIDENTIAL 1
 Annual Scientific Day
Orthopaedic Society of Oklahoma
Pushed back to 2018.
More information coming soon.

CONFIDENTIAL 2
Young Leaders Series 2017-2018:
Moved to Friday mornings after Grand Rounds in same
conference room. Starts after OITE.

2016-2017 Topics:
Career Paths in Orthopaedic Surgery
Foundation Building for Your Financial Future
Inventors and Angels Among Us: Technology Development
and Investment, Seed Funding, and Venture Capital
Contract Negotiation
Estate Planning
Always free for residents and fellows!
CONFIDENTIAL 3
• A 65-year-old man presents with chronic right shoulder
pain and crepitus. On physical exam his rotator cuff
strength is 5/5. He has pain with both passive and active
range of motion. Radiographs are shown in Figures A and B.
An MRI is performed and shows no evidence of a rotator
cuff tear. When comparing TSA versus hemiarthroplasty as
a treatment option in this patient, hemiarthroplasty results
in which of the following?
1. Improved pain relief
2. Increased rate of revision surgery
3. Increased blood loss
4. Increased postoperative instability
5. Increased postoperative infection rates
CONFIDENTIAL 4
CONFIDENTIAL 5
 PREFERRED RESPONSE

2.- Increased rate of revision surgery

CONFIDENTIAL 6
 Discussion
• The clinical scenario is consistent with a patient with shoulder
osteoarthritis and an intact rotator cuff. While both TSA and
hemiarthroplasty are treatment options, literature has shown the rate of
revision surgery to be higher in the hemiarthroplasty group compared to
the TSA group.

• In appropriately selected patients with glenohumeral osteoarthritis, the

results of total shoulder arthroplasty (TSA) are better than those of
hemiarthroplasty (no glenoid resurfacing) with respect to pain relief and
function. Historically, some surgeons have avoided glenoid resurfacing
because of concerns over wear and loosening of the glenoid component
which could lead to the need for revision surgery. However, literature has
shown the rate of revision surgery to be higher in the hemiarthroplasty
group compared to the TSA group. Figures A and B are radiographs which
show shoulder osteoarthritis.

CONFIDENTIAL 7
 Discussion
• Edwards et al studied the effect of an abnormal rotator cuff on the results of TSA.
Their results demonstrated that minimally retracted or nonretracted rotator cuff
tears limited to the supraspinatus tendon did not negatively affect outcome
parameters in shoulder arthroplasty performed for the treatment of primary
osteoarthritis. Conversely, involvement of the infraspinatous or subscapularis
musculature did adversely affect many of these parameters.

CONFIDENTIAL 8
 • RECOMMENDED READINGS

The Influence of Rotator Cuff Disease on the Results of Shoulder Arthroplasty for Primary Osteoarthritis: Results of a
Multicenter Study.
Edwards TB, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walch G
J Bone Joint Surg Am. 2002 Dec;84-A(12):2240-8. PMID: 12473715 (Link to Abstract)
Edwards, JBJS 2002

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study.
Norris TR, Iannotti JP
J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):130-5. PMID: 11988723 (Link to Abstract)
Norris, JSES 2002

CONFIDENTIAL 9
• Early reverse total shoulder designs (before the
development of the Grammont-style prosthesis)
had a high failure rate due to early loosening of
the glenoid component. What biomechanical
feature accounted for this problem?
1. Glenoid component did not have a neck
2. Humeral component too horizontal
3. Center of rotation too lateral
4. Center of rotation too anterior
5. Center of rotation too inferior

CONFIDENTIAL 10
PREFERRED RESPONSE
3.- Center of rotation too lateral

CONFIDENTIAL 11
 Discussion
• Early reverse ball-and-socket designs failed because their center of rotation remained lateral
to the scapula, which limited motion and produced excessive torque on the glenoid
component, leading to early loosening. The first modern reverse prosthesis was designed by
Paul Grammont. According to Boileau et al., Grammont's design "introduced 2 major
innovations (1) a large glenoid hemisphere with no neck and (2) a small humeral cup almost
horizontally oriented with a nonanatomic inclination of 155 degrees, covering less than half
of the glenosphere. This design medializes the center of rotation compared to earlier
versions which minimizes torque on the glenoid component. Furthermore, the humerus is
lowered relative to the acromion, restoring and even increasing deltoid tension. The
Grammont reverse prosthesis imposes a new biomechanical environment for the deltoid
muscle to act, thus allowing it to compensate for the deficient rotator cuff muscles."
According to Gerber, "moving the center of rotation more medial and distal as well as
implanting a large glenoid hemisphere that articulates with a humeral cup in 155 degrees of
valgus are the biomechanical keys to sometimes spectacular short- to mid-term results".

CONFIDENTIAL 12
 • RECOMMENDED READINGS

Grammont reverse prosthesis: design, rationale, and biomechanics.

Boileau P, Watkinson DJ, Hatzidakis AM, Balg F.
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):147S-161S. PMID: 15726075 (Link to Abstract)
Boileau, JSES 2005

Reverse total shoulder arthroplasty.

Gerber C, Pennington SD, Nyffeler RW.
J Am Acad Orthop Surg. 2009 May;17(5):284-95. PMID: 19411640 (Link to Abstract)
Gerber, JAAOS 2009

CONFIDENTIAL 13
• A 65-year-old right-hand-dominant man reports
acute right shoulder pain and inability to lift his
arm overhead after a glenohumeral dislocation
while skiing 2 weeks ago. Physical exam reveals
active forward elevation to 30 degrees and 3/5
external rotation strength, pain with motion, and
intact lateral arm sensation. An MRI is
contraindicated due to a pacemaker, and
therefore an arthrogram is performed and shown
in Figure A. What is the most appropriate
treatment option?

CONFIDENTIAL 14
CONFIDENTIAL 15
1. Shoulder hemiarthroplasty
2. Rotator cuff repair
3. Proximal humerus ORIF
4. Total shoulder arthroplasty
5. Sling immobilization

CONFIDENTIAL 16
PREFERRED RESPONSE
2.- Rotator cuff repair

CONFIDENTIAL 17
 Discussion
• The clinical presentation is consistent with an acute rotator cuff tear following a
shoulder dislocation, so the most appropriate treatment is a rotator cuff repair.

• A shoulder dislocation in a patient >40 years-old commonly results in a rotator cuff tear.
An arthogram may be helpful to confirm the diagnosis when an MRI is contraindicated.
The arthrogram shows extravasation of the dye into the subacromial space with no
evidence of arthritis. A rotator cuff tear allows the dye to leak into the subacromial
space, whereas in a normal MRI arthrogram the dye is contained within the joint
capsule (Illustration A).

• Craig et al described the geyser sign (Illustration B), which is when dye from a shoulder
arthrogram leaks into the subacromial space as well as into the AC joint. This is
indicative of a long-standing full-thickness RCT that has now involved the AC joint.

CONFIDENTIAL 18
 • RECOMMENDED READINGS

The geyser sign and torn rotator cuff: clinical significance and pathomechanics.
Craig EV.
Clin Orthop Relat Res. 1984 Dec;(191):213-5. PMID: 6499313 (Link to Abstract)
Craig, CORR 1984

Rotator cuff tear arthropathy.

Jensen KL, Williams GR Jr, Russell IJ, Rockwood CA Jr.
J Bone Joint Surg Am. 1999 Sep;81(9):1312-24. PMID: 10505528 (Link to Abstract)
Jensen, JBJS 1999

CONFIDENTIAL 19
• A 34-year-old male falls
from a roof and sustains a
right elbow dislocation that
is closed reduced in the
emergency room. An AP
radiograph is shown in
Figure A. This injury pattern
is at highest risk for which
of the following?
CONFIDENTIAL 20
1. Anterior interosseous nerve palsy
2. Varus posteromedial rotatory instability
3. Posterior interosseous nerve palsy
4. Valgus posterolateral rotatory instability
5. Elbow instability when pushing oneself up
from a seated position in a chair

CONFIDENTIAL 21
 PREFERRED RESPONSE

2.- Varus posteromedial rotatory instability

CONFIDENTIAL 22
 Discussion
• Anteromedial coronoid facet fracture and LCL injury following an elbow dislocation is commonly
associated with varus posteromedial rotatory instability. Varus and posteromedial rotation force on
the forearm results in rupture of the LCL from its humeral origin. As the LCL ruptures, the medial
coronoid process is fractured as it impacts against and under the medial trochlea. Fracture
involvement of the sublime tubercle, where the MCL attaches, can lead to more instability. The
lateral pivot shift test is similar to pushing oneself up from a seated position in a chair is an
indication of valgus posterolateral rotatory instability. Ulnar neuropathy can be seen following this
injury pattern but AIN and PIN nerve palsy do not commonly characterize this injury pattern.

• The review article by O'Driscoll highlights key points in diagnosis and management of capitellum,
distal humerus, coronoid, and terrible triad injuries.

• The article by Doornberg and Ring is a Level 4 study of 18 patients that sustained varus
posteromedial rotational injuries resulting in anteromedial facet coronoid fractures. They found
that lack of fixation at injury or malunion of the anteromedial facet were significant predictors of
suboptimal functional outcome and development of arthrosis.

• The anteromedial facet is highlighted in yellow as displayed in Illustration A. Illustration B depicts

the lateral collateral ligament injury evident during varus stress fluroscopic examination.

CONFIDENTIAL 23
CONFIDENTIAL 24
 • RECOMMENDED READINGS

Difficult elbow fractures: pearls and pitfalls.

O'Driscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD.
Instr Course Lect. 2003;52:113-34. PMID: 12690844 (Link to Abstract)
Fracture of the anteromedial facet of the coronoid process.
Doornberg JN, Ring DC
J Bone Joint Surg Am. 2006 Oct;88(10):2216-24. PMID: 17015599 (Link to Abstract)
Doornberg, JBJS 2006

CONFIDENTIAL 25
• What is the preferred treatment for a propionibacterium
acnes infection that has been symptomatic for 6 months
after total elbow arthroplasty with well-fixed components,
good bone stock, and a healthy patient?

1. Non-operative treatment with IV antibiotics for 6 weeks

2. Arthroscopic irrigation and debridement
3. Open irrigation and debridement with poly exchange
4. Single stage revision arthroplasty
5. Two stage revision arthroplasty

CONFIDENTIAL 26
 PREFERRED RESPONSE

5.-Two stage revision arthroplasty

CONFIDENTIAL 27
 Discussion
• Chronic propionibacterium acnes infections of elbow arthroplasty are best
treated with two staged revision arthroplasty in healthy patients with
adequate bone stock for reimplantation. The algorithm to treat infected
total elbow arthroplasty depends on a number of factors including patient
characteristics, bacteriology, duration of symptoms, and implant
fixation/bone stock.

• Yamaguchi et al discuss that poor health status or inadequate bone stock

may indicate resection arthroplasty, while acute (<1 month) infections
with staph aureus have a greater than 50% chance of success with
debridement and retention of components. Most chronic infections or
those caused by staph epidermidis or proprionibacterium acnes have high
recurrence rates with retention and a two stage revision should be
considered with antibiotic spacer and at least 6 weeks of IV antibiotics
between staged procedures. Immediate reimplantation in a single stage is
controversial and success rates range from 25-75% and are most
successful in staph aureus infections.

CONFIDENTIAL 28
 • RECOMMENDED READINGS

Infection after total elbow arthroplasty.

Yamaguchi K, Adams RA, Morrey BF
J Bone Joint Surg Am. 1998 Apr;80(4):481-91. PMID: 9563377 (Link to Abstract)
Yamaguchi, JBJS 1998

CONFIDENTIAL 29
• During shoulder arthroscopy of a 58-year-old female recreational
golfer, the rotator cuff is examined and is seen to be intact on the
articular side. After a bursectomy is performed in the subacromial
space, a bursal sided tear is found measuring 1.5 cm from anterior
to posterior and 4 mm in depth from the surface of the tendon with
surrounding cuff softening. What is the appropriate management?

1. Debride the tear and perform an acromioplasty

2. Abort surgery and start a physical therapy program
3. Convert it to a full-thickness tear and repair it with suture anchors
4. Consider it incidental, as this is a common finding in this age
group
5. Perform acromioplasty only

CONFIDENTIAL 30
 PREFERRED RESPONSE

3.-Convert it to a full-thickness tear and

repair it with suture anchors

CONFIDENTIAL 31
 Discussion
• Partial thickness rotator cuff tears on the articular side are more common than
their bursal counterparts; however, the bursal tears are typically more
symptomatic. Grading is based on depth (<25
• %, 25-50%, >50% for Grades 1, 2, and 3 respectively) and side (articular (A) or
bursal (B)).

• Cordasco et al performed a retrospective review of their patients who underwent

acromioplasty and debridement without rotator cuff repair. Included were patients
who had Grade 1 and 2 partial thickness rotator cuff tears. They found a 38%
failure rate due to continued pain and functional disability for those patients who
had Grade 2 bursal-sided rotator cuff tears. The patients who failed never had
improvement of their symptoms, even immediately after surgery.

• Wolff et al provide a succinct review of partial rotator cuff tears including

incidence, pathogenesis, presentation, evaluation and workup, natural history, and
treatment. They conclude the literature suggests that for articular-sided tears >6
mm in depth and for bursal-sided tears of >3 mm in depth, the surgeon should
consider repair.

CONFIDENTIAL 32
 • RECOMMENDED READINGS

The partial-thickness rotator cuff tear: is acromioplasty without repair sufficient?

Cordasco FA, Backer M, Craig EV, Klein D, Warren RF.
Am J Sports Med. 2002 Mar-Apr;30(2):257-60. PMID: 11912097 (Link to Abstract)
Cordasco, AJOSM 2002
Partial-thickness rotator cuff tears.
Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M.
J Am Acad Orthop Surg. 2006 Dec;14(13):715-25. PMID: 17148619 (Link to Abstract)
Wolff, JAAOS 2006

CONFIDENTIAL 33
• Which of the following is an indication for surgical
treatment of an acute humeral shaft fracture?

1. radial nerve palsy

2. long oblique fracture type
3. comminuted fracture
4. Holstein-Lewis fracture type
5. ipsilateral both bone forearm fracture

CONFIDENTIAL 34
 PREFERRED RESPONSE

5.- ipsilateral both bone forearm fracture

CONFIDENTIAL 35
 Discussion
• Humeral shaft fractures can be managed nonoperatively due to a
high union rate with infrequent complications. Certain situations,
however, favor operative osteosynthesis: failure of closed
reduction, associated articular injury, vascular or brachial plexus
injuries, associated ipsilateral forearm fractures, segmental
fractures, and pathologic fractures. Open fractures should be
irrigated and debrided if necessary with subsequent external or
internal fixation. Polytrauma patients with multiple extremity or
multi-system injuries may also be considered for operative
stabilization. A relative indication also may be the transverse or
short oblique fracture in an active patient since these fracture
patterns are more prone to delayed union. An acute radial nerve
palsy associated with a humeral shaft fracture is not an indication
for surgery.

CONFIDENTIAL 36
• Which of the following factors has the greatest
influence on early postoperative restrictions
following total shoulder arthroplasty through a
deltopectoral approach?
1. Release of the superior border of the pectoralis
2. Strength of the capsular repair
3. Strength of the subscapularis repair
4. Presence of glenoid retroversion
5. Quality of the patients' bone

CONFIDENTIAL 37
 PREFERRED RESPONSE

3.- Strength of the subscapularis repair

CONFIDENTIAL 38
 Discussion

• Using the deltopectoral approach for total shoulder arthroplasty requires that the
subscapularis is taken down. This can be performed trans-tendon, taking the tendon off
bone, or with a lesser tuberosity osteotomy. Regardless, excessive early passive external
rotation and active internal rotation past the plane of the body are rarely permitted during
the first 6 weeks.

• The Norris article is a multicenter cohort study reporting results of shoulder arthroplasty.
Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis
result in good or excellent pain relief, improvement in function, and patient satisfaction in
95% of cases. The most common intraoperative complications were intraoperative fractures.

• The Cameron paper is a review article that evaluates the factors affecting the outcome of
total shoulder arthroplasties, including rehabilitation.

CONFIDENTIAL 39
 • RECOMMENDED READINGS

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study.
Norris TR, Iannotti JP
J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):130-5. PMID: 11988723 (Link to Abstract)
Norris, JSES 2002

Factors affecting the outcome of total shoulder arthroplasty.

Cameron B, Galatz L, Williams GR Jr.
Am J Orthop (Belle Mead NJ). 2001 Aug;30(8):613-23. PMID: 11520017 (Link to Abstract)
Cameron, AJO 2001

CONFIDENTIAL 40
• A 35-year-old male is involved in
a motor vehicle accident and
suffers the fracture shown in
Figure A. This is an isolated
shoulder injury, and he has no
neurologic deficits on physical
exam. CT scan of the scapula
shows the glenoid to be
translated medially 3mm, and
anglulated 20 degrees from its
anatomic axis. What is the most
appropriate initial treatment for
this injury?

CONFIDENTIAL 41
1. Immobilization in sling x 2 weeks then PT
2. Immobilization in sling x 8 weeks then PT
3. ORIF via a deltopectoral approach
4. ORIF via a posterior approach
5. ORIF via a lateral approach

CONFIDENTIAL 42
 PREFERRED RESPONSE

1.- Immobilization in sling x 2 weeks then PT

CONFIDENTIAL 43
 Discussion
• The radiographs are consistent with a extra-articular glenoid
neck fracture, which by definition is not significantly
displaced. These fractures are best treated with a sling (2
weeks) and early mobilization. Significantly displaced
fractures, have translational displacement greater than or
equal to 1 cm or angulatory displacement greater than or
equal to 40°. These typically need ORIF.

• A schematic of the fracture types is shown in Illustration A.

• McGahan et al review the epidemiology of scapula fractures

and advocate conservative treatment with early
mobilization.

• Van Noort et al reviewed 13 scapular neck fractures and

found that non-operative treatment in the absence of
ipsilateral shoulder injury and associated neurological
impairment lead to good functional outcomes, with or
without significant translational displacement of the
fracture.

CONFIDENTIAL 44
 • RECOMMENDED READINGS

Fractures of the scapula.

McGahan JP, Rab GT, Dublin A.
J Trauma. 1980 Oct;20(10):880-3. PMID: 6252325 (Link to Abstract)
McGahan, JTACS 1980

Fractures of the scapula surgical neck: outcome after conservative treatment in 13 cases.
van Noort A, van Kampen A
Arch Orthop Trauma Surg. 2005 Dec;125(10):696-700. PMID: 16189689 (Link to Abstract)
van, AOTS 2005

CONFIDENTIAL 45
• A 75-year-old, right-hand-
dominant female has a
chronic rotator cuff tear
and shoulder pain for 10
years which has failed
conservative treatment. A
radiograph is shown in
Figure A. Your examination
and further imaging will
help you to decide
between which of the
following pairs of surgical
options for this patient?

CONFIDENTIAL 46
1. hemiarthroplasty or total shoulder arthroplasty
2. reverse total shoulder or total shoulder
arthroplasty
3. hemiarthroplasty or reverse total shoulder
arthroplasty
4. total shoulder arthroplasty or glenohumeral
arthrodesis
5. total shoulder arthroplasty or scapulothoracic
arthrodesis

CONFIDENTIAL 47
 PREFERRED RESPONSE

3.- hemiarthroplasty or reverse total

shoulder arthroplasty

CONFIDENTIAL 48
Seebauer Classification
 Discussion
• The radiograph shows superior migration of the humeral head with
significant glenohumeral degenerative joint disease suggestive of rotator
cuff arthropathy. Rotator cuff arthropathy is characterized by bony
erosion, superior migration of the humeral head, and erosion of the
acromion and acromioclavicular joint. The results of total shoulder
arthroplasty performed as management for rotator cuff arthropathy had
been disappointing due to poor function, continued superior migration,
and glenoid component loosening ("rocking horse" phenomenon). Two
better options are humeral head replacement (hemiarthroplasty) or
reverse total shoulder arthroplasty (R-TSA). Hemiarthroplasty was a
popular choice prior to the development of the reverse. Zuckerman et al
showed improved pain scores and mild functional improvements in a
small case series. Leung recently showed better results for the R-TSA than
for hemi in their patients. A hemiarthroplasty may still be preferred if their
is insufficient glenoid bone stock or poorly functioning deltoid which you
cannot rule out based on this single radiograph. Gerber discusses the
development of the R-TSA but notes that it has a significantly higher
complication rate than conventional arthroplasty.

CONFIDENTIAL 50
 Recommended Reading

Hemiarthroplasty for cuff tear arthropathy.

Zuckerman JD, Scott AJ, Gallagher MA
J Shoulder Elbow Surg. 9(3):169-72. PMID: 10888158 (Link to Abstract)
Zuckerman, JSES 2000

Reverse total shoulder arthroplasty.

Gerber C, Pennington SD, Nyffeler RW.
J Am Acad Orthop Surg. 2009 May;17(5):284-95. PMID: 19411640 (Link to Abstract)
Gerber, JAAOS 2009

Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear
arthropathy.
Leung B, Horodyski M, Struk AM, Wright TW
J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. PMID: 21872496 (Link to Abstract)
Leung, JSES 2012

CONFIDENTIAL 51
• In which of the following clinical circumstances would it be appropriate to
eccentrically ream the anterior glenoid?
1. 72-year-old male undergoing a shoulder arthroplasty due to rotator cuff
arthropathy
2. 65-year-old female with a glenoid retroversion of 13-degrees undergoing
shoulder arthroplasty
3. 70-year-old female with humeral anteversion of 13-degrees undergoing
shoulder arthroplasty
4. 65-year-old female with glenoid retroversion of 25-degrees undergoing
shoulder arthroplasty
5. 59-year-old male with significant glenoid bone stock deficiency and
severe osteoarthritis

CONFIDENTIAL 52
 PREFERRED RESPONSE

2. 65-year-old female with a glenoid

retroversion of 13-degrees undergoing
shoulder arthroplasty

CONFIDENTIAL 53
Discussion

CONFIDENTIAL 54
 Discussion
• The surgeon should consider eccentrically reaming the anterior glenoid when performing a total
shoulder arthroplasty on a patient with a retroverted glenoid due to posterior deficiency associated
with osteoarthritic changes which is most consistent with answer choice #2.

• Normal version of the glenoid is 0-3 degrees of retroversion, but when doing a total shoulder the
goal should be to place the glenoid component in neutral to slight anteversion. Reaming the
anterior glenoid to neutral is a technique to be considered by the operative surgeon when
presented with a patient undergoing total shoulder arthroplasty with a retroverted glenoid, as
failure to perform this step increases the chance for glenoid loosening. If reaming down the
anterior glenoid will take away too much bone stock (down to the coracoid process), one may
consider bone grafting the posterior glenoid. To perform a total shoulder arthroplasty patients will
need a functioning rotator cuff and appropriate glenoid bone stock.

• Clavert et al. performed cadaveric analysis to simulate glenoid retroversion of greater than 15
degrees and found that retroversion to this degree cannot be safely corrected with eccentric
anterior reaming when using a glenoid component with peripheral pegs due to penetration into the
glenoid vault.

CONFIDENTIAL 55
 Discussion
• Nowak et al. used 3D-CT models of patients with advanced shoulder osteoarthritis with varying
degrees of glenoid retroversion and simulated glenoid resurfacing. They found that smaller size
glenoid components may allow for greater version correction when using in-line pegged
components, as they would be less likely to result in peg penetration.

• Illustration A shows >25 degrees of glenoid retroversion seen by axial radiograph of the shoulder in
a patient with advanced osteoarthritis. In this case, anterior glenoid reaming is not the correct
answer and a posterior glenoid bone graft reconstruction would be appropriate.

• Incorrect Answers:
• Answer 1: This patient should undergo a reverse total shoulder due to the lack of rotator cuff where
anterior glenoid reaming is not applicable.
• Answers 3: Eccentric reaming is not a useful adjunct when the humerus is anteverted
• Answer 4: Excessive glenoid retroversion requires allograft reconstruction of the posterior defect
instead of anterior glenoid reaming
• Answer 5: Eccentric reaming is contraindicated when bone stock is insufficient to allow it.

CONFIDENTIAL 56
 • RECOMMENDED READINGS

Glenoid resurfacing: what are the limits to asymmetric reaming for posterior erosion?
Clavert P, Millett PJ, Warner JJ
J Shoulder Elbow Surg. 2007 Nov-Dec;16(6):843-8. PMID: 18061118 (Link to Abstract)
Clavert, JSES 2007

Simulation of surgical glenoid resurfacing using three-dimensional computed tomography of the arthritic glenohumeral joint:
the amount of glenoid retroversion that can be corrected.
Nowak DD, Bahu MJ, Gardner TR, Dyrszka MD, Levine WN, Bigliani LU, Ahmad CS
J Shoulder Elbow Surg. 2009 Sep-Oct;18(5):680-8.. PMID: 19487133 (Link to Abstract)
Nowak, JSES 2009

CONFIDENTIAL 57
• A large rotator cuff tear is repaired through 3 trans-osseous
tunnels by a mini-open approach. What is the most
appropriate post-operative therapy protocol?
1. early passive range-of-motion and active range-of-motion
at 6 weeks
2. early active range-of-motion with emphasis on eccentric
exercises
3. active range-of-motion with emphasis isometric exercises
4. early active range-of-motion with emphasis on plyometric
exercises
5. sling immobilization for 12 weeks, followed by delayed
active-assisted range-of-motion

CONFIDENTIAL 58
 PREFERRED RESPONSE

1.- early passive range-of-motion and active

range-of-motion at 6 weeks

CONFIDENTIAL 59
 Discussion
• With repair of a large rotator cuff tear with
tendon-bone tunnels, early passive range of
motion exercises are initiated to prevent
adhesive capsulitis. Active range of motion
exercises should be initiated no earlier than 6
weeks postoperatively.

CONFIDENTIAL 60
• Which of the following structures shares the
same origin site as the tendon that undergoes
angiofibroplastic hyperplasia during the
pathogenesis of tennis elbow?
1. Brachioradialis
2. Anconeus
3. Annular ligament
4. Flexor carpi ulnaris
5. Palmaris longus

CONFIDENTIAL 61
PREFERRED RESPONSE
2.-Anconeus

CONFIDENTIAL 62
 Discussion
• Lateral epidondylitis is classically thought to be caused by
histopathologic angiofibroblastic hyperplasia at the origin
of the extensor carpi radialis brevis. ECRB originates from
the common extensor wad, that also includes ECRL, EDC,
ECU. The anconeus shares the same attachment site at the
lateral epicondyle as the ECRB (as shown in Illustration A).

• The classic Level 4 study by Nirschl reviewed 1,213 patients

with tennis elbow of which 88 elbows underwent surgery.
Immature fibroblastic and vascular infiltration of the origin
of the ECRB was found, excised, and tendon repaired by
Nirschl with an improvement rate of 97%.

CONFIDENTIAL 63
 • RECOMMENDED READINGS

• Tennis elbow. The surgical treatment of lateral epicondylitis.

• Nirschl RP, Pettrone FA.
• J Bone Joint Surg Am. 1979 Sep;61(6A):832-9. PMID: 479229 (Link to Abstract)
• Nirschl, JBJS 1979

CONFIDENTIAL 64
• A patient develops shoulder dysfunction and is
noted to have medial winging of the scapula. If
the EMG shows an abnormality, which nerve is
most likely to be involved?
1. Suprascapular
2. Axillary
3. Long thoracic
4. Thoracodorsal
5. Radial

CONFIDENTIAL 65
 PREFERRED RESPONSE
• Medial scapular winging is usually due to loss of serratus anterior function due to long
thoracic nerve palsy.

• Injury to the long thoracic nerve can occur during repetitive trauma, penetrating trauma,
surgery, prolonged pressure due to positioning, or inflammatory processes. This results in
superior elevation and medial translation of the scapula, with medial rotation of the inferior
pole due to loss of serratus anterior muscle function. The patient will develop pain due to
compensation by other periscapular muscles, with impaired arm elevation. The diagnosis of
long thoracic nerve can be confirmed with EMG, with serial examinations every 3 months to
follow recovery, which occurs in most cases within 1 year depending on etiology. For those
patients with symptomatic serratus winging for longer than 1 year with EMG evidence of
denervation, surgical options such as scapulothoracic fusion, fascial sling suspension, or
muscle transfer can be considered.

• Kuhn et al review different causes of scapular winging. They classify the condition as primary,
secondary, or voluntary. Primary scapular winging may be due to neurologic injury, pathologic
changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging
occurs as a result of glenohumeral and subacromial conditions and resolves after the primary
pathologic condition has been addressed. Voluntary scapular winging is not caused by an
anatomic disorder and may be associated with underlying psychological issues.

CONFIDENTIAL 66
 • RECOMMENDED READINGS

Scapular Winging.
Kuhn JE, Plancher KD, Hawkins RJ.
J Am Acad Orthop Surg. 1995 Nov;3(6):319-325. PMID: 10790670 (Link to Abstract)
Kuhn, JAAOS 1995

CONFIDENTIAL 67
• At the elbow, the anterior bundle of the medial
collateral ligament inserts at which site?

1. Radial tuberosity
2. 3mm distal to the tip of the coronoid
3. Anteromedial process of the coronoid
4. Medial border of the olecranon fossa
5. Radial side of ulna at origin of annular ligament

CONFIDENTIAL 68
 PREFERRED RESPONSE

3.- Anteromedial process of the coronoid

CONFIDENTIAL 69
 Discussion

• The anterior bundle of the medial collateral

ligament of the elbow inserts at the
anteromedial process of the coronoid, also
known as the sublime tubercle. Fractures at this
site have been shown to have worse results with
nonoperative treatment, due to increased rates
of instability and post-traumatic arthrosis.

• The referenced articles by Ring and Steinmann

are great reviews of the topic of coronoid
fractures. They review the diagnosis, treatment
options, rehabilitation, and outcomes of these
injuries. They focus on the importance of the
coronoid in elbow stability, especially with base
fractures, or ones that involve the sublime
tubercle.

• Illustration A depicts the anterior bundle of the

MCL inserting at the sublime tubercle.

CONFIDENTIAL 70
 • RECOMMENDED READINGS

Coronoid process fracture.

Steinmann SP.
J Am Acad Orthop Surg. 2008 Sep;16(9):519-29. PMID: 18768709 (Link to Abstract)
Steinmann, JAAOS 2008

Fractures of the coronoid process of the ulna.

Ring D.
J Hand Surg Am. 2006 Dec;31(10):1679-89. PMID: 17145391 (Link to Abstract)
Ring, JHS 2006

CONFIDENTIAL 71
• A patient presents complaining of right shoulder pain
and weakness following a neck exploration surgery. On
exam, he is noted to have winging of the scapula. His
EMG shows denervation of the trapezius muscle. This
condition is best described as:

1. Lateral winging due to spinal accesory nerve injury

2. Medial winging due to spinal accesory nerve injury
3. Lateral winging due to long thoracic nerve injury
4. Medial winging due to long thoracic nerve injury
5. Scapular dyskinesia due to cervical radiculopathy

CONFIDENTIAL 72
 PREFERRED RESPONSE

1.- Lateral winging due to spinal accesory

nerve injury

CONFIDENTIAL 73
 Discussion
• The clinical presentation is consistent with lateral scapular winging due to iatrogenic injury to the spinal
accessory nerve.

• Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper
extremity. Causes include traumatic, iatrogenic, and idiopathic processes that most often result in nerve
injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Serratus anterior
paralysis, such as from the long thoracic nerve, results in medial winging of the scapula. This is in
contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus
anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius
paralysis is less effective.

• The review by Kuhn et al. classifies scapular winging as primary, secondary, or voluntary. Primary
scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-
tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial
conditions and resolves after the primary pathologic condition has been addressed.

• Romero et al described the Eden-Lange procedure with lateral transfer of the levator scapulae and
rhomboid muscles which can be helpful for lateral winging. They report satisfactory long-term results for
the treatment of isolated paralysis of trapezius, but in the presence of an additional serratus anterior
palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function.

• Levy et al describe a clinical forward elevation lag sign for trapezius palsy with resulting "Triangle sign" in
the prone position which differentiates this from serratus winging.
CONFIDENTIAL 74
 • RECOMMENDED READINGS

The active elevation lag sign and the triangle sign: new clinical signs of trapezius palsy.
Levy O, Relwani JG, Mullett H, Haddo O, Even T.
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):573-6. Epub 2009 May 7. PMID: 19423363 (Link to Abstract)
Levy, JSES 2009

Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure.
Romero J, Gerber C
J Bone Joint Surg Br. 2003 Nov;85(8):1141-5. PMID: 14653596 (Link to Abstract)
Romero, BJJ 2003

Scapular Winging.
Kuhn JE, Plancher KD, Hawkins RJ.
J Am Acad Orthop Surg. 1995 Nov;3(6):319-325. PMID: 10790670 (Link to Abstract)
Kuhn, JAAOS 1995

CONFIDENTIAL 75
During a bench press, when is the pectoralis
major insertion at greatest risk of rupture?
1. Initiation of upward motion
2. Point of maximum elevation
3. During downward deceleration
4. When bar is touching chest
5. No difference in rupture rate is seen

CONFIDENTIAL 76
 PREFERRED RESPONSE

3.- During downward deceleration

CONFIDENTIAL 77
 Discussion
• Pectoralis major (PM) injuries are most commonly seen in young
males, usually athletes involved with heavy lifting or weight
training. Injury most commonly occurs when the weight is taken
down, and eccentric contraction of the PM during the braking
motion prevents the weight from falling down. Diagnosis is often
made clinically, but MRI is the imaging modality of choice to
accurately assess the site and extent of the rupture. The most
common types of injuries of the pectoralis major muscle are the
tendon avulsions at the site of insertion followed by myotendinous
junction tears. Surgical repair provides the best outcomes in patient
satisfaction, strength, cosmesis and return to competitive sports.
Any complete tear of the tendon or myotendinous junction should
be surgically repaired. Non-surgical treatment is only recommended
for elderly, sedentary patients. The referenced article by Petilon et
al reviews these injuries and their treatment.

CONFIDENTIAL 78
 • RECOMMENDED READINGS

Pectoralis major muscle injuries: evaluation and management.

Petilon J, Carr DR, Sekiya JK, Unger DV.
J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):59-68. PMID:
15712983 (Link to Abstract)
Petilon, JAAOS 2005

CONFIDENTIAL 79
• A college baseball pitcher has posterior-
superior and anterior pain in his throwing
shoulder. On exam, he has a 30 degree loss of
internal rotation on the affected side and a
positive O'Brien's test. Radiographs and MRI
are normal. While all of the following may be
helpful, which of the following exercises
should be emphasized most in this patient's
rehabilitation program?
CONFIDENTIAL 80
1. Sleeper stretches, cross-body stretches, periscapular
strengthening
2. Sleeper stretches and subscapularis stengthening
3. External rotation stretches with cuff strengthening
4. External rotation stretches and periscapular
strengthening
5. Altering his arm slot and improving pitching
mechanics

CONFIDENTIAL 81
 PREFERRED RESPONSE

1.-Sleeper stretches, cross-body stretches,

periscapular strengthening

CONFIDENTIAL 82
 Discussion
• The clinical presentation is consistent with GIRD which is treated with aggressive
rehabilitation consisting of posterior capsular and cuff stretching.

• GIRD (glenohumeral internal rotation deficit) is now commonly recognized in

throwing shoulders. Posterior cuff and capsular tightness can cause decreased
internal rotation which may cause pain and is implicated in SLAP and articular-sided
rotator cuff tears. Radiographs and MRI are often normal.
• Kibler et al reviews scapular dyskinesis and its relation to shoulder pain. They
report treatment of scapular dyskinesis is directed at managing underlying causes
and restoring normal scapular muscle activation patterns by kinetic chain-based
rehabilitation protocols.

• Burkhart et al developed the acronym "SICK" to refer to the findings one sees in
this syndrome (Scapular malposition, Inferior medial border prominence, Coracoid
pain and malposition, and dysKinesis of scapular movement). This overuse
muscular fatigue syndrome is yet another cause of shoulder pain in the throwing
athlete.

CONFIDENTIAL 83
 • RECOMMENDED READINGS

Scapular dyskinesis and its relation to shoulder pain.

Kibler WB, McMullen J.
J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51. PMID: 12670140 (Link to Abstract)
Kibler, JAAOS 2003

The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and
rehabilitation.
Burkhart SS, Morgan CD, Kibler WB.
Arthroscopy. 2003 Jul-Aug;19(6):641-61. PMID: 12861203 (Link to Abstract)
Burkhart, ASCOPY 2003

CONFIDENTIAL 84
• Which of the
following is a
primary restraint of
anterior and
posterior humeral
translation at the
position of a
patient's right
shoulder as shown
in Figure A?
CONFIDENTIAL 85
1. Inferior glenohumeral ligament (IGHL)
2. Middle glenohumeral ligament (MGHL)
3. Superior glenohumeral ligament (SGHL)
4. Coracohumeral ligament (CHL)
5. Coracoacromial ligament (CA)

CONFIDENTIAL 86
 PREFERRED RESPONSE

2.- Middle glenohumeral ligament (MGHL)

CONFIDENTIAL 87
 Discussion
• Figure A shows a shoulder in 45 degrees of abduction and 45 degrees of
external rotation. The MGHL restrains anterior and posterior translation in
the midrange of abduction. The CHL limits inferior translation and external
rotation when then arm is adducted and limits posterior translation when
the arm is flexed, adducted, and in internal rotation. The SGHL also
restrains inferior translation and external rotation of the adducted
shoulder. The IGHL has an anterior band that is the primary restraint to
anterior translation at 90 degrees of shoulder abduction. It also has a
posterior band to limit posterior translation. The CA ligament prevents
superior head migration in rotator cuff deficient shoulders.

• The study by Kuhn et al was a cadaveric study of 20 shoulder specimens

mounted in a testing apparatus to simulate the thrower's late-cocking
position. They found that cutting the entire inferior glenohumeral
ligament resulted in the greatest increase in external rotation
(approximately 10 degrees).

CONFIDENTIAL 88
 • RECOMMENDED READINGS

• Ligamentous restraints to external rotation of the humerus in the late-

cocking phase of throwing. A cadaveric biomechanical investigation.
• Kuhn JE, Bey MJ, Huston LJ, Blasier RB, Soslowsky LJ.
• Am J Sports Med. 2000 Mar-Apr;28(2):200-5. PMID: 10750996 (Link to
Abstract)
• Kuhn, AJOSM 2000

CONFIDENTIAL 89
• Which of the following rehabilitation exercises
is most appropriate immediately following the
repair of the injury seen in figure A?

CONFIDENTIAL 90
1. Passive external rotation at 90 degrees of abduction

2. Isotonic rotator cuff strengthening

3. Isokinetic resistive elbow flexion

4. Passive and active assisted flexion in scapular plane

5. Concentric latissimus pull down exercises

CONFIDENTIAL 91
 PREFERRED RESPONSE

4.- Passive and active assisted flexion in

scapular plane

CONFIDENTIAL 92
 Discussion
• Figure A shows a superior labral anterior to posterior (SLAP) tear. Passive and
active-assisted flexion in scapular plane are usually allowed immediately post-
operatively. In general, the early focus is on healing and re-establishing motion,
followed by strength training. Post-operative protocols do vary among surgeons
(some delay active assisted range of motion) as there is no high level evidence
supporting a certain protocol.

• SLAP tears can occur as isolated lesions or associated with other injuries such as:
internal impingement commonly seen in overhead throwers, rotator cuff tears
(usually partial-articular sided), and instability (including micro-instability).

• In a biomechanical cadaver study, Shepard et al. tested if the direction of biceps

anchor loading would result in differences in the ultimate strength of the biceps
anchor and the generation of SLAP lesions. They found that the biceps anchor was
significantly weaker when loaded with a posterior vector, as opposed to an in-line
pull, and concluded that the superior labrum may be most vulnerable to injury in
late cocking.

• Figure A shows a T2 coronal MRI that demonstrates an isolated SLAP tear.

CONFIDENTIAL 93
 Discussion
• Incorrect answers:
• Answer 1- Would place stress on a SLAP repair, and is
usually avoided for about 4 weeks.
• Answer 2- Isotonic shoulder strengthening exercises are
usually initiated around weeks 4-6 (isometrics for muscle
activation may be started earlier).
• Answer 3- Resisted active isokinetic elbow flexion would
place stress on a SLAP repair, and is generally usually
avoided for 6 weeks.
• Answer 5- Concentric latissimus pull down exercises would
generally be avoided as immediate shoulder abduction and
active elbow flexion would place stress at the SLAP repair
site.

CONFIDENTIAL 94
 • RECOMMENDED READINGS

Differences in the ultimate strength of the biceps anchor and the generation of type II superior labral
anterior posterior lesions in a cadaveric model.
Shepard MF, Dugas JR, Zeng N, Andrews JR
Am J Sports Med. 32(5):1197-201. PMID: 15262642 (Link to Abstract)
Shepard, AJOSM 2004

CONFIDENTIAL 95
• During an open reduction internal fixation of a
humerus fracture using the posterior approach, a
surgeon can identify the posterior antebrachial
cutaneous nerve and trace it proximally to which
of the following nerves?
1. Ulnar
2. Musculocutaneous
3. Radial
4. Median
5. Axillary

CONFIDENTIAL 96
PREFERRED RESPONSE

3.-Radial

CONFIDENTIAL 97
Discussion

CONFIDENTIAL 98
 Discussion
• The posterior antebrachial cutaneous nerve (PABCN) branches from the radial nerve in the axilla.

• The posterior antebrachial cutaneous nerve branches from the radial nerve just distal to the
posterior brachial cutaneous nerve (PBCN) in the axilla and they course through the arm in closely to
each other. In the proximal forearm, the posterior antebrachial cutaneous nerve is found on the
lateral border of the brachioradialis muscle. The terminal branches innervate the posterior aspect of
the forearm distally.

• Gerwin et al recommended identifying the lower lateral brachial cutaneous nerve first when
approaching the humerus posteriorly. It can be traced proximally to safely identify the radial nerve
before any proximal exposure of the shaft is done. Gerwin et al in their review also found that the
radial nerve crossed the posterior aspect of the humerus an average of 20.7 +/- 1.2 centimeters
proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle.

• In their review, Zlotolow et al. review the multiple surgical approaches to the humerus.

• Illustration A depicts the course of the PABCN and its relation to the PBCN and the radial nerve

CONFIDENTIAL 99
 • RECOMMENDED READINGS

Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve.
Gerwin M, Hotchkiss RN, Weiland AJ.
J Bone Joint Surg Am. 1996 Nov;78(11):1690-5. PMID: 8934483 (Link to Abstract)
Gerwin, JBJS 1996

Surgical exposures of the humerus.

Zlotolow DA, Catalano LW, Barron OA, Glickel SZ
J Am Acad Orthop Surg. 2006 Dec;14(13):754-65. PMID: 17148623 (Link to Abstract)
Zlotolow, JAAOS 2006

CONFIDENTIAL 100
• On average, the radial nerve travels from the
posterior compartment of the arm and enters the
anterior compartment at which of the following
sites?
1. Spiral groove of the humerus
2. At the arcuate ligament of Osborne
3. 10 cm distal to the lateral acromion
4. 10 cm proximal to radiocapitellar joint
5. At the origin of the deep head of the triceps

CONFIDENTIAL 101
 PREFERRED RESPONSE

4.- 10 cm proximal to radiocapitellar joint

CONFIDENTIAL 102
 Discussion
• The radial nerve enters the anterior compartment
through the intercompartmental fascia on average 10
cm proximal to the radiocapitellar joint. It has never
been found to remain in the posterior compartment
within 7.5cm of this joint, leading to this area being
named the "safe zone". During the posterior approach
to the humerus, the radial nerve is found in the spiral
groove in the middle third of the posterior humerus,
medial to the lateral head and proximal to the deep
head of the triceps. When performing an ORIF of a
humerus fracture from a posterior approach it should
be identified and protected.

CONFIDENTIAL 103
 • Illustration A shows the radial
nerve as seen during the
posterior approach to the
humerus. Illustration B shows
the radial nerve along with a
ruler showing the transition at
10cm proximal to the
radiocapitellar joint.

CONFIDENTIAL 104
 Thanks and Good Luck!

This will be posted at:

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Password: Sooners

The previous years’ shoulder and elbow OITE reviews and ABOS Part 1 review
notes are on there also.

CONFIDENTIAL 105