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Complex shoulder disorders: evaluation and treatment.

Evaluation of patients with shoulder disorders often presents challenges. Among the most troublesome are revision surgery in patients with massive rotator cuff tear, atraumatic shoulder instability, revision arthroscopic stabilization surgery, adhesive capsulitis, and bicipital and subscapularis injuries. Determining functional status is critical before considering surgical options in the patient with massive rotator cuff tear. When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice. Arthroscopic revision of failed arthroscopic shoulder stabilization procedures may be undertaken when bone and tissue quality are good. Arthroscopic release is indicated when idiopathic adhesive capsulitis does not respond to nonsurgical treatment; however, results of both nonsurgical and surgical treatment of posttraumatic and postoperative adhesive capsulitis are often disappointing. Patients not motivated to perform the necessary postoperative therapy following subscapularis repair are best treated with arthroscopic débridement and biceps tenotomy.

2009 poster winners announced

This year, 567 posters were accepted for display during the Annual Meeting. Yesterday, the best of the posters were announced during the Breakfast in the Posters event. Posters determined to be among the best in their category were chosen by the relevant program subcommittees, and the final selections were made by members of the Program Committee. Following is the list of winning posters and their authors.

Overall winner—Spine

P378: The incidence of C5 palsy after multilevel cervical decompression procedures: A review of 750 consecutive cases

A Pat on the Back

CAPT Dana C. Covey, MD, chair of orthopaedic surgery at Naval Medical Center in San Diego, who received the first COL Brian Allgood, MD, Military Orthopaedic Leadership Award presented by the Society of Military Orthopaedic Surgeons John P. Dormans, MD, chief of orthopaedic surgery at The Children’s Hospital of Philadelphia, who will receive the Humanitarian Scientific Achievement Award from the MHE (Multiple Hereditary Exostoses) Research Foundation Gregory Brown, MD, PhD, a member of the AAOS Biomedical Engineering Committee, will be the 2009 recipient of the ASTM Joseph Barr Award, one of the highest awards conferred by Committee F04 on physician members, acknowledging his contributions to the development of medical device and materials standards Winners of the AAOS 2009 Annual Meeting Scientific Exhibit Awards of Excellence: J. Dennis Bobyn, PhD; Michael Tanzer, MD; Dorota Karabasz, RN; and Jan J. Krygier, CET (SE33: Locally Delivered Bisphosphonate for Enhancement of Bone Formation and Implant Fixation); Richard M. Dell, MD; David V. Anderson, MD; Denise Greene, RNP; Kathy Williams, MSG (SE66: Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know); and Dawn LaPorte, MD; Michael A. Mont, MD; David R. Marker, BS; Mike S. McGrath, MD; Slif D. Ulrich, MD; and Thorsten M. Seyler, MD (SE50, Orthopaedic Journal Publications and Their Role in the Preparation for the OITE) Winners of the AAOS 2009 Annual Meeting Best in Poster Category: Overall winner—Spine (P378) Ahmad N. Nassr, MD; Jason C. Eck, DO, MS; Ravi K. Ponnappan, MD; Rami R. Zanoun, BS; William F. Donaldson III, MD; James Kang, MD; Adult Reconstruction Hip—(P078) Seoug Yong Lee, MD; Barry J. Waldman, MD; Esther A. Schaftel, RNFA; Adult Reconstruction Knee—(P121) Eun Kyoo Song, MD; Jong-Keun Seon, MD; Sang Jin Park, MD; Young-Jin Kim, MD; Chang-Ich Hur, MD; Min-Sun Choi, MD; Sung Taek Jung, MD; Foot and Ankle—(P219) Matthew DiSilvestro, MD; Fabian Krause, MD; Mark Glazebrook, FRCSC; Murray J. Penner, MD; Alastair S. E. Younger, MD; Kevin J. Wing, MD; Hand and Wrist—(P240) Jonas L. Matzon, MD; Roger Cornwall, MD; Pediatrics—(P247) Alexandre Arkader, MD; Gökce Mik, MD; Alexander Manteghi, BS; John P. Dormans, MD; Practice Management/Rehabilitation—(P273) William C. Schroer, MD; Paul Diesfeld, PA-C; Mary E. Reedy, RN; Angela LeMarr, RN; Shoulder and Elbow—(P313) Nobuyuki Yamamoto, MD; Takayuki Muraki, PhD; Kai-Nan An, PhD; John W. Sperling, MD, MBA; Eiji Itoi, MD; Robert H. Cofield, MD; Gilles Walch, MD; Scott P. Steinmann, MD; Sports Medicine and Arthroscopy—(P451) John M. Tokish, MD; Colleen M. McBratney, MD; Daniel J. Solomon, MD; Lance E. LeClere, MD; Matthew T. Provencher, MD; Trauma—(P465) Keith D. Baldwin, MD; Surena Namdari, MD, MS; John L. Esterhai Jr., MD; Samir Mehta, MD; Tumor and Metabolic Disease—(P539) Ljiljana Bogunovic, BA; Lisa Shindle, NP; Brandon S. Beamer, BA; Nakul Karkare, MD; Abraham Kim, BA; Joseph Nguyen, MPH; Joseph M. Lane, MD

HOT TOPIC: Latarjet-Patte Procedure for the Treatment of Recurrent Anterior Instability of the Shoulder

The Latarjet procedure involves a transfer of the coracoid process to the medial glenoid via a slit in the subscapularis muscle. This increases the anterior-posterior diameter of the glenoid fossa and makes it more difficult for the humeral head to subluxate or dislocate. In addition, the conjoined tendon acts as a stabilizer with the arm abducted and externally rotated. In this video, I describe my preferred technique for this procedure. With proper patient selection and systematic surgical technique, instability can be eliminated without loss of external rotation in more than 98% of patients.

Arthroscopic Capsular Release of the Glenohumeral Joint

Dr. Murthi performs an arthroscopic capsular release of the glenohumeral joint on a 55-year-old, right-hand-dominant female with a year-long history of left shoulder pain and stiffness. A long period of nonsurgical treatment, including corticosteroid injections and physical therapy, has failed to produce range-of-motion improvement. Prior to surgery, the patient exhibits a forward elevation of approximately 70 degrees;, roughly 45 degrees of abduction, 5 degrees to 10 degrees of external rotation, and, within the limited amount of abduction, only 5 degrees of rotation in each plane. The goal of the arthroscopic procedure is to release the thickened and contracted capsular tissues surrounding the glenohumeral joint so as to improve the patient's range of motion. In a demonstration of his surgical approach, Dr. Murthi shows how to mark the shoulder for arthroscopic portal placement and complete the anterior and posterior capsular releases. Upon completion of the arthroscopy, Dr. Murthi examines the patient's range of motion, revealing the successful outcomes of the surgery: full elevation of the shoulder to 170degrees, external rotation of 80 degrees to 90 degrees, and greater than 90 degrees of abduction. Postsurgical therapy includes an interscalene block plus a combination of anti-inflammatory medications, ice machines to reduce swelling, and range-of-motion therapy.

Adhesive Capsulitis: Current Concepts

Adhesive capsulitis, commonly known as "frozen shoulder," affects from 2% to 5% of the general population, causing global loss of motion of the shoulder. Although the precise pathobiology of adhesive capsulitis remains unknown, this disease is marked by contraction of the shoulder capsule and an abundance of fibroblasts and myofibroblasts within the collagen matrix, accompanied by synovitis, inflammation, and pain. It can occur idiopathically, postoperatively, or following trauma. Diagnosis is based on a presentation of pain with absent or limited shoulder mobility. Although radiography fails to show any pathology, MRI reveals a reduced capsular volume, a small or absent inferior pouch, and thickened ligaments, especially in the rotator interval. The mainstay of treatment for adhesive capsulitis has been physical therapy with or without intra-articular injection of corticosteroids. However, manipulation can damage the shoulder and is unlikely to release adhesion of the rotator interval. Arthroscopic capsular release is a safe and reliable treatment option for recalcitrant adhesive capsulitis. The additional use of continuous regional anesthesia for up to 72 hours after arthroscopic surgery is a safe and reliable addition to this already proven technique, allowing patients to begin physical therapy without pain.

Recurrent Anterior Shoulder Instability with Glenoid Bone Deficiency

Shoulder instability secondary to bony glenoid deficiency is increasingly being recognized as a common cause for recurrence and poor outcomes. Glenoid bone deficiency may result from acute trauma to the anterior glenoid rim or from repeated contact with the humeral head during subsequent dislocation episodes. If glenoid bone loss is suspected in a patient with recurrent shoulder instability, a careful preoperative evaluation including history, physical examination, imaging studies, and arthroscopic assessment is necessary to accurately diagnose and quantify the extent of the deficiency. Treatment is guided by the amount of bone loss and patient factors such as activity level, expectations, and level of sports participation. In general, nonsurgical treatment—which consists of immobilization followed by progressive range-of-motion exercises and shoulder strengthening—is best suited for low-demand patients, patients with significant comorbidities, or those with smaller defects (<15% of glenoid surface area). Arthroscopic or open capsulolabral repair is recommended for patients with less than 15% glenoid bone loss. For patients with anterior glenoid bone loss between 15% and 25%, a variety of treatments are available, including both open and arthroscopic soft-tissue reconstruction and open bone-block procedures (Latarjet or Bristow procedure). As anteroinferior glenoid deficiency approaches 25% to 30% or more, open glenoid reconstruction with bony augmentation is required to restore stability.

Bone Defects in Shoulder Instability

Shoulder instability is a pathologic increase in translation of the humeral head on the glenoid fossa during shoulder range of motion, resulting in symptoms. In recurrent anterior shoulder instability, the underlying pathology typically involves compromise of the capsulolabral attachment of the inferior glenohumeral ligament. However, bone loss from either the glenoid rim or posterolateral humeral head can also occur, which can adversely affect traditional treatment. Even in the hands of experts, an unrecognized or neglected bony defect is the primary reason for failure after arthroscopic management of shoulder instability. Anatomic glenoid reconstruction with autogenous tricortical iliac crest bone graft is warranted when there is greater than 30% loss of inferior glenoid length. Latarjet reconstruction (coracoid transfer) is indicated for bone loss that involves 25% to 30% of inferior glenoid length, especially after failed stabilization, or for humeral Hill-Sachs lesions that engage the anterior glenoid rim when the arm is in a position of abduction and external rotation. Arthroscopic repair can be performed for patients with small osseous lesions (less than 20% bone loss).