American Shoulder and Elbow Surgeons
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Figure A shows an arthroscopic picture of a 62-year-old male undergoing repair of a torn subscapularis tendon. In the image shown, G represents the glenoid, H represents the humeral head, and the dotted line represents the superolateral border of the subscapularis tendon. Which two ligaments form the structure marked with the asterisk?
Inferior and middle glenohumeral ligaments
Middle and superior glenohumeral ligaments
Coracohumeral and coracoacromial ligaments
Coracohumeral and superior glenohumeral ligaments
Superior and inferior glenohumeral ligaments
Select Answer to see Preferred Response
The coracohumeral and superior glenohumeral ligaments form a complex that marks the superolateral margin of the subscapularis tendon.
In chronic or degenerative tears, the subscapularis will often retract medially and become scarred to the deltoid fascia. This makes identification difficult during arthroscopic repair. The coracohumeral and superior glenohumeral ligaments form a complex that inserts on the superolateral margin of the subscapularis. This "comma sign" can usually be identified during arthroscopic repair making identification of the subscapularis tendon an easier task.
Burkhart and Brady present surgical pearls for arthroscopic repairs of the subscapularis. Amongst other things, they state the subscapularis is almost always repairable with proper mobilization, but an Achilles tendon allograft or a subcoracoid pectoralis major transfer may be used for a severely degenerated subscapularis.
Lo and Burkhart describe the comma sign for repair of chronic subscapularis tears. They describe how the superior glenohumeral ligament/coracohumeral ligament complex and subscapularis tendon are intimately associated, and often tear off the humerus while remaining attached to each other. This complex, when torn, forms a "comma sign," that marks the superior and lateral margins of the subscapularis tendon.
Illustration A shows why the convergence of the superior glenohumeral and coracohumeral ligaments on the superolateral border of the subscapularis is referred to as the "comma sign."
Answers 1, 2, 3, 5: The superolateral margin of the subscapularis is attached to the coracohumeral and superior glenohumeral ligaments.
Burkhart SS, Brady PC.
Arthroscopy. 2006 Sep;22(9):1014-27. PMID: 16952733 (Link to Abstract)
Lo IK, Burkhart SS.
Arthroscopy. 2003 Mar;19(3):334-7. PMID: 12627163 (Link to Abstract)
Please rate question.
Average 3.0 of 14 Ratings
A 73-year-old right-hand dominant female presents with the right shoulder injury shown in Figure A. She denies having any shoulder pain prior to a fall at work after slipping on some water 4 weeks ago. She smokes a pack of cigarettes per week. Which of the following characteristics of this patient confer the highest risk of not healing the injury following surgical repair?
Pack of cigarette smoking per week
Surgical repair 4 weeks after injury
Worker's compensation case
73 years of age
Patient age older than 65 is the highest risk factor for nonhealing of the surgically repaired rotator cuff.
Relative surgical indications for rotator cuff tears include acute (<3 months from time of injury), traumatic tears in patients younger than age 60 years old. Additionally, full-thickness and partial-thickness rotator cuff tears that fail nonsurgical treatment are relative indications for surgical intervention. Advanced fatty infiltration and muscle atrophy as detected on MRI and significant glenohumeral arthritis are relative contraindications for rotator cuff repair.
Boileau et al. investigated 65 patients with chronic rotator cuff tears. They determined that patients over the age of sixty-five years (p = 0.001) and patients with associated delamination of the subscapularis and/or the infraspinatus (p = 0.02) have significantly lower rates of healing.
Bishop et al. performed a study of 72 patients with rotator cuff tears that either underwent open or arthroscopic rotator cuff repair. They found that arthroscopic and open repairs had similar rates of healing in tears <3cm in size with the arthroscopic group having greater strength of elevation and external rotation. However, they also found that in tears >3cm in size, that open repair conferred better healing rates than arthroscopic repair.
Figure A is an arthroscopic photo of a U-shaped rotator cuff tear as viewed from a lateral portal while in the subacromial space. The rotator cuff tendon is retracted off of the footprint with humeral head articular surface exposed, the glenoid seen in the distance, and the biceps tendon seen along the right edge of the tear. Illustration A shows the same view after a rotator cuff repair using a trans-osseous equivalent suture bridge construct.
Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG
J Bone Joint Surg Am. 2005 Jun;87(6):1229-40. PMID: 15930531 (Link to Abstract)
Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL
J Shoulder Elbow Surg. 2006 May-Jun;15(3):290-9. PMID: 16679227 (Link to Abstract)
Average 2.0 of 27 Ratings
Which of the following statements regarding rotator cuff repair is true?
Bone anchor drilling enhances vascularity following rotator cuff repair
Shoulder motion following rotator cuff repair should be restricted to enhance blood flow to repair site
Double row rotator cuff repairs have better clinical results when compared to single row repairs
Subacromial decompression increases rates of successful rotator cuff repair
Failure to heal the rotator cuff tendon to bone consistently results in poor patient outcomes
Suture anchor drilling into the humeral head has been shown to increase vascularity response during rotator cuff repair.
Rotator cuff tears are seen in all age groups, but primarily occur >40 years of age. Mechanisms can include chronic degenerative tears and acute avulsion injuries. Treatment options can include all-arthroscopic repairs, mini-open rotator cuff repair, and open repairs.
Fealy et al. studied the patterns of vascular and anatomical response after rotator cuff repairs utilizing Power Doppler sonography at 6 weeks, 3 months, and 6 months postoperatively. There was a significant decrease in vascular scores after rotator cuff repair over time. 48% of the patients had a rotator cuff repair defect postoperatively, but these findings did not correlate with functional assessment and outcome at 6 months.
In their study, Cadet et al. utilized contrast-enhanced ultrasound to characterize the vascularity of repaired rotator cuff tendons. Their findings suggested that the peribursal tissue and bone anchor site were the main conduits of blood flow for the rotator cuff tendon. Blood flow of repaired rotator cuff tendons decreased with time, but exercise significantly enhanced blood flow to the repaired rotator cuff.
Illustration A shows an arthroscopic picture of a rotator cuff tear. Illustration B shows the surgeon preparing the greater tuberosity for a suture anchor. Illustration C shows placement of the suture anchor.
Answer 2- Range of motion after rotator cuff tears, including pendulum exercises, are encouraged. They are thought to promote blood flow and prevent post-operative stiffness.
Answer 3- There is no consensus in the current literature to support double-row rotator cuff repairs having better clinical results when compared to single-row repairs.
Answer 4- There is no literature that supports subacromial decompression as a factor that increases rates of successful rotator cuff repair.
Answer 5- Nearly half of all rotator cuff repairs do not successfully heal tendon back to bone. However, this has not been shown to decrease patient outcomes.
Fealy S, Adler RS, Drakos MC, Kelly AM, Allen AA, Cordasco FA, Warren RF, O'Brien SJ
Am J Sports Med. 2006 Jan;34(1):120-7. PMID: 16260468 (Link to Abstract)
Cadet ER, Adler RS, Gallo RA, Gamradt SC, Warren RF, Cordasco FA, Fealy S.
J Shoulder Elbow Surg. 2012 May;21(5):597-603. Epub 2011 Jul 23. PMID: 21783386 (Link to Abstract)
Average 3.0 of 22 Ratings
A 45-year-old patient presents with pain and swelling after undergoing an arthroscopic rotator cuff repair 10 weeks ago. On physical exam the portal sites are healed and there is no drainage. Testing of the integrity of the rotator cuff is limited secondary to pain. He has a WBC of 11.0 (reference range, 3-11 cells/mL), ESR of 40 mm/hr (reference range, 0-22 mm/hr), and CRP of 1.5 mg/dL (reference range, 0-1 mg/dL). An aspiration is completed and no organisms are seen on the gram stain. Twelve days after the aspiration, positive cultures are reported. Which organism is most likely to have grown in culture medium?
Based on the delayed clinical presentation and laboratory findings, the most likely bacterium to have grown in culture is Propionibacterium acnes (P. acnes).
Infections after arthroscopic rotator cuff repairs have a reported prevalence of 0.006%-3.4%. The typical skin flora includes staph and strep as well as P. acnes, which has a propensity for the shoulder. Because it is an anaerobic organism, cultures may only become positive after 7-21 days.
Millett et al. reviewed 10 patients with post-operative shoulder infections and confirmed P. acnes infection. Cultures became positive at an average of 7 days after the start of incubation. They indicate that P. acnes shoulder infections may be insidious in onset and may lead to persistent shoulder pain.
Dodson et al. reviewed 11 patients who sustained P. acnes shoulder infections after undergoing shoulder arthroplasty. They found that cultures became positive at an average of 9 days from the start of incubation. They note that P. acnes shoulder infections are an important cause of implant failure, especially because patents may lack traditional signs of infection (clinical/laboratory).
Saltzman et al. review the microbiology, risk factors and management of infections after shoulder surgery. They indicate that deeper infections are more difficult to identify and can present in an insidious fashion. Cultures should be held for up to 21 days in order to account for fastidious organisms such as P. acnes., for 4 weeks to account for fungal organisms, and for 8 weeks to account for mycobacterium.
Matsen et al. studied the presence of P. acnes on skin and in surgical wounds of patients undergoing revision shoulder arthroplasty. Males were found to have more positive cultures for P.acnes than females; this included superficial and deep cultures. They recommend observing cultures for at least 17 days and being vigilant to minimize potential surgical wound contamination.
Illustration A shows a gram stain of P. acnes, a gram-positive rod. Illustration B shows a scanning electron microscopic view of P. acnes.
Answers 1, 3, 4: While these bacteria are found on the skin are cause post-operative infections, they are less likely to present with an indolent course and prolonged incubation times.
Answer 5: Pseudomonas is a water-borne gram-negative rod that is not typically implicated in infections after shoulder surgery.
Millett PJ, Yen YM, Price CS, Horan MP, van der Meijden OA, Elser F.
Clin Orthop Relat Res. 2011 Oct;469(10):2824-30. Epub 2011 Jan 15. PMID: 21240577 (Link to Abstract)
Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF.
J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. Epub 2009 Nov 1. PMID: 19884021 (Link to Abstract)
Saltzman MD, Marecek GS, Edwards SL, Kalainov DM.
J Am Acad Orthop Surg. 2011 Apr;19(4):208-18. PMID: 21464214 (Link to Abstract)
Matsen FA, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R
J Bone Joint Surg Am. 2013 Dec;95(23):e1811-7. PMID: 24306704 (Link to Abstract)
Average 3.0 of 10 Ratings
The rotator cuff in an overhead throwing athlete is most susceptible to tensile failure due to eccentric loading during which of the phases of throwing shown in Figure A?
Label E is the deceleration phase of throwing in the overhead athlete. During this phase of throwing, the rotator cuff is the principal decelerator of the arm. The rotator cuff is susceptible to tensile failure due to eccentric loading during this phase. In throwers, these tears often occur on the articular side of the posterior supraspinatus or the infraspinatus. They may complain of posterior shoulder pain that is worse after ball release.
Illustration A is labeled to show the names of all of the phases of the overhead throwing cycle.
Average 4.0 of 27 Ratings
A worker's compensation patient is scheduled for rotator cuff repair. His case manager asks you to comment on the expected outcomes of worker's compensation patients. In general, when compared to those of non-worker's compensation patients, the worker's compensation group shows which of the following?
Better functional outcomes and equivalent patient satisfaction
Less functional improvement and lower patient satisfaction
Equivalent functional outcomes and patient satisfaction
Equivalent functional outcomes and lower patient satisfaction
Less functional improvement and equivalent patient satisfaction
In general, worker's compensation patients undergoing shoulder surgery have been shown to have less functional improvement and lower patient satisfaction than non-worker's compensation patients.
Holtby et al looked at workers undergoing rotator cuff repair or subacromial decompression with acromioplasty. Compared to historical controls, they showed that injured workers reported a higher level of disability both before and after surgery. They did still show significant improvement from their baseline at 1-year follow-up, just not to the same level as non-work comp patients.
In a rotator cuff repair study by Misamore et al, of the 24 patients who were receiving worker's compensation, 54% rated themselves as good or excellent, compared with 92% of the patients who were not receiving worker's compensation. Only 42% of the worker's compensation patients returned to full activity, compared with 94% of the non-work comp patients.
Holtby R, Razmjou H
J Shoulder Elbow Surg. 2010 Apr;19(3):452-60. PMID: 19766021 (Link to Abstract)
Misamore GW, Ziegler DW, Rushton JL 2nd.
J Bone Joint Surg Am. 1995 Sep;77(9):1335-9. PMID: 7673282 (Link to Abstract)
Average 2.0 of 17 Ratings
Which patient has the best indication for latissimus dorsi transfer?
55-year-old man with cuff tear arthropathy and proximal humeral migration
85-year-old man with irreparable posterosuperior rotator cuff tear and 60 degrees of forward elevation and 0 degrees of active external rotation at his side
45-year–old man with complete irreparable supraspinatus and subscapularis tears with 90 degrees of active forward elevation
50-year-old man with large irreparable posterosuperior rotator cuff tear with 100 degrees of forward elevation and -10 degrees of external rotation
35-year-old with an acute traumatic complete posterosuperior cuff tear with 0 degrees of active external rotation
The best indication for latissimus dorsi tendon transfer is a younger adult patient with an irreparable posterosuperior rotator cuff tear, lack of advanced glenohumeral arthritis, has an intact subscapularis function to stabilize the humeral head after latissimus transfer, and who maintains some active forward elevation.
Gerber demonstrated that a dysfunctional subscapularis is a relative contraindication as those patients without a subscapularis did poorly. The functional value of subscapularis deficient shoulders valued only 48% clinically while those with intact subscapularis were at 84%.
A biomechanical study by Werner et al also confirmed the importance of the subscapularis. He found that the glenohumeral joint lost stability with a deficient subscapularis and a latissimus transfer.
Answer 1: Cuff tear arthropathy may continue to be painful after a latissimus dorsi transfer.
Answer 2: An elderly patient >80 with a pseudoparalytic shoulder may not regain enough strength from a latissimus dorsi transfer.
Answer 3: A deficient subscapularis has poor results after latissimus transfer likely because of imbalance and instability.
Answer 5: An acute cuff tear in a young patient should have an attempted repair prior to any transfer.
Clin Orthop Relat Res. 1992 Feb;(275):152-60. PMID: 1735206 (Link to Abstract)
Werner CM, Zingg PO, Lie D, Jacob HA, Gerber C.
J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):736-42. PMID: 17126245 (Link to Abstract)
Average 4.0 of 29 Ratings
A 55-year-old carpenter presents with 6 weeks of right shoulder pain after installing ceiling drywall. He has no symptoms of night pain. His examination reveals 30 degrees lack of full flexion and abduction. He has full strength of the right shoulder. Radiographs are shown in Figures A and B. Coronal and Abduction-external rotation (ABER) MR images are shown in Figures C-E. What is the next most appropriate stem in management?
Platelet rich plasma (PRP) injection
Arthroscopic rotator cuff repair
Arthroscopic SLAP repair
Arthroscopic subacromial decompression
The history, examination, and imaging are consistent with a partial articular-sided supraspinatus tendon avulsion (PASTA). Physical therapy including shoulder range of motion and rotator cuff/periscapular stabilizer strengthening is the most appropriate initial treatment for the options provided.
Partial-thickness rotator cuff tears are most commonly classified by location (articular- or bursal-sided) and size (greater or less than 50% thickness). If conservative treatment options fail, then partial-thickness, articular-sided rotator cuff tears >50% can be treated with completion and repair (open or arthroscopic). If the tear is <50% then treatment consists of débridement of the tuberosity and undersurface rotator cuff. Repair of the tendon in situ (ie, partial articular supraspinatus tendon avulsion [PASTA] repair) is possible when remaining attached tissue is healthy. There are several studies that describe the anatomy of the supraspinatus footprint with an average maximum insertional length and width of 23 x 16 mm. The ABER position for MRI reduces the effacement of its articular surface on the humeral head. This reduced tension allows intra-articular contrast to flow into the defect and increases the sensitivity of detecting partial-thickness tears.
Sher et al performed MR examinations of 94 subjects with asymptomatic shoulders. When including both partial and full-thickness tears, they found the overall prevalence in all age-groups was 34%, and that this increased with patient age. Over 50% of the patients older than 60 years old and 28% of patients 40-60 years old had evidence of a rotator cuff tear. Only 4% of the patients aged 19-39 had a rotator cuff tear.
Illustration A depicts a PASTA lesion of the supraspinatus of a left shoulder as viewed from a posterior portal in the lateral decubitus position. Video A demonstrates a partial articular-sided supraspinatus tendon avulsion (PASTA) undergoing side-to-side repair.
Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB.
J Bone Joint Surg Am. 1995 Jan;77(1):10-5. PMID: 7822341 (Link to Abstract)
Average 3.0 of 23 Ratings
Rotator cuff tears (full thickness and partial thickness) in asymptomatic individuals are seen on MRI or ultrasound in what percentage of patients over the age of 60?
The prevalence of asymptomatic rotator cuff tears diagnosed with MRI or ultrasound is quite high, with most studies noting tears in 30-54% of patients over the age of 60. The paper by Tempelhof et al utilized ultrasound and found tears in 30% of patients over 60. The study by Sher et al noted an overall prevalence of 54% on MRI in patients older than 60 (28% had full thickness and 26% with partial thickness). In both studies the frequency of tears increased substantially with increasing age.
Tempelhof S, Rupp S, Seil R.
J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):296-9. PMID: 10471998 (Link to Abstract)
Average 3.0 of 27 Ratings
A 64-year-old male suffers a fall while working on his farm and presents to the ER with the shoulder injury noted in Figure A. He undergoes reduction without complications, and post-reduction radiographs are shown in Figures B and C. At his 10 day clinic follow-up is noted to have an inability to abduct his arm. Which of the following studies will best confirm the most likely diagnosis in this patient?
MRI of the shoulder
CT-angiogram of the affected extremity
Repeat shoulder x-rays
MRI of the brachial plexus
This patient is most likley suffering from a massive rotator cuff tear which is accounting for his inability to raise his arm. The incidence of rotator cuff tear after acute dislocation in patients older than age 40 ranges from 35% to 86%. However, the incidence of rotator cuff pathology before the initial dislocation is not known. Axillary nerve injury can happen after acute shoulder dislocations, but usually are not severe enough to account for the significant weakness noted in this patient. Brachial plexus injuries are rare, and vascular injuries are associated with ischemic changes to the affected extremity. Shoulder fracture is unlikley in this case as the post-reduction radiographs show no bony injury. Stayner et al discuss the associated injuries, complications, and potential urgencies in diagnosis and treatment protocols of shoulder dislocations in the patient older than age 40. Simank et al documented the incidence of additional injuries in shoulder dislocations and compared the results of conservative to operative therapy for rotator cuff tears. In 54% of the patients enrolled a cuff tear was documented; the frequency increased with advancing age to 100% in patients over the age of 70. Symptomatic cuff tears did better with surgery than non-operative management.
Stayner LR, Cummings J, Andersen J, Jobe CM.
Orthop Clin North Am. 2000 Apr;31(2):231-9. PMID: 10736392 (Link to Abstract)
Simank HG, Dauer G, Schneider S, Loew M.
Arch Orthop Trauma Surg. 2006 May;126(4):235-40. Epub 2005 Sep 8. PMID: 16151824 (Link to Abstract)
Average 3.0 of 35 Ratings
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?
Debride the tear and perform an acromioplasty
Abort surgery and start a physical therapy program
Convert it to a full-thickness tear and repair it with suture anchors
Consider it incidental, as this is a common finding in this age group
Perform acromioplasty only
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.
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)
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)
Average 3.0 of 30 Ratings
What is the average medial-to-lateral distance of the supraspinatus tendon insertion at its footprint on the greater tuberosity?
Cadaveric studies have shown the average medial-to-lateral distance of the supraspinatus tendon footprint on the greater tuberosity is 14-16mm.
Curtis et al dissected 20 fresh-frozen cadavers in order to identify the length and width of each rotator cuff muscle insertion on the humerus. They found that the average maximum insertional length (anterior to posterior distance, distance Y in Illustration A) and width (medial to lateral distance, distance X in Illustration A) of the supraspinatus insertion was 23 x 16mm respectively.
Dugas et al dissected 20 cadaveric specimens to determine an accurate and reproducible method of measuring the area and dimensions of the rotator cuff tendon insertions and their distance from the articular surface. They found that the mean minimum medial-to-lateral distance across the rotator cuff insertion occurred at the mid-portion of the supraspinatous, and measured 14.7mm. They also determined that area of insertion of the 3 tendons on the greater tuberosity averaged 6.24 cm2, and that the rotator cuff inserts very closely to the articular margin along the anterior 2.1cm of the greater tuberosity.
Dugas JR, Campbell DA, Warren RF, Robie BH, Millett PJ.
J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):498-503. PMID: 12378171 (Link to Abstract)
Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR.
Arthroscopy. 2006 Jun;22(6):609.e1. PMID: 16762697 (Link to Abstract)
Average 2.0 of 43 Ratings
A 50-year-old man sustains a left shoulder injury after falling from a motorcycle. A physical examination test to examine for this shoulder injury is found in Figure A. What is the most likely diagnosis?
Teres minor tear
The concept tested in this question is whether you know what physical exam finding is associated with a subscapularis tear.
The key physical exam findings are positive Belly-press and Lift-off maneuvers, as well as weakness in internal rotation and increased passive external rotation. The MRI confirms the diagnosis with discontinuity of the subscapularis and the long-head of the biceps not located in the bicipital groove.
Sanders and Miller present a Level 5 review article detailing the correlation between MR images and clinic examinations for shoulder pathology. Part 2 of their 2-part series is also a valuable resource and discusses pathology of the knee.
Tennent et al. present a Level 5 review article discussing the key physical examination pearl for testing the rotator cuff. Part 2 of 2-part series discusses instability and SLAP lesion tests.
Figure A depicts an abnormal belly-press examination whereby the wrist flexes, and the elbow will fall posteriorly as the patient recruits the posterior deltoid to compensate for lack of the subscapularis. Illustration A demonstrates a normal belly-press examination. Illustration B demonstrates a subscapularis tear and associated long head of the biceps dislocation.
Sanders TG, Miller MD.
Am J Sports Med. 2005 Jul;33(7):1088-105. PMID: 15983127 (Link to Abstract)
Tennent TD, Beach WR, Meyers JF.
Am J Sports Med. 2003 Jan-Feb;31(1):154-60. PMID: 12531773 (Link to Abstract)
Average 4.0 of 15 Ratings
During diagnostic arthroscopic evaluation of a patient's shoulder, you identify a thickened portion of the coracohumeral ligament, near its avascular zone, running perpendicular to the supraspinatous tendon. The structure is identified in Figure A with black arrows. What is the name for this structure?
Middle glenohumeral ligament
The black arrows in Figure A identify the rotator cable, while the asterisk identifies the rotator crescent.
The rotator crescent and rotator cable are two anatomic structures closely associated with the rotator cuff that form the shoulder's "suspension bridge." The rotator crescent is a thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions. The crescent is bounded at its proximal margin by a thick bundle of fibers called the rotator cable, and thickened portion of supraspinatus. This cable-crescent spans the insertions of supraspinatus and infraspinatus tendons. The rotator cable is over 2.5 times thicker than the rotator crescent as measured by digital micrometer.
Clark and Harryman describe the complex anatomy of the rotator cuff including the "suspension bridge" of the rotator cuff and crescent in their anatomical sectioning of 32 grossly intact cuffs.
Burkhart and Lo review the anatomy, biomechanics, surgical techniques, and outcomes of the arthroscopic rotator cuff repair. They emphasize that achieving a biomechanically stable construct is critical to biologic healing, and discuss the different variables to obtain such a construct.
Illustration A shows an arthroscopic photo annotated with the rotator cable (arrows), rotator crescent (asterisk), biceps tendon (BT), and humeral head (HH). Illustration B illustrates the relationship between the rotator crescent (CRES) and rotator cable (Label C). Illustration C shows a coronal cut of the supraspinatus, and how a thickened portion contributes to the rotator cable.
1) Middle glenohumeral ligament - anterior shoulder capsular thickening which provides resistance to anterior translation with the arm in 45 degrees of abduction
2) Rotator interval - the "space" between the anterior leading edge of the supraspinatus tendon and the superior border of the subscapularis tendons.
3) Coracoid process - the "light-house" of the shoulder, a bone projection off the anterior portion of the scapula, just medial to the glenoid.
5) Rotator crescent - thin sheet of rotator cuff comprising the distal portion of the supraspinatus and infraspinatus tendon insertions.
Clark JM, Harryman DT 2nd.
J Bone Joint Surg Am. 1992 Jun;74(5):713-25. PMID: 1624486 (Link to Abstract)
Burkhart SS, Lo IK
J Am Acad Orthop Surg. 2006 Jun;14(6):333-46. PMID: 16757673 (Link to Abstract)
A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?
Nonsynergistic action of the transferred muscle
Fatty atrophy of the supraspinatus and infraspinatus
Deficiency of the subscapularis
Absence of the coracoacromial ligament
A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer. The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.
Warner JJ, Parsons IM 4th.
J Shoulder Elbow Surg. 2001 Nov-Dec;10(6):514-21. PMID: 11743528 (Link to Abstract)
Iannotti JP, Hennigan S, Herzog R, Kella S, Kelley M, Leggin B, Williams GR
J Bone Joint Surg Am. 2006 Feb;88(2):342-8. PMID: 16452746 (Link to Abstract)
Average 1.0 of 79 Ratings
Which of the following may be seen during arthroscopy in a patient with a subscapularis tear?
Uncovered lesser tuberosity
Retraction of the subscapularis tendon to the level of the glenoid
Avulsed superior glenohumeral ligament
Medial biceps subluxation
All of the above
Degenerative subscapularis tears often involve only the superior portions of the tendon. However, completely retracted tears also occur especially those occuring after trauma or previous surgery. All of the findings mentioned may be encountered.
The superior glenohumeral ligament(SGHL)/coracohumeral ligament(CHL) complex may show a partial tear which has been called the "comma sign" by Lo and Burkhart.
The David et al. reference describes an arthroscopic technique to improve visualization of subscapularis pathology.
Illustration A shows an arthroscopic image with a retracted subscapularis tear and a superimposed comma present (H = humerus, G = glenoid, SSc = subscapularis tendon, M = medial sling of the biceps formed by the SGHL and the medial aspect of the CHL).
David TS, Bravo H, Scobercea R.
Orthopedics. 2009 Sep;32(9):. PMID: 19751026 (Link to Abstract)
Average 4.0 of 21 Ratings
Which of the following patients is the optimal candidate for a latissimus dorsi transfer?
36-year-old laborer with massive rotator cuff tear and associated supraspinatus atrophy
67-year-old non-laborer with rotator cuff tear arthropathy and pseudoparalysis
34-year-old laborer with massive rotator cuff tear and thoracodorsal nerve palsy
63-year-old with supraspinatus rotator cuff tear and subacromial impingement
37-year-old non-laborer with extensive chondrolysis following a rotator cuff repair and indwelling pain catheter placement for postoperative pain
The most appropriate candidate for a latissimus transfer is the young laborer with a massive rotator cuff tear and atrophy of the supraspinatus fossa.
In 1988, Gerber et al described the technique of latissimus dorsi tendon transfer as a reconstructive option for irreparable posterosuperior rotator cuff defects. This procedure is predicated on restoring an active external rotation and flexion moment at the glenohumeral joint, as these motions constitute the primary functional deficits for this configuration of massive cuff tear.
Miniaci and Mcleod present Level 4 evidence of 17 patients who underwent latissimus dorsi tendon transfer after failed repair of a massive tear of the rotator cuff and found significant relief of pain (p<0.0001) and a significant improvement in function (p<0.001 for all activities except lifting more than fifteen pounds).
Warner and Parsons present Level 3 evidence of 16 patients who underwent latissimus dorsi transfer as a salvage procedure compared to 6 patients who had transfer as a primary procedure. They concluded that salvage reconstruction of failed prior rotator cuff repairs yields more limited gains in satisfaction and function than primary latissimus dorsi transfer.
Miniaci A, MacLeod M.
J Bone Joint Surg Am. 1999 Aug;81(8):1120-7. PMID: 10466644 (Link to Abstract)
Gerber C, Vinh TS, Hertel R, Hess CW.
Clin Orthop Relat Res. 1988 Jul;(232):51-61. PMID: 3383502 (Link to Abstract)
Average 4.0 of 17 Ratings
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?
early passive range-of-motion and active range-of-motion at 6 weeks
early active range-of-motion with emphasis on eccentric exercises
early active range-of-motion with emphasis isometric exercises
early active range-of-motion with emphasis on plyometric execises
sling immobilization for 12 weeks, followed by delayed active-assisted range-of-motion
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.
Craig et al. looked at open versus mini-open repairs for full thickness tears. They found that mini-open approaches lead to smaller incisions, a less involved recovery, and allows an intra-articular evaluation and management of pathology within the glenohumeral joint with the arthroscope that is used in the beginning of the case.
A 50-year-old recreational league baseball pitcher reports that 3 months ago he started having right shoulder pain after every game he had pitched. One month ago he injured his shoulder further when he fell off of a ladder. He has attempted to participate in a shoulder rehabilitation program but could not return to pitching secondary to pain and weakness. Figure A demonstrates an arthroscopic image taken from a lateral portal in the subacromial space (HH= humeral head, LHB= long head of the biceps) while in the beach-chair position. What is the injury pattern sustained as highlighted by the injured structure labeled with the asterisk in Figure A?
Humeral avulsion of the glenohumeral ligament (HAGL lesion)
Superior labrum anterior-posterior (SLAP) tear
Rotator cuff tendon tear
Anterior-inferior capsulolabral lesion (Bankart lesion)
Anterior labral periosteal sleeve avulsion (ALPSA lesion)
The arthroscopic camera is said to be positioned in a lateral subacromial portal in the beachchair position, however the intra-articular structures are visualized indicating a rotator cuff (asterisk) tear with retraction. Illustration A depicts an arthroscopic soft tissue grasper pulling the rotator cuff back over the humeral head. Full thickness rotator cuff tears need to be repaired (not debrided) in the throwing athlete. The rotator cuff is the primary dynamic stabilizer of the glenohumeral joint and is placed under significant stress during overhead and contact sports. Mechanisms of injury include repetitive microtrauma, usually seen in the athlete involved in overhead sports, and macrotrauma associated with contact sports. Rotator cuff injury and dysfunction in the overhead athlete may be classified based on etiology as primary impingement, primary tensile overload, and secondary impingement and tensile overload resulting from glenohumeral instability.
The 4-part series of articles by Burkhart et al published in Arthroscopy is an excellent overview of the biomechanics, pathoanatomy, kinetic chain considerations, surgical treatment, and rehabilitation of the throwing athlete. The article by Blevins is a Level 5 review of rotator cuff pathology in athletes participating in contact and/or throwing sports.
Burkhart SS, Morgan CD, Kibler WB.
Arthroscopy. 2003 Apr;19(4):404-20. PMID: 12671624 (Link to Abstract)
Sports Med. 1997 Sep;24(3):205-20. PMID: 9327536 (Link to Abstract)
Average 3.0 of 33 Ratings
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?
Rotator cuff repair
Proximal humerus ORIF
Total shoulder arthroplasty
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.
Jensen et al review the pathogenesis of rotator cuff arthropathy which they define as the end point in the continuum of severe degenerative changes in the glenohumeral joint.
Clin Orthop Relat Res. 1984 Dec;(191):213-5. PMID: 6499313 (Link to Abstract)
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)
Average 4.0 of 16 Ratings
A 34-year-old carpenter has left shoulder pain for the past 3 months following a fall from a ladder. Figure A displays a coronal T2 MR image. Which of the following diagnoses most appropriately describes this patient's lesion?
Anterior labral periosteal sleeve avulsion (ALPSA)
Partial articular surface tendon avulsion (PASTA)
Humeral avulsion of the glenohumeral ligament (HAGL)
Superior labral anterior to posterior tear (SLAP)
Glenolabral articular disruption (GLAD) lesion
The MR image shown in Figure A demonstrates a partial articular surface tendon avulsion (PASTA) lesion of the supraspinatus. PASTA lesions can be difficult to diagnose and intra-articular contrast can help to delineate the pathology as seen in Illustration A. Disrupted anterior scapular periosteum differentiates a Bankart lesion from its variants where periosteum remains intact. An ALPSA lesion (Illustration B) is where the labral-ligamentous complex is displaced medially and shifted inferiorly, rolling up on itself underneath intact periosteum. A GLAD lesion (Illustration C) is a tear of the anterior inferior labrum (nondisplaced) with avulsion of the adjacent glenoid cartilage. A HAGL lesion (Illustration D) is where the inferior glenohumeral ligament avulses from the inferior humeral neck. Superior labral tears anterior to posterior to the biceps root are known as SLAP tears (Illustration E) .
Gartsman et al provide Level 4 evidence of 85 shoulders taken to the OR for impingement symptoms and found a partial tear of the rotator cuff. These shoulders were treated with debridement of the tear and arthroscopic subacromial decompression and had greater than 80% success rate.
The study by Snyder et al reviews 31 patients with partial thickness rotator cuff tears that were treated by arthroscopic debridement of the lesion. They concluded that 84% of the patients had satisfactory results.
Gartsman GM, Milne JC.
J Shoulder Elbow Surg. 1995 Nov-Dec;4(6):409-15. PMID: 8665284 (Link to Abstract)
Snyder SJ, Pachelli AF, Del Pizzo W, Friedman MJ, Ferkel RD, Pattee G.
Arthroscopy. 1991;7(1):1-7. PMID: 2009105 (Link to Abstract)
Average 4.0 of 40 Ratings
Resection of the coracoacromial ligament during shoulder arthroscopy results in which of the following?
Increased glenohumeral joint translation
Increased passive shoulder internal rotation
Increased axillary recess volume
Decreased acromioclavicular joint reactive forces
Decreased resting tension in the long head of the biceps
The CA ligament provides a suspension function and restrains anterior and inferior translation through an interaction with the coracohumeral ligament. Resection of the coracoacromial ligament results in increased glenohumeral joint translation.
Lee et al, in a cadaveric study, showed that at 0 degrees and 30 degrees of abduction, release of the coracoacromial (CA) ligament resulted in a significant increase in glenohumeral joint translations, in both the anterior and inferior directions. The authors state that caution should be exercised in the release of the coracoacromial ligament in those with rotator cuff pain associated with glenohumeral instability. This is especially crucial in patients who may later undergo shoulder arthroplasty, as anterior escape leads to significantly worse clinical outcomes.
Illustration A shows the anatomy of the region, including the CA ligament. Illustration B is a radiograph showing anterosuperior escape after CA ligament resection.
Lee TQ, Black AD, Tibone JE, McMahon PJ.
J Shoulder Elbow Surg. 2001 Jan-Feb;10(1):68-72. PMID: 11182739 (Link to Abstract)
Average 4.0 of 24 Ratings
HPI - Patient was operated in Feb 2014 for supraspinatus tear right shoulder arthoscopically.Sympotms improved after surgery .At about 3 weeks post op patient developed sudden pain following physiotherapy which subsided after rest for few days.Three months after surgery patient developed severe sudden pain in right shoulder which progressively increased and was also present on rest.
Patient had no fever .
ESR was 50 and crp was negative ,counts were normal
Repeat MRI ON 26 JUNE 14 showed tear of supraspinatus infraspinatus and subscapularis along with signal changes at greater tuberosity.
After course of iv antibiotics symptoms subsided and pain releif was about 70%. After shifting to oral antibiotics pain also increased after about one week .At present pain is about 50%better and movements have slightly improved .
Serial xrays show increasing erosion around greater tuberosity
What is the diagnosis of this post operative complication
HPI - 43 yr old male with shoulder pain. Hx of cuff repair 4 years ago.
HPI - 45 yr old female with hx of shoulder pain had mini open cuff repair (anterior subscap / supra as per op note) 7 months ago by another surgeon.
What are her current options?
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