American Shoulder and Elbow Surgeons
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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Following open pectoralis major transfer to address chronic subscapularis insufficiency, which of the following movements would most likely show weakness if an iatrogenic nerve injury occurred during the pectoralis transfer?
Shoulder external rotation
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During open pectoralis major tendon transfer for chronic subscapularis deficiency, the musculocutaneous nerve is most at risk. Injury to this nerve would lead to weakness in elbow flexion.
Musculocutaneous nerve neurapraxia is a known complication of the procedure caused by increased tension on the nerve. The transferred tendon should be placed deep to the conjoint tendon, but superficial to the nerve to decrease tension. A proximal musculocutaneous nerve neurapraxia could cause weakness in elbow flexion, due to its innervation of the biceps and brachialis muscles.
Klepps et al. performed a cadaveric study to examine the surgically relevant anatomy of subcoracoid pectoralis transfer. Transfer of the pectoralis major superficial to the musculocutaneous nerve created less tension than transfer deep to the musculocutaneous nerve. They concluded release of the proximal musculocutaneous branches, or debulking of the pectoralis major muscle belly may be required in some instances to prevent tension on the musculocutaneous nerve.
Jost et al. found that in cases of irreparable subscapularis muscle function, pectoralis major transfer resulted in improvement for patients if they had an associated reparable supraspinatus tear. Patients with irreparable tears of both the subscapularis and supraspinatus had less favorable results.
Illustration A shows a figure of pectoralis transfer for subscapularis insufficiency. The transferred tendon is placed deep to the conjoint tendon, but superficial to the musculocutaneous nerve to decrease tension.
Answer 2: Elbow extension (triceps) is from radial nerve.
Answer 3: Shoulder external rotation (infraspinatus, teres minor) is from the suprascapular and axillary nerves, respectively.
Answer 4: Shoulder adduction (pectoralis major, latissimus dorsi, teres major) is from the medial and lateral pectoral nerves, thoracodorsal nerve, and lower subscapular nerve.
Answer 5: Shoulder abduction (supraspinatus, deltoid) is from the suprascapular and axillary nerves.
Klepps SJ, Goldfarb C, Flatow E, Galatz LM, Yamaguchi K.
J Shoulder Elbow Surg. 2001 Sep-Oct;10(5):453-9. PMID: 11641703 (Link to Abstract)
Klepps, JSES 2001
Jost B, Puskas GJ, Lustenberger A, Gerber C
J Bone Joint Surg Am. 2003 Oct;85-A(10):1944-51. PMID: 14563802 (Link to Abstract)
Jost, JBJS 2003
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Average 4.0 of 19 Ratings
A 75-year-old retired carpenter has had 2 years of increasing left shoulder pain and intermittent swelling of the left shoulder as shown in Figure A. He is right-hand dominant and an avid bowler. He denies constitutional symptoms. Physical examination reveals 80 degrees of active forward flexion and 170 degrees of passive range of motion. Palpation of the left shoulder reveals subcutaneous fluid with no distinct mass. A radiograph is shown in Figure B. What is the next most appropriate step in management?
Biopsy and referral to orthopaedic oncologist
Reverse total shoulder arthroplasty
Arthrocentesis of the shoulder with aspirate submitted for cell count and differential
Conventional unconstrained total shoulder arthroplasty
Cervical spine MRI to evaluate for the presence of a syrinx
The clinical presentation and radiograph is consistent with a diagnosis of rotator cuff arthropathy and of the options listed, a reverse total shoulder arthroplasty is most appropriate. A humeral head arthroplasty (e.g. hemiarthroplasty) would also be an appropriate treatment.
Figure A demonstrates the geyser sign indicating recurrent effusions with the synovial fluid free to communicate between the glenohumeral joint and subacromial bursa resulting from rotator cuff arthropathy. The classic surgical treatment of choice for these patients has been hemiarthroplasty. This patient also exhibits pseudoparalysis as he has active elevation of <90° (because of an unstable glenohumeral fulcrum rather than pain) with full passive range of motion.
Zuckerman et al reported Level 4 evidence with the use of shoulder hemiarthroplasty for rotator cuff tear arthropathy in 12 patients. They found that pain relief, satisfaction scores, and isokinetic strength were significantly improved following hemiarthroplasty.
Werner et al present Level 4 evidence of 58 patients with pseudoparalysis and rotator cuff arthropathy who underwent reverse total shoulder arthroplasty with a Delta III prosthesis. They found that subjective shoulder value, Constant score, active flexion, and active abduction were improved, however there was a 33% reoperation rate.
Zuckerman JD, Scott AJ, Gallagher MA
J Shoulder Elbow Surg. 9(3):169-72. PMID: 10888158 (Link to Abstract)
Zuckerman, JSES 2000
Werner CM, Steinmann PA, Gilbart M, Gerber C.
J Bone Joint Surg Am. 2005 Jul;87(7):1476-86. PMID: 15995114 (Link to Abstract)
Werner, JBJS 2005
Average 3.0 of 22 Ratings
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?
hemiarthroplasty or total shoulder arthroplasty
reverse total shoulder or total shoulder arthroplasty
hemiarthroplasty or reverse total shoulder arthroplasty
total shoulder arthroplasty or glenohumeral arthrodesis
total shoulder arthroplasty or scapulothoracic arthrodesis
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.
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
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
Average 3.0 of 40 Ratings
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HPI - 50M, RHD.
Known history of rotator cuff tear about 2 years ago.
History of 3 prior right shoulder surgeries (? RCR).
History of successful RCR on opposite (left) shoulder >1.5 years ago.
+ painful ADLS, + night pain, + pain with overhead activities.
Difficulty raising his right arm in forward flexion and abduction. Significant weakness.
How would you manage this patient?