American Shoulder and Elbow Surgeons Annual Meeting

AMERICAN SHOULDER AND ELBOW SURGEONS ANNUAL MEETING

September 10-12, 1992 Vail, Colorado

President Richard J. Hawkins, MD Program Committee Robert H. Bell, MD, Chairman Donald C. Ferlic, MD Richard J. Hawkins, MD

522

2

Abstracts

J. Shoulder Elbow Surg. January/February 7993

EXCURSION OF THE ROfATOR CUFF UNDER THE ACROMION: PATIERNS OF SUBACROMIAL CONTACT. E.L Flmow, MD, LJ. Soslowsky, PhD*, J.B. 7icktr, MD, R.}. Pawluk, MS, V.C. Mow, PhD, L.U. Bigliani, MD. The Shoulder Semee
conf'd

CONGENITAL SUBACROMIAL STENOSIS. Stephen S. Burkhart, M.D. Congenital subacromial stenosis is a previously undescribed syndrome. Radiographic narrowing of the acromiohumeral interval to less than 7mm has traditionally been felt to be a sign of rotator cuff tear, with superior migration of the humerus. However, narrowing of this degree can occur without proximal humeral migration in patients with a congenitally narrowed subacromial space. The author has identified 25 patients with congenital subacromial stenosis, with an average acromiohumeral interval of 4.7mm. Six patients with impingement underwent arthroscopic acromioplasty, and ten patients with rotator cuff tears underwent arthroscopic debridement and decompression, or rotator cuff repair. There was a bimodal age distribution, with younger patients having impingement symptoms (average age 42) and older patients having full-thickness rotator cuff tears (average age 66). Rotator cuff tears were present in 60 percent of the shoulders in this report. The natural history of this condition appears to be a relentless progression from impingement to rotator cuff tear by virtue of an "abrasion effect." This study indicates that there may be a place for "prophylactic" subacromial decompression in these patients to prevent the occurrence of later rotator cuff tear.

3

Results: The region of soft tissue contact starts at the antera-Iateral edge of the acromion with the arm positioned at 0° of elevation, and shifts medially with elevation. On the humeral side, the contact pattern shifts from the proximal end to the distal end of the supraspinatus tendon with arm elevation. When external rotation is decreased, a distal and posterior shift is noted in the contact pattern on the tendons covering the humeral head. The acromial undersurface and the rotator cuff tendons are in closest proximity between 60 ° and 120° of arm elevation, and is located at the supraspinatus insertion. Furthermore, the areas of closest proximity were consistently more pronounced for shoulders with Type III acromions. The AHI on the AP radiographs measured an average of 11.1 mm at O· of arm elevation. At 90° of arm elevation, when the crest of the greater tuberosity was in closest proximity to the anterior midpoint of the acromion, the AHI decreased to an average of 5.7 mm, a reduction of 49%. ConcIll'iiom: Radiographic analysis suggests that the interval accommodating the soft tissues of the subacromial space decreases with arm elevation in the scapular plane. While radiographs reveal the bone-to-bone relationship, SPG assesses contact on these soft tissues. Subacromial contact centers on the supraspinatus insertion into the greater tuberosity, where most rotator cuff damage initiates. Altered excursion of the tuberosity, (eg. with glenohumeral instability) might, therefore, force the supraspinatus insertion against the anteroinferior acromion. Removal of this region, by anterior acromioplasty, is generally reserved for older patients with primary impingement. However, the marked increase in contact with Type III acromions suggests that this procedure may have a role in selected younger &th1etes if it can be demonstrated clinically.

CDNSERVATIVE MAN1IGEMENl' FOR SUBA.aorrAL IMPINGmmI' OF 'mE SOOUIDER. D.s.~ison,

MD*, A.S.Frogamen:i, MD, Paul Woodworth, Pr. S.C.C.S.M., l.o1'xJ Beach CA 90806

616 patients with isolated subacranial inpin:]ement syrrlrcme were treated with antiinflanunatory medication am a specific isanetric-isotonic rotator cuff strerY,Jt:henin '!here were 386 males am 230 program. females of average age 42 with daninant shoulder involvedin 66%. Synptan duration averaged 16 nonths, follow-up averaged 27 nnnths. 67% of the patients had satisfactory results, 28% failed am went on to art:hroscq:>ic dec::a1'pression, 5% failed am d10se no surgery. sex had no influerre on ootcane, daninant shaliders fared better than J10IMkIninant (69% to 59% satisfactory) • Patients with 'IYPe I acranion fared better than those with 'IYPe II or III (91% vs 66% satisfactory). Patients with acraniaclavicular synptans had only 57%" satisfactory results. I Patients over 60 also fared poorly. 18% of' the satisfactory results had a recurrence of their pain durin:] the follow-up period, which resolved with rest am resunption of exercises. Initial response to therapy usually began within four weeks, am rarely did initial response begin after six

weeks.

Abstracts 523

1. Shoulder Elbow Surg. Volume 2, Number 7, Part 2

4

ARTHROSCOPIC ACROMIOPLASTY: LONG TERM RESULTS W.R. Lowe, MD, & J.E. Tibone, MD, The Kerlan-Jobe orthopaedic Clinic, Inglewood, CA This study evaluates long term results of arthroscopic acromioplasty in treatment of impingement syndrome for patients without full thickness rotator cuff tears. Eighty-nine patients had arthroscopic subacromial decompression, with 79 available for follow up. Average length of follow up was 42 months. The average age was 38 years. Seventy-one patients were active in sporting activities. Return to sports participation averaged 3.5 months, how-ever, full recovery and full return to sports was delayed approximately one year. Fifty-six patients were rated satisfactory (71%), 23 unsatisfactory (29%). In patients 35 years old and younger, there were 19 satisfactory (54%) and 16 unsatisfactory results (46%). In those over 35 years of age, there were 36 satisfactory results (82%) compared to 8 unsatisfactory results (18%). Younger patients had significantly worse results that the older group (p=.008). The postoperative diagnosis was impingement

conf'd

without rotator cuff lesions in 48 patients; 31 patients had partial rotator cuff tears. In addition to impingement, 7 had a diagnosis of calcific tendinitis, 2 had known anterior instability, and 2 had a coexistent diagnosis of adhesive c~psUlitis• . There were no significant dlfferences ln the final outcome based on the p~stoperative diagnosis. However, at the tlme of follow up examination 14 patients had instability findings; this group fared significantly worse than those without instability finds a only 3 had satisfactory res~lts (p=.OOl). Those patients with decreased external rotation compared to their other shoulder had significantly worse results. No other variables had a significant correlation with the final outcome inclUding g~enohumeral arthritis, sporting actiVlty, and workman's compensation status. Arthroscopic acromioplasty is a safe and effective procedure with r~sults comparable to open decompresSlon. However, full recovery from this procedure is also comparable to open decompression, and may take one year in an athlete. Coexisting instability has a poor prognosis with this operation.

conf'd

5

FUNCTIONAL AND STRUCTURAL CONSEQUENCES

OF EXPERIMENTAL SHOULDER I!'M)BILIZATION. G. Schollmeier, M.D., H.K. Uhthoff, M.D. and K. Sarkar, M.D. Departments of Surgery and Pathology University of ottawa, Canada To elucidate the functional and structural consequences of shoulder immobilization, one forelimb of 16 beagles was immobilized in a shoulder spica for periods of 4 to 16 weeks. In 8/16 dogs, the cast was removed at 12 Wand the limb allowed free activity before killing at 4, 8 and 12 W. We conclude that: 1. Forward bending and internal rotation were markedly (75%, 49% resp) decreased after 8 W of immob.; they improved after remobilization without reaching normal levels. 2. Pressure and volume decreased (approx. 50%) after 12 W of immob., they returned to normal values after 12 W of remob. 3. No structural changes occurred in the capsule during immob. but an increased vascularity and cellularity were seen in the superficial layer of the capsule after remob. The model is adequate to study similar changes in shoulder contracture (supported by the Medical Research Council of Canada).

6

ACROMIAL FRACTURE COMPLICATING ARTHROSCOPIC SUBACROMIAL DECOMPRESION REPORT OF SIX CASES. L.S.Matthews,MD, W. Z.Burkhead, MD,S.Gordon, MD,J.Racanelli, MD, L.J.Ruland, MD. Arthroscopic subacromial decoopression (ASAD) is being performed with increasing frequency and for many surgeons, has replaced open surgery for treatment of refractory irrpingement syndrome. A newly recognized corrplication of this procedure is fracture of the acromion process. we report six such cases. All patients were diagnosed after developing increasing shoulder pain in the post-operative period following ASAD. Commonly the pain was sudden in onset and developed during the course of post-operative therapy. Identifiable risk factors included osteopenia and overzealous bone resection. Diagnosis was frequently delayed and three of six fractures were only identifiable on axillary radiographs which were not initially obtained in the evaluation of the patients. Pain was a consistent symptom following fracture. The degree of disability varied depending on its size and location. Treatment varied from benign neglect to total acromionectamy. Results were consistently poor. Given the poor results seen following acromial fracture, enphasis must be placed on proper pre-operative planning and meticulous surgical technique.

524

7

Abstracts

1. Shoulder Elbow Surg. January/February 1993

THE SURGICAL TREATMENT OF AN UNFUSED ACROMIAL EPHIPIIYSIS IN ASSOCIATION WITH A TEAR OF THE ROTATOR CUFF: A REVIEW OF 41 CASES. L.U. Bigliani,MD, l.A. Barralkl, MD, D.A. BriJIis, MD, E.B. Self, MD, E.L. F1JJtow, MD. 17Ie Shoulikr SIma, New Yon OrthoptWlk Hospilol, ColumbiaPnsbytel'iall MtdiaJI Cellltr, New Yon, New Yon. An unfused ICromial epiphysis (UAE), "os ICromial", bas been associated with rotator cuff tears, but optimum surgical

9

GAUCHER"S DISEASE OF THE HUMERUS. Donald C. Ferlic, M.D.*Denver Orthopedic Clinic, Denver Colorado Gaucher's disease is an uncommon genetic disorder which is a result of the deposition of glucoserebrosides in the reticuloendothelial system, mostly in the spleen, liver, and bone marrow. This condition creates problems in the skeletal system with pathological fractures osteomyelitis, psuedosteomyelitis, and aseptic necrosis of the hip (most commonly) and the shoulder (secondly). Operative complications are frequent with infection, excessive bleeding and failure of implants. X-rays show lytic areas in the bone; MRls indicate marrow substitution with deposits of Gaucher's cells which are large multinucleated cells with foamy cytoplasma which reflects the accumulation of the glucocerebroside within the cells. Failure to relieve pain after surgery has been frequently reported in the literature although very little, except anecdotally, is reported regarding shoulder surgery. A case of aseptic necrosis of the head of the humerus is described which was successfully treated with a noncemented total shoulder replacement.

A SlUcIy of Acromloclavlcw. Joint " R. &11/. MD, R. Acus, MD. D. NOB, 85. M. AslrBw, Ph.D Akron CUy Hospilal, Akron, OH and the ery8taIClinlc, Akron, OH

10

SPONTANEOUS SEPTIC SHOULDER IN ADULTS. R.J. Curtis,MD,D.N.Walker,MD,C.A.Rockwood,MD,Univ of Texas,San Antonio,Tx. Seventeen adult patients with spontaneous septic arthritis of the glenohumeral joint were reviewed.Thirteen had at least one predisposing condition that would lead to immuno-compromise, three patients had a history of I.V.drug use, and one had multiple steroid injections.A greater than four week delay in diagnosis occurred in 13 of 17 patients.All patients presented with pain,12 of 17 with fever.9 of 17 were systemically ill.lS of 17 patients had an elevated WBC count. The ESR was uniformly elevated. Only 7 patients demonstrated xray changes consistent with an infectious process.Cultures were positive in all patients;Staph.aureus(12/17) ,Streptococcus species(4/17) ,Streptomyces(I/17) ,mixed infection

lIIlIII&gement of this anomaly is unclear. Between 1975 and 1991 we operated 01142 shoulders in 38 plItienls with UAE as well as a rotator cuff lear (RCT). There were 19 males and 19 females . The average age was 55 years, with a range of 19-71 years. All plItients had signs of impingement, but only 8 (19%) had a specific trauma. 63 % had associated ICromioclavicular tenderness. The most reliable x-ray view was the axillary view which demonstrated a mesoacromion in 32 (76 %) and prelCromion in 10 (24%). All full thickness rotator cuff tears were mobilized and repaired to bone as needed, and plIftial tears were debrided. Treatment of the UAE was divided into three groups: 1.) resection 9 (22%); 2.) ORIP 14 (33 %); 3.) modified acromioplasty 19 (45%). AC arthroplasty was performed in 35 (83 %) and the coracoacromialligament was excised in all patients. Overall, 28 (67 %) had excellent or good results. The hardware complications occurred in the ORIP group. The best results were in the ICromioplasty group, with 84 % having satisflCtory results.

8

DilIordeIlI 01 the acromioclavicular joint run the gamut Irom lraumallc Injuries tl frlll1k dl8locallonS and various tw1IYItides. AIlhOugh ex1llnSlve work has b88n done on the sulllicallr88Mlent ollhes8 variola dlsorders, lillie has b88n written regardIng 118 etloIogy 01118 nonspecific ar1hrilld8&, such • Idlopalhic astllolysls. This SlUdy w. designed tl ~ two queslIons reIalIve ID IhIs dIsold8r. FISt, what . . 118 q4811i1IIliv81orol18 generalBd _ Ih8l1CRll11lClClav joint? S8C0nd, whlc:h specilic shoulder motions genenUIIthe lJ88lBStlorals and, • such, may be conll1llullng tl joint deslruction ? IIaWt1llla 8IIlI1IeItIoda: r-,Iy-w paIIenIs 1den1ltl8d • hlIving acromioQlMcUIlIr joInllllt1llls unlllSpOllSlve tl8lllllln8Ne ~ ~, .-I wtlh iadiognlphic IndIngs oonslstIIlnl wfth ar1hritIs, _ evaIuIII8d. 1'h8nI_ 18 maIe& (average age 59 yen) and 6 fBmaI8s (average. 65 yen). N. pII'l oIlh8l1l8r1cBd surgical approach tllh8 shoulder, 118 acrornioclaVicU jointIoc8IzIld and a 5 nwn VIlI1lClIl capsulotlmy aeatBd. A IoRle-sensing poIym8r 1IanIcMl8I (FSRllI , IntBrink EIeclronlc8, SlwIII BarbBrlI, CA) _ Inlroduc8d and lI8CU8d wI1h a capeuIar swIlch. FOIIl8 - . s _1IlOllIdBd • tl8 shoulder _ placed inti 6 randomly ordered posItons: 8dduclIDn, atJductian, InlIImIII rolIIIIlon, lIXIIImaI rolaIion, IIelllon, lnt elltiln8lDn. ThJ88Il1peBt8d ~_ made lor -=II pasIlion and tl8 po5IlIon8 _ rlll1k8d accardIng tllDrll8lor -=II Uljecl The nri& _ tl8n lWIyZlld ~ by F11edrrBl'a melhad lor randomIz8d bIocka, IoIoMld by tl8 sign tIIlIt lor SlgniIcW1C8. RnuIta: FOIIl8S genenUIId varied 1rom:!O tll30 N:SIIll&lIcaI analysls 0I1he IDrll8 Iev8I nrilngs deli .. illIaIBd flat abduclion lII1d lMlducIon pnxllclld tl81ighest Ion:8B wth tl8 .... 1Drll8 0CClI'ring In extBmal rolIIllon. The rarlli'lgs 01 tl8 3 other poellIons did flOl slaIisticalIy diller Irom Ihe other. ~: PrvvloIIll*lrrl8Clw iIca/ alIlysls 01 AC joint moIon IllI& d8moIlSIratIId 31Drm1 01 motion; incUIing lIililtGpOldBriar gIdIng, rolilllon lII:JcU the long 1IlCllIs, lnt a ~ motion oIlhB acramIon an the clIIvicl8 wth adducIIan and abduc:lIon. lhiI SlUdy would ClOIlIrm the abducIon and adducIIan, due tll1iB ~ 1l18Chlrilm, I86UlIn the gl8lltlllltlorc8 being applied _11iB IdcuIlI" awfac8. Avoldanc8 0Ilhes8 apeclftc moIona dwIng rehabllIlaIion or 8.-cla8 PfI*lCOIs would help tl mlninlz8 joint d.....

0/17).

Treatment regimes included:open arthrotomy, open arthrotomy and closure over drains;or arthroscopic debridement with closed drainage.All patients) received appropriate antibiotic coverage.Results were similar in all patients irrespective of treatment, with 1 excellent,S good,and 9 fair results.No patient required further surgery for excessive pain, recurrence of infection or progression of osteomyelitis. Superior results were attained in those patients diagnosed and treated earlier than four weeks from onset of symptoms.

J. Shoulder Elbow Surg. Volume 2, Number 7, Part 2

11

2

Abstracts 525

ARTHROSCOPIC REFIXATION OF AVULSED ANTERIOR LABRAL TISSUES USING IMPLANTABLE ANCHORS & PERMANENT SUTURES Stephen J. Snyder. MD; 6815 Noble Ave .• Van Nuys. CA 91405 A technique has been developed to attempt to arthroscopically perform an anatomical reattachment of the anterior labrum in cases of shoulder instability. 15 patients have undergone the operation which includes implanting three miniature bone anchors. using arthroscopic techniques. exactly at the edge of the articular cartilage. A #2 nonabsorbable braided suture is then passed through the labrum and capsular tissues. allowing near anatomic refixation of the tissues with a capsular tuck if needed. A perfectly safe anterior "lateral" glenoid portal is used for the repair. The sutures are passed using either a hollow curved suture needle or a Caspari type suture punch. A new device called a suture Shuttle RelayTM allows us to pass this suture through the tissues with ease. The postoperative rehabilitation "is faster since the strong nonabsorbable suture securely fixes the ligament and labral tissues to the bone. All 15 patients have returned to their previous sporting and work activities.

cont'd

ARTHROSCOPIC SHOULDER STABILIZATION FOR RECURRENT SUBLUXATION AND DISLOCATION: Jeffrey S. Abrams, M.D. Princeton Orthopaedic Associates, Princeton, New Jersey. Thirty-five patients with recurrent anterior shoulder instability had arthroscopic stabilization by a transg1enoid suture technique. Ten patients with anterior shoulder dislocation and twenty-five patients with recurrent subluxation had a fo110wup of two and one-half years. Ten traumatic anterior dislocations had evidence of 1abra1 detachment below the level of the glenoid fovea. Three patients did not illustrate a typical Hill-Sachs lesion. Surgical reattachment of the labrum stabilized nine of the ten patients. Re-exp10ration of the traumatic failure illustrated a well healed labrum, but inadequate tension in the capsular ligaments. Twenty-five patients had recurrent subluxation. Physical exam including apprehension sign, reduction maneuver and load and shift reproduced or reduced the symptoms in these patients. There were two groups of operative findings: Eight with 1abra1 detachments and seventeen with 1abra1 fraying without detachment. Patients with 1abra1 detachment were anatomically fixed with one failure. Seventeen patients with fraying

13

cont'd

had detachment of the labrum, debridement, reattachment to an abraded glenoid and a capsular plication. Patients with successful stabilization had an "average loss of external rotation of 8° with elbow at side and 11° in the abducted position. Two failures with recurrent subluxation had a healed labrum but inadequate soft tissue restraint. One patient required arthroscopic lysis of adhesions. In conclusion, repair of significant 1abra1 detachments can stabilize most shoulders with minimal loss of external rotation. In sub1uxators, capsu10rrhaphy improved 82%, but patients need to accept loss of external rotation. Labra1 repair and restoring capsule tension is critical in correcting instability. Improved techniques for fixation with earlier mobilization might improve the motion, but risk stabilization failure.

THE ANATOMIC ARTHROSCOPIC BANKART SUTURE REPAIR D. T. Harryman, liMO, F. T. Ballmer. MD & S. L. Harris, MS. University of Washington, Orthopaedics Dept.. Seattle, WA The purpose of this study was to restore glenohumeral stability without compromising normal motion by using a new, accurate, safe, and reliable method which provides an anatomic intraarticular suture repair to the glenoid rim similar to that achieved open but without implants. We measured: Motionin 3 elevation planes, 2 arcs and 2 rotational positions to >2000N· mm torque limit and Laxity using the A-P drawer, sulcus, distraction, fulcrum and jerk test to >35N force limit. We measured the normal, incised and repaired preparations sequentially. Surgical release caused complete antero-inferior joint dislocation confirmed arthroscopically. The labrum and ligaments severed from the glenoid rim were reattached using sutures placed arthroscopically through the articular glenoid rim. Releasing the ligaments increased all passive motion ranges, but only motions with the arm elevated 60· were significant. Motion was never decreased after repair in comparison to normal. Laxity: GH trllnslation increased significantly on posterior drawer and fulcrum after release (eg., Fulcrum: NI-B.7mm vs. Rel-17.Bmm vs. Rep-B.1mm). After repair, there were no differences found in GH laxity or stability when compared to the normal joint. One suture in two specimens had failed at the glenoid rim which did not compromise the security of the repair. Repair time averaged 1.5 hrs.. Neurovascular structures were never injured or at risk during the repair. Conclusions: Our arthroscopic Bankerttype repair of the ligaments and labrum, provides anatomic reattachment and effective deepening the glenoid concavity which restores normal GH joint laxity and stability, preserves full motion. and can withstand forceful loads without failure.

526 Abstracts

14

STRENGTH AND POWER FOLLOWING ANTERIOR SHOULDER REPAIR. RR Richards, A Dumont, D Beaton,

J. Shoulder Elbow Surg. January/February 7993 16

EP Urovitz, University of Toronto, Toronto, Ont, CANADA. Forty-six patients (38 d, 8 9) were reviewed between 18 and 85 months (mean 46.6) after anterior capsulorrhaphy and Magnuson-Stack tendon transfer. The purpose ofthe investigation was to perform an objective outcome analysis. Isometric strength and isotonic power were tested on a BTE work simulator. All patients had unidirectional anterior shoulder instability. Mean age was 30, median 28, range 18 - 50. Forty-three patients (93%) felt they were improved by the procedure. Two patients had recurrent episodes of instability. None of the patients demonstrated any radiographic evidence of osteoarthritis. Mean loss of motion was: external rotation (arm at side) 13.9°, flexion 8.3°, abduction 7.5°. Mean isometric strength was: flexion (90~ 81%, internal rotation 92%, external rotation 81% (p<0.0001). The cause ofthe motor weakness was uncertain. Objective functional testing is required in order to quantitate shoulder function after anterior repair. Strength and power did not return to normal after successful anterior shoulder repair. Subjective outcome measures do not necessarily correlate with the objective functional outcome. To the authors' knowledge this study represents the largest reported series of patients who underwent strength testing following a single type of anterior shoulder repair.

5 IUlERAL IDI'ATIrn 0S'IE0ltMY FOR rom:RIOR SIIllLIER SUBUlXATIrn. R. Peter Welsh, Orthopaedic & Arthritic Hospital, Toronto, Canada.

Unintentional invohmtary posterior dislocation of the shoulder has been successfully treated by a canbined procedure incorporating internal rotation osteotany of the humerus with an anterior inferior capsular shift. Method: 10 individuals disabled by symptans developing in the late teens or early 20' s following minor trauma were operated on. Technique: The proximal humeral osteotany used an anterior approach and technique similar to that described by Weber. The distal humerus was thaJ.gh internally rotated 25° with regard to the proximal humerus to reduce huneral retroversion preventing the shoulder fran slipping posteriorly wen placed in flexion-adduction and internal rotation. The osteotany was secured with m:xIi.fied semi-turolar plate and screws and the inferior and posterior capsular redundancy was advanced upwards. Results: All osteotanies healed primarily. Blood supply to the huneral head was by bone scan unaffected. There was an average loss of 25° of external rotation rot overhead reach was excellent at a mininun of 12 IIDIlths follaw-up. The plate had to be rElOOVed in 3 cases. All rot 1 returned to full activity. The sole failure was due to persistent habitual invohmtary dislocation.

17

HABITUAL(POSITIONAL) POSTERIOR INSTABILITY OF THE SHOULDER IN THE ATHLETE. H.Fukuda,MD,K.Hamada,MD & M.Ikeda,MD, Tokai University Hospital, Isehara 259-11 Japan. Objective: The habitual(positional) posterior instability of the shoulder(HPIS) is defined as an involuntary posterior subluxation which occurs when the glenohumeral articulation assumes an elevation and internal rotation position. From that position,the humeral head is spontaneously reduced often with a snap on horizontal extension. In addition to this classical type(Grade II), an abortive type(Grade I) is also recognized, probably as a precursory stage. HPIS is not rare among athletes,especially throwers. An attempt was made to clarify its clinical nature. Patients & Methods: Twelve shoulders in 11 patients(lO men & 1 woman) were operated on with Neer's inferior capsular shift. All patients were engaged in sports. The average follow-up was 4 years and 4 months. There was no history of trauma in all but one patient. Results: The posterior soft tissue was redundant in all shoulders and the Bankart lesion was noted in 3 shoulders. The preoperative pain disappeared and shoulder became stable in all shoulders but one. Conclusions: HPIS can be classified into Grade I & II by the Jerk test. The Grade II lesion can be successfully treated with inferior capsular shift. The etiology of HPIS appears to be repeated microtrauma.

Alm!JUal AI'PRDllaI

m

Pam!:RIal IlBDlBILI'l'lC

John J Brans, MD, Dept of orthopaedic Surgery, '1he Cleveland Clinic Fourxlation, 9500 Eucl.id Avenue, Cleveland, Chic 44195

surgical managanent of recurrent posterior slntlder instability ranains oootroYersial. '1he relatively high failure rate of posterior repairs through traditialal posterior approaches is possibly related to surgical violation and -=x::n:Iary scarring of the infraspinatus. '1he advent of the inferior capsular shift procecIure by Near in 1980 proYed that the posterior CXllIpOllent of a nulticlirectialal laxity pattern can be surgically managed fran the anterior approach. Fran 1986 throogh 1990, surgical managanent of all instability patterns has been throogh the anterior approach regardless of the major direction of the instability as long as the posterior labrum was intact. Fourteen slntlders in 14 patients ...ere identified where historical, clinical, and operative findings established a primary posterior instability. seven patients had prior posterior repairs all via posterior approaches and llBIIeI1 had no previous surgery. After failure of a prolonged mhabilitation program, all had a posterior/inferior capsular shift through an anterior approach. At minilIun two year follcw-up, six of llBIIeI1 (86\) slntlders with no prior surgery ...ere clinically stable ard asynptanatic. Six of seven (86\) of those with prior surgery had failed, one remained asynptanatic. Although the overall failure rate was 50\ in this series, 86\ ...ere doing well when the anterior approach was the initial procecIure; I no l ~ use the anterior awroach for failed prior posterior instability repairs.

J. Shoulder Elbow Surg. Volume 2, Number 7, Part 2

Abstracts

527

18

THE USE OF MRI TO DIAGNOSE SUPRASCAPULAR NERVE ENTRAPMENT SYNDROME (SNESl CAUSED BY A GANGLION Thomas P. Goss, M.D.,Michael S. Aronow, M.D. (Department of Orthopedic Surgery) and James M. Coumas, M.D. (Department of Radiology), University of Massachusetts Medical Center, Worcester, Massachusetts 01655. Suprascapular Nerve Entrapment Syndrome (SNES) is a relatively uncommon hut probably under-recognized cause of chronic shoulder pain. Multiple etiologies have been described including compression of the nerve by an extrinsic lesion - a ganglion, a lipoma, and others. Diagnosis is difficult and generally made on lhe basis of clinical signs and symptoms; exclusion of more common causes of shoulder pain; and indirect diagnostic tests - EMG. local Xylocaine i.uections, and others. Ultrasound and CT scanning have been used to "visualize' such lesions but each has signiticant limitations. Recently, MRI has been found to be an excdlent, cost-eftective, non-invasive screening modality for individuals with undiagnosed shoulder pain. This paper presents several cases of individuals with SNES due to ganglia occurring in various locations - the suprascapular notch, the spinoglenoid notch, and the supraspinatus and infraspinatus fossae. In each case, MRI accurately detected the compressive lesion, predicted its nature, and visualized its exact location. All of the ganglia were excised via a posterior approach wilh complele resolution of symptoms. MRI is a cost-effective study which allows accurate detection of extrinsic compressive lesions responsible for SNES and provides important information needed for preoperative planning purposes.

20

PASSIVE RANGE OF MOTION EXERCISES OF THE SHOULDER: AN EMG ANALYSIS. G.W. Misamore, MD, D. Ziegler, MD, & G. Higginbotham, RPT, Methodist Sports Medicine Center, Indianapolis, IN. EMG analysis of selected shoulder muscles was performed on 10 healthy volunteers as they performed "passive" ROM exercises of the shoulder. Exercises included I) therapist assisted, 2) self performed using the contralateral arm for power, 3) self performed using a pulley and 4) CPM controlled motion. The study revealed that none of these techniques was consistently able to provide true passive range of motion. No technique accomplished passive motion in all subjects, and no subject accomplished passive motion by all techniques. Motion in the CPM most closely approximated passive activity with therapist assisted exercises being the best. Self performed and pulley exercises revealed significantly more muscle activity. Although passive range of motion exercises are commonly prescribed for shoulder rehabilitation following fractures or reconstructive surgery of the shoulder, this study suggests that true passive motion is not routinely achieved by the techniques evaluated.

19

SUPRASCAPULAR NEUROPATHY: A PROTOCOL OF CONSERVATIVE TREATMENT WITH SELECTED LATE SURGICAL DECOMPRESSION Scott D. Martin,MD Russell F. Warren,MD, Tamara L. Guion, MD,et a1. Hospital for Special Surgery, New York, NY This study repons long-term results of a protocol of conservative treatment and selected late surgical decompression for patients with isolated suprascapular neuropathy. From 1983 to 1992, IS patients diagnosed with isolated suprascapular neuropathy by EMG's and physical exam were followed conservatively with a protocol using comprehensive physical therapy. Patients showing no improvement at 6 months underwent selected surgical decompression. Current follow-up evaluations were performed at an average of 3 years 10 months (range 11 months to 8 years 10 months) and included detailed physical/neurologic exams, EMG's and Dynamic Isolcinetic Testing. 3/15 patients underwent selected late surgical intervention. EMG and follow-up demonstrated that 6/12 patients had persistent abnormalities despite improvement clinically; 2 were surgical. All of the non-operative patients had measurable weakness on LIDO testing. The persistent weakness (20%) may be significant in a high-level athlete suggesting that early decompression may be of value in that setting. 14/15 patients had good to excellent results (8 good, 6 excellent) following this protocol, with improved strength, pain relief, and good function. Conservative therapy with selected late surgical decompression utilizing this protocol offers a viable alternative to immediate' surgical release for the treatment of isolated suprascapular neuropathy.

21

PECTORALIS MAJOR TRANSFER FOR SERRATUS ANTERIOR PARALYSIS. M.POST,M.D.,E.GRINBLAT,M.D.,DEPT. OF ORTHOPAEDIC SURGERY, RUSH-PRESBYTERIAN-ST. LUKE'S HOSPITAL, CHICAGO, IL.

Scapular winging related to serratus paralysis can be a painful, disabling disease especially in patients who use their upper extremities rigorously in work or sports. For sedentary patients the condition does not pose a problem. An unique part of the technique essential for achieving a succesful outcome resides in the manner in which the graft is treated and avoids stretching of the graft. From Nov. 1988 to July,1992, 8 patients disabled with severe pain due to winging had pectoralis major transfers. The ages of 6 males and 2 females ranged from 18-37 yrs. (average 30.5). The preoperative duration of symptoms ranged from 12-35 mos. (average 22). Four patients had 5 failed previous operations to relieve shoulder pain. Postoperative followup ranged from 3-44 mos. (average 13). Excellent results were achieved in all patients. There was one complication consisting of a hematoma that spontaneously subsided.

J. Shoulder Elbow Surg. Jonuory / Februory 1993

528 Abstracts

22

23

INTIUNSIC STABWTY OF AN UNCONSTRAINED TOTAL ELBOW, K. N. An, GJ.W. King, S. Brannan, & B.F. Morrey, Orthopedic Biomechanics Lab, Mayo Clinic, Rochester, MN. The advent of semiconstrained and unconstrained prostheses has considerably reduced the problem of loosening. However, the choice of implant design and therefore intrinsic constraint has important implications on the overall stability of the joint. This study delineates the contribution of prosthetic articular design to the stability of the Capitellocondylar total elbow arthroplasty. Five Capitellocondylar prostheses were tested on a materials testing machine. Each implant underwent two series of tests. The first set applied valgus/varus torques from -250 to 250 Newton-em at flexion angles of 0, 45, and 90 degrees and compressive loads of 111,222,334, and 445 Newtons. The second test series applied supination/pronation torques using the same test parameters. Our results quantitate the association of compressive loading as an important factor in maintaining the joint's stability. Intrinsic prosthetic stability was increased at higher compressive loads as manifested by an increase in the measured stiffness and a decrease in the incidence of implant dislocations. The angle of joint flexion had 110 statistically significant influence on stability in valgus, supination, or pronation. Varus stability was greater in extension than with flexion. Adequate ligamentous and dynamic muscular supports appear to be essential to keep the components in apposition.

conf'd

ANATOMIC BASIS OF TOTAL SHOULDER DESIGN. EJ McPherson,' RJ Friedman, RL Dooley, Medical University of South Carolina, Charleston, SC, 29425. .To obtain stable, long-term fixation of a total shoulder arthroplasty (TSA), an optimum fit between the prosthesis and bone is mandatory to allow for physiologic load transfer. The purpose of this study is to define the anatomic relationships of the proximal humerus and glenoid cavity that allow for a precise bone-implant fit using a highly accurate, reproducible technique, and provide a database for TSA prosthetic design and the evaluation of existing prostheses. Thirty-three proximal humeri and matching scapulae were harvested with no evidence of shoulder pathology. High resolution roentgenograms were taken and digitized onto computer, and a custom program was used to obtain periosteal and endosteal dimensions. A conformity index (CFI~radius head/radius glenoid) and constraint index (CSI=arc of enclosure/ 360) were calculated for each shoulder. Pairwise correlations of the geometric parameters showed that many were significantly associated at the 5% level (P<. 05), with a high correlation coefficient (r>O. 4). The variations cont'd

24

between the parameters were related, and this relationship was useful in a predictive sense. No correlation was found between the radii of curvature for the humeral head and glenoid, in either the AP or lateral plane. Only 9% of the specimens had a CFI greater than 0.9, indicating the radii of curvature matched. The vast majority had a more curved humeral head and flatter glenoid that did not match, and there was even less conformity in the lateral vs. AP plane. Also, there was more constraint to the glenoid in the AP vs. lateral plane. These anatomic features help prevent superior-inferior translation of the humeral head, but allow translation in the AP plane. This database of basic anatomic geometry for the proximal humerus and glenoid allows guidelines to be developed for the functional dimensions of TSA components, defines the anatomic relationships that allow for a precise bone-implant fit, and assesses the match between the shape of existing components and the patient's anatomy. Attempting to match prosthetic design and anatomic geometry may optimize longterm component fixation.

GLENOHUMERAL KINEMATICS. R Kelkar,PM Newton,J Armengol,GA Ateshian,RJ Pawluk,EL Flatow,LU Bigliani & VC Mow, Orthop. Res. Lab.,Columbia Univ.,NY. Recent stereophotogrammetry (SPG) studies [1] have shown that although the glenoid subchondral bone surface is flatter than the humeral head bone surface (as also seen on radiographs), the articular surfaces of the glenoid and humeral head are accurately represented by close-fitting spheres. This geometry would suggest that normal motion would consist of rotatory motion with minimal translation, except at the extremes of motion. In this study, we have utilized SPG to accurately describe the kinematic motion of the GH joint by analyzing the 3D translations of the humeral head during abduction in the scapular plane. Seven fresh frozen human cadaveric shoulders (average age 48 y.o., range 42 to 59 y.o.) were tested in an apparatus designed to simulate shoulder function. The radii of the humeral head and glenoid articular surfaces were 25.23:t,1.62mm and 27.03:t,1.68mm respectively. For each 10· increment of elevation, the average translation of the center of the humeral head was calculated. In the medial-lateral direction, the translation values are very small (rrns of deviations = 0.257 mm) due to the restraint provided by the glenoid surface. In the inferior-supe,jor direction and the anterior-posterior direction, the center of curvature of the humeral head remains well-eentered (rms of deviation = 0.674 mm and 0.42'8 mm respectively) in the glenoid. Results demonstrating minimal translations of the center of the humeral head indicate that GH abduction is almost pure rotation, and confirm our previous finding that the articular surfaces of the GH joint are close fitting spheres.REFERENCES: 1)LJ Soslowsky et al: Trans Orthop Res Soc 14:228,1989.

Abstracts

J. Shoulder Elbow Surg. Volume 2, Number 7, Part 2

25

REVISIOO 9UJl.I:fR AA1lRJlLASTY David M. Dines, M.D., 935 Northern Blvd, Great Neck, N.Y. 11021, l£orge Cala...ell, Jr., M.D. 535 East 70th St., N.Y., N.Y. 10021, Russell F. warren, M.D. 535 East 70th St., N.Y., N.Y. 10021, David Altere<., M.D. 535 East 70th St., N.Y., N.Y. 10021 Prirrary heniarthroplasty am total stnJlcEr repla<:aTl2l1t have had relatively ~ 10ll':l tenn success in the treatnart of ostroarthritis, rtmnatoid arthritis am fractures of the stnJlcEr joint, lxIt there is IittIe reference in the literature to the clinical cutcaJe of patients that require revision surgery. This stOOy represents a revie.ol of revisiCfl stnJlcEr arthroplasties perfomed at OJr institution frun 1~ to 19l1l. There 'iEre sixteen patients tnJergoirg seventeen revision surgeries with an average a~ of 56 years (rarge 44 to 73). The prirrary surgery had been heniarthroplasty in seven shoolcErs follONirg fractures, avascular necrosis or degenerative arthritis of the tureral head. The six total shoolcEr replacaJaTts had been in patients with arthropathy of the glenotureral joint secoo:lary to avascular necrosis, , recurrent dislocations or degenerative arthritis. The , avera~ interval frun irdex proceliJre to revision surgery was 24 rronths (rarge 3 to 78). All heniarthroplasties 'iEre revised to total strolder replacaJaTts fror gleroid arthropathy am 00 of the seven surgeries also necessitated revision of the tureral carpanent at blre of prosthetic gleroid placerent. The revision surgeries of total strolcEr replacarents incl ucEd revision of the glemid ~ for loosenirg or gleroid rralposition in foor patients. Reroval of loose gleroid cont'd

26

OF

mmARTHROPLAS'lY wrm BIOI.DGIC RESlIlFN::::m; mE GLJ!H)ID FOR GLEl«HlMERAL AR'mRITIS.

W.Z. Burkhead, Jr., M.D., Dallas, Texas. A technique has been developed to treat the younger patient with glenohumeral arthritis. Biologic arthroplasty of the glenoid includes debridement and drilling of the sclerotic bone down to a smooth bleeding subchondral bone surface. The glenoid version is changed appropriately. A local capsular flap or fascia lata graft was utilized as an interposition bearing surface between an uncemented modular hlBlleral component and the newly resurfaced glenoid. A minimum 2 year followup is available on 6 patients, all male. The dominant ann was involved in all but 1. Their results are as follows: Average postop flexion 138° (increase 57°); external rotation average 50° (increase 45°); and internal rotation to the T12 spinous process (increase 6 spinal segments). Pain relief was excellent in 5, satisfactory in 1. There were 5 excellent results and 1 satisfactory result, Neer (1982). Compared to a control group of 5, after hemiarthroplasty alone, there was a significant difference in all parameters. Radiologic results reveal no glenoid erosion and all hlBlleral stems appear stable. Results of this series are comparable to that of total shoulder arthroplasty without the risks associated with glenoid replacement.

529

cont'd cCJ11)OO2l1t to allON tureral c(JlJXll1ent articulation with bony remant of gleroid was perfomed in 00 stnJlcErs with insufficient tale stock. All patients \>ere clinically evaluated p~ratively am post-operatively usirg the HSS stnJlcEr scorirg systan with at least 00 year follON up. Eleven patients had an average p~rative score of 47 (rarge 42 to 62). Postoperatively the avera~ score was 72 (rarge 38 to 99). There \>ere 00 post-operative infections or reurological seqt.elae. There \>ere several patients that re
Based on the results of this revie.ol, it was concluded that the cl inical outCarE of revision arthroplasty cannot be expected to approach that of prirrary arthroplasty for the average patient and SarE patients will be classified under limited goals ....nen rrassive soft tissue or bony cEfects are encOlJ1tered. It was observed that m:xlular shoolcEr prosthesis often had less carplex revisions. The raroval of the rrodular head allo..ed illlJroved exposure of the glemid and proper retensionirg of the soft tissues with variable neck am head sizes available, wittrut necessitatirg revision of the tureral cCJ11)OO2l1t.

530 Abstracts

27

LONG-TERM RESULTS OF THE CAPITELLO-CONDYLAR TOTAL ELBOW REPLACEMENT. Ewald, F. C. , Simmons, E.D., Sullivan, J.A., Thomas, W.H., Scott, R.D., POss, R., Thornhill, T.S., and Sledge, C.B. Three hundred twelve capitellocondylar total elbow replacements were performed between July, 1974, and June, 1987. Two hundred two elbows in 173 patients with follow-up of twenty-four to 178 months (mean-sixty-nine months) form the basis of this study. Marked improvements occurred in pain relief and functional status, and range of motion improved in all planes except extension. The elbow evaluation score improved from an average of twenty-six preoperatively to 91 at latest follow-up. Range of motion, functional status, pain relief and radiographic evaluation did not appear to deteriorate with time. Eight humeral and nineteen ulnar components were found to have radiolucencies, with the majority of these being incomplete and of one rom. or less in width. Revision surgery for aseptic loosening was necessary in three cases (1.5%), for dislocation in three cases (1.5%). Other complications were deep infection (1.5%), transient sensory ulnar nerve palsy (16%), permanent sensory ulnar nerve palsy (2.5%), dislocation (3.5%) and wound problems (8%).

28 THE CLINICAL RELEVANCE OF POSTTRAUMATIC AVASCULAR NECROSIS OF THE HUMERAL HEAD. C. Gerber & C. Berberat, Dept. of Orthopedics, University of Berne, Switzerland. 25 cases of avn after ORIF or CRIF of proximal humeral fractures were assessed clinically and radiologically after an average of 7.5ys. All patients had significant functional deficits with an average Constant score of 45 pts or 53% of an age- and gender adjusted normal. l~ cases were malunited (lor more of 40segments d~splaced more than lcm or more than 45 ). 13 cases had less displacement. Flexion averaged 0 0 73 in the first and 113 in the second group. 0 Abduction was 70 and 106 respectively, the Constant scores were 35 and 54 points or 43 and 62% of normal. Well reduced fractures had slight to moderate pain in 38%, never severe pain. Malunited fractures were painful in 84%. If these data were compared to a series of primary hemiarthroplasties performed for comparable fractures, the results were beeter for hernia. than for malreduced avn, but they were no better than vor avn with good alignment of the fragments. CONCLUSION= ORIF or CRIF of proximal humeral fxs which may undergo avn is only justified if anatomical reduction is obtained and maintained until fracture healing.

J. Shoulder Elbow Surg. January/February 7993 29

30

ARTERIAL INJURIES OF THE SHOULDER. Nuber, G.W.;Yao, J.T.S.; Mccarthy, W.J.; and Schafer, M.F.; Northwestern University Medical School, Chicago, IL Sixteen athletes involved in repetitive overhead activity were treated for arterial ischemic symptoms. Symptoms included forearm fatigue with repetitive activity, decrease in pitching velocity over a short time span, and difficulty with control. six patients had severe hand ischemia secondary to digital artery embolization. All patients underwent a complete history and physical examination. Noninvasive tests included Doppler finger systolic pressure recording, duplex scan and finger pulse registration by photoplethysmography. All patients underwent arteriography following the dye to the digits with both the arm at the side and in the functional position. Two patients were found to have subclavian artery aneurysms and cervical ribs. Arterial compression was seen in 11 patients, 7 by the anterior scalene muscle, 2 by the pectoralis minor tendon, and the humeral head in one. One had combined subclavian and axillary artery compression. Three pitchers had axillary artery damage due to humeral head compression. Fourteen of 16 patients underwent surgical treatment including resection of subclavian aneurysm and venous bypass with cervical rib resection. Others underwent resection of the anterior scalene or pectoralis minor tendon at the site of compression. The remaining patients had vein patch to the axillary artery and division of circumflex artery aneurysm.

INTRAMEDULLARY NAILING FOR FRACTURES OF THE HUMERAL SHAFT: MECHANICAL TESTING OF FRACTURE-FIXATION CONSTRUCTS. E. P.. Frankenburg, MS, R. B. Blasier, MD, & G. J. Gross, MS, Ortho Dept, Univof Mich, Ann Arbor, 481090328 The purpose of this stUdy was to evaluate and compare the fixation properties of five commercially-available intramedullary humeral fixation devices. Twenty-five fresh cadaver humeri were randomly assigned to be implanted with a 9 mm Kuntscher nail, triple Rush Rods, 9 mm locked Seidel nail, and two different designs of statically-locked 9 mm nails--the Russel-Taylor and the Biomet humeral nails. Prior to implantation, a transverse osteotomy was created 15 cm distal from the superior surface of the humeral head. The fractured, fixed, specimens were tested in torsion and bending on an MTS servohydraulic testing machine. Load and displacement data were collected and analyzed by one-way ANOVA to determine differences in peak load,. torsional stiffness, and bending stiffness between nail types. A p value of less than 0.05 was 1Jccepted as significant. The fracture constructs fixed by the Biomet nail were 2.6 times stiffer in torsion than those of any of the other nails (p<0.002). The fracture constructs fixed with the Russel-Taylor nail were nearly significantly stiffer in torsion than the Rush Rods (p=O.063), and the Kuntscher nail(p=0.086), but not the Seidel nail (p=0.408). There were no significant differences in bending stiffness.

Abstracts

J. Shoulder Elbow Surg. Volume 2, Number 7, Part 2

31

CONTOURED DC PLATE FOR COMMINUTED OLECRANON FRACTURES WITH ELBOW SUBLUXATION SW O'Driscoll, St. Michael's Hospital, University of Toronto The purpose of this paper is to present a reliable method for treating unstable olecranon fracture-subluxations. Six patients with this injury were treated by reduction of the elbow and OAIF using a 3.5 DC plate that had been bent at an 80 0 angle at the proximal end with the plate applied posteriorly. Five had open fractures - all were treated by immediate debridement and internal fixation. Two had associated comminuted type III coronoid fractures. All wounds and fractures healed within 12 weeks. At an average follow-up of 9 months range of motion was from 150 ± 250 extension to 1350 ± 100 flexion with an arc of 1200 ± 350 . A functional arc of motion was achieved in 5/6 patients. The results were excellent (funciotnal arc, no/minimal pain, excellent strength) in 4 cases. One who healed anatomically with full motion complained of pain even after plate removal and remained off work on WeB. His x-ray revealed mild arthritic changes. Another had residual displacement of a type III coronoid fracture that caused permanent instability and early arthritis. There were three reoperations: 1 for plate removal, 1 for ulnar nerve transposition (related to an open distal humerus fracture with soft tissue loss) and 1 for ligament repair and OAIF of the displaced coronoid fracture. This method of plating comminuted proximal ulnar fractures with elbow subluxation had the advantages of stable fracture fixation, excellent purchase on even small proximal fragments, buttressing against elbow subluxation, all of which permit immediate motion.

32

531

Nonunion of the Humerus in the Extremely Obese Patient. JB Jupiter, MD, U Goodman, BA. Harvard Medical School, Massachusetts General Hospital, Boston MA. The management of a humeral nonunion in the very obese patient is problematic as greater demands are made on the surgical exposure and skeletal fixation. This is a series of 10 patients, 6 female and 4 male with 2 proximal third, 5 mid-diaphyseal, and 3 distal third nonunions with an average of 3 prior operations each. The patients' average age was 44.6 yrs and average weight of 270 lbs. The average body mass index (WT (kg)/Height cm2) was 41.2 with 2 considered morbidly obese and 7 severely obese. Three patients were diabetic, two with cardiac problems, and one with renal failure. The surgical tactics involved extensile exposure with 6 having a medial approach; enhanced internal fixation with broad 4.5 mm plates in most; and autogenous bone graft featuring a vascularized fibula graft in 5. Complications included plate loosening in 3, local pressure problems in 2, and nerve palsy and delayed wound healing in one each. Seven nonunions united after the first procedure and the other 3 after a second procedure. Shoulder ROM was limited in 4 and elbow ROM limited in 3. Humeral nonunions in severely obese patients require careful preoperative planning, large implants, and extensile exposure of which a medial approach should be considered.