Common surgical approaches to the shoulder.
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Acromioclavicular Joint↗
Biomedical subjects
D T Harryman
Publications and source records attributed to D T Harryman.
Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy.
We investigated the structure of the myotendinous rotator cuff in thirty-two grossly intact cuffs from thirty fresh cadavera of subjects who had been seventeen to seventy-two years old at the time of death. We studied the gross anatomy of the capsule and ligaments of the cuff, as well as histological sections of the tendons of the subscapularis, supraspinatus, and infraspinatus muscles. The tendons were found to splay out and interdigitate to form a common, continuous insertion on the humerus. The biceps tendon was ensheathed by interwoven fibers derived from the subscapularis and supraspinatus tendons. The anterior margin and bursal surface of the supraspinatus tendon were enveloped by a thick sheet of fibrous tissue derived from the coracohumeral ligament. Fibers from the coracohumeral and glenohumeral ligaments were found concentrated in a plane between the capsule and the tendons of the cuff. Microscopically, in the region of the supraspinatus and infraspinatus tendons, the cuff was composed of five layers defined by the attachments and orientations of the fibrous elements in each of these layers.
Adolescent↗
The role of the rotator interval capsule in passive motion and stability of the shoulder.
The purpose of this study was to characterize the role of the capsule in the interval between the supraspinatus and subscapularis tendons with respect to glenohumeral motion, translation, and stability. We used a six-degrees-of-freedom position-sensor and a six-degrees-of-freedom force and torque-transducer to determine the glenohumoral rotations and translations that resulted from applied loads in eight cadaver shoulders. The range of motion of each specimen was measured with the capsule in the rotator interval in a normal state, after the capsule had been sectioned, and after it had been imbricated. Operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Modification of this portion of the capsule also affected obligate anterior translation of the humeral head on the glenoid during flexion. Limitation of motion and obligate translation were increased by operative imbrication and diminished by sectioning of the rotator interval capsule. Passive stability of the glenohumeral joint was evaluated with the use of anterior, posterior, and inferior stress tests. Instability and occasional frank dislocation of the glenohumeral joint occurred inferiorly and posteriorly after section of the rotator interval capsule. Imbrication of this part of the capsule increased the resistance to inferior and posterior translation.
Aged↗
Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff.
We evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. We correlated the functional result with the integrity of the cuff, as determined by ultrasonography. Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect. The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Mechanics of glenohumeral instability.
The glenohumeral joint is designed for mobility and is normally lax. It is stabilized in its midrange by its limited joint volume and concavity-compression. It is stabilized at the extremes of motion by its ligaments. An enhanced understanding of these stabilizing mechanisms helps us in the diagnosis and management of glenohumeral instability.
Humans↗
The effect of capsular venting on glenohumeral laxity.
Anesthetized shoulders are frequently stable against forces applied during drawer and sulcus tests, even though the shoulder muscles are inactive and do not contribute to stability. This passive stability is also evident in the glenohumeral joints of anatomic specimens. The translational laxity of anatomic specimen shoulders was measured, and it was demonstrated that this laxity was substantially increased when air was admitted into the capsule. Eight shoulders, aged 57-87 years, including six contralateral pairs, were analyzed using a six degrees-of-freedom force transducer and a six degrees-of-freedom spatial tracker. Capsules were vented by admitting air ad libitum through an 18-gauge needle. Venting reduced the force necessary to translate the humeral head with respect to the glenoid fossa by an average of 15.3 N (55%) for anterior forces, 10.8 N (43%) for posterior forces, and 19.0 N (57%) for inferior forces. It is likely that passive stability will also be diminished by a similar mechanism in patients with intact but excessively lax capsules. The principle of limited joint volume should be considered and tested when investigating glenohumeral stability.
Aged↗
Translation of the humeral head on the glenoid with passive glenohumeral motion.
We have demonstrated that certain passive motions of the glenohumeral joint are reproducibly accompanied by translation of the head of the humerus on the glenoid. We investigated the relationship of these translations to the position of the glenohumeral joint and to applied torques and forces in seven isolated glenohumeral joints from fresh cadavera, using a six-degrees-of-freedom position sensor and a six-axis force and torque transducer. Reproducible and significant translation occurred in an anterior direction with glenohumeral flexion and in a posterior direction with extension. We also observed translation with cross-body movement. The translation occurring with flexion was obligate in that it could not be prevented by the application of an oppositely directed force of thirty to forty newtons. Operative tightening of the posterior portion of the capsule increased the anterior translation on flexion and cross-body movement and caused it to occur earlier in the arc of motion compared with the intact glenohumeral joint. Operative tightening of the posterior part of the capsule also resulted in significant superior translation with flexion of the glenohumeral joint.
Aged↗
Physeal phalangeal fracture with flexor tendon entrapment. A case report and review of the literature.
A typical phalangeal epiphyseal fracture separation in a 12-year-old girl was complicated by a relatively unusual irreducible growth plate injury. Various tissues may become interposed between displaced phalangeal structures preventing realignment. Frequently, the flexor tendon has been implicated as the cause of complex joint dislocations or fracture-dislocations of the digits. However, entrapment of the flexor tendon by the displaced base of a buttonholed phalangeal metaphysis separated from its related epiphysis is quite rare. Treatment required early recognition to avoid further injury, open identification of the tissue derangement, and careful reduction to restore normal function.
Bone Nails↗
Complete fracture-dislocation of the thoracic spine associated with spontaneous neurologic decompression. A case report.
"Complete" fracture-dislocation of the thoracic spine without neurologic deficit, a rarely described injury, occurred in a 29-year-old coal miner. Partial lesions or those without neurologic deficit may be associated with spontaneous decompression. Gross translational displacement of one vertebrae on another generally compresses interposed neural structures between the columns and/or fragments. Multiple pedicular fractures or posterior column disruption from the displaced anterior column functionally widens the neural canal, even with vertebral bodies side by side. The rib cage stabilizes the thoracic spine, decreasing the risk of neurologic injury. Although many surgeons proclaim the advantages of early open reduction and internal fixation, reduction may not always be necessary in this type of severe injury. Reduction entails highly significant risks, especially in neurologically uncompromised individuals with severe thoracic displacement.
Adult↗
Ipsilateral femoral neck and shaft fractures. Report of two cases using an alternate technique.
A technique for ipsilateral femoral neck and shaft fracture using the sliding compression hip screw with plate combined with trochanteric antegrade Ender nailing of the femur was applied in two cases. Ender nails can be passed without difficulty past a compression hip screw and the bicortical plating screws. The hip and femur can be fixed internally through a single approach in a single position. Sliding compression hip screw devices can provide excellent preliminary stable femoral neck fixation. Blood supply to the femoral head is not disturbed while the femoral intramedullary fixation is performed. Antegrade Ender nailing avoids the common knee complications associated with other retrograde techniques. Decreased operative time, less blood loss, less technical difficulty, and early mobilization are important factors in the multiple-injured patient. Femoral intramedullary fixation may require open reduction, circlerage to ensure stability, and maintenance of alignment in case of significant comminution to allow early crutch ambulation. This mode of fixation may be advantageous for selected cases.
Adult↗
Useful boundaries of the subacromial bursa.
The anatomic boundaries the subacromial bursa may serve as a useful guide for surgical orientation and safety. The goals of this study were to measure the minimum distance between the subdeltoid reflection of the subacromial bursa and the circumflex branch of the axillary nerve and to identify relationships between the margins of the subacromial bursa and the acromion, rotator cuff, and acromioclavicular joint. Seventeen fresh-frozen cadavers (mean age, 69 years), were included. Eleven cadavera were dissected only after the subacromial bursa was injected with a latex solution to define the peripheral boundaries of the bursa. The bursal margins were always 2 cm or more from the anterolateral corner of the bursal acromial surface and the bursa lined the anterior half of the anteroposterior distance of the acromion. The mean distances from all points of the acromion to the axillary nerve averaged approximately 5 cm. The mean minimum distance from the subdeltoid bursal reflection to the axillary nerve was 0.8 +/- 0.5 cm with a range of 0.0 to 1.4 cm. In the unelevated extremity, the inferior bursal reflection was always cephalad to the axillary nerve even when the two structures were apposed. Surgeons should exercise caution when approaching the inferior boundary of the subdeltoid bursal reflection because of the proximity to the axillary nerve. We recommend coupling previously reported "safe deltoid-split" distances to this useful anatomic landmark to prevent nerve injury. Furthermore, the central location of the anterolateral corner of the acromion within the bursal space can be applied to needle placement for injection, arthroscopic diagnosis or treatment and mini-open rotator cuff repairs.
Acromioclavicular Joint↗
Optimizing arthroscopic knots using braided or monofilament suture.
Surgeons need to know how the material properties of a suture affect the security of a surgical knot. The purpose of this study was to compare the security of some clinically important arthroscopic knots when tied using a braided multifilament suture and to draw comparisons with results of similar knots tied with monofilament suture. Permanent braided polyester suture was used to test 10 knot configurations. Eight of the knots included (1) two types of initial cinching knots followed by (2) one of four combinations of half-hitches. We also tested the taut-line hitch locked with half-hitches and the original Revo knot. Each knot was subjected to cyclic loading followed by an ultimate load to failure. Clinical failure was defined as the maximum force that resulted in 3 mm of loop displacement. Force versus displacement data were obtained, and the maximal loop holding capacities were compared statistically. The Duncan loop with switched-post half-hitches and the Revo knot (Linvatec, Largo, FL) showed the highest knot-holding capacities (mean, 87N and 92N, respectively) when compared with all other configurations (P < .0001) for braided suture. A similar knot-holding capacity was described for monofilament suture using the Duncan loop locked with switched-post, reversed-direction half-hitches (mean, 81 N). All knots without post switching slipped completely at significantly lower loads than knots with post switching (monofilament, P < .001; braided, P < .0001). When compared with results of knots tied with monofilament suture, the braided switched-post configurations had smaller cyclic displacements (braided, 0.7 mm; monofilament, 1.7 mm). Although the Revo knot showed good strength for braided suture, it was significantly weaker than other configurations when tied with monofilament suture. Therefore, it is important to test the knot strength for a given suture material before applying it clinically.
Arthroscopy↗
Practical guidelines to safe surgery about the subscapularis.
Surgical mobilization of an adherent or retracted subscapularis tendon is often necessary whenever an attempt is made to restore function to the glenohumeral joint subsequent to failed anterior reconstructive surgery. Surgical guidelines drawn from this study emphasize how a surgeon might accomplish this task effectively and avoid denervating the subscapularis, a muscle that is essential to anterior glenohumeral stability and strength. In this study we examined subscapularis innervation in 11 fresh-frozen cadaveric shoulders. The position of the subscapular nerve insertion points were recorded relative to easily identified surgical landmarks such as the axillary nerve, the conjoined tendon, and the anterior glenoid rim. The palpable anterior border of the glenoid rim deep to the subscapularis along with the medical border of the conjoined tendon can serve as guides to the subscapularis nerve insertion points, because all the nerves are no closer than 1.5 cm medial to these landmarks for all positions of humeral rotation in the unelevated arm. The lower subscapular nerve was found immediately posterior or just lateral to the axillary nerve. During a standard deltopectoral approach potential injury to the subscapularis innervation can be minimized by locating and protecting the axillary nerve, because it serves as a guide to the insertion point of the lower subscapularis nerve, the nerve closet to the surgical field.
Aged↗
Posteroinferior glenoplasty can change glenoid shape and increase the mechanical stability of the shoulder.
The treatment of recurrent posterior glenohumeral instability remains an unsolved clinical problem. Although various types of capsulorraphy have been advocated, outcome studies indicate that it is difficult to achieve a balance between stability and mobility. Alterations of the bony glenoid for posterior instability have been proposed, but are not well understood from a mechanical perspective. This investigation had 2 purposes: (1) to determine in a cadaver model if posteroinferior glenoplasty can change the shape of the glenoid, and (2) to determine if altering the shape of the glenoid can increase the mechanical stability of the glenohumeral joint. We determined the effective glenoid shape in 7 normal cadaver glenoids by tracking the path of the center of the humeral head as it was translated across the glenoid face in 8 different directions. These determinations enabled us to calculate the maximum effective slope of the glenoid in each direction. We then determined the mechanical stability of the glenoids in each of the 8 directions by measuring the tangential force required to dislocate the shoulder under a 50-N compressive load. The ratio of the dislocating force to the compressive load was defined as the stability ratio. All measurements were repeated after a standardized posteroinferior glenoplasty was performed. Posteroinferior glenoplasty increased the posteroinferior glenoid depth from 3.8 +/- 0.6 mm to 7.0 +/- 1.8 mm and shifted the center of the humeral head an average of 2.2 mm anteriorly and 1.8 mm superiorly. These changes in dimension could be directly visualized as an immediate mechanical consequence of the glenoplasty procedure, particularly because of the insertion of the bone wedge. Glenoplasty increased the posteroinferior glenoid slope from 0.55 +/- 0.07 to 0.83 +/- 0.12 and increased the posteroinferior stability ratio from 0.47 +/- 0.10 to 0.81 +/- 0.17. This is a more than 70% increase in the tangential force that can be resisted before dislocation. The increase can be quantitatively understood as a direct mechanical consequence of the altered shape of the glenoid concavity. These numbers indicate that, in this cadaveric model, posteroinferior glenoplasty results in defined changes in the effective glenoid shape and in the mechanical stability of the glenohumeral joint. However, this study does not establish the role of this procedure in the clinical management of posterior glenohumeral instability.
Biomechanical Phenomena↗
A prospective, multipractice study of shoulder function and health status in patients with documented rotator cuff tears.
A total of 191 patients from 29 orthopedic practices are analyzed in this report. All had full-thickness tears documented by imaging tests and/or surgical observation; 190 had tears of the supraspinatus, 54 had tears of the infraspinatus, and 13 had tears of the subscapularis. The greatest functional deficits were in the ability to place 8 pounds on a shelf at the level of the head (93% unable), the ability to throw overhand (93% unable), and the ability to sleep on the affected side (86% unable). The SF-36 physical role function and comfort scores were 27% and 48%, respectively, of those of age- and sex-matched controls. Of the variables suggested by a review of the literature, only female sex, involvement of the infraspinatus in the cuff tear, and workers' compensation claims were significantly correlated with lower shoulder function in this series of patients.
Adult↗
Capsulolabral augmentation increases glenohumeral stability in the cadaver shoulder.
Multidirectional instability is not clearly understood. Excessive capsular laxity has been proposed as the key component. However, because ligaments fail to resist humeral head translation until they are tensioned, glenohumeral instability in the mid range of motion cannot be explained by capsuloligamentous pathology alone. Capsulolabral augmentation is designed to increase glenohumeral stability by 2 separate mechanisms: deepening the glenoid concavity and reducing capsular laxity. This is accomplished by shifting the capsule to buttress the glenoid labrum. Hence, the glenolabral concavity in which the humeral head is stabilized by compression throughout the entire range is enhanced. The purposes of this study were to examine glenolabral depth and glenohumeral stability before and after labral augmentation and to measure the effect of diminished capsular laxity on motion in clinically important positions. We compared glenolabral depth, resistance to humeral head displacement, and glenohumeral range of motion before and after capsulolabral augmentation. Glenolabral depth was measured as the lateral displacement of the center of the humeral head translating from the glenoid fossa. We recorded a mean increase in glenoid depth of 1.9 mm inferiorly, 2.0 mm posteroinferiorly, and 0.9 mm posteriorly (P <.02). Resistance to humeral head displacement was measured by use of the stability ratio, defined as the translatory force required to displace the humeral head divided by the force compressing the humeral head into the glenoid fossa. The mean stability ratio was increased by 0.24 inferiorly and 0.24 posteroinferiorly (P <.02). Motion was measured by achieving 30 degrees and 60 degrees elevation in the 0 degrees, 30 degrees, 60 degrees, and 90 degrees planes of elevation and measuring the extent of possible internal rotation for each of these 8 positions when the capsule was tensioned to exert 1000 N-mm of torque. Reduction of internal rotation in these positions was a mean of 15 degrees at 1000 N-mm of torque. This study demonstrates that humeral head stability within the glenolabral fossa is increased by local capsular augmentation. A simultaneous reduction in capsular laxity is achieved, which partially limits glenohumeral motion. Understanding the biomechanical effect of this procedure helps the physician to establish surgical goals and to explain to patients the rationale of why this procedure may be clinically efficacious.
Aged↗
Complications of open anterior stabilization of the shoulder.
Complications of surgery for glenohumeral instability are relatively uncommon. When they occur, salvaging failures and obtaining a stable joint can be awesome challenges. Accurate recognition of the cause of the instability and application of the appropriate surgical technique are critical. Deficiencies of the glenoid concavity, the anterior capsule, or the subscapularis may be present and require correction. Overtightening a shoulder and eliminating its normal laxity should be avoided. Loose or malpositioned hardware about the glenohumeral joint must be recognized as soon as possible and removed. The goal of treatment is to correct the deficient stabilizing mechanisms without altering normal glenohumeral function.
Adult↗