Faculty Bibliography

Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.

INTRODUCTION: Frozen shoulder (FS) is a common diagnosis treated by orthopaedic surgeons and other physicians caring for musculoskeletal problems. However, there is no standard definition and classification for this common condition. MATERIALS AND METHODS: We asked 211 clinician members of the American Shoulder and Elbow Surgeons to review our proposed definition of FS and its classification into primary and secondary types. Secondary FS was further divided into intrinsic, extrinsic, and systemic types. The survey required responses to 5 specific questions via an analog scale (1, strongly disagree; 5, strongly agree). Agreement was defined as a 4 or 5 on the analog scale. RESULTS: We received 190 responses (90%). Eighty-two percent agreed with the proposed definition of FS. Eighty-five percent agreed that FS should be divided into primary and secondary types. Sixty-six percent agreed with subdivision of secondary FS into intrinsic, extrinsic, and systemic types. Eighty-four percent agreed that there was a clinical entity of primary or idiopathic FS. Eighty-five percent agreed that obtaining a consensus definition and classification of FS was a worthwhile endeavor. DISCUSSION: Significant benefits can be gained from the development of a standard definition and classification of FS, achieved through a consensus of shoulder specialists, that provides a strong foundation for potential acceptance by all musculoskeletal specialists who treat this condition

The glenohumeral joint is the most commonly dislocated joint in the body. The prevalence of this condition and the instability that may result from it has been a focus of diagnosis and treatment since the original description of the Bankart lesion in 1923. Now, with the introduction of MRI, lesions causing anterior shoulder instability can be diagnosed more accurately. This has led to improved understanding of the pathoanatomy that must be addressed and corrected during surgical repair. Initial attempts at arthroscopic treatment, including staple repair, transosseus suture repair, rivets, and thermal capsulorraphy were fraught with complications and unacceptably high recurrence rates. The development of arthroscopic suture anchors have revolutionized the treatment of anterior shoulder instability, such that arthroscopic management is now the standard of care. In the hands of experienced surgeons, outcomes for arthroscopic treatment of shoulder instability now approaches the success of open treatment

BACKGROUND: Previous studies have documented a decrease in proprioceptive capacity in the unstable shoulder. The degree to which surgical approach affects recovery of strength and proprioception is unknown. MATERIALS AND METHODS: The recovery of strength and proprioception after open surgery for recurrent anterior glenohumeral instability was compared for 2 surgical procedures. A prospective analysis of 55 consecutive patients with posttraumatic unilateral recurrent anterior glenohumeral instability was performed. Thirty patients (group 1) underwent an open inferior capsular shift with detachment of the subscapularis, and 25 (group 2) underwent an anterior capsulolabral reconstruction. RESULTS: Mean preoperative proprioception and strength values were significantly lower for the affected shoulders in both groups. At 6 months after surgery, there were no significant differences for mean strength and proprioception values between the unaffected and operative sides for group 2 patients. In group 1 patients, however, there were still significant deficits in mean position sense and strength values. Complete restoration of proprioception and strength, however, was evident by 12 months in group 1. CONCLUSION: This study demonstrates that there are significant deficits in both strength and proprioception in patients with posttraumatic, recurrent anterior glenohumeral instability. Although both are completely restored by 1 year after surgery, a subscapularis-splitting approach allows for complete recovery of strength and position sense as early as 6 months postoperatively. Detachment of the subscapularis delays recovery of strength and position sense for up to 12 months after surgery

Coracoid fractures are uncommon injuries, in isolation or in association with other osseoligamentous injuries about the shoulder girdle. We report a case of successful operative management of symptomatic ipsilateral nonunions of a type I coracoid base fracture and a lateral one-third clavicular fracture, which developed following nonoperative treatment of this exceedingly rare injury pattern. Following open distal clavicle excision and reduction of the coracoclavicular interval with screw fixation, radiographic union and excellent clinical outcome were achieved. This rare and potentially troublesome injury pattern is discussed, and the literature regarding ipsilateral coracoid and osseoligamentous injuries about the shoulder is reviewed

Anterior glenohumeral instability complicated by bone loss is a challenging problem and, when severe, may require surgical treatment with bone grafting. We review our institution's experience with humeral head and glenoid bone grafting for large Hill-Sachs lesions and glenoid defects. MATERIALS AND METHODS: Patients who underwent intra-articular bone reconstruction for Hill-Sachs and large glenoid defects for anterior instability at our institution during 2002-2008 were retrospectively reviewed. Those who had undergone concomitant humeral head replacement were excluded. Six patients were identified as having undergone allograft or autograft iliac crest bone graft reconstruction of the glenoid, with four available for full follow-up (average 39 months; range, 7 to 63). Five patients were identified as having undergone humeral head allograft reconstruction and four were available for full follow-up (average 28 months; range, 11 to 40). The remaining three patients were available for telephone follow-up. American Shoulder and Elbow Society (ASES) and University of California, Los Angles (UCLA) scores were recorded and radiographs obtained. RESULTS: Average postoperative ASES and UCLA scores for glenoid bone graft patients were 91 and 33, respectively. Average postoperative ASES and UCLA scores for humeral bone graft patients were 85.3 and 28.4, respectively. Glenoid bone graft shoulders, when compared to the opposite normal side, lost an average of 3 degrees of forward flexion, 10 degrees of external rotation, and two levels of internal rotation. Humeral head bone-grafted shoulders, lost an average of 23 degrees of forward flexion, 8 degrees of external rotation, and two levels of internal rotation. No episodes of recurrent subluxation or dislocations were reported. Radiographs showed no evidence of graft resorption or hardware prominence. CONCLUSIONS: Bone grafting procedures around the shoulder for the treatment of instability provided relief from recurrent instability and good functional results

The use of arthroscopic techniques for excision of the pre-patellar bursa has become more common in recent years for the treatment of prepatellar bursitis. The current literature includes several case series that report few complications with this technique. We report the case of a 73-year-old male who sustained a low-energy patella tendon rupture 2 months after arthroscopic resection of the prepatellar bursa. We hypothesize that during arthroscopic excision of the prepatellar bursa there was an iatrogenic injury to the patellar tendon, which contributed to the subsequent rupture. Surgical repair was successfully performed using an open technique with a 1-year follow-up. To our knowledge, this is the first case report of patella tendon rupture following arthroscopic excision of the prepatellar bursa

Snapping scapula syndrome arises from either a soft-tissue or a skeletal anomaly within the scapulothoracic space that creates a cracking sound during scapulothoracic motion that patients associate with pain. Nonoperative measures consisting of supervised physical therapy, anti-inflammatory medications, and therapeutic injections are the mainstay of treatment. Open, arthroscopic, and combined operative approaches have been described for the treatment of refractory cases, with good overall outcomes in many relatively small case series. However, the optimal operative approach has yet to be determined