Controversies and Alternative Approaches

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1 Solid Foundations for Successful Shoulder Surgery Advantages of the 70 lens in specific procedures are shown in Table 1. Figure 1 Arthroscopic images of a loose body in an axillary pouch as viewed from the posterior portal using a 70 arthroscopic lens with the camera tip positioned at the 12-o clock position on the glenoid (A). This positioning allows free access of the grasper from the anterior portal (rotator interval) for en bloc removal of the loose body (B). Controversies and Alternative Approaches Exposure and Angles of Approach The authors of recent studies of portal placement continue to challenge established standards as demands for closer replication of benchmark open techniques grow. In anterior capsulolabral reconstruction procedures, the placement of suture anchors on the anterior-inferior glenoid from an accessory posterior (7-o clock; posterolateral) portal has been introduced as an alternative to the standard anterior and anterior-inferior portals. New portals have been recommended for access to the subdeltoid space, the retrocoracoid space, and the suprascapular and infrascapular fossae in an attempt to optimize working angles. The 70 arthroscopic lens has gained popularity as well. Although the 30 lens is the standard lens for most arthroscopic shoulder procedures, the more highly angled 70 lens offers certain advantages. As illustrated in the case presented in this chapter, the inflow direction, which often runs along the sheath of the arthroscope, diverges from the field of view. This setup avoids the tendency of the fluid inflow to drive loose materials away from the arthroscope and out of view. The view with the 70 lens is much closer to a 90 periscope-style view than it is to a straight-ahead view; therefore, a blind spot exists directly at the tip of the arthroscope. This blind spot allows use of the lens tip itself for deep retraction of tissues without blocking the aperture for viewing. Challenges associated with the 70 lens include the risk of iatrogenic scuffing of cartilage with the tip of the lens in the blind spot as well as the fact that it allows the surgeon to view structures that, nonetheless, cannot be easily accessed to perform procedures. An example of this difficulty of access to the viewed area occurs when the 70 lens is placed through the posterior portal and directed medially over the anterior glenoid rim, thereby bringing the subcoracoid space and anterior glenoid neck into view. The standard anterior portal may not allow safe access this far medially because of the presence of the conjoint tendon and neurovascular structures. In response to this challenge, an accessory anteromedial portal has been developed to allow the surgeon to complete advanced procedures in this space. Specific discussion of alternative portals is provided later in this chapter. Outside-in Versus Inside-out Technique A technical distinction exists concerning the methods of establishing subsequent portals after the initial blind portal is established. The results of published preclinical studies suggest that these methods create different deep pathways and entail different risks. Surgeons who use skin landmarks, awareness of the desired deep-tissue entry point, and tactile feedback to create portals from the skin to the deep area of interest use the outside-in method. In the visualized outside-in technique, a palpated landmark and arthroscopic view of internal structures are used to guide a spinal needle into position for optimal angle selection followed by portal placement. Conversely, in the inside-out technique, an established portal is used to guide a switching stick from deep space outward, resulting in tented skin that guides placement of the incision for the new portal. Particularly for anterior portals, the inside-out technique has been both advocated for increasing portal access and criticized for increasing proximity to neurovascular structures as a result of the limitations created by the established portal. The outside-in technique may require more advanced triangulation skill and be subject to variability related to surface landmarks, surgical experience, and tactile dexterity. Finally, a growing trend inspired by hip arthroscopy favors the Seldinger technique, or the passage of instruments such as anchors or deep retractors over a guidewire for precision and accuracy of placement. Use of this technique results in greater precision with the outside-in method compared with the method of spinal needle localization followed by complete removal of the needle and insertion of a separate device at the same angle. All recent publications reviewed for this work advocate outside-in techniques. The author of this 2 Advanced Reconstruction: Shoulder American Academy of Orthopaedic Surgeons

Use of Arthroscopic Portals in Shoulder Surgery: Technique and Strategy Figure 3 Diagram depicts the strategy for portal selection in shoulder arthroscopy.

Tactile feedback during portal creation and instrument passage should be smooth and consistent with the density of underlying tissues.

2 Use of Arthroscopic Portals in Shoulder Surgery: Technique and Strategy Figure 3 Diagram depicts the strategy for portal selection in shoulder arthroscopy. to maintain the same pathway to minimize the creation of leakage points for fluid and the obstruction of access by interposed tissue. Tactile feedback during portal creation and instrument passage should be smooth and consistent with the density of underlying tissues. Portal pathways traverse soft-tissue structures in the shoulder; thus, a sensation that the cannula or instrument will not pass smoothly typically indicates a need for adjustment in angle of approach, portal start location, or both. Slightly increased resistance of tissue to instrument passage is expected at the rotator cuff and capsule, but gentle twisting of the instrument with steady pressure should accomplish the goal. Increased resistance may suggest that a change in location is necessary to avoid injury to the patient. Within the safe zones for portal establishment, the surgeon should Figure 4 Illustration depicts alignment of established arthroscopy portals in three dimensions. The green arrow indicates the optimal path for instrument passage to preserve the tissue planes. Red arrows demonstrate inaccurate pathways to the target working zone that disrupt the tissue planes. balance the optimal angle of approach and viewing with the need to establish additional portals or reposition the patient s limb. Multifunctional access through few skin portals is typically possible with a combination of careful 2016 American Academy of Orthopaedic Surgeons Advanced Reconstruction: Shoulder 2 9

Solid Foundations for Successful Shoulder Surgery Figure 1 AP (A) and axillary (B) radiographs from a 33-year-old man with recurrent anterior shoulder dislocation.

3 Solid Foundations for Successful Shoulder Surgery Figure 1 AP (A) and axillary (B) radiographs from a 33-year-old man with recurrent anterior shoulder dislocation. C and D, Three-dimensional CT scans demonstrate substantial glenoid bone loss with an inverted pear appearance. Figure 2 Diagram shows the continuum of surgical options from the least disruptive to subscapularis integrity (subscapularis retraction) to the most disruptive (maximal exposure [subscapularis peel, complete tenotomy]). a Subscapularis integrity is defined by the entire subscapular complex, including the lesser tuberosity. (Figure 3, A). In patients with degenerative fraying of the subscapularis tendon insertion such that a healthy cuff is not available, care should be taken to repair the tenotomized subscapularis directly to the lesser tuberosity. With the arm in neutral to slight external rotation, the tenotomy is begun at the rotator interval and extended through the tendon to the inferior border of the subscapularis tendon (Figure 3, B and C). Typically, the circumflex vessels can be spared. By dissecting medially approximately 1 cm from the vertical incision in the tendon just proximal 2 Advanced Reconstruction: Shoulder American Academy of Orthopaedic Surgeons

The Deltopectoral Approach: Options for Management of the Subscapularis Tendon Figure 3 Intraoperative photographs show the steps of full tenotomy that can be performed while avoiding the anterior

4 The Deltopectoral Approach: Options for Management of the Subscapularis Tendon Figure 3 Intraoperative photographs show the steps of full tenotomy that can be performed while avoiding the anterior circumflex vessels. A, The vertical portion of the tenotomy is denoted by the dashed line. B, The tenotomy is started at the rotator interval. This patient does not exhibit degenerative fraying. C, The tenotomy is carried distally to the circumflex vessel. D, The tendon is carefully separated from the underlying capsule. E, A planned partial L-shaped tenotomy is indicated by the dashed lines. to the anterior circumflex vessels, it is possible to develop a plane separating the muscle from the capsule. The tendon can be separated from the capsule and the tendon released, with dissection from inferior to superior (Figure 3, D). The anterior circumflex vessels occasionally may be sacrificed because they do not provide the predominant blood supply to the proximal humerus. The capsule can be incised either with the tendon or separately depending on the surgical procedure performed. Anatomic repair of the tenotomy should be done meticulously with nonabsorbable No. 2 high tensile strength braided suture. The senior author (R.A.) has described a technique using a partial L-shaped tenotomy for exposure in patients with humeral avulsion of the inferior glenohumeral ligament. The vertical tenotomy is limited to the lower third of the tendon, thereby preserving the anterior circumflex vessels, and then is extended horizontally to create an L-shaped partial tenotomy (Figure 3, E). This technique affords better exposure of the inferior capsule than does an isolated subscapularis split. With partial tenotomy, it may be possible to leave some proprioceptive fibers intact American Academy of Orthopaedic Surgeons Advanced Reconstruction: Shoulder 2 3

5 Acromioclavicular Pathology Table 3 Results of Fusion of Symptomatic Os Acromiale a Author(s) Abboud et al Atoun et al Journal (Year) J Shoulder Elbow Surg (2006) J Shoulder Elbow Surg (2012) Type of Os Acromiale Mesoacromion Mesoacromion Outcomes Satisfactory results in 3 of 8 shoulders 100% union rate Mean Constant score improved from 49 to 81 7 of 8 shoulders united Failure Rate (%) Comments 0 Tension-band technique with wires or compression screws Hardware removal was required in 7 shoulders Workers compensation was associated with worse outcomes 4 shoulders presented with RCT Mean follow-up, 3.3 yr 12.5 Arthroscopic fixation Absorbable cannulated screws 5 shoulders (63%) presented with RCT Mean follow-up, 1.8 yr N/A = not available, ORIF = open reduction and internal fixation, RCT = rotator cuff tear, UCLA = University of California Los Angeles Shoulder Rating Scale. a All studies in this table used ORIF except as noted. AC joint is symptomatic. Mobility is not assessed intraoperatively because the surgical decision making was done based on the preoperative evaluation. In patients with a rotator cuff tear that is noted at the time of diagnostic arthroscopy, the tear is addressed in standard arthroscopic fashion before completion of the procedure. Fusion of the Os Acromiale The authors of this chapter prefer to use a transacromial approach in which a longitudinal incision is made in line with the synchondrosis. This helps to preserve the blood supply to the anterior and posterior segment. Large, full-thickness subcutaneous flaps are developed anteriorly and posteriorly, but the deltoid attachments should be preserved as much as possible except for directly at the synchondrosis site. The deltoid can be split in line with its fibers laterally to allow exposure of the subacromial space and evaluation of the rotator cuff. Figure 5 Treatment algorithm for symptomatic os acromiale. The synchondrosis must be fully resected to expose bleeding bone on both the anterior and posterior segments. Care should be taken to avoid introducing flexion at the synchondrosis site; preferably, the shape of the acromion should be flattened by fusing the segments in extension slightly greater than was present initially. The authors of this chapter prefer to 8 Advanced Reconstruction: Shoulder American Academy of Orthopaedic Surgeons

Rehabilitation The postoperative rehabilitation protocol may be influenced by procedures performed along with the synchondrosis excision, such as rotator cuff repair.

6 Management of Os Acromiale use cannulated screws with tension band wiring. All patients should be counseled preoperatively that they likely will require secondary surgery in the future for hardware removal. Rehabilitation The postoperative rehabilitation protocol may be influenced by procedures performed along with the synchondrosis excision, such as rotator cuff repair. The rehabilitation protocols in the absence of additional procedures are outlined in Tables 4 and 5. Avoiding Pitfalls The surgeon should maintain as much stability of the anterior fragment as possible while performing an adequate resection of the synchondrosis. To do this, the superior periosteal attachment and the posterior AC ligaments should be maintained. Most of the coracoacromial ligament should be preserved to provide additional stability to the anterior fragment. Preservation of this ligament is key to maintaining deltoid function and preventing secondary shoulder dysfunction, such as AC joint instability. Adequate anterior acromioplasty should be performed to prevent dynamic impingement. With resection of the synchondrosis, the anterior fragment becomes less stable and more prone to flexion with elevation of the arm. An adequate acromioplasty can help to prevent this effect. Although the amount of acromion that needs to be resected varies from patient to patient, the authors of this chapter advocate a slightly more aggressive acromioplasty than is typically undertaken, with the goal of Figure 6 Intraoperative arthroscopic Figure 7 Intraoperative arthroscopic image demonstrates the appearance of the os acromiale from the lateral viewing portal. image demonstrates the appearance of the os acromiale from the lateral viewing portal after excision of the synchondrosis. Table 4 Rehabilitation Protocol After Either Excision or Fusion to Manage Os Acromiale Postoperative Week ROM Strengthening Return to Play Comments/Emphasis 0-2 Sling None No Activities of daily living permitted 2-4 As tolerated None No Formal therapy only if restricted ROM at postoperative visit 4-12 As tolerated Yes No Progressive strengthening within limits of comfort >12 As tolerated Yes Yes No restrictions ROM = range of motion. Table 5 Rehabilitation Protocol After Decompression to Manage Os Acromiale Postoperative Week ROM Strengthening Return to Play Comments/Emphasis 0-2 Sling None No Sling at all times 2-6 Passive only None No Sling except for ROM exercises 6-12 As tolerated Progressive No Progressive ROM and strengthening as tolerated >12 As tolerated Functional When pain free Activity as tolerated ROM = range of motion American Academy of Orthopaedic Surgeons Advanced Reconstruction: Shoulder 2 9

Glenohumeral Arthritis Table 1 Infection Rates After Two-Stage Revision for the Management of Infected Shoulder Arthroplasty Authors Journal (Year) Technique (No.

7 Glenohumeral Arthritis Table 1 Infection Rates After Two-Stage Revision for the Management of Infected Shoulder Arthroplasty Authors Journal (Year) Technique (No. of Patients) Infection Rate (%) Seitz and J Arthroplasty (2002) Anatomic TSA (8) 0 Damacen Mileti et al J Shoulder Elbow Surg (2004) Anatomic TSA (4) 0 Cuff et al J Bone Joint Surg Br (2008) Reverse TSA (12) 0 Strickland et al J Bone Joint Surg Br (2008) Anatomic TSA (19) 37 Coffey et al J Shoulder Elbow Surg (2010) Reverse TSA (10), anatomic TSA (2) 0 Jawa et al J Bone Joint Surg Am (2011) Reverse TSA (10), anatomic TSA (5) 13 Sabesan et al Clin Orthop Relat Res (2011) Reverse TSA (17) 6 Weber et al Int Orthop (2011) Reverse TSA (3), anatomic TSA (1) 0 Romanò et al Int Orthop (2012) Reverse TSA (13), anatomic TSA (4) 0 TSA = total shoulder arthroplasty. process may aid in fi nding the deltopectoral interval. Adhesions in the subacromial space and subdeltoid bursae are released to help protect and mobilize the deltoid. The axillary nerve will be difficult to identify as a result of scarring. Care must be taken to localize and protect this nerve during the dissection. The subscapularis is released and tagged. All remaining suture material is removed. The capsular tissue is removed, and sections are sent for immediate pathologic evaluation to determine the number of leukocytes per high-power field. Specimens must be obtained for culture and sensitivity testing throughout the procedure. Releases are performed along the humeral neck to enable adequate external rotation of the humerus to dislocate the implant. INSTRUMENTS/EQUIPMENT/ IMPLANTS REQUIRED Removal of the prosthesis, cement (if present), and all nonviable tissue is essential to ensure adequate débridement. If the implant Figure 6 Photograph shows ultrasonic equipment for use in removal of humeral canal cement. manufacturer is known, the surgeon can preorder specific instruments for removal. Ultrasonic cement removal equipment, handheld burrs, curets, and flexible osteotomes are helpful in extracting the implant and any retained cement (Figures 6 and 7). If the implant cannot be removed with this equipment, an extended humeral osteotomy or window will be necessary for extraction of the implant. An antibiotic spacer may be created by mixing antibiotics and cement on the back table and using a mold; however, commercially available antibiotic spacers have been shown to provide a more concentrated elution of antibiotics over an extended period (Figure 8). If the surgeon uses a mold to create the spacer, metal reinforcement should be used because the cement may break down if the spacer is left in place for an extended period. 4 Advanced Reconstruction: Shoulder American Academy of Orthopaedic Surgeons

One- and Two-Stage Revision of Infected Total Shoulder Arthroplasty PROCEDURE After adequate exposure has been obtained, the prosthetic humeral head is removed to allow visualization of the glenoid

A handheld burr may be used for this removal. Tissue samples obtained at the glenoid bone-implant interface should be sent for culture and evaluation of the number of leukocytes per high-power field.

8 One- and Two-Stage Revision of Infected Total Shoulder Arthroplasty PROCEDURE After adequate exposure has been obtained, the prosthetic humeral head is removed to allow visualization of the glenoid implant. Removal of the glenoid implant is usually not difficult and can be accomplished with a rongeur and/or osteotomes. All remnants of cement are removed from the vault of the glenoid. A handheld burr may be used for this removal. Tissue samples obtained at the glenoid bone-implant interface should be sent for culture and evaluation of the number of leukocytes per high-power field. Tissue from this location typically has the highest yield of positive cultures and needs to be obtained if at all possible. The humeral stem is removed with the manufacturer s recommended removal equipment if available; if such equipment is not available, standard revision instrumentation is used. If the humeral stem is well fixed, then the use of a needle-tipped burr around the implant can aid in the extraction. Osteotomy may be necessary in patients with well-fi xed cemented implants. A straight longitudinal cut is made approximately 3 to 4 cm proximal to the tip of the distal cement plug. The cement mantle is loosened with a thin osteotome through the osteotomy site. This maneuver usually weakens the prosthesis-cement interface and/or the bone-cement interface. The prosthesis is removed using a bone tamp or the manufacturer s recommended instrumentation. Culture and biopsy specimens are obtained from the bone-implant interface. All cement, if present, is removed with the ultrasonic device. Figure 7 Photograph shows a bone tamp and a needle-tipped burr for use in implant removal. Adequate irrigation must be used during this procedure to avoid overheating the bone. To avoid radial nerve injury, care must be taken not to penetrate the humerus during cement removal. The osteotomy is protected with heavy polydioxanone suture or cerclage wires. The wound is copiously irrigated with pulsatile lavage using antibiotic solution. A small amount of antibioticimpregnated cement is used to form a collar for the spacer to sit on, and the spacer is placed. This cement also provides rotational stability. WOUND CLOSURE A deep drain is placed in the glenohumeral joint space, and the deltopectoral interval is closed. If the rotator cuff tissue can be repaired, the repair is performed with the use of heavy monofilament suture. Figure 8 Photograph shows a commercially available articulating antibiotic spacer (Tecres [Verona, Italy]; distributed by Exactech). The deltopectoral interval is closed with monofilament suture. The skin is closed with a monofilament suture or skin staples. The shoulder is immobilized in a sling or immobilizer for comfort and wound support. Stage 2 After the organism has been identified and the appropriate antibiotic regimen started, the patient s IL-6 value can be measured weekly to determine the timing of the second stage of the procedure. The second stage is typically performed approximately 4 to 8 weeks after the first stage. SETUP/EXPOSURE Patient positioning is the same as in stage American Academy of Orthopaedic Surgeons Advanced Reconstruction: Shoulder 2 5

D Degenerative joint disease, rotator cuff deficiency with, 149 Deltopectoral approach component removal with, 128

D Degenerative joint disease, rotator cuff deficiency with, 149 Deltopectoral approach component removal with, 128 Index A Abduction exercise, outpatient with, 193, 194 Acromioclavicular arthritis, with, 80 Acromiohumeral articulation, with, 149 Acromio-humeral interval (AHI), physical examination with, 9, 10 Active