ACJ Arthritis



Post-traumatic (type III clavicle fractures)



4 patterns 


1. OA with osteophytes 

-  contribute to impingement


 Acromioclavicular Arthritis


2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)


ACJ OsteolysisACj Osteolysis


3. RA


4. Hyperparathyroidism




Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm




ACJ OA Clinical Photo


Tenderness to direct palpation is most reliable sign

- may feel osteophytes

- must compare to ensure other side is not tender (but may have bilateral ACJ OA)


Cross body adduction of arm 

- tends to overlap with impingement




LA + Cortisone

- inject into joint

- diagnostic / therapeutic





- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis



- Cervical root C4/5

- shoulder tip pain from abdominal pathology




Zanca view

- AP 10° cephalic tilt with 50% penetration 


ACJ OA Inferior Clavicle Osteophyte


Bone Scan


Not usually necessary


ACJ OA Hot Bone Scan






Most patients respond well


Activity modification

Steroid injection




Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment




Resect sufficient distal clavicle to prevent abutment




1.  Open excision distal clavicle

2.  Arthroscopic resection


Open Excision of distal clavicle


Post Open ACJ Excision



- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact


90% success rate


Arthroscopic ACJ Resection



- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation




Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

- identified subtle intra-articular changes not seen on MRI  which were treated

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection




1.  Identify distal clavivle

- remove bursa and perform SAD

- use electrocautery from lateral portal to identify the distal clavicle (push down on clavicle repetitively)

- clean and identify clavicle anterior and posterior




2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

- must remove full thickness of distal clavicle superiorly / be able to visualise superior AC ligament

- must not leave posterior edge


ACJ OA 3 Anterior CannulaACJ OA Debridement 1ACJ OA Debridement 2


Post Arthroscopic ACJ resectionSuperior AC Ligament post arthroscopic resection




ACJ Dislocation

Type 3 ACJ Dislocation



Synovial joint with hyaline cartilage


Has fibrocartilage intra-articular disc

- complete or incomplete

- usually degeneration by 4th decade


Clavicle may lie superior to acromion in normal population


Acromioclavicular Ligaments


ACJ capsule

- strongest superiorly

- horizontal / AP stability


Coracoclavicular Ligaments / CCL


Primary restraint to superior translation

- primary suspensory ligament of upper limb


Trapezoid Ligament (anterolateral)

- anterolateral on coracoid

- inserts trapezoid ridge also anterolateral to conoid

- almost horizontal in sagittal plane

- primary restraint to axial compression


Conoid Ligament (posteromedial)

- arises postero-medial to trapezoid

- inverted cone

- inserts conoid tubercle

- apex of posterior clavicular curve

- junction lateral & medial 2/3

- lies vertically

- primary restraint to superior and anterior translation


Delto-trapezial fascia

- dynamic stabiliser


Motion at ACJ


Only small 5-8o

- 40o at SC joint

- motion is at scapulo-thoracic joint rather than ACJ




Usually direct force onto adducted shoulder joint

- clavicle remains in normal position

- arm falls down




Usually clinically obvious


Grade 3 ACJGrade 3 ACJ


Allman grades I-III 1967 / Rockwood modified 1989 Classification


I     ACJ sprain


II    ACJ Disrupted & CCL intact / sprained


ACJ Dislocation Grade 2


III  Rupture ACJ & CCL 

- displaced > 100% of clavicular width


Grade 3 ACJ Dislocation


IV   Into trapezius

- can be easily missed

- need axillary lateral


Type IV ACJ APType IV ACJ Axillary LateralType IV ACJ


V     High dislocation > 1 x clavicle width

- disrupted trapezius & deltoid

- end of clavicle subcutaneous


ACJ Dislocation Type 5


VI    Subcoracoid dislocation




Zanca view

- specific for ACJ

- 10ocephalad, 50% voltage


Stress views

- occasionally used

- hold weights in each arm

- bilateral xray



- 50% overriding clavicle

- 2% under riding

- 29% incongruent

- joint width 0.5-7 mm




Type I


Symptoms 7-10 days


- Avoid heavy stress & contact sport till FROM & no pain to palpation

- 2/52


Type II


Sling 2/52

- avoid heavy lifting, contact sports 8-10/52 to allow ligament healing

- OT if Persistent pain


Chronic Symptomatic I & II

- trapped capsular ligament / loose articular cartilage / detached meniscus

- excision outer end clavicle if continued symptoma


Acute Type III


RCT Operative vs Non-Operative


Tamaoki et al Cochrane Database 2010

- meta-analysis of 3 RCT

- operative v non operative

- multiple fixation techniques

- no obvious advantage in operative group

- RCT insufficient to decide merit of operative management


Surgical Indications



- heavy labourer

- < 25 years undecided on career

- not in athlete (will just destroy repair when next falls)




1.  Hook plate

- reduction of ACJ

- hook under posterior acromion

- allows CC ligaments to heal

- must be removed

- but can mobilise the shoulder at 4-6 weeks with implant in situ


Clavicle Hook Plate


Gstettner et al J Should Elbow Surg 2008 

- acute injuries

- hook plate or non operatively, patient choice

- 57 v 30

- hook plate removed after 3 months

- 1 hook plate cut up through acromion (still good result)

- 3 superficial infections

- slightly improved constant scores in surgical group

- similar ROM

- improved pain and power scores



- acromial cut out

- clavicle fracture


Clavicle Hook Plate Fracture


2.  Reconstruction


Chronic Symptomatic Grade III


Excision distal clavicle


Poor results

- convert long high riding clavicle to short high riding clavicle


Reconstruction Options

- Phemister technique

- Weaver Dunn

- CCL augmentation (anchors / tightrope)

- CCL Reconstruction

- combinations


1.  Phemister technique



- open reduction of ACJ

- 2 x K wires across ACJ

- suture repair AC and CC ligaments


Calvo J Should Elbow Surg 2006

- Phemister v Non operative

- similar rates of deformity (i.e. non anatomic reduction) 

- less radiographic OA in non surgically treated cases

- may be that K wires further damage joint

- similar functional results in each

- recommend non operative treatment


2.  Weaver Dunn Reconstruction



- reconstruction of CC ligament with coraco-acromial ligament (CAL)

- CA ligament left attached to coracoid

- excise 1.5 (2.5cm original recommendation) lateral clavicle

- CAL taken off anterior acromion with bone fragment

- transferred from acromion to clavicle end / intra-osseous suture repair


Supplement with

- hook plate

- Bosworth Screw

- anchor / sutures

- Lars Ligament / Hamstring / allograft


3.  CCL Augmentation



- 5 mm anchor with sutures about clavicle

- tightrope constructs

- Bosworth screw


Weaver Dunn with Twinfix AnchorACJ Reconstruction TightropeACJ Reconstruction Tightrope


4.  CCL Reconstruction



- pass allograft / autograft / LARS around coracoid

- pass around clavicle and suture or

- can pass through drill holes and secure with screws

- second technique risks clavicle fracture




Tauber et al J Should Elbow Surg 2007

- 12 revision cases of failed Weaver Dunn

- autogenous ST in figure 8 configuration

- through drill holes in clavicle, around coracoid, then over clavicle

- augmented with Bosworth / TBW removed at 3/12

- 4 weeks immobilised, then ROM to 90o for another 8 weeks

- good results, one clavicle fracture from wire



- intra-operative fracture coracoid

- failure repair (10 - 20%)

- recurrent deformity common in surgical groups

- clavicle fracture (due to sutures or metal work)


- continued pain

- posterior dislocation (due to non intact AC ligament)

- NV damage


Type IV, V, VI


Most recommend surgery

- hook plate / reconstruction acutely

- reconstruction late


Technique Weaver Dunn + Augmentation / Reconstruction



- 45o beach chair

- sabre incision over ACJ

- split fascia transversely along the clavicle and onto acromion

- must skeletalise distal end of clavicle to beyond former insertion of conoid and trapezoid

- expose anterior aspect of acromion

- resect 1 cm of distal clavicle with microsagittal saw

- find the CA ligament which will run from anterior acromion down to coracoid

- often a great deal of scar tissue in this area from injury

- expose the coracoid laterally and carefully medially

- take off anterior 5mm of acromion and carefully peel CAL off the underlying SSC

- will need to release some of CAL from coracoid to get sufficient length


Reduction / Reconstruction

- reduce clavicle down with preferred technique

- 5mm anchor / tightrope / allograft / autograft / Lars ligament through drill holes

- cross graft at clavicle so gives front to back stability as well as superior / inferior

- place drill holes through distal clavicle

- use 2 fibre wire to weave through CAL under bony fragment

- secure with intra-osseous sutures


Post op

- sling for 6/52

- no contact sports for 6/12


Post Weaver Dunn with Lars Ligament

Os Acromiale



Failure of fusion of adjacent ossification centers




Incidence 3%


Bilateral in 60%




4 ossification centers present in acromion

- pre-acromion

- mesoacromion

- metaacromion

- basiacromion


The basiacromion fuse to spine of scapula by 12


Pre / Meso / Meta appear by 18

- Unite by age 22 - 25

- If un-united = Os Acromiale 




1.  Meso-Acromion

-  most common

- level with posterior aspect clavicle


 Os Acominale XrayOs Acromionale MRI AxialOs Acromionale MRI Sagittal


2.  Pre-acromial

- less common

- level with anterior border acromion


 Os Acrominale MRI T2


3.  Meta-Acomial

- rare




Best seen on axillary lateral


Factors favoring diagnosis of os acromiale over fracture 

- bilateral occurrence (Xray other side)

- rounded borders with uniform space




Useful investigation

- may show oedema if problematic


Os Acromionale MRI 1Os Acromionale MRI 2


Bone scan


Can be very important

- unlikely to be symptomatic if cold

- may be symptomatic / need addressing if hot


Symptomatic Os Acromionale


1.  Non union

- painful

- MRI / bone scan shows inflammation


2.  Dynamic impingement

- fragment moves with deltoid contraction

- decreases size of SS outlet

- impingement symptoms


Os AcromionaleOs Acromionale 3





- failure of non operative treatment




1.  Excision

- small fragment / pre-acromion

- risk defunctioning deltoid

- can perform arthroscopically and leave deltoid attachment intact

- open excision with careful reattachment


Pagnani JSES 2006

- arthroscopic excision in 11 shoulders of athletes

- all returned to sport at 14 weeks

- no loss of strength detected


Os Acromiale Arthroscopic


2.  ORIF

- large fragment / mesoacromion

- take down non union

- bone graft / 2 x AP 3.5 mm screws / TBW

- especial care with deltoid reattachment


Os Acromionale ORIF 1 Os Acromionale ORIF 2Os Acromionale ORIF 3


Risk of nonunion


Os Acromionale Nonunion 1Os Acromionale Nonunion 2Os Acromionale Nonunion 3Os Acromionale Nonunion 4


Peckettet al JSES 2004

- ORIF in 26 patients

- Union 25/26, 2 fractures

- 30% required removal metalwork


3.  Arthroscopic SAD

AVN Shoulder

Shoulder AVN




Much less common than hip OA

- usually presents late




Similar causes as hip (AS IT GRIPS 3C)


Alcohol / Steroid / Trauma / Idiopathic




RA / RTx


Sickle Cell 

- commonest cause worldwide

- bilateral


Caisons / Chemotherapy


Blood Supply


Gerber JBJSA 1990


1.  Anterior Circumflex Humeral Artery

- primary blood supply

- becomes arcuate artery

- runs lateral aspect bicipital groove


2.  Posterior Circumflex Humeral Artery

- collateral circulation

- supplies head when GT / LT fracture


3.  Via Rotator Cuff




Wide range of AVN after 4 part fractures

- about 1/3


Recent studies to explain this


1.   Suggest 2nd anastomotic system 

- via posteromedial branches of PCHA along inferomedial capsule

- blood supply may be further compromised by large exposure in ORIF


2.  Creeping substitution

- occurs more extensively in humeral head


3.  Rich vascular tissue surrounding humeral head


Natural History



- Difficult to predict

- Somewhat related to aetiology

- Sickle cell disease tend not to progress to arthroplasty

- Steroid induced far more likely


Less severe than femoral

- non weight bearing

- less conforming joint

- scapulothoracic motion




Superior head collapse at 90° mark 

- area of peak contact stress in abduction

- ROM Maintained until late

- Glenoid rarely affected

- Soft tissue and SSC rarely contracted


Classification / Cruess modification of Ficat-Arlet 


Stage 1

- prexray change

- only seen with MRI


Stage 2

- sclerotic changes in superior central head

- sphericity maintained


Humeral AVN Stage 2Humeral AVN Stage 2 MRI


Stage 3 

- "Crescent" Sign

- mild flattening articular surface


Shoulder AVN Stage 3


Stage 4

- significant humeral collapse with loss integrity joint surface

- loose bodies


Shoulder AVN Stage 4Shoulder AVN Stage 4


Stage 5

- degeneration extends to involve glenoid


AVN Shoulder Xray




Pain is major problem

- pain before significant loss ROM

- difficulty sleeping




Shoulder AVN MRIShoulder AVN MRI Sagittal




Remove insult

- corticosteroids, alcohol


Non Operative


Maintain current shoulder ROM / Halt Progression


A.  Prevent disuse related stiffness

- passive physio


B.  Limit overhead activities

- Joint Reaction Force greatest > 90o


C.  Bisphosphonates




Core Decompression


Decrease intraosseous pressure & increase blood flow

- moderate success mainly in stage 1 or 2




Usually works well

- glenoid not usually affected

- Soft tissue and subscapularis rarely contracted 


Smith et al J Should Elbow Surg 2008

- steroid induced AVN

- survival 92% 10 year

- 2 patients needed revision for painful glenoid arthrosis

- good option




Indicated in stage V only

- beware in young patient < 65




Arthrodesis Shoulder



Indications have narrowed

- due to success of shoulder arthroplasty


1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Stabilization after resection for neoplastic lesions




Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers (no movement possible)

Charcot arthropathy (low chance union)




Permanent solution




Loss of movement at shoulder

Difficulty with activities at head level or behind the back 

Perineal care


Loss of movement at other joints 2° prolonged immobilisation




80-95% patient satisfaction


Union rates ~ 95%




Rowe 1974 Requisites after Shoulder Arthrodesis


1.  Hand should reach face / head / mid-line of the body anteriorly & posteriorly

- thumb to chin

- reach axilla, mouth and belt buckle

- combination of forward flexion and elbow flexion


2.  Shoulder be comfortable at rest / scapula should not be prominent

- arm should hang by side with scapula flat against thorax

- no winging




Rockwood et al JBJS Am April 2001

- Abduction 10-15°

- Flexion 10-15°

- Internal Rotation 45°



1.  Technically difficult to obtain correct position intra-operatively

2.  IR most important to later function

3.  Position in reference to trunk not scapula

4.  Avoid excessive abduction & flexion

- forces the scapula to rotate & wing at rest

- leads to fatigue & discomfort




1. Need painless, supple joints above & below

2. Rigidly stabilise congruent vascular cancellous surfaces under compression

3. Bone graft & splint as needed 




Intra-articular / glenohumeral


Extra-articular /  acromio-humeral








A.  Posterior

- detach deltoid from spine

- between IS and TM


B.  Anterior

- detach deltoid from clavicle



- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- arthrodesis between humeral head and glenoid / acromion

- temporarily fix with steinman pins GHJ and acromion-humerus

- check position / ROM / no winging

- if satisfactory, insert GHJ and acromial-humeral compression screws

- humerus - acromial plate if anterior approach

- humerus - scapular spine plate if posterior approach




Early skin breakdown

Loss elbow flexion



Painful metalwork

Breakage of metalwork

Suprascapular nerve entrapment

AC joint OA




Cofield & Briggs JBJS 1979

- 71 fused shoulders

- average 9 year follow up

- 96% union rate

- 75% adequate pain relief

- 70% good functional result






Hemiarthroplasty Osteoarthritis

Shoulder Anatomical HemiarthroplastyHemiarthroplasty OAShoulder Resurfacing




Fewer complications than TSR

Simpler procedure

Indicated in younger patient




Glenoid wear after hemiarthroplasty

- potential for medial migration & progressive glenoid wear

- revision to TSR almost always alleviates symptoms


Hemiarthroplasty V TSR for OA


Sandow et al J Should Elbow Surg 1999

- study randomized after inspection of glenoid

- less pain with TSR

- high revision rate in Hemiarthroplasty for glenoid wear over time

- had to cease study as TSR results significantly superior


Lo et al JBJS Am 2005

- metanalysis

- TSR superior pain relief / active ROM / patient satisfaction


Similar in AVN and fracture


Less clear for RA

- risk of glenoid component loosening


Hemiarthroplasty + Biological Resurfacing


Elhassen et al JBJS Am 2009

- 13 patients average age 34

- glenoid resurfacing with achilles allograft

- 10/13 required revision at average 14 months for pain

- all had glenoid wear with no evidence of allograft


Indications Hemiarthoplasty


1.  Normal glenoid

- AVN / trauma

- replace glenoid later if needed

- simple procedure for elderly


2.  Young patient


3.  Glenoid insufficient bone stock


Clinical Case


Patient with OA treated with Hemiarthroplasty


Shoulder Hemiarthroplasty for Osteoarthritis AP


The patient developed pain 2 years later

Infection was excluded with blood tests

CT and bone scan indicative of glenoid wear

US demonstrated intact rotator cuff


CT Shoulder Hemiarthroplasty for OsteoarthritisBone Scan Shoulder Hemiarthroplasty for Osteoarthritis


Revision to TSR

- cemented 3 peg glenoid inserted

- modular body removed to access glenoid

- shorter body used to decrease humeral head height

- intra-operative GT Fracture treated with trauma body and sutures


Hemiarthroplasty revised to TSR


Reverse TSR


Intraoperative glenoid fracture


Avoid by

- careful reaming and drilling osteoporotic bone



1.  Rotate metaglene

- use locking screws to stabilise glenoid

2.  PA screws

- cannulated 4.0 mm screws

- inserted percutaneously from posterior




Great deal of dead space is created

- always use a drain


Nerve injuries




Thought to be more prevalent due to increase stretch of plexus compared with TSR


TSR Brachial PlexusReverse TSR Plexus Stretch




Spacer for Infected Reverse TSR


Sabesan et al Clin Orthop Research 2010

- 17 patients treated with 2 stage revision

- 1 recurrence of infection

- 5 dislocations


Inferior scapula notching


Reverse TSR Notching



- metaglene not placed inferiorly enough

- humeral component impinges on scapular neck in adduction




Inferior tilt / inferior translation / overhand

- place metaglene very inferior

- use eccentric glenoidspheres / overhang inferiorly

- lateralised glenosphere



- may be cause for development of late pain


Simovitch et al JBJS Am 2007

- 77 reverse Delta III shoulders

- 44% inferior glenoid notching

- anterior and posterior notching also occurred

- related to height of implantation of glenosphere +++

- less so to the prosthesis-scapular neck angle

- inferior scapula notching related to poorer clinical outcome




Failed Glenoid Reverse TSRReverse TSR Loose Metaglene




Dislocated Reverse TSR AP


Dislocated Reverse TSRDislocated Reverse TSR Lateral


Acromial Stress Fracture


Probably due to overtightening


Reverse TSR OvertighteningReverse TSR Overtightening 2


Xray Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSRCT Acromial Stress Fracture Reverse TSR 2


Reverse TSR Acromial Fracture ORIF


Glenosphere loosening from Metaglene


Reverse TSR Loose Glenosphere from Metaglene




1.  Templating




Rotator Cuff Arthropathy


AP in plane of scapula

- template glenoid 

- most inferior screw is in thick bone of scapular axillary border


AP humerus

- size and fit of diaphyseal and metaphyseal humeral components





- assess glenoid bone stock / version

- normally no posterior wear in cuff arthropathy


Glenoid Pre Rev TSR Axial CT



- often superior wear


Glenoid Pre Rev TSR Coronal CTGlenoid Pre Rev TSR Coronal CT 2


2.  Deltopectoral approach



- long

- need to be able to access clavicle

- make need to perform clavicular osteotomy



- take SSC and capsule off LT and humerus

- often done with osteotomy as per TSR

- identify and protect axillary nerve

- take part of CAL

- remove capsule from inferior humeral neck + any osteophytes


3.  Humeral resection using guide


Make entry point in humeral head

- hand ream to determine size of stem

- insert stem with cutting block attached

- 0o or 20o (c.f. TSR)

- 155o cut

- plane of cut laterally just below anatomical neck

- usually takes a couple of millimetres of GT


4.  Glenoid


Remove capsule and labrum

- protect axillary nerve at all times

- mobilise SSC anteriorly

- need to be able to palpate anterior glenoid

- identify axillary border of scapula

- release triceps and capsule inferiorly

- must be able to feel inferior glenoid and spine


Good exposure of glenoid is key to reverse TSR

- sandbag behind spine / allows scapula to fall posterior

- tilt bed up on side of operation

- posterior and inferior glenoid retractors


Centering Guide wire passed 

- centre of inferior circle of glenoid

- should exit scapula anteriorly about 3cm medial to glenoid

- ensure not too anterior as anterior screws can have little purchase

- ensure inferior screw will be in inferior good bone

- metaglene needs to be positioned low to prevent inferior impingement and dislocation

- wire needs to angle slightly inferior rather than slightly superior



- symmetrically ream

- remove only cartilage, just to subchondral bone


Drill central peg hole


Insert metaglene

- press fit central peg

- usually only one size

- rotate so superior screw will be in line with base of coracoid


Inferior screw

- drill long screw (minimum 35 mm)

- should be in good bone

- is most important screw

- will exit cortex somewhere

- insert locking screw


 Reverse TSR APReverse TSR Axillary View


Superior locking screw

- feel anterior and posterior edges of coracoid

- aim between

- again will exit cortex

- 25 - 30 mm screw


Reverse TSR Coracoid ScrewReverse TSR Axillary


Anterior and posterior non locking screws/ not in every design

- are predetermined to be divergent

- get best bite possible

- can use locking or non locking


Add glenosphere

- can wait until have done humeral component and trial

- do have option for eccentric glenosphere

- this overhangs inferiorly, preventing notching / impingement / possible dislocation

- otherwise, if happy with position, choose size and screw in place


5.  Ream and trial humeral component


Set rotation

- is an eccentric option

- ream over trial

- insert stem and metaphyseal component

- add liner (+3, +6, +9)


Trial stability

- in full ER will open slightly

- adduct and ensure not dislocating / put hand in armpit

- shuck test - entire shoulder should move first


7.  L'Episcopo


Consider Latissmus Dorsi transfer

- if no functioning external rotators

- cannot raise hand to mouth

- severe fatty infiltration / tears in IS / Tm


Detach LD anteriorly

- pass front to back

- suture via drill holes to the posterior aspect of the humerus


LEpiscopo 1LEpiscopo 2


8.  Closure SSC / LT



- 5 ticron

- through drill holes in humerus

- pass around stem


9.  Rehab



- 6/52 passive forward flexion

- 6/52 active assist

- at 3-12 begin muscle strengthening




Rotator Cuff Arthropathy for Reverse TSR




1.  RC arthropathy / > 70 / low functional demand


2.  Revision TSR


3.  Failed Hemiarthoplasty in proximal humerus fracture




Reverse TSR Xray


In rotator cuff dysfunction

- humeral head superior causing early failure of conventional TSR


Professor Paul Grammont

- convex articular surface to glenoid

- concave surface humerus

- shifts centre of rotation medially and distally to glenoid

- improves lever arm of deltoid


Limitations of conventional TSR


1.  Inability to manage GH translation


Fully conforming surfaces

- humeral and glenoid components same radius curvature

- rim loading must occur with any translation

- rocking horse mechanism


Non conforming surfaces

- glenoid radius curvature > humeral head

- diminishes contact area

- increases local contact pressure

- risk poly failure


2.  Limitation of fixation of poly to glenoid

- subject to shear forces             


3.  Limitations of stability


Anterior instability

- defects SSC or anterior capsule / glenoid


Posterior instability

- posterior glenoid deficiency / dysplasia

- deficient posterior capsule or labrum


Superior instability

- deficient SS or CA ligament / acromion

- laxity of deltoid means it cannot function

- pseudoparalysis from antero-superior escape


4.  Deltoid dysfunction

- unable to raise / lower / medialise centre of rotation to compensate for deltoid dysfunction

- without risking loosening and failure of the glenoid component


Features of Reverse TSR  


1.  GH translation

- does not permit GH translation

- due to conforming concavity of humeral component

- full surface contact maintained during range

- nil rim loading


2.  Glenoid fixation

- metaglene fixed by locking and non locking screws along with a central press fit HA coated peg

- metal glenosphere fixed by press taper

- no poly to metal fixation issue

- medialisation of centre of rotation decreases the lever arm of forces

- reduces the moments that challenge fixation


Reverse TSR AP BiometReverse TSR Lateral


3.  Intrinsic stability

- nature of design has increased intrinsic stability

- humeral socket  forms an angle of 155o with humeral shaft

- deltoid force acts to stabilise the joint

- less dependence on soft tissue and CA arch


4.  Deltoid dysfunction

- able to lower or lateralise COR

- inherent stability allows prosthesis to work even if only part of deltoid functions






Cuff et al JBJS Am 2008

- 96 patients with minimum 2 years follow up

- abduction increased from 61 to 110o

- flexion 60 to 120o

- ER from 13 to 30o




Wall et al JBJS Am 2007

- 191 shoulders followed for a minimum two years

- worst results in post traumatic arthritis and revision TSR

- 15 cases of dislocation

- 8 cases of infection




Guery et al JBJS Am 2006

- calculated 10 year survival rate of 90%

- noted than Constant shoulder scores deteriorated over time

- 60% 10 year survival with Constant score < 30 as an end point


Revision Shoulder Arthroplasty



Rule out infection

Assess rotator cuff / bone stock preoperatively


- difficult / scarring +++

- very difficult to restore any loss of ROM

Removal of prosthesis


- may not be able to revise

Humeral component

- long stem




Rule out infection


- ultrasound or xray guided aspiration

- arthroscopy for fluid and tissue sampling



- good for cuff integrity

- MRI often not useful due to large amount of metal artefact


CT scan

- glenoid often deficient posteriorly 

- if ignore will either be unstable posteriorly

- or will expose glenoid to excessive forces, predisposing to failure


Implant Removal



- often very loose

- easy to remove


Revision TSR Loose GlenoidRevision TSR Loose Glenoid


Humeral component

- most uncemented stems only proximally coated

- flexible osteotomes


Revision TSR


Glenoid bone stock restoration


1.  Cortical ring allograft

- napkin ring type

- take from calcar of a femoral neck

- cut so is thicker posteriorly to reconstitute the glenoid

- place onto freshened glenoid surface

- use uncemented glenoid

- drill central plug, then superior and inferior screws



- bone can crack, making it unstable

- need long screws with good bite, locking screws preferable

- useful to have available custom made implant with longer central peg

- enables obtain fixation with native glenoid


2.  Bulk posterior allograft


 Revision Reverse TSR Glenoid Bulk Posterior Allograft



- use femoral head

- reconstitute posterior aspect of glenoid

- fix with 2 x cannulated 4mm screws via stab incisions posteriorly

- need to be able to fix glenoid component with screws still


Revision Humeral Component



- often need long stem

- often use cement in revision circumstance


Revision TSR Long Stem Cemented Humeral Component


Rheumatoid Shoulder

IssuesRheumatoid Shoulder


Rotator cuff

- often deficient


Bone stock

- often deficient



- often posterior version 






1.  TSR



- cuff intact

- sufficient bone stock


2. Hemiarthroplasty


Indications hemiarthroplasty

- young patient

- rotator cuff not intact, too young for reverse

- insufficient bone stock glenoid


Technique if rotator cuff deficient

- CTA head

- over size humeral head / increase valgus


Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR


3.  Reverse TSR



- ruptured cuff (30%)


Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects





TSR Technique




- head that translates 50% in all directions

- allows 30o ER with arm at side

- stable posteriorly



- antibiotics

- consider specific Propionobacterium cover

- assess ER pre-operatively




1.  Beach-chair position

- McConnell head rest

- patient at table edge / removable edge

- shoulder must overhand table

- allows GHJ extension

- need this to insert stem

- 500 ml saline bag between shoulder blades


2. T-max table with Spyder attachment


Incision / Dissection


Extended deltopectoral approach

- coracoid to deltoid insertion 


Separate deltoid & pectoralis major

- retracting cephalic vein laterally causes less bleeding

- retracting cephalic medially prevents cephalic avulsion from subclavian vein

- place Cobell retractors under deltoid


Deep dissection

- divide clavipectoral fascia on lateral edge conjoint

- elevate conjoint, feel for MCN

- replace medial retractor blade under conjoint tendon

- ER humerus and expose SSC



- blunt dissect subdeltoid space

- right up to coracoid and clavicle


Open Approach Shoulder




1.  Musculocutaneous nerve


Branch lateral cord

- penetrates coracobrachialis 3-8 cm distal to coracoid

- beware rare cases higher

- palpate MCN under conjoined tendon

- place finger under tendon and sweep downwards to palpate


Average 3 cm

- most common cause of damage = overzealous retraction

- avoid release of conjoined tendon if possible / protects MCN


2.  Axillary nerve


Terminal branch of posterior cord

- arises inferior to coracoid

- crosses anteroinferior border of subscapularis muscle

- exits quadrangular space with posterior circumflex humeral artery



- slide finger under conjoint tendon

- run downwards over SSC muscle

- hook finger anterolaterally to feel nerve

- relatively tight cord running posteriorly

- relatively protected with adduction & ER


Tug test

- palpate anterior axillary nerve under anterior deltoid

- tug on axillary nerve over SSC

- will feel the nerve moving back and forth

- ensures is intact at end of operation


Quadrangular space

- below SSC anteriorly / T minor posteriorly

- inferior is T Major posteriorly

- between long head triceps and SNOH


Splits into 2 trunks 

1. Posterior to teres minor & posterior deltoid

- terminates as superior lateral cutaneous nerve

2. Anterior passes to middle then anterior deltoid 


Releases / Exposure


1.  Coraco-acromial ligament

- place fang retractor on coracoid

- don't divide in full or risk superior escape of humeral component

- take anterior triangle with diathermy

- aids exposure


2.  Pect Major insertion

- divide upper 50%

- can release more if needed, but repair at end

- allows ER of humerus


Ligate Anterior Circumflex Humeral blood vessels

- 3 sisters

- at inferior SSC tendon

- can tie off with stay sutures


Identify rotator interval


3.  Identify and release biceps

- divide biceps at insertion with scissors

- perform tenodesis later


Feel and palpate supraspinatous / infraspinatous

- ensure that are intact

- otherwise repair / change to reverse TSR


4.  Release Lat Dorsi / Teres Major if needed

- ER humerus

- subperiosteal dissection with diathermy


5.  Clavicle osteotomy

- if exposure difficult

- revision / large muscular men

- divide fascia to expose clavicle

- anterior 1/3 of clavicle

- from ACJ (don't violate) to anterior curvature of clavicle

- complete with saw / osteotome

- repair with sutures at end of case


6.  Can release conjoint tendon if needed

- usually via coracoid osteotomy

- predrill

- secure with screw later


SSC options


A. Divide SSC tendon



- easy to do



- tendon - tendon healing less reliable

- need to protect ER post operatively

- high incidence of SSC failure / poor lift off test



- want to leave long

- so don't limit ER when repairing

- insert medial 2.0 vicryl stay sutures

- take vertically right on insertion on LT

- take entire tendon plus capsule

- will repair through drill holes at end of procedure


B.  LT Osteotomy



- bone to bone healing much more reliable



- expose inferior humeral flare

- don't want inferior cut venturing into humeral shaft / is a fracture risk

- release inferiorly

- pass ring handled spike behind the SSC
- IR humerus to neutral

- use oscillating saw

- begin in intertubercular groove

- aim to exit deep rather than shallow

- don't want saw exiting in SSC

- if take cartilage can simply excise with nibblers

- usually small 2 cm oval piece

- place ethibond stay sutures


Humeral Osteotomy



- soft tissue off inferior neck of humerus

- ER humerus to put tissues on tension

- use osteotome to remove beard osteophytes

- may need to release lat dorsi and teres major tendon

- release capsule anteriorly 12 to at least 6 O'clock from humerus +++

- stay on bone


Deliver humeral head

- Extend & ER humerus to dislocate


Identify true anatomical neck

- aided by removal of crown osteophytes

- saw blade should exit at superior and inferior edge of articular cartilage

- this is the osteotomy site


Cut in planned retroversion


Usually 25o of retroversion

- can match to patient's own retroversion

- i.e. osteotomy removes cartilage front and back

- can reduce retroversion if large amount of glenoid retroversion present


Varus / valgus 130° to long axis


Technique 1

- flex elbow

- use forearm as protractor

- ER forearm 25o

- cut directly posteriorly


Technique 2 (Global)

- use jig

- insert humeral reamers (long and straight)

- up to templated size

- attach jig to humeral reamer

- set one part of jig aligned to the forearm as reference

- dial in required retroversion

- set height of desired cut

- pin in situ


Use oscillating saw

- insert retractors to protect glenoid / infraspinatous /supraspinatous

- surprisingly small amount of bone removed


Remove humeral osteophytes

- anterior crown / often best with osteotome directed superior to inferior

- fully ER head and remove posterior neck osteotophytes




Deliver proximal humerus


Insert broach

- has fins to ensure correct rotation of prosthesis

- insert trial stem

- also have head caps

- leaving the stem in prevents fractures

- leaving cap on prevents crushing cancellous bone


Surface Replacment / No stems


May have improved outcome

- recreate anatomy including version

- stem does not dictate head placement

- very difficult to overstuff joint


Glenoid Releases


Glenoid Releases


Very important for the exposure


SSC releases


Use to be 360o release

- fatty infiltration post operatively was identified on MRI

- thought to be due to denervation anteriorly


180o release

- use stay sutures to pull SSC laterally

- posteriorly identify capsule interval

- divide capsule along posterior SSC (MGHL and IGHL)

- completely elevate from anterior glenoid

- superiorly identify CHL and divide

- use finger to free SSC superiorly and posteriorly right along scapula

- should now be able to mobilise SSC freely


Divide inferior capsule

- palpate axillary nerve

- place retractor over AXN

- divide capsule along inferior glenoid to 6 o'clock



- biceps insertion

- labrum




- push medially

- protect with sponge

- retract with fang retractor


Release anteriorly


Release inferiorly

- often more important for reverse TSR

- use cobb to elevate inferior capsule

- divide long head of triceps if needed


Continue humeral neck release

- release around neck all the way to posterior


Glenoid Exposure


TSR Glenoid Exposure 1TSR Glenoid Exposure 2


Need a straight shot at the glenoid



- flexed

- head pushed posteriorly

- IR



- on posterior lip of glenoid

- retractor displaces head posteriorly

- Fukuda retractor / Fang


Allow for stress relaxation to occur


Danger: Glenoid Fracture


Inferior retractor to protect axillary nerve
- above inferior capsule

- bunny ears / playboy retractor


Additional Techniques

- elevate patient's bed / drops arm

- tilt patient ipsilateral side up


Assess glenoid


Often posterior erosion

- OA may be due to subtle posterior instability


Posterior erosion options are


1.  Lower anterior rim 

- recreate version

- remove anterior half with reamer

- maximum 10o



- removing bone stock which is limited

- reduce vault and increase risk of vault penetration

- increase risk of difficulty seating glenoid

- medialise glenoid component

- there are no increased poly thicknesses


2.  Decrease humeral retroversion

- resect head with arm in < 25o ER


3.  Bone graft posteriorly

- use napkin ring femoral neck allograft thicker posteriorly


4.  Custom component with post wedge build up


Insert Glenoid Component


Glenoid options


1.  Cemented all poly curved back

- most common, best results


A.   Peg v central keel

- pegs may be single or multiple


B.  Flat v curved back

- curved backs may seat better


C.  Cementing

- trend now to minimize cement behind poly (place only in plug holes)

- this is because can get a very thin film of cement which can crack

- however, demonstrated increased pullout strength with increased cement thickness


2.  Uncemented metal back

- secured with screws

- advantage is can be same prosthesis as in reverse

- i.e. can convert later to reverse if failure of cuff

- problem is continued issues with metal / poly interface

- also problems with overstuffing

- higher rate of revision


Centre peg crucial


Vault is a triangle

- pilot hole critical

- must not penetrate vault



- usually slightly superior in TSR to equator

- if put glenoid too low the humeral head will ride high

- need to match tilt as well as version


"Glenoid Centering Point" (Matsen) 

- index finger anterior to glenoid palpates centering point in sulcus 

- bounded by upper & lower crura of scapula & flare of glenoid vault 

- 6-8 cm medial

- wire should exit anteriorly at this point



- glenoid is sufficient size if can take central peg



- insert guide pin

- gently ream central peg

- check intact cortex with arthroscopy probe


Vault blowout

- i.e. any drill hole comes out of vault

- especially important for central peg

- loose pressurisation of cement


TSR Central Peg BreachTSR Glenoid Vault Breach



- insert bone graft

- pressurise only intact holes


Cement Glenoid


TSR Cemented Glenoid APTSR Cemented Glenoid Lateral


Remove labrum

- allows sizing and correct orientation of glenoid


Trial size

- place trial

- ream central peg where you want it


Insert reamer

- take off cartilage

- can eccentrically ream if needed


Insert new broach

- ream for other pegs if needed

- three or five


Keep holes dry

- insert sponge


Insert cement into peg hole

- use syringe


Insert Poly

- pressurise




Overstuffing of joint causes poor ROM


1.  Height

- head sits only 3 mm above GT

- too high places excessive stress on RC


2.  Size

- small enough to close SSC

- too large a head limits ROM & increases risk of SS and SSC rupture


3.  Offset heads

- normal head offset from neck posteriorly and medially

- placing head more anterior than normal increases strain on cuff and glenoid

- i.e. can anteriorly impinge on SSC and cause late rupture




Should be able to

A.  Inferiorly sublux head 50% glenoid

B.  Posteriorly sublux head 50% and return to centre

C.  Able to close SSC without impingement on head

D.  Close SSC with arm in ER 30o

E.  Place hand on chest


Insert stem


A.  Cemented

- don't pressurise

- can crack stem


B.  Uncemented

- very good results


Posterior Instability


1.  Posterior capsule plication

- lamina spreader between stem and glenoid

- place east - west sutures / 3 x horizontal ethibond sutures


2.  Place sutures in capsule posteriorly

- run ethibond anteriorly through joint

- tie to conjoint tendon


3.  Place arm in ER post operatively

- de-tensions posterior capsule

- allows capsule to scar

- i.e. gunslinger position

- also keeps humeral head forward




A. Reattach SSC via drill holes in anterior neck of humerus

- insert sutures prior to cementing stem

- 5 x drill holes

- 4 x 5 ethibond

- place arm in 30o ER

- pass in horizontal mattress suture through SSC edge


B.  LT osteotomy

- lateral drill holes in humerus

- suture through drill holes and medial to LT into SSC

- this can tend to lateralise LT, limit ER

- various techniques to avoid this

- can pass sutures about stem


Biceps tenodesis

- suture usually



Total Shoulder Replacement

IndicationsTSR All Poly Glenoid










Paralysis of deltoid

Torn rotator cuff

Insufficient glenoid bone stock




1.  Functioning / Repairable rotator cuff

- maintain stability

- maintain centre of joint rotation

- early failure if cuff deficient


TSR plus cuff repair


2.  Intact Deltoid


3.  Resonable glenoid bone stock

- commonly posterior bone loss in OA

- glenoid component must be completely supported by peripheral bone rim or early failure

- beware glenoid hypoplasia







- 35 - 40 mm



- approximately 70% glenoids are pear shaped

- remainder elliptical

- upper width average 23 mm

- lower width average 29 mm


Shoulder CT Glenoid OvalShoulder Glenoid CT Pear Shaped



- approximately 4 - 5o superior




Healthy shoulders

- mean 2o anteversion

- large range

- 14o anteverted to 10o retroverted



- RC 8o retroversion mean

- OA 15o retroversion mean

- RA 15o degrees retroversion mean




Usually triangular




30o anteverted from coronal plane


Humeral head


Retroversion 30o







- never used

- high failure rates / peri-articular fracture


Semi Constrained

- cupped glenoid



- GE > 90%

- most common design 



- cemented v uncemented

- stems v resurfacing


TSR No StemTSR Uncemented StemTSR Cemented Stem



- metal backed

- all poly


TSR Metal Backed Glenoid





- Assess head



- Assess glenoid

- OA = Posterior bone loss

- RA = Medial bone loss  / protrusio




1.  Stem

- size


2.  Head

- neck osteotomy

- head diameter and depth


3. Glenoid size




1.  Assess bone stock

- sufficent bone in glenoid

- exclude glenoid hypoplasia


CT TSR Preop Glenoid CystsTSR Glenoid CT Good Bone StockTSR CT Glenoid Good Bone Stock


2.  Assess version / posterior deficiency



- can be suprisingly inaccurate


Hoenecke JBJS 2010

- 2D CT depends on angle CT gantry

- 20% error > 10o

- 3D CT best



- average is 2o anteversion

- up to 15o retroversion can be normal


Options for Management Glenoid Version


A.  Neutral inclination glenoid

- reduce retroversion of head to 25o


TSR Glenoid CT Neutral Inclination


B.  0 - 10o retroversion of glenoid



- alter with reaming / 10o change is the maximum

- otherwise can run into difficulty seating glenoid

- reduce retroversion of head further


TSR Glenoid CT Mild Retroversion


C.  20o + retroversion of glenoid / deficiency



- alter up to 100 with reaming

- reduce further the retroversion of head

- glenoid bone augments / augmented poly

- may require primary glenoid osteotomy


Glenoid Posterior Deficiency.jpgGlenoid Posterior Version and Deficiency


Assess Rotator Cuff







Neer's 3 Phase shoulder rehabilitation


Phase 1 Passive motion in forward flexion & ER

Phase 2 Active Assisted 6-8 weeks 

Phase 3 Advanced muscle strengthening 3/12




1.  Pain


Pain relief good 90%


2.  ROM


Range of motion variable

- OA with intact cuff = 120° elevation

- Post fracture or huge cuff tear = 40°


ROM gain

- OA 77o

- RA 57o

- post trauma 33o


3.  Survival


Deshmuhk et al J Shoulder Elbow Surg 2005

- 93% survivorship 10 years

- 88% 15 years

- average age 60 years

- mostly Neer II prosthesis


Sperling et al J Shoulder Elbow Surg 2004

- patients under 50 having TSR (Neer II)

- 97% 10 years, 84% 20 years




1.  Subscapularis Failure



- poor reattachment

- overstuffing anteriorly

- humeral anteversion

- denervation



- trial ER on table at end

- limit rehab to this



- decreased ROM

- pain

- instability



1.  Re-repair - limited success

2.  Pectoralis major transfer

- results poor in shoulder arthroplasty

- Jost et al JBJS Am 2003

3.  Achilles tendon bone allograft

4.  Bristow

5.  Reverse




TSR Loose glenoidGlenoid Component Loosening



- 5-40%

- clinical loosening relatively infrequent

- uncemented > cemented


Glenoid lucent lines 

- relatively common 

- ~ 30-96%

- not all are associated with pain

- not all require revision


Humeral component

- loosening rare


Instability 5%





- mal-rotation humeral component most common

- subscapularis rupture

- anterior deltoid dysfunction

- glenoid component loosening


TSR Anterior Instability LateralTSR Anterior Instability AP





- attenuation cuff or frank rupture

- dynamic muscle dysfunction



- must ensure don't leave humeral head proud

- restore shenton's line

- results in eccentric loading of glenoid component & loosening 

- "rocking horse glenoid"


Shoulder Hemiarthroplasty Rotator Cuff FailureTSR Superior Escape


Posterior (most common problem) 



- excess retroversion of glenoid or humerus

- posterior glenoid erosion

- ST imbalance


TSR Posterior DislocationRevision for Posterior Dislocation TSR Combined Anterior Posterior Approach



- may need posterior approach to reduce

- allows posterior capsular plication

- alter component version / increase anteversion

- anterior releases



- especially post fracture with shortening of humerus

- important to re-establish humeral length to restore resting tension of cuff & deltoid

- overstuffing of joint


Post-op rotator cuff failure



- 2%



- due to head malplacement or malposition

- respond poorly to reconstruction


TSR Failed Rotator CUff



- revise to reverse TSR


Peri-prosthetic Fracture



A:  Tip of prosthesis with proximal extension

B:  Fracture at tip only

C:  Fracture distal to tip and extends into distal metaphysis


Options Humeral Shaft Fracture


A.  Non operative Management

- prothesis stable

- acceptable aligment



- prothesis stable

- fracture distal to prosthesis

- anterolateral approach and plate


TSR Periprosthetic FractureTSR Periprosthetic Fracture


C.  Revise to long stem > 2 cortical diameters past fracture


TSR Humeral Fracture TSR Humeral Fracture United




Kumar et al JBJS Am 2004

- 16 patients

- 6 healed after 180 days of non operative treatment

- 5 required operation after 123 days non operative treatment

- recommended all fractures can be treated non operatively

- if well aligned and prosthesis stable

- if not united by 3 months, recommend intervention


Infection 1%


TSR Infected


NV injury




Ectopic Ossification




1.  Lateral decubitus

- stabilise patient with beanbag or lateral rests

- apply skin traction to forearm

- place traction pole at foot of table opposite surgeon

- suspend arm with 10 lb weight

- abduction 60°

- forward flexion of 20°

- tilt top shoulder posteriorly 30° so that glenoid is parallel wwith bed

- mark bony landmark

- prep & free drape


Lateral Decubitus Shoulder ArthroscopyShoulder Arthroscopy Lateral DecubitusShoulder Lateral Decubitus Arthrex


2.  Beachchair


A.  Beachchair table

- pillow under thighs

- arm draped free

- access to posterior shoulder

- head secured to Mayfield head ring


B.  Spyder / Tmax

- holds head secure

- good access to posterior shoulder

- hydraulic arm holder elminates need for assistant to hold arm


Shoulder Arthroscopy TmaxShoulder Arthroscopy Spyder




Shoulder Arthroscopy Portals


Posterior Portal


Shoulder Arthroscopy Posterior Portals


Main portal for arthroscopy


A.  Soft spot

- identify posterolateral acromion

- 2 cm medial & 2 cm inferior

- through deltoid

- between infraspinatous and T minor


Make stab wound at post portal

- introduce cannula & trocar

- tip towards coracoid process

- distract shoulder joint whilst inserting

- introduce arthroscope


B.  Variation

- if mainly performing subacromial / rotator cuff

- move portal lateral and superior

- 1 cm inferior and 1 cm medial to posterolateral acromion

- aims scope over cuff tear which is usually lateral

- increases distance from cuff vertically

- can view larger area


Additional portals


Anterior Glenohumeral Portals


Arthroscopy Anterior PortalShoulder Arthroscopy Portals Anterior


Rotator Interval

- biceps, glenoid & humeral head form a triangle with subscapularis in the base

- place anterior portals in this triangle above subscapularis, lateral to coracoid


Shoulder Arthroscopy Rotator IntervalRotator Interval


A.  Retrograde method

- direct scope into rotator interval

- advance until rests against anterior capsule at superior edge subscapularis

- light transilluminates skin at site of portal

- ensure lateral to coracoid

- remove scope from sheath

- insert Wissinger rod / switching stick through sheath

- make stab incision

- advance rod

- insert cannula over stick

- use portal for probe & instruments


B.  Direct / anterograde

- insert 19 gauge spinal needle

- always lateral to coracoid

- pass into rotator interval

- stab incision / switching stick / cannula


Anteroinferior portal

- just above SSC

- angle to get to anterior labrum / bankart repair

- 3 - 6 o'clock


Shoulder Scope Low Anterior Portal


Anterosuperior portal

- high in rotator interval

- in angle between humeral head and biceps

- working portal for suture exchange in stabilisation surgery

- good angle for anchor insertion for SLAP repair


Anterosuperior Glenohumeral portal


Posterior Portal



- insert switching stitch through camera cannula

- insert camera through anterior cannula

- pass cannula over switching stick



- inspect / probe / repair posterior portal


Shoulder Arthroscopy Posterior Portal


Posterolateral portal


For posterior labral tears

- inferior and lateral to posterior portal

- allows placement of the inferior anchor


Shoulder Posterior Portals 1Shoulder Posterior Portals 2


Posterior Subacromial Portal


Redirect posterior cannular with blunt trochar

- remove camers

- direct it superiorly immediately below acromion once through deltoid

- sweep trochar laterally to break adhesions


Lateral Subacromial portal


Working portal

- for subacromial decompression / ACJ resection / RC surgery

- 2 - 3 cm lateral to lateral acromion

- 1 - 2 cm posterior to anterior acromion

- usually in line midportion / posterior border of clavicle

- insert needle

- should be above cuff, below acromion

- parallel to acromion


Anterosuperiorlateral Portal / Port of Wilminton


Shoulder Scope Port WilmingtonShoulder Scope Port Wilmington 2




- passes through supraspinatous

- anterolateral border acromion

- can place more posteriorly to access posterior aspect of SLAP

- in this case will pass through infraspinatous


Superior portal Neviaser / Superomedial portal



- access posterior SLAP / decompress suprascapular nerve

- pass through RC / supraspinatous

- 1 cm medial to acromion

- 1 cm posterior to clavicle




A.  Pressure pump

- usually 40 - 50 mmHg

- can temporarily increase if required


B.  Adrenaline in bags

- 1 mg in each 3L bag


Examination of GHJ


Systematic Approach


A.  Glenoid medial / Humeral head lateral

- arthritis / chondral damage


Arthroscopy Humeral Head OAGlenoid OA Arthroscopy


B.  Biceps

- careful examination / probing of insertion

- examination of intra-articular portion for degeneration

- pull extra-articular portion into joint to confirm gliding well


Arthroscopy Normal Biceps InsertionArthroscopy Normal Biceps TendonArthroscopy Normal Biceps Tendon 2


C.  Labrum

- 360o examination

- anterior / inferior / posterior


Arthroscopy Normal Anterior LabrumShoulder Arthroscopy Inferior LabrumShoulder Arthroscopy Posterior Labrum


D.  Glenohumeral ligaments




Superior Glenohumeral Ligament



- crosses subscapularis vertically


MGHL Arthroscopy


Inferior / anterior aspect of IGHL

- attachment to labrum between 3 and 6 o'clock

- look down into inferior recess

- see attachment to inferior humerus

- exclude HAGL / exclude loose body


Arthroscopy Normal IGHL Humeral InsertionNormal IGHL Glenoid AttachmentShoulder Loose Body


E.  Rotator Cuff



- examine insertion

- ER the humerus


Arthroscopy Normal SubscapularisSubscapularis Normal Arthroscopy



- examine underside and insertion

- abduct and ER

- should be no gap between cartilage and insertion


Supraspinatous Normal ArthroscopySS normal arthroscopySupraspinatous Tendon Normal Crescent Variant



- insertion at posterior humerus next to bare area

- Hill Sach's lesion (has cartilage each side c.f. bare area)


Shoulder Arthroscopy Infraspinatous Insertion


Neurological Complications


Uncommon (0.1%)


1. Posterior Portal

- if placed inferiorly can damage AXN below Teres minor 


2. Anterior Portal

- damages MCN if medial to coracoid

- brachial plexus & axillary artery


Clavicle Fractures

Clavicle Fracture Displaced



Usually a direct blow 

- less commonly a fall on the outstretched hand


RTA / sporting accidents commonest causes


Can be pathological as a result of radionecrosis

- eg following radiotherapy for breast cancer.  




Fractures of the clavicle are common

- 5% of all fractures

- Up to 80% involve the middle third






First bone to ossify in 5th week of foetal life

- intramembranous ossification

- medial growth plate accounts for 80% length

- medial physis last to close at 22-25 years




The middle third of the clavicle is the junction of two curves

- medial convex anteriorly 

- lateral convex posteriorly  


At the junction there is little cancellous bone

- skeletal muscle covers only part of the cortical bone

- the volume of muscle in this region is small


The clavicle is secured firmly at each end by stout ligaments and joint capsules




It rotates approximately 40o when the scapula is elevated

- most of the rotation occurring after the arm passes the horizontal level 




Fractures may be divided into three regions of the clavicle 


Medial end

- fifth of the bone

- lying medial to a vertical line drawn upward from the center of the first rib 

- rare

- <5%  


Lateral clavicle fracture

- fifth of the clavicle

- lateral to a vertical line drawn upward from the center of the base of the coracoid process

- a point marked by the conoid tuberosity

- approximately 1/3 of all clavicle fractures 



- intermediate three-fifths between these two areas 

- most common

- 70% of clavicle fractures


Clavicle Diaphysis Fracture




Examine skin

- ensure skin not threatened by spike of bone


Examine AXN

- sensation in deltoid patch


Look for scapula winging

- may be an indication for fixation




Clavicle Midshaft Displaced



- the proximal end under the pull of SCM becomes elevated

- the shoulder tends to sag downwards and forwards

- with further displacement there is overlapping and shortening 

- the portions of the clavicle may also be rotated relative to one another


Non Operative Management


Sling for comfort

- followed by early mobilisation as the pain subsides


Figure of 8 bandage 

- these do not effectively reduce the fracture 


Complications Non Operative Management


1.  Persistent bony spike

- even after normal remodelling

- may require excision


2.  Thoracic outlet syndrome

- secondary to hypertrophic non-union of the clavicle

- also due to reduced subclavicular space in a shortened malunion

- late compression of ulna nerve, brachial plexus

- symptoms with overhead activities


2.  Non union 


Clavicle Non UnionClavicle Nonunion



Neer (6) 1960 JAMA

- 2235 closed clavicle fractures treated non-operatively

- non union in only 3 (0.1%) 

- his series of 45 fractures treated by open reduction, there was non union in 2 (4%)


Rowe Clin Orthop 1968

- nonunion in 0.8% of fractures treated by closed methods

- 3.7 % in those treated by open reduction


Robinson et al JBJS Am 2004

- prospective cohort study

- overall non union rate in clavicle fractures of 6.2%

- 4.5% of diaphyseal fractures / 11.5% lateral fractures / 8.3% medial fractures

- factors increasing risk non-union in diaphyseal fractures

- advancing age / female gender / complete displacement / comminution


3.  Malunion


Clavicle Fracture Shortened and Displaced


Hill et al JBJS Br 1997

- studied 52 completely displaced midshaft clavicle fractures

- all treated non operatively

- 8/52 (15%) developed non union

- 16/52 (31%) unsatisfactory (residual pain / brachial plexus symptoms)

- initial shortening of > 20 mm associated with non union and poor outcome


McKee et al JBJS Am 2003

- poorer functional outcome

- fractures > 2cm shortening


Clavicle Fracture Shortened


Canadian Orthopedic Trauma Society JBJS Am 2007

- multicentred RCT of op (62) v non op (49) treatment displaced midshaft clavicles

- 1 year followup

- average time to radiographic union 28 v 16 weeks

- non unions 2/62 v 7/49

- symptomatic malunion 0/62 v 9/49

- better shoulder scores at all times

- in operative group, 3 wound infections, 1 mechanical failure and 5 prominent hardware


Operative Management


Absolute indications 


Skin compromise (open fracture or severe skin tenting)

Neurovascular injury


Clavicle Fracture Skin Tenting


Open Clavicle Fracture


Relative indications


Floating shoulder 


High risk of non union / malunion

Non union


1.  Plate fixation


Clavicle PlateClavicle Plate



- fresh fractures of the middle third 

- gross displacement and angulation of the bone 

- shortening of the clavicle that was estimated to exceed 2.5 cm on plain radiographs




Bostman et al J Trauma 1997

- plate fixation (DCP / Pelvic Recon)

- ORIF in 103 (9.5%) of the total of 1081 patients

- complication rate 23% 

- infection rate was 7.8%

- both patients treated with a 1/3 tubular plate suffered plate breakages

- 10 patients required reoperation for loosening, infection, non union or plate breakage (10%)




Lazy beach chair

- square drape

- LA with Adrenalin


Transverse incision in Langer’s line

- can make incision inferior to clavicle

- pull it up, keeps wound away from plate

- can identify and protect supraclavicular nerves

- divide platysmus as a layer to repair later

- clean and reduce fracture

- application contoured locking plate

- need 6 cortices each side



- infection

- numbness infraclavicular (tends to reduce in size)

- non union

- hardware failure

- arterial injury

- pneumothorax


2.  IM Screw 


Clavicle IM Fixation




Boehme et al 1991 JBJS Am

- 21 patients established symptomatic non union

- intramedullary Hagie pin

- autologous bone grafting

- 20/21 union

- average time to healing of twenty-two weeks (range, twelve to thirty weeks)

- 17 / 21 the screw had to be removed due to development of a tender bursa




Open approach to fracture

- 2 - 3 cm

- hand drill medially 

- pass cannulated wire laterally and out through skin

- reduce fracture, retrograde pass wire medially

- drill lateral fragment

- insert cannulated 7.3 mm screw

- needs to be between 80 and 110 mm

- check x-ray to ensure good medial fixation

- BG if non union


Post op

- limit ROM above shoulder height for a period

- decreases rotational forces and reduce risk of non union


3.  External Fixation 



- open fractures 

- severely displaced fractures with damaged skin



- medial pins are anterior to posterior in an ascending direction to avoid the pleural dome

- lateral pins are superior to inferior in an almost vertical direction 


4.  Management Malunion


Clavicle Malunion ORIF




McKee et al JBJS Am 2003

- 15 patients mean age 37 years over 4 year period

- average shortening 2.9 cm

- complaining of pain and fatigueability

- also complaining of symptoms consistent with thoracic outlet syndrome

- many complained of cosmesis

- patients had scapula winging

- osteotomy and DCP (no bone graft required)

- 1 non union

- 8/12 patients with weakness and pain improved

- neurological symptoms eliminated in 7, decreased in 3, unchanged in 1




Infection / Wound Breakdown


Clavicle plate infection


Wound breakdown

- may be a result of vicryl reaction / stitch abcess

- may be better to close fascia over plate, then just use sutures to close wound



Lateral Clavicle Fracture



Elderly population

Less common in younger population


Lateral 1/3 Neer Classification


Type I


Lateral Clavicle Fracture Undisplaced


Fracture lateral to the CC ligaments

- does not extend into the ACJ

- non displaced

- most common 4:1


Type II


Lateral Clavicle Fracture



- medial to CC ligaments

- CCL ligaments attached to lateral fragment

- medial fragment displaced superiorly

- highest rate of non union



- between conoid and trapezoid

- conoid disrupted

- trapezoid remains attached to the lateral fragment

- more stable


Type III


Involves articular surface ACJ

- ligaments intact

- may present as late degenerative change


Type IV

- skeletally immature patient

- paediatric sleeve fracture

- ligaments attached to periosteum

- displacement of proximal fragment


Non Operative Management


Robinson JBJS Am 2004

- cohort of 100 displaced Type II fractures

- 20% asymptomatic non-union

- 14% of cohort required surgery

- recommended non operative treatment in middle aged / elderly


Operative Management


Operative Indications 

- Compound / skin compromise

- displaced fracture in young people

- non union




1.  Dorsal plate / locking wrist plate


Lateral Clavicle Plate


Case 1


Lateral Clavicle ORIFLateral Clavicle ORIF 2


The lateral clavice fracture has been cleaned and reduced

- held with K wire across ACJ

- high strength suture around clavicle and coracoid

- locking plate applied, reinforced with IM screw, and high strength tape around coracoid

- advantage: no need to remove hook plate


2.  Hook Plate


Lateral Clavicle Fracture Hook Plate PreopLateral Clavicle Fracture Hook Plate Post op


Halder et al J Should Elbow Surg 2006

- 22 patients treated with hook plate

- very limited ROM (90o flexion) until plates removed at 3-4 months

- 1 disengaged from acromion (should have used acromial screws)

- 1 disengaged from clavicle (should have used 6 not 4 hole plate)

- 1 clavicular fracture at end of plate

- 1 non union, 1 delayed union

- 1 infection

- most complications in patients > 60


Hook Plate Disengage


3.  Endobutton


Robinson et al JBJS Br 2010

- 16 patients under 60 with displaced type 2

- all treated under 3 weeks

- endobutton in coracoid, clavicle reduced, endobutton clavicle

- 1 symptomatic non union


Non Union


Lateral Clavicle Non unionLateral Clavicle Nonunion ORIF


Distal clavicle nonunionDistal Clavicle Nonunion




1.  Bone graft / ORIF


2.  Excise

- open

- arthroscopic


Floating Shoulder



Combination of scapular neck fracture and ipsilateral clavicle fracture / CC ligament disruption




Floating Shoulder


Floating Shoulder 1Floating Shoulder 2


Glenoid Neck Fracture CTClavicle Fracture CT




High velocity injuries




Fractures usually of scapular neck


Potential Problems


Disrupts the suspensory mechanism of the shoulder

- displacement disrupts normal stability of GHJ

- changes biomechanics

- subacromial pain / impingement




Little evidence

- concern with displacement of fractures

- weakness of abduction / subacromial pain / poor shoulder function

- risk of non / malunion


Used to be recommended surgery for floating shoulder


Non operative Management



- undisplaced fractures


Edwards et al JBJS Am 2000

- 20 patients with floating shoulder treated non operatively

- 11 with displaced clavicle fractures (>10mm)

- 5 with displaced scapula fracture (>5mm)

- 19/20 united (one had segmental clavicle bone loss from gunshot)

- excellent functional scores


Labler J Trauma 2004

- 8 treated non operative, 9 treated operative

- 5 good results in each group

- recommend nonoperative treatment for less displaced fractures

Egol et al JBJS Am 2001

- 19 patients with clavicle fracture and displaced fracture glenoid neck

- 12 non operative, 7 operative

- good results in each group

- recommend individualized treatment


Operative Management




1.  ORIF clavicle


Minimally displaced glenoid fracture


Floating Shoulder Clavicle ORIF


2.  ORIF glenoid and clavicle


Displaced scapular neck

- > 40o angulation

- > 1cm displacement

- CT useful


Leung et al JBJS Br 1993

- 15 patients floating shoulder

- all scapular neck

- ORIF clavicle + glenoid (posterior approach)

- good functional outcome in all patients



- risk of PTX during surgery if rib fracture (secondary to PPV)

- may need chest tube


Rib Fracture CT

Frozen Shoulder



Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 




2% incidence

- 40 - 60 years

- Women 2:1


Sedentary workers

- Non-dominant limb


Bilateral in 10 - 40%





- Unknown

- ? Autoimmune theory



- diabetes - 35% IDDM > 10yrs

- yhyroid disorders

- stroke

- MI

- cardiac surgery

- neurosurgery

- dupuytren's


Not Associated with

- OA

- Cuff Pathology





- post surgery i.e. RC

- trauma i.e. SNOH, stabilisation

- immobilisation



- cervical radiculopathy

- axillary node clearance

- long period immobilisation


Classification Neviaser


Each lasts 4-8 months


1.  Freezing

- painful stage

- capillary proliferation, synovial hypertrophy

- develop capsular adhesions


Shoulder Arthroscopy Frozen Shoulder


2.  Frozen

- decreasing pain, increasing stiffness

- maturation and development capsular contractures


3.  Thawing

- decreasing stiffness




Neviaser described pathology of frozen shoulder 

- contracture of capsuloligamentous structures

- inflammation followed by fibrosis


Cellular basis poorly understood

- a dense matrix of type 1 and II collagen

- laid down by fibroblasts and myofibroblasts


1° Frozen Shoulder


Initial synovitis of unknown cause results in

- intra-articular adhesions

- capsulitis

- obliteration of inferior axillary fold


Subsequent development of

- subacromial adhesions

- rotator cuff contracture


Eventually spontaneous resolution


2° Frozen Shoulder

- much less synovial inflammation

- 2° due to either intrinsic or extrinsic cause


Natural History


Traditionally thought to be benign & self-limiting


Grey 1978

- 24/25 resolved by 2 years 

- Maximum 10 years


Most have no significant symptoms or functional restriction

- But not as benign as previously thought


Reeves 1975

- 60 % have residual decreased ROM 

- usually limitation ER

- only 6% claimed functional disability


Shaffer 1992

- 50% pain or stiffness at mean 7 years

- never more than mild with little functional disability




Insidious onset /  No history of trauma





- at site of deltoid insertion

- at extremes of motion


Becomes more

- diffuse / severe / constant

- interferes with sleep


Then begins to decrease

- rest pain disappears

- pain only on movement




Develops after onset of pain

Difficulty reaching

- overhead

- behind back




Muscle atrophy


No point tenderness


Markedly decreased ROM

- abduction

- ER classically

- limited GH movement, increased ST movement


Frozen Shoulder Reduced ER


DDx Causes of reduced ER

1. Frozen shoulder

2. OA

3. Unreduced posterior dislocation


Pain on forced movement

- most sensitive indicator is pain on forced ER






Arthrogram / MRA


1. Reduced volume

- <10 ml of contrast can be injected

- normal = 20-30 ml

2. Obliterated axillary capsular recess

3. Thickened capsule





- Relieve pain

- Restore range

- Remove secondary cause


Non Operative


Reassurance as first treatment


Careful explanation of 

- nature of disease

- NHx

- reassurance




Freezing Phase

- directed towards pain relief

- simple Analgesics / NSAID

- sling / ice / TENS

- intra-articular HCLA

- avoid physio as makes it more painful / doesn't increase ROM


Frozen Phase

- encourage hand use to avoid RSD


Thawing Phase

- gentle ROM & strengthening 

- consider intervention if prolonged / major functional disability




Lorbach et al J Should Elbow Surg 2010

- compared oral corticosteroids to 3 doses of intra-articular corticosteroids

- best ROM and pain relief in intra-articular group although both effective


Operative Options


1.  MUA



- at least after 6/12

- in late frozen or early thawing  phases



- osteopenia

- previous fracture or surgery

- history instability



- fractures & dislocations

- cuff tears

- increased inflammation & scarring


Technique (Neviaser)

- GA or interscalene block

- confirm diagnosis with MUA (i.e. limited ROM)


1.  Abduction first

- gentle, 2 fingers

- sensation of tearing is the axillary fold tearing


2.  Rotation second

- must avoid fracture

- IR / ER in abduction


3.  HCLA +/- hydrodistension


Post-op physio




Weber Clin Rheum 1995

- average 6 months post diagnosis

- 73% full recovery

- needed 6 weeks off work


2.  Hydrostatic Distension



- needle into GHJ under LA

- joint forcefully distended by injection

- 5 ml LA

- 1 ml steroid

- up to 40 ml Saline

- distension till capsular ruptures 

- sudden drop in resistance

- immediate post-op physio




Rydell Clin Orthop 1992

- 22 patients

- 15 months

- MUA + hydrodistention + steroids

- 91% no or slight pain at 6 weeks

- 83% normal or almost normal ROM


Jacobs J Should Elbow Surg 2009

- 53 patients randomised to either MUA or steroid hydrodistention

- 2 year follow up

- no difference in two group


Quraishi et al JBJS Br 2007

- randomised trial of MUA v hydrodistention

- improved ROM in both groups

- more patients satisfaction and better shoulder scores in hydrodistention


3.  Open Release


Ozaki et al 1989 JBJS Am 1989

- one of first papers

- open release CH ligament and RC interval

- mean of 10 months post diagnosis

- MUA as part of procedure

- 94% relief of pain and complete ROM


Segmuller et al J Should Elbow Surg 1995

- released inferior and middle GH ligaments

- 24 patients

- 88% satisfied

- 76% normal function


4.  Arthroscopic release



- +++ synovitis

- very tight shoulder to arthroscope

- capsule very thick

- very limited ROM


Arthroscopy Frozen Shoulder Synovitis




1.  Release rotator interval

- remove all tissue in between biceps and SSC


Frozen Shoulder Interval Release 1Frozen Shoulder Interval Release 2


2.  Release anterior IGHL

- from 3 o'clock down to 5 o'oclock

- leave labrum intact / anterior to labrum

- release inferior capsule with scissors / 6 o'clock


Frozen Shoulder MGHL ReleaseFrozen Shoulder IGHL ReleaseFrozen Shoulder Release IGHL Complete


Frozen Shoulder Inferior Release with scissors


3.  Mobilise SSC

- release adhesions on posterior and superior aspect

- some advocate release of intra-articular tendinous portion


4.  Release posterior IGHL

- place camera in anterior portal

- posterior to posterior labrum

- complete inferior release


Frozen Shoulder Posterior Capsule ReleaseFrozen Shoulder Posterior Release CompleteFrozen Shoulder Complete Inferior Release


5.  MUA with abduction

- remove instruments and camera

- tears inferior aspect of capsule


6.  Injection of HCLA




Ogilvie-Harris et al Clin Orthop 1995

- MUA v arthroscopic release in 40 patients

- better outcomes in arthroscopic release at 2 and 5 years

- excellent in 15/20 arthroscopic

- excellent in 7/18 MUA




Glenoid & Scapula Fractures

Glenoid Fractures


Indications for Surgery



- > 5mm step

- > 1/4 glenoid rim and displaced


Ideberg Classification Intra Articular Fracture


Type I


Fractures of the Glenoid rim

I A anterior 

I B posterior


Differentiate from small bony Bankart

- ORIF if > 1/4th or > 10 mm displaced (Neer)


Case 1


Glenoid Rim Fracture 1Glenoid Rim Fracture 2Glenoid Rim Fracture 2Glenoid Rim ORIF


Case 2


Glenoid FractureGlenoid Fracture CTGlenoid Fracture CT 2Glenoid ORIF


Case 3


Scapular fracture intraarticular glenoid axialScapula ORIF APScapula ORIF Lateral


Case 4


Glenoid Frac APGlenoid Frac AxialGlenoid Fracture CT


Type II


Transverse fracture through glenoid fossa

- inferior triangular fragment 

- exits lateral border scapula


Glenoid FractureGlenoid ORIF


Scapula Fracture XrayScapula Fracture Intra articular CT SagittalScapula Fracture Intra articular Glenoid Coronal CT


Glenoid Fracture 1Glenoid Fracture 2Glenoid Fracture 3


Type III


Oblique fracture through the glenoid    

- exiting through superior border of the scapula

- associated with AC fracture or ACJ dislocation

- includes the Coracoid


Type IV


Similar to II, larger superior fragment

- horizontal

- exiting thru the medial border of the blade


Glenoid FractureGlenoid Fracture 2Glenoid Fracture 3


Glenoid ORIFGlenoid ORIF 2Glenoid ORIF 3


Type V



- Va =IV+II




Type VI


Extensive comminution


Glenoid Malunion


Case 1

- untreated glenoid rim fracture

- patient with chronic instability

- treated with glenoid osteotomy


Glenoid Fracture Malunion CTGlenoid Osteotomy APGlenoid Osteotomy Lateral


Scapular Fractures


A.  Body


Often don't need ORIF
- well splinted by fascia / haematoma

- can treat non operatively


Scapula Body FractureScapular Body Fracture CT


Scapular Blade Fracture CTScapular Blade Fracture CT 2


Indications for surgery

- > 45 degrees of angulation of body


Scapular Body /> 45 degrees


B.  Neck


Indications for surgery

- > 450 angulation

- > 10 mm displaced (i.e. medial displacement


Case 1

- > 1 cm medial displacement

- ORIF via posterior / modified Judet approach


Scapula Neck FractureGlenoid Neck Fracture


Scapula ORIFScapula ORIF 3


Case 2


Glenoid DisplacementGlenoid Displacement CT


Glenoid ORIF 1Glenoid ORIF 2


C.  Spine


Scapula Blade Fracture CTScapula Spine Fracture



D.  Acromion


Spine scapula fracture


E.  Coracoid


Coracoid Fracture 1Coracoid Fracture 2


Coracoid Fracture CT 1Coracoid Fracture CT 2Coracoid Fracture CT 3Coracoid Fracture CT 4


Combined Glenoid and Scapula Fractures


Case 1

- displaced glenoid fracture and neck fracture

- ORIF both through posterior / Judet approach


Glenoid Scapular FractureComplex Scapular Fracture CT 1Complex Scapular Fracture CT2Complex Scapular ORIF



Humeral Shaft Fracture


Non operative Mangement




< 20o sagittal

< 30o coronal

< 3 cm of shortening


Undisplaced Humeral Fracture APUndisplaced Humeral Fracture Lateral




1.  Vietnam Cast / hanging cast

2.  Functional bracing 3/52


Functional Humerus Brace




United Humeral Fracture LateralUnited Humeral Fracture


Denard et al Orthopedics 2010

- non operative v operative treatment 213 fractures

- non operative group nonunion 20% and 12% malunion

- operative group nonunion 8% v 1%

- no increased time to union or radial nerve palsy in operative group


Operative Managment





- compound fracture

- radial nerve palsy post reduction

- failure to obtain / maintain acceptable reduction

- displaced Holstein Lewis with radial nerve palsy



- multi-trauma

- floating elbow

- obese (very difficult to splint)

- pathological fracture - won't heal

- segmental fracture

- bilateral humeral fractures

- brachial plexus injury - allows early rehab


Humeral Fracture SegmentalDisplaced Humeral Fracture APDisplaced Humeral Fracture Lateral



- antegrade IM Nail

- retrograde IM Nail

- ORIF with plate


Indications Plate vs Nail


Chapman et al J Orthop Trauma

- RCT antegrade nail v plate 84 patients

- union rates similar in each - 90%

- shoulder discomfort and decreased ROM with nail

- decreased elbow ROM with plate especially distal third


1.  Antegrade Humeral Nail


Humeral Nail APHumeral Nail Lateral


Relative indications

- segmental fracture - need very long plate

- impending pathological fracture




Set up

- lazy beach chair

- need to get II of shoulder and distal forearm

- patient relatively supine to ensure ease of AP distal locking


Anterolateral approach shoulder

- longitudinal split SS

- entry point at medial aspect GT

- entry with K wire or awl

- check down IM canal of humerus with II

- most nails have mild valgus proximal angulation

- increase diameter proximally with hand reamers


Pass guide wire

- can do closed

- can perform mini open to blunt dissect and protect radial nerve


Minimal reaming


Pass nail

- bury enough to protect cuff

- need to consider hardware removal


Proximal locking screws

- ensure not in joint

- lateral and anterolateral

- protect biceps tendon


Distal AP locking screw


Careful repair of rotator cuff




Cox et al J Orthop Trauma 2000

- 37 patients treated with antegrade nail

- 4 non unions and 4 delayed unions (>4 months)

- 6 patients had poor shoulder function (4 due to stiffness, 2 due to pain)




Rotator cuff pain

- must not leave nail prominent

- must carefully repair cuff

- still incidence of shoulder pain


Humerus Prominent IM Nail


2.  Retrograde IM Nail


Relative indication

- distal 1/3 humeral fracture

- avoids shoulder pain




Set up

- Patient prone

- arm on table, need to flex elbow


Entry dorsal

- 3cm above Olecranon fossae

- gentle reaming to prevent blow-out


Distal locking with butterfly construct and screws


Proximal locking

- some have extendable hook




Distal blow out

- difficult problem


Nail removal

- not easy procedure




Cheng et al J Trauma 2008

- RCT of antegrade v retrograde IMN

- similar union rates (>90%)

- longer time to perform retrograde IMN

- longer time to recover shoulder function in antegrade group


3.  Plate Osteosynthesis


Humeral Plate LateralHumeral Plate Long AP



- nerve injury requiring exploratation



1.  Proximal 2/3

- anterior or anterolateral

2.  Distal 1/3

- posterior




A.  Anterior Approach Humerus


Sterile tourniquet


Incision lateral aspect of biceps

- incise deep fascia



- retract deltoid laterally and biceps medially


Identify plane between biceps and brachialis

- protect MCN between the two

- identify and split brachialis in midline


Internervous plane

- radial nerve lateral brachialis

- MCN medial brachialis


Distal extension

- between brachialis and BR in distal 1/4

- find and protect radial nerve


4.5 mm DCP

- minimum 6 cortices above and below


B.  Anterolateral approach


Allows more distal plating


Utilise interval between triceps and brachialis

- identify and protect radial nerve distally between brachialis and BR

- extend proximally into deltopectoral groove


C.  Posterior Approach


Humerus ORIF Posterior Approach



- lateral approach

- arm over bolster


Sterile tourniquet if needed


Midline incision

- interval between long and lateral heads

- Split medial head of triceps

- identify radial nerve proximally 


Radial Nerve Injury




4% incidence of radial nerve injury


Associated with Holstein Lewis fracture


Holstein - Lewis JBJS Am  1963

- series of 7 oblique distal third fractures with radial nerve injury

- all were treated operatively

- nerve in fracture gap in 2 / impaled in 1 / severed in 2 / contused +/- in callus in 2

- advised against attempted closed reduction

- risk of contusing nerve between fragments

- advised early open reduction through anterolateral approach


Holstein Lewis


Incidence of laceration / entrapment


Noaman et al Microsurgery 2008

- operative exploration of 36 patients with radial nerve palsy

- entrapped in fracture site in 9 and lacerated in 8

- 9 epineural repairs and 5 nerve grafts

- neurolyis in remainder




Average time to see recovery is 7 weeks

Average time to full recovery 15 weeks

Longest time to see recovery 7 months to 1 year




Sarmiento JBJS Am 2000

- 922 fractures managed in brace, 620 followed, no MUA

- radial nerve palsy in 11% / 101

- 1 radial nerve didn't recover


Pollock & Drake et al JBJS Am 1963

- 24 humeral shaft fractures with radial palsy (14/24 distal third)

- 9 of these were complete motor and sensory (8/9 distal third)

- treatment immobilisation or traction

- all had complete recovery




1.  Explore + ORIF

- easy to make this decision if fracture requires operative management


2.  Manage non operative

- if no recovery tendon transfer



Acute Anterior Dislocation

EpidemiologyAnterior Shoulder Dislocation


Most common form of shoulder instability

- young males 

- M:F = 2:1




Indirect ER and abduction moment on arm

- disruption of anterior stabilisers




Initial injury

- severe pain in shoulder

- ± transient paraesthesia / dead arm syndrome


History of dislocations




Very painful & tender shoulder

- significant muscle spasm

- arm held across abdomen


Hollow under acromion

- fullness in anterior shoulder


Axillary nerve palsy

- important to exclude

- look for parasthesis in badge area

- 20 years = 5% --> 90% recover

- 80 years = 90% --> 10% recover


Left Deltoid Wasting


Musculocutaneous Injury + Rotator Cuff Tear


Musculocutaneous nerve injuryMusculocutaneous Nerve Injury 2Supraspinatous Infraspinatous Wasting


Diagnostic Dilemma


Patient with history traumatic dislocation / wasting of shoulder / loss ROM

1.  Wasting deltoid (AXN)

2.  Wasting SS, not IS (RC tear)

3.  Wasting SS & IS (SSN injury or massive tear)

4.  Wasted deltoid + SS/IS (upper trunk brachial plexus or AXN palsy with RC tear)


Axillary nerve palsy with Massive Rotator Cuff Tear




True AP

- dislocation

- fracture GT

- bony bankart


Shoulder Dislocation Greater Tuberosity FractureAnterior Shoulder Dislocation AP


AP in IR

- Hill Sachs lesion


Scapular Lateral

- dislocation

- humeral head should be in centre of Y


Anterior Shoulder Dislocation0002Shoulder Anterior Dislocation Scapula Lateral


Axillary Lateral

- dislocation

- Hill Sachs


Shoulder Fracture DislocationAnterior Shoulder Dislocation Axillary LateralShoulder Hill Sachs Axillary Lateral



- aim beam caudally

- bony bankart


Bony Bankart Xray




According to direction seen on xrays

1. Subcoracoid / most common

2. Subglenoid

3. Intrathoracic







- appropriate analgesia & muscle relaxation / conscious sedation

- atraumatic closed reduction performed

- if unsuccessful, may require GA

- rarely need open reduction


Post-reduction xray

- confirm reduction

- rule out associated fracture


Shoulder Post Dislocation Check ReductionBony bankart xray




1.  Stimpson

- patient prone

- arm hanging over side of bed

- weight applied to wrist

- give mild sedation

- not appropriate if obese / sleep apnea etc


Stimpson Method


2.  Harvard / Traction & Countertraction method

- patient supine

- traction with abduction

- countertraction via sheet around axilla

- similar to Hippocratic but no foot in the axilla


3.  Kocher

- externally rotate and maximally abduct arm

- relocate via adduction

- nil IR til located to avoid humeral fracture


4.  Hippocrates

- foot in arm pit

- apply longitudinal traction 




No effect on re-dislocation rate

- no sport for 6/52 reduces dislocation rate



- sling for comfort

- avoid provocation 6/52

- no sport until painless FROM


ER brace



- tightens SSC
- reduces bankart lesion into anatomical location whilst healing

- may reduce redislocation rates

- problems with compliance as is uncomfortable and in young population


Itoi et al JBJS Am 2007

- RCT ER brace v sling 198 patients 3 weeks duration

- relative risk reduction 38%

- 26% recurrence v 42% (p < 0.03)

- particularly beneficial if < 30


Finestone et al JBJS Br 2009

- RCT 51 patients

- no difference




Start with ROM exercises

- pendulum / active Assisted / active


Progress to shoulder strengthening




1. Age at first dislocation


Increased in young

- the majority of recurrences occur within 2 years of the first traumatic dislocation


Classic paper Rowe CORR '61

- < 20    90% redislocation

- 20-30  60% redislocation

- 30-40   30% redislocation

- > 40     10% redislocation


McLaughlin and MacLellan 1967 

- 95% traumatic dislocations in teenagers recurred


Simonet and Cofield 1982 

- overall incidence of recurrence 33% over 4 years

- 66% in patients < 20 years

- 17% in patients 20 - 40 years


2. Trauma of First Dislocation


Decreased incidence of re-dislocation with 

- severe trauma

- associated fracture (usually LT / GT)


3. Activity


Re-dislocation more common in athletes

- 80% in athletes

- 30% in non-athletes


4. Rehabilitation


Activity restriction & effective muscle strengthening reduces re-dislocation

- overall re-dislocation rate 25% at 3 years in Army

- need strict adherence with program


Indications Operative Management in Acute Dislocation


1.  Rotator cuff tear

2.  Displaced GT fracture

3.  Large glenoid rim fracture

4.  ? Athlete


Rotator cuff tear




Important not to miss

- high incidence in patients > 40

- suspect if pain or decreased ROM





Berbig et al J Should Elbow Surg 1999

- prospect ultrasound on 167 patients with dislocation

- full thickness tears in 31.7%

- only acute tears in patients younger than 60

- control group had no FT tears in patients younger than 60


Management Options


A.  Repair RC / leave Bankart

B.  Repair RC and Bankart


Voos et al Am J Sports Med 2007

- retrospective review of arthroscopic repair of RC and labrum

- average age 47, 16 patients

- good or excellent results in > 90%


2.  Displaced GT Fracture



- > 5 mm displacement




- screw + suture repair

- screw alone in young patient


Shoulder Dislocation Non Displaced GT FractureGT ORIF


3.  Large Glenoid Rim Fracture



- > 25 - 30% and displaced



- open or arthroscopic

- fix with 1 or 2 cannulated screws


Glenoid Rim FractureGlenoid Rim Fracture CTGlenoid Rim ORIF


4.  Acute dislocation in professional athlete


Robinson et al JBJS Am 2008

- prospective randomised control trial arthroscopic surgery in first time dislocators

- 88 patients under 35, arthroscopic stabilisation v arthroscopic lavage

- reduced risk of recurrence by 80%

- patient satisfaction and shoulder scores significantly improved


Kirkley et al Arthroscopy 2005

- RCT of 40 patients for arthroscopic stabilisation v immobilisation

- 3 recurrences in surgical group, 9 in non surgical group

- small improvement in shoulder scores in operative group


Jakobsen et al Arthroscopy 2007

- RCT 76 patients

- arthroscopy to diagnose labral injury

- either open repair or non operative

- 74% unsatisfactory results at 8 years in non operative group

- 75% good results in operative group (1 redislocation)

Anterior Instability



Traumatic initial cause in 95%


M:F 2:1


Age of initial dislocation inversely related to recurrence rate

- patients younger than 20 have a redislocation rate of 90%

- between 20 - 40 years, redislocation rate of 60%

- patients > 40 years have a 10% rate of dislocation but a higher rate of cuff tears (up to 40% in patients > 60yrs)


Anatomy & Stability


1. Passive Stabilisers


Glenoid labrum 

- significant deepening by 50%

- labrum attaches capsule / ligaments / biceps


Negative intra-articular joint pressure


Joint fluid adhesion/ cohesion



- attaches to SNOH


Coracoacromial arch

- prevents superior displacement


Coracohumeral ligament

- attaches base of coracoid

- to lesser and greater tuberosity 

- passess through rotator interval between SS and SSC

- static restraint to anteroinferior translation in the adducted shoulder


Capsulo-ligamentous structures


1.  IGHL


Most important

- resists anterior translation in abduction and ER

- anterior & posterior band with sling between

- anteror band limits ER at abduction > 90°



- anterior band glenoid 3 o'clock

- posterior band 9 o'clock



- inferior anatomical neck / head


Arthroscopy Normal IGHL Humeral AttachmentIGHL


2.  MGHL


MGHL in Buford Complex



- behind SSC

- 2° restraint anterior translation

- limits ER at 45° Abduction

- present in 60% population



- supraglenoid tubercle below SGHL



- medial to LT


3.  SGHL





- adjacent to biceps tendon

- prevents inferior subluxation 

- functions only in adduction

- no function in decreasing anterior translation

- present 50% population



- supraglenoid Tubercle 



- LT


2. Dynamic Stabilisers


Rotator Cuff

- SSC resists anterior translation

- compresses head into glenoid socket


LH Biceps



- especially when arm is elevated 90o


Scapular Rotators 

- move glenoid into stable position




No essential pathological lesion responsible for every recurrent subluxation or dislocation


Thomas and Matsen Aetiology Classification



- Atraumatic, Multidirectional, Bilateral

- Rehabilitation, Inferior capsular shift, closure rotator Interval



- Traumatic, Unidirectional, Bankart, Surgery


1.  Labrum / Ligament / Capsule


A.  Bankart lesion



- described in 1938 

- humeral head forced through capsule

- humeral head tears fibrocartilaginous labrum from almost entire anterior 1/2 of glenoid rim 

- is an IGHL avulsion

- usually between 3 and 6 o'clock



- see detachment of anterior labrum


Anterior Bankart Lesion MRIShoulder MRI Anterior Bankart




Anterior bankart lesion ArthroscopyArthroscopy Soft Tissue Bankart



- present in 85% traumatic recurrent dislocations 

- may be associated with avulsion fracture of glenoid rim / bony bankart


B.  Excessive Capsular laxity 



- may be present alone or with Bankart lesion

- 30% have both

- 85% previous failed surgical procedures



- congenital collagen deficiency / MDI

- plastic deformation of capsuloligamentous complex

- single macro-traumatic event or repetitive micro-traumatic events


C. Capsular Tears


Capsular Tear 1Capsular Tear 2Capsular Tear 3


Capsular Repair 1Capsular Repair 2





- avulsion of IGHL from anterior humeral neck

- Humeral Avulsion of Glenohumeral Ligament



- 2 - 10%



- can be in combination with anterior bankart (Floating IGHL)

- association with subscapularis tear



- may see bony avulsion



- enlarged inferior  pouch

- discontinuity of IGHL / J sign


MRI Normal Humeral IGHL InsertionMRI HAGL J Sign



- will see exposed subscapularis muscle


Arthroscopy HAGL Normal Humeral attachment IGLH




A.  Open Repair

- take down SSC

- repair via bone anchors to inferior neck

- can cause limitation ER


B.  Arthroscopic repair

- 70o scope and 5 o'clock portal


E.  Bankart Variations



- anterior labrum periosteal sleeve avulsion

- labral-ligamentous structures shifted medially

- roll up under the periosteum


Perthes Lesion

- stripping of the scapular periosteum medially

- labrum may or may not be attached


Perthes Lesion MRI 1Perthes Lesion MRI 2Perthes Lesion MRI 3



- glenoid labrum articular disruption

- damage to the glenoid cartilage

- labrum undisplaced


Shoulder GLAD


F.  Muscle


Cuff Tears

- Present as pain or weakness 

- > 40 years = 30%

- > 60 years > 80% 


Increased Rotator Interval

- between SS and SSC

- tends to open up with AMBRI


2.  Bony


A.  Bony Bankart



- AP

- Garth (aim beam caudally)


Bony bankart XrayShoulder Garth ViewBony Bankart



- large bony bankart increases risk of failure of soft tissue bankart repair



- may need CT to decide the size best


Burkhart and De Beer Arthroscopy 2000

- described the inverted pear appearance

- loss of bone antero-inferior




CT Sagittal Small Bony Bankart




CT Axial Large Bony BankartCT Axial Large Bony BankartLarge Bony Bankart


Size calculation


Bony Bankart Size CalculationGlenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 1


Lo Parten and Burkhart, Arthroscopy 2004

- calculation of percentage bone loss arthroscopically


1.  Inferior glenoid is nearly a perfect circle

- centre is the bare area of the glenoid

- measure anterior radius v posterior radius at this level


2.  Calculate the diameter of the inferior circle

- twice the posterior radius


3.  Calculate the difference between anterior and posterior radius


The average diameter is 24 mm

- hence 12 mm posterior and 12 mm anterior

- if lose 8 mm anteriorly

- 12 mm posterior and 4 mm anterior

- calculation is 8/24 = 30%




25% loss and above poor prognostically

- means approximately 7.5 mm anterior bone loss

< 4mm anterior to bare area

- > 30%

- likely not amenable to soft tissue bankart repair alone


Acute Bankart Repair


Sugaya et al JBJS Am 2005

- demonstrated union of fragment with arthroscopic restoration

- must mobilise fragment, restore anatomically

- otherwise bony procedure


Decision Making


A.  Small fragment < 15%

- arthroscopic bankart repair

- can attempt to include fragment


B.  Intermediate 15 - 25%


C.  > 25%

- must restore glenoid rim

- acute restoration of bony frament or

- bony procedure / Latarjet / Bristow


B.  Hills Sachs Lesion 



- lesion posterior aspect of head

- where head engages on anterior glenoid



- AP with IR

- Garth view


Hill Sachs XrayLarge Hill Sachs Xray




Hill Sachs CT



- cartilage each side of lesion

- this differentiates it from the normal bare area next to infraspinatous


Arthroscopy Hill Sachs LesionLarge Hill Sachs



- large lesion can contribute to dislocation

- head engages defect in external rotation & abduction


Large Hill Sachs MRICT Hill SachsHill Sachs


Dynamic CT

Dynamic CT 1Dynamic CT 2Dynamic CT 3




Estimate percentage of articular surface

- concern if 25% or more


Hill SachsHill Sachs Measurement


Hill SachsHill Sachs measured


Management options for engaging Hill Sachs


1.  Posterior capsular advancement / Remplissage

2.  Humeral head allograft

3.  Anterior Bony Procedure / Latarjet / Bristow

- Hill Sach's lesion unable to engage on anterior glenoid rim

4.  Humeral osteotomy





- described by Wolf Arthroscopy 2008

- advance IS into Hill Sachs lesion

- makes lesion extracapsular



- perform arthroscopic transtendinous advancement of IS and capsule into defect

- tie knots from subacromial space




Zhu et al Am J Sports Med 2011

- 8.2% failure in 42 cases


Humeral head allograft


Humeral Head Allograft APHumeral Head Allograft Lateral.jpg



- anterior deltopectoral approach

- ER shoulder

- debride base of Hill Sachs

- secure allograft with 2 x screws



- late resorption of graft with recurrent instability


Humeral Head Allograft Resorption


Humeral Head Osteotomy


Weber et al JBJS Am 1984

- series of 180 patients

- very low risk of recurrence


C.  Abnormal Version 


Glenoid or Head

- rarely a cause

Arthroscopic Bony Bankart Repair

Case 1: Acute Presentation


Bony Bankart Xray


Bony Bankart Fixation 1Bony Bankart Fixation 2Bony Bankart Fixation 3


Bony Bankart Fixation 4Bony Bankart Fixation 5Bony Bankart Fixation 6


Bony Bankart Fixation 7


Arthroscopic Stabilisation

Labral Repair

Arthroscopic Shoulder Stabilisation



1.  EUA


Compare both shoulders


- anterior and posterior draw

- load and shift

- sulcus sign


2.  Labral Assessment


A.  Above equator


Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability


Beware normal variations in this area


Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types


1.  Sublabral foramen


Arthroscopy Anterior Sublabral ForamenShoulder Sublabral foramen


2.  Sublabral foramen with cord like MGHL


Buford Complex


3.  Absence of AS labrum with cord like MGHL

- Buford complex


Buford Complex


B.  Below equator 


Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)


Anterior Bankart LesionShoulder Anterior Bankart


C.  Exclude HAGL


Assess anterior IGHL attachment to humeral neck


Normal IGHL Humeral Attachment


D.  Posterior Labrum


Always assess

- place camera through anterior portal


Arthroscopy Posterior Labral Tear


3.  Bony Assessment


A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?


Shoulder Anterior Glenoid DeficiencyGlenoid Bone Loss


Glenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 2



- anterior bony procedure


B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

- only a problem if engages with head centred and ER < 30 - 40o


Hill Sachs ArthroscopyHill Sachs Lesion SuperiorShoulder Engaging Hill Sachs




1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid


2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular


3.  Humeral head allograft


4.  Humeral head osteotomy


Technique Anterior Bankart Repair


Labral Repair


Set up


Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg




Shoulder Portals Labral Repair


A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work


B.  Anteroinferior Portal (AI)

- for anchor placement

- rotator interval just above SSC
- 1 cm lateral to glenoid

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal


Shoulder Scope Anteroinferior Portal


Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula


Shoulder Arthroscopy Anterosuperior PortalShoulder Stabilisation 2 Anterior PortalsRotator Interval 2 cannulas



- can make rotator interval very crowded

- repair can be done through single portal


Mobilise labrum


Shoulder Scope Bankart RaspShoulder Stabilisation Labral Mobilisation


Labral mobiliser / rasp / scissors

- labral tear can be obvious, but may have partially healed or healed medially

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view


Shoulder Arthoscopy Bankart MobilisationShoulder Scope Bankart Mobilisation


Bony Fragments

- important to recognise




1.  Incorporate in repair

- pass sutures medially to bony fragments


2.  Remove / debride


Shoulder Arthroscopy Bony Bankart


Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs


Shoulder Stabilisation Anterior Labral MobilisationShoulder Stabilisation Anterior Labral Mobilisation 2


Labral Repair



- 2.3 or 3.2 mm bioabsorbably anchors


Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point


Arthroscopy Bankart Anchor Drill GuideInferior Glenoid Anchor


Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

- suture passer with loop / single nylon in anterior to posterior direction

- retrieve through portal

- retrieve suture posterior to anterior through portal


Shoulder Bankart Repair Suture PasserShoulder Instability inferior Suture passage


Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect


Arthroscopy Anterior Bankart Repair


Remaining anchors

- 5 mm apart

- beware lysis and risk of anterior glenoid / postage stamp fracture

- up to glenoid equator

- usually three in total


Shoulder Bankart RepairShoulder Scope Bankart Repair 2


Additional Issues / Continued Instability


Capsular Shift

- take bite of capsule with suture passer, then labrum


Shoulder Instability Capsular Plication



- contributes to inferior instability

- requires repair


Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30o ER

- do away from glenoid on humeral side or will make patient very stiff


- must do last




Primary Arthroscopic Stabilisation


Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

- identified patients < 25 / ligamentous laxity / Hill Sachs > 250mm3 high risk


Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability


Arthroscopic v Open Bankart Repair


Bottoni et al Am J Sports Med 2006

- RCT open v arthroscopic, 2 - 3 year follow up

- 2 failures in open group v 1 failure in arthroscopic group

- open took significantly longer and was associated with decreased ER


Revision of Failed Arthroscopic Stabilisation


Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

- redislocation in 3 shoulders all with engaging Hill Sachs and ligamentous laxity


Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence

Glenoid Allograft / Autograft

Distal Tibial Allograft




Bony defects > 30 %



- Latarjet - may be insufficient for lesions in the region of 50%

- Iliac crest - associated with high incidence of OA
- distal tibial allograft - radius of curvature matches glenoid highly


Distal Tibial Allograft 1Distal Tibial AllograftDistal Tibial Allograft 3


Humeral Head Autograft


After humeral head resurfacing


Chronic Anterior DislocationHumeral Head Autograft to Glenoid


Humeral Head Autograft to GlenoidHumeral Head Autograft


DefinitionHAGL Arthroscopy


Humeral Avulsion of Glenohumeral Ligament




Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%


Bhatia KSSTA 2012

- 10% incidence of HAGL


Bigliani et al J Ortho Research 1992

- cadaveric dislocations

- 25% HAGL


Why the difference with cadavers

- ? differences in tissue

- HAGL lesions heal / don't always cause instability




Bony avulsions (BHAGL)


Soft tissue

- humeral

- humeral and bankart (floating)

- posterior / Reverse HAGL




Pouliart J Should Elbow Surg 2006

- cadaveric study

- extensive capsular injury +/- SSC required for HAGL to cause instability






Shoulder MRI Normal Humeral IGHL InsertionMRI Normal IGHL



- J sign








Normal Humeral Attachment IGHL








1.  HAGL


Open Technique


Detach lower half SSC

- L Shaped tenotomy

- repair IGHL to surgical NOH


Arthroscopic Technique



- 70o scope

- 5 o'clock portal through SSC with arm adducted

- danger to MCN if arm abducted at all with insertion 5 o'clock portal

- ensure good angle to proximal humerus with needle, for insertion of anchors

- may use suture passers from posterior portal




2.  Bankart + HAGL (Floating)



- arthroscopic repair both

- open repair both

- arthroscopic repair bankart, open HAGL

- arthroscopic repair bankart, leave HAGL


Kim et al Arthroscopy Supplement 2006

- all arthroscopic, 8 good results


Rhee et al J Should Elbow Surg 2007

- 4 floating HAGL, open treatment

- loss 15o ER
- elected to leave humeral side in volleyballer for risk of loss of ER


Bhatia KSSTA 2012

- subscap sparing approach in 7 patients

- good outcome


Latarjet / Bristow





Non-anatomical bony block 

- transfer of coracoid process through subscapularis

- dynamic anteroinferior musculotendinous sling

- provides subscapularis tenodesis

- preventing lower portion from displacing proximally as arm abducted

- when shoulder in vulnerable position abduction and ER


BristowBristow CT




1.  Contact Sportsman

- sportsman who will return to dislocating action and loss of ER not a problem

- football, basketball


2.  Large bony bankart

- > 25 - 30%


Large Bony Bankart CT0001Large Bony Bankart CT0002


Glenoid bony defect



Large Bony BankartInverted Pear Glenoid


3. Large Hill Sachs

- prevent engagement


Large Hill SachsEngaging Hill Sachs


4.  Poor soft tissue

- multiple dislocations

- anterior labrum very poor quality


5.  Revision surgery

- i.e. failed arthroscopic or open soft tissue bankart




1.  Loss of ER 12-20°

- problem if throwing athlete

- subscapularis is relatively shortened 


2.  Screw problems 2-14%


3.  Instability 1-20%

- does not address bankart pathology

- difficult to revise with scarring in abnormal positions 


4.  Injury MCN





- correct positioning of transferred coracoid process critical to success 

- must be near but not over anterior glenoid rim


Good results can be correlated with


1. Coracoid process < 5 mm medial to glenoid rim

2. Coracoid positioned inferior to transverse equator of glenoid

3. Bony union develops between coracoid & scapula

4. Fixation screw purchases posterior glenoid cortex

5. Screw does not penetrate articular surface




Difference from Bristow


Transfers larger fragment

- allows 2 x screw fixation of coracoid to neck of scapula


Latarjet APLatarjet Lateral



- large > 20-25% bony Bankart

- revision surgery

- contact athlete


CT Large Bony Bankart



- ? throwing athlete

- can lose considerable ER






Deltopectoral approach

- divide clavipectoral fascia at lateral edge of conjoint




Identify coracoid

- use fang retractor on superior surface to identify entire coracoid

- strip Coracoacromial ligament off lateral coracoid

- take pectoralis minor off medially


Divide coracoid

- 3 cm long

- use 90o oscillating blade on microsagittal saw 100

- medial to lateral


Prepare coracoid

- release conjoint for length, identify and protect MCN

- pect minor surface will be placed onto glenoid

- remove cortex with burr

- opposite side clear soft tissue with diathermy

- hold coracoid with Kocher forceps

- make 2 indentations with small burr where 2 x drill holes will be

- stops drill spinning off, ensures drill holes are sufficiently far apart

- 2 x 2.5 mm drill holes, tap, countersink


Deep Approach



- identify 3 sisters inferiorly


A.  Divide muscle transversely at inferior 1/3 of SSC

- at muscle is easier to take off capsule

- also want to be inferior

- do so by inserting scissors and opening blades vertical

- use sponge to separate from capsule

- insert fang superiorly / blunt homan medially for view


B.  Take down superior half of SSC

- repair later



- feel joint line

- 2 x stay sutures 2 ethibond superiorly and inferiorly

- these must be medially over glenoid

- then divide capsule vertically with knife medial to stay sutures

- want maximum amount of capsule length to repair to anterior glenoid

- this prevents IR contracture


Dissect capsule from SSC

- inferiorly

- medially

- will have a free medial edge to repair to anterior edge glenoid

- may be easier to do this after osteotomy coracoid

- use scissors to dissect capsule superiorly

- beware inferiorly as AXN here



- remove retractorr

- insert fukuda to expose humeral head, joint, glenoid

- again use fang / blunt homan superiorly and medially for exposure


ORIF Bone Block


Bone block

- clear glenoid 3 - 6 o'clock

- need medial area to place bone

- can use burr

- place bone on glenoid using Kockers to hold

- 2 x drill bits, leave first one insitu

- bone must not overhang medially

- bicortical, tap, typically 30 - 40 mm partially threaded cancellous


Latarjet Scapular LateralLatarjet Axillary LateralLatarjet AP


Capsule repair


Remove Fucuda

- find capsue with stay sutures

- insert 2 x 3 mm absorbable anchors 3 and 5 o'clock

- pass in mattress formation through capsule

- can use Depuy Mitek Suture grasper

- pass this through capsule lateral to medial, grasp suture

- tie capsule down, ensure knot goes down past bone block to glenoid




Burkhart et al Arthroscopy 2007

- 102 procedures for patients with the inverted pear glenoid +/- engaging Hill Sachs

- 4.7% recurrence rate

- 5o loss or ER


Boileau et al Arthroscopy 2010

- arthroscopic Latarjet

- 6/47 had to be converted to open

- no recurrence of instability at 16 months

- 1 bony block fracture and  7 migrations

- potentially dangerous and difficult procedure




Failure of fixation


Non union of coracoid

- need to carefully prepare both surfaces

- good compression


Suprascapular nerve injury

- screws too long, or too superior



- bone block too medial



- too high, can dislocate under bone block

- too low, can dislocate over bone block


Failed Latarjet APFailed Latarjet Lateral


Open Bankart Repair



Repair of the anterior capsule & avulsed labrum to anterior glenoid 

- anatomic repair


Usually combined with a capsular shift




Bony bankart > 25% glenoid





- beach chair position

- arm free

- Mayfield head ring / Spyder and Tmax




Can perform axillary incision

- in axillary fold

- mobilise skin to gain view

- more cosmetic scar

- more difficult visualisation


Axilary Incision 1Axillary Incision 2


Superficial dissection

- deltopectoral approach

- cephalic vein lateral with deltoid

- divide clavipectoral fascia

- mobilise lateral aspect conjoint tendon

- insert shoulder retractor deep to conjoint

- expose subscapularis with three sisters inferiorly


Increase exposure

- +/- partially detach conjoint tendon from coracoid

- ± partially release P major tendon (1.5 cm) from humerus

- can take of tip of coracoid (predrill for lateral repair)


Deep Dissection Options



Always leave inferior 1/4 of SSC

- protects AXN


L shaped incision in SSC / Capsulotomy 



Mark lower 3/4 of SSC

- ER shoulder

- use knife to divide muscle belly transversely

- expose capsule underneach

- use Cobb / dissecting scissors

- pass artery forcep up between capsule and SSC to rotator interval

- open interval further by spreading forceps

- tagging sutures in SSC medially (artery clips)

- divide SSC tendon vertically down onto forcep protecting capsule

- carefully elevate SSC from capsule medially using Cobb


Separate vertical incision in capsule

- right on humeral insertion

- superior and inferior

- stay on articular margin at all times

- can release down past 6 o'clock if wish to perform capsular shift

- usually don't perform horizontal / T shaped capsulotomy if repairing labrum

- T shaped capsulotomy used for MDI



- insert Fukuda retractor to expose joint

- displaces head posteriorly, exposes labrum

- inspect for pathology: labral detachment / loose bodies / loose capsule

- labrum mobilised

- bony glenoid roughened to bleeding surface

- suture anchors at 3, 4 & 5.30 

- sutures passed through labrum and capsule


Capsular plication / shift as required

- always repair with arm ER 30o to prevent loss of ER

- check ER with arm adducted and abducted

- need 50% of normal ER / other side


Tie medial labral / capsular sutures

- recheck ER as above


Subscapularis repaired / close rotator interval if shoulder still loose



- shoulder immobiliser for 6/52 with pendulars

- no ER

- elbow & hand exercises

- ROM exercises at 6/52 (passive, active assist, active)

- muscle strengthening at 3/12

- return to sport at 6/12




Rowe et al JBJS Am 1978

- classic quoted paper

- 5 recurrences in 145 patient(3.5%)


Flatow et al Orthopedics 2006

- 41 open stabilisations followed for average 6 years

- one recurrence

- average loss of ER 4o





Other Surgical Techniques





Plication subscapularis & capsule




Loss ER 

Secondary OA if ER < 0°





- will force head out posteriorly




Divide SSC 2.5cm from insertion 

- may divide capsule in same plane

- re-attach lateral flap to convenient medial soft tissue eg under surface of capsule

- double breast medial muscle over lateral stump

- limit ER to neutral




Kiss et al J Should Elbow Surg 1998

- 70 Putti platts assessed clinically and with xray at average 9 years

- 11% redislocation rate

- 29% moderate and with 1 severe OA

- 11% pain at rest

- average loss of ER 23o

- 83% fully satisfied






Lateral advancement of SSC and capsule

- transfer of subscapularis from LT 

- across bicipital groove to GT

- Magnusson recommended distal transfer as well to allow subscapular sling


Bone Block Procedure




Transfer of bone graft to anterior glenoid rim

- Eden-Hybinette & Oudart procedures




Worse results than Putti-Platt with high incidence OA >10%


Osteotomy Humeral Head / Glenoid


No evidence to support either in most circumstances

- Glenoid neck osteotomy high rate of serious complications



- malunion post fracture


Glenoid MalunionGlenoid Osteotomy









Engaging Hill Sachs


Engaging Hill SachsEngaging Hill Sachs


Engaging Hill Sachs 1Engaging Hill Sachs 2





1.  Insert Hill Sachs anchors before performing bankart repair

- may be easier to do with humeral head subluxed over glenoid

- increases room to more

2.  May be best to clear subacromial space before inserting Hill Sachs anchors


Posterior portal glenohumeral jont

- camera anterior portal

- debride Hill Sachs


Hill Sachs DebridementRemplissage Anchors 1Remplissage Anchor 2


Insert 2 x anchors

- insert both via posterior portal

- leave one set of sutures out through portal

- separate stab incision posteriorly to retrieve other set of sutures into subacromial space

- use bird beaks or suture runner


Remplissage Anchors


Subacromial tying

- tip:  may be best to do this before passing anchors into Hill Sachs defect

- redirect posterior portal into subacromial space

- camera via lateral subacromial portal

- debride posterior subacromial space carefully to find sutures

- may want to place suture savers over sutures


Subacromial sutures



- separate with birds beak

- tie these knots (white) directly


Remplissage Subacromial Space


Knots / double pulley

- tie two limbs of separate anchors together

- use other limbs to oppose knots to tissue

- then tie other limbs


Remplissage Double PulleyRemplissage Subacromial Knots


Camera back into glenohumeral joint

- check capsule tied down into defect


Shoulder Post Remplissage

Revision Stabilisation

Causes for failure


1.  Patient factors


A.  Recurrent Trauma

- contact athletes higher risk


B.  MDI / Ligamentous Laxity / Voluntary dislocaters


C.  Poor rehabilitation

- poor motivation

- too rapid

- patients rarely get stiff, better to go very slow


2.  Surgeon Factors


A.  Unrecognised bony defect

- large bony bankart

- large engaging Hill Sachs


B.  Non Anatomical repair


C.  Poor sutures / poor knots / insufficient anchors


D. Unaddressed capsular laxity / Laxity RC interval / poor anterior labrum


E.  Posterior capsular tear / incorrect diagnosis / MDI




Identify cause of recurrent instability



- traumatic or atraumatic






- large Hill Sachs

- large Bony Bankart



- assess anchor position

- reassess labral repair / integrity




Long period non operative

- best results if muscle control  and strength are optimal


Revision Options


1.  Revision arthroscopic stabilisation



- no bony defect

- poorly done original surgery

- traumatic redislocation



- repair labrum

- capsular plication

- +/- rotator interval closure


2.  Open stabilisation



- as above


3.  Laterjet



- bony defect

- large Hill Sachs


Results of revision surgery in those without bony defects


Arthroscopic revision post failed arthroscopic stabilisation


Franchesci et al Am J Sports Med 2008

- revision labral repair / capsular plication +/- rotator interval closure

- 1 failure


Arthroscopic revision post failed open stabilisation


Boileau et al Arthroscopy 2009

- 22 cases post Latarjet and open Bankart

- arthroscopic labral reattachment / capsular plication +/- rotator interval closure

- 1 recurrent subluxation and 2 with positive apprehension


Open revision


Levine et al Am J Sports Med 2000

- 49 shoulders treated with capsular shift +/- Bankart repair if needed

- all patients who had a traumatic redislocation had a good result

- only 67% of patients with atraumatic recurrent instability had a good results




Case 1


Recurrence of instability without trauma

- anchors very high

- into glenoid face

- MRI suggests remaining inferior bankart

- no bony deficiency, no HAGL


Failed Open Stabilisation APFailed Open Stabilisation LateralFailed Open Stabilisation CT AxialFailed Open Stabilisation CT Sagittal


Failed Open Stabilisation MRIFailed Open Stabilisation MRI 2


Case 2


Recurrent instability

- non recognised bony defect

- revised with Latarjet


Revison Shoulder Stabilisation CT Bony DefectRevision Shoulder Stabilisation Bony Defect 2Revision Stabilisation with Latarjet






Locked Glenohumeral Dislocation



A GH dislocation which has been missed for a significant period of time

- time period is arbitary

- > 3-6 weeks




Humerus soft and osteoporotic

Significant soft tissue contractures


1.  Anterior / subcoracoid dislocation



- scarring to NV structures

- RC tears including SSC, especially > 40

- anterior glenoid wear / can have significant bone loss

- large engaging Hill Sachs / humeral head defects


2.  Posterior dislocation

- posterior glenoid wear

- reverse Hill Sach's / large anteromedial defects




Anterior 41%


Posterior 59%




Multi trauma


Poor patient mental function




Limitation ROM

History multi trauma / seizures

Previous treatment

- often have had inadequate X-rays

- extensive physiotherapy / injections




Usually some asymmetry


Some reduction ROM


Palpate humeral head anteriorly / posteriorly




Scapular AP view

Scapular lateral

Axillary lateral




Aids diagnosis and preoperative planning




Non Operative



- elderly 

- minimal functional limitation

- significant medical issues


Only operate if significant clinical problems

- anterior more difficult than posterior to solve




Closed reduction




1.  Timing 

- has been successful up to 6-8 weeks

- most successful outcomes in literature < 4 weeks


2.  Humeral head impression

- if this is locked on glenoid, closed reduction is contraindicated


3.  May be unstable afterwards

- need further open procedure

- need careful postoperative monitoring

- regular xray surveillance


Chronic Anterior Dislocation


1.  Large Humeral Head Defect


Hill Sach's

- posterolateral defect

- manage according to size


Defect < 40%


A.  Elevate and Bone graft defect

- < 4 weeks in young patient

- adequate bone, salvageable cartilage

- posterior approach

- split deltoid / L shaped Infraspinatous tenotomy


B. Advance Infraspinatous +/- GT

- posterior approach

- < 20% IS alone

- if larger must also take GT


Defect > 40%


A.  Allograft

- young patient

- pre-op CT to estimate humeral head size

- appropriate sized femoral / humeral head


B.  Prosthesis

- often significant OA with long standing dislocation

- anterior glenoid deficiency

- older patient

- increase retroversion of humeral component

- may need to address anterior glenoid deficiency


2.  Glenoid Deficiencies


Indicated when > 20-25% anterior glenoid eroded


Bristow / Latarjet


Glenoid Reconstruction

- humeral head

- iliac crest


Glenoid Reconstruction Humeral HeadGlenoid Reconstruction


3.  Soft tissue deficiencies 


Always combine with anterior labral repair +/- inferior capsular shift


4.  Rotator cuff tears


Significant issue

- if massive cuff tear, may lead to chronic instability

- very difficult to treat




50 year old, missed locked anterior dislocation one year

- head severely mis-shapen

- missing 50% glenoid

- massive rotator cuff tear



- open reduction

- shoulder hemiarthroplasty / humeral head used to bone graft glenoid / rotator cuff repair

- unfortunately rotator cuff repair failed, and developed recurrent instability

- option: Reverse TSR / fusion


Locked Anterior 1Locked anterior 2Locked Anterior 3


Locked anterior MRI 1Locked anterior MRI 2Locked anterior MRI 3


Locked anterior surgery 1Locked anterior surgery 2Locked anterior surgery 3




26 year old female

- ligamentous laxity, but no previous shoulder problems

- traumatic anterior shoulder dislocation

- leading to recurrent anterior subluxation

- had an arthroscopic anterior and posterior capsular plication

- shoulder now permanently dislocated anteriorly

- options: open posterior capsular release and latarjet / or fusion


Chronic anterior dislocation 1Chronic anterior dislocation 2Chronic anterior dislocation 3


Locked anterior 1Locked anterior 2Locked anterior 3


Chronic Posterior Dislocations




Standard DP approach

- manage SSC depending on operative plan for humeral head defect

- open capsule

- remove any fibrous tissue in glenoid

- use lever to reduce humeral head

- usually can ignore posterior capsular detachments


Manage humeral head / glenoid defects


See Posterior Shoulder Instability


1.  Humeral Head defects


Posterior dislocation

- anteromedial


Defects < 40%


A.  Disimpaction and bone graft

- < 4 weeks, young patient

- articular cartilage must be salvageable

- via anterior approach


B.  McLaughlin

- < 20%, SSC only

- < 40% transfer SSC + LT into defect

- secure with 2 x cancellous screws


Defects > 40%


A. Allograft

- young patient


B.  Hemiarthroplasty / TSR


2.  Posterior Glenoid Deficiency


May need posterior bone graft


Luxatio Erecta



Rare, inferior shoulder dislocation




Forced abduction injury




Shoulder is hyperabducted

- humeral shaft abuts the acromion

- humeral head is levered inferiorly

- tears inferior capusle


Head becomes locked inferior to glenoid


May button hole through inferior capsule

- becomes irreducible

- need open reduction


Has tear rotator cuff / GT fracture




Tear RC

GT fracture

AXN palsy

Thrombosis axillary artery


Clinical Presentation


Patient has shoulder abducted

- has elbow flexed

- elbow resting on head




Conscious sedation

- increased abduction initially

- then adduct


Post Reduction



- assess RC / biceps



- usually recovers





Multidirectional Instability

DefinitionMDI Shoulder


Instability in at least 2 planes

- postero-inferior

- antero-inferior

- antero-postero-inferior




Recognised as a common problem 

- often misdiagnosed


Most patients athletic

- average age 24 years (15 - 54 years)




1.  Inherent ligament laxity > 50%


2.  Repetitive overuse with capsular stretch 

- microtrauma


3.  Macro-trauma < 50%




Collagen abnormality


Increased joint volume 

- 2° enlarged inferior axillary capsular pouch

- patulous anterior and posterior


Often attenuated, broad rotator interval




Often bilateral


Instability of other joints


Feeling of shoulder "slipping down" while carrying heavy loads

- inferior instability


Often recurrent subluxation with minimal trauma

- sleeping


Shoulder pain

- fatigue 

- impingement type pain with overhead activities




Ligamentous laxity 75%


Inferior instability

- Sulcus Sign +


Shoulder Sulcus Sign


Anterior instability

- anterior draw

- anterior load and shift

- anterior apprehension, positive Jobe's relocation


Posterior instability

- posterior draw

- posterior load and shift

- posterior apprehension / jerk test




Traction xray

- patient standing with 5-10 kg in each hand

- Shows inferior subluxation of head


DDx of Inferior displacement of head


Torn superior rotator cuff

Suprascapular nerve palsy

Deltoid atony eg CVA

Deltoid / axillary nerve palsy






Mainstay of treatment

- operative results poor




Minimum 12/12

- initial shoulder strengthening

- strengthen 3 parts of deltoid, cuff & scapular stabilisers

- specific programme with rope & pulleys

- combined with education program

- ~ 90 % success





- never operate on voluntary dislocator

- MDI surgery less successful than surgery for unidirectional instability

- cannot perform isolated anterior surgery

- bristow procedures etc fail as capsule remains redundant 

- anterior surgery may displace head posteriorly


MDI with traumatic anterior bankart

- new symptomatic instability on a background of ligamentous laxity / MDI

- MRA diagnosis of anterior bankart

- is reasonable to operate on patient with new traumatic anterior instability with labral tear

- issue is whether to combine with capsular shift


Options for MDI


1. Neer and Foster inferior capsular shift

2. Arthroscopic capsular plication


1.  Open Inferior Capsular Shift ~ Neer & Foster 1980


MDI SubluxedMDI Reduced



- detach capsule from neck of humerus

- shift capsule superiorly to obliterate the inferior pouch

- decrease joint volume





- to confirm diagnosis


Deltopectoral Approach / Axillary fold



- must divide SSC separate to capsule

- need to leave capsule intact

- make horizontal incision in inferior border of SSC

- at muscular aspect

- insert curved artery forcep between SSC and capsule

- will exit at rotator interval

- insert medial stay sutures x 2 (use different colour to differentiate from capsular sutures)

- make vertical incision on artery forcep to avoid injury to capsule


T shape capsulotomy of capsule

- vertical component on humeral insertion

- transverse component to midpoint glenoid

- mark with pen first

- make vertical component on articular margin

- place inferior and superior stay sutures

- make horizontal incision

- creates superior and inferior capsular flaps


Capsular Shift 1Capsular Shift 2


Inspect joint

- ensure no loose bodies

- repair bankart lesion if needed


Inferior capsular flap

- must sharp dissect capsule off inferiorly around humeral head

- protect AXN at all times

- do so by following articular margin around

- ER shoulder +++

- must get past 6 o'clock into posterior aspect

- check that traction on interior flap reduces inferior capsular pouch


Superior advancement inferior capsular flap

- tension on flap aimed at eliminating inferior pouch

- must reduce posterior capsular redundancy

- multiple 0 pull off stay sutures through flap and into remnant humeral tissue

- +/- anchors

- begin inferiorly, care with AXN

- cut and clip each sutures

- then tie all sutures togther at end


Capsular Shift 3Capsular Shift 4


Check ER

- arm adducted, check ER 45o

- arm abducted to 90o, check ER 45o


Superior flap sutured down over inferior flap

- again multiple 0 pull off sutures

- tie

- check ER as above


Check not too tight

- can dislocated posteriorly


Closure of RI

- check ER as above


Subscapularis tendon brought over & reattached to normal location

- check ER as above


Post op

- Arm immobilised in sling 6/52

- No sport for 9/12 




Bigliani et al JBJS Am 2000

- 52 shoulders with open inferior capsular shift

- approach posterior or anterior depending on greatest instability

- 96% remained stable at average 61 months

- 60% excellent and 30% good results

- 70% athletes able to return to sport at same level


Ogilvie-Harris Br J Sports Med 2002

- contact athletes

- antero-inferior capsular shift in 37 with 3 recurrences (8%)

- posterior-inferior capsular shift in 16 with 2 recurrences (1 anterior / 1 posterior)(12%)

- 80% return to sport in antero-inferior capsular shift

- 75% return to sport in postero-inferior capsular shift

- only 17% return to sport if bilateral procedures


MDI Pre Capsular ShiftMDI Post Capsular Shift


2.  Arthroscopic






View via posterior and anterosuperior portal

- labrum is attached

- capsule very lax


Capsular laxity 1Capsular laxity 2Intact anterior capsule and labrum


Anterior plication

- use shaver to create capsular stimulation

- don't remove or resect capsule


Option 1

- pass through capsule, then through labrum
- inferior suture first

- take bite of anterior inferior capsule with suture passer

- advance suture passer

- then pass separately through anterior labrum at a more superior level

- tie

- repeat x 2


MDI Anterior Capsular PlicationMDI Anterior Capsular Plication 2MDI Anterior Capsular Plication 3


MDI 2 bites anterior capsuleMDI 3 x anterior capsular sutures



Option 2

- anchor in glenoid

- pass stures throught capsule and labrum


Capsular laxityCapsular plication with suture anchorsCapsular laxity post plication with suture anchor


Posterior plication

- camera inserted via anterior portal

- insert posterior cannula

- repeat inferior posterior sutures x 3


MDI Posterior capsular plication


May suture rotator interval if needed




Baker et al Am J Sports Med 2009

- 43 patients average age 19 years

- 86% return to sport


3.  Thermal Capsular Shrinkage


Recognised as poor procedure




Miniaci et al JBJS Am 2003

- 19 patients with MDI

- 9 recurrent instability

- 4 had parasthesia in AXN, one had deltoid weakness, all resolved

- worse results in posteroinferior compared with anteroinferior



Posterior Dislocation

Chronic Posterior Dislocation AP





- 2% of acute dislocations


Often missed

- < 1/ 52 25%

- < 6/52 25%

- < 6/12 25%

- > 6/12 25%




Usually secondary major trauma


- Seizures


- Electrocution

- Alcohol-related injuries




Loss of ER


Arm kept IR

- Hold arm across chest 


Beware of young patient with arm across chest & limited ROM

- don't think frozen shoulder only


AP Xray


1.  Light-bulb sign 

- globular head 2° IR


Posterior Shoulder Dislocation Light Bulb Sign


2.  Vacant Glenoid Cavity

- > 6 mm space between humeral head and anterior rim of glenoid


Posterior Shoulder Dislocation AP Non Concentric GHJ


Axillary Xray



- humeral head posterior to glenoid


Look for reverse Hill- Sachs


Posterior Shoulder Dislocation Axillary Lateral


Scapular lateral


Can be missed if any obliquity to Xray

- centre of the humeral head must be centred on the Y / Mercedes

- Y is formed by coracoid anteriorly / scapular spine posteriorly / scapula body inferiorly


Posterior Shoulder Dislocation LateralPosterior Shoulder Dislocation Scapula Lateral


CT scan


A.  Confirms dislocation


Posterior Shoulder Dislocation Sagittal CTPosterior Shoulder Dislocation CT 1Posterior Shoulder Dislocation CT 2


B.  Quantifies humeral head defect 

- very important to decide management if locked / chronic / unstable


Humeral Head Defect



- measured as a percentage of the articular surface


Case 1


CT Chronic Posterior Humeral Head DefectPosterior Shoulder Dislocation Anterior Hill Sachs


Case 2


Posterior Shoulder Dislocation Head Defect 1Posterior Shoulder Dislocaton Head Defect QuantificationPosterior Shoulder Dislocation CT




Posterior Shoulder DislocationPosterior Shoulder DislocationPosterior Shoulder Dislocation 2


Beware Chronic Case


Chronic Posterior Shoulder Dislocation MRI AxialChronic Posterior Shoulder Dislocation MRI Sagittal




Closed reduction



- injury more than 6 /52 ago

- large posterolateral defect locked on glenoid rim

- > 40% defect (will be unstable)




Consent for

- open reduction

- +/- bone grafting

- +/- McLaughlin procedure



- arm adducted

- arm flexed to 90o

- increasing IR first to unlock head

- traction


Unstable closed reduction 

- may have to use gun slinger cast

- arm abducted 90o and ER


Post Reduction


Assess anterior Hill Sachs


Posterior Shoulder Dislocation Post Reduction Anterior Hill SachsReverse Hill Sach's


Open reduction



- failure closed reduction

- inability to maintain reduction in gunslinger

- chronic posterior dislocation




1.  Anterior deltopectoral approach

- reduce humeral head


2.  Address instability / manage anterior humeral head defect


Humeral head Defect Management


1.  HS < 25% 



- treat non operatively if stable

- may be able to elevate and bone graft acutely in young patient

- +/- posterior labral repair


Reverse Hill Sachs less than 25 percent


2.  HS > 25%



- transfer SSC +/- LT

- osteochondral allograft young patient

- hemicap / resurfacing older patient


Reverse Hill Sachs Defect greater than 25%


3.  HS > 40%



- hemiarthroplasty / TSR (older patient)

- osteochondral allograft (younger patient)


Reverse Hill Sachs greater than 40 percent


SSC +/- LT transfers




SSC transfer / McLaughlin

- makes defect extra-articular


SSC + LT / Neer modification



- best for small defects = 25%

- young patient



- may weaken IR


Osteochondral Reconstruction


Shoulder McLaughlin APShoulder McLaughlin Lateral


Reverse Hill Sachs AllograftReverse Hill Sachs Allograft 2




Diklic et al JBJS Br 2010

- 13 patients with anteromedial defects between 25 and 50%

- all chronic / missed injuries

- open reduction

- SSC divided 1 cm from insertion, separated from capsule

- posterior labral repair / posterior plication if required

- femoral allograft inserted and fixed screws

- ER brace post op

- 9 patients pain free, 1 developed AVN, other 2 mild pain


Hemiarthroplasty / TSR



- older patient

- humeral defect > 40%



- may get recurrent posterior instability

- may have posteror glenoid bone defect



- anterior SSC Z lenthening

- posterior capsular plication +/- advancement IS / Tm

- glenoid poly insertion if posterior glenoid wear

- decreasing humeral head retroversion to 20o

- gunslinger post op for 6 weeks




Sperling et al J Should Elbow Surg 2004

- 12 patients, average age 55 years, average 26 months since dislocation

- mix of hemiarthroplasty and TSR depending on state of glenoid

- some posterior plications performed

- 2 patients had recurrent posterior instability

- one patient had advancement of IS / Tm and posterior capsular plication

- one hemi was revised to TSR with plication

Posterior Instability



Patients usually complain of subluxation rather than dislocation

- rarely requires reduction


Different entity to acute posterior dislocation usually








1.  Ligamentous laxity > 50%

- commonly associated with MDI

- posterior only 20%

- posterior & inferior 20%

- posterior / inferior & anterior 60%


2.  Trauma


A.  Repetitive microtrauma 

- common


B.  Macro-trauma 

- uncommon

- seizures

- electrocution


- alcohol related injuries





1.  Capsulo- ligamentous


A.  Reverse Bankart lesion 

- uncommon

- detached posterior labrum < 10%


B.  Capsular laxity

- much more common


C.  Posterior IGHL avulsion

- reverse HAGL


2.  Bony


A.  Humeral Head Defects  

- reverse Hill-Sachs lesion 

- defect in Ant humeral head

- seen in traumatic dislocations / chronic posterior dislocation

- can make humerus unstable

- compared with anterior Hill-Sachs which rarely does


CT Humeral Head Defect


B.  Posterior glenoid deficiency

- seen in traumatic / chronic dislocations


Posterior Glenoid DeficiencyPosterior Glenoid Deficiency Sagittal


C.  Humeral head / glenoid retroversion


Shoulder Posterior Instability Glenoid Retroversion




Must exclude voluntary dislocator


History of ligamentous laxity / other problems




Must assess for

- MDI / Ligamentous Laxity

- voluntary dislocator


Tender posterior joint line 

- fairly specific for OA rather than instability



- loss of ER (in locked posterior dislocation)


Ligamentous laxity


Sulcus sign

- indicates MDI


Anterior apprehension

- indicates MDI


Posterior stress test 

- supine

- adduct, forward flex and IR arm

- posterior force

- apprehension test


Load and Shift / Posterior Drawer


Altchek Grading


Grade 0       No translation

Grade 1+     Up to glenoid rim

Grade 2+     Beyond rim with spontaneous reduction

Grade 3+     Translation beyond rim without spontaneous reduction




1.  Define extent of Hill Sach's lesion


2.  Glenoid bone defect


3.  Glenoid version


Posterior Instability Glenoid Retroversion




Posterior bankart lesion


Shoulder MRI Posterior Labral Tear


Posterior labral cysts


Shoulder Posterior Labral Tear with Cysts0001Shoulder Posterior Labral Tear with Cysts0002Shoulder Posterior Labral Tear with Cysts0003






Not infrequently little functional problems


Prolonged initial physical treatment for all patients

- minimum 12 months

- treat similar to MDI patients

- Matson & Rockwood 80-90% success rate





- failed non-operative management

- moderate to severe disability




- voluntary dislocator

- ligamentous laxity

- minimal functional impairment




1.  Posterior Bankart lesion



- arthroscopic / open reconstruction


Posterior Labral Tear


Failure / Bony Block Revison

- posterior approach

- detach infraspinatous

- expose capsule

- divide capsule medial to glenoid

- take 2 cm long x 1 cm thick iliac crest

- secure to glenoid with 2 x small fragment screws

- reattach capsule lateral to bony block


Failed Posterior Arthroscopic Shoulder Stabilisation0001Failed Posterior Arthroscopic Shoulder Stabilisation0002Shoulder Posterior Bony Block0001Shoulder Posterior Bony Block0002


2.  Capsular laxity



- posterior capsular shift arthroscopic or open

- reverse Putti-Platt


Open capsular plication


Bigliani and Flatow July 1995

- 35 patients

- If primary operation 23 of 24 successful

- 89% stable at 5 yrs


Reverse Putti-Platt



- posterior approach

- posterior imbrication of IS & Tm 

- combine with posterior capsule imbrication

- shorten tendon 1cm = 20°

- limit IR to 20o


3.  Humeral Head Defect


Humeral Head Anterior Hill Sachs CT


1.  HS < 25% 

- leave


2.  HS > 25%

- transfer SSC + LT (McLaughlin)

- OC allograft


3.  HS > 40%

- hemiarthroplasty / TSR (older patient)

- OC allograft (younger patient)


4.  Posterior Glenoid Defects



- posterior glenoid bone graft


Posterior Glenoid Bone BlockPosterior Bone Block CT




Meuffels etal JBJS Br 2010

- 18 year follow up of 11 patients treated with posterior bone block

- 36% had had recurrent dislocation

- half would not have the surgery again

- all had evidence of OA


5.  Retroverted Glenoid Version / Static Posterir Shoulder Subluxation



- posterior shoulder subluxation > 65%

- shoulder OA

- young age

- glenoid osteotomy


Static Posterior Shoulder SubluxationGlenoid Retroversion SPSSSPSS MRISPSS Calculation



- posterior opening wedge glenoid osteotomy

- rarely indicated & technically hard



- congenital retroversion of glenoid > 30o



- only 5 mm medial to glenoid rim otherwise injure SS nerve

- must prevent penetration of glenoid



- anterior impingement of subscapularis on coracoid causing pain

- anterior subluxation of humeral head

Surgical Techniques

1.  Arthroscopic Posterior Bankart Repair +/- Capsular Plication


Posterior Labral TearPosteior Labral Repair




Posterior Portal

- make slightly inferior and lateral compare to normal

- inspect joint

- place anterior portal +/- ASL portal


Remove cameral and place thorough anterior portal

- place 8 mm cannula through posterior cameral portal (over switching stick)


Often need second portal lateral and inferior to place inferior anchor

- can use simple stab incision here


Assess labrum and capsule

- repair posterior bankart

- plicate redundant / patulous capsule




Kim et al JBJS Am 2003

- 27 patients with unidirectional posterior instability

- all with labral injuries, most with capsular laxity

- all had arthroscopic posterior labral repair and capsular shift

- only one recurrence


Pennington Arthroscopy 2010

- 28 athletes with pure posterior labral pathology

- 93% return to sport


Bradley et al Am J Sports Med 2006

- 91 athletes with 100 shoulders with unilateral posterior instability

- variations of suture anchor labral repair / anchor capsulolabral repair / capsular plication sutures

- 30% posterior labral tear, 43% patulous capsule with no labral pathology

- remainder combination injuries including partial labral tears

- 8% failure rate, all with capsular laxity

- patients had evidence of chondrolabral retroversion


2.  Open Posterior Capsular shift 


Open Technique



- lateral



- vertical incision

- posterior axillary fold


Shoulder Posterior Approach


Superficial dissection

- split deltoid to expose infraspintous

- elevate IS off capusle

- L shaped incision infraspinatous after tagging sutures medial

- T shaped capsulotomy of capsule for posterior shift (vertical limb on humeral insertion)



- no more than 1.5cm medial to glenoid to protech SS nerve

- axillary nerve through quadrangular space below Tm



- labral detachment reattached if present

- graft glenoid with bone from spine / iliac crest if defect

- inferior capsule shifted superiorly

- reinforced with superior limb of capsule

- may augment with IS tensioning


3. Posterior Glenoid Osteotomy


Reserved for in setting of severe posterior retroversion with instability


Posterior glenoid osteotomy






Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2




1. Establish portals


A.  Posterior portal for viewing


B.  Anterior portal

- need to keep low and away from biceps, otherwise difficult to get around biceps

- for suture passage, if in combination with bankart repair often use AI portal instead of AS


SLAP repair anterior portal


C.  Anterosuperolateral portal / Wilminton for insertion of anchors

- insert spinal needle first

- anterolateral border acromion

- needs to be close to acromion to get angle over humeral head

- check with needle

- need best angle to insert anchors to anterior and posterior aspect of biceps

- passes through supraspinatous

- use knife to cut in line with fibres

- insert portal


SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals


2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone


Shoulder SLAP Preparation Base


3.  Anchors


Drill and insert via Wilminton portal

Usually 3 anchors is a minimum



- insert anchor

- suture through each cannula

- limb through W portal will be the suture limb that is passed

- suture passer through anterior portal (right angled for left shoulder)


SLAP Anchor InsertionShoulder SLAP Repair Suture Management


Anterior anchor

- best to pass the suture passer above the biceps to get good bite

- retrieve sutures and tie from port of Wilmington


SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2


SLAP Anchor 1SLAP Tie anterior anchor


Posterior 2 anchors

- pass suture passer under biceps


SLAP Vertical MattressSLAP Second Anchor


SLAP third anchorSLAP 3 anchor repair


Can suture Portal of Wilminton if desired


Portal WilmingtonWilminton Repair 1Wilminton Repair 3


4.  Dfficult posterior anchors


Camera through anterior / anterosuperiorlateral portal


A.  Place anchor through posterior portal

- does not always give good angle


SLAP repair posterior portal


B.  Trans infraspinatous Portal


SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair


Biceps Tenodesis




- intra-articular

- suprapectoral



- suprapectoral

- subpectoral


A.  Arthroscopic Intra-articular


Biceps Tenodesis Intra articular



- suture biceps to superior capsule using figure 8 no 2 non absorbable



- anterior portal + portal of Wilmington

- debride capsule and biceps with shaver so will heal

- use curved suture passer with no 1 PDS

- suture shuttle no 2 fibre wire

- divide 90% biceps insertion so will rupture in time

- allows healing of biceps to capsule


Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture


Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut


Attempt Figure 8 Suture Configuration


Biceps Tenodesis Step 1Biceps Tenodesis Step 2


B.  Arthroscopic Suprapectoral Technique


1.  Secure Biceps Tendon - allows tensioning and prevents losing tendon


A.  Birds Beak Passer with 2 ethibond loop

- pass loop through intact tendon at entry through RC interval

- retrieve loop out through portal and lock

- this gives strong hold on tendon


B.  Pass 18 G spinal needle through biceps tendon

- thread 1 PDS or nylon

- retrieve both suture ends via portal in rotator interval

- secure with half hitches

- pass 1 loop of PDS about entire tendon and tie again


Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon


2.  Resect tendon with electrocautery at insertion


Arthroscopy Biceps Tenotomy


3.  Make portal over biceps interval into subacromial space

- release biceps tendon with electrocautery or arthroscopic scissors


4.  Secure tendon

- make drill hole

- insert tendon

- secure with biotenodesis screw

- multiple techniques with specifically designed equipment


C.  Open Technique for Intact Biceps


1.  Divide biceps arthroscopically

- may wish to place stay suture first to avoid retraction

- biceps normally has vinculae preventing complete retraction into arm


2.  Suprapectoral

- deltoid split

- between anterior and middle parts

- find biceps in groove

- pull out of wound and whip stitch with heavy suture

- drill appropriate size tunnel for fixation screw

- multiple biceps tenodesis devices

- push the tendon into the hole, then fixate with screw


3.  Subpectoral

- medial incision in arm

- below inferior edge of pectoralis major

- find biceps tendon

- whip stitch

- pass through drill holes / secure with screw / secure with anchor


Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis


D.  Open Technique for Ruptured LHB / Popeye in young patient


1.  Locate biceps




A.  Suprapectoral

- best to make deltopectoral approach

- biceps may be futher retracted


B.  Subpectoral approach


2.  Fixation

SLAP lesion

DefinitionMRI SLAP Tear


Superior labrum anterior & posterior


Injury to superior part of glenoid labrum involving region of biceps tendon insertion




2 groups


1.  Young patients

- most common in young males

- fall / trauma

- also associated with glenohumeral instability


2.  Older patients 

- have rotator cuff tear or other pathology

- don't repair in this group

- tenotomy / tenodesis




Three mechanisms


1.  Compression force applied to GHJ


- commonest

- arm in abduction & forward flexion

- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression


2.  Traction on Arm

- sudden pull on arm

- grab while falling


3.  Overhead motion

- throwing thlete

- repetitive microtrauma due to eccentric loading




Pain with overhead activities


Catching or popping with overhead activities


Acute trauma


Mimics impingement




Speed's Test 

Yergason's Test


O'Brien's test


Causes impingement of biceps on anterosuperior labrum


1.  Shoulder flexed 90o in plane of scapula

- adducted 30-45o / max IR

- i.e. thumb down

- resisted elevation produces pain


2.  Relieved when same again but with ER

- i.e. no pain with thumbs up


McMurray's Shoulder test


Compression-Rotation test

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus and humerus rotated

- attempt to trap torn labrum

- positive if pain & click




See fluid up under biceps insertion

- note: difficult to distinguish pathological v normal variant


MRI Slap with SS tearMRI Anterior Bankart


Supralabral ganglion cyst

- associated with posterior SLAP tears


Normal Arthroscopy


Normal Biceps Insertion


Arthroscopic Classification Snyder


Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 


Arthroscopy Meniscoid Biceps Insertion


Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   



- anterior

- posterior

- anterior and posterior


SLAP arthroscopyShoulder Scope SLAP Type 2


Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid


Shoulder Scope Type 3 SLAP


Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear


Type 4 SLAP Tear extends partially into bicepsSLAP Type 4


Type 5 - 7 added by Gartsman


Type 5
- SLAP 2 with anterior bankart extension


Type 6

- SLAP 2 with free flap of meniscal tissue


Type 7

- Slap 2 with anterior bankart extension and into MGHL


Normal Variations of the Superior Labrum


The superior labrum can be mobile

- normal cartilage extending over the tubercle

- no evidence of trauma

- the labrum and biceps is firmly attached to the tubercle

- this is not pathological

- do not repair


Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion


Davidson et al Am J Sports Medicine 2004

- described normal variations


1.  Triangular


2.  Bumper

- lump of fibrous tissue


3.  Meniscoid

- labrum extends down over glenoid face




Non Operative



- physio





Arthroscopic diagnosis

- high level of pre-operative suspicion

- must establish is pathological

- treated at time of arthroscopy




1. Debridement of frayed labrum / Type 1 & 3

2. Repair superior labrum and biceps / Type 2

3. Biceps tenodesis

4. Tenotomy




1.  Older patient with RC tear and SLAP


Francheschi Am J Sports Med April 2008

- RCT patients with SLAP and RC > 50

- tenotomy v SLAP repair in setting RC tear

- improved ROM and functional scores in tenotomy group


2.  Repair v Tenodesis Type II SLAP


Boileau et al Am J Sports Med May 2009

- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)

- repair group 40% satisified, 20% returned to previous level of sport

- tenodesis patients 93% satisified, 87% return to previous level of sport


Altcheck et al JBJS Am 2009

- case series of 37 athletes with SLAP 2 repair

- 87% rated outcome as good or excellent

- 75% able to return to previous level of sport

- this was higher (92%) if athlete described a discrete traumatic event


3.  SLAP and instability in young patient

- SLAP lesions can cause instability

- a SLAP lesion can contribute to inferior instability

- a SLAP and a Bankart can co-exist


MRI SLAPMRI Anterior Bankart


Management Algorithm


Type 1


Debride labrum


Type 2


A.  Arthroscopic repair


B.  Tenotomy / tenodesis


Type 3


Debride bucket handle labrum


Type 4


Remove labral flap


Repair / debride / tenodesis biceps

- may be evidence that do better with tenodesis


Types 5 - 7

- associated with instability

- repair as per treatment of instability

Tendinosis / Rupture / Subluxation / Hypertrophy

FunctionNormal Biceps


LHB primary function is humeral head depressor


Also accelerate / decelerate arm in overhead sports




Biceps problems usually occur with other pathology 

- rotator cuff / instability


3 main problems


1.  Degeneration

- "Tendinosis"

- usually associated with impingement

- can lead to rupture



- rarely associated with weakness

- 80% flexion strength from brachialis and short head biceps


2.  Instability


Stability contributed by

- transverse humeral ligament

- coracohumeral ligament

- superior GH ligament


Almost always associated with cuff tears

- SS tears

- medial subluxation with SSC tear


Lafosse et al Arthroscopy 2007

- biceps can be unstable anteriorly or posteriorly

- anterior with SSC tears

- posterior with SS tears


3.  Disorders of the origin (SLAP)


4.  Hourglass Biceps


Wiley etal J Shoulder Hand Surg 2004

- thickened intra-articular portion biceps

- unable to travel in groove

- with forward flexion of arm, arthroscopically see bunching of biceps

- requires double release  / tenotomy / tenodesis





- from postero-superior labrum and supraglenoid tubercule


Tendon is intra-articular

- passes deep to CH ligament, through rotator interval

- enters bicipital groove, beneath transverse humeral ligament




Tenderness over biceps tendon crucial



- Popeye appearance


Popeye Sign BicepsPopeye Biceps



- forward flexed shoulder against resistance

- elbow kept extended and supinated

- feel pain or palpate tenderness



- elbow flexed and pronated

- resist supination

- pain over LHB


O'Brien's / SLAP

- arm forward flexed and adducted in plane of scapula

- point thumb down and resist downwards force

- this generates pain

- no / less pain with thumb up






MRI Enlocated Biceps Tendon




Biceps Tendonitis MRI


Tendonosis / thickening


Biceps Tendinosis MRI


Medial Subluxation


Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC






Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit


Mild Tendonopathy


Biceps Tendonopathy Grade 2 Arthroscopy


Moderate Tendonopathy


Shoulder Biceps Moderate Tendonopathy


Severe Tendonopathy


Biceps Tendonopathy ArhroscopyBiceps Tear near complete


Dislocated Biceps in Presence of complete SSC Rupture


Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon




1.  Tendonitis


Non Operative


As per rotator cuff / impingement


- physio


Surgical Options


1.  SAD

2.  Manage rotator cuff pathology

3.  Consider for inflamed but intact LHB

- release THL

- spare CH ligament


2.  Tendon Fraying / Tendinosis / Rupture


Grade tendon integrity


I     Minor fraying <25%

II    Fraying 25-50%

III   Fraying >50%

IV   Complete rupture


Management Strategy


I & II

- SAD & debride tendon 



- SAD & biceps tenodesis / tenotomy


Tenotomy v Tenodesis


Frost et al Am J Sports Medicine April 2009

- reviewed all articles on tenotomy / tenodesis

- concluded that there is no evidence for superiority of one over another


Koh et al Am J Sports Med 2010

- tenotomy v tenodesis in setting RC tears

- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy

- no other difference in terms elbow flexion power / shoulder scores




Popeye deformity


Lim et al Am J Sports Med 2011

- incidence of pop-eye of 45% post tenotomy

- more common in men


Cosmetic deformity acceptable in elderly

- not in young

- avoided by tenodesis




Shank et al Arthroscopy 2011

- no evidence of decreased elbow flexion or supination strength





- young patient grade II, III, IV

- slim arm (where popeye would cause significant cosmetic problem)



- screw prominence / pain

- failure of fixation



- arthroscopic

- open

- see techniques




Soft tissue or bony fixation

- in inter-tubercular groove

- suprapectoral


Sheibel Am J Sports Med 2011

- soft tissue v bony anchor fixation

- superior cosmetic and functional outcome with bony




Suprapectoral or subpectoral


Nho et al J Should Elbow Surgery 2010

- 353 patients treated with subpectoral bioabsorbable tenodesis screw

- 2% complication rate

- 2 patients with popeye

- 2 with tenderness over screw

- 1 deep infection

- 1 MCN injury


3.  Subluxation




Usually medial from SSC tear

- must manage LHB or SSC repair will fail




1.  Tenodesis / Tenotomy + SSC repair


2.  Stabilisation + SSC repair



- can get stenosed painful tendon  


Maler et al JBJS Am 2007

- 21 patients with traumatic tear of SSC treated within 6 weeks

- open SSC repair and LHB stabilisation

- 7 had symptoms of mild tenodinopathy

- 2 recurrent instability and 1 rupture on US








Axillary Nerve Lesions



Terminal branch of the posterior cord

- lateral to radial nerve

- behind axillary artery

- runs over inferolateral border of SSC

- enters quadrangular space


Quadrangular space

- SSC superiorly anterior

- T major inferior

- T minor superiorly posterior

- long head triceps and humerus


Divides into anterior and posterior branches


Axillary Nerve Sagittal MRI 1Axillary Nerve Sagittal MRI 2


Anterior branch

- curves around SNOH

- deep to deltoid

- 4-7 cm inferior to corner acromion

- supplies anterior and middle portions deltoid


Posterior branch

- supplies T minor and posterior deltoid

- sensory branch


3 distinct fascicles

- T minor

- deltoid (supero-lateral)

- superior lateral cutaneous branch




1.  Traumatic

2.  Iatrogenic

3.  Quadrilateral Space Syndrome

4.  Brachial Neuritis

5.  SOL


1.  Traumatic


A. Shoulder Dislocation

- 10-20% incidence post dislocation


Blom et al Acta Chir Scand 1970

- 9 complete and 15 partial lesions

- all recovered within 1 - 2 years


Gumina JBJS Br 1997

- high rate in elderly > 40 (50%)

- all recovered by 3 years

- high rate of RC (20%)


B. Proximal Humeral fracture


C. Brachial Plexus injury

- rarely isolated

- in conjunction with other injuries

- upper trunk


D.  Blunt trauma to deltoid


2.  Surgery


A.  Deltoid-Splitting approach

- lies 5cm lateral to anterolateral corner of acromion


B.  Deltopectoral approach

- undue care at inferior level of SSC


3. Quadrilateral space syndrome



- Compression in position ER and abduction



- get pain and paraesthesia in shoulder 

- can have chronic dull ache



- usually no deltoid atrophy or sensory changes





- normal



- shows compression of posterior humeral circumflex artery with less than 60o abduction



- may shows changes in deltoid and Tm



- usually just observation

- occasionally need to decompress scar tissue or fibrous band


4.  Parsonage-Turner Syndrome


Brachial neuritis

- spontaneous development severe shoulder pain

- then develop loss of motor function

- usually also LTN, SS nerve, but occasionally isolated



- can treat with steroids

- usually good prognosis


5.  Nerve compression from mass effect



- aneurysm, tumour




No history trauma

- suspect mass effect / quadrilateral space syndrome / brachial neuritis


Pain then loss of function

- suspect brachial neuritis


History dislocation




Deltoid Wasting


Wasting Deltoid


Weakness of shoulder abduction


Numbness in Regimental patch 

- variable




1.  Upper trunk injury / root injury (C5/6)

- will also have injuries to


A.  SS nerve

- IS / SS

- remember dislocation may cause RC tear


B.  Subscapularis


C.  Biceps


2.  Posterior cord injury

- will also have injuries to


A.  Radial nerve

- triceps, WE, FE, thumb extension


B.  Thoracodorsal

- Lat Dorsi


C.  Upper and lower subscapular





Diagnose higher lesion

- reference point for recovery




Mass lesions

Atrophy of T minor

Assess RC 


Operative Management



- no clinical or NCS / EMG sign of recovery at 6/12

- open wounds / stab wounds




Best results 

- reinnervation must occur before one year

- otherwise get degeneration of NMJ

- i.e. surgery must occur by 9 months




No muscle transfer for deltoid

- nerve repair

- neurolysis

- nerve grafting

- nerve transfer


1.  Neurolysis



- if nerve intact but encased in scar or compressed by fibrous bands



- identify nerve

- use nerve stimulator intra-operatively

- stimulation of nerve will cause muscle contraction if intact

- uncommon


2.  Neurorrhaphy 



- laceration



- direct repair of laceration

- if in first few weeks


3.  Nerve grafting



- neuroma usually at or in quadrilateral space


2 Incision Technique


Sural nerve graft

- anastomose anteriorly, then pass through

- anastomose posteriorly


Lateral decubitus

- access anterior and posterior shoulder

- allows sural nerve harvest


Deltopectoral approach

- release half or all of P major (leave cuff for repair)

- must release conjoint tendon and P minor

- do so 1cm from origin

- expose axillary, radial and MCN

- use nerve stimulator to ensure nerve not working

- identify and protect axillary artery and vein

- if deltoid active, neurolysis


Identify neuroma

- if deep

- posterior approach to shoulder


Posterior vertical incision

- lateral border acromion to posterior axillary crease

- mobilise inferior border deltoid superiorly

- find nerve as exits quadrilateral space

- identify deltoid fascicle using nerve stimulator




Allnot Int Orthop 1991

- 23/25 isolated sural nerve grafting achieved M4 or M5 strength


4.  Neurotisation / Nerve transfer



- use branch of radial nerve

- transfer into motor branch axillary

- single incision



- posterior longitudinal approach to arm

- find AXN under wasted deltoid, exiting above T Major

- identify anterior branch of AXN going into muscle

- ensure not branch to T minor or sensory branch

- develop interval between long and lateral heads

- find radial nerve in groove between medial and lateral heads

- will be exiting below T Major between long and humerus

- harvest branch to long or medial head triceps

- long may be better as has two sources nerve supply and less functional impairment

- check with nerve stimulator

- repair with 9.0 nylon under microscope




Leechavengvongs et al J Hand Surg Am 2003

- all 7 patients had M4 power

- 5 excellent and 2 good results

- no demonstrable loss of elbow extension power

Constant Shoulder Score


Subjective Assessment 35 points





- work

- recreation

- sleep


Ability to work at specific level

- waist

- chest

- neck

- head

- above head


Objective Assessment 65 points











Pectoralis Major Rupture



Usually related to sporting activities including weight lifting

- bench press most common 

- higher risk with steroid use




Peak age 20 - 40


Often unrecognised





- intra-muscular

- MT junction

- tendon avulsion

- 2:1 tendon avulsions compared with musculotendinous junction


Partial or complete


Sternal / clavicular heads or both




Clavicular head

- medial clavicle and upper sternum

- inserts at lowermost aspect of biciptial groove


Sternal head

- sternum, aponeurosis external oblique and costal cartilages of first 6 ribs

- inserts at uppermost aspect of bicipital groove




2 tendons converge and rotate 90o

- insert lateral to bicipital groove

- superior fibres insert inferiorly and vice versa


Tendon is composed of two lamina

- anterior lamina is clavicular head

- posterior lamina is sternal head


Nerve supply


Lateral pectoral nerve C5-7

- clavicular head

- part of sternal head


Medial pectoral nerve C8-T1 

- sternal head

- passes through and supplies pec minor



- powerful adductor, flexor and internal rotator




Usually recall incident

- tearing sensation

- may hear a pop

- often severe swelling and bruising

- only later when it settles is the cosmetic and functional deficiency apparent


Acute Pectoralis Major Tear




Asymmetry chest wall


Pectoralis Major RupturePectoralis Major Tear Chronic


Frequently palpable cord present

- is pectoral fascia still attached to antebrachial fascia

- not to be mistaken for pectoralis tendon

- prevents full retraction


Pectoralis Ruture Palpable Cord


Resisted adduction is weak

- hand on hip

- feel tendon insertion




Useful in the acute setting


Will also identify site of rupture and amount of retraction




Non Operative



- partial tears

- muscle belly tears

- elderly






Pochini et al Am J Sports Med 2010

- 10 operative cases (70% excellent, 20% good, 10% poor)

- 10 non operative (20% good, 50% fair, 40% poor)

- strength in non operative group 50% of other arm




Chronic ruptures

- best to repair within 8 weeks

- have been successful repairs from 3 months up to 13 years



- may wish to have allograft / achilles tendon available

- especially needed if tendon has retracted beyond nipple line




Deltopectoral approach / axillary fold incision


Anterior lamina fibres of clavicular head are usually intact

- pectoral fascia also usually intact

- blunt dissection medially under clavicular head to find sternal head




1.  Make trough in bone lateral to biceps tendon with burr

- Krackow suture in tendon with no 5 non absorbable

- repair through drill holes

- +/- suture anchors

- + / - direct suture of MT junction


Pectoralis Major Repair 1Pectoralis Major Repair 2Pectoralis Major Repair 3


2.  Foot print technique

- roughen area of insertion lateral to LHB / osteotome

- insert 3 double loaded anchors in V formation ( 2 lateral and one medial)

- pass through tendon and suture down


3.  Allograft reconstruction

- fascia lata / tendo achilles

- pass graft through pec major

- double over and insert into bone tunnel


Post op

- sling 6 weeks

- ROM 6 weeks

- strengthening at 3/12





- higher than normal risk due to proximity to axilla


Humerus fracture

- case report with bone trough


LHB rupture

- case report



- most common

- up to 7%







Shoulder Xrays

AP Shoulder



- in plane of thorax

- oblique of GHJ


Shoulder AP Xray


AP in plane of scapula



- angle 45o lateral

- allows estimation of glenohumeral space


AP Plane Scapula




Demonstrates Hill Sach's and other humeral head morphology


Scapular lateral


Patient erect

- affected shoulder against plate

- rotate other shoulder 45o out of way

- beam aimed along spine of scapula


Scapular LateralScapula Lateral Posterior Shoulder Dislocation


Axillary lateral


Patient seated

- arm abducted

- plate under axilla

- beam angled down towards shoulder


Axillary Lateral XrayAxillary Lateral Posterior Subluxation


Supraspinatous outlet view


For acromial morphology and impingement


Similar to scapular lateral

- tilt beam caudal 10o


Supraspinatous Outlet View


West Point View


Variation axillary lateral

- tangential view anterior / inferior glenoid 

- for bony bankart


Patient prone with arm hanging off bed

- plate superior to shoulder

- camera 25° cephalad to horizontal / 25° to long axis body


Westpoint view Hill Sachs


Garth View / Apical Oblique


True AP with 45o caudal tilt

- to show anterior / inferior capsule 

- bony bankhart / Hill Sachs

- standing with plate behind joint

- 45° caudal tilt / 45° in coronal


Garth XrayShoulder Garth View


Stryker Notch view


Patient supine with cassette posterior to shoulder

- hand on head, elbow straight up

- beam 10o cephalic aiming at corocoid


Demonstrates Hill-Sach's


Stryker Notch View Hill Sachs


Zanca view




Patient erect with cassette behind shoulder

- aim beam at ACJ 10 - 15o cephalic

- half strength to not overexpose ACJ


Zanca View


Serendipity view





- prone with cassette under chest

- aim beam 40o cephalic


Sternoclavicular Joint Xray 1Sternoclavicular Joint Xrays 2






Sternoclavicular Pathology


Condensing Osteitis



- seen in women over 40



- sclerotic and overgrown


Condensing Osteitis Xray




Condensing Osteitis CT 2Condensing Osteitis CT




Sng Ann Acad Med Sing 2004

- follow up of 9 patients mean 34 months

- pain reduced over time





Will resolve with time



- HCLA injection

- excision


Friedrich's Disease


Very rare condition seen in young adults

- AVN of sternal end of clavicle / occasionally lateral end

- pain and swelling

- ESR may be raised

- irregular sclerotic appearance on xray

- rarely requires excision


Sternoclavicular Hyperostosis


Bilateral condition

- ossification of sternoclavicular ligaments

- may lead to solid ossification with restriction of shoulder motion

- associated with pustules and elevated Alk Phos




Sternoclavicular OA






1.  Intra-articular cortisone

2.  Fusion



Suprascapular Nerve



C5, 6 from Upper trunk


Posterior triangle

- arises upper trunk and passes backward through posterior triangle

- under belly of omohyoid

- deep to trapezius to the suprascapular notch


Suprascapular Ganglion Coronal MRI


Runs through suprascapular notch

- under superior transverse scapular ligament

- suprascapular artery and vein run over this ligament

- supplies SS 1 cm after passing under ligament

- give articular branch to the shoulder


Suprascapular Nerve Sagittal MRI 1Suprascapular Nerve Sagittal MRI 2


Passes around lateral border spinous process / Spinoglenoid notch

- under spinoglenoid ligament

- inferior transverse scapular ligament

- supplies IS



-  supplies supraspinatus & infraspinatus




- CA and CH ligaments


Sites of Compression / Injury


Suprascapular notch

- weakness wasting SS & IS



- trauma most common / driect blow / clavicle or scapula fracture

- iatrogenic / excessive rotator cuff release

- athletes / repetitive overhead motion


Spinoglenoid notch

- weakness wasting IS



- spinoglenoid cyst associated with superior labral tear / horizontal cleavage / acts as one way valve

- posterior approach to shoulder - > 1 cm medial to glenoid neck

- posterior shoulder OA causing a cyst




Pain at back of shoulder







Atrophy SS/IS


Atrophy of IS alone




Rotator Cuff tear




1.  Spinoglenoid cyst / labral tear

- may be better seen with MRA


Spinoglenoid cyst Coronal MRISpinoglenoid Cyst Sagittal MRISpinoglenoid Cyst MRI Axial


2.  Atrophy of SS / IS


Spinoglenoid Cyst Infraspinatous Fatty Atrophy


3.  Exclude cuff tear




Demonstrate denervation SS/IS or IS alone




Inject SS nerve at suprascapular notch




Non Operative


Reasonable if no ganglion cyst

- a neuropraxia which usually resolves

- avoid overhead activities if possible

- 6 - 9 months




Spinoglenoid Cyst


1.  Secondary to superior labral tear


Majority of cases


A.  Cyst Decompression + Arthroscopic labral repair



- identify horizontal cleavage tear

- decompress throught tear

- repair labrum


Posterior Labral Tear Cyst 1Posterior Labral Tear Cyst 2Posterior Labral Tear Cyst 3


Posterior Labral Tear 1Posterior Labral Repair 2Posterior Labral Tear 3


Piatt et al J Should Elbow Surg 2002

- excellent results


B.  Arthroscopic Labral Repair without cyst decompression


Schroder et al JBJS Am 2008

- 42 patients

- posterior labral repair without cyst decompression

- cyst resolved in 88% on MRI and smaller in remainder

- all patients satisfied with outcome


2.  Spinoglenoid Cyst without labral tear


Options to decompress cyst

- ultrasound drainage / not always effective but may be worth a try intially

- posterior approach

- arthroscopic glenohumeral approach / posterior capsulotomy

- subacromial approach / between supraspinatous and infraspinatous




Werner et al Arthroscopy 2007

- posterior capsulotomy above IGHL with decompression of cyst with shaver


Posterior Shoulder Capsulotomy to decompress cyst


Ghodadra et al Arthroscopy 2009

- subacromial space

- identify spine of scapula

- dissect between infraspinatous and supraspinatous

- accessory posterior portal, retract IS and nerve

- decompress with shaver


Shoulder Subacromial Space Spinous ProcessSubacromial Spinous Process 1


Suprascapular Notch Impingement


Decompression / Division of Suprascapular ligament 



- weakness atrophy of SS and IS without cuff tear

- massive irreparable cuff tear with intractable pain



- open

- arthroscopic




Lafosse et al Arthroscopy 2007

- 10 patients with clinical and EMG evidence of suprascapular nerve compression

- no complications

- good clinical outcome in all patients


Open Technique

- incision along spine of scapular

- sharply elevate trapezius off spine off scapula

- SS reflected inferiorly to expose notch

- preserve superior NV bundle

- suprascapular artery lies above ligament, (branch of Subclavian Artery)

- divide ligament


Arthroscopic Technique


Standard posterior portal

- subacromial portal to debride cuff and identify base of coracoid as landmark

- find coracoid by following CAL to it

- feel hard bony prominence


Anterolateral working portal

- need to be able to work lateral to medial along anterior aspect of humeral head



- clear space medial to coracoid along subscapularis

- identify the conoid ligament attaching to the base of the coronoid

- medial to this is fatty area with THL


SSN Release CoracoidSSN Release Coracoid and CHL


Suprascapular portal / accessory Nevasier

- 7cm from posterior edge of acromion

- insert blunt instruments posteriorly from suprascapular portal

- pass under clavicle

- elevates supraspinous muscle

- use blunt trochar to dissect area



- will usually see the artery passing over the top of the THL 

- be careful as this runs from subclavian

- can get torrential bleeding


Conoid Ligament  SSA over THLSuprascapular artery and transverse scapula ligament


Identify transverse ligament

- identify SSN passing under

- divide TSL with scissors from posterior ACJ portal

- whilst retracting SS artery with probe from SSN portal


SSN release Divided THLSSN Release Divided TSL

Thoracic Outlet Syndrome



Symptoms & signs due to compression of brachial plexus & /or subclavian vessels at root of neck




80% 30-50 years 


F:M = 2:1 








Thoracic Outlet forms communication at root of neck 

- for passage of nerves and vessels from mediastinum to axilla 

- vein is anterior to Scalenus Anterior




Anterior:  Scalaneus Anterior

Posterior: Scalaneus Medius

Floor:      First Rib

Roof:       Prevertebral fascia & clavicle




Bony / muscular / ligamentous compression of neurovascular bundle at Thoracic Outlet




1.  Cervical Rib

- 5 / 1000 

- only 10% of cervical ribs are symptomatic

- 10% of TOS have cervical rib


Varies from 

- enlarged TP 

- complete developed with cartilage uniting it to cartilage of 1st thoracic rib 


2.  1st Thoracic Rib

-  abnormal curve 

-  increased size or shape


3.  Clavicle

-  posterior fracture callus 

-  abnormal shape / malunion




Most important cause


1.  Fibrous Band


Cervical rib joined to 1st rib by congenital fibrous band 

-  elevates lower part of brachial plexus 

-  makes it more susceptible to scissor compression by clavicle from above 

-  9 variants recognised


2.  Scalenus Muscles


Abnormal insertion 

Decreased size of cleft between S Anterior & S Medius





- Precipitates condition in 2/3



- shoulder sags with middle age 

- hyperabduction in sleep

- scapular winging secondary to trapezius palsy



- hyperabduction of shoulders (painters, welders) 

- pressure (backpacks, soldiers)




1. Neurogenic


Compression of brachial plexus alone 

-  usually lower trunk C8,T1

-  most common 95%


2. Vascular


Compression of subclavian blood vessels alone 

- usually vein obstruction 

- occasionally arterial insufficiency 

- rare 2%


3. Combined


Compression of both nerves & vessels 

- rare 3%




2° compression of Plexus > Vessels



-  intermittent

-  suprascapular area and neck

-  may be whole arm

-  more common medial arm & ulnar forearm 

-  radiates to neck 


Worse after activity

- overhead

- carrying heavy weight



- C8 & T1 (mainly ulnar nerve distribution)

- may be whole arm



- most noticeable is grip



- duskiness & cyanosis of hand 



- cold, pale hand & forearm

- Raynaud's 




Pain from percussion or constant thumb pressure in supraclavicular region over plexus


Listen for bruit / compare arm BP



-  decreased in C8 / T1 distribution



-  decreased especially grip strength


1. Elevated Arm Stress Test (EAST)

- shoulder abducted 90° & ER 

- elbows at 90° 

- hands clasped / unclasped for 3min

- positive if symptoms reproduced or arms drop 2° pain & weakness


2.  Adson Manoeuvre

- head toward side tested, neck extended

- arm by side

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms


3.  Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm abducted and ER

- breath in

- loss of pulse or reproduction of symptoms

- highly sensitive


Xray neck / CXR


Cervical rib

Clavicle fracture






May show fibrous band 

- exclude cord pathology




Must do with arms abducted and by side

- will show compression of subclavian vein



-  unhelpful as symptoms intermittent 

-  stimulus cannot be placed proximal to site of compression or irritation 

-  exclude CTS / cubital tunnel Syndrome




Cervical Disc (C8/T1) / spinal cord lesion

Ulna nerve entrapment

Shoulder pathology

Pancoast tumour







Explanation & reassurance

- shoulder girdle exercises 

- posture improvement 

- analgesia







10% of patients

- intolerable pain 

- significant loss of function

- significant arterial or venous symptoms




Resection of cervical rib


Resection first rib

Clavicular osteotomy





- pneumothorax 

- empyema 


Nerve injury 

- phrenic nerve 

- T1 


Vessel injury 


Recurrence of symptoms



Throwing Athlete




- cocking

- ER up to 180o in pitcher



- large scapular muscles 

- acceleration - 7000o/sec

- rotatory acceleration similar to car tyre at 130 kph


Control and deceleration

- fragile cuff & glenohumeral ligament complex 




Pitchers have increased ER range, but corresponding decreased IR range

- have increased humeral head retroversion

- probably from adaptations of growth plate whilst young

- "little leaguer's shoulder" may be part of this


They have a "normal" abnormality


Treatment of posterior capsular stretching in athletes is debatable

- limited IR is normal state


Problems / Spectrum


1.  Subtle anterior instability / Posterior capsular contracture

- internal impingement


2.  SLAP


3.  Posterior instability


4.  RC injuries


Internal Impingement Posterior / Superior Glenoid




Described by Davidson 1997

- throwing athletes

- impingement in ER and abduction

- classic 90 / 90 position

- posterior aspect of SS impinges on posterosuperior rim of glenoid 




Posterosuperior labrum is damaged




Argument whether posterior capsule tightness or anterior instability

- can be either




Usually posterior shoulder pain




Careful comparison of shoulders

- normal to have increased ER / decreased IR



- load and shift examination of instability very important

- need to examine shoulder in 90 / 90 position

- i.e. 90o ER and 90o abduction

- this is the throwing position

- look carefully for anterior instability






Bennett's Lesion



- damaged posterosuperior labrum

- partial cuff tears



- place arthroscope anteriorly

- ER arm in 90o abducted position

- see posterior cuff impinge exactly on damaged area of labrum




A.  Posterior capsule tight and thickened

- feel / confirm thickening with probe

- careful release at edge of labrum


B.  Shoulder unstable anteriorly in EUA

- may see anteroinferior labral injury

- may simple be redundant tissue

- anterior labral injury (careful repair with sutures)

- capsule stretched (advance part of capsule to glenoid rim to tighten)


NB Must be very careful

- cannot afford to lose ER in throwing athlete


Partial Thickness Tears Cuff




Articular sided

- more posterior than in elderly

- at the SS / IS interval

- consistent with internal impingement





Posterior capsular contracture




1.  Repetitive trauma from massive eccentric forces in SS and IS during deceleration in throwing


2.  Internal impingement from anterior subluxation / posterior tightness with posterior glenoid impingement and microtrauma


Non Operative


1.  ROM / posterior capsular stretches

- decrease inflammation


2.  Balanced RC exercises




Debridement is mainstay

- acromioplasty and repair rarely indicated

- some major league pitchers have full thickness tears

- repair initially may end career


Little Leaguer's Shoulder




Present with painful shoulder




Physeal widening




Chronic SH 1 growth plate









Winged Scapula






Due to scapulothoracic articulation disorder


1.  Neurological Origin


A.  Spinal Accessory Nerve / Trapezius palsy

B.  Long Thoracic Nerve /  Serratus Anterior palsy

C.  Dorsal Scapular Nerve / Rhomboids palsy (rare)


2.  Osseous Origin


Osteochondromas (tangential x-rays, CT useful)

Fracture malunions


3.  Soft Tissue Origin


Muscular Origin

- traumatic ruptures of Serratus Anterior

- iatrogenic during thoracotomy




Due to GHJ articulation disorders

A.  Erb's palsy

B.  Deltoid fibrosis

C.  Painful conditions i.e. RC tear, fracture, impingement






Trapezius Winging / Spinal Accessory Nerve




C3, 4

-  supplies Sternocleidomastoid

-  then runs in posterior triangle of neck to supply Trapezius (Upper 1/2)




Stab wounds to neck

Operations on posterior triangle (Lymph node biopsy)

Traction injuries





- will attempt to compensate by using levator scapulae

- can lead to disabling pain and spasm

- pain can also be from secondary effects (impingement / radiculopathy / Brachial plexus traction)




Shoulder depressed

- scapula translated lateral 

- inferior angles rotated laterally


Trapezius wasting

- unable to shrug shoulders

- weakness with protraction


Non operative management


Reasonable for a time for traction injury

- physio

- wait 6 - 12 weeks




1.  Neurorrhaphy

- direct repair for open laceration


2.  Nerve Graft


3.  Levator scapulae and Rhomboid transfer

- Eden-Lange procedure

- most common



- L. Scapulae to medial acromion

- R. minor upper 1/3

- R. major middle 1/3


4.  Scapulothoracic Fusion

- reasonable pain relief

- poor function

- high complication rate


Serratus Anterior winging / Long Thoracic Nerve




C 5, 6, 7 from Roots

- runs down posterior axillary wall

- deep to fascia

- posterior to midaxillary line

- supplies Serratus Anterior



- boxer's muscle

- protracts scapula



- fleshy slips

- upper 8 or 9 ribs



- costal aspect medial margin





- shoulder or neck operations

- 1st rib resection

- mastectomy


Carrying loads on shoulder




Repetitive microtrauma - swimming




Winging of scapula

- scapula medial




1.  Nerve Transfer 

- TDN to LTN


2.  Stabilisation of scapula / Marmor-Bechtol transfer

- transferring sternocostal head Pectoralis major to inferior corner scapula

- require fascia lata extension







EpidemiologyShoulder OA


Usually 50-60 years old




1° uncommon


2° most common


- trauma

- cuff arthropathy (Neer)

- instability




Cuff & biceps intact as rule

- rare to have OA and rotator cuff pathology


Inferior osteophytes 

- beard


Retroversion of glenoid 

- posterior wear


Posterior subluxation not uncommon


Shoulder OA Posterior Subluxation


Tight anterior capsule & subscapularis

- limitation of ER


Post traumatic

- always soft tissue contracture

- limitation of ER

- CH ligament and rotator interval contracted

- malunion of tuberosities leads to impingement and offset of normal cuff action

- non-union results in extensive shortening of cuff

- scarring about axillary nerve


Shoulder OA post trauma




Global painful restriction of range of movement 

- due to incongruity of joint surfaces

- crepitus

- limitation of ER


DDx Limitation ER


Frozen Shoulder

Chronic posterior dislocation

Arthrodesis = Lack of ER

Post septic arthritis




Shoulder OAShoulder OA Xray


Typical changes of OA

1. Teardrop osteophytes on inferior head & glenoid

2. Osteochondral loose bodies


Shoulder Loose Body



- cuff arthopathy - proximal migration of head & subacromial sclerosis




Shoulder OA GlenoidShoulder OA Debridement






Education & Reassurance

- Analgesia


- Physio






1.  Arthroscopic Debridement



- if patient has acromial spur and acromioclavicular pathology

- may benefit from debridement

- concept of limited goals




A.  Glenohumeral joint

- deal with biceps tendon pathology if present (tenotomy / tenodesis)

- synovectomy


Shoulder OA Synovitis


B.  Subacromial space

- acromioplasty

- CA ligament left intact

- ACJ resection


C.  Removal beard osteophyte

- additional option

- may improve ROM

- risk of axillary nerve injury


2.  Arthrodesis



- may be considered in young active patient



- good pain relief but limitation movement

- difficult to perform

- rarely done in the modern age


3.  Excision Arthroplasty



- good pain relief but main problem is flail arm


4.  Arthroplasty



- hemiarthroplasty (young patient or insufficient glenoid bone stock)



Pectoralis Major Tears



Middle age men

Steroids / Growth Hormone




Usually occurs in gym

Bench Press




Significant bruising in the acute phase


In chronic setting, ask patient to adduct against hip / resistance


Pectoralis Major TearPectoralis Tear 2


Usually complain of weakness, mainly in gym




MRI Pectoralis Major TearPectoralis Tear MRI




Non operative


Good results

Will have cosmetic deformity

Weakness usually only in the gym with bench press





- acute tears in young patients

- cosmesis i.e. body builders


Acute repair


Pect Major Repair Through Bone TroughIncision Pec Major Repair



- deltopectoral approach / can alos make in skin crease

- find tendons medially

- drill one inche trough in humerus

- place sutures in tendon

- pass sutures through drill holes lateral to trough

- pull tendon into trough and tie sutures


Chronic Reconstruction



- tendoachilles graft

- pass through muscle in pul ve taft method

- tie down into bone trough in humerus


Pect Major Reconstruction 1Pec Major Reconstruction 2Pec Major Reconstruction 3

Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture



- third most common fracture after hip and distal radius




Neck shaft angle

- 130o


Head retroverted

- 20o relative to shaft


Anatomical neck

- junction of head and metaphysis


Surgical neck

- junction of diaphysis and metaphysis


Blood supply 


Gerber JBJS Am 1990 December

Anatomical cadaver study


1.  Anterior humeral circumflex


Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis


Nearly always disrupted in fractures


2.  Posterior Humeral circumflex


Small contribution posterior head

- allows head to survive with both tuberosities fractured


3.  RC

- supplies blood to tuberosities in fractures


Neer Classification 1970



-  any fragment > 1cm or > 45o


Number of displaced fragments

- 2 part (head/shaft, GT, LT)

- 3 part (head/shaft/GT, head/shaft/LT)

- 4 part (head/shaft/GT/LT)


Fracture / dislocation


Shoulder Fracture DislocationProximal Humerus Fracture DislocationShoulder Fracture Dislocation AnteriorPosterior Shoulder Fracture Dislocation


Head splitting fracture


SNOH Head Split CTProximal Humerus Head Split CT


Anatomical Neck Fracture


Humerus Anatomical Neck Fracture






In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- increases with amount of displacement


Rates AVN


4 part fracture 30%


3 part fracture 15%


Hertel Radiographic criteria


Hertel et al J Should Elbow Surg 2004


2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm


97% positive predictive of ischaemia if both factors present





- mostly elderly patients with osteoporotic



- high energy MVA


Deforming Forces


2 part fracture

- P. major displaces shaft medially

- head internally rotated by SSC


SNOH Fracture Displaced


GT fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor


Displaced Greater Tuberosity Fracture APDisplaced Greater Tuberosity Fracture LateralShoulder CT Displaced GT Fracture


LT fracture

- medially by SSC


Lesser Tuberosity FractureLesser Tuberosity Fracture 2




AP / Scapula Lateral / Axillary lateral





- delineate no of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF / in elderly


Surgical Neck of Humerus CT 4 Part CoronalSurgical Neck of Humerus CT 4 Part SagittalSNOH CT 3 Parts


Associated Injuries


Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid


Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand




Non operative 



- undisplaced

- elderly




85% are undisplaced and do not require surgery




Sling for 2/52 then mobilise




Koval et al JBJS Am 1997

- 104 patients minimally displaced fracture as per Neer

- < 1cm displacement and <45o

- 90% no pain, 77% good or excellent result

- ROM approximately 90% of the other side

- 10% moderate pain and 10% poor result

- poor function and ROM associated with phyio started > 14 days after injury

- poor function associated with pre-existing cuff problems


Olerudet al JSES 2011

- RCT nonop v hemiarthroplasty for displaced 4 part

- 55 patients, average age 77

- 2 year follow up

- significant advantage of hemiarthroplasty


Operative Management


1.  2 Part Fractures





- >1 cm or > 45o


Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP



- percutaneous wires / screws

- intra-osseous sutures

- proximal humeral nail

- locking plate


B.  GT 



- > 5mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step


Displaced Greater Tuberosity Fracture LateralCT Coronal Greater Tuberosity FractureCT GT Fracture Sagittal



- deltoid splitting approach

- young patient can ORIF with screw

- in elderly insert Mason Allen no 2 suture in cuff and tie over screw

- repair rotator cuff


 ORIF Greater Tuberosity FractureGreater tuberosity Tie over screw


Consequences Nonoperative Treatment


SNOH MalunionSNOH Malunion 2


C. LT Fractures


Soft tissue washer and screw


LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF




2.  3 & 4 Part fractures


A.  ORIF with plate


SNOH Plate



- need sufficient bone quality

- always attempt in young




Moonot et al JBJS Br 2007

- 32 patients with 3 or 4 part treated with Philos plate

- 31 of 32 united

- 27/32 (86%) excellent or satisfatory results

- 5/32 (16%) poor results

- 1 patient AVN and non union


Yang et al J Orthop Trauma 2010

- 64 patients treated with proximal humeral plate

- screw penetration into joint most common complication 5/64

- deep wound infection 2/64

- AVN 2/64

- 3 fixation failures requiring revision

- half good and half moderate shoulder scores, few excellent or poor

- all complications in 4 part fractures

- tuberosity malunion associated with poor outcome


B.  IM Nail




Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions


C.  Hemiarthroplasty


Shoulder Trauma HemiarthroplastyShoulder Trauma Hemiarthroplasty



- unreconstructable

- elderly

- 4 part fractures

- head splitting fractures

- anatomical neck

- head impression > 40% articular surface


Proximal Humerus Unreconstructable



- only good ROM if tuberosities heal



- best to do in first three weeks

- whilst GT / LT still easy to mobilise




ROM often poor

- better if anatomical union tuberosities

- early ROM gives better results (<2/52)

- rarely > 90o


SNOH Hemi 1SNOH Hemi 2


Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100o

- 16% moderate or severe pain


Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty


D.  Reverse total shoulder



- elderly patient

- poor cuff

- poor chance of tuberosity healing



- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding




Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90o v 60o) and abduction (90o v 53o) better in reverse

- rotation better in hemiarthroplasty


ORIF Locking Plate


SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CT


Proximal Humerus 4 Part Head Splitting ORIF APProximal Humeral 4 Part Head Splitting ORIF Lateral




Set up

- GA, IV ABx, lazy beach chair

- mark anatomy

- II (patient either in middle of radiolucent table or remove lateral aspect shoulder table) 


Deltopectoral approach 

- cephalic usually taken lateral

- take part of pec major off to facilitate exposure

- Hawkins Bell retractor (shoulder charnley retractor) / non pointed double gelpies 

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractor deep to tendon



- protect MCN under conjoint, minimal retraction

- find and protect the axillary nerve on inferior border of SSC, sweep finger inferiorly


Deep dissection

- clear sup deltoid bursa

- must elevate deltoid from head

- place a homan retractor over head to elevate deltoid


Identify structures

- remove callous

- reduce head onto shaft

- head is displaced posteriorly

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check for head splitting fractures


Find tuberosities

- secure with Mason Allen

- no 5 non absorbable


Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check II now to avoid having plate too high

- must not leave head in varus





- to prevent cutout must have head out of varus

- long inferomedial screws / kickstand screws

- similar concepts to NOF (don't want screws high in the head)


Closure over drain



- sling 6/52 with pendulars

- ROM 6/52





- uncommon

- associated with AVN






SNOH Malunion



- medial support very important

- must avoid varus malreduction


Plate impingement

- need to ensure place plate low on the head


Screw perforation of humeral head

- most common complication



- fortunately uncommon


Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral




Vascular Injury


Axillary / MCN / Brachial Plexus



- from signficant deformity

- TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy




Proximal Humerus 4 Part Fracture In Elderly


Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2TSR Post OA





Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height


Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades


Deltopectoral approach


Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities


Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation


Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities


Need retroversion of 30o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30o


Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets


Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture


Place on head with 12/14 taper


Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole


Biceps tenodesis


Close over drain, rehab as above




Malunion / Non union tuberosities



- increased in women

- increased with initial malposition

- excessive height or retroversion of humeral head



- 4-50%


Heterotropic ossification

- 10%


Glenoid degeneration

- 8% at 3 years


Prosthetic loosening

- 3-6%


Nerve injury




- 1-2%



- need realistic goals

- aim to achieve function at shoulder height

Rheumatoid Arthritis

EpidemiologyRheumatoid Shoulder




2/3 involved

- ACJ arthritis

- subacromial bursitis / rotator cuff pathology

- GHJ less commonly




1.  ACJ 

- erosive arthritis

- joint expands with severe involvement

- ACJ capsular destruction / instability / impingement


2.  Subacromial Bursa

- becomes inflamed & thickened

- rupture of LH of biceps / cuff rupture

- rotator cuff arthropathy


3.  GHJ

- develop marked soft tissue inflammation

- 2° laxity capsule & folds of synovium

- followed by severe cartilage & bone erosion


Neer described 3 types RA shoulder

- Wet = Synovitic with soft tissue pathology

- Dry = Articular Surface Erosion

- Resorptive = Severe Bony Erosion




Shoulder pain & swelling with flares of RA

- gradually decreasing ROM

- functional impairment


Cuff Tendonosis 

- pain with overhead activity





- muscle wasting

- humeral medialisation 2° bone loss in glenoid cavity with humeral protrusion

- effusion with swelling


Cuff rupture 

- loss of abduction


Biceps rupture / popeye


Painful arc




Typical changes of RA

- regional osteopenia

- marginal erosions and cysts

- humeral head erosions


Rheumatoid Shoulder Erosions


Symmetric Arthritis



- medialisation of humeral head

- can erode anteriorly or posterior

- inferior glenoid preserved


Rheumatoid Shoulder 2


Superior migration due to cuff rupture


Arthritis mutilans


Arthritis Mutilans RA


US / MRI / Arthrogram


30% have cuff tear


Rheumatoid Shoulder Arthrogram Cuff Tear




Assess glenoid stock


Rheumatoid Shoulder CT





- 20 000 WBC / ml

- 60-70% neutrophils



- > 100 000 WBC / ml

- > 75% neutrophils




Septic arthritis



- sodium urate



- calcium pyrophosphate


Milwaukee Shoulder

- calcium hydroxyapatite crystals


RC arthropathy


OA - beard osteophytes





- Medical treatment

- HCLA injections




Excision of outer 1/3 of clavicle


Subacromial Bursa







1.  Arthroscopic Synovectomy 



- mild arthritis / cuff intact



- synovectomy

- via anterior and posterior portals

- removal loose bodies

- biceps tenotomy

- bursectomy / ACJ resection if necessary

- minimal acromioplasty especially if cuff tear as must preserve CA ligament


Rheumatoid Shoulder Arthroscopy Rheumatoid Shoulder Post Debridement


Rheumatoid Shoulder Arthroscopy 2Rheumatoid Shoulder Arthroscopy 3


Cofield et al Arthroscopy 2006

- 16 shoulders followed up for 5 years

- 13/16 good pain relief

- some mild improvement in ROM

- arthritis tended to progress over time


2.  Hemiarthroplasty / TSR


Indications hemiarthroplasty

- young patient

- glenoid not involved / unusual


Indications TSR

- sufficient bone stock glenoid

- glenoid often deficient centrally and superior

- intact RC

Cofield et al J Should Elbow Surg 2001

- 187 TSR and 95 hemiarthroplasties with minimum 2 year follow up

- improved pain relief and abduction, and lower revision rate in TSR


4.  Reverse TSR



- ruptured cuff (30%)


Holcomb et al J Should Elbow Surg 2010

- prospective evaluation 21 shoulders followed up for 2 years

- good pain relief in all but one

- average forward elevation 126o, abduction 116o

- 3 revisions: 2 for infection and 1 for periprosthetic fracture

- 5 patients required bone grafting of glenoid defects


5.  Arthrodesis

- indicated for severe bone loss

- problem is actual or potential involvement of other joints


6.  Excision arthroplasty

- salvage procedure

Rotator Cuff

Calcific Tendonitis



Mid-substance calcification of the rotator cuff

- part of a metaplasia secondary to hypoxia


Supraspinatous CalciumSupaspinatous Large Deposits




2 groups of patients


1.  Degenerate Calcification


Dystrophic calcification of degenerative cuff

- necrotic fibrillated fibres act as nucleus for calcium

- occurs at the cuff insertion

- usually smaller


These patients do not have calcific tendonitis

- older patient group

- different histology


2.  Calcific Tendonitis




Reactive Hypoxic Calcification Theory


Cells undergo metaplasia to fibrocartilaginous cells

- fibrocartilage cells accumulate intracellular calcium


Codman proposed cuff hypoxia as the causative factor




1.  Pre-Calcific stage


Fibro-cartilaginous metaplasia

- tenocytes transformed to chondrocytes

- hypoxia


2. Calcific Stage


A. Formative Stage 

- no or chronic pain

- "Chalk" appearance

- calcium crystals in matrix vesicles

- crystals may be in the form of phosphates / carbonates / oxalates / hydroxyapatite


B. Resting Stage

- fibrocartilage surrounds deposits


C. Resorptive Stage

- acute pain

- "Toothpaste" or fluffy appearance

- macrophage resorption / calcium granuloma


3. Post-Calcific Stage


Area heals to scar

- granulation tissue fills space left by calcium

- Type III collagen -> Type I




Accounts for 10% all consultations for painful shoulder


Peak 40 years

- diabetes

- F > M 


SS most common tendon

- IS less common

- SSC rare


Asymptomatic patients can have cuff calcium on xray


Clinical Presentation


Usually acute pain

- Resorption Stage

- background of absent to mild chronic pain of the Formative Stage


Patients may present to ED

- severe pain


DDx infection




Cuff / Biceps Tendinopathy

Freezing Shoulder

Brachial Neuritis

Septic Shoulder

Gout / CPPD





Calcific Tendonitis APCalcific Tendonits Lateral


Calcium typically supraspinatous

- mid-cuff

- 1-1.5 cm from insertion

- 1-1.5 cm in size


ER AP Xray

- shows SSC


Subscapularis CalciumSubscapularis Calcium Lateral


IR AP Xray

- shows IS & Tm


Painful Resorptive / Type 1

- fluffy, with poorly defined margin

- irregular density

- can rupture into bursae as a crescent like streak


Chronic Formative / Type 2

- discrete, well defined deposit

- uniform density




Low signal on T1 

Oedema on T2


Shoulder MRI T1 Calcific TendonitisShoulder MRI Calcific Tendonitis T2



- more sensitive than Xray ~100%


Ultrasound Calcific TendonitisUltrasound Calcium Supraspinatous




Check serum glucose / uric acid & iron




Non operative Management





- may impair resorption

2.  HCLA

- no effect NHx

- may impair resorption

3.  ECSW Therapy

4.  Ultrasound guided needling and aspiration


Extracorporeal shock wave therapy


Extracorporeal Shock Wave Machine


Peters Skeletal Radiol 2004


- 90 patients

- treatment group complete resolution in 86%, reduction in size in 13.4%

- control group 0 disappeared completely, 9% partial reduction

- significant reduction in pain and improvement in function at 4 weeks

- no adverse affects


Effectiveness directly related to energy

- 0.44 mJ/mm3


Needle aspiration and irrigation



- drain a substantial portion of the calcium

- stimulate resorption of remainder



- resorption phase (soft, toothpaste material)



- small deposits

- formative phase (hard, chalky material)



- US guided procedure under LA

- one needle into deposit, inject saline

- one needle into deposit, aspirate

- create inflow outflow

- want minimal punctures for this to work

- distinguish Formative vs Resorptive



- very painful for first 2-3 days




Aina et al Radiology 2001

- excellent results in 74%


Serafini et al Radiology 2009

- non randomised controlled trial

- patients treated better at 1 month / 3 months and 1 year

- no difference long term


Krasny JBJS Br 2005

- prospective RCT

- improved results by performing US needling followed by ECSW therapy

- c.f. ECSW alone


Operative Management



- severe disabling symptoms > 6 months

- failure of needling / ECSW





- unknown

- alone has been shown to improve patients symptoms

- do so if any acromial or GT evidence of impingement


Marder et al J Should Elbow Surg 2011

- retrospective comparision of 2 groups

- calcium excision v excision + SAD

- SAD much longer time to return to non painful shoulder activity





Arthroscopic and mini open



Arthroscopic Technique


Find Calcium

- remove bursa with shaver

- deposit may be obvious

- however may have to use needle

- get cloud of calcium when find deposit


Calcium NoduleCalcium NeedleCalcium IncisionCalcium in Tendon


Attempt to longitudinally split tendon

- curette calcium

- lavage +++ to prevent secondary stiffness

- usually don't repair tendon to prevent stiffness


May need to remove entire diseased section and repair


Calcific Tendonitis Arthroscopy 1Calcific Tendonitis Arthroscopy 2Calcific Tendonitis Arthroscopy 3Calcific Tendonitis Arthroscopy 4




Secondary stiffness



- secondary to calcium deposits

- careful shoulder washout at the end of the case



Cuff Tear Arthropathy



Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch





- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases




Crystal induced arthropathy

- hydroxyapatite-mineral phase in altered capsule, synovium or degenerate articular cartilage

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally


Cuff tear theory

- loss of cuff leads to mechanical and nutritional alterations in shoulder

- due to loss of closed joint space and altered range of motion




4% of massive cuff tears go on to arthroplasty



- tears with unbalanced force couplet go on to arthropathy 

- massive tear that are balanced & / or above equator don't go onto to arthropathy




Women > men

60% bilateral




Recurrent swelling

Loss of Motion

Night pain




1.  Superior migration of head 

- defined as AHI / acromiohumeral interval of 7mm or less


Humeral Head Superior Migration


2.  Collapse of proximal head articular surface 


3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity


4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification


Acromial Acetabularisation




RC Arthropathy CT





- no superior migration

- beard osteophytes






Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia


Operative Management


1.  Acromioplasty & tendon debridement 


Not indicated with superior migration

- can consider biceps tenotomy if still intact


2.  Arthrodesis


Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid


3.  TSR 


Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 


4.  Hemiarthroplasty



- < 70

- intact CA arch

- anterior deltoid muscle



- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape





- 18 of 21 satisfactory

- good pain relief

- ROM often not improved



- concept of limited goals category

- 20° of ER and 90° of forward elevation


Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency


5.  CTA Humeral Head


Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER


CTA HemiarthroplastyCTA Head APCTA Head 2


6.  Reverse TSR



- > 70

- functioning deltoid



- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder





Arthroscopic Acromioplasty




- beach chair / lateral

- water pump, adrenaline in bags

- block pre-op useful as easier to control BP

- often inject the SAD with combination of LA with A prior to scope


Posterior portal

- 2 cm inferior, 1 cm medial

- soft spot between IS and Tm


Enter subacromial space

- sweep to clear adhesion

- saline on pump at 30 - 40 - 50

- keep BP  100 - 110

- can increase pump pressure to 60 - 80 if needed in short bursts


Midlateral portal

- spinal needle

- 3cm distal to anterior acromion

- midpoint clavicle

- slightly lower to aim up



- with shaver


Arthroscopic Bursectomy


Electrocautery / Shaver

- clear periosteum / coracoacomial Ligament off acromion

- avoid deltoid as bleeders

- beware thoroaco-acromial artery in CA ligament medial and inferior to acromion

- spinal needle ACJ to mark medial limits

- need to see anterior and lateral acromion


Arthroscopy Type 3 AcromionShoulder Scope Large Acromial Spur



- 5.5mm burr

- multiple techiques

- 5mm deep resection at midpoint clavicle

- taper anteriorly

- must ensure lateral edge is cleared


Arthroscopy Post AcromioplastyArthroscopy Cleared Subacromial Space


Residual Lateral Acromial Spur






DefinitionLateral Acromial Spur


Painful impingement of rotator cuff

- on anterior 1/3 of Acromion, CA ligament & ACJ

- causes tendinosis of the RC


Anatomy Subacromial Space


1.  Roof / CA Arch

- acromion

- CA ligament

- coracoid process

- ACJ is superior & posterior to CA ligament


2.  Floor 

- GT & superior aspect head

- rotator cuff





- extrinsic and intrinsic theories


1.  Extrinsic / Extra-tendinous / Bursal sided tears


CA arch impinges on RC

- true impingement syndrome

- causes tendinosis of the cuff




A.  Subtle GH Instability

- relationship poorly understood

- respond poorly to acromioplasty

- alteration in dynamics of shoulder


B.  Internal Impingement Posterior / Superior Glenoid


Described by Davidson 1997

- throwing athletes

- impinge in abduction & ER

- SS impinges on posterosuperior rim of glenoid 

- normally humeral head translates posterior in glenoid 

- this may be lost with instability or laxity of throwing athlete

- alternatively may be caused by posterior capsular tightness


See Miscellaneous/Throwing Athlete


C. Degeneration ACJ


OA Spurs


D.  Acromion Morphology


Neer = impingement on anteroinferior acromion 


E.  Os Acromiale

- mesoacromion most common

- hypermobile unfused epiphysis

- tilts anteriorly

- 1-15% normal population

- increased incidence with impingement


F.  CA Ligament Spurs 


Develop calcium in tendon


G.  CA Ligament Impingement

- common

- "Snapping shoulder"

- in flexion & IR

- SS & Biceps impinge on it

- Neer recommends division


H.  Coracoid Impingement

- less common

- subscapularis impingement between coracoid and LT

- may be exacerbated by anterior instability

- more medial pain with arm flexed, adducted and IR

- find SSC partial tears on arthroscopy


Coracoid Impingement Lateral Coracoid


2.  Intrinsic / Intra-tendinous / Articular sided tears


2° to bursal thickening or intrinsic problem in cuff

- ? Now thought to be most common




1. Muscle Fatigue

- overloaded weak muscles

- eccentric tension load

- associated with proximal humeral migration


2. Shoulder Overuse

- soft tissue inflammation

- repetitive microtrauma

- athletes / manual labourers


3. Degenerative Tendinopathy

- 1° intrinsic degeneration of RC

- ? hypovascularity

- increasing incidence with age




Impingement Zone 

- centered on supraspinatus tendon insertion

- Codman's "Critical Zone" 1cm from insertion

- zone of hypoperfusion


Neer's Pathological Classification


Stage I

- reversible

- oedema & haemorrhage

- < 25 years


Stage II

- irreversible change

- fibrosis & tendinitis

- 25-40 years


Subdivided by Gartsman

- Stage IIA = No tear

- Stage IIB = Partial thickness tears


Stage III

- > 40 years

- chronic

- partial & full thickness tears


Acromial Morphology


Bigliani / Assess on Supraspinatous Outlet View / Scapula Lateral


Type I:  Flat

- 20% of normal population


Type 1 AcromionType 1 Acromion


Type II:  Curved

- 40% of normal population


Type 2 Acromion


Type III:  Hooked

- 40% of normal population

- 80% of RC tears


Type 3 AcromionAcromion Type 3Acromial Spur Type 3


Cadaver study

- 30% of all cadavers had a full thickness cuff tear

- 75% type III & 25% type II & 3% type I


Morphology does change with age

- Spur more common > 50 years

- ? 2° event to cuff process

- most hooks appear to be acquired & lie in CA ligament 




Painful arc


Weakness overhead


If < 40 years look for instability




Painful Arc

- 70-120°

- > 120° - ACJ OA / terminal phase pain



- limitation of IR may suggest posterior capsular tightness


Neer Impingement Sign

- stabilize scapula from behind patient

- passively elevate arm in scapula plane

- pain between 70-120°


Hawkins Modification

- IR humerus at 90° flex


Neer Impingement Test 

- LA in SAD

- abolish pain & test for cuff tear / weakness



- anterior apprehension / Jobes relocation (young patient)

- ACJ assessment

- biceps assessment


- C spine




AP view (True AP)

- acromio-humeral interval:  Normal 1-1.5 cm, < 0.7cm abnormal

- sclerosis greater tuberosity / acromion

- lateral Acromion spur



Acromial Spur AP


Axillary Lateral

- os acromion

- bone scan to exclude symptomatic hypermobility


Os Acomionale Axillary Lateral Xray


Supraspinatus Outlet View

- Acromion morphology / calcification Coraco-Acromial Ligament

- scapula lateral variant

- plate on affected shoulder, other turned out of way 

- 10° caudal


Scapular Lateral for Acromial Morphology


Zanca view


- half voltage / centred on ACJ / 10o cephalad





- dynamic impingement

- bursitis


Shoulder Ultrasound Bursitis





- assess acromial morphology

- look for tendinosis / tears


MRI Type 3 Acromion




Non Operative


HCLA injection 



- decreases pain & inflammation

- diagnostic


Alvarez et al Am J Sports Med 2005

- RCT HCLA v LA in RC tendonosis

- no clinical difference between the two groups


Cuff Rehabilitation


Rockwood 3 Stages of Physio


1. Decrease Inflammation / Increase ROM

- rest

- gentle ROM 

- posterior capsular stretches

- scapula & trunk stabilisers

- modify activities



2. Cuff Stabilisation and Balancing

- strengthen humeral depressors

- work on SSC and IS

- takes load off SS

- theraband / IR / ER exercises

- avoid abduction drills


3. Deltoid strengthening

- task specific exercises


Operative Management






Believe primary problem is extrinsic impingement

- abnormal acromial morphology on outlet view

- spurs in CA ligament




Ketola et al JBJS Br 2009

- RCT of patients with impingement

- treated with exercise program or acromioplasty + exercise program

- no difference between the two groups


Henkus et al JBJS Br 2009

- RCT of bursectomy alone v bursectomy + acromioplasty

- no difference between the two groups


Open v Arthroscopic Acromioplasty




Sachhs JBJS 1997

- open v arthroscopic

- open longer return to work & in hospital stay

- results similar


Davis et al Am J Sports Med 2010

- meta-analysis of open v arthroscopic acromioplasty

- no significant difference in outcome

- longer return to work and inpatient stays

Open Acromioplasty

Described by Neer / modified by Rockwood


Two Step Acromioplasty


1.  Anterior acromioplasty

- resect anterior acromion back to ACJ

- prevent impingement in flexion


2.  Resect anteroinferior acromion 





- beach chair 

- mark anatomy

- limb draped free



- along anterolateral border acromion

- curve into anterolateral incision


Superficial Dissection 

- expose deltoid to ACJ

- find fibrous raphe at anterolateral corner acromion 

- marks anterior & middle parts of deltoid

- split raphe 3cm, ensure protect underlying cuff

- bursa is now exposed, separate subdeltoid space


Deep Dissection

- detach deltoid from anterior acromion to ACJ 

- release CA ligament 

- place retractor under acromion to protect cuff

- tablespoon, Langerhan's retractor turned on side


2 stage acromion resection with microsagittal saw

- anterior acromion level with ACJ

- antero-inferior acromion

- ensure surface smooth


Resect distal 2cm clavicle if OA

- < 4% of patients

- only if pain referable to ACJ 

- confirmed by LA preoperatively



- inspect cuff & repair defects

- abduct & rotate humerus

- biceps tenodesis if > 50% torn



- ? repair CA ligament

- reattach Deltoid No. 2 ethibond intraosseous sutures


Post Op

- rendulum exercises & passive flex

- sling for comfort

- no active abduction for 6/52 to protect deltoid




RC Tears

Arthoscopic Supraspinatous Repair


Large Supraspinatous TearSS tear arthroscopy GHJSS tear arthroscopy




Improved cosmesis

Shorter hospital stay / less immediate post operative pain

Deltoid not detached

Ability to evaluate and treat coexisting intra-articular pathology i.e. biceps




No quicker to rehab or return to activities 

- limiting factor is healing of tendon to bone

- healing rates not as high especially for large to massive tears

- steep learning curve / longer surgery




1.  Footprint

- 25 x 15 mm

- healing zone

- the greater the extent a repair covers, the greater the chance for tendon bone healing


2.  Suture technique


Note:  Most common means of failure is suture cutout


A.  Open transosseous



- performed in open surgery

- captures a wide section of cuff footpring

- very secure repair with uniform compression between cuff and bone


B.  Single row repair



- anchors placed in line laterally at insertion


C.  Double row repair



- medial anchor row at articular margin

- lateral anchor row at lateral footprint


Kim et al Am J Sports Med 2006

- biomechanical study

- more successful at restoring footprint

- less gap formation

- increased load to failure


D.  Transosseous equivalent / suture bridge



- biomechanically replicate tradional open transosseous

- sutures crossed as below in double row

- aiming to increase contact between cuff and footprint


Arthroscopic Suture Bridge Cuff Repair


Siskoksy et al AAOS 2007

- biomechanical study suture bridge v double row

- bridge higher load to failure

- no difference in gap formation




Outcome arthroscopic


Lafosse et al AA Should Elbow Surgeons 2006

- 105 patients treated with double row

- 11.45 structural failure on CT / MRI


Sugaya et al JBJS Am 2007

- prospective study 106 FT

- arthroscopic double row

- MRI follow up

- 17% retear

- 5 % small to medium

- 40% large and massive


Arthrocopy v mini-open


Kim et al Arthroscopy 2003

- arthroscopy v mini open

- similar outcomes in each group

- poor outcome related to size of tear, not method of repair


Verma et al Arthroscopy 2006

- arthroscopy v mini open

- US review

- 24% retear mini-open

- 25% retear arthroscopic

- no difference in outcome


Bishop et al AAOS 2004

- mini open v arthroscopic

- MRI review

- tears < 3 cm: 26% retear mini open, 16% arthroscopic

- tears > 3m: 38% v 76%

- do larger tears do better with open surgery?


Morse et al Am J Sports Med 2008

- meta-analysis of arthroscopic v open

- no difference in outcome or complications


Single v Double Row


Francheschi et al Am J Sports Med 2007

- RCT single v double row

- 60 patient

- no difference functional outcome

- improved cuff appearance on MRI


Burks et al Am J Sports Med 2009

- RCT single row v double row

- 20 in each group

- 1 retear in each group

- no difference in MRI appearance or clinical outcome




Churchill et al J Should Elbow Surg

- arthroscopic took average 10 minutes longer / cost $1000 dollars more

- even at high volume centres


Arthroscopic Supraspinatous Repair





- lateral decubitus with arm traction 10 lb or

- beachchair in Tmax / Spyder (can depress arm and ER to aid visualisation)

- water pump

- useful to have adrenalin in bags

- stable BP 110 (interscalene block can help)

- inject LA with A into subacromial space and prospective portals




Posterior Portal

- make more superior and lateral

- awkward for GHJ arthroscopy

- good visualisation in subacromial space

- will put camera over and high above tear


Lateral portal

- standard position

- insert large 8 mm cannula (will need to pass sutures)

- perform bursectomy +++ for visulisation

- bursa posteriorly and medially often bleeds

- perform SAD

- control bleeding with electrocautery and temporary increases in pump pressure


Anterior portal

- smaller 6 mm

- for suture shuttling




Prepare insertion

- debride tendon edges

- debride footprint to punctate bleeding


Arthroscopic Cuff TearArthroscopic Cuff Prepare InsertionArthroscopic Cuff Prepared Footprint


Assess tendon mobilisation / tear geometry

- perform releases if needed

- as per open surgery

- above and below tendon 1 cm medial to glenoid

- release coracohumeral ligament




Large U shaped tendon

- insert margin convergence sutures

- put camera in lateral portal

- insert posterior cannula over switching stick

- anterior and posterior bird beaks


Arthroscopic Cuff Repair Margin Convergance 1Arthroscopic Cuff Repair Margin Convergance 2


Place medial row anchors

- anterior first

- insert 18 G spinal needle and ensure good angle

- just medial to articular cartilage

- stab incision

- insert 5 mm anchor


RCR arthroscopic Spinal NeedleRCR Arthroscopic TapRCR Arthroscopic AnchorRCR Arthroscopic Anchor 2


Pass sutures in lateral margin cuff

- camera posterior

- elite / scorpion / concept suture passer via lateral portal

- pass sutures through cuff anterior to posterior

- retrieve sutures through anterior portal

- retrieve via anterior portal


Suture PassageSuture Retrieval


Repeat with posterior anchors


Large Cuff Repair 1Large Cuff Repair 2Large Cuff Repair 3


Tie sutures

- posterior to anterior / anterior to posterior


Double row

- either pass second lateral row of anchors or

- use foot print anchors, retrieve previous sutures

- can make suture bridge configuration

- check repair via lateral portal


Arthroscopic Supraspinatous RepairArthroscopic Cuff Suture Bridge RepairArthrscopic Cuff Repair






Full thickness tear (FTT)

- variable amount retraction from insertion


Rotator Cuff Tear Large


Partial thickness tear (PTT)

- incomplete

- bursal or articular sided


Articular sided tearBursal Tear




Older patients

- average age 60

- uncommon < 40

- cadavers  30%


Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years




Blood Supply


Proximal from muscle belly

- suprascapular artery

- subscapular artery


Distal from bone

- branch of anterior circumflex humeral


Vessels more abundant on bursal side than articular side




1.  Healing

- full thickness tears don't heal because of presence of synovial fluid


2.  Progression

- tears do not necessarily extend


3.  OA

- 5% FTT go on to cuff arthropathy if untreated




Chronic Tears

- 95% 

- abnormal tendon


Acute tears

- trauma 

- 5% 

- normal tendon




No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia



- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn




1.  Size 



- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm


2.  Extent


Partial Thickness


Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium


A.  Intra-tendinous

- in tendon

- no communication with bursa / joint


Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis


B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly


Supraspinatous articular sided tear


C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement


Full Thickness


One tendon 

- supraspinatus only


Multiple Tendons 

- more likely OA if multiple tendons involved


3.  Topography


Sagittal Plane


Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons


Coronal Plane


A. Minimal retraction

- close to insertion


Supraspinatous Tear Minimal Retraction


B. Moderate retraction

- humeral head


Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2


C.  Significant retraction

- at glenoid


Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1







- 2° to tear

- can be limited by pain

- can use LA to differentiate


History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon


Chronic Tear 95%

-  long history impingement

-  no history of injury




SS IS Clinical Photo 1SS IS Clinical Photo 2



- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears


Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear




1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate


2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o


3.  Shoulder hiking

- usually means massive cuff tear


Shoulder Hiking




1.  Resisted ER


2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags


3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor


Involvement of IS can often indicate a large or massive tear




1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test


2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly


3. Increased ER compared with other arm


Subscapularis tear increased ER




Improves pain and allows physio



- ensures pain from shoulder pathology




Views as for impingement

- assess acromion / GHJ OA / high riding head





- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery



- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)




O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable




Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal




Shoulder Ultrasound Supraspinatous Tear




Arthrogram Intact RC




Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 


Shoulder MRI Supraspinatous Fatty Infiltration


Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space


For more MRI see

- massive tears

- partial thickness tears

- full thickness tear




Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space


Management Guidelines


1. Repair all acute full thickness tears


2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain


3. Observe chronic tears with no disability

- especially in elderly


Non-operative Management


As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears




Full Thickness Tears

Surgical Options


1.  Open antero-lateral approach 


Large / Massive Cuff Tear


2.  Deltopectoral approach


Large Subscapularis tear


3.  Arthroscopic Assisted Mini-open



- Small / Moderate Cuff Tear < 3cm

- no retraction



- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split



- avoids deltoid detachment from acromion

- small scar

- still have to immobilise shoulder for 6/52 to protect cuff tear


4.  Arthroscopic repair




Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not


Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs


Biceps / SLAP


Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group




4 types of cuff tears


1.  Cresent shaped

- simple lateral repair


Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped


2.  U shaped

- larger

- need margin convergence, then lateral repair


Supraspinatous Tear U shaped


3.  L shaped


Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly


4.  Massive


Rotator cuff retracted to glenoid


1.  Open Rotator Cuff Repair



- large to massive tear



- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures



- reliable

- good results in terms of tendon healing and outcome



- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

- miss any intra-articular pathology if don't perform arthroscopy

- ? management of biceps





- lazy beachchair



- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid



- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

- must not extend incision > 5 cm from acromion or risk damaging anterior AXN

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery



- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure




Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint


Techiques to mobiise retracted SS tendon


1.  Release CHL (runs from coracoid to free edge SS / into rotator interval)

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

4.  Release above glenoid 1.5cm (beware suprascapular nerve)

5.  Interval slide - divide between SS and IS posteriorly, rotator interval anteriorly

6.  Medialise insertion - take away some of articular cartilage

7.  Repair SSC and IS for restoration of force couplet (if SS irrepairable)


Repair Options


1.  Direct suture of tendon

- margin convergence


2.  Suture of tendon to bone


A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across


Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral


B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors


C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)


3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head


Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow



- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery


Large - Massive Tear 


Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above


Post op


Must protect deltoid repair

- passive ROM 6/52, hand and elbow exercises, sling

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12


Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM


2.  Arthroscopic SAD + Mini open Rotator Cuff Repair



- perform subacromial decompression with arthroscope

- no need to detach deltoid

- made 2 - 5 cm deltoid split directly over tear and repair



- moderate size tear up to 3 cm



- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above




Open v Mini-open


Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years


Tear integrity


Papadopolous et al J Should Elbow Surg 2011

- ultrasound evaluation of tears at 3 years in 37 mini-open patients

- 48% intact in patients who tended to have smaller original tears and be 15 years younger

- most patients had satisfactory outcome





- up to 50%

- increased in older patients with larger tears


Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head


Shoulder High RIding Humersu





- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)


Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture




Deltoid avulsion


Axillary nerve injury


Acromial fracture


RC Tear / Anchor Pullout


Rotator Cuff Anchor Pull Out


Massive Tears

DefinitionsMassive RC Tear High Riding Humeral Head MRI


Massive tear 


1.  > 5cm 

- retracted to humerus / glenoid margin


2.  At least 2 complete tendons

- lose SS / IS or SS / SC





- SS + SSC


Postero-Superior defects

- SS + IS
- more common




Cuff works to compress / depress head in glenoid while deltoid acts as prime mover

- ff still have intact force couple often good function


Plan is to reproduce force couple 

- if tear is below equator of head 

- get uncoupling of cuff force couple

- lose cuff depressor effect & acts as head elevator


Integrity of coracoacromial arch integral component of repair

- acts as check rein to proximal migration 




Massive SS / IS wasting + rupture LHB

- weakness

- reduced active ROM

- atrophy


Shoulder Hiking due to massive cuff tearSupraspinatous and Infraspinatous wasting


2 classic signs


1.  ER lag sign


2.  Hornblowers

- 100% sensitive, 93% specific


Both indicate infraspinatous is torn which is usually a sign of a massive PS tear




Suprascapular nerve palsy

Brachial plexus injury

Cervical stenosis




Reduced acromiohumeral space

- < 7 mm RC tear

- < 5 mm massive tear


Rotator cuff OA

- acetabularisation


Decreased Acromioclavicular DistanceShoulder Massive Rotator Cuff Tear CTMassive Rotator Cuff Tear




1.  Level of retraction

- past coracoid irreparable


MRI Supraspinatous Retracted to Glenoid Margin


2.  Quantify fatty infiltration Goutallier


Parasagittal MRI T1

- atrophy and fatty replacement in SS / IS fossa


0 - no fat

1 - minimal fat

2 - more muscle than fat


Supraspinatous fatty infiltration grade 2


3 - fat equal muscle


MRI Fatty Infiltration Supraspinatous Infraspinatous


4 - more fat than muscle


Grade 4 Fatty Atrophy


3 & 4 have poor prognosis

- poor functional improvement with repair

- high incidence of retear


3.  Atrophy


Also poor prognosis


MRI Supraspinatous Atrophy




Non Operative


Physio /  HCLA

- improvement in 50-85%






A.  Primary repair / Debridement

1.  Mobilisation and repair

2.  Partial repair

3.  Decompression and debride

4.  Suprascapular nerve release


B.  Salvage

1.  Local tendon transfer - SSC

2.  Distant tendon transfer - P. major / Lat dorsi

3.  Allograft

4.  Synthetic Graft

5.  Arthroplasty


Repair / Debridement


1.  Rotator Cuff Mobilisation and repair


Technique of mobilisation

- release coracohumeral ligament

- anterior slide (between SS and SSC)

- posterior slide (between SS and IS)

- release above glenoid 1 cm

- medialise insertion

- transosseous repair




Bigliani et al J Should Elbow Surg 1992

- 61 patients massive cuff tears followed up 7 years

- open repair

- 50% excellent and 30% good


2.  Partial repair



- restore balanced force couplet

- SSC + partial SS / IS repair

- act in conjuction to depress humeral head

- allow deltoid to work


Massive Cuff TearMassive Cuff Tear Partial Repair 1Massive Cuff Tear Partial Repair 2


Massive Cuff Repair Partial Repair 3Massive Cuff Tear Partial Repair 4Massive Cuff Tear Partial Repair 5




Rhee et al Am J Sports Med 2008

- partial repair with interposition of biceps tendon to bridge gap

- MRI of 14 / 16 cases done arthroscopically

- complete healing in 60%


3. Decompress & debride alone



- doesn't restore power

- aiming for pain relief in elderly population



- maintain Coracoacromial arch to prevent humeral head escape

- don't perfrom SAD to preserve CA ligament

- debride cuff edges

- debride GT / tuberoplasty to decrease impingement

- biceps tenotomy / tenodesis




Boileau et al JBJS Am 2007

- demonstrated good results with tenotomy or tenodesis

- 61 patients with irreparable tears


Liem et al Arthroscopy 2008

- 31 patients average age 70

- debridement cuff edges + biceps tenotomy

- no SAD

- reasonable results


Walch et al Arthroscopy 2005

- arthroscopic tenotomy in 307 irreparable RC tears

- 87% satisfied with results


4.  Suprascapular nerve release



- retraction of cuff tethers / impinges SSN

- release of nerve arthroscopically relieves pain



- arthroscopic release

- see miscellaneous/suprascapular nerve for technique




Indications for tendon transfer / Graft


Young patient with poor function

- failed primary repair

- significant weakness

- good deltoid function

- CA arch intact / no superior escape

- good ROM

- either posterosuperior or anterosuperior defect


1.  Subscapularis Transfer



- may lose humeral depressor effect

- lose abduction with deltoid



- release upper 1/3 tendon from capsule




Karas et al JBJS Am 1996

- 20 patients

- good results in 17


2.  P.  Major Transfer



- functional deficit from SSC tear



- deltopectoral approach

- use sternal head rerouted under clavicular head for better line of pull




Jost et al JBJS Am 2003

- reasonable results in isolated SSC

- less so with combined SS and SSC (doesn't recommend)


3.  Lat Dorsii Transfer



- IS / SS tear




Lateral Decubitus position

- arm over mayo table


Standard deltoid splitting open approach to subacromial space

- acromioplasty - minimal, preserve CA arch

- ACJ excision if needed

- tag cuff edges medially with sutures to augment repair

- place lateral anchors / sutures


L shaped incision

- inferior margin deltoid, lateral aspect of latissimus dorsi

- arm forward flexed to 90 degrees and IR

- infraspinatous usually very wasted

- identify T major

- find L dorsi below T major, develop interval between the two

- identify tendon insertion on humerus, often have to release T major tendon from it

- place homan over humeral head

- release tendon from insertion / keep long

- is usually thin / 3 cm wide / 5 cm long

- suture each margin with strong suture, leave limbs long to pass tendon

- release muscle belly for length / above and below / must identify and preserve pedicle

- tunnel tendon under deltoid & acromion

- suture anchors repair to GT + subscapularis + medial cuff remnant

- repair with arm in abduction and ER

- maintain in abduction and external rotation splint for 6/52


LDTT exposureLDTT intervalLDTT find tendon


LDTT homanLDTT tendonLDTT tendon suture


LDTT ReleaseLDTT humeral headLDTT repair


Pre op Lat Dorsi TransferPost Op Lat Dorsi TransferLat Dorsi Transfer Lateral




Miniacci JBJS Am 1999

- 14 / 17 good results regarding pain relief and ROM


Tauber et al JBJS Am 2010

- compared patients with tendon transfer to those with tendon + bone block

- significantly improved results in bone block

- 4/22 reruptured on MRI in tendon v 0/20 in bone block group


4.  Allograft




Moore et al Am J Sports Med 2006

- 28 patients average age 59

- patella tendon or achilles

- sewn to tendon medially

- bone block laterally or sutured

- 15 repeat MRI - all complete failure of graft

- 1 infection and 1 allograft rejection

- similar functional results to debridement alone

- not recommended by authors


5.  Synthetic Allograft




Nada et al JBJS Br 2010

- dacron graft for massive cuff tears in 17 patients

- sutured medially, tied through bony tunnels laterally

- 90% satisfaction

- 15/17 intact on MRI

- 1 rupture, 1 deep infection


6. Arthroplasty


CTA Hemiarthroplasty / Reverse TSR

- salvage in patients > 65 years


Partial Thickness Tears



Pain & Stiffness

- often more pain than FT tears


Bursal side tears more painful than articular


Articular side more common


May see in young patient overhead throwing




Painful arc


Impingement signs


No weakness

- function good

- cable system intact




Articular sided more common than bursal



- A (articular)

- B (Bursal)


Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed




Sher et al JBJS Am 1995

- 19 - 39 years - 4% PT , no FT

- > 60 years - 26% PT, 28% FT




Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT




Articular Sided


Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear


Bursal Sided




Articular side




Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear



- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage


PASAT Arthroscopy 1PASTA Arthroscopy 2


Bursal Sided


Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear




Non Operative


Physio / HCLA






1.  Failure of non operative treatment (6-12 months)

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth




1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT


1.  Acromioplasty + debridement



- < 50% tears


Shoulder Scope PASTA Debridement




Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years


Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair


Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT



- bursal sided tears tend to do more poorly than articular sided

- repair > 50% especially in young patients


2.  Acromioplasty and repair


May be done open / arthroscopically / arthroscopically + mini open



A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open


A.  Convert to FT and repair


Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction


B.  Articular sided / transtendinous PASTA repair


Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation


Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair


C.  Bursal sided

- can repair top layer of tear only


Technique Transtendinous Arthroscopic PASTA Repair 



- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness




Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal


Shoulder Partial Articular Supraspinatous Tear PASTA


Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint


A.  Pass bird beak suture passers through cuff to retrieve sutures


B.  Pass 20G spinal needle and pass down 0 nylon, retrieve via anterior portal

- tie to thread, and pass suture back through tendon

- do so each time for each thread in horizontal mattress pattern


Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled


Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ


Shoulder PASTA Repair Sutures in Subacromial SpaceShoulder PASTA Repair Knots Tied Subacromial Space


Post op

- can range aggressively

- the repair is protected by the intact portion of the tendon

- prevents stiffness


Technique Open Articular PT Tears



- put spinal needle through torn portion

- pass suture through to mark tendon


Open approach over needle entry

- identify tear by suture

- convert to FT and repair


Technique Arthroscopic Bursal Sided Tear


Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion


Insert anchor

- pass sutures through top layer of torn tendon

- tie down


Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair

Revision Cuff Tears




- may be up to 50% retear over time

- many asymptomatic




Shoulder MRI Failed Rotator Cuff RepairShoulder MRI Failed RC Repair 2




1.  Debride / Biceps tenotomy or tenodesis


2.  Revision cuff repair

- open

- arthroscopic


Revision Rotator Cuff 1Revision Rotator Cuff Repair 2


3.  Tendon transfer







Subscapularis Arthroscopic Repair


- extra-articular



- posterior portal very lateral so can see anterior aspect subacromial space

- port of Wilminton at anterolateral acromion to access SSC

- anterior portal in normal position, slightly more lateral so becomes working portal


SSC Repair Portals 1SSC Repair Portals 2



- identify tendon

- work through portal Wilmington

- grasp, forms comma sign

- perform biceps tenodesis

- tag SSC with fibrewire


SSC tornSSC comma sign


Subacromial space

- place standard lateral portal as well

- total bursectomy plus acromioplasty

- use tagging sutures to identify SSC

- release as necessary

- may need long posterior cannula to see anteriorly

- may need to move camera to lateral portal to see around corner anteriorly

- can use 70 degree scope


SSC Tagging Suture Subacromial SpaceSSC Debridement Anterior Subacromial


Prepare footprint

- debride

- insert anchors (retract port of Wilminton into subacromial space)

- pass sutures with suture passer

- tie


SSC Debride FootprintSSC First AnchorSSC Suture Passage


SSC Second AnchorSSC Repair





Subscapularis Tears

AnatomySSC Longitudinal Tear


Largest and most powerful rotator cuff

- arises coastal border of scapula

- superior 2/3 tendon inserts into LT

- inferior 1/3 inserts into proximal humerus



- IR (with T major, P major, Lat Dorsi)

- part of force couplet depressing humeral head




Can be isolated event


More commonly seen with SS tears (2% in MRI study)

- anterosuperior tears




- biceps subluxation

- coracoid impingement





- hyperextension and ER






Pain anterior shoulder


Increased ER


Lift off test


Belly Press

- elbow falls posteriorly to harvest post deltoid




Subscapularis Tear MRISubscapularis FT Tear MRI Glenoid RetractionMRI Retracted Subscapularis TearMRI SSC tear minimal retraction




Complete absence of SSC


Subscapularis Retracted Tear Arthroscopy


Comma Sign


SSC tornSSC Comma Sign


Medially Subluxed Biceps


Medially Subluxed Biceps




Operative Indications



- failure of 6/12 non operative



- fix acutely



1.  Debridement

2.  Open Repair

3.  Arthroscopic Repair






Edwards et al Arthroscopy 2006

- 11 patients with SSC tears

- debridement

- tenotomy in 9 with dislocating / unstable biceps

- 9/11 good results


Open Repair




Deltopectoral approach

- preserve axillary nerve inferiorly

- mobilise SSC

- subscapular nerves on anterior surface medial to glenoid rim

- tenodesis LHB

- suture anchor repair to lesser tuberosity




Barti et al Am J Sports Med 2010

- 30 traumatic tears, patient average age 43

- associated biceps subluxation and HAGL's seen

- repair structurally intact in 93%

- 20% still unable to perform lift off / belly press tests

- these patients had higher degree of fatty infiltration preoperatively


Arthroscopic Repair


Intra-articular technique

- camera in GHJ

- anterosuperior portal

- mobilise tendon front and back

- must remove adhesions

- roughen insertion point on LT / gentle with burr as bone is soft

- insert twinfix anchors x 2 via stab incision

- pass birdsbeak suture passer through portal and through SSC

- retrieve 3 sutures through tendon

- retrieve 4th suture over top of SSC


Extra-articular Technique

- see article




Lafosse et al JBJS Am 2007

- isolated repair in 17 patients

- 15 intact repairs and 2 partial reruptures on CT arthrogram

- good outcomes


Late reconstruction


P. major transfer




Jost et al JBJS Am 2003

- good results in isolated SSC tears

- results poor in shoulder arthroplasty


Sternoclavicular Dislocations

EpidemiologySCJ Anterior DIslocation


Extremely uncommon

Stability provided by joint capsule /costoclavicular & interclavicular ligaments 


Recurrent instability uncommon


Many apparent dislocations in adolescents may be growth plate injuries 

-will remodel without treatment


If OA from chronic dislocation may resect SCJ




Anterior & posterior 



- more serious injury

- least common



- difficult on physical examination

- radiographs often are non diagnostic

- most consistent diagnostic modality = CT




SCJ CT Anterior DislocationSternoclavicular Anterior Dislocation


Usually managed non-operatively

- with activity modification and reassurance



- often will redislocate


Open reduction

- need to stabilise

- can use strip PL to stabilise

- uncertain if any benefit 




CT Posterior SCJ DislocationPosterior SCJ Dislocation CT


May require treatment because of proximity of major neurovascular structures and airway 


1.  Closed reduction

- performed under GA in operating room 

- chest surgeon available

- potential vascular / airway catastrophe associated with injuries to the mediastinum

- thorough vascular exam pre-operatively


2.  Assess stability


Successful closed reduction usually stable

- avoid internal fixation because of likelihood of hardware migration

- possible injury to the mediastinal structures


Closed reduction unsuccessful

- open reduction is indicated

- can stabilize with PL graft / intra-osseous sutures


SCJ Open ReductionSCJ Reduction 2SCJ Suture Fixation