1 American Shoulder and Elbow Surgeons 1. Curriculum Guide For Treatment of Shoulder Injury Welcome to the ASES curriculum guide for treatment of Shoulder injury. This guide has been developed by the ASES Education committee, with contributions by many ASES. members, to be used as a reference source by residents, fellows, Orthopedic Surgeons , and others who desire a basic foundation of information on evaluation and treatment of Shoulder injury and disease. The guide is organized by pathological topic. The organization in general follows the outline of topics found in the Iannotti and Williams textbook Disorders of the Shoulder Second Edition, which is felt to be a comprehensive overview of Shoulder problems. ASES. gratefully acknowledges the willingness of the editors Drs Joseph Iannotti and Gerald Williams, and the publishers Lippincott Williams and Wilkins, to allow ASES to use the textbook as the organizational source. An annotated bibliography of key references has been developed for each topic by an experienced Shoulder surgeon or other expert on the specific topic.
2 The annotations give a brief summary of the particular reference, and then place the reference in a context of its importance in the understanding of the topic. References are either a classic in the field, a review of the topic, or current research on the topic. It is expected that a broad background on each topic can be gained through all the references. Each topic reference list reflects the judgment of the individual author regarding which references to include, and as such is not inclusive of all possible references. Therefore, the list should be taken as a starting point for understanding each topic. The editors have reviewed the reference lists, and believe that information relating to the broad context for each topic has been included. It is expected that the list will be periodically updated, so that the basic information will reflect current knowledge. The editors would like to thank the many ASES members who contributed to the curriculum guide.
3 They include Drs Jonathan Ticker, Lawrence Higgins, Gerald Williams, Tony Romeo, Patrick McMahon, Brian Cole, Ed McFarland, Mike Wiater, Jeff Abrams, Answorth Allen, Peter Millet, David Collins, Sumant Krishnan, David Dines, Jed Kuhn, Evan Flatow, Anthony Rokito, Martin Kelly, and Tim Uhl. Dr Andy Green was the co- editor and contributed many chapters and long hours of work on the project. Special thanks go to Susan Shannon at ASES and Aaron Sciascia at the Lexington Clinic for their help in organizing the material. W. Ben Kibler MD. Chair, ASES Education Committee Editor, ASES Curriculum Guide American Shoulder and Elbow Surgeons 2. Curriculum Guide For Treatment of Shoulder Injury Table of Contents 1. Anatomy and Biomechanics of Rotator Cuff Pathophysiology 2. Diagnosis, Patient Selection, and Clinical Decision Making 3. Management of Impingement 4. Open Rotator Cuff Repair 5. Reparable Rotator Cuff Tears (Mini Open). 6. Arthroscopic Rotator Cuff Repair 7.
4 Management of Irreparable Rotator Cuff Tears 8. Complications of Rotator Cuff Surgery 9. Calcifying Tendinitis 10. Biceps 11. SLAP Lesions 12. Traumatic Muscle Ruptures 13. Anatomy, Biomechanics, and Pathophysiology of Glenohumeral Instability 14. Overhead Throwing Athlete 15. Diagnosis of Instability and Non-operative Treatment 16. Anterior-Inferior Instability: Open 17. Anterior and Anteroinferior Instability: Arthroscopic 18. Posterior Instability 19. Multidirectional Instability 20. Complications of Instability Surgery-References 21. Adhesive Capsulitis 22. Pathophysiology Glenohumeral Arthritis 23. Alternatives to Arthroplasty 24. Prosthetic Arthroplasty for Arthritis with Intact or Repairable Rotator Cuff 25. Cuff Deficiency Arthropathy: Conventional Arthroplasty Techniques 26. Reverse Total Shoulder Arthroplasty 27. Complications of Shoulder Arthroplasty 28. Fractures of the Scapula: Diagnosis and Treatment 29. Fractures of the Proximal Humerus Classification and Diagnosis 30.
5 ORIF 3 and 4 Part Fractures 31. Arthroplasty for Fracture 32. Late Reconstruction Following Fracture 33. Clavicle Fractures 34. Degenerative Disorders of the Acromioclavicular Joint 35. AC Separations 36. Disorders of the Sternoclavicular Joint: Pathophysiology, Diagnosis, and Management 37. Guide to Shoulder Disorders Scapular Disorders 38. Neurological Injuries Around the Shoulder 39. Rehabilitation 40. Techniques of Rehabilitation 41. Outcomes Measurement American Shoulder and Elbow Surgeons 3. Curriculum Guide For Treatment of Shoulder Injury 1. Anatomy and Biomechanics of Rotator Cuff Pathophysiology Brooks, CH; Revel, WJ; Heatley, FW. A quantitative histologic study of the vascularity of the rotator cuff tendon. Journal of Bone and Joint Surgery 74B: 151-153, 1992. This cadaveric study evaluated the blood supply in both supraspinatus and infraspinatus tendons. The tendons were first perfused, then were evaluated in serial histologic slices for blood vessels.
6 The study found there is an area about 15mm from the bony insertion in which there are fewer perfused blood vessels, but this area was as large in the infraspinatus as it was in the supraspinatus. It appears that hypovascularity alone is not an adequate explanation for the etiology of rotator cuff tears. Clark, JM; Harryman, DT. Tendons, ligaments, and capsule of the rotator cuff. Journal of Bone and Joint Surgery 74: 713-725, 1992. This cadaveric study looked at gross and microscopic anatomy of the rotator cuff muscles. This study demonstrated the cuff was composed of 5 distinct layers of tissue and that the tendons splayed out to form a common distal humeral insertion. The coracohumeral ligament was found to be a major part of the rotator interval and biceps sheath, and to reinforce the supraspinatus. Burkhart, SS. Reconciling the paradox of rotator cuff tear versus debridement: A unified biomechanical rationale for the treatment of rotator cuff tears.
7 Arthroscopy 10: 4-19, 1994. This current concepts review introduces many biomechanical principles upon which treatment guidelines may be based. They include the definitions of functional and non- functional rotator cuff tears, the suspension bridge of the rotator cuff, the cable/crescent concept, and coronal and transverse plane force couples. Guidelines for treatment include restoration of the force couples by restoration of the suspension bridge, partial rotator cuff repair in massive tears to restore transverse plane force couples, debridement/repair of unstable rotator cuff edges to reduce pain, and indications for arthroscopic debridement in massive tears. This paper should be one of the foundations for approaching, understabding, and treatment of rotator cuff disease. American Shoulder and Elbow Surgeons 4. Curriculum Guide For Treatment of Shoulder Injury Davidson, PA; Elattrache, NS; Jobe, CW et al. Rotator cuff and posterior superior glenoid labrum injury associated with increased glenohumeral motion: A new site of impingement.
8 Journal of Shoulder and Elbow Surgery 4: 384-390, 1995. This paper reported undersurface impingement and rotator cuff damage related to direct impact between the posterior superior labrum and the supraspinatus. Etiologic factors include anterior capsular laxity, muscle weakness, and increased scapular protraction. Direct impact/compression appeared to be the etiologic mechanism for the rotator cuff injury. Carpenter, JE. Basic science of the rotator cuff. AAOS OKU: Shoulder and Elbow : 19-29, 1997. This review and update highlights the clinically significant anatomy of each of the rotator cuff muscles, and discusses the etiology of cuff tears. It has a detailed discussion of the biomechanics of the rotator cuff. It describes the normal biomechanics of the rotator cuff in generating force and providing motion, and then explores how rotator cuff injury affects normal cuff function and may affect glenohumeral joint motion. If the rotator cable system is intact (supraspinatus small tear or infraspinatus/subscapularis repaired) then forces may be transmitted that allow humeral head depression and reasonable joint motion.
9 Carpenter, JE; Flanagan, CL; Thermopoulos, S et al. The effects of overuse combined with intrinsic or extrinsic alterations in an animal model of rotator cuff tendinosis. American Journal of Sports Medicine 26: 801-809, 1998. This basic science study evaluated different theoretical models of rotator cuff injury. Overuse alone, or overuse plus intrinsic damage or extrinsic compressions were the models. All 3 models demonstrated some histologic changes of injury, but overuse alone did not demonstrate any change in the mechanics of the tissue. Overuse plus other injury appears to lead to the most severe injury. Yamaguchi, K; Tetro, AM; Blam, O. Natural history of asymptomatic rotator cuff tears: A. longitudinal analysis of asymptomatic tears detected sonographically. Journal of Shoulder and Elbow Surgery 10: 199-203, 2001. This study followed patients who were found to have rotator cuff tears but who were not symptomatic. Over 5 years, 51% of those responding reported symptoms of rotator cuff disease, with increased pain and decreased activities of daily living score.
10 Only 50% of the symptomatic patients showed progression of tear size, but no patients, symptomatic or asymptomatic, showed a decrease in tear size. American Shoulder and Elbow Surgeons 5. Curriculum Guide For Treatment of Shoulder Injury Dugas, JR; Campbell, DA; Warren, RF et al. Anatomy and dimensions of rotator cuff insertions. Journal of Shoulder and Elbow Surgery 11: 498-503, 2002. This study evaluated the dimensions of the rotator cuff attachments to the humerus. It showed that the rotator cuff attaches very closely to the articular margin of the cartilage in the supraspinatus and the wisth of insertion is 12-14mm. The area of the insertions of all the tendons is quite large, about 6cm2. All the tendons attach over a broad area, except the lower portion of the subscapularis. Mehta, S; Gimbel, GA; Soslowsky, LJ. Etiologic and pathogenetic factors for rotator cuff tendinopathy. Clinics in Sports Medicine 22: 791-812, 2003. This is an excellent review of the gross and microscopic anatomy, the known etiologic factors, and basic science findings regarding rotator cuff disease.