Orthopedic Shoulder And Review | Dr Hutaif Shoulder & E -...

The patient sustained a complex injury pattern that included a comminuted fracture of the coronoid. This must be identified and distinguished from a simpler olecranon fracture at the time of the initial repair. Loss of the coronoid buttress can lead to residual elbow instability if not addressed. In this situation, the bony stabilization has failed, and an attempt should be made to revise it, with particular attention to stabilizing the coronoid. As in all complex elbow injuries, the status of the collateral ligaments should be assessed, and repaired/reconstructed as needed.
A spanning external fixator can be considered as a secondary option when adequate fixation and stability cannot be achieved, but that would not address the articular incongruity currently present. Total elbow arthroplasty is not indicated due to the patient's age and injury pattern, and physical therapy is unlikely to be successful without a congruently reduced joint.
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HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non- engaging or off-track Hill-Sachs lesion may be treated with an anterior soft- tissue (Bankart) repair. An on-track or engaging Hill-Sachs lesion may be treated by addressing any bony glenoid injury or anterior labral tear plus Hill- Sachs remplissage. An ALPSA lesion may be treated with a soft-tissue procedure, unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher risk of recurrent instability and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be considered in higher risk patients, such as collision athletes.

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and <3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range of motion is important to avoid stiffness.
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Acceptable angulation of humeral shaft fractures for nonoperative treatment is quite generous due to compensatory motion at the shoulder joint. Traditionally, 20° of anterior-posterior and 30° of varus-valgus angulation is acceptable. Indications for surgery have included angulation outside of this range, open fractures, brachial plexus injury, polytrauma, or other factors that preclude functional bracing. Increased amounts of angulation at the conclusion of healing can result in cosmetic dissatisfaction, but this has not been correlated with any specific degree of angulation, as patient factors are a strong influencer. Increased angulation has not been shown to affect functional outcomes within the angulation range previously described.

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The patient's radiographs show scapular notching, which is a common complication of reverse shoulder arthroplasty caused by repeated contact between the humeral component and/or medial humerus and the inferior pillar of the scapular neck. Despite this radiographic finding, the patient is doing well clinically and is completely asymptomatic. Therefore, continued observation is appropriate.
Notching can result in creation of particulate debris, causing osteolysis and ultimate implant failure. Therefore, this patient should be monitored with serial radiographs. The overall incidence of notching has been reported to be between 51% and 96%. This nearly ubiquitous finding has been attributed to implant positioning, altered glenoid and humeral anatomy, and duration of implantation. Recent studies have identified that increased lateral offset, increased glenosphere size, and inferior positioning of the base plate can reduce the incidence of scapular notching.

The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of the implant. In most studies that distinguish glenoid from humeral loosening, the glenoid component is more frequently affected. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise nearly 30% to 40% of all complications following shoulder arthroplasty for non-inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus 7% for infection and 7% for rotator cuff tearing.
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The MRI scan shows injuries to both the medial and lateral ligamentous structures of the elbow, with significant widening of the radiocapitellar joint space. The patient’s ongoing symptoms are consistent with posterolateral rotatory instability related to lateral collateral ligament insufficiency. After surgical repair versus reconstruction of the
lateral collateral ligament, it is important to avoid varus stress to the elbow, which can result in failure or loosening of the lateral structures. During shoulder abduction, gravity applies a varus stress to the elbow, and it should be avoided.
Limiting range of motion for the first 6 weeks would result in significant elbow stiffness. Valgus stress should be avoided in the setting of a medial collateral ligament repair or reconstruction. Strengthening is usually delayed until appropriate soft-tissue healing has been achieved.

The image shows scapular notching. Inferior scapular notching is caused by direct mechanical impingement of the humeral bone or humeral prosthesis on the inferior scapular neck. Particulate polyethylene debris may aggravate inferior notching and lead to osteolysis. Impingement-free range of motion (ROM) in all planes is
imperative. Gutiérrez and associates analyzed the factors that affect impingement of the humerus or humeral component against the scapula and the resultant effect on ROM. Varus humeral neck-shaft angle was found to be the most important factor in preventing notching, followed by inferior positioning of the glenosphere, lateral offset of the glenosphere, and increasing size of the glenosphere. Humeral stem length and cementation have not been shown to have an impact on notching.

Surgical indications for scapular fractures are debatable in the literature. Historical indications for extra-articular fractures of the glenoid neck have ranged from 10-25 mm of medial displacement, 25-40⁰ of angular deformity of the glenoid, and a glenopolar angle cut-off of 20-30⁰. While the Judet approach can offer access to the entire scapular body, a modified Judet approach is a more limited approach that allows access to the glenoid neck in the interval
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between the infraspinatus and teres minor. The infraspinatus is innervated by the suprascapular nerve, whereas the teres minor is innervated by the axillary nerve. The long thoracic nerve innervates the serratus anterior muscle. The spinal accessory nerve innervates the sternocleidomastoid and trapezius muscles.

Patients with primary elbow osteoarthritis tend to be active and are often involved in manual occupations that place greater demands on a total elbow implant. Such patients are most often treated with nonprosthetic options because of concerns about prosthetic longevity. As a result, few cases of primary osteoarthritis are included in published studies. However, complications such as stem fracture and aseptic loosening appear to be more common in this population than in any other subgroup, including revision patients. The poor soft-tissue quality associated with rheumatoid arthritis leads to a high-risk ligamentous attenuation and is a general contraindication to use of an unlinked implant. The same poor soft tissue leads to a higher rate of triceps insufficiency and wound dehiscence.

The patient had a failed attempt at primary repair of her proximal humerus fracture with subsequent malunion. Because of the position of her greater tuberosity and concern about the status of her rotator cuff on examination, a reverse shoulder prosthesis is the most reliable option to maximize her shoulder function. Given the length of time since her index procedure, additional physical therapy is unlikely to provide significant benefit. A hemiarthroplasty or revision ORIF would have a lower likelihood of success due to the position of the greater tuberosity and presumed rotator cuff compromise.

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The most distal locking screw in this intramedullary nail construct was placed from anterior to posterior, passing through the distal portion of the biceps and brachialis muscle bellies. The median nerve, along with the brachial artery, is at risk as it lies between these 2 muscles. Malrotation of the nail, producing a more anteromedial starting point for the screw, can lead to a path that intersects with the nerve. Blunt dissection and soft-tissue protection is warranted with this screw placement. Median nerve injury would affect innervations of the flexor digitorum superficialis and profundus to the index finger (among other motors). Although the dissection violates the muscle belly of these 2 elbow flexors, measurable weakness is not typically seen. The radial nerve has already provided function to triceps (elbow extension) proximal to this level and lies sufficiently lateral to be more of a concern with a lateral screw placement (thumb IP extension). The ulnar nerve (index MCP abduction) is further medial at this level and would be at considerably lower risk than the median.

The patient has evidence of osteoarthritis with eccentric glenoid wear. Hemiarthroplasty outcomes are worse in patients with eccentric glenoid wear, as compared to those with a concentric joint. Additionally, hemiarthroplasty has been shown to have inferior functional outcomes compared to total shoulder arthroplasty, with low long-term satisfaction rates. Revision rates are equal to or greater than total shoulder arthroplasty at mid to long term follow-up, and glenoid erosion remains a problem.

Both arthroscopic and open management of elbow arthritis can be successful. Prior ulnar nerve transposition is a relative contraindication to arthroscopy, unless the nerve is specifically identified and protected intra- operatively. In general, arthroscopic management is indicated for mild to moderate arthritis. In advanced arthritis, there is decreased visualization and an increased risk for neurovascular insult. In contrast, open surgery can be utilized regardless of arthritis severity. Arthroscopy has the advantage of allowing easy access to both the anterior and posterior compartments of the elbow. Cohen and associates has shown better recovery of motion with open osteocapsular arthroplasty (Outerbridge-Kashiwagi procedure) compared with the same technique performed arthroscopically.
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The patient is showing signs of posterolateral rotatory instability after elbow dislocation. The lateral ulnar collateral ligament is responsible for stabilizing the elbow against this type of instability. The posterior and anterior bands of the medial collateral ligament are primarily resistors of valgus load, with the anterior band being the most significant contributor. The radial collateral ligament does not control the posterolateral rotatory instability described.

The patient has medial epicondylitis. Nonsurgical treatment is the hallmark of treatment and has been shown to relieve pain in approximately 90% of cases within one year. Nonsurgical modalities include bracing, physical therapy, nonsteroidal anti-inflammatory medications, activity modification, and injections.
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TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at intermediate-term follow-up.

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Several investigations continue to elucidate the difference between dual row and single row repairs. Modern dual row repairs involve fixating the rotator cuff tendon along both the medial and lateral aspect of the greater tuberosity as well as linking both points of fixation together. This allows closer restoration of native footprint coverage in comparison with single row repairs. However, doubling the number of implants results in increased healthcare costs without a clear clinical or biomechanical benefit. Several studies report statistically similar outcomes, retear rates, and biomechanical properties between single and dual row repair when the number of suture limbs across the repair site is the same.

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This is a young, high-demand patient with early posttraumatic arthritis of the elbow. A debridement and capsular release has the ability to address his mechanical symptoms, improve his range of motion, and not result in any post- operative functional restrictions. While this may be a temporizing procedure in this patient, it will allow him to return to weight bearing recreational activities in the near term, which is his goal. A TEA would not be indicated based on the patient's age, his degree of arthritis, and his desire to remain active post- operatively. A radial head replacement would not address the patient's ulnohumeral arthritis. Similarly, an ulnohumeral distraction interposition arthroplasty would not address the patient's radiocapitellar arthritis. Both procedures would also require adjustments to his recreational activities post- operatively to prevent progressive failure of the reconstruction.

Risk factors for instability after a reverse total shoulder arthroplasty include previous surgery (especially open surgery), loss of humeral tuberosities, inadequate restoration of humeral length,
male sex, BMI >30, and Grammont-style implant. Fixation method for the humeral stem has no impact on instability risk.
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Radial head fractures are thought to occur as a result of valgus posterolateral rotary load across the elbow, although the mechanism can certainly vary. Minimally or nondisplaced fractures without any clinical instability or block to motion can often be successfully managed non-surgically. Fractures with >2 mm of displacement or fragments that block motion require surgical repair. A critical aspect during surgery is identifying concomitant injury to the lateral collateral ligament complex (LCL). When encountered, the LCL is most often avulsed from its origin at the lateral epicondyle, resulting in a bare area. After the radial head is either repaired or replaced (Figures 4 and 5), the LCL should
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be repaired back to its anatomic origin. Postoperatively, the surgeon must communicate to the therapist that elbow extension exercises should be performed with the forearm in pronation as a result of the compromised LCL, as this position places the least stress on the ligamentous repair. Elbow extension exercises in supination or neutral are recommended for compromise of the medial collateral ligament, or combined medial and lateral ligament injury, respectively. Without any medial elbow bruising, swelling, or tenderness, it is unlikely that the patient has an injury to the medial collateral ligament.

The patient underwent a reverse arthroplasty for cuff tear arthropathy. Her preoperative radiograph shows some superior glenoid wear, which was not corrected at the time of surgery. This has resulted in superior tilt to the glenosphere, which has been identified as a risk factor for scapular notching. This occurs as a result of mechanical impingement between the medial humerus and scapular neck during arm adduction. The Beta angle and reverse shoulder angle have been proposed as measurements that can help identify pathologic glenoid tilt preoperatively. Risk factors for scapular notching include superior tilt of the glenosphere, superior placement of the glenoid baseplate on the glenoid, a 155° humeral implant angle, and incomplete lateralization of the construct.
The humeral component appears well-positioned in this radiograph. Over tensioning of the deltoid and excessive humeral lateralization would risk an acromial stress fracture and could limit shoulder range of motion. This is an inlay humeral stem, which does not lateralize the humerus.

In the MRI scans, the patient has a high-grade tear of the undersurface of the superior rotator cuff. This is known as a partial articular-sided tendon avulsion lesion. This is often seen in overhead athletes and is associated with internal impingement. Given the length of symptoms, failure to respond to nonsurgical treatment, and the high-grade nature of the tear in a young patient, an arthroscopic repair should be performed. The available images do not demonstrate evidence of SLAP tear, Bankart lesion, or suprascapular nerve compression.

"Ream and run" shoulder arthroplasty can allow for arthroplasty without the complications of a polyethylene glenoid. Ten-year conversion to total shoulder arthroplasty has been shown in one study to be 12%. Recovery is reported to be slower and requires more rehabilitation than arthroplasty done with glenoid resurfacing. Careful patient selection has been emphasized by the pioneering surgeon.

This is a classic presentation of an acute traumatic distal biceps tendon rupture. In the dominant extremity of a manual laborer, this injury can result in approximately 40% loss of supination strength. Although not required, an MRI scan can confirm
the diagnosis. In general, a single incision anterior or two incision anterior/ posterior repair can be utilized for surgical intervention with similar success rates. Although the percentage of complications is similar between surgical approaches, the type of complications can vary. Anterior only repairs have a
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higher risk of traction injury to the lateral antebrachial cutaneous nerve (LABC) secondary to the degree of retraction required for exposure in muscular patients. Posterior repairs have a higher risk for radiographic heterotopic bone formation. Fortunately, most LABC injuries are neuropraxias and resolve with observation, but resolution may take up to 6 months. In this case, ongoing observation is appropriate, with surgical exploration being considered only in chronic cases. Patients should be appropriately counseled about this issue prior to surgery.

The medial antebrachial cutaneous and medial brachial cutaneous are nerves that can be injured during ulnar nerve decompression at the elbow. The medial antebrachial cutaneous nerve crosses the surgical field at an average of 3.1 cm distal to the medial epicondyle. The medial brachial cutaneous nerve crosses the field 7 cm proximal to the medial epicondyle and arborizes into two to three terminal branches. Because the surgical approach involves dissection on the medial side, the posterior antebrachial cutaneous nerve is distant from the exposure. Although the median nerve potentially can be located in the deep dissection of a submuscular transposition, it is considered distant to an in situ decompression.

There have been many prospective and retrospective studies evaluating outcomes after surgical and nonsurgical treatment of displaced middle third clavicle fractures. Surgery results in a lower nonunion rate and higher patient reported outcomes. However, approximately 30% of these patients will have symptoms of hardware irritation and request subsequent plate removal. Nonunion is very low with plate fixation and is more common with nonsurgical treatment. AC joint instability is unlikely to be an issue with middle third clavicle fractures, and there is no evidence of AC malalignment on the images provided. Deltoid origin stripping is necessary for anterior plating, but is much less of an issue with superior plating, as was performed in this patient. Anterior plating is biomechanically inferior to superior plating but may pose a lower risk to neurovascular structures and has the theoretic opportunity to decrease implant irritation, although this has not been clearly demonstrated in the literature.

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The radiograph reveals a Charcot neuropathic shoulder. The atraumatic destruction of the humeral head is concerning for a neuropathic etiology and warrants MR imaging of the cervical spine to evaluate for the presence of a syrinx. Shoulder arthroplasty in the setting of a neuropathic joint is challenging given the local bone and soft-tissue loss, in addition to the loss of protective sensation. The scant literature on the use of shoulder arthroplasty in these challenging patients reports an improvement in pain but only modest improvements in shoulder function.

The patient presents with a coronoid fracture involving the anteromedial facet. This poses a risk for varus posteromedial rotary instability of the elbow. Appropriate treatment involves coronoid ORIF (this fracture involves the sublime tubercle, so fixing the coronoid will repair the medial collateral ligament) and a repair of the lateral ligament complex. Coronoid reconstruction is not needed with graft because the fracture fragment can be repaired. However, in chronic cases, the coronoid can be reconstructed with autograft
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olecranon, autograft radial head, or allograft. There is no injury to the radial head, so arthroplasty is not required. Failing to address the lateral ligaments will lead to continued instability.

The history and examination are consistent with recurrent anterior shoulder instability. The patient has significant anteroinferior glenoid bone loss, no identifiable Bankart tear, and a non-engaging Hill Sachs. The glenoid bone deficiency is the most notable contributor to his recurrent instability, and a Latarjet coracoid transfer to the anterior glenoid would most likely provide long-term stability to his shoulder. A remplissage with tenodesis of the infraspinatus into the Hill-Sachs lesion can be helpful if the symptoms are related to engagement of the Hill-Sachs lesion. An open capsular shift and Bankart would not address the bony deficiency. There is no role for PRP in this clinical setting.
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Complications encountered following reverse total shoulder arthroplasty include dislocation, infection, hardware failure, hematoma, neurologic injury, periprosthetic fracture, scapular notching, and acromial/scapular spine fractures. The incidence and risks of these complications are related to the indication for the procedure. Dislocation is the most common complication, with an incidence of 1.5% to 31%. Risk factors associated with postoperative dislocation include male sex, previous shoulder surgery, proximal humeral bone loss, axillary nerve injury, and subscapularis deficiency. Commonly used methods to prevent instability include lateralization of the glenosphere and/or baseplate, eccentric baseplate placement, humeral lateralization or distalization, use of large glenosphere, and increased socket constraint.

TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower reoperation rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population.
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PLRI of the elbow is the most common form of chronic elbow instability. The mechanism occurs following a fall onto an outstretched hand, where a valgus force is applied to the elbow and the forearm rotates into progressive supination. This allows the radial head to translate posterior to the capitellum, with progressive injury from lateral to medial sides of the elbow. The pivot shift test is a useful examination maneuver to confirm the presence of PLRI. With the forearm in maximal supination and valgus stress applied to the elbow, the radial head is forced posterior to the capitellum as the elbow is brought into progressive extension, revealing a dimple on the lateral aspect of the elbow. This typically occurs at roughly 30° of flexion. As the elbow is flexed, the radial head reduces.

Rheumatoid arthritis remains a common inflammatory arthropathy that can lead to progressive synovitis of the elbow joint. Patients often present with recalcitrant elbow pain and loss of motion. In the early
stages, the joint space can be fairly well preserved. With progressive synovitis, cartilage destruction leads to symmetric joint space narrowing and joint destruction. For the younger patient with recalcitrant synovitis and a relatively well-preserved joint space, open or arthroscopic synovectomy provides successful improvement for 70% to 80% of patients. In most cases, radial head resection is not required. Synovitis that encircles the radial head and neck can lead to pain and crepitus with forearm rotation. Preserving the radial head prevents the rapid progression of wear at the ulnohumeral joint. A total elbow replacement, while a successful treatment modality for the older, lower demand patient with rheumatoid arthritis, would not be ideal for the younger patient given the significant postoperative restrictions imparted.

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This patient has multidirectional instability as evidenced by her hyperlaxity and excessive range of motion. Patients with pain after activities often have weak rotator cuff musculature and improve with strengthening of the rotator cuff and proprioceptive retraining. Subacromial injection likely cannot help this patient because it will not treat her underlying motor weakness in the rotator cuff or her dyskinesia. MRI arthrogram is not indicated unless she fails nonsurgical treatment. Arthroscopic stabilization also would be reserved for patients who fail nonsurgical treatment.

The axillary nerve originates from the posterior cord of the brachial plexus. It passes down the anteroinferior aspect of the subscapularis, courses posteriorly beneath the glenoid and inferior capsule, then wraps around the humerus from posterior to anterior on the deep surface of the deltoid. In the setting of glenoid and humeral head deformity, the inferior border of the subscapularis can be a useful landmark to ensure the nerve is appropriately protected intraoperatively.

The patient has developed recurrent shoulder instability following a previous Latarjet. Radiographs and CT scans demonstrate resorption of the coracoid graft and failure of hardware. At this point, in a contact athlete with failed hardware and recurrent instability, the most appropriate surgical intervention would be an open procedure with hardware removal and revision bone grafting of the anterior glenoid with iliac crest autograft or distal tibial allograft.
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Arthroscopic debridement with anteroinferior labral repair and capsular shift and open implant removal and repair of damaged soft-tissue structures are incorrect because an isolated soft-tissue procedure would place the patient at high risk for recurrence. A Putti Platt reconstruction is a nonanatomic reconstruction that has been correlated with progressive glenohumeral arthrosis.

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The patient’s clinical presentation is consistent with inflammatory arthritis. The MRI shows a large effusion with synovitis, particularly around the radial neck. There is bone edema in the proximal ulna, but no evidence of joint destruction, and radiographs reveals maintained joint space. These findings support the diagnosis of early-stage inflammatory arthritis. Because there is no joint destruction, surgical treatment would emphasize preservation of the native elbow joint. Arthroscopic synovectomy has been shown to be very effective in these cases. Referral to a rheumatologist for further workup is also recommended. The other options listed would be considered in the setting of more advanced joint degeneration.

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The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor.
Correcr

End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on
38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.
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Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.

The patient's radiographs demonstrate bone loss of the medial humeral head. He has risk factors for both septic arthritis/osteomyelitis, and metastatic cancer, and it is important to understand the extent of his pathology before moving forward with surgical intervention. An MRI scan would assist in the diagnosis and demonstrate the extent of disease/tissue involvement. Administration of IV antibiotics prior to obtaining appropriate cultures would decrease the success rate of treatment in the setting of infection, and mistreat the pathology in the setting of metastasis. Similarly, obtaining cultures from the draining sinus tract would fail to account for the possible tumor diagnosis and may result in inaccurate culture results.

The rotator cuff serves as a humeral head compressor that stabilizes the humeral head in the glenoid concavity, so that the deltoid can convert a vertical force into abduction and forward elevation. The deltoid functions normally in patients with chronic rotator cuff arthropathy, so no atony is present. Glenoid concavity can be lost over time as joint degeneration progresses, but this is not the primary mechanism for failure of elevation. The biceps tendon does not serve as a humeral head compressor and does not prevent proximal migration of the shoulder when it is present.

RSA has been shown to result in better clinical outcomes with a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients. If an RSA is necessary in a delayed fashion to salvage failed nonoperative management, a systematic review and meta-analysis have shown no significant difference in outcomes between acute versus delayed RSA in this patient population.
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This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.
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The patient has cuff tear arthropathy associated with significant pain and poor function. At age 68, a reverse total shoulder arthroplasty is the most reliable option to address her complaints. Arthroscopic debridement with superior capsular reconstruction would be a consideration in a younger patient with an irreparable posterosuperior rotator cuff tear, little to no glenohumeral arthritis, and little to no humeral head elevation. Total shoulder arthroplasty would have a high rate of glenoid component failure and limited function, regardless of the type of glenoid component utilized. Clinical outcomes of reverse total shoulder arthroplasty are superior to hemiarthroplasty in the setting of cuff tear arthropathy.
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Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

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Humeral shaft fractures can be associated with palsy of the radial nerve, which will result in deficits of wrist and finger extension. Most will resolve with observation, consistent with a neuropraxia. Radial nerve palsy is not a contraindication to functional bracing. Distal interphalangeal (IP) joint flexion of the index finger is from the flexor digitorum profundus of the index finger, supplied by the median nerve. Froment's sign results from weakness of the adductor pollicis, which is innervated by the ulnar nerve. In this maneuver, patients compensate with flexion of the IP joint of the thumb (flexor pollicis longus, innervated by the median nerve) when asked to pinch a piece of paper between their thumb and index finger. Vascular injuries are uncommon with isolated humeral shaft fractures.

The MR arthrogram shows a rupture of the ulnar collateral ligament (UCL) from the ulnar insertion, with the classic T-sign of contrast extravasation. Medial UCL reconstruction, using either ipsilateral palmaris longus or allograft tendon, is
indicated for UCL injuries that fail nonsurgical management. Primary repair has been shown to be successful in select cases, but appropriate patient selection is essential. An arthroscopic elbow debridement would be indicated for early elbow arthritis or intra-articular loose body, which is not demonstrated here. An ulnar nerve decompression would be indicated in the setting of cubital tunnel syndrome, but this patient has no complaints of paresthesias.
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During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on the radial tuberosity.
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This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation.
Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.
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Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.

The patient's radiographs demonstrate humeral head elevation and anterior translation, suggesting a massive traumatic rotator cuff tear. In this setting, a rotator cuff repair is unlikely to be successful, and a revision to reverse total shoulder arthroplasty is indicated. A latissimus dorsi transfer can address only a portion of the patient's rotator cuff deficiency. Physical therapy may result in some degree of improvement, but this cannot address the joint instability and malalignment. If the shoulder remains in its current position, progressive glenoid loosening would be expected due to the “rocking horse” phenomenon resulting in eccentric glenoid edge loading. Shields and Wiater compared conversion of an anatomic total shoulder to a reverse total shoulder for rotator cuff deficiency with primary reverse total shoulder arthroplasty and found similar American Shoulder and Elbow Surgeons Standardized Shoulder Assessment and visual analog scale pain scores at 2-year follow-up.

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The patient has a clinical history and physical examination consistent with UCL pathology. In an overhead athlete, deficits in the kinetic chain can contribute to the development of medial elbow pathology due to increased force transmission across the elbow. As a result, it is important to examine the shoulder to ensure that total arc of motion remains equivalent to the contralateral arm. Decreases in total arc of motion, commonly associated with glenohumeral internal rotation deficits (GIRD), can predispose athletes to medial elbow injuries. These shoulder deficits can be addressed with physical therapy. The MRI scan shows a structurally intact UCL, therefore, UCL repair or reconstruction is not indicated. The MRI scans demonstrate no evidence of osteochondral injury, which would be an indication for arthroscopic debridement and microfracture.

This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. It may be necessary to splint the elbow in pronation if the medial collateral ligament (MCL) is intact and the lateral collateral ligament (LCL) is disrupted, or in supination if the LCL is intact but the MCL disrupted. Surgical repair of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If the elbow remains unstable after repair, then application of a hinged external fixator may be considered.
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The patient has a clinical history and physical examination consistent with degenerative superior labral pathology, which is supported by the MRI scan. She has failed appropriate nonoperative treatment, and surgical intervention would be indicated. In a middle-aged patient with a degenerative superior labral tear, biceps tenodesis has been shown to have better outcomes and return to sport than SLAP repair. In a young patient with a traumatic superior labral tear, repair would be indicated. The other MRI findings noted are incidental and asymptomatic in this patient. As a result, rotator cuff repair or distal clavicle excision is not indicated.

The anatomic structure labeled is the biceps tendon, which has subluxated medially from the intertubercular groove as a result of disruption of the biceps pulley that occurs with subscapularis tears. The anterior labrum is adjacent to the glenoid and is not normally torn with subscapularis pathology. The middle glenohumeral ligament may appear cord-like, but is shown more medial to the subluxated biceps tendon. The rotator interval tissue, or "comma" tissue, is generally along the upper border of the subscapularis and is pulled toward the coracoid base in subscapularis tears.

The superior shoulder suspensory complex (SSSC) is a bone and soft-tissue ring secured to the trunk by superior and inferior bony struts, from which the upper extremity is suspended. The ring is composed of the glenoid process, coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular joint, and acromial process. Double lesions of the SSSC are referred to as “floating shoulder” injuries, as in this case in which the injury involves a fractured scapular neck and ipsilateral clavicle fracture. Ipsilateral acromioclavicular dislocation and coracoid fracture is a less common double disruption of the SSSC. Although several case studies have been published on surgical and nonsurgical management of these injuries, no study provides measurable surgical indications beyond the simple presence of the double lesion. This is often referred to as an unstable shoulder girdle.
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The patient has valgus extension overload. This is a spectrum of pathologies, often seen in pitchers, that begins with posteromedial impingement between the medial olecranon and posterior trochlea during forceful elbow extension. As a result, a medial olecranon osteophyte is typically the first notable imaging finding. As pathology increases, there can be progressive damage to the medial collateral ligament (MCL), degeneration of the radiocapitellar articulation, and neuritis of the ulnar nerve. VPMRI is often associated with a large anteromedial coronoid fracture and posterior band MCL rupture. VPLRI occurs when the lateral collateral ligament complex is ruptured. Olecranon bursitis presents with focal swelling or a fluid collection over the posterior aspect of the olecranon.

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The anterior approach to the mid-humerus courses along the lateral margin of the biceps brachii. This muscle is swept medially allowing exposure of the brachialis. The brachialis has a dual innervation, with the lateral fibers innervated by the radial nerve and the medial fibers innervated by the musculocutaneous nerve. The humerus is exposed by splitting this muscle in its midline. The lateral head of the triceps resides in the posterior compartment of the arm and is not involved in the anterior approach to the humerus. The interval between brachialis and coracobrachialis is not an internervous plane, as both muscles are supplied by the musculocutaneous nerve.

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This is a young patient who has sustained an elbow dislocation with a radial neck and coronoid fracture to her dominant extremity. Her current radiographs reveal a considerably displaced radial head fragment, along with a small coronoid fracture, and potentially some residual ulnohumeral joint incongruity. A repeat closed reduction is unlikely to be successful, as the radial head is significantly displaced and can block a congruent reduction. Open reduction is required to successfully address this complex injury pattern. Although removal of the radial head can be considered, fixing or replacing the radial head with repair of the lateral collateral ligament is often recommended in the setting of acute trauma to restore adequate stability to the elbow, decrease long-term risk for progressive ulnohumeral arthrosis, and limit sequelae in the setting of an unappreciated longitudinal forearm axis injury.

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The radiographs provided show lysis of the greater tuberosity and a high-riding humeral head, indicating failure of the rotator cuff. Both anatomic shoulder arthroplasty and revision hemiarthroplasty would suffer from the same functional limitations and risk of instability as the current construct, due to the lack of a functional rotator cuff. Resection arthroplasty is usually reserved for situations of recurrent infection or lack of enough structural bone to allow prosthetic placement. Revision to a reverse total shoulder arthroplasty can bypass the cuff deficiency and treat any component of glenohumeral degeneration and is the best option to reduce pain and improve function in this setting.

Several studies have demonstrated that degenerative symptomatic rotator cuff tears enlarge over time, which raises some concern regarding treating these injuries nonsurgically. The rate of rotator cuff tear enlargement at 2 years ranges from 20% to 49%, and at 5 years is estimated to be 50%. The risks associated with rotator cuff tear progression includes worsening fatty atrophy and fatty infiltration, decreased tendon pliability, and increased tendon retraction, which can lead to worse clinical outcomes following surgery.

Fundamental to understanding the pathogenesis of rotator cuff tears is an appreciation of the likely initiation site of the disease process. Although authors initially postulated that rotator cuff tears originated in the anterior margin of the supraspinatus tendon near the biceps tendon, recent research has challenged this notion. Kim and associates analyzed 360 full-thickness or partial-thickness rotator cuff tears using ultrasonograms. They separated stratified tears based on their anteroposterior size and whether they were partial- or full-thickness tears. The mean width and length of tear size was 16.3 mm and 17 mm, respectively. Histograms showed that the most common tear location for all tears regardless of size was approximately 15 mm posterior to the biceps tendon. This corresponds to the center of the rotator crescent initially described by Burkhart and associates. This location is described as being more susceptible to degeneration secondary to its diminished vascular supply and mechanical properties. The rotator cable is an arch-shaped thick bundle of fibers that is thought to shield the crescent from stress.

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The patient has an os acromiale. The type shown is of the meso-acromion. This is not an acute fracture; well corticated ends are seen on the axillary radiograph, and there is no bone edema on the T2 axial MRI scan. A trial of nonsurgical care that includes rest, ice, and anti-inflammatory medications is recommended. If a patient continues to have symptoms, an arthroscopic evaluation is needed to determine if the os acromiale is mobile and if surgical fixation is appropriate.

Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which will normally correct the medial instability. Articulated versus static external fixation can be considered if the joint remains unstable despite repair/reconstruction of the damaged stabilizing structures.
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The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened, and there is marked fracture displacement. This signifies disruption to the coracoclavicular ligaments. The inferior glenohumeral ligament is important to glenohumeral joint stability, but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects two parts of the scapula (coracoid and acromion) and is part of the arch that supports the rotator cuff.

C acnes is the most common organism recovered in prosthetic shoulder infections (33%), Coagulase-negative Staphylococcus is second (21%), Methicillin-sensitive S aureus (13%), and S epidermidis (10%). MRSA accounts for 5% and Enterococcus species, 1.5%.
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Historically, orthopaedic surgeons considered early range-of-motion programs following rotator cuff surgery secondary to concerns about potential postsurgical stiffness. Although this may have been a concern with primary open repair, arthroscopic surgery appears to substantially decrease this risk. More recently, investigators are reporting similar results in terms of range of motion, retear rate, and functional outcome scores among patients who undergo early versus delayed rehabilitation programs.

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Glenoid exposure, while better than with surface replacements, is not improved over traditional stemmed replacements. Metaphyseal comminution would make it unlikely that a stemless implant could be used in most four-part fractures. Stemless replacement does have the unique advantage of allowing placement of a prosthesis in the setting of a proximal humerus malunion without the need for an osteotomy, as the prosthesis is not constrained by the position of the stem. While early results are encouraging, there is no long-term data to suggest that survivorship is increased with stemless arthroplasty.

The MRI scan shows evidence of a medial collateral ligament (MCL) tear. In a patient with a chronic MCL injury that has failed non-operative treatment, MCL reconstruction would be indicated. Initial MCL reconstruction technique involved routine transposition of the ulnar nerve and detachment of the flexor- pronator mass. Subsequent.
technique modifications have been made to minimize complications by avoiding routine ulnar nerve transposition and performing a muscle-splitting approach. Despite these improvements, transient ulnar nerve neuropraxia remains the most common complication, and patients should be counseled about its occurrence pre-operatively. Flexor pronator mass avulsion is more likely with a muscle-detaching approach, but is not more common than ulnar nerve neuropraxia. Posterolateral rotatory instability is a complication of lateral collateral ligament repair or reconstruction, not medial collateral ligament reconstruction. Symptomatic hardware is not a common complication from this procedure
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The patient has sustained a displaced lesser tuberosity fracture with medial displacement following a posterior shoulder dislocation. Nonoperative management would risk long-term loss of normal subscapularis function, as well as anterior shoulder instability. An ORIF of lesser tuberosity is recommended. The current radiographs do not demonstrate any obvious compromise of glenoid bone stock that would necessitate a coracoid transfer. The humeral head is not compromised; therefore, a hemiarthroplasty is not indicated.
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The patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

In patients with primary osteo- arthritis of the shoulder, eccent- ric wear on the face of the glenoid is frequently combined with static subluxation of the humeral head. Current studies have clarified that patients with Walch B2 glenoid develop wear along the posterior inferior face of the glenoid and not directly posterior. At the time of shoulder arthroplasty, the eccentric center of rotation must be corrected by soft-tissue, bony, and/or implant
techniques to minimize the risk for poor outcomes. The surgeon should orient
his correction along the posterior inferior to anterior superior plane.

Distal third humeral shaft fractures are associated with the highest incidence of radial nerve palsy at 23.6% The classic example is a Holstein Lewis fracture, which is a spiral fracture of the mid-third / distal-third junction. Open fractures are not associated with a higher incidence of radial nerve palsy than closed fractures. Comminution has not been associated with an increase in radial nerve palsy. In fact, transverse and spiral fractures are associated with a higher incidence of radial nerve palsy than comminuted fractures. Proximal humerus fractures have an incidence of only 1.8%.
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The radiograph shows a well-positioned reverse total shoulder and the axial CT image demonstrates a minimally displaced fracture through the midacromion. Acromial fracture is a concerning and not uncommon complication that can have devastating effects after reverse shoulder arthroplasty, as function is highly dependent on the deltoid muscle. Fractures can occur at the scapular spine, which may be related to placement of peripheral baseplate screws. Acromial fracture has been reported to occur as early as 1 month postoperatively and as late as 8 years postoperatively. The reported incidence is <8%, and multiple authors note decreases in shoulder elevation and shoulder outcome scores compared with those in patients with reverse shoulder arthroplasty without a fracture. Patients with a fracture can complain of superior shoulder pain that may radiate to the deltoid area and usually report an acute onset of pain or loss of function after initially good clinical progress. The diagnosis can be difficult to determine and is missed on plain radiographs in up to 20% of cases. CT scans are helpful. Treatment is typically nonoperative with sling immobilization for 6 weeks and then
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advancing activities as tolerated. A bone stimulator and ORIF would not be indicated initially, but could be used if healing does not progress as expected. Continued physical therapy with strengthening would be contraindicated until fracture union is achieved.

When compared to initial treatment with reverse total shoulder arthroplasty, patients who initially undergo ORIF with subsequent revision to reverse total shoulder arthroplasty demonstrate a higher complication rate, increased rate of revision surgery, increased risk of instability, and similar functional outcomes.

The patient appears to be experiencing a recurrent gout flare. The best way to confirm the diagnosis is to aspirate the joint and send it for culture, cell count, and crystal examination. This will identify the diagnosis of infection, gout, or pseudogout. An MRI scan will confirm the presence of an effusion, but it will not reveal the cause. A splint may result in pain improvement, but it will not contribute to a diagnosis or definitive treatment. Sedimentation rate and
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C-reactive protein levels can be elevated in either inflammatory or infectious processes, but these are non-specific and cannot differentiate between the two.

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The patient's radiographs and CT scan show advanced glenohumeral osteoarthritis with posterior humeral head subluxation and mild posterior glenoid erosion (Walch type B2 glenoid). The preferred type of shoulder arthroplasty in this setting remains controversial, as there are data to support both anatomic and reverse total shoulder arthroplasty. There is no significant atrophy of the rotator cuff musculature on sagittal CT to suggest a rotator cuff tear, and a rotator cuff repair is likely contraindicated by the degree of underlying arthritis. A glenohumeral joint debridement would be expected to provide only partial/short-term pain improvement, and is unlikely to be a long- term solution. A shoulder hemiarthroplasty has been shown to result in worse pain relief and functional outcomes than total shoulder arthroplasty in this setting.

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Internal impingement is a condition that affects overhead throwing athletes, as the greater tuberosity and articular surface of the rotator cuff contact the posterosuperior glenoid during maximal shoulder abduction and external rotation. The etiology is typically multifactorial, but common contributors include posterior capsular contracture, scapular dyskinesia, and subtle anterior shoulder laxity. Nonoperative management, the mainstay of treatment, includes rest, stretching, scapular strengthening, and proprioception. Results of surgical intervention are variable; therefore, nonoperative measures should be exhausted first. While PRP is currently being investigated as a biologic augmentation in a number of shoulder pathologies, it is not considered first- line treatment.

The patient's history and physical exam are consistent with adhesive capsulitis, or frozen shoulder. Adhesive capsulitis is most commonly an idiopathic process that results in joint pain and loss of motion from capsular contracture. It is reported to affect approximately 2% to 5% of the general population, typically affecting middle-age women. Secondary causes include previous trauma, as well as associated medical conditions such as diabetes, stroke, and cardiac and thyroid disease. Debate remains as to whether a genetic predisposition for the development of adhesive capsulitis exists, despite the increased frequency noted in twin studies. Although the underlying etiology and pathophysiology are not well understood, the consensus is that synovial inflammation and capsular fibrosis result in pain and joint volume loss. It is hypothesized that in patients with diabetes, an increased rate of glycosylation and cross-linking of the shoulder capsule raises the incidence of frozen shoulder.
The natural history of adhesive capsulitis is spontaneous resolution, therefore, conservative measures are the mainstay of treatment. As the patient has seen little benefit from NSAIDs and a home exercise program, more aggressive intervention is reasonable. In terms of injections, glenohumeral corticosteroid injection, subacromial corticosteroid injection, and hydrodilation have all 64
demonstrated benefit. Radiographs are usually obtained to exclude other causes of shoulder pain such as glenohumeral arthrosis, malignancy, calcific tendonitis, impingement, and acromioclavicular degeneration. If pain and stiffness persist beyond 6 months, surgical intervention may be considered in the form of closed manipulation or arthroscopic release. Complications of closed manipulation include humerus fracture, glenohumeral dislocation, hematoma, rotator cuff and labral tears, and brachial plexus injury. Arthroscopic release is advocated by some, as it allows for examination of concomitant pathology and controlled release of capsular tissue, with the potential for reduced force when performing the manipulation portion of the procedure. Controversy remains as to whether posterior capsular release should be routinely performed because studies have shown outcomes to be similar with anterior and combined approaches. Therapy should be initiated early after intervention, with some surgeons advocating admission to the hospital with inpatient therapy for pain management and compliance.

The patient is young, active, and has evidence of post-traumatic elbow osteoarthritis. His motion is limited by capsular contracture and large osteophytes in the anterior and posterior compartments. He has failed nonoperative treatment, and surgery is indicated to improve his range of motion and function. Arthroscopic osteocapsular arthroplasty allows removal of impinging osteophytes and release of hypertrophied capsule and has been shown to be effective at relieving pain and improving motion in patients with mild to moderate osteoarthritis. Anterior capsular contracture and posterior bony impingement limit extension and must be addressed to improve motion. Posterior capsular contracture and anterior osteophytes limit flexion.

Traditionally, recurrence rates associated with open stabilization procedures have been lower than rates associated with arthroscopic repair. Recent studies show that for patients without significant bone loss, however, the recurrence rate is the same for open and arthroscopic surgeries.

RA is a systemic inflammatory disorder marked by erosive arthritis in multiple joints. Elbow involvement is common. The pathologic lesion in RA is pannus, a hyperplastic synovial proliferation that ultimately results in proteoglycan and collagen digestion. Rheumatoid factor mutations, traumatic insults resulting in complement activation, and osteoblast paracrine signaling are not involved in the pathologic process. The Larsen classification assesses the progression of rheumatoid changes in the elbow. Stage I is characterized by osteopenia without joint space narrowing. Stage II indicates joint space narrowing but a normal joint contour. Stage III is marked by joint space loss. This patient has stage IV disease, as seen by the advanced erosive changes with trochlear groove deepening and resulting deformity. Stage V is ankylosis.
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In a patient with end-stage glenohumeral arthritis, the preferred treatment after failing nonoperative treatment would be anatomic shoulder arthroplasty. Recent literature has demonstrated good outcomes even in the setting of partial rotator cuff tears, with or without repair. Stem cell injections are costly and have not been shown to be effective. Arthroscopic treatment may improve pain and function in the short term, but results are unlikely to be long-lasting. Reverse shoulder arthroplasty could be considered; however, there are more long-term studies supporting anatomic total shoulder arthroplasty in this patient population.

Proper soft-tissue tension is critical to prevent instability of a reverse total shoulder. The arm position implicated in reverse total shoulder instability is extension, adduction, and internal rotation, such as pushing out of a chair. The other positions described do not involve extension of the shoulder.

Patients with a positive nasal swab for MRSA can be treated preoperatively with 2% mupirocin to the nares twice daily for 5 days, or 5% povidone-iodine solution to each nostril for 10 seconds per nostril, 1 hour before surgery. S aureus is a gram-positive bacterium capable of both aerobic and anaerobic metabolism. The addition of MRSA and/or methicillin-sensitive S aureus nasal screening, along with a perioperative decolonization protocol, has resulted in a 69% decrease in surgical site infection. It has been shown that prevention programs for staphylococcal periprosthetic joint infections can result in substantial cost savings.
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The patient has atrophy of the infraspinatus. This would be consistent with either a massive rotator cuff tear or suprascapular neuropathy/compression. Given the
patient's age and the atraumatic onset of symptoms, a significant rotator cuff injury is unlikely, making a suprascapular nerve issue the most likely diagnosis. Electrodiagnostic studies would be most accurate in confirming nerve compression and would aid in localizing the area of compression between the spinoglenoid notch and the suprascapular notch. An MRI scan also would be beneficial to evaluate for any compressive lesion on the nerve, such as a paralabral cyst. Because rotator cuff pathology is unlikely, ultrasonography of the rotator cuff would be of little benefit. CT scan of the shoulder may allow grading of the atrophy of the muscle, but will not be as sensitive for a paralabral cyst/labral tear. Vascular studies would not aid in the diagnosis.

The patient has historical and clinical evidence of significant anterior shoulder instability. The imaging demonstrates significant anteroinferior glenoid bone loss, with a very shallow Hill-Sachs deformity. Patient factors that contribute to recurrent instability
risk include type of sport/activity, age at the time of first dislocation, hyperlaxity, and glenoid bone loss (and/or bipolar bone loss), and these can be utilized to determine if an arthroscopic or open solution is most appropriate. In this patient, restoring glenoid bone stock appears to be the most important variable in stabilizing the shoulder. “Critical” glenoid bone loss has frequently been reported to be >20-25%. In this case, significant bone loss can be suspected from the patient's history, including the number of dislocations, ease of dislocation and reduction, and instability in mid-range of motion.

Over the years, indications for total elbow arthroplasty (TEA) have evolved. With the introduction of better medications for rheumatoid arthritis and other inflammatory arthritides, end-stage arthritis of the elbow from this pathology has become less common. At the same time, there has been increased interest in TEA for treatment of acute distal humerus fractures, and ongoing use for fracture sequelae and osteoarthritis. Fevang and associates found in the Norwegian registry that fracture sequelae led to a 5.8 relative risk of failure
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compared with inflammatory arthritis. Data from the state of New York found that revision rates for osteoarthritis were 14.7%, whereas those for inflammatory arthritis were only 8.3%. All patients require a 5-lb lifetime lifting limit postoperatively to improve the longevity of the prosthesis.

Multiple studies have shown that the most common associated injury following traumatic shoulder dislocation (besides anteroinferior labral lesions) are full-thickness rotator cuff tears, especially in patients >40 years of age. Robinson and associates found a
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33.4% incidence of traumatic rotator cuff tears in this setting. Ro and associates reported rotator cuff tears in 18% of their study population. A level IV systematic review found that patients with rotator cuff tears following shoulder dislocations have more persistent pain and shoulder dysfunction. Rotator cuff repair surgery resulted in improved pain and patient satisfaction compared with those treated nonoperatively.

Numerous approaches can be used to implant a total elbow arthroplasty. The Morrey approach identifies, transposes, and protects the ulnar nerve, and then subperiosteally reflects the triceps off the ulna. The sleeve of tissue is very thin distally, and the triceps need to be meticulously repaired at the time of closure. Implant dislocation and malposition are less likely with an extensile approach, and dislocation is unlikely with a semiconstrained implant. The development of heterotopic ossification is unrelated to the surgical approach used for elbow arthroplasty.

The MRI scan shows a distal biceps tendon rupture with retraction. Tendon rerupture and PIN palsy are the two most common major complications following distal biceps repair surgery. Major complication rates are not found to differ by sex, history of tobacco use, age, exposure type (single versus two
incisions), tear morphology (full versus partial), or type of fixation used.

When comparing operative fixation of displaced clavicle fractures with nonoperative treatment, ORIF results in lower rates of nonunion, faster time to union, and similar outcome scores. There is an increased risk of complication, including infection, neurovascular insult, and the need for additional surgery.
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The important ligaments on the lateral side of the elbow are thickenings of the capsule. The lateral collateral ligament complex consists of four components: the lateral (radial) collateral ligament (LCL), the LUCL, the accessory LCL, and the annular ligament. The medial collateral ligament complex is a capsular thickening consisting of three components: the anterior band, the posterior band, and the transverse ligament. The LUCL is the most important portion of the lateral ligament in terms of posterolateral rotatory instability.
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