Salvage Procedures

The many surgical procedures summarized in previous chapters allow successful management of most shoulder conditions and result in improved pain, motion, and function. However, salvage procedures that sacrifice the glenohumeral joint or the scapulothoracic joint represent the best surgical option for a few patients. These salvage procedures are uncommon, but shoulder surgeons need to be familiar with their indications, surgical technique, and reported outcomes. This chapter addresses glenohumeral arthrodesis, scapulothoracic arthrodesis, and glenohumeral resection arthroplasty.

The Clavicle, the Acromioclavicular Joint, and the Sternoclavicular Joint

The management of traumatic injuries to the clavicle and its two joints, acromioclavicular and sternoclavicular, has evolved substantially over the last few years. Regarding clavicle fractures, we now realize that nonoperative treatment of certain fracture patterns does lead to poor outcomes more frequently than previously thought; precontoured plates and modern intramedullary devices facilitate fixation techniques. Regarding the acromioclavicular joint, more emphasis is placed on anatomical reconstruction of all ligamentous structures, and there is substantial interest in arthroscopically assisted techniques. Fear of a major vascular complication when dealing with sternoclavicular joint pathology still lingers, but more and more surgeons feel they can manage this particular area of the shoulder region with reliable reconstructive techniques.

Surgical Exposures

Adequate exposure is critical for any of the open surgical procedures described in this book. Although exposures may need to be modified, most of the time the same approaches are used for various procedures. Small variations on exposures also exist that are based on surgeons’ preferences. All shoulder exposures are somewhat complicated by three particular issues related to the anatomy of the shoulder region. First, the deltoid is a large muscle that wraps around the front, side, and back of the shoulder. Second, the rotator cuff, so important for shoulder function, oftentimes needs to be divided and repaired. Finally, a number of neurovascular structures are very close to the shoulder joint and at risk for injury.

Rehabilitation and Injections

Rehabilitation modalities, particularly physical therapy exercises, are extremely important for the operative and nonoperative management of shoulder conditions. Shoulder surgeons must understand the principles of shoulder rehabilitation so that they can guide physical therapists and patients through treatment plans. Injections of local anesthetic, corticosteroids, or other pharmacological agents are used commonly in the diagnosis and treatment of shoulder conditions. Shoulder surgeons must know how to perform these injections (with and without imaging guidance); they must also be aware of the potential adverse effect of multiple corticosteroid injections to be able to inform patients and prevent unwanted sequelae.

Shoulder Arthritis and Arthroplasty

Progressive degeneration of the articular cartilage and other articular structures is the hallmark of glenohumeral arthritis. These structural changes may occur primarily or they may be a consequence of a number of conditions, including dysplasia, inflammatory conditions, trauma, avascular necrosis, instability, infection, and prior surgery. The pathology underlying various arthritic conditions is different, and these differences have direct practical implications on treatment. Shoulder arthroplasty is the surgical treatment of choice for most patients with advanced symptomatic arthritis. This chapter addresses shoulder arthritis and arthroplasty as it relates to structural pathology in shoulder arthritis, evaluation, nonoperative treatment, shoulder arthroplasty, nonarthroplasty surgical options, surgical management of specific conditions, and complex and revision surgery.

Shoulder Instability and the Labrum

The glenohumeral joint architecture allows for a very ample range of motion. This same architecture, so beneficial for shoulder mobility, also makes the glenohumeral joint particularly prone to instability. Damage to the glenoid labrum is present in many patients with shoulder instability, although the complexity of the pathology involved in shoulder instability goes beyond labral tears. The rotator cuff and the biceps tendon, discussed in chapter 6, The Rotator Cuff and Biceps Tendon, are intimately involved with instability and the labrum; some of the concepts described in chapter 6 will apply here as well. This chapter covers shoulder instability and the labrum, including management of the acute glenohumeral joint dislocation, recurrent posterior instability and posterior labral tears, multidirectional instability, superior labral tears, failed instability surgery, and salvage procedures.

Adhesive Capsulitis

Some individuals experience a condition characterized by spontaneous shoulder pain and stiffness due to synovitis, fibrosis, and loss of capsule elasticity without a clear-cut inciting cause. Most commonly, this condition is named adhesive capsulitis or frozen shoulder, terms applied only when shoulder radiographs are essentially normal and other reasons for shoulder pain and stiffness (e.g., cuff disease, fractures, dislocations, and arthritis) can be excluded. Although this condition resolves spontaneously in many patients, its course is protracted and a number of individuals may experience permanent restrictions in motion and function. This chapter discusses various aspects of adhesive capsulitis including pathogenesis, natural history, patient evaluation, and treatment.

Proximal Humerus Fractures

Fractures of the proximal humerus are common. A relatively large number of these injuries will heal with nonoperative treatment without major residual pain or functional loss. However, internal fixation or arthroplasty leads to a much better outcome for selected fractures. The orthopedic surgeon dealing with these injuries is faced with three challenges. First, it is difficult to understand these fractures based on imaging studies and to select those patents that will do better with surgery. Second, internal fixation and arthroplasty for proximal humerus fractures are difficult procedures and fraught with technical complications. And third, complications often require challenging salvage procedures.

The Rotator Cuff and Biceps Tendon

Rotator cuff disease is the most common condition responsible for shoulder pain worldwide. The understanding and treatment of rotator cuff disease has advanced tremendously over the last few years, mostly due to both technological advances (magnetic resonance imaging, ultrasonography, arthroscopic surgery, and reverse arthroplasty) and a better understanding of the biology of healing and of muscle changes over time. Not uncommonly, the long head of the biceps tendon presents structural pathology in patients with cuff disease; however, determining the contribution of biceps pathology to patients’ symptoms is not always straightforward. This chapter discusses these issues and covers aspects of assessment and treatment of rotator cuff disease such as anatomy and function, basic science, rotator cuff tears, calcifying tendinitis, neuropathies and the rotator cuff, and biceps tendon pathology.

Arthroscopic Shoulder Surgery

Arthroscopic surgery involves performing surgical procedures using a camera inserted in the joint for visualization and one or more additional access points (or portals) to the joint using stab incisions. Endoscopic surgery uses a camera and portals to complete similar procedures outside of joint cavities. Most shoulder surgeons do not distinguish between endoscopic and arthroscopic procedures, and the term shoulder arthroscopy is oftentimes used to refer to both. Currently, many shoulder surgeries are largely or exclusively performed arthroscopically. This is due to improvements in equipment, instrumentation, and implants; better surgeon understanding and training in arthroscopic anatomy and techniques; and interest by surgeons and patients in less invasive, more accurate surgeries.