Sports

Acromioclavicular joint and shoulder arthrosis

Shoulder arthrodesis, acromioclavicular dislocation, glenohumeral arthritis and humeral head AVN.

21 questions 4 source pages

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Q1What is the goal of shoulder arthrodesis?▸

Q2What are the indications and contraindications for shoulder arthrodesis?▸

Indications: stabilize paralytic disease (brachial plexus injury); recurrence of instability with multiple failed operations; irreparable deltoid and cuff arthropathy
C/I: advanced bilateral shoulder disease, contralateral arthrodesis, ipsilateral elbow arthrodesis
C/I: no scapulothoracic movement (need residual 60 degrees scapulothoracic movement)

Q3What position is the shoulder arthrodesed in?▸

Q4Describe the technique of shoulder arthrodesis.▸

Cuff resected; LH biceps tenodesis; decortication
Extra-articular: 4.5mm recon plate from scapular spine/acromion to humeral shaft
Intra-articular: humeral head to glenoid neck; acromion to humeral head; clavicle to glenoid
Check intraoperatively able to reach mouth and adduction close to body

Q5What does the X-ray show and what must be considered?▸

Q6How is an ACJ injury assessed?▸

Acute versus chronic (>3 weeks)
Compare contralateral side; axillary view (AP translation)
Zanca view: 10 degrees cephalic tilt (vertical translation); +/- stress view

Q7How does the Rockwood classification guide management?▸

1-3: static stabilizers disrupted (AC sprain, AC torn, CC torn) -> conservative
4-6: dynamic (posterior through trapezius, deltoid + trapezius torn, inferior below coracoid) -> surgical
3 +/- operation

Q8How does the surgical treatment differ between acute and chronic ACJ dislocation?▸

Acute – repair; CC fixation with Bosworth screw, CC sling, fibre tape or tightrope
ACJ fixation: hook plate
If associated arthritis: modified Weaver-Dunn
Chronic – reconstruct; with ACJ arthrosis, resect the distal clavicle

Q9What is the modified Weaver-Dunn procedure?▸

Q10What is done for isolated ACJ arthritis without instability, and what is the ACJ anatomy?▸

Excision of 7-8mm (<1.5cm) of distal clavicle (too much jeopardizes capsule); can be done arthroscopically
ACJ is a diarthrodial joint with an articular disc connecting axial to appendicular skeleton
Stabilizers: superior (most important)/anterior/posterior/inferior; ~8 degrees rotation; Kenny Howard brace

Q11What happens if an ACJ dislocation is left untreated?▸

Q12What are the causes of glenohumeral arthritis?▸

More common in females
Primary osteoarthritis
Secondary: post-traumatic, arthritis of dislocation, inflammatory/crystalline arthritis, osteonecrosis, neuropathic (Charcot arthropathy)
Rotator cuff arthropathy

Q13What is the primary OA triad and X-ray finding?▸

Anterior capsular contracture, posterior glenoid wear, posterior humeral subluxation
XR: osteophytes circumferentially at the humeral head, "goat's beard"

Q14What are the nonoperative and operative options for GHJ arthritis?▸

Nonoperative: physical therapy, NSAIDs, intra-articular injections
Operative: total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty
Also arthroscopic debridement, CAM procedure, arthrodesis

Q15What are the contraindications, survival and complications of total shoulder arthroplasty?▸

C/I: lack of deltoid or rotator cuff function, active infection, Charcot arthropathy
10-year survival 92-95%
Complications: glenoid/humeral component loosening, infection, fracture, nerve injury, cuff tear
Higher prosthetic joint infection risk within 3 months of prior arthroscopy

Q16When are hemiarthroplasty and reverse shoulder arthroplasty indicated?▸

Hemi: younger patient, irreparable RC tear + insufficient bone stock, osteonecrosis without glenoid involvement
Ream-and-run over glenoid has early failure, not recommended, poorer outcomes
RSA: irreparable/large RC tear with intact deltoid; 10-year survival ~90-95%
RSA complications: scapular notching, infection, dislocation/instability, nerve injuries (higher than TSA)

Q17When is arthroscopic debridement or a CAM procedure performed?▸

Debridement: mild-moderate OA without structural alteration; mechanical symptoms from loose bodies or small humeral head lesions due to AVN
CAM (comprehensive arthroscopic management): younger patient
Debridement, chondroplasty, synovectomy, loose body removal, humeral osteoplasty (goat's beard), capsular release, decompressions, axillary nerve decompression, biceps tenodesis

Q18When is shoulder arthrodesis indicated in glenohumeral arthritis?▸

Paralysis, recurrent infection, severe soft tissue deficiency, failed replacement surgery

Q19What is the most common initial site of avascular necrosis of the humeral head?▸

Q20What is the nonoperative management of humeral head AVN?▸

Q21What operations are used for humeral head AVN and when?▸

Core decompression + arthroscopy (confirm cartilage integrity) for early disease (Cruess I-II)
Humeral head resurfacing for stage III with focal chondral defects and sufficient epiphyseal bone stock
Hemiarthroplasty for moderate disease (Cruess III-IV)
Total shoulder arthroplasty for advanced stage (Cruess V)

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