Operative Techniques: Shoulder and Elbow Surgery [2 ed.] 0323508804, 9780323508803, 9780323547901

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Operative Techniques: Shoulder and Elbow Surgery Second Edition

Donald H. Lee, MD Professor of Orthopaedic Surgery and Rehabilitation Vanderbilt Orthopaedic Institute Vanderbilt University School of Medicine Nashville, Tennessee

Robert J. Neviaser, MD Professor and Emeritus Chairman Department of Orthopaedic Surgery George Washington University School of Medicine and Health Sciences Washington, DC

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

OPERATIVE TECHNIQUES: SHOULDER AND ELBOW SURGERY, SECOND EDITION

ISBN: 978-0-323-50880-3

Copyright © 2019 by Elsevier, Inc. All rights reserved. Procedure 21: Pascal Boileau retains copyright for the original images/figures appearing in his contribution. Procedure 35: Jesse Alan McCarron retains copyright for the original images/figures appearing in his contribution. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the ­Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and ­experience broaden our understanding, changes in research methods, professional practices, or medical ­treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of ­products liability, negligence or otherwise, or from any use or operation of any methods, products, ­instructions, or ideas contained in the material herein. Previous edition copyright © 2011. Library of Congress Cataloging-in-Publication Data Names: Lee, Donald H., editor. | Neviaser, Robert J., editor. Title: Shoulder and elbow surgery / [edited by] Donald H. Lee, Robert J. Neviaser. Other titles: Operative techniques. Description: Second edition. | Philadelphia : Elsevier, [2019] | Series: Operative techniques | Includes bibliographical references and index. Identifiers: LCCN 2017056979 | ISBN 9780323508803 (hardcover : alk. paper) Subjects: | MESH: Shoulder--surgery | Elbow--surgery | Shoulder Joint--surgery | Elbow Joint--surgery | Orthopedic Procedures--methods | Atlases Classification: LCC RD557.5 | NLM WE 17 | DDC 617.5/72059--dc23 LC record available at https://lccn.loc.gov/2017056979 Senior Content Strategist: Kristine Jones Director, Content Development: Taylor Ball Publishing Services Manager: Catherine Jackson Project Manager: Kate Mannix Design Direction: Amy Buxton Illustrations Manager: Lesley Frazier Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

I would like to dedicate this book to my wife, Dawn, and our children, David, Dana, Diane, Daniel, and Dustin, for all their support and joy that they provide. I also dedicate this book to my parents, Kwan and Kay, for their guidance. I would like to thank my co-editor, Robert Neviaser, for all the advice and encouragement that he has provided over the years. Finally, thank you to all our co-authors who have shared their time and knowledge with us. Donald H. Lee, MD To my wife, Anne, “the wind beneath my wings”; my children, Niki, Rob, Ian, and Andy; and grandchildren, Isabel, Mac, Bozie, Kenzie, J.B., Maddie, Geordie, A.J., Katie, Emily, and Abby, the rest of my raisons d’être. Finally, to my father, Julius S. Neviaser, MD, a pioneer and giant of shoulder surgery. Robert J. Neviaser, MD

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Contributors

Adham A. Abdelfattah, MD Florida Orthopaedic Institute Tampa, Florida

Robert M. Baltera, MD Indiana Hand to Shoulder Center Indianapolis, Indiana

Julie E. Adams, MD Associate Professor Orthopedic Surgery Mayo Clinic and Mayo Clinic Health System Rochester, Minnesota

Mark E. Baratz, MD Clinical Professor Department of Orthopaedic Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Christopher S. Ahmad, MD Head Team Physician, New York Yankees Chief, Sports Medicine Service Professor of Orthopaedic Surgery The Center for Shoulder, Elbow and Sports Medicine NYP/Columbia University Medical Center New York, New York

Jonathan Barlow, MD, MS Senior Associate Consultant Orthopedic Surgery Mayo Clinic Rochester, Minnesota

Raj M. Amin, MD Orthopaedic Surgery Resident Physician Johns Hopkins Hospital Baltimore, Maryland James R. Andrews, MD Program Director Orthopedic Sports Medicine Fellowship Andrews Institute for Orthopaedics & Sports Medicine Gulf Breeze, Florida John M. Apostolakos, BS Medical Student University of Connecticut School of Medicine Farmington, Connecticut Robert A. Arciero, MD Professor Department of Orthopaedic Surgery University of Connecticut School of Medicine Farmington, Connecticut April D. Armstrong, BSc (PT), MSc, MD, FRCSC Professor Department of Orthopaedics and Rehabilitation Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania

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Louis U. Bigliani, MD Professor of Orthopedic Surgery Department of Orthopedic Surgery Columbia University New York, New York Julie Bishop, MD Professor of Clinical Orthopaedics Chief, Division of Shoulder Team Physician The OSU Sports Medicine Center The Ohio State University Columbus, Ohio Pascal Boileau, MD Professor Orthopaedics University Institute of Locomotion and Sports Pasteur 2 Hospital Nice, France Aydin Budeyri, MD, FEBOT Postdoctoral Research Fellow The Shoulder Center Baylor University Medical Center Dallas, Texas; Assistant Professor Orthopaedics and Traumatology SANKO University Sehitkamil, Gaziantep, Turkey

Contributors

Wayne Z. Burkhead, MD WB Carrell Memorial Clinic Dallas, Texas Paul J. Cagle, Jr., MD Assistant Professor Department of Orthopaedics Mount Sinai Medical Center New York, New York James H. Calandruccio, MD Assistant Professor Hand Surgery Fellowship Director Department of Orthopaedic Surgery University of Tennessee–Campbell Clinic Memphis, Tennessee Jake Calcei, MD Resident in Orthopedic Surgery Hospital for Special Surgery New York, New York R. Bruce Canham, MD Fellow, Shoulder and Elbow Surgery Department of Orthopaedics MedStar Union Memorial Hospital Baltimore, Maryland Jue Cao, MD Orthopaedic Hand Surgery Fellow Indiana Hand to Shoulder Center Indianapolis, Indiana Neal C. Chen, MD Interim Chief, Hand and Upper Extremity Service Massachusetts General Hospital; Assistant Professor Harvard Medical School Boston, Massachusetts

Edward V. Craig, MD, MPH Chief Executive Officer TRIA Orthopaedic Center; Professor Department of Orthopaedic Surgery University of Minnesota Minneapolis, Minnesota Lynn A. Crosby, MD Director of Shoulder Surgery Department of Orthopaedic Surgery Augusta University Augusta, Georgia Alexander B. Dagum, MD, FRCS (C), FACS Professor of Surgery and Orthopaedic Surgery Chief of Plastic Surgery Stony Brook Medicine Stony Brook, New York Allen Deutsch, MD Assistant Professor Department of Orthopaedic Surgery University of Texas Health Science Center at Houston Houston, Texas Christopher C. Dodson, MD Assistant Professor of Orthopaedic Surgery Thomas Jefferson University; Attending Orthopaedic Surgeon Division of Sports Medicine Rothman Institute Philadelphia, Pennsylvania Edward Donley, BSc Research Assistant Department of Orthopaedic Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Kaitlyn Christmas, BS Foundation for Orthopaedic Research and Education Tampa, Florida

Jason D. Doppelt, MD Advanced Center for Orthopedics and Plastic Surgery Marquette, Michigan

Tyson Cobb, MD Director of Hand & Upper Extremity Surgery Orthopaedic Specialists, PC Davenport, Iowa

Christopher J. Dy, MD, MPH Asssistant Professor Department of Orthopaedic Surgery Division of Hand Surgery Washington University School of Medicine St. Louis, Missouri

Mark S. Cohen, MD Professor Director, Hand and Elbow Section Director, Orthopaedic Education Department of Orthopaedic Surgery Rush University Medical Center Chicago, Illinois

George S.M. Dyer, MD Clinical Instructor in Orthopaedic Surgery Harvard Medical School; Hand and Upper Extremity Service Department of Orthopaedic Surgery Brigham and Women’s Hospital Boston, Massachusetts

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Contributors

Benton A. Emblom, MD Andrews Sports Medicine & Orthopedic Center Birmingham, Alabama Vahid Entezari, MD Department of Orthopaedic Surgery The Cleveland Clinic Cleveland, Ohio Brandon J. Erickson, MD Sports Medicine and Shoulder Division Hospital for Special Surgery New York, New York John M. Erickson, MD Hand and Upper Extremity Surgeon Raleigh Hand Center Raleigh, North Carolina Evan L. Flatow, MD Professor, Orthopaedic Surgery Icahn School of Medicine at Mount Sinai; President, Mount Sinai Roosevelt Hospital New York, New York Christina Freibott, BA Research Assistant Orthopaedic Surgery Columbia University Medical Center New York, New York Matthew J. Furey, MD, MSc Clinical Associate, Hand and Wrist Surgery Toronto Western Hospital Toronto, Ontario, Canada Leesa M. Galatz, MD Mount Sinai Professor and Chair Leni and Peter May Department of Orthopedic Surgery Icahn School of Medicine Mount Sinai Health System New York, New York Andrew Green, MD Chief, Division of Shoulder & Elbow Surgery Department of Orthopaedic Surgery Warren Alpert Medical School Brown University Providence, Rhode Island Jeffrey A. Greenberg, MD, MS Clinical Assistant Professor Department of Orthopaedics Indiana University; Indiana Hand to Shoulder Center Indianapolis, Indiana

Alicia K. Harrison, MD Assistant Professor Department of Orthopaedic Surgery University of Minnesota Minneapolis, Minnesota Robert U. Hartzler, MD, MS The San Antonio Orthopaedic Group San Antonio, Texas Taku Hatta, MD, PhD Assistant Professor Department of Orthopaedic Surgery Tohoku University School of Medicine Sendai, Japan Joseph P. Iannotti, MD, PhD Department of Orthopaedic Surgery The Cleveland Clinic Cleveland, Ohio Oduche R. Igboechi, MD, MPH, MBA Resident Department of Orthopaedic Surgery Tulane University School of Medicine New Orleans, Louisiana John V. Ingari, MD Associate Hand Fellowship Director Assistant Professor Department of Orthopaedic Surgery Johns Hopkins Hospital Baltimore, Maryland Eiji Itoi, MD, PhD Professor and Chair Department of Orthopaedic Surgery Tohoku University School of Medicine Sendai, Japan Kristopher J. Jones, MD Assistant Professor Department of Orthopaedic Surgery Division of Sports Medicine and Shoulder Surgery David Geffen School of Medicine at UCLA Los Angeles, California Jesse B. Jupiter, MD Hansjorg Wyss AO Professor of Orthopedic Surgery Harvard Medical School; Division of Hand and Upper Extremity Service Massachusetts General Hospital Boston, Massachusetts Nami Kazemi, MD OrthoAspen Aspen Valley Hospital Aspen, Colorado

Contributors

W. Ben Kibler, MD Medical Director Shoulder Center of Kentucky Lexington Clinic Lexington, Kentucky

Donald H. Lee, MD Professor of Orthopaedic Surgery and Rehabilitation Vanderbilt Orthopaedic Institute Vanderbilt University School of Medicine Nashville, Tennessee

Graham J.W. King, MD, MSc, FRCSC Professor Department of Surgery University of Western Ontario; Director, Roth | McFarlane Hand and Upper Limb Centre St. Joseph’s Health Centre London, Ontario, Canada

William N. Levine, MD Frank E. Stinchfield Professor and Chairman Department of Orthopedic Surgery NYP/Columbia University Medical Center New York, New York

Toshio Kitamura, MD, PhD Vice-Director Kumamoto Orthopaedic Hospital Kumamoto, Japan Steven M. Koehler, MD Director, Hand and Microsurgery Assistant Professor Department of Orthopaedic Surgery SUNY Downstate Medical Center Brooklyn, New York Zinon T. Kokkalis, MD, PhD Assistant Professor of Orthopaedic Surgery Department of Orthopaedics University of Patras School of Medicine Patra, Greece Marc S. Kowalsky, MD Shoulder and Elbow Surgeon Orthopaedic and Neurosurgery Specialists ONS Foundation for Clinical Research and Education Greenwich, Connecticut Sumant G. Krishnan, MD Director The Shoulder Center Baylor University Medical Center at Dallas; Associate Professor Department of Surgery Texas A&M Health Science Center College of Medicine Dallas, Texas John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics and Rehabilitation Chief of Shoulder Surgery Vanderbilt University Medical Center Nashville, Tenessee

Eddie Y. Lo, MD Shoulder Service Bay Area Orthopedic Institute San Francisco, California Lauren M. MacCormick, MD Resident Physician Department of Orthopaedic Surgery University of Minnesota Minneapolis, Minnesota Leonard C. Macrina, MSPT, SCS, CSCS Co-Founder Director of Physical Therapy Champion PT & Performance Waltham, Massachusetts Chad J. Marion, MD Pacific Medical Centers Seattle, Washington Jed I. Maslow, MD Department of Orthopaedic Surgery Vanderbilt University Medial Center Nashville, Tennessee Augustus D. Mazzocca, MD Professor Department of Orthopaedic Surgery University of Connecticut School of Medicine Farmington, Connecticut Jesse Alan McCarron, MD Shoulder and Elbow Surgeon Rebound Orthopaedics and Neurosurgery Portland, Oregon Vancouver, Washington

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Contributors

George M. McCluskey III, MD Clinical Professor Department of Orthopaedic Surgery Medical College of Georgia Augusta, Georgia; Clinical Assistant Professor Department of Orthopaedic Surgery Tulane University School of Medicine New Orleans, Louisiana; Director, St. Francis Shoulder Center Director, St. Francis Shoulder Fellowship Program Columbus, Georgia

Andrew S. Neviaser, MD Associate Professor Department of Orthopaedic Surgery The Ohio State School of Medicine Columbus, Ohio

Patrick J. McMahon, MD McMahon Orthopedics; Adjunct Associate Professor Department of Bioengineering University of Pittsburgh Pittsburgh, Pennsylvania

Michael J. O’Brien, MD Associate Professor of Clinical Orthopaedics Director of Tulane Sports Medicine Tulane University School of Medicine New Orleans, Louisiana

Steven W. Meisterling, MD Twin Cities Orthopaedics Oak Park Heights, Minnesota Mark A. Mighell, MD Florida Orthopaedic Institute Tampa, Florida Anthony Miniaci, MD, FRCSC Professor of Surgery Cleveland Clinic Lerner College of Medicine Case Western Resever University Cleveland, Ohio Anand M. Murthi, MD Chief, Shoulder and Elbow Surgery Department of Orthopaedics MedStar Union Memorial Hospital Baltimore, Maryland Surena Namdari, MD, MSc Associate Professor, Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Rothman Institute Philadelphia, Pennsylvania Thomas Naslund, MD Chief, Vascular Surgery Professor of Surgery Vascular Surgery Vanderbilt University Medical Center Nashville, Tennessee

Robert J. Neviaser, MD Professor and Emeritus Chairman Department of Orthopaedic Surgery George Washington University School of Medicine and Health Sciences Washington, DC

Stephen J. O’Brien, MD, MBA Attending Orthopaedic Surgeon Hospital for Special Surgery; Professor of Clinical Orthopedic Surgery Weill Cornell Medical College New York, New York Jason Old, MD, FRCSC Assistant Professor University of Manitoba Panam Clinic Winnipeg, Manitoba, Canada Victor A. Olujimi, MD Shoulder/Elbow Fellow Department of Orthopaedics Mount Sinai Medical Center New York, New York A. Lee Osterman, MD Professor and Chairman Division of Hand Surgery Department of Orthopaedic Surgery Thomas Jefferson University; President, The Philadelphia Hand Center Philadelphia, Pennsylvania Georgios N. Panagopoulos, MD Hand Fellow Department of Orthopaedic Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Contributors

Rick F. Papandrea, MD Partner, Orthopedic Associates of Wisconsin Waukesha, Wisconsin; Assistant Clinical Professor Department of Orthopaedic Surgery Medical College of Wisconsin Milwaukee, Wisconsin Loukia K. Papatheodorou, MD, PhD Orthopaedic Surgeon, Orthopaedic Specialists - UPMC University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Ryan A. Paul, MD, FRCSC Clinical Fellow Roth | McFarlane Hand and Upper Limb Centre St. Joseph’s Health Care London, Ontario, Canada William Thomas Payne, MD Northwestern Medicine Regional Medical Group Warrenville, Illinois Christine C. Piper, MD Orthopaedic Surgery Resident George Washington University Hospital Washington, DC Matthew L. Ramsey, MD Shoulder and Elbow Specialist Rothman Institute Thomas Jefferson University Philadelphia, Pennsylvania Lee M. Reichel, MD Associate Professor of Orthopedic Surgery Department of Surgery and Perioperative Care Dell Medical School Austin, Texas Herbert Resch, MD Professor and Former Head of Department of Trauma Surgery and Sports Injuries Paracelsus Medical University Salzburg, Austria Eric T. Ricchetti, MD Department of Orthopaedic Surgery The Cleveland Clinic Cleveland, Ohio David Ring, MD, PhD Associate Dean for Comprehensive Care Department of Surgery and Perioperative Care Dell Medical School University of Texas at Austin Austin, Texas

Chris Roche, MS, MBA Director of Engineering, Extremities Exactech Gainesville, Florida Anthony A. Romeo, MD Department Head, Shoulder and Elbow Division Midwest Orthopedics at Rush Chicago, Illinois Melvin Paul Rosenwasser, MD Carroll Professor of Orthopedic and Hand Surgery Columbia University Department of Orthopedic Surgery Director of Orthopedic Trauma Service Director of Hand and Microvascular Service New York Presbyterian Hospital New York, New York David S. Ruch, MD Vice-Chair, Head of Hand Section Duke Orthopaedic Surgery Duke University School of Medicine Durham, North Carolina Vikram M. Sampath, MD Resident Department of Orthopaedic Surgery Augusta University Augusta, Georgia Javier E. Sanchez, MD Medical Student Columbia University Medical Center New York, New York Michael G. Saper, DO, ATC, CSCS Assistant Professor Orthopedics & Sports Medicine Seattle Children’s Seattle, Washington Felix H. Savoie III, MD Ray J. Haddad Professor and Chairman Department of Orthopaedic Surgery Tulane University School of Medicine New Orleans, Louisiana Andrew Schannen, MD Presbyterian Rust Medical Center Albuquerque, New Mexico Bradley S. Schoch, MD Assistant Professor Department of Orthopaedics and Rehabilitation University of Florida Gainesville, Florida

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Contributors

Robert J. Schoderbek, Jr., MD Orthopaedic Specialists of Charleston Roper St. Francis Sports Medicine Charleston, South Carolina

John W. Sperling, MD, MBA Department of Orthopedic Surgery Mayo Clinic Rochester, Minnesota

Aaron Sciascia, PhD, ATC, PES Assistant Professor Exercise and Sport Science Eastern Kentucky University Richmond, Kentucky; Orthopedic Research Specialist Orthopedics-Sports Medicine Lexington Clinic Lexington, Kentucky

Murphy M. Steiner, MD Hand Surgery Fellow Department of Orthopaedic Surgery University of Tennessee–Campbell Clinic Memphis, Tennessee

William H. Seitz, Jr., MD Professor of Orthopaedic Surgery Cleveland Clinic Lerner College of Medicine Case Western Reserve University; Chairman, Orthopaedic Surgery Lutheran Hospital Cleveland Clinic Orthopaedic and Rheumatologic Institute Cleveland, Ohio Jon K. Sekiya, MD Professor of Orthopaedic Surgery Medsport University of Michigan Ann Arbor, Michigan Anup A. Shah, MD Orthopedic Surgeon – Sports Medicine/Shoulder Reconstruction Kelsey-Seybold Clinic; Clinical Assistant Professor of Orthopedic Surgery Department of Orthopedic Surgery Baylor College of Medicine Houston, Texas Evan J. Smith, MD Orthopaedic Surgery Resident George Washington University Hospital, Washington, DC Mia Smucny, MD Cleveland Clinic Cleveland, Ohio David H. Sonnabend, MBBS, BSc (Med), MD, FRACS Emeritus Professor in Orthopaedic Surgery University of Sydney Sydney, Australia Dean G. Sotereanos, MD Clinical Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine Orthopaedic Specialists - UPMC Pittsburgh, Pennsylvania

Scott P. Steinmann, MD Orthopedic Surgery Mayo Clinic and Mayo Clinic Health System Rochester, Minnesota Laura Stoll, MD Shoulder and Elbow Fellow Rothman Institute Thomas Jefferson University Philadelphia, Pennsylvania Robert J. Strauch, MD Professor of Orthopaedic Surgery Orthopaedic Surgery Columbia University Medical Center New York, New York Mark Tauber, MD Associate Professor Department of Orthopaedics and Traumatology Paracelsus Medical University Salzburg, Austria; Shoulder and Elbow Service ATOS Clinic Munich, Germany Samuel A. Taylor, MD Assistant Attending Orthopedic Surgeon Hospital for Special Surgery; Assistant Professor of Orthopedic Surgery Weill Cornell Medical College New York, New York Richard J. Tosti, MD Assistant Professor Orthopaedic Surgery Thomas Jefferson University Philadelphia, Pennsylvania Katie B. Vadasdi, MD Orthopaedic and Neurosurgery Specialists Greenwich, Connecticut Danica D. Vance, MD Resident, Department of Orthopaedic Surgery NYP/Columbia University Medical Center New York, New York

Contributors

Peter S. Vezeridis, MD Orthopaedic Surgeon Shoulder and Sports Medicine Surgery Excel Orthopedic Specialists Woburn, Massachusetts Russell F. Warren, MD Professor, Orthopaedic Surgery Weill Cornell Medical College; Attending Orthopaedic Surgeon Hospital for Special Surgery New York, New York Jeffry T. Watson, MD Colorado Springs Orthopaedic Group Colorado Springs, Colorado Neil J. White, MD Clinical Lecturer University of Calgary Calgary, Alberta, Canada Gerald R. Williams, Jr., MD John M. Fenlin, Jr., MD Professor of Shoulder and Elbow Surgery Department of Orthopaedic Surgery The Rothman Institute The Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania Megan R. Wolf, MD Orthopaedic Resident University of Connecticut School of Medicine Farmington, Connecticut

Scott W. Wolfe, MD Attending Orthopedic Surgeon Hospital for Special Surgery; Professor of Orthopedic Surgery Weill Medical College of Cornell University New York, New York Nobuyuki Yamamoto, MD, PhD Lecturer Department of Orthopaedic Surgery Tohoku University School of Medicine Sendai, Japan Allan A. Young, MBBS, MSpMed, PhD, FRACS (Orth) Shoulder Surgeon Sydney Shoulder Specialists Sydney, Australia Bertram Zarins, MD Augustus Thorndike Clinical Professor of Orthopaedic Surgery Harvard Medical School; Chief of Sports Medicine Service Emeritus Massachusetts General Hospital Boston, Massachusetts Helen Zitkovsky, BA Tufts University School of Medicine Boston, Massachusetts

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Preface

Operative Techniques: Shoulder and Elbow Surgery is intended to provide a clear and well illustrated step-by-step review of state-of-the art shoulder and elbow surgical procedures described by some of the most respected surgeons in this field. As opposed to traditional book chapters, this book concentrates on surgical techniques that provide the orthopedic surgeon with the finer surgical points, tips, and pitfalls. It also helps give ancillary medical care providers the insight into how these procedures are performed. This book, a continuation of the series of Operative Techniques books provided by Elsevier, concentrates on shoulder and elbow surgical procedures. Each chapter is constructed in a similar fashion. The surgical indications, physical examination, appropriate imaging studies, surgical anatomy, and treatment options are reviewed. The surgical technique portion of each chapter includes recommendations on surgical positioning, surgical portals and exposure, and step-by-step descriptions of the surgical procedure. Illustrations, surgical photographs, and in some cases, videos of the surgical procedure accompany

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the detailed surgical descriptions. The postoperative rehabilitation, the expected outcomes, and an annotated reference list are also provided. Throughout each chapter, surgical pearls, pitfalls, and controversies are discussed. We hope that these detailed surgical descriptions and discussions provide surgeons with an accessible, comprehensive reference that will provide surgical insight, increase surgical efficiency, and minimize complications when performing these operative procedures. We are fortunate to have a distinguished group of contributing authors and want to express our deep appreciation to them for sharing their time and expertise in providing their contributions to this book. We would also like to acknowledge Daniel Pepper, Berta Steiner, and Julie Daniels for their invaluable assistance in making this book possible. We hope you enjoy this book and that it is helpful to you. Donald H. Lee, MD Robert J. Neviaser, MD

Foreword

Education in the field of medicine includes many things: developing professionalism, acquiring a sense of human needs, incorporating knowledge from many sources, applying the basic sciences, studying in-depth focused problems and solutions, integrating patient-based indications, understanding structural deficiencies, knowing what medicine and surgery have to offer, and assimilating all these things and making a judgment about what should be done to help a patient. All of this is so complex. Why aren’t there books that just tell you how to do it? Early in one’s career this is very useful. Later in one’s career it’s always helpful to see how other skilled people approach a procedure, and recognize ways one can improve techniques to address a problem. The learned editors of this volume have stepped up and formulated a book focusing on when and how to do it. These experienced editors have selected the most commonly performed procedures and offered information that will be helpful to almost anyone in any stage of his or her career. The shoulder segment focuses on rotator cuff and other ­tendon-related problems, fractures, arthritis, and instability. Similarly, the elbow segment has material on musculotendinous attachment problems, fractures, arthritis, and instability. This content is supplemented by information on how to handle nerve lesions and stiffness. Chapters on approaches and on soft tissue coverage are also featured in the elbow section. Surgeons performing procedures contained in this book may be generalists or may have a focused background in trauma, sports, or adult reconstruction. But no matter from what direction one approaches shoulder and elbow surgery, one can learn from others in the discipline who may have a different subspecialization—plus the bonus of having added input from experts with one’s own background and direction.

Applied anatomy is a foundation for surgery. It is strange but true that the usual anatomy texts often don’t contain the useful anatomy that one would apply for surgical procedures. In this text, that applied anatomy is carefully displayed. It is wonderful to have a step-wise approach to surgery, but also to have subtleties explained. A number of problems can be approached by open surgery or by arthroscopic surgery. Many are primary cases, but some are revision procedures. This is a kind of textbook that one would want to pick up, read, and set down; pick up and read again; and on and on as one approaches cases in practice. It seems to me that this is the kind of book one would want to have on the shelf rather than in a library. This book will have repeated use by surgeons operating in these anatomic regions. Another bonus is the limited and focused literature on each procedure, allowing a surgeon to expand knowledge even more when addressing a specific situation. Kudos yet again to these insightful, selfless editors and the talented authors who have devoted their energy and time to putting this user-friendly book together. Robert H. Cofield, MD Professor of Orthopedics Mayo Clinic College of Medicine Emeritus Chairman, Department of Orthopedic Surgery Mayo Clinic; Past-President American Shoulder and Elbow Surgeons Past-Chairman, International Board of Shoulder and Elbow Surgery Emeritus Editor-in-Chief, Journal of Shoulder and Elbow Surgery

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PROCEDURE 1

Acromioplasty William N. Levine, Danica D. Vance, and Javier E. Sanchez INDICATIONS

INDICATIONS PITFALLS

• Massive rotator cuff tears with early proximal humeral migration INDICATIONS CONTROVERSIES

• Some authors have advocated no acromioplasty in any condition. However, this is highly controversial and not well supported by the literature over the past 3 decades.

TREATMENT OPTIONS

• Open acromioplasty • Arthroscopic acromioplasty

FIG. 1.1

4

• Symptomatic anterosuperior shoulder pain consistent with “impingement syndrome” • In association with symptomatic rotator cuff tears that are not massive • In association with partial-thickness rotator cuff tears especially on the bursal side

EXAMINATION/IMAGING • A complete shoulder examination should be performed, but the following tests are critical: • The Neer sign: pain on passive forward elevation of the shoulder while the examiner uses one hand to prevent scapular rotation. Pain is usually elicited in the arc between 70 and 120 degrees (Fig. 1.1). • The Neer impingement test: injection of local anesthetic beneath the anterior acromion with the elimination of pain with forward elevation. • Hawkin test: pain with forward flexion of the humerus to 90 degrees and then passive internal rotation (Fig. 1.2). • Acromioclavicular joint (ACJ) exam: this is important to rule out as another possible contributor to pain. Two tests are most sensitive—direct tenderness to palpation over the ACJ and a positive cross-body adduction maneuver where the patient experiences pain over the ACJ with cross-arm adduction. • Imaging • Plain films: true anteroposterior (AP), scapular outlet, and axillary lateral should be obtained in all patients. The outlet view will demonstrate the acromial morphology and any acromial pathology (spurs; Fig. 1.3). • Magnetic resonance imaging (MRI): evaluates the integrity of the rotator cuff and biceps tendon. Also identifies bony anomalies such as os acromiale, significant spurs, tuberosity cysts, or degenerative changes in the acromioclavicular or glenohumeral joints (Fig. 1.4).

FIG. 1.2

PROCEDURE 1  Acromioplasty

A

B

C FIG. 1.3 A–C

Acromioclavicular joint capsule Coracoacromial ligament

Infraspinatus tendon

Subscapularis muscle Biceps brachii tendon

FIG. 1.4

SURGICAL ANATOMY • With the arm in anatomic position the supraspinatus tendon, the anterior portion of the infraspinatus tendon and the long head of biceps lie anterior to the acromion. • Elevation of the arm in internal rotation or in the anatomic position causes these structures to pass under the anterior portion of the acromion and the coracoacromial ligament (CAL) (Fig. 1.5).

FIG. 1.5

Supraspinatus muscle

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6

PROCEDURE 1  Acromioplasty

POSITIONING PEARLS

• Use of a hydraulic arm positioner is invaluable to allow the arm to be placed in any position desired by the surgeon and obviates the need for an assistant. • The beach chair position is preferred if rotator cuff repair or conversion to an open procedure are necessary • Ensure all bony prominences are well padded.

FIG. 1.6

AC joint POSITIONING PITFALLS

• Avoid excessive traction in the lateral decubitus or beach chair position because this can lead to brachial plexus stretch injury. • Ensure that the patient is brought far lateral (in the beach chair position) to avoid mechanical block of access to the shoulder by the operating table. • When using the beach chair position, caution should be taken to ensure the head and neck are properly padded and in the neutral position. Excessive flexion or extension can endanger airway access in cases of emergency.

Coracoid Acromion

FIG. 1.7 POSITIONING EQUIPMENT

• Hydraulic-controlled arm holder • Specific beach chair with table with back that slides from one side to the other to allow unencumbered access to the operative shoulder POSITIONING CONTROVERSIES

• Lateral decubitus versus beach chair. For this procedure, there is no clear superiority. However, we prefer beach chair because this procedure is usually performed in conjunction with a rotator cuff repair. We prefer lateral decubitus position for labral and capsulorrhaphy procedures.

• Bone spurs on the anterior surface of the acromion may lead to impingement on the cuff, resulting in cyclic microtrauma with repetitive overhead use of the arm.

POSITIONING • Arthroscopy can be performed with the patient placed in either the beach chair positioning or in the lateral decubitus position. We prefer the beach chair position for this procedure (Fig. 1.6). • A hydraulic arm positioner is helpful to maintain the arm in the desired position throughout the procedure. • Once correctly positioned, the bed is rotated so that the operative shoulder is at the center of the operating room. • The coracoid process, ACJ, acromion, and distal clavicle are palpated and outlined with a marking pen (Fig. 1.7).

PROCEDURE 1  Acromioplasty

Anterior

Midlateral Posterior PORTALS/EXPOSURES PEARLS

FIG. 1.8

PORTALS/EXPOSURES • The posterior portal is placed at the “soft spot” located approximately 1 cm medial and 1–2 cm inferior to the posterolateral corner of the acromion. • While viewing from the posterior portal, the anterior portal is placed lateral to the coracoid process, in the rotator interval between the supraspinatus and subscapularis. • A third midlateral portal is placed using a spinal needle under visualization of the arthroscope, 3 cm lateral to the acromial edge and parallel to the under surface of the acromion (Fig. 1.8). • Seven-millimeter clear cannulas are inserted to enable instrument removal and insertion.

PROCEDURE Step 1 • A diagnostic glenohumeral arthroscopy is performed from the posterior portal evaluating for loose bodies, synovitis, fraying or tearing of the biceps tendon, labrum, glenohumeral ligaments, or rotator cuff. • The entire articular surface of the humeral head and glenoid is examined by rotating the arthroscope superiorly and the humeral head into internal and external rotation. • The right shoulder is seen through the posterior portal on Fig. 1.9.

Instrumentation/Implantation • Standard 4.0-mm arthroscope

Step 2 • The arthroscope is introduced into the subacromial space from the posterior portal. • A blunt trocar is inserted into the posterior portal, and the posterior acromion is palpated. • The trocar is slid directly underneath the acromion and aimed toward the CAL to gain access to the subacromial space. • Keep the scope trochar at the CAL as you switch to the scope maintain orientation. • The midlateral or anterolateral subacromial portal is established after localization with an 18-gauge spinal needle. An arthroscopic shaver or cautery is introduced into the midlateral portal and used to perform a synovectomy and debridement of the subacromial bursa (Fig. 1.10). • The soft tissues from the undersurface of the acromion are debrided, extending from 2.5 cm posterior to the anterior edge of the acromion to the CAL. • The bursal “veil” is identified and resected to increase visualization. The arrows in Fig. 1.11 point to the superior and inferior aspects of the bursal veil. • If a partial tear of the rotator cuff is observed a limited debridement of the frayed portion is performed. The torn portion is not expanded or sutured.

• Use a spinal needle before committing to any portal position to ensure appropriate trajectory to the glenohumeral joint (anterior portal) and subacromial space (anterolateral or midlateral subacromial portal). PORTALS/EXPOSURES PITFALLS

• Avoid too proximal position of the midlateral subacromial portal—difficulty with trajectory and access to acromion for acromioplasty. • Avoid too distal position of the midlateral subacromial portal—potential damage to the circumflex branch of the axillary nerve. STEP 1 PEARLS

• Tactile feedback during initial insertion of the trocar can be achieved by keeping the arm out of the arm positioner. An assistant can provide shoulder abduction to help distract the glenohumeral space. STEP 1 PITFALLS

• Do not place in arm positioner until after the arthroscope has been successfully placed in the glenohumeral joint to avoid a “transhumeral” portal. STEP 2 PEARLS

• Sweep the subacromial bursa with the blunt scope obturator to create a space within the bursa to aid in visualization. • The bursa veil demarcates the anterior one-third and posterior two-thirds of the acromion. By removing the bursal veil early in the procedure, the subacromial space is easily visualized and exposed. • When moving laterally into the gutter of the cuff, one can turn the protective sheath of the shaver away from the deltoid fascia to avoid any significant bleeding. • Hemostasis can be achieved by controlled induced hypotension by anesthesia, increasing pump pressure and use of electrocautery. STEP 2 PITFALLS

• Never shave blindly. If you cannot visualize the shaver, take a moment to triangulate or repeat step 1.

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PROCEDURE 1  Acromioplasty

Biceps

Humeral head Glenoid Labrum Subscapularis

FIG. 1.9

FIG. 1.10

FIG. 1.11

Instrumentation/Implantation • Standard 4.0-mm arthroscope • Arthroscopic shaver • Arthroscopic electrocautery

Step 3 • The CA ligament is completely detached from its acromial end, exposing the acromial spur. The double-ended arrow in Fig. 1.12 indicates the size of the spur. • An anterior acromioplasty is preformed viewing from the posterior portal while using an arthroscopic shaver or burr via the lateral portal. • The shaver or burr is used to begin the acromioplasty from the anterolateral aspect of the acromion, working toward the anteromedial aspect. • The anterior third of the undersurface of the acromion is resected using the anterior deltoid periosteal fibers as a guide to indicate an adequate resection of the spur while preserving the deltoid origin and avoiding deltoid dehiscence.

PROCEDURE 1  Acromioplasty

FIG. 1.12

• The entire anterior edge of the acromion is debrided to remove any protuberances. • The arthroscope is placed in the anterolateral portal to ensure a smooth transition from posterior acromion to the resected anterior acromion. A burr can be inserted into the posterior portal to smooth any retained ridge.

Instrumentation/Implantation • Aggressive shaver, cautery, or burr. • Be prepared for biceps tenodesis, labral repair, and rotator cuff repair.

Step 4 • The ACJ should be resected only if the examiner elicited tenderness to palpation or AC joint pain with the adduction maneuverer preoperatively. • Radiographic assistance in decision making on the ACJ should generally not be relied upon due to the high incidence of “abnormal findings” on preoperative radiographs and MRIs. However, edema in the lateral clavicle and/or medial acromion in a T2-weighted MRI is highly suspicious of a symptomatic ACJ.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperatively the arm can be supported using a sling for no more than 3 days. • Pendulum exercises may be started on postoperative day 1. • Active and passive elevation may be started between postoperative days 1 and 4. • Isometric exercises of the deltoid and rotator cuff may begin by the fourth day. • Starting in the second postoperative week, light exercises against resistance may be started. • Patients are encouraged to use their arm as normally as possible with the exception of athletics or overhead work. • Patients are expected to return to activities of daily living within the first few days after surgery, and those who have desk jobs return to work in 2–3 days. • Most patients have full return of active range of motion by 3 weeks. • Patients whose jobs require heavy lifting or repetitive overhead activity took 6 weeks or longer. • Return to overhead sports is allowed after 6 weeks.

STEP 3 PEARLS

• View from multiple portals to ensure an even resection. STEP 3 PITFALLS

• Avoid deltoid detachment. • Underresection will cause continued impingement and symptoms.

STEP 4 PITFALLS

• Avoid iatrogenic instability by preserving the posterior and superior aspects of the ACJ.

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PROCEDURE 1  Acromioplasty

EVIDENCE Altchek DW, Warren RF, Wickiewicz TL, Skyhar MJ, Ortiz G, Schwarz E. Arthroscopic acromioplasty: technique and results. J Bone Joint Surg [Am] 1990;72:1198–207. The study provides the technique and results of arthroscopic acromioplasty on 40 patients over a 2-year period. After a minimum follow-up of 12 months all but one patient had improvement in pain. Seventy-three percent of patients had good or excellent results. Ten percent of patients had a failed result. Andrews JR, Carson WG, Ortega K. Arthroscopy of the shoulder: technique and normal anatomy. Am J Sports Med 1984;12:1–7. A review of the technique for shoulder arthroscopy. Bigliani LU, Levine WN. Subacromial impingement syndrome. J Bone Joint Surg [Am] 1997;79:1854–68. A review of the current concepts in the etiology, diagnosis, and treatment of impingement syndrome. Ellman H, Kay SP. Arthroscopic subacromial decompression for chronic impingement: two to five year results. J Bone Joint Surg [Br] 1991;73:395–8. Analysis of the long-term results of 65 cases of arthroscopic subacromial decompression for impingement syndrome, without full-thickness rotator cuff tears. Gartsman GM. Arthroscopic acromioplasty for lesions of the rotator cuff. J Bone Joint Surg [Am] 1990;72:169–80. Comparison of the results of arthroscopic acromioplasty for subacromial impingment in 165 patients without rotator cuff tears (100 patients), with partial tears (40 patients), and with complete tears (25 patients). Acromioplasty was found to be effective in patients with no tear or with a partial tear. Patients with massive rotator cuff tears had unsatisfactory results. Harrison AK, Flatow EL. Subacromial impingement syndrome. J Am Acad Orthop Surg 2011;19:701–8. An overview of subacromial impingement syndrome including nonsurgical and surgical management. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med 1980;8:151–8. An overview of shoulder impingement in athletes, including: functional anatomy, differential diagnosis, physical examination, and treatments based on stage of the disease. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg 1972;54:41–50. The author reported on 50 shoulders of 47 patients treated with anterior acromioplasty over the course of 5 years. There was an average follow up of 2.5 years. He also described the anatomy and pathophysiology of symptomatic impingement syndrome. Potter HG, Birchansky SB. Magnetic resonance imaging of the shoulder: a tailored approach. Tech Shoulder Elbow Surg 2006;6:43–56. Seeger LL, Gold RH, Bassett LW, Ellman H. Shoulder impingment: MR findings in 53 shoulders. AJR Am J Roentgenol 1988;150:343–7. MR scans of 107 shoulders in 96 patients reviewed, those who had undergone invasive procedures prior to imaging were not included; 53 shoulders with impingement syndrome were identified. Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Am J Sports Med 2003;31:154–60.

PROCEDURE 2

Rotator Cuff Repair: Open Technique for Partial-Thickness or Small or Medium Full-Thickness Tears Allan A. Young and David H. Sonnabend INDICATIONS PITFALLS

INDICATIONS • Rotator cuff repair is indicated in patients with a documented tear ± subacromial impingement syndrome who remain symptomatic despite 3–6 months of nonoperative management. • Acute repair is indicated in younger symptomatic patients (