Shoulder Surgery

TWO CASES FOR THOUGHT - TWO TREATMENT MODALITIES
The Theme: No Surgery or ONLY Key Hole Surgery
NO SURGERY for Shoulder Impingement Pain
Introduction:
Shoulder pain is a common problem around forty year old. The common reason for pain in the
shoulder is Subacromial bursitis, impingement syndrome and rotator cuff tendinitis. The mobility of
the shoulder gets reduced with stiffness in the shoulder joint dominating the presentation. Night
pain is not uncommon.
Case example:
Though we get plenty of cases with this problem, we wish to demonstrate one case as an example
for the purpose of understanding. In patients of mid forty there are multitude of factors that would
play. The reduction in blood supply to the tendon at the insertion site and change of morphology of
acromion are the key factors. The change of morphology of acromion is due to scapula dyskinesia
which lot of patients around mid forties have without their knowledge.
Scapula dyskinesia:
Normal shoulder joint movement is very rhythmic of which two third comes from Glenohumeral joint
and one third comes from scapulothoracic joint. Stooping in posture is a sign one can witness in
many patients with shoulder pain. The malfunction of periscapular muscles is the key factor that
causes postural change in the shoulder. The muscles that are important are Rhomboids, Levator
Scapula, Trapezius, Lattisimus dorsi and Serratus Anterior.
Our patient is 42 year old man with shoulder pain for around 6 months time. He had few
consultations elsewhere and underwent supportive treatment with no big relief. Clinically his flexion
and internal rotation of the shoulder joint is painful. Scapula is dysrhythmic on assessment.
Management:
This patient is subject to our Madurai Shoulder Pain Cure Programme’s Protocol. This protocol
constitutes of two phases. Phase 1 is for two weeks. During these two weeks he was made to do
7 types of Scapula exercises that will focus on individual scapula muscle function. It involves doing
isometric activity to recruit the fibres. Each muscle activity is done for a count of 10 and it is
repeated 10 times every day. These exercises were done for three days. Then Stretching
exercises for the shoulder are started. Stretching exercises would constitute Inferior capsular,
Anterior capsular and Posterior capsular stretching exercises. Stretches are done for a period of 10
counts and it was done for 10 times. These exercises are started from 4th day onwards along with
Scapula exercises. From 8th day onwards Rotator cuff isometric exercises are started. Every day
these exercises are carried under strict supervision of physiotherapist and by 14th day, the patient
has achieved around 60% improvement of pain and function.
After completion of Phase one, phase two is done for a period of 4 weeks. Instruction is given to
the patient to do the exercises at home. A review of the improvement is done on a weekly basis.
The pain relief and improvement of range of motion has occurred over the end of 6 weeks. Now
the patient is completely satisfied with pain free range of motion
Discussion:
Rotator cuff tendinitis is a common problem around the middle age. The incidence is much higher
in diabetics and hypothyroid patients. The pain severity ranges from mild pain to night pain that can
disturb sleep. If identifiable at an early stage then the rehabilitation with our protocol will make
relief in symptoms. Our experience suggest about 8 out of 10 patients can be well treated with this
protocol. The non responders of the protocol will need arthroscopy.
Key hole Surgery for Big Bony Bankart Lesion
Introduction:
Anteroinferior labral lesion is the pathology in the recurrent shoulder

dislocators. The treatment modalities consists of Arthroscopic repair or
open repair. When a bone graft is needed, an open procedure is sought
due to complexity. Now we have followed a technique by which even a
bone graft procedure can be done arthroscopically. This arthroscopic
procedure also adds an advantage of performing soft tissue procedure
also along with bone grafting. Being an arthroscopic procedure the
recovery is quick along with excellent results.
Case report:
A 20 year-old, kabbadi player, right-hand dominant, came to our
OPD with a history of 27 episodes of dislocation to his right shoulder in a
time frame of 2 months. He developed the first episode of dislocation
which was managed in the field two months back. The second episode
of dislocation occured two weeks later while playing kabaadi.
Following this he developed 25 further episodes of dislocation within the

short period. The joint was so unstable that he dislocates his shoulder
during sleep. On doing clinical assessment, apprehension and
relocation tests were strongly positive. He was evaluated with CT and
MRI shoulder to assess the extent of bone loss, labral and other soft
tissue injury respectively. His scans showed Bony Bankart lesion with
bone loss in glenoid quantified as 15%, Hill Sachs defect in the humoral
head of 1.6cm and the labral tear is documented from the 1'0 clock to
7'0 clock position.
Management:
Considering his age and level of activity, the management for

restoring the shoulder stability is by surgical augmentation of glenoid
with bone graft.
These procedures include the Open or Arthroscopic Latarjet Bristow

technique (transfer of an autologous coracoid graft to the anterior
glenoid), Iliac crest bone graft(ICBG) transfer technique.
Arthroscopic modifications of Latarjet and ICBG procedures are well

documented too in the literature.
In general, arthroscopy allows the assessment and management of

coexisting shoulder pathologies and being minimally invasive, it can
allow easier rehabilitation, earlier return to work, and better cosmesis
than equivalent open procedures.
Procedure:
We proceeded with arthroscopic iliac crest bone graft for glenoid and
labral repair for this patient. The positioning of the patient is no different
from routine arthroscopic bankart procedure. The affected extremity as
well as the ipsilateral iliac crest are prepared and draped in a sterile
fashion. Diagnostic arthroscopy is performed to identify actual bone
defect volume. With a measuring gauge the size of the bone loss an d
bone graft needed is assessed arthroscopically.
The capsulolabral complex is elevated off the scapular neck, and the
glenoid rim is prepared with a motorized burr.The autologous tricortical
iliac crest bone block is harvested from the ipsilateral side and is
contoured appropriately. A specifically designed drill-guide is used to
make transglenoid tunnels through which sutures are shuttled to railroad
the sutures looped through the graft. When the final graft position is
satisfactory, the sutures are fastened from the posterior side to achieve
the compression of the graft to the glenoid. This method is a nonrigid
fixation technique for reconstructing the anterior glenoid defect. Finally,
the capsulolabral complex is reattached with suture anchors to complete
the anatomic reconstruction. The anatomic pear-shaped configuration of
the glenoid can be successfully reconstructed with this reproducible
technique.
Preparation of Glenoid Bed
Insertion of Bone Graft

Following anchoring of Bone Graft & Labral Repair
Discussion:
The anteroinferior labral tear and anteroinferior glenoid bone defect
are the primary lesions in traumatic anterior shoulder instability. When
the bone loss in the glenoid exceeds 20%, the glenoid shape changes to
an inverted-pear shape, in which the superior half is wider than the
lower half. This is an indication for bone reconstruction of the glenoid.
The other indications are when glenoid bone loss is between 10% and
20% in younger patients (aged <20 yr) involved in competitive or contact
sports, in bipolar lesions involving glenoid and humeral head.
For patients with significant glenoid bone loss and other risk factors
for failure of surgical repair, procedures involving augmentation of the
anterior glenoid with a bone graft yield lower rates of recurrent instability.
The Latarjet technique is a successful procedure whether performed

by an open technique or by arthroscopy. It accomplishes skeletal
stability by rigid fixation using screws. The complications include
hardware impingement, bone graft nonunion, secondary osteoarthritic
change. This method is not an anatomic repair, as it involves
subscapularis splitting and coracoid transfer and insertion. Arthroscopy
variant of this technique offers the advantage of in addition to potential
cosmetic benefits, the preservation of the integrity of the subscapularis
tendon insertion. A fatty degeneration and atrophy of the subscapularis
muscle can therefore be prevented.
Arthroscopic iliac crest bone graft for glenoid has the several
advantages. This technique doesn’t involve any metal implants. It can be
customised to accommodate any amount of bone loss and shape. The
procedure allows anatomic reconstruction of the glenoid. The technique
is less abrasive and achieves a better contour than use of the coracoid.
Performing the technique is faster than performing coracoid osteotomy.
Soft-tissue balancing can be achieved.The all-arthroscopic approach
offers better cosmesis, faster rehabilitation, and a return to preinjury
activity levels. Disadvantages include donor-site morbidity is possible.
The insertion of the bone graft through those small keyhole incisions is a
skill demanding step. The procedure requires good sets of arthroscopic
skills to work inside the shoulder joint to earn good results. Clinically,
good to excellent results can be achieved consistently.

Shoulder Surgery

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TWO CASES FOR THOUGHT - TWO TREATMENT MODALITIES

The Theme: No Surgery or ONLY Key Hole Surgery

NO SURGERY for Shoulder Impingement Pain

Anteroinferior labral lesion is the pathology in the recurrent shoulder

Following this he developed 25 further episodes of dislocation within the

Considering his age and level of activity, the management for

These procedures include the Open or Arthroscopic Latarjet Bristow

Arthroscopic modifications of Latarjet and ICBG procedures are well

In general, arthroscopy allows the assessment and management of

Preparation of Glenoid Bed

Insertion of Bone Graft

The Latarjet technique is a successful procedure whether performed

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