Shoulder Injuries in the Throwing Athlete

The throwing athlete with shoulder pain presents a diagnostic and treatment challenge to the orthopaedic surgeon. Because pitching a baseball requires the arm to accelerate at 7,000 degrees per second, tremendous forces are experienced at the shoulder joint. Electromyographic studies have shown that the larger scapular and trunk muscles are primarily responsible for arm acceleration. The smaller and more fragile rotator cuff muscles play a significant role in decelerating the arm. During the entire throwing mechanism, the rotator cuff and the capsulolabral complex act to stabilize the humeral head on the glenoid fossa. As a result, the labrum, the capsule, and the rotator cuff are frequently the site of shoulder injury in throwers. The diagnosis of injury to these structures is based on the findings from the history, physical examination, and imaging studies. The majority of throwing injuries respond well to a carefully designed rehabilitation program. Athletes who do not improve within 6 months are candidates for surgical repair. The procedure is planned so as to minimize the amount of surgical trauma and thereby to facilitate an early return to sport. Arthroscopy is a valuable first step to confirm the pathologic diagnosis. The arthroscope alone is used to perform subacromial debridement, labral repair, or debridement of undersurface partial-thickness rotator cuff tears. If the athlete has clinical evidence of shoulder instability and arthroscopic evidence of capsular stretch, an open stabilization procedure is performed.     

Therapiestrategie bei vorderer Schulterinstabilität

The treatment for instability of the shoulder joint depends on pathologic alterations, the frequency of reluxation and the patient’s ambitions in terms of function. The arthroscopic stabilization is indicated following a first luxation and in the presence of recurrent traumatic instability of the shoulder (up to 5 recurrences) without hyperlaxity. Otherwise instability should be treated by open surgical techniques. The arthroscopic Bankart operation using suture anchors is a reliable technique, but it is the classic open Bankart operation that is still regarded as the gold standard. The adjuvant capsuloplasty techniques also have to be regarded as classic open surgical procedures. A severe defect of the glenoid rim can be built up in ¶J-span technique, or treated extraanatomically with a coracoid transfer. Specific indications for operative stabilisation are concomitant rotator cuff tears in older patients, a concomitant subscapularis tear, and the so-called “terrible triad”. The voluntary, multidirectional positional instability according to Gerber VI is a special case, being inoperable in our opinion.     

Osteonecrosis of the Humeral Head

Current understanding of osteonecrosis of the humeral head is largely based on previous studies of the femoral head. Similarities between the two sites are numerous, but the shoulder has many unique characteristics. The anatomy of the glenohumeral joint, motion at the scapulothoracic joint, the rich vascular supply of the surrounding soft tissues, and the accommodations for the different forces (shear, compression) exerted across the glenohumeral joint all allow the shoulder to tolerate a greater amount of deformity. A number of pathologic agents can cause bone death by disrupting the blood supply, among them corticosteroid use, trauma, dysbarism, hemoglobinopathies, and various systemic diseases that disrupt the vascular system, such as Gaucher's disease and systemic lupus erythematosus. Management is similar to that of femoral osteonecrosis; the earlier stages respond well to nonoperative approaches, and the more advanced stages require surgical intervention. Hemiarthroplasty and total shoulder arthroplasty have produced good outcomes. Surgical intervention with core decompression, vascular flaps, and arthroscopic debridement have also shown promise, but further studies are necessary to define their optimal use.     

肩关节镜带线锚钉内固定术治疗复发性肩关节脱位

目的：探讨肩关节镜下带线锚钉内固定术治疗复发性肩关节脱位的效果。方法：选取复发性肩关节脱位患者76例,随机分为观察组与对照组各38例,观察组采用肩关节镜下带线锚钉内固定术治疗,对照组给予改良Bristow手术治疗。结果：观察组UCLA评分（33.13±1.49）分,VAS评分（0.54±0.49）分,外展90°位外旋角度（73.62±13.98）°,肩关节前屈上举角度为（157.24±17.38）°,优良率97.37%,均优于对照组的78.9%（P＜0.05）。结论：肩关节镜下带线锚钉内固定术治疗复发性肩关节脱位,具有良好的应用价值,改善肩关节功能。     

Technik und Stellenwert der arthroskopischen Implantatentfernung an der Schulter

Arthroscopic implant removal involves innovative minimally invasive surgical techniques which offer the advantages of minimally invasive surgery in addition to the possibility of glenohumeral inspection, arthrolysis and treatment of concomitant intraarticular pathologies compared to open surgical procedures. In the following article the surgical techniques and significance of arthroscopic implant removal from the shoulder joint will be described. The first results of a complete arthroscopic plate removal from the humeral head will be described. Compared to the open technique, greater satisfaction of the patients, more rapid pain relief and improvement of the shoulder function in the early postoperative time could be observed. During the follow-up interval the results of the two techniques converge.     

Arthroscopic rotator cuff tear repair

Rotator cuff injuries or disease can be particularly troubling to patients by causing them pain, weakness, and dysfunction of the shoulder. Surgery of the shoulder and, in particular, of the rotator cuff, has evolved over the years from open surgery to include arthroscopic treatment for many conditions. Although technically demanding, arthroscopic repair of full- and partial-thickness rotator cuff tears has been shown to produce satisfactory results. Along with the advantages of the arthroscopic technique, smaller skin incisions, access to the glenohumeral joint for inspection and treatment of intra-articular lesions, no detachment of the deltoid, and less soft-tissue dissection, patients' results are comparable with those obtained with the open method of repair. The three phases of shoulder rehabilitation for patients who have undergone surgical treatment of rotator cuff disease are described: Phase 1, the immediate postoperative, or protective, phase; phase 2, the progressive strengthening phase; and phase 3, the advanced conditioning and return-to-sport phase. The postoperative rehabilitation programs for the arthroscopic and mini-open rotator cuff repair are essentially the same.     

Plica: Pathologic or Not?

A fold that occurs within a joint is referred to as a plica synovialis. Three such plicae are seen with regularity within the human knee joint. These folds are normal structures that represent remnants of mesenchymal tissue and/or septa formed during embryonic development of the knee joint, and can be seen during arthroscopic inspection of the knee joint. Controversy exists within the orthopaedic community as to whether a plica can develop pathologic changes sufficient to cause disabling knee symptoms. The author defines the clinical syndrome, describes the arthroscopic appearance of pathologic plica, and outlines nonsurgical and surgical methods of management of this uncommon condition.     

Endoprotheseninfektionen der Schulter

Periprosthetic shoulder joint infections are encountered by orthopedic surgeons mainly as complex situations which are highlighted by difficult treatment modalities. In a confirmed infection the general therapeutic principle is a surgical procedure. Several strategies orientate on the cause of an infection, the time course of postoperative symptoms, the pathogenicity of the isolated species and the specific comorbidities of the patient. An arthroscopic joint lavage with open debridement and component change may suffice in selected acute cases whereas a two-stage revision augmented by an articulating antibiotic spacer is mandatory in chronic infections. Early recognition is of paramount importance in order to prevent further spread, sepsis or even fatal outcome. Low grade infections are challenging conditions in terms of diagnosis and treatment. This article summarizes the principles of current classification, detection and treatment strategies for periprosthetic shoulder joint infections.     

Arthroscopy of the shoulder: general principles and stages for promoting competence

Arthroscopic surgery of the shoulder has replaced several open procedures because of minimal morbidity. However, like other joint arthroscopic procedures, it involves a significant learning curve. In addition, it requires availability of special equipment and certain operating conditions. It is advisable to achieve enhanced experience and competence in diagnostic arthroscopy and then to practice arthroscopic surgery in a staged manner. This review aims to provide an outline of current knowledge about general principles of shoulder arthroscopy, diagnostic arthroscopy, and arthroscopic surgical procedures.     

关节镜技术的发展与创新

本期刊登了关节镜外科临床应用相关的一组论文,展示了我国关节镜技术临床应用相应现状。关节镜技术用于关节内疾病观察检查、诊断和治疗,是一种微创骨科手术技术,符合现代外科的发展趋势。随着在临床广泛开展了对膝关节疾病的关节镜下手术治疗,关节镜技术逐步应用到肩、肘、腕以及髋、踝等关节,更有在小关节应用关节镜技术。手术范畴也从初始的关节清理发展到今天众多的修复、重建技术以及在关节外应用的系列创新术式,并对关节镜技术的基础和临床进行了深入的研究和探讨。关节镜外科已成为现代骨科不可或缺的分支。     

肩关节镜手术沙滩椅位患者脑氧饱和度的研究进展

随着微创技术的发展和现代生活日益增长的需求，关节镜因其创伤小、恢复快在手术中应用日趋广泛，其中肩关节镜手术发展日渐成熟，在肩关节疾病治疗中占有重要地位。因为手术部位的特殊性，在肩关节镜操作过程中往往采用特殊的手术体位，导致患者脑氧饱和度降低，其围术期管理具有不同于一般手术的特点，如何更好地进行围术期管理是麻醉科医师不断追求的目标。本文将介绍肩关节镜手术沙滩椅位患者术中脑氧饱和度问题，为减少围术期并发症的发生，加速患者康复提供新的思路和视角。     

巨大肩袖损伤关节镜手术治疗进展

巨大肩袖损伤的手术治疗是骨科医师面临的一个挑战,且肩袖撕裂后肌腱回缩、粘连及脂肪浸润会进一步加大手术修复难度,所以如何更好地修复巨大肩袖损伤成为了目前研究的热点与难点。近年来,随着关节镜技术不断发展,肩关节镜手术已成为治疗巨大肩袖损伤的金标准,但其不同术式的适应证、效果及联合应用仍存在争议。笔者认为对于功能要求较低的老年患者,可行肩关节清理联合肩峰成形术或肱骨大结节成形术,可短期缓解患者肩关节疼痛;对于伴有肱二头肌长头腱损伤的患者,肱二头肌长头腱切断或固定术效果显著;完全修补术依旧是巨大肩袖撕裂的一线治疗方法,而对于无法完全修补的巨大肩袖撕裂可行部分修补术;对于功能需求较高的年轻患者,补片增强技术可带来良好的效果;对于肩关节内外旋能力受限且功能要求较高的患者,建议选用肌腱转位术;对于无明显盂肱关节炎、三角肌力量较好、功能要求较高的患者,上关节囊重建术更具优势。此外,肩峰下假体植入术因其创伤小、费用低、相对安全等优点成为目前研究热点,其长期效果仍需进一步证实。     

The shoulder in baseball pitching: biomechanics and related injuries-part 2

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. The athlete's symptoms and signs, as well as radiographic imaging, are key elements in arriving at a diagnosis of shoulder injuries. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance.     

Arthroscopic biologic total shoulder resurfacing—Are you kidding?

The treatment of large, bipolar osteochondral lesions of the glenohumeral joint in young, active patients is challenging. When conservative treatment fails to provide acceptable results, restorative and reconstructive options are often considered. Despite its success in relieving pain and restoring function, total shoulder arthroplasty has significant drawbacks for young patients. One surgical option is an all-arthroscopic osteochondral total shoulder resurfacing using fresh osteochondral allografts. By using an arthroscopic approach, damage to surrounding structures, including the subscapularis, is minimized, resulting in decreased morbidity and rehabilitation required after surgery when compared to standard total shoulder arthroplasty.     

Arthroscopic resection of the distal clavicle in osteoarthritis of the acromioclavicular joint

Background:Symptomatic acromioclavicular joint (ACJ) lesions are a common cause of shoulder complaints that can be treated successfully with both conservative and surgical methods. There are several operative techniques, including both open and arthroscopic surgery, for excising the distal end of the clavicle. Here, we present a new modified arthroscopic technique for painful osteoarthritis of the ACJ and evaluate its clinical outcomes. Our hypothesis was that 4- to 7-mm resection of the distal clavicle in an en bloc fashion would have several advantages, including no bony remnants, maintenance of stability of the ACJ, and reduced prevalence of heterotopic ossification, in addition to elimination of the pathologic portion of the distal clavicle.Results:The overall UCLA score was 13.7 preoperatively, which improved to 33.4 postoperatively. All subscores were improved significantly (P < 0.001). There were no specific complications at the latest followup.Conclusion:It is critical in this procedure to resect the distal clavicle evenly from superior to inferior in an en bloc fashion without any small bony remnants and to preserve the capsule and acromioclavicular ligament superoposteriorly. This arthroscopic procedure is a reliable and reproducible technique for painful osteoarthritis of the ACJ lesions in active patients engaged in overhead throwing sports and heavy labor.     

关节镜下肩胛下肌松解术治疗肩胛下肌损伤28例疗效观察

背景:关节镜下治疗肩袖损伤技术已经成为主流治疗手段,但对于肩胛下肌引起的肩袖问题的手术治疗研究较少.目的:观察关节镜下肩胛下肌松解术治疗肩胛下肌损伤的疗效.方法:回顾性研究关节镜下松解术治疗的28例肩胛下肌损伤患者的病例资料.其中男13例,女15例,年龄33～52岁,平均(42.7±5.8)岁.LafosseⅠ型10例...     

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.     

术前肩关节功能训练对合并冻结肩的肩袖损伤患者手术效果的影响

背景:目前对合并冻结肩的肩袖损伤患者的手术时机有一定争议,部分研究认为应先通过肩关节功能训练在一定程度上缓解冻结肩后再手术,也有研究认为推迟修复肩袖的手术可能会导致肩袖损伤进一步扩大,影响修复效果.目的:探讨合并冻结肩的肩袖损伤患者术前肩关节功能训练后行关节镜下肩袖修复关节松解术与入院后一期行关节镜手术的临床疗效差别....