Suprascapular nerve – anterior approach

Yesterday I compared the traditional lateral approach to the suprascapular nerve to the anterior approach described by Butch Krishnan. I am more familiar with the lateral (Lafosse) approach but the anterior approach was quite straightforward. I have done it in cadavers and on a few patients but not in quite a while. I was in the area because the patient might have had some conjoined tendon / pectoralis minor trauma (he did). I saw the nerve more clearly from the anterior approach but the ligament more clearly from the lateral approach. I wonder if anyone has had similar (or different) experiences?

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Update from San Diego Shoulder Meeting 2011

It’s hard to use the term, San Diego Shoulder Meeting or San Diego Shoulder Institute. Everyone (including me) refers to it as the Esch Meeting. Jim’s hand is everywhere insuring that the quality he has demonstrated over the last 28 years continues.

The meeting was outstanding once again. Wednesday started with Lab sessions with shoulder models. The lectures started at 1 with a focus on Shoulder Arthroplasty and then Reverse Shoulder Arthroplasty. If an 8-5 day wasn’t enough you could go 7-9 with a Fracture Fixation or Total Shoulder Workshop.  Thursday morning was instability and the afternoon focused on rotator cuff issues. 12-1:30 was blocked out for a Shoulder Arthroscopy workshop.  Friday morning started with a Shoulder Ultrasound workshop. Led by Don Buford, MD and Ben DuBois, MD, this one had plenty of Sonosite machines and models for a real “hands-on” experience. You also had the option of a morning cadaver lab at UCSD. Friday afternoon focused on Shoulder Rehabilitation lectures and then was time for either a Shoulder Arthroplasty workshop or an interesting session on Improving Your Practice with a lot of Q&A.  Saturday morning started with Fractures, Complications and Advanced Practice Issues and moved to Massive Rotator Cuff Tears in the late morning. At 2 the bus left for UCSD and another cadaver laboratory. What a meeting!

I’ll go into more detail but even the summary above is impressive.

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Shoulder surgery recent articles on

Samer Hasan and I wrote the first What’s New in Shoulder and Elbow Surgery for the JBJS. Actually, it was the first What’s New JBJS review article. I have always felt that there should be a location for this type of information that came out more than once a year. Dr. Hasan has undertaken this project and we will evaluate the interest level and then determine if it should continue. A surgeon can go to each of the meetings or use PubMed or one of the many excellent search tools to review recent articles by keywords but there are two fundamental issues. First, how does the surgeon (or medical industry professional) select which of the hundreds (or thousands) of articles to read and second, how relevant (truthful, useful etc) are each of these articles. We think there is a place for some sort of expert-refereed summary of recent articles.

Here is a sample of what he wrote.

G9-MD What’s New in Shoulder Surgery 2011

Samer S. Hasan, MD, PhD

  1. Rotator Cuff

Several studies explored the demographics of partial thickness and full thickness rotator cuff tears.

  1. Asymptomatic Rotator Cuff Tears: Patient Demographics and Baseline Shoulder Function

Keener and colleagues reported on the demographic features and physical function of subjects with asymptomatic rotator cuff tears. The study included 196 subjects with an asymptomatic rotator cuff tear as well as a control group of 54 subjects with an intact rotator cuff tear presenting with a symptomatic contralateral rotator cuff tear. The authors found similar demographic features for both study and control groups. Subjects with an intact rotator cuff had greater American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores than those with an asymptomatic tear, but these differences were felt to be clinically insignificant. Hand dominance was associated with the presence of shoulder pain. The authors found no differences in functional scores, range of motion, or strength between partial-thickness tears and full-thickness tears, or in functional scores among full-thickness tears of various sizes. The authors concluded that the asymptomatic rotator cuff tear is associated with a clinically insignificant loss of shoulder function compared with an intact rotator cuff. Consequently, a clinically detectable decline in shoulder function may signal an “at-risk” asymptomatic tear. The onset of pain may be important for creating a measurable loss of shoulder function in cuff-deficient shoulders.2.

2.       Symptomatic Progression of Asymptomatic Rotator Cuff Tears

In a complementary study by the same group (Mall et al.), the authors found that pain development was associated with progression of the tear. Specifically 18% of full-thickness tears increased > 5 mm in size and 40% of partial-thickness tears had progressed to a full-thickness tear.  The onset of pain was associated with a decline in range of motion and ASES score. Furthermore, subjects who developed pain were found to have larger tears at initial evaluation compared with subjects who remained asymptomatic. The authors suggested that further research into prophylactic treatment of asymptomatic shoulders to maintain comfort and function is needed.

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Proximal Humerus Fractures – Joseph Zuckerman, MD

Dr. Zuckerman makes some excellent points in the presentation he gave at the Current Solutions Shoulder and Elbow Course held in Tampa, Florida this January.  Many of you call it the Frankle Meeting. One of the many things I like is his lecture style. He tells you what he is going to say, says it, and then tells what he said. It is an old trick performed brilliantly by a not-so-old rhetorician.

He makes the point of treating the person with the fracture, not just the fracture. This is something we are all aware of but it came to life today when I saw an 83 year old woman who had fallen three days previously and sustained a humeral surgical neck fracture with a mildly displaced (posterior) greater tuberosity fracture. We talked about treatment options and she just wanted a sling since “I didn’t use that arm very much overhead before.”

Interestingly, Zuckerman states that he uses open reduction and  internal fixation more commonly than he did a decade ago, as our understanding of medial calcar importance and bone grafting techniques has improved, along with the increased sophistication and efficacy of internal fixation devices.

I was struck by his comments in regard to using an arthroplasty to treat an acute fracture. He feels comminution and poor bone quality remain indications in his practice but the risk of avascular necrosis alone is insufficient for him to insert a prosthesis. He makes the point that AVN in the shoulder is better tolerated than AVN of the hip.

View his presentation on Wise words from an expert. Look under meetings, Current Solutions in Shoulder and Elbow 2011.

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Frankle Current Solutions in Shoulder Elbow Surgery 2011

The Foundation for Orthopedic Research and Education (FORE), Current Solutions in Shoulder and Elbow Surgery is online and available. Shoulder and elbow surgeon Mark Frankle organized this superb meeting with the help of Tampa based FORE staff Mindy Gregory and Derek Pupello. The 71 presentations cover a wide range of important topics.

David Dines and Buddy Savoie are among the faculty who participated in expanded discussions. Both faculty interviews demonstrate two very experienced surgeons discussing how they think about complex shoulder and elbow problems. The faculty interview is a forum that allows surgeons sufficient time to explain more of the steps behind their successful operations. We can also learn more about the thought processes that allow these key opinion leaders to reason their way through a complex problem.

The first meeting session is Management of Proximal Humerus Fractures and Joe Zuckerman does his usual outstanding job as session monitor. Rockwood’s presentation is classic Rockwood. The Elbow Solutions section is superb but what would you expect with Bernie Morrey, Joaquin Sanchez-Sotelo and Scott Steinmann? Tom Norris is the lone non-Mayo surgeon but holds his own.

Friday night is a fascinating session titled “Obama Care and the Value Driven Health Plan.” Surgeons, PhD policymakers, Industry leaders, Medical Society representatives all join in a very spirited discussion.

Shoulder arthroplasty and Reverse shoulder arthroplasty each have separate sessions as do glenohumeral instability and rotator cuff disease.

Any one of these sessions is worth a few hours of your time.

CME credits coming soon to this meeting on

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Napa 2010 Shoulder Controversies – PRP – Platelet Rich Plasma

I am reviewing the content for the Napa/Nottage/Getelman Shoulder Controversies course that  filmed in October. What an outstanding session on orthobiologics! Truly an all-star cast that includes Stephen Abelow, Brian Cole, Allan Mishra, Stephen Snyder, and Stephen Weber. I think they give a fair and balanced view of RPP and grafting for irreparable rotator cuff tears. This meeting should be online within the month and I definitely recommend it.

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Annecy Live Surgery

The most unique meeting of the year is the Annecy Live surgery put on by Babette Lafosse and her assistant, Laurent. Nowhere else will you see the world’s expert surgeons perform challenging cases, live. No editing. No re-live, just surgery as it happens to all of us everyday. A must attend for everyone but if for some reason you cannot attend, We hope to have it on by September.

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Scribd feedback

Shouldn’t be any problem now. They sent me an automated reply with a link to the website. Probably just missed something. Let’s give it a go.

First I have to click the Share & Embed button on the navigation toolbar.

Nothing here. Maybe I have to publish post first and then embed.

Will try. Too bad. There is a share button but no embed option. The screen shot on the help page does not exist in my blog..

There is no format button

Will try support again.

I did get a nice comment from Dott. Digiacomo yesterday about coracoid position and capsule. To read it look under the post and you will see comment 1. Click there and see what he had to say.

Interesting. There is something down at the bottom of the page that asks you if you want to load documents in bulk. I downloaded it, the screen shots look familiar, easy to use and Voila! a tag appears. Victory!!

How about another.

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Latarjet coracoid position

I attended the Matcalf / AANA course in Snowbird last week and had an interesting discussion and then interview with Dr. Giovanni DiGiacomo from Rome. He developed a plate for the coracoid to meet two needs. 1. Support against possible screw cut out. 2. The coracoid in the traditional position does not always lie flush to the angled surface of the anterior scapular neck. His plate is built up on one side so that it applies force unevenly, compresses the coracoid medially and helps it lie flat against the anterior scapular neck. He has wonderful animations and video from surgery but I have not tried it yet. I spoke to my local Arthrex rep today. I have done the traditional Latarjet as explained to me by Gilles Walch and recently have tried the medial side down, congruent arc technique of Burkhart and Joe DeBeers. The congruent arc technique is aptly named as the medial side fits the glenoid rim perfectly. The downside is that the coracoacromial ligament is no longer intra-articular. Does this matter?

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Frankle Meeting 2011

We are now in the process of uploading all the presentations from the 2011 Current Solutions in Shoulder and Elbow. The meeting was held in Tampa, January 21-23. Most people call this the Frankle meeting since Mark Frankle started it. The meeting is outstanding and I am sorry this is the first one I attended. Good hotel, easy access to meeting areas. Excellent speakers and topics. Shoulder and elbow arthroscopy and arthroplasty, shoulder and elbow fractures and replacements were covered by world experts. There are about 80 presentations and panels over the 3 days and will bring every one of them to you online within the next few weeks. Our content is growing rapidly now and by July we will have 7 meetings covered and over 400 presentations. I want to develop a website where you can “be” at a meeting but still stay at home. I want to be able to see what I want, in the order I want, when I want. I want to decide whether or not I want to pay for CME. I want to stop some presentations or hear some again. I think we’ve done it. Stay tuned.

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