Recurrent posterior shoulder instability is an uncommon condition. It is often unrecognized, leading to incorrect diagnoses, delays in diagnosis, and even missed diagnoses. Posterior instability encompasses a wide spectrum of pathology, ranging from unidirectional posterior subluxation to multidirectional instability to locked posterior dislocations. Nonsurgical treatment of posterior shoulder instability is successful in most cases; however, surgical intervention is indicated when conservative treatment fails. For optimal results, the surgeon must accurately define the pattern of instability and address all soft-tissue and bony injuries present at the time of surgery. Arthroscopic treatment of posterior shoulder instability has increased application, and a variety of techniques has been described to manage posterior glenohumeral instability related to posterior capsulolabral injury. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
This is a short presentation on shoulder instability, biomechanics, pathology, diagnostic modalities, clinical picture and treatment methods available.
This is a short presentation on shoulder instability, biomechanics, pathology, diagnostic modalities, clinical picture and treatment methods available.
Multidirectional instability of the shoulder 2014Lennard Funk
Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.
Open Operative Treatment for Anterior Shoulder Instability | Orthopedic Surge...Peter Millett MD
Open surgical treatment for primary anterior glenohumeral instability is reliable and time-tested and can yield excellent clinical results. With advancements in arthroscopic technique, there has been a growing trend toward arthroscopic treatment of anterior shoulder instability. In many instances, arthroscopic treatment is preferred by patients and surgeons because it is minimally invasive, obviating the need for releasing and repairing the subscapularis; because it allows better identification and treatment of associated pathological conditions; and because it decreases morbidity and facilitates an outpatient approach. Furthermore, recent studies have demonstrated that the results of arthroscopic treatment of recurrent traumatic anterior instability are comparable with those achieved historically with open procedures. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Multidirectional instability of the shoulder 2014Lennard Funk
Multidirectional Instability is still a term that is used for a number of patients with shoulder instabiliity. In this lecture I discuss the confusion in definitions, applications and my understanding and management of this complex group of patients.
Open Operative Treatment for Anterior Shoulder Instability | Orthopedic Surge...Peter Millett MD
Open surgical treatment for primary anterior glenohumeral instability is reliable and time-tested and can yield excellent clinical results. With advancements in arthroscopic technique, there has been a growing trend toward arthroscopic treatment of anterior shoulder instability. In many instances, arthroscopic treatment is preferred by patients and surgeons because it is minimally invasive, obviating the need for releasing and repairing the subscapularis; because it allows better identification and treatment of associated pathological conditions; and because it decreases morbidity and facilitates an outpatient approach. Furthermore, recent studies have demonstrated that the results of arthroscopic treatment of recurrent traumatic anterior instability are comparable with those achieved historically with open procedures. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Management of Posterior Glenohumeral Instability with Large Humeral Head DefectPeter Millett MD
Traumatic posterior instability may occasionally cause a large osteochondral lesion when the anterior humeral head is compressed against the posterior glenoid rim. This is termed a reverse Hill–Sachs lesion. Such osteochondral defects may be very large in the case of chronic locked dislocations. Even in acute posterior disclocations, closed reduction may be difficult when the humeral head is locked posteriorly over the glenoid. In such cases closed or open reduction under general anesthesia with muscle relaxation may be necessary. In cases where the anterior humeral head defect is large, reconstruction may be necessary to maintain stability. Management must be tailored to the individual patient and depends on several factors, which include the size of the defect, the duration of the dislocation, the quality of the bone, the status of the articular cartilage, and the patient’s overall health. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Early Physiotherapy and Management of Deformities.pptxICDDelhi
Dr. Mansoor Alam is a child developmental specialist from ICD, New Delhi. He is a medicine graduate with specialization in Developmental Disability Management. After his graduation, he joined Spastic Society of Northern India, New Delhi to have a Post-Graduation Diploma in Developmental Therapy under RCI. Later, he went to Bobath Centre in London, (United Kingdom) to have specialized training in Bobath Approach to the treatment of Children with Cerebral Palsy, which is popularly known as Neurodevelopment Treatment (NDT). While, he was in Sydney, Australia, he did an advance course on the Use of Botox in Spasticity Management. He is one of the few professionals in India who attended Gait Analysis Course in Australia. To have in-depth knowledge to work with children neurodevelopmental disabilities, he pursued specialized training programs on GMA (General Movements Assessment), Constrained Induced Manual Therapy (CIMT), Early Intervention, Sensory Integration Therapy, Clinical Pathology and Acupuncture.
He joined SSNI as an associate professional in 1993 and worked for 8 continuous years. He became the technical director of “Udaan for the Disabled, New Delhi” to manage the India’s first Multimode Therapy Project in 2001. The MMT Project was the first project in India which conducted studies on the efficacy of Hyperbaric Oxygen Therapy (HBOT) along with other medical therapies including pediatric Therapy in children with neurodevelopmental disabilities ( Cerebral Palsy and Autism).On completion, the MMT Project, he joined Prerna Welfare Society as the Chief Consultant and Executive Director. In 2013, he started an organization named “Institute for Child Development, New Delhi”. Presently, he is the Executive Director of ICD, New Delhi and associated consultant to many organizations.
Similar to Recurrent Posterior Shoulder Instability | Orthopaedic Surgeon | Vail Colorado (20)
Colorado shoulder surgeon, Dr. Peter Millett taught in Portland, Oregon on the Steelhead Surgical Advanced Shoulder Course. Here is a sneak peek of his presentation.
Colorado shoulder specialist Dr. Peter Millett analyzes a case study of a 48 year-old active male with a supraspinatus tear with Grade 2 atrophy. The goal of arthroscopic rotator cuff repair is to restore the anatomy, biomechanics, shoulder function and promote healing. The advantages of arthroscopic repair is lower complication rates than RSTA and tendon transfer and overall improved functional outcomes.
Depending on the type of rotator cuff tear will help establish the reconstruction classification. In Dr. Millett's study from AAOS in 2014 there are four tear pattern recognitions: crescent, L/Reverse L, U-Shape and Massive Contracted. These pattern recognitions are required for modern arthroscopic rotator cuff repair to help facilitate anatomic restoration, optimize biomechanical properties and tendon biology, along with decrease failure rates.
For older patients, Dr. Millett conducted a study on the outcomes of rotator cuff repairs in older patients. The study found that the mean patient satisfaction was 9/10 improvement in pain affecting ADLs and ability to participate in sporting activities.
The “Bony Bankart Bridge” Procedure Shoulder Instability | Shoudler Surgery |...Peter Millett MD
Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure. Key Words: Arthroscopy—Bony Bankart lesion—Suture bridge—Instability—Shoulder. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, The Steadman Clinic, Greater Denver Area http://drmillett.com/shoulder-studies
Open Anterior Capsular Reconstruction of the Shoulder for Chronic Instability...Peter Millett MD
Stability of the shoulder comes from a complex interaction of various factors. Dynamic and static components are provided by soft tissue and bony structures creating joint stability. Recurrent anterior glenohumeral instability can be a difficult problem because there is a wide variety of possible pathologies. For more shoulder surgery and shoulder instability studies, visit Dr. Millett, Orthopedic Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
Arthroscopic Treatment of Anterior Glenohumeral Instability Indications and T...Peter Millett MD
The arthroscopic treatment of anterior glenohumeral instability is becoming increasingly accepted as a viable treatment option because reported success rates parallel those of open stabilization techniques. This improved success rate is largely the result of advances in surgical techniques and technology. An improved understanding of the pathoanatomy associated with shoulder instability and continuing education initiatives have also been instrumental in expanding the indications for arthroscopic stabilization of the unstable shoulder. For more shoulder surgery and instability studies, visit Peter Millett, Shoulder Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder...Peter Millett MD
Arthroscopic treatment of the unstable shoulder has evolved rapidly and significantly in recent years. Better understanding of the pathoanatomy, advancements in technology, and improved surgical techniques have led to dramatic improvements in outcome. An arthroscopic approach includes significant advantages. Arthroscopy provides better identification of concomitant pathology, lower morbidity, less soft tissue dissection, maximal preservation of motion, shorter surgical time, and improved cosmesis. There is less pain, and many patients have an easier functional recovery, with greater returns in motion compared with traditional open techniques. Finally, some of the inherent risks of open procedures, such as postoperative subscapularis rupture, are virtually eliminated. Surgeons can now routinely expect results that are at least comparable, if not better than, those achieved with open techniques. For more shoulder surgery and instability studies, visit Dr. Millett, Orthopedic Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
Anatomical Glenoid Reconstruction for Recurrent Anterior Glenohumeral Instabi...Peter Millett MD
Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
A 57-year-old man with type II diabetes mellitus presented with right shoulder pain and weakness. The onset of symptoms was insidious and progressive over a two year period. The patient thought he initially injured his shoulder while swimming but noted that his symptoms had become much worse since re-injuring it while throwing a tennis ball 6 months before presentation. The pain was localized to his right shoulder and often awakened him from sleep. He had taken nonsteroidal anti-inflammatory drugs (NSAIDS) for the 6 months after re-injuring the shoulder and completed an intermittent course of physical therapy that included a rotator cuff strengthening program. He was an active person who enjoyed hunting and fishing but had been unable to do either because of the shoulder problems. For more shoulder surgery and rotator cuff studies, visit Peter Millett, MD, Orthopedic Surgeon, Vail Colorado http://drmillett.com /shoulder-studies
Split Pectorales Major and Teres Major Tendon Transfers for Reconstruction of...Peter Millett MD
Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. In certain circumstances, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. A pectoralis major tendon transfer is an acceptable salvage option for irreparable subscapularis tendon ruptures. Although limited functional goals may be expected in most cases, the majority of patients obtain a good pain relief, which improves their function below chest level. Addition of the teres major component to the transfer may be beneficial in cases where both the upper and lower portion of the subscapularis muscle is irreparable. For more shoulder surgery and rotator cuff studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Shoulder Problems in Older Adults | Rotator Cuff | Sports Medicine Doctor - C...Peter Millett MD
Shoulder problems occur frequently in older adults. Four syndromes are particularly frequent, and they all share the common symptom of pain when reaching overhead: (1) rotator cuff tendinitis or impingement syndrome, (2) rotator cuff tear, (3) osteoarthritis, and (4) frozen shoulder. In addition to pain, each can cause significant long-term disability. For more shoulder surgery and rotator cuff studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Shoulder pain is the third most common musculoskeletal symptom encountered in medical practice after back and neck pain, accounting for almost 3 million patient visits each year in the United States. A wide range of potential pathoanatomic entities can give rise to shoulder pain, from simple sprains to massive rotator cuff tears. The majority of these conditions are amenable to conservative treatment. Rotator cuff dysfunction is a particularly important entity because it occurs frequently and may necessitate surgical treatment. This report will provide a critical overview of current diagnostic and treatment techniques for rotator cuff disease. For more shoulder surgery and rotator cuff studies, visit Dr. Millett, shoulder surgeon, Greater Denver http://drmillett.com/shoulder-studies
In an effort to increase the immediate strength of a rotator cuff repair and to simulate the standard open reconstruction with its effective suture fixation, we have developed a novel technique for suture anchor reconstruction of the rotator cuff. The technique, termed mattress double anchor (MDA), is simple and adaptable. It makes use of 2 suture anchors that are placed independently and then connected by a suture loop. The technique produces a repair construct that distributes the stress across 2 anchors. The method also restores a large surface area for healing between the rotator cuff and the tuberosity.
Patient Management with Greater Tuberosity Fracture and Rotator Cuff Tear | G...Peter Millett MD
Patients with hyperflexion/hyperabduction injury to the glenohumeral joint are at risk for isolated greater tuberosity fractures, which are often undiagnosed or misdiagnosed. In this case report, we describe the clinical decision-making process that led to the diagnosis of an isolated greater tuberosity fracture and subsequent rotator cuff tear.
For more shoulder surgery and rotator cuff studies, visit Dr. Millett, Greater Denver Area http://drmillett.com/shoulder-studies
Arthroscopic Single Row Versus Double-Row Suture Anchor Rotator Cuff Repair |...Peter Millett MD
Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row suture anchor rotator cuff repair technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. For more shoulder surgery and rotator cuff studies, visit Peter Millett, MD, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Shoulder Injuries in Throwing Athletes | Peter Millett MD - Shoulder Surgeon ...Peter Millett MD
Due to the ongoing controversy regarding the exact causes of injury in the thrower's shoulder, the authors will not attempt to provide a single unifying theory. Instead, we will provide an overview clarifying the terminology and describing common pathologic findings, and presenting the various theories on shoulder injuries in throwing athletes. The purpose of this chapter is to discuss the biomechanics, presentation, diagnosis and treatment of common shoulder injuries in overhead throwing athletes. For more studies on athletic shoulder injuries, please visit http://drmillett.com/shoulder-studies
Pathologic conditions in the shoulder of a throwing athlete frequently represent a breakdown of multiple elements of the shoulder restraint system, both static and dynamic, and also a breakdown in the kinetic chain. Physical therapy and rehabilitation for shoulder injuries should be, with only a few exceptions, the primary treatment for a throwing athlete before operative treatment is considered. Articular-sided partial rotator cuff tears and superior labral tears are common in throwing athletes. Operative treatment for shoulder injuries can be successful when nonoperative measures have failed. Throwing athletes who have a glenohumeral internal rotation deficit have a good response, in most cases, to stretching of the posteroinferior aspect of the capsule. For more studies visit Dr. Millett, orthopedic surgeon, http://drmillett.com/shoulder-studies
Golf Shoulder Injuries | Dr. Peter Millett | Orthopedic Surgeon - Vail Colorado Peter Millett MD
Although often perceived as a leisurely activity, golf can be a demanding sport, which can result in shoulder injuries, usually from overuse and sometimes from poor technique. The shoulder is a commonly affected site, with the lead shoulder, or the left shoulder in the right-handed golfer, particularly vulnerable to injury. A thorough understanding of the biomechanics of the golf swing is help- ful in diagnosing and managing these injuries. Common shoulder injuries affecting golfers include subacromial impingement, acromioclavicular arthrosis, rotator cuff tear, glenohumeral instability, and glenohumeral arthrosis. Although the majority of patients with these disorders will respond to nonsurgical treatment, including rest and a structured program of physical therapy, further benefits can be obtained with subtle modifications of the golf swing. Those golfers who fail to respond to nonsurgical management can often return to competitive play with appropriate surgical treatment. For more studies visit Dr. Peter Millett, Orthopedic Surgeon - Vail Colorado http://drmillett.com/shoulder-studies
Peter Millett MD | Orthopaedic Surgeon | The Steadman Clinic Sports Medicine ...Peter Millett MD
Dr. Millett is a Partner at the Steadman Hawkins Clinic. An expert in shoulder disorders, he also specializes in disorders of the knee, and elbow as well as all sports-related injuries. He uses advanced open and arthroscopic surgical techniques to restore damaged joints, ligaments, and bones. A focus of his is complex and revision shoulder surgery. He held a faculty appointment at Harvard Medical School, and was formerly Co-Director of the Harvard Shoulder Service, and Co-director of the Harvard Shoulder Fellowship. He also directed the Musculoskeletal Proteomics Research Group at Harvard. His clinical practice in Boston was based at the prestigious Brigham & Women's and Massachusetts General Hospitals. He has authored over numerous peer-reviewed, scientific articles, numerous book chapters, and a review book on orthopaedics. His academic work has been recognized with awards from several international societies. Dr. Millett serves as a shoulder and sports medicine consultant for Bermuda. A member of numerous societies including AAOS, AOSSM, ASES, AANA, and ORS, Dr. Millett has cared for athletes from the NFL, MLB, NHL, USTA, PGA, US ski team, and X-games. Dr. Millett serves as a team physician for the U.S. Ski Team. He is a consultant to the Montreal Canadiens Professional Hockey Club and the Volkl/Marker ski companies. Dr. Millett has performed live surgery for courses in North America (Massachusetts, Florida, California, Colorado, Missouri, Illinois), Europe (Germany, The Netherlands, France) and the Caribbean (Bermuda).
A native of Pennsylvania, Dr. Millett received his undergraduate degree from the University of Scranton, and his medical degree from Dartmouth Medical School in Hanover, New Hampshire. He also served as a visiting research scholar at the University of Cambridge in England, where he was awarded a master’s degree in science (M.Sc.) for his work in skeletal biology.
Dr. Millett performed his orthopaedic residency training at the Hospital for Special Surgery in New York City, part of Cornell University's Medical School and the oldest and most prestigious orthopaedic residency program in the country. While there, he received the Lewis Clark Wagner Award for excellence in orthopaedic research as well as the American Orthopaedic Association – Zimmer Travel Award, a national award for orthopaedic research.
Dr. Millett earned additional subspecialty, fellowship training in sports medicine, knee and shoulder surgery at the internationally renown Steadman Hawkins Sports Medicine Foundation in Vail, CO. While there, he also served as an associate physician for the Denver Broncos professional football team, the Colorado Rockies Major League Baseball team, and the U.S. Ski Team.
Specialty:
Shoulder, knee, and elbow surgery
Sports medicine
Orthopaedic trauma
Joint replacement surgery
Orthopedic Surgery
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Recurrent Posterior
Shoulder Instability
Abstract
Recurrent posterior shoulder instability is an uncommon
condition. It is often unrecognized, leading to incorrect diagnoses,
delays in diagnosis, and even missed diagnoses. Posterior
instability encompasses a wide spectrum of pathology, ranging
from unidirectional posterior subluxation to multidirectional
instability to locked posterior dislocations. Nonsurgical treatment
of posterior shoulder instability is successful in most cases;
however, surgical intervention is indicated when conservative
treatment fails. For optimal results, the surgeon must accurately
define the pattern of instability and address all soft-tissue and bony
injuries present at the time of surgery. Arthroscopic treatment of
posterior shoulder instability has increased application, and a
variety of techniques has been described to manage posterior
glenohumeral instability related to posterior capsulolabral injury.
Recurrent posterior shoulder in-
stability is an uncommon condi-
tion that is often unrecognized, lead-
ing to incorrect diagnoses, delays in
diagnosis, and even missed diag-
noses.1
Posterior instability encom-
passes a wide spectrum of pathoanat-
omy that may affect the labrum,
capsule, rotator interval, and bony ar-
chitecture of the shoulder. Recurrent
posterior subluxation is the most
common type of posterior instability.
Background and
Epidemiology
Glenohumeral instability is com-
mon, affecting approximately 2% of
the general population.2
However,
posterior instability occurs in only
2% to 5% of those with shoulder in-
stability.3 Trauma is thought to be
the underlying cause in approxi-
mately half of patients with posteri-
or instability.3
Although posterior
dislocation represents only 4% of all
joint dislocations,4
it is often easily
missed on clinical examination. Spe-
cific imaging assessment is impor-
tant. Recurrent posterior sublux-
ation, which may present with
instability symptoms or simply as
pain, is more common, particularly
in those who participate in high-risk
athletic activities.
Relevant Anatomy and
Biomechanics
The shoulder is the most mobile, but
also the least stable, joint in the
body because less than one third of
the humeral head articulates with
the glenoid. Stability is conferred by
a series of static and dynamic soft-
tissue restraints that maintain the
articulation of the humeral head
with the glenoid while simulta-
neously providing for a large range of
motion.5
Peter J. Millett, MD, MSc
Philippe Clavert, MD
G. F. Rick Hatch III, MD
Jon J. P. Warner, MD
Dr. Millett is Co-Director, Harvard
Shoulder Service/Sports Medicine,
Brigham & Women’s Hospital,
Massachusetts General Hospital,
Boston, MA, and Assistant Professor,
Department of Orthopaedic Surgery,
Harvard Medical School. Dr. Clavert is
Associate Professor, Department of
Orthopaedics, CHRU Hautepierre,
Strasbourg, France. Dr. Hatch is
Assistant Professor, Sports Medicine/
Shoulder & Elbow Services, Department
of Orthopaedic Surgery, USC Keck
School of Medicine, Los Angeles, CA.
Dr. Warner is Professor, Department of
Orthopaedics, Harvard Medical School,
Boston, MA, and Chief, Harvard
Shoulder Service, Department of
Orthopedics, Massachusetts General
Hospital.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Millett, Dr. Clavert, Dr. Hatch, and
Dr. Warner.
Reprint requests: Dr. Millett, Steadman
Hawkins Clinic, 181 West Meadow
Drive, Vail, CO 81657.
J Am Acad Orthop Surg 2006;14:464-
476
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
464 Journal of the American Academy of Orthopaedic Surgeons
2. Static Restraints
Articular factors such as joint
congruency, glenoid version, and hu-
meral retrotorsion contribute to
static joint stability. Bony abnormal-
ities such as glenoid retroversion or
posterior glenoid erosion can be pre-
disposing causative factors for poste-
rior shoulder instability.1
The glenoid labrum, a wedge-
shaped fibrous structure consisting
of densely packed collagen bundles,
increases the depth and surface area
of the glenoid. It serves as an anchor
point for the capsuloligamentous
structures, deepens the glenoid con-
cavity, and reduces glenohumeral
translation with arm motion.6 La-
bral excision decreases the depth of
the socket by 50% and reduces resis-
tance to instability by 20%.6
The glenohumeral ligaments are
thickened fibrous bands within the
joint capsule; these ligaments act at
the end ranges of motion and pro-
vide static stability. Their function
is dependent on the position of the
arm and the direction of the force ap-
plied.7 For example, when the arm is
adducted, the superior glenohu-
meral ligament (SGHL) and coraco-
humeral ligament (CHL) limit infe-
rior translation and external
rotation of the humeral head. Addi-
tionally, the SGHL and the CHL re-
sist posterior translation of the hu-
meral head when the shoulder is in
flexion, adduction, and internal ro-
tation. The inferior glenohumeral
ligament (IGHL) complex is com-
posed of discrete anterior and poste-
rior bands with an interposed axil-
lary pouch that acts like a
hammock, undergoing reciprocal
tightening and loosening depending
on arm position. The posterior band
of the IGHL complex is the main re-
straint to posterior translation of the
humeral head when the arm is ab-
ducted.
The posterior capsule is defined
as the area superior to the posterior
band of the IGHL complex. The
posterior capsule is the thinnest
(≤1 mm) and perhaps weakest por-
tion of the shoulder capsule. It may
limit posterior translation when the
arm is flexed, adducted, and inter-
nally rotated.
The rotator interval plays a role
in static stability and is defined by
the borders of the supraspinatus su-
periorly, the subscapularis inferi-
orly, the coracoid process medially,
and the biceps and humerus later-
ally. The SGHL, medial glenohu-
meral ligament, and CHL provide
variable reinforcement to the rota-
tor interval. The rotator interval and
its constituents provide stability
against inferior and posterior trans-
lations, particularly when the arm is
adducted and externally rotated.8
Evidence suggests that deficiencies
in the rotator interval can contrib-
ute to instability in patients with
excessive inferior or posterior trans-
lation.9
In some individuals, the ro-
tator interval may be composed of
loosely arranged collagen, whereas
in others, it may be completely
devoid of tissue. This represents a
rotator interval “capsular defect”
that may need to be addressed in
the symptomatic shoulder, but it
may also be considered a normal
anatomic variant in the stable
shoulder.
Dynamic Restraints
Dynamic stability is provided by
the rotator cuff, the deltoid, and the
biceps tendon through a concavity-
compression effect on the humeral
head within the glenoid socket.10 Of
the four muscles of the rotator cuff,
the subscapularis provides the great-
est resistance to posterior transla-
tion.10,11
In addition, dynamic stabil-
ity of the shoulder also is provided
by the trapezius, serratus anterior,
teres major, and latissimus dorsi
muscles. Scapulothoracic motion
must be properly coordinated with
glenohumeral motion so that the
glenoid can be appropriately posi-
tioned to provide a stable platform
beneath the humeral head.
Definitions: Laxity and
Instability
The term instability is reserved for
symptomatic shoulders—specifical-
ly, the sensation of the humeral head
translating in the glenoid, which is
frequently associated with pain and
discomfort.12 Instability is defined as
pathologic joint translation that
causes symptoms, or as the inability
to keep the humeral head centered
within the glenoid cavity during ac-
tive motion. Laxity is defined as a
specific translation for a particular
direction or rotation.13 Individuals
may have significant laxity and yet
remain asymptomatic. Conversely,
others with only minimal degrees of
laxity may have significant symp-
toms of instability. The distinction
is important. Frequently, patients
with excessive shoulder laxity sus-
tain a traumatic injury and subse-
quently develop symptoms of insta-
bility. Individuals with recurrent
posterior subluxation generally have
symptomatic pain yet may or may
not have symptoms of instability.
Classification of
Posterior Instability
Posterior shoulder instability can be
classified by direction, degree, cause,
and volition. Unidirectional posteri-
or subluxation is the most frequent
form of posterior instability. Posteri-
or instability also can occur as bidi-
rectional or multidirectional insta-
bility.14
The degree of posterior instabili-
ty can range from mild subluxation
to frank dislocation. Recurrent pos-
terior subluxation is the most com-
mon form.
Posterior instability may be trau-
matic (acquired) or atraumatic. The
traumatic type is the more common
form.1 This can occur as a single
traumatic event with the shoulder in
an “at risk” position (ie, flexion, ad-
duction, and internal rotation) or as
a culmination of multiple, smaller
traumatic episodes. For example, an
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 465
3. electrical shock producing posterior
dislocation is a classic example of a
single traumatic event. An offensive
lineman with the arms in the block-
ing position would typify a predispo-
sition to recurrent posterior sublux-
ation because of the repetitive
loading. Posterior instability occur-
ring secondary to overhead sports
presents more insidiously because of
the gradual capsular failure from re-
petitive microtrauma. Common pro-
vocative activities include the back-
hand stroke in racket sports, the
pull-through phase of swimming,
and the follow-through phases in a
throwing activity or golf.
Posterior instability in the set-
ting of an atraumatic history should
alert the clinician to the possibility
of an underlying collagen disease or
bony abnormality (eg, glenoid hypo-
plasia, excessive glenoid retrover-
sion). In such situations, surgical in-
tervention should be approached
cautiously.
Finally, posterior instability may
be defined by its volitional compo-
nent. Involuntary posterior instabil-
ity typically results from a traumat-
ic event (acute or repetitive) and
most commonly manifests as mild
subluxation. The symptoms do not
occur willfully and usually are not
controllable. Voluntary posterior in-
stability occurs when a patient can
willfully dislocate or subluxate the
shoulder. Two different patterns
have been described—voluntary
muscular and voluntary positional
posterior instability. In voluntary
muscular (or habitual) posterior in-
stability, an underlying muscular
imbalance typically exists that
allows voluntary subluxation/
dislocation of the shoulder with the
arm in adduction. Patients with ha-
bitual voluntary posterior instabili-
ty are generally considered poor sur-
gical candidates. However, patients
with the second voluntary form, po-
sitional voluntary posterior instabil-
ity, can respond well to surgery pro-
vided they do not have underlying
psychiatric or secondary gain is-
sues.15 Typically, these individuals
have instability when the arm is
flexed and adducted. Although these
individuals may be able to voluntar-
ily reproduce their instability, they
usually avoid the provocative ma-
neuvers.15
Evaluation
History
Although posterior shoulder in-
stability is uncommon, an aware-
ness of the disorder, together with a
thoughtful evaluation beginning
with the clinical history, usually
leads to the proper diagnosis. The
first step is to inquire about a histo-
ry of trauma. In the case of a single
traumatic episode, the direction of
the applied force and the position of
the arm at the time of injury may
provide insight into the diagnosis.
Classically, posterior subluxation
occurs with a traumatic event when
the arm is in an at-risk position (eg,
forward flexion, adduction, internal
rotation).16
A fall or blow to the arm
while in an at-risk position can re-
sult in a posterior labral detachment
(reverse Bankart lesion).16
Repetitive
stresses on the posterior capsule, ei-
ther from sports or other activities,
may lead to acquired posterior sub-
luxation.
Patients with recurrent posterior
subluxation most commonly report
pain and feelings of weakness. Insta-
bility symptoms may or may not be
present. With careful questioning,
the direction, frequency, and severi-
ty of the patient’s symptoms can be
ascertained. Overhead athletes often
describe insidious pain that may oc-
cur in the later phases of their sport-
ing activities, when muscle fatigue
and dynamic stability are compro-
mised. Mechanical symptoms, such
as giving way, slipping, popping,
catching, or clicking, are less com-
mon than in anterior instability. Vo-
litional components should be as-
sessed.
Physical Examination
The physical findings of patients
with posterior instability often are
more subtle than those of patients
with anterior instability. Active and
passive ranges of motion usually are
normal and symmetric. The posteri-
or joint line may be tender to palpa-
tion. Crepitus is sometimes noted as
the arm is internally rotated.
Strength testing is usually symmet-
ric, except in rare cases of posterior
rotator cuff muscle deficiency or
nerve injury with external rotation
weakness. In these cases, atrophy of
the posterior rotator cuff muscles
may be apparent on inspection.
Patients should be assessed for
generalized ligamentous laxity by
evaluating the contralateral shoul-
der, elbows, and knees, and by test-
ing the patient’s ability to oppose the
thumb to the forearm. In addition,
sulcus testing should be performed.
The sulcus can be quantified by the
distance from the greater tuberosity
to the acromion. A sulcus sign
>2 cm is virtually pathognomonic
for multidirectional instability, but
pain and symptoms of inferior insta-
bility must also be present for this
diagnosis. If the sulcus does not re-
duce as the arm is externally rotated,
it should be considered pathologic,
with a defect in the rotator interval
that should be addressed at the time
of surgery.
Scapulohumeral rhythm and
scapulothoracic mechanics should
be assessed to exclude the possibili-
ty of scapular winging, which is fre-
quently confused with posterior in-
stability.17 In some instances, a
compensatory scapular winging may
occur. As the scapula wings, it effec-
tively anteverts the glenoid and dy-
namically increases the bony stabil-
ity.17 In such instances, a thorough
neurologic examination should be
performed with appropriate neuro-
logic testing, as indicated.
Specific Posterior
Instability Tests
The posterior stress test (Figure 1)
Recurrent Posterior Shoulder Instability
466 Journal of the American Academy of Orthopaedic Surgeons
4. is performed with the individual in
the supine position; the arm is flexed
to 90° and internally rotated. The ex-
aminer axially loads the humerus
against the posterior glenoid by
pushing the arm posteriorly with
one hand while the other hand is ap-
plied to the back of the shoulder.
The posterior stress test is positive
when a subluxation of the humeral
head over the glenoid rim is palpat-
ed or observed.
The jerk test (Figure 2) is per-
formed with the patient sitting up-
right; the arm is flexed 90° and in-
ternally rotated, and the elbow is
flexed to 90°. A posterior force is
generated by applying an axial load
to the humerus by pushing on the
flexed elbow. In patients with signif-
icant laxity, this will cause a poste-
rior dislocation or subluxation of
the glenohumeral joint. The arm is
then extended and, as this occurs,
the glenohumeral joint will reduce
with a jerk. If a painful relocation oc-
curs, the jerk test is positive. Usu-
ally the reduction is observed as
there is a sudden change in velocity
as the humeral head reenters the
glenoid fossa.
The load and shift test (Figure 3,
A) is performed with the patient
seated upright, arm at the side. The
humeral head and proximal hu-
merus are grasped and compressed
into the glenoid socket, and anterior
and posterior stress is applied with
grading of the degree of translation.
This test is used to determine the
amount of glenohumeral transla-
tion, but it is difficult to accurately
quantitate results. A 50% displace-
ment of the humeral head is consid-
ered the upper limit of normal. It is
not unusual to find symmetric pos-
terior translation between the af-
fected and unaffected shoulders.5,14
The modified load and shift test
(Figure 3, B) is performed with the
patient supine and the affected
Figure 1
Posterior stress test. A posterior force is applied through the humerus. The test is
positive if there is palpable crepitus or subluxation. Often pain is elicited, but this is
not as specific a finding.
Figure 2
Jerk test. A, A posterior force is applied along the axis of the humerus with the arm in forward flexion and internal rotation. This
will cause the humeral head to subluxate posteriorly out of the glenoid socket. B, As the arm is brought into extension, a clunk
will be felt as the humerus reduces into the glenoid cavity.
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 467
5. shoulder at the edge of the examin-
ing table. The shoulder is positioned
in the scapular plane and in neutral
rotation. Manual force is placed at
the ipsilateral elbow to concentrical-
ly reduce the humeral head. Anteri-
or and posterior forces are then
applied to the proximal humerus in
varying degrees of rotation and ele-
vation with grading of the amount of
translation.14
The load and shift and
modified load and shift tests are typ-
ically graded as follows: grade 0,
minimal translation; grade 1, hu-
meral head translates to the glenoid
rim; grade 2, humeral head trans-
lates over the glenoid rim but spon-
taneously reduces; and grade 3, hu-
meral head dislocates and does not
spontaneously reduce.
Imaging
Radiographs
Plain radiographs of the shoulder
should include true anteroposterior
views in neutral, internal, and exter-
nal rotation; a transscapular view or
Y view; and an axillary view. These
views are needed to ensure that the
joint is located, to evaluate the pos-
terior glenoid rim, and to look for
impaction fractures of the humeral
head. In addition to humeral head
position, these studies demonstrate
glenoid rim morphology (hypoplasia,
excessive retroversion, and/or frac-
ture of the posterior glenoid rim).
However, most individuals with re-
current posterior instability do not
have bony abnormalities. For those
with a volitional component, dy-
namic radiographs can confirm the
diagnosis (Figure 4).
Multiplanar Imaging
Computed tomography (CT) or
magnetic resonance imaging (MRI)
is essential to assess the version and
morphology of the glenoid. These
tests also help detect subtle anterior
Figure 3
A, Load and shift test. The patient is seated upright. A compressive force is applied through the humeral head to center the
humeral head within the glenoid cavity. Posterior or anterior forces can then be applied to assess the amount of joint translation.
This can be compared with the contralateral shoulder. B, Modified load and shift. The patient is supine. A compressive force is
applied along the long axis of the humerus to center the humeral head in the glenoid cavity. A posterior force can then be applied
to assess the degree of translation of the humeral head.
Figure 4
Axillary radiographs of an individual with voluntary posterior instability showing the
humeral head dislocated (A) and reduced (B).
Recurrent Posterior Shoulder Instability
468 Journal of the American Academy of Orthopaedic Surgeons
6. humeral head defects and glenoid
fractures. Contrast can enhance the
ability to evaluate the posterior la-
brum and capsule, particularly with
injuries such as capsulolabral disrup-
tions or lateral capsular injuries.18
Contrast also enhances assessment
of the superior labrum. For surgical
candidates, it is critically important
to identify the pathoanatomy so that
the appropriate surgical approach
can be chosen. For example, an indi-
vidual with significant retroversion
of the glenoid will have an unaccept-
ably high failure rate if a soft-tissue
capsulorrhaphy is performed and the
bony abnormality is not addressed.
Preoperative diagnosis helps in sur-
gical planning, particularly as ar-
throscopic treatment becomes more
popular. Depending on the surgeon’s
skill level, some injuries (eg, glenoid
erosion, posterior humeral avulsion
of the glenohumeral ligaments, cap-
sular rupture) are more appropriate-
ly addressed through an open surgi-
cal approach.
Although the gadolinium-
enhanced magnetic resonance ar-
throgram provides excellent soft-
tissue detail, we think that a CT
scan with intra-articular contrast
provides the best information with
regard to bony anatomy and articular
orientation. CT is superior in its
ability to determine the glenoid
morphology as well as the degree of
glenoid retroversion. Glenoid retro-
version is best measured on axial CT
scan images through the mid-
glenoid; this corresponds with the
first inferior image, on which the tip
of the coracoid process is no longer
visible.19
At this level, glenoid retro-
version between −2° and −8° is con-
sidered normal.19
Initial Treatment
Nonsurgical treatment is successful
for the great majority of patients
with recurrent posterior sublux-
ation. The aim of physical therapy is
to strengthen the dynamic muscular
stabilizers to compensate for the
damaged or deficient static stabiliz-
ers.20 The focus should be on exercis-
es that strengthen the posterior del-
toid, the external rotators, and the
periscapular muscles. These exercis-
es are typically used in conjunction
with activity modification and bio-
feedback. Nonsurgical treatment of
posterior instability is successful in
approximately 65% to 80% of cas-
es.20,21
Surgical Treatment
Open procedures have been the
mainstay of treatment when nonsur-
gical treatment fails and have led to
good results when implemented ap-
propriately1,15,22 During the past de-
cade, the arthroscopic treatment of
posterior shoulder instability has at-
tracted increasing interest as a
means to restore stability without
the morbidity of open surgery. A va-
riety of arthroscopic techniques
have been described to manage pos-
terior glenohumeral instability in re-
lation to posterior capsulolabral in-
jury and redundancy.23-26 The
perceived advantages of the arthro-
scopic approach include less morbid-
ity, shorter surgery time, improved
cosmesis, and less postoperative
pain.27,28
Prerequisites
Because of the multifactorial na-
ture of posterior instability, as well
as the lack of a single consistent “es-
sential pathologic lesion,” the sur-
geon must consider all potential
contributing factors and correct the
relevant pathoanatomy encountered
in that individual case (Table 1). The
best surgical candidates are those
with recurrent, posttraumatic, uni-
directional subluxation. These pa-
tients are also the ideal candidates
for arthroscopic stabilization, either
by suture anchors or simple posteri-
or capsular plication with sutures
(Figure 5). The procedures used to
address posterior instability may be
subdivided into soft-tissue and bony
procedures.
Before any surgical procedure, an
examination under anesthesia is per-
formed. The amount of humeral
head translation on the glenoid sur-
face is graded as follows: 0, stable or
trace laxity; 1, up to 50% transla-
tion; 2, dislocatable with spontane-
ous reduction; and 3, dislocates and
does not spontaneously reduce. Sul-
Table 1
Surgical Decision Making for Posterior Instability According
to Pathoanatomy
Pathologic Lesion Procedure of Choice
Posterior Bankart lesion Arthroscopic or open posterior Bankart
repair
Excessive capsulolabral laxity Arthroscopic or open posterior capsular
shift ± rotator interval closure
Glenoid erosion Posterior glenoid bone grafting
Increased glenoid retroversion Posterior opening wedge glenoid osteot-
omy
Figure 5
Arthroscopic photograph of a posterior
capsulolabral disruption (posterior or
reverse Bankart lesion). The probe is in
the defect.
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 469
7. cus testing and passive range of mo-
tion are compared with the opposite
shoulder.
Soft-Tissue Procedures
Open Posteroinferior Capsular
Shift
The open posteroinferior capsular
shift procedure is best for patients
with recurrent posttraumatic sub-
luxation and those with involuntary,
recurrent, atraumatic subluxation.
The procedure also may be indicated
in those with recurrent voluntary
positional posterior subluxation.15
Positioning
The procedure may be performed
under general anesthesia, regional
anesthesia alone, or general anes-
thesia combined with a regional an-
esthetic. The patient is positioned
on a full-length beanbag, in the later-
al decubitus position (Figure 6, A). A
mechanical arm holder from the op-
posite side of the operating table can
be helpful to support the arm in in-
ternal or external rotation.
Incision
The shoulder is approached poste-
riorly; we prefer the incision in the
posterior axillary fold. The deltoid
Figure 6
Open posteroinferior capsular shift. A, The patient is positioned in the lateral decubitus position in a beanbag. A posterior axillary
incision is used (broken line). B, The deltoid is split in line with its fibers to expose the underlying infraspinatus and teres minor.
Inset, Split in the infraspinatus and the location of the T-plasty in capsule. C, The infraspinatus is split and a T-shaped
capsulotomy is performed. The capsule is opened just lateral to the labrum. D, The capsulotomy is performed at the glenoid
side. Labral detachments are repaired. E, The inferior capsule is shifted superiorly. F, This is reinforced with the superior limb of
the capsule.
Recurrent Posterior Shoulder Instability
470 Journal of the American Academy of Orthopaedic Surgeons
8. can then be split in line with its fi-
bers, detached from its origin on the
scapular spine, or abducted and ele-
vated to reach the infraspinatus over
the joint line (Figure 6, B). The in-
fraspinatus is then split at the level
of the equator of the glenoid to ex-
pose the underlying posterior gleno-
humeral joint capsule. Care is taken
not to divide the muscle more than
1.5 cm medial to the glenoid in order
to avoid damage to the branches of
the suprascapular nerve to the in-
fraspinatus.
Capsular Shift
The capsule is then divided hori-
zontally from medial to lateral at the
equator of the glenoid. Although
both medial and lateral capsular
shifts have been described,29,30
we
prefer a medially based shift with a
T-plasty of the capsule performed at
the level of the glenoid. The posteri-
or capsule is often quite thin and the
medial capsule is of better quality
than the lateral capsule. We open the
capsule just lateral to the labrum
(Figure 6, C). The remaining capsulo-
labral sleeve is then elevated from
the glenoid rim inferiorly to the six
o’clock position. The joint is in-
spected and any posterior labral inju-
ry is repaired with two or three bio-
absorbable suture anchors (Figure 6,
D). The suture anchors are placed at
intervals along the posterior glenoid
rim, just at the articular margin. The
capsulolabral lesion is then repaired
anatomically, although the labrum
is often quite small.
During capsular repair, the pa-
tient’s arm is positioned in 20° of ab-
duction and in neutral rotation. The
inferior flap of capsule is shifted from
inferior to superior to remove redun-
dancy (Figure 6, E). The superior flap
is then shifted inferiorly over the in-
ferior flap to reinforce the posterior
capsule (Figure 6, F). In the setting of
capsular rupture or insufficiency, the
posterior capsule may be augmented
with the infraspinatus tendon. Non-
absorbable transosseous sutures or
suture anchors are used to repair the
infraspinatus.31 The deltoid is closed
in a side-to-side fashion with
braided, nonabsorbable sutures.
Arthroscopic Posterior
Stabilization
The indications for the arthro-
scopic approach are identical to
those for the open posteroinferior
capsular shift. Ideal candidates are
those with a posterior Bankart le-
sion. Relative contraindications to
arthroscopic treatment of recurrent
posterior instability include failed
prior arthroscopic stabilization pro-
cedures, humeral avulsions of the
glenohumeral ligaments, or gross
symptomatic bi- or multidirectional
instability from excessive general-
ized laxity, such as with Ehlers-
Danlos syndrome. A distinction
must be made, however, between
these patients and those who have
multidirectional laxity but remain
symptomatic only in the posterior
direction. This latter group makes
up a large number of patients with
recurrent posterior instability, and
they respond well to arthroscopic
stabilization. Absolute contraindica-
tions to arthroscopic stabilization
are the rare individuals with either
glenoid erosion (acquired or develop-
mental) or excessive glenoid retro-
version. In these settings, bony pro-
cedures are required to reconstruct
or reorient the glenoid.
Patient Positioning
The procedure can be performed
in either the lateral decubitus or
beach chair position. For the lateral
decubitus position, the arm is placed
in a traction device (Arthrex Star
Sleeve; Arthrex, Naples, FL) with 20°
of abduction and 20° of extension.
Direct lateral traction also can be ap-
plied to the proximal humerus.
Arthroscopic Portals
Three or four portal techniques
can be used, with one or two poste-
rior portals and two anterior portals.
The posterior portal must be placed
slightly lateral to allow access to the
posterior glenoid rim and the pos-
teroinferior capsule. If the posterior
portal position is not ideal, a second
posterior portal can be used. Both an
anterosuperior portal and a midante-
rior portal are created in the rotator
interval region. The former is used
for viewing, and the latter for instru-
mentation and suture passage (Fig-
ure 7, A).
Arthroscopic Shift
A significant capsulolabral injury
(posterior Bankart lesion) can be
repaired with suture anchors; other-
wise the capsular redundancy,
which is more typically encoun-
tered, can be reduced with a poste-
rior capsular shift. The shift begins
at the 6 o’clock position. Using a
shuttling-type angled instrument,
the capsule is grasped 10 to 15 mm
lateral to the glenoid rim and is
shifted to the labrum with three to
five sutures (Figure 7, B through D),
depending on the size of the shoul-
der, the laxity present, and the de-
gree of shift desired. For patients
with significant inferior laxity, a ro-
tator interval closure is performed
to provide additional stability
against inferior translation.8 We per-
form the rotator interval closure as a
capsular closure, plicating the mid-
dle glenohumeral ligament to the
superior glenohumeral ligament.
Bony Procedures
In the setting of severe glenoid
dysplasia or retroversion, defined as
retroversion >20° (Figure 8, A), an
opening wedge posterior glenoid os-
teotomy is indicated. For patients
with significant focal posterior gle-
noid defects, a bone block or bony
glenoid reconstruction is indicated.
Although corrective humeral rota-
tional osteotomies have been de-
scribed in several European series,
they are not widely used in North
America.
Opening Wedge Glenoid
Osteotomy
Patients are positioned in the lat-
eral decubitus position, and expo-
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 471
9. sure is similar to that described for
the open capsular shift. The postero-
medial neck of the glenoid is ex-
posed. An autologous tricortical
bone graft is used. The width of the
graft is variable depending on the de-
gree of correction (10 to 25 mm) and
should be contoured in a wedge fash-
ion (Figure 8, B). The osteotomy
should be incomplete, leaving the
anterior glenoid cortex intact to
maintain stability. When the desired
correction has been obtained, the tri-
cortical bone graft is inserted to cor-
rect the retroversion. The graft may
be press-fit (our preference) or se-
cured by screws (Figure 8, D). Resid-
ual capsular redundancy may then
be treated, as described. This is a
technically challenging procedure;
numerous complications have been
reported, including intra-articular
fracture, nerve injury, loss of reduc-
tion, and hardware problems.
Posterior Bone Graft
For patients with acquired focal
glenoid defects, the glenoid can be
reconstructed with an anatomic
intra-articular bone graft to restore
the glenoid arc, or with an extra-
articular bone graft that serves as
a buttress for the humeral head (Fig-
ure 9). We prefer the extra-articular
approach, advancing the capsule an-
terior and medial to the graft to serve
as a soft-tissue interposition. Care
must be taken to avoid either medi-
al placement with ineffective but-
tressing or excessive lateral place-
ment with impingement on the
humeral head.32
The preferred graft
source is the inner table of the iliac
crest.
Postoperative
Rehabilitation
Postoperative management requires
the use of an orthosis to maintain
abduction, neutral rotation, and ex-
tension of the shoulder. The elbow
should be positioned posterior to the
plane of the body to decrease tension
on the repair. Immobilization is
maintained for 4 to 6 weeks, depend-
ing on the degree of instability, the
quality of the tissue, and the securi-
ty of the repair. At 6 weeks, active
assisted range-of-motion exercises
are started. Strengthening is delayed
until the third postoperative month.
Collision sports should be avoided
for the first 6 months.
Results
Published results are summarized in
Table 2. Although initial surgical re-
sults were so poor that some authors
concluded that recurrent posterior
Figure 7
Arthroscopic posterior stabilization technique. A, Portal placement using a three-
portal technique. The arthroscope is initially introduced into the posterior portal but
is then switched to the anterosuperior portal to visualize the posterior capsule.
The posterior capsule is addressed as viewed arthroscopically from the
anterosuperior portal. The superior aspect of the glenoid is oriented to the bottom
of the page and the inferior aspect oriented to the top. B, The capsule is being
shifted to the labrum using a shuttling-type suture passer, which is gentle on the
tissues. C, Both limbs of a permanent suture are retrieved through the posterior
cannula and tied. D, The steps are repeated from inferior to superior, with three to
five sutures typically being used.
Recurrent Posterior Shoulder Instability
472 Journal of the American Academy of Orthopaedic Surgeons
10. instability should not be treated sur-
gically,1
most of the early failures
and recurrences resulted from a lack
of knowledge of the pathoanatomy
and the relevant biomechanics. Im-
proved patient selection and surgical
techniques have led to better out-
comes.
Fronek et al30 and Hurley et al21
reported a 63% to 91% success rate
with nonsurgical treatment, with no
limitations in activities of daily liv-
ing and only moderate disability in
sports activities. Many of these pa-
tients had positive examination
findings for posterior instability but
did not require any further treat-
ment. Fronek et al30 also reported
good results with open posterior cap-
sulorrhaphy. Hawkins et al1
advocat-
ed the use of the infraspinatus ten-
don to reinforce the capsule and
reported an 85% success rate at aver-
age follow-up of 7 years (range, 2 to
15 years). Pollock and Bigliani32 re-
ported an overall satisfactory rate of
80% with this procedure at average
follow-up of 5 years. When revision
cases were excluded, the success rate
improved to 96%, highlighting the
importance of meticulous soft-tissue
repair at the first surgery.
Over the last decade, advances in
arthroscopy have made this ap-
proach quite attractive. Although a
variety of techniques has been de-
scribed, the key features include re-
storing the labrum and eliminating
capsular redundancy. In 1998, Wolf
and Eakin25 reported success in 16 of
17 patients who underwent an ar-
throscopic posterior capsular plica-
tion for unidirectional posterior in-
stability. Eleven returned to their
preinjury level of function, and there
were no reported complications. An-
toniou et al16
reported on 41 patients
with posterior instability treated
with an arthroscopic posteroinferior
capsulolabral augmentation proce-
dure. Thirty-five patients noted im-
provement, although 28 actually re-
ported a perception of shoulder
stiffness. Williams et al23
reported on
27 shoulders (26 patients) with trau-
matic posterior Bankart lesions sur-
gically treated with arthroscopic re-
pair using bioabsorbable tack
fixation; 55% of patients (11 pa-
tients) were American football play-
ers. Symptoms of pain and instabil-
ity were eliminated in 24 patients
(92%). Two patients required addi-
tional surgery.
Kim et al24 reported on 27 shoul-
ders (27 patients) with traumatic
unidirectional recurrent posterior
subluxation treated with arthroscop-
ic labral repair and posterior capsular
shift using suture anchors. In all cas-
es, symptoms were preceded by a
traumatic event. Symptoms of pain
and instability were eliminated in
Figure 8
Posterior opening wedge osteotomy. Significant retroversion (>20°) of the glenoid,
as shown here (A), is best addressed with this procedure. The opening wedge
osteotomy should be performed using a standard posterior approach. The
osteotomy (B) should begin approximately 10 mm medial to and parallel to the
articular surface. Stacking multiple broad flat osteotomes (C) helps achieve
distraction posteriorly while the anterior cortex is preserved. Care should be taken
to avoid an intra-articular fracture. The tricortical graft from the iliac crest may be
press-fit (our preference) or carefully secured with small fragment screws (D).
Peter J. Millett, MD, MSc, et al
Volume 14, Number 8, August 2006 473
11. all patients except one, who had re-
current instability. Postoperatively,
all patients had improved shoulder
scores. Twenty-six of 27 were able to
return to their prior sports with lit-
tle or no limitation.24
Thermal shrinkage of the capsu-
lar tissues also has been advocated to
shrink the patulous posterior cap-
sule.33 Reported results for this tech-
nique vary from failure rates as low
as 4%33
to as high as 60%,34
with
capsular insufficiency present in up
to 33%.35 There have been alarming
reports of capsular necrosis and cap-
sular rupture.35 We have found the
visual response of capsular shrink-
age at the time of arthroscopy to be
variable and the clinical results of
thermal capsulorrhaphy to be unpre-
dictable, with unacceptably high
failure rates. For these reasons, this
technique is not recommended.
The surgical treatment of volun-
tary posterior instability remains
controversial. Recurrence after soft-
Figure 9
A, A posterior glenoid bone graft can be used for erosions and osseous defects to
restore concavity to the glenoid. B, Care must be taken to position the graft
appropriately to effectively lengthen the articular arc while avoiding abutment of the
graft on the humeral head.
Table 2
Results and Complications Reported After Posterior Instability Surgery
Study Procedure (No. of Patients) Recurrence
Complications (Other
Than Recurrence)
Neer and Foster29
Open posterior inferior capsular shift 0% (0/15) DJD 1 patient
Hawkins et al1
Glenoid osteotomy (17), reverse Putti-Platt
(6), biceps transfer (3)
50% (13/26) DJD with glenoid
osteotomy 35 patients
Hurley et al21
Reverse Putti-Platt without bone block 73% (16/22) DJD 2 patients
Fronek et al30 Open medial-based posterior shift (6) and
with bone block (5)
9% (1/11) 1 superficial infection
McIntyre et al26 Arthroscopic posterior shift with sutures
tied over clavicle or scapular spine
25% (5/20) Recurrence only
Wolf and Eakin25 Arthroscopic posterior shift with and
without suture anchors
7% (1/14) Recurrence only
Antoniou et al16
Arthroscopic posterior shift with and
without suture anchors
15% (6/41) 28 subjective stiffness
with normal range of
motion
Fuchs et al15 Open lateral-based posterior inferior shift
with and without bone grafting (1) or
osteotomy (3)
23% (6/26) 8 discomfort, 1 anterior
subcoracoid
impingement
Williams et al23 Arthroscopic posterior Bankart repair with
bioabsorbable tack fixation
7% (2/27) Recurrence only
Kim et al24
Arthroscopic posterior Bankart repair and
posterior shift with suture anchors
4% (1/27) Recurrence only
DJD = degenerative joint disease
Recurrent Posterior Shoulder Instability
474 Journal of the American Academy of Orthopaedic Surgeons
12. tissue procedures has been reported
to vary from 0% (0/15 patients)29 to
72% (18/25 patients).21
A conserva-
tive nonsurgical approach is advo-
cated in these patients. Fuchs et al15
reported good to excellent results in
24 of 26 shoulders (92%) with volun-
tary posterior instability treated
with open surgery.
Complications and
Pitfalls
The complications of surgery are in-
cluded in Table 2 and are procedure-
specific and technique-dependent.
Recurrence is the most frequently re-
ported complication.1,30 Recurrence
may result from a new injury or from
a failure of the initial procedure. In-
dividuals with traumatic recurrence
of the instability usually have better
results after revision surgery than do
patients with atraumatic recurrence
of the posterior instability.
Stiffness after surgery for posteri-
or instability presents as loss of in-
ternal rotation. It is infrequently re-
ported in the literature, and its
incidence may be underestimated.30
In certain circumstances, stiffness
may be acceptable to maintain sta-
bility, but it is likely to be patient-
specific. For example, internal rota-
tion losses of 10° may have few
functional consequences for most
individuals, but they may be devas-
tating for certain populations, such
as professional baseball pitchers,
tennis players, or swimmers who, re-
spectively, need to throw a ball, hit
a serve, or pull a stroke at high
speed. The phenomenon of subcora-
coid impingement also may occur
when excessive posterior capsular
tightness creates an obligate anteri-
or shift of the humeral head and
causes the subscapularis and anteri-
or soft tissues to impinge on the cor-
acoid.36
Excessive tightness can have ma-
jor consequences on joint kinemat-
ics and joint reactive forces, creating
shearing forces on the glenoid rim
that result in cartilage erosion and
early osteoarthrosis.37 This has been
called capsulorrhaphy arthropathy.
Osteoarthrosis is also a complica-
tion that has been reported after pos-
terior glenoid osteotomy and poste-
rior glenoid bone grafting. This
complication is usually the result of
an intra-articular fracture or im-
pingement of the humeral head on
the glenoid rim or the bone block.
Both the axillary38 and suprascap-
ular nerves39 are at risk during open
surgery for posterior instability. Inju-
ries may occur during sharp dissec-
tion, tissue retraction, and suture
placement.
Summary
The diagnosis and management of
posterior shoulder instability remain
challenging. Posterior instability is
uncommon, and the diagnosis may
be subtle. The most common pre-
senting complaint is pain. Thorough
evaluation and appropriate imaging
will demonstrate the pathoanatomy,
which can be variable and may in-
volve soft-tissue and/or bony ele-
ments. Careful classification of the
instability will yield insight into the
natural history and help guide treat-
ment. In the great majority of indi-
viduals, nonsurgical treatment is the
preferred initial management. In
those who fail conservative mea-
sures, surgery may be indicated.
Careful preoperative planning, sur-
gery targeted at the specific pathol-
ogy, and thoughtful aftercare can
maximize the chance for success and
minimize the risk of complications.
Individuals with voluntary instabil-
ity, multidirectional instability, or
bony defects will require a more care-
ful assessment of the cause of the in-
stability. If an extended rehabilitation
program is unsuccessful, combined
soft-tissue and bony procedures may
be needed to restore stability.
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476 Journal of the American Academy of Orthopaedic Surgeons