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Complex Issues in Shoulder Surgery: Instability and Rotator Cuff

Maloney, Michael D., MD

Sports Medicine and Arthroscopy Review: September 2018 - Volume 26 - Issue 3 - p 87
doi: 10.1097/JSA.0000000000000209

Division of Sports Medicine, URMC Surgery Center, University of Rochester Medical Center, Rochester, NY

Disclosure: The author declares no conflict of interest.

Reprints: Michael D. Maloney, MD, Division of Sports Medicine, URMC Surgery Center, University of Rochester Medical Center, 180 Sawgrass Drive Rochester, NY 14620.

Even though our understanding of the shoulder has greatly increased over the last 20 years, it remains a complex joint, and injuries continue to not only perplex treating clinicians, but cause significant disability to patients of all ages and athletes at all levels. We are exploring the most common injury scenarios as well as those that present more rarely in an effort to provide comprehensive understanding of the challenges patients and clinicians face. Advances in our understanding of the basic science of soft tissue injury as well as mechanisms for healing and repair have lessened the burden; however, optimal treatments are still being honed both via nonsurgical means as well as with surgery.

One of the challenges we continue to face is the understanding of the biology of rotator cuff disease. It is truly a multifactorial condition, and there are many factors at play contributing to successful treatment of these injuries. Our authors provide an excellent overview of the current understanding as well as the evolution of surgical techniques for treatment.

Shoulder instability remains a challenge for young athletes. It has been well established that instability is a spectrum, and every effort should be made to provide an opportunity for conservative management, emphasizing a restoration of dynamic balance and endurance, with ultimate translation to functional and athletic endeavors. Surgical repair techniques, both arthroscopically and open, have been optimized along with the evolution of improved surgical instrumentation.

Finally, we have recently seen a greater implementation of soft tissue allograft techniques for shoulder instability. Superior capsular reconstruction with a dermal allograft is becoming more prominent in the hands of arthroscopists treating superior humeral migration as a result of irreparable rotator cuff tear arthropathy. Biomechanical and long-term outcome studies have shown promise in this challenging patient population. Further understanding of the biology of allograft incorporation and the impact of glenohumeral joint restoration is warranted. We also present a novel technique for patients who have failed efforts at managing complex shoulder instability. Patients who have underlying inherited collagen disorders such as Ehlers-Danlos syndrome, those who have failed previous capsulorrhaphy procedures, have had failed postsurgical rehab efforts, and those who have experienced capsular injury or attrition due to thermal necrosis present a unique challenge to surgeons. We highlight a new technique that has shown promise with a 5-plus year follow-up.

It has been an honor to oversee this edition of Sports Medicine Arthroscopy Review. I commend all the authors for their efforts and outstanding contribution. I hope you find the work presented stimulating and useful for your clinical practice.

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