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vi Contributors

Benton A. Emblom, MD Alicia K. Harrison, MD

Andrews Sports Medicine & Orthopedic Center Assistant Professor
Birmingham, Alabama Department of Orthopaedic Surgery
University of Minnesota
Vahid Entezari, MD Minneapolis, Minnesota
Department of Orthopaedic Surgery
The Cleveland Clinic Robert U. Hartzler, MD, MS
Cleveland, Ohio The San Antonio Orthopaedic Group
San Antonio, Texas
Brandon J. Erickson, MD
Sports Medicine and Shoulder Division Taku Hatta, MD, PhD
Hospital for Special Surgery Assistant Professor
New York, New York Department of Orthopaedic Surgery
Tohoku University School of Medicine
John M. Erickson, MD Sendai, Japan
Hand and Upper Extremity Surgeon
Raleigh Hand Center Joseph P. Iannotti, MD, PhD
Raleigh, North Carolina Department of Orthopaedic Surgery
The Cleveland Clinic
Evan L. Flatow, MD Cleveland, Ohio
Professor, Orthopaedic Surgery
Icahn School of Medicine at Mount Sinai; Oduche R. Igboechi, MD, MPH, MBA
President, Mount Sinai Roosevelt Hospital Resident
New York, New York Department of Orthopaedic Surgery
Tulane University School of Medicine
Christina Freibott, BA New Orleans, Louisiana
Research Assistant
Orthopaedic Surgery John V. Ingari, MD
Columbia University Medical Center Associate Hand Fellowship Director
New York, New York Assistant Professor
Department of Orthopaedic Surgery
Matthew J. Furey, MD, MSc Johns Hopkins Hospital
Clinical Associate, Hand and Wrist Surgery Baltimore, Maryland
Toronto Western Hospital
Toronto, Ontario, Canada Eiji Itoi, MD, PhD
Professor and Chair
Leesa M. Galatz, MD Department of Orthopaedic Surgery
Mount Sinai Professor and Chair Tohoku University School of Medicine
Leni and Peter May Department of Orthopedic Surgery Sendai, Japan
Icahn School of Medicine
Mount Sinai Health System Kristopher J. Jones, MD
New York, New York Assistant Professor
Department of Orthopaedic Surgery
Andrew Green, MD Division of Sports Medicine and Shoulder Surgery
Chief, Division of Shoulder & Elbow Surgery David Geffen School of Medicine at UCLA
Department of Orthopaedic Surgery Los Angeles, California
Warren Alpert Medical School
Brown University Jesse B. Jupiter, MD
Providence, Rhode Island Hansjorg Wyss AO Professor of Orthopedic Surgery
Harvard Medical School;
Jeffrey A. Greenberg, MD, MS Division of Hand and Upper Extremity Service
Clinical Assistant Professor Massachusetts General Hospital
Department of Orthopaedics Boston, Massachusetts
Indiana University;
Indiana Hand to Shoulder Center Nami Kazemi, MD
Indianapolis, Indiana OrthoAspen
Aspen Valley Hospital
Aspen, Colorado
 Contributors vii

W. Ben Kibler, MD Donald H. Lee, MD

Medical Director Professor of Orthopaedic Surgery and Rehabilitation
Shoulder Center of Kentucky Vanderbilt Orthopaedic Institute
Lexington Clinic Vanderbilt University School of Medicine
Lexington, Kentucky Nashville, Tennessee

Graham J.W. King, MD, MSc, FRCSC William N. Levine, MD

Professor Frank E. Stinchfield Professor and Chairman
Department of Surgery Department of Orthopedic Surgery
University of Western Ontario; NYP/Columbia University Medical Center
Director, Roth | McFarlane Hand and Upper Limb Centre New York, New York
St. Joseph’s Health Centre
London, Ontario, Canada Eddie Y. Lo, MD
Shoulder Service
Toshio Kitamura, MD, PhD Bay Area Orthopedic Institute
Vice-Director San Francisco, California
Kumamoto Orthopaedic Hospital
Kumamoto, Japan Lauren M. MacCormick, MD
Resident Physician
Steven M. Koehler, MD Department of Orthopaedic Surgery
Director, Hand and Microsurgery University of Minnesota
Assistant Professor Minneapolis, Minnesota
Department of Orthopaedic Surgery
SUNY Downstate Medical Center Leonard C. Macrina, MSPT, SCS, CSCS
Brooklyn, New York Co-Founder
Director of Physical Therapy
Zinon T. Kokkalis, MD, PhD Champion PT & Performance
Assistant Professor of Orthopaedic Surgery Waltham, Massachusetts
Department of Orthopaedics
University of Patras School of Medicine Chad J. Marion, MD
Patra, Greece Pacific Medical Centers
Seattle, Washington
Marc S. Kowalsky, MD
Shoulder and Elbow Surgeon Jed I. Maslow, MD
Orthopaedic and Neurosurgery Specialists Department of Orthopaedic Surgery
ONS Foundation for Clinical Research and Education Vanderbilt University Medial Center
Greenwich, Connecticut Nashville, Tennessee

Sumant G. Krishnan, MD Augustus D. Mazzocca, MD

Director Professor
The Shoulder Center Department of Orthopaedic Surgery
Baylor University Medical Center at Dallas; University of Connecticut School of Medicine
Associate Professor Farmington, Connecticut
Department of Surgery
Texas A&M Health Science Center College of Medicine Jesse Alan McCarron, MD
Dallas, Texas Shoulder and Elbow Surgeon
Rebound Orthopaedics and Neurosurgery
John E. Kuhn, MD, MS Portland, Oregon
Kenneth D. Schermerhorn Professor of Orthopaedics and Vancouver, Washington
Rehabilitation
Chief of Shoulder Surgery
Vanderbilt University Medical Center
Nashville, Tenessee
viii Contributors

George M. McCluskey III, MD Andrew S. Neviaser, MD

Clinical Professor
Department of Orthopaedic Surgery
Medical College of Georgia
Augusta, Georgia;
Clinical Assistant Professor
Department of Orthopaedic Surgery
Tulane University School of Medicine
New Orleans, Louisiana;
Director, St. Francis Shoulder Center
Director, St. Francis Shoulder Fellowship Program
Columbus, Georgia
Associate Professor
Department of Orthopaedic Surgery
The Ohio State School of Medicine
Columbus, Ohio
Robert J. Neviaser, MD
Professor and Emeritus Chairman
Department of Orthopaedic Surgery
George Washington University School of Medicine and
Health Sciences
Washington, DC

Patrick J. McMahon, MD Michael J. O’Brien, MD

McMahon Orthopedics; Associate Professor of Clinical Orthopaedics
Adjunct Associate Professor Director of Tulane Sports Medicine
Department of Bioengineering Tulane University School of Medicine
University of Pittsburgh New Orleans, Louisiana
Pittsburgh, Pennsylvania
Stephen J. O’Brien, MD, MBA
Steven W. Meisterling, MD Attending Orthopaedic Surgeon
Twin Cities Orthopaedics Hospital for Special Surgery;
Oak Park Heights, Minnesota Professor of Clinical Orthopedic Surgery
Weill Cornell Medical College
Mark A. Mighell, MD New York, New York
Florida Orthopaedic Institute
Tampa, Florida Jason Old, MD, FRCSC
Assistant Professor
Anthony Miniaci, MD, FRCSC University of Manitoba
Professor of Surgery Panam Clinic
Cleveland Clinic Lerner College of Medicine Winnipeg, Manitoba, Canada
Case Western Resever University
Cleveland, Ohio Victor A. Olujimi, MD
Shoulder/Elbow Fellow
Anand M. Murthi, MD Department of Orthopaedics
Chief, Shoulder and Elbow Surgery Mount Sinai Medical Center
Department of Orthopaedics New York, New York
MedStar Union Memorial Hospital
Baltimore, Maryland A. Lee Osterman, MD
Professor and Chairman
Surena Namdari, MD, MSc Division of Hand Surgery
Associate Professor, Orthopaedic Surgery Department of Orthopaedic Surgery
Sidney Kimmel Medical College Thomas Jefferson University;
Thomas Jefferson University President, The Philadelphia Hand Center
Rothman Institute Philadelphia, Pennsylvania
Philadelphia, Pennsylvania
Georgios N. Panagopoulos, MD
Thomas Naslund, MD Hand Fellow
Chief, Vascular Surgery Department of Orthopaedic Surgery
Professor of Surgery University of Pittsburgh Medical Center
Vascular Surgery Pittsburgh, Pennsylvania
Vanderbilt University Medical Center
Nashville, Tennessee
 Contributors ix

Rick F. Papandrea, MD Chris Roche, MS, MBA

Partner, Orthopedic Associates of Wisconsin Director of Engineering, Extremities
Waukesha, Wisconsin; Exactech
Assistant Clinical Professor Gainesville, Florida
Department of Orthopaedic Surgery
Medical College of Wisconsin Anthony A. Romeo, MD
Milwaukee, Wisconsin Department Head, Shoulder and Elbow Division
Midwest Orthopedics at Rush
Loukia K. Papatheodorou, MD, PhD Chicago, Illinois
Orthopaedic Surgeon, Orthopaedic Specialists - UPMC
University of Pittsburgh Medical Center Melvin Paul Rosenwasser, MD
Pittsburgh, Pennsylvania Carroll Professor of Orthopedic and Hand Surgery
Columbia University Department of Orthopedic Surgery
Ryan A. Paul, MD, FRCSC Director of Orthopedic Trauma Service
Clinical Fellow Director of Hand and Microvascular Service
Roth | McFarlane Hand and Upper Limb Centre New York Presbyterian Hospital
St. Joseph’s Health Care New York, New York
London, Ontario, Canada
David S. Ruch, MD
William Thomas Payne, MD Vice-Chair, Head of Hand Section
Northwestern Medicine Regional Medical Group Duke Orthopaedic Surgery
Warrenville, Illinois Duke University School of Medicine
Durham, North Carolina
Christine C. Piper, MD
Orthopaedic Surgery Resident Vikram M. Sampath, MD
George Washington University Hospital Resident
Washington, DC Department of Orthopaedic Surgery
Augusta University
Matthew L. Ramsey, MD Augusta, Georgia
Shoulder and Elbow Specialist
Rothman Institute Javier E. Sanchez, MD
Thomas Jefferson University Medical Student
Philadelphia, Pennsylvania Columbia University Medical Center
New York, New York
Lee M. Reichel, MD
Associate Professor of Orthopedic Surgery Michael G. Saper, DO, ATC, CSCS
Department of Surgery and Perioperative Care Assistant Professor
Dell Medical School Orthopedics & Sports Medicine
Austin, Texas Seattle Children’s
Seattle, Washington
Herbert Resch, MD
Professor and Former Head of Department of Trauma Felix H. Savoie III, MD
Surgery and Sports Injuries Ray J. Haddad Professor and Chairman
Paracelsus Medical University Department of Orthopaedic Surgery
Salzburg, Austria Tulane University School of Medicine
New Orleans, Louisiana
Eric T. Ricchetti, MD
Department of Orthopaedic Surgery Andrew Schannen, MD
The Cleveland Clinic Presbyterian Rust Medical Center
Cleveland, Ohio Albuquerque, New Mexico

David Ring, MD, PhD Bradley S. Schoch, MD

Associate Dean for Comprehensive Care Assistant Professor
Department of Surgery and Perioperative Care Department of Orthopaedics and Rehabilitation
Dell Medical School University of Florida
University of Texas at Austin Gainesville, Florida
Austin, Texas
x Contributors

Robert J. Schoderbek, Jr., MD John W. Sperling, MD, MBA

Orthopaedic Specialists of Charleston Department of Orthopedic Surgery
Roper St. Francis Sports Medicine Mayo Clinic
Charleston, South Carolina Rochester, Minnesota

Aaron Sciascia, PhD, ATC, PES Murphy M. Steiner, MD

Assistant Professor Hand Surgery Fellow
Exercise and Sport Science Department of Orthopaedic Surgery
Eastern Kentucky University University of Tennessee–Campbell Clinic
Richmond, Kentucky; Memphis, Tennessee
Orthopedic Research Specialist
Orthopedics-Sports Medicine Scott P. Steinmann, MD
Lexington Clinic Orthopedic Surgery
Lexington, Kentucky Mayo Clinic and Mayo Clinic Health System
Rochester, Minnesota
William H. Seitz, Jr., MD
Professor of Orthopaedic Surgery Laura Stoll, MD
Cleveland Clinic Lerner College of Medicine Shoulder and Elbow Fellow
Case Western Reserve University; Rothman Institute
Chairman, Orthopaedic Surgery Thomas Jefferson University
Lutheran Hospital Philadelphia, Pennsylvania
Cleveland Clinic Orthopaedic and Rheumatologic Institute
Cleveland, Ohio Robert J. Strauch, MD
Professor of Orthopaedic Surgery
Jon K. Sekiya, MD Orthopaedic Surgery
Professor of Orthopaedic Surgery Columbia University Medical Center
Medsport New York, New York
University of Michigan
Ann Arbor, Michigan Mark Tauber, MD
Associate Professor
Anup A. Shah, MD Department of Orthopaedics and Traumatology
Orthopedic Surgeon – Sports Medicine/Shoulder Paracelsus Medical University
Reconstruction Salzburg, Austria;
Kelsey-Seybold Clinic; Shoulder and Elbow Service
Clinical Assistant Professor of Orthopedic Surgery ATOS Clinic
Department of Orthopedic Surgery Munich, Germany
Baylor College of Medicine
Houston, Texas Samuel A. Taylor, MD
Assistant Attending Orthopedic Surgeon
Evan J. Smith, MD Hospital for Special Surgery;
Orthopaedic Surgery Resident Assistant Professor of Orthopedic Surgery
George Washington University Hospital, Weill Cornell Medical College
Washington, DC New York, New York

Mia Smucny, MD Richard J. Tosti, MD

Cleveland Clinic Assistant Professor
Cleveland, Ohio Orthopaedic Surgery
Thomas Jefferson University
David H. Sonnabend, MBBS, BSc (Med), MD, FRACS Philadelphia, Pennsylvania
Emeritus Professor in Orthopaedic Surgery
University of Sydney Katie B. Vadasdi, MD
Sydney, Australia Orthopaedic and Neurosurgery Specialists
Greenwich, Connecticut
Dean G. Sotereanos, MD
Clinical Professor of Orthopaedic Surgery Danica D. Vance, MD
University of Pittsburgh School of Medicine Resident, Department of Orthopaedic Surgery
Orthopaedic Specialists - UPMC NYP/Columbia University Medical Center
Pittsburgh, Pennsylvania New York, New York
 Contributors xi

Peter S. Vezeridis, MD Scott W. Wolfe, MD

Orthopaedic Surgeon Attending Orthopedic Surgeon
Shoulder and Sports Medicine Surgery Hospital for Special Surgery;
Excel Orthopedic Specialists Professor of Orthopedic Surgery
Woburn, Massachusetts Weill Medical College of Cornell University
New York, New York
Russell F. Warren, MD
Professor, Orthopaedic Surgery Nobuyuki Yamamoto, MD, PhD
Weill Cornell Medical College; Lecturer
Attending Orthopaedic Surgeon Department of Orthopaedic Surgery
Hospital for Special Surgery Tohoku University School of Medicine
New York, New York Sendai, Japan

Jeffry T. Watson, MD Allan A. Young, MBBS, MSpMed, PhD, FRACS (Orth)

Colorado Springs Orthopaedic Group Shoulder Surgeon
Colorado Springs, Colorado Sydney Shoulder Specialists
Sydney, Australia
Neil J. White, MD
Clinical Lecturer Bertram Zarins, MD
University of Calgary Augustus Thorndike Clinical Professor of Orthopaedic
Calgary, Alberta, Canada Surgery
Harvard Medical School;
Gerald R. Williams, Jr., MD Chief of Sports Medicine Service Emeritus
John M. Fenlin, Jr., MD Professor of Shoulder and Elbow Massachusetts General Hospital
Surgery Boston, Massachusetts
Department of Orthopaedic Surgery
The Rothman Institute Helen Zitkovsky, BA
The Sidney Kimmel Medical College Tufts University School of Medicine
Thomas Jefferson University Boston, Massachusetts
Philadelphia, Pennsylvania

Megan R. Wolf, MD
Orthopaedic Resident
University of Connecticut School of Medicine
Farmington, Connecticut
 Preface
Operative Techniques: Shoulder and Elbow Surgery is
intended to provide a clear and well illustrated step-by-step
review of state-of-the art shoulder and elbow surgical pro-
cedures described by some of the most respected surgeons
in this field. As opposed to traditional book chapters, this
book concentrates on surgical techniques that provide the
orthopedic surgeon with the finer surgical points, tips, and
pitfalls. It also helps give ancillary medical care providers the
insight into how these procedures are performed. This book,
a continuation of the series of Operative Techniques books
provided by Elsevier, concentrates on shoulder and elbow
surgical procedures.
Each chapter is constructed in a similar fashion. The sur-
gical indications, physical examination, appropriate imag-
ing studies, surgical anatomy, and treatment options are
reviewed. The surgical technique portion of each chapter
includes recommendations on surgical positioning, surgical
portals and exposure, and step-by-step descriptions of the
surgical procedure. Illustrations, surgical photographs, and
in some cases, videos of the surgical procedure accompany
xii
the detailed surgical descriptions. The postoperative reha-
bilitation, the expected outcomes, and an annotated ref-
erence list are also provided. Throughout each chapter,
surgical pearls, pitfalls, and controversies are discussed. We
hope that these detailed surgical descriptions and discus-
sions provide surgeons with an accessible, comprehensive
reference that will provide surgical insight, increase surgi-
cal efficiency, and minimize complications when performing
these operative procedures.
We are fortunate to have a distinguished group of con-
tributing authors and want to express our deep appreciation
to them for sharing their time and expertise in providing their
contributions to this book. We would also like to acknowl-
edge Daniel Pepper, Berta Steiner, and Julie Daniels for their
invaluable assistance in making this book possible.
We hope you enjoy this book and that it is helpful to you.
Donald H. Lee, MD
Robert J. Neviaser, MD
Foreword
Education in the field of medicine includes many things:
developing professionalism, acquiring a sense of human
needs, incorporating knowledge from many sources, apply-
ing the basic sciences, studying in-depth focused problems
and solutions, integrating patient-based indications, under-
standing structural deficiencies, knowing what medicine and
surgery have to offer, and assimilating all these things and
making a judgment about what should be done to help a
patient. All of this is so complex. Why aren’t there books that
just tell you how to do it? Early in one’s career this is very
useful. Later in one’s career it’s always helpful to see how
other skilled people approach a procedure, and recognize
ways one can improve techniques to address a problem.
The learned editors of this volume have stepped up and for-
mulated a book focusing on when and how to do it.
These experienced editors have selected the most com-
monly performed procedures and offered information that
will be helpful to almost anyone in any stage of his or her ca-
reer. The shoulder segment focuses on rotator cuff and other
­tendon-related problems, fractures, arthritis, and instability.
Similarly, the elbow segment has material on musculotendi-
nous attachment problems, fractures, arthritis, and instabil-
ity. This content is supplemented by information on how to
handle nerve lesions and stiffness. Chapters on approaches
and on soft tissue coverage are also featured in the elbow
section. Surgeons performing procedures contained in this
book may be generalists or may have a focused background
in trauma, sports, or adult reconstruction. But no matter from
what direction one approaches shoulder and elbow surgery,
one can learn from others in the discipline who may have a
different subspecialization—plus the bonus of having added
input from experts with one’s own background and direction.
Applied anatomy is a foundation for surgery. It is strange
but true that the usual anatomy texts often don’t contain the
useful anatomy that one would apply for surgical procedures.
In this text, that applied anatomy is carefully displayed. It
is wonderful to have a step-wise approach to surgery, but
also to have subtleties explained. A number of problems can
be approached by open surgery or by arthroscopic surgery.
Many are primary cases, but some are revision procedures.
This is a kind of textbook that one would want to pick up,
read, and set down; pick up and read again; and on and on
as one approaches cases in practice. It seems to me that
this is the kind of book one would want to have on the shelf
rather than in a library. This book will have repeated use by
surgeons operating in these anatomic regions. Another bo-
nus is the limited and focused literature on each procedure,
allowing a surgeon to expand knowledge even more when
addressing a specific situation.
Kudos yet again to these insightful, selfless editors and
the talented authors who have devoted their energy and time
to putting this user-friendly book together.
Robert H. Cofield, MD
Professor of Orthopedics
Mayo Clinic College of Medicine
Emeritus Chairman, Department of Orthopedic Surgery
Mayo Clinic;
Past-President
American Shoulder and Elbow Surgeons
Past-Chairman, International Board of Shoulder and Elbow
Surgery
Emeritus Editor-in-Chief, Journal of Shoulder and Elbow
Surgery
xiii
 Contents

SECTION I S HOULDER Procedure 13 Arthroscopic Treatment of

Procedure 1 Acromioplasty 4 Traumatic Anterior Instability of the
William N. Levine, Danica D. Vance, and
Javier E. Sanchez
Procedure 2  otator Cuff Repair: Open Technique
R Procedure 14
for Partial-Thickness or Small or
Medium Full-Thickness Tears 11
Allan A. Young and David H. Sonnabend
Procedure 3  otator Cuff Repair: Arthroscopic
R U. Bigliani
Technique for Partial-Thickness or
Small or Medium Full-Thickness
Tears 28
Allen Deutsch and Anup A. Shah
Procedure 4  pen Repair of Rotator Cuff
O Robert A. Arciero, and Augustus D.
Tears 46
Andrew S. Neviaser and Robert J. Neviaser
Procedure 5  rthroscopic Repair of Massive
A Associated With Glenoid or Humeral
Rotator Cuff Tears 64
Marc S. Kowalsky and Leesa M. Galatz
Procedure 6  perative Fixation of Symptomatic
O
Os Acromiale 79
Neal C. Chen, Jon K. Sekiya, and April D.
Armstrong
Procedure 7  umeral Head Resurfacing
H
Arthroplasty 85
Vikram M. Sampath, Chris Roche, and Lynn
A. Crosby
Procedure 8 Humeral Hemiarthroplasty With
Biologic Glenoid Resurfacing 92
Eddie Y. Lo and Wayne Z. Burkhead
Procedure 9 Total Shoulder Arthroplasty 102
Bradley S. Schoch, Robert U. Hartzler, and
John W. Sperling
Procedure 10  otator Cuff Tear Arthroplasty: Open
R
Surgical Treatment With Reverse
Shoulder 113
Christine C. Piper and Andrew S. Neviaser
Procedure 11  pen Unconstrained Revision
O Lesion: Arthroscopic Reconstruction
Shoulder Arthroplasty 119
Victor A. Olujimi, Paul J. Cagle, Jr., Nami
Kazemi, and Evan L. Flatow
Procedure 12  losed Treatment of Shoulder
C
Dislocations 133
Eiji Itoi, Toshio Kitamura, Nobuyuki
Yamamoto, and Taku Hatta
Shoulder 136
Evan J. Smith and Andrew S. Neviaser
 pen Treatment of Anterior-Inferior
O
Multidirectional Instability of the
Shoulder 140
Katie B. Vadasdi, Chad J. Marion, and Louis
Procedure 15 Arthroscopic Treatment of
Multidirectional Instability of the
Shoulder 148
John M. Apostolakos, Megan R. Wolf,
Mazzocca
Procedure 16  nterior Glenohumeral Instability
A
Bone Deficiency: The Latarjet
Procedure 159
Kristofer J. Jones, Christopher C. Dodson,
and Russell F. Warren
Procedure 17  pen Treatment of Posterior-
O
Inferior Multidirectional Shoulder
Instability 167
George M. McCluskey III
Procedure 18  rthroscopic Treatment of Posterior-
A
Inferior Multidirectional Instability of
the Shoulder 179
Danica D. Vance and Christopher S. Ahmad
Procedure 19  pen Bankart Procedure for Recurrent
O
Anterior Shoulder Dislocation 191
Peter S. Vezeridis and Bertram Zarins
Procedure 20 Mini-Open Biceps Tenodesis 202
Andrew S. Neviaser and Robert J. Neviaser
Procedure 21 Arthroscopic Biceps Tenodesis 209
Pascal Boileau and Jason Old
Procedure 22 S uperior Labrum Anterior-Posterior
of the Superior Labrum and Biceps
Anchor 220
Samuel A. Taylor, Helen Zitkovsky, Jake
Calcei, and Stephen J. O’Brien
Procedure 23 T reatment of the Unstable Shoulder
With Humeral Head Bone Loss 232
Anthony Miniaci and Mia Smucny

xiv
 Contents xv

Procedure 24 Open Distal Clavicle Excision 244 Procedure 40 Arthroscopic Treatment of Calcific
Lauren M. MacCormick, Alicia K. Harrison, Tendinitis in the Shoulder 395
and Edward V. Craig Oduche R. Igboechi, Felix H. Savoie III, and
Procedure 25  rthroscopic Distal Clavicle
A Michael J. O’Brien
Resection 250 Procedure 41  erve Transfers for Shoulder and
N
R. Bruce Canham and Anand M. Murthi Elbow Restoration After Upper Trunk
Procedure 26  pen Treatment of Acute and
O Brachial Plexus Injuries 403
Chronic Acromioclavicular Christopher J. Dy and Scott W. Wolfe
Dislocations With Soft Tissue Repair Procedure 42 Thoracic Outlet Syndrome 414
and Reconstruction 257 Thomas Naslund
Andrew Green Procedure 43 Suprascapular Nerve
Procedure 27 S ternoclavicular Joint Reconstruction Neuropathy 422
Using Semitendinosus Graft 268 Brandon J. Erickson and Anthony A. Romeo
John E. Kuhn
Procedure 28  pen Reduction and Internal
O SECTION II E LBOW
Fixation of Acute Midshaft Clavicular Procedure 44 Surgical Approaches to the
Fractures 276 Elbow 433
Richard J. Tosti and Jesse B. Jupiter Matthew J. Furey, Neil J. White, and
Procedure 29 I ntramedullary Fixation of Clavicle Robert J. Strauch
Fractures 282 Procedure 45 Arthroscopy of the Elbow: Setup and
Jason D. Doppelt and Robert J. Neviaser Portals 454
Procedure 30 Operative Treatment of Two-Part Julie E. Adams and Scott P. Steinmann
Proximal Humerus Fractures 287 Procedure 46 Elbow Arthritis and Stiffness: Open
Gerald R. Williams, Jr. and Treatment 458
Surena Namdari Julie E. Adams and Scott P. Steinmann
Procedure 31  pen Reduction and Internal
O Procedure 47 E lbow Arthritis and Stiffness:
Fixation of Three- and Four-Part Arthroscopic Treatment 463
Proximal Humerus Fractures 301 Julie E. Adams and Scott P. Steinmann
Julie Bishop and Jonathan Barlow Procedure 48 Radial Head Fractures: Radial Head
Procedure 32  ercutaneous Fixation of Proximal
P Replacement 468
Humerus Fractures 316 Donald H. Lee and John M. Erickson
Mark Tauber and Herbert Resch Procedure 49 Total Elbow Arthroplasty 475
Procedure 33  emiarthroplasty for Proximal
H Steven M. Koehler and David S. Ruch
Humeral Fracture 327 Procedure 50 Total Elbow Arthroplasty for the
Adham A. Abdelfattah, Kaitlyn Christmas, Treatment of Distal Humerus
and Mark A. Mighell Fractures 484
Procedure 34 Surgical Treatment of Scapular Ryan A. Paul and Graham J.W. King
Fractures 340 Procedure 51 Radiocapitellar Replacement 501
Donald H. Lee and Jed I. Maslow Rick F. Papandrea
Procedure 35 Surgical Approaches to the Procedure 52 Revision Total Elbow
Shoulder 354 Arthroplasty 513
Jesse Alan McCarron William H. Seitz, Jr. and Donald H. Lee
Procedure 36 Arthrodesis of the Shoulder 361 Procedure 53  pen Treatment of Medial
O
Vahid Entezari, Eric T. Ricchetti, and Epicondylitis 545
Joseph P. Iannotti Murphy M. Steiner and James H.
Procedure 37  pen and Arthroscopic
O Calandruccio
Suprascapular Nerve Procedure 54 Lateral Epicondylitis: Arthroscopic
Decompression 370 and Open Treatment 553
Aydin Budeyri and Sumant G. Krishnan Mark S. Cohen
Procedure 38 Scapular Surgery 380 Procedure 55  epair of Distal Biceps Tendon
R
W. Ben Kibler and Aaron Sciascia Ruptures 561
Procedure 39 Adhesive Capsulitis 385 Jue Cao, William Thomas Payne, and
Patrick J. McMahon Jeffrey A. Greenberg
xvi Contents

Procedure 56  epair and Reconstruction of the

R Procedure 63 S urgical Reconstruction of
Ruptured Triceps 571 Longitudinal Radioulnar Dissociation
Jue Cao and Robert M. Baltera (Essex-Lopresti Injury) 650
Procedure 57 Endoscopic Cubital Tunnel Julie E. Adams and A. Lee Osterman
Release 586 Procedure 64 Ulnar Collateral Ligament
Tyson Cobb Reconstruction Using the Modified
Procedure 58 S ubmuscular Ulnar Nerve Jobe Technique 658
Transposition 594 Michael G. Saper, Benton A. Emblom,
Raj M. Amin and John V. Ingari James R. Andrews, and Leonard C. Macrina
Procedure 59 S urgical Decompression for Radial Procedure 65 L ateral Ulnar Collateral Ligament
Tunnel Syndrome 597 Reconstruction 667
Loukia K. Papatheodorou, Zinon T. Kokkalis, Michael G. Saper, Robert J. Schoderbek, Jr.,
and Dean G. Sotereanos Steven W. Meisterling, and James R.
Procedure 60 Distal Humerus Fractures, Including Andrews
Isolated Distal Lateral Column and Procedure 66 Elbow Coverage: Principles of Soft
Capitellar Fractures 603 Tissue Reconstruction 676
Jeffry T. Watson Alexander B. Dagum
Procedure 61  adial Head Fractures: Open
R Procedure 67  perative Treatment of Olecranon
O
Reduction and Internal Bursitis 700
Fixation 628 Melvin Paul Rosenwasser, Andrew
Georgios N. Panagopoulos, Edward Donley, Schannen, and Christina Freibott
and Mark E. Baratz Procedure 68 T reatment of Osteochondritis
Procedure 62  pen Treatment of Complex
O Dissecans of the Elbow 707
Traumatic Elbow Instability 637 Laura Stoll, Michael J. O’Brien, and
Lee M. Reichel, George S.M. Dyer, and Matthew L. Ramsey
David Ring Index 717
Video Contents
Video 9.1 Complete Surgical Total Shoulder
Arthroplasty Procedure
Video 9.2 Surgical Approach to the Shoulder
Video 9.3 Placement of Humeral Component
Video 9.4 Trial Reduction of Humeral Component
and Soft Tissue Balancing
Video 9.5 Placement of Glenoid Component
Video 9.6 Wound Closure
Video 14.1 Elevation and Separation of Subscauplaris
from Anterior Joint Capsule
Video 14.2 Arthrotomy and Elevation of Anterior
Capsule
Video 14.3 Capsular Shift and Reconstruction
Video 18.1 Arthroscopic Dissection of Posterior-
Inferior Labrum with an Arthroscopic
Elevation
Video 18.2 Preparation of Posterior-Inferior Glenoid
Rim with an Arthroscopic Shaver
Video 18.3 Drilling for Inferior Suture Anchor
Video 18.4 Placement of Inferior Suture Anchor
Video 18.5 Transferring Suture Limb to a Separate
Portal
Video 18.6 Passing Suture Passing Through Labrum
Video 18.7 Passing Suture Through Labrum
Video 18.8 Tying Suture over Labrum
Video 18.9 Preparation of Posterior-Inferior Glenoid
Rim with an Arthroscopic Rasp
Video 23.1 Surgical Dissection
Video 23.2 Partial Humeral Head Resurfacing
Arthroplasty
Video 25.1 Distal Clavicle Resection
Video 33.1 Operative Technique for Hemiarthroplasty
for Four-Part Proximal Humeral Fracture
Video 34.1 Anterior Shoulder Incision
Video 34.2 Clavipectoral Fascia
Video 34.3 Subscapularis Release 1
Video 34.4 Subscapularis Release 2
Video 34.5 Glenoid Fracture Exposure
Video 34.6 Posterior Scapular Incision 1
Video 34.7 Posterior Scapular Incision 2
Video 34.8 Posterior Fascial Dissection 1
Video 34.9 Posterior Fascial Dissection 2
Video 34.10 Scapular Spine Dissection 1
Video 34.11 Scapular Spine Dissection 2
Video 34.12 Acromial Fracture Dissection 1
Video 34.13 Acromial Fracture Dissection 2
Video 34.14 Acromial Fracture Dissection 3
Video 34.15 Scapular Medial Border Dissection 1
Video 34.16 Scapular Medial Border Dissection 2
Video 34.17 Infraspinatus-Teres Minor Dissection
Video 34.18 Posterior Glenoid Fracture Exposure with
Probe
Video 34.19 Scapular Fracture Exposure 1
Video 34.20 Scapular Fracture Exposure 2
Video 34.21 Posterior Scapular Plate
Video 34.22 Superior Glenoid Screw 1
Video 34.23 Superior Glenoid Screw 2
Video 34.24 Superior Glenoid Screw 3
Video 34.25 Acromial Fracture Fixation 1
Video 34.26 Acromial Fracture Fixation 2
Video 34.27 Acromial Fracture Fixation 3
Video 34.28 Acromial Fracture Fixation 4
Video 34.29 Subscapularis Repair
Video 34.30 Infraspinatus Repair 1
Video 34.31 Infraspinatus Repair 2
Video 34.32 Infraspinatus Repair 3
Video 34.33 Deltoid-Trapezius Repair 1
Video 34.34 Deltoid-Trapezius Repair 2
Video 34.35 Final Wound Closure 1
Video 34.36 Final Wound Closure 2
Video 43.1 Arthroscopic Suprascapular Nerve
Decompression
Video 48.1 Incision
Video 48.2 Arthrotomy 1
Video 48.3 Arthrotomy 2
Video 48.4 Head Sizing
Video 48.5 Radial Neck Resection
Video 48.6 Broach
Video 48.7 Trial Stem Insertion
Video 48.8 Trial Head Insertion
Video 48.9 Set Screw Insertion
Video 48.10 Intraoperative Fluoroscopy
Video 48.11 Final Stem Insertion
Video 48.12 Final Head Insertion
Video 48.13 Final Fluoroscopy
Video 48.14 Annular Ligament Repair
Video 48.15 Fascial Repair
Video 51.1 Lateral Epicondylar Osteotomy
Video 52.1 V-Y or “Tongue” Repair of the Triceps
Video 57.1 ECuTR Procedure
xvii
xviii Video Contents

Video 57.2 New ECuTR Portal
Video 57.3 ECuTR Cadaver
Video 60.1 Patient Positioning and Surgical Approach
for a Distal Humeral Fracture, Including
Olecranon Osteotomy and Exposure of
Fracture
Video 60.2 Provisional and Final Fixation of Distal
Humeral Fracture
Video 60.3 Repair of Olecranon Osteotomy and
Wound Closure
 PART IIII
SECTION

Shoulder
A: Rotator Cuff

PROCEDURE 1 Acromioplasty 4
PROCEDURE 2  otator Cuff Repair: Open Technique for
R
­Partial-Thickness or Small or Medium
Full-Thickness Tears 11
PROCEDURE 3  otator Cuff Repair: Arthroscopic Technique
R
for Partial-Thickness or Small or Medium
Full-Thickness Tears 28
PROCEDURE 4 Open Repair of Rotator Cuff Tears 46
PROCEDURE 5 Arthroscopic Repair of Massive Rotator Cuff Tears 64
PROCEDURE 6 Operative Fixation of Symptomatic Os A
­ cromiale 79

B: Arthritic Shoulder

PROCEDURE 7 Humeral Head Resurfacing Arthroplasty 85

PROCEDURE 8  umeral Hemiarthroplasty With Biologic
H
Glenoid Resurfacing 92
PROCEDURE 9 Total Shoulder Arthroplasty 102
PROCEDURE 10  otator Cuff Tear Arthroplasty: Open Surgical
R
Treatment With Reverse Shoulder 113
PROCEDURE 11  pen Unconstrained Revision Shoulder
O
Arthroplasty 119

C: Instability

PROCEDURE 12 Closed Treatment of Shoulder Dislocations 133

PROCEDURE 13  rthroscopic Treatment of Traumatic Anterior
A
Instability of the Shoulder 136
PROCEDURE 14  pen Treatment of Anterior-Inferior Multidirectional
O
Instability of the Shoulder 140

1
 PROCEDURE 15  rthroscopic Treatment of Multidirectional
A
Instability of the Shoulder 148
PROCEDURE 16  nterior Glenohumeral Instability Associated With
A
Glenoid or Humeral Bone Deficiency: The Latarjet
Procedure 159
PROCEDURE 17  pen Treatment of Posterior-Inferior
O
Multidirectional Shoulder Instability 167
PROCEDURE 18  rthroscopic Treatment of Posterior-Inferior
A
Multidirectional Instability of the Shoulder 179
PROCEDURE 19  pen Bankart Procedure for Recurrent Anterior
O
Shoulder Dislocation 191

D: Biceps Tendon

PROCEDURE 20 Mini-Open Biceps Tenodesis 202

PROCEDURE 21 Arthroscopic Biceps Tenodesis 209
PROCEDURE 22  uperior Labrum Anterior-Posterior Lesion:
S
Arthroscopic Reconstruction of the Superior
Labrum and Biceps Anchor 220
PROCEDURE 23  reatment of the Unstable Shoulder With Humeral
T
Head Bone Loss 232

E: Clavicle

PROCEDURE 24 Open Distal Clavicle Excision 244

PROCEDURE 25 Arthroscopic Distal Clavicle Resection 250
PROCEDURE 26  pen Treatment of Acute and Chronic
O
Acromioclavicular Dislocations With Soft Tissue
Repair and Reconstruction 257
PROCEDURE 27  ternoclavicular Joint Reconstruction Using
S
Semitendinosus Graft 268

F: Trauma

PROCEDURE 28  pen Reduction and Internal Fixation of Acute

O
Midshaft Clavicular Fractures 276
PROCEDURE 29 Intramedullary Fixation of Clavicle Fractures 282
PROCEDURE 30  perative Treatment of Two-Part Proximal
O
Humerus Fractures 287
PROCEDURE 31  pen Reduction and Internal Fixation of Three-
O
and Four-Part Proximal Humerus Fractures 301

2
F: Trauma

PROCEDURE 32  ercutaneous Fixation of Proximal Humerus

P
Fractures 316
PROCEDURE 33  emiarthroplasty for Proximal Humeral
H
Fracture 327
PROCEDURE 34 Surgical Treatment of Scapular Fractures 340
PROCEDURE 35 Surgical Approaches to the Shoulder 354
PROCEDURE 36 Arthrodesis of the Shoulder 361
PROCEDURE 37  pen and Arthroscopic Suprascapular Nerve
O
Decompression 370
PROCEDURE 38 Scapular Surgery 380
PROCEDURE 39 Adhesive Capsulitis 385
PROCEDURE 40  rthroscopic Treatment of Calcific Tendinitis in the
A
Shoulder 395
PROCEDURE 41  erve Transfers for Shoulder and Elbow Restoration
N
After Upper Trunk Brachial Plexus Injuries 403
PROCEDURE 42 Thoracic Outlet Syndrome 414
PROCEDURE 43 Suprascapular Nerve Neuropathy 422

3
PROCEDURE 1

Acromioplasty
William N. Levine, Danica D. Vance, and Javier E. Sanchez

INDICATIONS PITFALLS INDICATIONS

• Massive rotator cuff tears with early proximal
humeral migration
INDICATIONS CONTROVERSIES
• Some authors have advocated no
acromioplasty in any condition. However, this is
highly controversial and not well supported by
the literature over the past 3 decades.
TREATMENT OPTIONS
• Open acromioplasty
• Arthroscopic acromioplasty
• Symptomatic anterosuperior shoulder pain consistent with “impingement syndrome”
• In association with symptomatic rotator cuff tears that are not massive
• In association with partial-thickness rotator cuff tears especially on the bursal side
EXAMINATION/IMAGING
• A complete shoulder examination should be performed, but the following tests are
critical:
• The Neer sign: pain on passive forward elevation of the shoulder while the exam-
iner uses one hand to prevent scapular rotation. Pain is usually elicited in the arc
between 70 and 120 degrees (Fig. 1.1).
• The Neer impingement test: injection of local anesthetic beneath the anterior ac-
romion with the elimination of pain with forward elevation.
• Hawkin test: pain with forward flexion of the humerus to 90 degrees and then pas-
sive internal rotation (Fig. 1.2).
• Acromioclavicular joint (ACJ) exam: this is important to rule out as another pos-
sible contributor to pain. Two tests are most sensitive—direct tenderness to pal-
pation over the ACJ and a positive cross-body adduction maneuver where the
patient experiences pain over the ACJ with cross-arm adduction.
• Imaging
• Plain films: true anteroposterior (AP), scapular outlet, and axillary lateral should be
obtained in all patients. The outlet view will demonstrate the acromial morphology
and any acromial pathology (spurs; Fig. 1.3).
• Magnetic resonance imaging (MRI): evaluates the integrity of the rotator cuff
and biceps tendon. Also identifies bony anomalies such as os acromiale, signifi-
cant spurs, tuberosity cysts, or degenerative changes in the acromioclavicular or
glenohumeral joints (Fig. 1.4).

FIG. 1.1 FIG. 1.2

4
 PROCEDURE 1 Acromioplasty 5

A B

FIG. 1.3 A–C

Supraspinatus
Acromioclavicular muscle
joint capsule

Coracoacromial
ligament

Infraspinatus
tendon

Subscapularis
muscle
Biceps brachii
tendon

FIG. 1.4 FIG. 1.5

SURGICAL ANATOMY
• With the arm in anatomic position the supraspinatus tendon, the anterior portion of
the infraspinatus tendon and the long head of biceps lie anterior to the acromion.
• Elevation of the arm in internal rotation or in the anatomic position causes these
structures to pass under the anterior portion of the acromion and the coracoacromial
ligament (CAL) (Fig. 1.5).
Another random document with
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been found. Unless connected with cirrhosis or other serious disease
of the hepatic tissue, their presence seems to have no pathological
significance.
Carcinoma. This has been recorded in the liver of cattle by Gurlt,
Brückmüller, Kitt and others. From the walls of the gall bladder it
grows in pyriform masses, and on the surface and in the interior of
the liver, it may appear as hard, cancerous masses of all sizes.
Epithelioma. This has been described by Kitt, Martin, Blanc,
Leblanc, Morot, Cadeac, and Besnoit. It appears in masses varying in
size from a millet seed up, bulging from the surface of the organ or
deeply hidden in its substance, and stained yellow or green with bile.
The liver is usually enlarged, amounting to even 34 pounds (Cadeac).
The formation commencing in the acini invades all surrounding
parts causing compression and atrophy of the liver cells, and the
formation of nests of epithelioid cells often with multiple nuclei and
nucleoli. Cirrhosis is not uncommon, and fatty and other
degenerations. Microbic invasion and necrobiosis are also common.
 NEOPLASMS IN THE SHEEP’S LIVER.
Adenoma has been met with by McFadyean, Johne, Kitt and
Bollinger. They hung as pediculated tumors from the surface of the
liver, and were in part wedged into its substance displacing the
hepatic tissue and vessels. In general they consisted of a dense
fibrous stroma with cylindroid and biliary cells in great abundance,
sometimes arranged in tubular form. Specimens described by Kitt
and Bollinger attained to the size of a man’s head and were stained of
a deep green color.
Carcinoma. Casper reports a case of hepatic cancer in the sheep
secondary to cancer of the mesentery.
 NEOPLASMS IN THE DOG’S LIVER.

Lipoma. Trasbot describes two fatty tumors in the liver of a bitch,

one of them as large as an infant’s head. It had a yellowish white
color, and had taken the place of the proper hepatic tissue.
Malignant Tumors. These are rather common. Sarcomatous
masses with round and fusiform cells in a fibrous stroma;
encephaloid with a delicate stroma and large alveoli filled with cells,
and having a soft brainlike consistency; carcinoma with dense and
thick fibrous stroma and nests of cells in comparatively small
numbers; and epithelioma with flattened, cylindroid or other
epithelial cells in masses often affecting a tubular aggregation, are
seen in different cases. Sometimes apparently primary, they can
more commonly be traced to pre-existing centres of the same
formation on the course of the portal vein or elsewhere.
Symptoms. A gradual wasting and emaciation with a yellowish
pallor of the mucous membranes are characteristic. Trasbot gives the
excessive atrophy of the temporal and masseter muscles as
pathognomonic. Ascites is a usual complication. Enlargement of the
liver, as shown by percussion of the right hypochondrium, and, in
case of flaccid abdomen, by manipulation, and attendant signs of
tenderness are corroborative. Variability or loss of appetite, and
vomiting is not uncommon, and in case of primary or secondary
deposits in other organs in the abdomen, thorax or elsewhere, the
symptoms resulting from functional derangement of such organ may
be found. Treatment is hopeless.
 CALCAREOUS NODULES AND
DEGENERATIONS OF THE LIVER.

Calcified roundish nodules, in groups, under capsule. Mostly in solipeds.

Theories of origin: parasites, microbes, emboli, omphalitis, intestinal disease,
biliary obstructions. Calcification of liver with large abdominal aneurisms.
Cszoker’s case, Diagnosis and specific treatment impossible.

In the domestic animals in general the liver may become the seat
of imperfectly spherical nodules of a white, yellow or brownish white
color, varying in size from a millet seed to a pea or hazel nut, and of a
gritty consistency and feeling, from the deposition of earthy salts.
These may be seen in groups under the proper capsule, the adjacent
hepatic tissue being healthy, or atrophied, sclerosed or pigmented.
These lesions have been found most abundantly in solipeds.
Pathogenesis. The most varied doctrines have been advanced as to
the origin of these lesions. They have been attributed to the previous
presence in the liver of linguatula, echinococcus, cœnurus, oxyurus,
distoma, and other parasites (Cadeac, Mazanti, Olt, Ostertag, Gripp,
Leuckart, Ratz), to glanders, to microbian attacks (Dieckerhoff), to
minute embolic infarcts in omphalitis in the foal, or intestinal
disease in the adult (Kitt), and to obstructions by the eggs of
distomata in the biliary ducts (Galli-Vallerio). It is not improbable
that the lesion may be due to any one of these in a specific case, and
this may be ascertained by the existence of certain definite features
and conditions. Linguatula, echinococcus and cœnurus can only be
suspected in districts where these prevail, and a careful examination
of the central mass of the nodule should reveal the presence of the
indestructible hooklets, as certified for given cases by Olt, Ostertag
and Gripp. In case of nematoid worms or distomata, the eggs may
possibly be found as in the cases of Villach and Ratz, or the embryos
(Mazanti). Or there may be traces of channels formerly hollowed out
by the worms in the vicinity of the nodules, as seen by Leuckart.
Coincident tumors of the intestinal mucosa from larval nematodes,
or aneurism or emboli in the anterior mesenteric artery would
corroborate this conclusion. If distomata had started the lesions, the
distension of the gall ducts and the thickening of their walls would be
likely to indicate their former presence. Glander nodules might be
suspected from the absence of a distinct rounded or oval outline,
from the lack of a distinct, clear line of demarcation between the
nodule and the adjacent liver tissue, and by the manifestation in the
periphery of the nodule and around it of free cell proliferation,
showing the mode of progression by the invasion of new tissue. If
still active, the bacilli should be discoverable in stained scrapings or
sections. There should also be distinct indications of the lesions of
glanders in the lymph glands of the portal fissure, of the
mediastinum, of the submaxillary region and of other parts.
Heiss records an interesting case of general calcification of the
horse’s liver, with large aneurism of the abdominal aorta, mesenteric
and renal arteries. The liver was thirty-two pounds, puckered on the
surface and showed calcic degeneration of the walls of the vessels
and hepatic tissue, to such an extent that when the organ was dried it
did not add materially to its hardness. Microscopically the diseased
centres indicated minute blood clots (thrombi), with fibrinous
development and cretifaction. The lesions in this case were
attributed to multiple emboli in connection with the aneurism. It
might suggest further, microbian infection of both the aneurismal
and hepatic vessels. In another case of extensive cretifaction of the
horse’s liver reported by Cszoker, the calcified masses tended to
assume rounded forms like tubercle, and had a clear glistening
surface.
These lesions are mainly interesting in a pathological sense, and
unless they are very extensive do not give rise to appreciable
symptoms.
Treatment could only be prophylactic and directed to the removal
of the special conditions, in which the calcification originated in a
given locality.
 ACTINOMYCOSIS OF THE LIVER.

On damp infested soil, in cattle and swine. Round tumors, hard

surface, soft centre, fibrous sac, club-shaped cells in tufts. Symptoms
of liver disorder. Coincident external actinomycosis. Treatment:
potassium iodide.
In damp soils where actinomyces are present in the soil and
vegetation, it is not uncommon to find the characteristic growths in
the liver of cattle and swine. Rasmussen saw twenty-two cases of
hepatic actinomycosis in one year (1890) and in a number of cases he
has found the liver, spleen, peritoneum and intestine simultaneously
affected. Jensen who has also recorded hepatic cases, found tumors
extending from the liver to the diaphragm. He describes them as
rounded masses, of different sizes, enclosed in a fibrous envelope of
variable thickness, hard and resistant at the surface and somewhat
softened toward the centre. Microscopic examination detects the
club-shaped cells arranged in tufts and radiating from a common
centre.
Symptoms are only the general indications of hepatic disease
differing according to the size, and position of the morbid product
and its interference with normal functions. When, however,
superficial actinomycosis is found these symptoms may be fairly
attributed to the existence of similar products in the liver.
Treatment consists in the administration of potassium iodide in
full doses, daily for a week, followed by a laxative, and then, after an
interval of two days, repeat the treatment for a second week, and so
for a third, fourth and fifth until the microbe has been destroyed.
 PARASITES OF THE LIVER.

Lying as it does in the channel of the blood charged with the

products of absorption from the intestine, the liver is especially liable
to parasites. Among protozoa are: Monocercomonas hepatica
(pigeon), saccharomyces guttulatus (rabbit), eimeria falciformis
(rabbit), coccidium oviforme (rabbit, pig, dog). Among the lower
cryptogams are actinomyces (ox, pig). Of the tapeworm family are:
Cysticercus tenuicollis (ruminants, pig), c. pisiformis (rabbit), c.
cellulosa (dog, pig), echinococcus veterinorum (animals, man), tænia
fimbriata (sheep, deer), and an undetermined cœnurus (cat). Of
trematodes are: Distoma hepatica (herbivora, man), distoma
lanceolatum (herbivora, man), distoma giganteum, or Americanum
(cattle), d. truncatum, d. conjunctum, d. campanulatum (dog),
amphistoma explanatum (ox). Of nematodes are: Stephanurus
dentatus, ascaris suis, oesophagostoma dentatum (pig), sclerostoma
equinum, ascaris megalocephala (horse), ascaris bovis (ox),
oesophagostoma columbiana (in ruminants), filaria hepatica,
enstrongylus gigas, ascaris marginata (dog), ollulanus tricuspis,
ascaris mystax (cat). (See Parasites).
 DISEASES OF THE PANCREAS.
Obscure. Shown only by digestion or hepatic disorder. Excess of fat in stools
suggests suppression of secretion. Intestinal fermentations. Suspension of
glycogenesis and consequent emaciation, stunting or poisoning. Pancreatic
calculus and icterus.
Diseases of the pancreas are even more obscure than those of the
liver. Situated on the course of the duodenum, beneath the lumbar
vertebræ and their right transverse processes, and separated from
the lateral walls and floor of the abdomen by the great mass of the
intestines, it is not open to manipulation or satisfactory percussion,
and its secretions being used up in the function of digestion, so that
they cannot be perceived and tested externally like the secretions of
the kidneys. Beside the general constitutional disorder therefore, we
must look rather to the derangements of the digestive functions, to
the abnormal condition of the fæces, and to the alterations in
subordinate functions like the glycogenic action of the liver, for
indications of an unhealthy state of the pancreas. The suppression of
the pancreatic secretion has long been associated with the
occurrence of fat in the stools, yet this may result from the lack of
bile which has important functions to fulfill in emulsionizing fat, and
in securing its endosmosis. On the other hand the lack of pancreatic
juice may hinder the complete digestion of the albuminoids, and
favor their fermentation and the occurrence of tympanies,
congestions, abnormal secretions, etc., which may be easily
attributed to another origin. Then again the dependence of the liver
on the pancreas for its stimulus to glycogenesis, would suggest a
series of disturbances from the abundance of the unused food
principles, from the hindrance to nutrition and growth, and perhaps
from the toxic action of the hepatic products. Once more, through
the common excretory duct, infection of the pancreas may extend to
and involve the liver, and blocking of the common duct by pancreatic
parasites, or calculi, may stop the flow of bile and cause jaundice or
other icteric disorder. And yet, it is rarely the case that pancreatic
disorder is successfully diagnosed, and it is too often only at the post
mortem examination that the actual lesions are revealed.
 CATARRHAL PANCREATITIS.
Probable causation by parasites, calculi, irritants, microbes. Lesions: mucosa
reddened, thickened, ducts dilated, epithelium fatty, granular, desquamating, pus,
connective tissue indurated. Interdependence of pancreatitis and hepatitis in
horse, sheep and goat. Liver lesions. Symptoms: loss of vigor, endurance, appetite,
and condition. Icterus, costiveness, fœtid, fatty stools, percussion tenderness—
right side. Treatment: antithermics, eliminants, antiseptics, derivatives, alkalies,
salicylates, ether.
Causes. We know little of the causes of this affection, but it may be
inferred that parasites, calculi and other irritants, will produce in this
as in other mucosæ a mucopurulent inflammation. Then again the
presence of pus suggests the coöperation of pus microbes as in the
infective catarrhal icterus. The blocking of the common gall and
pancreatic duct, by gall stones or biliary products, will entail arrest of
the discharge of pancreatic juice, and a consequent pancreatitis, just
as blocking with pancreatic products will cause hepatitis and icterus.
Lesions. The mucosa of the pancreatic ducts is reddened,
congested and thickened and their lumen blocked by a white,
granular matter, containing pus globules, fibrine filaments, and
granular, ciliated epithelium. The blocked ducts become dilated, and
their walls thickened, the epithelium is desquamated to a greater or
less extent, and the raw exposed surface may present ulcers or
granulations. The pancreatic cells undergo fatty degeneration and
the connective tissue becomes steadily indurated (sclerosis). These
lesions were especially noted by Megnin and Nocard in a case of
pancreatitis in the horse.
In the horse, sheep and goat, which have a common outlet for the
bile and pancreatic juice, the blocking of the latter and the arrest of
the bile almost of necessity causes hepatitis, and infection in the one
gland is directly transferred to the other so that pancreatitis and
hepatitis are mutually causative of each other. In the ox, pig, dog and
cat, in which the bile and pancreatic juice are poured into the
duodenum through separate ducts and orifices, this mutual
pathogenic action is not so certain.
 When the liver is implicated, there is catarrh and dilatation of the
bile ducts, fatty degeneration commencing in the centre of the acini,
pigmentation appearing at their periphery, and sclerosis of the organ
follows.
Symptoms. In Nocard’s equine case there was progressive loss of
spirit, energy, and endurance; appetite was poor and eating listless;
after two weeks jaundice set in, the visible mucosæ and skin showing
a yellow tinge, and the scanty urine becoming brownish yellow; the
bowels became costive the fæces being formed of small hard
discolored balls, but no excess of fatty matter is recorded.
Emaciation advanced rapidly, the most marked wasting being in the
muscles of the back, loins and croup. Death ensued at the end of two
months from the commencement of the illness. In man sudden,
violent colic, with nausea, tympany and collapse are prominent
symptoms.
Diagnosis is more satisfactory when with digestive disorder,
tardily developing icterus, and rapid emaciation, there is an excess of
fat in the ill-smelling fæces. Pain on percussion of the right
hypochondrium would be an additional feature.
Treatment can rarely be adopted because of the uncertainty of the
diagnosis. It would proceed on general principles, antithermics,
eliminants, antiseptics, and counter-irritants being resorted to as the
conditions seem to demand. Alkaline laxatives and diuretics,
salicylates of soda or potash, and guarded doses of sulphuric ether to
solicit the action of the pancreas, might be resorted to. The disorder
of the liver would require attention along the lines indicated under
catarrh of that organ.
 INTERSTITIAL PANCREATITIS.
Causes: paresis, marasmus, septic infection, blood diseases. Lesions: connective
tissue in excess—pancreas and liver; catarrhal complications; calcic points;
congestion and petechiæ in septic infection. Areas of fat necrosis in the pancreas
and abdominal adipose tissue. Stearates of lime. Calcic foci in animals. Symptoms:
obscure. Treatment.
This is especially liable to accompany paretic and wasting diseases,
septic infection, and diseases of the blood. Radionow examined the
pancreas in animals that had suffered from chronic paralysis, gastro-
intestinal catarrh, hepatic catarrh, chronic anæmia and marasmus,
and found fatty degeneration of the epithelium, with atrophy and
pigmentary degeneration of the glandular epithelium. The fibrous
tissue of the gland was in excess in the pancreas and in the liver
(sclerosis), and mucous cysts were found.
Siedamgrotzky found a chronic interstitial pancreatitis connected
with alopecia, œdema and leucocythæmia. The pancreas was
indurated, fibrous, resisting the edge of the knife and sprinkled with
gritty particles. Much of the glandular tissue had been destroyed, and
the ducts were filled with a dense, grayish, grumous mucus.
Kirilow and Stalnikow have found interstitial pancreatitis marked
by congestion and ecchymosis, with intervening anæmic areas, in
animals injected with septic matter. There was increased secretion in
the early stages.
A marked feature of pancreatitis in man is the occurrence in the
interlobular tissue of the gland, the omentum, mesentery and
abdominal fatty tissue generally, of circumscribed areas of fat
necrosis, each varying in size from a pin’s head upward even to a
hen’s egg. On section these show a soft tallowy consistency and
Langerhans has shown that they are composed of lime and fatty
acids in combination. When lime is in excess they become gritty.
According to Osler they may be dependent on some other primary
affection (Bright’s disease). The partially calcified concretions found
in the pancreatic ducts, and the yellowish white, gritty areas, which
represent the degenerate lobules in animals (Seidamgrotzky) are
suggestive of a similar morbid condition of the pancreas or it may be
of some distant organ. Of late years a number of cases have been
recorded in man and a very high mortality noted.
The symptoms in the lower animals are very obscure, and an
accurate diagnosis is looked upon as almost impossible. They are
essentially the same as given above under catarrhal pancreatitis.
Treatment too has the same narrow limitations.
 PANCREATIC ABSCESS, SUPPURATIVE
PANCREATITIS.
A complication of strangles or purulent infection. Symptoms: Colics, chill, tender
right hypochondrium, emaciation, fatty stools. Treatment: Constitutional.
Reimers has reported several cases of pancreatic abscess, as a
phase of irregular strangles (rhinoadenitis). In one case multiple
abscesses with an aggregate capacity of 2½ quarts were found, and
some of the pus had escaped by rupture into the peritoneum and
produced infective inflammation. The abscesses had destroyed the
greater portion of the gland, only a few isolated lobules being left.
Galland found an abscess as big as a walnut in the pancreas of a
horse which had multiple tumors in the abdomen.
Symptoms. Colics occur from the local phlegmon, and it may be
from its pressure on the duodenum so as to obstruct it, and this
appearing in the course of strangles would indicate a forming
abdominal abscess. Staring coat or shivering may coincide.
Tenderness of the abdominal walls has been noticed by Reimers,
together with a partial loss of appetite and a characteristically rapid
emaciation. Fatty stools, if present, would be almost the only
pathognomonic symptom.
Prognosis is that the abscess will open into the abdomen, and
cause fatal infective peritonitis. It is only as an exceptional
occurrence that its rupture into the duodenum or colon can be hoped
for, yet in such a case recovery is possible.
Treatment. Little can be done. It would be well to treat the
constitutional symptoms, and await results.
 FOREIGN BODIES IN THE PANCREAS.
Brückmüller has noticed needles and other sharp objects in the
pancreas of the dog, determining abscess and the formation of a
thick, greenish pus in the adjacent glandular follicles. Goubaux once
found a fragment of straw in the pancreatic duct of the horse. Such
conditions are not likely to be diagnosed, but if this could be done
laparotomy might be permissible in the dog for the removal of the
foreign body.
 PANCREATIC CALCULI.

Mostly in cattle from over feeding, dry feeding, inactivity. Small. Multiple.
Round, angular, lobulated. Nucleus. Composition. Dilated ducts. Atrophied or
sclerosed glandular tissue. Prevention: succulent food, water at will, open air life,
correction of local catarrh.

Pancreatic like biliary calculi have been found especially in cattle.

They appear to be predisposed by their stimulating, forcing feeding,
by their quiet life apart from all causes of excitement and especially
by the combined effect of dry feeding and prolonged confinement in
the stall through the long winter.
The calculi are usually small but numerous, Jungers having found
36 weighing 38 grammes. Bär has found a mass with an aggregate
weight of 23 grammes.
The form of the calculus varies; many are angular from mutual
attrition in the large ducts; others from the smaller ducts are
rounded; those from the glandular follicles may be even lobulated, in
keeping with the divisions of the cavity. The color is white and each
shows a distinct central nucleus of epithelial, mucus, or other origin.
Their specific gravity is 2.397 (Fürstenberg), and their composition
92 per cent. calcium carbonate, 4 per cent. magnesia, and traces of
calcium phosphate (Gurlt).
The pancreatic ducts are as a rule greatly dilated and thickened (in
man they form enormous cysts, Senn, Osler), and the glandular
tissue is atrophied, indurated (sclerosed), and of a brownish yellow
color.
Treatment of such cases would be unsatisfactory. By way of
prevention succulent food, abundance of pure water, and the
correction of any infective catarrhal affection of the duodenum, or of
the bile or pancreatic ducts would be specially indicated. Free
exercise in the open air would be desirable.
 PANCREATIC NEOPLASMS. TUMORS.

Often malignant, and secondary. Melanoma in white horse. Carcinoma in mare

and dog. Epithelioma. Debility, icterus, abdominal swelling, emaciation.
Treatment: laparotomy, or potassium iodide.

Tumors of the pancreas are quite frequently malignant, and show a

preference for the head of the organ. They may be primary but are
more frequently secondary.
In gray horses melanotic tumors are found, in connection with
similar formations externally, and especially as age advances.
Brückmüller found them of varying size, from a pea to a hazel nut,
scattered through the pancreas and adjacent tissues.
Gamgee records a carcinoma of the pancreas of a mare.
Carcinoma is more frequent in this organ in dogs, the neoplasm
having an irregular form, an imperfect line of delimitation from
surrounding parts and a hard, fibrous stroma enclosing caseous
centers, undergoing fatty degeneration.
Nocard reports an epithelial tumor of the head of the pancreas in a
bitch. The animal which had been ill for six weeks was debilitated,
emaciated, and icteric with a marked abdominal swelling. It died two
weeks later, and necropsy revealed a whitish sublumbar tumor, the
size of a large apple, with irregular rounded projections. This pressed
on the posterior vena cava, surrounded the vena portæ and gall duct
and completely closed the latter. Microscopic examination showed it
to be an epithelioma. The liver was undergoing cirrhosis.
Treatment, usually hopeless, would be by laparotomy. If
actinomycosis were present give potassium iodide.
 DISEASES OF THE SPLEEN.

No guidance through palpation or secretion. Leukæmia. Lymphadenoma. Spleen

a favorite culture ground for microbes. Congestions, engorgements, ruptures.
Safety valve to portal system and liver. Rhythmic splenic contractions under reflex
action.

The spleen even more than the pancreas is so deeply seated and so
surrounded by other organs, that its diseases are not readily
appreciable by physical examination, while the absence of any special
secretion excludes the possibility of diagnostic deductions through
this channel. Even the relation of the condition of the organ to the
number of the leucocytes and red globules fails to afford trustworthy
indications of disease, since leucocytes originate in other tissues as
well as the spleen, and the destruction of red globules may take place
elsewhere. Yet an excess of eosinophile leucocytes in the blood
suggests hypertrophy or disease of the spleen, and an excess of
leucocytes in general is somewhat less suggestive of disease of this
organ (see Leucocythemia). If adenoma is further shown, in
enlargement of lymphatic glands elsewhere there is the stronger
reason to infer disease of the spleen.
The physiological relation of the spleen to the blood especially
predisposes it to diseases in which the blood is involved. The
termination of splenic capillaries, in the pulp cavities, so that the
blood is poured into these spaces and delayed there, opens the way,
not only for the increase of the leucocytes, and the disintegration of
red globules, but for the multiplication of microörganisms which
may be present in the blood, and for a poisoning (local and general)
with their toxins. Hence we explain the congestions, sanguineous
engorgements and ruptures of the spleen in certain microbian
diseases (anthrax, Southern cattle fever, septicæmia, etc.)
 We should further bear in mind that the spleen is in a sense a
safety valve for the blood of the portal vein, when supplied in excess
during digestion. In this way it protects the liver against sudden and
dangerous engorgements, but it is itself subjected to extreme
alternations of vascular plenitude and relative deficiency. This may
be held to take place largely under the influence of the varying force
of the blood pressure in the portal vein, but according to the
observations of Roy on dogs and cats, it is also powerfully influenced
by muscular and nervous action. He found rhythmic contractions of
the organ due to the muscles contained in the capsule and trabeculæ,
repeating themselves sixty times per hour, and which might be
compared to tardy pulsations. He further found that electric
stimulation of the central end of a cut sensory nerve, of the medulla
oblongata, or of the peripheral ends of both splanchnics and both
vagi caused a rapid contraction of the spleen. The spleen may thus be
looked on not only as a temporary store-house for the rich and
abundant blood of the portal system of veins during active digestion,
but also as a pulsating organ acting under the control of nerve
centres in the medulla. That the various ascertained normal
functions of this viscus may be vicariously performed by others, as
shown in animals from which it has been completely extirpated, does
not contradict the occurrence of actual disease in the organ, nor the
baleful influence of certain of its diseases on the system at large.
 ANÆMIA OF THE SPLEEN.
General anæmia, debility, wasting diseases, starvation, hæmorrhage, stimulus to
formation of red globules, asphyxia, electricity, cold, quinine, eucalyptus, ergot.
Symptoms: lack of eosinophile leucocytes in the blood of a debilitated subject may
lead to suspicion. Treatment: tonic, light, sunshine, pure air, exercise, nutritive
food, iron, bitters.
In cases of general anæmia the spleen is liable to be small,
shrunken, wrinkled, and when cut the surface is drier and lighter
colored than in the normal condition. This condition may be seen
after old standing debilitating diseases, but is common in animals
that have been reduced by starvation, just as the opposite condition
of hyperæmia and enlargement comes of abundance of rich food and
an active digestion. It may shrink temporarily as the result of profuse
hemorrhage, but Bizzozero and Salvioli found that several days after
such loss of blood it became enlarged and its parenchyma contained
many red nucleated hæmatoblasts. The result of hemorrhage is
therefore to stimulate the organ to enlargement and to the
resumption of its embryonic function of producing red blood
globules. Contraction of the spleen further occurs under asphyxia,
the deoxidized blood being supposed to operate through the medulla
oblongata. As already noted the spleen shrinks under stimulation of
the central end of a sensory nerve (vagus, sciatic). An induced
current of electricity applied to the skin over the spleen causes
marked contraction (Botkin). Cold, quinine, eucalyptus, ergot and
other agents also induce contraction. In the normal condition there
is an inverse ratio between the bulk of the spleen and the liver, the
enlargement of the one entailing a diminution of the other, but in
certain diseased states, such as anthrax, ague, etc., both are liable to
enlargement at the same time.
Symptoms of splenic anæmia are wanting, through a lack of
eosinophile leucocytes, in the blood of a starved or otherwise
debilitated animal, may lead to suspicion of the condition.
The treatment of such a case would be addressed rather to the
general debility which induced the splenic contraction than to the
contraction itself. Light, sunshine, pure air, exercise, grooming,