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Sling immobilization is continued for a full 8 weeks or more depending on tissue quality. Motion is progressed slower than with smaller repairs to avoid placing excessive tension on the healing tissue. Active tension through the tissue is not done before 8 to 10 weeks . At this point, a gradual restoration of strength is also begun starting with the scapular muscles, progressing to the rotator cuff muscles, and finally to the deltoid. Obtaining a balance of posterior and anterior cuff musculature is the key for massive repairs . Once the normal or near normal force couples have returned , active shoulder motion can commence. A weakness of the posterior cuff mus cles "uncouples " the rotator cuff force couple that

allows normal arthrokinematics of normal shoulder motion . This uncoupling will allow an anterior superior translation of the humeral head with active shoulder elevation.

Conclusion

It should always be stressed to the patient that

although they may be pain free and most substantial. gains will be seen in the first 6 months , full unrestricted return to activity and full potential will not be achieved until about 1 full year (Matson et al. 2004; Rokito 1996) . Rotator cuff rehabilitation is a long and slow process!

SHOULDER INSTABILITY TREATMENT AND REHABILITATION

Sameer Lodha, MD; Sean Mazloom, MS; Amy G. Resler, OPT, CMP. CSCS; Rachel M. Fronk, BS; Neil S. Ghodadro, MD; Anthony A Romeo, MD;jonathan Yang Kim, CDR; R.jason jadgchew, ATC, CSCS; and Matthew T. Provencher, MD, CDR, MC, USN

Introduction

Glenohumeral instability is a relatively common orthopaedic problem, encompassing a wide spectrum of pathological mobility at the shoulder joint ranging from symptomatic laxity to frank dislocation. The glen ohumeral joint allows greater mobility than any other joint in the human body; however, this comes at the expense of stability. Perhaps more so than other joints, shoulder stability is predicated on adequate soft tissue (muscular and ligamentous) function and integrity, rather than bony congruity and alignment. Instability of the joint can easily result from impairments or imbalances in muscle function, ligamentous laxity, and/ or bony abnormalities. Given this inherent laxity, it is not surprising that there is a relatively high incidence of instability events. A Danish registry study suggested a 1. 7% overall incidence rate for the population as a whole (Hovelius et al 1996) . Young, athletic populations are at even higher risk, with a study of cadets at the United States Military Academy demonstrating an overall incidence of shoulder instability of 2.8%. In this population, trauma was identified as the most common etiology, with more than 85% of patients reporting antecedent trauma. More than 90% of shoulder dislocations are in the anterior direction, particularly because the position of combined external rotation and abduction, common in many contact sports, places the shoulder in an extremely vulnerable position. Most conceming regarding first-time shoulder dislocations is the high recurrence rate, which has been reported as between 20 % and 50 % and as high as 90 % in young patients. These epidemiologic findings highlight the importance of accurately identifying and appropriately treating shoulder instability. There is still, however, considerable controversy concerning appropriate treatment algorithms for shoulder instability. Prior to deciding on an appropriate treatment course, factors including patient age, type of activity / sport, activity / sport level,

goals, and likelihood of compliance must be considered. In addition, the mechanism of injury and the type of damage incurred, which may include labral, capsule, biceps, and/ or rotator cuff lesions, in addition to bony avulsions, will influence the most appropriate course of treatment for the patient. Understanding these factors will permit the treating clinician to determine (1) whether nonoperative versus operative treatment is indicated, and (2) if operative intervention is required, what form this should take. In this section we briefly review the anatomy and biomechanics of the glenohumeral joint, describe the classification of instability events, discuss the available nonoperative and operative interventions for treating the spectrum of instability disorders, and provide rehabilitation protocols.

Anatomic Considerations

The range of motion permitted at the glenohumeral joint is a consequence of minimal bony constraint provided by the humeral head and glenoid articulation. The glenoid fossa is a shallow structure, covering only 25% of the humeral head surface. Stability in the joint is therefore primarily a consequence of its static and dynamic stabilizers. The static stabilizers consist of the bony anatomy, the glenoid labrum, and capsular and ligamentous complexes and are typically only improved with surgical intervention once injured. Of note, the superior, middle, and inferior glenohumeral ligaments (SGHL, MGHL, IGHL) are especially important structures with regard to shoulder instability and thus have major implications with regard to rehabilitation following injury and/ or surgery (Fig. 3-30). Specifically, the SGHL (along with the coracohumeral ligament) and MGHL are important stabilizers with regard to limiting external rotation of the adducted arm (when the arm is at the side). The IGHL is especially important in preventing anterior translation of the shoulder when

Shoulder Instability Treatment and Rehabilitation

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Figure 3-30 A, The ligaments of the glenohumeral joint are shown, including the superior glenohumeral ligament (SGHL), inferior glenohumeral ligament (IGHL), and middle glenohumeral ligament (M GHL). B, An anterior (coronal) view of the rotator cuff and coracohumeral ligament (CHL) of the glenohumeral joint.

in the provocative position of abduction and external rotation. The dynamic stabilizers, including the rotator cuff muscles and long head of the biceps tendon, can often be improved with an appropriate nonoperative rehabilitation program after an instability event. In fact, proper strengthening of the rotator cuff musculature and scapular stabilizers are critical components of any rehabilitation protocol, including those for nonoperative management of shoulder instability and part of the rehabilitation following surgery. It is particularly important to note the integrity and condition of the subscapularis with regard to rehabilitation following shoulder surgery. In many open surgical techniques, the subscapularis is detached from the lesser tuberosity of the shoulder, requiring strict limitations in the amount of permitted postoperative external rotation and internal rotation strengthening, whereas this is not as much a concern when the subscapularis is left intact (such as through a subscapularis split). Ensuring excellent communication with the surgical team and the postoperative rehabilitation team of exactly what was performed during the surgery is critical to postoperative success.

Terminology

It is first important to differentiate laxity from instabil-

ity. Instability is symptomatic laxity-as all shoulders have and require some level of laxity to move through a functional arc of motion. Instability refers to the patient experiencing symptoms of having a shoulder joint that is unstable in certain positions and is usually accompanied by increased laxity in that direction. Similar to other joints, shoulder instability varies in severity from microinstability to subluxation and ultimately to frank dislocation. Microinstability refers to pathologic motion of the humeral head, most often in multiple directions, secondary to generalized capsular laxity. Subluxation denotes translation of the humeral head beyond normal physiologic limits while still maintaining contact with

the glenoid. Dislocation differs from subluxation in that the translation of the humeral head is significant enough to completely disassociate the articular surfaces of the humerus and the glenoid; this magnitude of instability will commonly require manual reduction. Shoulder instability is typically described in relation to the direction of the instability event: anterior, posterior, and multidirectional. Anterior instability is the most common manifestation of unidirectional instability, comprising more than 90% of shoulder dislocations. This type of injury most commonly occurs as the result of a one-time traumatic episode to a shoulder in a vulnerable position of combined abduction and external rotation. The injury may involve an avulsion of the anteroinferior labrum from the glenoid, commonly referred to as the Bankart lesion. Occasionally a fragment of the underlying glenoid rim also may be fractured off; this lesion is referred to as a bony Bankart lesion. Other lesions can also present with symptoms of anterior instability, including subscapularis tears, humeral avulsions of the glenohumeral ligament (HAGL) , superior labrum anterior to posterior (SLAP) injuries, and rotator interval lesions. Posterior instability is far less common than anterior instability, accounting for 2% to 10% of shoulder dislocations. Posterior dislocations are often associated with axial loads applied to the adducted arm and are classically associated with electrocution and seizures. Structural changes associated with posterior instability include avulsions of the posterior labrum (a reverse Bankart lesion), which may be associated with a posterior glenoid rim fracture. Injuries to the SGHL, the posterior band of the IGHL, the subscapularis muscle, and the coracohumeral ligament (CHL) can also be seen in posterior instability. The most common form of posterior instability is recurrent posterior instability, usually resulting in a posterior labral tear and posteroinferior capsular stretch resulting from repetitive loading with the arm in flexion and internal rotation (i.e., the bench press exercise) . ·

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Finally, multidirectional instability (MDI) is not typically associated with traumatic episodes. Instead, the primary dysfunction here involves either congenital or acquired capsuloligamentous laxity. As such, it may be indicative of an underlying connective tissue disorder or a result of repeated minor stretching injuries to the capsuloligamentous complex. Presenting pathology typically consists of symptomatic, abnormal humeral head translation in more than one direction, which may include recurrent subluxations or even dislocations with minimal trauma. Often multidirectional instability may be associated with general ligamentous laxity signs such as hyperextension of the thumb to wrist and hyperextension of the elbows.

Diagnostic Evaluation: History, Physical Examination, and Imaging

· Anterior and posterior apprehension, relocation, load and shift (to assess for posterior instability) (Fig. 3-31), and sulcus tests (Fig. 3-32) are widely used to assess shoulder anterior and/or inferior instability. Imaging Studies Finally, radiographs can be extremely helpful in the evaluation of shoulder instability. Generally, a series of radiographs including a true AP, scapular Y, and axillary · view will provide significant information. Additionally, a Stryker notch view is helpful for evaluating Hill-Sachs lesions (bony injury of the humeral head from anterior dislocation), whereas the West Point view may be utilized to determine glenoid bone loss. Advanced imaging may be helpful, especially in evaluating an unstable but reduced shoulder. Computed tomography (CT) scanning

History A thorough history provides a foundation for accurate diagnosis of the type and magnitude of shoulder instability, which is essential for choosing appropriate treatment options. The history should identify the mechanism of the injury, previous surgical and/or nonsurgical treatment of the shoulder, and the activity level of the patient. The patient should be asked several questions concerning if the injury was traumatic, if there was dislocation/subluxation and if a reduction was required, if the shoulder has been previously injured, and how the arm was positioned at the time of injury. Although these questions seem standard for any initial shoulder evaluation, the answers to these questions may rule a patient out for surgery or otherwise assist the surgeon in avoiding intraoperative and postoperative complications. Physical Examination Following the history, a detailed physical examination should be completed, beginning with observation. · The clinician should examine the entire body from head to toe to determine postural alignment, scapular position, and overall core strength. · Progressing to the shoulders, it is important to note any asymmetry, muscular atrophy, abnormal motion, edema, or scapular winging. · The structure, function, neurologic status, and strength of the injured shoulder should be compared with the contralateral shoulder. · Palpation will alert the clinician to specific areas of tenderness, whereas both active and passive range of motion testing will demonstrate stiffness. · In particular, if significant stiffness is noted, range of motion must be optimized prior to any operative stabilization procedure to avoid progressive loss of motion. · Next, strength and sensation in all planes should be evaluated because weakness in one or more planes may be significant for concomitant pathology, including rotator cuff tears. · Shoulder stability testing should also be addressed because provocative shoulder tests and maneuvers may be used to evaluate the extent and direction of any instability.

Figure 3-31 An example of a patient with posterior shoulder instability and a positive load and shift test.

Figure 3-32 An example of a sulcus finding demonstrating space between the acromion and the humeral head with downward traction on the arm at the side. This is not necessarily pathologic and is present in patients without documented instability and just normal laxity of the joint.

Shoulder Instability Treatment and Rehabi litation

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Figure 3-33 Various imaging studies to demonstrate examples of glenohumeral instability. Anteroposterior (A) and axillary (B) radiographs that demonstrate an anterior bony Bankart injury sustained after an anterior shoulder dislocation.A magnetic resonance arthrogram that demonstrates an anterior labral tear (C). A computed tomography (CT) scan with three-dimensional reconstruction demonstrating a large Hill-Sachs injury (D). A CT scan sagittal obl iqu e image that shows glenoid bone loss (approximately 25%) and bony Bankart injury with some attrition of the injured bone (E) .

is useful in evaluating glenoid hypoplasia, fracture, glenoid and humeral bone loss, and retroversion. MRI is useful in visualizing the integrity of soft tissue structures, allowing an assessment of the capsulolabral structures, the rotator cuff, the rotator interval, and the tendon of the long head of the biceps (Fig. 3-33).

Treatment Options

Treatment options for shoulder instability include nonoperative and operative approaches. Nonoperative therapies aim to address instability symptoms by altering the pathologic mechanics of the unstable shoulder. These therapies therefore involve programs to address kinetic chain deficits, shoulder strength and flexibility, proprioception, neuromuscular control, and scapulothoracic mechanics. Surgical treatment, however, aims to directly address the structural deficiencies that may be contributing to instability through various reconstructive techniques. Considerable controversy exists over the appropriate initial therapy for patients with instability. There is general agreement, however, on the appropriate treatment for an acute shoulder dislocation. Any unreduced dislocation must undergo closed reduction with radiographic confirmation of reduction. It is unknown whether reduction should be performed immediately (i.e., on the field after an athlete has dislocated) or after the patient has been seen in a controlled, emergency room setting with the aid of analgesics and radiographs. Regardless, it is imperative to perform a thorough pre-reduction and postreduction neurovascular examination, especially with regard to anterior shoulder instability where the axillary nerve is particularly vulnerable. In general, the shoulder should be reduced as soon as possible utilizing a variety of well-described reduction techniques.

anterior dislocation, the arm is most commonly immobilized in internal rotation to avoid the vulnerable and susceptible position of external rotation and abduction. However, recent studies have suggested little to no benefit to this immobilization, considering it as much a source of comfort as actual protection and stability. In fact, Itoi et a!. (2007) suggested there actually may be some benefit to immobilizing the injured arm in a position of external rotation instead. The rationale for placement of the arm in external rotation centers on the fact that the Bankart lesion is forced to separate from the glenoid when the arm is placed in internal rotation, which may be detrimental to healing. In contrast, the authors describe how placing the arm in external rotation approximates the lesion to its correct anatomic position, allowing for a better healing process. The nonoperative treatment options for anterior, posterior, and multidirectional glenohumeral instability all center on the same core issues. The immediate goals are to decrease pain and edema, protect the static stabilizers, and strengthen the dynamic stabilizers . The ultimate aim is to increase overall shoulder stability, which is facilitated via exercises designed to enhance joint proprioception and address kinetic chain deficits. With specific regard to posterior dislocations, recommendations have typically revolved around immobilization of the arm in external rotation and slight extension. More recently, however, Edwards et a!. (2002) suggested that immobilization in internal rotation may be more appropriate, although this has yet to be fully studied.

Special Considerations

· First-time dislocator: · Overall, the nonoperative treatment options for patients following first-time shoulder dislocation are controversial, and regardless of the treatment, reported recurrence rates are high, especially for young, highly active patients. The initial results reported with immobilization in external rotation are interesting; however, larger, longer-term clinical

Nonoperative Treatment and Rehabilitation

Nonoperative treatment protocols typically consist of immobilization followed by rehabilitation with an experienced physical therapist. Traditionally, following

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studies are needed before any single immobilization technique can be universally recommended. · Chronic/ recurrent dislocator: · Nonoperative treatment has been shown to be less successful in the chronic dislocator, especially in the young athlete. Specifically, in patients younger than 20 years old with a one-time acute shoulder dislocation treated nonoperatively, recurrence rates have been reported as high as 90%. · Consideration to level of athletics, level of patient symptoms (how often does the shoulder become unstable) , and level of trauma to provoke instability (does it occur with little force such as while sleeping or lifting overhead, or with higher level sporting activities) , and patient desires. · In-season athlete: · A unique situation that requires special consideration with regard to treatment options involves the in-season athlete who wishes to continue to play. In 2004 Buss et al. studied 30 competitive in-season athletes who experienced either anterior dislocation or subluxation of the shoulder followed by treatment with rehabilitation and bracing that restricted external rotation and abduction. The authors found that 26 of the 30 patients were able to return to play and complete the season after approximately 10 days of missed time; however, 37% experienced at least one episode of recurrent instability during the season. Further, 16 athletes required surgical intervention following their competitive season. Thus, the treatment of a dislocation in an in-season athlete is generally to finish the season (possibly with the use of an external rotation protection brace) and then consider surgery once the season is finished. However, recurrences during the season after an initial dislocation require more careful discussions with the athlete for his or her desires and return-to-play capability.

with improvements in arthroscopic techniques and devices have allowed for postoperative results rivaling those of open stabilization. In the open procedure, the labrum is anatomically reduced and repaired to the anterior glenoid. Given the common coexistence of capsular injury and stretch, a concomitant capsular s shift procedure is often performed. Various method, for the capsular shift have been described; the essential underlying goal is to repair the injured anteroinferior capsule and labral repair. Recurrence rate for open repair has been reported to be approximately 4 %. As mentioned, both of these procedures are now increasingly performed arthroscopically (Figs. 3-34, 3-35) . Although initial reports described a higher recurrence rate after arthroscopic repair, recent studies have shown that recurrence rates are nearly comparable to open repair, especially in those patients without significant glenoid bone loss or other structural abnormalities . With the ultimate focus of regaining and then maintaining shoulder stability, the goals of postoperative rehabilitation commonly focus on avoiding common

Postoperative Treatment and Rehabilitation

Anterior Instability Traumatic dislocations are often associated with significant structural injury. Despite this, studies have demonstrated that good clinical results can be obtained with nonoperative treatment in patients who are older and less active. However, the same cannot be said for patients who are young and active, particularly those involved in contact sports. In these patients, operative treatment has been shown to have a lower risk of recurrent dislocation as compared to nonoperative therapy. Patients with significant bone injury-glenoid defects (20% to 25 % or more) , displaced tuberosity fractures, and irreducible dislocations-should be treated with operative stabilization. Other indications for operative intervention include three or more recurrent dislocations in a year and dislocations that occur at rest or during sleep. The open Bankart repair was once considered the gold standard in the treatment of anterior shoulder instability; however, proper patient selection combined

Figure 3-34 An arthroscopic image of an anterio r labral tear (soft tissue Bankart) (black arrows) .

Figure 3-35 The patient from Figure 3-34 afte r repai r with four anchors and suture construct (capsulolabral repair).The anch ors are located at the black arrows.

Shoulder Instability Treatment and Rehabilitation

III

omplications following anterior stabilization procedures. These complications include limited postoperative ROM related to residual stiffness; the development of recurrent mstability; an inability to return to preinstability activity evels, especially in competitive overhead athletes; and, rver the longer term, the development of osteoarthritis . .... hus the goals of rehabilitation are to protect the surgical ·epair long enough to permit healing, restore full ROM, ptimize stability by strengthening the dynamic stabilizers, and ultimately return to full preinjury activity. See Rehabilitation Protocols 3-5 through 3-8 for -pecific rehabilitation programs.

Posterior Instability he initial treatment for posterior instability is usually nonoperative, especially in the case of an atrauatic etiology, because successful outcomes following onoperative therapy in atraumatic subluxators have een reported. Appropriately planned strengthening proams have been shown to be effective in augmenting ~lability and reducing pain, especially for patients sufering from laxity secondary to repetitive microtrauma. owever, the efficacy of nonoperative therapy in treatng traumatic posterior dislocators is significantly lower, estimated at approximately 16%. Indications for surgial treatment therefore include the common sequelae of raumatic dislocations, including posterior glenoid rim ractures greater than 25%, displaced lesser tuberosity ractures, reverse Hill-Sachs lesions of greater than 40% f the humeral head, recurrent instability episodes, nd irreducible dislocations. Patients with mechanical rmptoms also often respond poorly to conservative b erapy and thus may be indicated for surgical treatent. Failure of 3 to 6 months of conservative therpy is also an indication for operative repair. The most ommon presenting complaint in a patient with pasteor shoulder instability is pain and pain with provoca.tve exercises (the arm in flexion and internal rotation), uch as bench press, push-ups, and presses. Specific operative treatment techniques for poste·or instability are similar in theory to the treatments for anterior instability. Both open and arthroscopic reverse Bankart, capsular shift and plication, and a host of bonyanatomy restorative procedures have been developed. rverall, the results of open surgical treatment of pasteor instability have not been as good as those for anterior nstability. This is likely a consequence both of the difculties in obtaining adequate visualization and related o the different biomechanical properties of the posterior ~apsule and labrum (Figs. 3-36 and 3-37}. Nevertheless, .h e goals of postoperative rehabilitation for posterior -houlder instability echo those of anterior stabilization rocedures and include reducing pain and edema, proecting the surgical repair to allow healing, restoring full OM, and facilitating a return to full activity. See Rehabilitation Protocols 3-9 through 3-11 for pecific rehabilitation programs. Multidirectional Instability imilar to anterior and posterior instability, the iniial treatment for MDI is nonoperative management. .:;ood results have been obtained in patients with

Figure 3-36 Arthroscopic image of a posterior labral tear and associated labral flap as a result of recurrent posterior instability.

Figure 3-3 7 The patient from Figure 3-36 after arthroscopic repair with suture anchors of a posterior instability injury.

generalized laxity in more than one direction, the hallmark of MDI. Operative treatment is considered only after an exhaustive course of nonoperative therapy has failed; generally, at least 6 months of therapy should be attempted. When nonoperative treatment has failed, properly selected patients may benefit from operative interventions. Neer and Foster (1980) described an open surgical procedure to treat MDI, utilizing an inferior capsular shift permitting tensioning of both the anterior and posterior capsule. Several other studies have reported similarly excellent results with this technique. Arthroscopic techniques have also shown excellent success rates (Figs. 3-38 and 3-39). These procedures have sought to reduce capsular redundancy through a combination of strategies, including capsular plication, closure of the rotator interval, and repair of any labral lesions. Thermal capsulorrhaphy techniques have fallen into disfavor and are no longer widely used secondary to high failure rates and numerous observations of subsequent glenohumeral chondrolysis. See Rehabilitation Protocol 3-12 for multidirectional shoulder instability surgery (inferior capsular shift) .

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Figure 3-38 An example of a patient with multidirectional instability with an en larged and patu lous capsu le (/eft side of image) attached to t he bony glenoid.

Figure 3-39 Arthroscopic repair of a patient with multidirectional instability utilization capsu lar pli cation (repair of the capsule to the labrum without suture anchors).

SHOULDER INSTABILITY-REHABILITATION

George). Davies, DPT, MEd, SCS,ATC, CSCS

Shoulder instability accounts for a percentage of all shoulder pathologies and creates significant functional disabilities in patients. Because of the functional demands of the shoulder from demands of activities of daily living, ergonomic-related requirements, and sporting activities, the shoulder has inherent laxity. Therefore the shoulder complex has the greatest motion in the body. The shoulder has demands that range from repetitive lifting of heavy weights in a work environment and repetitively throwing a baseball more than 90 miles per hour with the shoulder exceeding 7000-9000 degrees/second angular velocity. As a result, numerous mechanisms of injuries can lead to compromise of the glenohumeral (GH) joint, such as abduction/external rotation, hyperflexion, hyperabduction, or hyperhorizontal extension. Consequently the GH joint is the most commonly dislocated large joint in the body. For consistency in the interpretation of shoulder instability, it is important to define terminology commonly associated with this condition. Translation is defined as the movement of the glenohumeral joint, and laxity is the amount of translation that occurs. Shoulder instability is the lack of control of the glenohumeral joint that can occur from several causes such as (1) static stabilizers (ligaments, capsule, labrum, noncontractile tissue) -being incompetent, (2) dynamic stabilizers (muscle tendon unit) , and (3) sensorimotor system (joint mechanoreceptors, proprioception, kinesthesia, joint position sense). Shoulder instabilities are divided into many different classification systems with numerous subcategories in each category. These categories include degree of instability, force required to create the instability, direction of instability, chronology of instability, and the patient's control over the instability. The degree of instability ranges in a continuum from congenital laxity, occult instability,

microinstabilities, multidirectional instabilities, subluxations, and luxations. The force required to create the instability was originally described as traumatic, unilateral, and Bankart, and surgery (acronym TUBS) to correct the condition was often required. Davies et al. (1993) recommended that the "U" also indicate unidirectional. Generalized ligamentous laxity is thought to be atraumatic, multidirectional, bilateral, responsive to rehabilitation, or surgically an inferior (capsular shift) (AMBRI). Davies et al. also added the acronym ALL to represent acquired ligamentous/ capsular laxity. The direction of instability includes anterior, anterior-inferior, posterior, inferior, superior, and multidirectional. The chronology of instability includes congenital, occult, acute, chronic/ recurrent, and fixed/locked. The patient's control over the instability is classified into voluntary or involuntary. Voluntary is where the patient can actively subluxate the shoulder, whereas the involuntary condition is where the patient does not have neuromuscular dynamic control over the shoulder and it results in a functional disability. Itoi et al. (2003) were the first to describe a revolutionary approach to treating patients nonsurgically with a first-time shoulder dislocation. Instead of the conventional position of immobilizing the shoulder in adductionaljinternal rotation, Itoi et al. recommended the shoulder be immobilized in external rotation, which created better coaptation of the injured tissues of the Bankart lesion. Numerous surgical procedures (Abrams et al. 2002, Arciero and St. Pierre 1995, Cooper and Brems 1992, Gill and Zarins 2003 , Kim et al. 2003, Neer and Foster 1980) have been described for treating the various instabilities. Each orthopedic surgeon will perform the surgical procedure indicated for the patient based on the type of injury, comorbidities, demands of the patient, and surgeon experience.

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