Shoulder arthroscopy

SHOULDER ARTHROSCOPY
MODERATOR
DR.PRABU ETHIRAJ SIR
ASSOCIATE PROFESSOR
DEPARTMENT OF ORHTOPAEDICS
PRESENTER :DR.MADHAVAN

INTRODUCTION
• Arthroscopy: A surgical technique in which a tube-
like instrument is inserted into a joint to inspect,
diagnose, and treat .
• It is most commonly performed in patients with
diseases of the knees, shoulders ,elbow ,wrist and
ankle .
Canale, S T, James H. Beaty, and Willis C. Campbell. Campbell's Operative Orthopaedics.
Philadelphia, PA: Elsevier/Mosby, 2013

• The first ever use of arthroscopy
was performed in 1918
orthopedic surgery by Dr Kenji
Takagi(1888-1963) a Japanese
orthopedic surgeon by using
Charrier number 22 cystoscope
in cadaver knee joint
HISTORY

• In 1931 American surgeon Michael Burman
examined 25 shoulders in cadaver using
arthroscope
• Initially it was used
for diagnostic purpose
• Now with well established
training and skills labs ,
shoulder Arthroscopy
is used for treatment as well!

• Painful syndromes in the shoulder , altered function,
and signs and symptoms of instability and
associated with internal derangement are frequent in
the shoulder

• For conditions which can not be controlled by
conservative managements such as
• Developmental
• Traumatic
• Degenerative
• Inflammatory conditions
Resulting
pain instability disability
arthroscopic treatment is performed by a skilled
surgeon to tackle such conditions

INDICATIONS
1. Diagnostic
2.Labral/SLAP repair
3.Rotator cuff repair or debridement

4.Loose body removal
5.Subacromial decompression
6.AC joint pathology

7.Distal clavicle resection
8.Release of suprascapular nerve entrapment
9.Release of scar tissue
/contractures

10.Synovectomy
11.Biceps tenotomy/tenodesis

BASIC ARTHROSCOPIC KIT
• Arthroscopy
• Light source and cable
• Camera system and monitor with recorder
• Arthroscopic probe
• Arthroscopic grasper
• Arthroscopic scissor
• Arthroscopy cautery
• Arthroscopic Punches (basket forcepes 2.7 mm
upcutting right and left Rotatory )
• Motorized shaver

Esch JC, Baker CL Jr. Arthroscopic surgery: the shoulder and elbow. Philadelphia, PA: JB
Lippincott, 1993:38
The angle of inclination is 0°, 30°, or 70° relative to the arthroscope axis.
The angular field-of-view cone is oriented along the axis of the angle of
inclination

Rotating the arthroscope’s field of view enhances arthroscopic viewing by creating overlapping
circular images with a 30° arthroscope (center). With a 0° arthroscope (top), the field of view is
unchanged with rotation. With a 70° arthroscope (bottom), rotation occurs around a central
blind spot. (Illustration by Susan Brust.)

PATIENT POSITION
Two basic positions
Lateral Decubitus “Beach chair”
(Most commonly used)

LATERAL DECUBITUS POSITION
• The patient is placed in the lateral decubitus
position with the affected shoulder exposed
and is supported by a vacuum beanbag and
kidney rest.

All pressure points
Padded with a pillow
Acromion, ASIS, Below knee, lateral
malleolus and one or more pillows between the
knees and ankles.

By tilting the patient 20 to 30 degrees posteriorly,
glenoid will be parallel to the floor
1. Less traction: Decrease the risk of neurapraxia of
the brachial plexus
2. Accentuation of tears in the glenoid labrum as it
pulled away from their beds
3. Improved arthroscopic access to the inferior third
of the glenoid labrum and capsule.

Vertical and longitudinal traction, with
most of the traction applied vertically to distract the
glenohumeral joint without subluxing it inferiorly
• 10 to 13 lb of traction is applied
• 30 to 60 degrees of abduction
• 20 to 30 degrees of forward flexion
• 23% and 30%: neurapraxia after excessive arm
traction.

BEACH CHAIR POSITION
The benefits of the “beach chair” position
1. Interscalene block
2. Faster and easier positioning
3. Reduced risk of neurapraxia
4. Less distortion of intra articular capsular anatomy,
5. Improved mobility of the patient’s arm
6. Ease in orientation
7. Surgical manipulation in the subacromial space
8. Ease in conversion to an open surgical procedure.

COMPLICATIONS
1. Difficulty in working from posterior portals
2. Stroke
3. Death due to hypotensive episodes

CONTRAINDICATIONS
1. Local skin conditions
2. Remote infections that might spread to the joint
3. Associated co-morbidity

CONTROL OF BLEEDING DURING
ARTHROSCOPY
• One method of controlling bleeding is to add 1 mL
of 1 : 1000 epinephrine to each 3L bag of irrigant
• A systolic-to-pump pressure gradient of
approximately 30 mm Hg should be maintained
• Elevation of the fluid bags 3 feet above the level
produces a similar pressure gradient of 66 mm fluid
flow pressure

• It has been recommended that this pressure be
maintained at 49mmHg or less below the systolic
blood pressure to preserve the clarity of view
• An isotonic solution, such as saline (0.9%,
300mOsm/L) or lactated ringer's (273 mOsm/L), is
commonly used and safely proven for joint irrigation
during arthroscopy

FLUID EXTRAVASATION
• Established portals should be maintained by an
interchangeable cannula system while instruments
are being exchanged
• Lo and Burkhart evaluated 53 patients immediately
after shoulder arthroscopy and found an average
fluid weight gain of 8.7 lb.

PORTAL PLACEMENT
Before making arthroscopic portals, a thorough
understanding the local anatomy is necessary to
prevent damage to neurovascular structures

AXILLARY NERVE
1. Passes ~ 7 cm below tip of acromoium
2. At risk if the posterior portal is made too
inferior
SUPRASCAPULAR NERVE
At risk if the posterior portal is made too medial
NEUROVASCULAR ANATOMY

• The axillary nerve
• Cephalic vein
• Suprascapular artery and nerve
Are the structures most at risk during shoulder
arthroscopy
Meyer M, Graveleau N, Hardy P, Landreau P: Anatomic risks of shoulder arthroscopy portals:
Anatomic cadaveric study of 12 portals. Arthroscopy 2007; 23(5):529-536

• The axillary nerve travels posterior to the
coracoid and inferior to the lateral border of the
subscapularis medial to the musculotendinous
junction
• The nerve has been reported to be from 3 to 7 cm
from the lateral acromion

• The suprascapular nerve (SSN) arises from the
upper trunk of the brachial plexus, traveling through
the posterior triangle of the neck
• The suprascapular artery runs with the nerve until it
reaches the suprascapular notch
• The nerve lies 3 cm (range, 2.5 to 3.9 cm) medial to
the supraglenoid tubercle at the suprascapular notch

Standard Portal Placement
Posterior portal
Indication : Primary viewing portal used
for diagnostic arthroscopy
Location and technique
1.Posterior soft point 1.5 cm inferior and 2 cm
medial to the posterolateral corner of the acromion
towords coracoid
2.Pass between infraspinatus (suprascapular nerve)
and teres minor (axillary nerve)
3.First portal placed
4.Direct anteriorly towards tip of coracoid

Anterior central portal(Matthews)
Indication :To View and do subacromial decompression
Location & technique
1. Lateral to coracoid process and anterior to AC joint
2. Portal passes between pectoralis major (medial and
lateral pectoral nerves) and deltoid (axillary nerve)
This portal is usually placed under direct
supervision from the posterior portal with aid of spinal
needle

Lateral portal
Indication :For subacromial decompression
Location & technique
1. Located 1-2 cm distal to lateral edge of
acromium
2. Portal passes through deltoid (axillary nerve)

2CMS DISTAL TO
TIP OF
ACROMION

ADDITIONAL PORTALS
Portal Location indication
5 o’clock portal Anteroinferior
transubscapularis
Bankart repair
7 o’clock portal Posteroinferior Posterior labral repair,
loose body removal
Neviaser portal Superior, posterior to
acromioclavicular joint
Suture passage during
slap repair and rotator
cuff repair
Portal of wilmington Posterolateral, 1 cm
lateral to posterolateral
acromion
Anchor insertion during
slap repair and rotator
cuff repair
Paxton ES, Backus J, Keener J, Brophy RH. Shoulder arthroscopy: Basic principles of positioning,
anesthesia, and portal anatomy. J Am Acad Orthop Surg 2013;21:332-342

• The 5 o’clock, 7 o’clock,
and anteroinferior portals are
safely created using an inside-
out technique
1. Posterior portal
2. Anterior central portal
3. Antero lateral portal
4. Postero lateral portal
5. Supero lateral portal
6.Anterosuperior portal
7.7 o’clock portal
8.Axillary pouch portal
9.Neviaser portal
10.portal of Wilmington
11. Trans rotator cuff portal

(5 o'clock) portal: Davidson
Indication : Anterior labral repair & Bankart lesions
Inside out technique:
1. Located slightly inferior to coracoid
2. This portal is usually placed under direct
supervision from the posterior portal with aid
of spinal needle
3. Located lateraly an average of 13 mm from
axillary A, 15 mm from axillary N, and 17
mm from cephalic V
Davidson PA, Tibone JE: Anteriorinferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy
1995;11(5):519-525

• Bankart lesion is an avulsion of the anterior labrum
and anterior band of the IGHL from the anterior
inferior glenoid.

ANTEROINFERIOR
PORTAL(WOLF)
• Indication : Bankarts lesion
• Technique :Inside out
• The arthroscope sides off the inferior edge of
corocoid tip

ANTERIOSUPERIOR(WOLF)
• Indication :Biceps tenotomy ,SLAP repair
Bankarts lesion
• Technique :Inside out and outside in
• The arthroscope sides mid distance between
corocoid and acromion

ANTEROLATERAL (ELMANNS)
• Indication :subacromion decompression
• Technique : outside in
• 2cms below the lateral edge of acromion in its
elongation anterior edge

POSTEROLATERAL (ELMANNS)
• Indication :Subacromion decompression
• Technique : Outside in
• 2cms below the lateral edge of acromion in its
elongation of posterior edge

superior Nevasier (supraspinatus) portal
Indication: Anterior glenoid visualization, SLAP repairs
And rotator cuff repair
Location & technique: Outside in
1.Located just medial to lateral acromion
2.Goes through supraspinatus muscle
3.The suprascapular nerve and artery are only 3 cm from
the supraglenoid tubercle and are at risk when using the
Neviaser portal
Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve.
Arthroscopy 1990; 6(4):301-305.

course of the suprascapular nerve along the posterior scapula. In a cadaver study by
Bigliani et al line A, the distance from the supraglenoid tubercle to the suprascapular
notch, averaged 3.0 cm (range, 2.5 to 3.9 cm); line B, the distance from the
supraglenoid tubercle to the base of the scapular spine, averaged 2.5 cm (range, 1.9 to
3.2 cm); and line C, the distance from the midline posterior glenoid rim to the base of
the scapular spine, averaged 1.8 cm (range, 1.4 to 2.5 cm)
Suprascapular
notch
Supraglnoid
tubercule
Midline posterior
glenoid
Base of
scapular
spine

SUPERIOR SUPRASCASPULAR
NERVE PORTAL (LAFOSSE )
• Indication : Suprsascapular never entrapment
release
• Technique:
1. Outside in
2. 7cm medial to the lateral border of acromion

7 o'clock portal Davidson
Indication: Posterior labral repair and loose body
removal
location & technique: Outside in
1. 3 to 4cms inferior, 1cm lateral to the posterior
lateral acromion edge
2. The structures at risk are the the axillary nerve, and
the posterior circumflex humeral artery

Wilmington portal
• Indication: SLAP lesions ,acromioclavicular joint
pathology and subacromial impingement,Rotator cuff
tear
location & technique: Outside in
1. 1cm anterior and 1cm lateral to the posterior
lateral corner of acromion
Burkhead WZ Jr, Scheinberg RR, Box G: Surgical anatomy of the axillary nerve. J Shoulder Elbow
Surg 1992;1(1):31-36

TRAN ROTATOR CUFF
(O’BRIEN)
Indication: Rotator cuff repair and subacromial
decompresion
Technique :outside in
1. 1 cm posterior and 2 cm lateral to the
anterolateral corner of the acromion
2. To the 11-o’clock position in the glenoid labrum
medial to the rotator arch

PRECAUTIONS
1. Avoid chondral injury by using blunt obturators
(Do not plunge!)
2. Avoid rotator cuff tendon tears during posterior
portal placement by internal rotation of the humerus
3. Minimize risk of neurovascular injury by placing
the anterior portal lateral to the coracoid and
humerus in adduction when creating anterior portal

• Awareness of the axillary nerve is important in
portal placement anteriorly, posteriorly, and laterally.
• Posteriorly, the suprascapular nerve and circumflex
scapular artery are approximately 2 cm from the
portal site.
• Later portals, which are used to work on the
glenohumeral space, should be directed to enter
medial to the rotator arch

Snyder, S. J. (2015). Shoulder arthroscopy. Philadelphia: Wolters Kluwer Health.

10 steps visualizing from posterior port
1.Biceps tendon and superior labrum:
• Evaluate both surfaces of intra articular
segments
• There should be no fraying
• Grasping tool to pull and to check for any
damage to biceps tendon
• Evaluate anterior and posterior pully

• Vinculae biceps : mesentery like synovium
Should not mistaken for tear
Rare cases
• Biceps tendon is partically or completely encased by
synovial tissue and capsule
• Bifid biceps one portion attached to supragleniod
and another to rotator cuff
• Some times to completely to rotator cuff
• Complete absence of biceps tendon with no history
of trauma with normal function

SUPERIOR LABRUM
• Inspect the superior labrum and palpate the
attachment to the glenoid
• If the superior labrum is damaged or loosely
attached, pull on the biceps tendon with a probe to
determine whether the labrum will arch away from
superior glenoid

• In young patients: The edge of the labrum intimately
attached
• Patients mature: Labrum separates from the
cartilage so that by age 40 to 50 most people have a
prominent cleft under the superior labrum
(MENISCOID APPEARCNCE )

• Acute trauma in a younger individual (15 to 30 years
of age) can result in avulsion of the superior labrum
and biceps anchor
• The tissue below the superior labrum will be
frayed, torn, and irregular
• chronic degenerative conditions of the
glenohumeral joint or biceps tendon will cause the
superior labrum to appear damaged
• suggesting a type 2 SLAP lesion

2.The Posterior Labrum and Posterior
Capsular Recess
• The posterior labrum should be smooth and is
usually tightly fused to the glenoid surface
• The outer edge of the healthy labrum is higher than
the cartilage edge, creating a chock block–like
border
• multidirectional instability, the labrum can be
hypoplastic

HYPOPLASTIC POSTERIOR LABRUM IN MULTIDIRACTIONAL INSTABILITY

3.The Inferior Axillary Recess, the Inferior
Capsular Attachment to the Humeral Head
• Scope tip positioned in the axillary pouch, the bevel
is rotated in an arc from inferior to superior to see
the inferior capsule
• Smooth with a delicate synovial covering will be
present
• There may be small normal fenestrations near the
attachment to the head

• Early chondromalacia lesions or osteophytes are
seen in this position
• In adhesive capsulitis the inferior Capsule is
contracted and closing off the pouch will be present
• Inferior capsular attachment tear to the humerus :
seen in traumatic dislocation, especially with luxatio
erecta.

Axillary recess with smooth synovial covering , articular cartilage of humerus

4.Inferior Labrum and Glenoid
Articular Surface
• The normal inferior labrum is smoothly fused with
the cartilage
• Congenital laxity, the labrum may appear deficient
or flat
• Torn inferior labrum always associated with
anterior instability
• “Thin spot” : Inferior half of the glenoid which is
Normal
• superior pole of the glenoid may also become
thinner with aging: Normal

The articular surface of the glenoid is slightly concaved with a thin area in the center

5. Supraspinatus Tendon of the Rotator Cuff
• Rotate the bevel of the arthroscope upward to the
11, 12, and 1 o’clock positions to visualize the
undersurface of the supraspintatus tendon as it
attaches into the humeral head
• The rotator cuff tendon is covered by layer of
capsule and synovium

• “Rotator cuff ridge” or “cable: it’s a capsule
thikening perpendicular biceps tendon
• A rich vascular supply above the lateral border of
the rotator cuff ridge known as the rotator cuff
crescent

The supraspinatus tendon attaches to the humeral head adjacent to the articular
cartilage. The rotator ridge or cable is a capsular band extending from the anterior edge
of the cuff to the posterior humeral head enclosing the area called the crescent.

6.The Posterior Rotator Cuff insertion
the “Bare Area” of the Humeral Head
1. The rotator cuff in this posterior area frequently
appears fenestrated with openings in the superficial
layers
2. The “bare area” of the humerus is a portion of the head
that is devoid of articular cartilage
3. Located adjacent to the posterior lateral rotator cuff
attachment
4. 2 to 3 cm in size

1. Within this area there can be deep pits representing
vascular channels in the bone
2. We should not confuse this bare area with a post-
dislocation osteochondral fracture known as the
Hill-Sachs lesion.
3. The Hill-Sachs lesion is found in a more medial
location

The bare area of the humeral head is located adjacent to the infraspinatus attachment to the
humeral head and may have multiple blood vessel channels

7. Articular surface of humeral head
1. Rotate the bevel of the scope both clockwise and
counterclockwise to visualize globe of the humeral
head
2. Center of the humeral head break down in
chondrolysis, osteochondritis, or degenerative
arthritis
3. Blistering of the cartilage is a sign of impending
chondral breakdown

The globe of the normal humeral head is smooth with firm articular
cartilage.

8. Anterior-Superior Labrum, the Superior
Glenohumeral Ligament, Subscapularis
Tendon, and the MGHL
In 14% of normal patients, there will be an opening
or sublabral foramen beneath the labral attachment
Know as cleft which is normal

• Anterior-superior labral detachment is the so-called
Buford complex
• Variant occurs in approximately 2.5% of shoulders.
There are three features included in the complex:
(1) There is a thick cordlike MGHL
(2) The MGHL attaches to the superior labrum just
anterior at the base of the biceps anchor
(3) Absence of labral tissue on the anterior-superior
glenoid

The Buford complex is easily confused with anteriorsuperior Labral
detachment.

• Anatomic variations region of anterosuperior
labrum and MGHL has wide anatomic
variability
–Attached labrum with broad MGHL is most
common
–Sublabral hole with cordlike MGHL
–Buford complex
• Has absent labrum and cordlike MGHL

• The subscapularis tendon is a very prominent
landmark demarcating the inferior boundary of the
anterior-superior triangle.

The superior glenohumeral ligament attaches to the Lateral edge of the subscapularis
tendon.

9.Includes the Anterior-Inferior Labrum
1. Rotate the bevel inferiorly to visualize the entire
anterior-inferior labral attachment to the glenoid
2. 95% of cases, the labrum has a smooth
attachment to the glenoid cartilage
3. “meniscoid type” in which the articular edge of
the labrum is separated from the glenoid
cartilage

The anterior-inferior labrum and the attachment of the anterior-
inferior ligaments are best seen when viewing from the anterior portal

10. Anterior-Inferior Capsule and ligament
1. The anterior capsular ligaments insert into the
labrum and are firmly attached with it to the
neck of the glenoid.
2. The capsular tissues are smooth and covered
with a thin synovial membrane

11. Posterior Labrum and the Capsule insertion in to the
humeral head
1. To evaluate the posterior-inferior labrum
2. Firmly attached at the periphery
3. Posterior capsular recess cannot be well-visualized
but capsular laxity can be assessed by pinching a
fold of capsule with a pincer clamp
4. Tear in the capsule called as Reverse Humeral
Avulsion Of The Glenohumeral Ligament
“RHAGL” lesion

1. Reverse Humeral Avulsion Of The
Glenohumeral Ligamen “RHAGL” lesion
opposite to HAGL
2. HAGL is inferior gleno humeral ligament injury

The posterior capsule can be seen attaching to the posterior aspect of the
humeral head

12. Posterior-Superior Capsule and the
Posterior Aspect of the Rotator Cuff
1. The normal surface of the rotator cuff is smooth,
with regular vascularity
2. The posterior attachment of the rotator cuff ridge or
cable arches to attach to the humeral head

13.The Anterior Labrum and the Attached
Anterior-Inferior Ligament to the Humeral
Head
1. To evaluate the anterior-inferior labrum
2. Assess the status and quality of the supporting
ligaments, labrum, and capsular tissue when
evaluating for instability
3.The labrum can be palpated with a probe passed
through a posterior portal to assess the security of
the attachment to the glenoid

The lateral humeral attachment of the anterior capsule must be evaluated
by turning the scope bevel to view in a lateral direction

14.Includes the Anterior Attachment of the MGHL
and the Subscapularis Recess
1. The superior edge of the subscapularis tendon must
be carefully evaluated for fraying below the level
of the glenoid rim, the so-called Frayed Upper
Subscapularis with Impingement (FUSSI) lesion
2. Loose bodies are present in the shoulder, they will
be located in the subscapularis recess
3. The anterior attachment of the MGHL crosses the
tendon to insert into the labrum or glenoid neck

The subscapularis recess may have several compartments that can hide loose bodies.

The attachment of the MGHL into the labrum or glenoid neck is seen crossing the
subscapularis tendon

15.Attachment of the Subscapularis Tendon ,
the Anterior Surface of the Humeral Head,
and the Adjacent Biceps Tendon
1. Tip of the arthroscope follows the leading
edge of the subscapularis tendon up to its
attachment into the humerus at the lesser
tuberosity
2. Visualize the anterior articular surface of the
humeral head.
3. There is sometimes a normal “bare area”
similar to that found on the posterior humeral
head

• This area should not be confused with an anterior
humeral head defect found in conjunction with
posterior instability

The anterior surface of the humeral head is an important area to evaluate the subscapularis
attachment

Shoulder arthroscopy

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