3. History
• 1931 First Cadaver Shoulder Arthroscopy Burman
• 1974 First Shoulder Arthroscopy in vivo Johnson LL
• 1982 First Arthroscopic repair Johnson LL
of Shoulder Instability
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7. Glenohumeral Ligament
Variations
66% - Well defined SGHL, MGHL & IGHL
7% - Confluent MGHL & IGHL
19% - Cordlike MGHL with a high riding
attachment
8% - No discernable MGHL – IGHL but one
confluent anterior capsular sheath
12. Shoulder Arthroscopy
the evolution of the technique
Diagnostic
Tool
Final
Treatment
www.shoulder.gr
From tool of the devil the treatment of choice of most shoulder
pathologies
20. RC Arthroscopic Repair
1. Recognition, of the type of the tear
2. Retraction and releases
3. Repair Options:
Anchors: metallic or absorbable
Type of stitch: Mason-Allen,
Mc Stitch,
Mattress sutures,
Horizontal mattress,
Simple sutures
Restoration of footprint: Double row or
Single row www.shoulder.gr
21. Risk to Benefit Ratio
• Rot cuff tears DO NOT heal spontaneously
• Tear repairability
• Think of Size, Elasticity and Chronicity
• Fatty infiltration is not fully reversible
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Operative Treatment
Act aggressive and early
22. Act early try to avoid irreversible
bad tissue quality.
23. What is Bad Tissue Quality?
• Large or massive tears,
• Retracted tears,
• Coutallier three or four fatty infiltration
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24. ANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOAD
OF THE REPAIR
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25. Recognize the Tear Pattern
Tears must be repaired in the direction
of greatest mobility -> minimal strain
26. L-Shaped & U-Shaped Tears
• Side to side sutures from medial to lateral
• Progressively converge the margin of the
tear lateral to bone bed
• Closing 50% of a U-Shaped tear ->
reduces strain at converge margin by a
factor of 6
[Burkhart S]
32. Final Repair
Double row fixationDouble row fixation
Stronger repair biologically
attractive but
Time consuming and of
raised difficulty www.shoulder.gr
33. Massive Contracted Immobile
Tears
• No mobility from medial to lateral or from
anterior to posterior
• Subcategories:
– Massive Contracted Longitudinal Tears
– Massive Contracted Crescent Tears
• Represent 9.6% of massive tears
[Burkhart]
36. Rotator Cuff
• Rot cuff tears that can be repaired with
open techniques can be repaired with
arthroscopic techniques also
• Irreparable Tears:
• Partial repair
• Medialized repair
• Grafts and substitutes
• Tendon transfers
www.shoulder.gr
47. The Spectrum of Instability Lesions
– Minor instability with
activity related pain
– Recurrent subluxation
– Recurrent dislocation
– Locked dislocation with
loss of motion
49. Bankart Lesion
the essential lesion
Avulsion of the IGHL from the glenoid rim
from 2 o’clock to 6 o’clock
Primary restraint to anterior translation
at 90o
of abduction
85% in traumatic anterior dislocations
Not enough to induce symptomatic instability
54. Our findings in first shoulder
dislocation
• Hemarthrosis 100%
• Bankart 78.2%
• Bony Bankart 13.04%
• Hill-Sachs 65.21%
• capsular laxity 8.69%
• SLAP lesions 21.73%
C. Yiannakopulos E Mataragas E.Antonogiannakis
Arthroscopy Sep 2007
55. Arthroscopic Shoulder
Reconstruction
Goal of the Operation: Define the pathology
Restoration of the Labrum to its anatomic attachment
Reestablishment of the appropriate tension
in the IGHL complex and capsule
Repair bony Bankart and large Hill-Sachs lesions
Repair SLAP lesions
Repair rot cuff tears
56. Patients of all ages and all activity levels with
recurrent anterior instability who are impaired
functionally and in whom nonoperative treatment
has failed
Revision stabilization
First-time, acute shoulder dislocations
Arthroscopic Shoulder Stabilization
Patient Selection
74. Glenoid Bone Loss > 30%
Engaging Hill-Sachs
HAGL lesions
Limitations of the
Arthroscopic Techniques
75. Future of instability repair
• HAGL lesions can be repaired with
arthroscopic techniques
• Engaging Hill-Sachs. The remplisage
technique of Eugene Wolf
76. Future of instability repair
Glenoid bone loss:
• arthroscopic bone grafting described
by E. Taverna
• Arthroscopic coracoid transfer
described by L. Laffosse
78. Trends in arthroscopic surgery
•Mechanically stronger repair
techniques
•Arthroscopic techniques for tendon
substitutes
•Better tendon mobilization
techniques
• Arthroscopic repair of Bone
defects in instability surgery
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79. Conclusion
Today, apart from Shoulder Replacement
and major Shoulder Fractures,
nearly all Shoulder Pathology
can be treated
With arthroscopic techniques
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81. Conclusion
Combined with
Lower Morbidity
Day Case surgery
Smalls Incisions
No Deltoid injury
Earlier Mobilization
Less Pain
Earlier Return to Daily Activities
Better Understanding of Shoulder Pathology
www.shoulder.gr
82. Elbow arthroscopy
• 1931 Burman concluded the elbow joint is
not suitable for arthroscopic examination
• Confind space, complex articulation,
proximity of major neurovascular
structures
• Today an accepted technique to treat
intraarticular pathology with expanding
indications
83. Elbow clinical examination-medial
compartment
• Valgus instability check with the elbow in 30o of
flexion and the arm in full supination-possible
ulnakr collateral injury
• Palpate medial epicondyle and and proximal
flexor pronator mass
• Test resisted wrist flexion and elbow pronation
and
• Palpate the ulnar nerve and check for Tinel sign
• Flex and extend the elbow as the nerve is
palpated to detect nerve subluxation
84. Elbow examination posterior
compartment
• Check for pain in the posterolateral and
posteromedial side of the olecranon
• Stabilize the arm and extend the elbow
forcefully to check for compression of the
olecranon in its fossa
85. Elbow clinical examination –lateral
compartment
• Palpate the lateral epicondyle
• Pain in resisted elbow supination and wrist
extension for lateral epicondylatis
• Palpate the radiocapitellar joint while
pronating and supinating the hand to
check for crepitus and pain
91. Capsular volume may be as little as
6 mL in elbows with capsular contracture
92. Prone Elbow Arthroscopy
Advantages
• Best access to
posterior portal
• No arm support
necessary
Disadvantages
• More difficult
anesthesia
• Difficult to convert
to open
• Image reversal
99. Location of medial and lateral portals with respect
to key neurovascular structures
100. Anteromedial Portal
•2 cm. distal and 2 cm. anterior to the medial
epicondyle in line with the joint
•Passes through common flexor origin
(2 cm. distal, 2 cm anterior - Lynch, Whipple,
Meyers)
102. Anteromedial Portal
At Risk
• Median (19mm distended, 12mm non-
distended)
– sheath lies in contact with nerve in 56% of
extended elbows
• Brachial Artery
104. Proximal Medial Portal
• Usually start medially
• 2-3 cm. Proximal to the Medial Humeral
epicondyle
• Just Anterior to the Medial Intermuscular
Septum
108. Anterolateral Portal
2 cm. anterior and 2 cm. distal to
the lateral epicondyle
Passes through ECRB and
Supinator posterolateral to radial
nerve (3cm distal and 2cm anterior
Andrews and Carson)
110. Anterolateral Portal
At Risk
• Radial Nerve (as close as 3 mm)
• PIN (1 to 13 mm increasing with
pronation)
• Posterior Antebrachial Cutaneous Nerve
(2mm)
• Out of favor due to proximity of the radial
nerve
111. Midlateral and proximal
anterolateral portal
• Miblateral 2 cm direct anterior to the
epicondyle
• Proximal anterolateral 2 cm proximal and
1 cm anterior to the epicondyle
• Both provide good visualazation of the
anterior ulnohumeral and radiocapitellar
joint but the proximal anterolateral portal is
safer
112. Soft Spot Portal
Center of triangle formed by the radial head, lateral epicondyle,
and olecranon
Passes through anconeus and triceps
Posterior Antebrachial Cutaneous Nerve (7 mm average)
113. Soft Spot Portal
Best Visualization
• Posterior Surface of Radial Head
• Posterior Capitellum
• Radial Surface of Olecranon
125. Conclusions
• Elbow arthroscopy is a difficult procedure
with a steep learning curve
• As experience is gained indications are
expanding
• Start with easier procedures and stay in
the safe side
