Arthroscopic Approach to the shoulder
Arthroscopic Approach to the shoulder is used for:
- Diagnostic surgery
- Loose body removal
- Rotator cuff repair or debridement
- Labral/SLAP and instability repair
- Subacromial decompression
- AC joint pathology
- Distal clavicle resection
- Release of suprascapular nerve entrapment
- Release of scar tissue/contractures
- Synovectomy
- Biceps tenotomy/tenodesis
Position of the patient during Arthroscopic Approach to the shoulder:
- Beach chair:
- Advantages:
- Easy conversion to open deltopectoral approach if needed.
- Decreased venous pressure and bleeding.
- Disadvantages:
- Failure to properly position and pad the patient can result in neuropraxia:
- Supraorbital nerve: face mask too tight or poorly padded across forehead,
- paresthesia over forehead and anterior scalp.
- Great auricular nerve: face mask straps too right or poorly padded at mastoid process,
- paresthesia over ear, posterior auricular area and angle of mandible.
- Lateral femoral cutaneous nerve: lateral abdominal support poorly positioned and padded:
- paresthesia over anterolateral thigh.
- higher risk in obese patients due to weight of pannus.
- Supraorbital nerve: face mask too tight or poorly padded across forehead,
- Failure to position the neck in neutral:
- hyperextension: increased risk of stroke and cranial nerve palsy (CN12 hypoglossal).
- hyperflexion: increased risk of spinal cord ischemia and resultant paraplegia.
- Increased risk of cerebral hypo-perfusion compared to lateral position.
- Failure to properly position and pad the patient can result in neuropraxia:
- Advantages:
- Lateral decubitus:
- Advantage of joint distraction:
- can be associated with neuropraxias from traction.
- Advantage of joint distraction:
-
Primary Portals in Arthroscopic Approach to the shoulder:
- Posterior portal:
- Function:
- primary viewing portal used for diagnostic arthroscopy.
- Location and technique:
- located 2 cm inferior and 1 cm medial to posterolateral corner of acromion.
- portal may pass between infraspinatus (suprascapular nerve) and teres minor (axillary nerve) or pass through the substance of infraspinatus.
- this is usually the first portal placed.
- direct anteriorly towards tip of coracoid.
- Function:
- Anterior portal:
- Function:
- viewing and subacromial decompression.
- Location & technique:
- lateral to coracoid process and anterior to AC joint.
- 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.
- Function:
- Lateral portal:
- Function:
- subacromial decompression
- Location & technique:
- located 1-2 cm distal to lateral edge of acromion.
- portal passes through deltoid (axillary nerve).
- Function:
- Posterior portal:
-
Secondary Portals Arthroscopic Approach to the shoulder:
- Anteroinferior (5 o’clock) portal:
- Function:
- placement of anchors in anterior labral repair.
- Location & technique:
- located slightly inferior to coracoid.
- this portal is usually placed under direct supervision from the posterior portal with aid of spinal needle.
- Function:
- Postero-inferior (7 o’clock) portal:
- Function:
- placement of anchors for posterior labral repair
- Location & technique:
- this portal is usually placed under direct supervision from the posterior portal with aid of spinal needle.
- Function:
- Nevasier (supraspinatus) portal:
- Function:
- anterior glenoid visualization and SLAP repairs.
- Location & technique:
- located just medial to lateral acromion
- goes through supraspinatus muscle (suprascapular nerve)
- Function:
- Port of Wilmington (anterolateral) portal:
- Function:
- Used to evaluate/repair posterior SLAP and RTC lesions
- Location & technique:
- just anterior to posterolateral corner of acromion
- this portal is usually placed under direct supervision from the posterior portal with aid of spinal needle
- Function:
- Anteroinferior (5 o’clock) portal:
There is no Internervous plane in Arthroscopic Approach to the shoulder.
Diagnostic Scope:
- Performed with 30° scope through the posterior portal to identify:
- Biceps tendon
- Supraspinatus
- Infraspinatus and teres minor.
- Rotator interval (formed by biceps tendon, superior edge of subscapularis, and glenoid)
- Anterior ligamentous complex (MGHL, IGHL)
- Subscapularis recess (loose bodies)
- Anterior labrum
- Glenoid
- Humeral head
- 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
- Bare areas of cartilage are normal on:
- central glenoid
- posterior humeral head
- Region of anterosuperior labrum and MGHL has wide anatomic variability:
Structures at risk in Arthroscopic Approach to the shoulder include:
- Posterior portal:
- Axillary nerve:
- leaves axilla through quadrangular space and winds around humerus on deep surface of the deltoid muscle and passes ~ 7 cm below tip of acromoin.
- at risk if the posterior portal is made too inferior.
- Suprascapular nerve:
- runs through supraspinatus fossa and infraspinatus fossa before innervating both of these muscles.
- at risk if the posterior portal is made too medial.
- Axillary nerve:
- Anterior portal:
- Cephalic vein:
- runs in deltopectoral groove & at risk if portal is too lateral.
- Musculocutaneous nerve:
- enters muscles 2-8 cm distal to tip of coracoid.
- at risk if anterior portal is made too inferior.
- Cephalic vein:
- Anesthesia:
- Phrenic nerve:
- with intra-scalence block (anesthesia).
- Phrenic nerve:
- Campbel's Operative Orthopaedics book 12th