Shoulder Resources

Shoulder arthroscopy (R) Shoulder arthroscopy (R)


Advantages
• Allows much better vision of interior of joint, and undersurface of cuff, to allow identification of articular sided PTRCT.
• Smaller skin incisions result in less pain and better cosmesis.
• Can be done on an outpatient basis with cost savings (although arthroscopy costs more to set up and uses more disposable instruments).
• Quicker return to ADLs and sedentary occupation.
• Risk of catastrophic deltoid problems removed.

Disadvantages
• More difficult to learn arthroscopic acromioplasty than open acromioplasty
• Inability to retract scarred tissues
• Need equipment
Positioning
Beach chair positioning allows normal vertical orientation of the glenohumeral joint, free movement of the arm and easy conversion to an open procedure if required. Assistant is required for traction, however.
Portals
• Posterior
• In soft spot, 2cm distal and medial to posterolateral border of acromion, used for arthroscope. The portal is often opposite the coracoid process. The cannula usually passes between the supraspinatus and infraspinatus tendons
• Anterior
• 1 cm lateral to coracoid and below biceps; used for instrumentation. The cannula usually passes through the rotator interval, directly inferior to the biceps tendon
• Additional anterior
• Used in treatment of anterior instability
• The regular anterior portal is placed a little superiorly, and the additional anterior portal is placed 1cm inferior to this.
• Straight lateral
• Positioned 3cm lateral to acromion
• Used to get an instrument into the subacromial space.
• Supraspinatus portal
• Sometimes used as an adjunct to subacromial arthroscopy
• Positioned in angle between clavicle and scapular
• Port of Wilmington
• Posterolateral corner of acromion
• Useful for repair of SLAP lesions
• Acromioclavicular
• The AC joint is usually accessed via the subacromial space, but if the AC joint alone is to be accessed this can be via incisions made 1cm anterior and 1cm posterior to the joint. A wrist arthroscope may be needed until the joint is opened up by shaving.

Procedure
Perform EUA to determine passive ROM and presence of instability.
Establish posterior portal, distend joint with fluid, then establish anterior portal.
Find the biceps tendon to get oriented.
Examine humeral head, glenoid, labrum, biceps tendon, rotator cuff and glenohumeral ligaments.

Landmarks
The biceps tendon is the landmark for the upper margin of the rotator interval.

Interventions
The subacromial portal allows subacromial bursectomy, coraco-acromial ligament resection, acromioplasty and distal clavicular resection.

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