Gartsman's Shoulder Arthroscopy [3 ed.] 0323529011, 9780323529013

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Gartsman’s Shoulder Arthroscopy THIRD EDITION

Hussein Elkousy, MD Attending Shoulder Surgeon Fondren Orthopedic Group Texas Orthopedic Hospital Houston, Texas

T. Bradley Edwards, MD Attending Shoulder Surgeon Fondren Orthopedic Group Texas Orthopedic Hospital Houston, Texas

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

GARTSMAN’S SHOULDER ARTHROSCOPY, THIRD EDITION

ISBN: 978-0-323-52901-3

Copyright © 2019 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyright © 2009, 2003. Library of Congress Cataloging-in-Publication Data Names: Elkousy, Hussein, author. | Edwards, T. Bradley, author. | Preceded by (work): Gartsman, Gary M. Shoulder arthroscopy. Title: Gartsman’s shoulder arthroscopy / Hussein Elkousy, T. Bradley Edwards. Other titles: Shoulder arthroscopy Description: 3rd edition. | Philadelphia, PA : Elsevier, [2019] | Preceded by Shoulder arthroscopy / Gary M. Gartsman. 2nd ed. c2009. | Includes bibliographical references and index. Identifiers: LCCN 2017056977 | ISBN 9780323529013 (hardcover : alk. paper) Subjects: | MESH: Shoulder Joint–surgery | Arthroscopy–methods | Rotator Cuff–surgery Classification: LCC RD557.5 | NLM WE 810 | DDC 617.5/72059–dc23 LC record available at https://lccn.loc.gov/2017056977

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Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

I dedicate this book to the man who bears its name, Gary Gartsman. Dr. Gartsman added immensely to my knowledge of shoulder surgery and helped me advance my skills when I was a young surgeon. He has provided me with innumerable opportunities to become involved in the shoulder surgery community and has opened many doors for me. I will never forget how much he has helped my career and me as a person. I miss his humor and wish him the best in his retirement. I would also like to dedicate this book to my wife, Iman, and our three sons, Laith, Sayf al Din, and Zain al Din. I appreciate their patience, understanding, and support while this book was written. They are truly my source of joy, happiness, and strength. Hussein Elkousy, MD

I would be remiss if I did not dedicate this book to my mentor in shoulder arthroscopy and good friend, Gary Gartsman. Gary truly changed my life and career path when he offered me a position with him in Houston 15 years ago. While I miss his personality and intellect every day in Houston, I am truly glad that he is enjoying a well-deserved retirement. T. Bradley Edwards, MD

Preface In the last edition of this textbook, Gary Gartsman referenced the 1992 publication Arthroscopic Shoulder Surgery and Related Procedures, co-authored by himself and Harvard Ellman. He describes that text as an attempt to bridge the gap between traditional open shoulder operations and newer arthroscopic approaches. Although we are likely to see many more changes in the techniques of shoulder arthroscopy, many of those gaps have been closed. At present, nearly all shoulder procedures that have been done with open surgery can be done, or have been attempted to be done, arthroscopically. In fact, many procedures are now more commonly done arthroscopically. For this reason, the tone of this text has changed slightly from the prior editions. The main goal is still to present a perspective on how to approach shoulder arthroscopy and give the reader concepts to consider based on our techniques. This is not an exhaustive presentation of current evidence-based medicine or a literature review. However, the techniques described and our approach to address shoulder pathology incorporate the present-day prevailing opinions based on published data, presenting them in a way for readers to apply to their own practice. In the past, this text was written as an introductory text for the established orthopedic surgeon transitioning from open to arthroscopic surgery techniques. Although it still serves that purpose, it can also be used for the resident or young surgeon already trained in these techniques who needs a reminder or refresher to tackle their own cases when not observed by a senior surgeon.

The content is similar to the prior editions, but we have elaborated on the sections addressing biceps lesions and acromioclavicular joint pathology. We have added more videos, techniques, and images on how to address rotator cuff and labral pathology. We have moved on to focus on the newer types of non-metallic implants and have incorporated newer knotless techniques. At the same time, however, we have kept some of the traditional concepts and videos because they illustrate basic skills with which all shoulder arthroscopists should be familiar. We have updated more than 70% of the images and videos to reflect these changes in shoulder arthroscopy since the last edition. The final major change in this textbook is the role of Gary Gartsman in the publication of this text. The first edition of this book was published in 2003 and the second edition in 2009. In both editions, Dr. Gartsman references some of the great names and pioneers of shoulder arthroscopy. Dr. Gartsman has now moved past his career as a practicing shoulder surgeon, leaving an indelible mark on the history of shoulder arthroscopy. This book bears his name because his career accomplishments have placed him among the elite figures in shoulder arthroscopy. We are both honored to say that he was our mentor, colleague, and friend. Hussein Elkousy, MD, and T. Bradley Edwards, MD

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Video Contents SECTION I The Basics Knot-Tying Fundamentals Chapter 1, Video 1.1 Diagnostic and Normal Anatomy Chapter 3, Video 3.1 Brachial Plexus Dissection—Cadaver Chapter 3, Video 3.2

SECTION II Glenohumeral Joint Surgery Anterior Instability EUA Chapter 4, Video 4.1 Posterior Instability Injury Pathology Chapter 4, Video 4.2 Posterior Repair Portal Placement Chapter 4, Video 4.3 Posterior Labral Repair Chapter 4, Video 4.4 Posterior Capsular Tightening Chapter 4, Video 4.5 Posterior GLAD Repair Chapter 4, Video 4.6 Anterior Instability Pathology Chapter 4, Video 4.7 Anterior Repair Viewed from Posterior with Simple Suture Technique Chapter 4, Video 4.8 Anterior Repair Viewed from Posterior with Mattress Suture Technique Chapter 4, Video 4.9 Anterior Repair Viewed from Anterior for Acute Injury Chapter 4, Video 4.10 ALPSA Repair with Capsular Shift from Anterior View Chapter 4, Video 4.11 SLAP Repair with Simple Knotless Technique Chapter 4, Video 4.12 MDI Capsular Shift with no Anchors Chapter 4, Video 4.13 MDI Capsular Shift with Anchors Chapter 4, Video 4.14 MDI Posterior Portal Closure Chapter 4, Video 4.15 MDI Interval Closure Chapter 4, Video 4.16 Arthroscopic Latarjet Chapter 4, Video 4.17 Arthroscopic Follow-up of the Latarjet Procedure Chapter 4, Video 4.18 Biceps Pathology Chapter 5, Video 5.1 SLAP Repair with Mattress Cinch Technique Chapter 5, Video 5.2 Biceps Tenodesis in the Glenohumeral Joint Chapter 5, Video 5.3 Biceps Tenodesis with the PITT Technique Chapter 5, Video 5.4 Biceps Tenodesis with Anchor Technique Chapter 5, Video 5.5 Arthroscopic Contracture Release Chapter 6, Video 6.1

Axillary Nerve Chapter 6, Video 6.2 Osteoarthritis and Chondral Pathology Chapter 7, Video 7.1 Suprascapular Nerve Decompression—Cadaver Chapter 8, Video 8.1 Suprascapular Nerve Decompression at the Suprascapular Notch Chapter 8, Video 8.2 Suprascapular Nerve Decompression at the Spinoglenoid Notch Chapter 8, Video 8.3

SECTION III Subacromial Space Surgery Subacromial Decompression Chapter 10, Video 10.1 Coracoid Impingement Chapter 10, Video 10.2 Management of Partial Thickness Rotator Cuff Tear Chapter 11, Video 11.1 Rotator Cuff Repair Single Row—Animation Chapter 12, Video 12.1 Rotator Cuff Repair Single Row—Model Chapter 12, Video 12.2 Rotator Cuff Repair Single Row—Clinical Chapter 12, Video 12.3 Single Row with Non-Metal Anchors—Clinical Chapter 12, Video 12.4 In vivo Knot Tying Chapter 12, Video 12.5 Double Row Repair Chapter 12, Video 12.6 Transosseous Equivalent Repair Chapter 12, Video 12.7 Repair of Longitudinal Rotator Cuff Tear—Model Chapter 12, Video 12.8 Repair of Longitudinal Rotator Cuff Tear—Clinical Chapter 12, Video 12.9 Repair of Horizontal Cleavage Rotator Cuff Tear—Model Chapter 12, Video 12.10 Subscapularis Repair Chapter 12, Video 12.11 Rotator Cuff Tear Patterns and Releases Chapter 13, Video 13.1 Repair of Acute Tear of the Supraspinatus and Infraspinatus Chapter 13, Video 13.2 Repair of Chronic Massive Tear with Horizontal Delamination Chapter 13, Video 13.3 Partial Repair of Massive Tear Chapter 13, Video 13.4 Arthroscopic Distal Clavicle Excision Chapter 15, Video 15.1 Arthroscopic-Assisted Acromioclavicular Joint Stabilization Chapter 15, Video 15.2 Calcific Tendinopathy Chapter 16, Video 16.1 Active-Assist Range of Motion Exercises—Clinical Demonstration Chapter 19, Video 19.1 Strengthening Exercises—Animation Chapter 19, Video 19.2

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THE BASICS

I

Shoulder Arthroscopy Concepts and Tools

In the initial edition of this text, we approached teaching shoulder arthroscopy from the vantage point that a minority of the current surgeons in practice had trained in shoulder arthroscopy. We therefore titled the first chapter “Making the Transition.” However, at present, most young orthopedic surgeons have already learned the basic skills of shoulder arthroscopy during their residency or fellowship. Despite this shift, it is still necessary for any surgeon who is learning how to do arthroscopic shoulder surgery to develop a plan or framework. The two basic types of skills to achieve this are the same as in the previous text: technical and intellectual. Even though orthopedic surgeons may learn the basic skills of shoulder arthroscopy during residency or fellowship, this experience varies widely among training programs.

ARTHROSCOPY VERSUS OPEN REPAIR The fundamental decision is whether to perform shoulder arthroscopy or to use open repair techniques. If surgeons are more comfortable with open procedures and if they are satisfied with their patient outcomes, they may see no reason to adopt shoulder arthroscopy. However, surgeons have various reasons for deciding to acquire or advance their arthroscopic skills (e.g., the belief that arthroscopic techniques produce better results, peer pressure, a desire to learn new concepts and techniques, and patient demand). Various publications and presentations have documented equal or superior results with arthroscopic techniques compared with open techniques for the performance of subacromial decompression for stage 2 impingement, resection of the acromioclavicular joint for arthritis, repair of the rotator cuff, and the treatment of glenohumeral instability. Orthopedic surgeons are subject to peer pressure. When they talk among themselves about various

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shoulder conditions and their treatment, surgeons who perform only open operations may feel that they are behind the times. Orthopedic surgeons are also conditioned to consider new approaches to patient care, and although many surgeons obtain good results with open repair, they are ready and willing to try something new. Owing to the dramatic increase in available knowledge, many patients are aware of arthroscopic techniques and inquire whether the surgeon performs a certain procedure arthroscopically or with an open technique. Patients have the perception that arthroscopic procedures result in less pain, smaller scars, and more rapid rehabilitation, although strong arguments can be made to refute all of these assertions. Nonetheless, patients are increasingly insistent on finding surgeons who will perform their operations arthroscopically, viewing the arthroscope as a magical tool capable of miraculous cures. Some surgeons see the arthroscope as a wonderful addition to the surgical toolbox, whereas others, based on their experience, see only its negatives. It is the surgeon’s skill that achieves the proper balance (Figs. 1.1–1.4). Before embarking on a mission to acquire arthroscopic skills, each orthopedic surgeon must evaluate his or her practice patterns and answer some questions: Do you perform a sufficient number of shoulder operations to justify learning a new skill? All orthopedic surgeons should be comfortable with diagnostic glenohumeral joint arthroscopy, but not everyone needs to learn more advanced techniques. If you perform fewer than 20 to 30 shoulder procedures a year and are comfortable with the open technique, we would not advise you to invest the time and effort required to perform these few procedures arthroscopically. Do you have the emotional stability to handle the inevitable frustration when learning to perform procedures arthroscopically? Remember, you will be making a transition from the familiar and comfortable to the new and awkward. Do you have

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FIGURE 1.4 Balance. FIGURE 1.1  Magic instrument?

the necessary technical skills? If you cannot perform routine arthroscopic subacromial decompression in 30 minutes or less, you do not have the skills required to perform more complicated reconstructive arthroscopic procedures. Improve your basic skills and speed before taking on a bigger challenge. How do you acquire the necessary skills? Each surgeon must develop a learning plan that focuses on two central issues: technical skills and intellectual skills. In reality, it is hard to separate the two. Learning how to pass a suture through the anterior inferior glenohumeral ligament is of little use if you do not know when this step is necessary.

TECHNICAL SKILLS

FIGURE 1.2  Wand of angels?

FIGURE 1.3  Tool of the devil?

Most orthopedic surgeons learn the basics of shoulder arthroscopy during residency or fellowship, but for those who did not, other resources are available. The Orthopaedic Learning Center, developed and administered by the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America, hosts numerous courses that cover both basic and advanced shoulder arthroscopy. Didactic lectures, panel discussions, and video demonstrations are presented in state-of-the-art lecture halls. The center, located in Rosemont, Illinois, also houses a wet cadaveric laboratory with 48 workstations so that participants can practice with cadaver specimens and arthroscopic instruments. The only true way to master the technical skills of arthroscopy is through practice and repetition. There are several courses that use cadavers to allow the participants to hone their skills. However, many surgeons find this inadequate because a typical course might include lectures and cadaver instruction on arthroscopic subacromial decompression, distal clavicle excision, open and arthroscopic rotator cuff repair, and



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FIGURE 1.5  Knot-tying board. FIGURE 1.7  Rotator cuff repair in two dimensions.

FIGURE 1.6  Rotator cuff repair in two dimensions.

open and arthroscopic glenohumeral reconstruction. There is insufficient time for participants to become comfortable with all procedures. Other options are to practice on models or simulators (Figs. 1.5–1.9). This is not unreasonable and can improve technical skills to a point. We used to offer a small course limited to 12 registrants that focused solely on one topic—either arthroscopic rotator cuff repair or arthroscopic glenohumeral joint instability. Over a 2-day period, techniques using arthroscopic instruments and video arthroscopy were gradually introduced as participants performed repairs on anatomically detailed plastic shoulder models. This allowed everyone ample opportunity to master the requisite intellectual and technical skills (Fig. 1.10). We have since discontinued this course. The best way to advance your arthroscopic skills is by focusing on the details of your open repairs. First, take the opportunity to view arthroscopically all rotator cuff tears and unstable glenohumeral joints before performing the open repair or reconstruction. Learn what the typical glenohumeral joint looks like in a 63-year-old patient with a full-thickness rotator cuff

FIGURE 1.8  Glenohumeral joint reconstruction model.

tear. From the glenohumeral joint, try to identify the tear. Move the arthroscope into the subacromial space, identify the rotator cuff tear, and estimate its size and shape. Ask the circulating nurse to write down these measurements. Next, open the shoulder and record the size and shape of the tear. With practice, you will find that you can accurately assess the size and shape of tears arthroscopically. Before performing an open Bankart procedure, use the arthroscope to identify the Bankart lesion and estimate its size, then compare that with your impression during the open repair. As your experience increases, make your observations more precise. When you are viewing a rotator cuff tear from the subacromial space, insert a probe and use it to measure the length and width of the tear. Insert a grasper and try to determine the tear’s reparability. Grasp different portions of the tear edge and advance them

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FIGURE 1.11  Laser line on the inserter to align the eyelet.

FIGURE 1.9  Shoulder arthroscopy model.

While you hone your basic arthroscopic skills and add to your knowledge, learn the principles of and technical steps required for an arthroscopic repair. For instance, an arthroscopic rotator cuff repair starts with all of the following elements: glenohumeral joint arthroscopy, subacromial bursectomy, coracoacromial ligament management, and possible acromioplasty. You must be expert in these aspects of the procedure. After you are able to evaluate tear size, geometry, and reparability, you must then learn to insert suture anchors, pass sutures through the tendon, manage sutures, and tie secure knots. Fortunately, you can master these techniques before you enter the operating room.

Suture Anchors

FIGURE 1.10  Students in the Joe W. King invitational rotator cuff repair course.

to different locations near the greater tuberosity. This will help you learn to appreciate tear geometry and repair geometry as viewed through the arthroscope. Make note of the tendon quality. After you perform the open repair and close the skin, reinsert the arthroscope into the subacromial space to see how a completed repair should appear. As you can appreciate from the preceding description, we believe that the transition from open to arthroscopic repair should proceed slowly as the surgeon makes incremental improvements in his or her technical skills and adds to his or her knowledge base. It is extremely difficult for any surgeon to learn about arthroscopic rotator cuff repair on one day and perform the procedure from beginning to end the next day. It may take up to 1 year to make the transition using the approach described later.

Since the first two editions of this text, suture anchor technology has changed significantly. Anchors in the past were made exclusively of metal. Now we have polyetheretherketone (PEEK), bioabsorbable, suturebased, and biocomposite anchors. These anchors can be preloaded with one, two, or three sutures, or they can have no suture at all. Important characteristics for metal anchors in the past, such as eyelet orientation, are no longer pertinent because many of the nonmetal anchors have the suture loaded into the central core of the anchor. Surgeons should ask their local manufacturer’s representative for a spare suture anchor and familiarize themselves with its characteristics. Practice inserting the anchor into a board, and learn how much force is required. Most of these anchors need to have a pilot hole created prior to placement. The traditional metal anchors do not. If you are using the most basic metal anchor, learn how to orient the eyelet so that the sutures slide easily. In addition, most, if not all anchors, have a laser line that indicates the appropriate depth of penetration, and the metal anchors often have a line that orients the eyelet (Figs. 1.11–1.13).



CHAPTER 1

FIGURE 1.12  Having the eyelet parallel to the edge of the tendon allows either suture to slide freely.

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FIGURE 1.13  Having the eyelet parallel to the edge of the tendon allows either suture to slide freely.

Sutures Through Tendon There are two basic methods of passing a braided suture through a tendon or ligament, and you should be familiar with both (Figs. 1.14–1.31). The direct method involves using an instrument to pierce the ligament or tendon and pulling or pushing the suture through it. The indirect method requires that you use some sort of monofilament suture passed through the tendon. This monofilament suture is then used to pull the braided suture through the soft tissue.

Suture Management Suture management is critical to arthroscopic shoulder reconstruction. Whether the surgeon is in the subacromial space for a rotator cuff repair or in the glenohumeral joint for a glenohumeral reconstruction, the fundamental problem is too many sutures in too little space. There are two basic solutions: tie the sutures as you insert them, or move the sutures out of the way through cannulas or percutaneous incisions. Experiment with both techniques to determine which one is better for you. Even if you tie the sutures after you insert each one, suture management is important. To avoid nicking

FIGURE 1.14  Suture loaded in needle passing device.

the suture (risking suture breakage) when inserting sharp instruments through cannulas, the basic principle is to keep the working cannula free from sutures. Percutaneous anchor insertion is an option in the subacromial space but is not as easy in the glenohumeral joint, owing to the mass of soft tissue the anchor must penetrate. To practice suture management, write out in detail each step of the operation and decide when you must Text continued on page 8.

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FIGURE 1.15  Needle advances suture through the tissue.

FIGURE 1.16  Withdraw the needle, leaving the suture loop.

FIGURE 1.17  Remove the instrument, leaving the suture loop.

FIGURE 1.18  In vivo photo of needle-passing device.

FIGURE 1.19  Needle-passing device grasping rotator cuff.

FIGURE 1.20  Suture deployed as the needle is advanced.



CHAPTER 1

FIGURE 1.21  Tissue penetrator in place to pierce rotator cuff.

FIGURE 1.23  Tissue penetrator grasping suture. The suture will be allowed to slide distally into the eyelet prior to pulling it through the cuff.

FIGURE 1.25  Nylon suture used to shuttle a braided suture.

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FIGURE 1.22  Tissue penetrator through cuff preparing to grasp suture from anchor.

FIGURE 1.24  Nylon suture passed through a felt model.

FIGURE 1.26  Nylon suture used to pull the braided suture through the felt model.

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FIGURE 1.27  Braided suture passed through the felt. FIGURE 1.30  Looped end of nylon passed through the labrum.

FIGURE 1.28  In vivo photo of shuttle suture passer tip. FIGURE 1.31  Nylon loop shuttles braided suture through the labrum.

FIGURE 1.29  Shuttle suture passer penetrating the anterior labrum of a right shoulder.

move sutures. When you write out the operative steps in detail, it gives you an accurate impression of how many suture manipulations are needed. Reviewing these steps with members of your operative team gives them a much better idea of what needs to be accomplished, as well as an appreciation of the operation’s complexity. You can practice these steps before you get to the operating room. Simple models can be created with plywood, felt, and picture eyelets to simulate portal locations. Place cannulas through the eyelets and insert an anchor in the center. Practice moving the sutures from cannula to cannula until the motions become automatic (see Figs. 1.24–1.27 and 1.37–1.99). Lanny Johnson is fond of saying that when professional golfers



CHAPTER 1

FIGURE 1.32  Correct hand positions.

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finish playing golf, they practice golf; when surgeons finish performing surgery, they practice golf. Perhaps we could learn a lesson from professional golfers. It is amazing to see the progress students make after they practice an operation 20 times. It is difficult to teach operations of this complexity with only a lecture and a video. Each step (holding the instruments, passing the sutures, suture management, and so forth) must be taught and mastered as an individual event (Figs. 1.32–1.36). These individual events must then be performed in the correct sequence. After the sequence is mastered, the fluidity of the steps must be improved until they become routine. All this

FIGURE 1.33  Incorrect hand positions. FIGURE 1.35  Use the thumb to rotate the arthroscope.

FIGURE 1.34  Use the index finger to rotate the arthroscope.

FIGURE 1.36  Do not use two hands to rotate the arthroscope.

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should be done under the constant supervision of an experienced arthroscopist so that bad habits are corrected immediately before they become ingrained. Practice does not make perfect, but practice does make permanent, and it is of no benefit to practice an operation either incorrectly or inefficiently. When I was learning to perform arthroscopic procedures, I drew out the essential steps of the operation on a piece of paper; borrowed a suture passer, knot pusher, crochet hook, loop grasper, sutures, and hemostats from the operating room; and practiced the required maneuvers until I felt comfortable. I have included here the exercises I used and encourage you to rehearse the procedure with your assistant until both of you are familiar with your roles and the necessary steps. Although this may seem time consuming, this level of preparation yields great dividends during the actual operation. Exercise 1 (see Figs. 1.37–1.47) simulates a one-anchor,

FIGURE 1.37  Exercise 1 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon.

FIGURE 1.38  Insert an anchor with two sutures—four suture strands.

FIGURE 1.39  Pull the four suture strands out through the anterior cannula.

FIGURE 1.40  Pull one blue strand through the lateral cannula.

FIGURE 1.41  Place it through the felt with a suture passer.



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FIGURE 1.42  Pull one white suture strand through the lateral cannula.

FIGURE 1.43  Place it through the felt with a suture passer.

FIGURE 1.44  Retrieve both white suture strands from the anterior cannula, and pull them through the lateral cannula.

FIGURE 1.45  Tie the white sutures.

FIGURE 1.46  Retrieve the blue suture strands from the anterior cannula, and pull them through the lateral cannula.

FIGURE 1.47  Tie the blue sutures.

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two-suture rotator cuff repair. The steps are written out later in the blue boxes as if it were done with a needlepassing type of device passing the suture. Exercise 2 (see Figs. 1.48–1.66) simulates a two-anchor, four-suture rotator cuff repair. Exercise 3 (see Figs. 1.67–1.99)

simulates a three-anchor, six-suture complex rotator cuff repair. One scenario of clinical steps is described in the blue box for double-loaded suture anchors used for a Bankart repair. Text continued on page 22.

Arthroscopic Rotator Cuff Repair—Needle-Passing Device Technique (One Anchor, Two Sutures; See Figs. 1.37–1.47)

• Insert the anchor in the anterior position through the lateral cannula. • Use a crochet hook to pull the blue and white sutures out through the anterior cannula. • Use a crochet hook to pull one blue suture strand from the anterior to the lateral cannula. • Load the blue suture on the needle-passing instrument. • Insert the needle-passing instrument through the lateral cannula. • Grasp the tendon. • Advance the needle and push the blue suture through the tendon. • Withdraw the needle. • Insert a grasper through the anterior cannula and grasp the blue suture exiting the tendon. • Remove the needle-passing instrument from the lateral cannula. • Use a grasper to pull the suture out through the anterior cannula. • Apply a hemostat to the two blue sutures. • Use a crochet hook to pull one white suture strand from the anterior to the lateral cannula. • Load the white suture on the needle-passing instrument.

• Insert the needle-passing instrument through the lateral cannula. • Grasp the tendon. • Advance the needle, and push the white suture through the tendon. • Withdraw the needle. • Insert a grasper through the anterior cannula, and grasp the white suture strand exiting the tendon. • Remove the needle-passing instrument from the lateral cannula. • Use a grasper to pull the suture out through the anterior cannula. • Remove the hemostat from the white sutures. • Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula. • Use a loop grasper to untangle the sutures. • Tie the white sutures. • Remove the hemostat from the blue sutures. • Move the blue sutures from the anterior cannula to the lateral cannula. • Use the loop grasper to untangle the sutures. • Tie the blue sutures.

Arthroscopic Bankart Repair—Shuttle Suture Passer, Double-Loaded Suture Anchors

• Insert the arthroscope posteriorly. • Use a spinal needle to identify the anteroinferior portal immediately superior to the subscapularis tendon. • Insert an 8-mm cannula. • Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval. • Insert a metal cannula and move the arthroscope anteriorly to view the posterior joint. • Return the arthroscope posteriorly and place a 5.5 mm working cannula anteriorly. • Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion. • Insert a shaver through the anterosuperior cannula to débride soft tissue from the anterior scapular neck. • Insert a bur to decorticate the anterior scapular neck. • Remove the anterosuperior cannula.

• Insert a metal cannula and trocar into the anterosuperior portal. • Observe the anterior scapular neck decortication. • Move arthroscope to posterior cannula. • Determine how many anchors are required to repair the Bankart lesion. • Mark the anchor locations with a punch or bur. • Insert a drill through the anterosuperior cannula to drill anchor holes. • Insert an anchor through the anterosuperior cannula, and place it in the most inferior drill hole. • Remove the inserter. • Four suture strands from the inferior anchor should be exiting the anterosuperior cannula. • Insert the suture shuttle passing device through the anteroinferior cannula, and pierce the capsule and labrum. • Advance the looped end of the nylon or wire loop passer into the joint.



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Arthroscopic Bankart Repair—Shuttle Suture Passer, Double-Loaded Suture Anchors—cont’d

• Retrieve the looped end with a crochet hook placed in the anterosuperior cannula. • Remove the suture shuttle passing device from the anteroinferior cannula, and place a hemostat on the free end that exits the anteroinferior cannula. • The nylon or wire loop should be outside the anterosuperior cannula. • Through the anteroinferior cannula, use a crochet hook to grasp one strand of anchor suture, taking care not to unload the suture from the anchor. • Through the anterosuperior cannula, insert a loop grasper, and encircle the looped end of the nylon passing suture or the wire loop and the other end of the suture that was pulled out the anteroinferior cannula.

FIGURE 1.48  Exercise 2 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are two drill holes for anchors.

FIGURE 1.49  Insert two anchors—four sutures, eight suture strands.

• Place 6 cm of this designated suture through the nylon or wire loop (anterosuperior cannula). • Apply traction to a hemostat, and pull the designated anchor suture from the anterosuperior cannula into the joint, through the labrum, and out the anteroinferior cannula. • Two sister limbs of the same suture are now through the anteroinferior cannula. • Tie the two limbs together. • Repeat for the second set of sutures from the most inferior anchor. • Repeat these steps from additional anchors as needed.

FIGURE 1.50  Pull the sutures from the anterior anchor out through the anterior cannula. Apply a hemostat.

FIGURE 1.51  Pull the sutures from the posterior anchor out through the anterior cannula. Apply a hemostat.

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FIGURE 1.52  Retrieve one blue suture strand from the anterior anchor, and bring it out through the lateral cannula.

FIGURE 1.53  Insert this suture strand through the felt, and pull it out through the anterior cannula.

FIGURE 1.54  Retrieve one white suture strand from the anterior anchor, and bring it out through the lateral cannula.

FIGURE 1.55  Insert this suture strand through the felt, and pull it out through the anterior cannula.

FIGURE 1.56  Retrieve one blue suture strand from the posterior anchor, and bring it out through the lateral cannula.

FIGURE 1.57  Insert this suture strand through the felt, and pull it out through the anterior cannula.



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FIGURE 1.58  Retrieve one white suture strand from the posterior anchor, and bring it out through the lateral cannula.

FIGURE 1.60  Retrieve both posterior anchor white strands from the anterior cannula, and pull them out through the lateral cannula.

FIGURE 1.62  Retrieve both posterior anchor blue strands from the anterior cannula, and pull them out through the lateral cannula.

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FIGURE 1.59  Insert this suture strand through the felt, and pull it out through the anterior cannula.

FIGURE 1.61  Tie these sutures.

FIGURE 1.63  Tie these sutures.

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FIGURE 1.64  Repeat the steps for the anterior anchor white suture.

FIGURE 1.66  Tie the sutures. The repair is complete.

FIGURE 1.68  Insert three anchors—6 sutures and 12 suture strands.

FIGURE 1.65  Retrieve both anterior anchor blue strands from the anterior cannula, and pull them out through the lateral cannula.

FIGURE 1.67  Exercise 3 simulating the repair of a large or massive rotator cuff tear. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are three anchor holes.

FIGURE 1.69  Pull the anterior anchor sutures out through the anterior cannula.



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FIGURE 1.70  Pull the middle anchor suture strands out through the anterior cannula.

FIGURE 1.71  Move the posterior anchor strands to the left of the lateral cannula, simulating removing them through a posterolateral percutaneous stab wound.

FIGURE 1.72  Move the middle anchor sutures from the anterior cannula, simulating an anterolateral percutaneous stab wound.

FIGURE 1.73  Retrieve one anterior anchor blue suture from the anterior cannula, and pull it out through the lateral cannula.

FIGURE 1.74  Place this suture through the felt, and withdraw it through the anterior cannula.

FIGURE 1.75  Retrieve one anterior anchor white suture from the anterior cannula, and pull it out through the lateral cannula.

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FIGURE 1.76  Place this suture through the felt, and withdraw it through the anterior cannula.

FIGURE 1.77  Retrieve one middle anchor blue suture from the anterolateral stab wound, and withdraw it through the lateral cannula.

FIGURE 1.78  Place this suture through the felt, and withdraw it through the anterior cannula.

FIGURE 1.79  Withdraw the suture strand that is through the felt, and pull it out the anterolateral stab wound.

FIGURE 1.80  Retrieve one middle anchor white suture from the anterolateral stab wound, and withdraw it through the lateral cannula.

FIGURE 1.81  Place this suture through the felt, and withdraw it through the anterior cannula.



CHAPTER 1

FIGURE 1.82  Withdraw the suture strand that is through the felt, and pull it out the anterolateral stab wound.

FIGURE 1.84  Tie the sutures.

FIGURE 1.86  Tie the sutures.

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FIGURE 1.83  Retrieve the anterior anchor white suture strands from the anterior cannula, and pull them out through the lateral cannula.

FIGURE 1.85  Retrieve the anterior anchor blue suture strands from the anterior cannula, and pull them out through the lateral cannula.

FIGURE 1.87  Withdraw the posterior anchor blue suture strand from the posterolateral stab wound, and pull it out through the lateral cannula.

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FIGURE 1.88  Place this suture through the felt, and withdraw it through the anterior cannula.

FIGURE 1.90  Place this suture through the felt, and withdraw it through the anterior cannula.

FIGURE 1.92  Retrieve the posterior anchor white strand from the anterior cannula, and withdraw it through the lateral cannula.

FIGURE 1.89  Withdraw the posterior anchor white suture strand from the posterolateral stab wound, and pull it out through the lateral cannula.

FIGURE 1.91  Retrieve the posterior anchor white strand from the posterolateral stab wound, and withdraw it through the lateral cannula.

FIGURE 1.93  Tie the white sutures from the posterior anchor.



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FIGURE 1.94  Retrieve both posterior anchor blue sutures, and withdraw them through the lateral cannula.

FIGURE 1.95  Tie the blue sutures from the posterior anchor.

FIGURE 1.96  Retrieve both middle anchor white sutures, and withdraw them through the lateral cannula.

FIGURE 1.97  Tie the middle anchor white sutures.

FIGURE 1.98  Retrieve both middle anchor blue sutures, and withdraw them through the lateral cannula.

FIGURE 1.99  Tie the middle anchor blue sutures.

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Arthroscopic Knot Tying (Video 1.1) Because reconstructive arthroscopic shoulder surgery involves soft tissue repair, knot tying is a critical skill. Surgeons’ reluctance to tie arthroscopic knots has created a booming industry in pretied knots or “knotless” devices. Each of these devices requires a number of steps that may be as tedious as tying a knot. Furthermore, these devices are not always available and have an associated cost that may make them less appealing. Learning to tie an arthroscopic knot can be difficult, but with instruction and practice, it can be mastered. Surgeons tie knots in open surgery on a daily basis. Arthroscopic knots are similar, with the exception that the knot pusher replaces the surgeon’s index finger. The knots can lie flat as square knots or they can be a series of half hitches with alternating configurations. If done correctly, arthroscopic knots are as strong as knots tied in the open technique. Knotless anchors certainly have their place and can offer features that make them superior to traditional knot tying in specific scenarios, but it is always useful to have the skill to tie a knot in those situations when something goes awry and you need to use your knot-tying skills.

FIGURE 1.100  In vivo photo of knot pusher on nonpost strand with half hitch wrapped around post strand.

Knot-Tying Concepts It is often helpful to understand the properties of knots. Knots have two general properties that are important to a surgeon: loop security and knot security. Loop security refers to how tightly a knot apposes two tissues. It differs among knots based on the initial knot configuration. High loop security is the desired goal. Knot security refers to the internal friction of a knot that prevents it from losing its integrity or unraveling in the face of external loads. High knot security is desirable and would mean that the knot does not unravel and lose tension. Knot security has been shown in several studies to be dependent on the number of half hitches thrown on top of the initial knot. It is generally accepted that high knot security can be achieved by throwing three half hitches alternating the direction of throw and alternating posts or using a square knot configuration. The concept of a post and nonpost is also critical to understand. The post strand is defined as the one that stays under tension while the other suture is wrapped around it. It is not necessarily the strand that is through the knot pusher (Figs. 1.100 and 1.101). In fact, it is more often the strand that is not through the knot pusher. The post strand can be altered by simply applying differential tension to the suture strands. By understanding and altering the post strand, square knots and half hitches can be thrown in any scenario to achieve secure fixation of adjacent tissues (Figs. 1.102–1.105).

FIGURE 1.101  In vivo photo of knot pusher on post strand prior to pulling second limb back down the post.

Knot Types Arthroscopic knots are generally divided into two types: sliding and nonsliding knots. A sliding knot is one in which pulling on one limb of suture, generally passing through an anchor, will result in the knot sliding down to the tissue or point of fixation. During this maneuver, the suture will slide through the tissue or anchor or both. Common sliding knots are a Duncan loop, a Tennessee Slider, a Weston knot, and a Samsung Medical Center (SMC) knot. A nonsliding knot is fixed at some point between the two suture limbs, generally at the tissue or anchor level; therefore pulling on one strand will not result in any sliding of the suture. The most common nonsliding knot is the simple half hitch.



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FIGURE 1.102  Knot pusher on nonpost strand with half hitch around it.

FIGURE 1.104  Past pointing with knot pusher and releasing tension on second limb switches the post to the knot pusher strand.

FIGURE 1.103  Equal tension placed on both suture limbs.

FIGURE 1.105  Restoring equal tension to both strands result in a square knot or “flat” throw.

Sliding knots are further subdivided into locking and nonlocking as well. Locking knots are exactly what their name suggests. Once the first configuration is thrown, the knot is set and locked in position. Nonlocking knots will not hold their position after the initial throw. An example is a Duncan loop (Fig. 1.106). The advantage of locking knots is that they will maintain loop security of the initial knot while the subsequent half hitches are placed for knot security. However, the disadvantage of locking knots is that they may prematurely lock if not done well and can render the passed suture useless or make it very difficult to unlock the knot and repeat the throw. On the other hand, although nonlocking knots will not prematurely lock, the disadvantage is that loop

security may be compromised with manipulation of the subsequent throw and tissue apposition may be lost. Examples of sliding locking knots are the Tennessee Slider, the Weston knot, and the SMC knot. A surgeon should be familiar with how to tie both types of knots. However, the nonsliding type is the most useful and it is the one that surgeons can least afford to not be familiar with. This is because nonsliding knots are the most utilitarian and are used when the suture will not slide through the tissue. So, for example, once a sliding knot or nonsliding knot has been placed and deployed, the subsequent knots are all nonsliding knots. The most common pattern or technique for nonsliding knots is simply the one-handed knot-tying

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KNOT-TYING TECHNIQUE 1

3

4

2

FIGURE 1.108  One-handed underhand knot. 3

4

5

6

5

6

FIGURE 1.109  One-handed underhand knot. 7

8

FIGURE 1.106  Duncan loop knot (sliding nonlocking). 1

2

FIGURE 1.110  One-handed underhand knot. 9

10

FIGURE 1.107  One-handed underhand knot.

technique, which incorporates underhand and overhand throws (Figs. 1.107–1.113 and 1.114–1.170). These are the throws that result in the knot security mentioned previously.

FIGURE 1.111  One-handed overhand knot. 11

12

Knot-Tying Steps After the suture has been passed through the soft tissue, verify that no tangles exist. Use the loop grasper to encircle one suture limb and then withdraw the instrument. Perform this step before tying every knot. Place one limb of the suture through the knot-tying instrument. This suture limb is usually the one closest to Text continued on page 34.

FIGURE 1.112  One-handed overhand knot.



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FIGURE 1.113  One-handed overhand knot.

FIGURE 1.114  One-handed knots.

FIGURE 1.115  One-handed knots.

FIGURE 1.116  One-handed knots.

FIGURE 1.117  One-handed knots.

FIGURE 1.118  One-handed knots.

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FIGURE 1.119  One-handed knots.

FIGURE 1.120  One-handed knots.

FIGURE 1.121  One-handed knots.

FIGURE 1.122  One-handed knots.

FIGURE 1.123  One-handed knots.

FIGURE 1.124  One-handed knots.



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FIGURE 1.125  One-handed knots.

FIGURE 1.126  One-handed knots.

FIGURE 1.127  One-handed knots.

FIGURE 1.128  One-handed knots.

FIGURE 1.129  One-handed knots.

FIGURE 1.130  One-handed knots.

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FIGURE 1.131  One-handed knots.

FIGURE 1.132  One-handed knots.

FIGURE 1.133  One-handed knots.

FIGURE 1.134  One-handed knots.

FIGURE 1.135  One-handed knots.

FIGURE 1.136  One-handed knots.



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FIGURE 1.137  One-handed knots.

FIGURE 1.138  One-handed knots.

FIGURE 1.139  One-handed knot using a knot pusher.

FIGURE 1.140  One-handed knot using a knot pusher.

FIGURE 1.141  One-handed knot using a knot pusher.

FIGURE 1.142  One-handed knot using a knot pusher.

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FIGURE 1.143  One-handed knot using a knot pusher.

FIGURE 1.144  One-handed knot using a knot pusher.

FIGURE 1.145  One-handed knot using a knot pusher.

FIGURE 1.146  One-handed knot using a knot pusher.

FIGURE 1.147  One-handed knot using a knot pusher.

FIGURE 1.148  One-handed knot using a knot pusher.



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FIGURE 1.149  One-handed knot using a knot pusher.

FIGURE 1.150  One-handed knot using a knot pusher.

FIGURE 1.151  One-handed knot using a knot pusher.

FIGURE 1.152  One-handed knot using a knot pusher.

FIGURE 1.153  One-handed knot using a knot pusher.

FIGURE 1.154  One-handed knot using a knot pusher.

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FIGURE 1.155  One-handed knot using a knot pusher.

FIGURE 1.156  One-handed knot using a knot pusher.

FIGURE 1.157  One-handed knot using a knot pusher.

FIGURE 1.158  One-handed knot using a knot pusher.

FIGURE 1.159  One-handed knot using a knot pusher.

FIGURE 1.160  One-handed knot using a knot pusher.



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FIGURE 1.161  One-handed knot using a knot pusher.

FIGURE 1.162  One-handed knot using a knot pusher.

FIGURE 1.163  One-handed knot using a knot pusher.

FIGURE 1.164  One-handed knot using a knot pusher.

FIGURE 1.165  One-handed knot using a knot pusher. FIGURE 1.166  One-handed knot using a knot pusher.

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FIGURE 1.167  One-handed knot using a knot pusher.

FIGURE 1.168  One-handed knot using a knot pusher.

FIGURE 1.169  One-handed knot using a knot pusher.

FIGURE 1.170  One-handed knot using a knot pusher.

you. For example, in rotator cuff repair, the knot pusher is placed on the suture limb that exits from the suture anchor and comes out through the cannula. The free end is the suture limb that has been placed through the tendon and is farther away. Apply a hemostat to the suture strand that is through the knot pusher so that you have something to pull against as you push the knot down the cannula. The initiation of the knot begins a little differently than the remaining throws for the sake of achieving loop security prior to achieving knot security. This difference is due to the need to slip the second throw. Usually the tendon or ligament to be tied is under tension and retracts slightly after the first knot throw. One method to deal with this problem is to eliminate the tension on the soft tissue by having an assistant hold the soft tissue with a tissue grasper. Another method is to place a traction suture through the soft tissue. A third method, which we describe here, involves slipping the second throw. Create the first throw routinely with either an underhand or overhand throw. Make a second half hitch in the same direction and slowly advance it down the cannula. Check to see that the suture is not tangled. Pull on the post limb, and release all tension on the other limb. The knot will slide down to the soft tissue without locking, enabling you to approximate the soft tissue. Past point and lock the second throw. If you created two overhand throws first, then the third throw is an underhand throw. It is best to keep the same sequence. Try to make the steps of tying your arthroscopic knots as similar as possible to those of your open knots. Use the knot pusher to past point on the third throw. Place a fourth throw in the same direction as the first, and tighten the knot without past pointing. Now reverse the direction of



CHAPTER 1

the throw one last time, and place a third hitch for the fifth throw. Once again, past point on this throw. Reversing the posts of the knot by past pointing on alternate throw after the second throw optimizes knot security. As an alternative, rather than past pointing and completely alternating the post, careful equal tension can be applied in a 180-degree vector of force to create a square knot on any one of the throws starting with the third throw. To be proficient in tying arthroscopic knots, the surgeon must be able to tie the basic one-handed underhand and overhand knots commonly taught in medical school or surgery internship. One way to do this is to gradually incorporate arthroscopic knot tying into surgery by tying knots with the knot pusher during an open repair and moving to arthroscopic knot tying as your skills improve. These steps are illustrated in Figs. 1.107 through 1.170, showing one-handed knots placed in a slip knot followed by a square configuration. As shown in the illustrations, it is often easier to practice with clothesline than with surgical suture initially. All of the knots described here are shown on the video.

INTELLECTUAL SKILLS Intellectual skills can be honed by attending instructional courses presented by the American Academy of Orthopaedic Surgeons, the American Shoulder and Elbow Surgeons, and the Arthroscopy Association of North America. These courses are held throughout the United States. Perhaps the most important intellectual tool a surgeon can possess is a plan to master reconstructive arthroscopic operations. As a general approach, we recommend the following: learn the individual steps of the arthroscopic repair, practice these techniques outside the operating room, gradually incorporate these techniques into open repair, perform arthroscopic repair and then open the shoulder, and finally perform the operation exclusively with arthroscopic technique. Although, theoretically, it seems reasonable to make the transition to arthroscopic repair in one step, in practice, it can result in a 6-hour arthroscopic rotator cuff repair that benefits neither patient nor surgeon. We advise a more gradual transition.

THE GRADUAL TRANSITION When making the transition from open to arthroscopic rotator cuff repair, be sure to scope all tears before performing the open repair. Establish time limits for

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your arthroscopic procedures. Give the circulating nurse authority to inform you that 1 hour has passed and it is time to open the shoulder. Consider a plan similar to the one described here.

Stage 1 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space, and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability, and determine what goes where. 5. Perform arthroscopic decompression. 6. Open and repair the rotator cuff tear. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 5 in 30 minutes, advance to the next stage.

Stage 2 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space, and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability, and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Open and repair the rotator cuff tear. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 6 in 30 minutes, advance to the next stage.

Stage 3 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space, and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability, and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Open and repair the rotator cuff tear. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 8 in 30 minutes, advance to the next stage.

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Stage 4 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space, and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability, and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Pass the anterior anchor sutures through the tendon. 10. Pass the posterior anchor sutures through the tendon. 11. Open and complete the rotator cuff repair. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 10 in 40 minutes, advance to the next stage.

Stage 5 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space, and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability, and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor, and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Pass the anterior anchor sutures through the tendon. 10. Pass the posterior anchor sutures through the tendon. 11. Tie the knots. 12. Open and inspect the repair. Check the tension on the tendon, ensuring that it is neither too tight nor too loose. Are the knots secure? Is the spacing of the knots on the tendon correct? Are they too close together or too far apart? Are they too close to the lateral edge or too far away from the edge? 13. Review the video recording (I strongly suggest that you record your procedures). If the knots are too closely spaced, determine at what point in the procedure this occurred. Why did the spacing look good at arthroscopy but not when you inspected

the repair open? Apply this same level of analysis to all aspects of the repair until you are satisfied. At this final stage, you will gain confidence that your arthroscopic repairs are as good as or better than your open repairs. After your particular threshold of excellence has been met, you can stop opening your arthroscopic repairs.

INSTRUMENT HANDLING Arthroscopic shoulder reconstructions are complex operations, and success depends on a number of small details. One area that surgeons often overlook is the appropriate handling of arthroscopic instruments. Correct hand position and movement can be mastered with little effort.

Arthroscope Practice holding and manipulating the arthroscope with both hands. If you are comfortable holding the arthroscope with only one hand, operating on the opposite shoulder will force you into an awkward position. Practice with both hands during diagnostic glenohumeral arthroscopy until you can smoothly and rapidly maneuver the arthroscope and view all critical areas of the joint. Everyone has a dominant or preferred hand, but some surgeons prefer to use this hand to control the arthroscope, and others use the dominant hand to manipulate the surgical instruments. Ideally, you should be able to hold the camera and manipulate the instruments with either hand. A second skill is arthroscope rotation. Many surgeons rotate the arthroscope with the hand not holding the scope. This may be satisfactory during the diagnostic phase, but when you have an instrument in the opposite hand, this becomes difficult. Learn to rotate the arthroscope by using the index finger of the hand holding the scope (see Figs. 1.32–1.36).

Needle-Passing Device These instruments are designed to pass braided sutures directly through a tendon or ligament without using a shuttle relay. Take some time to learn how to load the needle, load the suture, deploy the needle, grasp the suture, withdraw the needle, and finally remove the instrument (see Figs. 1.14–1.20).

Shuttle Suture Passer This series of instruments is used to shuttle sutures with a nylon loop. They are often reusable. The loading



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eyelet is usually large enough so that the nylon loop can be loaded either loop end first or free end first, depending on the specific requirements of the operation. Sometimes, a braided suture or a metal loop can be passed. Many tip configurations are available bent at variable angles or curved in left or right directions (see Figs. 1.28–1.31).

Knot Pusher There are a variety of knot-tying instruments available, and you should examine a number of them to determine which one feels most comfortable. A simple instrument often suffices (Fig. 1.171). This instrument is essentially an extension of the surgeon’s index finger. Finding the optimal shaft length is accomplished by trial and error.

FIGURE 1.171  Knot pushers.

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2

Operating Room Setup

 

This chapter covers the general organization of the operating room, anesthesia, patient positioning, as well as equipment and instruments.

CLINICAL DATA It is helpful to have a copy of the patient’s record in the operating room. This allows the surgeon to compare the examination under anesthesia with the examination documented in the office. For patients with glenohumeral instability, the surgeon can compare the patient’s report of which activities or motions produce pain to the amount of translation observed during examination under anesthesia. The patient record also includes a summary of the pertinent findings on magnetic resonance imaging, ultrasonography, and computed tomography, allowing the surgeon to assess these to the findings at arthroscopy. The pertinent imaging studies are also placed in plain view for review if needed (Figs. 2.1–2.3). With the advent of electronic medical records, this goal may be achieved by having a computer or laptop in the room displaying the pertinent data.

on the floor. The foot pedals that control the power instruments and cautery are placed for easy access (Figs. 2.5–2.9). The shoulder preparation table contains the skin razor and adhesive tape for removing hair. We use an iodine-based product (Duraprep); for individuals with iodine allergy, a chlorhexidine gluconate (Hibiclens) scrub is followed by an isopropyl alcohol solution. We prefer to have the patient’s hair shaved from the area that will be covered by the bandage. It is not necessary to shave the axilla. Only those instruments required for the operation are placed on the Mayo stand. The back table contains rarely used instruments and the postoperative dressing (Fig. 2.10). Text continued on page 42.

SETUP AND PREPARATION The operating room layout is shown in Fig. 2.4. There must be adequate space to maneuver between the head of the table and the anesthetist. The cart with the arthroscopy equipment is angled toward the surgeon so all of the settings can be seen if needed. Similarly, the arthroscopic pump and fluid bags should be visible so the surgeon can see the pressure and flow at any time. The surgeon should also ask the anesthetist to rotate the blood pressure monitor so that he can check it during the procedure without disturbing his or her concentration. An absorbent mat to collect fluid is placed

38

FIGURE 2.1  Patient record in the operating room.



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Operating Room Setup

No history of prior similar shoulder problem Previous treatment consisted of selective rest and activity modification Allergies: Patient has no known drug allergies Current Medication: None Social History: Patient denies the use of any tobacco products; patient occasionally drinks socially Clinical Examination: Dominant Hand: Right Right Shoulder Examination: Tenderness — Shoulder: Present at the bicipital groove and biceps muscle Swelling: None Ecchymosis: None Crepitus: None Deformity: None present Atrophy: None present Skin: No incisions, lacerations, or abrasions noted Effusion: Absent Passive Range of Motion: elevation = 120 degrees external rotation (shoulder adducted) = 85 degrees internal rotation to the lumbar level 1-2 Strength: Strength was normal when the patient was tested for resisted elevation, external rotation, internal rotation and subscapularis push-off Muscle Pain Tests (resisted): Resisted internal rotation — not painful Elevation — no pain External rotation — no pain Abduction — no pain Belly-press test — no pain Subscapularis push-off — no pain Stability: Stability was normal when the patient was tested for sulcus, Rowe, abduction/external rotation and posterior translation Neurovascular Examination: Normal Office Radiographs: RIGHT Anterior-posterior radiographic findings: AP normal

FIGURE 2.2  Close-up of patient record.

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FIGURE 2.3  Magnetic resonance imaging study in the operating room.



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Back table

Technician

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Operating Room Setup

Absorbent mat Assistant

Anesthesia equipment

Surgeon

Mayo stand

Operating table

Anesthesia

FIGURE 2.5  Foot pedals and absorbent mat.

Camera power monitor video recorder

Fluid/pump electrogenerator

FIGURE 2.4  Operating room setup.

FIGURE 2.6  Instrument cart and fluid management equipment.

FIGURE 2.7  Fluid management system.

FIGURE 2.8  Final setup example.

FIGURE 2.9  Mayo stand.

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FIGURE 2.10  Back table.

FIGURE 2.12  Laryngeal mask air tube secured in place with tape.

FIGURE 2.11  Laryngeal mask air tube.

ANESTHESIA We routinely perform an interscalene block in the preoperative holding area, but this is surgeon preference. The patient is then moved to the operating room, where general anesthesia is started. Because many patients find remaining motionless in the seated position uncomfortable, and we find patient movement and conversation distracting, we prefer to use general anesthesia rather than operating under regional block alone. The interscalene block has no direct effect on blood pressure. With sensory input blocked, there is no sympathetic response to the otherwise painful stimuli, and catecholamine release is avoided. The beta-antagonistic effects (vasodilation and bradycardia) of the general anesthetic agents are then more pronounced, without the pain response to offset them. This causes relative bradycardia and hypotension. The result is improved visualization. Because the operated area is anesthetized, only light general anesthesia is necessary, minimizing postoperative nausea. Some anesthesiologists prefer a laryngeal mask airway, which eliminates the need for endotracheal intubation. Immediate postoperative pain is well controlled (Figs. 2.11 and 2.12). To avoid “wrong site” surgery, always confirm with the patient which shoulder is to be operated on. This is done in the preoperative holding area before the patient receives any sedation. The anesthesiologist uses

FIGURE 2.13  Skin marking.

a surgical marking pen to write “yes” on that shoulder prior to administering the block. The surgeon also asks the patient to confirm the correct site and writes his or her initials and a “yes” on the correct shoulder (Fig. 2.13).

PATIENT POSITIONING Successful shoulder arthroscopy is the result of planning and organization. Many seemingly minor details can have a profound effect on the procedure, and we encourage all surgeons to invest the necessary time to adequately prepare the operating room and the surgical staff. Patients are positioned in either the lateral decubitus or the sitting (beach-chair) orientation. Each position has its advantages and disadvantages, and surgeon preference should dictate the choice. Both diagnostic and reconstructive shoulder arthroscopy can be performed successfully in either position. We generally



CHAPTER 2

use the beach-chair position. Patient positioning is critical as this aids in portal placement and facilitates the procedure. Incorrect positioning adds complexity to an already difficult procedure.

Lateral Decubitus Position The lateral decubitus position offers excellent access to the glenohumeral joint and allows arm suspension (and distraction, as necessary) without the need for an assistant. The surgeon can choose to terminate the arthroscopic procedure and can easily perform an open operation in the subacromial space. Disadvantages include the need to lift and turn the patient, the possibility of excessive distraction across the glenohumeral joint and potential nerve injury, limited access to the anterior shoulder in the subacromial space, and the need to reposition the patient if an open anterior glenohumeral reconstruction is required. Another potential disadvantage is the tendency for the suspension apparatus to place the arm in internal rotation. This is important in glenohumeral reconstruction because repair of the glenohumeral ligaments or rotator interval with the arm in internal rotation may result in permanent loss of external rotation. The surgeon can overcome all these difficulties with appropriate care. Before the patient is brought to the operating room, a vacuum beanbag is placed on the operating table and smoothed (Table 2.1). The patient is assisted onto the table and centered on the beanbag. The cephalad edge of the beanbag should be level with the patient’s upper thorax, but not high enough to protrude into the axilla. After general endotracheal anesthesia has been established, the tube is secured on the side of the mouth away from the surgical site. Both shoulders are examined for range of motion and translation. The patient is then turned over on the unaffected side, with the pelvis and shoulders perpendicular to the table. The beanbag is gathered up around the patient and deflated so that it is firm. The operating table is tilted 20 to 30 degrees posteriorly so that the glenoid is parallel to the floor. Considerable attention is given to protecting the neurovascular structures, soft tissues,

TABLE 2.1  Table Positioning Aids—Decubitus U-shaped Vacupak beanbag, 3 feet long Axillary roll Kidney rest supports for operating table (2) Contoured foam head and neck support Arm board Pillows (2) Foam pads for ankles, knees, and arms Three-inch–wide cloth adhesive tape

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43

and bony prominences. A soft sheet is rolled into a cylinder approximately 6 inches in diameter and placed under the upper thorax to raise the patient’s chest off the table and thereby minimize pressure on the neurovascular structures within the axilla. The roll should not be placed in the axilla. A 1-L fluid bag wrapped in a towel also works nicely. The downside hip and knee are slightly flexed to stabilize the patient. Pillows are placed between the legs to protect the ankles, knees, and peroneal nerves, and the breasts are carefully padded. Kidney rests are useful to support the beanbag, and broad adhesive tape may be used to further stabilize the patient. The cervical spine must be supported to prevent any hyperextension or lateral angulation during the procedure. An electrosurgical grounding pad is placed over the muscular area of the lateral thigh. The surgeon should inspect the patient’s position carefully and check each pressure area to make sure it is adequately padded. The circulating nurse prepares the entire shoulder, arm, and hand. An assistant grasps the patient’s wrist with a sterile towel, and the surgeon and scrub nurse place the lower U-drape over the patient. The forearm and hand are then placed in the traction device. The wrist is carefully padded to avoid pressure on the sensory branch of the radial nerve. The arm is placed on the lower drape, the upper drape is put into position, and the fluid collection pouch is applied. The arm is attached to the suspension device. Usually 10 pounds of weight is sufficient, but the weight may be increased slightly for larger individuals. The surgeon should think of the suspension device as a stabilizing mechanism rather than a method of producing traction. The shoulder is positioned in 60 degrees of abduction and 10 degrees of flexion.

Sitting Position We prefer the term sitting position rather than the older beach-chair position because the patient’s thorax must be placed 70 to 80 degrees relative to the floor. This upright position is necessary to place the acromion parallel to the floor and allow access to the posterior shoulder. A more recumbent position forces the surgeon to “work uphill” and makes entry into the inferior– posterior shoulder difficult if such a portal is required for glenohumeral reconstruction. One advantage of the sitting position is that it is similar to that used during traditional open operations, so conversion from an arthroscopic to an open rotator cuff repair or glenohumeral reconstruction does not require a change in patient position. Also, the anterior shoulder is more approachable than in the lateral decubitus position; the surgeon need not lean over the patient to gain anterior access. In this position, the arthroscopic

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The Basics

orientation seems more familiar to surgeons, with the vertical orientation of the glenoid similar to that seen during physical examination or radiographic review. Shoulder distraction is not continuous, which minimizes the chance of neurologic injury; the assistant can provide a distraction force during the brief periods when this is needed. A mechanical arm holder can maintain the shoulder in external rotation during glenohumeral reconstruction and in elevation during rotator cuff repair. A special bed needs to be used in which the corner around the shoulder is either absent or removable to allow access to the upper quadrant of the extremity. A regular bed can be used with the patient pulled over to the operative side partially off of the bed, but access to the shoulder and the security of cervical spine stabilization is compromised. This special bed and the arm-holding device are helpful, but not essential, and they do add a fixed cost to the procedure that is not present in lateral decubitus positioning (Table 2.2). Once the patient is assisted onto the operating table, general anesthesia is induced. The head of the table supporting the patient torso is then raised, a small amount of Trendelenburg is applied, and the legs are lowered. The position is adjusted until the patient’s acromion is nearly parallel to the floor. The head and neck are positioned for patient comfort and secured. Pillows are placed under the knees, and a foam pad protects the contralateral elbow. Check to make sure that no pads or drapes interfere with access to the anterior or posterior shoulder. The shoulder, arm, and hand are prepared, and an assistant grasps the wrist while the scrub nurse positions the bottom drape. The hand–wrist support is attached, and the forearm is placed on the patient’s lap. The upper drape is applied, and the suction drainage bag is affixed around the shoulder. The applicable surface anatomy is drawn, and the surgery begins (Figs. 2.14–2.26).

but that is surgeon preference as it can sometimes facilitate visualization of the subscapularis or anterior structures from the posterior portal. An alternative would be to move the arthroscope to an anterior–superior portal to improve visualization of these structures.

FIGURE 2.14  Positioning the patient.

FIGURE 2.15  Patient in the sitting position.

EQUIPMENT Arthroscope A standard 4-mm arthroscope with a 30-degree angled lens is used for all shoulder arthroscopy. We do not generally find it necessary to use a 70-degree arthroscope,

TABLE 2.2  Table Positioning Aids—Sitting Specialized patient table/positioner to expose shoulder blade Specialized arm holder Foam pads for ankles, knees, and arms

FIGURE 2.16  Check the relationship of the acromion to the floor.



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45

FIGURE 2.17  Secure the breathing tube.

FIGURE 2.18  Position the cervical spine.

FIGURE 2.19  Secure the cervical spine with a chin strap.

FIGURE 2.20  Check the cervical spine alignment from the front.

FIGURE 2.21  Pad the legs and contralateral arm.

FIGURE 2.22  Base of the arm holder.

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The Basics

FIGURE 2.25  Access to the anterior shoulder.

FIGURE 2.23  Recheck the position of the acromion.

FIGURE 2.26  Access to the posterior shoulder.

FIGURE 2.27  Body of needle-passing device.

Suture Passers

FIGURE 2.24  Position the shoulder with arm holder.

Sutures are passed through soft tissue either directly or indirectly. There are three types of direct methods briefly described in Chapter 1. In the first method, a device passes a needle loaded with a braided suture directly through the soft tissue (Figs. 2.27–2.30). We use a needle-passing device to pass sutures through the rotator cuff during repair. The second involves piercing the soft tissue with an instrument and then grabbing the suture and pulling it back through the soft tissue



CHAPTER 2

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47

FIGURE 2.31  Body of arthroscopic tissue penetrator. FIGURE 2.28  Close-up of mouth of needle-passing device.

FIGURE 2.32  Tip of arthroscopic tissue penetrator.

FIGURE 2.29  Body of different needle-passing device. FIGURE 2.33  Handle of straight eyelet direct suture passer.

FIGURE 2.30  Close-up of needle-passing device with the needle deployed.

FIGURE 2.34  Tips of straight eyelet direct suture passer.

(Figs. 2.31 and 2.32). This is used if the target tendon or structure is thick and fibrotic, and it is difficult or impossible to pass a suture through it using the needlepassing device or for side-to-side rotator cuff repairs. In the third method, an instrument passes the suture

through the tendon or ligament using a standard needle with an eyelet to hold the suture (Figs. 2.33–2.38). This can also be used for side-to-side rotator cuff repairs. The indirect method involves placing a passing suture through the soft tissue and using this transport suture

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The Basics

FIGURE 2.39  Handle of disposable cannulated shuttle suture passer. FIGURE 2.35  Handles of left curved eyelet direct suture passers.

FIGURE 2.36  Tips of left curved eyelet direct suture passers.

FIGURE 2.40  Tips of cannulated shuttle suture passer.

FIGURE 2.37  Handles of right curved eyelet direct suture passers.

FIGURE 2.41  Tips of cannulated shuttle suture passer. FIGURE 2.38  Tips of right curved eyelet direct suture passers.

to pull the repair suture through the soft tissue (Figs. 2.39–2.41). A standard 2-0 nylon can be used as a loop or as two free ends with a loop on the other end (Figs. 2.42 and 2.43). The looped end will transfer the repair suture. We often use this method for instability repairs.

Soft Tissue Management A soft tissue grasper is used to test the tension of the glenohumeral ligaments before instability repair and to evaluate the excursion and reparability of a torn rotator cuff. Regular and locking graspers are helpful.



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FIGURE 2.44  Nonaggressive soft tissue grasper.

FIGURE 2.42  Clinical photo of cannulated shuttle suture passer with looped ends. FIGURE 2.45  Close-up of nonaggressive soft tissue grasper.

FIGURE 2.46  More aggressive soft tissue grasper. FIGURE 2.43  Clinical photo of cannulated shuttle suture passer with free ends.

A grasper with less aggressive teeth allows one to pull on sutures without shredding them. A blunt probe is useful to evaluate for the presence of a subtle Bankart or a superior labrum anterior to posterior (SLAP) lesion. When a Bankart lesion has healed with a fibrous union, the lesion may not be apparent, and a sharp chisel dissector can peel the labrum off the anterior glenoid. To ensure that the capsule is not adherent to the subscapularis, a blunt soft tissue instrument can be used to dissect between the two structures. A large soft tissue punch is useful to excise portions of a contracted capsule during contracture release. We have found the capsular punches designed by Harryman to be the most effective for capsular release in patients with shoulder

stiffness. Two of the instruments were modified so that they bend downward rather than upward, which gives a more comfortable angle of approach to the capsular tissue. A blunt-ended probe is used for dissection around nerves or blood vessels. The markings on the end of the probe are useful for measuring distances and the size of lesions (Figs. 2.44–2.62).

Suture Management A crochet hook is used to retrieve sutures from within the subacromial space or glenohumeral joint. If a suture gets caught in the tendon or labrum, a fine-toothed crochet hook is less likely to damage the suture or the articular cartilage. A looped suture grasper is used to ensure that Text continued on page 52.

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The Basics

FIGURE 2.48  Suture grasper with locking handle.

FIGURE 2.47  Close-up of more aggressive soft tissue grasper.

FIGURE 2.50  Chisel dissector.

FIGURE 2.52  Blunt dissector.

FIGURE 2.49  Close-up of suture grasper. FIGURE 2.53  Close-up view of blunt dissector.

FIGURE 2.51  Chisel dissector.

FIGURE 2.54  Close-up view of blunt dissector.



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FIGURE 2.55 Rasp.

FIGURE 2.56  Close-up view of two-sided rasp.

FIGURE 2.57  Straight capsular resection punch.

FIGURE 2.58  Close-up of capsular resection punch.

FIGURE 2.59  Close-up of capsular resection punch.

FIGURE 2.60  Modified angled capsular punch.

FIGURE 2.61  Close-up view of modified angled capsular punch.

FIGURE 2.62  Blunt probe with measuring guide markings.

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The Basics

there are no suture tangles within the working cannula before tying each suture. A larger instrument is useful during rotator cuff repairs, and a smaller one is easier to maneuver within the glenohumeral joint. There are a number of knot-tying instruments available, but a single-lumen knot pusher suffices, which can double as a knot pusher and puller. Arthroscopic scissors are needed to cut suture and soft tissue. End-cutting scissors are used when the knot is not visualized well during a rotator interval repair, or simply to cut the suture in the cannula containing the suture (Figs. 2.63–2.75).

FIGURE 2.63  Close-up of crochet hook.

FIGURE 2.68  Small loop grasper.

FIGURE 2.69  Close-up of small loop grasper with jaws open.

FIGURE 2.64  Close-up of fine-toothed crochet hook.

FIGURE 2.70  Knot pusher.

FIGURE 2.65  Large loop grasper.

FIGURE 2.66  Close-up of large loop grasper.

FIGURE 2.67  Loop grasper with the jaws open.

FIGURE 2.71  Close-up of knot pusher.



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FIGURE 2.76 Shaver. FIGURE 2.72 Scissors.

Sutures

FIGURE 2.73  Close-up of scissors.

Several different sutures are used during shoulder arthroscopy. Most repairs are done with one of the many No. 2 braided high-tensile strength sutures on the market that often depend on the anchor that is used. A 2-0 nylon is a good transfer suture to bring the braided sutures through the rotator cuff or glenoid labrum. Prolene and PDS were often used in the past, but are now rarely used. 3-0 Monocryl or nylon can be used for the skin closure of portal incisions.

Power Instruments

FIGURE 2.74  End-cutting scissors.

Relatively few power instruments are needed. Shavers range in size from 3.5 to 5 mm; and burs may range from a 4-mm round bur to a 5.5-mm acromionizer bur. A 4.5-mm acromionizer bur can be used during abrasion arthroplasty for arthritis, or for coracoid preparation during an arthroscopic Latarjet procedure. The 3.5- or 4-mm shaver and 4-mm round bur are used within the glenohumeral joint for glenohumeral instability and SLAP repair, and a power drill is used to predrill the bone anchor holes for these repairs. A larger shaver is used to remove bursal tissue during arthroscopic subacromial decompression, and an acromionizer is used for acromioplasty. A round or oval bur can be used within the subacromial space to prepare the rotator cuff repair site. Cautery or ablation instruments are very helpful to remove soft tissue and maintain hemostasis. Some instruments come as a hybrid of a shaver and cautery, and can be useful as well (Figs. 2.76–2.87).

Cannulas FIGURE 2.75  Close-up of end-cutting scissors.

A metal cannula is used for the arthroscope and may have ports for inflow, outflow, and pressure. In addition

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FIGURE 2.78 Electroblade.

FIGURE 2.77  Close-up of shaver. FIGURE 2.80  Round bur.

FIGURE 2.79  Close-up of Electroblade. FIGURE 2.82  Close-up of round bur.

FIGURE 2.84  Close-up of acromionizer bur.

FIGURE 2.81  Close-up of round bur.

FIGURE 2.83  Acromionizer bur.

FIGURE 2.85  Close-up of acromionizer bur.



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Operating Room Setup

FIGURE 2.86  Less aggressive oval bur. FIGURE 2.88  Cannula (8 mm).

FIGURE 2.89  Cannula (5.5 mm). FIGURE 2.87  Close-up of oval bur.

to the metal cannula and blunt trocar for the arthroscope, plastic, translucent cannulae are very helpful when performing arthroscopic reconstructive shoulder surgery. During anchor insertion or knot tying, using a cannula can prevent adjacent soft tissue from interfering with the insertion. Because the cannula is translucent, anchors can be inserted and knots can be tied even with the cannula covering the involved area. An 8-mm cannula is large enough to accommodate the power tools and the large suturing instruments; larger cannulas (8.5 and 10 mm) are also available. A 5.5-mm cannula is used if smaller instruments will be passed (Figs. 2.88 and 2.89).

FIGURE 2.90 Electrocautery.

Thermal Instruments Two types of thermal instruments can be used during shoulder arthroscopy. The first instrument can cauterize or ablate tissue (Figs. 2.90–2.92). This is helpful during arthroscopic subacromial decompression to remove soft tissue from the undersurface of the acromion; and the coagulation setting can be used to control bleeding from branches of the coracoacromial artery or from vascularized bursal tissue. A probe that has

FIGURE 2.91  Close-up of electrocautery.

55

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The Basics

FIGURE 2.92  Close-up of electrocautery. FIGURE 2.93  Switching stick.

suction attached to it is helpful so that the bubbles produced during ablation or coagulation are removed from the operative field. The second instrument is the combination shaver and cautery (see Figs. 2.78 and 2.79).

Fluid Management An arthroscopic pump system for delivering fluid to the shoulder is a valuable asset. A pump system eliminates the need to hang bags of irrigating fluid high above the floor and allows the surgeon to increase pump pressure and flow rate when bleeding is encountered. We use lactated Ringer’s solution without epinephrine. If a surgeon considers epinephrine helpful, it is advisable to add it to every other bag of Ringer’s solution to minimize any potential cardiotoxic effects.

FIGURE 2.94  Tip of switching stick.

for cyst formation. We rarely use biocomposite because of cost issues as well.

Transfer Rods Surgeons who prefer to create portals with the inside-out technique will find the Wissinger rod useful (described in Chapter 3). Switching rods are blunt on both ends and are used to maintain the cannula position when the arthroscope is moved from one position to another (Figs. 2.93 and 2.94).

Anchors The number of anchor types on the market is too cumbersome to discuss in detail. In general, we prefer PEEK 4.5 to 5.5 mm for primary rotator cuff repairs and smaller 2.5- to 3.0-mm PEEK anchors for labral repair. We only use metal anchors for revision rotator cuff repairs in patients with poor bone stock and multiple previously placed anchors. We virtually never use bioabsorbable anchors due to cost and the potential

Photography and Video Recording It is extremely helpful to take intraoperative photographs. They record the lesions found during the operation more precisely than the description in the operative notes. They have the added advantage of documenting normal findings that surgeons commonly omit from the operative record. Most arthroscopy systems have the ability to take photographs during surgery with the use of a foot switch or a control button on the camera. The photographs can be printed directly or stored on recordable media or a computer hard drive. Video recordings of the operations also can be helpful if hard drive space is available, and if the surgeon has the time to review it with the patient. We often use video to capture interesting pathology, but do not use it on a regular basis as it can be cumbersome to review it with patients.



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DEDICATED TEAM We cannot emphasize enough the advantages of having a trained, dedicated, operating room team (Fig. 2.95). Reconstructive shoulder arthroscopy is complicated, and it is helpful when the scrub nurse, assistant, and circulating nurse can perform their jobs without instruction from the surgeon. The surgical nurse can load the instruments so they are ready for the next step; can clean the shavers and burs so they function appropriately; and can have the next instrument ready so the operation will run smoothly. FIGURE 2.95  World’s best operating room team.

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3

 

Diagnostic Arthroscopy and Normal Anatomy

Only with an understanding of normal glenohumeral joint and subacromial space anatomy can the surgeon appreciate which structures are damaged.

DIAGNOSTIC GLENOHUMERAL ARTHROSCOPY Portal placement is critical, so it is important to take sufficient time to mark the portal sites precisely. Draw the bone outlines of the acromion, the distal clavicle, and the coracoid with a surgical skin marker. Be careful not to draw the most superficial bone landmarks, but rather draw their inferior surfaces (which takes into account bone thickness), because portal entry points are referenced from these surfaces (Figs. 3.1 and 3.2). Although trocar entry into the glenohumeral joint is simple and almost intuitive for an expert, surgeons new to arthroscopy may find joint entrance difficult. The standard advice to “start in the soft spot and aim for the coracoid” is only slightly helpful. Actual joint entry requires precision, and even small deviations of 3 to 5 mm from the desired portal location make the operation more difficult. An additional complication is that portals vary from patient to patient because they are related to the patient’s position on the operating table as well as his or her size, rotundity, and kyphosis. The ideal portal location changes throughout the operation as soft tissue swelling increases and alters the local anatomy. Portal placement is also affected by the underlying diagnosis. For instance, posterior portal placement for an acromioclavicular joint resection differs from that for a superior labrum anterior to posterior (SLAP) lesion repair. There are no absolute rules, but there are a number of guidelines that are helpful. The most reliable landmarks are bone. Anteriorly, outline the coracoid process, the acromioclavicular joint, and the anterior acromion. Laterally, identify the lateral acromial border, and posteriorly, outline the posterior

58

acromion. The most important landmark is the posterolateral corner of the acromion, which can be palpated even in large patients (Fig. 3.3). Even with these initial landmarks outlined, be prepared to use them only as a guide.

Posterior Portals Traditionally, surgeons describe the location of the posterior portal as being in the “soft spot” approximately 2 cm inferior and 2 cm medial to the posterolateral acromial edge. Although this location is adequate for glenohumeral joint arthroscopy, it is not optimal for subacromial space operations. If you make the incision in the traditional soft spot, you will enter the joint parallel to the glenohumeral joint line and slightly superior to the glenoid equator. This site allows you to enter and adequately visualize the glenohumeral joint, but you will be at a disadvantage if you try to use the same incision to enter the subacromial space. Once you insert the cannula into the subacromial space, the soft-spot portal directs the cannula superiorly and medially, and causes two problems. First, because the arthroscopic view is now directed medially, the lateral insertion of the rotator cuff is more difficult to visualize. Second, the superior angle of the arthroscope makes it difficult to “look down” on the rotator cuff tendons and appreciate the geometry of rotator cuff lesions. One solution to this problem is a second posterior portal; another solution is to alter the posterior portal’s location (Fig. 3.4). As noted, the exact location of the posterior portal varies with the clinical diagnosis. For rotator cuff repairs and subacromial decompressions, we make the posterior incision for the portal in a more superior and lateral position, approximately 1 cm inferior and 1 cm medial to the posterolateral acromion, or virtually at the acromial corner. The more superior and lateral location minimizes the aforementioned difficulties.



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FIGURE 3.3  Posterolateral acromial corner.

FIGURE 3.1  Bone landmarks.

FIGURE 3.4  Posterior portal in a more superior and lateral position (rather than in the soft spot) for subacromial surgery.

FIGURE 3.2  Superior and inferior bone edges (arrows).

The superior entry allows the cannula to enter the subacromial space immediately beneath the acromion, parallel to its undersurface. This maximizes the distance between the arthroscope and the rotator cuff, allowing a better appreciation of rotator cuff lesions. The superior position (parallel to and immediately inferior to the acromion) also facilitates acromioplasty because the surgeon is afforded a better view of the acromial shape. The more lateral position (immediately medial to the lateral acromion) places the arthroscope in line with the rotator cuff tendon insertion. The glenohumeral joint can be easily viewed with this more lateral portal with simple medial translation of the arthroscope cannula after entry through the skin. For operations restricted to the glenohumeral joint, such as a Bankart or SLAP

repair, the joint can be entered with the more traditional medially placed portal, but we still prefer the more lateral portal placement for nearly all of our procedures (see Fig. 3.4).

Lateral Portals A lateral subacromial portal is not routinely used during diagnostic glenohumeral joint arthroscopy. More commonly, a lateral portal is used during arthroscopic subacromial decompression and rotator cuff repair. This portal will be discussed in more detail in the applicable chapters. Briefly, the portal location is marked with a skin marker 2 to 5 cm distal to the lateral acromial border and at the midway point of the lateral acromial width (Fig. 3.5). This portal is only marked as an approximation as the best way to create it is with an outside-to-in technique. Once the camera has been placed in the subacromial space through the posterior portal, the exact location of the lateral portal is identified

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FIGURE 3.5  Midlateral portal for arthroscopic subacromial decompression. FIGURE 3.7  Arthroscopic view of outside-in marking of midlateral portal accessing supraspinatus tear.

FIGURE 3.6  Outside-in marking of lateral portal with spinal needle.

with a spinal needle before incising the skin. This allows for the assessment of the caudad/cephalad and the anterior/posterior position of this portal (Figs. 3.6 and 3.7) An anterolateral portal is very helpful for rotator cuff repairs. The initial posterior portal can be considered a posterolateral portal. An equivalent anterolateral portal is made with an outside-to-in technique. This portal is often more distal as it needs to allow for work access to the suprapectoral region to work on biceps pathology, and it provides excellent access for a needle-passing device for supraspinatus and subscapularis repairs (Figs. 3.8–3.10).

FIGURE 3.8  Outside-in marking of anterolateral portal with spinal needle.

Anterior Portals There are two basic anterior portals: anterior-inferior and anterior-superior (Fig. 3.11). These are used for glenohumeral reconstruction, SLAP repair, and subscapularis repair. Several other anterior portals may be used, but care must be paid to the neurovascular structures as the portals venture more medial past the

FIGURE 3.9  Arthroscopic view of outside-in marking of anterolateral portal accessing biceps groove.



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FIGURE 3.12  Superior clavicular portal for distal clavicle excision. FIGURE 3.10  Arthroscopic view of outside-in marking of anterolateral portal accessing supraspinatus tear.

FIGURE 3.11  Anterior portals for glenohumeral joint surgery.

coracoid and more inferior. The anterior-inferior portal is marked 5 mm lateral to the coracoid tip with the anterior-superior portal at least 1.5 cm lateral and 1 cm superior to the anterior-inferior portal. However, these marks are only approximations as the best way to assess the portal is with an outside-to-in technique to confirm the angle of approach to the target pathology. Sometimes, a high anterior–superior portal that enters over the biceps can be most useful for viewing and as access for superior labral tears (see Fig. 3.11). A superior portal also can be helpful for acromioclavicular joint resections (Fig. 3.12). This is in the same area as the more classically described Neviaser portal.

Physical Examination Because a patient’s pain on physical examination may cause the surgeon to underestimate the range of motion or stability of the shoulder, both shoulders should be examined after the induction of anesthesia. The range of

FIGURE 3.13 Elevation.

motion in elevation, in external rotation with the arm adducted, and in external and internal rotation with the arm abducted 90 degrees should all be recorded. The shoulder should then be examined for stability by applying anterior, posterior, and inferior force while changing the positions of abduction and rotation (Figs. 3.13–3.21).

Arthroscopic Procedure (Videos 3.1 and 3.2) Only incise the skin and avoid plunging the knife into the underlying structures. Superficial skin nerves are

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FIGURE 3.14  External rotation in adducted position.

FIGURE 3.16  Internal rotation in abduction in the coronal plane.

FIGURE 3.15  External rotation in abduction with anterior stress.

FIGURE 3.17  Internal rotation in abduction in the scapular plane.

susceptible to neuroma formation, and muscle bleeding unnecessarily complicates the procedure. Some surgeons prefer to insufflate the joint with saline prior to the procedure. We prefer to not insufflate the joint with a needle because it allows us to better determine the entry point into the glenohumeral joint using the rigid trocar to palpate the humeral head and the glenoid rim. Only a blunt-tipped trocar is used; never use a sharp trocar. To begin, insert the cannula and trocar through the skin incision and gently advance them through the deltoid muscle until bone resistance is felt. With your

opposite hand pushing the humeral head posteriorly against the trocar tip, you can tell by palpation whether the bone is the glenoid or the humeral head. Alternatively, you can grasp the forearm and rotate the shoulder; if you feel the bone rotate, the trocar tip is resting against the humeral head and you must direct the arthroscope medially to enter the joint. If no rotation is felt, the trocar is touching the glenoid and you must direct it laterally to enter the joint. When the trocar tip is at the joint line, a slight lateral movement allows you to palpate the head, and a slight medial movement results in contact with the glenoid. The posterior joint



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63

FIGURE 3.18  Sulcus test in internal rotation. FIGURE 3.21  Posterior stress.

FIGURE 3.19  Sulcus test in external rotation.

FIGURE 3.22  Bone palpation with trocar.

FIGURE 3.20  Inferior stress.

line is medial to the posterolateral acromion, and the direction of entry is generally oriented toward the tip of the coracoid. Angle the cannula slightly superiorly and advance it into the joint. Usually a distinct “pop” is felt as the trocar enters the glenohumeral joint. It is

often helpful to place the arm in a neutral or internal rotation when placing the trocar as this distracts the posterior capsule, increasing the surface area for entry. Remove the trocar, insert the arthroscope through the cannula, and begin the diagnostic inspection. If you have not entered the joint, remove the cannula and trocar to check the bone landmarks drawn on the skin (Fig. 3.22).

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TABLE 3.1  Diagnostic Examination of the Shoulder Anterior View—Arthroscope in Posterior Cannula Biceps-labrum complex Biceps tendon Biceps exit from the joint Articular surface of supraspinatus Superior glenohumeral ligament Rotator interval Subscapularis tendon Subscapularis recess Middle glenohumeral ligament Anterior labrum Anterior-inferior glenohumeral ligament Inferior labrum Inferior capsule Posterior-inferior glenohumeral ligament Posterior labrum Infraspinatus tendon Posterolateral humeral head

FIGURE 3.23  Glenohumeral joint, vertical orientation.

Posterior View—Arthroscope in Anterior Cannula Posterior glenoid labrum Posterior capsule Posterior rotator cuff (site of internal impingement) Subscapularis recess Middle glenohumeral ligament and its humeral attachment Anterior-inferior glenohumeral ligament and its humeral attachment

The diagnostic examination of the shoulder is systematic to ensure that no lesions are overlooked. The plan described in Table 3.1 can serve as a guide. Once you have entered the glenohumeral joint, identify the biceps tendon–labrum complex and rotate the camera to orient the glenoid on the monitor screen. Most surgeons prefer the vertical orientation when using the beach-chair position (Fig. 3.23). This is the orientation that will be used throughout this book. For a right shoulder, advance the arthroscope into the joint and rotate it so that it is looking at the 1 o’clock position relative to the glenoid surface. Inspect the rotator interval and superior glenohumeral ligament. Apply inferior distraction and observe the tension that develops. Distract the arm with the shoulder externally rotated and internally rotated, and note any difference. Perform this portion of the examination first because when the anterior cannula is introduced, it passes through the rotator interval and alters the local anatomy. The rotator interval may appear normal in subacromial impingement, contracted in patients with shoulder stiffness, and widened or lax in patients with glenohumeral instability (Figs. 3.24–3.30). There are two basic techniques to establish an anterior portal: inside out or outside in. To establish the anterior portal with the inside-out technique, advance the arthroscope until it is in the middle of the triangular space bordered by the glenoid rim, the superior border

FIGURE 3.24  Rotator interval.

of the subscapularis tendon, and the biceps tendon. Press the arthroscope against the rotator interval and hold the cannula in position while you remove the arthroscope from the cannula. Insert a blunt-tipped rod (Wissinger) through the cannula and advance it through the capsule until it tents the skin anteriorly. Maintain pressure on the rod and make a skin incision directly over its tip. Advance the rod anteriorly so that it projects 5 to 10 cm. Slide a second cannula over the rod tip anteriorly and advance this cannula into the joint until you can feel the two cannulas touch each other. Remove the rod and reinsert the arthroscope into the posterior cannula. Adjust the anterior cannula until 15 to 20 mm is visible within the joint. Outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula, as desired. I used this technique early in my arthroscopic experience

FIGURE 3.25  Rotator interval—normal superior glenohumeral ligament.

FIGURE 3.26  Rotator interval—prominent superior glenohumeral ligament.

FIGURE 3.27  Partial tear in the superior glenohumeral ligament.

FIGURE 3.28  Contracted rotator interval.

FIGURE 3.29  Widened rotator interval.

FIGURE 3.30  Rotator interval synovitis.

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because it enabled me to reliably enter the glenohumeral joint. As I began doing more reconstructive shoulder operations, I discovered some inadequacies with this approach. The inside-out approach allows variability in the precise entry spot for the anterior portal because there is some inevitable manipulation of the arthroscope during the necessary sequence of maneuvers. For glenohumeral joint reconstruction for instability, I need two anterior cannulas, and their positions are critical. If the inferior cannula is too superior, there will not be enough space for the anterior-superior cannula. If the cannulas are too medial or too lateral, the anchor insertion is complicated, and the suture placement is compromised. For these reasons, I now establish the anterior portals with an outside-in approach. To establish the anterior portal with the outsidein technique, point the arthroscope at the rotator interval and use your index finger to push on the skin of the anterior shoulder lateral and superior to the coracoid process. Observe where your finger indents the anterior capsule, and move that location until the anterior capsule is indented in the middle of the rotator interval. Note this location on the anterior shoulder with a marking pen and then use a spinal needle to enter the joint at this point. The exact position and angle of entry is dictated by the target pathology and the intended number of portals. Once the location is marked, remove the spinal needle, make a small incision, and place the cannula and trocar into the joint. As with the inside-out technique, outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula (Figs. 3.31–3.33).

Rotate the arthroscope so that the camera is facing the 7 o’clock position for a right shoulder (light cord is positioned at 1 o’clock) or facing 5 o’clock for a left shoulder. Advance it anteriorly and inspect the subscapularis recess and the superior border of the subscapularis tendon. Rotate the arthroscope to have the camera face the 9 o’clock position for a right shoulder (light cord is positioned at 3 o’clock), advance it anteriorly, and inspect the anterior labrum and the middle glenohumeral ligament (Fig. 3.34). The normal opening of the foramen at the anterior–superior labrum should not be confused with a Bankart lesion. Observe the anterior labrum for signs of glenohumeral instability, such as fraying, tearing,

FIGURE 3.32  Cannula and trocar entry.

FIGURE 3.31  Entry point for anterior–inferior cannula.

FIGURE 3.33  Trocar removed.



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FIGURE 3.34  Light cord at 3 o’clock corresponds to arthroscope facing 9 o’clock.

FIGURE 3.36  Broad middle glenohumeral ligament.

FIGURE 3.35  Thick middle glenohumeral ligament.

or separation from the glenoid. Insert a probe through the anterior cannula and test the anterior labrum’s attachment to the glenoid. Use the probe to test the tension of the middle glenohumeral ligament. Translate the humeral head anteriorly, inferiorly, and posteriorly, and observe the tension that develops in the ligament. Perform these maneuvers with the arm internally and then externally rotated. The middle glenohumeral ligament has a variable appearance and may be poorly defined, prominent, or cordlike (Figs. 3.35–3.46). Rotate the arthroscope to face the 6 o’clock position (light cord at 12 o’clock) and inspect the anterior-inferior labrum and glenohumeral ligament. Test their tension and insertion integrity as described earlier. Move the arthroscope inferiorly and note the presence or absence of a “drive-through sign.” This sign describes

FIGURE 3.37  Middle glenohumeral ligament with the subscapularis poorly defined.

the ease with which the arthroscope passes between the humeral head and the glenoid surface at the 6-o’clock position. Remember that the drive-through sign is a measure of glenohumeral laxity or translation, and is not an indication of glenohumeral instability per se. Observe the laxity of the inferior capsule as the shoulder is distracted inferiorly and laterally, and then rotated. Determine whether there is an inferior labral lesion and carefully inspect the humeral attachment of the inferior capsule for signs of trauma (Figs. 3.47–3.57). Text continued on page 71.

FIGURE 3.38  Partial tear in the middle glenohumeral ligament.

FIGURE 3.39  Cordlike middle glenohumeral ligament.

FIGURE 3.40  Cordlike middle glenohumeral ligament.

FIGURE 3.41 Subscapularis.

FIGURE 3.42 Subscapularis.

FIGURE 3.43  Subscapularis with a synovial tear.

FIGURE 3.44  Subscapularis with a partial tear in the superior border.

FIGURE 3.45  Subscapularis with a partial tear in the superior border.

FIGURE 3.47  Light cord at 12 o’clock corresponds to arthroscope facing 6 o’clock.

FIGURE 3.46  Subscapularis recess.

FIGURE 3.48  Anterior-inferior glenohumeral ligament.

FIGURE 3.49  Anterior-inferior glenohumeral ligament less well defined.

FIGURE 3.50  Anterior–inferior capsule.

FIGURE 3.51  Axillary recess.

FIGURE 3.52  Inferior–posterior capsule.

FIGURE 3.53  Palpate the anterior-inferior glenohumeral ligament.

FIGURE 3.54  Palpate the inferior capsule.

FIGURE 3.55  Inferior-posterior labrum.



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FIGURE 3.58 Pinch arthroscope.

the

cannula

and

withdraw

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the

FIGURE 3.56  Posterior-inferior labrum.

FIGURE 3.59  Biceps-labrum complex.

FIGURE 3.57  Posterior labrum, with the arthroscope posterior.

Return the arthroscope to the biceps-labrum complex. To view the posterior labrum adequately from a posterior cannula, you must maximize the distance from the arthroscope to the labrum. This requires that you withdraw the arthroscope until it is immediately anterior to the posterior capsule. As a novice, I would repeatedly pull the arthroscope completely out of the joint. My technique to minimize (but not eliminate) the problem is as follows: Rotate the objective lens of the arthroscope so that it points to the 6 o’clock position. Pinch your index finger and thumb around the cannula where it exits the skin. This increased sensory feedback helps

you control the distance the cannula moves and gives you immediate control. Gently withdraw the arthroscope as posteriorly as possible to obtain the best view of the biceps–labrum complex (Figs. 3.58–3.60). Examine the biceps tendon and use an instrument to draw the intraarticular portion into the joint and inspect it for inflammation or tearing. Carefully examine the anterior and posterior pulleys for signs of trauma that may indicate biceps tendon instability. Follow the biceps tendon to its joint exit. Adhesions may exist between the biceps tendon and the supraspinatus tendon; these may be either congenital or post-traumatic (Figs. 3.61–3.79). Rotate the arthroscope to view at 9 o’clock in a right shoulder. Alter the angle of view as needed; follow the Text continued on page 75.

FIGURE 3.60  Biceps tendon synovitis.

FIGURE 3.61  Biceps tendon exiting from the glenohumeral joint.

FIGURE 3.62  Biceps tendon entering the bicipital groove.

FIGURE 3.63  Bicipital groove.

FIGURE 3.64  Bicipital groove.

FIGURE 3.65  Bicipital groove, with synovial lining.

FIGURE 3.66  Bordering ligament, anterior pulley.

FIGURE 3.68  Partial biceps tendon tear.

FIGURE 3.70  Partial biceps tendon tear.

FIGURE 3.67  Partial biceps tendon tear.

FIGURE 3.69  Partial biceps tendon tear.

FIGURE 3.71  Partial biceps tendon tear.

FIGURE 3.72  Introduce the shaver.

FIGURE 3.73  Medial to biceps.

FIGURE 3.74  Lateral to biceps.

FIGURE 3.75  Pull the extra-articular biceps tendon into the glenohumeral joint.

FIGURE 3.76  Pull the extra-articular biceps tendon into the glenohumeral joint.

FIGURE 3.77  Pull the extra-articular biceps tendon into the glenohumeral joint.



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FIGURE 3.78  Extra-articular biceps tendon synovitis.

FIGURE 3.80  Minor fraying of the superior labrum.

FIGURE 3.79  Normal superior labrum.

FIGURE 3.81  Minor separation of the superior labrum.

posterior labrum from superior to inferior and note any labrum separation, fraying, or tears. Continue inferiorly until you can see the posterior-inferior glenohumeral ligament. Internally rotate the arm and observe the normal tightening of this ligament. Introduce a blunt instrument from the anterior portal and evaluate the biceps-labrum complex. Sometimes, a SLAP lesion is obvious, but often probing is necessary. Abduct and externally rotate the shoulder to see whether the superior labrum peels off the glenoid (Figs. 3.79–3.85). Adhesions may exist between the biceps tendon and the rotator cuff; these too may be either congenital or post-traumatic (Figs. 3.86 and 3.87).

Move your hand and the camera toward the floor to point the arthroscope superiorly and view the rotator cuff tendons. Abduct and externally rotate the shoulder until you see the anterior supraspinatus that is marked anteriorly by the biceps tendon. The anterior margin of the supraspinatus forms the posterior biceps tendon pulley. Move the camera medially and inferiorly (so that the arthroscope tip moves laterally and superiorly) and follow the cuff insertion from its anterior to posterior margins. At the same time, abduct and rotate the humeral head so that the arthroscope follows the cuff insertion from anterior to posterior. Note the insertion of the supraspinatus into the footprint area.

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FIGURE 3.82  Probe for separation.

FIGURE 3.83  Superior labrum anterior to posterior lesion.

FIGURE 3.84  Superior labrum anterior to posterior lesion continuing into the anterior-superior labrum.

FIGURE 3.85  Normal anterior-superior labral foramen.

FIGURE 3.86  Biceps–rotator interval adhesions.

FIGURE 3.87  Biceps–rotator interval adhesions.



CHAPTER 3

There should be no exposed bone between the articular margin of the humeral head and the supraspinatus tendon insertion. Partial articular surface tears can be diagnosed by observing the amount of exposed bone in millimeters between the remaining tendon and the articular margin. The infraspinatus does not insert at the articular margin, and exposed bone in this area is normal. The small holes in the humeral head near the posterior cuff are normal vascular channels. When you identify the posterior cuff insertion, tilt the arthroscope inferiorly and continue to externally rotate the shoulder. You can now see the posterolateral humeral head and document the presence or absence of a Hill-Sachs lesion. Withdraw the arthroscope slightly so that the lens does not scrape against the humeral head and allow it to return to the biceps tendon–labrum complex (Figs. 3.88–3.101). Inspect the cartilage on the humeral head and glenoid for signs of osteoarthrosis, such as eburnation and cobblestoning. The cartilage is normally thin in the central glenoid, and this should not be confused with osteoarthrosis (Figs. 3.102–3.107). Remove the arthroscope from the posterior cannula, reinsert it in the anterior cannula, and again inspect the posterior labrum, capsule, and posterior rotator cuff. Move the arm into abduction and external rotation, and evaluate the shoulder for internal impingement between the posterior–superior labrum and the posterior cuff and capsule. Observe the normal pear shape of the glenoid from this perspective. The glenoid widens inferiorly. Loss of this pear shape corresponds to bone loss in the anterior-inferior glenoid and may be seen in patients with glenohumeral instability (Figs. 3.108–3.111).

FIGURE 3.88  Anterior supraspinatus.

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This completes the routine inspection of the glenohumeral joint. Withdraw both cannulas and proceed to the subacromial space.

DIAGNOSTIC SUBACROMIAL SPACE ARTHROSCOPY The diagnostic examination of the subacromial space is systematic to ensure that no lesions are overlooked. The plan described in Table 3.2 can be used as a guide. Text continued on page 81.

FIGURE 3.89  Anterior supraspinatus.

FIGURE 3.90  Articular surface of a partial-thickness rotator cuff tear of the supraspinatus.

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FIGURE 3.91  Full-thickness supraspinatus tear.

FIGURE 3.92 Mid-supraspinatus.

FIGURE 3.93  Mid-posterior supraspinatus.

FIGURE 3.94  Posterior supraspinatus.

FIGURE 3.95  Posterior supraspinatus.

FIGURE 3.96 Infraspinatus.

FIGURE 3.98  Bare area.

FIGURE 3.97  Capsular reflection.

FIGURE 3.99  Vascular channels.

FIGURE 3.100  Bare area.

FIGURE 3.101  Shallow Hill-Sachs lesion.

FIGURE 3.102  Anterior glenoid cartilage loss.

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FIGURE 3.103  Anterior glenoid cartilage loss.

FIGURE 3.104  Osteoarthrosis of the glenoid.

FIGURE 3.105  Humeral head cartilage tear.

FIGURE 3.106  Full-thickness cartilage loss of humeral head.

FIGURE 3.107 Osteoarthrosis.

FIGURE 3.108  Pear shape of the glenoid.



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TABLE 3.2  Diagnostic Examination of the Subacromial Space View From Posterior Portal Acromial undersurface Coracoacromial ligament Anterior bursa Supraspinatus insertion into greater tuberosity Subdeltoid adhesions Acromioclavicular joint View From Lateral Portal Posterior rotator cuff Posterior bursa Rotator interval Acromioclavicular joint

FIGURE 3.109  Posterior-inferior labrum.

FIGURE 3.110  Posterior-superior labrum.

FIGURE 3.111  Posterior labral tear.

The subacromial space is a pseudoarticulation that permits gliding between the proximal humerus and the coracoacromial arch. Arthroscopic experience has allowed us to define the subacromial space, which has welldefined borders when cleared of the hypertrophic bursal

tissue associated with chronic subacromial impingement. The arthroscopic subacromial space begins halfway back from the anterior acromion, and posterior entry requires the surgeon to penetrate a veil or curtain of bursal tissue that separates the anterior from the posterior space. Anterior, posterior, and lateral gutters can be defined. The medial confines are below the acromioclavicular joint, and exposure of the lateral clavicle requires the resection of thick fibrofatty and vascular tissue. The lateral wall lies beyond the greater tuberosity, and the anterior margin is the anterior acromial border (Fig. 3.112). It is often difficult to visualize the subacromial space owing to reactive bursitis and fibrosis. When you have difficulty visualizing the subacromial space, it is usually because the arthroscope is positioned too far posteriorly. It is helpful to position the arthroscope anteriorly in the subacromial space to minimize the effect of the bursal tissue located posteriorly within the space. Use the same posterior skin incision to enter the subacromial space. Place the trocar and cannula through the skin incision and palpate the posterior edge of the acromion. Slide immediately beneath the bone and advance the trocar and cannula anteriorly. The cannula should remain in contact with the acromion. With your other hand, palpate the anterior acromion and advance the trocar beyond the anterior acromion until you can feel the trocar tip. Withdraw the trocar until it is just posterior to the anterior acromion. Usually you can palpate the coracoacromial ligament. Maintain the cannula position while you remove the trocar and insert the arthroscope. Rotate the arthroscope so that it is directed toward the acromion, and determine whether there are any alterations in the coracoacromial ligament or the acromion (Fig. 3.113). Now orient the arthroscope lens so that it is pointing directly down at the rotator cuff. If you maneuver the shoulder through a range of motion and rotate the arthroscope, you will obtain a view of the superior portion of the subscapularis, the supraspinatus, and the superior portion of the infraspinatus. If you desire

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FIGURE 3.114  Subacromial space obscured.

FIGURE 3.112  Bursa anatomy.

FIGURE 3.113  Palpate the anterior acromion with the trocar tip.

a better view of the posterior rotator cuff or if you cannot see clearly, establish a lateral portal. Identify the precise location of the lateral portal with a spinal needle. Introduce the needle percutaneously until it is 1 to 2 cm posterior to the anterior acromion and located midway between the acromion and the rotator cuff. The lateral cannula should enter the subacromial space parallel to, and immediately beneath, the inferior surface of the acromion. The distance between the incision and the lateral acromial border varies, depending on the patient’s size; in general, place the lateral portal 2 to 3 cm distal to the lateral acromial border.

If you still cannot see well, advance the arthroscope anteriorly to free it of any surrounding bursal tissue and then withdraw it posteriorly until the acromion is visualized. If visualization remains poor, I have found a triangulation technique helpful. Insert the cannula and trocar as described earlier. Create a lateral portal by incising the skin 1 to 2 cm posterior to the anterolateral acromial border. The distance between the incision and the lateral acromial border varies depending on the patient’s size; in general, place the lateral portal 2 to 3 cm distal to the lateral acromial border. The lateral cannula should enter the subacromial space parallel to and immediately beneath the inferior surface of the acromion. Insert a cannula and trocar through the lateral portal and, with one hand holding each, position them so that they touch each other. Often you can sense bursal tissue interposed between the two cannulas. Rub them together to remove the bursal tissue until you feel the two cannulas making direct contact. Advance the lateral cannula medially until it is past the tip of the posterior trocar. Push the posterior trocar until it is in direct contact with the lateral cannula. Press both cannulas together, remove the trocar from the posterior cannula, and insert the arthroscope. You should now be looking directly at the lateral cannula. Remove the lateral trocar and insert a motorized soft tissue resector. Palpate the acromion above and the rotator cuff below with the resector tip to help with orientation. Use the resector to remove bursal tissue until you can see clearly. If the shaver is on the rotator cuff, direct the shaver blade superiorly to avoid causing damage. Direct the shaver blade inferiorly when you are working near the acromion. Be careful not to contact the cuff or the acromion with the resector, because this will alter the subacromial space anatomy (Figs. 3.114–3.119).



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B FIGURE 3.115  (A) Palpate the lateral cannula with the trocar tip. (B) Visualize the lateral cannula.

FIGURE 3.116  Withdraw the arthroscope slightly.

FIGURE 3.118  Visualize the shaver within the lateral cannula.

FIGURE 3.117  Introduce the shaver.

FIGURE 3.119  Withdraw the lateral cannula.

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Once you can see clearly, perform a diagnostic inspection of the subacromial space. Observe the acromion and the coracoacromial ligament for signs of impingement, such as fraying or erythema. Rotate the arthroscope so that it looks directly at the rotator cuff; at the same time, move the arthroscope tip superiorly to maximize the distance between the arthroscope and the rotator cuff. This improves your perception of the extent of any pathology. Signs of impingement include fraying, fibrillation, and partial tearing of the rotator cuff bursal surface. Advance the arthroscope anteriorly to view the anterior gutter. Rotate the arthroscope to observe the lateral gutter. Move the arthroscope to the lateral portal. This allows a better view of the subscapularis tendon, the acromioclavicular joint, and the posterior rotator cuff. If bursa is covering the rotator cuff tendons, resect it until you can see the tendon fibers. This completes the diagnostic examination of the glenohumeral joint and the subacromial space (Figs. 3.119–3.142).

FIGURE 3.122  Anterolateral gutter.

FIGURE 3.123  Musculotendinous junction. FIGURE 3.120  Rotator cuff.

FIGURE 3.121  Anterior gutter.

FIGURE 3.124  Lateral gutter.



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FIGURE 3.125  Coracoacromial ligament.

FIGURE 3.126  Coracoacromial ligament fraying.

FIGURE 3.127  Coracoacromial ligament fraying.

FIGURE 3.128  Spinal needle.

FIGURE 3.129  Os acromiale.

FIGURE 3.130  Os acromiale.

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FIGURE 3.131  Lateral subacromial adhesion.

FIGURE 3.132  Resect the adhesion.

FIGURE 3.133  Partial-thickness rotator cuff tear in the bursal surface.

FIGURE 3.134  Partial-thickness rotator cuff tear in the bursal surface.

FIGURE 3.135  Near full-thickness bursal, partial-thickness rotator cuff tear.

FIGURE 3.136  Full-thickness rotator cuff tear.



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FIGURE 3.137  Coracoacromial ligament, with the arthroscope in the lateral cannula.

FIGURE 3.138  Rotator cuff, with the arthroscope in the lateral cannula.

FIGURE 3.139  Rotator interval, with the arthroscope in the lateral cannula. A needle probes the anterior supraspinatus.

FIGURE 3.140  Rotator interval, with the arthroscope in the lateral cannula. A needle probes the superior subscapularis.

FIGURE 3.141  Needle palpates the rotator interval.

FIGURE 3.142  Rotator interval opened.

SECTION

GLENOHUMERAL JOINT SURGERY

II

Glenohumeral Instability

CHAPTER

4

 

Orthopedic surgeons have a fundamental desire to find a simple solution to glenohumeral instability, leading to various operative approaches. Despite the fact that Bankart and Perthes had independently described anterior labral pathology in the 1900s, surgeons in the mid-1900s observed that abduction and external rotation resulted in glenohumeral joint dislocation. Consequently, several operations were popularized to eliminate dislocation by limiting the offending motion—external rotation. These procedures such as the Magnuson-Stack and Putti-Platt succeeded in controlling the dislocation, but some patients were unhappy with the loss of shoulder movement and function; others continued to have instability. Furthermore, many of these patients developed premature osteoarthritis due to overtightening. Subsequently, the Bankart lesion came to be regarded as the essential lesion, so labrum repair predominated. Labrum repair operations were successful in some but not all patients, and the underlying rationale—that lesions of the labrum were the sole cause of instability—could not explain dislocations that occurred without such lesions. Further, as DePalma observed, many patients had degeneration of the labrum that appeared to be an aging phenomenon, yet few of these patients developed glenohumeral joint instability. Subsequently, patients with recurrent anterior dislocations without labrum detachment were treated with an anterior capsular tightening procedure. Again, many patients benefited, but others continued to suffer shoulder dislocation or subluxation. With the understanding that some shoulders are unstable in multiple directions (with or without labrum lesions), interest shifted to global capsular tightening. The capsular shift as described by Neer offered a solution to this challenging condition. More recently, the desire to control glenohumeral instability while retaining function for overhead sports

has motivated the search for new techniques involving arthroscopy. The advantages of arthroscopic stabilization include smaller skin incisions, more complete glenohumeral joint inspection, ability to treat all intraarticular lesions, access to all areas of the glenohumeral joint for repair, less soft tissue dissection, preservation of subscapularis integrity, and maximal preservation of external rotation. Arthroscopy enables surgeons to inspect the entire glenohumeral joint and observe lesions in the unstable shoulder. Concurrently, clinical and basic science investigations have increased our understanding of the pathophysiology of glenohumeral instability. We now have the background, knowledge, and technical skill to more effectively address glenohumeral instability. We also have a better understanding of when arthroscopic procedures are indicated and when open procedures may be more effective.

LITERATURE REVIEW Because current treatments are directly linked to the past, the intellectual history of arthroscopic shoulder stabilization is summarized. Early arthroscopic repairs used a staple to advance the Bankart lesion superiorly and medially, and were associated with failure rates up to 30%. Owing to potential complications from staples within the glenohumeral joint, other surgeons used a transglenoid suture repair of the Bankart lesion. Early publications reported initial success rates up to 100%, but these results deteriorated with longer follow-up. The two essential elements of these techniques are passage of sutures through the avulsed labrum and then passage through drill holes in the scapular neck. The sutures are tied posteriorly over soft tissue or bone. Later research and outcomes documented two flaws with these approaches: the medial location of the

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repaired labrum and failure to address capsular laxity. Neviaser first identified the anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion in shoulders with anterior-inferior glenohumeral instability. The detached labrum-ligament complex healed medially on the scapular neck, which allowed excessive humeral translation. It was apparent that the staple and transglenoid suture techniques described earlier repaired the labrum medially but created an ALPSA lesion. Savoie examined shoulders that had dislocated following arthroscopic stabilization and found that the labrum had been repaired 5 mm medial to the glenoid rim. He was the first to point out that the attachment site of the repaired ligaments was critical. Savoie subsequently modified his technique by moving the entry position of the anchor from the medial scapular neck to the glenoid articular surface and reported improved results with the new technique. Other implants and techniques were tested, including the use of rivets and tacks to repair the labrum. These all had some higher level of complications and failure rates that were not acceptable. Ultimately, the use of suture anchors enabled repair of the detached labrum directly to the glenoid rim. Wolf pioneered this approach for arthroscopic instability repairs. Improved outcomes occurred as surgeons learned to position the glenoid labrum more appropriately on the glenoid rim. Harryman and associates introduced the term concavity-compression to explain the important role of the labrum in glenohumeral instability. However, further investigation raised two questions: Was the Bankart lesion the only labrum lesion responsible for anterior-inferior instability? Could any labrum lesion or combination of labrum lesions produce glenohumeral instability alone, without the presence of any other lesion? Attention was then returned to the shoulder capsule. Capsular stretch or elongation, with or without a Bankart lesion, was determined to be a primary pathology in instability. Tibone emphasized that the rate of capsular stretch is an important variable because the speed of the injury may determine where the capsular ligament is damaged. In a laboratory study, Bigliani demonstrated that faster strain rates result in ligament injury, whereas slower strain rates result in a higher percentage of failures at the ligament insertion site. Bigliani also studied the tensile properties of the shoulder capsule in patients with acute dislocation and found that some degree of capsular damage was usually present, even with a Bankart lesion. Baker arthroscopically inspected the shoulders of 45 patients within 10 days of acute dislocation and found that the capsule had been stretched or torn in all patients with or without an associated Bankart lesion. Based on these findings and subsequent

studies, the capsule became a primary focus for repair and tensioning. Leaping ahead a few years, it was noted that perhaps the most subjective and difficult pathology to address in instability is capsular tensioning. The orthopedic community, therefore, greeted thermal treatment with great interest. However, clinical application outpaced basic scientific investigation. We soon learned that thermal treatment was associated with the devastating complications of capsular necrosis, capsular rupture, and chondrolysis. The use of thermal capsulorrhaphy has largely been abandoned. Other structures have been implicated in playing roles in shoulder instability. Rodosky described the role of the biceps-labrum complex in anterior-inferior instability. Detachments of the superior labrum—tear of the superior labrum from anterior to posterior (SLAP lesion)—performed in the laboratory allowed increased anterior humeral head translation. Speer also used a cadaver model to determine that although a Bankart lesion allows increased humeral head translation, it alone does not result in humeral head dislocation. Subsequently, several studies have been equivocal on the role of the superior labrum and biceps complex in glenohumeral stability. Most descriptions of arthroscopic technique initially omitted treatment of the rotator interval. This area of the glenohumeral joint capsule is the soft tissue between the superior border of the subscapularis tendon and the anterior edge of the supraspinatus tendon, and includes the superior glenohumeral ligament and a portion of the coracohumeral ligament. Subsequently, Neer and Rowe described the role of the rotator interval in open repair of shoulder instability. Rowe and Zarins inspected the superior aspect of the rotator cuff and found that 20 of 37 patients undergoing operation had a large opening in the capsule between the supraspinatus and subscapularis. Harryman’s laboratory studies advanced our understanding of the rotator interval. He found that opening the rotator interval increased inferior-posterior translation. Based on these studies and observations, the rotator interval became an issue that was often addressed for both anterior and posterior instability. However, with more recent biomechanical and clinical studies, the role of the rotator interval has been called into question as a primary contributor to instability, and interest in aggressively addressing it surgically has diminished once again. Initially, arthroscopic stabilization techniques were reported to have higher failure rates than open techniques. These were due to technical factors detailed in several studies, such as medial repair of the anterior labrum and failure to recognize and address bone loss on the humeral and glenoid sides. There are several concepts



to keep in mind in order to approach and effectively address glenohumeral instability arthroscopically: 1. Glenohumeral instability occurs in several directions. 2. These directions are classified as anterior, posterior, bidirectional (anterior-inferior or posteriorinferior), and multidirectional (inferior, anterior, and posterior). 3. The classification of direction is somewhat arbitrary. 4. The primary direction of instability is determined through a combination of patient history, physical examination, radiographic analysis, examination under anesthesia, and evaluation of the glenohumeral joint at the time of arthroscopic surgery. 5. Lesions are usually multiple. 6. Instability in any direction may be the result of various combinations of lesions. 7. The same combination of lesions may produce instability in different directions in different patients. 8. Instability correction requires that all lesions be identified and repaired. 9. It may be necessary to operate on areas of the glenohumeral joint on the side opposite the primary instability to balance the shoulder and prevent iatrogenic instability. 10. Glenohumeral instability should probably be considered a single entity, defined as symptomatic excessive humeral head translation. 11. The clinical expression of this translation is variable in each individual. 12. Humeral head and glenoid bony deficits may necessitate open procedures or more advanced reconstructive techniques and may not respond to simply primary repair of soft tissue pathology. Orthopedic surgeons use patient history, physical examination, radiographic analysis, and operative findings to diagnose the clinical expression of glenohumeral instability. Unidirectional instabilities are well appreciated and are generally categorized as anterior or posterior. On physical examination, patients with multidirectional instability have symptoms of pain and apprehension when the shoulder is stressed in anterior, posterior, and inferior directions. Neer’s pioneering concepts were twofold: glenohumeral instability can occur in multiple directions, and correction of all three symptomatic directions is necessary. However, there is a group of patients who are symptomatic in only two directions. There is little in the literature concerning bidirectional glenohumeral instability—that is, inferior instability with either an anterior or a posterior component—which is a separate entity from multidirectional instability and unidirectional anterior or posterior instability. Neer discussed instability in two directions in his paper on multidirectional instability. Altchek described his results with operation for multidirectional

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instability of the anterior and inferior types. Pollock and Bigliani specifically used the term bidirectional in their paper on recurrent posterior shoulder instability. In a search for a unifying approach to the many forms of glenohumeral instability, Pollock and Bigliani’s analysis may be most helpful. In their article on anterior-inferior shoulder instability, they discussed the complexities of instability classification and stressed the need to address all components of glenohumeral laxity to balance the shoulder. They were the first to report that an area of asymptomatic laxity must be treated to correct symptomatic instability in another direction, whereas previous articles had focused on correcting the laxity in the direction of the instability. The clinical expression of glenohumeral joint laxity is termed instability. The direction or directions of instability are, to a large degree, the result of laxity in various areas of the glenohumeral capsule and insertion tears of the labrum. Other factors undoubtedly play a role. Some of these factors require nonoperative treatment (muscular strengthening and neuromuscular conditioning), and others require modification of the surgical technique, such as when anterior glenoid bone loss dictates an operation such as the Latarjet procedure. Successful arthroscopic treatment requires that the surgeon identify the direction and degree of clinical instability preoperatively, identify the areas responsible for excessive translation arthroscopically, and then correct all necessary areas of the glenohumeral joint. A prime example of this approach is a patient with recurrent posterior glenohumeral subluxation. This patient likely has excessive laxity in the posterior-inferior capsule, but correction of that area alone may not necessarily control excessive humeral head translation. Even though the patient is not symptomatic in the direction of the rotator interval or the anterior-inferior glenohumeral ligament, tightening of one or both these areas may be needed. There are many similarities between arthroscopic rotator cuff repair and arthroscopic glenohumeral reconstruction, but there are also important fundamental differences. Arthroscopic rotator cuff repair has certain advantages over the traditional open approach, as described in Chapter 12. Fundamentally, however, the primary goal of both the arthroscopic and the open procedure is identical: to reattach the torn edge of the rotator cuff tendon to its normal point of anatomic insertion. Operations within the glenohumeral joint are technically less demanding than those within the tight confines of the subacromial space, but arthroscopic glenohumeral reconstruction is not a simple operation. Although the glenohumeral joint is better visualized and the surgeon has more space to manipulate instruments than within the subacromial space, the less demanding

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Superior SLAP Interval

Cuff Internal impingement Posterior

Anterior

PIGHL

in anterior-inferior instability was described by Snyder and Rodosky. Harryman reminded us of the role the rotator interval plays in glenohumeral joint motion and translation. Morgan, Burkhart, and Jobes pioneered our thinking on the influence of glenohumeral joint translation (if any) on internal impingement. Obviously, as we learn more about the glenohumeral joint structures in both normal and pathologic shoulders, surgical decision-making becomes more complex.

AIGHL

DIAGNOSIS Inferior capsule Inferior

FIGURE 4.1  The circle concept of instability. AIGHL, Anteriorinferior glenohumeral ligament; PIGHL, posterior-inferior glenohumeral ligament; SLAP, superior labrum from anterior to posterior.

technical aspects of the procedure are offset by a greater deficit in knowledge. For example, there are no objective standards by which to judge ligament or capsular tension, so the surgeon can only estimate the amount of tightening needed. The most critical part of the procedure is the one that lacks objective guidelines. The circle concept is helpful to understand some of the factors involved in glenohumeral joint instability (Fig. 4.1). Think of the circle in the figure as a sagittal view of the right shoulder, with the arrow representing the direction of anterior-inferior translation. The most common form of shoulder instability occurs in the anterior-inferior direction, and our initial understanding was that the lesion was in the anterior-inferior portion of the shoulder. Depending on the surgeon’s country of origin, this lesion is termed the Bankart, Broca, or Perthes lesion. The search for this “essential” lesion dominated research for 50 years, and other surgeons presented their clinical and laboratory work questioning this idea. DePalma thought this explanation was inadequate because he had identified unstable shoulders without any labrum abnormality, as well as shoulders with labrum abnormalities that were stable. Nonetheless, the Bankart lesion became the focus of operative repair. This thinking persisted with few challenges until Neer and Foster’s article on multidirectional instability emphasized the importance of an inferior capsular lesion. Rowe and Zarins also described operative correction of a shoulder with anterior-inferior instability in which no Bankart lesion was found. Further investigation identified the importance of the inferior-posterior capsule and ligaments as additional static stabilizers, as well as the importance of the rotator cuff muscles as dynamic stabilizers. The role of the superior labrum

Patient History Shoulder instability can be classified in many ways including chronicity, degree, direction, and traumatic onset. We document whether the instability is a chronic or acute event (50% but not dislocatable), or 3 (dislocatable). The grading of instability is somewhat subjective but appears to be relatively consistent for each examiner. Record the presence of laxity in the contralateral shoulder, elbows, and knees, and the patient’s ability to bring the thumb to the forearm. Beighton’s signs may be used as a formal grading system for the degree of generalized ligament laxity, but a simple general assessment may be sufficient. Other sources of shoulder pain (rotator cuff lesions, acromioclavicular joint arthritis, thoracic outlet syndrome, brachial plexus lesions, glenohumeral arthritis) may need to be excluded through the patient history, physical examination, and radiographic analysis.

FIGURE 4.5  Radiographs of anterior-inferior dislocation.

Radiographs Routine radiographs that we use include anteroposterior glenoid, Bernageau, and supraspinatus outlet views. Most of the time, patients have already had magnetic resonance imaging, with or without arthrography (MRI or MRA). If not, we will obtain one or the other study depending on acuity of the injury and the clinical or radiographic suspicion that surgery may be indicated. In patients with a traumatic dislocation that occurred within days, often the arthrogram is not needed, as the hemarthrosis provides sufficient contrast. Also, depending on the radiographic and MRI findings, a computed tomography (CT) scan may be added with or without reconstructions to assess humeral and glenoid bone loss or if the patient has failed prior surgery to more thoroughly assess the anatomy and hardware placement. Direct radiographic evidence of glenohumeral instability consists of humeral head dislocation. Indirect radiographic signs of instability include calcification adjacent to the anterior glenoid, a bony Bankart lesion, anterior glenoid bone loss, or a Hill-Sachs lesion. On MRI and CT, additional evidence of instability includes detachment of the glenoid labrum from the glenoid bone, capsular stripping from the glenoid, and ligament insufficiency (Figs. 4.5–4.15). If the diagnosis is in doubt, an arthroscopic examination and examination under anesthesia are helpful. I observe humeral head movement under direct arthroscopic visualization. The presence of intraarticular lesions may allow the surgeon to diagnose a predominant direction of instability or an unrecognized direction of instability. These lesions are located in the humeral head and glenoid (chondral or osteochondral defects),

FIGURE 4.6  Radiograph of glenoid rim fracture.

FIGURE 4.7  Bony Bankart lesion.



CHAPTER 4

FIGURE 4.8  Bony Bankart lesion (circled), axillary view.

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FIGURE 4.9  Superior labrum from anterior to posterior lesion.

FIGURE 4.11  Hill-Sachs lesion. FIGURE 4.10  Bankart lesion.

RA

SP

FIGURE 4.12  Anterior capsular stripping.

95

FIGURE 4.13  Glenoid rim fracture.

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FIGURE 4.14  Posterior humeral glenohumeral ligament tear (arrow).

FIGURE 4.16  Labral fraying.

weights (maximum 5 pounds). Patients are instructed in exercises to improve neuromuscular coordination and proprioception. Areas of contracture are identified and corrected with specific stretching. Posterior contracture commonly occurs in patients with traumatic anterior-inferior glenohumeral instability (Fig. 4.17). FIGURE 4.15  Three-dimensional computed tomographic reconstruction with anterior bone loss.

labrum (fraying or separation from the glenoid), and capsular ligaments (tear or laxity; Fig. 4.16).

NONOPERATIVE TREATMENT Nonoperative treatment consists of avoidance of painful activities, nonsteroidal antiinflammatory medication for pain if necessary, and a home physical therapy program designed to eliminate contractures and maintain or improve shoulder girdle strength and neuromuscular coordination. The goal is to improve the strength of those muscles responsible for glenohumeral stability. Therefore patients perform resistive exercises of the internal rotators, external rotators, biceps, triceps, and scapular muscles with surgical tubing and light

OPERATIVE TREATMENT Indications The indications for surgery are not clearly elucidated as patient choice does play a role. The most commonly accepted medical indication for surgery is persistent shoulder pain or recurrent glenohumeral instability that has not responded to a minimum of 3 to 6 months of nonoperative treatment. The second indication is a patient at high risk for recurrence after a primary traumatic dislocation event. Fundamentally, the decision to operate is the patient’s, based on appropriate counseling by the surgeon. When a patient sustains an initial dislocation that occurs with sufficient energy that it can be classified as traumatic, surgical repair is an option. There are several factors that may favor surgical intervention, as they suggest a high risk of recurrence:



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there is a 25% recurrence rate (much higher in certain patients). Arthroscopic treatment has a 90% to 95% success rate, yet it is not routinely performed. Orthopedic surgeons operate on acute ligament injuries of the knee and ankle but rarely on the shoulder. As our techniques and equipment continue to improve, and as our ability to identify patients at high risk of recurrent symptomatic dislocation increases, patients with acute shoulder dislocation will have greater access to surgical care.

Contraindications

FIGURE 4.17  Adduction stretch.

1. Patient age younger than 20 years. 2. Traumatic dislocation (as opposed to dislocations that occur with minimal force). 3. The need for a closed reduction (this also supports the diagnosis of a dislocation as opposed to the patient’s subjective account). 4. Involvement of the dominant arm. 5. High level of current activity. 6. Desired high level of activity. 7. Sensation of instability with minimal provocation. 8. Radiographic findings of a bony Bankart, large HillSachs lesion, or persistent subluxation or dislocation. 9. CT or MRI findings that suggest moderate soft tissue or bony structural compromise. We explain the chance of recurrent instability in light of the patient’s particular situation and let the patient and family decide on operative or nonoperative care. Our experience correlates with much of the recent literature. Patients who are younger than 20 years and participate in vigorous overhead activities or contact sports have a high rate of recurrent dislocation. However, unless the patient falls into the select subgroup described earlier with factors influencing early repair, the chances of recurrent dislocation are less than 50%, and of those in whom repeat dislocation occurs, only 50% request surgery. Historians will likely view our past treatment of traumatic shoulder dislocation as suboptimal. Essentially,

Absolute contraindications to surgery include glenohumeral instability with selective voluntary muscle contractions and questionable emotional stability. Patients who can activate their muscles and demonstrate glenohumeral subluxation or dislocation with the arm by the side seem to have a poor prognosis after operative care. Evaluating a patient’s emotional stability is, of course, subjective. Relative contraindications to arthroscopic shoulder stabilization include failed prior instability surgery, poor-quality ligaments, and large bone defects of the glenoid or humeral head. The potential solution in the last case is the Latarjet procedure, discussed later in this chapter. Most small Hill-Sachs lesions do not affect the arthroscopic surgical result because with restoration of soft tissue tension, the Hill-Sachs lesion does not engage the anterior glenoid. However, when the humeral head defect is large enough, there is insufficient surface area to allow adequate external rotation. If the patient regains external rotation, he or she may experience a sensation of catching and recurrent dislocation as the Hill-Sachs lesion rides over the anterior rim (Figs. 4.18–4.20). Earlier operations dealt with this issue by intentionally restricting external rotation, but such an approach limits function and may lead to asymmetric loading and arthrosis. There have been several publications that try to use CT scans or MRIs to predict the amount of glenoid or humeral bone loss or patterns of loss that would predict when an arthroscopic anterior capsulolabral repair is not sufficient to restore stability. It is still not clear that there is a definitive answer, but generally, a glenoid defect of more than 15% to 20% of the diameter of the inferior circle of the glenoid or a Hill-Sachs lesion that involves more than 30% of the humeral head should be approached cautiously with isolated arthroscopic capsulolabral repair. Arthroscopy as a diagnostic tool is effective to evaluate whether the Hill-Sachs lesion is engaging or if the anterior glenoid bone loss or labral loss is too significant to manage the patient with a capsulolabral repair. If the Hill-Sachs lesion is engaging, a remplissage procedure can be considered in conjunction

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FIGURE 4.18  Large Hill-Sachs lesion

FIGURE 4.21  Arthroscopic view of Remplissage.

with the capsulolabral repair (Fig. 4.21). Alternative options include arthroscopic or open humeral head allograft placement, rotational osteotomy, or placement of a partial humeral head metal implant.

OPERATIVE APPROACH Operative Rationale

FIGURE 4.19  Large Hill-Sachs lesion in external rotation perched on the anterior glenoid.

FIGURE 4.20  Large Hill-Sachs lesion in external rotation anteriorly dislocated.

The underlying principle of arthroscopic repair is to identify and repair all lesions that contribute to glenohumeral instability. This involves débridement, repair of ligament and labral tears, capsular tensioning, and if needed, repair of the rotator interval. The first step to approach a patient with glenohumeral instability is to determine the direction or directions of instability by conducting a thorough history, physical examination, examination under anesthesia, and examination during glenohumeral arthroscopy. All of the structures within the glenohumeral joint are then evaluated to determine which ones need to be addressed. A patient with anterior-inferior instability may require an anterior labral repair, but if capsular stretching has occurred, anterior capsular imbrication may be necessary as well. Another patient with the same direction but a higher degree of translation may need a more aggressive capsular plication, simply based on the history, imaging, and exam under anesthesia (Fig. 4.22; Video 4.1). A patient with posterior-inferior instability may not be stabilized after posterior labrum and posterior capsule repair, and may require tightening of the inferior capsule and anterior-inferior glenohumeral ligament. A rotator interval repair may be necessary. The decision-making is complex, but it accurately reflects the reality of the clinical situation. Often the decision is made prior to



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FIGURE 4.24  Posterior labral faying after débridement.

FIGURE 4.22  Anteroposterior radiographs of static anterior inferior humeral subluxation.

FIGURE 4.23  Posterior labral fraying.

surgery, but surgical findings definitely impact what is addressed and the level of aggressiveness to address different structures. The goals of débridement are to remove sources of mechanical irritation or functional instability. Only minor labrum flap tears (10%) or the anterior labrum is deficient, we prefer the Latarjet. An exception to this rule is the throwing athlete with the dominant arm involved. We will consider a soft tissue repair in that scenario or advise the athlete that a Latarjet is a salvage option but return to high-level throwing is not predictable. The presence of a large Hill-Sachs lesion may prompt us to perform a Latarjet or add a remplissage, or both are done together. We

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rarely have needed to fill in the Hill-Sachs with allograft, but that is an option as well. These techniques should be used only by an experienced orthopedic surgeon familiar with the normal and abnormal anatomy seen during both open and arthroscopic shoulder operations. A thorough understanding of the various conditions that produce shoulder pain is needed. An orthopedic surgeon who infrequently performs open glenohumeral instability repair should not attempt the arthroscopic procedure.

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Hayashi K, Thabit G, Bogdanske JJ, et al. The effect of nonablative thermal probe energy on the ultrastructure of joint capsular collagen. Arthroscopy. 1996;12:474–481. Itoi E, Lee SB, Berglund LJ, et al. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82:35–46. Kartus C, Kartus J, Matis N, et al. Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks: a clinical and radiographic study with a seven to ten-year follow-up. J Bone Joint Surg Am. 2007;89:1442–1448. Kohn D. The clinical relevance of glenoid labrum lesions. Arthroscopy. 1987;3:223–230. Lafosse L, Lejeune E, Bouchard A, et al. The arthroscopic Laterjet procedure for the treatment of anterior shoulder instability. Arthroscopy. 2007;23:1242.e1–1242.e5. Levy DM, Cole BJ, Bach BR Jr. History of surgical intervention of anterior shoulder instability. J Shoulder Elbow Surg. 2016;25(6):e139–e150. Lippitt SB, Vanderhooft JE, Harris SL, et al. Glenohumeral stability from concavity-compression: a quantitative analysis. J Shoulder Elbow Surg. 1993;2:27–35. Lopez MJ, Hayashi K, Fanton GS, et al. The effect of radiofrequency energy on the ultrastructure of joint capsular collagen. Arthroscopy. 1996;14:495–501. Lubiatowski P, Dlugosz J, Slezak M, et al. Effect of arthroscopic techniques on joint volume in shoulder instability: Bankart repair versus capsular shift. Int Orthop. 2016. McIntyre LF, Caspari RB, Savoie FH. The arthroscopic treatment of multidirectional shoulder instability: two-year results of a multiple suture technique. Arthroscopy. 1997;13:418–425. McIntyre LF, Caspari RB, Savoie FH. The arthroscopic treatment of posterior shoulder instability: two-year results of a multiple suture technique. Arthroscopy. 1997;13:426–432. McMahon PJ, Tibone JE. The anterior bond of the inferior glenohumeral ligament: biomechanical properties from tensile testing in the position of apprehension. J Shoulder Elbow Surg. 1998;7:467–471. Mihata T, McGarry MH, Tibone JE, Fitzpatrick MJ, Kinoshita M, Lee TQ. Biomechanical assessment of Type II superior labral anterior-posterior (SLAP) lesions associated with anterior shoulder capsular laxity as seen in throwers: a cadaveric study. Am J Sports Med. 2008;36(8):1604–1610. Mologne TS, Provencher MT, Menzel KA, et al. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35:1276–1283. Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT. The addition of rotator interval closure after arthroscopic repair of either anterior or posterior shoulder instability: effect on glenohumeral translation and range of motion. Am J Sports Med. 2008;36(6):1123–1131. Morgan CD, Bodenstab AB. Arthroscopic Bankart suture repair: technique and early results. Arthroscopy. 1987;3:111–122. Morrey BF, Janes JM. Recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am. 1976;58:252–256. Neer CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am. 1980;62:897–908.

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Neviaser TJ. The anterior labroligament periosteal sleeve avulsion lesion: a cause of anterior instability of the shoulder. Arthroscopy. 1993;9:17–21. Nottage WM. Thermal probe-assisted shoulder surgery. Arthroscopy. 1997;13:635–638. Pappas AM, Goss TP, Kleinman PK. Symptomatic shoulder instability due to lesions of the glenoid labrum. Am J Sports Med. 1983;11:279–288. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J Sports Med. 2006;34(10):1656–1661. Provencher MT, Mologne TS, Hongo M, Zhao K, Tasto JP, An KN. Arthroscopic versus open rotator interval closure: biomechanical evaluation of stability and motion. Arthroscopy. 2007;23(6):583–592. Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med. 2006;34:979–985. Richards RR, An K-N, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3:347–352. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994;22:121–130. Rowe CR, Zarins B. The Bankart procedure: long-term end-result study. J Bone Joint Surg Am. 1978;60:1–16. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63:863–872. Savoie FH, Miller CD, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: the Caspari technique. Arthroscopy. 1997;13:201–209. Shafer BL, Mihata T, McGarry MH, Tibone JE, Lee TQ. Effects of capsular plication and rotator interval closure in simulated multidirectional shoulder instability. J Bone Joint Surg Am. 2008;90(1):136–144. Sodl JF, McGarry MH, Campbell ST, Tibone JE, Lee TQ. Biomechanical effects of anterior capsular plication and rotator interval closure in simulated anterior shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2016;24(2):365–373. Speer K, Deng X, Borrero S, et al. Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am. 1994;78:1819–1825. Strauss EJ, Salata MJ, Sershon RA, et al. Role of the superior labrum after biceps tenodesis in glenohumeral stability. J Shoulder Elbow Surg. 2014;23(4):485–491. Szabo 2008 Sports med arthr Review.pdf. Ticker JB, Bigliani LU, Soslowsky LJ, et al. Inferior glenohumeral ligament: geometric and strain-rate dependent properties. J Shoulder Elbow Surg. 1996;5:269–279. Warner JJ, Johnson D, Miller M, Caborn DN. Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg. 1995;4:352–364. Williams MM, Snyder SJ, Buford D. The Buford complex— the “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy. 1994;10:241–247. Wirth MA, Groh GI, Rockwood CA. Capsulorrhaphy through an anterior approach for the treatment of atraumatic

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posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am. 1998;80:1570– 1578. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995;11:600–607. Wolf EM, Eakins CL. Arthroscopic plication for posterior shoulder instability. Arthroscopy. 1998;14:153–163. Wolf EM, Wilk RM, Richmond JC. Arthroscopic Bankart repair using suture anchors. Oper Tech Orthop A. 1991;184–191.

Youm T, ElAttrache NS, Tibone JE, McGarry MH, Lee TQ. The effect of the long head of the biceps on glenohumeral kinematics. J Shoulder Elbow Surg. 2009;18(1):122–129. Youm T, Tibone JE, ElAttrache NS, McGarry MH, Lee TQ. Simulated type II superior labral anterior posterior lesions do not alter the path of glenohumeral articulation: a cadaveric biomechanical study. Am J Sports Med. 2008;36(4):767–774. Zuckerman JD, Matsen FA. Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am. 1984;66:175–180.

Biceps Tendon Lesions

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The long head of the biceps tendon has both intraarticular and extra-articular segments. Biceps lesions can occur at the supraglenoid attachment, intra-articularly (lateral to the supraglenoid attachment), or extraarticularly. Regardless of the specific site of pathology, the long head of the biceps tendon is a common source of pain in the shoulder. Debridement, “superior labrum anterior-to-posterior” (SLAP) repair, biceps tenodesis, or biceps tenotomy are options for the treatment of the following lesions (Video 5.1): 1. Superior labrum tears from anterior to posterior 2. Partial biceps tears 3. Biceps instability (subluxation or dislocation) 4. Biceps synovitis (the tendon, sheath, or both) 5. Biceps hypertrophy with entrapment 6. Biceps adhesions

SUPERIOR LABRUM ANTERIOR-TOPOSTERIOR LESIONS SLAP lesions offer an interesting and complex challenge to shoulder surgeons. Patients with such lesions present with a wide spectrum of clinical complaints; the findings on physical examination are variable, the clinical findings are nonspecific, and radiographic diagnosis is imprecise. Even at operation the findings are variable, and the decision whether to repair a SLAP lesion requires a thorough understanding of the patient’s clinical condition and shoulder pathophysiology.

Anatomy The anterior, inferior, and posterior labra are firmly attached to the glenoid, and separation of any of these areas from the glenoid is pathologic. An exception to this is the normal sublabral hole that exists near the anterior-superior glenoid (Figs. 5.1 and 5.2). The superior labrum, in contrast, has wide variability in terms of its attachment to the glenoid. A normal superior labrum is not always attached, or it may have only a flimsy connection to the glenoid. If the glenoid underlying the superior labrum is covered with smooth cartilage and

neither the superior labrum nor the glenoid demonstrates any evidence of trauma, we consider this superior labrum separation to be a normal anatomic variant and not a pathologic lesion (Figs. 5.3 and 5.4). Evidence of trauma includes fraying or tearing of the superior labrum or damage to the glenoid cartilage directly underneath the labrum separation. Superior labrum separation without evidence of trauma does not require repair. A SLAP lesion is an abnormal separation of the superior labrum from anterior to posterior. The entity was first described by Andrews, but Snyder subsequently documented four variations. In a type 1 lesion, the superior labrum is attached to the glenoid rim, but there is fraying of the leading edge of the labrum. In a type 2 lesion, the superior labrum is detached from the glenoid. A type 3 lesion is similar to type 2, but there is also a bucket-handle tear, whereas a type 4 lesion has a longitudinal split in the biceps tendon (Figs. 5.5–5.11). Several variations of SLAP lesions have subsequently been noted that are essentially on a continuum, based on the propagation of the tear. Labral tearing can propagate anteriorly, posteriorly, or both. SLAP lesions have been identified in many settings and can often be noted in patients with full-thickness rotator cuff tears and those with glenohumeral instability. A number of publications have addressed this lesion’s frequency and the clinician’s ability to diagnose it. There is quite a bit of variability in the normal insertion of the biceps on the supraglenoid tubercle. There can often be a normal cleft that is mistaken for a pathologic lesion. Because of the variability of the anatomy and the lack of clarity on how symptomatic SLAP tears are, the diagnosis is very inconsistent. Some authors have noted that there is a moderate lack of interobserver agreement and a more than expected lack of intraobserver reliability in assessing SLAP tears arthroscopically. Many magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) reports overestimate SLAP tears, and there was a period of time in the past decade when SLAP tear repair reached an alarmingly high rate, suggesting overdiagnosis of symptomatic lesions. That trend has since changed, but it is still not clear if the diagnosis is made appropriately.

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FIGURE 5.1  Normal anterior-superior labral hole.

FIGURE 5.4  Normal variant of the superior labral attachment.

FIGURE 5.2  Normal superior labrum separation.

FIGURE 5.5  Type 2 superior labrum anterior to posterior.

FIGURE 5.3  Normal superior labral attachment.



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FIGURE 5.8  Type 3 superior labrum anterior to posterior.

FIGURE 5.6  Type 2 superior labrum anterior to posterior.

FIGURE 5.9  Type 4 superior labrum anterior to posterior.

Making the Diagnosis

FIGURE 5.7  Type 3 superior labrum anterior to posterior.

Patients may present with symptoms of intermittent catching, locking, or simply pain of the shoulder during overhead sports or activities of daily living. The pain is often sharp and localized vaguely as “deep within the shoulder joint.” The classic mechanism of acute injury is either a traction event or a fall on an outstretched arm. The other mechanism is recurrent microtrauma such as occurs with overhead throwing.

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Compress

External rotation

FIGURE 5.10  Type 4 superior labrum anterior to posterior.

FIGURE 5.12  O’Brien or active compression test.

FIGURE 5.11  Type 4 superior labrum anterior to posterior.

A This occurs because of the “peel back” mechanism and is also classified with internal impingement. Physical examination findings are variable. There have been a plethora of special physical examination maneuvers that can detect SLAP tears. We commonly rely on the active compression test, also known as the O’Brien test (Fig. 5.12). Other tests include the biceps active tests (I and II), the Kim test, the crank test, the clunk test, Speed’s test, and even the apprehension/ relocation test (Fig. 5.13). The issue is that several of these tests can be positive for acromioclavicular joint pathology, more distal biceps pathology, and even rotator cuff pathology. However, none of these tests have been noted to be extremely sensitive and specific. Rather, a combination of them will increase sensitivity and specificity to the point where the diagnosis can reasonably be entertained.

B FIGURE 5.13  (A and B) Relocation test.

As already mentioned, imaging studies are imperfect. MRI is neither highly sensitive nor specific for SLAP tears, but the addition of contrast helps (Fig. 5.14). Even with this, there are many normal variants that make it difficult to diagnose SLAP tears by imaging.



FIGURE 5.14  Magnetic resonance arthrogram of superior labrum anterior-to-posterior tear.

Management of SLAP Tears Although history, clinical examination, and imaging are very helpful, management of SLAP tears depends greatly on the clinical scenario and associated lesions. Patients with SLAP lesions may present in the setting of subacromial impingement, partial or complete rotator cuff tearing, or glenohumeral instability. In these cases, the surgeon must determine if the SLAP lesion is important. If it is deemed important, does it need to be addressed? Finally, the surgeon must determine how it should be addressed. This issue may have to be resolved prior to surgery or during surgery.

Nonsurgical Treatment Prior to surgery, clinical examination findings (besides the special exams to diagnose a SLAP tear) include assessment of motion and contractures. Not uncommonly, a posterior capsular contracture or limitation of internal rotation may contribute to symptoms of a SLAP lesion. The symptoms may resolve over time with an effective posterior capsular stretching program. Additionally, scapular dyskinesis may also result in excessive pressure or impingement on the superior labrum. This can be addressed with a scapular stabilizer strengthening program and muscular re-education, along with anterior capsular and pectoralis minor stretching.

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FIGURE 5.15  Normal superior labral attachment versus type 1 superior labrum anterior to posterior.

Several scenarios can be considered for each type of SLAP tear.

Type 1 Superior Labrum Anterior-to-Posterior Lesion Most often type 1 SLAP lesions are considered nonpathologic, so they are often not addressed. If there is an obvious rotator cuff tear or other labral pathology that is consistent with presentation, there is no reason to address a likely incidental type 1 SLAP lesion. On the other hand, there is likely little negative impact of performing a minor debridement. We leave it alone in most cases. There are a couple of scenarios in which this lesion may present an issue. The first is that of a young patient, less than 40 years of age, who has impingement symptoms by history and impingement signs on examination. MRI is normal or equivocal. The patient has failed adequate conservative management and a diagnostic arthroscopy is done. At the time of arthroscopy, if there are no other findings in the glenohumeral joint, the type 1 SLAP can be debrided along with a subsequent subacromial decompression upon entry into the subacromial space. If there are any other intra-articular findings that can explain the pain, the type 1 SLAP can be left alone or addressed with debridement if desired (Figs. 5.15 and 5.16). There would not be any indication to repair a type 1 SLAP tear.

Surgical Treatment

Type 2 Superior Labrum Anterior-to-Posterior Lesions

Surgical treatment of SLAP tears varies depending on the several factors we have mentioned. At the time of surgery, the decision on how to manage the tear depends on the type of tear and the associated pathology.

Type 2 SLAP lesions are the ones that cause the most confusion and angst for the surgeon. These lesions are often found at the time of surgery, particularly in older patients. It is difficult to determine if they are

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FIGURE 5.16  Normal superior labral attachment versus type 1 superior labrum anterior to posterior.

FIGURE 5.17  Type 2 superior labrum anterior to posterior in an older patient.

FIGURE 5.18  Type 2 superior labrum anterior to posterior in an older patient.

FIGURE 5.19  Biceps tenodesis for type 2 superior labrum anterior to posterior.

symptomatic; whether to address them or not is truly a matter of the surgeon’s judgment. In younger patients, there are often fewer abnormalities to cloud the issue, but it still may be difficult to determine if the SLAP lesion should be addressed. A simple scenario is that of a young overheadthrowing athlete with an isolated type 2 SLAP tear in the dominant arm. Those tears are addressed with SLAP repair. Another relatively straightforward scenario is that of an older patient (>40 years) with an isolated type 2 SLAP tear in the nondominant arm. This could be addressed with either a SLAP repair or biceps tenodesis, but we generally gravitate toward a tenodesis. SLAP repairs may tend to result in some level of stiffness in older patients, so we generally try to avoid the issue with a tenodesis. The more difficult scenarios are those involving younger patients with isolated type 2 SLAP tears in the nondominant arm or an older patient with an isolated type 2 SLAP tear in the dominant arm. Either SLAP repair or biceps tenodesis would be appropriate in such cases, but the final decision depends on the patient’s symptoms, goals, personality, and exam. For older patients, we still tend to lean toward a tenodesis (Figs. 5.17–5.19). A common, difficult scenario in a younger patient arises when the surgeon strongly suspects a SLAP tear on clinical grounds, based on history and exam, but the MRI or MRA is either negative or equivocal. There are no other findings on imaging. However, primary impingement, tendinosis, or microinstability with secondary impingement cannot be ruled out by exam or imaging. At the time of surgery, the type 2 SLAP tear may obviously be traumatic, which would make the decision to address it easier. However, often, it simply appears abnormal, with some fraying of the labral



FIGURE 5.20  Superior labrum anterior to posterior or normal variant?

FIGURE 5.21  Superior labrum anterior to posterior or normal variant?

attachment, and it can be lifted off the supraglenoid tubercle, revealing underlying cartilage that is worn or damaged but is not obviously pathologic (Figs. 5.20–5.23). Despite this abnormal appearance, it still may be an anatomic variant with mild chronic injury that is not the cause of the symptoms. In this setting, the surgeon must carefully check for subtle signs of anterior-inferior instability, such as labral fraying, fissures, or minor separations. The surgeon should be aware that the SLAP lesion might be causing or exacerbating subtle anterior-inferior glenohumeral instability and that the “impingement” symptoms are secondary. It is usually impossible to determine whether (1) the SLAP lesion is the result of the altered shoulder biomechanics that accompany chronic impingement, (2) the SLAP lesion involves enough altered shoulder biomechanics to cause impingement, or (3) there is any relationship between the two. It is possible that two separate

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FIGURE 5.22  Superior labrum anterior to posterior or normal variant?

FIGURE 5.23  Superior labrum anterior to posterior or normal variant?

pathologic processes are involved. The clinical history is the ultimate guide as to how to address the lesion. The surgical options are not to address the lesion at all, implement SLAP repair, or do a biceps tenodesis. If there is concern about microinstability and secondary impingement based on the examination or other findings, a SLAP repair is done. If there is any concern that the patient is more likely to have issues with stiffness postoperatively and instability is not the primary issue, a biceps tenodesis may be done. One concept that helps the surgeon reach a decision is whether he or she believes that a subacromial decompression will help. If that is the case, it means that instability is likely not the major concern and perhaps a tenodesis is a better option. However, in overhead-throwing athletes or patients below the age of 30 years, a SLAP repair is usually the preferred option.

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Another common scenario is the type 2 SLAP tear encountered when a known rotator cuff tear is being addressed. With the increasing use of arthroscopy, surgeons now routinely inspect the glenohumeral joint and identify type 2 SLAP lesions almost incidentally. Type 2 SLAP lesions are not seen during open rotator cuff repair, so their incidence has been underreported in publications dealing with open techniques. The issue then becomes whether the type 2 SLAP tear is related to the current presentation and whether it should be addressed surgically. We generally use a few factors to make a decision. First, we do not want to divide the patient’s care into two surgeries, one to address the rotator cuff and another to address the SLAP tear later if it is left alone and the patient has persistent symptoms. Therefore we tend to be more aggressive about addressing it surgically if the damage is significant. Second, if the lesion appears minor, we will leave it alone. Third, on the basis of our experience and the published literature, we will not, as a rule, address it with SLAP repair, as we feel that there is a risk of moderate stiffness and pain postoperatively. We will more likely do either a biceps tenodesis or a tenotomy. The tenotomy may be done for patients above 70 years of age, those who are obese, or low-demand patients. The reason for the tenotomy is that even a tenodesis may result in some pain anteriorly, as the tendon in older patients is likely to have some more distal pathology that may generate symptoms. Additionally, the reason to address the lesion at all is that the recovery will be incorporated in the recovery for the rotator cuff repair. If a tenodesis is done, the postoperative care is altered only by limiting active elbow flexion for 4 to 6 weeks. Type 2 SLAP lesions may contribute to glenohumeral instability directly and indirectly. Some studies indicate that the biceps and its intact attachment play a role in glenohumeral stability. Other studies suggest no role in stability. Regardless of the studies, the superior labrum is continuous with the posterior labrum, so whenever a posterior labral repair is done, the superior labrum, if detached, is also addressed. As for anterior instability, if at the time of arthroscopy it is noted that the superior labrum is continuous with the superior and middle glenohumeral ligaments (as it often is), this suggests that it plays a role in anterior shoulder stability, so it is addressed surgically. Therefore, in a young patient who is undergoing an anterior or posterior labral repair for instability, we will generally repair the type 2 SLAP at the same time (Figs. 5.24–5.27). Care must be taken to do only an in situ repair with no increased tension on the proximal biceps, and the anterior superior labral attachment is left alone.

FIGURE 5.24  Anterior labral tear with a type 2 superior labrum anterior to posterior.

FIGURE 5.25  Superior labrum anterior to posterior of the anterior labral tear from the prior figure.

FIGURE 5.26  Type 2 superior labrum anterior to posterior repaired.



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FIGURE 5.27  Repaired anterior labral tear. FIGURE 5.29  Resection of the type 3 superior labrum anterior to posterior.

FIGURE 5.28  Type 3 superior labrum anterior to posterior in a right shoulder viewed from the anterior portal.

Type 3 Superior Labrum Anterior-to-Posterior Lesions Unlike type 1 and 2 lesions where the diagnosis is not clear and the decision-making process is complex, type 3 and 4 SLAP lesions do not pose a diagnostic dilemma. This makes addressing them more straightforward. A true type 3 SLAP tear is not detached from the superior glenoid. It generally needs only debridement, regardless of the associated pathology (Figs. 5.28–5.30).

Type 4 Superior Labrum Anterior-to-Posterior Lesions Type 4 SLAP lesions can be addressed with debridement, biceps tenotomy, or biceps tenodesis. Usually, the bucket-handle component is detached; once it is debrided, there is no true detachment to repair. If there is a residual detachment, repair may result in

FIGURE 5.30  Type 3 superior labrum anterior to posterior after resection.

overtightening, since some of the labral tissue will have been lost. For this reason we generally do not repair a type 4 lesion. This is surgeon preference; others may consider repair (Figs. 5.31–5.37).

Operative Technique (Video 5.2) Before undergoing general anesthesia, patients receive an interscalene block to diminish postoperative pain. The patient is placed in the sitting position. Recordings are made of the range of motion for external and internal rotation with the arm in 90 degrees abduction and the range of motion for external rotation with the arm in 0 degrees abduction. The shoulder is examined for anterior, inferior, and posterior translation and the results are recorded. The shoulder is then prepared and

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FIGURE 5.31  Type 4 superior labrum anterior to posterior appears subtle viewed from the posterior portal of a left shoulder.

FIGURE 5.32  Blunt probe defines the type 4 superior labrum anterior to posterior.

FIGURE 5.33  After excision of the type 4 superior labrum anterior to posterior.

FIGURE 5.34  After excision of the type 4 superior labrum anterior to posterior, the anchor is attached.

FIGURE 5.35  Type 4 superior labrum anterior to posterior with more than 50% tendon thickness involved in a left shoulder viewed from the posterior portal.

FIGURE 5.36  Type 4 superior labrum anterior to posterior after resection with residual moderate proximal damage.



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FIGURE 5.37  Type 4 superior labrum anterior to posterior from Figs. 5.35 and 5.36 managed with tenodesis.

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FIGURE 5.39  Illustration of sites for anterior portals.

FIGURE 5.38  Skin markings for anterior portals.

draped routinely. The bony outlines of the acromion and coracoid process are palpated and marked with a surgical marking pen (Fig. 5.38). The shoulder joint is entered with a cannula and blunt trocar through a posterior skin incision placed approximately 1 cm inferior and 1 cm medial to the posterolateral border of the acromion. The arthroscope is inserted into the glenohumeral joint. The glenohumeral joint is then visually examined. Once the interval has been examined, the location of the anterior-inferior portal is identified with a spinal needle, so that the cannula enters the shoulder immediately superior to the subscapularis tendon and 1 cm lateral to the glenoid. An 8-mm cannula is inserted. The glenohumeral joint is then examined again using a probe from the anterior portal to palpate the labrum, capsule, and biceps tendon. The biceps is pulled into the joint to identify any lesions more distally. If other pathology not involving the biceps is identified that is more easily addressed before establishing an anterior superior portal, that pathology is addressed prior to establishing the

FIGURE 5.40  Rotator interval defect from prior surgery defines location for the anterior portal in this right shoulder viewed from the posterior portal.

anterior superior portal. For example, debridement of an undersurface supraspinatus tear may be done more easily through the anterior inferior cannula with the anterior superior cannula not present. If the superior labrum is the only pathology that needs to be addressed, an anterior superior portal is established with an 8-mm cannula. The reason for two 8-mm cannulas is that often curved suture passers will be used and they will not fit in a 5-mm cannula. If an anterior or posterior labral tear needs to be addressed first, a switching stick is placed at the site of the anterior superior portal to allow the camera to be moved to the anterior superior portal. Even if the superior labrum is all that needs to be addressed, once the 8-mm cannula is placed in the anterior superior portal, the camera can be briefly shuttled here, if desired, to view the posterior structures (Figs. 5.39–5.45).

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FIGURE 5.41  Cannula (8-mm) placed.

FIGURE 5.44  Partial-thickness supraspinatus tear associated with superior labrum anterior to posterior in a left shoulder viewed from the posterior portal.

FIGURE 5.45  Partial-thickness tear after debridement. FIGURE 5.42  Probe from the anteroinferior cannula pulls biceps out of the way to view site for anterosuperior portal placement.

Type 1 Superior Labrum Anterior-to-Posterior Lesions These are addressed with simple debridement, as mentioned earlier.

Type 2 Superior Labrum Anterior-to-Posterior Lesions

FIGURE 5.43  Anterosuperior portal placed.

The high anterior superior portal is critical to obtain a proper angle for the bur and drill. The spinal needle is always used to identify both the entry point and the angle for this cannula. The spinal needle should enter the joint very close to where the biceps exits from the glenohumeral joint and should approach the superior glenoid perpendicularly. Our prior technique was to use suture anchors preloaded with suture. Our current technique is to use knotless suture anchors. The preloaded suture anchor technique was a very good one, but it left sizable knots in the joint that can be a source of irritation and failure



FIGURE 5.46  Type 2 superior labrum repair anterior to posterior with anchors and knots tied.

FIGURE 5.47  Type 2 superior labrum repair anterior to posterior with anchors and knots tied.

(Figs. 5.46 and 5.47). Regardless of the technique used, the main obstacle for SLAP repair is attaining a good angle of approach for anchor placement. This is an issue with loaded suture anchors or knotless anchors, which is why we emphasize placement of the anterosuperior portal in a high anterior position. Other techniques have been published, using trans-rotator cuff portals such as the port of Wilmington and the Neviaser portal. Our preference is to avoid damage to the rotator cuff if at all possible. The reason for the difficulty in approach to the superior labrum is that the main sites of fixation are between 10 and 12 o’clock in a right shoulder (12 and 2 o’clock in a left shoulder). Usually one or two anchors are sufficient for most repairs. It is generally accepted that placing anchors further anterior will result in overtightening, which can cause pain and stiffness.

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The “peel-back” mechanism also suggests that the main area of pathology is the attachment of the posterior portion of the biceps. Access to the more posterior site of fixation can be difficult from the anterior superior portal and risks skiving off of the posterior medial aspect of the glenoid and not having sufficient bone stock to place an anchor. The suprascapular nerve may be at risk if this occurs. Placement of the high anterior portal as far posteriorly as possible can allow for a safe approach to the 10 o’clock position. However, if it is not possible to predrill and insert the posterior anchor through the anterior-superior portal, the arthroscope can be moved to the anterior-superior portal and the posterior anchor inserted from the posterior portal. The site of repair is first prepared. A shaver or a small bur can be used to abrade the glenoid beneath the detached superior labrum to expose cancellous bone. This shaver or bur can be inserted from either anterior portal. Sometimes the anterior inferior portal provides a better approach to simultaneously protect the labrum and expose a broader surface of attachment. Sometimes the superior labrum is very meniscoid, with the labrum margin extending down the glenoid and obscuring the view of the superior glenoid. In this situation, an assistant inserts a probe through the other portal and retracts the labrum superiorly. Cancellous bone is exposed from the anterior to the posterior margins of the superior labrum detachment. The sutures are now passed first, using a suture shuttle device. As a rule a suture shuttle curved in the opposite direction as the shoulder that is being operated on is used. For example, a device curved to the right is used for a left shoulder and vice versa. The device is passed through the inferior or superior portal and the labrum is pierced on the superior surface posteriorly first. Passing the sutures from superior to inferior places less stress on the labrum; the sutures exit the labrum inferiorly, making their retrieval easier. If two anchors will be placed, one at the 10:30 and one at the 11:30 position in a right shoulder, the first site that is pierced is around 10:30. The supraglenoid surface should have been prepared from 10 to 12 o’clock. Once the nylon suture is shuttled through, it is pulled through the other portal using a crochet hook or looped suture grasper. Either the looped or two free ends may have been loaded in the suture shuttle device. Next, the passing suture is used to shuttle a #2 braided nonabsorbable suture back through the labrum. If only a simple suture pass is desired, both ends of the passed suture are then shuttled through the anterior superior cannula. The drill guide can be used through this cannula while protecting the previously passed sutures to drill a pilot hole for the anchor. The drill hole is placed on the articular edge at 10:30 if possible. The

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passed sutures are then placed in the anchor; it is deployed and the sutures are cut. After passing the first suture, if a mattress cinch pattern is desired, the suture passing device is loaded with the two free ends at the tip. The first pass in this scenario should have been a little more anterior than 10:30, closer to 10:45. This second pass is done like the first, with the entry site around 10:15 or 10:30. The free ends are controlled with a crochet hook or looped suture grasper through the anterior inferior cannula, as with the first pass. The free end of the braided suture is shuttled through using the looped end in the anterior superior portal, but care is taken to make sure that there is enough suture slack that the braided suture mattress does not get pulled all the way to the labrum. The looped end of the braided suture is maintained in the anterior superior portal to allow for the creation of the mattress cinch. This

is done by passing the looped suture grasper through the anterior superior portal and grasping the two free ends of the same braided suture through the loop on the labral side. This series of steps creates the mattress cinch and places both suture ends in the anterior superior cannula. Drilling and placement of the anchor is done using both ends of the suture (Figs. 5.48–5.63). The same series of steps is now repeated for the second or third anchor if needed. Which anchor is placed first can vary, but the most posterior anchor is usually placed first. If a preloaded suture anchor technique is preferred, the anchor is placed first before the suture passer is passed through the labrum. The shuttle suture is used to pull one of the anchor sutures through the labrum, and it is then tied down (Figs. 5.64–5.69).

FIGURE 5.48  Type 2 superior labrum anterior to posterior with posterior extension in a right shoulder viewed from the anterior portal.

FIGURE 5.50  Anchor placed from posterior portal.

FIGURE 5.49  Tear prepared with rasp from posterior portal.

Text continued on page 150.

FIGURE 5.51  Completed posterosuperior labrum repair from anterior to posterior.



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FIGURE 5.52  Type 2 superior labral lesion anterior to posterior in a right shoulder viewed from the posterior portal.

FIGURE 5.53  View from the anterior portal shows posterior extension with poor anterior access for anchor placement.

FIGURE 5.54  First anchor placed from the posterior portal.

FIGURE 5.55  Final posterior repair.

FIGURE 5.56  Camera moved posteriorly and tear prepared.

FIGURE 5.57  The posterior anchor can be seen. Curved suture passer placed from anteroinferior portal.

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FIGURE 5.58  Suture passer penetrates the labrum.

FIGURE 5.60  Once the suture is shuttled through the labrum, the anchor can be deployed.

FIGURE 5.62  Completed repair with simple sutures.

FIGURE 5.59  Passing suture through the labrum.

FIGURE 5.61  The next suture is passed after the prior anchor is placed.

FIGURE 5.63  Completed repair with mattress cinch suture pattern.



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FIGURE 5.64  Preloaded anchor already passed. Curved suture shuttle in place.

FIGURE 5.65  Curved suture shuttle penetrates the labrum.

FIGURE 5.66  Crochet hook retrieves nylon suture.

FIGURE 5.67  Crochet hook retrieves nylon suture.

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Type 3 Superior Labrum Anterior-to-Posterior Lesions The bucket-handle tear is generally excised. If the surgeon feels that the bucket-handle portion is vascular and may heal, it can be repaired like a type 2 SLAP tear. We will usually excise it, since there is little likelihood of its healing. If the fragment is excised, the remainder of the attachment may be stable and can be left alone. If it is felt that it warrants repair, it can be done like the type 2 SLAP tear already described.

Type 4 Superior Labrum Anterior-to-Posterior Lesions As noted, we usually consider a biceps tenodesis, as described in the subsequent text.

Postoperative Treatment

FIGURE 5.68  The shuttled suture from the anchor is tied.

After repair of a type 2 SLAP component, the patient’s arm is placed in a sling that is worn at all times except while bathing. Active range of motion is allowed in all planes except external rotation in abduction, with pain as the guide, between 2 and 4 weeks. The sling is worn until week 4, at which time passive range of motion is added, with an emphasis on stretching of the posterior capsule. Six weeks after surgery, external rotation in abduction is allowed, and stretching continues. The patient is started on a progressive strengthening program using surgical tubing for the deltoid, rotator cuff, scapular muscles, biceps, and triceps at 3 months. Throwing begins at 4 months after operation with low-velocity, short-distance throwing and the athlete concentrating on proper throwing mechanics. Distance and velocity are gradually increased until 6 to 7 months after operation, at which point the patient may consider return to competitive sports.

BICEPS LESIONS DISTAL TO THE SLAP LESION Isolated biceps pathology is occasionally the cause of shoulder pain, but it is more commonly found in conjunction with rotator cuff pathology. Biceps lesions that may require arthroscopic treatment include tendinitis, partial-thickness tears, hypertrophy, adhesions, and instability (Figs. 5.70–5.74).

Literature Review

FIGURE 5.69  The shuttled suture from the anchor is tied.

Since the publication of the first edition of this book, the literature on the arthroscopic treatment of biceps lesions has become more robust. These data and publications focus on two issues: Should the surgeon perform



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FIGURE 5.70  Biceps adhesions forming a sling at the biceps outlet.

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FIGURE 5.73  Medial subluxation of the biceps tendon into the subscapularis in this left shoulder.

FIGURE 5.71  Band-like biceps adhesions.

FIGURE 5.74  Chronic-appearing type 4 superior labrum anterior to posterior, variant extending into the intra-articular biceps.

FIGURE 5.72  High-grade partial tear of the intra-articular biceps tendon.

a tenodesis or a tenotomy, and if a tenodesis is performed, what is the preferred technique? Hawkins and Walch have questioned the value of any tenodesis operation. Their results suggest that equal or better results can be achieved with tenotomy. Tenotomy is faster, is easier to perform, does not appear to affect elbow flexion strength significantly, and does not always result in a cosmetic deformity. Some patients express concern about the possible cosmetic deformity, particularly men who lift weights. If a patient has any concerns about the appearance of the arm, we consider a tenodesis. If the patient participates in overhead or throwing sports, we also consider a tenodesis. The final decision is made at the time of surgery, however, on the basis of tissue quality. If the tendon is macerated and does not look as though it will maintain fixation for a tenodesis, a tenotomy may be done. The results

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with tenodesis have been favorable, but many patients complain of pain around the site of the tenodesis for months. Patients who have a tenodesis must also be warned that it may fail up to 40% of the time in some studies and can still result in a cosmetic deformity. For those surgeons who prefer tenodesis, there are several basic methods of fixation. Here we review techniques with suture anchors, with interference screws, and finally a soft tissue fixation technique with sutures.

Diagnosis The diagnosis of a biceps tendon lesion is based on a combination of patient history, physical examination, radiographic imaging, and findings at arthroscopic surgery. The patient’s history and physical examination may point to a problem in the biceps tendon, but that information is usually nonspecific. Patients often indicate the biceps area as the source of their pain. This seems to be much more specific than the diffuse area of pain described with a rotator cuff tear. Of course such localization by the patient does not eliminate the possibility that the biceps is normal and the lesion is in the anterior supraspinatus or superior subscapularis. In fact, such an “anterior corner” injury is not uncommon. Patients often describe pain with activities that involve internal rotation, such as pressing an object together with both arms, reaching out to the side to close a car door, or reaching up behind the back. Some specifically describe the feeling of something rolling into and out of place or the sensation of slipping. Patients commonly describe painful popping or catching in the anterior shoulder area. Sometimes the pain is felt more acutely within the substance of the biceps muscle. These complaints are nonspecific and are also reported by patients with subacromial impingement syndrome and other more serious forms of rotator cuff disease. In patients who appear to have a mechanical block to full elevation yet maintain normal external rotation, the surgeon should consider biceps tendon entrapment due to tendon hypertrophy. On examination, the patient is often tender to palpation over the proximal biceps. However, this can also sometimes be noted without any pathology. The primary (Neer) and secondary (Hawkins) impingement signs may also produce pain on physical examination. Special tests such as Speed test can be helpful, and the O’Brien test may also be positive. A lidocaine or steroid injection placed with ultrasound guidance in the proximal biceps tendon sheath may be helpful in differentiating subacromial impingement from biceps tendinitis. MRI can be helpful if the biceps is statically subluxated or dislocated or if the tendon is thickened. Fluid in the biceps sheath on an MRI is not always specific for biceps

FIGURE 5.75  Subacute subscapularis tear with medial subluxation of the biceps.

FIGURE 5.76  Subacute subscapularis tear with medial subluxation of the biceps.

pathology. A tear of the superior third of the subscapularis can be an indirect sign of biceps pathology (Figs. 5.75 and 5.76). Ultrasound can be helpful to assess heterogeneity of the biceps and dynamic or static subluxation (Figs. 5.77–5.79). Arthroscopy is the most sensitive way to identify lesions of the proximal biceps tendon. Unfortunately there is no one definitive diagnostic modality and, in the end, the decision to address the biceps stems from a combination of all diagnostic modalities.



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TABLE 5.1  Indications for Treatment Biceps Lesion

Treatment

Inflamed Partially torn 30% Biceps quality good, cuff repair good Biceps quality good, cuff repair poor Biceps quality poor, cuff repair good Biceps quality poor, cuff repair poor

Tenosynovectomy Debride Tenodesis or tenotomy Tenodesis Tenodesis or tenotomy Tenotomy Tenotomy

FIGURE 5.77  Ultrasound of intrasubstance biceps tendon tear with fluid in the sheath.

FIGURE 5.80  Clinical photo of long head of the biceps rupture deformity.

Indications for Treatment

FIGURE 5.78  Ultrasound of medial biceps subluxation.

FIGURE 5.79  Ultrasound of medial biceps subluxation.

Partial-thickness biceps tendon tears within the glenohumeral joint are not uncommon; they may occur subsequent to a traumatic event, or they may be the result of chronic subacromial impingement. When the tear is less than 30% of the tendon width, the frayed edges may be debrided. If the tear is greater than 30% of the tendon width, we recommend a tenodesis. When the tendon is subluxated medially, a biceps tenodesis or tenotomy, usually in combination with a subscapularis repair, is done. If a biceps lesion is found in the area of the bicipital groove during subacromial decompression for a full-thickness rotator cuff tear, the surgeon has four options: ignore the biceps lesion, debride the lesion and the sheath, perform a tenodesis, or do a tenotomy (Table 5.1). Because there is no scientific evidence for guidance, treatment is determined by personal preference. We tend to favor a tenodesis in younger patients who have good-quality rotator cuff tendons and tenotomy in older patients who have poorer quality biceps and rotator cuff tendons. Spontaneous rupture of the long head of the biceps tendon is usually managed nonoperatively, but some patients are very concerned about the injury and request repair (Fig. 5.80). On the very rare occasion that this

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is done, an arthroscopy may first be performed to debride the biceps stump at the level of the superior labrum. The bicipital sheath is accessible arthroscopically from the level of the rotator interval to the insertion of the pectoralis major tendon. If the proximal end of the tendon is identified here, it may be tenodesed arthroscopically. Otherwise, an incision and open repair will be needed.

Operative Technique Soft Tissue Biceps Tenodesis Technique (Video 5.3) A soft tissue biceps tenodesis can be done if two conditions are satisfied. First, only proximal biceps pathology such as an advanced SLAP tear or an isolated intraarticular tear should be addressed. If the MRI, ultrasound, or arthroscopic examination suggests that there is more distal pathology, a more distal subacromial technique should be utilized. The other condition that must be present is an intact rotator interval, since this is tissue to which the tendon is attached. There are several techniques that use different devices to penetrate the interval and the tendon, including sharp tissue penetrators, curved-needle passing devices, and spinal needles. Our preferred soft tissue technique is the PITT (percutaneous intra-articular transtendon technique). This technique uses spinal needles and braided nonabsorbable suture passed by using monofilament suture to pass the braided suture. Two mattress sutures are placed in the tendon and tied in the subacromial space. In this technique, the knots are placed in the subacromial space. Other techniques may place the knots on the articular side (Figs. 5.81 and 5.82).

FIGURE 5.81  Use of tissue penetrators for intra-articular biceps tenodesis.

The step-by-step technique for the PITT is described here (Figs. 5.83–5.98; Video 5.4) and in the following text: • Position the patient in the beach-chair position with the acromion parallel to the floor. • Perform a diagnostic arthroscopy from a standard posterior portal. • Insert a spinal needle lateral to the coracoid and into the glenohumeral joint, penetrating the rotator interval. • Remove the needle, incise the skin, and insert a 5-mm cannula. • Evaluate the biceps tendon from its insertion medially to its passage laterally into the bicipital groove. • Elevate the shoulder with the elbow extended to examine the biceps tendon gliding, and evaluate for biceps entrapment (i.e., “hourglass” biceps). Text continued on page 157.

FIGURE 5.82  Completed intra-articular tenodesis.

FIGURE 5.83  Superior-third subscapularis tear as an indication for biceps tenodesis with otherwise healthy-appearing biceps.



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FIGURE 5.84 Percutaneous intra-articular transtendon technique initiated in a right shoulder with two spinal needles penetrating the tendon percutaneously.

FIGURE 5.85  Spinal needles on the articular side.

FIGURE 5.86  Left shoulder showing the suture grasper grasping the PDS suture.

FIGURE 5.87  Absorbable monofilament suture used to pull one end of the #2 nonabsorbable suture back through the tendon.

FIGURE 5.88  Absorbable monofilament suture used to pull second end of the same #2 nonabsorbable suture back through the tendon.

FIGURE 5.89  A #2 nonabsorbable suture being pulled through the skin to form an articular-sided mattress.

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FIGURE 5.90  Right shoulder showing the #2 nonabsorbable suture.

FIGURE 5.91  Final mattress with second pass of spinal needles.

FIGURE 5.92  Final pair of mattress sutures.

FIGURE 5.93  Biceps pulled into the joint to show the sutures passing through the interval tissue and into the biceps.

FIGURE 5.94  Biceps after it has been cut.

FIGURE 5.95  Suture limbs on the bursal side.



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FIGURE 5.96  Looped suture grasper pulls one set of sutures through a lateral portal to be tied.

FIGURE 5.97  First set of sutures tied.

FIGURE 5.98  Both sets of sutures tied.

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• Insert a probe through the anterior cannula to pull the biceps tendon into the joint, improving visualization of the distal tendon. • Insert a spinal needle percutaneously just distal to the anterolateral acromion into the glenohumeral joint, penetrating the rotator interval and the biceps. • Repeat this with a second spinal needle. • Pass a 0 PDS suture through each spinal needle. • Use a grasper to grasp one of the polydioxanone (PDS) sutures. Pull out the spinal needle used to pass the suture prior to pulling the suture out the anterior cannula. If the suture is pulled while the spinal needle is still in the skin, the suture may be lacerated by the end of the needle. • Repeat this for the other suture in the second spinal needle. • Tie the end of each PDS suture that emanates from the anterior cannula around each end of a #2 braided nonabsorbable suture. Tie with two half hitches approximately 5 cm from the end of the suture. • Pull each of the PDS sutures out the skin, thereby shuttling each end of the #2 braided nonabsorbable suture out the skin and deploying a mattress suture on the articular side of the biceps. • Repeat the same series of steps to place a second #2 braided nonabsorbable suture. • Cut the biceps near its origin and debride the stump. • Place the camera in the subacromial space. • Identify the four limbs of the two sutures with minimal or no use of the shaver. Place a lateral subacromial cannula. • Pull each set of sutures out of the cannula sequentially and tie them to complete the tenodesis.

Subacromial Techniques After removing the arthroscope from the joint and redirecting it into the subacromial space, place the arm in mild forward flexion and external rotation. The biceps can be palpated in its groove from a lateral portal. Alternatively, the arthroscope can be moved to the lateral portal and an anterolateral portal can be established at this point. It is easier to see the biceps and the entire groove from this position and to instrument the biceps from the anterolateral portal (Figs. 5.99–5.101). An electrocautery device can be used to open the sheath, taking care not to damage the biceps tendon itself. The biceps can then be examined to determine if the tissue quality is adequate for repair. The surgeon must decide whether to tenotomize or tenodese the tendon based on the tissue quality, extent and severity of the tear, the patient’s symptoms, the patient’s personality, concomitant procedures, the patient’s age, and the patient’s desired function (Figs. 5.102 and 5.103).

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FIGURE 5.99  Biceps in sheath in a right shoulder viewed from the lateral portal. The spinal needle is marking the site of the anterolateral portal.

FIGURE 5.102  Long head of the biceps in a right shoulder with medial subluxation and continued partial tear.

FIGURE 5.100  Cautery used on the lateral side of the biceps groove to initiate exposure.

FIGURE 5.103  Same biceps tendon pulled proximally to demonstrated tearing and inflammation. BICEPS TENODESIS—SUTURE ANCHOR TECHNIQUE (Video 5.5).  The biceps tenodesis is performed after the sub-

FIGURE 5.101  The lateral aspect of the biceps sheath has been opened.

acromial decompression but before the arthroscopic rotator cuff repair. The arthroscope is in the lateral portal. Three other portals are helpful. The initial posterior portal is used by placing the grasper on the cut end of the tendon. The tendon can be manipulated medially, laterally, and pulled proximally along the groove when needed. This portal is also used to pull out the sutures from the anchor for suture management. The anterolateral portal is used to place the anchor and pass the sutures. The anterior portal is used to retrieve sutures (Figs. 5.104–5.117). The steps are as follows: • Place the patient in the upright beach-chair position with the acromion parallel to the floor. Text continued on page 161.



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FIGURE 5.104  Long head of biceps tendon pulled out of its groove in a right shoulder.

FIGURE 5.105  Cautery on the pectoralis major tendon.

FIGURE 5.106  Shaver used to debride the groove.

FIGURE 5.107  Rasp used to roughen the cortical surface of the groove.

FIGURE 5.108  Awl used to create a pilot hole for the anchor.

FIGURE 5.109  Pilot hole for anchor 1 cm proximal to the pectoralis tendon, leaving roughened surface in the interval to encourage healing.

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FIGURE 5.110  PEEK anchor placed.

FIGURE 5.111  Sutures shuttled out the posterior portal for suture management.

FIGURE 5.112  One limb of one suture grasped from the anterolateral portal for the first pass.

FIGURE 5.113  Suture-passing device passes from medial to lateral to allow for a cerclage suture.

FIGURE 5.114  Both passes done with incomplete cerclage. The cerclage is completed when the suture is retrieved.

FIGURE 5.115  One suture tied and second suture about to be tied.



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FIGURE 5.116  Completed tenodesis.

FIGURE 5.117  Tenodesis shown with tension on the biceps and proximity to the pectoralis major tendon.

• Perform routine diagnostic glenohumeral joint arthroscopy from the posterior portal. • Insert a spinal needle lateral to the coracoid tip and into the glenohumeral joint through the rotator interval. • Remove the spinal needle and make a small stab incision using a scalpel. • Insert a 5-mm cannula. • Use a shaver or probe to pull the biceps tendon into the joint to visualize and document the extra-articular proximal biceps tendon. • Insert an arthroscopic scissors into the joint and transect the long head of the biceps tendon at its proximal insertion. The transection should be at the level of the superior labrum. Try to avoid leaving a medial stump of biceps tendon. (Insert the shaver to debride a medial biceps tendon stump if necessary.) • Remove the arthroscope from the joint.

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• Insert the metal cannula and trocar posteriorly into the subacromial space. • Insert the arthroscope. • Make a small stab incision at the midlateral position approximately 1 to 2 cm distal to the lateral acromial border. • Insert a blunt metal trocar into the subacromial space and locate it using the arthroscope. • Remove the trocar and replace it with the shaver. • Clear the subacromial bursa as needed for clear visualization of the bursal surface of the rotator cuff. (Achieve adequate visualization of the anterior and lateral subacromial space.) • Remove the shaver and replace it with a metal switching stick. • Remove the arthroscope from the posterior portal and insert it laterally. • Place a 5-mm cannula in the posterior portal. A knife may be needed to enlarge the incision. • Position the shoulder in approximately 60 degrees of anterior elevation and neutral rotation using the arm-positioning device. • With the arthroscope in the lateral portal, visualize the biceps sheath if possible. Place a spinal needle to define the anterolateral portal, which is 3 to 4 cm distal to the anterior corner of the acromion. This should have direct access to the biceps sheath. • Place an 8-mm cannula as the anterolateral portal. • Use an electrocautery device to clean off any bursal tissue and expose the sheath; use the device to palpate the biceps in its sheath. • Using the cautery, carefully debride the fascia lateral to the sheath in order to open the sheath and identify the biceps without damaging it. • Once the sheath is open, insert a locking grasper through the posterior cannula and grasp the free end of the tendon. This can now be used to manipulate the position of the tendon, allowing for debridement and fixation. • Continue to debride the groove and sheath from the level of the transverse humeral ligament to the superior border of the pectoralis insertion, using both the cautery and the shaver. Keep the blades of the shaver and the face of the cautery pointed away from the biceps in order to avoid damaging the tendon. • Use a rasp and the shaver to abrade the bony surface of the distal 2 cm of the groove. • Use an awl to create a pilot hole if a nonmetal anchor is to be used. We generally use double-loaded polyetheretherketone (PEEK) anchors. Depending on the bone quality, a 4.5-mm or 5.5-mm anchor is utilized. • Release the grasp on the tendon from the posterior cannula and place a looped suture grasper in its

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place. Use the looped suture grasper to pull all four limbs of the two sutures out of the posterior cannula. • Place the suture grasper in the posterior cannula again and regrasp the tendon. • Use a crochet hook to pull one limb of one suture out of the anterolateral portal. • Use a needle-passing device to pass that limb of the suture through the tendon. Use the locking grasper to pull the biceps tendon longitudinally along the length of the groove with some mild tension. The assistant holding the grasper should lower his or her hand to hold the tendon away from the cortical surface, which assists in suture passing. • Ιn passing the limb of the suture, grasp the suture and pull it out through the anterior cannula. An extra tip is to rotate the hand while passing the suture so that the needle is passed from medial to lateral. This will allow the suture to cerclage the tendon when it is tied down. • Repeat these steps with the second suture. The sutures should be passed through the biceps approximately 1 cm apart and at differing angles to each other. • Once both sutures are passed, use the crochet hook to retrieve both limbs of one suture out the anterolateral cannula. In order to cerclage the tendon, a knot pusher or looped suture grasper may be needed in the anterior cannula to feed the suture passed through the tendon to the crochet hook. • Sequentially retrieve, tie, and cut each suture. Tie the sutures using arthroscopic square knots. • Once the sutures are tied, place an arthroscopic scissor in the anterolateral cannula and cut the remaining excess biceps proximal to the anchor. • Use the grasper in the posterior cannula that is holding the biceps to remove the excess tendon that was cut. The entire cannula may have to be removed if the tendon is hypertrophied. If the subscapularis is also torn, the biceps tenodesis with the suture anchor technique is done first. The subscapularis repair is done second. If the supraspinatus is torn, the order of repair is biceps tenodesis, subscapularis repair, and finally supraspinatus repair.

FIGURE 5.118  Socket, 20 mm by 8 to 10 mm in diameter, reamed in the biceps groove from the anterolateral portal in a right shoulder. Viewed from the lateral portal.

FIGURE 5.119  A cannulate metal two-pronged fork is used to push the tendon into the socket.

BICEPS TENODESIS—INTERFERENCE SCREW TECHNIQUE (Figs. 5.118–5.123). 

• Place the patient in the upright beach-chair position with the acromion parallel to the floor. • Perform routine diagnostic glenohumeral joint arthroscopy from the posterior portal. • Insert a spinal needle lateral to the coracoid tip and into the glenohumeral joint through the rotator interval. • Remove the spinal needle and make a small stab incision using a scalpel. • Insert a 5-mm cannula.

FIGURE 5.120  A cannulate metal two-pronged fork is used to push the tendon into the socket.



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FIGURE 5.121  A central guide pin passed through the fork holds the tendon in position.

FIGURE 5.122  The interference screw is placed.

FIGURE 5.123  Final tenodesis.

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• Use a shaver or a probe to pull the biceps tendon into the joint to visualize and document the extraarticular proximal biceps tendon. • Insert an arthroscopic scissor into the joint and transect the long head of the biceps tendon at its proximal insertion. The transection should be at the level of the superior labrum. Try to avoid leaving a medial stump of biceps tendon. (Insert the shaver to debride a medial biceps tendon stump if necessary.) • Remove the arthroscope from the joint. • Insert the metal cannula and trocar posteriorly into the subacromial space. • Insert the arthroscope. • Make a small stab incision at the midlateral position approximately 1 to 2 cm distal to the lateral acromial border. • Insert a blunt metal trocar into the subacromial space and locate it using the arthroscope. • Remove the trocar and replace it with the shaver. • Clear the subacromial bursa as needed for clear visualization of the bursal surface of the rotator cuff. (Achieve adequate visualization of the anterior and lateral subacromial space.) • Remove the shaver and replace it with a metal switching stick. • Remove the arthroscope from the posterior portal and insert it laterally. • Place a 5-mm cannula in the posterior portal. A knife may be needed to enlarge the incision. • Position the shoulder in approximately 60 degrees of anterior elevation and neutral rotation using the arm-positioning device. • With the arthroscope in the lateral portal, visualize the biceps sheath if possible. Place a spinal needle to define the anterolateral portal, which is 3 to 4 cm distal to the anterior corner of the acromion. This should have direct access to the biceps sheath. • Place an 8-mm cannula as the anterolateral portal. • Use an electrocautery device to clean off any bursal tissue to expose the sheath, and use the device to palpate the biceps in its sheath. • Using the cautery, carefully debride the fascia lateral to the sheath in order to open the sheath and identify the biceps without damaging it. • Once the sheath is open, insert a locking grasper through the posterior cannula and grasp the free end of the tendon. This can now be used to manipulate the position of the tendon to allow for debridement and fixation. • Continue to debride the groove and sheath from the level of the transverse humeral ligament to the superior border of the pectoralis insertion using both the cautery and the shaver. Keep the blades of the

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shaver and the face of the cautery pointed away from the biceps in order to avoid damage to the tendon. • Place the guide pin for the screw through the anterolateral portal about 0.5 to 1 cm proximal to the pectoralis insertion. Drill it to a depth of at least 20 mm. • The diameter of the reamer will vary from 8 to 9 mm. But regardless of this, it will not fit through the cannula, so the cannula must be removed to allow the reamer to be placed on the cortex. • Reaming is done to 20 mm in depth. • The reamer is removed and the guide pin is used as a guide to replace the cannula. • At this point, many systems vary, but in general, an inserter with a two-pronged fork can be used to reduce the biceps into the tunnel. On the other hand, the screw inserter itself has a two-pronged fork that can be used to place the tendon into the tunnel. We use a PEEK screw with a two-pronged fork that allows for insertion of the tendon, followed by its fixation. If this type of system is used, the cannula must be removed prior to screw placement, as the screw and inserter will not fit. The screw is generally the same size as diameter as the tunnel. • Excess tendon is then cut. • The tendon is fixed under mild tension only, so about 2 to 3 cm of tendon is left proximal to cut.

Postoperative Treatment Postoperative treatment for SLAP repair and biceps tenodesis differ. Active elbow flexion is discouraged for 6 weeks after tenodesis but is allowed for SLAP repair. At 6 weeks, active elbow flexion is allowed for both, but not against resistance for another 6 weeks for tenodesis. At 3 months, unlimited strengthening is allowed for both. For a tenotomy, there are no changes in the normal postoperative rehabilitation regimen for the primary operation, rotator cuff repair, arthroscopic subacromial decompression, or debridement of an irreparable rotator cuff tear.

DISCUSSION Surgeons now recognize that the biceps has an important role in the cause of shoulder pain, and they are performing more biceps tendon operations. Whether this represents an actual increase in our knowledge base or is simply a cyclic variation remains to be seen. It is not known which tenodesis technique is superior or whether any of these techniques provide better results than simple tenotomy. Surgeons must rely on their own experience, training, and judgment until science can guide us.

BIBLIOGRAPHY Tenotomy The primary indication for biceps tenotomy is a poor-quality biceps tendon that will not hold sutures. Patients should be informed of this possibility before the operation. Tenotomy is also done more frequently if the patient is older or less active, if the nondominant arm is involved, or if the patient is obese. Larger patients with less muscle definition generally will not notice any cosmetic deformity. For those patients with an irreparable rotator cuff tear, tenotomy has major benefits in terms of pain relief, and there are no adverse effects. Tenotomy is not difficult to accomplish. If the rotator cuff is intact, a scissor can be placed through the anterior portal and the biceps cut proximally near the anchor. The biceps will generally retract distally, but it may autotenodese in the groove. If this is not desired, the groove can be opened in the subacromial space and further resection can be done. If the rotator cuff is torn, the tenotomy can be done at any time prior to repairing the rotator cuff. It can be done from the anterior cannula or from a lateral cannula once the arthroscope is in the subacromial space.

Ahmad CS, DiSipio C, Lester J, et al. Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon. Arthroscopy. 2007;23:537–541. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007;89:1001–1009. Armstrong A, Teefey SA, Wu T, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg. 2006;15:7–11. Barber A, Field LD, Ryu R. Biceps tendon and superior labrum injuries: Decision-marking. J Bone Joint Surg Am. 2007;89:1844–1855. Boileau P, Ahrens PM, Hatzidakis AM. Entrapment of the long head of the biceps tendon: The hourglass biceps—a cause of pain and locking of the shoulder. J Shoulder Elbow Surg. 2004;13:249–257. Boileau P, Baqué F, Valerio L, et al. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89:747–757. Boileau P, Krishnan SG, Coste JS, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Tech Shoulder Elbow Surg. 2001;2: 153–165. Boileau P, Krishnan SG, Coste JS, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Arthroscopy. 2002;18:1002–1012.



Boileau P, Neyton L. Arthroscopic tenodesis for lesions of the long head of the biceps. Oper Orthop Traumatol. 2005;17:601–623. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: Spectrum of pathology. Part I. Pathoanatomy and biomechanics. Arthroscopy. 2003;19:404–420. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: Spectrum of pathology. Part II. Evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003;19:531–539. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: Spectrum of pathology. Part III. The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19:641–661. Checchia SL, Doneux PS, Miyazaki AN, et al. Biceps tenodesis associated with arthroscopic repair of rotator cuff tears. J Shoulder Elbow Surg. 2005;14:138–144. Choi CH, Kim SK, Jang WC, Kim SJ. Biceps pulley impingement. Arthroscopy. 2004;20(suppl 2):80–83. Dines DM, Warren RF, Inglis AE. Surgical treatment of lesions of the long head of the biceps. Clin Orthop Relat Res. 1982;164:165–171. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis: Operative technique. Arthroscopy. 2000;16:550–552. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg Am. 1998;80:832–840. Gartsman GM, Taverna E. The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy. 1997;13:450–455. Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med. 2007;35:1334–1340. Glueck DA, Mair SD, Johnson DL. Shoulder instability with absence of the long head of the biceps tendon. Arthroscopy. 2003;19:787–789. Hitchcock HH, Bechtol CO. Painful shoulder: Observation on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am. 1948;30:263–273. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: Comparison with arthroscopic findings. Arthroscopy. 2004;20:231–236. Jobe CM. Posterior superior glenoid impingement: Expanded spectrum. Arthroscopy. 1995;11:530–536. Kelly AM, Drakos MC, Fealy S, et al. Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med. 2005;33:208–213. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36:189–198. Kibler WB. Scapular involvement in impingement: Signs and symptoms. Instr Course Lect. 2006;55:35–43. Kibler WB, Uhl TL, Maddux JW, et al. Qualitative clinical evaluation of scapular dysfunction: A reliability study. J Shoulder Elbow Surg. 2002;11:550–556. Kim SH, Yoo JC. Arthroscopic biceps tenodesis using interference screw: End-tunnel technique. Arthroscopy. 2005;21:1405. Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy. 2002;18:1040–1045.

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Kohn D. The clinical relevance of glenoid labrum lesions. Arthroscopy. 1987;3:223–230. Kuhn JE, Lindholm SR, Huston LJ, et al. Failure of the biceps superior labral complex: A cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy. 2003;19: 373–379. Lafosse L, Reiland Y, Baier GP, et al. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: A new classification based on arthroscopic observations. Arthroscopy. 2007;23:73–80. Lunn JV, Castellanos-Rosas J, Walch G. Arthroscopic synovectomy, removal of loose bodies and selective biceps tenodesis for synovial chondromatosis of the shoulder. J Bone Joint Surg Br. 2007;89:1329–1335. Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995;23:93–98. Maier D, Jaeger M, Suedkamp NP, Koestler W. Stabilization of the long head of the biceps tendon in the context of early repair of traumatic subscapularis tendon tears. J Bone Joint Surg Am. 2007;89:1763–1769. Mazzocca AD, Bicos J, Santangelo S, et al. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21:1296–1306. Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy. 2005;21:896. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14:553–565. Motley GS, Osbahr DC, Holovacs TF, Speer KP. An arthroscopic technique for confirming intra-articular subluxation of the long head of the biceps tendon: The ramp test. Arthroscopy. 2002;18:E46. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 1972;54:41–50. O’Donoghue DH. Subluxing biceps tendon in the athlete. Clin Orthop Relat Res. 1982;164:26–34. Osbahr DC, Diamond AB, Speer KP. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy. 2002;18:483–487. Pagnani MJ, Deng XH, Warren RF, et al. Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am. 1995;77:1003–1010. Post M, Benca P. Primary tendinitis of the long head of the biceps. Clin Orthop Relat Res. 1989;246:117–124. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994;22: 121–130. Rodosky MW, Rudert MF, Harner CH, et al. Significance of a superior labral lesion of the shoulder: A biomechanical study. Trans Orthop Res Soc. 1990;15:276. Sekiya LC, Elkousy HA, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy. 2003;19:1137–1141.

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Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4:243–248. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy. 1990;6:274–279. Tuoheti Y, Itoi E, Minagawa H, et al. Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy. 2005;21:1242–1249. Vangsness CT, Jorgenson SS, Watson T, Johnson DL. The origin of the long head of the biceps from the scapula and glenoid labrum: An anatomical study of 100 shoulders. J Bone Joint Surg Br. 1994;76:951–954.

Walch G, Boileau P, Noel E, et al. [Surgical treatment of painful shoulders caused by lesions of the rotator cuff and biceps, treatment as a function of lesions: Reflections on the Neer’s concept]. Rev Rhum Mal Osteoartic. 1991;58:247–257. Walch G, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg. 1992;1:238–245. Walch G, Nove-Josserand L, Boileau P, Levigne C. Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg. 1998;7:100–108.

Stiffness

CHAPTER

6

 

There are three basic conditions that produce shoulder stiffness and are amenable to arthroscopic treatment: idiopathic adhesive capsulitis, posttraumatic stiffness, and postoperative stiffness. The treatment of the stiff, osteoarthritic shoulder is discussed in Chapter 7. Idiopathic adhesive capsulitis is widely believed to be a painful but self-limited condition that resolves between 6 months and 2 years. Recent reports suggest that although most patients improve, many have some residual limitations of movement. Fortunately, this residual loss of motion is generally not functionally disabling and is often unnoticed. However, those who suffer from disabling pain are often unwilling to wait for their condition to resolve and inquire about operative treatment. Shoulder stiffness in diabetic patients seems to cause greater pain, more profound stiffness, and is more refractory to nonoperative treatment than in their nondiabetic counterparts. The impairment from posttraumatic stiffness can often be correlated to the severity of the trauma. Postoperative stiffness can be the result of excessive scarring in the area of surgery (subacromial adhesions after rotator cuff repair, anterior glenohumeral capsule contracture after a Bankart procedure), but profound glenohumeral joint contracture can be seen after surgery that does not violate the capsule (Figs. 6.1–6.3). Release of the capsular contracture or subacromial adhesions can be done in open fashion. However, the arthroscopic technique offers the great advantage of allowing release of intra-articular, subacromial, and subdeltoid adhesions without dividing the subscapularis for glenohumeral adhesions and without creating more adhesions from the open incision. Active range of motion can be started immediately after surgery without concern for tendon repair failure or wound dehiscence.

LITERATURE REVIEW Arthroscopic treatment is generally successful, with the degree of improvement related to the patient’s underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results.

Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great as that seen in patients with idiopathic adhesive capsulitis.

CLINICAL PRESENTATION Patients with all types of adhesive capsulitis present with painful, limited shoulder motion. Pain at night interferes with sleep. Routine activities of daily living that require reaching overhead or behind the back are difficult and painful. Rapid movements cause especially severe pain. Most patients either recall a trivial antecedent injury or cannot identify an inciting event. Patients demonstrate restricted passive and active motion, with the degree of motion loss dependent on the timing of presentation. Radiographs are usually normal, but mild osteopenia due to disuse may be present.

DIAGNOSIS A number of other shoulder conditions that produce painful, limited motion can be eliminated by patient history, physical examination, and radiographic evaluation. Patients with rotator cuff tears present with passive motion greater than active motion, weakness on manual muscle testing, and abnormal magnetic resonance images or arthrograms. In patients with osteoarthrosis, plain radiographs depict loss of the glenohumeral joint space (Fig. 6.4). Patients with posttraumatic stiffness may have malunited fractures, and those with postoperative stiffness may have internal fixation devices that interfere with motion. It is important to obtain a thorough history that ascertains prior trauma or shoulder difficulties. Patients should also be asked about diabetes and thyroid

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FIGURE 6.1  Postsurgical stiffness after rotator cuff repair.

FIGURE 6.2  Postsurgical stiffness after a Bristow procedure.

FIGURE 6.4 Osteoarthrosis.

dysfunction. Evaluate and record passive range of motion in elevation, abduction, and external rotation (in adduction with the arm at the side and in maximal allowable abduction). Measure internal rotation as the vertebral level to which the patient can reach with the extended thumb. Behind-the-back internal rotation is usually decreased, but it is occasionally close to normal because internal rotation measured in this manner includes not only glenohumeral movement but also scapulothoracic motion. With prolonged shoulder stiffness, scapulothoracic motion may increase to compensate for the loss of glenohumeral rotation. For this reason, the scapula should be stabilized with one hand and the arm abducted with the other. Range of motion is compared with the contralateral shoulder. Muscle strength in forward flexion and external rotation may be recorded, but it is often decreased due to pain, so it may not be helpful.

INDICATIONS FOR SURGERY

FIGURE 6.3  Posttraumatic and postsurgical stiffness after open reduction and internal fixation.

As a general principle, we consider operation if the patient has persistent pain and stiffness after 6 months of appropriate nonoperative care. Even then, the patient makes the choice to proceed with surgery. There is no rigid definition of what constitutes stiffness that is significant enough to consider surgery, but we consider severe stiffness as 0 degrees of external rotation and less than 30 degrees of abduction. Moderate stiffness is defined as a decrease of 30 degrees in either plane compared with the contralateral shoulder. If stiffness persists, but pain has diminished after 6 months, nonoperative care can be continued for an additional 2 months in case the decrease in pain indicates that the stiffness is about to resolve or “thaw” spontaneously. If there is no improvement in the range of motion 2



CHAPTER 6

months later, surgery is considered. Of note, it seems that external rotation is an important predictor of success or failure of nonoperative treatment. If external rotation remains at neutral or worse 4 to 6 months after the start of nonoperative treatment, earlier operative intervention is advisable.

LIMITATIONS OF ARTHROSCOPIC SURGERY Relative contraindications to arthroscopic treatment apply mainly to patients with postoperative and posttraumatic stiffness. Patients who have had instability surgery with subscapularis takedown or shortening may develop profound soft tissue contracture. The contracture in these patients is typically extra-articular between the subscapularis and the conjoined tendon. Often, adhesions can be identified between the subscapularis and the conjoined tendon when the arthroscope is placed in the lateral subacromial portal. If this area cannot be well-visualized, open release may be a necessary addition to an arthroscopic glenohumeral joint release. Patients with mildly malunited fractures of the greater tuberosity or proximal humerus can be treated arthroscopically, but those with badly malunited fractures or internal fixation require open release, removal of hardware, and fracture osteotomy, as indicated (see Fig. 6.3). Patients in the inflammatory or contracting phase of idiopathic adhesive capsulitis should not undergo operation because the surgery may accelerate the contracture or simply not be as effective. Once the range of motion has stabilized and is not improving, surgery can be considered. Heterotopic ossification and myositis ossificans are also a contraindication to arthroscopic release (Fig. 6.5).

FIGURE 6.5  Myositis ossificans.

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OPERATIVE TECHNIQUE (Video 6.1) Examination Under Anesthesia The patient is given a regional block for postoperative pain control and then placed under general anesthesia. After the induction of anesthesia, examine both shoulders for range of motion in elevation, abduction, and external rotation in adduction. Place the shoulder in maximal abduction, and record internal and external rotation.

Manipulation A gentle closed manipulation is attempted first (Figs. 6.6–6.11). It is difficult to quantify gentle as it depends on the patient’s habitus. For a thin 60-year-old female with osteopenia, minimal force is applied, and it is better to err on the side of less manipulation and focus on the arthroscopic capsular release. For a more robust younger male, a little more force can be applied. The order of application of force is important. Force is applied gradually and first in forward flexion. This avoids torsional forces that may result in a spiral fracture, and it avoids stress on the acromion. Often the release of adhesions or the tearing of the capsule can be felt and

FIGURE 6.6  Premanipulation forward flexion.

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FIGURE 6.7  Premanipulation external rotation.

FIGURE 6.8  Premanipulation abduction and external rotation showing poor extension.

FIGURE 6.9  Postmanipulation forward flexion.

FIGURE 6.10  External rotation after manipulation in forward flexion and external rotation.



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Superior Superior entry

Inferior entry

Inferior

FIGURE 6.12  Location of joint entry.

FIGURE 6.11  Postmanipulation abduction and external rotation showing improved extension.

heard. If the motion improves with forward flexion, the arm can then be manipulated in abduction. Internal and external rotation in adduction and abduction are done last and may not need to be done at all if the motion improved with the manipulation in forward flexion and abduction. The specific order of motion is important because external rotation and internal rotation involve torsional stresses and may cause a spiral fracture to the humerus. If the shoulder does not respond to abduction and elevation, we do not attempt any rotational movements and proceed directly to arthroscopy. Regardless of whether the motion is improved, we generally still proceed with an arthroscopy to ensure that all adhesions have been released and to release any that remain.

Joint Entry Entry into the stiff shoulder is always difficult because, by definition, the joint volume is reduced. Forceful entry may damage the articular surfaces of either the glenoid or the humeral head. The joint is difficult to enter with a spinal needle because of the tight, thickened posterior capsule; in addition, the generalized capsular stiffness limits the amount of fluid that can be injected. We generally

enter with a standard metal cannula and a rounded trocar. This allows for palpation of the posterior glenohumeral joint line to facilitate entry. The entry position is critical. Joint entry through the traditional soft spot (at the level of the glenoid equator) increases the risk of cartilage surface damage. At this level, the glenohumeral joint space is narrowest, making trocar entry difficult. It is easier in the scenario of capsular contraction to enter more superiorly where there is more space and a lower likelihood of chondral damage (Fig. 6.12). The skin is incised and the cannula is inserted with the trocar until bone is palpated. The shoulder is internally and externally rotated to determine whether the trocar tip rests on the humeral head (movement detected) or glenoid (no movement). The hand can then be lowered (this elevates the trocar tip) until the superior glenoid rim is palpated. At that point, an attempt can be made to enter the joint (Fig. 6.13). Once the arthroscope is in the glenohumeral joint, it is directed at the rotator interval. The scene that usually greets the surgeon after a successful manipulation is one of blood and poor visualization (Fig. 6.14). This generally can be cleared by evacuating the scope cannula by withdrawing the arthroscope. Once the anterior interval can be visualized, a spinal needle is inserted anteriorly, lateral to the coracoid process, to allow for placement of a plastic 5-mm cannula and trocar.

Rotator Interval The first step in the operation is to release the rotator interval (Figs. 6.15 and 6.16). This can be done with a shaver, cautery, or both. The instrument is inserted through the cannula into the joint. The cannula is

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FIGURE 6.15  Synovitis of the rotator interval.

FIGURE 6.13  Palpate the bone to determine the entry point.

FIGURE 6.16  Initiation of anterior interval resection.

Anterior Capsule

FIGURE 6.14  Bloody joint after manipulation.

then backed out of the joint, leaving the instrument tip in the rotator interval. Soft tissue is excised from an area bounded by the biceps tendon medially, the superior border of the subscapularis tendon inferiorly, and the humeral head laterally. The coracoacromial ligament should be visible as a shiny structure at the anterior border of the acromion once this is completed. Reinsert the cannula into the joint and remove the instrument.

Identify the point where the middle glenohumeral ligament (MGHL) crosses the subscapularis tendon. It is important to separate the subscapularis tendon from the MGHL in order to not damage the subscapularis. A blunt dissector may help separate the two structures. The MGHL is then divided using a soft tissue punch, shaver, or cautery. The capsule posterior to the subscapularis including the anterior inferior glenohumeral ligament is then divided as well. This can be done with an electrocautery near the equator of the joint, but a punch or a shaver should be used more inferiorly. The adhesions on the anterior surface of the subscapularis are released as well, using a shaver or a cautery. Essentially, the subscapularis is skeletonized (Figs. 6.17–6.24). At this point, usually a small amount of increased lateral humeral head displacement is possible. The arthroscope can be advanced anteriorly and inferiorly to provide a better view of the posterior portion of the



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FIGURE 6.17  Release of the middle glenohumeral ligament.

FIGURE 6.18  After excision of the middle glenohumeral ligament.

FIGURE 6.19  Anterior capsular release with a punch.

FIGURE 6.20  Anterior capsular release with a shaver.

FIGURE 6.21  Shaver débriding the capsule posterior to the subscapularis.

FIGURE 6.22  Cautery excision the adhesions and tissue anterior to the subscapularis.

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FIGURE 6.23  Interval created between the subscapularis on the left and the coracoid/conjoined tendon on the right.

FIGURE 6.24  Skeletonized subscapularis.

FIGURE 6.26  Right shoulder with anterior capsule excised.

anterior inferior glenohumeral ligament and the inferior capsule. The punch is advanced, placing the bottom, blunt jaw exterior to the capsule, and dividing the capsule from anterior to posterior as far from the glenoid labrum as possible (Figs. 6.25 and 6.26). The level at which to stop the inferior-anterior release depends on the amount of axillary pouch contracture. A tight pouch limits the degree to which the punch can safely be advanced without losing direct visualization. This is usually at about the 5-o’clock position for a right shoulder. To access and safely release the axillary pouch, the posterior and inferior-posterior areas of the capsule must first be addressed. The soft tissue punch is removed from the anterior cannula. The camera is then placed in the anterior cannula. Under direct vision, a blunt metal trocar is placed through the posterior portal. This allows for an assessment of the trajectory needed to insert instruments. This metal trocar is then replaced with a shaver that is used to débride the posterior capsule and develop a capsular plane to allow resection of the posterior inferior and inferior capsule from posterior to anterior. Once this plane is developed, a punch can be used to cut the capsule along the inferior labral and glenoid margin. Caution must be exercised to avoid injury to the axillary nerve. Occasionally, if there is any concern, a small layer of capsule is left as a barrier. The arm is placed in slight abduction and external rotation to protect the axillary nerve (Figs. 6.27–6.38; Video 6.2.)

Subacromial Space The arthroscope is then placed into the subacromial space. If the subacromial space is not clearly seen, a FIGURE 6.25  Right shoulder with anterior capsule excised.

Text continued on page 177.



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FIGURE 6.27  Posterior view of inferior capsular tear from the manipulation.

FIGURE 6.28  Same shoulder with lateral distraction to show the capsular tear.

FIGURE 6.29  Posterior view of left shoulder showing inferior extent of capsular incision.

FIGURE 6.30  Anterior view of same left shoulder showing capsular incision to the 7 o’clock position.

FIGURE 6.31  Anterior view of a right shoulder showing complete release of anterior capsule from the anterior glenoid.

FIGURE 6.32  Anterior view of right shoulder with posterior capsular portal hole.

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FIGURE 6.33  Anterior view of right shoulder with development of the posterior capsular defect done with a shaver.

FIGURE 6.35  Axillary nerve beneath the shaver.

FIGURE 6.37  Anterior view of right shoulder showing completed connection of anterior and posterior releases.

FIGURE 6.34  Anterior view of right shoulder showing posterior and inferior capsular resection with shaver and punch.

FIGURE 6.36  Axillary nerve beneath the shaver.

FIGURE 6.38  Anterior view of left shoulder showing a thin barrier of capsule left to protect the axillary nerve.



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FIGURE 6.39  Lateral view of a right shoulder showing the coracoacromial ligament with mild subacromial adhesions.

FIGURE 6.40  Same shoulder with subacromial adhesions resected.

shaver and cautery can be inserted and used to remove bursa and adhesions (Figs. 6.39 and 6.40). An acromioplasty may not be advisable, even if there is arthroscopic evidence of impingement, such as rotator cuff or coracoacromial ligament fraying. By definition, a patient with adhesive capsulitis cannot move his or her shoulder into the positions consistent with the clinical diagnosis of impingement. The raw acromial bone surface produced after acromioplasty creates the opportunity for postoperative adhesions and should be avoided.

If covered by insurance, the patient is immediately placed in a continuous passive motion (CPM) chair, and they are encouraged to use it at least 4 hours per day, preferably in 1-hour increments. The patient is encouraged to discard the postoperative sling as soon as the regional block has worn off. They are encouraged to use the shoulder for activities of daily living. The patients will still often be frustrated postoperatively, as their motion is not immediately restored and it still may take 3 to 6 months to see significant improvement. We routinely take photographs in the operating room showing the pre- and postmanipulation range of motion, and we give them to the patient to provide them with hope and an incentive to work hard to achieve better motion. They can often become discouraged, and even distrustful, early in the postoperative course. Often the postoperative visit at 6 weeks can be a difficult one, even if the postoperative expectation of slow improvement in motion was detailed prior to surgery. If the patient still has poor motion or is frustrated with poor improvement at 3 months, we send them for aggressive myofascial release techniques. Rarely, if ever, has a repeat surgery needed to be done, but this is an option after 4 to 6 months.

POSTOPERATIVE CARE Many patients with surgical adhesive capsulitis have diabetes or prediabetes. The anesthesia and surgery itself is a physiologic challenge that may increase the patient’s serum blood sugar. For these reasons, oral and injectable steroids are often not used. Instead, the patient is started on oral nonsteroidal antiinflammatory drugs (NSAIDs) immediately, and as long as the patient can tolerate it, they are continued for 4 to 6 weeks. Prior to surgery, the patient will have arranged 2 weeks of daily outpatient physical therapy that transitions to three times per week for weeks 2 to 4. Insurance companies often limit the amount of physical therapy, so we take care to have it approved and scheduled prior to surgery.

CHAPTER

7

Arthrosis

 

Articular cartilage pathology in the shoulder can present in many scenarios. The most common is some degree of osteoarthrosis or chondromalacia. The less common scenarios are avascular necrosis, rheumatoid arthritis, chondrolysis, and osteochondromatosis. The current arthroscopic treatment of these conditions is limited with little scientific evidence to guide orthopedic surgeons, but with increased knowledge and technology, this will inevitably change. The lesions that surgeons encounter in these conditions and may need to address surgically include chondral damage and deficiency, labral tearing, loose bodies, capsular thickening or hypertrophy, and synovitis. These findings can cause pain, stiffness, and mechanical symptoms that the surgeon tries to address (Video 7.1).

DIAGNOSIS The diagnosis of osteoarthrosis, rheumatoid arthritis, or avascular necrosis is made clinically with a combination of patient history, physical examination, laboratory tests, and imaging studies (Figs. 7.1–7.3). There are still often situations in which cartilage lesions are unsuspected and are encountered during arthroscopic treatment for impingement, rotator cuff tear, or glenohumeral instability (Figs. 7.4 and 7.5).

be counseled that these interventions have no definitive proven benefit at the present time to modify the natural history of any of the conditions listed previously, and they may not improve pain relief either.

INDICATIONS FOR SURGERY Surgical indications vary with the underlying disease process. The main indications for surgery are pain, stiffness, and mechanical symptoms not manageable with conservative measures. Certainly, for advanced stages of avascular necrosis, rheumatoid arthritis, chondrolysis, and osteoarthritis, arthroplasty is the definitive option. However, some patients may wish to avoid these options for various reasons, including young age. Mechanical symptoms are the most reliably improved symptoms, particularly if there is a loose body or displacing flap of cartilage. Stiffness may be improved with a capsular release, but unlike adhesive capsulitis, it is rarely restored to normal. The main issue with surgical management is that pain is not as predictably improved in most of the pathologies addressed, although it can be improved if the main component of surgery is a synovectomy, such as in rheumatoid arthritis.

CONTRAINDICATIONS TO SURGERY NONOPERATIVE TREATMENT Nonoperative treatment is largely palliative and consists of medication or injections to diminish the inflammatory response and physical therapy to maintain or improve shoulder range of motion and strength. Some alternative options such as the use of platelet rich plasma and stem cell injections have gained popularity and can be considered options. However, patients should

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Contraindications to the arthroscopic treatment of arthrosis also vary with the underlying disease process. Synovectomy does not benefit a patient with articular incongruity. Core decompression cannot be expected to reverse bone collapse. Débridement of a small labrum tear will not help a patient with severe advanced osteoarthrosis. Manipulation under anesthesia is not helpful for patients with osteoarthritis.



CHAPTER 7

FIGURE 7.1  Radiograph of osteoarthritis.

FIGURE 7.2  Radiograph of avascular necrosis.

OSTEOARTHRITIS Osteoarthrosis is probably the most common clinical cause of glenohumeral incongruity seen in the office. The source of pain in osteoarthrosis is multifactorial and consists of joint surface irregularity, mechanical disturbances from loose or displaced labrum and chondral fragments, loose bodies, and joint contracture (Figs. 7.6–7.9). Arthroscopic lavage reportedly achieves temporary, limited pain relief owing to either the placebo effect or alterations in the chemical composition of the

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FIGURE 7.3  Magnetic resonance imaging of early to mid-stage avascular necrosis.

FIGURE 7.4  Chondral damage of the glenoid in the left shoulder prior to fragment displacement.

glenohumeral joint fluid. However, patients return to their baseline states relatively quickly, so such procedures are not advisable. If a surgeon wishes to treat a patient with glenohumeral arthrosis arthroscopically, the approach must be comprehensive and include removal of loose bodies and labrum fragments, release of soft tissue contracture, and restoration of joint surface congruity. Restoration of joint surface congruity may include débridement of glenoid and humeral head osteophyte. Unless the surgeon is capable of dealing with all these elements, an arthroscopic approach is unwarranted. The surgeon must also carefully explain that the procedure is not guaranteed to

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FIGURE 7.5  Chondral damage of the glenoid in the left shoulder after fragment displacement.

FIGURE 7.8  Synovial inflammation, hypertrophy, and contracture of the anterior interval of a right shoulder in osteoarthrosis.

Joint contracture Capsule Coracohumeral lig.

Surface irregularity Loose bodies

Mechanical Labrum fragments

FIGURE 7.9  Loose body and humeral head donor site in a right shoulder. FIGURE 7.6  Sources of pain in osteoarthrosis.

FIGURE 7.7  Chondral delamination of the humeral head of the right shoulder.

succeed, but offers a less invasive option for relief than arthroplasty. After the administration of anesthesia, the shoulder is examined for range of motion but closed manipulation is not useful. Standard posterior and anterior portals are established. This can sometimes be difficult due to joint contracture and capsular volume loss. In order to facilitate entry, it is helpful to insert the posterior cannula and trocar first, placing the entry point more superior than normal, just inferior to the posterior acromion and about 1 cm medial to the posterolateral corner of the acromion. This more superior entry into the glenohumeral joint circumvents the need for the trocar to enter the joint between the humeral head and glenoid (Fig. 7.10). A complete glenohumeral joint inspection is done, observing in particular the presence and extent of cartilage loss, labrum flap tears, loose



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Superior Superior entry

Inferior entry

Inferior

FIGURE 7.10  There is more space for the trocar at the superior aspect of the glenohumeral joint.

FIGURE 7.12  Rotator interval débridement with a cautery.

FIGURE 7.11  Rotator interval débridement with a shaver.

FIGURE 7.13  Thickened middle glenohumeral ligament prior to excision.

bodies, synovitis, rotator cuff fraying or tearing, biceps pathology, and capsular contracture. The anterior portal may also be difficult to establish, as the anterior capsule is also difficult to penetrate. It is sometimes necessary to use only the metal trocar (without the cannula) to create an entrance to the glenohumeral joint and subsequently place either a standard shaver or cautery to débride the rotator interval to allow access to the joint (Figs. 7.11 and 7.12). A complete capsular release is then initiated starting anteriorly, moving inferiorly, and finally, posteriorly. The inferior release is also completed posteriorly. Particular attention is paid to the subscapularis, as it seems critical to restore subscapularis muscle excursion. The middle glenohumeral ligament (MGHL) is adherent to the posterior (articular) surface of the subscapularis. The plane between these two structures should be identified, and the MHGL is excised. A complete

“skeletonization” is done of the subscapularis, releasing adhesions posteriorly, anteriorly, and superomedially into the subcoracoid recess. This can be done with blunt dissectors, shavers, or cautery. This process of subscapularis release is often completed after an anterior superior portal is established to better view the subcoracoid recess, while instrumentation is done through the anterior or more anterior inferior portal (Figs. 7.13–7.17). The surgeon should carefully inspect the subcoracoid space and the bicipital sheath, where loose bodies may be overlooked (Figs. 7.18 and Fig. 7.19). The biceps sheath should be inspected later as well, after entry into the subacromial space distally to the level of the pectoralis major tendon insertion (Figs. 7.20 and 7.21). The anterior and posterior capsule releases are similar to those performed for adhesive capsulitis, but the inferior release is different. With adhesive capsulitis,

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FIGURE 7.14  Thickened middle glenohumeral ligament after excision.

FIGURE 7.15  Anterior superior portal view of subcoracoid space releasing adhesions.

FIGURE 7.16  Undersurface of the coracoid exposed.

FIGURE 7.17  Subscapularis exposed with anterior portal view.

FIGURE 7.18  Loose bodies in the subcoracoid recess of a right shoulder viewed from the anterior portal.

FIGURE 7.19  Loose bodes removed from the shoulder in Fig. 7.18.



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FIGURE 7.20  Biceps sheath of right shoulder expanded due to loose bodies.

FIGURE 7.23  Anterior capsule excised in a left shoulder to reveal the posterior aspect of the subscapularis.

FIGURE 7.21  Loose bodies removed from the biceps sheath of the shoulder in Fig. 7.20.

FIGURE 7.24  Anterior superior portal view of punch used from the posterior portal to release the posterior inferior capsule of this left shoulder.

FIGURE 7.22  Punch used to release the anterior inferior capsule of a left shoulder.

the inferior capsule can often be released by shoulder manipulation after the division of the anterior and posterior capsule. Patients with arthrosis have an extremely thick inferior capsule, however, and such an approach is generally not successful. The inferior capsule must be divided with a capsular resector. This requires the surgeon to release the anterior-inferior capsule from an anterior approach and the posterior-inferior capsule from a posterior approach (Figs. 7.22–7.24). Next, attention can be turned to the bone and chondral surfaces of the glenoid and the humeral head. Any prominences that are easily accessible are removed. The typical inferior humeral head osteophyte is often difficult to access, so it is often left alone. Other prominences that are addressed include intralesional osteophytes, any flaps of torn labrum, or disrupted and

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delaminating chondral surfaces. These are addressed with débridement and not repair. We perform whatever intervention will not require the patient to be immobilized postoperatively. Previously we have advocated bony resection to improve congruency. This can be done, but we no longer do this routinely or, if it is done, it is not done aggressively. After surgery, patients begin active and passive range of motion exercises immediately either with formal physical therapy (PT) or on their own. The results in this carefully selected and counseled group of patients have been gratifying. Approximately 50% report satisfaction with the procedure and experience a significant decrease in pain and an increase in motion and function.

RHEUMATOID ARTHRITIS As in other joints, synovectomy of the rheumatoid shoulder is most beneficial when carried out early in the disease process, before the cartilage and bone have been destroyed and the rotator cuff eroded (Fig. 7.25). The patient is staged according to the Steinbrocker radiographic and functional classification (Table 7.1). Subsequent patient evaluation allows the surgeon to

reassess the disease progression. Patients in radiographic stages I and II and functional classes I and II have the best chance of benefiting from arthroscopic synovectomy and débridement. The glenohumeral joint is entered through a standard posterior portal. A standard anterior inferior cannula is then established. Because of the bleeding that often occurs with rheumatoid synovectomy, an electrocautery or thermal probe is used to “paint” all areas of proliferative synovitis before resection. A pump is essential also to help control bleeding. A grasping forceps is used to remove large pieces of loose cartilage or soft tissue, and a motorized resector is used to débride labrum flap tears. A whisker resector allows for a thorough synovectomy with minimal damage to the glenohumeral joint capsule. After the synovectomy is done anteriorly, the arthroscope is placed anteriorly and the resector posteriorly to complete the removal of soft tissue in the posterior-inferior and posterior regions. After carefully inspecting the subscapularis recess for additional synovitis or loose bodies, the arthroscope is placed into the subacromial space. Bursal proliferation is often profound. The hypertrophic bursa is removed with the cautery and the shaver, along with an arthroscopic subacromial decompression and acromioclavicular joint resection if indicated by clinical examination (Figs. 7.26–7.37). Postoperative rehabilitation is identical to that described for the treatment of osteoarthritic glenohumeral joints.

TABLE 7.1  Steinbrocker Radiographic and Functional Classification of Rheumatoid Arthritis Radiographic Classification Stage I No destructive change; osteoporosis and soft tissue change only Stage II Mild to moderate erosive change or joint space reduction Stage III Joint markedly narrowed (