Arthroscopy of the Upper Extremity

Diagnostic and surgical arthroscopy of the upper extremity has become much more common as surgeons have developed proficiency with the arthroscope and appropriate instrumentation has been developed. A thorough knowledge of the anatomy, disorders, arthroscopic variations, and pathologic findings of each joint is essential to perform the procedures successfully and to minimize complications. This chapter discusses indications for arthroscopic treatment, patient preparation, portal anatomy, specific arthroscopic techniques, and complications after arthroscopy of the shoulder, acromioclavicular, and elbow joints.

Shoulder

Painful syndromes, altered function, and signs and symptoms of instability and internal derangement are frequent in the shoulder. The causes of such dysfunctions can be difficult to prove. The underlying cause often can be established by a careful history and physical examination combined with appropriate radiographic evaluation of the shoulder girdle, cervical spine, and thoracic cavity. Further workup may include other diagnostic studies, including stress radiographs, CT with or without intraarticular contrast dye, MRI with or without intraarticular contrast dye, ultrasound, and electromyographic studies/nerve conduction studies.

Appropriate radiographs should be obtained and include anteroposterior view with arm in external rotation, true anteroposterior view (Grashey view) with arm in internal rotation, scapular outlet view, and axillary lateral view. In an adolescent athlete, with dominant-side pain during sports requiring overhead motion, anteroposterior views with the shoulder in internal and external rotation help to evaluate for physeal injury. Young adults with symptoms of instability may require further radiographs, including West Point, Bergeneau, and Stryker notch views, to evaluate for potential glenoid and humeral head bony defects.

MRI is useful to evaluate the soft-tissue structures surrounding the shoulder and is most useful in identifying rotator cuff pathology. Magnetic resonance arthrography (MRA) is most commonly used to identify capsulolabral pathology which can be difficult to visualize with standard MRI. In acute instability, hemarthrosis provides good contrast medium; thus MRA may not be necessary. MRA is especially helpful in evaluation of biceps labral complex or superior labral anterior to posterior (SLAP) tears and better delineates humeral avulsion of the glenohumeral ligament. For chronic instability or if radiographs indicate bony defects from instability, three-dimensional CT is the best means of quantifying bone loss in deciding whether an arthroscopic or open reconstruction is warranted.

Careful thorough preoperative planning is essential for all arthroscopic surgical procedures. The surgeon also should consider potential unexpected findings and mentally prepare for an open procedure when necessary to obtain the best results.

Indications

For developmental, traumatic, degenerative, or inflammatory conditions of the shoulder resulting in pain, instability, or disability that cannot be controlled by conservative measures, arthroscopic treatment performed by a skilled surgeon results in a low-risk, high-reward reproducible procedure. Contraindications to shoulder arthroscopy include local skin conditions, remote infections that might spread to the joint, and increased medical risks. Surgeons considering arthroscopic procedures should adhere to appropriate indications for the technique and should advise patients about the possibility of an open procedure if arthroscopic findings warrant it.

Patient Positioning and Anesthesia

Two basic positions for shoulder arthroscopy have been described: the lateral decubitus and the “beach-chair” positions. Both positions have potential advantages and disadvantages, and the decision between the two is largely dependent on the surgeon’s training and comfort with each position. Advantages of the lateral decubitus position include better ability to apply traction to the arm, better access to the posterior shoulder, and ease and safety of position. Advantages of the beach-chair position include more anatomic orientation, greater ease of manipulating the arm with an arm positioner, less risk of traction neuropraxia, and ability to easily convert to an open procedure. There remain concerns over cerebral perfusion with the beach-chair position because complications of stroke and death have been reported from hypotensive episodes. Blood pressure at the brachium is lower than that in the cerebrum and potentially significantly lower if carotid artery disease is present. Because blood pressure measured in the calf of a patient in the beach-chair position can be easily 40 mm Hg higher than the accurate cerebral perfusion pressure, pressure should be monitored on the opposite brachium or with cerebral perfusion monitors when possible. Recent studies, however, have demonstrated safety with shoulder arthroscopy in the beach-chair position with no cognitive deficits and much lower frequency of clinical deoxygenation events.

Lateral Decubitus Position

The patient is placed in the lateral decubitus position with the affected shoulder exposed and is supported by a vacuum beanbag and kidney rest. A chest strap is used for additional support. The patient’s head is supported by a foam rest, and care is taken to protect the eyes and the downside ear. An axillary roll often is requested by anesthesiologists to improve ventilation.

Peripheral pulses and pulse oximeter readings should be evaluated to ensure axillary structures are not compromised. All pressure points are padded, with a pillow beneath the down leg protecting the peroneal nerve and lateral malleolus and one or more pillows between the knees and ankles. This straight lateral decubitus position can be modified by tilting the patient 20 degrees posteriorly, so that the glenoid surface is placed parallel to the floor.

Using a commercially available sterile arm traction device, 10 to 13 lb of traction is applied. Overdistraction with excessive weight should be avoided. The principle is more one of balanced suspension. Only the amount of traction required for clear viewing should be used. Most arthroscopists use 30 to 60 degrees of abduction and 20 to 30 degrees of forward flexion and pay more attention to the amount of traction and the length of the procedure ( Fig. 52.1 ). A small, soft bolster can be placed in the axillary area to provide lateral displacement of the humeral head.

FIGURE 52.1, Traction for distraction of glenohumeral joint with minimal inferior subluxation. Wide 4-inch sling should be used; amount of traction and length of procedure should be monitored.

The arm position for arthroscopy of the subacromial space and acromioclavicular joint is slightly different. The arm is brought down to 20 to 45 degrees of abduction and 0 degrees of flexion. This position permits mild inferior subluxation of the humeral head, opening up the subacromial space.

Beach-Chair Position

The patient is placed supine on the operating room table with a commercially available beach-chair attachment. Pillows or commercially available pads are placed under the knees to take tension off the sciatic nerve. The patient’s head is securely fastened to the headrest with a foam facemask. Eye protection is ensured, and the endotracheal tube is placed to exit from the contralateral side of the mouth. The patient is carefully inclined so that the undersurface of the acromion is roughly parallel with the floor, generally 70 to 80 degrees of inclination after satisfactory blood pressure is obtained. If concerns over blood pressure are present the patient can be inclined halfway and repeat blood pressure measurement obtained. Once in position, special attention is paid to the alignment of the cervical spine to avoid cervical extension. The patient is secured to the bed with straps over the waist and lower extremity as well as kidney rests ( Fig. 52.2 ).

Commercially available arm positioners with sterile attachments are valuable in allowing the surgeon to easily position the upper extremity during the surgical procedure and freeing up a surgical assistant who now does not have to hold the arm.

Control of Bleeding During Arthroscopy

Hemostasis is paramount during shoulder arthroscopy. Bleeding during shoulder arthroscopy decreases visualization and lengthens the surgical procedure. One method of controlling bleeding is to add 1 mL of 1:1000 epinephrine to each 3000-mL bag of irrigant, if the patient has a stable pressure and no cardiac contraindications. We have not experienced any anesthetic problems with this mixture. Another technique, and perhaps the most effective, is to use hypotensive anesthesia, with a systolic blood pressure of 90 to 100 mm Hg. A systolic-to-pump pressure gradient of approximately 40 mm Hg should be maintained when possible. Elevation of the fluid bags 3 feet above the level produces a similar pressure gradient of 66 mm fluid flow pressure. The surgeon also should be aware of locations that have a tendency to bleed, including the areas around the scapular spine, coracoacromial ligament, and coracoid base.

Fluid Extravasation

Fluid extravasation also is more of a problem during shoulder arthroscopy than during knee arthroscopy. The increased depth of tissue traversed makes reinsertion of cannulas difficult. Tissue is traumatized, or “new” portals are created with subsequent passes, and fluid extravasation is worsened. Established portals should be maintained by an interchangeable cannula system or by cannulas with rubber diaphragms that close while instruments are being exchanged. Procedures such as subacromial decompression are extraarticular, and fluid extravasation can be pronounced. Lo and Burkhart evaluated 53 patients immediately after shoulder arthroscopy and found an average fluid weight gain of 8.7 lb. Keeping arthroscopy portals with a tight fit, avoiding violation of the deltoid fascia, and increasing pump pressure only when necessary can help avoid fluid extravasation.

Portal Placement

The number of described arthroscopic portals for the shoulder has greatly increased as shoulder surgical procedures have become more complex. The nomenclature for various portals often is confusing because authors have used the same descriptive terms for anatomically different portal sites. Before making arthroscopic portals, a thorough understanding of the local anatomy is necessary to prevent damage to neurovascular structures ( Fig. 52.3 ). The portal that passes closest to a neurovascular structure is the low anterior portal approximately 1 cm from the cephalic vein. Awareness of the axillary nerve is important in portal placement anteriorly, posteriorly, and laterally. Posteriorly, the suprascapular nerve and circumflex scapular artery are approximately 2 cm from the portal site. Later portals, which are used to work on the glenohumeral space, should be directed to enter medial to the rotator cable ( Table 52.1 ).

FIGURE 52.3, A, Bony landmarks outlined on skin. B, Anterior neurovascular structures.

TABLE 52.1

Description of Portals

ANTERIOR	5-o’clock portal (Davidson)	The leading edge of the inferior glenohumeral ligament at the 5-o’clock position of the glenoid rim (right shoulder)	The arthroscope is placed through the posterior “soft point” portal, withdrawn, and replaced by a Wissinger rod, which is passed through the anterior capsule while the humerus is maximally adducted. Better with spinal needle outside-in technique. Percutaneous for better localization and angle to the glenoid. Percutaneous localization approximately 1 cm inferior and just lateral to coracoid 1 cm from cephalic vein entering joint just superior to the inferior glenohumeral ligament through junction of mid third and inferior third of subscapular tendon
	Anterior inferior (Wolf)	The arthroscope slides off the inferior edge of the coracoid tip	The arthroscope placed through the posterior “soft point” portal is withdrawn and replaced by a Wissinger rod, which is passed through the anterior capsule
	Anterior central (Matthews)	Skin point lateral to the coracoid	The space limited by the humeral head lateral, the glenoid rim medially, the long head of the biceps tendon superiorly, the subscapularis tendon inferiorly
	Anterior superior (Wolf)	Mid distance between the coracoid and the acromion	Enters the joint just anterior to the long head of the biceps tendon
	Superolateral (Laurencin)	Lateral to the acromion on a line drawn from the acromion to the coracoid	Enters the joint obliquely directly above the biceps tendon, where it pierces the rotator interval tissue
	Anterolateral (Ellman)	2 cm below the lateral edge of the acromion in the prolongation of its anterior edge	Medially to the subacromial bursa
POSTERIOR	Soft point	1.5 cm inferior and 2 cm medial to the posterolateral corner of the acromion	To the coracoid
	Central posterior (Wolf)	2 cm medial and 3 cm inferior to the posterolateral corner of the acromion	To the coracoid
	Posterolateral (Ellman)	2 cm below the lateral edge of the acromion in the prolongation of its posterior edge	Medially to the subacromial bursa, just medial to the ledge of the acromion
	7-o’clock portal (Davidson)	3–4 cm inferior and approximately 1 cm lateral to the posterolateral acromial edge
LATERAL	Portal of Wilmington	1 cm anterior and 1 cm lateral to the posterolateral corner of the acromion	45-degree approach angle to the posterosuperior glenoid labrum
	Transrotator cuff (O’Brien)	1 cm posterior and 2 cm lateral to the anterolateral corner of the acromion	To the 11-o’clock position in the glenoid labrum (right shoulder) medial to the rotator arch
SUPERIOR	Neviaser portal	Superior “soft spot” surrounded by the clavicle anteriorly, the medial edge of the acromion 1 cm medially, and the spine of the scapula posteriorly	Down at 30 degrees laterally and slightly posteriorly into the glenohumeral joint
	Superior suprascapular nerve portal (Lafosse)	Percutaneous, approximately 7 cm medial to lateral border of acromion, approximately 2 cm medial to Neviaser portal. Approach to suprascapular notch.

Posterior Portal

The posterior portal is the primary entry portal for shoulder arthroscopy. It allows examination of most of the joint and assists in the placement of subsequent portals. Thus, before making the posterior portal, its purpose and functions should be known ( Fig. 52.4 ). For visualization, the “soft spot” portal works well. This portal is located 1.5 to 3 cm inferior and 1 cm medial to the posterolateral tip of the acromion. Thus, the location attempts to pass through the posterior soft spot between the infraspinatus and teres minor muscles. By placing the portal 1 cm medial to the posterolateral acromion, the portal can be made approximately parallel to the glenoid articular surface, making for easier passage of the arthroscopic instrumentation to the anterior part of the joint. To locate this spot, one places a hand on the top of the shoulder and palpates the coracoid process with the index or long finger and the posterior soft spot with the thumb. By rotating the humerus with the opposite hand, the posterior glenohumeral joint line often can be located with the thumb. If a posterior stabilization procedure is contemplated, or if two posterior portals are necessary, the portal is made 1.5 to 2 cm inferiorly in line with the acromial edge. For subacromial procedures, a portal 15 cm inferior and in line with the acromion works nicely. A second posterior portal can subsequently be made under direct vision. When a posterior procedure is the main focus, an anterior portal should be made first and then the posterior portals under direct vision.

FIGURE 52.4, Posterior shoulder portal risks injury to suprascapular nerve if too medial and to axillary nerve if too inferior or lateral.

Establishing A Posterior Portal

Technique 52.1

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Establish a posterior portal by inserting an 18-gauge spinal needle through the posterior soft spot into the joint. Place the index or long finger on the coracoid tip to direct the needle anteromedially toward the coracoid. The needle should meet little resistance entering the joint, but sometimes it abuts the humeral head.
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After the capsule has been entered, inject 30 to 40 mL of saline into the joint; far less fluid may be accepted if adhesive capsulitis is significant. There should be free flow into the joint and free backflow. Preinsufflation of the joint produces some distraction of the humeral head from the glenoid and makes entry into the joint with the cannulas easier. If the needle is extraarticular, however, the initial fluid bolus is injected into the soft tissues, distorting the anatomy. Some authors prefer using a blunt trocar to enter the joint before joint distention because the glenoid neck and humeral head are more easily palpable without distention. The blunt trocar is used to palpate the neck and head area before entering into the triangle just superior to the glenohumeral articulation.
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After the skin site for the posterior portal is selected, inject this area and other planned arthroscopic portal areas with local anesthetic and epinephrine to decrease bleeding.
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Incise the superficial skin layer with a No. 11 knife blade. Avoid deeper penetration because it may precipitate excessive bleeding.
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Insert a cannula and blunt trocar along the path of the needle, anteriorly and medially toward the anterior joint line. Palpate the bony scapular neck and glenoid with the blunt tip of the trocar to determine the midpoint in a superoinferior direction. Slide the trocar laterally to locate the rim of the glenoid as a small ridge. Immediately lateral to this ridge is the entry site for the joint capsule. This position ensures that the entry site is as far medial as possible and that it passes through the muscular portions of the rotator cuff instead of damaging the tendinous portions.

Posteroinferior Seven-O’clock Portal

Davidson and Rivenburgh described a 7-o’clock accessory posterior working portal for shoulder arthroscopy that allows direct access to the inferior glenohumeral capsule and avoids damage to the nearby structures. The inside-to-outside portal is created by using a switching stick passed through the 3-o’clock portal and directed posteroinferiorly. The switching stick is brought through a small skin incision and left in place. The outside-to-inside 7-o’clock portal is established by making a small skin incision 2 to 3 cm inferior and 1 cm anterior to the posterior acromial edge. A blunt-tipped rod is then inserted into the glenohumeral joint under direct vision.

Anterior Portal

Multiple anterior portals have been described for diagnostic and surgical stabilization techniques. For complete diagnostic examination of the shoulder, an anterior portal is essential to allow observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon. The most commonly described anterior portal is made slightly lateral to a point halfway between the anterolateral tip of the acromion and the coracoid process. Other described portals are superior or inferior to this portal and lateral to a line drawn from the coracoid toward the anterolateral aspect of the acromion. The anteroinferior portal is made just lateral and slightly superior to the palpable coracoid process. The anterolateral portal is made approximately 1 cm lateral to the anterolateral tip of the acromion and enters the glenohumeral joint through the rotator interval. If this portal is made, a large inflow sheath should not be used to prevent damage to the rotator cuff musculature. When anterior stabilization procedures are contemplated, the anterior portals should be separated as much as is safely possible to allow easy placement of instruments without overcrowding and disrupting vision. For repair of superior labral pathologic conditions, an accessory anterosuperior portal just anterior to the acromioclavicular joint may be needed.

The anterior portal is established after the posterior portal, and the posteriorly placed arthroscope is used to assist visually with its establishment. Two basic methods are used to establish the anterior portal: antegrade (outside-in) and retrograde (inside-out). With both methods, the cannula passes through the anterior soft spot, which corresponds to an intraarticular triangle bounded by the intraarticular portion of the biceps tendon superiorly, the superior intraarticular portion of the subscapularis tendon inferiorly, and the anterior edge of the glenoid at the base. Accessory portals are made by using a spinal needle to confirm appropriate placement of the portal that allows access to the pathologic process. The portal is made using an outside-in (antegrade) technique.

Antegrade Method

Technique 52.2

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Before joint distention, when anatomic landmarks can be palpated, mark on the skin the approximate sites for arthroscopic anterior portal placement.
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Push the arthroscope, which is already in the posterior portal, up into the anterior soft spot triangle formed by the glenoid articular surface, the biceps tendon, and the subscapularis tendon. Push the arthroscope up against the area of the joint capsule and, with the overhead lights off, transilluminate the area of intended portal placement.
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Back the arthroscope slightly away from this area and palpate externally from the intended portal site while observing arthroscopically the soft spot area. Pass a spinal needle from this spot into the joint. Manipulate the spinal needle within the joint to ensure ease of instrumentation.
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Withdraw the needle and, with a No. 11 blade, make a portal in this chosen spot.
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Pass a cannula with a blunt trocar into the joint capsule. Before penetrating the capsule, move the arthroscope superiorly so that the lens is not damaged as the trocar enters into the joint. Maintain careful control of the trocar to prevent damage to articular structures or to the arthroscope.
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If an accessory anterior portal is necessary, the decision about its location should be made before making the initial anterior portal. The accessory anterior portals should be separated by at least 2 to 3 cm. The appropriate position of an accessory portal also can be confirmed with a spinal needle.

Retrograde Method

Technique 52.3

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“Drive” the arthroscope, which is in the posterior portal, directly into the soft spot. Then remove the arthroscope from its sheath, keeping the sheath against the anterior capsule.
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Pass a Wissinger rod or large blunted Steinmann pin into the cannula and advance it through the anterior capsular structures until the anterior skin is tented.
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Make a skin incision over the tip of the rod and advance the rod past the skin. Pass a cannula sheath over the Wissinger rod and advance it retrograde into the joint. Remove the rod to establish the anterior portal. This method is easier with larger shoulder joints but affords less flexibility in positioning.
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The anterior portal traverses the clavicular portion of the deltoid muscle and enters the rotator cuff interval of the anterior capsule. The structures at risk include the cephalic vein laterally and the musculocutaneous nerve, brachial plexus, and axillary artery and vein anteromedially. Generally, the musculocutaneous nerve passes 3 to 5 cm inferior to the tip of the coracoid, but several anatomic variations have been described, and staying lateral to the coracoid process is safer. Remaining superior to the leading edge of the subscapularis tendon avoids injury to the brachial plexus and vascular structures.

Anteroinferior Five-O’clock Portal (Used With Caution)

The intraarticular starting point for establishing the retrograde anteroinferior portal is along the leading edge of the inferior glenohumeral ligament at the 5-o’clock position along the glenoid rim. The portal travels through the subscapularis and lateral to the conjoined tendon. Both the cephalic vein and the anterior humeral circumflex artery are in the path of this portal, but a blunt passer rod or cannula can effectively push these aside. The portal passes lateral to the musculocutaneous nerve and superolateral to the axillary nerve and approximately 1 cm from the cephalic vein. The distances between the portal and the musculocutaneous and axillary nerves have been measured at 22.9 + 4 mm (mean + SD) and 24.4 + 5.7 mm, respectively. The convexity of the humeral head should be moved away from the starting site, not only for visualization but also so that a Wissinger rod can be directed laterally. When the arm is unweighted, removed from traction, and placed alongside the body, the humeral head convexity moves superiorly. This allows appropriate access to the leading edge of the inferior glenohumeral ligament. Placing an object such as a rolled towel in the axilla distracts the joint and allows visualization of the starting site for the 5-o’clock portal. Conversely, using the outside-in 5-o’clock portal allows the portal to be created from a point lateral and inferior to the coracoid using spinal needle localization for best access to the inferior glenoid.

Superior Portal

Neviaser is credited with the description of the superior portal (supraclavicular or suprascapular portal). This portal is most useful for passage of suture retrieval devices for rotator cuff repair. It is bound anteriorly by the clavicle, laterally by the acromion, posteriorly by the base of the acromion and the scapular spine, and inferiorly by the posterosuperior rim of the glenoid. This portal penetrates the trapezius muscle and passes through the supraspinatus muscle belly. The suprascapular nerve and artery lie approximately 3 cm medial to the superior portal at its closest point.

Establishing The Superior Portal

Technique 52.4

(NEVIASER)

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The entry site is easily palpable as a soft spot. Introduce an 18-gauge spinal needle 1 cm medial to the medial acromion at an angle of 30 to 45 degrees to the skin and 10 degrees posteriorly to enter the joint at the superior margin of the glenoid just posterior to the attachment of the long head of the biceps tendon.
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Observe passage of the needle arthroscopically to confirm proper position before making a small skin incision.

Suprascapular Nerve Portal As Described By Lafosse

The suprascapular nerve portal is positioned between the clavicle and the scapular spine approximately 7 cm medial to the lateral border of the acromion. This portal is approximately 2 cm medial to the Neviaser portal.

Lateral, Posterolateral, and Anterolateral Portals

The lateral portal is the primary operative portal for the subacromial space. It is located 3 cm lateral to the lateral border of the acromion and passes through the deltoid muscle. One must ensure that instrumentation can be used and not be hindered by impingement on the lateral acromial edge. When advancing the cannula, it is initially directed downward and toward the tuberosity to enter the lateral extent of the bursa, allowing for a full view and ease of instrumentation. Accessory portals can be spaced anteriorly or posteriorly as necessary. The axillary nerve lies approximately 5 cm distal to the lateral border of the acromion.

Arthroscopy of the subacromial space usually can be accomplished through the initial posterior portal and the central anterior portal. The cannulas are easily redirected up into the bursa from the same skin incisions, after passing through the deltoid muscle.

When passing the anterior cannula, gentle palpation with the cannula tip can reveal the extent of the coracoacromial ligament, allowing redirection of the cannula just lateral to the ligament. In a very muscular individual or if the posterior portal has been placed too far inferiorly, a new portal, 1.5 cm inferior to the posterior acromion, may be required. Burkhart described two lateral portals for repair of SLAP lesions. Depending on the site of disruption, he used an anterolateral portal, 1 cm lateral and posterior to the anterolateral corner of the acromion, or a posterolateral portal, 1 cm anterior and lateral to the posterolateral corner of the acromion.

Portal of Wilmington

This posterolateral accessory portal is used to approach posterior type II SLAP lesions, providing access to the glenoid and superior labrum. The location is 1 cm anterior and 1 cm lateral to the posterior acromial angle. Care should be taken when placing this portal so as not to damage the rotator cuff near its attachment to the greater tuberosity.

Diagnostic Arthroscopy and Arthroscopic Anatomy

As with arthroscopy of other joints, a thorough knowledge of the major anatomic structures around the shoulder is necessary. The surgeon must be familiar with the normal anatomy to identify abnormal or pathologic processes.

The examination begins with identification of the soft spot between the biceps and subscapularis tendons ( Fig. 52.5 ). The subscapularis is evaluated by having an assistant rotate and then lever the humerus posteriorly by placing a posterior force on the proximal humerus while pushing anteriorly at the elbow. The subscapularis recess is inspected for loose bodies. The examination consists of arthroscopically circling the joint, viewing the labral attachment at the biceps, and following the labral attachment to the glenoid and the capsular attachment to the humerus circumferentially around the shoulder back to the biceps superiorly. Capsular laxity is demonstrated by a drive-through sign and a rotator interval of more than 1.5 cm. A large sublabral hole or Buford complex variant where the middle glenohumeral ligament inserts at the base of the biceps must be distinguished from a true Bankart lesion, which extends inferiorly from the glenoid equator. Inferior glenohumeral ligament injuries may be off the glenoid, midsubstance, or off the humerus (humeral avulsion of the glenohumeral ligament [HAGL] lesions) or bipolar lesions and, when identified, should later be reexamined through an anterosuperior portal.

FIGURE 52.5, Patient is in lateral decubitus position, and glenoid is oriented horizontally. A, Superior part of shoulder joint with biceps tendon inserting into superior labrum. Humeral head is superior right, and glenoid is inferior. B, Superior glenohumeral ligament and subscapularis tendon on right with middle glenohumeral ligament inferiorly. C, Normal sublabral hole. D, Buford complex showing insertion of middle glenohumeral ligament directly into biceps anchor (see text). E, Middle cord variant of glenohumeral ligament crossing subscapularis tendon. F, Inferior pouch. Glenohumeral ligaments and labrum are seen. G, Capsular attachment to humeral head observed through inferior pouch. H, Rotator cuff evaluated for fraying, partial tears, or calcification. Supraspinatus tendon is seen superiorly with biceps tendon in center of picture. I, Posterior articular surface, posterior labrum, posterior pouch, and posterior capsule observed with arthroscope inserted anteriorly. J, Posterior band of inferior glenohumeral ligament. K, Anterior band of inferior glenohumeral ligament observed from anterior portal. Humeral insertion of ligament is superior. L, Capsulolabral attachment to glenoid observed through anterior portal. M, View of subacromial space with cuff below and acromion above.

The biceps attachment to the superior labrum is thoroughly evaluated by applying traction to the biceps with a probe and by taking the arm out of traction to check for peel-back due to a SLAP lesion. The biceps tendon is followed to the bicipital arch while one evaluates for fraying, inflammation, instability, and chondromalacia where the tendon rubs against the humeral head.

Using the scope and looking superiorly, a circumferential examination in the reverse direction, starting at the biceps and progressing posteriorly, is undertaken to evaluate the rotator cuff insertion. The anterior footprint insertion of the rotator arch is just posterior to the biceps and is the key component of the supraspinatus insertion. The cuff is followed posteriorly; a healthy cuff attaches just off the articular surface of the humeral head. The posterior attachment of the rotator arch marks the overlap of the attachments of the supraspinatus and infraspinatus onto the humeral head and the start of the bare area. This area is evaluated for chondromalacia or a Hill-Sachs lesion. If a Hill-Sachs lesion is noted, the Hill-Sachs interval is measured from the posterior cuff insertion to the medial edge of the lesion. This loss of humeral articulation, as well as the amount of loss of anterior glenoid articulation (determined by using the glenoid bare area to measure the posterior radius compared with the anterior radius), is used to identify on-track or off-track lesions resulting from shoulder instability (described later).

The arthroscope is now moved to the anterosuperior portal, and the posterior portal can be used for probing. The arthroscope is inserted anteriorly to view the posterior articular surface, posterior labrum, posterior pouch, and posterior capsule for redundancy, synovitis, fraying from instability, or inflammatory processes ( Fig. 52.5I ). Although not as prevalent as the anterior band of the inferior glenohumeral ligament, the posterior band may be visible with internal rotation as it approaches its insertion at the 7-o’clock to 9-o’clock positions posteriorly ( Fig. 52.5J ). After examination of the bare area in the humeral articular cartilage, the arthroscope is moved anteriorly to evaluate the rotator cuff by looking superiorly and the biceps-labral complex by looking inferiorly toward the glenoid. As the arthroscope is moved more anteriorly and directed back toward the inferior pouch, the glenohumeral ligaments can be seen from their humeral insertion down to the glenoid insertion. Careful observation for the ligamentous insertion to the humerus is indicated to rule out humeral avulsion of the glenohumeral ligament (HAGL). Figure 52.5K shows a normal glenohumeral ligament. By turning the arthroscope more inferiorly, the attachment of the anteroinferior glenohumeral ligament and the capsulolabral attachment can be seen ( Fig. 52.5L ). The middle glenohumeral ligament and subscapularis tendon and the subscapularis recess also can be observed, and the arthroscope can be moved inferiorly into the subscapular recess for evaluation of the subscapularis tendon and muscle. Loose bodies and loose implants in previously operated shoulders may be found in the subscapular recess. Glenoid bone loss is best evaluated by measuring the posterior radius of the bare area and comparing it with the radius of the anterior bare area through the anterosuperior portal.

To complete diagnostic arthroscopy of the shoulder for impingement, rotator cuff calcification, and inflammatory conditions, the subacromial bursa should be examined. The bursa extends from at least 2 cm anterior to the anterior edge of the acromion to approximately the midacromion posteriorly. To enter this space, all distention from the glenohumeral joint should be removed before removing any cannulas. The posterior cannula can be used to enter the subacromial space. The cannula is withdrawn from its previous placement and redirected so that the blunt edge of the trocar abuts the posterior edge of the acromion just medial to the posterolateral edge. It is redirected slightly inferior to the acromion so as to slide up under the acromion without probing into the soft tissue under the bone. At the tip of the acromion, the cannula is directed toward the surgeon’s finger, which is placed at the anterolateral edge of the acromion. The cannula should not be aimed toward the acromioclavicular joint. The subacromial space can be increased, and the approach can be made easier by placing the arm in approximately 30 degrees of abduction. When the tip of the cannula is felt up under the anterolateral edge of the acromion, it is gently swept back and forth to free the area in the bursa.

The arthroscope is placed in the subacromial bursa, and contiguous structures are examined carefully. If the view is limited at this time, attempts can be made to reinsert the cannula or to sweep the cannula back and forth to open the bursa further. During this portion of the procedure, as in all arthroscopic shoulder procedures, maintaining a systolic blood pressure of no more than 30 mm Hg above the pump pressure is helpful. Initially, viewing superiorly, the undersurface of the acromion can be seen and evaluated for roughening or fraying, with an associated kissing lesion on the rotator cuff indicating impingement. The shoulder is rotated internally and externally, and increased abduction can be applied to evaluate the area for impingement. The arthroscope is turned to view medially the area of the acromioclavicular joint and the coracoacromial ligament as it ascends under the acromion. If the shoulder has impingement or inflammation, vision may be limited, and an anterolateral portal can be made using an outside-in technique. A shaver is placed into the bursa under direct vision, and bursectomy is performed to allow better exposure of the rotator cuff. The rotator cuff and bursa should be cleaned from the area of the insertion to the tuberosity, which is the usual area of attrition, impingement, or calcification ( Fig. 52.5M ).

After rotation of the arm to evaluate the cuff through the posterior portal, the arthroscope can be placed in the lateral portal and directed toward the posterior bursal wall. The same procedure can be used to view directly the acromion superiorly and the clavicle for evidence of bony prominence or fraying indicating impingement.

The subacromial space should be examined thoroughly, which may require partial or subtotal bursectomy to see the rotator cuff and the undersurface of the acromion clearly. Any bony prominences of the acromion or the acromioclavicular joint should be evaluated and resected. The rotator cuff itself should be palpated for roughness, fraying, or calcifications. Although calcifications may be difficult to delineate, generally they can be palpated, or a slight bulge or vascular blush of the tendon can be seen.

The internal extent of the bursa is approximately 4 cm from the acromial edge with the axillary nerve always lateral to the bursa, on average 0.8 cm. The lateral extent of the bursa should not be violated arthroscopically. If an open repair technique is used, the palpable internal extent of the bursa can be used as the limit of safely splitting the deltoid.

General evaluation of the acromioclavicular joint can be accomplished through the subacromial portal. If an acromioclavicular spur is present, electrocautery and a shaver should be used to resect the soft tissue from the undersurface of the acromion; inferiorly directed pressure places the clavicle into the joint for better vision. The acromioclavicular joint also can be seen directly through the anterosuperior and posterosuperior portals by placing the spinal needles at approximately a 45-degree angle into the acromioclavicular joint from just anterior and posterior to the joint.

Loose Bodies

Loose bodies occasionally are encountered during shoulder arthroscopy. Small ones sometimes can be removed from the joint with suction applied to a large-caliber outflow cannula. Often by increasing the rate of inflow, the joint can be vacuumed without applying suction to the outflow.

Arthroscopic Removal of Loose Body

Technique 52.5

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Remove larger loose bodies with grasping forceps and triangulation techniques. Loose bodies tend to bob like apples, and turning off the inflow or outflow to decrease turbulence makes it easier to grasp the loose body. When securely grasped, extract the loose body with a slow, twisting movement to minimize the chance of its slipping from the jaws of the grasper. If necessary, enlarge the portal by spreading the joint capsule and soft tissues with the grasper or hemostat tips to prevent pulling the loose body from the jaws of the grasper.
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Extremely large loose bodies may have to be broken into smaller fragments by cutting them with a burr before they can be extracted through the portals. Keep the loose bodies contained to a localized accessible space when breaking the larger fragments. If the loose body floats away, insert a suction tip or apply suction to the outflow cannula to pull the loose body to the tip and stabilize it. Insert a grasping instrument to grasp it.
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Loose bodies tend to gravitate into the axillary pouch of the shoulder or occasionally into the subscapular recess. Loose implants likewise may be found in these areas. Other hiding places include the posterior recess behind the glenoid, the synovial folds behind the biceps tendon insertion on the glenoid, and at the site where the biceps tendon exits the joint. If a loose body is seen on a radiograph, but is not readily visible arthroscopically and is hidden within the subscapularis bursa, “milk” the loose body from the bursa by palpating in the subcoracoid area. From an anterior portal, drive the arthroscope into the subscapular bursa to examine this area fully.
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In addition to removing the loose body, determine its source because the underlying abnormality may need correction. Loose bodies may form from Hill-Sachs lesions or glenoid rim fractures in patients who have sustained dislocations. They also may be produced in shoulders with advanced arthritis or osteonecrosis where portions of the lesion have broken free.

Synovectomy

The arthroscope allows almost complete inspection of the shoulder joint and can be used successfully for selective biopsy of the synovium. A near-total synovectomy is possible using the arthroscope without the debilitating disruption of the deltoid or rotator cuff. The lateral decubitus position with the affected arm suspended in skin traction is preferred, and the three-portal (anterior, posterior, and superior) technique usually allows complete access. The superior and anterior portions of the joint are reached with operative instruments placed through the anterior portal and the arthroscope in the posterior or superior portal. The posterior and superior portions of the joint are reached with the operative instruments in the posterior portal and the arthroscope in the anterior or superior portal. For involvement of the inferior recess, accessory posterior and inferior operating portals may be necessary. Motorized synovial resectors are required for adequate arthroscopic synovectomy. Large-diameter (>5 mm) blades allow for more efficient resection of synovial tissue. Maintaining a systolic-to-joint distention pressure of 30 mm Hg or less and adding one ampule of epinephrine to the 3-L arthroscopy bag helps maintain clear vision.

Drainage and Debridement

As in the knee, the arthroscope has been recommended for drainage and debridement of a septic shoulder joint; however, few clinical studies have been reported. Arthroscopic debridement (1) improves inspection, irrigation, and debridement compared with multiple needle aspirations; (2) allows breaking up of intraarticular loculations; (3) decreases the potential for postoperative scarring and stiffness that occur after formal arthrotomies; and (4) can be done several times if necessary. A contraindication to arthroscopic debridement is an adjacent soft-tissue abscess.

Labral Tears

The glenoid labrum consists of dense fibrocartilaginous tissues and some elastic fibers. On the inner side, the labrum is continuous with the hyaline cartilage of the glenoid, and on the outer side, it is continuous with the fibrous tissue of the capsule. The capsule and ligaments of the shoulder, including the biceps tendon, are attached to and become part of the glenoid labrum, which attaches to the glenoid. The labrum encircles the glenoid, increasing its depth around the humeral head, and provides increased stability. Saha has shown that adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% in the horizontal direction. Karzel et al., in biomechanical testing of cadaver shoulder specimens, showed that the labrum affects the distribution of contact stresses when a compressive load is applied to the shoulder at 90 degrees of abduction.

The most common mechanisms of injury to the superior labrum (i.e., SLAP lesions) are extrinsic secondary to traction on the upper extremity and intrinsic during the throwing motion, which likewise produces traction on the biceps anchor. A second proposed mechanism of injury is torsional peel-back of the posterior superior labrum during the cocking phase of throwing. Compression, shear, and degenerative changes associated with decreased peripheral vascularity and age increase the likelihood of labral tears and decrease the likelihood of a successful repair.

To aid in localizing the site of labral injury, the glenoid labrum has been divided into six areas: (1) the superior labrum, (2) the anterior labrum above the midglenoid notch, (3) the anterior labrum below the midglenoid notch, (4) the inferior labrum, (5) the posteroinferior labrum, and (6) the posterosuperior labrum ( Fig. 52.6 ). Lesions located above the equator of the glenoid (a line drawn between the 3-o’clock and 9-o’clock positions on the glenoid) often are associated with rotator cuff or biceps disease. Lesions located below the equator are highly suggestive of shoulder instability.

FIGURE 52.6, Glenoid labrum can be divided into six areas.

Snyder further classified superior labral anterior to posterior lesions and coined the term SLAP lesions. He categorized them into four basic varieties and a complex variety that involves a combination of two or more of the other SLAP lesions. These descriptive categorizations are used to determine treatment alternatives and to predict long-term results. Type I lesions, which can be treated with simple debridement, are described as fraying of the superior labrum with a solid biceps tendon anchor attachment. Type II lesions involve pathologic detachments of the labrum and biceps anchor from the superior part of the glenoid ( Fig. 52.7A ). These lesions most commonly progress posterior to the biceps but may progress anterior to or both anterior and posterior to the biceps attachment at the supraglenoid tubercle. Biceps-labral instability is evidenced by labral displacement of 5 mm or more with traction on the biceps tendon, hemorrhage, or fibrous granulation tissue at the insertion with long-standing lesions and superior articular cartilage changes. The peel-back test as described by Burkhart is used to evaluate for posterior extension of the lesion by removing the arm from traction and placing it in 90 degrees of abduction. The labrum is observed to displace medially on the scapular neck as the shoulder is externally rotated to 90 degrees.

FIGURE 52.7, Labral tears. A, Type II. B, Type IV SLAP lesion with displaced labral fragment and tear extending into base of biceps. Biceps anchor was stable, and labrum was excised.

Type III lesions, which occur with the meniscoid-type labrum, are vertical tears within the labrum that produce bucket-handle fragments. These can be excised, provided that the biceps anchor is securely fixed to the supraglenoid tubercle. Type IV lesions are bucket-handle type tears that extend up into the biceps tendon ( Fig. 52.7B ). These lesions also can be excised if less than 30% of the thickness of the biceps tendon is involved. Snyder suggested that if approximately one third of the biceps tendon is involved, suture repair of the segment should be considered. In older patients, if more than a third of the tendon is involved, he suggested performing biceps tenodesis or tenotomy after resection of the labral tear. Complex tears involving a combination of two or more of the previously described lesions should be treated with repair of the type II portion if present and resection of the other lesions, provided that there is a stable biceps anchor.

With multiple authors showing poor results with SLAP repairs in older individuals, the current thinking is that it is best to perform SLAP repairs in symptomatic athletes who do not respond to conservative therapy. Age is a determining factor: In general, for patients 40 years of age or younger, SLAP repair is recommended; 40 to 60 years, tenodesis; and over 60 years of age, tenodesis or tenotomy, depending on patient preference. Repairs must have low-profile knots or knotless constructs to prevent knot impingement. If a tenodesis is chosen and a component of shoulder instability is present, repair of the superior labrum probably is warranted.

Arthroscopic Fixation of Type II Slap Lesions

Technique 52.6

(MODIFIED FROM BURKHART, MORGAN, AND KIBLER)

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Place the patient in the lateral decubitus position and place the arm in 30 to 45 degrees of abduction and 20 degrees of forward flexion with 5 to 10 lb of balanced suspension. Administer general anesthesia and place a warming blanket to prevent hypothermia. Use an arthroscopic pump to maintain intraarticular pressure at 50 to 60 mm Hg. Use serial compression devices on the lower extremities.
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Establish a viewing portal 2 cm below the posterolateral acromion and an anterior central working portal for routine diagnostic arthroscopy. Findings such as a superior sulcus of more than 5 mm in depth, a displaceable biceps root, a positive drive-through sign, and a positive peel-back sign are indicative of a SLAP lesion ( Fig. 52.8 ).
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Use an arthroscopic probe to test the stability of the biceps-superior labral attachments to the glenoid. A normal superior sublabral sulcus covered with articular cartilage can be seen 5 mm medially beneath the labrum. If the sublabral sulcus is deeper than 5 mm, or if the labral attachments at the medial limit of the sulcus are tenuous, a SLAP lesion may be present.
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Assess whether the biceps root is easily displaceable with a probe. An unstable biceps root and superior labrum are easily displaced medially on the glenoid neck. Occasionally, the biceps root is unstable to probing, yet tenuous superior labral attachments are present. Such cases represent interstitial disruption of medially located attachments and require completion of the lesions, bone bed preparation, and repair.
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Sweep the arthroscope from superior to inferior between the glenoid and humeral head to see if the arthroscope can be easily “driven through” the joint. Although a positive drive-through sign indicates instability, “pseudolaxity” associated with SLAP lesions also may be the cause.
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The positive peel-back sign is diagnostic for a posterior SLAP lesion; however, isolated anterior SLAP lesions often have a negative peel-back test, but other arthroscopic signs, as described earlier, usually are positive. To perform the peel-back test, remove the arm from traction and observe the superior labrum arthroscopically as an assistant brings the arm to 90 degrees of abduction and 90 degrees of external rotation ( Fig. 52.9 ). Performing this dynamic peel-back maneuver in a shoulder with a posterior SLAP lesion causes the entire biceps–superior labrum complex to drop medially over the edge of the glenoid.
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When the diagnosis of a SLAP lesion is made, repair the lesion immediately because swelling may occur that obliterates the supralabral recess and obscures exposure. For the SLAP lesion repair, make three portals: a standard posterior viewing portal, an anterior portal located just above the lateral border of the subscapularis tendon, and an anterosuperior portal. The anterosuperior portal is located just lateral to the anterolateral corner of the acromion ( Fig. 52.10 ). Use a spinal needle to locate this portal precisely so that it provides a 45-degree angle of approach to the anterosuperior corner of the glenoid for proper placement of the suture anchor. Alternatively, use a percutaneous shuttle through the superomedial (Neviaser) portal.
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Through the anterior portal, prepare the bone bed on the superior neck of the glenoid, beneath the detached labrum, using a motorized shaver ( Fig. 52.11 ). Debride the soft tissues carefully down to a bleeding base of bone, but do not remove bone.
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For fixation of SLAP lesions, use small-size suture anchors and simple translabral loop sutures, preferably small PEEK suture anchors ( Fig. 52.12A ). The most critical element to resisting peel-back forces in a mechanically effective manner is to position a tight suture loop just posterior to the root of the biceps, with the loop attached to a suture anchor placed beneath the root of the biceps ( Fig. 52.12B ).
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To prevent suture or knot impingement, a vertical suture through the labrum or horizontal suture behind the biceps can be helpful in some cases ( Fig. 52.12C to E ). The strength of the different suture configurations is similar in laboratory studies. Using knotless suture anchors is now our preferred technique for helping to prevent knot impingement on the cuff or humeral head ( Fig. 52.12F and G ).
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For superior labral lesions that extend posteriorly to overlie the posterosuperior quadrant, place a second anchor through a posterolateral portal ( Fig. 52.13 ).
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Pass a Spear guide (Arthrex, Naples, FL) through the rotator cuff near the musculotendinous junction of the infraspinatus by this approach. Because the diameter of the Spear guide is only 3.5 mm, it is preferred over a standard 7-mm arthroscopy cannula for delivery of the suture anchor through the posterolateral portal. To minimize damage to the rotator cuff from portal placement, place only the 3.5-mm Spear guide through the posterolateral portal. This posterolateral portal is used for anchor placement only; suture passage and knot-tying for the posterior anchor are accomplished through the anterosuperior portal.
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Use the BirdBeak suture passers (Arthrex, Naples, FL) to pass the suture through the labrum. The 45-degree BirdBeak is ideal for passing sutures posterior to the biceps through the anterosuperior cannula, and the 22-degree BirdBeak is best for passing sutures anterior to the biceps through the anterior cannula. Penetrate the labrum with the BirdBeak from superior to inferior and grasp the suture; withdraw the BirdBeak to pull the suture out of the anterosuperior cannula. If the SLAP lesion extends anteriorly beyond the 1-o’clock position, place a separate suture anchor in that position for fixation of that portion of the labrum. A suture shuttle device through an anterior or a percutaneous Neviaser portal allows for less trauma and more accurate placement and is necessary for knotless anchors ( Fig. 52.12H ). The shuttle suture is placed before drilling to prevent inadvertent damage to the permanent sutures.
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After the repair, perform the peel-back and drive-through test again to be sure that they are negative, indicating that the pathologic process has been corrected ( Fig. 52.14 ). If the drive-through sign remains positive, consider adjunctive measures for capsular tightening.

Postoperative Care

The operated arm is placed at the side in a sling with a small pillow. Passive external rotation of the shoulder with the arm at the side (not in abduction) and flexion and extension of the elbow are emphasized immediately. Patients who require posteroinferior capsulotomy are started on posteroinferior capsular stretches (sleeper stretches) on the first postoperative day. The sling is discontinued after 3 weeks, and passive elevation is initiated. From weeks 3 to 6, progressive passive motion as tolerated is permitted in all planes, and sleeper stretches are begun in patients who did not have posteroinferior capsulotomy. From weeks 6 to 16, stretching and flexibility exercises are continued. Passive posteroinferior capsular stretching is continued, as is external rotation stretching in abduction. Strengthening exercises for the rotator cuff, scapular stabilizers, and deltoid are initiated at 6 weeks. Biceps strengthening is begun 8 weeks postoperatively.

At 4 months, athletes begin an interval throwing program on a level surface. They continue a stretching and strengthening program, with particular emphasis on posteroinferior capsular stretching. At 6 months, pitchers may begin throwing at full speed, and at 7 months they are allowed full-velocity throwing from the mound. All throwing athletes are instructed to continue posteroinferior capsular stretching indefinitely. A tight posteroinferior capsule probably initiates the pathologic cascade to a SLAP lesion, and recurrence of the tightness can be expected to place the repair at risk in a throwing athlete ( Table 52.2 ).

TABLE 52.2

Rehabilitation Protocol for Superior Labral Anterior-Posterior Lesion

Phase I—Immediate Postsurgical
Weeks 0–2 Postoperative (Type II and IV)	Goals (By End OF 2 WK)
1. P/AAROM with following restrictions FL <120 degrees ER/IR <30 degrees 2. Table slides in FL/pendulums 3. Scapular mobility exercises 4. Passive elbow FL 5. Active hand, wrist ROM and gripping exercises 6. Submaximal pain-free isometrics IR/ER ABD/ADD Scapular retraction/depression	1. Independent with HEP 2. PROM 120 degrees maximum FL/scaption 3. PROM 30 degrees maximal ER/IR 4. Full hand, wrist AROM 5. Active elbow EXT to 30 degrees, full passive elbow FL Precautions 1. Sling compliance 2. No active biceps contraction 3. Full active elbow EXT
PHASE II—GRADED AROM/STRENGTHENING
WEEKS 3–6 POSTOPERATIVE	GOALS (BY END OF 6 WK)
1. Glenohumeral joint mobilizations (grades I and II) 2. Progressing PROM to tolerance 3. Progress AAROM/AROM 4. Progress scapular mobility exercises (side lying) 5. Elbow FL—no resistance 6. UBE with low resistance 7. Initiate TheraBand ER/IR isometrics in neutral (sidestepping) 8. Rhythmic stabilization progression 9. PNF diagonals with light/moderate manual resistance	1. Independent with HEP 2. Gradually restore full PROM 3. Discontinue sling as pain decreases and proximal stability increases (wk 3–4) 4. Restore correct shoulder girdle mechanics (scapulohumeral rhythm) 5. Full active elbow FL (pain-free) 6. Full EXT by 4–6 WK depending on physician input 7. Able to comb hair (if dominant arm) 8. Sleep uninterrupted Precautions 1. No lifting 2. No ER with ABD >90 degrees
WEEKS 7–9 POSTOPERATIVE	GOALS (BY END OF 9 WK)
1. Continue progressing PROM—more aggressive mobilizations if needed (progress joint mobilizations grades III and IV as needed) 2. Elbow FL with light weights (1–5 lb) 3. UBE—increase intensity 4. Progress isotonics as able (TheraBand/light weight) 5. Progress rhythmic stabilization/PNF diagonals 6. Progress closed-chain exercises (especially wall push-ups)	1. Independent with HEP 2. AROM WNL 3. Able to reach behind back for wallet 4. Able to lift plate into eye-level cabinet Precaution No lifting >5 lb
WEEKS 10–11 POSTOPERATIVE	GOALS (BY END OF 11 WK)
1. Progress above exercises as tolerated 2. TheraBand ER/IR 45 to 90 degrees increase speed/intensity (must be pain-free and demonstrate correct mechanics) 3. Closed-chain scapular stability exercises (quadruped, tripod, side lying) 4. Progress proprioceptive training to include progressive weight-bearing exercises on unstable surfaces	1. MMT elbow FL 4/5 2. MMT shoulder FL 4/5 3. MMT shoulder ABD 4/5 4. MMT shoulder ER 4/5 5. MMT shoulder IR 4/5 6. Able to lift 3 lb into overhead cabinet 7. Maintain scapulohumeral rhythm with strengthening and functional activities 8. Able to tuck shirt and fasten bra Precaution No unilateral lifting overhead >5 lb
PHASE III—ADVANCED STRENGTHENING FOR RETURN TO SPORT
WEEKS 12–15 POSTOPERATIVE	GOALS (BY END OF 15 WK)
1. Progress isotonics increasing resistance/repetitions (exercises, throwing, lunges) 2. Plyoball exercises if appropriate Chest pass Overhead throw Sideway throw One-handed ball on wall 3. Progress shoulder strengthening (lateral pull-downs, rows) 4. Isokinetic strengthening as needed	1. MMT shoulder musculature 5/5 2. Able to place ≥10 lb in overhead cabinet
WEEKS 16 TO 24 POSTOPERATIVE	GOALS (BY END OF 6 MO)
1. Initiate interval throwing (per physician input) 2. Initiate sport-specific/functional training 3. Isokinetic testing if requested	1. Return to sport/activity of choice 2. Independent with exercise progression

Protocol was developed for patients after SLAP lesion repair. Surgery and rehabilitation differ depending on type of lesion. Types I and III usually are treated with debridement. The biceps tendon is stable, so postoperative rehabilitation usually can progress as tolerated. Types II and IV indicate an unstable biceps tendon requiring repair. This protocol addresses range-of-motion limitations and limited active biceps work necessary for type II/IV repairs. This is a guideline and may be adjusted to the clinical presentation and physician’s guidance.

ABD , Abduction; ADD , adduction; AROM , active range of motion; ER , external rotation; EXT , extension; HEP , home exercise programs; FL , flexion; IR , internal rotation; MMT , manual muscle testing; P/AAROM , passive or active-assisted range of motion; PNF , proprioceptive neuromuscular facilitation; PROM , passive range of motion; ROM , range of motion; UBE , upper body exercises; WNL , within normal limits.

Biceps Tendon Lesions

Biceps tendon lesions may be inflammatory, degenerative, or traumatic as a result of repetitive microtrauma or macrotrauma. The injury site or sites may include the attachment to the supraglenoid tubercle, SLAP, the tendon (intraarticular or extraarticular), and the bicipital arch. The bicipital arch consists of the conglomerate of the superior glenohumeral ligament and the coracohumeral ligament attachment at the superior bicipital groove. The ligaments are reinforced anteriorly by the subscapular tendon attachment and posteriorly by the supraspinatus attachment. In a study of 200 consecutive patients undergoing arthroscopic cuff repair, Lafosse et al. found 45% to have anterior, posterior, or both anterior and posterior biceps instability. Larger tears correlated with a higher incidence and degree of biceps instability. The researchers suggested internal and external rotation of the humerus in 0 to 30 degrees of abduction for dynamic evaluation of the biceps followed by probing to evaluate for static stability.

Boileau et al. described an hourglass-shaped biceps deformity that is associated with inflammation and triggering through the proximal pulley. Persistence of the triggering can result in pulley instability. The treatment is arthroscopic tendon debulking or tenodesis. In patients who have chronic impingement and persistent biceps tendinitis with more than 50% of the biceps tendon disrupted, or with biceps tendon subluxation as described by Lafosse et al., Habermeyer et al., and Bennett, an arthroscopic or mini–open tenodesis can be used ( Fig. 52.15 ).

FIGURE 52.15, Mazzocca et al. subpectoral mini-open biceps tenodesis. A, Skin incision. B, Location of biceps tendon made by dissecting through superficial fascia using blunt dissection to palpate tendon. C, Probe is used to withdraw tendon from joint and out of incision. D, To ensure appropriate tensioning, 20 mm of diseased portion of tendon is excised. E, Guidewire is placed in center of bicipital groove, usually at junction of middle and distal thirds of intertubercular groove between lesser and greater tuberosities. A 7- or 8-mm acorn reamer is placed over this and reamed to 15 to 20 mm. F, Suture is placed through Arthrex Bio-Tenodesis driver, and one suture is left out. G, Bio-Tenodesis screw inserted into bone tunnel, and suture that was left out of driver is tied to suture that is in cannulated portion of tenodesis screw. H, Musculotendinous junction rests in its anatomic location underneath inferior border of pectoralis major tendon.

Tenodesis is favored over tenotomy in active patients for cosmesis and prevention of biceps cramping. Multiple articles support various fixation techniques, including interference screws, suture anchors, and soft-tissue fixation (percutaneous intraarticular transtendon [PITT] procedure). The method of fixation seems to be less important than the quality of the tissue fixed.

Subpectoral tenodesis has been recommended to prevent the groove pain reported in some series. The potential for plexus and musculocutaneous nerve injury or humeral diaphyseal stress fractures has been reported with these techniques and must be considered.

Biceps tenodesis to treat type 2 SLAP tears has been reported to be successful in approximately two thirds of athletes, comparable to primary SLAP repair. Pitchers treated with tenodesis tend to have persistence of some anterior shoulder pain, as reported by Smith et al.

Biceps Tendon Release

Technique 52.7

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Perform arthroscopy of the shoulder through standard anterior and posterior portals.
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Release the biceps tendon at its glenoid attachment with an arthroscopic electrode or arthroscopic scissors to allow for a thickened biceps tip, which should hang up in the bicipital sling, thus preventing a severe “Popeye” deformity.
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Debride any attached stump with a shaver.

Postoperative Care

Patients are given a sling to wear for 3 to 5 days for comfort; a full range of motion is allowed. No resisted elbow flexion is allowed for 1 month.

Arthroscopic Biceps Tenodesis: Percutaneous Intraarticular Transtendon Technique

Sekiya et al. described a technique that should be used in middle-aged patients who are not participating in high-level sports or heavy lifting. Indications are as for other biceps tendon problems with chronic bicipital tendinitis and an associated tear, medial subluxation, or bicipital pain with an associated SLAP tear.

Technique 52.8

(SEKIYA ET AL.)

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Place the patient in a beach-chair or lateral decubitus position.
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Insert a spinal needle from the anterior aspect of the shoulder into the bicipital groove and through the transverse humeral ligament and the lateral aspect of the internal capsule.
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Under direct view, pierce the biceps tendon with the spinal needle. Thread a No. 1 PDS (Ethicon, Somerville, NJ) through the spinal needle and pull it through the anterior portal with a grasper.
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Insert a second spinal needle through the transverse humeral ligament from the anterior shoulder and pierce the biceps tendon near the first suture. Thread a second No. 1 PDS through the spinal needle and pull it out of the anterior portal.
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These two sutures are used to pull a No. 2 braided, nonabsorbable suture through the biceps tendon. Tie the No. 2 suture to one strand of the PDS and pull it from the puncture wound in the anterior aspect of the shoulder through the biceps tendon and out of the anterior cannula. Tie the end of the suture that was pulled through the anterior cannula to the other PDS and pull it back through the anterior cannula, through the biceps tendon, and out of the anterior shoulder puncture wound. This creates a mattress suture, which secures the biceps tendon to the transverse humeral ligament in the bicipital groove.
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Repeat these steps to create a second mattress suture to secure the biceps tendon. Sutures of different colors can be used to simplify suture management.
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After the biceps tendon is adequately secured, use an arthroscopic scissors or biter to transect the biceps tendon proximal to the suture.
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Debride the stump of the biceps anchor down to a smooth, stable rim on the superior labrum.
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At this point, direct the arthroscope into the subacromial space. Establish a lateral portal and perform any concomitant procedures, such as a subacromial decompression or rotator cuff repair. Avoid transection of the previously passed sutures. We prefer to perform a subacromial bursectomy before passing tenodesis sutures.
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Locate the sutures securing the biceps tendon to the transverse humeral ligament in the bicipital groove in the subacromial space and pull through the lateral portal.
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Sequentially tie the sutures using standard arthroscopic knot-tying techniques or pass them through a swivel-lock device and secure them to the proximal groove.
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Remove all fluid and debris and close portals in the standard fashion. Dress the wound and place the shoulder in a sling.

Postoperative Care

If an isolated arthroscopic biceps tenodesis was done, the patient is immediately started on passive pendulum exercises and active wrist and hand range-of-motion exercises. At 1 week after surgery, gentle passive elbow and shoulder range of motion is begun in all planes under the guidance of a physical therapist. The sling is used for 3 to 4 weeks. Active motion and gentle strengthening of the shoulder and elbow can begin 8 weeks after surgery. By 12 to 16 weeks after surgery, the patient is “weaned” from physical therapy to a home exercise program. Unrestricted use of the extremity is allowed 4 to 6 months after surgery.

Arthroscopic “Loop ‘N’ Tack” Tenodesis

A suture “loop ‘n’ tack” tenodesis, performed by passing a FiberSnare (Arthrex) around and through the proximal biceps, is a quick and effective method for tenodesis. We have had good success with this technique.

Technique 52.9

(DUERR ET AL.)

▪
With the patient in the beach-chair or lateral position, perform diagnostic arthroscopy through a standard posterior portal.
▪
After pathology of the long head of the biceps is identified, use an 18-gauge spinal needle to localize the anterior portal within the rotator interval directly over the biceps tendon; place a cannula for suture passing.
▪
Pass a looped nonabsorbable FiberSnare suture (Arthrex) around the biceps tendon ( Fig. 52.16A ); pass the free tail end through the looped end, and pull the tail to cinch the loop over the biceps tendon near its insertion at the superior labrum ( Fig. 52.16B ).
▪
Pass a tissue penetrator through the center of the biceps tendon, distal to the cinched loop, and grasp the free end and pull it through the tendon ( Fig. 52.16C ), tacking the loop in place ( Fig. 52.16D ).
▪
Cut the biceps tendon at its insertion.
▪
Load the free end of the suture into a PushLock suture anchor (Arthrex).
▪
Drill a pilot hole at the most distally visualized portion of the intraarticular bicipital groove, just above the subscapularis tendon.
▪
Seat the anchor with all slack taken out of the suture, allowing the tendon to translate distally with the bicipital groove, “tacking” the biceps in place.

Postoperative Care

After isolated biceps tenodesis, patients are allowed immediate shoulder and elbow range of motion. A sling is worn for comfort for a week. When this procedure is combined with another procedure (e.g., rotator cuff repair), the other procedure typically dictates the rehabilitation protocol.

Biceps Tenodesis: Arthroscopic or Mini-Open Technique with Screw Fixation

Tenodesis can be done with a PEEK tenodesis screw, with two suture anchors, or with the use of a FiberSnare. The resistance to cyclic loading is comparable in both techniques, whereas the ultimate pull-out strength of the biotenodesis screw is stronger than the suture anchors. Whether done arthroscopically or through a mini-open approach with a small anterior incision or a small subpectoral incision, long-term results are comparable, and the technique should be chosen based on the skills and experience of the operating surgeon.

Technique 52.10

(ROMEO ET AL. MODIFIED)

▪
Place the patient in the lateral decubitus position, with the shoulder abducted 30 to 40 degrees and forward flexed 30 degrees.
▪
Pass an 18-gauge needle from the anterolateral corner of the acromion through the rotator cuff interval and into the biceps tendon.
▪
Pass a No. 1 monofilament suture through the 18-gauge needle, capture it with a grabber from the anterior portal and then extract it.
▪
Use a No. 11 blade along the same plane as the spinal needle to make a vertical incision in the lower portion of the visible biceps tendon sheath to aid in finding the tendon later in the subacromial space.
▪
After the tendon is marked with a suture, use an arthroscopic basket to release the tendon from its origin just lateral to the superior labrum. This completes the preparation for the biceps tenodesis during the glenohumeral joint arthroscopy.
▪
Make an anterolateral portal 2 to 3 cm below the palpable edge of the anterior acromion in the center of the anterior third of the acromion. Visualization is maintained through the lateral portal or with a 70-degree scope through the posterior portal; the anterior portal is the working portal.
▪
Place an arthroscopic shaver in the anterior portal and remove all adventitial tissue. Anatomic landmarks and the monofilament suture are used for localizing the tendon in the groove. The falciform ligament of the pectoralis tendon is a reproducible landmark. The biceps tendon is directly under this structure.
▪
Using an arthroscopic basket, identify the sheath and open it. Use electrocautery to clean surrounding tissues and use a probe to free the tendon. Extend the dissection proximally to the lateral aspect of the rotator interval. Avoid proceeding too far medially. Otherwise, the dissection to expose the biceps tendon from the biceps sheath may lead to a partial displacement of the superficial attachment of the subscapularis tendon.
▪
Debride soft tissues to expose the bicipital groove.
▪
Pull the tendon directly out through the skin incision of the anterolateral portal.
▪
Place a hemostat on the tendon at the level of the skin to prevent it from retracting underneath the skin.
▪
The placement and tension of the tenodesis are important for anatomic repair. To approximate the intraarticular distance, remove 20 mm of tendon and place a Krackow stitch of No. 2 FiberWire.
▪
Allow the sutures to fall back into the subacromial space.
▪
Place cannulas into the anterior and anterolateral portals and shuttle the sutures into the anterior portal so that they are out of the way for the bone tunnel preparation.
▪
Use a lateral portal for exposure and identify the bicipital groove.
▪
For instrumentation, use an 8.25-mm clear cannula in the anterior portal to enhance exposure and minimize soft-tissue distention. Through the anterolateral portal, insert a tenodesis reamer into the center of the bicipital groove, 10 to 15 mm below the insertion of the supraspinatus lateral to the subscapularis insertion at the level of the transverse humeral ligament. The depth of insertion is 20 mm. For most men, an 8-mm reamer is used, and for most women, a 7-mm reamer. The tendon can be contoured slightly to make sure it fits easily. Ream to a depth of 25 mm.
▪
Retrieve the sutures out of the anterolateral portal and slide an 8-mm cannula over the sutures to align them over the tunnel.
▪
Pull the sutures through a swivel-lock tip and hold tension on the construct to push the biceps into the base of the tunnel.
▪
Insert the tenodesis screw flush with the cortex.
▪
Check for stability by rotating the humerus.

Postoperative Care

Postoperative management depends largely on the types of procedures that were performed in conjunction with the biceps tenodesis. If only a biceps tenodesis was done, the postoperative procedure is the same as for arthroscopic acromioplasty (see Technique 52.17). Strengthening activities related to elbow flexion or forward elevation of the arm with the elbow extended should be restricted until 6 weeks after the biceps tenodesis.

Subpectoral Biceps Tenodesis

Successful arthroscopic subpectoral tenodesis has been described by several authors. Currently, mini-open or open subpectoral tenodesis with a small nonabsorbable screw is indicated in patients who are not athletes participating in contact sports or overhead throwing (see Fig. 52.15 ).

Anterior Instability

Since Detrisac and Johnson first introduced the staple capsulorrhaphy in the 1970s, arthroscopic shoulder stabilization procedures have evolved with continued development of technology and procedure modifications. Arthroscopic suture anchors, capsular plication, and interval closure repair techniques were developed, with a recurrence rate in appropriately selected patients being comparable to that of open techniques.

As the technique evolved, so did the indications and contraindications. In a study of 190 patients, Burkhart and DeBeer noted an increased recurrence rate (from 6.5% to 89%) in contact athletes when a 25% glenoid defect or an engaging Hill-Sachs lesion alone or in combination was present. Di Giacomo et al. developed the concept of “on-track” and “off-track” lesions based on evaluation of bipolar bone loss at the glenoid and humeral head ( Fig. 52.17 and Box 52.1 ). Glenoid lesions involving more than 25% are treated with a Bankart-Bristow-Latarjet procedure. Glenoid lesions that involve less than 25% but are nonetheless off track are treated with an arthroscopic Bankart procedure with the addition of a remplissage procedure. This is especially important in contact athletes and has been shown to significantly decrease recurrence rates. Balg and Boileau developed an injury severity index ( Table 52.3 ) and found a recurrence rate of 75% with glenoid bone loss and hyperlaxity. Shaha et al. showed that in the active military population, bone loss of 13.5% resulted in a significant decrease in functional outcomes. Likewise, Neviaser noted inferior results when treating anterior periosteal sleeve avulsions in young patients.

FIGURE 52.17, Off-track Hill-Sachs lesion. A, Three-dimensional CT showing glenoid face with bone loss of width d . In this case, the glenoid track is 83% of normal glenoid width minus d. A2-B2 is the long axis of glenoid. B, Relation of glenohumeral joint in abduction and external rotation. Note loss of contact of intact humeral articular surface with glenoid articular surface because of anteroinferior glenoid bone loss. Large Hill-Sachs interval (distance from posterior rotator cuff attachments to medial margin of Hill-Sachs lesion) is wider than glenoid track width of which has been reduced by glenoid bone loss.

BOX 52.1

Determining If a Hill-Sachs Lesion Is “On Track” or “Off Track”

From DiGiacomo G, Itoi E, Burkhart SS: Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion, Arthroscopy 30:90, 2014.

1.
Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from a three-dimensional CT scan or three-dimensional MRI.
2.
Determine the width of the anterior glenoid bone loss (d).
3.
Calculate the width of the glenoid track (GT) by following the formula: GT = 0.83 D – d.
4.
Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the Hill-Sachs lesion: HSI = HS + BB.
5.
If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or nonengaging.

TABLE 52.3

Instability Severity Index Score

From Balg F, Boileau P: The instability severity index score, J Bone Joint Surg 89B:1470, 2007. Copyright British Editorial Society of Bone and Joint Surgery.

Prognostic Factors	Points
Age at surgery (yr)
≤ 20	2
>20	0
Degree of sport participation (preoperative)
Competitive	2
Recreational or none	0
Type of sport (preoperative)
Contact or forced overhead	1
Other	0
Shoulder hyperlaxity
Shoulder hyperlaxity (anterior or inferior)	1
Normal laxity	0
Hill-Sachs on anteroposterior radiograph
Visible in external rotation	2
Not visible in external rotation	0
Glenoid loss of contour on anteroposterior radiograph
Loss of contour	2
No lesion	0
Total (points)	10

At this time, we believe that the arthroscopic procedure with plication and interval closure as indicated and repair of the capsulolabral defects produces comparable results to an open procedure. Surgeons should evaluate their skills and technical expertise and choose between an open and arthroscopic procedure based on the best procedure for their level of expertise and the pathologic process present.

Indications for shoulder stabilization procedures include primary dislocation in high-risk patients involved in contact or collision sports near the season’s end or dislocation of the dominant shoulder in an athlete who uses an overhead motion. In-season instability treated aggressively with rehabilitation allows 75% of athletes to return to competition, though two thirds of those returning have additional instability episodes. Instability episodes produce bone loss and chondral damage of the glenoid and humeral head, as well as further soft-tissue damage. Long-term sequelae should be discussed with the patient. Recurrence of instability despite conservative treatment also is an indication for shoulder stabilization ( Box 52.2 ). Contraindications include an uncooperative or medically unstable patient. Relative contraindications include glenoid bone loss of 25% (≈6 mm) and an off-track Hill-Sachs lesion and an anterior HAGL lesion.

BOX 52.2

Indications for Shoulder Stabilization Modifiers

ALPSA , Anterior labroligamentous periosteal sleeve avulsion; HAGL , humeral avulsion of glenohumeral ligament; SLAP , superior labral tear anterior to posterior.

Bone loss >25% (6 mm) of glenoid—Latarjet procedure
Humeral head >6 mm deep or 18 mm wide—Consider remplissage for collision athletes
Soft-tissue multidirectional instability—Arthroscopic capsular shift
ALPSA—Restore anatomy anteriorly; consider plication
Anterior HAGL—Mini-open or arthroscopic repair
Posterior HAGL—Arthroscopic repair
SLAP lesion—Concomitant repair
Cuff lesion—Concomitant repair

The HAGL lesion was originally described by Nicola in 1942 and subsequently by Bach, Wolf, and Baker et al. Wolf described the HAGL lesion in 9.3% of patients with shoulder instability. Both anterior and posterior humeral avulsions with and without a piece of bone and a floating inferior glenohumeral ligament both anteriorly and posteriorly have been reported. Preoperative MRI in the acute setting or MRA in the subacute setting as well as thorough arthroscopic examination are needed to identify and treat all points of damage ( Fig. 52.18 ). Open and arthroscopic repairs of HAGL lesions have been described, and at this time most authors believe that an open procedure is the easiest and most reproducible way to repair anterior lesions.

FIGURE 52.18, A, Humeral avulsion of glenohumeral ligament with exposure of posterior cuff. B, Posterior glenoid avulsion of glenohumeral ligament same patient. C, Repaired floating humeral avulsion of glenohumeral ligament.

Pertinent technical points for the success of arthroscopic Bankart repair include the following:

Realistic patient goals and time frames
Careful evaluation and identification of all significant pathologic conditions, including preoperative MRI or a three-dimensional CT scan to evaluate significant bone defects associated with recurrent instability. An arthroscopic examination through an anterosuperior portal is performed to evaluate glenoid bone loss forming the so-called inverted-pear defect.
Release of the capsular ligamentous complex to approximately the 6-o’clock position so that the underlying subscapularis muscle can be clearly seen to allow appropriate superior advancement of the capsule
Abrasion of the glenoid neck to promote bony bleeding for a well-vascularized bed for optimal capsular healing
Superior advancement of the glenohumeral complex to restore physiologic tension and eliminate any potential drive-through sign; an injury to the posterior inferior glenohumeral ligament is often present and should be repaired to restore normal tension; any appreciable Hill-Sachs lesion in a collision athlete is repaired with a remplissage procedure, except for a lesion of the dominant shoulder in a throwing athlete; secure anatomic fixation 1 to 2 mm over the articular surface with a minimum of three suture anchors and secure loop and knot fixation to compress the capsuloligamentous complex to the bone surface and provide adequate fixation during the early healing stage; placement of knots or knotless anchors to avoid impingement.
Repair of significant rotator interval, labral, and cuff defects
Supervised, goal-oriented rehabilitation

Arthroscopic Bankart Repair Technique

Technique 52.11

▪
Place the patient on the operating table in the lateral decubitus position with a beanbag and kidney rest. Carefully protect all bony prominences as well as the axillary area. Apply a heating blanket and serial compression devices around the lower extremities. Prepare and drape the patient so that there is wide exposure to the anterior, posterior, and superior aspects of the shoulder. Place the arm in 45 to 60 degrees of abduction and 20 degrees of forward flexion using 12 to 14 lb of traction.
▪
Outline the bony landmarks and mark the potential portals on the skin.
▪
Place the posterior portal 2 cm inferior and just medial to the posterolateral edge of the acromion.
▪
Before making additional portals, thoroughly examine the shoulder through the posterior portal to identify the most appropriate sites for placement of the anterior portals and for any additional posterior portals that may be necessary. Carefully visualize the entire labrum, 360 degrees of the shoulder joint, and the attachment of the glenohumeral ligament to the humerus from anterior to posterior. Thoroughly evaluate the glenohumeral joint for bony loss of the glenoid or humeral head. Defects of the humeral head measured from the cuff to the medial edge of the lesion should be repaired by remplissage if the defect is more than 80% of the glenoid articular surface as measured anterior to posterior using a calibrated probe (see Technique 52.16). Glenoid bone loss greater than 6 mm should be restored with a Latarjet procedure. Proper preoperative planning eliminates surprises.
▪
After identifying the quadrant or quadrants of injury to the labrum, create the planned portals using spinal needle localization according to the quadrant approach as shown in Figure 52.19 .
▪
Make an anterosuperior portal with the cannula entering the shoulder just posterior to the biceps tendon and anterior to the leading edge of the supraspinatus tendon. It is the best portal to visualize the full extent of the capsular ligamentous damage and bone loss ( Fig. 52.20 ).
▪
Make an anterior central portal to place an 8.25-mm clear cannula just above the superior edge of the subscapularis tendon at an angle of approximately 45 degrees to the glenoid articular surface. This is used for placement of anchors and for instrumentation using a suture shuttle.
▪
If the lesion extends posterior, make a 7-o’clock portal posteriorly using spinal needle localization. Enter the joint at an appropriate angle for placement of a suture anchor in the inferior part of the glenoid if necessary or for placement of a shuttle for passing sutures along the capsular ligamentous complex.
▪
While viewing from the anterosuperior portal, use an elevator to free up the capsule down to the subscapularis muscle, which should be visible. Abrade the glenoid neck to stimulate healing (see Fig. 52.22A ).
▪
While viewing from the anterosuperior portal if necessary, perform a capsular plication procedure posteriorly, extending along to the attachment of the posterior band of the inferior glenohumeral ligament. Using a rasp, freshen the soft tissue and the intended area of plication to incite some inflammation without damaging the tissue.
▪
Use a suture shuttle to pass PDS sutures, starting at about the 6-o’clock position and taking a bite of approximately 1 cm of capsule in a pinch-tuck technique, making sure that the needle comes out through the capsule and passes up under the labrum in its appropriate position. The sutures can be tied at the time they are passed, but it may be easier to pass multiple sutures first, store them outside the cannula, and tie them later. Generally, three sutures are passed, with the upper extent being at the attachment of the posterior band of the inferior glenohumeral ligament.
▪
Now perform the anterior part of the Bankart procedure. Abrade the anterior neck and free up the capsule and labral complex so it can be advanced superiorly ( Fig. 52.21A ). Plan the position of the suture anchors, trying to get three or four anchors placed below the 3-o’clock position.
▪
The most inferior anchor often is best placed using a 5-o’clock percutaneous portal made with the help of a spinal needle for localization. Place the spinal needle at a 45-degree angle to the articular surface. The Spear point guide can be placed at the 5:30 position on the neck, 1 to 2 mm on the articular surface for reaming and placement of the suture anchor. Note the exact position of the drill hole, observe the anchor as it is placed in the hole, use a mallet to tap the anchor down, and then check security by tugging on the sutures. To obtain the best area of bone for drilling at a lower level, an angled reamer and anchor inserter can be placed percutaneously. This provides excellent fixation in this position ( Fig. 52.21B ).
▪
The second and third anchors may be either single-loaded or double-loaded anchors and usually are PEEK double-loaded anchors. Recently, we have used knotless anchors to provide secure fixation without the risk of knot impingement. When knots are used, use the cannula to direct the knot away from the articular surface as it is being seated. With this technique, take the most inferior suture out the posteroinferior cannula using a suture grasper. Obtain a good bite of the capsule and labrum just distal to the intended site of the anchor ( Fig. 52.21C ). Take the shuttle out of the posterior inferior cannula and secure it around the inferior suture limb of the anchor, and then retrieve it out the anterior cannula. Grasp the two sutures not involved in the first knot with a suture retrieval device from the posterior cannula, take them out the posterior cannula, and store them for later tying. The arthroscopic knot is then tied.
▪
Firmly secure the first suture that was passed through the labrum to the capsule and labrum up to the edge of the glenoid, creating an anterior bumper. Pass the superior of the two suture limbs that were passed out the posterior cannula back through the anterior cannula. Use the shuttle to pass the shuttle loop through the capsule and labrum. Carry this shuttle out the posterior cannula and shuttle the second suture through the capsule and out the anterior cannula. Use the cannula to direct the knot away from the joint surface as it is secured.
▪
Place a third anchor either single-loaded or double-loaded using the same technique. Sometimes, some of the lower sutures can be used in either a single simple repair or as a mattress suture, depending on the type of tear and tissue involved. This is determined at the time of surgery. Place three or four anchors, each separated by 5 to 7 mm. Tie the knots securely, re-creating a soft-tissue bumper ( Figs. 52.21D and 52.22 ). At this time, if the plication sutures have not been tied, they should be tied posteriorly from the posterior cannula and secured. In our practice, we generally tie these earlier in the procedure when they are placed, but some authors prefer to tie them later.
▪
If the patient had hyperlaxity and significant sulcus associated with the Bankart lesion, perform a rotator interval closure at this time by withdrawing the anterior central cannula to just outside the capsule. Pass a crescent spectrum needle through the middle glenohumeral ligament several millimeters into the ligament and out into the joint. Maintain one limb outside the capsule while the limb in the joint is retrieved using a penetrator device through the anterior central cannula. Grasp the intraarticular limb of the suture at the level of the superior glenohumeral ligament and retrieve it out of the cannula for extracapsular tying using an SMC (Samsung Medical Center, Seoul, South Korea)–type knot (see Fig. 52.57 ). Generally, two sutures are passed in securing the rotator interval if it is thought that the slight loss of external rotation is offset by the added stability of these additional sutures ( Figs. 52.23 and 52.24 ).
▪
Upon completion, close the portals with subcuticular poliglecaprone 25 (Monocryl). Apply a sterile dressing and an UltraSling (DJO Global, Vista, CA).

Postoperative Care

The sling is applied after surgery and worn for 4 to 6 weeks. Physical therapy is started 2 to 3 weeks after surgery. Active-assisted range of motion is performed from weeks 2 to 8, and isometric strengthening is performed from weeks 8 to 12. The athlete is allowed to return to preinjury conditioning programs and weight training at 12 weeks, and at 6 months he or she is allowed to participate in contact sports based on range-of-motion and strength guidelines dictated by the contralateral shoulder ( Table 52.4 ).

TABLE 52.4

Bankart Repair Rehabilitation Protocol

Preoperative Goals
1. Independent with postoperative exercise program 2. Independent with preoperative strengthening with isometrics and isotonics in pain-free, stable range
Phase i
Weeks 1–2 Postoperative	No Formal PT if Patient has Achieved Preoperative Goals
1. Pendulum exercises 2. Elbow, forearm, wrist AROM 3. Wrist isotonics and grip exercises 4. Sling at all times
Weeks 3–4 Postoperative (PT QIW-TIW)	Goals (BY end OF 4 WK)
1. Initiate PT approximately 15 d postoperatively 2. PROM with the following restrictions FL <160 degrees Scaption to <150 degrees ER neutral to 30 degrees at 3 wk and 40 degrees at 4 wk IR in 45 degrees scaption <60 degrees 3. Gentle AAROM with cane FL <160 degrees ER neutral as above 4. Table slides in FL 5. Scapular mobility exercises Protraction/retraction Elevation/depression	1. Independent with HEP BID 2. PROM 150 degrees maximal FL 3. PROM 150 degrees maximal scaption 4. PROM 40 degrees maximal ER 5. PROM 60 degrees maximal IR in 45 degrees scaption 6. Full wrist, elbow AROM Precautions 1. Sling at all times except PT 2. No true ABD PROM 3. No ER with arm abducted from body
WEEKS 5–6 POSTOPERATIVE (PT QIW-TIW)	GOALS (BY END OF 6 WK)
1. PROM with the following restrictions: FL <170 degrees Scaption <160 degrees ER 45 degrees, scaption <60 degrees IR 45 degrees, scaption to 60 degrees Home ADD to WNL 2. AAROM—cane, pulley, wall walks 3. Submaximal (25%) isometrics at side for IR and ER, and ABD 4. Submaximal manual resistance scapular protraction/retraction and elevation/depression 5. AROM—prone EXT and rows, supine protraction and reverse Codman	1. Independent with HEP BID 2. PROM 170 degrees maximal FL 3. PROM 160 degrees maximal scaption 4. PROM 60 degrees maximal ER at 45 degrees scaption 5. PROM 60 degrees maximal IR at 45 degrees scaption 6. Home ADD to WNL Precautions 1. Use of sling during sleep and in crowds 2. No true ABD PROM 3. No ER with arm ABD from body >45 degrees
PHASE II—GRADED AROM AND STRENGTHENING
WEEKS 7–8 POSTOPERATIVE (PT BIW)	GOALS (BY END OF 8 WK)
1. PROM with the following restrictions FL to WNL Scaption to WNL ER 70 degrees, scaption to 70 degrees by end of wk 7 ER 90 degrees, scaption to 70 degrees by end of wk 8 IR to WNL 2. Continued AAROM activities as needed 3. AROM FL and scaption to 90 degrees 4. Isotonics when able FL and scaption with 1–2 lb ER and IR with 1–2 lb (side lying) or TheraBand (standing) Prone EXT, rows, and horizontal ABD <90 degrees Biceps curls; triceps EXT 5. UBE for endurance 6. Proprioceptive training (ball wall dribble, weighted reverse Codman, submaximal manual resistance PNF)	1. Independent with HEP QID 2. Discontinue sling at all times without increased pain 3. PROM FL to WNL 4. PROM scaption to WNL 5. PROM 70 degrees maximal ER at 90 degrees scaption 6. PROM IR to WNL 7. AROM FL and scaption at least 90 degrees with proper scapular mechanics 8. Able to lift 2 lb to eye-level cabinet 9. Able to perform all grooming and dressing activities independently and with normal mechanics 10. Able to retrieve wallet from back pocket 11. Able to open/close car door Precautions 1. Avoid terminal ER/ABD 2. Light-weight/high-repetition isotonics
WEEKS 9–10 POSTOPERATIVE (PT BIW)	GOALS (BY END OF 10 WK)
1. PROM ER 90 degrees, scaption to WFL 2. Progress all AROM to WFL 3. Progress isotonic strengthening—Jobe rotator cuff program 4. Initiate isotonics—lateral pull-downs to chest, wall push-ups with elbows tight to side, step-ups, throwing lunges 5. Advance proprioceptive training to include progressive weight-bearing exercises on unstable surface 6. Advance endurance training for upper extremity and entire body	1. PROM WFL all directions 2. AROM WFL all directions 3. MMT 4/5 FL 4. MMT 4/5 scaption 5. MMT 4/5 ER 6. MMT 4+/5 IR 7. MMT 5/5 EXT 8. Able to place gallon milk in refrigerator 9. Able to lift 5 lb to eye-level cabinet 10. Able to lift 2 lb to overhead cabinet Precaution Evaluate for posterior capsular tightness; stretch if necessary
WEEKS 11–14 POSTOPERATIVE (PT BIM)	GOALS (BY END OF 14 WK)
1. Progress isotonics—increase resistance 2. Progress ER and IR isotonics toward 90 degrees ABD (TheraBand, weights) 3. Plyoball exercises if appropriate Chest pass Sideway throw Overhead throw 4. Isokinetic strengthening as needed	1. Independent with isotonic HEP 2. MMT 5/5 FL 3. MMT scaption 5/5 4. MMT ER 5/5 5. MMT IR 5/5 6. Able to lift 10 lb to eye-level cabinet 7. Able to lift 5 lb to overhead cabinet 8. Full return to strenuous work Precaution No bench press or flies until 6 months postoperatively

The Bankart repair is intended to stabilize the anterior portion of the shoulder capsule that has lost integrity owing to repetitive or traumatic insult. It is paramount to protect healing tissue of the anterior capsule during early stages of rehabilitation. Avoidance of terminal ABD/ER is crucial during this period. This protocol is a guideline and may be adjusted according to the clinical presentation and physician’s guidance.

AAROM , Active-assisted range of motion; ABD , abduction; ADD , adduction; AROM , active range of motion; BID , twice a day; BIW , twice a week; BIM , twice a month; ER , external rotation; EXT , extension; FL , flexion; HEP , home exercise program; IR , internal rotation; MMT , manual muscle testing; PNF , proprioceptive neuromuscular facilitation; PT , physical therapy; QID , four times a day; QIW , four times a week; TIW , three times a week; UBE , upper body exercise; WFL , within functional limits; WNL , within normal limits.

Arthroscopic Bankart-Bristow-Latarjet Technique

Boileau, Mercier, and Olds proposed the combined technique as an alternative to capsulolabral repair in patients with anterior instability and significant glenoid bone loss. They reported a high rate of return to sports and a low rate of instability. Tasaki et al. reported 40 rugby players who had anterior dislocations treated with this procedure. All players returned to competitive rugby with no recurrent anterior dislocations at 2-year follow-up.

Posterior Instability

Arthroscopic posterior shoulder stabilization has rapidly gained favor in recent years, with the results of open procedures having been less than adequate. Arthroscopic repairs have been shown to be effective in athletic and nonathletic patients. In a study by Bradley et al. reviewing 100 shoulder procedures for posterior recurrent shoulder instability, the American Shoulder and Elbow Surgeons score improved from 50.36 to 85.66 at a mean follow-up of 27 months. Overall, 89% of their patients were able to return to sports and 67% were able to return to the same level of sports as preoperatively. We likewise believe that arthroscopic repair allows full exposure and correction of intraarticular pathology of the shoulder, and it allows the surgeon to fully define hidden pathologic lesions that often are not evident on MRI. At this time, we use the procedure described by Kim et al. and often incorporate a rotator interval closure in contact athletes or in any patients who have an inferior component to their posterior instability. For traumatic posterior Bankart lesions, anatomic repair is performed with minimal plication to prevent over-constraint of the joint which results in anterior glenoid wear and arthritis from an eccentric humeral head. As with anterior instability, excessive bone loss of more than 25% of the glenoid, a large anterior Hill-Sachs lesion, excessive glenoid retroversion of more than 15%, or a pathologic collagen deficiency syndrome will result in inferior results; these conditions are relative contraindications to arthroscopic soft-tissue techniques.

Posterior Shoulder Stabilization

Technique 52.12

(KIM ET AL.)

▪
Place the patient in the lateral decubitus position and prepare and drape the shoulder.
▪
Maintain the arm with lateral traction in 30 degrees of abduction and 10 degrees of forward flexion.
▪
Create a posterior portal 2 cm inferior to the posterolateral acromial angle. This position, which is about 1 cm lateral to a standard posterior glenohumeral portal, is used to improve access to the posteroinferior aspect of the glenoid labrum and capsule. We usually make the anterior-superior portal first to visually confirm the best angle for the posterior working portal.
▪
Create two anterior portals, just distal to the acromioclavicular joint and proximal to the leading edge of the subscapularis, with at least 1 cm of distance maintained between them. If, while viewing through the anterosuperior portal, a loose flap of the posteroinferior aspect of the labrum is encountered, debride the labrum.
▪
Introduce a small meniscal rasp (CONMED, Utica, NY) through the posterior portal to abrade the incomplete tear of the posteroinferior aspect of the labrum and the corresponding glenoid wall. If the posteroinferior aspect of the labrum is detached from the inner surface, and the junction between the labrum and the glenoid articular cartilage is intact, completely detach the labrum with use of a Liberator knife (CONMED).
▪
Abrade the inferior and posterior aspects of the capsule to enhance healing.
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Place a suture anchor at the posteroinferior glenoid surface, within 2 mm of the margin of the glenoid, through the posterior portal. If a proper angle for suture anchor insertion cannot be achieved through the posterior portal, use an accessory posterior portal at about 1 cm inferior and lateral to the standard posterior portal under the guidance of a spinal needle to maintain a downward angle toward the posteroinferior aspect of the glenoid ( Fig. 52.25 ).
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Retrieve one end of the suture through the anterior midglenoid portal.
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Introduce a 90-degree angle suture hook, loaded with a Shuttle Relay (CONMED), through the posterior portal to pierce the posterior band of the inferior glenohumeral ligament at the same level as the glenoid surface. The posterior band of the inferior glenohumeral ligament is always incorporated into the first suture.
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Shift the suture hook about 1 cm superiorly and pass it under the posteroinferior aspect of the labrum. Retrieve the Shuttle Relay through the anterior midglenoid portal.
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Load the suture into the Shuttle Relay and pull it back out of the posterior portal and tie an SMC knot. Use two or three suture anchors. Knotless anchors can be used and are our preference for posterior repairs ( Fig. 52.26 ).

Postoperative Care

The shoulder is immobilized in an abduction sling with an external rotation pillow for 6 weeks. The arm is maintained posterior to the longitudinal axis of the trunk. Pendulum and active-assisted range-of-motion exercises are initiated at 3 weeks. At that time, forward elevation in the scapular plane and external rotation exercises with the arm at the side are regularly executed. Internal rotation behind the back is started at 4 weeks postoperatively, but internal rotation with the arm elevated (the cross-body adduction position) is prohibited until 6 weeks postoperatively. At 6 weeks, internal rotation with the arm elevated and strengthening exercises are initiated. When the result of manual strength testing is 4+ or more, professional and collegiate-level athletes may perform more vigorous strengthening exercises. Sports activities are allowed after 4 to 6 months.

Multidirectional Instability

Capsular laxity producing unidirectional and multidirectional instability can be successfully treated arthroscopically with plication or a shift procedure in one or more quadrants of the shoulder. Results of capsular volume reduction have been shown to be comparable with open techniques, although the capsular reinforcement by the open shifting of one leaf over the other is not replicated. We have had success arthroscopically comparable with open techniques but with much less morbidity. Bradley has shown that the use of anchors greatly increases the reliability and security of the shift. When posterior-inferior instability with a 2 to 3+ sulcus sign is present, a rotator interval closure is performed, and the capsule is shifted along the entire inferior glenohumeral ligament from the 3-o’clock to the 9-o’clock position. Overtightening of the capsule can result in eccentric wear and arthritis.

Capsular Shift

Technique 52.13

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After examining the anesthetized patient and determining the amount of hyperlaxity present, place the patient in a lateral decubitus position and maintain the position with a beanbag and kidney rest. Carefully pad bony prominences. Apply a heating blanket and serial compression devices to the lower extremity. Place the arm in 45 degrees of abduction and 20 degrees of flexion with 10 lb of traction. During the procedure, it is helpful to have an assistant to position the shoulder to obtain the most advantageous view and to place gentle pressure anteriorly or posteriorly when slight traction is necessary.
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Outline bony landmarks and potential portal sites on the skin. Make a posterior portal is made about 3 cm distal and in line with the posterolateral acromial edge to evaluate the shoulder. The anterior portals are the anterosuperior lateral portal and the anterior central portal, which usually is about 1 cm lateral to the coracoid. Place working 8.25-mm cannulas later in the procedure in the posterior and anterior central portals. The anterosuperior portal is used for viewing.
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Use a small arthroscopic rasp to abrade the capsule and labrum around the area to be plicated, which generally extends from the length of the glenohumeral ligament attachment, starting posteriorly at the 9-o’clock position and extending anteriorly through the 3-o’clock position. Freshen the soft tissue.
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Starting on the side of the shoulder where the most instability is present, place 2-mm PEEK anchors at the articular edge spaced 3 cm or more apart. Use a shuttle to take 1-cm plication bites, using a combination of simple and mattress sutures to plicate the capsule. Advance the capsule superiorly and use the cannula to direct the knots away from the joint surface. Use a Spectrum suture passer (CONMED) to pass additional No. 0 PDS sutures to plicate as necessary.
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Carry the capsular plication around inferiorly, taking care not to get too deep or too far from the labrum so as to catch the axillary nerve. Extend the plication up to about the 9-o’clock position.
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Close the rotator interval. For significant multidirectional or posterior instability, this is done using a Spectrum suture after having withdrawn the anterior cannula to just anterior to the capsule. Pass a PDS through the superior portion of the middle glenohumeral ligament and then retrieve it with a penetrator-type grasper just superior to the superior glenohumeral ligament. Close the interval with two sutures anteriorly. On completion, close the posterior capsule similarly by passing a suture on each side of the rent and closing it with the cannula just outside the capsule. These techniques can be done most easily by viewing the anterior interval closure from the posterior portal and then moving the scope to the anterosuperior portal to view the posterior capsular closure.
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Close the arthroscopic portals with subcuticular Monocryl sutures and place sterile dressings.

Postoperative Care

An UltraSling (DJO Global) is applied with the arm in neutral rotation. The arm is kept in the sling postoperatively for 6 weeks.

Humeral and/or Glenoid Avulsion of the Inferior Glenohumeral Ligament

Humeral avulsion of the inferior glenohumeral ligament can be most easily repaired with a mini-open technique for anterior lesions. Posterior lesions can be repaired using dual posterior portals. The glenoid avulsion of the anterior inferior glenohumeral ligament must be visualized and repaired back to the labrum, which usually is stable (see Technique 52.14.

Arthroscopic Repair of Posterior Humeral Avulsion of the Glenohumeral Ligament

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Shoulder

Indications

Patient Positioning and Anesthesia

Lateral Decubitus Position

Beach-Chair Position

Control of Bleeding During Arthroscopy

Fluid Extravasation

Portal Placement

Posterior Portal

Establishing A Posterior Portal

Technique 52.1

Posteroinferior Seven-O’clock Portal

Anterior Portal

Antegrade Method

Technique 52.2

Retrograde Method

Technique 52.3

Anteroinferior Five-O’clock Portal (Used With Caution)

Superior Portal

Establishing The Superior Portal

Technique 52.4

Suprascapular Nerve Portal As Described By Lafosse

Lateral, Posterolateral, and Anterolateral Portals

Portal of Wilmington

Diagnostic Arthroscopy and Arthroscopic Anatomy

Loose Bodies

Arthroscopic Removal of Loose Body

Technique 52.5

Synovectomy

Drainage and Debridement

Labral Tears

Arthroscopic Fixation of Type II Slap Lesions

Technique 52.6

Postoperative Care

Biceps Tendon Lesions

Biceps Tendon Release

Technique 52.7

Postoperative Care

Arthroscopic Biceps Tenodesis: Percutaneous Intraarticular Transtendon Technique

Technique 52.8

Postoperative Care

Arthroscopic “Loop ‘N’ Tack” Tenodesis

Technique 52.9

Postoperative Care

Biceps Tenodesis: Arthroscopic or Mini-Open Technique with Screw Fixation

Technique 52.10

Postoperative Care

Subpectoral Biceps Tenodesis

Anterior Instability

Arthroscopic Bankart Repair Technique

Technique 52.11

Postoperative Care

Arthroscopic Bankart-Bristow-Latarjet Technique

Posterior Instability

Posterior Shoulder Stabilization

Technique 52.12

Postoperative Care

Multidirectional Instability

Capsular Shift

Technique 52.13

Postoperative Care

Humeral and/or Glenoid Avulsion of the Inferior Glenohumeral Ligament

Arthroscopic Repair of Posterior Humeral Avulsion of the Glenohumeral Ligament

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