Shoulder Arthroscopy, 2nd Edition

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Author: Gary M. Gartsman MD

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

SHOULDER ARTHROSCOPY

ISBN: 978-1-4160-4649-3

Copyright ! 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Gartsman, Gary M. Shoulder arthroscopy / Gary M. Gartsman. 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4160-4649-3 1. Shoulder jointEndoscopic surgery. I. Title. [DNLM: 1. Shoulder Jointsurgery. 2. Arthroscopymethods. 3. Rotator Cuffsurgery. WE 810 G244s 2009] RD557.5.G376 2009 617.50 72059dc22 2008020052

Acquisitions Editor: Daniel Pepper Developmental Editor: John Ingram Publishing Services Manager: Tina Rebane Senior Project Manager: Jodi Kaye Design Direction: Lou Forgione

Printed in China Last digit is the print number:

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I’m not much of a sailor, but when our friends Bill and Christy get me on the Lone Star, my wife Carol enjoys the sea and I spend a lot of my time looking at the boats and wondering how and why they were named. The best I have ever seen was a beautiful sailboat, the Never Again 2.

After Harvard Ellman and I wrote Arthroscopic Shoulder Surgery and Related Procedures, I told Carol I would never write another textbook. Ten years later I wrote Shoulder Arthroscopy and promised her, never again.

Here we are at Shoulder Arthroscopy 2nd edition, the Never Again 2 of textbooks. Carol, you are the greatest. Thank you for your patience and love, again.

G.M.

PREFACE

Seventeen years have passed since the publication of Arthroscopic Shoulder Surgery and Related Procedures. Harvard Ellman and I co-authored that text in an attempt to bridge the gap between traditional open operations and newer arthroscopic approaches. Many today did not have the opportunity to know Dr. Ellman; he was a wonderful man and a true pioneer. He was the perfect person to introduce this fledgling field of shoulder arthroscopy to the world. The Ralph Bunche quote ‘‘If you want to get across an idea, wrap it up in a person’’ applied to Harvard. The first edition of Shoulder Arthroscopy was published 6 years ago. The pace of progress and the rate at which we have accumulated knowledge has accelerated in shoulder arthroscopy, as it has in practically all other forms of human endeavor. It is for this reason that we have decided to publish the second edition of Shoulder Arthroscopy. Thermal capsulorrhaphy did not survive prolonged follow-up. Double-row rotator cuff repair is more common. Biceps lesions are treated more aggressively. The Latarjet procedure for shoulder instability has entered the United States, and the Bristow is making a comeback! Diagnostic ultrasound is more mainstream. Suprascapular nerve lesions can be treated arthroscopically. Many readers requested more information about rehabilitation, and I think Mike De la Flor’s video animations are superb. Use them to instruct your patients. The purpose of this textbook is to present the current state of arthroscopic shoulder surgery as seen by one author. There are, of course, many different methods to treat shoulder lesions with arthroscopy, but I have chosen to present my own views and trust that the reader will also seek out the opinions of others.

My focus in this book is primarily on operative technique, and my goal is to present an approach to arthroscopic shoulder operations in enough detail so that the reader can manage both the routine and complex problems he or she encounters. This required that I exclude some important nonsurgical material. There are a number of texts currently available that devote hundreds of pages to patient history, diagnosis, pathogenesis, physical examination, and imaging studies. Their bibliographies are complete and extensive. So what kind of textbook is this? This is a book for orthopedic surgeons who want to perform reconstructive arthroscopic shoulder surgery. In order to do this, the surgeon must understand why certain procedures are performed and have them described in adequate detail. I have tried to take the reader through the operations in stepwise fashion; however, for complex procedures text is not sufficient. State-of-the-art communication in arthroscopy involves more than thoughts and words on a printed page. The accompanying DVD contains videos that illustrate the concepts and techniques that I describe in the text. Since 1982 I have been privileged to instruct thousands of practicing orthopedic surgeons, residents, and fellows in shoulder arthroscopy. In this textbook I have adopted a tone that I hope captures the many conversations we have had. Imagine that you and I are in the operating room performing shoulder arthroscopy. You can ask all the questions you wish and I have all the time in the world to answer. Let’s begin! GARY M. GARTSMAN, M.D. Houston, Texas

vii

CHAPTER

1

Making the Transition

Surgeons who are considering making the transition from open shoulder surgery to arthroscopic shoulder surgery need to develop a plan or framework. There are two basic types of skills: technical and intellectual. At present, orthopedic surgeons learn the basic skills of shoulder arthroscopy during their residency or fellowship, but more advanced reconstructive surgical techniques require sufficient time with an experienced mentor. This experience varies widely among training programs.

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

who perform only open operations may feel that they are behind the times. Orthopedic surgeons are also conditioned to consider new approaches to patient care, and although many surgeons obtain good results with open repair, they are ready and willing to try something new. Owing to the dramatic increase in available knowledge, many patients are aware of arthroscopic techniques and inquire whether the surgeon performs a certain procedure arthroscopically or with an open technique. Patients have the perception that arthroscopic procedures result in less pain, smaller scars, and more rapid rehabilitation, although strong arguments can be made to refute all these assertions. Nonetheless, patients are increasingly insistent on finding surgeons who will perform their operations arthroscopically, viewing the arthroscope as a magical tool capable of miraculous cures. Some surgeons see the arthroscope as a wonderful addition to the surgical tool box, whereas others, based on their experience, see only its negatives. It is the surgeon’s skill that achieves the proper balance (Figs. 1-1 through 1-4). Before embarking on a mission to acquire arthroscopic skills, each orthopedic surgeon must evaluate his or her practice patterns and answer some questions: Do you perform a sufficient number of shoulder operations to justify learning a new skill? All orthopedic surgeons should be comfortable with diagnostic glenohumeral joint arthroscopy, but not everyone needs to learn more advanced techniques. If you perform fewer than 20 to 30 shoulder procedures a year and are comfortable with the open technique, I would not advise you to invest the time and effort required to perform these few

3

4

Section One

The Basics

Figure 1-4 Figure 1-1

Figure 1-2

Balance.

Magic instrument?

Wand of angels?

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

TECHNICAL SKILLS

Figure 1-3

Tool of the devil?

Most orthopedic surgeons learn the basics of shoulder arthroscopy during residency or fellowship, but for those who did not, other resources are available. The Orthopaedic Learning Center, developed and administered by the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America, hosts numerous courses that cover both basic and advanced shoulder arthroscopy. Didactic lectures, panel discussions, and video demonstrations are presented in state-of-the-art lecture halls. The center, located in Rosemont, Illinois, also houses a wet cadaveric laboratory with 48 workstations so that participants can practice with cadaver specimens and arthroscopic instruments.

Chapter 1

The Orthopaedic Learning Center is a good resource for learning basic shoulder arthroscopy, but many surgeons find it inadequate for more complex procedures such as rotator cuff repair and glenohumeral reconstruction. Generally, the 2- to 3-day courses cover a broad range of topics. A typical course might include lectures and cadaver instruction on arthroscopic subacromial decompression, distal clavicle excision, open and arthroscopic rotator cuff repair, and open and arthroscopic glenohumeral reconstruction. There is insufficient time for participants to become comfortable with all procedures. Because of the breadth of topics, it is unusual for every instructor to have expertise in all the areas covered. Participants also demonstrate great disparity in arthroscopic skill; for instance, one surgeon interested in learning arthroscopic rotator cuff repair may be paired with a beginner who wants to focus on glenohumeral joint inspection. Other programs are available. The Arthroscopy Association of North America offers more individualized instruction through its Masters Series, and several surgeons I know have found the program extremely worthwhile. James Esch has been active in shoulder arthroscopy education for years and annually organizes a superior course that combines lectures and cadaver work. Stephen Snyder has a wonderful facility in California that combines state-of-the art video learning with an opportunity to watch a superb surgeon at work. My own approach to surgeon education has been to offer a small course limited to 12 registrants that focuses solely on one topic—either arthroscopic rotator cuff repair or arthroscopic glenohumeral joint instability. Enrollment is restricted to surgeons with advanced arthroscopic skills. Over a 2-day period, techniques using arthroscopic

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

Figure 1-5

Figure 1-6


5

Laser line on the inserter to align the eyelet.

instruments and video arthroscopy are gradually introduced as participants perform repairs on anatomically detailed plastic shoulder models. This allows everyone ample opportunity to master the requisite intellectual and technical skills (Fig. 1-5). You can also advance your arthroscopic skills by focusing on the details of your open repairs. First, take the opportunity to view arthroscopically all rotator cuff tears and unstable glenohumeral joints before performing the open repair or reconstruction.

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

Figure 1-7

6

Section One

The Basics

Figure 1-10

Rotator cuff repair in two dimensions.

Figure 1-11

Rotator cuff repair in two dimensions.

Figure 1-8 Having the eyelet parallel to the edge of the tendon allows either suture to slide freely.

Learn what the typical glenohumeral joint looks like in a 63-year-old with a full-thickness rotator cuff tear. From the glenohumeral joint, try to identify the tear. Move the arthroscope into the subacromial space, identify the rotator cuff tear, and estimate its size and shape. Ask the circulating nurse to write down these measurements. Next, open the shoulder and record the size and shape of the tear. With practice, you will find that you can accurately assess the size

Figure 1-9

Knot tying board.

Figure 1-12

Glenohumeral joint reconstruction model.

Chapter 1

Figure 1-16

Figure 1-13

Figure 1-15


7

Load the suture.

Shoulder arthroscopy model.


Suture is held in the instrument’s jaw.

Elite suture punch needle.

Depress the handle bottom to load it.

Figure 1-18

Depress the handle top to advance the needle.

8

Section One

Figure 1-19

The Basics

Withdraw the needle, leaving the suture loop.

Two free ends are inserted into the back hole of the Caspari suture passer.

Figure 1-22

Figure 1-20

Remove the instrument, leaving the suture

loop.

Figure 1-21

in half.

and shape of tears arthroscopically. Before performing an open Bankart procedure, use the arthroscope to identify the Bankart lesion and estimate its size, then compare that to your impression during the open repair. As your experience increases, make your observations more precise. When you are viewing a rotator cuff tear from the subacromial space, insert a probe and use it to measure the length and width of the tear. Insert a grasper and try to determine the tear’s reparability. Grasp different portions of the tear edge and advance them to different locations near the greater tuberosity. This will help you learn to appreciate tear geometry and repair geometry as viewed through the arthroscope. Make note of the

Two free ends of 2-0 nylon suture folded Figure 1-23

Caspari suture passer in the operating room.

Chapter 1

Figure 1-24


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Figure 1-26

Loaded Caspari suture passer and tying board.

Figure 1-27

Two free ends of nylon suture placed through

Proper thumb position.

tendon quality. After you perform the open repair and close the skin, reinsert the arthroscope into the subacromial space to see how a completed repair should appear. As you can appreciate from the preceding description, I believe that the transition from open to arthroscopic repair should proceed slowly as the

the felt.

Figure 1-28 Remove the Caspari suture passer, and the Figure 1-25

Improper thumb position.

nylon suture remains in the felt.

10

Section One

The Basics

Use the thumb to advance the suture in the AccuPass device.


Loop braided through the looped end of a

nylon suture.

Figure 1-33 One option is to load the suture loop first in the

Pull on the free ends of the nylon suture, and pull the braided suture through the felt.

Figure 1-30

Figure 1-31

Braided suture passed through the felt.

AccuPass.

Figure 1-34 Another option is to pass the braided suture directly through soft tissue with the AccuPass.

Chapter 1

Figure 1-35

Figure 1-37


11

Correct hand positions.

Figure 1-38

Figure 1-36

Incorrect hand positions.

Use the index finger to rotate the arthroscope.

Use the thumb to rotate the arthroscope.

surgeon makes incremental improvements in his or her technical skills and adds to his or her knowledge base. It is extremely difficult for any surgeon to learn about arthroscopic rotator cuff repair one day and perform the procedure from beginning to end the next day. I spent 1 year making the transition using the approach described later. While you hone your basic arthroscopic skills and add to your knowledge, learn the principles of and technical steps required for an arthroscopic repair. For instance, an arthroscopic rotator cuff repair consists of the following elements: glenohumeral joint arthroscopy, subacromial bursectomy, coracoacromial

Figure 1-39 Do not use two hands to rotate the arthroscope.

12

Section One

The Basics

ligament release, and acromioplasty. You must be expert in these aspects of the procedure. Once you are able to evaluate tear size, geometry, and reparability, you must learn to insert suture anchors, pass sutures through the tendon, manage sutures, and tie secure knots. Fortunately, you can master these techniques before you enter the operating room.

through it. The indirect method requires that you use some sort of monofilament suture passed through the tendon. This monofilament suture is then used to pull the braided suture through the soft tissue. You can attach a piece of felt or foam rubber to a wooden board and practice using instruments to pass sutures.

Suture Management Suture Anchors Ask your local manufacturer’s representative for a spare suture anchor and familiarize yourself with its characteristics. Are the sutures preloaded, or must they be loaded in the operating room? Are the sutures desirable for your particular rotator cuff repair? If not, can you switch them? Does the suture anchor accept multiple sutures or just one? If the anchor has two sutures, how are they arranged? Which suture do you have to tie first? Practice inserting the anchor into a board, and learn how much force is required. Learn how to orient the eyelet so that the sutures slide easily. You should practice reloading the anchor in case you pull the sutures out (Figs. 1-6 through 1-8).

Sutures through Tendon There are two basic methods of passing a braided suture through a tendon or ligament, and you should be familiar with both (see Figs. 1-9 through 1-29). The direct method involves using an instrument to pierce the ligament or tendon and pulling or pushing the suture

Suture management is critical to arthroscopic shoulder reconstruction. Whether the surgeon is in the subacromial space for a rotator cuff repair or in the glenohumeral joint for a glenohumeral reconstruction, the fundamental problem is too many sutures in too little space. There are two basic solutions: tie the sutures as you insert them, or move the sutures out of the way through cannulas. Experiment with both techniques to determine which one is better for you. Even if you tie the sutures after you insert each one, suture management is important. To avoid nicking the suture (risking suture breakage) when inserting sharp instruments through cannulas, the basic principle is to keep the working cannula free from sutures. Percutaneous anchor insertion is an option in the subacromial space but not in the glenohumeral joint, owing to the mass of soft tissue the anchor must penetrate. To practice suture management, write out in detail each step of the operation and decide when you must move sutures. For example, the steps for two types of rotator cuff repair follow:

Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)

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

Chapter 1


Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)—cont’d

Advance the needle and push the white Ethibond suture through the tendon. Withdraw the needle. Insert a grasper through the anterior cannula and grasp the white suture strand exiting the tendon. Remove the Elite Pass instrument from the lateral cannula. Use a grasper to pull the suture out through the anterior cannula. Remove the hemostat from the white sutures. Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula. Loop the grasper to untangle the sutures. Tie the white sutures. Remove the hemostat from the green sutures. Move the green sutures from the anterior cannula to the lateral cannula. Loop the grasper to untangle the sutures. Tie the green sutures.

Arthroscopic Rotator Cuff Repair—Caspari Technique (1 Anchor, 2 Sutures)

Insert the anchor in the anterior position through the lateral cannula. Use a crochet hook to pull the green and white sutures out through the anterior cannula. Insert a Caspari suture punch with 2-0 looped nylon through the lateral cannula. Grasp the tendon. Check to ensure that the needle hole is clear. Advance the nylon suture. Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat. Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat. Remove the Caspari from the nylon suture. Use the crochet hook from the lateral cannula to retrieve one strand of the green suture. Loop the grasper from the lateral cannula to untangle the sutures. Pass 6 cm of suture through the nylon loop. Pull on the hemostat and nylon suture to bring the green suture through the tendon and out the anterior cannula. Apply the hemostat to the two green sutures. Insert the Caspari with 2-0 looped nylon through the lateral cannula. Grasp the tendon. Check to ensure that the needle hole is clear. Advance the nylon suture. Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat. Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat. Remove the Caspari from the nylon suture. Use the crochet hook from the lateral cannula to retrieve one limb of the white suture. Loop the grasper from the lateral cannula to untangle the sutures. Pass 6 cm suture through the nylon loop. Pull on the hemostat and nylon suture to bring the white suture through the tendon. Remove the hemostat from the white sutures. Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula. Loop the grasper to untangle the sutures. Tie the white sutures. Remove the hemostat from the green sutures. Loop the grasper to untangle the sutures. Tie the green sutures.

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14

Section One

The Basics

For a glenohumeral reconstruction, some of the steps are as follows:

Arthroscopic Bankart Repair—Suture Passer, Single-Suture Anchors

Insert the arthroscope posteriorly. Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon. Insert an 8-mm cannula. Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval. Insert a metal cannula and move the scope anteriorly to view the posterior joint. Remove the scope and cannula and replace them with a 5.5-mm working cannula. Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion. Insert a shaver through the anterior-superior cannula to de´bride soft tissue from the anterior scapular neck. Insert a bur to decorticate the anterior scapular neck. Remove the anterior-superior cannula. Insert a metal cannula and trocar into the anterior-superior portal. Observe the anterior scapular neck decortication. Move the scope to the posterior cannula. Determine how many anchors are required to repair the Bankart lesion. Mark the anchor locations with a punch or bur. Insert a drill through the anterior-superior cannula to drill anchor holes. Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole. Remove the inserter. Two suture strands from the inferior anchor should be exiting the anterior-superior cannula. Insert a Spectrum suture passer through the anterior-inferior cannula and pierce the capsule and labrum. Advance the free ends of nylon into the joint. Retrieve the free ends of nylon suture with a crochet hook placed in the anterior-superior cannula. Apply a hemostat to the tips of the nylon suture. Place the tip of the hemostat at the entrance of the anterior-superior cannula to decrease tension on the nylon suture. Remove the Spectrum from the anterior-inferior cannula. The nylon loop should be outside the anterior-inferior cannula. Use Prolene suture to reverse the direction of the loop. The loop of Prolene should be outside the anterior-superior cannula. Have an assistant hold one limb of each anchor suture in each hand. Insert a crochet hook through the anterior-inferior cannula and retrieve one limb of anchor suture from the anteriorsuperior cannula to the anterior-inferior cannula. Place 6 cm of anchor suture through the Prolene loop (anterior-superior cannula). Apply traction to the hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the labrum, and out the anterior-inferior cannula. Two anchor sutures are now through the anterior-inferior cannula. Tie the sutures. Repeat these steps from additional anchors as needed.

Chapter 1


15

Arthroscopic Bankart Repair—AccuPass, Double-Suture Anchors

Insert the arthroscope posteriorly. Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon. Insert an 8-mm cannula. Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval. Insert a metal cannula and move the scope anteriorly to view the posterior joint. Remove the scope and cannula and replace them with a 5.5-mm working cannula. Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion. Insert a shaver through the anterior-superior cannula to de´bride soft tissue from the anterior scapular neck. Insert a bur to decorticate the anterior scapular neck. Remove the anterior-superior cannula. Insert a metal cannula and trocar into the anterior-superior portal. Observe the anterior scapular neck decortication. Move scope to posterior cannula. Determine how many anchors are required to repair the Bankart lesion. Mark the anchor locations with a punch or bur. Insert a drill through the anterior-superior cannula to drill anchor holes. Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole. Remove the inserter. Four suture strands from the inferior anchor should be exiting the anterior-superior cannula. Insert the AccuPass through the anterior-inferior cannula and pierce the capsule and labrum. Advance the loop end of the nylon into the joint. Retrieve the loop end of nylon suture with a crochet hook placed in the anterior-superior cannula. Remove the AccuPass from the anterior-inferior cannula. The nylon loop should be outside the anterior-superior cannula. The free ends of the loop should be outside the anterior-inferior cannula. Through the anterior-inferior cannula, use a crochet hook to grasp one strand of green anchor suture. Through the anterior-superior cannula, insert a loop grasper and encircle the two nylon strands and the other green anchor suture strand. Place 6 cm of anchor suture through the nylon loop (anterior-superior cannula). Apply traction to a hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the labrum, and out the anterior-inferior cannula. Two green anchor sutures are now through the anterior-inferior cannula. Tie the sutures. Repeat for the second white sutures from the most inferior anchor (white). Repeat these steps from additional anchors as needed.

16

Section One

The Basics

When you write out the operative steps in detail, it gives you an accurate impression of how many suture manipulations are needed. Reviewing these steps with members of your operative team gives them a much better idea of what needs to be accomplished, as well as an appreciation of the operation’s complexity. You can practice these steps before you get to the operating room. Get a 12- by 12-inch board and insert picture eyelets to simulate portal locations. Place cannulas through the eyelets and insert an anchor in the center. Practice moving the sutures from cannula to cannula until the motions become automatic (Figs. 1-30 through 1-34). My friend Lanny Johnson is fond of saying that when professional golfers finish playing golf, they practice golf; when surgeons finish performing surgery, they practice golf. Perhaps we could learn a lesson from professional golfers. It is amazing to see the progress students make after they practice an operation 20 times. I am absolutely convinced that operations of this complexity cannot be taught with a lecture and a video. Each step (holding the instruments, passing the sutures, suture management, and so forth) must be taught and mastered as an individual event (Figs. 1-35 through 1-39). These individual events must then be performed in the correct sequence. Once the sequence is mastered, the fluidity of the steps must be improved until they become routine. All this must be done under the constant supervision of an expert so that bad habits are corrected immediately before they become ingrained. Practice does not make perfect, but practice does make permanent, and it is of no benefit to practice an operation either incorrectly or inefficiently. When I was learning to perform arthroscopic procedures, I drew out the essential steps of the operation on a piece of paper; borrowed a suture passer, knot pusher, crochet hook, loop grasper, sutures, and hemostats from the operating room; and practiced the required maneuvers until I felt comfortable. I have included here the exercises I used and encourage you to rehearse the procedure with your assistant until both of you are familiar with your roles and the necessary steps. Although this may seem time-consuming, this level of preparation yields great dividends during the actual operation. Exercise 1 (Figs. 1-40 through 1-50) simulates a one-anchor, two-suture rotator cuff repair. Exercise 2 (Figs. 1-51 through 1-69) simulates a two-anchor, four-suture rotator cuff repair. Exercise 3 (Figs. 1-70 through 1-102) simulates a three-anchor, six-suture complex rotator cuff repair. Exercise 4 (Figs. 1-103 through 1-112) simulates a Bankart repair.

Figure 1-40 Exercise 1 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon.

Knot Tying Because reconstructive arthroscopic shoulder surgery involves soft tissue repair, knot tying is a critical skill. Surgeons’ reluctance to tie arthroscopic knots has created a booming industry in pretied knots or ‘‘knotless’’ devices. Each of these devices requires a number of steps that are just as difficult (or as simple) as the steps required to tie a knot. As I explain to the registrants in my arthroscopy courses in Houston, there is another option: learn how to tie an arthroscopic knot. It is difficult, but with instruction and practice, it can be mastered. Surgeons tie knots in open surgery on a daily basis. Arthroscopic knots are identical,

Figure 1-41

strands.

Insert an anchor with two sutures—four suture

Chapter 1

Figure 1-42 Pull the four suture strands out through the anterior cannula.

Figure 1-43

Pull one blue strand through the lateral

Figure 1-45


17

Pull one white suture strand through the lateral

cannula.

Figure 1-46

Place it through the felt with a suture passer.

cannula.

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


Place it through the felt with a suture passer.

18

Section One

Figure 1-48

The Basics

Tie the white sutures.

Figure 1-49 Retrieve the blue suture strands from the anterior cannula and pull them through the lateral cannula.

Figure 1-50 Tie the blue sutures.

Figure 1-51 Exercise 2 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are two drill holes for anchors.

Figure 1-52

Insert two anchors—four sutures, eight suture

strands.

Figure 1-53 Pull the sutures from the anterior anchor out through the anterior cannula. Apply a hemostat.

Chapter 1

Figure 1-54 Pull the sutures from the posterior anchor out through the anterior cannula. Apply a hemostat.


19

Figure 1-57 Retrieve one white suture strand from the anterior anchor and bring it out through the lateral cannula.

Figure 1-55

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

Figure 1-58 Insert this suture strand through the felt and pull it out through the anterior cannula.


Figure 1-59 Retrieve one blue suture strand from the posterior anchor and bring it out through the lateral cannula.

20

Section One

The Basics


Figure 1-63 Retrieve both posterior anchor white strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-64

Figure 1-61 Retrieve one white suture strand from the posterior anchor and bring it out through the lateral cannula.

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

Figure 1-65

Insert this suture strand through the felt and pull it out through the anterior cannula. Figure 1-62

Tie these sutures.

Chapter 1

Figure 1-66

Figure 1-67

Tie these sutures.

Repeat the steps for the anterior anchor white

suture.

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

Figure 1-69


21

Tie the sutures. The repair is complete.

Figure 1-70 Exercise 3 simulating the repair of a large or massive rotator cuff tear. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are three anchor holes.

Figure 1-68

Figure 1-71 Insert three anchors—6 sutures and 12 suture

strands.

22

Section One

The Basics

Figure 1-72 Pull the anterior anchor sutures out through the anterior cannula.

Figure 1-75 Move the middle anchor sutures from the anterior cannula, simulating an anterolateral percutaneous stab wound.

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

Figure 1-76 Retrieve one anterior anchor blue suture from

Figure 1-73

Figure 1-74 Move the posterior anchor strands to the left of the lateral cannula, simulating removing them through a posterolateral percutaneous stab wound.

the anterior cannula and pull it out through the lateral cannula.

Figure 1-77 Place this suture through the felt and withdraw it through the anterior cannula.

Chapter 1


23

Figure 1-78



Figure 1-82 Withdraw the suture strand that is through the

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

Figure 1-83

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

Figure 1-80

felt and pull it out the anterolateral stab wound.

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

24

Section One

The Basics


Figure 1-85 Withdraw the suture strand that is through the felt and pull it out the anterolateral stab wound.

Figure 1-86 Retrieve the anterior anchor white suture strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-87

Tie the sutures.

Figure 1-88 Retrieve the anterior anchor blue suture strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-89

Tie the sutures.

Chapter 1

Withdraw the posterior anchor blue suture strand from the posterolateral stab wound and pull it out through the lateral cannula. Figure 1-90


25


Figure 1-91

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

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

Figure 1-95

Figure 1-94

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

Figure 1-92

Retrieve the posterior anchor strand from the anterior cannula and withdraw it through the lateral cannula.

26

Section One

Figure 1-96

The Basics

Tie the white sutures from the posterior anchor.

Figure 1-99 Retrieve both middle anchor white sutures and

withdraw them through the lateral cannula.

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

Figure 1-97

Figure 1-98

Tie the blue sutures from the posterior anchor.

Figure 1-100

Tie the middle anchor white sutures.

Figure 1-101 Retrieve both middle anchor blue sutures and withdraw them through the lateral cannula.

Figure 1-102

Tie the middle anchor blue sutures.

Figure 1-105 Place a nylon passing suture through the green cannula. The two free ends are exiting the orange cannula, and the looped end is exiting the green cannula.

Figure 1-103 Exercise 4 simulating a right shoulder Bankart repair with three suture anchors. The green cannula is anterior-inferior, and the orange cannula is anterior-superior.

Insert the inferior anchor and withdraw the sutures through the orange cannula.

Figure 1-104

Pull one suture strand from the orange cannula out through the green cannula.

Figure 1-106

Figure 1-107 Place the end of the blue suture through the looped end of the nylon suture.

28

Section One

The Basics

7 cm

Figure 1-108

Close-up view of Figure 1-7.

Figure 1-111 Continue to pull on the nylon suture, and bring the blue suture out through the orange cannula.

Figure 1-109

Pull on the two free ends of the nylon (white)

suture.

Figure 1-112

Tie the suture. Repeat for the two additional

anchors.

Pull the blue suture from the green cannula through the felt.

Figure 1-110

with the exception that the knot pusher replaces the surgeon’s index finger. The knots lie flat, are square, and are as strong as knots tied in the open technique. My advice is to learn arthroscopic knot tying and use knotless systems only when they are superior to or offer an advantage over a traditional knot. Before learning arthroscopic knots, the surgeon must be proficient with the basic one-handed knots commonly taught in medical school or surgery internship. Although there are many knot variations, only two basic knots are necessary: an overhand knot and a sliding knot. When learning the steps required to tie

Chapter 1

knots, it is easier to practice with clothesline than with surgical suture. All the knots described here are shown on the video.

1


2

Knot Tying After the suture has been inserted through the soft tissue, verify that no tangles exist. Use the loop grasper to encircle one suture limb and then withdraw the instrument. Perform this step before tying every knot. Place one limb of the suture through the knot tying instrument. This suture limb is usually the one closest to you. For example, in rotator cuff repair, the knot pusher goes on the suture limb that exits from the suture anchor and comes out through the cannula. The free end is the suture limb that has been placed through the tendon and is farther away. Apply a hemostat to the suture strand that is through the knot pusher so that you have something to pull against as you push the knot down the cannula. Gently push the half hitch down the cannula. Slowly place tension on the two strands and observe which strand must be pushed away for the knot to lie flat. If you push the other strand away, the knot will not lie flat. It is not important whether the first throw is overhand or underhand, but it is important that you always use the same technique when tying knots. I recommend that surgeons use the same sequence of knot tying for arthroscopic procedures that they use for open techniques. For example, if you perform two throws, bringing the strands from top to bottom, and then the third throw goes from below to above, I advise you to keep the same sequence. Try to make the steps of tying your arthroscopic knots as similar as possible to those of your open knots. Use the knot pusher to past-point. This allows you to pull the suture strands tight with a 180-degree angle. Place another throw in the same direction as the first, past-point, and tighten the knot. Now reverse the direction of the throw and place a third hitch. Reverse the post of the knot for greater knot security and place a fourth throw. Reverse the post and the direction of the throw for the fifth half hitch. It is critical that you become skilled in tying knots with a one-handed technique. Gradually incorporate arthroscopic knot tying into surgery by tying knots with the knot pusher during an open repair and moving to arthroscopic knot tying as your skills increase. These steps are illustrated in Figures 1-113 through 1-178. An additional skill that is critical is learning to slip the second throw. Usually the tendon or

OVERHAND KNOT

Figure 1-113

3

Knot tying illustrations.

4

Figure 1-114

5


6

Figure 1-115

7


8

Figure 1-116


29

30

Section One

The Basics

9

10

Figure 1-117

13


ligament to be tied is under tension and retracts slightly after the first knot throw. One method to deal with this problem is to eliminate the tension on the soft tissue by having an assistant hold the soft tissue with a tissue grasper. Another method is to place a traction suture through the soft tissue. A third method (and the one I prefer) involves slipping the second throw. Tie the first throw routinely. Make a second half hitch in the same direction and slowly advance it down the cannula. Check to see that the suture is not tangled. Pull on the post limb and release all tension on the other limb. The knot will slide down to the soft tissue without locking, enabling you to approximate the soft tissue. Past-point and lock the second throw. Finish the remaining throws, and complete the knot. There are dozens of types of sliding knots, but it is necessary to learn only one. If you wish to learn more at a later date, you can always do so. After placing the suture through the soft tissue, grasp both ends and confirm that it slides freely. Pull on one end so that it becomes the shorter one. Make a loop with the longer strand and pinch it between your thumb and index finger. Pass the longer suture over the shorter

Figure 1-119

Knot tying illustration.

one four times. Bring the end of the longer suture strand up through the loop to complete the Duncan loop. Freshen the knot by applying tension to each strand. Pull on the shorter strand to advance the knot. Place three alternating half hitches to secure the knot.

KNOT TYING TECHNIQUE 1

2

3

4

5

6

SLIDING KNOT

11

12

Figure 1-118


Figure 1-120


Chapter 1


Figure 1-121

One-handed knot.

Figure 1-124

One-handed knot.

Figure 1-122

One-handed knot.

Figure 1-125

One-handed knot.

Figure 1-123

One-handed knot.

Figure 1-126

One-handed knot.

31

32

Section One

The Basics

Figure 1-127

One-handed knot.

Figure 1-130

One-handed knot.

Figure 1-128

One-handed knot.

Figure 1-131

One-handed knot.

Figure 1-129

One-handed knot.

Figure 1-132

One-handed knot.

Chapter 1


Figure 1-133

One-handed knot.

Figure 1-136

One-handed knot.

Figure 1-134

One-handed knot.

Figure 1-137

One-handed knot.

Figure 1-135

One-handed knot.

Figure 1-138

One-handed knot.

33

34

Section One

The Basics

Figure 1-139

One-handed knot.

Figure 1-142

One-handed knot.

Figure 1-140

One-handed knot.

Figure 1-143

One-handed knot.

Figure 1-141

One-handed knot.

Figure 1-144

One-handed knot.

Chapter 1

Figure 1-145

One-handed knot.

Figure 1-146

Figure 1-147


Figure 1-148

One-handed knot using a knot pusher.

Figure 1-149


Figure 1-150


Knot pusher.


35

36

Section One

The Basics

Figure 1-151


Figure 1-154


Figure 1-152


Figure 1-155


Figure 1-153


Figure 1-156


Chapter 1


Figure 1-157


Figure 1-160


Figure 1-158


Figure 1-161


Figure 1-159


Figure 1-162


37

38

Section One

The Basics

Figure 1-163


Figure 1-166


Figure 1-164


Figure 1-167


Figure 1-165


Figure 1-168


Chapter 1


Figure 1-169


Figure 1-172


Figure 1-170


Figure 1-173


Figure 1-171


Figure 1-174


39

40

Section One

Figure 1-175

The Basics


Figure 1-178


INTELLECTUAL SKILLS

Figure 1-176


Figure 1-177


Intellectual skills can be honed by attending instructional courses presented by the American Academy of Orthopaedic Surgeons, the American Shoulder and Elbow Surgeons, and the Arthroscopy Association of North America. These courses are held throughout the United States. A full day of current shoulder information is given at the open meeting of the American Shoulder and Elbow Surgeons, which is held at the annual meeting of the American Academy of Orthopaedic Surgeons. The best shoulder arthroscopy course I have attended is the biennial meeting held in Val d’Isere, France. This weeklong course covers the spectrum of shoulder arthroscopy topics in detail. Excellent textbooks are also available, such as The Shoulder by Rockwood and Matsen, or you can subscribe to the Journal of Shoulder and Elbow Surgery and Arthroscopy, Arthroscopy, and the American Journal of Sports Medicine, which are sources of current thought on shoulder problems. Perhaps the most important intellectual tool a surgeon can possess is a plan to master reconstructive arthroscopic operations. As a general approach, I recommend the following: learn the individual steps of the arthroscopic repair, practice these techniques outside the operating room, gradually incorporate these techniques into open repair, perform arthroscopic repair and then open the shoulder, and finally perform the operation exclusively with arthroscopic technique. Although, theoretically, it seems reasonable to make the transition to arthroscopic repair in one step, in practice, it can result in a 6-hour arthroscopic

Chapter 1

rotator cuff repair that benefits neither patient nor surgeon. I advise a more gradual transition. As noted earlier, I took 1 year to move from open rotator cuff repair to a fully arthroscopic technique.

THE GRADUAL TRANSITION


41

3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Open and repair the rotator cuff tear.

When making the transition from open to arthoscopic rotator cuff repair, be sure to scope all tears before performing the open repair. Establish time limits for your arthroscopic procedures. Give the circulating nurse authority to inform you that 1 hour has passed and it is time to open the shoulder. Consider a plan similar to the one described here.

Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 8 in 30 minutes, advance to the next stage.

Stage 1

Stage 4

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

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

Stage 3 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy.

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

Stage 5 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site.

42

Section One

The Basics

7. Insert an anterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Pass the anterior anchor sutures through the tendon. 10. Pass the posterior anchor sutures through the tendon. 11. Tie the knots. 12. Open and inspect the repair. Check the tension on the tendon, ensuring that it is neither too tight nor too loose. Are the knots secure? Is the spacing of the knots on the tendon correct? Are they too close together or too far apart? Are they too close to the lateral edge or too far away from the edge? 13. Review the video recording (I strongly suggest that you record your procedures). If the knots are too closely spaced, determine at what point in the procedure this occurred. Why did the spacing look good at arthroscopy but not when you inspected the repair open? Apply this same level of analysis to all aspects of the repair until you are satisfied. At this final stage you will gain confidence that your arthroscopic repairs are as good as or better than your open repairs. Once your particular threshold of excellence has been met, you can stop opening your arthroscopic repairs.

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

Arthroscope Practice holding and manipulating the arthroscope with both hands. If you are comfortable holding the arthroscope with only one hand, operating on the opposite shoulder will force you into an awkward position. Practice with both hands during diagnostic glenohumeral arthroscopy until you can smoothly and rapidly maneuver the arthroscope and view all critical areas of the joint. Everyone has a dominant or preferred hand, but I have observed that some surgeons

prefer to use this hand to control the arthroscope, and others use the dominant hand to manipulate the surgical instruments. Ideally, you should be able to hold the camera and manipulate the instruments with either hand. A second skill is arthroscope rotation. Many surgeons rotate the arthroscope with the hand not holding the scope. This may be satisfactory during the diagnostic phase, but when you have an instrument in the opposite hand, this becomes difficult. Learn to rotate the arthroscope by using the index finger of the hand holding the scope (see Figs. 1-35 through 1-39).

Caspari Suture Punch You should learn to use the Caspari suture punch with either hand—a skill you can master on a practice station. It is also necessary to advance the suture with the thumb of the hand holding the instrument so you are not forced to use the opposite hand (see Figs. 1-16 through 1-20). The scrub nurse will hand you the Caspari numerous times during an arthroscopic repair, and this phase of instrument transfer can be either awkward or smooth. Rehearse the instrument transfer with your scrub nurse so that both of you are familiar with the correct technique.

Elite Pass This modern instrument is designed to pass braided sutures directly through a tendon or ligament without using a shuttle relay. Take some time to learn how to load the needle, load the suture, deploy the needle, grasp the suture, withdraw the needle, and finally remove the instrument (see Figs. 1-9 through 1-15).

Spectrum Familiarize yourself with the proper handling and transfer of this instrument. Have the scrub nurse load the looped nylon suture from the opposite side of the thumb so that the suture does not get tangled as you advance it.

AccuPass This series of instruments is used to shuttle sutures with a nylon loop. They are reusable, so the tip is always sharp. The loading eyelet is large enough so that the nylon loop can be loaded either loop end first or free end first, depending on the specific requirements of the

Chapter 1

operation. Many tip configurations are available. Try to load the nylon loop on the side opposite the thumb wheel so that the loop does not get caught in your glove (see Figs. 1-27 through 1-29).

Knot Pusher There are a variety of knot tying instruments available, and you should examine a number of them to determine which one feels most comfortable. I prefer a


43

simple instrument and view the tip of it as an arthroscopic projection of my index finger. Finding the optimal shaft length is accomplished by trial and error. I shorten the standard shaft length to fit my thumb motion during the tying maneuver.

CHAPTER

2

Operating Room Setup

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

CLINICAL DATA I find it helpful to have a copy of the patient’s record in the operating room. This allows me to compare the examination under anesthesia with the examination documented in the office. For patients with glenohumeral instability, I can compare the patient’s report of which activities or motions produce pain to the amount of translation observed during examination under anesthesia. The patient record also includes a summary of the pertinent findings on magnetic resonance imaging, ultrasonography, and computed tomography, allowing me to compare these to the findings at arthroscopy. I also display the relevant radiographic study so that I can review it if necessary (Figs. 2-1 through 2-3).

44

Figure 2-1

Patient record in the operating room.

Chapter 2


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

Figure 2-2

Close-up of patient record.

45

46

Section One

The Basics

Figure 2-3

Magnetic resonance imaging study in the operating room.

Chapter 2


SETUP AND PREPARATION The operating room layout is shown in Figure 2-4. I must have adequate space to maneuver between the head of the table and the anesthetist. I angle the cart with the arthroscopy equipment toward me so that I can see all the gauges. Similarly, the arthroscopic pump and fluid bags should be visible so that I can see the pressure and flow at any time. I also ask the anesthetist to rotate the blood pressure monitor so that I can check it during the procedure without disturbing his or her concentration. An absorbent mat to collect fluid is placed on the floor underneath my feet. I arrange the foot pedals that control the power instruments and cautery to permit easy access (Figs. 2-5 through 2-9). Figure 2-6 Back table

Technician

Instrument cart.

Absorbent mat

Assistant

Anesthesia equipment

Surgeon

Mayo stand

Operating table

Anesthesia

Fluid/pump electrogenerator

Figure 2-4

Figure 2-5

Camera Power Monitor Video recorder

Figure 2-7

Arthroscopic pump.

Operating room setup.

Equipment position.

Figure 2-8

Fluid bags.

47

48

Section One

The Basics

The shoulder preparation table contains the skin razor and adhesive tape for removing hair. My team uses an iodine-based product (Duraprep); for individuals with iodine allergy, a chlorhexidine gluconate (Hibiclens) scrub is followed by an isopropyl alcohol solution. I prefer to have the patient’s hair shaved from the area that will be covered by the bandage. It is not necessary to shave the axilla. Only those instruments required for the operation are placed on the Mayo stand. The back table contains rarely used instruments and the postoperative dressing (Figs. 2-10 and 2-11).

Figure 2-11

Back table.

ANESTHESIA

Figure 2-9

Absorbent mat and foot pedals.

Figure 2-10

Mayo stand.

My team’s routine is to perform an interscalene block in the preoperative holding area. The patient is then moved to the operating room, where general anesthesia is started. Because many patients find remaining motionless in the seated position uncomfortable, and I find patient movement and conversation distracting, I prefer to use general anesthesia rather than operating under regional block alone. The interscalene block has no direct effect on blood pressure. With sensory input blocked, there is no sympathetic response to the otherwise painful stimuli, and catecholamine release is avoided. The beta-antagonistic effects (vasodilation and bradycardia) of the general anesthetic agents are then more pronounced, without the pain response to offset them. This causes relative bradycardia and hypotension. The result is improved visualization. Because the operated area is anesthetized, only light general anesthesia is necessary, minimizing postoperative nausea. Some anesthesiologists prefer a laryngeal mask airway, which eliminates the need for endotracheal intubation. Immediate postoperative pain is well controlled (Figs. 2-12 and 2-13).

Figure 2-12

Laryngeal mask air tube.

Chapter 2

Figure 2-13

Laryngeal mask air tube secured in place with

tape.

To avoid ‘‘wrong site’’ surgery, always confirm with the patient which shoulder is to be operated on. The is done in the preoperative holding area before the patient receives any sedation. The anesthesiologist uses a surgical marking pen to write ‘‘yes’’ on that shoulder and ‘‘no’’ on the contralateral shoulder. I ask the patient and confirm the correct site myself and write a ‘‘G’’ for Gary on the correct shoulder (Fig. 2-14).

PATIENT POSITIONING Successful shoulder arthroscopy is the result of planning and organization. Many seemingly minor details can have a profound effect on the procedure, and I encourage all surgeons to invest the necessary time to prepare the operating room and surgical staff adequately. Patients are positioned in either the lateral decubitus or the sitting (beach-chair) orientation. Each position has its advantages and disadvantages,

Figure 2-14

Skin marking.


49

and surgeon preference should dictate the choice. Both diagnostic and reconstructive shoulder arthroscopy can be performed successfully in either position. I used the lateral decubitus position for 10 years and found it very satisfactory for diagnostic arthroscopy and for arthroscopic subacromial decompression and acromioclavicular joint resection. As I began to perform rotator cuff repair and glenohumeral reconstruction, I found that the disadvantages of the lateral position became more noticeable, and I made the transition to the sitting position, which I have used exclusively for the past 15 years. I pay considerable attention to patient positioning because this aids in portal placement and facilitates the procedure. Incorrect positioning adds complexity to an already difficult procedure.

Lateral Decubitus Position The lateral decubitus position offers excellent access to the posterior shoulder and allows arm suspension (and distraction, as necessary) without the need for an assistant. The surgeon can choose to terminate the arthroscopic procedure and can easily perform an open operation in the subacromial space. Disadvantages include the need to lift and turn the patient, the possibility of excessive distraction across the glenohumeral joint and potential nerve injury, limited access to the anterior shoulder, and the need to reposition the patient if an open anterior glenohumeral reconstruction is required. Another potential disadvantage is the tendency for the suspension apparatus to place the arm in internal rotation. This is important in glenohumeral reconstruction because repair of the glenohumeral ligaments or rotator interval with the arm in internal rotation may result in permanent loss of external rotation. The surgeon can overcome all these difficulties with appropriate care. Before the patient is brought to the operating room, a vacuum beanbag is placed on the operating table and smoothed (Table 2-1). The patient is assisted onto the table and centered on the beanbag. The cephalad edge of the beanbag should be level with the patient’s upper thorax, not high enough to protrude into the axilla. After general endotracheal anesthesia has been established, the tube is secured on the side of the mouth away from the surgical site. Both shoulders are examined for range of motion and translation. The patient is then turned over on the unaffected side, with the pelvis and shoulders perpendicular to the table. The beanbag is gathered up around the patient and deflated so that it is firm. The operating table is tilted 20 to 30 degrees posteriorly so that the glenoid is parallel to the floor.

50

Section One

The Basics

Table 2-1 TABLE POSITIONING AIDS—DECUBITUS U-shaped Vacupak beanbag, 3 feet long Axillary roll Kidney rest supports for operating table (2) Contoured foam head and neck support Arm board Pillows (2) Foam pads for ankles, knees, and arms 3-inch-wide cloth adhesive tape

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

Sitting Position I prefer the term sitting position rather than the older beach-chair position because the patient’s thorax must be placed 70 to 80 degrees perpendicular to the floor. This upright position is necessary to place the acromion parallel to the floor and allow access to the posterior shoulder. A more recumbent position forces the surgeon to ‘‘work uphill’’ and makes entry into the inferiorposterior shoulder difficult if such a portal is required for glenohumeral reconstruction. One advantage of the sitting position is that it is similar to that used during traditional open operations, so conversion from an arthroscopic to an open rotator cuff repair or glenohumeral reconstruction does not require a change in patient position. Also, the anterior shoulder is more approachable than in the lateral decubitus position; the surgeon need not lean over the patient to gain anterior access. In this position, the arthroscopic orientation seems more familiar to surgeons, with the vertical orientation of the glenoid similar to that seen during physical examination or radiographic review. Shoulder distraction is not continuous, which minimizes the chance of neurologic injury; the assistant can provide a distraction force during the brief periods when this is needed. A mechanical arm holder can maintain the shoulder in external rotation during glenohumeral reconstruction and in elevation during rotator cuff repair. I use the McConnell arm holder (McConnell Orthopedics, Greenville, Tex). A newer, more sophisticated pneumatic positioning device called the Spyder Arm Positioner (Smith-Nephew Endoscopy, Andover, Mass) is available to aid the surgeon in rapidly positioning the shoulder. One disadvantage of the sitting position is that these patient-positioning devices are expensive. I currently use the Schloein patient positioner (Orthopedic Systems Inc., Union City, Calif). Before the patient is brought to the operating room, the mechanical support is positioned and secured to the operating table (Table 2-2). The patient is assisted onto the operating table, and general anesthesia induced. The back of the mechanical support is then raised, a small amount of Trendelenburg is applied, and the legs are lowered. The position is adjusted until the patient’s

Table 2-2 TABLE POSITIONING AIDS—SITTING Mechanical patient positioner (Schloein, Steris) Spyder or McConnell foam wrist support and pole Foam pads for ankles, knees, and arms

Chapter 2

acromion is nearly parallel to the floor. This places the patient in a nearly vertical sitting position rather than a semirecumbent beach-chair position. It is important to select a mechanical patient positioner that allows the 70- to 80-degree angle necessary. The head and neck are positioned for patient comfort and secured. Pillows are placed under the knees, and a foam pad protects the contralateral elbow. I check to make sure that no pads or drapes interfere with access to the anterior or posterior shoulder. The shoulder, arm, and hand are prepared, and an assistant grasps the wrist while the scrub nurse positions the bottom drape. The hand-wrist support is attached, and the forearm is placed on the patient’s lap. The upper drape is applied, and the suction drainage bag is affixed around the shoulder. The applicable surface anatomy is drawn, and the surgery begins (Figs. 2-15 through 2-27).

Figure 2-15

Figure 2-17


Check the relationship of the acromion to the

floor.

Figure 2-18

Secure the breathing tube.

Figure 2-19

Position the cervical spine.

Positioning the patient.

Figure 2-16 Patient in the sitting position.

51

52

Section One

Figure 2-20

Figure 2-21

The Basics

Secure the cervical spine with a chin strap.

Figure 2-23 Base of the McConnell arm holder.

Check the cervical spine alignment from the

front.

Figure 2-24

Figure 2-22

Pad the legs and contralateral arm.

Recheck the position of the acromion.

Figure 2-25 Position the shoulder with McConnell arm holder.

Chapter 2


53

Suture Passers

Figure 2-26

Access to the anterior shoulder.

Figure 2-27

Access to the posterior shoulder.

Sutures are passed through soft tissue either directly or indirectly. There are three types of direct methods. In the first, the instrument passes the suture through the tendon or ligament to a standard needle (Cuff-Stitch, Smith-Nephew Endoscopy). The second involves piercing the soft tissue with an instrument and then grabbing the suture and pulling it back through the soft tissue (Arthropierce, Smith-Nephew Endoscopy). The third direct method involves a flexible needle that passes the braided suture directly through the soft tissue (Elite Pass, Smith-Nephew Endoscopy) (Figs. 2-28 through 2-50). The indirect method involves placing a passing suture through the soft tissue and using this transport suture to pull the repair suture through the soft tissue. The Linvatec shuttle relay is one type of transfer suture, but I prefer standard 2-0 nylon. I cut the needle off and place the two ends together. This forms a loop on the other end that will transfer the repair suture. The cost saving is significant.

Figure 2-28

Elite suture passer.

EQUIPMENT Arthroscope I use a standard 4-mm arthroscope with a 30-degree angled lens for all shoulder arthroscopy. I have not found it necessary to use a 70-degree arthroscope. The increased lens angle may be useful when it is desirable, while viewing from the posterior portal, to see more of the anterior glenoid during a Bankart repair. I prefer to move the arthroscope to an anterior-superior portal during this portion of the procedure. The time it takes to move the arthroscope is more than offset by the superior view with the 30degree arthroscope compared with the distorted view of the 70-degree arthroscope.

Figure 2-29

Close-up of Elite suture passer.

54

Section One

The Basics

Figure 2-33

Figure 2-30

Close-up of the Caspari’s tip.

Close-up of Elite suture passer with the needle

deployed.

Figure 2-34

AccuPass.

Figure 2-31 Caspari suture passer. Figure 2-35 AccuPass deploying a nylon loop.

Figure 2-32

Close-up of Caspari suture passer.

Figure 2-36

AccuPass deploying a braided suture.

Chapter 2

Figure 2-37

Figure 2-38


Spectrum suture passer.

Figure 2-41

Tips.

Figure 2-42

Tips.

Close-up of Spectrum suture passer.

Figure 2-39

Tips.

Figure 2-43 Straight Cuff-Stitch.

Figure 2-40

Tips.

Figure 2-44 Instrument tips.

55

56

Section One

The Basics

Figure 2-45 Left-angled Cuff-Stitch. Figure 2-49

Figure 2-50

Figure 2-46

Figure 2-47

Instrument tips.

Right-angled Cuff-Stitch.

Figure 2-48

Instrument tips.

Arthropierce.

Instrument tip.

My preference is to use the direct method with the Elite Pass for rotator cuff repairs and the indirect method for instability repairs. The problem with direct suture instruments in glenohumeral joint instability repair is that once the instrument is through the soft tissue, the instrument’s maneuverability is extremely limited. Unless the desired repair suture is directly in line with the instrument, I cannot retrieve it. With the indirect method, I can place the transfer suture at the exact point required. I then retrieve the repair suture with a crochet hook and use the transfer suture to place the repair suture through the soft tissue. This is my personal preference; other surgeons may find another method superior.

Hand Instruments I use several hand instruments during reconstructive shoulder surgery. As noted earlier, I use the Elite Pass to pass sutures through the rotator cuff during repair. I now rarely use the Caspari suture punch, which I have modified by increasing the length of the needle tip from 4 to 5 mm. I found that the 4-mm tip was often too short to pass through a rotator cuff tendon, and the small increase in length solved this problem. The Cuff-Stitch (Smith-Nephew Endoscopy) allows the surgeon to pass a suture directly through the tendon, ligament, or labrum and is preferred by some. I use the Cuff-Stitch in two particular situations. First, if the tendon is thick and fibrotic and it is difficult or impossible to pass a suture through it

Chapter 2

using the Elite or the Caspari, the Cuff-Stitch is very effective. Second, when a rotator cuff tear is massive, I can best determine its geometry and perform the repair with the arthroscope in the lateral portal, in which case it is most convenient to insert the Cuff-Stitch through the anterior and posterior cannulas. The Arthropierce can either pass or retrieve sutures during margin convergence in rotator cuff or rotator interval repair. I find the AccuPass instruments (Smith-Nephew Endoscopy) especially useful during glenohumeral reconstruction for instability. These instruments function like the original Caspari suture punch but are angled such that the surgeon can reach inferiorly to grasp the capsule or labrum.

Figure 2-52


Close-up of soft tissue grasper.

Soft Tissue Management I use a soft tissue grasper to test the tension of the glenohumeral ligaments before instability repair and to evaluate the excursion and reparability of a torn rotator cuff. Regular and locking graspers are helpful. A grasper with less aggressive teeth allows one to pull on sutures without shredding them. A blunt probe is useful to evaluate for the presence of a subtle Bankart or a superior labrum anterior to posterior (SLAP) lesion. When a Bankart lesion has healed with a fibrous union, the lesion may not be apparent, and a sharp chisel dissector can peel the labrum off the anterior glenoid. To ensure that the capsule is not adherent to the subscapularis, I use a blunt soft tissue instrument to dissect between the two structures. A large soft tissue punch is useful to excise portions of a contracted capsule during contracture release. I have found the capsular punches designed by Harryman to be most effective for capsular release in patients with shoulder stiffness. I modified two of the instruments so that they bend downward rather than upward; I am more comfortable with this angle of approach to the capsular tissue. I use a blunt-ended probe for dissection around nerves or blood vessels. I also find the markings on the end of the probe useful for measuring distances and the size of lesions (Figs. 2-51 through 2-62).

Figure 2-51

Soft tissue grasper.

Figure 2-53

Less aggressive soft tissue grasper.

Figure 2-54

Chisel dissector.

Figure 2-55

Chisel dissector.

Figure 2-56

Blunt dissector.

57

58

Section One

Figure 2-57

The Basics

Close-up of blunt dissector.

Figure 2-62

Blunt probe with measuring guide markings.

Suture Management

Figure 2-58

Figure 2-59

Close-up view of blunt dissector.

A crochet hook is used to retrieve sutures from within the subacromial space or glenohumeral joint. If a suture gets caught in the tendon or labrum, I prefer to use a fine-toothed crochet hook that does not damage the suture. I use a looped suture grasper to ensure that there are no suture tangles within the working cannula before tying each suture. A larger instrument is useful during rotator cuff repairs, and a smaller one is easier to maneuver within the glenohumeral joint. There are a number of knot tying instruments available, but I prefer a single-lumen knot pusher, which can double as a knot pusher and puller. I modify the length of the instrument to fit my hand comfortably. Arthroscopic scissors are needed to cut suture and soft tissue. I also use endcutting scissors when I cannot see the knot during a rotator interval repair (Figs. 2-63 through 2-75).

Straight capsular resection punch. Figure 2-63

Figure 2-60

Close-up of capsular resection punch. Figure 2-64

Figure 2-61

Crochet hook.

Close-up of capsular resection punch.

Figure 2-65

Close-up of crochet hook.

Fine-toothed crochet hook.

Chapter 2

Figure 2-66

Figure 2-67

Figure 2-68

Large loop grasper.

Figure 2-71


Knot pusher.

Close-up of large loop grasper.

Loop grasper with the jaws open.

Figure 2-72

Close-up of knot pusher.

Figure 2-69 Small loop grasper.

Figure 2-73

Figure 2-70

Close-up of small loop grasper.

Scissors.

Figure 2-74 Close-up of scissors.

59

60

Section One

The Basics

Figure 2-76

Figure 2-75

Shaver.

End-cutting scissors.

Sutures I use several different sutures during shoulder arthroscopy. The 5-mm rotator cuff anchor is preloaded with No. 2 Ultrabraid. The BioRaptor is loaded with No. 1 Ultrabraid. I use 2-0 nylon as a transfer suture to bring the braided sutures through the rotator cuff or glenoid labrum. If I am repairing tendon to tendon, I may use No. 1 PDS or No. 1 Prolene instead of No. 2 Ethibond. I use 3-0 Monocryl for the subcutaneous skin closure of portal incisions.

Figure 2-77

Close-up of shaver.

Power Instruments Relatively few power instruments are needed. I use 4- and 5-mm shavers, a 4-mm round bur, and a 5.5-mm acromionizer bur. I occasionally use a 4.5-mm acromionizer bur during abrasion arthroplasty for arthritis or for coracoid preparation during an arthroscopic Latarjet procedure. The 4-mm shaver and round bur are used within the glenohumeral joint for glenohumeral instability and SLAP repair, and I use a power drill to predrill the bone anchor holes for these repairs. I use the larger shaver to remove bursal tissue during arthroscopic subacromial decompression, and I use the acromionizer for acromioplasty. I use the round bur within the subacromial space to prepare the rotator cuff repair site. A new instrument that is useful is the Electroblade (Smith-Nephew Endoscopy)—a power shaver with cautery connected to it. This is helpful when de´briding in the subacromial space. When a bleeding vessel is encountered, rather than removing the shaver and inserting the cautery, the surgeon can merely identify the vessel and step on the electrocautery pedal. The Electroblade is extremely helpful during synovectomy for rheumatoid arthritis, resection of the rotator interval during capsular contracture release, and rotator cuff repair when medical contraindications prevent an interscalene block and the bleeding is thus a bit more robust (Figs. 2-76 through 2-87).

Figure 2-78

Figure 2-79

Electroblade.

Close-up of Electroblade.

Figure 2-80

Round bur.

Chapter 2



61

Close-up of acromionizer bur.

Close-up of round bur.

Figure 2-86

Figure 2-82

Less aggressive oval bur.

Close-up of round bur.

Figure 2-83

Acromionizer bur. Figure 2-87

Close-up of oval bur.

Cannulas

Figure 2-84

Close-up of acromionizer bur.

The metal cannula I use for the arthroscope has ports for inflow, outflow, and pressure. In addition to the metal cannula and blunt trocar for the arthroscope, I consider three plastic, translucent cannulas vital when I perform arthroscopic reconstructive shoulder surgery. During anchor insertion or knot tying, I often use a cannula to prevent adjacent soft tissue from interfering with the procedure. Because the cannula is translucent, I can

62

Section One

The Basics

insert an anchor or tie a knot even with the cannula covering the involved area. An 8-mm cannula is large enough to accommodate the power tools and the large suturing instruments; larger cannulas (8.5 and 10 mm) are also available. A 5.5-mm cannula is used for the anterior-superior portal during glenohumeral reconstruction or SLAP repair because it is large enough to accept the 4-mm round bur. I also place it anteriorly during rotator cuff repair to act as both an outflow cannula and a retrieval cannula for the bone anchor sutures (Figs. 2-88 and 2-89). Figure 2-90

Figure 2-88

Figure 2-89

Electrocautery.

Eight-mm cannula. Figure 2-91

Close-up of electrocautery.

Figure 2-92

Close-up of electrocautery.

Five-and-one-halfmm cannula.

Thermal Instruments I use two types of thermal instruments during shoulder arthroscopy. The first instrument can cauterize or ablate tissue. I use the ablation setting during arthroscopic subacromial decompression to remove soft tissue from the undersurface of the acromion, and I use the coagulation setting to control bleeding from branches of the coracoacromial artery or from vascularized bursal tissue. I prefer a probe that has suction attached so that the bubbles produced during ablation or coagulation are removed from the operative field. The second instrument is the Electroblade, the combination shaver and cautery described earlier (Figs. 2-90 through 2-92).

Fluid Management An arthroscopic pump system for delivering fluid to the shoulder is a valuable asset. A pump system eliminates the need to hang bags of irrigating fluid high above the floor and allows the surgeon to increase pump pressure and flow rate when bleeding is encountered. I use lactated Ringer’s solution. I do not use epinephrine because I find it provides no major improvement in visualization. If a surgeon considers epinephrine helpful, I advise adding it to every other bag of Ringer’s solution to minimize any potential cardiotoxic effects.

Chapter 2

Transfer Rods Surgeons who prefer to create portals with the insideout technique will find the Wissinger rod useful (described in Chapter 3). Switching rods are blunt on both ends and are used to maintain the cannula position when the arthroscope is moved from one position to another (Figs. 2-93 through 2-95).

Figure 2-93

Wissinger rod.


63

in the operative notes. They have the added advantage of documenting normal findings that surgeons commonly omit from the operative record. Most arthroscopy systems have the ability to take photographs during surgery with the use of a foot switch or a control button on the camera. The photographs can be printed directly or stored on recordable media or on a computer hard drive. Since I began performing shoulder arthroscopy I have also made video recordings of the operations. Typically I save approximately 30 to 45 seconds of each video; this includes the lesions found at operation and their appearance after correction. The video is captured in MPEG format. I create an electronic folder with the patient’s name and save the still photos and the video in it. When patients are doing either very well or very poorly postoperatively, it is helpful to review these records to recollect the details of the operation. I do not routinely provide patients with copies of photographs or videos, but I do so if they request it.

DEDICATED TEAM Figure 2-94

Figure 2-95

Handle of Wissinger rod.

Tip of Wissinger rod.

I cannot emphasize enough the advantages of having a trained, dedicated operating room team (Fig. 2-96). Reconstructive shoulder arthroscopy is complicated, and it is helpful when the scrub nurse, assistant, and circulating nurse can perform their jobs without instruction from the surgeon. The surgical nurse can load the Caspari or Spectrum suture instruments so that they are ready for the next step, clean the shavers and burs so that they function appropriately, and have the next instrument ready so that the operation runs smoothly.

Anchors I most commonly use 5-mm metallic TwinFix anchors for rotator cuff repair and the BioRaptor for glenohumeral joint instability and labrum repair. I have recently started to use the KINSA knotless system and the Arthrex Suture Bridge when appropriate. For patients with superior 25% to 33% subscapularis insertion tears, the QuickT is extremely efficient. It passes directly through the tissue and is secured with a special knot pusher; no knot tying is necessary.

Photography and Video Recording I find it extremely helpful to take intraoperative photographs. They record the lesions found during the operation more precisely than the description

Figure 2-96 World’s best operating room team.

CHAPTER

3

Diagnostic Arthroscopy and Normal Anatomy

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

DIAGNOSTIC GLENOHUMERAL ARTHROSCOPY Portal placement is critical, and I take sufficient time to mark the portal sites precisely. Draw the bone outlines of the acromion, distal clavicle, and coracoid with a surgical skin marker. Be careful to draw not the most superficial bone landmarks but rather their inferior surfaces (which takes into account bone thickness), because portal entry points are referenced from these surfaces (Figs. 3-1 and 3-2). Although trocar entry into the glenohumeral joint is simple and almost intuitive for an expert, surgeons new to arthroscopy may find joint entrance difficult. The standard advice to ‘‘start in the soft spot and aim for the coracoid’’ is only slightly helpful. Actual joint entry requires precision, and even small deviations of 3 to 5 mm from the desired portal location make the operation more difficult. An additional complication is that portals vary from patient to patient because they are related to the patient’s position on the operating table as well as his or her size, rotundity, and kyphosis. The ideal portal location changes throughout the operation as soft tissue swelling increases and alters the local anatomy. Portal placement is also affected by the underlying diagnosis.

64

For instance, posterior portal placement for an acromioclavicular joint resection differs from that for a superior labrum anterior to posterior (SLAP) lesion repair. There are no absolute rules, but there are a number of guidelines that I find helpful. The most reliable landmarks are bone. Anteriorly, I outline the coracoid process, the acromioclavicular joint, and the anterior acromion. Laterally, I identify the lateral acromial border, and posteriorly, I outline the posterior acromion. The most important landmark is the posterolateral corner of the acromion, which can be palpated even in large patients. I base my measurements on this point (Fig. 3-3).

Posterior Portals Traditionally, surgeons describe the location of the posterior portal as being in the ‘‘soft spot’’ approximately 2 cm inferior and 2 cm medial to the posterolateral acromial edge. Although this location is adequate for glenohumeral joint arthroscopy, it is not optimal for subacromial space operations. If you make the incision in the traditional soft spot, you will enter the joint parallel to the glenohumeral joint line and slightly superior to the glenoid equator. This site allows you to enter and visualize the glenohumeral joint adequately, but you will be at a disadvantage if you try to use the same incision to enter the subacromial space. Once you insert the cannula into the subacromial space, the soft-spot portal directs the cannula superiorly and medially and causes two problems.

Chapter 3


Figure 3-3

Figure 3-1

Bone landmarks.

First, because the arthroscopic view is now directed medially, the lateral insertion of the rotator cuff is more difficult to visualize. Second, the superior angle of the arthroscope makes it difficult to ‘‘look down’’ on the rotator cuff tendons and appreciate the geometry of rotator cuff lesions. One solution to this problem is a second posterior portal, but I prefer to alter the posterior portal’s location (Fig. 3-4). As noted, the exact location of the posterior portal varies with the clinical diagnosis. For rotator cuff repairs and subacromial decompressions, I make the posterior incision for the portal in a more superior and lateral position, approximately 1 cm inferior

Figure 3-2

Superior and inferior bone edges (arrows).

65

Posterolateral acromial corner.

and 1 cm medial to the posterolateral acromion. The more superior and lateral location minimizes the aforementioned difficulties. The superior entry allows the cannula to enter the subacromial space immediately beneath the acromion, parallel to its undersurface. This maximizes the distance between the arthroscope and the rotator cuff, allowing a better appreciation of rotator cuff lesions. The superior position (parallel to and immediately inferior to the acromion) also facilitates acromioplasty because the surgeon is afforded a better view of the acromial shape. The more lateral position (immediately medial to the lateral acromion) places the arthroscope in line with the rotator cuff tendon insertion. I can adequately visualize the glenohumeral joint with this more lateral portal, and given that only a brief inspection is usually needed, I find this approach satisfactory.

Figure 3-4 Posterior portal in a more superior and lateral position (rather than in the soft spot) for subacromial surgery.

66

Section One

The Basics

Superior Superior entry

Inferior entry

Figure 3-7

Superior-lateral portal for acromioclavicular joint

resection. Inferior

Lateral Portals Figure 3-5

Glenohumeral joint space.

For operations restricted to the glenohumeral joint, such as a Bankart or SLAP repair, I enter the joint more medially than for those operations involving primarily the subacromial space, such as a rotator cuff repair (Figs. 3-5 and 3-6). If I am performing an acromioclavicular joint resection, I move the posterior incision 5 mm more laterally to obtain a better view of the distal clavicle (Fig. 3-7).

I do not routinely use a lateral subacromial portal during diagnostic glenohumeral joint arthroscopy. More commonly, I use a lateral portal during arthroscopic subacromial decompression and rotator cuff repair and discuss its placement in more detail in the applicable chapters. Briefly, I mark the portal location with a skin marker 3 to 5 cm distal to the lateral acromial border and 1 to 3 cm posterior to the anterior acromion. I regard this mark as only an approximation. Once I have entered the subacromial space by placing the arthroscope through the posterior portal, I identify the exact location of the lateral portal with a spinal needle before I incise the skin. I occasionally use two additional lateral portals during rotator cuff repair. An anterolateral or posterolateral portal may be required to retrieve sutures during the repair of a massive rotator cuff tear. These portals are positioned midway between the anterior and lateral or posterior and lateral portals, respectively, and are identified with the use of a spinal needle (Figs. 3-8 and 3-9).

Anterior Portals

Figure 3-6

surgery.

Superior-medial portal for glenohumeral joint

There are four basic anterior portals: anterior-inferior, anterior-superior, lateral, and medial (Figs. 3-10 and 3-11). The anterior-inferior and anterior-superior portals are used for glenohumeral reconstruction or SLAP repair. I use the lateral portal during rotator cuff repair and the medial portal for acromioclavicular joint resection. I mark the anterior-inferior portal 5 mm lateral to the coracoid; the anterior-superior portal is then located 1.5 cm lateral and 1 cm superior to the anterior-inferior portal. The lateral portal is 2 to 3 cm distal to the anterior acromion and parallel with its

Chapter 3


67

Midlateral portal for arthroscopic subacromial decompression.

Figure 3-8

lateral border. The medial portal is 1 to 3 cm distal to the acromioclavicular joint. Again, these marks are only approximations; the exact portal sites are identified during arthroscopy with a spinal needle. For a glenohumeral reconstruction or SLAP repair, I make the posterior portal 2 cm medial and 1 to 1.5 cm inferior to the posterolateral acromial border.

Physical Examination Because a patient’s pain on physical examination may cause the surgeon to underestimate the range of motion or stability of the shoulder, I examine both shoulders after the induction of anesthesia. I record the range of motion in elevation, in external rotation with the arm adducted, and in external and internal

Anterior-inferior and anterior-superior portals for glenohumeral reconstruction.

Figure 3-10

rotation with the arm abducted 90 degrees. I then examine the shoulder for stability by applying anterior, posterior, and inferior force while changing the positions of abduction and rotation (Figs. 3-12 through 3-20).

Arthroscopic Procedure I incise only the skin and avoid plunging the knife into the underlying structures. Superficial skin nerves

Figure 3-9

Anterior and posterior lateral portals.

Figure 3-11 Anterior-medial portal for acromioclavicular joint resection.

68

Section One

The Basics

Figure 3-14

External rotation in abduction with anterior

stress. Figure 3-12

Elevation.

are susceptible to neuroma formation, and muscle bleeding unnecessarily complicates the procedure. I do not insufflate the joint with a needle because I can better determine the entry point into the glenohumeral joint with the more rigid trocar. I use only a blunt-tipped trocar in shoulder arthroscopy and advise surgeons never to use a sharp trocar. To begin, insert the cannula and trocar through the skin incision and gently advance them through the deltoid muscle until bone resistance is felt. With your opposite hand pushing the humeral head

posteriorly against the trocar tip, you can tell by palpation whether the bone is the glenoid or the humeral head. Alternatively, you can grasp the forearm and rotate the shoulder; if you feel the bone rotate, the trocar tip is resting against the humeral head and you must direct the arthroscope medially


External rotation.

plane.

Internal rotation in abduction in the coronal

Chapter 3


Figure 3-19

Figure 3-16

Internal rotation in abduction in the scapular

plane.

Figure 3-17

Inferior stress.

to enter the joint. If no rotation is felt, the trocar is touching the glenoid and you must direct it laterally to enter the joint. When the trocar tip is at the joint line, a slight lateral movement allows you to palpate the head, and a slight medial movement results in contact with the glenoid. The posterior joint line is medial to the posterolateral acromion, and the direction of entry is generally oriented toward the tip of the coracoid. Angle the cannula slightly superiorly and advance it into the joint. Usually a distinct ‘‘pop’’ is felt as the trocar enters the glenohumeral joint. Remove the trocar, insert the arthroscope through the cannula, and begin the diagnostic inspection. If you have not entered the joint, remove the cannula and trocar to check the bone landmarks drawn on the skin (Fig. 3-21).

Sulcus test in internal rotation.

Figure 3-18 Sulcus test in external rotation.

69

Figure 3-20 Posterior stress.

70

Section One

The Basics

Table 3-1 DIAGNOSTIC EXAMINATION OF THE SHOULDER Anterior View—Arthroscope in Posterior Cannula Biceps-labrum complex Biceps tendon Biceps exit from the joint Anterior articular surface of supraspinatus Superior glenohumeral ligament Rotator interval Subscapularis tendon Subscapularis recess Middle glenohumeral ligament Anterior labrum Anterior-inferior glenohumeral ligament Inferior labrum Inferior capsule Posterior-inferior glenohumeral ligament Figure 3-21

Bone palpation with trocar.

Diagnostic and Normal Anatomy

Posterior labrum Infraspinatus tendon Posterolateral humeral head Posterior View—Arthroscope in Anterior Cannula Posterior glenoid labrum Posterior capsule

Brachial Plexus Dissection—Cadaver The diagnostic examination of the shoulder is systematic to ensure that no lesions are overlooked. The plan described in Table 3-1 can serve as a guide. Once you have entered the glenohumeral joint, identify the biceps tendonlabrum complex and rotate the camera to orient the glenoid on the monitor screen. Some surgeons prefer the glenoid oriented vertically so that it is similar to its position with the patient standing or seated in the beach-chair position or on an anteroposterior radiograph. Other surgeons prefer to orient the glenoid so that it appears parallel to the floor. Neither technique is superior; it is a matter of surgeon preference (Figs. 3-22 and 3-23). Advance the arthroscope into the joint and rotate it so that it is looking at the 1-o’clock position relative to the glenoid surface. Inspect the rotator interval and superior glenohumeral ligament. Apply inferior distraction and observe the tension that develops. Distract the arm with the shoulder externally rotated and internally rotated and note any difference. Perform this portion of the examination first because when the

Posterior rotator cuff (site of internal impingement) Subscapularis recess Middle glenohumeral ligament and its humeral attachment Anterior-inferior glenohumeral ligament and its humeral attachment

anterior cannula is introduced, it passes through the rotator interval and alters the local anatomy. The rotator interval may appear normal in subacromial impingement, contracted in patients with shoulder stiffness, and widened or lax in patients with glenohumeral instability (Figs. 3-24 through 3-30). There are two basic techniques to establish an anterior portal: inside out or outside in. To establish the anterior portal with the inside-out technique, advance the arthroscope until it is in the middle of the triangular space bordered by the glenoid rim, the superior border of the subscapularis tendon, and the biceps tendon. Press the arthroscope against the rotator interval and hold the cannula in position while you remove the arthroscope from the cannula. Insert a

Chapter 3

Figure 3-22

Glenohumeral joint, vertical orientation.


Figure 3-25

71

Rotator interval—normal superior glenohumer-

al ligament.

Rotator interval—prominent superior glenohumeral ligament.


Glenohumeral joint, horizontal orientation.

Figure 3-27 Figure 3-24 Rotator interval.

ligament.

Partial tear in the superior glenohumeral

72

Section One

Figure 3-28

The Basics

Contracted rotator interval.

Figure 3-29 Widened rotator interval.

Figure 3-30

Rotator interval synovitis.

blunt-tipped rod (Wissinger) through the cannula and advance it through the capsule until it tents the skin anteriorly. Maintain pressure on the rod and make a skin incision directly over its tip. Advance the rod anteriorly so that it projects 5 to 10 cm. Slide a second cannula over the rod tip anteriorly and advance this cannula into the joint until you can feel the two cannulas touch each other. Remove the rod and reinsert the arthroscope into the posterior cannula. Adjust the anterior cannula until 15 to 20 mm is visible within the joint. Outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula, as desired. I used this technique early in my arthroscopic experience because it enabled me to reliably enter the glenohumeral joint. As I began doing more reconstructive shoulder operations, I discovered some inadequacies with this approach. The inside-out approach allows variability in the precise entry spot for the anterior portal because there is some inevitable manipulation of the arthroscope during the necessary sequence of maneuvers. For glenohumeral joint reconstruction for instability, I need two anterior cannulas, and their positions are critical. If the inferior cannula is too superior, there will not be enough space for the anterior-superior cannula. If the cannulas are too medial or too lateral, anchor insertion is complicated, and suture placement is compromised. For these reasons, I now establish the anterior portals with an outside-in approach. To establish the anterior portal with the outside-in technique, point the arthroscope at the rotator interval and use your index finger to push on the skin of the anterior shoulder lateral and superior to the coracoid process. Observe where your finger indents the anterior capsule and move that location until the anterior capsule is indented in the middle of the rotator interval. Note this location on the anterior shoulder with a marking pen and then use a spinal needle to enter the joint at this point. I prefer to place the anterior cannula immediately superior to the superior border of the subscapularis tendon and 1 cm lateral to the glenoid surface. Note the angle that the needle makes with respect to the patient’s anterior shoulder. Remove the spinal needle, make a small incision, and place the cannula and trocar into the joint. As with the inside-out technique, outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula (Figs. 3-31 through 3-33). Rotate the arthroscope so that it is pointed at 1 o’clock for a right shoulder (11 o’clock for a left shoulder). Advance it anteriorly and inspect the subscapularis recess and the superior border of the subscapularis tendon. Rotate the arthroscope until it is pointed at 3 o’clock (9 o’clock for a left shoulder),

Chapter 3

Figure 3-31

Entry point for anterior-inferior cannula.

Figure 3-32

Cannula and trocar entry.

Figure 3-33

Trocar removed.


Figure 3-34

73

Thick middle glenohumeral ligament.

advance it anteriorly, and inspect the anterior labrum and the middle glenohumeral ligament. The normal opening of the foramen at the anterior-superior labrum should not be confused with a Bankart lesion. Observe the anterior labrum for signs of glenohumeral instability such as fraying, tearing, or separation from the glenoid. Insert a probe through the anterior cannula and test the anterior labrum’s attachment to the glenoid. Use the probe to test the tension of the middle glenohumeral ligament. Translate the humeral head anteriorly, inferiorly, and posteriorly and observe the tension that develops in the ligament. Perform these maneuvers with the arm internally and then externally rotated. The middle glenohumeral ligament has a variable appearance and may be poorly defined, prominent, or cordlike (Figs. 3-34 through 3-45).

Figure 3-35

Broad middle glenohumeral ligament.

74

Section One

The Basics

Figure 3-36 Middle glenohumeral ligament with the subscapularis poorly defined.

Figure 3-37

Figure 3-39

Cordlike middle glenohumeral ligament.

Partial tear in the middle glenohumeral

Figure 3-40

Subscapularis.

Cordlike middle glenohumeral ligament.

Figure 3-41

Subscapularis.

ligament.

Figure 3-38

Chapter 3

Figure 3-42

Figure 3-43

Subscapularis with a synovial tear.

Subscapularis with a partial tear in the superior

border.

Figure 3-44

border.


Figure 3-45

75

Subscapularis recess.

Rotate the arthroscope until it is pointed at 5 o’clock and inspect the anterior-inferior labrum and glenohumeral ligament. Test their tension and insertion integrity as described earlier. Move the arthroscope inferiorly and note the presence or absence of a ‘‘drive-through sign.’’ This sign describes the ease with which the arthroscope passes between the humeral head and the glenoid surface at the 6-o’clock position. Remember that the drivethrough sign is a measure of glenohumeral laxity or translation and is not an indication of glenohumeral instability per se. Observe the laxity of the inferior capsule as the shoulder is distracted inferiorly, laterally, and then rotated. Determine whether there is an inferior labral lesion and carefully inspect the humeral attachment of the inferior capsule for signs of trauma (Figs. 3-46 through 3-56). Return the arthroscope to the biceps-labrum complex. To view the posterior labrum adequately from a posterior cannula, you must maximize the distance

Subscapularis with a partial tear in the superior Figure 3-46

Rotate the arthroscope.

76

Section One

Figure 3-47

Figure 3-48

The Basics

Figure 3-50

Anterior-inferior glenohumeral ligament.

Anterior-inferior glenohumeral ligament less

Figure 3-51

Axillary recess.

Inferior-posterior capsule.

well defined.

Figure 3-52 Palpate the anterior-inferior glenohumeral Figure 3-49

Anterior-inferior capsule.

ligament.

Chapter 3

Figure 3-53

Palpate the inferior capsule.

Figure 3-54

Inferior-posterior labrum.

Figure 3-55

Posterior-inferior labrum.

Figure


3-56

Posterior

labrum,

with

the

77

arthroscope

posterior.

from the arthroscope to the labrum. This requires that you withdraw the arthroscope until it is immediately anterior to the posterior capsule. As a novice, I would repeatedly pull the arthroscope completely out of the joint. My technique to minimize (but not eliminate) the problem is as follows: Rotate the objective lens of the arthroscope so that it is pointed to the 6-o’clock position. Pinch your index finger and thumb around the cannula where it exits the skin. This increased sensory feedback helps you control the distance the cannula moves and gives you immediate control. Gently withdraw the arthroscope as posteriorly as possible to obtain the best view of the biceps-labrum complex (Figs. 3-57 through 3-59). Examine the biceps tendon and use an instrument to draw the intra-articular portion into the joint and inspect it for inflammation or tearing. Carefully examine the anterior and posterior pulleys for

Figure

3-57 Pinch

arthroscope.

the

cannula

and

withdraw

the

78

Section One

Figure 3-58

The Basics

Rotate the arthroscope. Figure 3-60

signs of trauma that may indicate biceps tendon instability. Follow the biceps tendon to its joint exit. Adhesions may exist between the biceps tendon and the supraspinatus tendon; these may be either congenital or post-traumatic (Figs. 3-60 through 3-78). Rotate the arthroscope so that it is pointed to 6 o’clock. Follow the posterior labrum from superior to inferior and note any labrum separation, fraying, or tears. Continue inferiorly until you can see the posterior-inferior glenohumeral ligament. Internally rotate the arm and observe the normal tightening of this ligament. Introduce a probe from the anterior portal and evaluate the biceps-labrum complex. Often, a SLAP lesion is obvious, but sometimes probing is necessary. Abduct and externally rotate the shoulder to see whether the superior labrum peels off the glenoid (Figs. 3-79 through 3-85). Adhesions may exist between the biceps tendon and the rotator cuff; these too may be either congenital or posttraumatic (Figs. 3-86 and 3-87).

Figure 3-59

Biceps-labrum complex.

Figure 3-61

Biceps tendon synovitis.

Biceps tendon exiting from the glenohumeral

joint.

Figure 3-62

Biceps tendon entering the bicipital groove.

Chapter 3


Figure 3-66

Bordering ligament, anterior pulley.

Figure 3-63

Bicipital groove.

Figure 3-64

Bicipital groove.

Figure 3-67 Partial biceps tendon tear.

Bicipital groove, with synovial lining.

Figure 3-68 Partial biceps tendon tear.

Figure 3-65

79

80

Section One

The Basics

Figure 3-69

Partial biceps tendon tear.

Figure 3-70


Figure 3-71


Figure 3-72

Introduce the shaver.

Figure 3-73

Lateral to biceps.

Figure 3-74

Medial to biceps.

Chapter 3

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

Figure 3-75


Figure 3-76



Figure 3-78

Extra-articular biceps tendon synovitis.

Figure 3-79

Normal superior labrum.

Figure 3-77

Figure 3-80 Minor fraying of the superior labrum.

81

82

Section One

The Basics

Figure 3-81 Minor separation of the superior labrum.

Figure 3-84

SLAP lesion continuing into the anterior-superior

labrum.

Figure 3-82

Probe for separation.

Figure 3-83

SLAP lesion.

Figure 3-85

Normal anterior-superior labral foramen.

Figure 3-86

Bicepsrotator cuff adhesion.

Chapter 3

Figure 3-87


Bicepsrotator cuff adhesion.

Move your hand and the camera toward the floor to point the arthroscope superiorly and view the rotator cuff tendons. Abduct and externally rotate the shoulder until you see the anterior supraspinatus that is marked anteriorly by the biceps tendon. The anterior margin of the supraspinatus forms the posterior biceps tendon pulley. Move the camera medially and inferiorly (so that the arthroscope tip moves laterally and superiorly) and follow the cuff insertion from its anterior to posterior margins. At the same time, abduct and rotate the humeral head so that the arthroscope follows the cuff insertion from anterior to posterior. Note the insertion of the supraspinatus into the footprint area. There should be no exposed bone between the articular margin of the humeral head and the supraspinatus tendon insertion. Partial articular surface tears can be diagnosed by observing the amount of exposed bone in millimeters between the remaining tendon and the articular margin. The infraspinatus does not insert at the articular margin, and exposed bone in this area is normal. The small holes in the humeral head near the posterior cuff are normal vascular channels. When you identify the posterior cuff insertion, tilt the arthroscope inferiorly and continue to externally rotate the shoulder. You can now see the posterolateral humeral head and document the presence or absence of a Hill-Sachs lesion. Withdraw the arthroscope slightly so that the lens does not scrape against the humeral head and allow it to return to the biceps tendonlabrum complex (Figs. 3-88 through 3-101). Inspect the cartilage on the humeral head and glenoid for signs of osteoarthrosis, such as eburnation and cobblestoning. The cartilage is normally thin in

Figure 3-88

Anterior supraspinatus.

Figure 3-89

Anterior supraspinatus.

83

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

Figure 3-90

84

Section One

Figure 3-91

The Basics

Full-thickness supraspinatus tear.

Figure 3-94 Posterior supraspinatus.

Mid-supraspinatus.

Figure 3-95 Posterior supraspinatus.

Midposterior supraspinatus.

Figure 3-96 Infraspinatus.

Figure 3-92

Figure 3-93

Chapter 3

Figure 3-97

Capsular reflection.

Figure 3-98

Figure 3-99

Bare area.

Vascular channels.


Figure 3-100

85

Bare area.

the central glenoid, and this should not be confused with osteoarthrosis (Figs. 3-102 through 3-107). Remove the arthroscope from the posterior cannula, reinsert it in the anterior cannula, and again inspect the posterior labrum, capsule, and posterior rotator cuff. Move the arm into abduction and external rotation, and evaluate the shoulder for internal impingement between the posterior-superior labrum and the posterior cuff and capsule. Observe the normal pear shape of the glenoid from this perspective. The glenoid widens inferiorly. Loss of this pear shape corresponds to bone loss in the anterior-inferior glenoid and may be seen in patients with glenohumeral instability (Figs. 3108 through 3-111). This completes the routine inspection of the glenohumeral joint. Withdraw both cannulas and proceed to the subacromial space.

Figure 3-101

Shallow Hill-Sachs lesion.

86

Section One

The Basics

Figure 3-102

Anterior glenoid cartilage loss.

Figure 3-105

Humeral head cartilage tear.

Figure 3-103

Anterior glenoid cartilage loss.

Figure 3-106

Full-thickness cartilage loss.

Figure 3-104

Osteoarthrosis of the glenoid.

Figure 3-107

Osteoarthrosis of the humeral head.

Chapter 3

Figure 3-108

Posterior-superior labrum.


Figure 3-111

87

Posterior-inferior glenohumeral ligament.

DIAGNOSTIC SUBACROMIAL SPACE ARTHROSCOPY The diagnostic examination of the subacromial space is systematic to ensure that no lesions are overlooked. The plan described in Table 3-2 can be used as a guide. The subacromial space is a pseudoarticulation that permits gliding between the proximal humerus and the coracoacromial arch. Arthroscopic experience has allowed us to define the subacromial space, which has well-defined borders when cleared of the hypertrophic bursal tissue associated with chronic subacromial impingement. The arthroscopic subacromial space begins halfway back from the anterior acromion, and posterior entry requires the surgeon to penetrate a veil or curtain of bursal tissue that separates the anterior Figure 3-109

Posterior labrum and gutter.

Table 3-2 DIAGNOSTIC EXAMINATION OF THE SUBACROMIAL SPACE View from Posterior Portal Acromial undersurface Coracoacromial ligament Anterior bursa Supraspinatus insertion into greater tuberosity Subdeltoid adhesions Acromioclavicular joint View from Lateral Portal Posterior rotator cuff Posterior bursa Figure 3-110

Inferior-posterior labrum.

Rotator interval

88

Section One

The Basics

Figure 3-113

Palpate the anterior acromion with the

trocar tip.

Figure 3-112

Bursa anatomy.

from the posterior space. Anterior, posterior, and lateral gutters can be defined. The medial confines are below the acromioclavicular joint, and exposure of the lateral clavicle requires resection of thick fibrofatty and vascular tissue. The lateral wall lies beyond the greater tuberosity, and the anterior margin is the anterior acromial border (Fig. 3-112). It is often difficult to visualize the subacromial space owing to reactive bursitis and fibrosis. When you have difficulty visualizing the subacromial space, it is usually because the arthroscope is positioned too far posteriorly. It is helpful to position the arthroscope anteriorly in the subacromial space to minimize the effect of the bursal tissue located posteriorly within the space. Use the same posterior skin incision to enter the subacromial space. Place the trocar and cannula through the skin incision and palpate the posterior edge of the acromion. Slide immediately beneath the bone and advance the trocar and cannula anteriorly. The cannula should remain in contact with the acromion. With your other hand, palpate the anterior acromion and advance the trocar beyond the anterior acromion until you can feel the trocar tip. Withdraw the trocar until it is just posterior to the anterior acromion. Usually you can palpate the coracoacromial ligament. Maintain the cannula position while you remove the trocar and insert the arthroscope.

Rotate the arthroscope so that it is directed toward the acromion, and determine whether there are any alterations in the coracoacromial ligament or the acromion (Figs. 3-113 and 3-114). Now orient the arthroscope lens so that it is pointing directly down at the rotator cuff. If you maneuver the shoulder through a range of motion and rotate the arthroscope, you will obtain a view of the superior portion of the subscapularis, the supraspinatus, and the superior portion of the infraspinatus. If you desire a better view of the posterior rotator cuff or if you cannot see clearly, establish a lateral portal. Identify the precise location of the lateral portal with a spinal needle. Introduce the needle percutaneously until it is 1 to 2 cm posterior to the anterior acromion and located midway between the acromion and the rotator cuff. The lateral cannula should enter the subacromial space parallel to and immediately beneath the inferior surface of the acromion. The distance

Figure 3-114

Lateral cannula location too anterior.

Chapter 3

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

A


Figure 3-115

Subacromial space obscured.

to help with orientation. Use the resector to remove bursal tissue until you can see clearly. If the shaver is on the rotator cuff, direct the shaver blade superiorly to avoid causing damage. Direct the shaver blade inferiorly when you are working near the acromion. Be careful not to contact the cuff or the acromion with the resector, because this will alter the subacromial space anatomy (Figs. 3-115 through 3-120). Once you can see clearly, perform a diagnostic inspection of the subacromial space. Observe the acromion and the coracoacromial ligament for signs of impingement such as fraying or erythema. Rotate the arthroscope so that it looks directly at the rotator cuff; at the same time, move the arthroscope tip superiorly to maximize the distance between the

B Figure 3-116

89

A, Palpate the lateral cannula with the trocar tip. B, Visualize the lateral cannula.

90

Section One

Figure 3-117

The Basics

Withdraw the arthroscope slightly.

Figure 3-120

Withdraw the lateral cannula.

arthroscope and the rotator cuff. This improves your perception of the extent of any pathology. Signs of impingement include fraying, fibrillation, and partial tearing of the rotator cuff bursal surface. Advance the arthroscope anteriorly to view the anterior gutter. Rotate the arthroscope to observe the lateral gutter. Move the arthroscope to the lateral portal. This allows a better view of the subscapularis tendon and posterior rotator cuff. If bursa is covering the rotator cuff tendons, resect it until you can see the tendon fibers. This completes the diagnostic examination of the glenohumeral joint and subacromial space (Figs. 3-121 through 3-143). Figure 3-118

Figure 3-119

Introduce the shaver.

Visualize the shaver within the lateral cannula.

Figure 3-121

Rotator cuff.

Chapter 3

Figure 3-122

Figure 3-123

Figure 3-124

Anterior gutter.

Anterolateral gutter.

Musculotendinous junction.


Figure 3-125

Figure 3-126

Figure 3-127

Lateral gutter.

Coracoacromial ligament.

Coracoacromial ligament fraying.

91

92

Section One

Figure 3-128

The Basics

Coracoacromial ligament fraying.

Figure 3-129

Spinal needle.

Figure 3-130

Os acromiale.

Figure 3-131

Figure 3-132

Os acromiale.

Lateral subacromial adhesion.

Figure 3-133

Resect the adhesion.

Chapter 3

Figure 3-134

Partial-thickness rotator cuff tear in the bursal


Figure 3-137

93

Full-thickness rotator cuff repair.

surface.

Coracoacromial ligament, with the arthroscope in the lateral cannula.

Partial-thickness rotator cuff tear in the bursal

Figure 3-138

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

Figure 3-139

Figure 3-135

surface.

Figure 3-136

eral cannula.

Rotator cuff, with the arthroscope in the lat-

94

Section One

The Basics

Right shoulder

Figure 3-140 Rotator interval, with the arthroscope in the lateral cannula. A needle probes the anterior supraspinatus.

Figure 3-143

Rotator interval opened.

INCISIONS I include a section on incisions here to emphasize the many variations on the basic theme of posterior, lateral, and anterior portals. Although the incisions required for each procedure are discussed in the applicable chapters, these discussions are separated by many pages, and the small differences among them may go unnoticed. These small but critical variations among the incisions are better appreciated as the complexity of the operation increases.

Rotator Cuff Repair Viewing Portals Figure 3-141 Rotator interval, with the arthroscope in the lateral cannula. A needle probes superior subscapularis.

In addition to the portals already mentioned, a posterior-lateral viewing portal may be necessary. Some patients have an increased posterior slope to the acromion, so even if the surgeon enters the subacromial space immediately inferior to the posterolateral acromion, the angle of the arthroscope is too vertical. In other patients, the rotator cuff extends too far laterally; with the arthroscope in the normal posterior portal, a tear is difficult to visualize. Moving the arthroscope to a more lateral position improves the surgeon’s view. Many surgeons prefer the lateral portal as the routine viewing portal. My general preference is to view posteriorly or posterolaterally and to insert instruments laterally. However, with larger tears or small, complex tears, I do not hesitate to move the arthroscope to the lateral portal if doing so results in a better understanding of the tear’s geometry.

Instrument Portals

Figure 3-142

Needle palpates the rotator interval.

Additional anterior-lateral or posterior-lateral portals may be necessary. With large or massive rotator cuff tears that require many more sutures than usual,

Chapter 3

95


4

1

2

3

2 3 1

Figure 3-144

Anterior incisions for rotator cuff repair. Figure 3-146

Posterior incisions for rotator cuff repair.

suture management is complex, and it is often necessary to move sutures out of the cannulas to insert instruments. Portals immediately lateral to the acromion (with the shoulder adducted) are needed to insert anchors medially for a double-row repair (Figs. 3-144 through 3-146).

Acromioclavicular Joint Resection

2

1

The necessary incisions are illustrated in Figures 3-147 and 3-148.

Glenohumeral Joint Reconstruction Viewing Portals The posterior portal is 2 cm inferior and medial to the posterolateral acromion. This allows parallel access to the glenohumeral joint in the superior third of the glenoid. This viewing portal provides access to the rotator interval and the anterior and inferior areas of the glenohumeral joint. If I need to move

Figure 3-147

Anterior incisions for acromioclavicular joint

resection.

7 6 1

5

2

2 4

1

3


3

Lateral incisions for rotator cuff repair.

resection.

Lateral incisions for acromioclavicular joint

96

Section One

The Basics

the arthroscope to the anterior-superior portal to view the posterior glenohumeral joint, I can insert instruments through the posterior portal and gain access to the posterior-inferior glenohumeral joint. However, if I need access to the inferior-posterior glenohumeral joint, I require a second posterior portal located more inferiorly. In this situation I make my initial posterior portal more superior. This leaves sufficient space to insert a second posterior portal more inferiorly that allows access to the inferior-posterior glenohumeral joint.

Instrument Portals I generally insert instruments through the anteriorinferior portal or the routine posterior portal (Fig. 3-149).

SLAP

Latarjet Viewing Portals The standard glenohumeral joint portal is used for the initial examination and identification of anterior lesions and for coracoid preparation. I use a lateral incision placed slightly anterior to the anterior acromion to better view the superior and inferior coracoid surfaces, the rotator interval, the anterior scapular neck, and the insertion of the coracoid through the subscapularis split. I use a more distal and anterior portal if the anterior scapular neck is not well visualized. This portal is also used for visualizing the anterior subscapularis during the longitudinal split. An anterior portal lateral to the coracoid is useful to view the superior surface of the coracoid and to position the drill holes (Fig. 3-150).

Viewing Portals

Instrument Portals

I use a routine posterior glenohumeral joint portal for the initial inspection. I use the anterior-superior portal to view the posterior-superior glenoid if I cannot see it clearly with the arthroscope in the posterior portal.

The anterior-lateral portal is used for lateral coracoid dissection, and the lateral-anterior portal is used for inferior and superior coracoid dissection. I use the superior coracoid portal (the haut portal of Lafosse) for pectoralis minor release and coracoid drilling.

Instrument Portals I establish an anterior-inferior portal for outflow and so that I can insert curved suture passers. If the anterior portion of the SLAP lesion is at the 10- to 11-o’clock position (for a right shoulder), I may pass a straight suture passer through the anterior-superior portal. If the SLAP lesion extends more posteriorly, I may insert the posterior suture anchor through the posterior portal.

Suprascapular Nerve Decompression at the Suprascapular Notch Viewing Portals I use a lateral portal in line with the posterior clavicle. The portal is 2 cm posterior to the anterior acromion (Figs. 3-151 and 3-152).

4 2

1

3 2

1 5

6

Figure 3-149

reconstruction.

Anterior incisions for glenohumeral joint Figure 3-150

Latarjet anterior incisions.

Chapter 3

4 2

Figure 3-151

1


5

3

Lateral incisions for suprascapular nerve

decompression.

Instrument Portals

Figure 3-153

Anterior incisions combined.

The portal is just anterior to the anterior acromion. The lateral-superior portal (for nerve dissection and suprascapular ligament division) is 4 cm medial to the medial acromion. The medial-superior portal (for nerve retraction) is 6 cm medial to the medial acromion.

Suprascapular Nerve Decompression at the Spinoglenoid Notch Viewing Portals The lateral-posterior portal is 4 cm inferior to the posterior acromion. I also use a portal placed more anterior and lateral so that I can see the scapular spine and the spinoglenoid ligament more clearly. Figure 3-154

Lateral incisions combined.

5 4

2

1

3

Posterior and superior incisions for suprascapular nerve decompression.

Figure 3-152

Figure 3-155

Posterior incisions combined.

97

98

Section One

The Basics

Instrument Portals The medial-posterior portal is 4 cm medial to the lateral-posterior portal. I insert a soft tissue dissector to dissect the infraspinatus muscle from the infraspinatus fossa of the posterior scapula. I insert a scissors to divide the spinoglenoid ligament through a portal positioned along the lateral acromion.

Incision Overview It is interesting to see all the incisions side by side. This emphasizes the small but significant changes each surgeon makes to adapt to the particular demands of a specific operation (Figs. 3-153 through 3-155).

CHAPTER

4

Glenohumeral Instability

Orthopedic surgeons have a fundamental desire to find a simple solution to glenohumeral instability, leading to various operative approaches. Initially, surgeons observed that abduction and external rotation resulted in glenohumeral joint dislocation, and early operations sought to eliminate that dislocation by limiting the offending motion—external rotation. In many patients, this succeeded in controlling the dislocation, but some were unhappy with the loss of shoulder movement and function; others continued to have instability. Subsequently, the Bankart lesion came to be regarded as the essential lesion, so labrum repair predominated. Labrum repair operations were successful in some but not all patients, and the underlying rationale—that lesions of the labrum were the sole cause of instability—could not explain dislocations that occurred without such lesions. Further, as DePalma observed, many patients had degeneration of the labrum that appeared to be an aging phenomenon, yet few of these patients developed glenohumeral joint instability. Subsequently, patients with recurrent anterior dislocations without labrum detachment were treated with an anterior capsular tightening procedure. Again, many patients benefited, but others continued to suffer shoulder dislocation or subluxation. With the understanding that some shoulders are unstable in multiple directions (with or without labrum lesions), interest shifted to global capsular tightening. The capsular shift as described by Neer provided a solution to this challenging condition. More recently, the desire to control glenohumeral instability while retaining function for overhead sports has motivated the search for new techniques involving arthroscopy. The advantages of arthroscopic

stabilization include smaller skin incisions, more complete glenohumeral joint inspection, ability to treat all intra-articular lesions, access to all areas of the glenohumeral joint for repair, less soft tissue dissection, and maximal preservation of external rotation. Arthroscopy enables surgeons to inspect the entire glenohumeral joint and observe lesions in the unstable shoulder. Concurrently, clinical and basic science investigations have increased our understanding of the pathophysiology of glenohumeral instability. We now have the background, knowledge, and technical skill to solve the problems of glenohumeral instability, and the past decade has brought both exciting advances and better patient outcomes.

LITERATURE REVIEW Because current treatments are directly linked to the past, here I summarize the intellectual history of arthroscopic shoulder stabilization. Early arthroscopic repairs used a staple to advance the Bankart lesion superiorly and medially and were associated with failure rates up to 30%. When immobilization was extended, the failure rate approached 10% to 15%. Owing to potential complications from staples within the glenohumeral joint, other surgeons used a transglenoid suture repair of the Bankart lesion. Early publications reported initial success rates up to 100%, but these results deteriorated with longer follow-up. The two essential elements of these techniques are passage of sutures through the avulsed labrum and then passage through drill holes in the scapular neck. The sutures are tied posteriorly over soft tissue or bone.

101

102

Section Two

Glenohumeral Joint Surgery

Later research and outcomes documented two flaws with these approaches: the medial location of the repaired labrum and failure to address capsular laxity. Neviaser first identified the anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion in shoulders with anterior-inferior glenohumeral instability. The detached labrum-ligament complex healed medially on the scapular neck, which allowed excessive humeral translation. It was apparent that the staple and transglenoid suture techniques described earlier repaired the labrum medially but created an ALPSA lesion. Savoie examined shoulders that had dislocated following arthroscopic stabilization and found that the labrum had been repaired 5 mm medial to the glenoid rim. He was the first to point out that the attachment site of the repaired ligaments was critical. Savoie subsequently modified his technique by moving the entry position of the anchor from the medial scapular neck to the glenoid articular surface and reported improved results with the new technique. Bone suture anchors enabled repair of the detached labrum directly to the glenoid rim. Wolf pioneered this approach for arthroscopic instability repairs. Improved outcomes occurred as surgeons learned to position the glenoid labrum correctly on the glenoid rim. Harryman and associates introduced the term concavity-compression to explain the important role of the labrum in glenohumeral instability. However, further investigation raised two questions: Was the Bankart lesion the only labrum lesion responsible for anterior-inferior instability? Could any labrum lesion or combination of labrum lesions produce glenohumeral instability alone, without the presence of any other lesion? Rodosky described the role of the biceps-labrum complex in anterior-inferior instability. Detachments of the superior labrum—tear of the superior labrum from anterior to posterior (SLAP lesion)—performed in the laboratory allowed increased anterior humeral head translation. Speer also used a cadaver model to determine that although a Bankart lesion allows increased humeral head translation, it alone does not result in humeral head dislocation. Capsular stretch or elongation, along with a Bankart lesion, is necessary for dislocation. Tibone emphasized that the rate of capsular stretch is an important variable because the speed of the injury may determine where the capsular ligament is damaged. In a laboratory study, Bigliani demonstrated that faster strain rates result in ligament injury, whereas slower strain rates result in a higher percentage of failures at the ligament insertion site. Bigliani also studied the tensile properties of the shoulder capsule in patients

with acute dislocation and found that some degree of capsular damage was usually present, even with a Bankart lesion. Baker arthroscopically inspected the shoulders of 45 patients within 10 days of acute dislocation and found that the capsule had been stretched or torn in all patients with or without an associated Bankart lesion. We are all indebted to Gross, who elegantly summarized much of this information. Most descriptions of arthroscopic technique have omitted treatment of the rotator interval. This area of the glenohumeral joint capsule is the soft tissue between the superior border of the subscapularis tendon and the anterior edge of the supraspinatus tendon and includes the superior glenohumeral ligament and a portion of the coracohumeral ligament. Neer and Rowe described the role of the rotator interval in open repair of shoulder instability. Rowe and Zarins inspected the superior aspect of the rotator cuff and found that 20 of 37 patients undergoing operation had a large opening in the capsule between the supraspinatus and subscapularis. Harryman’s laboratory studies advanced our understanding of the rotator interval. He found that opening the rotator interval increased inferior-posterior translation. Perhaps the most subjective (and therefore difficult) type of instability treatment is capsular tensioning. The orthopedic community greeted thermal treatment with great interest; however, clinical application outpaced basic scientific investigation. Recently we gained some appreciation of the thermal technique’s complexity, appropriate role, limitations, and complications. Thermal treatment has been associated with the devastating complications of capsular necrosis, capsular rupture, and chondrolysis. To what degree the application of heat causes these problems is unknown, but at present, the use of thermal capsulorrhaphy has largely been abandoned. I believe that the high failure rates previously reported for arthroscopic repairs were due to technical factors, such as medial repair of the anterior labrum, as well as failure to treat all lesions that contribute to glenohumeral instability. My colleagues and I have reported our early results, and we emphasize the following 11 ideas. 1. Glenohumeral instability occurs in several directions. 2. These directions are classified as anterior, posterior, bidirectional (anterior-inferior or posterior-inferior), and multidirectional (inferior, anterior, and posterior). 3. The classification of direction is somewhat arbitrary.

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4. The primary direction of instability is determined through a combination of patient history, physical examination, radiographic analysis, examination under anesthesia, and evaluation of the glenohumeral joint at the time of arthroscopic surgery. 5. Lesions are usually multiple. 6. Instability in any direction may be the result of various combinations of lesions. 7. The same combination of lesions may produce instability in different directions in different patients. 8. Instability correction requires that all lesions be identified and repaired. 9. It may be necessary to operate on areas of the glenohumeral joint on the side opposite the primary instability to balance the shoulder and prevent iatrogenic instability. 10. Glenohumeral instability should probably be considered a single entity defined as symptomatic excessive humeral head translation. 11. The clinical expression of this translation is variable in each individual. Orthopedic surgeons use patient history, physical examination, radiographic analysis, and operative findings to diagnose the clinical expression of glenohumeral instability. Unidirectional instabilities are well appreciated and are generally categorized as anterior or posterior. On physical examination, patients with multidirectional instability have symptoms of pain and apprehension when the shoulder is stressed in anterior, posterior, and inferior directions. Neer’s pioneering concepts were twofold: glenohumeral instability can occur in multiple directions, and correction of all three symptomatic directions is necessary. In my experience, however, there is a group of patients who are symptomatic in only two directions. There is little in the literature concerning bidirectional glenohumeral instability—that is, inferior instability with either an anterior or a posterior component—which is a separate entity from multidirectional instability and unidirectional anterior or posterior instability. Neer discussed instability in two directions in his paper on multidirectional instability. Altchek described his results with operation for multidirectional instability of the anterior and inferior types. Pollock and Bigliani specifically used the term bidirectional in their paper on recurrent posterior shoulder instability. In a search for a unifying approach to the many forms of glenohumeral instability, I found Pollock and Bigliani’s analysis most helpful. In their article on anterior-inferior shoulder instability, they discussed the complexities


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of instability classification and stressed the need to address all components of glenohumeral laxity to balance the shoulder. They were the first to report that an area of asymptomatic laxity must be treated to correct symptomatic instability in another direction, whereas previous articles had focused on correcting the laxity in the direction of the instability. The clinical expression of glenohumeral joint laxity is termed instability, and my philosophy is that the direction or directions of instability are, to a large degree, the result of laxity in various areas of the glenohumeral capsule and insertion tears of the labrum. Other factors undoubtedly play a role. Some of these factors require nonoperative treatment (muscular strengthening and neuromuscular conditioning), and others require modification of the surgical technique, such as when anterior glenoid bone loss dictates an operation such as the Latarjet procedure. Successful arthroscopic treatment requires that the surgeon identify the direction and degree of clinical instability preoperatively, identify the areas responsible for excessive translation arthroscopically, and then correct all necessary areas of the glenohumeral joint. A prime example of this approach is a patient with recurrent posterior glenohumeral subluxation. This patient likely has excessive laxity in the posterior-inferior capsule, but correction of that area alone will not necessarily control excessive humeral head translation. Even though the patient is not symptomatic in the direction of the rotator interval or the anterior-inferior glenohumeral ligament, tightening of both these areas is usually required. There are many similarities between arthroscopic rotator cuff repair and arthroscopic glenohumeral reconstruction, but there are also important fundamental differences. Arthroscopic rotator cuff repair has certain advantages over the traditional open approach, as described in Chapter 12. Fundamentally, however, the primary goal of both the arthroscopic and the open procedure is identical: to reattach the torn edge of the rotator cuff tendon to its normal point of anatomic insertion. Operations within the glenohumeral joint are technically less demanding than those within the tight confines of the subacromial space, but arthroscopic glenohumeral reconstruction is not a simple operation. Although the glenohumeral joint is better visualized and the surgeon has more space to manipulate instruments than within the subacromial space, the less demanding technical aspects of the procedure are offset by a greater deficit in knowledge. For example, there are no objective standards by which

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Section Two


Superior SLAP Cuff

Interval

Internal impingement Posterior

Anterior

PIGHL

AIGHL Inferior capsule Inferior

Figure 4-1 The circle concept of instability. AIGHL, anteriorinferior glenohumeral ligament; PIGHL, posterior-inferior glenohumeral ligament.

to judge ligament or capsular tension, so the surgeon can only estimate the amount of tightening needed. The most critical part of the procedure is the one that lacks objective guidelines. I have found it helpful to use a circle to conceptualize some of the factors involved in glenohumeral joint instability (Fig. 4-1). Think of the circle in the figure as a sagittal view of the right shoulder, with the arrow representing the direction of anteriorinferior translation. The most common form of shoulder instability occurs in the anterior-inferior direction, and our initial understanding was that the lesion was in the anterior-inferior portion of the shoulder. Depending on the surgeon’s country of origin, this lesion is termed the Bankart, Broca, or Perthes lesion. The search for this ‘‘essential’’ lesion dominated research for 50 years, and other surgeons presented their clinical and laboratory work questioning this idea. DePalma thought this explanation was inadequate because he had identified unstable shoulders without any labrum abnormality, as well as shoulders with labrum abnormalities that were stable. Nonetheless, the Bankart lesion became the focus of operative repair. This thinking persisted with few challenges until Neer and Foster’s article on multidirectional instability emphasized the importance of an inferior capsular lesion. Rowe and Zarins also described operative correction of a shoulder with anterior-inferior instability in which no Bankart lesion was found. Further investigation identified the importance of the inferior-posterior capsule and ligaments as additional static stabilizers, as well as the importance of the rotator cuff muscles as dynamic stabilizers. The role of the superior labrum

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

DIAGNOSIS Patient History I collect sufficient data to rate patients according to the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Constant scoring system, the scoring system of Rowe, and the University of California at Los Angeles (UCLA) Shoulder Scale. Recently, my colleagues and I developed our own scoring system that allows us to compare patients with high as well as low levels of shoulder function without an excessive response burden. Before operation, all patients complete self-assessment questionnaires to document their levels of shoulder pain, satisfaction, and function. To increase diagnostic precision, I classify each shoulder by chronicity, degree, and traumatic onset. I document (according to the patient’s description) whether the instability is chronic or acute (< 6 weeks) and further classify the instability as recurrent dislocation, recurrent subluxation after a single dislocation, or recurrent subluxation without prior dislocation. I record whether the patient developed instability after a traumatic event of a magnitude sufficient to damage the glenohumeral ligaments (traumatic or atraumatic) and use guidelines similar to those described by Wirth. A traumatic cause is supported by an injury with the arm forcefully abducted, externally rotated, and extended; sudden sharp pain; the need for manipulative reduction; and residual aching in the shoulder for several weeks. Atraumatic instability is characterized by an insidious onset or following minor trauma and is associated with mild pain and a spontaneous reduction. All patients are questioned about arm position or activity that reproduces their symptoms. Additionally, I record the sports participation, if any, of each patient. I classify sports according to the method described by Allain. Type 1 sports are nonimpact and consist of breaststroke swimming, rowing, running, or sailing. Type 2 sports are high impact and

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include bicycle riding, snow skiing, soccer, and water skiing. Type 3 sports require overhead use of the arm with hitting movments, such as crawl-stroke swimming, golf, tennis, throwing, and weight lifting. Type 4 sports involve overhead hitting movements and sudden stops such as basketball, football, handball, ice hockey, judo, karate, kayaking, lacrosse, polo, rodeo, volleyball, wind surfing, and wrestling. I also record which shoulder is dominant.

Physical Examination I measure active ranges of motion according to the Constant rating system, which includes forward flexion, abduction, external rotation in abduction, and behind-the-back internal rotation. Passive elevation and external rotation (with the arm adducted), as well as external rotation and internal rotation with the arm abducted 90 degrees, are measured. I measure internal rotation at 90 degrees of abduction in the coronal as well as the scapular plane. Elevation strength is measured using a dynamometer with the arm elevated 90 degrees in the scapular plane and internally rotated, with the result recorded in pounds. The instability examination is performed on both shoulders. I compress (load) the humeral head into the glenoid during all maneuvers. I assess glenohumeral translation in eight directions: anterior-superior, anterior, anterior-inferior, inferior-anterior, inferior, inferior-posterior, posterior-inferior, and posterior. An essential element of the instability examination is patient relaxation; an effective examination is not possible if the patient’s muscles are tense. This may occur as a result of pain during the examination or fear that pain will follow a particular maneuver. If the patient is comfortable, I perform the examination with the patient standing; if relaxation is not adequate, I examine him or her seated or supine. I assess anterior-superior translation with the shoulder in 0 degrees of abduction and the arm externally rotated 90 degrees while I grasp the humeral head and move it anterosuperiorly. Anterior translation is assessed with an anterior force applied to the shoulder with the arm in 90 degrees of abduction; anterior-inferior translation is tested with the arm in the same position, but the direction of force is changed to anteroinferior (Fig. 4-2). I also perform the relocation test (Fig. 4-3). A particularly useful maneuver is the Rowe test to assess inferior-anterior translation. To perform this examination, have the patient stand and flex the trunk from the hips approximately 30 degrees. Instruct the patient to relax the arms and let them hang from the shoulder toward the floor. In this relaxed position, the shoulders

Figure 4-2

Dr. Rowe examines a patient for anterior

instability.

are effectively elevated 30 degrees (Fig. 4-4); the examiner then applies a distraction force. Inferior translation is assessed with an inferior force applied with the shoulder at 0 degrees of abduction (sulcus test). If the translation force is applied in an inferior-posterior direction, the surgeon can gain additional information. Posterior translation is examined with the arm elevated 90 degrees, adducted slightly, and rotated internally approximately 30 degrees. I translate the shoulder in a posterior-inferior direction and record the result. I then apply a posterior force and assess the translation. Typically, posterior translation produces minimal complaints, but as the shoulder is extended, the humeral head reduces, and the patient reports pain.

A

B Figure 4-3

A and B, Relocation test.

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30°

Figure 4-5

Figure 4-4

Patient position for the Rowe test.

I record the presence or absence of pain and apprehension for each instability maneuver and grade the amount of humeral head translation on the glenoid surface as 0 (stable or trace laxity), 1 (up to 50%), 2 (> 50% but not dislocatable), or 3 (dislocatable). The grading of instability is somewhat subjective but appears to be relatively consistent for each examiner. I record the presence of laxity in the contralateral shoulder and elbows and the patient’s ability to bring the thumb to the forearm, but I use no formal grading system for the degree of generalized ligament laxity. I simply record ligament laxity as present or absent. I exclude other sources of shoulder pain (rotator cuff lesions, acromioclavicular joint arthritis, thoracic outlet syndrome, brachial plexus lesions, glenohumeral arthritis) through the patient history, physical examination, and radiographic analysis.

Anterior-inferior dislocation.

glenohumeral instability consists of humeral head dislocation. Indirect radiographic signs of instability include calcification adjacent to the anterior glenoid, a bone Bankart lesion, anterior glenoid bone loss, or a HillSachs lesion. On magnetic resonance imaging and computed tomography, additional evidence of instability includes detachment of the glenoid labrum from the glenoid bone, capsular stripping from the glenoid, and ligament insufficiency (Figs. 4-5 through 4-14). If the diagnosis is in doubt, an arthroscopic examination and examination under anesthesia are helpful. I observe humeral head movement under direct arthroscopic visualization. The presence of intra-articular lesions may allow the surgeon to diagnose a predominant direction of instability or an unrecognized direction of instability. These lesions are located in the humeral head and glenoid (chondral or osteochondral defects), labrum (fraying or separation from the glenoid), and capsular ligaments (tear or laxity).

Radiographs Routine radiographs include anteroposterior glenoid, axillary, and supraspinatus outlet views. I recently added the Bernejeau view to my routine radiographs because I think it best demonstrates the presence or absence of anterior glenoid bone loss. I obtain Bernejeau views of both shoulders for comparison. Other radiographic imaging (magnetic resonance imaging, computed tomography, arthrography) is not routinely performed. Direct radiographic evidence of

Figure 4-6

Glenoid rim fracture.

Chapter 4

Figure 4-7


Bone Bankart lesion. Figure 4-10 Bankart lesion.

Figure 4-8

Bone Bankart lesion (circled), axillary view.

Figure 4-9

SLAP lesion.

Figure 4-11

Hill-Sachs lesion.

Figure 4-12 Anterior capsular stripping.

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RA

SP


Contracted posterior-inferior capsule.

Glenoid rim fracture.

commonly occurs in patients with traumatic anteriorinferior glenohumeral instability (Figs. 4-15 and 4-16).

NONOPERATIVE TREATMENT Nonoperative treatment consists of avoidance of painful activities, nonsteroidal anti-inflammatory medication for pain if necessary, and a home physical therapy program designed to eliminate contractures and maintain or improve shoulder girdle strength and neuromuscular coordination. The goal is to improve the strength of those muscles responsible for glenohumeral stability. Therefore, patients perform resistive exercises of the internal rotators, external rotators, biceps, triceps, and scapular muscles with surgical tubing and light weights (maximum 5 pounds). Patients are instructed in exercises to improve neuromuscular coordination and proprioception. Areas of contracture are identified and corrected with specific stretching. Posterior contracture

Figure 4-14

(arrow).

OPERATIVE TREATMENT Indications The primary indication for operation is persistent shoulder pain due to glenohumeral instability that

Posterior humeral glenohumeral ligament tear Figure 4-16

Adduction stretch.

Chapter 4

has not responded to a minimum of 6 months of nonoperative treatment as described earlier. The only exceptions are patients who desire operative repair acutely (within 6 weeks after an initial traumatic dislocation). Fundamentally, I believe the decision to operate is the patient’s, and I present the natural history of an initial shoulder dislocation in the context of the particular situation. When a patient sustains an initial dislocation that occurs with sufficient energy that it can be classified as traumatic, surgical repair is an option. I consider nine factors: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Patient age Amount of trauma involved in the dislocation Reduction method Arm dominance Present activity level Desired activity level Patient’s sensation of instability Radiographic findings Timing during a sports season

Seven factors influence the decision in favor of acute repair: 1. Age younger than 20 years 2. Traumatic dislocation (as opposed to dislocations that occur with minimal force) 3. Reduction required (as opposed to spontaneous reduction) 4. Dominant arm 5. High activity level 6. Desire to continue that activity level 7. Sensation of instability while in a sling or with movement during sling removal or dressing A displaced bone fragment indicates that the labrum does not lie in its anatomic location and will heal with the attached soft tissue in a medial position. If the patient is currently participating in a team sport and the season is less than 2 months from completion, we discuss the patient’s desire to return to that sport or another seasonal sport. For example, a high school junior with an interest in football may elect to have his shoulder repaired so that he can play during his senior year. A patient who also participates in a spring sport may not want to risk missing baseball season, for example, particularly if that is his area of concentration. I explain the chance of recurrent instability in light of the patient’s particular situation and let the patient and family decide on operative or nonoperative care. My experience correlates with much of the recent literature. Patients who are younger than 20 years and participate in vigorous overhead activities have a high


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rate of redislocation. However, unless the patient falls into the select subgroup described earlier with factors influencing early repair, the chances of recurrent dislocation are less than 50%, and of those in whom redislocation occurs, only 50% request surgery. Historians will likely view our past treatment of traumatic shoulder dislocation as suboptimal. Essentially, there is a 25% recurrence rate (much higher in certain patients). Arthroscopic treatment has a 90% to 95% success rate, yet it is not routinely performed. Orthopedic surgeons operate on acute ligament injuries of the knee and ankle but rarely on the shoulder. I think that as our techniques and equipment continue to improve, and as our ability to identify patients at high risk of recurrent symptomatic dislocation increases, patients with acute shoulder dislocation will have greater access to surgical care.

Contraindications Absolute contraindications to surgery include glenohumeral instability with selective voluntary muscle contractions and questionable emotional stability. Patients who can activate their muscles and demonstrate glenohumeral subluxation or dislocation with the arm by the side seem to have a poor prognosis after operative care. Evaluating a patient’s emotional stability is, of course, subjective. Relative contraindications include failed prior instability surgery, poorquality ligaments, and large bone defects of the glenoid or humeral head. The solution in the last case is the Latarjet procedure, discussed later in this chapter (Fig. 4-17).

Figure 4-17 Three-dimensional computed tomographic reconstruction with anterior bone loss.

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Most Hill-Sachs lesions do not affect the operative result because, with restoration of soft tissue tension, the Hill-Sachs lesion does not engage the anterior glenoid. However, when the humeral head defect is large enough, there is insufficient surface area to allow adequate external rotation. If the patient regains external rotation, he or she may experience a sensation of catching as the Hill-Sachs lesion rides over the anterior rim. Earlier operations dealt with this issue by intentionally restricting external rotation, but such an approach limits function and may lead to asymmetric loading and arthrosis. I have found that arthroscopy is the most effective means of evaluating whether the Hill-Sachs lesion is large enough to require an open procedure such as a humeral head allograft or rotational osteotomy. For those rare patients with very large, engaging Hill-Sachs lesions, I recently began using a metallic cap (ArthroSurface) to fill in the defect and have been very pleased with the short-term results. Wolf has described his arthroscopic remplissage procedure, which involves advancement of the infraspinatus tendon and posterior capsule into the humeral head defect.

OPERATIVE APPROACH Here, I describe why I choose to repair various structures within the glenohumeral joint and when during the operation I do so. Because I consider glenohumeral instability to be a single entity with variable clinical expression, I do not present separate sections on the treatment of each direction of instability.

Operative Rationale The underlying principle of arthroscopic repair is to identify and repair all lesions that contribute to glenohumeral instability. This involves de´bridement, repair of ligament and labrum tears, capsular tensioning, and, if needed, repair of the rotator interval. My approach to a patient with glenohumeral instability is first to determine the direction or directions of instability by conducting a thorough history, physical examination, examination under anesthesia, and examination during glenohumeral arthroscopy. I then evaluate all the structures within the glenohumeral joint and decide which ones require operation. A patient with unidirectional anterior instability may require an anterior labrum repair, but if capsular stretching has occurred, anterior capsular imbrication may be necessary as well. Another patient with the

same direction and degree of translation may not be stabilized with these two maneuvers and may require a superior labrum repair. A patient with posteriorinferior instability may not be stabilized after posterior labrum and posterior capsule repair and may require tightening of the inferior capsule and anterior-inferior glenohumeral ligament. A rotator interval repair may be necessary. The decision making is complex, but it accurately reflects the reality of the clinical situation. The goals of de´bridement are to remove sources of mechanical irritation or functional instability. Only minor labrum flap tears (< 50% of the labrum thickness) are removed, and every attempt is made to repair the lesions. The purpose of ligament and labrum reattachment to bone is twofold. First, adequate capsular tension is impossible to achieve unless the labrum and ligament are securely attached to the glenoid. I repair all traumatic tears of the superior, anterior, posterior, and inferior labra because all these lesions contribute to glenohumeral instability. Second, anatomic repair of the ligament and labrum restores cavity-compression to the glenohumeral joint. Lippitt has demonstrated that compression of the humeral head into the glenoid by muscular force is an effective stabilizer to humeral translation, and resection of the labrum decreases stability by 20%. Reattaching the anterior-inferior ligamentlabrum complex to the glenoid may not restore sufficient stability to the glenohumeral joint. Speer demonstrated only a small increase in humeral translation with a simulated Bankart lesion and concluded that capsular stretching or elongation is necessary to produce glenohumeral instability. Therefore, the final portion of the operation is to restore capsular tension. I classify capsular elongation as primary or secondary. Primary elongation refers to permanent deformation of the capsular fibers due to a single traumatic event or multiple episodes of instability. Secondary elongation occurs when there is a tear at the insertion site, thereby decreasing capsular tension. This may occur within the anterior-inferior capsule after a Bankart lesion or as a result of a superior labrum tear. The biceps-labrum complex contributes to anterior-inferior translation, and its detachment results in increased humeral translation. Thus, I repair all traumatic superior labrum detachments. Rotator interval and superior glenohumeral ligament tears also affect glenohumeral stability. I have observed at operation that repair of the rotator interval decreases inferior and posterior translation of the humeral head. If the

Chapter 4

repair also incorporates the superior portion of the middle glenohumeral ligament, anterior capsular tension is increased. Thus the surgeon can restore capsular tension by two methods: primary capsular elongation requires operation directly on the capsule, and secondary elongation responds to repair of insertion site tears. I correct primary capsular elongation by three techniques used singly or in combination: (1) advancement of the capsule to the labrum, (2) advancement of the capsule to the glenoid with suture anchors, and (3) capsular imbrication. The goal of this portion of the procedure is to restore ligament and capsule tension and to eliminate excessive humeral head translation, which I define as greater than 25%. To estimate the percentage of translation, I visually divide the humeral head into four segments and observe how much of the humeral head translates with relation to the glenoid. Any or all of the following areas may require tightening: middle glenohumeral ligament, anterior-inferior glenohumeral ligament, inferior capsule, posteriorinferior glenohumeral ligament, and posterior capsule. My preference is to advance the capsule to the intact or repaired labrum with braided sutures. Only if the labrum is small or absent is the capsule repaired to the glenoid rim with bone suture anchors. Drill holes for the suture anchors are placed through the glenoid articular surface approximately 1 to 2 mm from the peripheral glenoid rim. The detached labrum is sutured so that it contacts the scapular neck and extends onto the glenoid articular surface. This reestablishes the labrum ‘‘bumper’’ and re-creates an optimal surface for concavity-compression. I estimate the amount of tightening based on both the degree and the direction of translation, using guidelines similar to those described by Warner for open operations. A soft tissue grasper is used to apply traction to the various portions of the capsule while the arm is positioned in different degrees of abduction and external rotation and I apply translation forces. I try to establish tension in different parts of the capsule according to their role in glenohumeral stability. I estimate appropriate tension of the inferior capsule with the arm in 60 degrees of abduction and 60 degrees of external rotation, the middle glenohumeral ligament with the arm in 30 degrees of abduction and external rotation, and the rotator interval with the arm in 0 degrees of abduction and 30 degrees of external rotation (Figs. 4-18 through 4-22). Because I am technically unable to perform the repair with the arm in complete abduction or

Figure 4-18


111

Inferior translation with the shoulder internally

rotated.

external rotation, I estimate the appropriate amount of tension, return the arm to 20 degrees of abduction and 30 degrees of external rotation, and then complete the arthroscopic repair. With the greater visualization afforded by the arthroscope, the surgeon can selectively repair damaged portions of the capsule. This is an advantage over open reconstructions for anterior instability. With the increased selectivity of arthroscopic repair comes the promise of improved patient outcomes, but also a new set of decisions to be made. This is less of a problem with tears of the labrum insertion, because the goal of returning the labrum to its anatomic location is relatively well understood. More difficult are decisions regarding ligament or capsule tightening; the surgeon has to decide what portions of the capsule should be tightened, how much

Figure 4-19

rotated.

Inferior translation with the shoulder externally

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tightening is necessary, and by which technique tightening should occur.

Intraoperative Decision Making and Indications De´bridement

Figure 4-20

Inferior translation in abduction.

I de´bride only minor flap tears of the labrum. Flap tears greater than 50% are repaired with absorbable monofilament sutures. I find that labrum palpation with a probe is necessary to determine the presence of minor flap tears, cleavage tears that exist within the labrum substance, and minor separations of the labrum from the glenoid. Loose bodies are removed with surgical forceps.

Labrum Repair

Figure 4-21

Anterior translation.

The labrum is normally attached securely to the glenoid bone anteriorly, inferiorly, and posteriorly below the glenoid equator; I consider separations in these areas to be lesions. The anterior-superior labrum is usually not well attached to the glenoid (sublabral foramen), and separation in this area is considered normal. The superior labrum attachment is variable, and a mobile superior labrum without evidence of trauma is not classified as a SLAP lesion. When the superior labrum separation is a normal variant, the superior glenoid is covered with smooth cartilage, and the labrum shows no evidence of trauma. Signs of traumatic separation include tears within the substance of the superior labrum, cartilage loss with exposed bone at the site of labrum attachment, and an increase in superior labrum separation with abduction and external rotation of the arm. I repair the superior labrum anatomically and make no attempt to shift the superior labrum anteriorly or posteriorly. In contrast, during repair of the anterior, inferior, or posterior labrum, I will, if necessary, shift the labrum laterally so that it projects onto the glenoid surface and reestablishes the labrum as a bumper to aid in concavity-compression.

Capsular Tensioning

Figure 4-22 Posterior translation.

I estimate the location of the ligament repair site (and therefore the ligament tension) by grasping the ligament and placing it at different locations on the glenoid. Humeral head translation is performed with the torn ligament positioned at possible repair sites until humeral head translation is less than 25% of the glenoid diameter. Typically, 5 to 15 mm of lateral and superior ligament advancement is required. Arm position affects ligament and capsule tension, so I routinely maintain the shoulder in 20 degrees of abduction and 30 degrees of external rotation during

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this portion of the operation. I alter the arm position when operating on the dominant arm of a competitive, throwing athlete. In these patients, I determine the ligament repair site after I position the arm in 60 degrees of external rotation.

Rotator Interval If the shoulder demonstrates persistent excessive translation after de´bridement, labrum repair, and capsular tensioning, I turn my attention to the rotator interval. If the direction of translation is inferior or inferiorposterior, I place a monofilament suture through the soft tissue immediately adjacent to the anterior border of the supraspinatus and then through the soft tissue superior to the subscapularis tendon. I place the suture as far laterally as possible so as not to interfere with postoperative external rotation. While applying traction on this suture, I again assess humeral head translation. If the correction is adequate, the suture is tied. If the correction is inadequate, the suture is removed and placed in a more medial position until excessive translation is corrected. If the direction of persistent translation is inferior-anterior, the inferior limb of the suture is passed through the superior portion of the middle glenohumeral ligament to increase tension in that portion of the capsule.

OPERATIVE TECHNIQUE The patient receives an interscalene block to diminish postoperative pain and is then placed under general anesthesia. The anesthesiologist administers 1 g cephalosporin intravenously. I place the patient in the sitting position and examine both shoulders as described earlier. The shoulder joint is entered with a cannula and blunt trocar through a posterior skin incision placed 1.5 cm inferior and 2 cm medial to the posterolateral border of the acromion. I place the posterior portal in a more superior location than the soft spot. This allows me more access if I must introduce a second inferiorposterior portal later during the procedure. I perform a brief inspection and evaluate the rotator interval for evidence of trauma or laxity. This must be done before placement of the anterior portals because they will pass through the rotator interval and alter its appearance. An anterior portal site is identified with a spinal needle so that the cannula enters the shoulder joint immediately superior to the subscapularis tendon and 1 cm lateral to the glenoid. The more lateral the anteriorinferior cannula, the easier it is to place anchors perpendicular to the glenoid surface, but the more difficult it is to reach the inferior aspects of the glenohumeral joint. If

Figure 4-23 Portal sites for arthroscopic subacromial decompression and glenohumeral reconstruction, in the traditional soft spot.

the anterior-inferior cannula is placed more medially, it is easier to reach the inferior glenohumeral joint but more difficult to place suture anchors. I then inspect the glenohumeral joint completely. I reexamine the shoulder for translation while viewing it through the arthroscope and use a probe to examine the labrum for tears and palpate the capsule to evaluate ligament tension (Figs. 4-23 through 4-38). I then establish the anterior-superior portal with a spinal needle. The anterior-superior cannula is placed 1 cm superior and 5 mm lateral to the anterior-inferior cannula (Figs. 4-39 through 4-42).

Figure 4-24

Widened, thin rotator interval.

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Section Two


Figure 4-25

Anterior portals.

At this point I remove the arthroscope and insert it through the anterior-superior cannula to inspect the posterior glenohumeral joint more completely, paying particular attention to the glenoid shape. Anterior glenoid bone loss can be observed by loss of the normal glenoid pear shape. If my observations with the

Figure 4-26

Anterior-inferior portal location.

Figure 4-27 Cannula in the anterior-inferior portal.

arthroscope positioned posteriorly lead me to conclude that the anterior ligaments are inadequate for surgical repair or my view with the arthroscope positioned anteriorly demonstrates a loss of anterior glenoid bone, I perform an arthroscopic Latarjet procedure (Figs. 4-43 through 4-46). I then return the arthroscope to the posterior cannula. All structures within the glenohumeral joint are examined systematically, and all lesions consistent with instability are recorded. These lesions are variable and may include tears of the rotator cuff (partial and complete), rotator interval, glenoid labrum, glenohumeral ligaments, and biceps tendon. I have noted, as

Figure 4-28

Superior labrum tear.

Chapter 4

Figure 4-29

Palpating for a superior labrum tear.

Figure 4-30

Poorly defined middle glenohumeral ligament.

Figure 4-31

Palpation of the anterior-inferior glenohumeral

ligament.

Figure 4-32

Figure 4-33


Anterior cartilage loss.

Chisel exposing a small Bankart lesion.

Figure 4-34 Bankart lesion.

115

116

Section Two

Figure 4-35


Palpation of the inferior capsule.

Figure 4-38

Shallow Hill-Sachs lesion.

Figure 4-39

Anterior-inferior cannula.

Figure 4-36 Loose body removal.


Humeral head cartilage lesion.

location.

Needle identifies the anterior-superior portal

Chapter 4

Introduce the anterior-superior cannula and palpate the rotator interval. Figure 4-41

Metal cannula and arthroscope moving to the anterior-superior portal.

Figure 4-42

Anterior Bankart lesion seen from the anteriorsuperior cannula.

Figure 4-44

Figure 4-45


Posterior labrum fraying.

Posterior labrum split.

Figure 4-43

Figure 4-46

Posterior Bankart lesion.

117

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Section Two


have others, that the glenohumeral ligaments can tear at either the glenoid or humeral head insertion. To evaluate the glenohumeral ligaments for midsubstance tears or plastic deformation, I assess them for laxity by directly observing and palpating them (with an arthroscopic probe) and applying translation stresses as I rotate the shoulder. I document the location on the glenoid and the extent (superior to inferior and medial to lateral) of labrum detachment. Labra that are frayed or have midsubstance tears are noted. The presence or absence of loose bodies is also recorded. The cartilage is inspected for damage to the glenoid and humeral head (Hill-Sachs lesion). I carefully examine the glenoid and use an arthroscopic probe inserted through the anterior-inferior cannula to measure the glenoid width. The inferior portion below the glenoid equator should have a greater anterior-posterior width than the glenoid superior to the equator. If it does not, there has been too much bone loss, and a bone graft is necessary to restore glenoid width. Previously, I performed this operation with the open Latarjet technique; more recently, based on the work of Lafosse, I have made the transition to an all-arthroscopic Latarjet. I then examine the Hill-Sachs lesion and record its location, dimensions, and orientation. A posterolateral location indicates anterior instability, and an anteromedial location is consistent with posterior instability. I note the lesion’s length, width, and depth and maneuver the shoulder until I can determine what amount of external rotation will allow the Hill-Sachs lesion to engage the glenoid rim. I center the humeral head by compressing it against the glenoid while performing this maneuver. Usually the Hill-Sachs lesion does not engage the glenoid rim without anterior translation. If the Hill-Sachs lesion engages the glenoid rim with the humeral head centered and the amount of external rotation is 40 degrees or less, I suture the posterior capsule into the humeral head defect (the remplissage of Wolf). This rarely occurs. If the external rotation is greater than 40 degrees, I continue with arthroscopic stabilization. To examine the orientation of the Hill-Sachs lesion, I position the arm so that the lesion is parallel to the anterior glenoid rim and observe the amount of abduction and external rotation. This is the position of the arm during the moment of dislocation and indicates which areas of the capsule are damaged. As a rule, the greater the amount of abduction needed to align the Hill-Sachs lesion with the anterior glenoid rim, the more damage there is to the inferior capsule. A smaller amount of abduction indicates more anterior capsule (middle glenohumeral ligament) damage (Figs. 4-47 and 4-48).

Figure 4-47

Hill-Sachs lesion, with the arm resting at the

patient’s side.

If a posterior repair is necessary, I perform this before superior, anterior, or inferior capsular repair. Repair in any of these areas dramatically limits access to the posterior, and especially the posterior-inferior, glenohumeral joint (Figs. 4-49 through 4-61).

Posterior Repair The principles of posterior repair are similar to those for anterior and inferior repair, but there are some specific distinctions. Because posterior repair is performed less frequently than anterior repair, the surgeon is

Figure 4-48 Hill-Sachs lesion, with the arm positioned until the lesion is parallel to the anterior glenoid rim.

Chapter 4

Figure 4-49

Figure 4-50


Figure 4-52

Drill an inferior anchor hole.

Figure 4-53

Drill a superior anchor hole.

De´bride the posterior labrum.

Abrade the posterior glenoid with a round bur.

Figure 4-51

The posterior glenoid is prepared.

Figure 4-54

Insert the anchor.

119

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Section Two

Figure 4-55


Retrieve the braided suture. Figure 4-58

Figure 4-56 Pass through the labrum and retrieve the suture with a nylon loop through the anterior-inferior cannula.

Retrieve the braided suture from the anteriorinferior cannula to the posterior cannula.

Figure 4-59

Tie knots.

Tighten the inferior-posterior capsule.

Figure 4-57

Figure 4-60

Repair of the now-intact labrum.

Chapter 4


121

is technical: I cannot maneuver the posteriorly located drill to penetrate the articular cartilage at an appropriate angle. Second, in most posterior repairs, I suture the posterior capsule and incorporate enough capsule with the labrum to re-create the labrum bumper, even with anchors located in this position. The posterior labrum bumper is smaller than the one I create anteriorly, but this corresponds to the normal labrum anatomy. I locate the drill holes 2 to 3 mm posterior to the articular surface. The angle is parallel to the surface or slightly posterior to it. I insert the anchors and repair the labrum and capsule from inferior to superior. Figure 4-61

Completed repair.

not as familiar with the hand maneuvers needed to position instruments within the glenohumeral joint. I recognize that my movements will be slower and less fluid than when operating anteriorly, so I mentally allow myself some leeway during posterior operations.

Portal Placement To establish the posterior portal, I move the arthroscope to the anterior-superior cannula. I leave the anterior-inferior cannula in place to provide outflow, and I can insert the crochet hook through it to retrieve sutures. While I view the posterior capsule through the arthroscope, I remove the posterior metal cannula and insert a larger-diameter plastic cannula through the same skin incision. I advance it until the tip tents the capsule. I then move the tip inferiorly and advance it external to the capsule until it reaches the appropriate entry point. This point is located near the inferior glenoid for inferior-posterior capsular tensioning; it may be at the glenoid equator if the labrum is the only damaged structure.

Scapular Neck Preparation I use a 4-mm round bur. Because of the portal location, the bur enters the glenohumeral joint parallel to the glenoid surface. I advance it into the joint and move it superiorly and inferiorly over the desired distance. It helps to advance the arthroscope as far into the joint as possible and rotate it to obtain the best view of the posterior glenoid.

Drill Holes I leave the arthroscope in the anterior-superior cannula and insert the drill posteriorly. I place the posterior drill holes on the posterior scapular neck. In contrast, for an anterior repair, I position the drill holes on the glenoid articular surface. One reason for the difference

Suture Passing I use the Smith-Nephew or Spectrum crescent hook and pierce the posterior-inferior capsule and advance it superiorly. The instrument tip penetrates the capsule and is visible. I then proceed through the soft tissue superiorly, pierce the labrum, and advance the two free ends of the 2-0 nylon suture into the glenohumeral joint. Dr. Hammerman (my assistant) inserts a crochet hook through the anterior-inferior cannula, retrieves the sutures, and applies a hemostat. I remove the crescent hook from the joint. The anchor sutures exit the joint through the posterior cannula. We then reverse the loop with another monofilament suture so that the loop end comes out the anterior-inferior cannula and the two free ends exit the posterior cannula. I insert a crescent hook through the anteriorinferior cannula and retrieve one of the anchor suture strands. I place it through the looped end of the monofilament suture and pull it through the labrum and posterior cannula until it exits posteriorly. I tie the knot through the posterior cannula. I then repeat this sequence until the posterior repair is complete and then go on to capsular tensioning. If no posterior repair is needed, I return the arthroscope to the posterior cannula and continue with the glenohumeral reconstruction.

Anterior-Inferior Repair Bankart Bankart Release of Labrum and Capsule with Cautery Bankart Complications The repair sequence varies and depends on the specific combination of lesions identified. I follow a pattern of

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Section Two


de´bridement, ligament or labrum reattachment, and capsular tensioning.

De´bridement De´bridement is performed to smooth frayed labrum fragments or to remove torn fragments. It is also performed, if necessary, to identify the depth of partialthickness rotator cuff tears. Loose bodies are removed, but doing so is usually frustrating because the inflow blows the pieces around the joint. I find it helpful to attach suction to the outflow cannula, let the flow of fluid bring the loose body to the mouth of the cannula, and then grasp it with a forceps.

Type B

Insertion Tears I then treat labrum and ligament insertion site tears. Technical considerations dictate the order of labrum repair. Posterior labrum tears are repaired first, followed by tears in the inferior, anterior, and superior labrum. As the labrum (and attached ligaments) is repaired, the ability to displace the humeral head and insert bone or soft tissue suture anchors or sutures is compromised. I repair the posterior labrum first because access to this lesion becomes difficult after superior or anterior labrum repair. Posterior, inferior, and superior labrum tears are usually easily identified and minimally displaced. This is not the case with anterior labrum tears. I classify three types of anterior labrum detachment: type A, in which the labrum is separated from the glenoid bone but remains at the level of the glenoid articular surface; type B, in which the labrum is separated and retracted medially; and type C, in which the labrum is retracted and has

Type A

Figure 4-62

Type A lesion.

Figure 4-63

Type B lesion.

healed medially on the glenoid (equivalent to an ALPSA lesion) (Figs. 4-62 through 4-64). Type B and C lesions require that the surgeon dissect the labrum from the glenoid and place it laterally on the glenoid articular surface. I perform this with a combination of a thermal probe, power bur, scissors, and blunt dissection. If the anterior-inferior or middle glenohumeral ligaments are retracted and adherent to the subscapularis, I release the ligaments before insertion site repair.

Type C

Figure 4-64 Type C lesion.

Chapter 4

I make an incision with a scissors along the superior border of the middle glenohumeral ligament and insert a blunt instrument (posterior to the capsule and anterior to the subscapularis tendon) to separate the two structures. If the labrum or capsule has healed medially, I insert a sharp chisel dissector along the scapular neck to peel these structures from the bone. I advance the arthroscope (located in the posterior cannula) as far anteriorly as possible and rotate it to obtain the best anterior view. If the view is not satisfactory, I transfer the arthroscope to the anteriorsuperior cannula. Once the capsule and labrum have been separated from the bone, I try to advance them laterally. If further mobilization is necessary, I insert arthroscopic scissors through the anterior-inferior cannula and divide the soft tissue attachment in the base of the V formed by the scapular neck posteriorly and the capsule anteriorly. I continue to divide the soft tissue until I can see the muscular fibers of the subscapularis (Figs. 4-65 through 4-68).


Figure 4-66

Chisel to dissect the labrum from the glenoid.

Figure 4-67

Use scissors to mobilize the labrum and

capsule.

Figure 4-65

repair.

123

Location of two anterior cannulas for anterior Figure 4-68 Muscular fibers of the subscapularis.

124

Section Two


Bankart, Bone Fragment Bankart Acute Dislocation Patients with traumatic unidirectional instability often have a piece of bone attached to the anterior labrum that was avulsed from the glenoid during dislocation. These fragments are often too small to be seen on radiographs, but they are easily seen and palpated during arthroscopy. I try to retain these fragments and incorporate them in the labrum repair to add bulk. The tip of the suture passer must pass underneath the fragment so that the fragment is lifted by the suture and reduced laterally. With larger bony Bankart lesions, it is more critical to retain the fragment. If the fragment is excised, the glenoid width decreases. Studies have shown that glenoid narrowing as small as 4 mm significantly compromises containment of the humeral head by the glenoid. In addition, if the fragment is excised, the glenohumeral ligaments will not be long enough. I prefer to repair the labrum and ligaments with the shoulder in external rotation. If there is insufficient ligament length, the surgeon is forced to perform the repair with the shoulder internally rotated, which makes it very difficult for the patient to regain adequate external rotation.

Figure 4-69 Abrade the anterior scapular neck.

Anterior Scapular Neck Preparation After labrum and ligament mobilization, the scapular neck is abraded to a depth of 1 mm. The abraded area begins at the level of the glenoid cartilage and extends 2 cm medially on the scapula. It is important not to abrade too deeply and risk compromising the glenoid width and creating the problems discussed earlier. This can be done with the arthroscope in the posterior portal and the bur in the anterior-inferior cannula, or the arthroscope can be moved to the anterior-superior cannula (Figs. 4-69 through 4-71).

Figure 4-70

Anterior view.

Drill Holes Drill holes for the suture anchors are placed through the glenoid articular surface approximately 1 to 2 mm from the lateral glenoid margin. I space the drill hole sites (typically three are used) proportionally along the anterior glenoid. I use the round bur to remove a small area of cartilage and mark the drill hole site. I do so for five reasons: 1. The cartilage in these patients is usually thick, and because the length of the drill is fixed, the greater the amount of cartilage present, the less distance the screw will insert in the bone.

Figure 4-71

Completed abrasion.

Chapter 4


125

2. If the drill hole is made in cartilage, it can be hard to identify. 3. I want to recess the screw as far as possible. 4. I can create a small shelf in the bone to decrease the acuity of the approach angle. 5. I want to maximize the area of labrum-bone contact because the labrum heals more securely to bone than to cartilage. Drill holes are created in the anterior and inferior glenoid with a power drill inserted through the anterior-superior cannula. To reach the most inferior portion of the glenoid, I ask the assistant to distract the humeral head laterally and posteriorly. Distraction is needed at three stages of the operation: placing the drill hole, passing the suture passer through the inferior capsule or labrum, and tying the suture. The assistant provides distraction during these brief times. During the remaining portions of the procedure, the arm rests in the arm holder without any distraction force. The surgeon’s ability to distract the glenohumeral joint is one reason why some surgeons prefer the lateral decubitus position. Continuous traction is not present in the sitting position. I find either approach acceptable and consider patient position a matter of surgeon preference. I place the drill holes through the anterior-superior cannula for two reasons: the angle of approach to the glenoid is easier, and it minimizes the number of times I must transfer sutures from the anterior-inferior to the anterior-superior cannula. The anterior-superior cannula is located slightly more superior and posterior to the anterior-inferior cannula and presents a less tangential approach to the articular glenoid surface. It is also easier to insert the anchors through the same cannula used for the drill because they enter the glenoid at the same angle as the drill. If I place the drill holes (and anchors) through the anterior-inferior cannula, I have to transfer the sutures to the anterior-superior cannula before inserting the suture passer. The suture passer must be inserted through the larger anterior-inferior cannula because the anterior-inferior aspect of the glenoid cannot be reached from the anterior-superior cannula. By avoiding having sutures in this cannula, I eliminate the possibility of the sharp tip of the suture passer cutting one of the sutures.

Figure 4-72

Insert the anchor through the anterior-superior

cannula.

the most inferior glenoid drill hole. The number of suture anchors varies, depending on the size of the labrum detachment, but I typically use three anchors. As Dr. Hammerman inserts each anchor, I distract the humeral head to allow him easier access to the drill hole. The anchor inserter has two vertical lines that mark the eyelet orientation. As he seats the anchor, he checks to see that the vertical lines (and eyelet) are oriented anterior-posterior rather than superior-inferior. This minimizes suture strand twisting and allows the suture to slide freely in the anchor during knot tying (Figs. 4-72 through 4-75).

Anchor Insertion I prefer to insert an anchor, pass the suture and tie it, and then go on to the next anchor rather than inserting all the anchors at one time. This minimizes the number of suture strands within the glenohumeral joint. I place the anchors inferiorly to superiorly. The first suture anchor is inserted through the anterior-superior cannula into

Figure 4-73

Anchor inserted on the glenoid surface.

126

Section Two


Figure 4-76

Advance the labrum onto the glenoid articular

surface.

Figure 4-74

Inserter orientation lines.

Suture Passing The most difficult suture to place is the most inferior, because access to the glenohumeral joint is generally quite limited. Suture passing is less difficult in patients with multidirectional instability because the inferior capsular laxity that accompanies this condition allows the surgeon greater access. The first decision I make is whether to repair only the detached labrum or to incorporate the inferior capsule with the repair to perform capsular imbrication. If capsular imbrication is not necessary and I want to repair the labrum alone, I use the suture passer to pierce the labrum at a point the brings the labrum to its normal anatomic insertion site on the glenoid. The torn labrum is usually displaced medially and inferiorly. Therefore, I must pierce the labrum with the suture passer so

Figure 4-75 Anchor and suture in the glenoid.

that when the knot is tied, the labrum is translated superiorly and laterally. This brings the labrum above the glenoid articular surface so that I can reestablish the labrum as a bumper and restore concavitycompression (Fig. 4-76). I often use the empty suture passer to grasp the labrum at various points and bring it to the glenoid until I am satisfied that the appropriate entry point has been established. Only then do I load the suture passer with the nylon passing suture for the final repair. I prefer to use the angled Smith-Nephew or Spectrum suture passer for this portion of the procedure. I use a right-angled instrument for right shoulders and a left-angled instrument for left shoulders. I normally incorporate some amount of capsule along with the labrum to correct capsular laxity. I find it easier to choose the correct spot in the capsule with the tip of the instrument before inserting the suture passer through the labrum. If the right-angled instrument is used in a left shoulder, the surgeon must pass it from the labrum to the capsule, and once the instrument has pierced the labrum, it is hard to manipulate and find the appropriate area of capsule (Figs. 4-77 and 4-78). The left-angled instrument allows me to pierce the capsule and advance it so that I can clearly see where the tip of the instrument exits the soft tissue near the glenoid. When I advance the nylon passing suture, it then lies on the glenoid, within reach of the crochet hook. Once the nylon suture is in the joint, I distract the humeral head, and Dr. Hammerman inserts a crochet hook through the anterior-superior cannula, retrieves the suture strands, and places a hemostat on the two free ends. The suture instrument is then removed from the anterior-inferior cannula. The loop end now exits from the anterior-inferior cannula, and the two free

Chapter 4

Figure 4-77

Left-angled instrument in the right shoulder.

Figure 4-79


127

Piercing the capsule.

ends exit from the anterior-superior cannula (Figs. 4-79 through 4-83). This description is reversed for a right shoulder.

Loop Reversal Because I have passed the suture in the manner described earlier, if I place an anchor suture in the loop end, it will pass through the labrum in the wrong direction—from anterior to posterior. This loop around the labrum inhibits suture sliding and therefore threatens the security of the knot. I want the anchor suture to pass from the anchor through the labrum from posterior to anterior. Therefore, I use a monofilament suture to reverse the loop. The two free ends of the monofilament suture are placed through the loop of the nylon. By pulling on the two free nylon ends, the loop of monofilament is brought

Figure 4-80

Advance the capsule to the labrum.

Figure 4-81 Puncture the labrum and advance the nylon Figure 4-78

Right-angled instrument in the right shoulder.

suture.

128

Section Two

Figure 4-82


Access to the nylon suture with the crochet hook.

into the anterior-inferior cannula, through the labrum and capsule, and out the anterior-superior cannula. The loop of monofilament suture is now in the same anterior-superior cannula that contains the suture anchor sutures (Fig. 4-84). Obviously, these steps can be avoided by initially passing the suture passer in the opposite direction. However, loop reversal takes about 10 seconds to accomplish, and the advantages of piercing the labrum from anterior to posterior far outweigh the inconvenience of this extra step. Because the SmithNephew instrument can be loaded with the loop end first, the surgeon can eliminate this portion of the procedure by using the AccuPass instrument. An exception to this technique occurs during repair of a shoulder with a large Bankart bone fragment. Because of the size of the bone, the suture cannot be

Figure 4-83

cannula.

Retrieve the suture through the anterior-superior

Figure 4-84

Reverse the loop direction with the Prolene

(blue) suture.

passed from the labrum or capsule toward the glenoid (lateral to medial). In this situation, I use a rightangled suture passer for a left shoulder, place the instrument tip under the bone fragment, and rotate the instrument so that I obtain an adequate amount of soft tissue. No loop reversal is needed.

Bankart Acute Dislocation Passing the Anchor Suture I insert a crochet hook through the anterior-inferior cannula and grab one of the suture anchor limbs. I remove the most posterior anchor suture limb out the anteriorinferior cannula. The anterior suture anchor limb and the monofilament loop are now in the anterior-superior cannula. Dr. Hammerman places 8 cm of the suture

Retrieve the posterior anchor suture strand out the anterior-inferior cannula.

Figure 4-85

Chapter 4

Figure 4-86 Pass the anterior anchor suture strand from the anterior-superior cannula, through the labrum and capsule, to the anterior-inferior cannula.

anchor limb through the loop. He then pulls the hemostat clamped to the two free ends of the monofilament suture in the anterior-inferior cannula and, while I provide humeral head distraction, pulls the suture from the anterior-superior cannula into the joint, through the labrum and capsule, and out the anteriorinferior cannula. He then removes the monofilament suture. Both suture anchor limbs are now out the anterior-inferior cannula, and I tie the knot (Figs. 4-85 and 4-86).

Knot Tying I first apply traction to both suture ends to eliminate any twists in the sutures. I then pass the loop suture grasper into the joint and encircle the suture that does not pass through the labrum. I select this suture because I want the other strand to be the post. This allows me to slide the knots and obtain better knot security. I then place a half-hitch throw and use the knot pusher to push the throw into the joint and bring the labrum to the glenoid. I throw another half hitch in the same direction and push it into the joint. I pull on the post strand while releasing any tension from the other suture anchor strand, slipping the knot and labrum until the labrum is in its desired location and the knot is tied firmly. I then throw a half hitch in the opposite direction and tighten it, reverse the post and tie another half hitch, and reverse the post again and tie another half hitch. This results in a secure knot (Figs. 4-87 and 4-88).

Figure 4-87


129

Retrieve both limbs of the anchor suture.

Superior Labrum Repair SLAP Repair After the inferior and anterior labra are repaired, any tear of the labrum from the superior glenoid bone is identified. The superior glenoid bone is abraded with a power bur, and two suture bone anchors are inserted. The location of the suture anchors varies and depends on the anatomy of the lesion; I typically place one suture anchor one third of the tear length from the posterior margin and a second anchor one third of the tear length from the anterior margin. I prefer nonabsorbable No. 2 braided suture and currently use a plastic tap-in anchor exclusively. The details of this portion of the procedure are described in Chapter 5 (Fig. 4-89).

Figure 4-88

Final repair.

130

Section Two


Figure 4-89

SLAP repair.

Figure 4-91 Spectrum pierces the middle glenohumeral ligament inferior to the tear.

Capsular Repair The better view obtained with arthroscopic inspection (compared to open surgery) has allowed me to become increasingly selective in performing capsular repair. I can identify and repair lesions restricted to only one of the glenohumeral ligaments without tightening the undamaged portions of the capsule. A typical example is a tear of the middle glenohumeral ligament. Once I identify the tear, I use braided, permanent sutures to repair it to the intact labrum. I insert the suture passer through the anterior-inferior cannula, pierce the torn capsule, and puncture the labrum at the site of desired repair. I then advance the suture and use a crochet hook to retrieve it out the anterior-superior cannula. I retrieve the suture limb and tie the strands through the large anteriorinferior cannula. These steps are repeated as needed (Figs. 4-90 through 4-102).

Figure 4-90

Middle glenohumeral ligament tear.

Advance the intact middle glenohumeral ligament superiorly.

Figure 4-92

Figure 4-93 Pierce the capsule.

Chapter 4

Figure 4-94

Figure 4-95

Pierce the labrum.

Advance the nylon suture.


131

Figure 4-97 Remove the Spectrum and withdraw the suture limb out the anterior-inferior cannula.

Figure 4-98

Both suture limbs exit the anterior-inferior

cannula.

Figure 4-96

cannula.

Retrieve the suture limb out the anterior-superior

Test the tension in the repaired middle glenohumeral ligament.

Figure 4-99

132

Section Two


Determining Capsular Tension

Figure 4-100

Tie knots.

I have experimented with various techniques for determining the appropriate amount of capsular tension, including measuring the amount of translation in centimeters and measuring capsular tension with various types of strain gauges, but none has been successful. My current technique is to maximally tighten the capsule while varying the position of the shoulder. As in an open capsular shift procedure, it is possible to selectively tighten different areas of the capsule. I position the shoulder in elevation and internal rotation, grasp the posterior capsule with a forceps, and determine its maximum superior advancement on the glenoid. I then suture it in this position. I tighten the inferior capsule in 0 degrees of abduction and neutral rotation. I tighten the anterior capsule in 45 degrees of abduction and 45 degrees of external rotation. If persistent inferior or inferior-posterior translation remains, I proceed to a rotator interval repair. The repair sequence is to place the rotator interval sutures, test the capsular tension, and tie the rotator interval sutures.

Capsular Tightening

Figure 4-101

Figure 4-102

Repeat as needed.

Final middle glenohumeral ligament repair.

If capsular tightening is necessary, there are two options. One is to repair the labrum to its anatomic location and then use a second suture to advance the capsule to the now repaired labrum. A second option is to repair the labrum and tighten the capsule in one step. There are advantages and disadvantages to each approach. If the surgeon chooses the first option, two suture-passing steps are required. If the surgeon chooses the second option, the decision making is more complex and the amount of tightening possible is more limited. The goal is to advance the capsule superiorly and laterally as well as repair the labrum. Therefore, the surgeon must determine precisely where the suture passer should enter both the capsule and the labrum. Once the suture passer enters the capsule, the surgeon’s ability to maneuver the needle tip and pierce the labrum is limited. It is also difficult to achieve more than 1 cm of capsular tightening with this technique. This may be sufficient for most cases of traumatic unidirectional instability, but more capsular tightening may be necessary for bidirectional and multidirectional instability. I also lightly de´bride the capsule with an arthroscopic rasp because the synovial bleeding aids capsular healing (Figs. 4-103 through 4-105). I modify the repair technique when the labrum is intact but the glenohumeral ligament has been torn from the labrum. If the labrum is of sufficient size to allow suture placement within its substance, the ligament is repaired directly to the labrum with monofilament or braided suture. If the labrum is absent, the

Chapter 4

Figure 4-103

Use a whisker shaver to lightly abrade the

capsule.


133

capsule is advanced onto the glenoid articular cartilage surface and repaired with suture anchors (as described earlier), creating a labrum bumper. If the labrum-ligament complex is attached to the glenoid but the ligament lacks sufficient tension to contain the humeral head, I operate directly on the capsule using the methods described earlier. The goal of this portion of the procedure is to restore ligament and capsule tension and to eliminate excessive humeral head translation. The capsule can be tightened by advancing it radially and suturing it to the labrum, or it can be translated superiorly 1 to 2 cm and then sutured. I load a braided suture into a Smith-Nephew suture passer, insert it through the anterior-inferior cannula, and pierce the capsule at the point where I want to advance to the glenoid. For sutures in the inferior labrum or capsule, the assistant provides distraction to the humerus as I reach down to grab the capsule. After the instrument has pierced the capsule, I advance the tip of the suture passer to the labrum and penetrate it. I advance the monofilament suture into the joint. I maintain distraction while Dr. Hammerman reaches into the joint with a crochet hook and retrieves the suture out the anterior-superior cannula. I then insert the crochet hook through the anterior-inferior cannula and retrieve the other suture limb. The monofilament suture is used to feed a braided suture into the glenohumeral joint. I then tie the knot. These steps are repeated as necessary. I examine the shoulder for translation, and if I have established adequate tension, the operation is concluded.

Capsular Shift Figure 4-104

Use a rasp to lightly abrade the capsule.

Bankart Capsular Shift

Multidirectional Instability

Figure 4-105

Use a rasp to lightly abrade the capsule.

In patients with multidirectional or bidirectional instability, the capsule may not tighten adequately with simple advancement or 1 to 2 cm of superior translation. If further capsular movement is necessary, I perform a capsular shift. To shift the anterior capsule superiorly, I divide the attachment of the middle glenohumeral ligament to the subscapularis. I use scissors to incise along the superior border of the middle glenohumeral ligament from a point overlying the subscapularis to the glenoid. I then use a blunt dissector to separate these two structures. I divide the capsular attachment to the glenoid with scissors, starting anteriorly and continuing until I reach the 6-o’clock position. I then incise

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the capsule radially approximately 2 cm. I use the blunt dissector to free the anterior and inferior capsule from the underlying subscapularis muscle. The capsule is now mobilized sufficiently to allow significant advancement superiorly and is sutured as described earlier. If a posterior capsular shift is necessary, I transfer the arthroscope to the anterior-superior cannula and divide the posterior capsule from the glenoid.

Rotator Interval Repair Interval Repair Rotator interval repair is the last step performed within the glenohumeral joint, because cannulas cannot be inserted anteriorly once this repair is completed. A suture passer through the anterior-inferior cannula is used to place a monofilament suture through the capsule superior to the subscapularis tendon. I advance the suture into the joint and withdraw it through the anterior-superior cannula. I then load a doubled 2-0 nylon suture into the suture passer, insert it through the anterior-superior cannula, and position it in the joint. I withdraw the anterior-superior cannula until it is external to the capsule. I then withdraw the suture passer external to the capsule and pierce the superior capsule. I advance this suture into the joint and withdraw the two free ends out the anterior-inferior cannula. The monofilament suture through the anterior-superior cannula is placed in the nylon loop. Traction on the two free ends of the nylon (exiting the anterior-inferior cannula) draws the suture through the superior capsule and out the anterior-inferior cannula. The knot is then tied, and an additional suture is placed if necessary. If a greater degree of tightening is required, the superior capsular tissue is sutured to the middle glenohumeral ligament (Figs. 4-106 through 4-114).

Pierce the middle glenohumeral ligament with a suture passer.

Figure 4-106

Figure 4-107

Advance the monofilament suture.

Figure 4-108 Insert a crochet hook through the anteriorsuperior cannula.

Figure 4-109

cannula.

Retrieve the suture out the anterior-superior

Chapter 4

Figure 4-110


135

Puncture the superior glenohumeral ligament.

Figure 4-111 Advance the nylon suture and withdraw it out the anterior-inferior cannula.

Figure 4-113

Test the capsular tension.

Figure 4-114

Completed interval repair.

Rotator Cuff Lesions

Figure 4-112

Test the tension of the repair.

Overhead throwing athletes may have rotator cuff lesions that range from minor fraying to full-thickness tears. When these tears are partial-thickness grade 3 or full thickness, I repair them after I complete the glenohumeral joint reconstruction. I mark the area of the tear with a spinal needle or monofilament suture and reinsert the arthroscope into the subacromial space. Anterior lesions are usually small tears and are easily repaired. Posterior lesions are repaired with the arthroscope in the lateral portal, and instruments are passed through the anterior and posterior portals.

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Posterior Bankart with Posterior Rotator Cuff Repair

POSTOPERATIVE MANAGEMENT Postoperative management is similar for all patients. A soft pillow sling supports the arm in 15 degrees of abduction. If the primary direction of instability repair is anterior, I position the elbow anterior to the coronal plane of the shoulder with the arm internally rotated. If the primary direction is posterior, I position the elbow posterior to the coronal plane with the arm in 10 degrees of external rotation. I place the elbow of a patient with multidirectional instability in neutral rotation and 25 degrees of abduction. An ice-pack wrap decreases postoperative shoulder swelling and pain. I administer 1 g cephalosporin 8 hours postoperatively. Patients may choose to go home the afternoon of surgery or the next morning. Active range-of-motion exercises of the fingers, wrist, and elbow, as well as deltoid muscle isometric exercises, are started the morning after the operation and continued at home for 2 weeks. At 2 weeks, I obtain an anteroposterior radiograph to document the position of the humeral head. Patients are allowed to remove the sling for active elevation and external rotation exercises twice daily but wear the sling at all other times. If the patient had an anterior repair, I allow active elevation as tolerated. I instruct patients to limit external rotation to 20 degrees at week 2, 40 degrees at week 4, and 60 degrees at week 6. If the patient had a posterior repair (either as the only operation or along with an anterior or inferior repair), I restrict active elevation to

Table 4-1

90 degrees and internal rotation to neutral but allow unlimited external rotation. If the patient had a multidirectional instability operation, I instruct him or her to limit shoulder motion as much as possible. Generally, these patients have some degree of ligament laxity, and achieving full range of motion is not a problem. The sling is worn for 6 weeks, after which it is removed and the patient begins active range-of-motion (without restrictions), strengthening, and neuromuscular exercises. Patients continue rangeof-motion and strengthening exercises for 1 year.

RESULTS Operative Repair The lesions repaired at operation are variable, and most patients have more than one. My experience is summarized in Tables 4-1 through 4-3. These early reports are consistent with my findings in my last 1000 operations. The average number of bone or soft tissue anchors used is 2.4 (range, 0 to 5).

Postoperative Scores and Shoulder Rating Systems Shoulder rating systems reflected an improvement in shoulder status (see Table 4-3). Comparing the scores before surgery to those at final follow-up, paired t-tests revealed significant increases in total and subscale scores for the ASES, Constant, Rowe, and UCLA shoulder scores (P = .0001). Neither the Constant nor the ASES system provides guidelines that allow the

PREOPERATIVE PHYSICAL EXAMINATION FINDINGS: BIDIRECTIONAL

Abd/ER (IA)

0+

1+

2+

6

26

4

3+

Pain

0

31

Apprehension

14

Abd/ER (IP)

2

12

2

0

14

7

Abd/Down (IA)

3

19

14

0

25

12

Abd/Down (IP)

0

7

9

0

9

6

Sulcus (IA)

0

13

23

0

36

23

Suclus (IP)

0

9

7

0

16

9

Rowe (IA)

2

10

24

0

32

22

Rowe (IP)

0

8

8

0

16

10

24 6

11 6

1 1

0 3

2 4

0 4

Posterior (IA) Posterior (IP)

Abd/Down, abduction and downward force; Abd/ER, abduction and external rotation; IA, inferior-anterior; IP, inferior-posterior.

Chapter 4


137

Table 4-2 OPERATIVE FINDINGS BIDIRECTIONAL (n = 33) UNIDIRECTIONAL (n = 53)

Inferior-Anterior

31

16

7

10

48

9

0

10

Inferior-Posterior

MULTIDIRECTIONAL (n = 47)

Labrum repair Superior Anterior Type A

25

Type B

15

Type C

8

Inferior

2

2

0

2

Posterior

0

0

2

6

Anterior

46

25

5

47

Middle

41

33

11

47

Inferior

31

19

7

47

Posterior

0

0

9

47

Ligament suture imbrication

Thermal tightening Anterior

48

7

1

Middle

5

5

2

Inferior

11

17

9

Posterior Rotator interval repair

0

0

7

14

22

14

28

Table 4-3 FINAL RESULTS* ASES

Pre

CONSTANT

ROWE

UCLA

Post

Pre

Post

Pre

Post

Pre

Post

Unidirectional Instability Score

45.5

91.7

56.4

91.8

11.3

91.9

17.6

32.0

SD

18.6

13.7

13.3

11.3

5.7

20.8

4.8

4.7

Bidirectional Instability Score

45.5

94.0

57.0

92.4

20.3

92.1

18.6

32.7

SD

16.2

9.3

12.9

10.4

13.3

19.5

4.4

3.7

94.7 9.3

60 11.5

91.7 8.5

14.2 13

93.7 13.2

17.4 4.5

33.1 2.9

Multidirectional Instability Score SD

45.4 18.8

*All postoperative scores significant: P = .0001. ASES, American Shoulder and Elbow Surgeons Shoulder Index; Post, postoperative; Pre, preoperative; SD, standard deviation; UCLA, University of California at Los Angeles.

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surgeon to determine which scores reflect excellent or poor results. Ellman categorized UCLA shoulder scores of 29 to 35 as equivalent to good to excellent results and those less than 29 as fair to poor. In Rowe’s system, scores of 90 to 100 are excellent and 75 to 89 are good. In my experience with all three types of glenohumeral instability (traumatic unidirectional anterior, bidirectional, and multidirectional), about 90% of shoulders have achieved good to excellent results according to both the Rowe and UCLA scores. The details of these results are summarized in the following sections.

Range of Motion No patient lost more than 5 degrees of forward elevation. External rotation at 90 degrees of abduction averaged 88 degrees, compared with 83 degrees preoperatively. The gain in movement reflects the preoperative loss of external rotation that is typical in patients with traumatic anterior instability caused by medial healing of the Bankart lesion (ALPSA). Patients without ALPSA lesions have a similar loss of external rotation because they tend to limit that motion to avoid pain or instability.

Return to Sports Participation Among my patients with unidirectional traumatic anterior glenohumeral instability, 43 participated actively in sports before the onset of their shoulder problems: 0 patients participated in type 1, 5 in type 2, 30 in type 3, and 8 in type 4 sports. When stratified by level of participation, 7 patients participated at level 1 (high school team sports), 1 at level 2 (college team sports), and 35 at level 3 (recreational athletes). At final follow-up evaluation, 5 patients did not participate in sports owing to issues unrelated to their shoulders. The reasons most commonly cited were work or family commitments, graduation from high school or college (and the associated lack of team sports), and injuries to the knee or lumbar spine. The remaining 38 patients participated in sports: 1 in type 1, 6 in type 2, 26 in type 3, and 5 in type 4. The level of participation at final follow-up was 3 at level 1, 0 at level at 2, and 35 at level 3. Four patients with persistent shoulder instability had decreased their level of participation at final follow-up.

Ligament Laxity The final Rowe score was stratified according to the presence or absence of generalized ligament laxity. Patients without evidence of ligament laxity (n = 47)

had a final mean Rowe score of 94, and those with ligament laxity (n = 6) had a final score of 74. The difference was statistically significant (P = .02). The poorer results in patients with generalized ligament laxity may stem from technically inadequate repairs, or they may suggest that patients with anteriorinferior instability and generalized ligament laxity require an open capsular reconstruction to achieve adequate soft tissue tension.

Complications No major intraoperative or perioperative complications (permanent nerve injuries, wound infections) occurred. Two patients noted paresthesias in the musculocutaneous nerve distribution. All had resolved by the 6-week postoperative visit. One patient noted minor wound drainage that resolved within 1 week without the use of antibiotics. I did not observe any complications from suture anchors.

LATARJET As noted earlier, in some cases I have found the results of soft tissue reconstruction of the glenohumeral joint ligaments unsatisfactory. There are four situations in which no combination of labrum repair and capsular tensioning is successful: 1. 2. 3. 4.

Anterior-inferior glenoid bone loss Poor-quality ligaments Suboptimal patient compliance Extreme sports participation

An demonstrated in a cadaver experiment that anterior glenoid defects greater than 4 mm result in glenoid insufficiency that the surgeon cannot correct with soft tissue repair. I use 4 mm only as a guideline because An’s laboratory experiment did not take into account the variability of capsular advancement that can be achieved in a particular patient. I have found threedimensional computed tomography reconstruction or the Bernejeau view to be helpful radiographic aids; however, I rely more on my inspection of the glenoid shape at the time of arthroscopic examination. After I inspect the glenohumeral joint with the arthroscope in the posterior portal, I create an anterior portal and move the arthroscope there. This allows me to look down the anterior glenoid and observe the presence or absence of the normal pear shape. If I am unsure whether there is bone loss anteriorly, I insert a probe through the posterior cannula and note the distance from the glenoid bare spot to the anterior and posterior glenoid (Figs. 4-115 through 4-118).

Chapter 4

Figure 4-117 RT should

Figure 4-115

Magnetic resonance image shows anterior

bone loss.

Poor ligament quality may be due to prior surgery or multiple dislocations. The surgeon gains some information about ligament quality as the ligaments are palpated and maneuvered with surgical instruments. However, the assessment of ligament quality is subjective and therefore imprecise. The literature contains multiple articles listing poor-quality ligaments as an indication for open surgery, but usually this involves some type of ligament repair. I do not

Figure 4-116

Insufficient bone to contain the glenoid.


139

Absent anterior capsule and glenohumeral

ligaments.

understand why surgeons who decide that the glenohumeral joint ligaments are insufficient for arthroscopic repair would proceed to do an open ligament repair. I am not aware of any experimental evidence that exposing inadequate glenohumeral ligaments to air or light causes these deficient ligaments to improve. It is my opinion that if the ligaments are inadequate, the surgeon must find some other operative method. Patient compliance with any postoperative regimen is variable, but in my experience, young patients with an active lifestyle may disregard some or all postoperative instructions and restrictions. Only a flawless preoperative character analysis and a prescient understanding of perioperative behavior would eliminate this as an issue. When I have doubts about the patient’s maturity, I sleep better knowing that my repair is held with two large bone screws rather than five No. 1 sutures. Certain sports or activities are so demanding that participation requires not a normal shoulder but a ‘‘better than normal’’ shoulder. The demands of

Figure 4-118

Insufficient bone to contain the glenoid.

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rock climbing, competitive kayaking, and weight lifting are so great that few patients return to these activities after conventional surgical repair (open or arthroscopic). I tell patients that a soft tissue repair is sufficient to allow them a return to almost all highdemand activities, but certain activities require a different approach. Failed prior surgery (open or arthroscopic) is the most common indication for the Latarjet procedure. I have successfully treated such patients with the Latarjet procedure as published and taught to me by Gilles Walch. More recently, I have successfully treated these patients with an arthroscopic Latarjet procedure as described and taught to me by Laurent Lafosse from Annecy, France (as of this writing, he has yet to publish his results). He is the pioneer in the arthroscopic approach, and I am grateful for the time he spent teaching me his techniques. Interestingly, the evolution of the Latarjet from an open to an arthroscopic procedure, its reception in the orthopedic community, and my transition from open to all-arthroscopic repair (described later) are eerily reminiscent of my experiences with arthroscopic subacromial decompression, arthroscopic distal clavicle resection, arthroscopic glenohumeral reconstruction, and arthroscopic rotator cuff repair. The Latarjet procedure involves placing the coracoid and the attached muscles through a longitudinal split in the subscapularis muscles and fixing it to the anterior-inferior glenoid with two screws. This accomplishes several objectives: the glenoid is enlarged, the potential space for the humeral head to move anterior and inferior to the glenoid is eliminated, and the coracoid prevents a portion of the subscapularis from moving superiorly as the shoulder is moved into a position of abduction and external rotation. The inferior surface of the coracoid matches the anterior-inferior scapular neck quite nicely. The coracoid is good-quality bone, and its fixation to the scapular neck is very secure. Because of this secure fixation, patients can discontinue the sling after 1 week for most activities of daily living. The coracoacromial ligament remains attached to the coracoid and is used to reinforce the anterior capsule. Several publications have documented excellent clinical results (Figs. 4-119 through 4-122). The Latarjet has a long and well-documented history of success, and experienced shoulder surgeons such as Gilles Walch and Christian Gerber use it almost exclusively to treat traumatic anteriorinferior glenohumeral instability. However, I am not certain why the operation is effective. Even the most perfect placement of the coracoid cannot create a

Coracoacromial ligament

Graft Glenoid bone loss

Screws Graft

Figure 4-119

Latarjet procedure.

surface that approaches the graceful concavity of the native glenoid. Is the inferior position of the lower subscapularis a dynamic or static block to anterior translation when the arm is abducted and externally rotated? What is the role of the transferred conjoined tendon? Braly and Tullos attempted to answer some of these questions in their classic article. It is obvious that the Latarjet controls glenohumeral joint instability by a different mechanism from those procedures that repair the labrum and capsule. Both operations are effective yet seem to approach the problem from diametrically opposite directions.

Figure 4-120

Radiograph of the Latarjet open technique.

Chapter 4

Figure 4-121

Radiograph of the Latarjet arthroscopic

technique.

Can both approaches be right? A similar (but more complex) problem was faced by physicists at the dawn of the 20th century when they tried to reconcile the behavior of light. In some experiments, light behaved as a wave; in others, it clearly acted as a particle—photons of energy. The great Danish physicist Niels Bohr reflected on this issue and concluded, ‘‘The opposite of a correct statement is a false statement. But the opposite of a profound truth may well be another profound truth.’’

Figure 4-122

technique.

Radiograph of the Latarjet arthroscopic


141

My current thinking on this issue is that labrum and capsule repairs control glenohumeral joint instability by altering the static restraints to humeral head motion, whereas the Latarjet and Bristow procedures alter the dynamic factors. We know that both mechanisms are involved. For example, consider a patient with asymptomatic glenohumeral joint laxity. He is active in sports, and the stabilizing muscles are strong. When this patient enters law school, the demands of study cut into his exercise routine, and his muscles lose tone. When this individual attempts to get back in condition and begins a weight-lifting program, the shoulders sublux, and he presents to the orthopedic surgeon complaining of pain. The solution to this patient’s dilemma is not surgery but simply a strengthening program for the rotator cuff and the scapular stabilizing muscles. Now consider a second law school student who has no laxity and sustains a traumatic dislocation during a rugby match. Emergency room reduction is necessary. Owing to continued dislocations, this patient undergoes surgery during which a Bankart lesion is found and corrected. Both patients had glenohumeral joint instability, but one cause was dynamic and the other was loss of the static stabilizers. Although these polar opposites present clear choices, I am uncertain where the vast majority of patients fall. Perhaps both mechanisms exist in all patients, but the relative contributions of the dynamic and static stabilizers vary from one individual to another. Perhaps our surgical corrections should reflect that. Although there are some conditions for which a Latarjet-type procedure is definitely indicated (as outlined earlier), there are other situations (e.g., multidirectional, bidirectional, posterior instability) in which the more global correction afforded by arthroscopic soft tissue repair and balancing is required. At present, the orthopedic surgeon can correct most forms of anterior-inferior glenohumeral joint instability with either approach and achieve a successful result. There are a number of issues that deserve discussion regarding an arthroscopic approach: What are the potential advantages? Is it technically possible to reproduce the appropriate steps? What are the potential risks? How difficult is the technique? The criticism of the arthroscopic Latarjet is familiar to those of us who witnessed the transition from open subacromial decompression and rotator cuff repair to arthroscopic techniques. The criticism has a predictable pattern. Leading orthopedic surgeons on editorial boards and lecture panels inevitably proclaim that the

142

Section Two


developer of an arthroscopic technique cannot do the following: 1. 2. 3. 4. 5. 6.

Insert the arthroscope into the appropriate area. Visualize the relevant structures. Insert instruments to repair the lesions. Repair the lesions adequately. Perform the operation within a reasonable time. Achieve results equivalent to those of the open procedure. 7. Improve on the results of the open procedure. 8. Teach others to perform the operation. When Lafosse first presented his technique for arthroscopic Latarjet, all these criticisms were voiced, as they were in 1983 (arthroscopic subacromial decompression), 1985 (arthroscopic distal clavicle resection), 1987 (arthroscopic glenohumeral reconstruction), 1992 (arthroscopic rotator cuff repair), and 1995 (arthroscopic treatment of irreparable rotator cuff tears). The first question to answer was, why perform the operation arthroscopically? Although the results of the open Latarjet are excellent, they are not perfect. Perhaps an arthroscopic technique could improve the results owing to increased technical precision or treatment of lesions unrecognized during open repair (e.g., posterior ligament tears, SLAP lesions). I knew it was possible to insert the arthroscope and instruments into the subdeltoid space and visualize quite clearly the coracoid, conjoined tendon, and anterior subscapularis. The next step in the transition from open to arthroscopic repair involved detailing the individual steps performed during an open Latarjet: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Anterior skin incision Exposure of the deltopectoral groove Lateral retraction of the cephalic vein Separation of the deltoid from the pectoralis major Identification of the coracoid Identification of the coracoacromial ligament Division of the clavipectoral fascia along the lateral border of the conjoined tendon Release of the coracoacromial ligament from the acromion Release of the pectoralis minor from the medial coracoid Coracoid osteotomy Coracoid decortication Drilling of holes in the coracoid Subscapularis split Capsulotomy Preparation of the anterior scapula

16. Passage of the coracoid through the subscapularis split 17. Precise coracoid placement on the anterior scapula 18. Secure fixation with screws 19. Capsular repair with the coracoacromial ligament 20. Skin closure The next phase was to determine which of the steps was necessary and which could be performed with the arthroscopic technique. Steps 1 to 4 are not needed because the cannula passes directly into the requisite areas, and step 20 is self-evident. I reviewed videos of the surgical technique with Lafosse and saw that he could do all the necessary steps. My experience with other arthroscopic operations convinced me that I already knew how to perform steps 5 to 8, 11, and 15. I performed steps 9, 10, 12 to 14, and 16 to 19 in the cadaver laboratory. I had stopped repairing the capsule and coracoacromial ligament during my open Latarjet procedures and saw no need to perform it arthroscopically. At this point, I was convinced that I could perform an arthroscopic Latarjet. I then began to perform portions of the arthroscopic repair. I arthroscopically examined all patients who were to undergo an open Latarjet. I set a 1-hour time limit and performed different parts of the arthroscopic procedure: 1. Scapular neck preparation. I had already developed skill at anterior scapular neck preparation during my experience with arthroscopic glenohumeral joint stabilization. 2. Release of the rotator interval. Release of the rotator interval is commonly performed in the treatment of shoulder stiffness. I accomplish this with an electrocautery device and a power shaver. 3. Identification of the coracoid. I had performed a few coracoid osteotomies for coracoid impingement, so I was somewhat familiar with the method of coracoid exposure through the rotator interval. During operations for repair of the subscapularis, I routinely visualize the coracoid, so I was familiar with the view with the arthroscope placed in the lateral portal. 4. Release of the coracoacromial ligament. I typically visualize the coracoacromial ligament through the rotator interval during a contracture release to ensure that I resect all interval tissue. I did not find it difficult to follow the ligament laterally and release it from the acromion.

Chapter 4

5. Coracoid decortication. With the arthroscope in the posterior portal and a shaver inserted anteriorly, the coracoid can be identified by palpating it with the shaver. Soft tissue can be removed from the superior and lateral surfaces. I use electrocautery alone or a power shaver equipped with electrocautery. Once the lateral surface is clean, I begin to clean the inferior surface. I then use a power bur to remove a small thickness of cortical bone from the inferior surface. These first five steps were all accomplished with the arthroscope inserted through standard portals, the posterior glenohumeral joint, and the lateral subacromial locations. The next steps required that I learn and master the use of various anterior portals: 6. Division of the clavipectoral fascia. I move the arthroscope to an anterior-lateral portal, immediately lateral to the coracoid. This portal is in line with the anterior acromion and 3 to 5 cm lateral to the lateral acromion. The coracoid can be seen medially, and I orient myself to the location of the glenohumeral joint posteriorly, the subscapularis inferiorly, the pectoralis minor medially, and the lateral border of the conjoined tendon and clavipectoral fascia laterally. I use the previously created anterior portal and introduce an electrocautery instrument to divide the clavipectoral fascia immediately lateral to the border of the conjoined tendon. The area is well seen, and division is not difficult. 7. Release of the pectoralis minor. I advance the arthroscope deeper (more medially) until I see the pectoralis minor tendon. I insert a spinal needle percutaneously, immediately anterior to the midcoracoid, and make a small incision. Through this incision I insert the metal trocar and use it as a soft tissue dissector. The superior portion of the tendon (and the brachial plexus) is easily seen. The distal portion of the pectoralis minor tendon is harder to identify. I then remove the trocar, introduce the electrocautery, and begin releasing the pectoralis minor tendon from the medial coracoid. I continue distally until the tendon is released. 8. Drilling of holes in the coracoid. Up to this point, I have used conventional arthroscopic instruments, but some specialized instruments are now necessary. I insert a special drilling guide through the anterior coracoid incision and place it against the anterior coracoid. If the distal coracoid tip is not evident, I insert a spinal


143

needle to mark its location. The drill guide must be positioned midway between the medial and lateral cortical borders. The proximal-distal position is determined by allowing sufficient coracoid bone distal to the distal screw hole so the screw will not cut out. The two drill holes are then made. 9. Coracoid osteotomy. I insert a 1=4-inch osteotome through the anterior incision and perform the osteotomy under direct vision. Once the coracoid is free, I insert a suture through the drill holes and leave the suture coming out through the anterior coracoid portal. 10. Subscapularis split. To help locate the correct site of the split (from superior to anterior), I pass a long switching stick into the glenohumeral joint from anterior to posterior. With the arthroscope in the anterolateral portal, I can see into the joint through the rotator interval and determine the location of the anteriorinferior glenoid. I advance the rod past this and into the subscapularis. I look anterior to the subscapularis and insert a retractor to move the coracoid (and neurovascular structures) medially. I continue to advance the rod through the subscapularis muscle. I insert electrocautery through the anterior coracoid portal and divide the subscapularis muscle medially and the tendon more laterally. When entering the joint laterally, there is a danger of scoring the humeral head; to minimize the chance of this occurring, I use the rod to push the capsule anteriorly and develop a little space between the capsule and the articular cartilage. 11. Passage of the coracoid through the subscapularis. Once I have created sufficient space for the coracoid, I advance the rod anteriorly until the rod tip tents the skin. The rod passes through the deltoid muscle. I incise the skin and advance the rod. The next step also involves a specialized tool. I insert a grasper through the inferior anterior-medial portal, grasp the sutures transfixing the coracoid, and bring them out this portal. The sutures are placed through the double-barrel inserter, and the coracoid is positioned against the end of the device. Temporary fixation screws secure the coracoid to this device. 12. Coracoid placement. With the inserter device and its attached coracoid, I find the transfixation rod and withdraw it posteriorly as I advance the coracoid through the subscapularis and into the glenohumeral joint.

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Section Two


13. Coracoid fixation. At this point, I have an excellent view of the anterior glenoid. The coracoid is positioned at the site of the glenoid defect. I make sure the coracoid does not project laterally into the glenohumeral joint and contact the humeral head. I replace the temporary screws with longer permanent fixation screws. I then remove the inserter and inspect the completed repair. 14. I make no attempt to repair the subscapularis, because such tightening would restrict internal and external rotation. 15. The instruments are removed, and the small skin incisions are closed with subcuticular absorbable sutures. I place the patient in a shoulder immobilizer that can be removed for bathing, dressing, and pendulum exercises. At the 1-week visit, I remove the sling and allow the patient to use the arm for all routine activities of daily living. I obtain an anteroposterior radiograph. At the 6-week visit, I obtain a Bernejeau view to evaluate the position of the coracoid. I encourage active shoulder stretching and begin a home strengthening program. Once bone healing is seen on the Bernejeau or axillary view, I allow unrestricted activity.

DISCUSSION The wide variety of treated lesions, patient populations, operative techniques, length of follow-up, and scoring systems can complicate comparisons of results of arthroscopic and open operations. However, improvements in various parameters described in multiple investigations allow me to conclude that arthroscopic repair of glenohumeral instability using the techniques I have described can produce outcomes that are better than those achieved with prior arthroscopic treatments and equivalent to those of open repair. The spectrum of operative findings does not support the concept of any ‘‘essential lesion.’’ On the contrary, it appears that the cause of glenohumeral instability is multifactorial, and successful treatment requires that any operative approach be sufficiently flexible to deal with the variety of lesions found. The arthroscopic approach allows the surgeon to identify and treat all the lesions of shoulder instability. I believe that the success of arthroscopic treatment is based on our ability to perform an anatomic repair of anterior, superior, and inferior labrum tears; correct capsular elongation; and, if necessary, repair the rotator interval.

My goal is to repair the patient’s shoulder by whatever technique will be most effective. At present, my operative treatment of glenohumeral instability is arthroscopic. With the arthroscopic technique, I inspect the entire glenohumeral joint and avoid soft tissue dissection. No division of the subscapularis is required. Although I have no statistical evidence, my impression is that arthroscopic repair provides improved cosmesis, decreased postoperative pain, and more rapid gains in motion compared with open operative treatment of similar lesions. These techniques should be used only by an experienced orthopedic surgeon familiar with the normal and abnormal anatomy seen during both open and arthroscopic shoulder operations. A thorough understanding of the various conditions that produce shoulder pain is needed. An orthopedic surgeon who infrequently performs open glenohumeral instability repair should not attempt the arthroscopic procedure.

BIBLIOGRAPHY Abrams JS: Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions. Orthop Clin North Am 34:475-483, 2003 Ahmad CS, Wang VM, Sugalski MT, et al: Biomechanics of shoulder capsulorrhaphy procedures. J Shoulder Elbow Surg 14(1 Suppl):12S-18S, 2005 Allain J, Goutalliler D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 80:841-852, 1998 Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 18:25-28, 1990 Bigliani LU, Kurziil PR, Schwartzbach CC, et al: Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 22:578-584, 1994 Bigliani LU, Pollock RG, Soslowsky LJ, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 10:187-197, 1992 Blasier RB, Soslowsky LJ, Palmer ML: Posterior glenohumeral subluxation: Active and passive stabilization in a biomechanical model. J Bone Joint Surg Am 79:433-440, 1997 Boileau P, Villalba M, He´ry JY, et al: Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 88:1755-1763, 2006 Braly WG, Tullos HS: A modification of the Bristow procedure for recurrent anterior shoulder dislocation and subluxation. Am J Sports Med 13:81-86, 1985 Burkhart SS, De Beer JF, Barth JR, et al: Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 23:1033-1041, 2007

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Burkhart SS, Morgan CD: The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 14:637-640, 1998 Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 74:890-896, 1992 Caspari R, Savoie F: Arthroscopic reconstruction of the shoulder: The Bankart repair. In McGinty J (ed): Operative Arthroscopy, New York, Raven, 1991 DePalma A: Recurrent dislocation of the shoulder joint. Ann Surg 132:1052-1065, 1950 Ellman H, Gartsman GM: Arthroscopic Shoulder Surgery and Related Procedures, Philadelphia, Lea & Febiger, 1993 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of anterior-inferior glenohumeral instability: Two to five-year follow-up. J Bone Joint Surg Am 8:991-1003, 2000 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of bi-directional glenohumeral instability: Two- to five-year follow-up. J Shoulder Elbow Surg 10:28-36, 2001 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of multidirectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy 17:236-243, 2001 Gartsman GM, Taverna E, Hammerman SM: Arthroscopic rotator interval repair in glenohumeral instability: Description of an operative technique. Arthroscopy 15:330-332, 1999 Gartsman GM, Taverna E, Hammerman SM: Arthroscopic treatment of acute traumatic anterior glenohumeral dislocation and greater tuberosity fracture. Arthroscopy 15:648-650, 1999 Gross RM: Open and Arthroscopic Glenohumeral Instability Repairs, New Orleans, American Academy of Orthopaedic Surgeons, 1998 Habermeyer P, Gleyze P, Rickert M: Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 8:66-74, 1999 Harryman DT, Sidles JA, Harris SL, Matsen FA: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 74:53-66, 1992 Hayashi K, Thabit G, Bogdanske JJ, et al: The effect of nonablative thermal probe energy on the ultrastructure of joint capsular collagen. Arthroscopy 12:474-481, 1996 Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am 82:35-46, 2000 Kartus C, Kartus J, Matis N, et al: Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks: A clinical and radiographic study with a seven to ten-year follow-up. J Bone Joint Surg Am 89:1442-1448, 2007 Kohn D: The clinical relevance of glenoid labrum lesions. Arthroscopy 3:223-230, 1987


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Lafosse L, Lejeune E, Bouchard A, et al: The arthroscopic Laterjet procedure for the treatment of anterior shoulder instability. Arthroscopy 23:1242el-5, 2007 Lippitt SB, Vanderhooft JE, Harris SL, et al: Glenohumeral stability from concavity-compression: A quantitative analysis. J Shoulder Elbow Surg 2:27-35, 1993 Lopez MJ, Hayashi K, Fanton GS, et al: The effect of radiofrequency energy on the ultrastructure of joint capsular collagen. Arthroscopy 14:495-501, 1996 McIntyre LF, Caspari RB, Savoie FH: The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 13:418-425, 1997 McIntyre LF, Caspari RB, Savoie FH: The arthroscopic treatment of posterior shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 13:426-432, 1997 McMahon PJ, Tibone JE: The anterior bond of the inferior glenohumeral ligament: biomechanical properties from tensile testing in the position of apprehension. J Shoulder Elbow Surg 7:467-471, 1998 Mologne TS, Provencher MT, Menzel KA, et al: Arthroscopic stabilization in patients with an inverted pear glenoid: Results in patients with bone loss of the anterior glenoid. Am J Sports Med 35:1276-1283, 2007 Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3:111-122, 1987 Morrey BF, Janes JM: Recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 58:252-256, 1976 Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am 62:897-908, 1980 Neviaser TJ: The anterior labroligament periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 9:17-21, 1993 Nottage WM: Thermal probe-assisted shoulder surgery. Arthroscopy 13:635-638, 1997 Pappas AM, Goss TP, Kleinman PK: Symptomatic shoulder instability due to lesions of the glenoid labrum. Am J Sports Med 11:279-288, 1983 Rhee YG, Ha JH, Cho NS: Anterior shoulder stabilization in collision athletes: Arthroscopic versus open Bankart repair. Am J Sports Med 34:979-985, 2006 Richards RR, An K-N, Bigliani LU, et al: A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 3:347-352, 1994 Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 22:121-130, 1994 Rowe CR, Zarins B: The Bankart procedure: Long-term endresult study. J Bone Joint Surg Am 60:1-16, 1978 Rowe CR, Zarins B: Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am 63:863-872, 1981 Savoie FH, Miller CD, Field LD: Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 13:201-209, 1997

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Speer K, Deng X, Borrero S, et al: Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 78:1819-1825, 1994 Ticker JB, Bigliani LU, Soslowsky LJ, et al: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 5:269-279, 1996 Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 4:352-364, 1995 Williams MM, Snyder SJ, Buford D Jr: The Buford complex— the ‘‘cord-like’’ middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 10:241-247, 1994 Wirth MA, Groh GI, Rockwood CA Jr: Capsulorrhaphy through an anterior approach for the treatment of

atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am 80:1570-1578, 1998 Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 11:600-607, 1995 Wolf EM, Eakins CL: Arthroscopic plication for posterior shoulder instability. Arthroscopy 14:153-163, 1998 Wolf EM, Wilk RM, Richmond JC: Arthroscopic Bankart repair using suture anchors. Oper Tech Orthop A: 184-191, 1991 Zuckerman JD, Matsen FA: Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am 66:175-180, 1984

CHAPTER

5

Biceps Tendon Lesions

The biceps tendon represents a transition from the glenohumeral joint to the subacromial space. Biceps lesions occurring at the glenoid attachment are intimately involved in the treatment of glenohumeral instability, and biceps abnormalities in the region of the bicipital groove (subluxation and synovitis) are part of subacromial impingement. I often perform biceps tenodesis as part of the treatment for a rotator cuff tear. Biceps tenotomy is one option for the treatment of irreparable rotator cuff tears. There are seven basic mechanisms by which biceps lesions cause shoulder dysfunction proximally at the biceps-labrum complex: 1. Mechanical abnormalities such as labrum flap tears 2. Labrum pathology resulting in glenohumeral joint instability (e.g., loss of concavity-compression and the attachment site for the glenohumeral ligaments) 3. Part of the pathophysiology of cyst development 4. Lesions within the tendon substance, which may be painful due to intrinsic biceps tendinitis or a partial tear; with more extensive damage, an enlarged tendon may cause pain due to biceps entrapment 5. Entrapment with arm elevation—the hourglass biceps, as described by Boileau 6. Biceps tendon dislocation or subluxation; even a normal biceps tendon may become part of a pathologic process, such as that seen with rotator cuff and subscapularis tears 7. Biceps adhesions accompanying a proximal humerus fracture or after glenohumeral arthroplasty

PROXIMAL BICEPS LESIONS Superior labrum from anterior to posterior (SLAP) lesions offer an interesting and complex challenge to shoulder surgeons. Patients with SLAP lesions present with a wide spectrum of clinical complaints; the findings on physical examination differ, the clinical findings are nonspecific, and radiographic diagnosis is imprecise. Even at operation the findings are variable, and the decision whether to repair a SLAP lesion requires a thorough understanding of the patient’s clinical condition and shoulder pathophysiology.

Anatomy The anterior, inferior, and posterior labrum is firmly attached to the glenoid, and separation of any of these areas from the glenoid is pathologic. An exception to this is the normal sublabral hole that exists near the anterior-superior glenoid (Fig. 5-1). The superior labrum, in contrast, has wide variability in terms of its attachment to the glenoid. A normal superior labrum is not always attached, or it may have only a flimsy connection to the glenoid. If the glenoid underlying the superior labrum is covered with smooth cartilage and neither the superior labrum nor the glenoid demonstrates any evidence of trauma, I consider this superior labrum separation to be a normal anatomic variant and not a pathologic lesion (Fig. 5-2). Evidence of trauma includes fraying or tearing of the superior labrum or damage to the glenoid cartilage directly underneath the labrum separation. Superior labrum separation without evidence of trauma does not require repair.

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Figure 5-1


Normal anterior-superior labral hole.

A SLAP lesion is an abnormal separation of the superior labrum from anterior to posterior. It was first described by Snyder, who noted four variations. In a type 1 lesion, the superior labrum is attached to the glenoid rim, but there is fraying of the leading edge of the labrum. In a type 2 lesion, the superior labrum is detached from the glenoid. A type 3 lesion is similar to type 2, but there is also a bucket-handle tear, whereas a type 4 lesion has a longitudinal split in the biceps tendon (Figs. 5-3 through 5-6). There are many variations of these four basic lesions. This is particularly true with regard to the glenohumeral ligaments. The middle and rarely the anterior-inferior glenohumeral ligaments may be attached to the glenoid only through the superior labrum. SLAP lesions have been identified in patients with full-thickness rotator cuff tears and in those with glenohumeral instability. A number of publications

Figure 5-2

Normal superior labrum separation.

Figure 5-3

SLAP type 1.

Figure 5-4

SLAP type 2.

Figure 5-5

SLAP type 3.

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Compress

External rotation

Figure 5-6

SLAP type 4.

have addressed this lesion’s frequency and our ability to diagnose it. Rodosky made an important contribution when he demonstrated the contribution of the superior labrum to anterior glenohumeral instability. Walch, Jobe, Morgan, and Burkhart have discussed the role of the superior labrum in internal impingement.

Figure 5-7

Shoulder compressed and rotated.

Rotator Cuff Disease Secondary Impingement

Mechanical Irritation Patients may present with symptoms of intermittent catching or locking of the shoulder during overhead sports or activities of daily living. The pain is sharp, severe, and localized vaguely as ‘‘deep within the shoulder joint.’’ Physical examination findings are variable. The examiner applying compression to the abducted shoulder and rotating the arm may reproduce pain (Fig. 5-7). Placing the internally rotated arm in adduction and having the patient resist a downward force (the O’Brien test) may be painful. The Speed test may be positive. A magnetic resonance imaging study without contrast occasionally demonstrates a detached superior labrum, but the addition of contrast material seems to improve its sensitivity (Fig. 5-8). An orthopedic surgeon with a high index of suspicion who excludes other more common causes of shoulder pain such as impingement, acromioclavicular joint arthrosis, and glenohumeral instability most commonly diagnoses SLAP lesions. There are no definitive patient complaints or physical examination findings that will always enable the surgeon to diagnose a labrum tear. I diagnose most SLAP lesions at arthroscopy.

SLAP lesions are infrequent in the classic outlet impingement of stage 2 rotator cuff disease. I suspect SLAP lesions in younger patients who present with impingement symptoms and a type 1 or type 2 acromion. Magnetic resonance images are normal, and the physical examination is usually consistent with impingement. Physical findings suggestive of a SLAP lesion are absent. In this setting, I carefully evaluate the superior labrum attachment at the time of arthroscopy.

Figure 5-8

Magnetic resonance imaging with contrast.

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The presence of normal cartilage covering the superior glenoid or the absence of trauma leads me to believe that the superior labrum separation is a normal anatomic variation that plays no role in the patient’s shoulder pain. In these individuals, I ignore the labrum and treat the patient for subacromial impingement. A more confusing situation exists in patients with classic outlet impingement, as diagnosed by history and physical examination, and a traumatic superior labrum separation (SLAP type 2). Once I have confirmed that the SLAP lesion is traumatic and not an anatomic variation, I begin to question the accuracy of my preoperative diagnosis of impingement. In patients younger than 40 years, I carefully check for subtle signs of anterior-inferior instability such as labrum fraying, fissures, or minor separations. In this clinical setting, the surgeon should be aware that the SLAP lesion might cause or exacerbate subtle anterior-inferior glenohumeral instability and that the ‘‘impingement’’ symptoms are secondary. It is usually impossible to determine whether (1) the SLAP lesion is the result of altered shoulder biomechanics that accompany chronic impingement, (2) the SLAP lesion has altered shoulder biomechanics enough to cause impingement, or (3) there is any relationship between the two. It is possible that two separate pathologic processes are involved. I am convinced, based on personal experience and the publications of Walch, that the long head of the biceps is not a major depressor of the humeral head, but perhaps more subtle processes are at work.

SLAP Lesion with Acute Rotator Cuff Tear With the increasing use of arthroscopy, surgeons now routinely inspect the glenohumeral joint and identify SLAP lesions. SLAP lesions are not seen during open rotator cuff repair, so their incidence has been underreported in publications dealing with open techniques. They occur more frequently in younger patients following significant trauma. A typical example is a worker who falls backward and lands on his elbow with the shoulder in extension. The humeral head is driven superiorly, and presumably the biceps tendon attachment is avulsed from the glenoid. I repair SLAP lesions that are noted in the setting of an acute full-thickness rotator cuff tear.

Chronic Full-Thickness Rotator Cuff Tear My experience is that SLAP lesions are found infrequently in patients with chronic full-thickness rotator cuff tears. Taverna and I found an incidence of 2.5% (5 of 200), and we could not determine whether the SLAP lesion preceded the rotator

cuff tear, followed the tear, or was an independent entity. One of the reasons for repairing the rotator cuff tendons is to restore their ability to center the humeral head during overhead elevation. It seems reasonable to repair another possible source of humeral head depression—the biceps-labrum complex. Here again, theory collides with reality. My goal after rotator cuff repair is to restore full passive range of motion, but if the SLAP lesion is repaired, I must restrict full external rotation so as not to disrupt the SLAP repair. Unless the SLAP lesion is significant, I prefer to repair only the rotator cuff. The average age of my patients who undergo arthroscopic rotator cuff repair is 62 years, and I am not concerned about the SLAP lesion and its effect on glenohumeral joint stability. I prefer to perform a tenodesis of the biceps tendon rather than a labrum repair. With the tenodesis, patients can perform my standard rehabilitation regimen after rotator cuff repair, without any concerns about external rotation. I alter their postoperative care by instructing patients not to perform elbow flexion against resistance for 3 weeks.

Glenohumeral Instability SLAP lesions contribute to glenohumeral instability directly and indirectly. Rodosky demonstrated in the laboratory that less force is required to translate the humerus on the glenoid when a SLAP lesion is present. Pagnani demonstrated in cadavers an increase in anterior-posterior and superior-inferior translation when a SLAP lesion is created. The presence of a SLAP lesion therefore contributes indirectly to glenohumeral instability, so it seems reasonable to repair a SLAP lesion along with other lesions found during a glenohumeral reconstruction. The SLAP lesion can also directly affect glenohumeral stability. The anatomy of glenohumeral ligament insertions is variable, and I have seen cases in which the middle and even anterior-inferior glenohumeral ligaments are attached not to the anteriorinferior glenoid but directly to the superior labrum. Superior labrum detachment removes the connection stabilizing the glenohumeral ligament and the glenoid. A SLAP lesion in such an individual is functionally a ‘‘Bankart’’ lesion, and I think superior labrum repair is indicated. Morgan and Burkhart presented a third type of relationship between SLAP lesions and glenohumeral instability. They postulate that repetitive overload stress in a throwing athlete creates a posteriorsuperior SLAP lesion. The ‘‘bumper’’ and ‘‘suctioncup’’ effects of the labrum are destroyed, and

Chapter 5

posterior-superior instability is the result. This type of instability can cause articular surface partialthickness rotator cuff tears and anterior-inferior glenohumeral instability. This is supported by Pagnani’s cadaver study, in which he found that an experimentally produced SLAP lesion resulted in increased anterior-posterior and superior-inferior translation. My experience supports repair of the SLAP lesion in this setting.

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Inte r

nal rotation

Anterior

The Throwing Athlete Tight posterior capsule producing avulsion SLAP

Diagnosis Patients with SLAP lesions may present with symptoms of mechanical abnormalities. They complain of locking or catching when they participate in athletics or vigorous activities of daily living. They also complain of painful catching or popping with passive shoulder compression and rotation. The relocation test may be positive (Fig. 5-9). The physician can perform a variety of clinical tests, but in my experience, they may not produce pain when a SLAP lesion is present, or they may produce pain when no SLAP lesion exists. Although such tests are helpful, the examiner must put them in the context of the patient’s clinical situation. Patients with SLAP lesions may present with findings typical of subacromial impingement or

A

Figure 5-10

Tight posterior capsule producing avulsion.

a full-thickness rotator cuff tear. Alternatively, the physical examination findings and patient complaints may be consistent with glenohumeral instability. In addition, patients may complain of posterior-superior subdeltoid pain when the arm is placed in abduction and external rotation during athletics or work. I pay close attention to posterior soft tissue contracture and evaluate the shoulder’s internal rotation in neutral extension as well as in the scapular plane. Internal rotation may be quite limited. The source of the underlying soft tissue contracture is unclear; some patients have significant loss of internal rotation yet also have excessive posterior glenohumeral translation. This suggests that in some patients, the posterior capsule may be contracted, whereas others have a normal or lax capsule with contracture of the posterior rotator cuff. Morgan and Burkhart believe that the posterior contracture is primary. With forceful internal rotation, the tight posterior capsule causes traction on the superior labrum and produces an avulsion injury (Fig. 5-10). Although this hypothesis is reasonable, it does not explain those patients with SLAP lesions and normal internal rotation or those with internal rotation loss but no SLAP lesion. Clearly, our knowledge on this topic is incomplete.

Nonoperative Treatment

B Figure 5-9

A and B, Relocation test.

Nonoperative treatment is directed at correctable, underlying causes of shoulder pain. Limitations of passive range of motion are corrected with appropriate stretching exercises. Impingement is treated with activity modification and selective rest of the shoulder. Glenohumeral instability is treated with exercises

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to strengthen the glenohumeral stabilizing muscles and to improve neuromuscular coordination, as described in Chapter 4. Pay particular attention to scapular kinematics and stress rehabilitation in this area. Read the works of Kibler.

Indications and Contraindications for Surgery SLAP lesions that produce mechanical symptoms of locking or catching are the least likely to respond to rehabilitation, and operation is indicated if symptoms are present for 3 to 6 months. In patients with SLAP lesions that coexist with glenohumeral instability or rotator cuff disease, indications are based on the underlying condition. All SLAP lesions are technically reparable, but there are some SLAP lesions that should not be repaired. Because SLAP repair requires postoperative immobilization, I do not repair SLAP lesions that are found during operation for adhesive capsulitis or chronic rotator cuff tears.

Operative Technique SLAP Repair Before a surgeon repairs a SLAP lesion, two questions must be answered: Is the superior labrum separation from the glenoid a lesion, or is it an anatomic variant? What is the relationship between the labrum separation and the patient’s clinical presentation? Before undergoing general anesthesia, patients receive an interscalene block to diminish postoperative pain. Patients are placed in the sitting position. The range of motion for external and internal rotation with the arm in 90 degrees abduction and the range of motion for external rotation with the arm in 0 degrees abduction are recorded. I examine the shoulder for anterior, inferior, and posterior translation and record the results. The shoulder is then prepared and draped routinely. The bony outlines of the acromion and coracoid process are palpated and marked with a surgical marking pen. The shoulder joint is entered with a cannula and blunt trocar through a posterior skin incision placed approximately 1.5 cm inferior and 2 cm medial to the posterolateral border of the acromion. The arthroscope is inserted into the glenohumeral joint. An anteriorinferior portal is identified with a spinal needle so the cannula enters the shoulder immediately superior to the subscapularis tendon and 1 cm lateral to the

Figure 5-11

Anterior portal sites.

glenoid. The arthroscope is then inserted through the anterior portal, and the posterior structures are inspected. The arthroscope is then reinserted posteriorly (Figs. 5-11 through 5-17). All structures within the glenohumeral joint are examined systematically. Lesions are variable and include tears of the rotator cuff (partial and complete), rotator interval lesions, biceps tendon fraying, and glenohumeral ligament tears. I specifically examine the labrum below the glenoid equator, anteriorly

Anterior Anterolateral

Figure 5-12

necessary.

Superior portal placed more laterally, if

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153

Figure 5-13 Skin markings.

Figure 5-15

Anterior-inferior cannula entering the joint.

Figure 5-16


Figure 5-17


and posteriorly, for signs of fraying and detachment. Attention is then turned to the superior labrum. An arthroscopic probe is useful to assess the labrum attachment accurately because fibrous healing may have occurred after trauma. A normal labrum cannot be separated with the probe.

SLAP 1 Lesions I do not regard the minor fraying at the free edge of the labrum as pathologic and therefore do not perform any de´bridement.

Figure 5-14 Cannula orientation.

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SLAP 2 Lesions If a SLAP 2 lesion is identified, an anterior-superior portal is created. A spinal needle is inserted at the anterolateral acromial corner and enters the joint lateral to the biceps tendon. The second cannula is introduced. It is critical to position the anterior-superior cannula precisely. To obtain a proper angle for the bur and drill, this cannula must be placed as far lateral and superior as possible. I always use a spinal needle to identify both the entry point and the angle for this cannula. The spinal needle should enter the joint very close to where the biceps exits from the glenohumeral joint and should approach the superior glenoid perpendicularly (Figs. 5-18 through 5-23). I prefer suture anchor repair rather than the tack technique. I am more comfortable with the fixation afforded by the anchors and the superior holding power of the sutures as they surround the labrum. Often the superior labrum is robust, and the amount of tack inserted into the superior glenoid seems marginal. There are two drawbacks to the suture anchor method: knot tying is necessary, and the posterior anchors can be difficult to insert. Knot tying is a skill that can be mastered with practice. The surgeon can usually place an anchor posterosuperiorly on the glenoid through the anterolateral portal. If it is not

Figure 5-19 Spinal needle identifying the site for the anterior-superior cannula.

Figure 5-20 Anterior-superior cannula entering through the rotator interval.

Angle for spinal needle insertion to determine the site of the anterior-superior cannula.

Figure 5-18


Chapter 5

Figure 5-24


possible to insert the posterior anchor through the anterior-superior portal, I move the arthroscope to the anterior-superior portal and insert the posterior anchor through the posterior portal. I use a 4-mm power bur to abrade the glenoid beneath the detached superior labrum to expose cancellous bone. I usually insert it through the anterior-superior portal because this provides the best angle of approach. On occasion, the superior labrum is very meniscoid, with the labrum margin extending



155

Preparation to expose cancellous bone.

down the glenoid and obscuring my view of the superior glenoid. In this situation, I insert the bur through the anterior-inferior portal, and Dr. Hammerman (my assistant) inserts a probe through the anterior-superior portal and retracts the labrum superiorly. This reveals the superior glenoid surface. Cancellous bone is exposed from the anterior to the posterior margins of the superior labrum detachment (Fig. 5-24). Holes for the suture anchors are then made with a power drill. The drill is inserted through the anteriorsuperior cannula, and the two holes are spaced evenly along the length of the defect. I drill the anterior hole first and then the posterior hole. Owing to the curvature of the glenoid, the posterior hole is more oblique than the anterior hole. As the posterior drill hole is moved posteriorly along the glenoid rim, it becomes more oblique. It is a matter of surgical judgment how much obliquity is permissible. The greater angle of approach causes the screw to be located more superficially in the bone. If the angle is unacceptable, there are two options: move the cannula more posteriorly so that it approaches the glenoid less acutely, or change the curvature of the superior glenoid rim. If the superior labrum separation extends more posteriorly than normal, anchor placement is made easier with a technique modification. Both the superior portal of Neviaser and a posterior-superior portal pass through the substance of the rotator cuff tendons and might lead to tendon rupture. Thus, when the SLAP lesion extends farther posteriorly than normal, I try to move the anterior-superior portal posteriorly. I use a spinal needle placed 1 cm posterior to the anterior acromial border. If the drill angle is still too acute, I insert a 4-mm round bur through the anteriorsuperior portal and remove a small amount of

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Bur creating shelf

Figure 5-25 Drill at the normal angle of approach.

Abrade the superior surface of the glenoid to allow the drill to penetrate.

Figure 5-27

glenoid bone to create a ‘‘shelf’’ whose face is now more perpendicular to the drill (Figs. 5-25 through 5-28). The posterior anchor is inserted through the anterior-superior cannula, and the two anchor sutures remain in this cannula. A Smith-Nephew AccuPass instrument is inserted through the anterior-inferior portal. The right-angled instrument is passed from the superior aspect of the detached labrum to the inferior aspect. Passing the suture from inferior to superior may result in detachment of the bucket handle as pressure is placed on the suturing device; it also causes the nylon sutures to exit the suture passer and move superiorly, making them harder to retrieve. Passing the sutures from superior to inferior places less stress on the labrum; the sutures exit the labrum and move inferiorly, making their retrieval easier. The nylon suture is advanced fully into the glenohumeral

joint, and the suture instrument is withdrawn. A crochet hook is used to retrieve both suture ends. Insert the crochet hook through the anterior-superior cannula. To avoid tangling the sutures, pass the crochet hook underneath (medial to) the sutures coming from the anterior-inferior cannula. The loop portion of the nylon suture protrudes from the anterior-superior cannula, and the two free ends from the anteriorinferior cannula. I prefer to repair the labrum with the suture knot on the superior surface of the labrum rather then bury the knot and interpose it between

Drilling into shelf

Figure 5-26

Drill at a tangential angle.

Figure 5-28

Anchor insertion.

Chapter 5

Figure 5-29


the detached superior labrum and its repair site. Place a hemostat on the two free ends of the sutures. Use a crochet hook to retrieve one of the anchor’s suture strands and bring it out the anterior-inferior cannula. The remaining anchor suture (in the anterior-superior cannula) is placed through the looped nylon and pulled through the labrum and out the anterior-inferior cannula. Both sutures from the posterior anchor now exit the anterior-inferior cannula (Figs. 5-29 through 5-38). Occasionally, the braided suture anchor sutures do not pull smoothly through the labrum. Using additional force would cause the nylon passing sutures to tear. I prefer to use the technique developed by Hammerman. He threads the two free ends of the nylon suture through the knot tying instrument and then advances the tip of the instrument near the

Figure 5-30



157

Retrieve the nylon suture through the anteriorsuperior cannula.

Figure 5-31

Figure 5-32

Figure 5-33

Bring the nylon suture underneath.

Reverse the direction of the loop.

158

Section Two


Move one suture strand from the anteriorsuperior cannula to the anterior-inferior cannula.

Figure 5-34

Figure 5-35 Pass the anchor suture through the labrum.

Figure 5-36

Tie the knot.

Figure 5-37

Past-point.

labrum. Rather then pull the nylon sutures, he uses the knot tying instrument to push the sutures through the labrum. Because the instrument is adjacent to the point where the sutures exit from the labrum, he is able to exert significant force without danger of suture breakage (Figs. 5-39 and 5-40). The second anchor is inserted into the anterior drill hole through the anterior-superior cannula. I insert the anterior anchor before I tie the posterior sutures because the anterior hole is obscured after the posterior sutures are tied. The posterior anchor sutures are tied with an arthroscopic knot tying instrument through the anterior-inferior cannula, and the sutures are cut with arthroscopic scissors. The anterior anchor suture is then placed through the anterior portion of the detached superior labrum as described earlier,

Figure 5-38

Completed repair.

Chapter 5

Figure 5-39

Anchor suture caught in the labrum.

and the sutures are tied and cut. For small labrum lesions, a single anchor (loaded with two sutures) will suffice for repair. The technique is similar to that described for two anchors.

SLAP 3 Lesions If the bucket handle is less than one third of the labrum width, it is excised, and I repair the major portion of the superior labrum to the glenoid, as described earlier. If the bucket handle is one third or greater, I repair the detached portion. The posterior anchor is inserted, and one limb of the suture anchor suture is passed through the major portion of the labrum, as described earlier. Both suture strands, which are now in the anterior-inferior cannula, are retrieved out the anterior-superior cannula with a

Figure 5-41


159

SLAP type 3.

crochet hook. Failure to perform this step may result in the suture instrument cutting the suture during the next portion of the operation. Place a hemostat on one of the suture limbs to identify which suture limb passes through the bucket-handle fragment. The AccuPass instrument is then inserted through the anterior-inferior cannula and pierces the bucket handle from lateral to medial so as not to avulse the fragment. The loop end of the nylon suture is retrieved out the anterior-superior cannula with a crochet hook. The first suture (already passed through the labrum) is transferred from the anterior-superior cannula to the anterior-inferior cannula to minimize tangling. The second posterior anchor suture is then passed from the anterior-superior cannula, through the labrum, and out the anterior-inferior cannula. The sutures are tied and cut. This technique is repeated with the anterior anchor sutures to repair the anterior portion of the superior labrum and the anterior portion of the bucket-handle tear (Figs. 5-41 through 5-44).

SLAP 4 Lesions

Figure 5-40

Advance into the joint with a knot pusher.

If the longitudinal tear in the biceps tendon is less than one third of the tendon diameter, I excise the torn fragment. If the fragment is one third or greater, I repair the torn fragment to the major portion of the biceps tendon. The superior labrum is repaired first, as described earlier. The AccuPass instrument is used to place a No. 1 PDS suture through the torn fragment and then through the major portion of the biceps tendon. The suture is then tied. One or two sutures are sufficient to accomplish the repair (Figs. 5-45 through 5-50).

160

Section Two

Figure 5-42


First anchor suture strand through a major

Figure 5-45 SLAP type 4.

Second anchor suture strand through a minor

Figure 5-46

Biceps repair.

Completed repair.

Figure 5-47

Biceps repair.

fragment.

Figure 5-43

fragment.

Figure 5-44

Chapter 5


161

Postoperative Treatment

Figure 5-48

Biceps repair.

The patient is placed in a sling that is worn at all times except while bathing. At 2 weeks, active range of motion is allowed in all planes except external rotation in abduction. The sling is worn until week 4, at which time passive range of motion is started, with an emphasis on posterior capsule stretching. Six weeks after surgery, external rotation in abduction is allowed, and stretching continues. The patient is started on a progressive strengthening program using surgical tubing for the deltoid, rotator cuff, scapular muscles, biceps, and triceps. Upper extremity sports are allowed 3 months after surgery, with the exception of throwing. Throwing begins 4 months after operation with lowvelocity, short-distance throwing, with the athlete concentrating on proper throwing mechanics. Distance and velocity are gradually increased until 7 months after operation, at which point I allow the patient to resume competitive throwing.

BICEPS LESIONS DISTAL TO THE SLAP LESION

Figure 5-49

Biceps repair.

Biceps tendinitis and partial tears are occasionally isolated causes of significant shoulder pain, but they are more commonly found in conjunction with subacromial impingement and rotator cuff tears. Although arthroscopic subacromial decompression and rotator cuff repair have been thoroughly described, arthroscopic biceps treatment has rarely been mentioned. Since 2001, there has been a significant shift in our thinking, and I now treat biceps lesions more frequently. Biceps lesions requiring arthroscopic treatment include tendinitis, partialthickness tears, hypertrophy, and subluxation (Figs. 5-51 and 5-52).

Literature Review

Figure 5-50

Biceps repair.

Since the publication of the first edition of this book, the literature on the arthroscopic treatment of biceps lesions has become more robust. These presentations focus on two issues: should the surgeon perform a tenodesis or a tenotomy, and if a tenodesis is performed, what is the preferred technique? Hawkins and Walch have questioned the value of any tenodesis operation. Their results suggest that equal or better results can be achieved with tenotomy. Tenotomy is faster, is easier to perform, does not appear to affect elbow flexion strength, and does not normally result in a cosmetic deformity. Some patients express concern about the possible cosmetic deformity, particularly men who lift weights.

162

Section Two


Diagnosis

Figure 5-51

Biceps synovitis.

If a patient has any concerns about the appearance of the arm, I perform a tenodesis. If the patient participates in overhead or throwing sports, I prefer tenodesis. My results with tenodesis have been favorable, but many patients complain of pain around the site of tenodesis for months. When patients ask about my preference, I usually tell them that if it were my shoulder, I would have a tenotomy. For those surgeons who prefer tenodesis, there are three basic methods of fixation. My colleagues and I have described our technique with suture anchors, and Boileau has described his experience with a bioabsorbable screw. Elkousy and Rodosky published an elegant technique for soft tissue fixation with sutures. I have no experience with the Boileau screw, but in my hands, both the soft tissue suture technique and the suture anchor technique are very effective.

I make the diagnosis of a biceps tendon lesion based on a combination of patient history, physical examination, radiographic imaging, and findings at arthroscopic surgery. The patient history and physical examination may point to a problem in the biceps tendon, but that information is usually nonspecific. Patients often indicate the biceps area as the source of their pain. This seems to be much more specific than the diffuse area of pain described with a rotator cuff tear. Of course, such localization by the patient does not eliminate the possibility that the biceps is normal and the lesion is in the anterior supraspinatus or superior subscapularis. Patients often describe pain with activities that involve internal rotation, such as pressing an object together with both arms, reaching out to the side to close a car door, or reaching up behind the back. Some specifically describe the feeling of something rolling into and out of place or the sensation of slipping. Sometimes the pain is felt more acutely within the substance of the biceps muscle. These complaints are nonspecific and are also reported by patients with subacromial impingement syndrome and other more serious forms of rotator cuff disease. In patients who appear to have a mechanical block to full elevation yet maintain normal external rotation, I am suspicious of biceps tendon entrapment due to tendon hypertrophy. The primary (Neer) and secondary (Hawkins) impingement signs may also produce pain on physical examination. I have not found the Yergason test helpful and prefer the Speed test. Patients commonly describe painful popping or catching in the anterior shoulder area. A lidocaine injection into the area of the proximal biceps tendon sheath may be helpful in differentiating subacromial impingement from biceps tendinitis, but I often find it more useful to determine the degree to which the biceps lesion is producing pain. The definitive diagnosis is usually made on magnetic resonance imaging or at the time of arthroscopic surgery. When reviewing the magnetic resonance image, I pay particular attention to the subscapularis, because biceps subluxation and tendinitis can be associated with partial-thickness tears of the articular surface of the subscapularis (Figs. 5-53 through 5-56).

Indications for Treatment

Figure 5-52

Biceps partial tear.

Partial-thickness biceps tendon tears within the glenohumeral joint are not uncommon; they may occur subsequent to a traumatic event, or they may be the result of chronic subacromial impingement. When the tear is less than 30% of the tendon width, the frayed edges are de´brided. If the tear is greater than 30% of the tendon width, I perform a tenodesis. When the tendon is

Chapter 5

Figure 5-53


163

Subscapularis partial tear. Figure 5-55

subluxed medially, I prefer biceps tenodesis or tenotomy, usually in combination with a subscapularis repair. If a biceps lesion is found in the area of the bicipital groove during subacromial decompression for a fullthickness rotator cuff tear, the surgeon has four options: ignore the biceps lesion or perform stabilization, tenodesis, or tenotomy (Table 5-1). Because there is no scientific evidence to guide us, treatment is determined by personal preference. I have experience with all four options but have seen the best results with tenodesis in younger patients who have good-quality rotator cuff tendons and tenotomy in older patients who have poorer quality biceps and rotator cuff tendons.

Figure 5-54

Subscapularis partial tear.


I usually treat full-thickness tears of the biceps tendon nonoperatively, but some patients are very concerned about the injury and request repair (Fig. 5-57). Because the remnant stump within the glenohumeral joint may cause mechanical symptoms, I perform an arthroscopic de´bridement of the biceps tendon back to the level of the superior labrum. The bicipital sheath is accessible arthroscopically from the level of the rotator interval to the insertion of the pectoralis major tendon. I identify the sheath and open it, find the tendon, and repair it with a suture anchor as far proximal as possible to restore resting tension in the muscle.

Figure 5-56


164

Section Two


Table 5-1 INDICATIONS FOR TREATMENT Biceps Lesion

Treatment

Inflamed

Tenosynovectomy

Partially torn < 30%

De´bride

Partially torn > 30% Biceps quality good, cuff repair good

Tenodesis

Biceps quality good, cuff repair poor

Tenodesis or tenotomy

Biceps quality poor, cuff repair good

Tenotomy

Biceps quality poor, cuff repair poor

Tenotomy

Operative Technique Intra-articular Biceps Tendinitis I use a standard posterior portal and enter the glenohumeral joint. I visualize the biceps tendon and areas of fraying, inflammation, or partial tear. An anterior portal is established, and a probe is introduced to pull the tendon and bring its extra-articular portion into view (Figs. 5-58 and 5-59). If the fraying or inflammation is localized to the intra-articular portion of the biceps tendon, a shaver is introduced through the anterior portal, and de´bridement is performed. If a portion of the biceps tendon lesion lies within the bicipital groove, external to the glenohumeral joint, I prefer to use a subacromial approach to treat the lesion.

Figure 5-57

Patient with complete biceps tear.

Figure 5-58

Figure 5-59

Shaver retracting the biceps tendon.

Extra-articular biceps pulled into view.

Chapter 5

Partial Tear of the Intra-articular Biceps Tendon This lesion is immediately observed upon entry into the glenohumeral joint. I establish an anterior portal with an 8-mm cannula. If the biceps tear is the only lesion within the glenohumeral joint, I prefer to repair it with a one-cannula technique. I use an AccuPass right-angled instrument loaded with monofilament suture and pierce the entire tendon from the area of the tear flap toward the more normal tendon. I advance 15 to 20 cm of the suture into the joint and then withdraw the instrument. I grasp the free end of the suture with a crochet hook and withdraw it through the anterior cannula. I tie the suture and repeat these steps with additional sutures as necessary, depending on the length of the tear area. Other instruments can be used to repair the biceps tendon, but they require two cannulas because one instrument is used to pass the suture and another instrument is needed to retrieve the suture.

Subacromial Techniques TENDINITIS AND PARTIAL-THICKNESS TEARS WITH INTACT ROTATOR CUFF I use a standard posterior portal and

enter the glenohumeral joint. The biceps tendon is visualized, and areas of fraying, inflammation, or partial tear are noted. I establish an anterior portal and introduce a probe so that I can pull on the tendon to bring the extra-articular portion into view. I introduce a spinal needle percutaneously near the anterolateral acromial border and pierce the tendon just proximal to its exit from the joint. The needle is advanced until it is lodged in bone so that it does not


move when I remove the arthroscope from the glenohumeral joint and reinsert it into the subacromial space (Fig. 5-60). After removing the arthroscope from the joint and redirecting it into the subacromial space, I locate the spinal needle and establish a lateral portal. I use a scissors or motorized shaver to divide the flimsy capsular tissue of the rotator interval and expose the biceps tendon and the bicipital groove. I then insert an arthroscopic probe through the anterior portal, lift the biceps tendon from its groove, and inspect it. If the tendon is intact and of good quality but inflamed, I perform a tenosynovectomy using a power shaver. If the biceps is partially torn, I perform a tenodesis using the technique described next. BICEPS TENODESIS—SUTURE ANCHOR TECHNIQUE The biceps tenodesis is performed after the subacromial decompression but before the arthroscopic rotator cuff repair. Standard anterior and lateral portals are used. I move the outflow to the posterior portal and the arthroscope to the lateral portal. If the bicipital groove is flattened, as is common in chronic cuff tears, I retract the tendon medially and use a 4-mm round bur to deepen the bicipital groove. If the shape of the groove appears normal, I insert a bur and abrade the cortical margins of the groove for a distance of 2 cm. I then insert an anchor into the center of the deepened groove. The anchor can be inserted through the anterior cannula, but often the angle is too oblique. If this is the case, I insert the anchors through a percutaneous stab wound. I use a spinal needle and

Biceps long head tendon

A

165

B Figure 5-60 A, Spinal needle piercing the biceps tendon. B, Biceps fraying in the groove.

166

Section Two


pierce the anterior shoulder until the needle tip is within the bicipital groove and the angle of approach is satisfactory for anchor placement. I then incise the skin at this location and insert the suture anchor. The anchor sutures are exiting the anterior cannula, the arthroscope is in the lateral cannula, and the Elite suture punch (my preferred instrument for this technique) is inserted through the posterior cannula. One of the anchor sutures is moved from the anterior cannula to the lateral cannula with a loop grasper or crochet hook. The suture is loaded on the Elite punch, which passes through the posterior cannula into the subacromial space and pierces the biceps tendon. This suture is retrieved out the anterior cannula. The second suture from that same anchor is placed in a similar fashion, completing the mattress suture. These steps are repeated for both suture limbs of the second anchor. The sutures are usually tied from the posterior cannula. If the surgeon prefers a Caspari suture punch, it is loaded with doubled 2-0 nylon suture and inserted through the lateral cannula to pierce the biceps tendon. The 2-0 nylon suture is advanced and drawn out the anterior cannula. One limb of the first anchor suture is brought from the anterior cannula (or stab wound) to the lateral cannula and passed through the biceps tendon using the nylon loop. This process is repeated with the second limb of the same color anchor suture, which is placed 5 mm from the first suture. A mattress suture has now been placed through the biceps tendon. This process is repeated with sutures from the second anchor, and the sutures are tied. I excise the intra-articular portion of the biceps tendon and repair the rotator cuff tear with arthroscopic technique (Figs. 5-61 through 5-70).

Figure 5-62

Identifying the biceps tendon.

If the subscapularis is also torn, I first perform the biceps tenodesis with the suture anchor technique just described and then repair the subscapularis. If the supraspinatus is torn, the order of repair is biceps tenodesis, subscapularis repair, and finally supraspinatus repair.

Abrading flattened bone surface, creating a new groove

Dividing rotator interval

Figure 5-61 Division of the rotator interval, exposing the biceps tendon.

Figure 5-63

Abrading the repair site.

Chapter 5

Percutaneously placing anchor screws

Anchor screws

A


167

Percutaneously placing anchor screws

A

B B Figure 5-64

Figure 5-66

A and B, Suture placement.

A and B, Anchor insertion.

A

B Figure 5-67 Figure 5-65

Anchor insertion.

tendon.

A and B, Suture spacing along the biceps

168

Section Two


Anchor sutures tied

A Excising biceps tendon

A Rotator interval sutured

B Figure 5-69

A and B, Excise the intra-articular biceps

stump.

B Figure 5-68

A and B, Sutures tied.

Abrading bone surface medial to the lesser tuberosity

A

Subscapularis tendon sutured medial to biceps tendon

B Anchors set in place

C Figure 5-70

A-C, Subscapularis repair, if necessary.

Chapter 5


169

Biceps Tenodesis—Extra-Articular Technique Place the patient in the upright beach-chair position with the acromion parallel to the floor. Perform routine diagnostic glenohumeral joint arthroscopy from the posterior portal. Insert a spinal needle lateral to the coracoid tip and into the glenohumeral joint through the rotator interval. Remove the spinal needle and make a small stab incision using a scalpel. Insert a blunt metal trocar through the anterior incision and into the glenohumeral joint to facilitate passage of the mechanical shaver. Remove the trocar and insert the shaver percutaneously into the joint. Use the shaver as a probe to pull the biceps tendon into the joint to visualize and document the extra-articular proximal biceps tendon. Resect the lateral rotator interval tissue overlying the biceps tendon at its entry into the joint (a triangle of tissue bounded posteriorly by the anterolateral supraspinatus tendon and anteriorly by the superolateral subscapularis). Remove the shaver. Insert a spinal needle at the anterolateral corner of the acromion through the opening in the rotator interval and pierce the biceps tendon. Insert an arthroscopic scissors into the joint through the anterior stab incision and transect the long head of the biceps tendon at its proximal insertion. The transection should be at the level of the superior labrum. Try to avoid leaving a medial stump of biceps tendon. (Insert the shaver to de´bride a medial biceps tendon stump, if necessary.) Remove the arthroscope from the joint. Insert the metal cannula and trocar posteriorly into the subacromial space. Insert the arthroscope. Make a small stab incision at the midlateral position approximately 1 cm distal to the lateral acromial border. Insert a blunt metal trocar into the subacromial space and locate it using the arthroscope. Remove the trocar and replace it with the shaver. Clear the subacromial bursa as needed for clear visualization of the bursal surface of the rotator cuff. (Achieve adequate visualization of the anterior and lateral subacromial space and the previously placed spinal needle.) Remove the shaver and replace it with a metal cannula and trocar. Remove the arthroscope from the posterior portal and insert it laterally. Enlarge the posterior incision and insert an 8-mm cannula. Move the outflow from the arthroscope to the 8-mm cannula. Position the shoulder in approximately 60 degrees of anterior elevation and neutral rotation using the McConnell arm positioning device. With the arthroscope in the lateral portal, visualize the biceps tendon through the opening in the rotator interval. Insert the shaver through the anterior incision to enlarge the interval window if necessary, further exposing the biceps tendon.

Insert a nonlocking grasper through the posterior cannula, remove the spinal needle piercing the biceps tendon, and deliver the tendon into the subacromial space through the opening in the rotator interval using the grasper. Insert a locking grasper through the anterior incision and grasp the proximal end of the biceps tendon (this instrument maintains control of the tendon for the remainder of the procedure). Remove the posterior grasper. Insert a spinal needle percutaneously approximately 1 cm distal to the anterolateral tip of the acromion, directed toward the bicipital groove. Make a small skin incision and insert a 5-mm cannula. (Insert the cannula until it touches the humerus, and then pull it backward. This maneuver aids in retraction of the subdeltoid fascia for visualization.) Use the locking grasper to pull the biceps tendon medially, introduce the shaver through the 5-mm cannula, and resect approximately 1 to 1.5 cm of tissue overlying the biceps tendon from proximal to distal. Expose the bicipital groove by ‘‘pushing’’ the biceps tendon laterally using the locking grasper. Use the shaver to remove soft tissue from the bicipital groove (keep the blades pointed toward the humerus medially, and the guard will protect the biceps tendon laterally). Insert a small round bur through the 5-mm cannula, and carve away the exposed bicipital groove to bleeding bone. (Do not go completely through to cancellous bone, because the anchor fixation may be compromised.) Pass a double-loaded Arthrex FT (full-thread) anchor through the 5-mm cannula, and insert it into the base of the bicipital groove. (A small amount of internal or external rotation and elevation of the shoulder may be required to insert the anchor perpendicular to the bone.) The base of the anchor is seated at the level of the remaining cortical bone. Remove the 5-mm cannula and then replace it, with the sutures exiting outside the cannula. Use the locking grasper to pull the biceps tendon back to a medial position. The assistant holding the grasper should lower his or her hand to hold the tendon superior to the groove, which assists in suture passing. Complete suture passing and knot tying through the posterior cannula. Sutures are passed through the biceps tendon in a mattress configuration from distal to proximal. Pass a crochet hook from posterior through the 8-mm cannula to retrieve one limb of the solid (blue) suture. Use an Elite Pass to pass this suture through the biceps tendon as distal along the tendon as possible. (Use the locking grasper to pull the tendon medially during passage of the most lateral suture.) Retrieve the suture using a grasper through the 5-mm cannula. Retrieve the second limb of blue suture and pass it in the same fashion. The sutures should be passed through the biceps approximately 1 cm apart and at differing angles to each other. Retrieve the tiger-stripe sutures and pass them through the biceps tendon from the posterior cannula, proximal to the blue sutures, using the same technique. Continued

170

Section Two


Make sure the shoulder is externally rotated slightly (approximately 15 degrees) for suture retrieval and knot tying. Retrieve the two lateral sutures (blue) through the posterior cannula. Use a loop grasper to ensure that the sutures are not crossed. Tie the sutures using arthroscopic square knots. Cut the sutures with fiber-wire scissors, leaving a small tail.

Biceps Tenodesis Glenohumeral Joint Biceps Tenodesis in Bicipital Groove Biceps Tenodesis Near Pectoralis Major BICEPS TENODESIS—INTRA-ARTICULAR TECHNIQUE Standard shoulder arthroscopy equipment is required for this procedure, including 5- and 8-mm arthroscopic cannulas, a tissue-penetrating suture passer, and No. 1 Ethibond braided polyester suture. I prefer to put patients in the beach-chair position; however, this technique can also be performed with the patient in the lateral decubitus position. I inspect the glenohumeral joint through a standard posterior portal and then place an anterior cannula through the rotator interval superior to the subscapularis tendon. The anterior glenohumeral joint cannula is the ‘‘working’’ cannula and should be 8 mm in size. The biceps tendon is evaluated from its glenoid origin medially and followed into the bicipital groove laterally; instability, inflammation, degeneration, and tears are noted. The shoulder is elevated with the elbow extended as described by Boileau to examine tendon gliding and evaluate for possible biceps entrapment—the hourglass biceps (Fig. 5-71). A probe is placed through the anterior cannula to pull the biceps into the joint, improving distal tendon visualization. Sutures used to complete the tenodesis are passed through an accessory anterior cannula. Proper accessory cannula placement is ensured by using a spinal needle. The needle is inserted through the anterolateral shoulder into the subacromial space and then into the glenohumeral joint, penetrating the anterior border of the supraspinatus. The needle is removed, and a small skin incision is made to allow placement of a 5-mm cannula. A metal trocar is

Retrieve, tie, and cut the tiger-striped sutures in the same fashion. Pass a grasper from posterior through the 8-mm cannula to grip the proximal biceps tendon stump. Remove the locking grasper. Pass arthroscopic scissors through the 5-mm cannula to transect the remaining biceps tendon proximal to the tenodesis sutures. Remove the tendon stump from posterior through the 8mm cannula, completing the procedure.

inserted through the skin incision into the subacromial space. The trocar is swept in a circular manner to release any adhesions between the rotator cuff tissue and the subacromial bursa. The mechanical release of adhesions is important to ensure that the mattress suture is pulled against the interval tissue after knot tying and is not caught within the bursa, which could loosen the tenodesis suture. The 5-mm cannula is then advanced into the subacromial space and pushed against, but not through, the rotator interval tissue superior to the biceps tendon. A grasper is inserted through the 8-mm anterior cannula to secure the biceps tendon and pull it proximally into the glenohumeral joint. A No. 1 Ethibond braided polyester suture is loaded onto a Cuff-Stitch (Smith-Nephew Endoscopy, Andover, Mass) through the convex side of the device, leaving a 4-cm length of suture on the concave side. The Cuff-Stitch is passed down the smaller cannula and through the anterior supraspinatus until the tip of the suture passer pierces the biceps tendon. A grasper is used to retrieve the suture from the concave side of the Cuff-Stitch inside the joint and pull the end out through the 8-mm working portal. The Cuff-Stitch is removed from the cannula, allowing the suture to slide within the eyelet without completely unloading the device, until approximately 4 cm of suture remains. A second pass is made down the 5-mm cannula through the supraspinatus and the biceps tendon. The suture is retrieved again from the concave side of the Cuff-Stitch, unloading the device, and is pulled out the larger portal. If desired, a second tenodesis suture can be passed by repeating these steps. The suture is now transtendinous and pierces the biceps tendon in a mattress configuration. A loop grasper is used to ensure that the sutures are not crossed within the cannula, and a knot pusher facilitates the tying of arthroscopic knots, through the 8-mm cannula, to tenodese the biceps. I prefer arthroscopic square knots. The suture strands are cut with a sliding suture scissors, and the intra-articular portion of the biceps tendon is excised with arthroscopic scissors. I use a power shaver to smooth the cut edges. The tenodesis is now complete, and any

Chapter 5


171

Biceps long head tendon entrapment

A

B

C

D Figure 5-71

A-D, Hourglass biceps of Boileau.

associated procedures can be carried out without interference from the biceps tendon. Following the procedure, the cannulas and scope are removed from the joint, fluid is expressed, and portals are closed in a standard fashion, my preference being subcuticular

3-0 absorbable monofilament suture. Sterile dressings are applied, and the arm is secured in a sling. The step-by-step technique for intra-articular biceps tenodesis is described here:

Position the patient in the beach-chair position with the acromion parallel to the floor. Perform a diagnostic arthroscopy from a standard posterior portal. Insert a spinal needle lateral to the coracoid and into the glenohumeral joint—penetrating the rotator interval. Remove the needle, incise the skin, and insert an 8mm cannula. Evaluate the biceps tendon from its insertion medially to its passage laterally into the bicipital groove. Elevate the shoulder with the elbow extended to examine the biceps tendon gliding, and evaluate for biceps entrapment (i.e., hourglass biceps).

Insert a probe through the anterior cannula to pull the biceps tendon into the joint, improving distal tendon visualization. Insert a spinal needle just distal to the anterolateral acromion into the glenohumeral joint, penetrating the anterior border of the supraspinatus. Remove the spinal needle and make a skin incision to accommodate a 5-mm cannula. Insert a blunt metal trocar percutaneously into the subacromial space. Sweep the trocar in a circular manner to release any adhesions between the rotator cuff tissue and the subacromial bursa. Continued

172

Section Two


Insert the 5-mm cannula and advance it against, but not through, the rotator interval tissue superior to the biceps tendon. Insert a suture grasper into the joint through the 8-mm anterior cannula. Secure the biceps tendon, and pull it medially into the glenohumeral joint. Load a No. 1 Ethibond braided polyester suture onto a Cuff-Stitch through the convex side of the device, leaving a 4-cm length of suture on the concave side. Pass the Cuff-Stitch through the 5-mm cannula, through the anterior margin of the supraspinatus tendon, and pierce the biceps tendon. Use the grasper holding the biceps to retrieve the suture from the concave side of the Cuff-Stitch, inside the joint, and pull the end out through the 8mm working portal. Remove the Cuff-Stitch from the cannula, allowing the suture to slide within the eyelet without completely unloading the device, until approximately 4 cm of suture remains.

Tenotomy My primary indication for biceps tenotomy is a poorquality biceps tendon that will not hold sutures. Patients should be informed of this possibility before the operation. I have no hard-and-fast rules for moving from tenodesis to tenotomy, but I tend to perform tenotomy more frequently if the patient is older or less active or if the nondominant arm is involved. Larger patients with less muscle definition note no cosmetic deformity. For those patients with an irreparable rotator cuff tear, tenotomy has major benefits in terms of pain relief and no adverse effects.

Figure 5-72

Pass the suture through the biceps tendon.

Pass the Cuff-Stitch down the 5-mm cannula a second time through the supraspinatus and the biceps tendon. Unload the Cuff-Stitch by retrieving the suture from the concave side of the device with a suture grasper and pulling it out the 8-mm cannula. If a second tenodesis suture is desired, repeat the previous seven steps. Insert a loop grasper through the 8-mm cannula to ensure that the sutures are not crossed. Secure the tenodesis with arthroscopic square knots tied through the anterior 8-mm cannula. Cut the suture strands using arthroscopic sliding suture scissors. Excise the intra-articular portion of the biceps tendon with arthroscopic scissors. Use a power shaver to smooth the cut ends of the biceps. The tenodesis is complete. Any associated procedures can be completed without interference of the biceps tendon (Figs. 5-72 through 5-77).

If the rotator cuff is intact, I establish two intraarticular anterior portals. I insert an arthroscopic forceps through the anterior-inferior cannula, grasp the biceps tendon, and pull the tendon into the glenohumeral joint as far as I can. I hold the tendon in this position, insert a scissors through the anteriorsuperior portal, and divide the tendon as far distal as possible. I then grasp the remaining stump of tendon distally and incise it near the superior labrum. The tendon stump is retrieved out through the anteriorinferior cannula. If the rotator cuff is torn, I perform a tenotomy before repairing the rotator cuff. The arthroscope is

Figure 5-73

Retrieve the suture out the anterior cannula.

Chapter 5

Figure 5-74

Pass the suture through the biceps tendon a

Figure 5-77


173

Completed tenodesis.

second time.

positioned in the posterior portal. My assistant places a grasper through the anterior portal and retracts the edge of the torn supraspinatus superiorly so that I can see the biceps-labrum junction. I insert a scissors through the lateral cannula and divide the biceps tendon at the glenoid attachment. The assistant uses the grasper in the anterior cannula to pull the divided biceps tendon into the subacromial space. I use a scissors placed through the lateral cannula to divide the tendon distally. Because the anterior cannula is usually too small to accommodate the biceps tendon, I insert a grasper through the lateral cannula and bring the tendon through the larger cannula or bring the tendon and cannula out together.

Figure 5-75

Tie the suture.

Postoperative Treatment Postoperative treatment for biceps tendon repair and tenodesis are identical. I discourage active elbow flexion for 3 weeks. I then allow active elbow flexion and extension but do not allow flexion against resistance for 6 weeks after the operation. If I perform a tenotomy, there are no changes in the normal postoperative rehabilitation regimen for the primary operation, rotator cuff repair, arthroscopic subacromial decompression, or de´bridement of an irreparable rotator cuff tear.

DISCUSSION

Figure 5-76

Cut the tendon.

Surgeons now recognize that the biceps has an important role in the cause of shoulder pain and are performing more biceps tendon operations. Whether this represents an actual increase in our knowledge base or is simply a cyclical variation remains to be

174

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seen. It is not known which tenodesis technique is superior or whether any of these techniques provide better results than simple tenotomy. Surgeons must rely on their own experience, training, and judgment until science can guide us.

BIBLIOGRAPHY Ahmad CS, DiSipio C, Lester J, et al: Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon. Arthroscopy 23:537-541, 2007. Ahrens PM, Boileau P: The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 89:1001-1009, 2007. Armstrong A, Teefey SA, Wu T, et al: The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg 15:7-11, 2006. Barber A, Field LD, Ryu R: Biceps tendon and superior labrum injuries: Decision-marking. J Bone Joint Surg Am 89: 1844-1855, 2007. Boileau P, Ahrens PM, Hatzidakis AM: Entrapment of the long head of the biceps tendon: The hourglass biceps—a cause of pain and locking of the shoulder. J Shoulder Elbow Surg 13:249-257, 2004. Boileau P, Baque´ F, Valerio L, et al: Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am 89:747-757, 2007. Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Tech Shoulder Elbow Surg 2: 153-165, 2001. Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Arthroscopy 18:1002-1012, 2002. Boileau P, Neyton L: Arthroscopic tenodesis for lesions of the long head of the biceps. Oper Orthop Traumatol 17: 601-623, 2005. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I. Pathoanatomy and biomechanics. Arthroscopy 19:404-420, 2003. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part II. Evaluation and treatment of SLAP lesions in throwers. Arthroscopy 19:531-539, 2003. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III. The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19:641-661, 2003. Checchia SL, Doneux PS, Miyazaki AN, et al: Biceps tenodesis associated with arthroscopic repair of rotator cuff tears. J Shoulder Elbow Surg 14:138-144, 2005. Choi CH, Kim SK, Jang WC, Kim SJ: Biceps pulley impingement. Arthroscopy 20(Suppl 2):80-83, 2004.

Dines DM, Warren RF, Inglis AE: Surgical treatment of lesions of the long head of the biceps. Clin Orthop Relat Res 164:165-171, 1982. Gartsman GM, Hammerman SM: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16:550-552, 2000. Gartsman GM, Khan M, Hammerman SM: Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg Am 80:832-840, 1998. Gartsman GM, Taverna E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997. Gill HS, El Rassi G, Bahk MS, et al: Physical examination for partial tears of the biceps tendon. Am J Sports Med 35:1334-1340, 2007. Glueck DA, Mair SD, Johnson DL: Shoulder instability with absence of the long head of the biceps tendon. Arthroscopy 19:787-789, 2003. Hitchcock HH, Bechtol CO: Painful shoulder: Observation on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am 30:263-273, 1948. Holtby R, Razmjou H: Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: Comparison with arthroscopic findings. Arthroscopy 20:231-236, 2004. Jobe CM: Posterior superior glenoid impingement: Expanded spectrum. Arthroscopy 11:530-536, 1995. Kelly AM, Drakos MC, Fealy S, et al: Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med 33:208-213, 2005. Kibler WB: Scapular involvement in impingement: Signs and symptoms. Instr Course Lect 55:35-43, 2006. Kibler WB, Press J, Sciascia A: The role of core stability in athletic function. Sports Med 36:189-198, 2006. Kibler WB, Uhl TL, Maddux JW, et al: Qualitative clinical evaluation of scapular dysfunction: A reliability study. J Shoulder Elbow Surg 11:550-556, 2002. Kim SH, Yoo JC: Arthroscopic biceps tenodesis using interference screw: End-tunnel technique. Arthroscopy 21:1405, 2005. Klepps S, Hazrati Y, Flatow E: Arthroscopic biceps tenodesis. Arthroscopy 18:1040-1045, 2002. Kohn D: The clinical relevance of glenoid labrum lesions. Arthroscopy 3:223-230, 1987. Kuhn JE, Lindholm SR, Huston LJ, et al: Failure of the biceps superior labral complex: A cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy 19:373-379, 2003. Lafosse L, Reiland Y, Baier GP,et al: Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: A new classification based on arthroscopic observations. Arthroscopy 23:73-80, 2007. Lunn JV, Castellanos-Rosas J, Walch G: Arthroscopic synovectomy, removal of loose bodies and selective biceps tenodesis for synovial chondromatosis of the shoulder. J Bone Joint Surg Br 89:1329-1335, 2007.

Chapter 5

Maffet MW, Gartsman GM, Moseley B: Superior labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 23:93-98, 1995. Maier D, Jaeger M, Suedkamp NP, Koestler W: Stabilization of the long head of the biceps tendon in the context of early repair of traumatic subscapularis tendon tears. J Bone Joint Surg Am 89:1763-1769, 2007. Mazzocca AD, Bicos J, Santangelo S,et al: The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 21:1296-1306, 2005. Mazzocca AD, Rios CG, Romeo AA, Arciero RA: Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 21:896, 2005. Morgan CD, Burkhart SS, Palmeri M, Gillespie M: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 14:553-565, 1998. Motley GS, Osbahr DC, Holovacs TF, Speer KP: An arthroscopic technique for confirming intra-articular subluxation of the long head of the biceps tendon: The ramp test. Arthroscopy 18:E46, 2002. Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am 54:41-50, 1972. O’Donoghue DH: Subluxing biceps tendon in the athlete. Clin Orthop Relat Res 164:26-34, 1982. Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 18:483-487, 2002. Pagnani MJ, Deng XH, Warren RF, et al: Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 77:1003-1010, 1995. Post M, Benca P: Primary tendinitis of the long head of the biceps. Clin Orthop Relat Res 246:117-124, 1989.


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Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 22:121-130, 1994. Rodosky MW, Rudert MF, Harner CH, et al: Significance of a superior labral lesion of the shoulder: A biomechanical study. Trans Orthop Res Soc 15:276, 1990. Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 19:1137-1141, 2003. Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 4: 243-248, 1995. Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 6:274-279, 1990. Tuoheti Y, Itoi E, Minagawa H, et al: Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy 21:1242-1249, 2005. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL: The origin of the long head of the biceps from the scapula and glenoid labrum: An anatomical study of 100 shoulders. J Bone Joint Surg Br 76:951-954, 1994. Walch G, Boileau P, Noel E, et al: [Surgical treatment of painful shoulders caused by lesions of the rotator cuff and biceps, treatment as a function of lesions: Reflections on the Neer’s concept]. Rev Rhum Mal Osteoartic 58:247-257, 1991. Walch G, Noel E, Donell ST: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1:238-245, 1992. Walch G, Nove-Josserand L, Boileau P, Levigne C: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 7:100-108, 1998.

CHAPTER

6

Stiffness

There are four basic conditions that produce shoulder stiffness and are amenable to arthroscopic treatment: idiopathic adhesive capsulitis, diabetic stiff shoulder, and post-traumatic and postoperative stiffness. I discuss the treatment of the stiff, osteoarthritic shoulder in Chapter 7. Idiopathic adhesive capsulitis is widely believed to be a painful but self-limited condition that resolves after 1 to 2 years. Recent reports suggest that although many patients improve, they have significant limitations of movement and function. Additionally, those who suffer from disabling pain are unwilling to wait for their condition to resolve and inquire about operative treatment. Shoulder stiffness in diabetic patients seems to cause greater pain and is more refractory to nonoperative treatment than is idiopathic stiffness. The impairment from post-traumatic stiffness is directly related to the severity of the trauma. Postoperative stiffness can be the result of excessive scarring in the area of surgery (subacromial adhesions after rotator cuff repair, anterior glenohumeral capsule contracture after a Bankart procedure), but I have also seen profound glenohumeral joint contracture after surgery that does not violate the capsule (Figs. 6-1 through 6-3). One advantage of the arthroscopic technique is that it enables the release of intra-articular, subacromial, and subdeltoid adhesions without dividing the subscapularis. Active range of motion can be started immediately after surgery without concern for tendon dehiscence.

176

LITERATURE REVIEW Arthroscopic treatment is generally successful, with the degree of improvement related to the patient’s underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results. Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great

Figure 6-1

Postsurgical stiffness after rotator cuff repair.

Chapter 6

Stiffness

177

DIAGNOSIS

Figure 6-2

Postsurgical stiffness after a Bristow procedure.

as that seen in patients with idiopathic adhesive capsulitis.

CLINICAL PRESENTATION Patients with all types of adhesive capsulitis present with painful, limited shoulder motion. Pain at night interferes with sleep. Routine activities of daily living that require reaching overhead or behind the back are difficult and painful. Rapid movements cause especially severe pain. Most patients either recall a trivial antecedent injury or cannot identify an inciting event. Patients demonstrate restricted passive and active motion, with motion usually less than 50% that of the contralateral shoulder. Radiographs are usually normal, but mild osteopenia due to disuse is typical.

Figure 6-3 Post-traumatic and postsurgical stiffness after open reduction and internal fixation.

A number of other shoulder conditions that produce painful, limited motion can be eliminated by patient history, physical examination, and radiographic evaluation. Patients with rotator cuff tears present with passive motion greater than active motion, weakness on manual muscle testing, and abnormal magnetic resonance images or arthrograms. In patients with osteoarthrosis, plain radiographs depict loss of the glenohumeral joint space (Fig. 6-4). Patients with posttraumatic stiffness may have malunited fractures, and those with postoperative stiffness may have internal fixation devices that interfere with motion. It is important to obtain a thorough history that ascertains prior trauma or shoulder difficulties. Patients should also be asked about diabetes and thyroid dysfunction. Evaluate and record passive range of motion in elevation, abduction, and external rotation (in adduction with the arm at the side and in maximal allowable abduction). Measure internal rotation as the vertebral level to which the patient can reach with the extended thumb. Behind-the-back internal rotation is usually decreased, but it is occasionally close to normal because internal rotation measured in this manner includes not only glenohumeral movement but also scapulothoracic motion. With prolonged shoulder stiffness, scapulothoracic motion may increase to compensate for the loss of glenohumeral rotation. For this reason, I use a more sensitive technique that eliminates scapulothoracic motion: I stabilize the scapula with one hand and abduct the arm with the other. I then record external and internal rotation in this maximally abducted position and compare it with the contralateral shoulder. I assess muscle strength in elevation

Figure 6-4

Osteoarthrosis.

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and external rotation and obtain anteroposterior, axillary, and supraspinatus (scapular) outlet plain radiographs.

INDICATIONS FOR SURGERY As a general principle, I consider operation if the patient has persistent pain and stiffness after 6 months of appropriate nonoperative care. I define severe stiffness as 0 degrees of external rotation and less than 30 degrees of abduction; moderate stiffness is defined as a decrease of 30 degrees in either plane compared with the contralateral shoulder. Although it is clinically significant to the patient, I do not consider loss of internal rotation in any plane an indication for arthroscopic release. One exception is throwing athletes; in these patients, posterior contracture and decreased internal rotation may be the only lesion. I discuss the management of this special group in Chapter 5. If stiffness persists, but pain has diminished after 6 months, I continue nonoperative care for an additional 2 months in case the decrease in pain indicates that the stiffness is about to resolve or ‘‘thaw’’ spontaneously. If there is no improvement in the range of motion 2 months later, I consider operation. I have found external rotation to be the most important predictor of success or failure of nonoperative treatment. If external rotation remains at neutral or worse 4 to 6 months after the start of nonoperative treatment, I do not recommend further nonoperative management and consider operation. In my opinion, the persistent loss of external rotation to such a degree indicates a stiff shoulder that will not respond to nonoperative care, making earlier operative intervention advisable.

Figure 6-5

Myositis ossificans.

joint release. Patients with mildly malunited fractures of the greater tuberosity or proximal humerus can be treated arthroscopically, but those with badly malunited fractures or internal fixation require open release, removal of hardware, and fracture osteotomy, as indicated (see Fig. 6-3). Patients in the inflammatory or contracting phase of idiopathic adhesive capsulitis should not undergo operation because the surgery may accelerate the contracture. I measure range of motion sequentially and wait until the motion has stabilized. Myositis ossificans is a contraindication to arthroscopic release (Fig. 6-5).

OPERATIVE TECHNIQUE Contracture Release

CONTRAINDICATIONS TO SURGERY Contraindications to arthroscopic treatment apply mainly to patients with postoperative and posttraumatic stiffness. Patients who have had instability surgery with subscapularis takedown or shortening may develop profound soft tissue contracture. The contracture in these patients is typically extraarticular between the subscapularis and the conjoined tendon. I can often identify adhesions between the subscapularis and the conjoined tendon when the arthroscope is placed in the lateral subacromial portal. If this area cannot be well visualized, open release may be a necessary addition to an arthroscopic glenohumeral

Examination under Anesthesia After the induction of anesthesia, examine both shoulders for range of motion in elevation, abduction, and external rotation in adduction. Place the shoulder in maximal abduction, and record internal and external rotation.

Manipulation I attempt gentle closed manipulation (Figs. 6-6 through 6-11). It is difficult to quantify gentle, but I apply only a small amount of force to the shoulder in elevation and then in abduction. If the shoulder

Chapter 6

Figure 6-6

Elevation.

Figure 6-8

Stiffness

External rotation.

responds to closed manipulation, it should move with minimal force. If I think that motion is improving with abduction and elevation, only then do I attempt to externally rotate the shoulder. I externally rotate the shoulder in maximal abduction and then in adduction. If motion continues to improve, I begin internal rotation stretching—first internally rotating the shoulder in maximal abduction and, if the motion improves, then stretching the shoulder in cross-body adduction and finally behind-the-back internal rotation. The specific order of motion is important because external rotation and internal

Figure 6-7

Abduction.

Figure 6-9

External rotation of 90 degrees.

Figure 6-10

Internal rotation of 90 degrees.

179

180

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Inferior entry

Inferior

Figure 6-12 Location of joint entry. Figure 6-11

Adduction.

rotation involve torsion stresses and may cause a spiral fracture to the humerus. If the shoulder does not respond to abduction and elevation, I do not attempt any rotational movements and proceed directly to arthroscopy. If the shoulder responds to manipulation but full movement is not achieved, I perform arthroscopy and release the remaining adhesions. If full range of motion is obtained after manipulation, I insert the arthroscope and confirm that the capsule is completely released. I have observed a number of shoulders with full range of motion after manipulation but with persistent capsular contracture; in these cases, the manipulation released only the extra-articular adhesions.

Joint Entry Entry into the stiff shoulder is always difficult because, by definition, the joint volume is reduced. Forceful entry may damage the articular surfaces of either the glenoid or the humeral head. The joint is difficult to enter with a spinal needle because of the tight, thickened posterior capsule; in addition, the generalized capsular stiffness limits the amount of fluid that can be injected. I have had better success with a standard metal cannula and a rounded trocar, which are larger and stiffer than a spinal needle. With these instruments, I can palpate the posterior glenohumeral joint line with greater ease. The entry position is critical. Joint entry through the traditional soft spot (at the level of the glenoid equator) increases the risk of cartilage surface damage. At this level, the glenohumeral joint

space is narrowest, making trocar entry difficult. I prefer to enter the joint superiorly, in an area bounded by the superior glenoid, the rotator cuff, and the humeral head, where the joint space is wider (Fig. 6-12). I incise the skin and insert the cannula and trocar until I can palpate bone. I then rotate the shoulder internally and externally to determine whether the trocar tip rests on the humeral head (movement detected) or glenoid (no movement). I lower my hand (and elevate the trocar tip) until I can palpate the superior glenoid rim. Only then do I attempt to enter the joint. If I cannot clearly palpate the interval between the humeral head and the glenoid, a plastic cannula and trocar may allow more forceful joint entry with a decreased risk of bone damage (Fig. 6-13). Once the arthroscope is in the glenohumeral joint, it is directed at the rotator interval. I insert a spinal needle anteriorly, lateral to the coracoid process, until I can see the needle enter the joint. I incise the skin and insert a plastic 5-mm cannula and trocar.

Rotator Interval The first step in the operation is to release the rotator interval (Figs. 6-14 and 6-15). I use a motorized soft tissue resector to do so. Insert the resector through the cannula into the joint; then back the cannula out of the joint, leaving the resector tip in the rotator interval. Soft tissue is excised from an area bounded by the biceps tendon medially, the superior border of the subscapularis tendon inferiorly, and the

Chapter 6

Figure 6-15

Stiffness

181

Synovitis of the rotator interval.

humeral head is properly located. If full range of motion is not achieved, or if motion has improved but the capsule is not completely divided, go to the next step. Figure 6-13

Palpate the bone to determine the entry point.

humeral head laterally. The coracoacromial ligament should be clearly visible as a shiny structure at the anterior border of the acromion. Reinsert the cannula into the joint and remove the resector. Withdraw the arthroscope from the posterior cannula in the joint, leaving the cannula in place, and attempt a closed manipulation as described earlier. If full range of motion is obtained, reinsert the arthroscope posteriorly and verify that the capsule is divided and that the

Figure 6-14 Contracted rotator interval.

Anterior Capsule Identify the point where the middle glenohumeral ligament crosses the subscapularis tendon. It is important to separate the subscapularis tendon from the middle glenohumeral ligament. I find electrocautery helpful to gradually divide the fibers of the middle glenohumeral ligament until the tendinous portion of the superior subscapularis is visualized. I then insert a blunt dissector anterior to the middle glenohumeral ligament to separate the two structures. I use a Harryman soft tissue punch (Smith-Nephew Endoscopy, Andover, Mass) to remove a 5- to 10-mm strip of anterior capsule. This includes the middle glenohumeral ligament and the superior portion of the anterior-inferior glenohumeral ligament. Electrocautery can also be used for this portion of the procedure (Figs. 6-16 through 6-22). I always use a blunt dissector to release any adhesions anterior and posterior to the subscapularis (Figs. 6-23 and 6-24). No harm is done if the surgeon resects the superior tendinous border of the subscapularis, particularly in the area of the coracohumeral ligament. Usually a small amount of increased lateral humeral head displacement is possible. I then advance the arthroscope anteriorly and inferiorly so that I have a better view of the posterior portion of the anteriorinferior glenohumeral ligament and the inferior capsule. I advance the punch, placing the bottom,

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Section Two


Figure 6-16

Contracted anterior capsule.

Figure 6-18 Divide the superior portion of the middle glenohumeral ligament.

blunt jaw exterior to the capsule, and divide the capsule from anterior to posterior as far from the glenoid labrum as possible (Figs. 6-25 through 6-32). The level at which I stop the inferior-anterior release depends on the amount of axillary pouch contracture. A tight pouch limits the degree to which I can safely advance the punch without applying excessive distraction to the glenohumeral joint. This is usually at about the 5-o’clock position for a right shoulder. To access and safely release the axillary pouch, I treat the posterior and inferior-posterior areas of the capsule. I keep the punch and capsular resection adjacent to the glenoid and try to maintain Figure 6-19 Cauterize the middle glenohumeral ligament covering the subscapularis.

Identify the superior portion of the middle glenohumeral ligament.

Figure 6-17

Figure 6-20 Cauterize the middle glenohumeral ligament covering the subscapularis.

Chapter 6


Stiffness

183

Figure 6-23

Blunt dissector anterior to the subscapularis.

Figure 6-24

Blunt dissector posterior to the subscapularis.

the arm in slight abduction and external rotation to protect the axillary nerve. I remove the soft tissue punch and cannula from the anterior portal and insert a metal cannula and trocar in their place. I remove the arthroscope from the posterior portal and insert it anteriorly. Under direct vision, I insert the small plastic cannula and trocar posteriorly. The glenohumeral joint is usually too contracted to allow the insertion of a larger-diameter cannula. I insert a motorized shaver and resect 5 to 10 mm of posterior capsule, beginning superiorly and moving inferiorly. Once I have resected the posterior capsule, I can easily insert a large-diameter


Figure 6-25

Contracted inferior capsule.

184

Section Two

Figure 6-26


Capsular punch in the anterior-inferior capsule.

Figure 6-29

Complete the posterior capsule resection with

a punch.

cannula that will accommodate the capsular resection punch. I insert the punch and resect a 10-mm strip of the posterior-inferior capsule 5 to 10 mm from the glenoid labrum to avoid any damage to it. The last step in the intra-articular portion of the procedure is complete release of the inferior capsule. Often, surgical division is not necessary because the last portion of the capsule can be released through manipulation. The use of manipulation avoids the placement of instruments near the axillary nerve. After I manipulate the shoulder, I insert the arthroscope to inspect the gap between the resected Figure 6-27

Shaver resecting the posterior capsule.

Return the arthroscope to the posterior portal and complete the inferior capsule resection.


Insert the large cannula posteriorly.

Chapter 6


Stiffness

185

Remove subacromial adhesions, if present.

Inferior capsule resection.

edges of the capsule and to confirm that the humeral head is normally located. If I cannot gain full range of motion with manipulation, I insert the arthroscope posteriorly and the cannula and punch anteriorly and resect the inferior capsule.

cuff or coracoacromial ligament fraying. By definition, a patient with adhesive capsulitis cannot move his or her shoulder into the positions consistent with the clinical diagnosis of impingement. The raw acromial bone surface produced after acromioplasty creates the opportunity for postoperative adhesions and should be avoided.

Subacromial Space I introduce the arthroscope into the subacromial space. If the subacromial space is not clearly seen, I insert a motorized soft tissue resector and remove bursa and adhesions (Fig. 6-33). I do not advise an acromioplasty even if there is arthroscopic evidence of impingement, such as rotator

Figure 6-32

Inferior capsule resection.

POSTOPERATIVE CARE I use pharmacologic techniques to reduce postoperative inflammation and adhesion formation. After I confirm the diagnosis of capsular contracture arthroscopically, but before I begin soft tissue resection, the anesthesiologist gives the patient 100 mg hydrocortisone sodium succinate intravenously. I do not use intra-articular cortisone at the conclusion of the procedure because operative resection of the capsule causes the steroid to extravasate and lose its effectiveness. In patients with post-traumatic or postsurgical stiffness and subacromial adhesions requiring release, I inject 100 mg hydrocortisone sodium succinate (Solu-Cortef) into the subacromial space at the conclusion of the operation. Postoperatively, I place the patient on a methylprednisolone (Medrol) Dosepak. I do not use steroids in diabetic patients. I admit patients to the hospital overnight. I do not place the arm in a sling or immobilizer. A pillow is placed under the axilla to keep the arm away from the chest, and the patient and nursing staff are encouraged to avoid placing the patient’s arm in internal rotation. Beginning on the afternoon of surgery, I use a continuous passive motion chair to maintain the full range of motion gained at surgery. I find it extremely helpful

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to visit the patient on the afternoon of surgery and demonstrate that he or she now has full range of motion. This is easily done because the patient’s shoulder is still anesthetized from the interscalene block. This visual demonstration of full movement impresses on the patient that the operation was successful. I emphasize that complete recovery depends on adherence to the postoperative rehabilitation program. Upon discharge from the hospital, the patient uses the continuous passive motion chair four times a day for 1 hour each session. This continues for 2 weeks. I then see the patient in the clinic, and if movement is satisfactory, chair use is discontinued. Passive elevation while supine and external rotation with the aid of a dowel or pulley are continued. The patient is encouraged to use the arm for all activities and motions that are comfortable. I see the patient again at 6 weeks, 3 months, and 6 months after surgery. If the patient has not achieved full range of motion by 3 months, I offer a repeat contracture release. At this point, however, usually only a gentle closed manipulation is necessary.

BIBLIOGRAPHY Berghs BM, Sole-Molins X, Bunker TD: Arthroscopic release of adhesive capsulitis. J Shoulder Elbow Surg 13: 180-185, 2004. Buchbinder R, Green S, Youd JM: Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev (online) 1:CD004016, 2003. Buchbinder R, Green S, Youd JM, Johnston RV: Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev (online) 4:CD006189, 2006. Ponti A, Vigano` MG, Taverna E, Sansone V: Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy. J Shoulder Elbow Surg 15:188-190, 2006. Diwan DB, Murrell GA: An evaluation of the effects of the extent of capsular release and of postoperative therapy on the temporal outcomes of adhesive capsulitis. Arthroscopy 21:1105-1113, 2005. Green S, Buchbinder R, Hetrick S: Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev (online) 2:CD004258, 2003. Green S, Buchbinder R, Hetrick S: Acupuncture for shoulder pain. Cochrane Database Syst Rev (online) 2:CD005319, 2005. Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 82:1398-1407, 2000. Harryman DT II: Shoulders: Frozen and stiff. Instr Course Lect 42:247-257, 1993.

Harryman DT II: Arthroscopic management of shoulder stiffness. Oper Tech Sports Med 5:264-274, 1997. Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 13:133-147, 1997. Harzy T, Benbouazza K, Amine B, et al: Idiopathic hypoparathyroidism and adhesive capsulitis of the shoulder in two first-degree relatives. Rev Rhum 71:234-236, 2004. Ide J, Takagi K: Early and long-term results of arthroscopic treatment for shoulder stiffness. J Shoulder Elbow Surg 13:174-179, 2004. Jerosch J, Filler TJ, Peuker ET: Which joint position puts the axillary nerve at lowest risk when performing arthroscopic capsular release in patients with adhesive capsulitis of the shoulder? Knee Surg Sports Traumatol Arthrosc 10:126-129, 2002. Levine WN, Kashyap CP, Bak SF, et al: Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg 16:569-573, 2007. Loew M, Heichel TO, Lehner B: Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg 14:16-21, 2005. Mullett H, Byrne D, Colville J: Adhesive capsulitis: Human fibroblast response to shoulder joint aspirate from patients with stage II disease. J Shoulder Elbow Surg 16:290-294, 2007. Ogilvie-Harris DJ, Myerthall S: The diabetic frozen shoulder: Arthroscopic release. Arthroscopy 13:1-8, 1997. Quraishi NA, Johnston P, Bayer J, et al: Thawing the frozen shoulder: A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br 89:1197-1200, 2007. Richards DP, Glogau AI, Schwartz M, Harn J: Relation between adhesive capsulitis and acromial morphology. Arthroscopy 20:614-619, 2004. Scarlat MM, Harryman DT II: Management of the diabetic stiff shoulder. Instr Course Lect 49:283-293, 2000. Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am 74:738-746, 1992. Warner JJP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg 5:130-140, 1997. Warner JJP, Answorth A, Marks PH, Wong P: Arthroscopic release for chronic refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am 78:1808-1816, 1996. Warner JJP, Greis PE: The treatment of stiffness of the shoulder after repair of the rotator cuff. J Bone Joint Surg Am 79:1260-1269, 1997. Warner JJP, Goitz JJ, Groff YJl: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 79:1151-1158, 1997. Wolf JM, Green A: Influence of comorbidity on self-assessment instrument scores of patients with idiopathic adhesive capsulitis. J Bone Joint Surg Am 84:1167-1173, 2002. Yamaguchi K, Sethi N, Bauer GS: Postoperative pain control following arthroscopic release of adhesive capsulitis: A short-term retrospective review study of the use of an intra-articular pain catheter. Arthroscopy 18:359-365, 2002.

CHAPTER

7

Arthrosis

Arthroscopic treatment of glenohumeral arthrosis is a controversial subject with little scientific evidence to guide orthopedic surgeons. At present, the surgical options are limited, but with increased knowledge and technology, this will inevitably change. Surgeons encounter diverse lesions, including minor areas of chondromalacia in patients with glenohumeral instability, loose bodies in osteochondromatosis, areas of full-thickness cartilage loss, and osteophytes in patients with avascular necrosis, rheumatoid arthritis, or osteoarthrosis.

DIAGNOSIS The diagnosis of osteoarthrosis, rheumatoid arthritis, or avascular necrosis is made clinically with a combination of patient history, physical examination, laboratory tests, and plain radiographs. I do not use arthroscopy to evaluate the glenohumeral joint and stage the disease. There are situations in which cartilage lesions are unsuspected, and I find them during arthroscopic treatment for impingement, rotator cuff tear, or glenohumeral instability. These unsuspected lesions are usually small, and treatment is directed at removing loose bodies and de´briding unstable cartilage flaps. The role of microfracture and marrow stimulation is unproved at this time.

response and physical therapy to maintain or improve shoulder range of motion and strength.

INDICATIONS FOR SURGERY Surgical indications vary with the underlying disease process. Arthroscopic synovectomy may be beneficial in the treatment of early rheumatoid arthritis. Synovectomy may retard the disease process and produce results similar to those seen in the rheumatoid knee, elbow, and wrist (Fig. 7-1). The earliest stage of avascular necrosis may be amenable to arthroscopic de´bridement and humeral head drilling. Before subchondral and articular surface collapse (stage 1 and early stage 2 disease), core decompression may produce outcomes similar to those

NONOPERATIVE TREATMENT Nonoperative treatment is largely palliative and consists of medication to diminish the inflammatory

Figure 7-1

Rheumatoid arthritis.

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Figure 7-2

Avascular necrosis. Figure 7-4

in the hip. The potential for success may be greater than in the hip because the glenohumeral joint is nonweight bearing (Fig. 7-2). De´bridement of cartilage flap tears may help a patient with chondromalacia whose symptoms are caused by mechanical locking and catching (Figs. 7-3 through 7-5). Loose bodies in osteochondromatosis may cause mechanical symptoms, and pain relief can be substantial following their removal. The surgeon should carefully inspect the subcoracoid space and the bicipital sheath, where loose bodies may be overlooked. The biceps sheath should be inspected distally to the level of the pectoralis major tendon insertion. Osteoarthrosis is probably the most common clinical cause of glenohumeral incongruity seen in the

Figure 7-3

De´bridement of cartilage fragments.

De´bridement of a cartilage lesion.

office. The source of pain in osteoarthrosis is multifactorial and consists of joint surface irregularity, mechanical disturbances from loose or displaced labrum fragments, loose bodies, and joint contracture (Figs. 7-6 through 7-9). Arthroscopic lavage reportedly achieves temporary, limited pain relief owing to either the placebo effect or alterations in the chemical composition of the glenohumeral joint fluid. Patients return to their baseline states relatively quickly, however, and I do not perform or advise such procedures. If a surgeon wishes to treat a patient with glenohumeral arthrosis arthroscopically, the approach must be comprehensive and include removal of loose bodies and labrum fragments, release of soft tissue contracture, and restoration of joint surface congruity, including de´bridement of glenoid and humeral head osteophytes if necessary.

Figure 7-5

Glenoid cartilage defect.

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Joint contracture Capsule Coracohumeral lig.

Surface irregularity Loose bodies

Mechanical Labrum fragments

Figure 7-9

Figure 7-6

Osteoarthrosis.

Sources of pain in osteoarthrosis.

Unless the surgeon is capable of dealing with all these elements, an arthroscopic approach is unwarranted. The surgeon must also carefully explain the investigational nature of the procedure to the patient. Within these confines, the indications for arthroscopic treatment are lmited.

CONTRAINDICATIONS TO SURGERY

Figure 7-7

Loose bodies.

Contraindications to the arthroscopic treatment of arthrosis also vary with the underlying disease process. Synovectomy does not benefit a patient with articular incongruity. Core decompression cannot be expected to reverse bone collapse. De´bridement of a small labrum tear will not help a patient with osteoarthrosis. I have treated many patients with pain and stiffness from osteoarthritis who have undergone manipulation—an approach that should be abandoned. Orthopedic surgeons must appreciate that although idiopathic adhesive capsulitis and osteoarthritis both produce pain and decreased range of motion, they have different causes and require different treatments. Arthrosis patients have capsular contractures, as do patients with adhesive capsulitis, but extra-articular adhesions and articular incongruity are important additional causes of their shoulder stiffness.

CHONDRAL LESIONS

Figure 7-8

Osteoarthrosis at arthroscopy.

My approach is conservative for chondral lesions. I remove loose pieces and flap tears but do not drill or microfracture the bone surface. I gently abrade areas of cortical bone.

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OSTEOARTHRITIS Glenohumeral Joint Arthrosis Microfracture After the administration of anesthesia, I examine the shoulder for range of motion but do not attempt a closed manipulation. I establish standard posterior and anterior portals and perform a complete glenohumeral joint inspection, observing in particular the presence and extent of cartilage loss, labrum flap tears, rotator cuff fraying or tearing, and capsular contracture. Entry into the glenohumeral joint is always difficult owing to the loss of joint space from absent articular cartilage and soft tissue contracture. I insert the posterior cannula and trocar first and place the entry point more superior than normal, just inferior to the posterior acromion and about 2 cm medial to the posterolateral corner of the acromion. The superior portal allows easier access to the glenohumeral joint at the level of the superior glenoid, so the trocar does not have to enter the joint between the humeral head and glenoid (Fig. 7-10). If the glenohumeral joint is particularly tight, I enter the joint with a plastic cannula and trocar so as not to penetrate the scapula or the humeral head. I prefer a plastic cannula and trocar to minimize articular damage, but often the capsule is so thick that the plastic trocar cannot penetrate it. The anterior capsule is also difficult to penetrate, and it is sometimes necessary to use only the metal trocar (without the cannula) to create an entrance to the glenohumeral

Figure 7-11

Rotator interval de´bridement.

joint. I use a standard shaver to de´bride the rotator interval and any labrum tears (Fig. 7-11). I then perform a complete capsule release anteriorly, posteriorly, and inferiorly. I pay particular attention to the subscapularis because my experience with shoulder arthroplasty has convinced me how critical it is to restore subscapularis muscle excursion. The middle glenohumeral ligament is adherent to the posterior (articular) surface of the subscapularis, and I use cautery to identify the plane between the two structures (Fig. 7-12). A scissors is useful to divide firm bands of scar tissue. I then use a blunt dissector to sweep any adhesions off the subscapularis muscle. The next step is to release adhesions from the anterior surface of the subscapularis, for which the blunt dissector is particularly useful (Fig. 7-13).


Inferior entry

Inferior

Figure 7-10 There is more space for the trocar at the superior aspect of the glenohumeral joint.

Cautery to define the plane between the subscapularis and middle glenohumeral ligament.

Figure 7-12

Chapter 7

Soft tissue dissection anterior and posterior to the subscapularis.

Figure 7-13

The anterior and posterior capsule releases are similar to those I perform for adhesive capsulitis, but the inferior release is different. With adhesive capsulitis, the inferior capsule can often be released by shoulder manipulation after the division of the anterior and posterior capsule. Patients with arthrosis have an extremely thick inferior capsule, however, and such an approach is not successful. The inferior capsule must be divided with a capsular resector. This requires the surgeon to release the anterior-inferior capsule from an anterior approach and the posterior-inferior capsule from a posterior approach (Figs. 7-14 through 7-16). The third area of subscapularis release involves the connections between the subscapularis and the coracoid. This portion of the operation is performed with the

Figure 7-14

Anterior-inferior capsule release.

Figure 7-15

Arthrosis

191

Inferior-posterior capsule release.

arthroscope in the glenohumeral joint after the rotator interval has been opened. The coracohumeral ligament is thick and contracted, limiting subscapularis excursion. This area is not normally seen during routine glenohumeral joint arthroscopy but can be visualized arthroscopically with the technique described later. After I excise the contracted tissue, open the rotator interval, and remove adhesions from the anterior and posterior surfaces of the subscapularis, the coracoid process comes into view. With a scissors or blunt dissector I release any connections between the superior surface of the subscapularis and the coracoid (Fig. 7-17). This completes the soft tissue release. Next, I turn my attention to the bone surfaces of the glenoid and the humeral head.

Figure 7-16 Posterior capsule release.

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Figure 7-17 Coracohumeral ligament release. Figure 7-18 Bur in the posterior portal as viewed from the anterior portal.

The degree and type of glenoid wear can be seen on preoperative imaging studies. There are two types of glenoid abnormalities that are amenable to arthroscopic treatment. The first occurs when the glenoid conforms to the humeral head but the space is diminished. My goal is to increase the space between the two structures. In the second type of glenoid abnormality, there is posterior glenoid erosion or a step-off, usually resulting from chronic anterior contracture and posterior humeral head subluxation. I inspect the radiographs to determine both glenohumeral congruency and glenoid bone stock. To create more space between the humeral head and a conforming glenoid, I place the arthroscope posteriorly and the round bur through the anterior cannula. I begin removing bone 10 mm from the superior glenoid and remove a 1-mm strip from anterior to posterior. I then remove bone from that strip to the superior glenoid margin, taking care not to damage the biceps-labrum anchor. I complete the glenoid bone removal by leveling the glenoid from superior to inferior. It is usually necessary at some point to move the arthroscope anteriorly and the bur posteriorly to reach all areas of the glenoid and create a level surface. Matsen introduced the phrase ream and run for such treatment when he inserts a prosthetic hemiarthroplasty (Fig. 7-18). To form a conforming glenoid surface when there is a posterior step-off, I follow the same general technique as just described, beginning with the arthroscope in the posterior cannula and the power bur in the anterior cannula. I then remove the anterior surface from superior to inferior to eliminate the step-off and create a smooth, uniform surface (Figs. 7-19 through 7-23).

After operation, patients begin continuous passive motion in a motorized chair. They undergo 1-hour sessions in the chair four times a day for 2 weeks. During this time, active range of motion and activities are encouraged as much as pain allows. I continue to

A Remnant cartilage being abraded

Bone to be abraded

B Figure 7-19

abrasion.

A and B, Posterior step-off and area of bone

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A A

C

B Figure 7-20 A and B, Area of bone abrasion.

B Figure 7-22

A-C, Abrasion arthroplasty.

emphasize range of motion at each patient visit and start strengthening when manual muscle testing is painless. To monitor disease progression, plain anteroposterior and axillary radiographs are obtained every 3 months for the first year, every 6 months for the next year, and then yearly.

A Area to be abraded 2 mm

B Figure 7-21

Depth of bone abrasion.

Figure 7-23

A and B, Completed abrasion arthroplasty.

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The results in this carefully selected and counseled group of patients are preliminary, but so far, they have been gratifying. Approximately 50% report satisfaction with the procedure and experience a significant decrease in pain and an increase in motion and function. It is unknown whether the bone removal will compromise glenohumeral joint integrity to such an extent that humeral head medialization will occur. This has been reported by some surgeons. New approaches to arthritis in young patients are being developed and revolve around the interposition of material between the humeral head and the glenoid. These materials are either biologic (fascia lata and meniscal allograft) or synthetic (biologic ingrowth materials). Both types have vocal champions, but little science and experience are available to guide orthopedic surgeons. My technique for inserting the interposition is described in the steps described in the box. Joe de Beer has the largest experience with this type of operation.

RHEUMATOID ARTHRITIS As in other joints, synovectomy of the rheumatoid shoulder is most beneficial when carried out early in the disease process, before cartilage and bone have been destroyed and the rotator cuff eroded. The patient is staged according to the Steinbrocker radiographic and functional classification (Table 7-1). Subsequent patient evaluation allows the surgeon to reassess the disease progression. Patients in radiographic stages I and II and functional classes I and II have the best chance of benefiting from arthroscopic synovectomy and de´bridement. I enter the glenohumeral joint through a standard posterior portal and establish an anterior-inferior and then an anterior-superior cannula. Because of the bleeding that often occurs with rheumatoid synovectomy, the anterior-superior cannula is helpful for outflow. A pump is essential. I use a grasping forceps to remove large pieces of loose cartilage or soft tissue and a motorized resector to de´bride labrum flap tears.

Arthroscopic Graft Jacket Placement Graft Preparation Follow the manufacturer’s directions for hydrating the graft (which may require up to 30 minutes). Secure the graft jacket (after hydration) to the SMH Graft-Jacket Racket using No. 1 Ethibond sutures. (The appropriate graft jacket size is determined at the initial arthroscopy.)

Procedure Protocol

Position the patient in the beach-chair position. Prepare and drape the patient for a routine shoulder arthroscopy. Affix the Tornier proximal humeral fracture jig to the patient’s arm using a Coban-type wrap. Fix the Graft-Jacket Racket to the fracture jig, and position the device anterior and inferior to the shoulder. Perform a diagnostic arthroscopy from the posterior portal. Establish an anterior-inferior portal using a 10-mm cannula. Measure the size of the glenoid using the calibrated probe. (The hydrated graft jacket can now be cut to size and secured to the holder.) Open the rotator interval using a motorized shaver. Perform an abrasion arthroplasty of the glenoid surface with a round bur through the anterior portal. Insert a metal cannula into the anterior-superior position. Remove the arthroscope from the posterior cannula and insert it into the anterior-superior cannula to visualize the posterior-inferior glenoid. Complete the abrasion arthroplasty of the posterior-inferior glenoid with the small bur through the posterior portal. Insert a spinal needle percutaneously from the lateral position into the glenohumeral joint and through the supraspinatus tendon under arthroscopic visualization. Remove the needle, incise the skin, and insert a metal cannula and trocar into the joint. The arthroscope is now moved to this ‘‘trans-cuff’’ portal for visualization of the anterior and posterior glenoid. Remove the metal cannula and insert an 8-mm cannula into the anterior-superior portal. Insert an orange 5-mm cannula into the posterior portal. Insert a double-loaded bioabsorbable suture anchor through an accessory posterior-inferior portal (localized with a spinal needle) into the glenoid at the posterior-inferior quadrant (7-o’clock position on a right shoulder, and 5 o’clock on a left).

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Suture Passing

Use a crochet hook to pull the most inferior white suture out the anterior-inferior cannula. Pass the suture through the graft jacket at the corresponding position using a suture passer. Pull one limb of green suture through the anterior-inferior cannula. Pass this suture through the graft just superior and medial to the white strand using the Elite Pass. Tie a knot in the green suture, securing it to the graft jacket. Use a crochet hook to pull the superior white suture limb out the anterior-inferior cannula. Pass the strand through the graft using the Elite Pass. Secure the two white suture strands using a hemostat. The remaining strand of green suture should not be passed and should exit through the accessory portal. Insert a second double-loaded suture anchor in the posterior-superior quadrant (10 o’clock on a right shoulder, and 2 o’clock on a left) through an accessory portal (localized with a spinal needle) and repeat the previous nine steps. Insert a third suture anchor into the glenoid at the 12-o’clock position. Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula. Pass the suture through the graft jacket using the Elite Pass at the corresponding position. Pull one limb of green suture out the anterior-inferior cannula. Pass the suture through the graft inferior and medial to the previously passed white strand. Tie a knot in the green suture, securing it to the graft jacket. Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula. Pass the suture through the graft using the Elite Pass. Secure the white strands together using a hemostat. Pull the remaining green suture strand out the anterior-inferior cannula. Insert a fourth anchor into the anterior-superior quadrant of the glenoid (5 o’clock on a right shoulder, and 10 o’clock on a left) and repeat the previous nine steps. Insert a fifth anchor into the anterior-inferior quadrant of the glenoid (5 o’clock on a right shoulder, and 7 o’clock on a left). Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula. Pass the suture through the graft jacket using the Elite Pass at the corresponding position. Pull one limb of green suture out the anterior-inferior cannula. Pass the suture through the graft inferior and medial to the previously passed white strand. Tie a knot in the green suture, securing it to the graft jacket. Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula. Pass the suture through the graft using the Elite Pass. Secure the white strands together using a hemostat. Allow the remaining green suture to stay within the anterior-superior cannula.

Preparing to Insert the Graft Jacket

Pass all sutures through the graft and secure with hemostats. Remove the diaphragm from the anterior-superior cannula. Roll the graft jacket into a cylinder from superior to inferior. Keep all white sutures taut while passing the graft. Use a grasper to ‘‘push’’ the graft through the 10-mm cannula, and use the posterior green sutures exiting the accessory portals as traction sutures to ‘‘pull’’ the graft into the joint. Once the graft enters the joint, pull the anterior green sutures taut to flatten the graft.

Tying the Posterior-Inferior Sutures Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the posterior-inferior accessory portal. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Tying the Posterior-Superior Sutures Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the posterior-superior accessory portal. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Continued

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Section Two


Arthroscopic Graft Jacket Placement—cont’d Tying the Superior (12 o’clock) Suture

Use a loop grasper to pull the white sutures out through the anterior-superior cannula. Pass the loop grasper a second time to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Tying the Anterior-Superior Sutures

Use a loop grasper to pull the white sutures out through the anterior-superior cannula. Pass the loop grasper a second time to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Tying the Anterior-Inferior Sutures

Allow the sutures to remain in the anterior-inferior cannula. Use a loop grasper to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Completing the Procedure Remove the arthroscope. Close the portals using 3-0 Monocryl sutures. Apply sterile dressing.

Because the synovium is vascular, I prefer to use the thermal coagulation probe to ‘‘paint’’ all areas of proliferative synovitis before resection (Fig. 7-24). The whisker resector allows me to perform a thorough synovectomy without violating the glenohumeral joint capsule (Fig. 7-25). The Electroblade shaver, with its built-in cautery system, is extremely valuable in these situations. I prefer to start the synovectomy inferiorly and move to the anterior and then superior aspects of the joint. I move the arthroscope anteriorly and the resector posteriorly to complete the removal of soft tissue in the posterior-inferior and posterior regions. After carefully inspecting the subscapularis recess for additional synovitis or loose bodies, I remove the arthroscope and, through the same posterior incision, insert it into the subacromial space. Bursal proliferation is often profound. I remove the hypertrophic bursa and perform an arthroscopic subacromial decompression and acromioclavicular joint resection if indicated by clinical examination. Postoperative rehabilitation is identical to that described for the treatment of osteoarthritic glenohumeral joints.

AVASCULAR NECROSIS Arthroscopic treatment of avascular necrosis is limited to those individuals with stage 1 or early stage 2 disease, before any collapse has occurred. I place the guide pin from a hip compression set on the anterior shoulder and, with the use of fluoroscopic imaging, adjust the angle and direction of the pin until it is correctly positioned. I then mark the pin location on the lateral deltoid and incise the skin with a scalpel. To avoid injury to the axillary nerve, I use a hemostat to spread the deltoid fibers until I reach the lateral humeral cortex. A drill guide is placed into the wound until it rests on the humerus. I use biplane radiographic imaging to insert a guide pin in the center of the humeral head to within 3 mm of the articular surface. I place a cannulated drill over this and, under radiographic control, perform a single core decompression. Postoperatively, patients are allowed unlimited active and passive range of motion but no sports or heavy lifting for 3 months. I follow patients with serial radiographs or magnetic resonance imaging studies as needed.

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Table 7-1 STEINBROCKER RADIOGRAPHIC AND FUNCTIONAL CLASSIFICATION OF RHEUMATOID ARTHRITIS Radiographic Classification Stage I

No destructive change; osteoporosis and soft tissue change only

Stage II

Mild to moderate erosive change or joint space reduction

Stage III

Joint markedly narrowed (

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