SHOULDER ARTHROSCOPYSetup, Positioning And Portals

DR SAMEER ASHARASSISTANT PROFESSORORTHOPAEDICS DEPARTMENTG.G.GOVT.HOSPITAL JAMNAGARINDIA

HISTORICAL DEVELOPMENTS

• AS EARLY AS 1931, THE AMERICAN

SURGEON MICHAEL BURMAN EXAMINED 25 SHOULDER JOINTS IN CADAVERS WITH AN ARTHROSCOPE

• INITIALY -DIAGNOSTIC ONLY NOW - WELL ESTABLISED

THERAPEUTIC ROLE ALSO

INDICATIONS

• ROTATOR CUFF LESIONS

• SHOULDER INSTABILITIES

• LABRAL LESIONS

• LIMITATIONS OF MOTION

• BICEPS TENDON

• SUB ACROMIAN IMPINGEMENT

• AC JOINT PAIN

• INFECTION

• LOCKING

• LOOSE BODY

• CHRONIC PAIN

INSTRUMENTS

INSTRUMENTS

INSTRUMENTS

source- Arthrex website educational material; images are used just for educational purposes

OPERATING ROOM

FLUID

POSITIONING

• ADVANTAGES • FREE ACCESS TO THE SCAPULA• CONTROLLED AMOUNT OF ARM TRACTION• FACILITATES GLENO HUMERAL SURGERY

• DISADVANTAGES• NEED FOR TRACTION DEVICE (ARM HOLDER)• TIME CONSUMING• GREATER RISK OF POSITION-RELATED INJURIES• COMPLEX PADDING• COMPLEX DRAPING• DIFFICULT CONVERSION TO AN OPEN

PROCEDURE

POSITIONING• ADVANTAGES

• ALLOWS FOR RAPID CONVERSION TO AN OPEN PROCEDURE

• NORMAL VERTICAL ORIENTATION OF SHOULDER ANATOMY

• WELL SUITED FOR SUB-ACROMIAL PROCEDURES

• LOWER COST

• SAVES TIME

• FACILITATES DRAPING

• DISADVANTAGES• DIFFICULT OR POOR VISUALIZATION OF THE

MEDIAL SCAPULAR MARGIN

• RISK OF HYPOTENSION

CONTROL OF BLEEDING

Arthroscopic pump• Constant flow is maintained and pressure OF 60-70 MM HG

• Chances of extravasation and increase compartment pressure is high

• Be aware of the system you use regarding pressure mechanisms

1 ml of 1;1000 epinephrine in each 3000 ml bag of irrigation fluid if not contraindicated

Most effective method is hypotensive anaesthesia

PORTALS

SOME COMMON PORTALS-POSTERIOR

• POSTERIOR PORTAL • primary viewing portal used for diagnostic

arthroscopy

• LOCATION AND TECHNIQUE• located 2 cm inferior and 1 cm medial to

posterolateral corner of acromion

• portal may pass between infraspinatus (suprascapular nerve) and teres minor (axillary nerve) or pass through the substance of infraspinatus

• this is usually the first portal placed

• direct anteriorly towards tip of coracoid

SOME COMMON PORTALS-ANTERIOR

• ANTERIOR PORTAL

• function• viewing and subacromial decompression

• LOCATION & TECHNIQUE• lateral to coracoid process and anterior to AC joint• portal passes between rotator interval• Inside out or outside in

• THIS PORTAL IS USUALLY PLACED UNDER DIRECT SUPERVISION FROM THE POSTERIOR PORTAL WITH AID OF SPINAL NEEDLE

SOME COMMON PORTALS-LATERAL

• LATERAL PORTAL• FUNCTION

• SUBACROMIAL DECOMPRESSION

• LOCATION & TECHNIQUE

• LOCATED 1-2 CM DISTAL TO LATERAL EDGE OF ACROMIUM

• PORTAL PASSES THROUGH DELTOID (AXILLARY NERVE)

SOME COMMON PORTALS-SUPERIOR

• The superior portal (Neviaser portal, supraspinatus portal) is placed approximately 1 em medial to the acromion between the clavicle and scapular spine and is used for instrumentation or inflow.

• STRUCTURES AT RISK

• suprascapular nerve and suprascapular artery, located about 2 mm medial to this portal.

OTHER PORTALS

• Anterior superior portal. This portal is established just anterior to the biceps tendon.• Anterior inferior portal.

This portal is placed just proximal to the subscapularis tendon.Structures at risk from the anterior portals are- The cephalic vein and The musculocutaneousnerve.

• Posterior subacromial portal

• Anterior subacromial portal

COMPLICATIONS

POSITION AND DISTRACTION

• Lateral- pressure injury to ulnar nerve in arm and peroneal nerve in leg

• Beach chair-hypotension and CVA

• Traction- more than 8 kg of weight and more

than 450 of abduction can cause nerve palsy

PORTAL RELATED

• Cartilage lesions

• Nerve lesions

• Axilary- too posterior portal

• Supra scapular-too medial portal

• Musculo-cutaneous- keep anterior portals lateral to coracoid

TECHNIQUE RELATED

• Cuff tear

• Glenoid injury

• Acromian fracture

• Hardware breakage

• Infection

• Post operative haemarthrosis

DOCUMENTATION

• Must for any arthroscopic procedure

• Includes video recording and still images

• Images are powerful tool than description

• Pre and post procedure images are better for comparison.

SOME PIONEERS IN SHOULDER SURGERY

THANK YOU