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Shoulder and elbow

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Shoulder and elbow

  1. 1. Shoulder and Elbow Arthroscopy Indications and Limits Manos Antonogiannakis Director
  2. 2. Shoulder Arthroscopy first Where we are where we are heading for? www.shoulder.gr
  3. 3. History • 1931 First Cadaver Shoulder Arthroscopy Burman • 1974 First Shoulder Arthroscopy in vivo Johnson LL • 1982 First Arthroscopic repair Johnson LL of Shoulder Instability www.shoulder.gr
  4. 4. Diagnostic arthroscopy The way everything began back in the 80ies !!
  5. 5. Arthroscopy in its infancy
  6. 6. Diagnostic Arthroscopy • Distinguish Normal Anatomy • Anatomic Variants • Variation of GHLs • Sublaral Hole • Cord-like middle GHL • Buford Complex • Rotator Crescent Sign (cuff “ridge”) • SLAP lesions • Bursal side RC tears • Internal Impingement www.shoulder.gr
  7. 7. Glenohumeral Ligament Variations 66% - Well defined SGHL, MGHL & IGHL 7% - Confluent MGHL & IGHL 19% - Cordlike MGHL with a high riding attachment 8% - No discernable MGHL – IGHL but one confluent anterior capsular sheath
  8. 8. Diagnostic Tool • Bufford Complex www.shoulder.gr
  9. 9. Diagnostic Tool • Sublabral hole www.shoulder.gr
  10. 10. Diagnostic Tool • SLAP Lesions www.shoulder.gr
  11. 11. Diagnostic Tool • Internal Impingement www.shoulder.gr
  12. 12. Shoulder Arthroscopy the evolution of the technique Diagnostic Tool Final Treatment www.shoulder.gr From tool of the devil the treatment of choice of most shoulder pathologies
  13. 13. Therapeutic Arthroscopy • Rotator Cuff disease • Tears (Full, Partial, Intratendinous) • Calcifying Tendonitis • Instability • Anterior, Posterior, Multidirectional • Bony Bankart lesions • Glenoid defects • HAGL and reverse HAGL lesions www.shoulder.gr
  14. 14. Therapeutic Arthroscopy • SLAP lesions • Frozen Shoulder • AC joint • Arthritis • Dislocation • Biceps Pathology www.shoulder.gr
  15. 15. Arthroscopic Evolution Metal Anchors Absorbable Anchors Peek Anchors Single suture Double sutures www.shoulder.gr
  16. 16. Cuff repair Tendon to bone repair www.shoulder.gr
  17. 17. Rotator Cuff Single Row Double Row Triple Row Different Suture Passing techniques www.shoulder.gr
  18. 18. RC Arthroscopic Repair 1. Recognition, of the type of the tear 2. Retraction and releases 3. Repair Options: Anchors: metallic or absorbable Type of stitch: Mason-Allen, Mc Stitch, Mattress sutures, Horizontal mattress, Simple sutures Restoration of footprint: Double row or Single row www.shoulder.gr
  19. 19. Risk to Benefit Ratio • Rot cuff tears DO NOT heal spontaneously • Tear repairability • Think of Size, Elasticity and Chronicity • Fatty infiltration is not fully reversible www.shoulder.gr Operative Treatment Act aggressive and early
  20. 20. Act early try to avoid irreversible bad tissue quality.
  21. 21. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration www.shoulder.gr
  22. 22. ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR www.shoulder.gr
  23. 23. Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain
  24. 24. L-Shaped & U-Shaped Tears • Side to side sutures from medial to lateral • Progressively converge the margin of the tear lateral to bone bed • Closing 50% of a U-Shaped tear -> reduces strain at converge margin by a factor of 6 [Burkhart S]
  25. 25. Side to Side Repair Cuff repair www.shoulder.gr
  26. 26. Double Row Fixation Restoration of the footprint www.shoulder.gr
  27. 27. 1st Anchor Insertion – Medial Row www.shoulder.gr
  28. 28. Lateral Row 1st Anchor Insertion www.shoulder.gr
  29. 29. Inspection of Suture Position www.shoulder.gr
  30. 30. Final Repair Double row fixationDouble row fixation Stronger repair biologically attractive but Time consuming and of raised difficulty www.shoulder.gr
  31. 31. Massive Contracted Immobile Tears • No mobility from medial to lateral or from anterior to posterior • Subcategories: – Massive Contracted Longitudinal Tears – Massive Contracted Crescent Tears • Represent 9.6% of massive tears [Burkhart]
  32. 32. Massive Contractive Tears better mobilization techniques • Anterior Interval Slide and/or • Posterior Interval Slide
  33. 33. Massive Tears • Easily repaired • Difficult repair (anterior & posterior Slide) • Medialized repair • Impossible repair • Incomplete Repair • Graft Jackets • Tendon transfers
  34. 34. Rotator Cuff • Rot cuff tears that can be repaired with open techniques can be repaired with arthroscopic techniques also • Irreparable Tears: • Partial repair • Medialized repair • Grafts and substitutes • Tendon transfers www.shoulder.gr
  35. 35. Rotator Cuff Massive Tears www.shoulder.gr
  36. 36. Rotator Cuff Massive Tears www.shoulder.gr
  37. 37. Rotator Cuff Subscapularis Tear www.shoulder.gr
  38. 38. Rotator Cuff Subscapularis Tear www.shoulder.gr
  39. 39. Rotator Cuff Calcifying Tendonitis www.shoulder.gr
  40. 40. Rotator Cuff Calcifying Tendonitis www.shoulder.gr
  41. 41. Frozen Shoulder www.shoulder.gr
  42. 42. AC Joint Distal Clavicle Excision www.shoulder.gr
  43. 43. AC Joint • Dislocation www.shoulder.gr
  44. 44. Shoulder Instability www.shoulder.gr
  45. 45. The Spectrum of Instability Lesions – Minor instability with activity related pain – Recurrent subluxation – Recurrent dislocation – Locked dislocation with loss of motion
  46. 46. Bankart Lesion
  47. 47. Bankart Lesion the essential lesion  Avulsion of the IGHL from the glenoid rim from 2 o’clock to 6 o’clock  Primary restraint to anterior translation at 90o of abduction  85% in traumatic anterior dislocations  Not enough to induce symptomatic instability
  48. 48. ALPSA lesion
  49. 49. humerus Bankart lesion glenoid 1. Identify and Define Pathology
  50. 50. Our findings in first shoulder dislocation • Hemarthrosis 100% • Bankart 78.2% • Bony Bankart 13.04% • Hill-Sachs 65.21% • capsular laxity 8.69% • SLAP lesions 21.73% C. Yiannakopulos E Mataragas E.Antonogiannakis Arthroscopy Sep 2007
  51. 51. Arthroscopic Shoulder Reconstruction Goal of the Operation: Define the pathology Restoration of the Labrum to its anatomic attachment Reestablishment of the appropriate tension in the IGHL complex and capsule Repair bony Bankart and large Hill-Sachs lesions Repair SLAP lesions Repair rot cuff tears
  52. 52.  Patients of all ages and all activity levels with recurrent anterior instability who are impaired functionally and in whom nonoperative treatment has failed  Revision stabilization  First-time, acute shoulder dislocations Arthroscopic Shoulder Stabilization Patient Selection
  53. 53. Instability Anterior Instability – Bankart Lesion www.shoulder.gr
  54. 54. humerus labrum completed repair 6. Assessment of the Final Repair
  55. 55. SLAP repair
  56. 56. Instability Posterior Instability www.shoulder.gr
  57. 57. Instability • Posterior Instability www.shoulder.gr
  58. 58. Posterior capsule reefing
  59. 59. Posterior Instability
  60. 60. Posterior Instability
  61. 61. Instability • Multidirectional Instability www.shoulder.gr
  62. 62. Multidirection instability Plication of the posterior capsule
  63. 63. Instability Anterior Instability. Bony defects – Hill Sachs www.shoulder.gr
  64. 64. Instability Anterior Instability –Hill Sachs -Remplisage www.shoulder.gr
  65. 65. Instability Anterior Instability – Hill Sachs -Remplisage www.shoulder.gr
  66. 66. Instability Anterior Instability. Bony defects Glenoid bone loss
  67. 67. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  68. 68. The normal glenoid shape
  69. 69. Inverted pear glenoid
  70. 70.  Glenoid Bone Loss > 30%  Engaging Hill-Sachs  HAGL lesions Limitations of the Arthroscopic Techniques
  71. 71. Future of instability repair • HAGL lesions can be repaired with arthroscopic techniques • Engaging Hill-Sachs. The remplisage technique of Eugene Wolf
  72. 72. Future of instability repair Glenoid bone loss: • arthroscopic bone grafting described by E. Taverna • Arthroscopic coracoid transfer described by L. Laffosse
  73. 73. Arthroscopic success rate • Savoie 1997 93% • Burchart, De Bear 2000 96% • J Tauro 2000 93% • Kim 2003 96% • Snyder 2006 93% • Fabbriciani 2004 100%
  74. 74. Trends in arthroscopic surgery •Mechanically stronger repair techniques •Arthroscopic techniques for tendon substitutes •Better tendon mobilization techniques • Arthroscopic repair of Bone defects in instability surgery www.shoulder.gr
  75. 75. Conclusion Today, apart from Shoulder Replacement and major Shoulder Fractures, nearly all Shoulder Pathology can be treated With arthroscopic techniques www.shoulder.gr
  76. 76. Conclusion Literature suggests equal or better results than Open Surgery www.shoulder.gr
  77. 77. Conclusion Combined with Lower Morbidity Day Case surgery Smalls Incisions No Deltoid injury Earlier Mobilization Less Pain Earlier Return to Daily Activities Better Understanding of Shoulder Pathology www.shoulder.gr
  78. 78. Elbow arthroscopy • 1931 Burman concluded the elbow joint is not suitable for arthroscopic examination • Confind space, complex articulation, proximity of major neurovascular structures • Today an accepted technique to treat intraarticular pathology with expanding indications
  79. 79. Elbow clinical examination-medial compartment • Valgus instability check with the elbow in 30o of flexion and the arm in full supination-possible ulnakr collateral injury • Palpate medial epicondyle and and proximal flexor pronator mass • Test resisted wrist flexion and elbow pronation and • Palpate the ulnar nerve and check for Tinel sign • Flex and extend the elbow as the nerve is palpated to detect nerve subluxation
  80. 80. Elbow examination posterior compartment • Check for pain in the posterolateral and posteromedial side of the olecranon • Stabilize the arm and extend the elbow forcefully to check for compression of the olecranon in its fossa
  81. 81. Elbow clinical examination –lateral compartment • Palpate the lateral epicondyle • Pain in resisted elbow supination and wrist extension for lateral epicondylatis • Palpate the radiocapitellar joint while pronating and supinating the hand to check for crepitus and pain
  82. 82. Elbow Arthroscopy - Contraindications • Bony Ankylosis • Coagulopathy • History of nerve transposition or muscle/tendon transfer
  83. 83. Elbow Arthroscopy – Patient Positioning • Prone • Supine • Lateral decubitus
  84. 84. Positioning
  85. 85. Topographic anatomy
  86. 86. Capsular volume may be as little as 6 mL in elbows with capsular contracture
  87. 87. Prone Elbow Arthroscopy Advantages • Best access to posterior portal • No arm support necessary Disadvantages • More difficult anesthesia • Difficult to convert to open • Image reversal
  88. 88. Lateral decubitus elbow arthroscopy • Same advandages with the prone position • It does not compromise the airway
  89. 89. Prone Elbow Arthroscopy
  90. 90. Supine Elbow Arthroscopy Advantages • Best anterior access • Easier anesthesia • Easy conversion to open • Familiar arm support (shoulder holder) Disadvantages • Difficult posterior access and orientation • Posterior scope-under fogging
  91. 91. Supine Elbow Arthroscopy
  92. 92. Supine Elbow Arthroscopy
  93. 93. Elbow Arthroscopy – Portals • Anterior –Proximal Medial (superomedial) –Anteromedial –Anterolateral –Midlateral –Proximal lateral • Posterior –Soft Spot (direct lateral) –Posterolateral –Trans-Triceps Tendon (straight posterior)
  94. 94. Location of medial and lateral portals with respect to key neurovascular structures
  95. 95. Anteromedial Portal •2 cm. distal and 2 cm. anterior to the medial epicondyle in line with the joint •Passes through common flexor origin (2 cm. distal, 2 cm anterior - Lynch, Whipple, Meyers)
  96. 96. Anteromedial Portal Best Visualization for: • Radiocapitellar Joint • Coronoid Fossa • Trochlea • Anterior Capsule
  97. 97. Anteromedial Portal At Risk • Median (19mm distended, 12mm non- distended) – sheath lies in contact with nerve in 56% of extended elbows • Brachial Artery
  98. 98. Anteromedial View
  99. 99. Proximal Medial Portal • Usually start medially • 2-3 cm. Proximal to the Medial Humeral epicondyle • Just Anterior to the Medial Intermuscular Septum
  100. 100. Proximal Medial Portal
  101. 101. Proximal Medial Portal At Risk • Ulnar Nerve • MABC Nerve • Median • Brachial Artery
  102. 102. Proximal Medial Portal Best Visualization for: • Radiocapitellar joint • Coronoid • Trochlea • Radio-ulnar joint • Anterior capsule
  103. 103. Anterolateral Portal 2 cm. anterior and 2 cm. distal to the lateral epicondyle Passes through ECRB and Supinator posterolateral to radial nerve (3cm distal and 2cm anterior Andrews and Carson)
  104. 104. Anterolateral Portal Best Visualization for: • Coronoid • Trochlea • Radioulnar articulation • Anterior Capsule
  105. 105. Anterolateral Portal At Risk • Radial Nerve (as close as 3 mm) • PIN (1 to 13 mm increasing with pronation) • Posterior Antebrachial Cutaneous Nerve (2mm) • Out of favor due to proximity of the radial nerve
  106. 106. Midlateral and proximal anterolateral portal • Miblateral 2 cm direct anterior to the epicondyle • Proximal anterolateral 2 cm proximal and 1 cm anterior to the epicondyle • Both provide good visualazation of the anterior ulnohumeral and radiocapitellar joint but the proximal anterolateral portal is safer
  107. 107. Soft Spot Portal Center of triangle formed by the radial head, lateral epicondyle, and olecranon Passes through anconeus and triceps Posterior Antebrachial Cutaneous Nerve (7 mm average)
  108. 108. Soft Spot Portal Best Visualization • Posterior Surface of Radial Head • Posterior Capitellum • Radial Surface of Olecranon
  109. 109. Soft Spot Portal Trochlea (above) Radial Head (left) Olecranon Bare Spot Tip of Olecranon (right)
  110. 110. Posterolateral Portal Best Visualization for: • Olecranon Process • Olecranon Fossa • Posterior Ulnar Gutter
  111. 111. Posterolateral Portal Radiocapitellar Articulation
  112. 112. Elbow Arthroscopy - Indications • Loose Bodies removal • DJD - Debridement and Osteophyte Removal • Capsular Contracture • OCD • Synovectomy • Radial head excision • Olecranon Bursectomy (Kerr) • Septic Arthritis • Internal Fixation • Lateral Epicondyle Release www.shoulder.gr
  113. 113. Low Advanced Most experienced only Diagnostic arthroscopy Loose body removal Plicae excision Debridement of OCD • Synovectomy • Capsulotomy • Radial head excision • Lateral epicondylitis release • Capsulectomy • Osteocapsular arthroplasty • Fracture fixation Level of Experience www.shoulder.gr
  114. 114. 1. Synovectomy Synovectomy and removal of any soft tissue that may block motion due to its bulk, such as scar tissue in the
  115. 115. Removal of loose bodies and osteophytes
  116. 116. 3. Radial Head Excision
  117. 117. 5. Excision of Spurs
  118. 118. Elbow Arthroscopy – Advantages • Excellent Visualization • Smaller Scars • Rapid Return To Function
  119. 119. Elbow Arthroscopy - Disadvantages Technique Depended Relatively few cases Steep learning curve
  120. 120. Conclusions • Elbow arthroscopy is a difficult procedure with a steep learning curve • As experience is gained indications are expanding • Start with easier procedures and stay in the safe side

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