Arthroscopic approaches, patient positioning, portals

1. SHOULDER ARTHROSCOPY
DR. MUHAMMAD JAWAD
PGT ORTHOPEDICS
SHL

2. INTRODUCTION
• Modern era of management of shoulder pathology began in the
1930s with the work of Codman
• Significant contributions to understanding of rotator cuff pathology
originated with Neer
• Bankart and Rowe - the major proponents of concepts underlying the
current understanding of shoulder instability.
• Arthroscopy of the shoulder did not become routine practice until the
1980s
• Developments in technology - routine use of arthroscopy

3. PREOPERATIVE CONSIDERATIONS
• Review all pertinent medical records
• Athorough history and physical examination
• Appropriate imaging to confirm the diagnosis
to reduce the risk of surprises
• Anesthesia - general, general with regional nerve blocks, or regional
anesthesia alone.
• Examination under anesthesia (EUA)
• Systematic examination should be performed including evaluation of
ROM and stability of the shoulder

4. PATIENT POSITIONING
• THE LATERAL DECUBITUS.
• In the supine position - general anesthesia and examination.
• The patient is placed in the lateral decubitus position using a bean
bag, often rotated backward 20 degrees. An axillary roll - to protect
the brachial plexus and padding is placed between the down leg and
table, as well as between the knees, as all bony prominences must be
well padded
• Arm is placed in sterile traction device with the arm in 45 to 70
degrees of abduction and 20 to 30 degrees of forward flexion. A 10 to
15 lbs of traction is usually adequate.

5. LATERAL DECUBITUS POSITION
Dual traction for distraction of glenohumeral joint with minimal inferior
subluxation. Wide 4-inch sling should be used; amount of traction and length of
procedure should be monitored.

6. • All arthroscopic shoulder procedures can be performed from this
position, with posterior shoulder stabilization a little easier in the
lateral decubitus position
• Higher risk of neuropraxia
• Conversion to an open procedure may require repositioning and re-
draping the patient
• Regional anesthesia by itself is often not well tolerated in this
position.

7. BEACH CHAIR
• Patient is placed supine and an examination under anesthesia is performed .
• Then placed in a beach chair position
• Be careful to monitor the blood pressure
• Be careful of the neck position and head support
• Protect the elbow/ulnar nerve of both arm
• Easier for anesthesia control during surgery
• Position makes conversion to open procedure easier.
• Risk of cerebral hypoperfusion with hypotensive anesthesia as well as the small
risk of air embolism
• Difficulty performing posterior stabilization
• Easier to perform dynamic assessment (no traction to remove from the arm)

9. CONTROL OF BLEEDING
• 3 techniques can help
1. Arthroscopy pump for inflow, maintaining a constant fluid flow and
pressure of 60 to 70 mm Hg
2. second measure is to add 1 mL of 1:1000 epinephrine to each 3000-mL
bag of irrigant,
3. The final technique, and perhaps the most effective, is to use
hypotensive anesthesia, with a systolic BP of 90 to 100 mmHg.
• Elevation of the fluid bags 3 feet above the level produces a similar
pressure gradient of 66 mm fluid flow pressure

10. PORTAL PLACEMENT

11. POSTERIOR PORTAL
• 1 to 2 cm distal and 1 to 2 cm medial to the
posterolateral corner of the acromion
• Verify position with spinal needle prior to incision
• Primary viewing portal
• Pierces posterior deltoid muscle and travels in the interval between
the infraspinatus and the teres minor
• The axillary nerve and suprascapular nerve are at risk with this portal,
but are relatively safe

12. POSTEROINFERIOR 7-O’CLOCK PORTAL
• 2cm above the posterior axillary fold
• Used as inflow portal
• Dangerous portal due to proximity of
the axillary nerve,
posterior humeral circumflex artery,
and suprascapular nerve

13. ANTERIOR SUPERIOR PORTAL
• Superior and lateral to the coracoid—just anterior to the AC joint
• Localized with spinal needle in an outside-in technique just anterior to the
biceps tendon next to the superior glenoid
• Primarily an instrument portal but can be used to visualize the anterior
glenoid rim and labrum, the posterior joint, as well as to visualize internal
impingement dynamically
• Pierces the anterior deltoid and travels through the rotator interval,
avoiding injury to the rotator cuff
• Neurovascular structures at risk include the musculocutaneous nerve,
axillary nerve, as well as the cephalic vein, brachial plexus, and axillary
artery

14. ANTERIOR INFERIOR PORTAL
• Lateral to the coracoid
• Pierces anterior deltoid muscle and enters joint just above
subscapularis
• If too low, risk of injury to the axillary nerve
• If too medial, risk of injury to musculocutaneous nerve
• Minimal risk of injury to cephalic vein, brachial plexus, and axillary
artery

15. ANTEROINFERIOR PORTAL
• Inferior and lateral to the coracoid
• Localized with spinal needle using
outside-in technique superior to the
subscapularis
• Used primarily for instrumentation
for anterior Bankart repair
suture anchor placement

16. SUPERIOR PORTAL (NEVIAZER)
• Corner of the supraspinatus fossa
• Enters joint just medial to the supra-glenoid tubercle
• penetrates the trapezius muscle and passes through the
supraspinatus muscle belly
• Used for SLAP and rotator cuff repairs

17. LATERAL PORTAL
• 1 to 2 cm distal to the acromion
• Either mid acromion (anterior to posterior)
or junction of the (anterior 1/3 , posterior 2/3)
• Localized with spinal needle while viewing subacromial space
• Used for subacromial decompression and rotator cuff repairs
• Can be extended for mini-open deltoid splitting rotator cuff repairs
• Pierces middle deltoid muscle
• Axillary nerve at risk, because this averages 5 to 6 cm from the lateral
acromial border, but may be as close as 3 cm from the acromion

18. POSTEROLATERAL PORTAL (WILMINGTON)
• 1 cm anterior and 1 cm distal to the posterolateral corner of the
acromion
• Used for instrumentation during SLAP repair

21. COMMON ARTHROSCOPIC PROCEDURES
• Rotator cuff repair
• SLAP (superior labral anterior to posterior) repairs
• Biceps tendon pathology
• Repair of labral tears
• Acromioplasty and distal clavicle resection
• Adhesive capsulitis
• Release of the suprascapular nerve

22. COMPLICATIONS
• Neurovascular injury
• most commonly when lateral decubitus position and traction are used
• Infection
• Deep vein thrombosis (DVT)
• Anesthesia complications
• Arthrofibrosis
• More likely to happen with concomitant rotator cuff and SLAP repair
• Iatrogenic chondromalacia