Principles of Shoulder Arthroscopy.pptx

Principles of
Shoulder Arthroscopy
Arojuraye Soliudeen MBBS, FWACS, FMCOrtho
Consultant Orthopaedic & Tauma Surgeon
National Orthopaedic Hospital, Dala
22 - 07 - 2022

Outline
• Introduction
• Indications & Contraindications
• Preoperative Evaluation
• Operative Technique
• Postoperative Rehabilitation
• Conclusions
doctoraroju@yahoo.com

Introduction
Shoulder arthroscopy
• Increasingly popular
• Modality of choice for interventional shoulder surgery
• 1st performed by Dr Michael Burman in 1931 on cadavar
• Clinical: Andren & Lundbery in 1965 for treatment of frozen shoulder

Introduction...
Arthroscopic Rx has evolved over time:
• Better understanding of pathoanatomy
• Advances in technology
• Improved surgical technique
Results for instability & rotator cuff disease
• Comparable with open procedures
• With much reduced morbidity

Indications
• GHJ instability
• Rotator cuff pathology
• Capsular pathology
• Biceps tendinopathies
• Synovil disorders
• Septic arthritis
• Ganglia / cysts
• ACJ instability
• Suprascapular nerve entrapment
Depending on the expertise,
almost all shoulder pathologies
can be managed
arthroscopically

Contraindications
• Infection of overlying skin
• Lack of approriate instrumentation
• Gross osteoarthritis (relative)

Preoperative Evaluation
Diagnosis
• Clinical History
• General
• Specific
• Physical Examination
• Instabilty
• Rotator cuff pathology
• Radiological Investigations
• Xray
• MRI (Gold standard)
Even though diagnostic imaging
has become more reliable;
physical examination still
remains a fundamental element
in any accurate diagnosis

Preoperative Evaluation...
Counselling & Consent
• Expectations
• Conversion to open surgery
• Complications
• Nerve injury
• Infection (very rare)
• Vascular injury (very rare)
Nerve injury:
Musculoc. Nv (anterior portal)
Axillary nerve (lateral portal)
Suprascapular nerve

Preoperative Preparation
Instrumentation
• Specific, Complex & Expensive
• Proper utilization & maintenance
its the responsibility of the
surgeon to ensure the
equipment & instrumentation
are in good condition

Operative Technique
Anaesthesia
• General
• Interscalene block
Hypotensive Anaesthesia
Mean BP 70 - 90mmHg
Systolic BP 100mmHg
A combination of general
anesthesia & interscalene
regional blockade is preferred.

Operative Technique...
Prophylactic Antibiotics
Systematic Review:
No compelling evidence
exists that prophylactic
antibiotics prevents
infections in shoulder
arthroscopy
Infection post-arthroscopic
surgery is rare though its
frequency is increasing
as the number of arthroscopic
procedures increases.

Positioning
Depends on Surgeons training & Preference:
• Beech Chair
• Lateral Decubitus
Considerations
• Ease of set up
• Access & visualization
• Risks & complications

Positioning...
• Lateral decubitus

Lateral Decubitus
Advantages
• Excellent access & visualization
• Gravity works for the surgeon
• Less assistance needed
Disadvantages
• Possibility of excessive traction
• Need to reposition for open

Beech Chair
• More natural Position
• Easier orientation of anatomy
• Both shoulder can be examined
• Facilitates interscalene block
Complications
• High risk of cardiac events
• Brain & spinal cord ischaemia

Examination under Anaesthesia
• Mobility
• Stability
EUA can reveal valuable
information that can
occasionally lead to a change
in the operative plan

Anatomic Landmarks
• Suprascapular fossa
• Acromion
• Clavicle
• Coracoid process
• AC Joint
• Lateral orientation line
An understanding of
the surface anatomy of
the shoulder is
absolutely imperative

Arthroscopic Portals
• Posterior portal: Glenohumeral & Subacromial
• Posterolateral portal: Subacromial
• Lateral portal: Subacromial
• Supeolateral: Sub-bicipital
• Anterior Portal

Diagnostic Arthroscopy (15points Review)
Steps 1–10: Viewing from the Posterior Portal
1) Biceps tendon & superior labrum
2) Posterior labrum & posterior capsule recess
3) Inferior axillary recess and inferior capsular
insertion to the humeral head
4) Inferior labrum & glenoid articular surface
5) Supraspinatus tendon of rotator cuff

Steps 1–10: Visualizing from the Posterior Portal
6. Posterior rotator cuff insertion & bare area of
the humeral head
7. Articular surface of humeral head
8. Anterior-superior labrum, superior & middle
GHL, and subscapularis tendon
9. Anterior-inferior labrum
10. Anterior-inferior ligament

Steps 11–15: Visualizing from the Anterior Portal
11) Posterior glenoid labrum & capsule insertion
12) Posterior rotator cuff
13) Anterior glenoid labrum & inferior GHL
attachments 14) Subscapularis tendon &
middleGHL attachment
15) Anterior surface of humeral head with
subscapularis attachment and biceps tendon

Postoperative Management
Pain management
• Excellent pain management postop reduce hospital stay and facilitates
rehabilitation - Ruiz-Suarez et al
Rehabilitation
• Goals
• Reduce pain & swelling
• Regain full ROM (PROM & AAROM)
• Activation of the stabilizing muscles
Rehabilitation is vital to
regaining motion, strength and
function of the shoulder after
arthroscopic surgery

Conclusion
Arthroscopy has not only provided us with an
extremely significant surgical tool used in
treatment of shoulder conditions;
but also an improved well understanding of
shoulder anatomy, & mechanics of different
diseases which were previously misdiagnosed
e.g. SLAP lesions.

References
• Stephen JS, Ronald PK, Mark HG, Joseph PB, Michael SB, David MA.
Shoulder Arthroscopy. Wolters Kluwer 2015; 3 (2): 18 - 39
• Ruiz-Suarez M, Barber FA. Postoperative pain control after shoulder
arthroscopy. Orthopedics. 2008 Nov;31(11):1130. doi:
10.3928/01477447-20081101-25. PMID: 19226085.
• Johnson, L. Arthroscopy of the shoulder. Orthop Clin North Am, (1980).
, 197-204.
• Andren, L, & Lundberg, B. Treatment of rigid shoulders by joint
distension during arthroscopy. Acta Orthop Scand, (1965). , 45-53.

Principles of Shoulder Arthroscopy.pptx

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