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Shoulder and elbow
- 1. Shoulder and Elbow Arthroscopy Indications and Limits Manos Antonogiannakis Director
- 2. Shoulder Arthroscopy first Where we are where we are heading for? www.shoulder.gr
- 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. Diagnostic arthroscopy The way everything began back in the 80ies !!
- 5. Arthroscopy in its infancy
- 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. 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. Diagnostic Tool • Bufford Complex www.shoulder.gr
- 9. Diagnostic Tool • Sublabral hole www.shoulder.gr
- 10. Diagnostic Tool • SLAP Lesions www.shoulder.gr
- 11. Diagnostic Tool • Internal Impingement www.shoulder.gr
- 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. 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. Therapeutic Arthroscopy • SLAP lesions • Frozen Shoulder • AC joint • Arthritis • Dislocation • Biceps Pathology www.shoulder.gr
- 15. Arthroscopic Evolution Metal Anchors Absorbable Anchors Peek Anchors Single suture Double sutures www.shoulder.gr
- 16. Cuff repair Tendon to bone repair www.shoulder.gr
- 17. Rotator Cuff Single Row Double Row Triple Row Different Suture Passing techniques www.shoulder.gr
- 20. 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
- 21. 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
- 22. Act early try to avoid irreversible bad tissue quality.
- 23. What is Bad Tissue Quality? • Large or massive tears, • Retracted tears, • Coutallier three or four fatty infiltration www.shoulder.gr
- 24. ANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOAD OF THE REPAIR www.shoulder.gr
- 25. Recognize the Tear Pattern Tears must be repaired in the direction of greatest mobility -> minimal strain
- 26. 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]
- 27. Side to Side Repair Cuff repair www.shoulder.gr
- 28. Double Row Fixation Restoration of the footprint www.shoulder.gr
- 29. 1st Anchor Insertion – Medial Row www.shoulder.gr
- 30. Lateral Row 1st Anchor Insertion www.shoulder.gr
- 31. Inspection of Suture Position www.shoulder.gr
- 32. Final Repair Double row fixationDouble row fixation Stronger repair biologically attractive but Time consuming and of raised difficulty www.shoulder.gr
- 33. 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]
- 34. Massive Contractive Tears better mobilization techniques • Anterior Interval Slide and/or • Posterior Interval Slide
- 35. Massive Tears • Easily repaired • Difficult repair (anterior & posterior Slide) • Medialized repair • Impossible repair • Incomplete Repair • Graft Jackets • Tendon transfers
- 36. 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
- 44. AC Joint Distal Clavicle Excision www.shoulder.gr
- 47. The Spectrum of Instability Lesions – Minor instability with activity related pain – Recurrent subluxation – Recurrent dislocation – Locked dislocation with loss of motion
- 48. Bankart Lesion
- 49. 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
- 50. ALPSA lesion
- 51. humerus Bankart lesion glenoid 1. Identify and Define Pathology
- 54. 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
- 55. 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
- 56. 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
- 57. Instability Anterior Instability – Bankart Lesion www.shoulder.gr
- 58. humerus labrum completed repair 6. Assessment of the Final Repair
- 59. SLAP repair
- 66. Multidirection instability Plication of the posterior capsule
- 67. Instability Anterior Instability. Bony defects – Hill Sachs www.shoulder.gr
- 68. Instability Anterior Instability –Hill Sachs -Remplisage www.shoulder.gr
- 69. Instability Anterior Instability – Hill Sachs -Remplisage www.shoulder.gr
- 70. Instability Anterior Instability. Bony defects Glenoid bone loss
- 71. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
- 72. The normal glenoid shape
- 74. Glenoid Bone Loss > 30% Engaging Hill-Sachs HAGL lesions Limitations of the Arthroscopic Techniques
- 75. Future of instability repair • HAGL lesions can be repaired with arthroscopic techniques • Engaging Hill-Sachs. The remplisage technique of Eugene Wolf
- 76. Future of instability repair Glenoid bone loss: • arthroscopic bone grafting described by E. Taverna • Arthroscopic coracoid transfer described by L. Laffosse
- 77. Arthroscopic success rate • Savoie 1997 93% • Burchart, De Bear 2000 96% • J Tauro 2000 93% • Kim 2003 96% • Snyder 2006 93% • Fabbriciani 2004 100%
- 78. 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
- 79. Conclusion Today, apart from Shoulder Replacement and major Shoulder Fractures, nearly all Shoulder Pathology can be treated With arthroscopic techniques www.shoulder.gr
- 80. Conclusion Literature suggests equal or better results than Open Surgery www.shoulder.gr
- 81. 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
- 82. 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
- 83. 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
- 84. 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
- 85. 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
- 86. Elbow Arthroscopy - Contraindications • Bony Ankylosis • Coagulopathy • History of nerve transposition or muscle/tendon transfer
- 87. Elbow Arthroscopy – Patient Positioning • Prone • Supine • Lateral decubitus
- 88. Positioning
- 91. Capsular volume may be as little as 6 mL in elbows with capsular contracture
- 92. Prone Elbow Arthroscopy Advantages • Best access to posterior portal • No arm support necessary Disadvantages • More difficult anesthesia • Difficult to convert to open • Image reversal
- 93. Lateral decubitus elbow arthroscopy • Same advandages with the prone position • It does not compromise the airway
- 95. 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
- 98. Elbow Arthroscopy – Portals • Anterior –Proximal Medial (superomedial) –Anteromedial –Anterolateral –Midlateral –Proximal lateral • Posterior –Soft Spot (direct lateral) –Posterolateral –Trans-Triceps Tendon (straight posterior)
- 99. Location of medial and lateral portals with respect to key neurovascular structures
- 100. 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)
- 101. Anteromedial Portal Best Visualization for: • Radiocapitellar Joint • Coronoid Fossa • Trochlea • Anterior Capsule
- 102. Anteromedial Portal At Risk • Median (19mm distended, 12mm non- distended) – sheath lies in contact with nerve in 56% of extended elbows • Brachial Artery
- 103. Anteromedial View
- 104. Proximal Medial Portal • Usually start medially • 2-3 cm. Proximal to the Medial Humeral epicondyle • Just Anterior to the Medial Intermuscular Septum
- 106. Proximal Medial Portal At Risk • Ulnar Nerve • MABC Nerve • Median • Brachial Artery
- 107. Proximal Medial Portal Best Visualization for: • Radiocapitellar joint • Coronoid • Trochlea • Radio-ulnar joint • Anterior capsule
- 108. 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)
- 109. Anterolateral Portal Best Visualization for: • Coronoid • Trochlea • Radioulnar articulation • Anterior Capsule
- 110. 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
- 111. 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
- 112. 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)
- 113. Soft Spot Portal Best Visualization • Posterior Surface of Radial Head • Posterior Capitellum • Radial Surface of Olecranon
- 114. Soft Spot Portal Trochlea (above) Radial Head (left) Olecranon Bare Spot Tip of Olecranon (right)
- 115. Posterolateral Portal Best Visualization for: • Olecranon Process • Olecranon Fossa • Posterior Ulnar Gutter
- 117. 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
- 118. 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
- 119. 1. Synovectomy Synovectomy and removal of any soft tissue that may block motion due to its bulk, such as scar tissue in the
- 120. Removal of loose bodies and osteophytes
- 121. 3. Radial Head Excision
- 122. 5. Excision of Spurs
- 123. Elbow Arthroscopy – Advantages • Excellent Visualization • Smaller Scars • Rapid Return To Function
- 124. Elbow Arthroscopy - Disadvantages Technique Depended Relatively few cases Steep learning curve
- 125. 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