Shoulder Arthroscopy, 2nd Edition

1600 John F. Kennedy Blvd. Ste. 1800 Philadelphia, PA 19103-2899

SHOULDER ARTHROSCOPY

ISBN: 978-1-4160-4649-3

Copyright ! 2009, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Author assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher Library of Congress Cataloging-in-Publication Data Gartsman, Gary M. Shoulder arthroscopy / Gary M. Gartsman. — 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4160-4649-3 1. Shoulder joint—Endoscopic surgery. I. Title. [DNLM: 1. Shoulder Joint—surgery. 2. Arthroscopy—methods. 3. Rotator Cuff—surgery. WE 810 G244s 2009] RD557.5.G376 2009 617.50 72059—dc22 2008020052

Acquisitions Editor: Daniel Pepper Developmental Editor: John Ingram Publishing Services Manager: Tina Rebane Senior Project Manager: Jodi Kaye Design Direction: Lou Forgione

Printed in China Last digit is the print number:

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I’m not much of a sailor, but when our friends Bill and Christy get me on the Lone Star, my wife Carol enjoys the sea and I spend a lot of my time looking at the boats and wondering how and why they were named. The best I have ever seen was a beautiful sailboat, the Never Again 2.

After Harvard Ellman and I wrote Arthroscopic Shoulder Surgery and Related Procedures, I told Carol I would never write another textbook. Ten years later I wrote Shoulder Arthroscopy and promised her, never again.

Here we are at Shoulder Arthroscopy 2nd edition, the Never Again 2 of textbooks. Carol, you are the greatest. Thank you for your patience and love, again.

G.M.

PREFACE

Seventeen years have passed since the publication of Arthroscopic Shoulder Surgery and Related Procedures. Harvard Ellman and I co-authored that text in an attempt to bridge the gap between traditional open operations and newer arthroscopic approaches. Many today did not have the opportunity to know Dr. Ellman; he was a wonderful man and a true pioneer. He was the perfect person to introduce this fledgling field of shoulder arthroscopy to the world. The Ralph Bunche quote ‘‘If you want to get across an idea, wrap it up in a person’’ applied to Harvard. The first edition of Shoulder Arthroscopy was published 6 years ago. The pace of progress and the rate at which we have accumulated knowledge has accelerated in shoulder arthroscopy, as it has in practically all other forms of human endeavor. It is for this reason that we have decided to publish the second edition of Shoulder Arthroscopy. Thermal capsulorrhaphy did not survive prolonged follow-up. Double-row rotator cuff repair is more common. Biceps lesions are treated more aggressively. The Latarjet procedure for shoulder instability has entered the United States, and the Bristow is making a comeback! Diagnostic ultrasound is more mainstream. Suprascapular nerve lesions can be treated arthroscopically. Many readers requested more information about rehabilitation, and I think Mike De la Flor’s video animations are superb. Use them to instruct your patients. The purpose of this textbook is to present the current state of arthroscopic shoulder surgery as seen by one author. There are, of course, many different methods to treat shoulder lesions with arthroscopy, but I have chosen to present my own views and trust that the reader will also seek out the opinions of others.

My focus in this book is primarily on operative technique, and my goal is to present an approach to arthroscopic shoulder operations in enough detail so that the reader can manage both the routine and complex problems he or she encounters. This required that I exclude some important nonsurgical material. There are a number of texts currently available that devote hundreds of pages to patient history, diagnosis, pathogenesis, physical examination, and imaging studies. Their bibliographies are complete and extensive. So what kind of textbook is this? This is a book for orthopedic surgeons who want to perform reconstructive arthroscopic shoulder surgery. In order to do this, the surgeon must understand why certain procedures are performed and have them described in adequate detail. I have tried to take the reader through the operations in stepwise fashion; however, for complex procedures text is not sufficient. State-of-the-art communication in arthroscopy involves more than thoughts and words on a printed page. The accompanying DVD contains videos that illustrate the concepts and techniques that I describe in the text. Since 1982 I have been privileged to instruct thousands of practicing orthopedic surgeons, residents, and fellows in shoulder arthroscopy. In this textbook I have adopted a tone that I hope captures the many conversations we have had. Imagine that you and I are in the operating room performing shoulder arthroscopy. You can ask all the questions you wish and I have all the time in the world to answer. Let’s begin! GARY M. GARTSMAN, M.D. Houston, Texas

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CHAPTER

1

Making the Transition

Surgeons who are considering making the transition from open shoulder surgery to arthroscopic shoulder surgery need to develop a plan or framework. There are two basic types of skills: technical and intellectual. At present, orthopedic surgeons learn the basic skills of shoulder arthroscopy during their residency or fellowship, but more advanced reconstructive surgical techniques require sufficient time with an experienced mentor. This experience varies widely among training programs.

ARTHROSCOPY VERSUS OPEN REPAIR The fundamental decision is whether to perform shoulder arthroscopy or continue to use open repair techniques. Most surgeons are comfortable with open procedures. If they are satisfied with their patient outcomes, they may see no reason to change. However, surgeons have various reasons for deciding to acquire or advance their arthroscopic skills, for example, the belief that arthroscopic techniques produce better results, peer pressure, a desire to learn new concepts and techniques, and patient demand. Various publications and presentations have documented equal or superior results with arthroscopic techniques compared with open techniques for the performance of subacromial decompression for stage 2 impingement, acromioclavicular joint resection for arthritis, and rotator cuff repair, as well as for the treatment of glenohumeral instability. Orthopedic surgeons are subject to peer pressure. When they talk among themselves about various shoulder conditions and their treatment, surgeons

who perform only open operations may feel that they are behind the times. Orthopedic surgeons are also conditioned to consider new approaches to patient care, and although many surgeons obtain good results with open repair, they are ready and willing to try something new. Owing to the dramatic increase in available knowledge, many patients are aware of arthroscopic techniques and inquire whether the surgeon performs a certain procedure arthroscopically or with an open technique. Patients have the perception that arthroscopic procedures result in less pain, smaller scars, and more rapid rehabilitation, although strong arguments can be made to refute all these assertions. Nonetheless, patients are increasingly insistent on finding surgeons who will perform their operations arthroscopically, viewing the arthroscope as a magical tool capable of miraculous cures. Some surgeons see the arthroscope as a wonderful addition to the surgical tool box, whereas others, based on their experience, see only its negatives. It is the surgeon’s skill that achieves the proper balance (Figs. 1-1 through 1-4). Before embarking on a mission to acquire arthroscopic skills, each orthopedic surgeon must evaluate his or her practice patterns and answer some questions: Do you perform a sufficient number of shoulder operations to justify learning a new skill? All orthopedic surgeons should be comfortable with diagnostic glenohumeral joint arthroscopy, but not everyone needs to learn more advanced techniques. If you perform fewer than 20 to 30 shoulder procedures a year and are comfortable with the open technique, I would not advise you to invest the time and effort required to perform these few

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Section One



The Basics

Figure 1-4 Figure 1-1

Figure 1-2

Balance.

Magic instrument?

Wand of angels?

procedures arthroscopically. Do you have the emotional stability to handle the inevitable frustration when learning to perform procedures arthroscopically? Remember, you will be making a transition from the familiar and comfortable to the new and awkward. Do you have the necessary technical skills? If you cannot perform routine arthroscopic subacromial decompression in 30 minutes or less, you do not have the skills required to perform more complicated reconstructive arthroscopic procedures. Improve your basic skills and speed before taking on a bigger challenge. How do you acquire the necessary skills? Each surgeon must develop a learning plan that focuses on two central issues: technical skills and intellectual skills. In reality, it is hard to separate the two. Learning how to pass a suture through the anterior inferior glenohumeral ligament is of little use if you do not know when this step is necessary.

TECHNICAL SKILLS

Figure 1-3

Tool of the devil?

Most orthopedic surgeons learn the basics of shoulder arthroscopy during residency or fellowship, but for those who did not, other resources are available. The Orthopaedic Learning Center, developed and administered by the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America, hosts numerous courses that cover both basic and advanced shoulder arthroscopy. Didactic lectures, panel discussions, and video demonstrations are presented in state-of-the-art lecture halls. The center, located in Rosemont, Illinois, also houses a wet cadaveric laboratory with 48 workstations so that participants can practice with cadaver specimens and arthroscopic instruments.

Chapter 1

The Orthopaedic Learning Center is a good resource for learning basic shoulder arthroscopy, but many surgeons find it inadequate for more complex procedures such as rotator cuff repair and glenohumeral reconstruction. Generally, the 2- to 3-day courses cover a broad range of topics. A typical course might include lectures and cadaver instruction on arthroscopic subacromial decompression, distal clavicle excision, open and arthroscopic rotator cuff repair, and open and arthroscopic glenohumeral reconstruction. There is insufficient time for participants to become comfortable with all procedures. Because of the breadth of topics, it is unusual for every instructor to have expertise in all the areas covered. Participants also demonstrate great disparity in arthroscopic skill; for instance, one surgeon interested in learning arthroscopic rotator cuff repair may be paired with a beginner who wants to focus on glenohumeral joint inspection. Other programs are available. The Arthroscopy Association of North America offers more individualized instruction through its Masters Series, and several surgeons I know have found the program extremely worthwhile. James Esch has been active in shoulder arthroscopy education for years and annually organizes a superior course that combines lectures and cadaver work. Stephen Snyder has a wonderful facility in California that combines state-of-the art video learning with an opportunity to watch a superb surgeon at work. My own approach to surgeon education has been to offer a small course limited to 12 registrants that focuses solely on one topic—either arthroscopic rotator cuff repair or arthroscopic glenohumeral joint instability. Enrollment is restricted to surgeons with advanced arthroscopic skills. Over a 2-day period, techniques using arthroscopic

Students in the Joe W. King invitational rotator cuff repair course.

Figure 1-5

Figure 1-6



Making the Transition

5

Laser line on the inserter to align the eyelet.

instruments and video arthroscopy are gradually introduced as participants perform repairs on anatomically detailed plastic shoulder models. This allows everyone ample opportunity to master the requisite intellectual and technical skills (Fig. 1-5). You can also advance your arthroscopic skills by focusing on the details of your open repairs. First, take the opportunity to view arthroscopically all rotator cuff tears and unstable glenohumeral joints before performing the open repair or reconstruction.

Having the eyelet parallel to the edge of the tendon allows either suture to slide freely.

Figure 1-7

6

Section One



The Basics

Figure 1-10

Rotator cuff repair in two dimensions.

Figure 1-11

Rotator cuff repair in two dimensions.

Figure 1-8 Having the eyelet parallel to the edge of the tendon allows either suture to slide freely.

Learn what the typical glenohumeral joint looks like in a 63-year-old with a full-thickness rotator cuff tear. From the glenohumeral joint, try to identify the tear. Move the arthroscope into the subacromial space, identify the rotator cuff tear, and estimate its size and shape. Ask the circulating nurse to write down these measurements. Next, open the shoulder and record the size and shape of the tear. With practice, you will find that you can accurately assess the size

Figure 1-9

Knot tying board.

Figure 1-12

Glenohumeral joint reconstruction model.

Chapter 1

Figure 1-16

Figure 1-13

Figure 1-15

Making the Transition

7

Load the suture.

Shoulder arthroscopy model.

Figure 1-17 Figure 1-14



Suture is held in the instrument’s jaw.

Elite suture punch needle.

Depress the handle bottom to load it.

Figure 1-18

Depress the handle top to advance the needle.

8

Section One

Figure 1-19



The Basics

Withdraw the needle, leaving the suture loop.

Two free ends are inserted into the back hole of the Caspari suture passer.

Figure 1-22

Figure 1-20

Remove the instrument, leaving the suture

loop.

Figure 1-21

in half.

and shape of tears arthroscopically. Before performing an open Bankart procedure, use the arthroscope to identify the Bankart lesion and estimate its size, then compare that to your impression during the open repair. As your experience increases, make your observations more precise. When you are viewing a rotator cuff tear from the subacromial space, insert a probe and use it to measure the length and width of the tear. Insert a grasper and try to determine the tear’s reparability. Grasp different portions of the tear edge and advance them to different locations near the greater tuberosity. This will help you learn to appreciate tear geometry and repair geometry as viewed through the arthroscope. Make note of the

Two free ends of 2-0 nylon suture folded Figure 1-23

Caspari suture passer in the operating room.

Chapter 1

Figure 1-24



Making the Transition

9

Figure 1-26

Loaded Caspari suture passer and tying board.

Figure 1-27

Two free ends of nylon suture placed through

Proper thumb position.

tendon quality. After you perform the open repair and close the skin, reinsert the arthroscope into the subacromial space to see how a completed repair should appear. As you can appreciate from the preceding description, I believe that the transition from open to arthroscopic repair should proceed slowly as the

the felt.

Figure 1-28 Remove the Caspari suture passer, and the Figure 1-25

Improper thumb position.

nylon suture remains in the felt.

10

Section One



The Basics

Use the thumb to advance the suture in the AccuPass device.

Figure 1-32 Figure 1-29

Loop braided through the looped end of a

nylon suture.

Figure 1-33 One option is to load the suture loop first in the

Pull on the free ends of the nylon suture, and pull the braided suture through the felt.

Figure 1-30

Figure 1-31

Braided suture passed through the felt.

AccuPass.

Figure 1-34 Another option is to pass the braided suture directly through soft tissue with the AccuPass.

Chapter 1

Figure 1-35

Figure 1-37

Making the Transition

11

Correct hand positions.

Figure 1-38

Figure 1-36



Incorrect hand positions.

Use the index finger to rotate the arthroscope.

Use the thumb to rotate the arthroscope.

surgeon makes incremental improvements in his or her technical skills and adds to his or her knowledge base. It is extremely difficult for any surgeon to learn about arthroscopic rotator cuff repair one day and perform the procedure from beginning to end the next day. I spent 1 year making the transition using the approach described later. While you hone your basic arthroscopic skills and add to your knowledge, learn the principles of and technical steps required for an arthroscopic repair. For instance, an arthroscopic rotator cuff repair consists of the following elements: glenohumeral joint arthroscopy, subacromial bursectomy, coracoacromial

Figure 1-39 Do not use two hands to rotate the arthroscope.

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Section One



The Basics

ligament release, and acromioplasty. You must be expert in these aspects of the procedure. Once you are able to evaluate tear size, geometry, and reparability, you must learn to insert suture anchors, pass sutures through the tendon, manage sutures, and tie secure knots. Fortunately, you can master these techniques before you enter the operating room.

through it. The indirect method requires that you use some sort of monofilament suture passed through the tendon. This monofilament suture is then used to pull the braided suture through the soft tissue. You can attach a piece of felt or foam rubber to a wooden board and practice using instruments to pass sutures.

Suture Management Suture Anchors Ask your local manufacturer’s representative for a spare suture anchor and familiarize yourself with its characteristics. Are the sutures preloaded, or must they be loaded in the operating room? Are the sutures desirable for your particular rotator cuff repair? If not, can you switch them? Does the suture anchor accept multiple sutures or just one? If the anchor has two sutures, how are they arranged? Which suture do you have to tie first? Practice inserting the anchor into a board, and learn how much force is required. Learn how to orient the eyelet so that the sutures slide easily. You should practice reloading the anchor in case you pull the sutures out (Figs. 1-6 through 1-8).

Sutures through Tendon There are two basic methods of passing a braided suture through a tendon or ligament, and you should be familiar with both (see Figs. 1-9 through 1-29). The direct method involves using an instrument to pierce the ligament or tendon and pulling or pushing the suture

Suture management is critical to arthroscopic shoulder reconstruction. Whether the surgeon is in the subacromial space for a rotator cuff repair or in the glenohumeral joint for a glenohumeral reconstruction, the fundamental problem is too many sutures in too little space. There are two basic solutions: tie the sutures as you insert them, or move the sutures out of the way through cannulas. Experiment with both techniques to determine which one is better for you. Even if you tie the sutures after you insert each one, suture management is important. To avoid nicking the suture (risking suture breakage) when inserting sharp instruments through cannulas, the basic principle is to keep the working cannula free from sutures. Percutaneous anchor insertion is an option in the subacromial space but not in the glenohumeral joint, owing to the mass of soft tissue the anchor must penetrate. To practice suture management, write out in detail each step of the operation and decide when you must move sutures. For example, the steps for two types of rotator cuff repair follow:

Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)                

Insert the anchor in the anterior position through the lateral cannula. Use a crochet hook to pull the green and white sutures out through the anterior cannula. Use a crochet hook to pull one green suture strand from the anterior to the lateral cannula. Load the green suture on the Elite Pass instrument. Insert the Elite Pass through the lateral cannula. Grasp the tendon. Advance the needle and push the green Ethibond suture through the tendon. Withdraw the needle. Insert a grasper through the anterior cannula and grasp the green suture exiting the tendon. Remove the Elite Pass instrument from the lateral cannula. Use a grasper to pull the suture out through the anterior cannula. Apply a hemostat to the two green sutures. Use a crochet hook to pull one white suture strand from the anterior to the lateral cannula. Load the white suture on the Elite Pass. Insert the Elite Pass through the lateral cannula. Grasp the tendon.

Chapter 1



Making the Transition

Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)—cont’d             

Advance the needle and push the white Ethibond suture through the tendon. Withdraw the needle. Insert a grasper through the anterior cannula and grasp the white suture strand exiting the tendon. Remove the Elite Pass instrument from the lateral cannula. Use a grasper to pull the suture out through the anterior cannula. Remove the hemostat from the white sutures. Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula. Loop the grasper to untangle the sutures. Tie the white sutures. Remove the hemostat from the green sutures. Move the green sutures from the anterior cannula to the lateral cannula. Loop the grasper to untangle the sutures. Tie the green sutures.

Arthroscopic Rotator Cuff Repair—Caspari Technique (1 Anchor, 2 Sutures)                                

Insert the anchor in the anterior position through the lateral cannula. Use a crochet hook to pull the green and white sutures out through the anterior cannula. Insert a Caspari suture punch with 2-0 looped nylon through the lateral cannula. Grasp the tendon. Check to ensure that the needle hole is clear. Advance the nylon suture. Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat. Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat. Remove the Caspari from the nylon suture. Use the crochet hook from the lateral cannula to retrieve one strand of the green suture. Loop the grasper from the lateral cannula to untangle the sutures. Pass 6 cm of suture through the nylon loop. Pull on the hemostat and nylon suture to bring the green suture through the tendon and out the anterior cannula. Apply the hemostat to the two green sutures. Insert the Caspari with 2-0 looped nylon through the lateral cannula. Grasp the tendon. Check to ensure that the needle hole is clear. Advance the nylon suture. Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat. Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat. Remove the Caspari from the nylon suture. Use the crochet hook from the lateral cannula to retrieve one limb of the white suture. Loop the grasper from the lateral cannula to untangle the sutures. Pass 6 cm suture through the nylon loop. Pull on the hemostat and nylon suture to bring the white suture through the tendon. Remove the hemostat from the white sutures. Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula. Loop the grasper to untangle the sutures. Tie the white sutures. Remove the hemostat from the green sutures. Loop the grasper to untangle the sutures. Tie the green sutures.

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14

Section One



The Basics

For a glenohumeral reconstruction, some of the steps are as follows:

Arthroscopic Bankart Repair—Suture Passer, Single-Suture Anchors                                   

Insert the arthroscope posteriorly. Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon. Insert an 8-mm cannula. Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval. Insert a metal cannula and move the scope anteriorly to view the posterior joint. Remove the scope and cannula and replace them with a 5.5-mm working cannula. Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion. Insert a shaver through the anterior-superior cannula to de´bride soft tissue from the anterior scapular neck. Insert a bur to decorticate the anterior scapular neck. Remove the anterior-superior cannula. Insert a metal cannula and trocar into the anterior-superior portal. Observe the anterior scapular neck decortication. Move the scope to the posterior cannula. Determine how many anchors are required to repair the Bankart lesion. Mark the anchor locations with a punch or bur. Insert a drill through the anterior-superior cannula to drill anchor holes. Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole. Remove the inserter. Two suture strands from the inferior anchor should be exiting the anterior-superior cannula. Insert a Spectrum suture passer through the anterior-inferior cannula and pierce the capsule and labrum. Advance the free ends of nylon into the joint. Retrieve the free ends of nylon suture with a crochet hook placed in the anterior-superior cannula. Apply a hemostat to the tips of the nylon suture. Place the tip of the hemostat at the entrance of the anterior-superior cannula to decrease tension on the nylon suture. Remove the Spectrum from the anterior-inferior cannula. The nylon loop should be outside the anterior-inferior cannula. Use Prolene suture to reverse the direction of the loop. The loop of Prolene should be outside the anterior-superior cannula. Have an assistant hold one limb of each anchor suture in each hand. Insert a crochet hook through the anterior-inferior cannula and retrieve one limb of anchor suture from the anteriorsuperior cannula to the anterior-inferior cannula. Place 6 cm of anchor suture through the Prolene loop (anterior-superior cannula). Apply traction to the hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the labrum, and out the anterior-inferior cannula. Two anchor sutures are now through the anterior-inferior cannula. Tie the sutures. Repeat these steps from additional anchors as needed.

Chapter 1



Making the Transition

15

Arthroscopic Bankart Repair—AccuPass, Double-Suture Anchors                                 

Insert the arthroscope posteriorly. Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon. Insert an 8-mm cannula. Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval. Insert a metal cannula and move the scope anteriorly to view the posterior joint. Remove the scope and cannula and replace them with a 5.5-mm working cannula. Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion. Insert a shaver through the anterior-superior cannula to de´bride soft tissue from the anterior scapular neck. Insert a bur to decorticate the anterior scapular neck. Remove the anterior-superior cannula. Insert a metal cannula and trocar into the anterior-superior portal. Observe the anterior scapular neck decortication. Move scope to posterior cannula. Determine how many anchors are required to repair the Bankart lesion. Mark the anchor locations with a punch or bur. Insert a drill through the anterior-superior cannula to drill anchor holes. Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole. Remove the inserter. Four suture strands from the inferior anchor should be exiting the anterior-superior cannula. Insert the AccuPass through the anterior-inferior cannula and pierce the capsule and labrum. Advance the loop end of the nylon into the joint. Retrieve the loop end of nylon suture with a crochet hook placed in the anterior-superior cannula. Remove the AccuPass from the anterior-inferior cannula. The nylon loop should be outside the anterior-superior cannula. The free ends of the loop should be outside the anterior-inferior cannula. Through the anterior-inferior cannula, use a crochet hook to grasp one strand of green anchor suture. Through the anterior-superior cannula, insert a loop grasper and encircle the two nylon strands and the other green anchor suture strand. Place 6 cm of anchor suture through the nylon loop (anterior-superior cannula). Apply traction to a hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the labrum, and out the anterior-inferior cannula. Two green anchor sutures are now through the anterior-inferior cannula. Tie the sutures. Repeat for the second white sutures from the most inferior anchor (white). Repeat these steps from additional anchors as needed.

16

Section One



The Basics

When you write out the operative steps in detail, it gives you an accurate impression of how many suture manipulations are needed. Reviewing these steps with members of your operative team gives them a much better idea of what needs to be accomplished, as well as an appreciation of the operation’s complexity. You can practice these steps before you get to the operating room. Get a 12- by 12-inch board and insert picture eyelets to simulate portal locations. Place cannulas through the eyelets and insert an anchor in the center. Practice moving the sutures from cannula to cannula until the motions become automatic (Figs. 1-30 through 1-34). My friend Lanny Johnson is fond of saying that when professional golfers finish playing golf, they practice golf; when surgeons finish performing surgery, they practice golf. Perhaps we could learn a lesson from professional golfers. It is amazing to see the progress students make after they practice an operation 20 times. I am absolutely convinced that operations of this complexity cannot be taught with a lecture and a video. Each step (holding the instruments, passing the sutures, suture management, and so forth) must be taught and mastered as an individual event (Figs. 1-35 through 1-39). These individual events must then be performed in the correct sequence. Once the sequence is mastered, the fluidity of the steps must be improved until they become routine. All this must be done under the constant supervision of an expert so that bad habits are corrected immediately before they become ingrained. Practice does not make perfect, but practice does make permanent, and it is of no benefit to practice an operation either incorrectly or inefficiently. When I was learning to perform arthroscopic procedures, I drew out the essential steps of the operation on a piece of paper; borrowed a suture passer, knot pusher, crochet hook, loop grasper, sutures, and hemostats from the operating room; and practiced the required maneuvers until I felt comfortable. I have included here the exercises I used and encourage you to rehearse the procedure with your assistant until both of you are familiar with your roles and the necessary steps. Although this may seem time-consuming, this level of preparation yields great dividends during the actual operation. Exercise 1 (Figs. 1-40 through 1-50) simulates a one-anchor, two-suture rotator cuff repair. Exercise 2 (Figs. 1-51 through 1-69) simulates a two-anchor, four-suture rotator cuff repair. Exercise 3 (Figs. 1-70 through 1-102) simulates a three-anchor, six-suture complex rotator cuff repair. Exercise 4 (Figs. 1-103 through 1-112) simulates a Bankart repair.

Figure 1-40 Exercise 1 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon.

Knot Tying Because reconstructive arthroscopic shoulder surgery involves soft tissue repair, knot tying is a critical skill. Surgeons’ reluctance to tie arthroscopic knots has created a booming industry in pretied knots or ‘‘knotless’’ devices. Each of these devices requires a number of steps that are just as difficult (or as simple) as the steps required to tie a knot. As I explain to the registrants in my arthroscopy courses in Houston, there is another option: learn how to tie an arthroscopic knot. It is difficult, but with instruction and practice, it can be mastered. Surgeons tie knots in open surgery on a daily basis. Arthroscopic knots are identical,

Figure 1-41

strands.

Insert an anchor with two sutures—four suture

Chapter 1

Figure 1-42 Pull the four suture strands out through the anterior cannula.

Figure 1-43

Pull one blue strand through the lateral

Figure 1-45



Making the Transition

17

Pull one white suture strand through the lateral

cannula.

Figure 1-46

Place it through the felt with a suture passer.

cannula.

Retrieve both white suture strands from the anterior cannula and pull them through the lateral cannula.

Figure 1-47 Figure 1-44

Place it through the felt with a suture passer.

18

Section One



Figure 1-48

The Basics

Tie the white sutures.

Figure 1-49 Retrieve the blue suture strands from the anterior cannula and pull them through the lateral cannula.

Figure 1-50 Tie the blue sutures.

Figure 1-51 Exercise 2 simulating a right shoulder repair. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are two drill holes for anchors.

Figure 1-52

Insert two anchors—four sutures, eight suture

strands.

Figure 1-53 Pull the sutures from the anterior anchor out through the anterior cannula. Apply a hemostat.

Chapter 1

Figure 1-54 Pull the sutures from the posterior anchor out through the anterior cannula. Apply a hemostat.



Making the Transition

19

Figure 1-57 Retrieve one white suture strand from the anterior anchor and bring it out through the lateral cannula.

Figure 1-55

Retrieve one blue suture strand from the anterior anchor and bring it out through the lateral cannula.

Figure 1-58 Insert this suture strand through the felt and pull it out through the anterior cannula.

Figure 1-56 Insert this suture strand through the felt and pull it out through the anterior cannula.

Figure 1-59 Retrieve one blue suture strand from the posterior anchor and bring it out through the lateral cannula.

20

Section One



The Basics

Figure 1-60 Insert this suture strand through the felt and pull it out through the anterior cannula.

Figure 1-63 Retrieve both posterior anchor white strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-64

Figure 1-61 Retrieve one white suture strand from the posterior anchor and bring it out through the lateral cannula.

Retrieve both posterior anchor blue strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-65

Insert this suture strand through the felt and pull it out through the anterior cannula. Figure 1-62

Tie these sutures.

Chapter 1

Figure 1-66

Figure 1-67

Tie these sutures.

Repeat the steps for the anterior anchor white

suture.

Retrieve both anterior anchor blue strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-69



Making the Transition

21

Tie the sutures. The repair is complete.

Figure 1-70 Exercise 3 simulating the repair of a large or massive rotator cuff tear. The anterior cannula is on the right, and the lateral cannula is at the bottom. Black felt represents the rotator cuff tendon. There are three anchor holes.

Figure 1-68

Figure 1-71 Insert three anchors—6 sutures and 12 suture

strands.

22

Section One



The Basics

Figure 1-72 Pull the anterior anchor sutures out through the anterior cannula.

Figure 1-75 Move the middle anchor sutures from the anterior cannula, simulating an anterolateral percutaneous stab wound.

Pull the middle anchor suture strands out through the anterior cannula.

Figure 1-76 Retrieve one anterior anchor blue suture from

Figure 1-73

Figure 1-74 Move the posterior anchor strands to the left of the lateral cannula, simulating removing them through a posterolateral percutaneous stab wound.

the anterior cannula and pull it out through the lateral cannula.

Figure 1-77 Place this suture through the felt and withdraw it through the anterior cannula.

Chapter 1



Making the Transition

23

Figure 1-78

Figure 1-81 Place this suture through the felt and withdraw it through the anterior cannula.

Figure 1-79 Place this suture through the felt and withdraw it through the anterior cannula.

Figure 1-82 Withdraw the suture strand that is through the

Retrieve one middle anchor blue suture from the anterolateral stab wound and withdraw it through the lateral cannula.

Figure 1-83

Retrieve one anterior anchor white suture from the anterior cannula and pull it out through the lateral cannula.

Figure 1-80

felt and pull it out the anterolateral stab wound.

Retrieve one middle anchor white suture from the anterolateral stab wound and withdraw it through the lateral cannula.

24

Section One



The Basics

Figure 1-84 Place this suture through the felt and withdraw it through the anterior cannula.

Figure 1-85 Withdraw the suture strand that is through the felt and pull it out the anterolateral stab wound.

Figure 1-86 Retrieve the anterior anchor white suture strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-87

Tie the sutures.

Figure 1-88 Retrieve the anterior anchor blue suture strands from the anterior cannula and pull them out through the lateral cannula.

Figure 1-89

Tie the sutures.

Chapter 1

Withdraw the posterior anchor blue suture strand from the posterolateral stab wound and pull it out through the lateral cannula. Figure 1-90



Making the Transition

25

Figure 1-93 Place this suture through the felt and withdraw it through the anterior cannula.

Figure 1-91

Retrieve the posterior anchor strand from the posterolateral stab wound and withdraw it through the lateral cannula.

Withdraw the posterior anchor white suture strand from the posterolateral stab wound and pull it out through the lateral cannula.

Figure 1-95

Figure 1-94

Place this suture through the felt and withdraw it through the anterior cannula.

Figure 1-92

Retrieve the posterior anchor strand from the anterior cannula and withdraw it through the lateral cannula.

26

Section One

Figure 1-96



The Basics

Tie the white sutures from the posterior anchor.

Figure 1-99 Retrieve both middle anchor white sutures and

withdraw them through the lateral cannula.

Retrieve both posterior anchor blue sutures and withdraw them through the lateral cannula.

Figure 1-97

Figure 1-98

Tie the blue sutures from the posterior anchor.

Figure 1-100

Tie the middle anchor white sutures.

Figure 1-101 Retrieve both middle anchor blue sutures and withdraw them through the lateral cannula.

Figure 1-102

Tie the middle anchor blue sutures.

Figure 1-105 Place a nylon passing suture through the green cannula. The two free ends are exiting the orange cannula, and the looped end is exiting the green cannula.

Figure 1-103 Exercise 4 simulating a right shoulder Bankart repair with three suture anchors. The green cannula is anterior-inferior, and the orange cannula is anterior-superior.

Insert the inferior anchor and withdraw the sutures through the orange cannula.

Figure 1-104

Pull one suture strand from the orange cannula out through the green cannula.

Figure 1-106

Figure 1-107 Place the end of the blue suture through the looped end of the nylon suture.

28

Section One



The Basics

7 cm

Figure 1-108

Close-up view of Figure 1-7.

Figure 1-111 Continue to pull on the nylon suture, and bring the blue suture out through the orange cannula.

Figure 1-109

Pull on the two free ends of the nylon (white)

suture.

Figure 1-112

Tie the suture. Repeat for the two additional

anchors.

Pull the blue suture from the green cannula through the felt.

Figure 1-110

with the exception that the knot pusher replaces the surgeon’s index finger. The knots lie flat, are square, and are as strong as knots tied in the open technique. My advice is to learn arthroscopic knot tying and use knotless systems only when they are superior to or offer an advantage over a traditional knot. Before learning arthroscopic knots, the surgeon must be proficient with the basic one-handed knots commonly taught in medical school or surgery internship. Although there are many knot variations, only two basic knots are necessary: an overhand knot and a sliding knot. When learning the steps required to tie

Chapter 1

knots, it is easier to practice with clothesline than with surgical suture. All the knots described here are shown on the video.

1



Making the Transition

2

Knot Tying After the suture has been inserted through the soft tissue, verify that no tangles exist. Use the loop grasper to encircle one suture limb and then withdraw the instrument. Perform this step before tying every knot. Place one limb of the suture through the knot tying instrument. This suture limb is usually the one closest to you. For example, in rotator cuff repair, the knot pusher goes on the suture limb that exits from the suture anchor and comes out through the cannula. The free end is the suture limb that has been placed through the tendon and is farther away. Apply a hemostat to the suture strand that is through the knot pusher so that you have something to pull against as you push the knot down the cannula. Gently push the half hitch down the cannula. Slowly place tension on the two strands and observe which strand must be pushed away for the knot to lie flat. If you push the other strand away, the knot will not lie flat. It is not important whether the first throw is overhand or underhand, but it is important that you always use the same technique when tying knots. I recommend that surgeons use the same sequence of knot tying for arthroscopic procedures that they use for open techniques. For example, if you perform two throws, bringing the strands from top to bottom, and then the third throw goes from below to above, I advise you to keep the same sequence. Try to make the steps of tying your arthroscopic knots as similar as possible to those of your open knots. Use the knot pusher to past-point. This allows you to pull the suture strands tight with a 180-degree angle. Place another throw in the same direction as the first, past-point, and tighten the knot. Now reverse the direction of the throw and place a third hitch. Reverse the post of the knot for greater knot security and place a fourth throw. Reverse the post and the direction of the throw for the fifth half hitch. It is critical that you become skilled in tying knots with a one-handed technique. Gradually incorporate arthroscopic knot tying into surgery by tying knots with the knot pusher during an open repair and moving to arthroscopic knot tying as your skills increase. These steps are illustrated in Figures 1-113 through 1-178. An additional skill that is critical is learning to slip the second throw. Usually the tendon or

OVERHAND KNOT

Figure 1-113

3

Knot tying illustrations.

4

Figure 1-114

5

Knot tying illustrations.

6

Figure 1-115

7

Knot tying illustrations.

8

Figure 1-116

Knot tying illustrations.

29

30

Section One



The Basics

9

10

Figure 1-117

13

Knot tying illustrations.

ligament to be tied is under tension and retracts slightly after the first knot throw. One method to deal with this problem is to eliminate the tension on the soft tissue by having an assistant hold the soft tissue with a tissue grasper. Another method is to place a traction suture through the soft tissue. A third method (and the one I prefer) involves slipping the second throw. Tie the first throw routinely. Make a second half hitch in the same direction and slowly advance it down the cannula. Check to see that the suture is not tangled. Pull on the post limb and release all tension on the other limb. The knot will slide down to the soft tissue without locking, enabling you to approximate the soft tissue. Past-point and lock the second throw. Finish the remaining throws, and complete the knot. There are dozens of types of sliding knots, but it is necessary to learn only one. If you wish to learn more at a later date, you can always do so. After placing the suture through the soft tissue, grasp both ends and confirm that it slides freely. Pull on one end so that it becomes the shorter one. Make a loop with the longer strand and pinch it between your thumb and index finger. Pass the longer suture over the shorter

Figure 1-119

Knot tying illustration.

one four times. Bring the end of the longer suture strand up through the loop to complete the Duncan loop. Freshen the knot by applying tension to each strand. Pull on the shorter strand to advance the knot. Place three alternating half hitches to secure the knot.

KNOT TYING TECHNIQUE 1

2

3

4

5

6

SLIDING KNOT

11

12

Figure 1-118

Knot tying illustrations.

Figure 1-120

Knot tying illustrations.

Chapter 1



Making the Transition

Figure 1-121

One-handed knot.

Figure 1-124

One-handed knot.

Figure 1-122

One-handed knot.

Figure 1-125

One-handed knot.

Figure 1-123

One-handed knot.

Figure 1-126

One-handed knot.

31

32

Section One



The Basics

Figure 1-127

One-handed knot.

Figure 1-130

One-handed knot.

Figure 1-128

One-handed knot.

Figure 1-131

One-handed knot.

Figure 1-129

One-handed knot.

Figure 1-132

One-handed knot.

Chapter 1



Making the Transition

Figure 1-133

One-handed knot.

Figure 1-136

One-handed knot.

Figure 1-134

One-handed knot.

Figure 1-137

One-handed knot.

Figure 1-135

One-handed knot.

Figure 1-138

One-handed knot.

33

34

Section One



The Basics

Figure 1-139

One-handed knot.

Figure 1-142

One-handed knot.

Figure 1-140

One-handed knot.

Figure 1-143

One-handed knot.

Figure 1-141

One-handed knot.

Figure 1-144

One-handed knot.

Chapter 1

Figure 1-145

One-handed knot.

Figure 1-146

Figure 1-147



Making the Transition

Figure 1-148

One-handed knot using a knot pusher.

Figure 1-149

One-handed knot using a knot pusher.

Figure 1-150

One-handed knot using a knot pusher.

Knot pusher.

One-handed knot using a knot pusher.

35

36

Section One



The Basics

Figure 1-151

One-handed knot using a knot pusher.

Figure 1-154

One-handed knot using a knot pusher.

Figure 1-152

One-handed knot using a knot pusher.

Figure 1-155

One-handed knot using a knot pusher.

Figure 1-153

One-handed knot using a knot pusher.

Figure 1-156

One-handed knot using a knot pusher.

Chapter 1



Making the Transition

Figure 1-157

One-handed knot using a knot pusher.

Figure 1-160

One-handed knot using a knot pusher.

Figure 1-158

One-handed knot using a knot pusher.

Figure 1-161

One-handed knot using a knot pusher.

Figure 1-159

One-handed knot using a knot pusher.

Figure 1-162

One-handed knot using a knot pusher.

37

38

Section One



The Basics

Figure 1-163

One-handed knot using a knot pusher.

Figure 1-166

One-handed knot using a knot pusher.

Figure 1-164

One-handed knot using a knot pusher.

Figure 1-167

One-handed knot using a knot pusher.

Figure 1-165

One-handed knot using a knot pusher.

Figure 1-168

One-handed knot using a knot pusher.

Chapter 1



Making the Transition

Figure 1-169

One-handed knot using a knot pusher.

Figure 1-172

One-handed knot using a knot pusher.

Figure 1-170

One-handed knot using a knot pusher.

Figure 1-173

One-handed knot using a knot pusher.

Figure 1-171

One-handed knot using a knot pusher.

Figure 1-174

One-handed knot using a knot pusher.

39

40

Section One

Figure 1-175



The Basics

One-handed knot using a knot pusher.

Figure 1-178

One-handed knot using a knot pusher.

INTELLECTUAL SKILLS

Figure 1-176

One-handed knot using a knot pusher.

Figure 1-177

One-handed knot using a knot pusher.

Intellectual skills can be honed by attending instructional courses presented by the American Academy of Orthopaedic Surgeons, the American Shoulder and Elbow Surgeons, and the Arthroscopy Association of North America. These courses are held throughout the United States. A full day of current shoulder information is given at the open meeting of the American Shoulder and Elbow Surgeons, which is held at the annual meeting of the American Academy of Orthopaedic Surgeons. The best shoulder arthroscopy course I have attended is the biennial meeting held in Val d’Isere, France. This weeklong course covers the spectrum of shoulder arthroscopy topics in detail. Excellent textbooks are also available, such as The Shoulder by Rockwood and Matsen, or you can subscribe to the Journal of Shoulder and Elbow Surgery and Arthroscopy, Arthroscopy, and the American Journal of Sports Medicine, which are sources of current thought on shoulder problems. Perhaps the most important intellectual tool a surgeon can possess is a plan to master reconstructive arthroscopic operations. As a general approach, I recommend the following: learn the individual steps of the arthroscopic repair, practice these techniques outside the operating room, gradually incorporate these techniques into open repair, perform arthroscopic repair and then open the shoulder, and finally perform the operation exclusively with arthroscopic technique. Although, theoretically, it seems reasonable to make the transition to arthroscopic repair in one step, in practice, it can result in a 6-hour arthroscopic

Chapter 1

rotator cuff repair that benefits neither patient nor surgeon. I advise a more gradual transition. As noted earlier, I took 1 year to move from open rotator cuff repair to a fully arthroscopic technique.

THE GRADUAL TRANSITION



Making the Transition

41

3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Open and repair the rotator cuff tear.

When making the transition from open to arthoscopic rotator cuff repair, be sure to scope all tears before performing the open repair. Establish time limits for your arthroscopic procedures. Give the circulating nurse authority to inform you that 1 hour has passed and it is time to open the shoulder. Consider a plan similar to the one described here.

Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 8 in 30 minutes, advance to the next stage.

Stage 1

Stage 4

1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Open and repair the rotator cuff tear. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 5 in 30 minutes, advance to the next stage.

Stage 2 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Open and repair the rotator cuff tear. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 7 in 30 minutes, advance to the next stage.

Stage 3 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy.

1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site. 7. Insert an anterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Pass the anterior anchor sutures through the tendon. 10. Pass the posterior anchor sutures through the tendon. 11. Open and complete the rotator cuff repair. Repeat this sequence with each rotator cuff repair. When you can perform steps 1 through 10 in 40 minutes, advance to the next stage.

Stage 5 1. Arthroscope the glenohumeral joint. 2. Enter the subacromial space and expose the tear with bursectomy. 3. Measure the length and width (retraction). 4. Use a grasper to estimate reparability and determine what goes where. 5. Perform arthroscopic decompression. 6. Use a round bur to abrade the rotator cuff tear repair site.

42

Section One



The Basics

7. Insert an anterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 8. Insert a posterior anchor and pull the sutures out through the anterior cannula. Apply a hemostat. 9. Pass the anterior anchor sutures through the tendon. 10. Pass the posterior anchor sutures through the tendon. 11. Tie the knots. 12. Open and inspect the repair. Check the tension on the tendon, ensuring that it is neither too tight nor too loose. Are the knots secure? Is the spacing of the knots on the tendon correct? Are they too close together or too far apart? Are they too close to the lateral edge or too far away from the edge? 13. Review the video recording (I strongly suggest that you record your procedures). If the knots are too closely spaced, determine at what point in the procedure this occurred. Why did the spacing look good at arthroscopy but not when you inspected the repair open? Apply this same level of analysis to all aspects of the repair until you are satisfied. At this final stage you will gain confidence that your arthroscopic repairs are as good as or better than your open repairs. Once your particular threshold of excellence has been met, you can stop opening your arthroscopic repairs.

INSTRUMENT HANDLING Arthroscopic shoulder recontructions are complex operations, and success depends on a number of small details. One area that surgeons often overlook is the appropriate handling of arthroscopic instruments. Correct hand position and movement can be mastered with little effort.

Arthroscope Practice holding and manipulating the arthroscope with both hands. If you are comfortable holding the arthroscope with only one hand, operating on the opposite shoulder will force you into an awkward position. Practice with both hands during diagnostic glenohumeral arthroscopy until you can smoothly and rapidly maneuver the arthroscope and view all critical areas of the joint. Everyone has a dominant or preferred hand, but I have observed that some surgeons

prefer to use this hand to control the arthroscope, and others use the dominant hand to manipulate the surgical instruments. Ideally, you should be able to hold the camera and manipulate the instruments with either hand. A second skill is arthroscope rotation. Many surgeons rotate the arthroscope with the hand not holding the scope. This may be satisfactory during the diagnostic phase, but when you have an instrument in the opposite hand, this becomes difficult. Learn to rotate the arthroscope by using the index finger of the hand holding the scope (see Figs. 1-35 through 1-39).

Caspari Suture Punch You should learn to use the Caspari suture punch with either hand—a skill you can master on a practice station. It is also necessary to advance the suture with the thumb of the hand holding the instrument so you are not forced to use the opposite hand (see Figs. 1-16 through 1-20). The scrub nurse will hand you the Caspari numerous times during an arthroscopic repair, and this phase of instrument transfer can be either awkward or smooth. Rehearse the instrument transfer with your scrub nurse so that both of you are familiar with the correct technique.

Elite Pass This modern instrument is designed to pass braided sutures directly through a tendon or ligament without using a shuttle relay. Take some time to learn how to load the needle, load the suture, deploy the needle, grasp the suture, withdraw the needle, and finally remove the instrument (see Figs. 1-9 through 1-15).

Spectrum Familiarize yourself with the proper handling and transfer of this instrument. Have the scrub nurse load the looped nylon suture from the opposite side of the thumb so that the suture does not get tangled as you advance it.

AccuPass This series of instruments is used to shuttle sutures with a nylon loop. They are reusable, so the tip is always sharp. The loading eyelet is large enough so that the nylon loop can be loaded either loop end first or free end first, depending on the specific requirements of the

Chapter 1

operation. Many tip configurations are available. Try to load the nylon loop on the side opposite the thumb wheel so that the loop does not get caught in your glove (see Figs. 1-27 through 1-29).

Knot Pusher There are a variety of knot tying instruments available, and you should examine a number of them to determine which one feels most comfortable. I prefer a



Making the Transition

43

simple instrument and view the tip of it as an arthroscopic projection of my index finger. Finding the optimal shaft length is accomplished by trial and error. I shorten the standard shaft length to fit my thumb motion during the tying maneuver.

CHAPTER

2

Operating Room Setup

This chapter covers the general organization of the operating room, anesthesia, patient positioning, and equipment and instruments.

CLINICAL DATA I find it helpful to have a copy of the patient’s record in the operating room. This allows me to compare the examination under anesthesia with the examination documented in the office. For patients with glenohumeral instability, I can compare the patient’s report of which activities or motions produce pain to the amount of translation observed during examination under anesthesia. The patient record also includes a summary of the pertinent findings on magnetic resonance imaging, ultrasonography, and computed tomography, allowing me to compare these to the findings at arthroscopy. I also display the relevant radiographic study so that I can review it if necessary (Figs. 2-1 through 2-3).

44

Figure 2-1

Patient record in the operating room.

Chapter 2



Operating Room Setup

No history of prior similar shoulder problem Previous treatment consisted of selective rest and activity modification Allergies: Patient has no known drug allergies Current Medication: None Social History: Patient denies the use of any tobacco products; patient occasionally drinks socially Clinical Examination: Dominant Hand: Right Right Shoulder Examination: Tenderness — Shoulder: Present at the bicipital groove and biceps muscle Swelling: None Ecchymosis: None Crepitus: None Deformity: None present Atrophy: None present Skin: No incisions, lacerations, or abrasions noted Effusion: Absent Passive Range of Motion: elevation = 120 degrees external rotation (shoulder adducted) = 85 degrees internal rotation to the lumbar level 1-2 Strength: Strength was normal when the patient was tested for resisted elevation, external rotation, internal rotation and subscapularis push-off Muscle Pain Tests (resisted): Resisted internal rotation — not painful Elevation — no pain External rotation — no pain Abduction — no pain Belly-press test — no pain Subscapularis push-off — no pain Stability: Stability was normal when the patient was tested for sulcus, Rowe, abduction/external rotation and posterior translation Neurovascular Examination: Normal Office Radiographs: RIGHT Anterior-posterior radiographic findings: AP normal

Figure 2-2

Close-up of patient record.

45

46

Section One



The Basics

Figure 2-3

Magnetic resonance imaging study in the operating room.

Chapter 2



Operating Room Setup

SETUP AND PREPARATION The operating room layout is shown in Figure 2-4. I must have adequate space to maneuver between the head of the table and the anesthetist. I angle the cart with the arthroscopy equipment toward me so that I can see all the gauges. Similarly, the arthroscopic pump and fluid bags should be visible so that I can see the pressure and flow at any time. I also ask the anesthetist to rotate the blood pressure monitor so that I can check it during the procedure without disturbing his or her concentration. An absorbent mat to collect fluid is placed on the floor underneath my feet. I arrange the foot pedals that control the power instruments and cautery to permit easy access (Figs. 2-5 through 2-9). Figure 2-6 Back table

Technician

Instrument cart.

Absorbent mat

Assistant

Anesthesia equipment

Surgeon

Mayo stand

Operating table

Anesthesia

Fluid/pump electrogenerator

Figure 2-4

Figure 2-5

Camera Power Monitor Video recorder

Figure 2-7

Arthroscopic pump.

Operating room setup.

Equipment position.

Figure 2-8

Fluid bags.

47

48

Section One



The Basics

The shoulder preparation table contains the skin razor and adhesive tape for removing hair. My team uses an iodine-based product (Duraprep); for individuals with iodine allergy, a chlorhexidine gluconate (Hibiclens) scrub is followed by an isopropyl alcohol solution. I prefer to have the patient’s hair shaved from the area that will be covered by the bandage. It is not necessary to shave the axilla. Only those instruments required for the operation are placed on the Mayo stand. The back table contains rarely used instruments and the postoperative dressing (Figs. 2-10 and 2-11).

Figure 2-11

Back table.

ANESTHESIA

Figure 2-9

Absorbent mat and foot pedals.

Figure 2-10

Mayo stand.

My team’s routine is to perform an interscalene block in the preoperative holding area. The patient is then moved to the operating room, where general anesthesia is started. Because many patients find remaining motionless in the seated position uncomfortable, and I find patient movement and conversation distracting, I prefer to use general anesthesia rather than operating under regional block alone. The interscalene block has no direct effect on blood pressure. With sensory input blocked, there is no sympathetic response to the otherwise painful stimuli, and catecholamine release is avoided. The beta-antagonistic effects (vasodilation and bradycardia) of the general anesthetic agents are then more pronounced, without the pain response to offset them. This causes relative bradycardia and hypotension. The result is improved visualization. Because the operated area is anesthetized, only light general anesthesia is necessary, minimizing postoperative nausea. Some anesthesiologists prefer a laryngeal mask airway, which eliminates the need for endotracheal intubation. Immediate postoperative pain is well controlled (Figs. 2-12 and 2-13).

Figure 2-12

Laryngeal mask air tube.

Chapter 2

Figure 2-13

Laryngeal mask air tube secured in place with

tape.

To avoid ‘‘wrong site’’ surgery, always confirm with the patient which shoulder is to be operated on. The is done in the preoperative holding area before the patient receives any sedation. The anesthesiologist uses a surgical marking pen to write ‘‘yes’’ on that shoulder and ‘‘no’’ on the contralateral shoulder. I ask the patient and confirm the correct site myself and write a ‘‘G’’ for Gary on the correct shoulder (Fig. 2-14).

PATIENT POSITIONING Successful shoulder arthroscopy is the result of planning and organization. Many seemingly minor details can have a profound effect on the procedure, and I encourage all surgeons to invest the necessary time to prepare the operating room and surgical staff adequately. Patients are positioned in either the lateral decubitus or the sitting (beach-chair) orientation. Each position has its advantages and disadvantages,

Figure 2-14

Skin marking.



Operating Room Setup

49

and surgeon preference should dictate the choice. Both diagnostic and reconstructive shoulder arthroscopy can be performed successfully in either position. I used the lateral decubitus position for 10 years and found it very satisfactory for diagnostic arthroscopy and for arthroscopic subacromial decompression and acromioclavicular joint resection. As I began to perform rotator cuff repair and glenohumeral reconstruction, I found that the disadvantages of the lateral position became more noticeable, and I made the transition to the sitting position, which I have used exclusively for the past 15 years. I pay considerable attention to patient positioning because this aids in portal placement and facilitates the procedure. Incorrect positioning adds complexity to an already difficult procedure.

Lateral Decubitus Position The lateral decubitus position offers excellent access to the posterior shoulder and allows arm suspension (and distraction, as necessary) without the need for an assistant. The surgeon can choose to terminate the arthroscopic procedure and can easily perform an open operation in the subacromial space. Disadvantages include the need to lift and turn the patient, the possibility of excessive distraction across the glenohumeral joint and potential nerve injury, limited access to the anterior shoulder, and the need to reposition the patient if an open anterior glenohumeral reconstruction is required. Another potential disadvantage is the tendency for the suspension apparatus to place the arm in internal rotation. This is important in glenohumeral reconstruction because repair of the glenohumeral ligaments or rotator interval with the arm in internal rotation may result in permanent loss of external rotation. The surgeon can overcome all these difficulties with appropriate care. Before the patient is brought to the operating room, a vacuum beanbag is placed on the operating table and smoothed (Table 2-1). The patient is assisted onto the table and centered on the beanbag. The cephalad edge of the beanbag should be level with the patient’s upper thorax, not high enough to protrude into the axilla. After general endotracheal anesthesia has been established, the tube is secured on the side of the mouth away from the surgical site. Both shoulders are examined for range of motion and translation. The patient is then turned over on the unaffected side, with the pelvis and shoulders perpendicular to the table. The beanbag is gathered up around the patient and deflated so that it is firm. The operating table is tilted 20 to 30 degrees posteriorly so that the glenoid is parallel to the floor.

50

Section One



The Basics

Table 2-1 TABLE POSITIONING AIDS—DECUBITUS U-shaped Vacupak beanbag, 3 feet long Axillary roll Kidney rest supports for operating table (2) Contoured foam head and neck support Arm board Pillows (2) Foam pads for ankles, knees, and arms 3-inch-wide cloth adhesive tape

Considerable attention is given to protecting the neurovascular structures, soft tissues, and bony prominences. A soft sheet is rolled into a cylinder approximately 6 inches in diameter and placed under the upper thorax to raise the patient’s chest off the table and thereby minimize pressure on the neurovascular structures within the axilla. The roll should not be placed in the axilla. A 1-L fluid bag wrapped in a towel also works nicely. The downside hip and knee are slightly flexed to stabilize the patient. Pillows are placed between the legs to protect the ankles, knees, and peroneal nerves, and the breasts are carefully padded. Kidney rests are useful to support the beanbag, and broad adhesive tape may be used to further stabilize the patient. The cervical spine must be supported to prevent any hyperextension or lateral angulation during the procedure. An electrosurgical grounding pad is placed over the muscular area of the lateral thigh. The surgeon should inspect the patient’s position carefully and check each pressure area to make sure it is adequately padded. The circulating nurse prepares the entire shoulder, arm, and hand. An assistant grasps the patient’s wrist with a sterile towel, and the surgeon and scrub nurse place the lower U-drape over the patient. The forearm and hand are then placed in the traction device. The wrist is carefully padded to avoid pressure on the sensory branch of the radial nerve. The arm is placed on the lower drape, the upper drape is put into position, and the fluid-collection pouch is applied. The arm is attached to the suspension device. Usually 10 pounds of weight is sufficient, but the weight may be increased slightly for larger individuals. The surgeon should think of the suspension device as a stabilizing mechanism rather than a method of producing traction. The shoulder is positioned in 60 degrees of abduction and 10 degrees of flexion.

Sitting Position I prefer the term sitting position rather than the older beach-chair position because the patient’s thorax must be placed 70 to 80 degrees perpendicular to the floor. This upright position is necessary to place the acromion parallel to the floor and allow access to the posterior shoulder. A more recumbent position forces the surgeon to ‘‘work uphill’’ and makes entry into the inferiorposterior shoulder difficult if such a portal is required for glenohumeral reconstruction. One advantage of the sitting position is that it is similar to that used during traditional open operations, so conversion from an arthroscopic to an open rotator cuff repair or glenohumeral reconstruction does not require a change in patient position. Also, the anterior shoulder is more approachable than in the lateral decubitus position; the surgeon need not lean over the patient to gain anterior access. In this position, the arthroscopic orientation seems more familiar to surgeons, with the vertical orientation of the glenoid similar to that seen during physical examination or radiographic review. Shoulder distraction is not continuous, which minimizes the chance of neurologic injury; the assistant can provide a distraction force during the brief periods when this is needed. A mechanical arm holder can maintain the shoulder in external rotation during glenohumeral reconstruction and in elevation during rotator cuff repair. I use the McConnell arm holder (McConnell Orthopedics, Greenville, Tex). A newer, more sophisticated pneumatic positioning device called the Spyder Arm Positioner (Smith-Nephew Endoscopy, Andover, Mass) is available to aid the surgeon in rapidly positioning the shoulder. One disadvantage of the sitting position is that these patient-positioning devices are expensive. I currently use the Schloein patient positioner (Orthopedic Systems Inc., Union City, Calif). Before the patient is brought to the operating room, the mechanical support is positioned and secured to the operating table (Table 2-2). The patient is assisted onto the operating table, and general anesthesia induced. The back of the mechanical support is then raised, a small amount of Trendelenburg is applied, and the legs are lowered. The position is adjusted until the patient’s

Table 2-2 TABLE POSITIONING AIDS—SITTING Mechanical patient positioner (Schloein, Steris) Spyder or McConnell foam wrist support and pole Foam pads for ankles, knees, and arms

Chapter 2

acromion is nearly parallel to the floor. This places the patient in a nearly vertical sitting position rather than a semirecumbent beach-chair position. It is important to select a mechanical patient positioner that allows the 70- to 80-degree angle necessary. The head and neck are positioned for patient comfort and secured. Pillows are placed under the knees, and a foam pad protects the contralateral elbow. I check to make sure that no pads or drapes interfere with access to the anterior or posterior shoulder. The shoulder, arm, and hand are prepared, and an assistant grasps the wrist while the scrub nurse positions the bottom drape. The hand-wrist support is attached, and the forearm is placed on the patient’s lap. The upper drape is applied, and the suction drainage bag is affixed around the shoulder. The applicable surface anatomy is drawn, and the surgery begins (Figs. 2-15 through 2-27).

Figure 2-15

Figure 2-17



Operating Room Setup

Check the relationship of the acromion to the

floor.

Figure 2-18

Secure the breathing tube.

Figure 2-19

Position the cervical spine.

Positioning the patient.

Figure 2-16 Patient in the sitting position.

51

52

Section One

Figure 2-20

Figure 2-21



The Basics

Secure the cervical spine with a chin strap.

Figure 2-23 Base of the McConnell arm holder.

Check the cervical spine alignment from the

front.

Figure 2-24

Figure 2-22

Pad the legs and contralateral arm.

Recheck the position of the acromion.

Figure 2-25 Position the shoulder with McConnell arm holder.

Chapter 2



Operating Room Setup

53

Suture Passers

Figure 2-26

Access to the anterior shoulder.

Figure 2-27

Access to the posterior shoulder.

Sutures are passed through soft tissue either directly or indirectly. There are three types of direct methods. In the first, the instrument passes the suture through the tendon or ligament to a standard needle (Cuff-Stitch, Smith-Nephew Endoscopy). The second involves piercing the soft tissue with an instrument and then grabbing the suture and pulling it back through the soft tissue (Arthropierce, Smith-Nephew Endoscopy). The third direct method involves a flexible needle that passes the braided suture directly through the soft tissue (Elite Pass, Smith-Nephew Endoscopy) (Figs. 2-28 through 2-50). The indirect method involves placing a passing suture through the soft tissue and using this transport suture to pull the repair suture through the soft tissue. The Linvatec shuttle relay is one type of transfer suture, but I prefer standard 2-0 nylon. I cut the needle off and place the two ends together. This forms a loop on the other end that will transfer the repair suture. The cost saving is significant.

Figure 2-28

Elite suture passer.

EQUIPMENT Arthroscope I use a standard 4-mm arthroscope with a 30-degree angled lens for all shoulder arthroscopy. I have not found it necessary to use a 70-degree arthroscope. The increased lens angle may be useful when it is desirable, while viewing from the posterior portal, to see more of the anterior glenoid during a Bankart repair. I prefer to move the arthroscope to an anterior-superior portal during this portion of the procedure. The time it takes to move the arthroscope is more than offset by the superior view with the 30degree arthroscope compared with the distorted view of the 70-degree arthroscope.

Figure 2-29

Close-up of Elite suture passer.

54

Section One



The Basics

Figure 2-33

Figure 2-30

Close-up of the Caspari’s tip.

Close-up of Elite suture passer with the needle

deployed.

Figure 2-34

AccuPass.

Figure 2-31 Caspari suture passer. Figure 2-35 AccuPass deploying a nylon loop.

Figure 2-32

Close-up of Caspari suture passer.

Figure 2-36

AccuPass deploying a braided suture.

Chapter 2

Figure 2-37

Figure 2-38



Operating Room Setup

Spectrum suture passer.

Figure 2-41

Tips.

Figure 2-42

Tips.

Close-up of Spectrum suture passer.

Figure 2-39

Tips.

Figure 2-43 Straight Cuff-Stitch.

Figure 2-40

Tips.

Figure 2-44 Instrument tips.

55

56

Section One



The Basics

Figure 2-45 Left-angled Cuff-Stitch. Figure 2-49

Figure 2-50

Figure 2-46

Figure 2-47

Instrument tips.

Right-angled Cuff-Stitch.

Figure 2-48

Instrument tips.

Arthropierce.

Instrument tip.

My preference is to use the direct method with the Elite Pass for rotator cuff repairs and the indirect method for instability repairs. The problem with direct suture instruments in glenohumeral joint instability repair is that once the instrument is through the soft tissue, the instrument’s maneuverability is extremely limited. Unless the desired repair suture is directly in line with the instrument, I cannot retrieve it. With the indirect method, I can place the transfer suture at the exact point required. I then retrieve the repair suture with a crochet hook and use the transfer suture to place the repair suture through the soft tissue. This is my personal preference; other surgeons may find another method superior.

Hand Instruments I use several hand instruments during reconstructive shoulder surgery. As noted earlier, I use the Elite Pass to pass sutures through the rotator cuff during repair. I now rarely use the Caspari suture punch, which I have modified by increasing the length of the needle tip from 4 to 5 mm. I found that the 4-mm tip was often too short to pass through a rotator cuff tendon, and the small increase in length solved this problem. The Cuff-Stitch (Smith-Nephew Endoscopy) allows the surgeon to pass a suture directly through the tendon, ligament, or labrum and is preferred by some. I use the Cuff-Stitch in two particular situations. First, if the tendon is thick and fibrotic and it is difficult or impossible to pass a suture through it

Chapter 2

using the Elite or the Caspari, the Cuff-Stitch is very effective. Second, when a rotator cuff tear is massive, I can best determine its geometry and perform the repair with the arthroscope in the lateral portal, in which case it is most convenient to insert the Cuff-Stitch through the anterior and posterior cannulas. The Arthropierce can either pass or retrieve sutures during margin convergence in rotator cuff or rotator interval repair. I find the AccuPass instruments (Smith-Nephew Endoscopy) especially useful during glenohumeral reconstruction for instability. These instruments function like the original Caspari suture punch but are angled such that the surgeon can reach inferiorly to grasp the capsule or labrum.

Figure 2-52



Operating Room Setup

Close-up of soft tissue grasper.

Soft Tissue Management I use a soft tissue grasper to test the tension of the glenohumeral ligaments before instability repair and to evaluate the excursion and reparability of a torn rotator cuff. Regular and locking graspers are helpful. A grasper with less aggressive teeth allows one to pull on sutures without shredding them. A blunt probe is useful to evaluate for the presence of a subtle Bankart or a superior labrum anterior to posterior (SLAP) lesion. When a Bankart lesion has healed with a fibrous union, the lesion may not be apparent, and a sharp chisel dissector can peel the labrum off the anterior glenoid. To ensure that the capsule is not adherent to the subscapularis, I use a blunt soft tissue instrument to dissect between the two structures. A large soft tissue punch is useful to excise portions of a contracted capsule during contracture release. I have found the capsular punches designed by Harryman to be most effective for capsular release in patients with shoulder stiffness. I modified two of the instruments so that they bend downward rather than upward; I am more comfortable with this angle of approach to the capsular tissue. I use a blunt-ended probe for dissection around nerves or blood vessels. I also find the markings on the end of the probe useful for measuring distances and the size of lesions (Figs. 2-51 through 2-62).

Figure 2-51

Soft tissue grasper.

Figure 2-53

Less aggressive soft tissue grasper.

Figure 2-54

Chisel dissector.

Figure 2-55

Chisel dissector.

Figure 2-56

Blunt dissector.

57

58

Section One

Figure 2-57



The Basics

Close-up of blunt dissector.

Figure 2-62

Blunt probe with measuring guide markings.

Suture Management

Figure 2-58

Figure 2-59

Close-up view of blunt dissector.

A crochet hook is used to retrieve sutures from within the subacromial space or glenohumeral joint. If a suture gets caught in the tendon or labrum, I prefer to use a fine-toothed crochet hook that does not damage the suture. I use a looped suture grasper to ensure that there are no suture tangles within the working cannula before tying each suture. A larger instrument is useful during rotator cuff repairs, and a smaller one is easier to maneuver within the glenohumeral joint. There are a number of knot tying instruments available, but I prefer a single-lumen knot pusher, which can double as a knot pusher and puller. I modify the length of the instrument to fit my hand comfortably. Arthroscopic scissors are needed to cut suture and soft tissue. I also use endcutting scissors when I cannot see the knot during a rotator interval repair (Figs. 2-63 through 2-75).

Straight capsular resection punch. Figure 2-63

Figure 2-60

Close-up of capsular resection punch. Figure 2-64

Figure 2-61

Crochet hook.

Close-up of capsular resection punch.

Figure 2-65

Close-up of crochet hook.

Fine-toothed crochet hook.

Chapter 2

Figure 2-66

Figure 2-67

Figure 2-68

Large loop grasper.

Figure 2-71



Operating Room Setup

Knot pusher.

Close-up of large loop grasper.

Loop grasper with the jaws open.

Figure 2-72

Close-up of knot pusher.

Figure 2-69 Small loop grasper.

Figure 2-73

Figure 2-70

Close-up of small loop grasper.

Scissors.

Figure 2-74 Close-up of scissors.

59

60

Section One



The Basics

Figure 2-76

Figure 2-75

Shaver.

End-cutting scissors.

Sutures I use several different sutures during shoulder arthroscopy. The 5-mm rotator cuff anchor is preloaded with No. 2 Ultrabraid. The BioRaptor is loaded with No. 1 Ultrabraid. I use 2-0 nylon as a transfer suture to bring the braided sutures through the rotator cuff or glenoid labrum. If I am repairing tendon to tendon, I may use No. 1 PDS or No. 1 Prolene instead of No. 2 Ethibond. I use 3-0 Monocryl for the subcutaneous skin closure of portal incisions.

Figure 2-77

Close-up of shaver.

Power Instruments Relatively few power instruments are needed. I use 4- and 5-mm shavers, a 4-mm round bur, and a 5.5-mm acromionizer bur. I occasionally use a 4.5-mm acromionizer bur during abrasion arthroplasty for arthritis or for coracoid preparation during an arthroscopic Latarjet procedure. The 4-mm shaver and round bur are used within the glenohumeral joint for glenohumeral instability and SLAP repair, and I use a power drill to predrill the bone anchor holes for these repairs. I use the larger shaver to remove bursal tissue during arthroscopic subacromial decompression, and I use the acromionizer for acromioplasty. I use the round bur within the subacromial space to prepare the rotator cuff repair site. A new instrument that is useful is the Electroblade (Smith-Nephew Endoscopy)—a power shaver with cautery connected to it. This is helpful when de´briding in the subacromial space. When a bleeding vessel is encountered, rather than removing the shaver and inserting the cautery, the surgeon can merely identify the vessel and step on the electrocautery pedal. The Electroblade is extremely helpful during synovectomy for rheumatoid arthritis, resection of the rotator interval during capsular contracture release, and rotator cuff repair when medical contraindications prevent an interscalene block and the bleeding is thus a bit more robust (Figs. 2-76 through 2-87).

Figure 2-78

Figure 2-79

Electroblade.

Close-up of Electroblade.

Figure 2-80

Round bur.

Chapter 2

Figure 2-85 Figure 2-81

Operating Room Setup

61

Close-up of acromionizer bur.

Close-up of round bur.

Figure 2-86

Figure 2-82



Less aggressive oval bur.

Close-up of round bur.

Figure 2-83

Acromionizer bur. Figure 2-87

Close-up of oval bur.

Cannulas

Figure 2-84

Close-up of acromionizer bur.

The metal cannula I use for the arthroscope has ports for inflow, outflow, and pressure. In addition to the metal cannula and blunt trocar for the arthroscope, I consider three plastic, translucent cannulas vital when I perform arthroscopic reconstructive shoulder surgery. During anchor insertion or knot tying, I often use a cannula to prevent adjacent soft tissue from interfering with the procedure. Because the cannula is translucent, I can

62

Section One



The Basics

insert an anchor or tie a knot even with the cannula covering the involved area. An 8-mm cannula is large enough to accommodate the power tools and the large suturing instruments; larger cannulas (8.5 and 10 mm) are also available. A 5.5-mm cannula is used for the anterior-superior portal during glenohumeral reconstruction or SLAP repair because it is large enough to accept the 4-mm round bur. I also place it anteriorly during rotator cuff repair to act as both an outflow cannula and a retrieval cannula for the bone anchor sutures (Figs. 2-88 and 2-89). Figure 2-90

Figure 2-88

Figure 2-89

Electrocautery.

Eight-mm cannula. Figure 2-91

Close-up of electrocautery.

Figure 2-92

Close-up of electrocautery.

Five-and-one-half—mm cannula.

Thermal Instruments I use two types of thermal instruments during shoulder arthroscopy. The first instrument can cauterize or ablate tissue. I use the ablation setting during arthroscopic subacromial decompression to remove soft tissue from the undersurface of the acromion, and I use the coagulation setting to control bleeding from branches of the coracoacromial artery or from vascularized bursal tissue. I prefer a probe that has suction attached so that the bubbles produced during ablation or coagulation are removed from the operative field. The second instrument is the Electroblade, the combination shaver and cautery described earlier (Figs. 2-90 through 2-92).

Fluid Management An arthroscopic pump system for delivering fluid to the shoulder is a valuable asset. A pump system eliminates the need to hang bags of irrigating fluid high above the floor and allows the surgeon to increase pump pressure and flow rate when bleeding is encountered. I use lactated Ringer’s solution. I do not use epinephrine because I find it provides no major improvement in visualization. If a surgeon considers epinephrine helpful, I advise adding it to every other bag of Ringer’s solution to minimize any potential cardiotoxic effects.

Chapter 2

Transfer Rods Surgeons who prefer to create portals with the insideout technique will find the Wissinger rod useful (described in Chapter 3). Switching rods are blunt on both ends and are used to maintain the cannula position when the arthroscope is moved from one position to another (Figs. 2-93 through 2-95).

Figure 2-93

Wissinger rod.



Operating Room Setup

63

in the operative notes. They have the added advantage of documenting normal findings that surgeons commonly omit from the operative record. Most arthroscopy systems have the ability to take photographs during surgery with the use of a foot switch or a control button on the camera. The photographs can be printed directly or stored on recordable media or on a computer hard drive. Since I began performing shoulder arthroscopy I have also made video recordings of the operations. Typically I save approximately 30 to 45 seconds of each video; this includes the lesions found at operation and their appearance after correction. The video is captured in MPEG format. I create an electronic folder with the patient’s name and save the still photos and the video in it. When patients are doing either very well or very poorly postoperatively, it is helpful to review these records to recollect the details of the operation. I do not routinely provide patients with copies of photographs or videos, but I do so if they request it.

DEDICATED TEAM Figure 2-94

Figure 2-95

Handle of Wissinger rod.

Tip of Wissinger rod.

I cannot emphasize enough the advantages of having a trained, dedicated operating room team (Fig. 2-96). Reconstructive shoulder arthroscopy is complicated, and it is helpful when the scrub nurse, assistant, and circulating nurse can perform their jobs without instruction from the surgeon. The surgical nurse can load the Caspari or Spectrum suture instruments so that they are ready for the next step, clean the shavers and burs so that they function appropriately, and have the next instrument ready so that the operation runs smoothly.

Anchors I most commonly use 5-mm metallic TwinFix anchors for rotator cuff repair and the BioRaptor for glenohumeral joint instability and labrum repair. I have recently started to use the KINSA knotless system and the Arthrex Suture Bridge when appropriate. For patients with superior 25% to 33% subscapularis insertion tears, the QuickT is extremely efficient. It passes directly through the tissue and is secured with a special knot pusher; no knot tying is necessary.

Photography and Video Recording I find it extremely helpful to take intraoperative photographs. They record the lesions found during the operation more precisely than the description

Figure 2-96 World’s best operating room team.

CHAPTER

3

Diagnostic Arthroscopy and Normal Anatomy

Only with an understanding of normal glenohumeral joint and subacromial space anatomy can the surgeon appreciate which structures are damaged.

DIAGNOSTIC GLENOHUMERAL ARTHROSCOPY Portal placement is critical, and I take sufficient time to mark the portal sites precisely. Draw the bone outlines of the acromion, distal clavicle, and coracoid with a surgical skin marker. Be careful to draw not the most superficial bone landmarks but rather their inferior surfaces (which takes into account bone thickness), because portal entry points are referenced from these surfaces (Figs. 3-1 and 3-2). Although trocar entry into the glenohumeral joint is simple and almost intuitive for an expert, surgeons new to arthroscopy may find joint entrance difficult. The standard advice to ‘‘start in the soft spot and aim for the coracoid’’ is only slightly helpful. Actual joint entry requires precision, and even small deviations of 3 to 5 mm from the desired portal location make the operation more difficult. An additional complication is that portals vary from patient to patient because they are related to the patient’s position on the operating table as well as his or her size, rotundity, and kyphosis. The ideal portal location changes throughout the operation as soft tissue swelling increases and alters the local anatomy. Portal placement is also affected by the underlying diagnosis.

64

For instance, posterior portal placement for an acromioclavicular joint resection differs from that for a superior labrum anterior to posterior (SLAP) lesion repair. There are no absolute rules, but there are a number of guidelines that I find helpful. The most reliable landmarks are bone. Anteriorly, I outline the coracoid process, the acromioclavicular joint, and the anterior acromion. Laterally, I identify the lateral acromial border, and posteriorly, I outline the posterior acromion. The most important landmark is the posterolateral corner of the acromion, which can be palpated even in large patients. I base my measurements on this point (Fig. 3-3).

Posterior Portals Traditionally, surgeons describe the location of the posterior portal as being in the ‘‘soft spot’’ approximately 2 cm inferior and 2 cm medial to the posterolateral acromial edge. Although this location is adequate for glenohumeral joint arthroscopy, it is not optimal for subacromial space operations. If you make the incision in the traditional soft spot, you will enter the joint parallel to the glenohumeral joint line and slightly superior to the glenoid equator. This site allows you to enter and visualize the glenohumeral joint adequately, but you will be at a disadvantage if you try to use the same incision to enter the subacromial space. Once you insert the cannula into the subacromial space, the soft-spot portal directs the cannula superiorly and medially and causes two problems.

Chapter 3



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-3

Figure 3-1

Bone landmarks.

First, because the arthroscopic view is now directed medially, the lateral insertion of the rotator cuff is more difficult to visualize. Second, the superior angle of the arthroscope makes it difficult to ‘‘look down’’ on the rotator cuff tendons and appreciate the geometry of rotator cuff lesions. One solution to this problem is a second posterior portal, but I prefer to alter the posterior portal’s location (Fig. 3-4). As noted, the exact location of the posterior portal varies with the clinical diagnosis. For rotator cuff repairs and subacromial decompressions, I make the posterior incision for the portal in a more superior and lateral position, approximately 1 cm inferior

Figure 3-2

Superior and inferior bone edges (arrows).

65

Posterolateral acromial corner.

and 1 cm medial to the posterolateral acromion. The more superior and lateral location minimizes the aforementioned difficulties. The superior entry allows the cannula to enter the subacromial space immediately beneath the acromion, parallel to its undersurface. This maximizes the distance between the arthroscope and the rotator cuff, allowing a better appreciation of rotator cuff lesions. The superior position (parallel to and immediately inferior to the acromion) also facilitates acromioplasty because the surgeon is afforded a better view of the acromial shape. The more lateral position (immediately medial to the lateral acromion) places the arthroscope in line with the rotator cuff tendon insertion. I can adequately visualize the glenohumeral joint with this more lateral portal, and given that only a brief inspection is usually needed, I find this approach satisfactory.

Figure 3-4 Posterior portal in a more superior and lateral position (rather than in the soft spot) for subacromial surgery.

66

Section One



The Basics

Superior Superior entry

Inferior entry

Figure 3-7

Superior-lateral portal for acromioclavicular joint

resection. Inferior

Lateral Portals Figure 3-5

Glenohumeral joint space.

For operations restricted to the glenohumeral joint, such as a Bankart or SLAP repair, I enter the joint more medially than for those operations involving primarily the subacromial space, such as a rotator cuff repair (Figs. 3-5 and 3-6). If I am performing an acromioclavicular joint resection, I move the posterior incision 5 mm more laterally to obtain a better view of the distal clavicle (Fig. 3-7).

I do not routinely use a lateral subacromial portal during diagnostic glenohumeral joint arthroscopy. More commonly, I use a lateral portal during arthroscopic subacromial decompression and rotator cuff repair and discuss its placement in more detail in the applicable chapters. Briefly, I mark the portal location with a skin marker 3 to 5 cm distal to the lateral acromial border and 1 to 3 cm posterior to the anterior acromion. I regard this mark as only an approximation. Once I have entered the subacromial space by placing the arthroscope through the posterior portal, I identify the exact location of the lateral portal with a spinal needle before I incise the skin. I occasionally use two additional lateral portals during rotator cuff repair. An anterolateral or posterolateral portal may be required to retrieve sutures during the repair of a massive rotator cuff tear. These portals are positioned midway between the anterior and lateral or posterior and lateral portals, respectively, and are identified with the use of a spinal needle (Figs. 3-8 and 3-9).

Anterior Portals

Figure 3-6

surgery.

Superior-medial portal for glenohumeral joint

There are four basic anterior portals: anterior-inferior, anterior-superior, lateral, and medial (Figs. 3-10 and 3-11). The anterior-inferior and anterior-superior portals are used for glenohumeral reconstruction or SLAP repair. I use the lateral portal during rotator cuff repair and the medial portal for acromioclavicular joint resection. I mark the anterior-inferior portal 5 mm lateral to the coracoid; the anterior-superior portal is then located 1.5 cm lateral and 1 cm superior to the anterior-inferior portal. The lateral portal is 2 to 3 cm distal to the anterior acromion and parallel with its

Chapter 3



Diagnostic Arthroscopy and Normal Anatomy

67

Midlateral portal for arthroscopic subacromial decompression.

Figure 3-8

lateral border. The medial portal is 1 to 3 cm distal to the acromioclavicular joint. Again, these marks are only approximations; the exact portal sites are identified during arthroscopy with a spinal needle. For a glenohumeral reconstruction or SLAP repair, I make the posterior portal 2 cm medial and 1 to 1.5 cm inferior to the posterolateral acromial border.

Physical Examination Because a patient’s pain on physical examination may cause the surgeon to underestimate the range of motion or stability of the shoulder, I examine both shoulders after the induction of anesthesia. I record the range of motion in elevation, in external rotation with the arm adducted, and in external and internal

Anterior-inferior and anterior-superior portals for glenohumeral reconstruction.

Figure 3-10

rotation with the arm abducted 90 degrees. I then examine the shoulder for stability by applying anterior, posterior, and inferior force while changing the positions of abduction and rotation (Figs. 3-12 through 3-20).

Arthroscopic Procedure I incise only the skin and avoid plunging the knife into the underlying structures. Superficial skin nerves

Figure 3-9

Anterior and posterior lateral portals.

Figure 3-11 Anterior-medial portal for acromioclavicular joint resection.

68

Section One



The Basics

Figure 3-14

External rotation in abduction with anterior

stress. Figure 3-12

Elevation.

are susceptible to neuroma formation, and muscle bleeding unnecessarily complicates the procedure. I do not insufflate the joint with a needle because I can better determine the entry point into the glenohumeral joint with the more rigid trocar. I use only a blunt-tipped trocar in shoulder arthroscopy and advise surgeons never to use a sharp trocar. To begin, insert the cannula and trocar through the skin incision and gently advance them through the deltoid muscle until bone resistance is felt. With your opposite hand pushing the humeral head

posteriorly against the trocar tip, you can tell by palpation whether the bone is the glenoid or the humeral head. Alternatively, you can grasp the forearm and rotate the shoulder; if you feel the bone rotate, the trocar tip is resting against the humeral head and you must direct the arthroscope medially

Figure 3-15 Figure 3-13

External rotation.

plane.

Internal rotation in abduction in the coronal

Chapter 3



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-19

Figure 3-16

Internal rotation in abduction in the scapular

plane.

Figure 3-17

Inferior stress.

to enter the joint. If no rotation is felt, the trocar is touching the glenoid and you must direct it laterally to enter the joint. When the trocar tip is at the joint line, a slight lateral movement allows you to palpate the head, and a slight medial movement results in contact with the glenoid. The posterior joint line is medial to the posterolateral acromion, and the direction of entry is generally oriented toward the tip of the coracoid. Angle the cannula slightly superiorly and advance it into the joint. Usually a distinct ‘‘pop’’ is felt as the trocar enters the glenohumeral joint. Remove the trocar, insert the arthroscope through the cannula, and begin the diagnostic inspection. If you have not entered the joint, remove the cannula and trocar to check the bone landmarks drawn on the skin (Fig. 3-21).

Sulcus test in internal rotation.

Figure 3-18 Sulcus test in external rotation.

69

Figure 3-20 Posterior stress.

70

Section One



The Basics

Table 3-1 DIAGNOSTIC EXAMINATION OF THE SHOULDER Anterior View—Arthroscope in Posterior Cannula Biceps-labrum complex Biceps tendon Biceps exit from the joint Anterior articular surface of supraspinatus Superior glenohumeral ligament Rotator interval Subscapularis tendon Subscapularis recess Middle glenohumeral ligament Anterior labrum Anterior-inferior glenohumeral ligament Inferior labrum Inferior capsule Posterior-inferior glenohumeral ligament Figure 3-21

Bone palpation with trocar.

Diagnostic and Normal Anatomy

Posterior labrum Infraspinatus tendon Posterolateral humeral head Posterior View—Arthroscope in Anterior Cannula Posterior glenoid labrum Posterior capsule

Brachial Plexus Dissection—Cadaver The diagnostic examination of the shoulder is systematic to ensure that no lesions are overlooked. The plan described in Table 3-1 can serve as a guide. Once you have entered the glenohumeral joint, identify the biceps tendon—labrum complex and rotate the camera to orient the glenoid on the monitor screen. Some surgeons prefer the glenoid oriented vertically so that it is similar to its position with the patient standing or seated in the beach-chair position or on an anteroposterior radiograph. Other surgeons prefer to orient the glenoid so that it appears parallel to the floor. Neither technique is superior; it is a matter of surgeon preference (Figs. 3-22 and 3-23). Advance the arthroscope into the joint and rotate it so that it is looking at the 1-o’clock position relative to the glenoid surface. Inspect the rotator interval and superior glenohumeral ligament. Apply inferior distraction and observe the tension that develops. Distract the arm with the shoulder externally rotated and internally rotated and note any difference. Perform this portion of the examination first because when the

Posterior rotator cuff (site of internal impingement) Subscapularis recess Middle glenohumeral ligament and its humeral attachment Anterior-inferior glenohumeral ligament and its humeral attachment

anterior cannula is introduced, it passes through the rotator interval and alters the local anatomy. The rotator interval may appear normal in subacromial impingement, contracted in patients with shoulder stiffness, and widened or lax in patients with glenohumeral instability (Figs. 3-24 through 3-30). There are two basic techniques to establish an anterior portal: inside out or outside in. To establish the anterior portal with the inside-out technique, advance the arthroscope until it is in the middle of the triangular space bordered by the glenoid rim, the superior border of the subscapularis tendon, and the biceps tendon. Press the arthroscope against the rotator interval and hold the cannula in position while you remove the arthroscope from the cannula. Insert a

Chapter 3

Figure 3-22

Glenohumeral joint, vertical orientation.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-25

71

Rotator interval—normal superior glenohumer-

al ligament.

Rotator interval—prominent superior glenohumeral ligament.

Figure 3-26 Figure 3-23

Glenohumeral joint, horizontal orientation.

Figure 3-27 Figure 3-24 Rotator interval.

ligament.

Partial tear in the superior glenohumeral

72

Section One

Figure 3-28



The Basics

Contracted rotator interval.

Figure 3-29 Widened rotator interval.

Figure 3-30

Rotator interval synovitis.

blunt-tipped rod (Wissinger) through the cannula and advance it through the capsule until it tents the skin anteriorly. Maintain pressure on the rod and make a skin incision directly over its tip. Advance the rod anteriorly so that it projects 5 to 10 cm. Slide a second cannula over the rod tip anteriorly and advance this cannula into the joint until you can feel the two cannulas touch each other. Remove the rod and reinsert the arthroscope into the posterior cannula. Adjust the anterior cannula until 15 to 20 mm is visible within the joint. Outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula, as desired. I used this technique early in my arthroscopic experience because it enabled me to reliably enter the glenohumeral joint. As I began doing more reconstructive shoulder operations, I discovered some inadequacies with this approach. The inside-out approach allows variability in the precise entry spot for the anterior portal because there is some inevitable manipulation of the arthroscope during the necessary sequence of maneuvers. For glenohumeral joint reconstruction for instability, I need two anterior cannulas, and their positions are critical. If the inferior cannula is too superior, there will not be enough space for the anterior-superior cannula. If the cannulas are too medial or too lateral, anchor insertion is complicated, and suture placement is compromised. For these reasons, I now establish the anterior portals with an outside-in approach. To establish the anterior portal with the outside-in technique, point the arthroscope at the rotator interval and use your index finger to push on the skin of the anterior shoulder lateral and superior to the coracoid process. Observe where your finger indents the anterior capsule and move that location until the anterior capsule is indented in the middle of the rotator interval. Note this location on the anterior shoulder with a marking pen and then use a spinal needle to enter the joint at this point. I prefer to place the anterior cannula immediately superior to the superior border of the subscapularis tendon and 1 cm lateral to the glenoid surface. Note the angle that the needle makes with respect to the patient’s anterior shoulder. Remove the spinal needle, make a small incision, and place the cannula and trocar into the joint. As with the inside-out technique, outflow can remain connected to the arthroscope cannula or it can be moved to the anterior cannula (Figs. 3-31 through 3-33). Rotate the arthroscope so that it is pointed at 1 o’clock for a right shoulder (11 o’clock for a left shoulder). Advance it anteriorly and inspect the subscapularis recess and the superior border of the subscapularis tendon. Rotate the arthroscope until it is pointed at 3 o’clock (9 o’clock for a left shoulder),

Chapter 3

Figure 3-31

Entry point for anterior-inferior cannula.

Figure 3-32

Cannula and trocar entry.

Figure 3-33

Trocar removed.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-34

73

Thick middle glenohumeral ligament.

advance it anteriorly, and inspect the anterior labrum and the middle glenohumeral ligament. The normal opening of the foramen at the anterior-superior labrum should not be confused with a Bankart lesion. Observe the anterior labrum for signs of glenohumeral instability such as fraying, tearing, or separation from the glenoid. Insert a probe through the anterior cannula and test the anterior labrum’s attachment to the glenoid. Use the probe to test the tension of the middle glenohumeral ligament. Translate the humeral head anteriorly, inferiorly, and posteriorly and observe the tension that develops in the ligament. Perform these maneuvers with the arm internally and then externally rotated. The middle glenohumeral ligament has a variable appearance and may be poorly defined, prominent, or cordlike (Figs. 3-34 through 3-45).

Figure 3-35

Broad middle glenohumeral ligament.

74

Section One



The Basics

Figure 3-36 Middle glenohumeral ligament with the subscapularis poorly defined.

Figure 3-37

Figure 3-39

Cordlike middle glenohumeral ligament.

Partial tear in the middle glenohumeral

Figure 3-40

Subscapularis.

Cordlike middle glenohumeral ligament.

Figure 3-41

Subscapularis.

ligament.

Figure 3-38

Chapter 3

Figure 3-42

Figure 3-43

Subscapularis with a synovial tear.

Subscapularis with a partial tear in the superior

border.

Figure 3-44

border.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-45

75

Subscapularis recess.

Rotate the arthroscope until it is pointed at 5 o’clock and inspect the anterior-inferior labrum and glenohumeral ligament. Test their tension and insertion integrity as described earlier. Move the arthroscope inferiorly and note the presence or absence of a ‘‘drive-through sign.’’ This sign describes the ease with which the arthroscope passes between the humeral head and the glenoid surface at the 6-o’clock position. Remember that the drivethrough sign is a measure of glenohumeral laxity or translation and is not an indication of glenohumeral instability per se. Observe the laxity of the inferior capsule as the shoulder is distracted inferiorly, laterally, and then rotated. Determine whether there is an inferior labral lesion and carefully inspect the humeral attachment of the inferior capsule for signs of trauma (Figs. 3-46 through 3-56). Return the arthroscope to the biceps-labrum complex. To view the posterior labrum adequately from a posterior cannula, you must maximize the distance

Subscapularis with a partial tear in the superior Figure 3-46

Rotate the arthroscope.

76

Section One

Figure 3-47

Figure 3-48



The Basics

Figure 3-50

Anterior-inferior glenohumeral ligament.

Anterior-inferior glenohumeral ligament less

Figure 3-51

Axillary recess.

Inferior-posterior capsule.

well defined.

Figure 3-52 Palpate the anterior-inferior glenohumeral Figure 3-49

Anterior-inferior capsule.

ligament.

Chapter 3

Figure 3-53

Palpate the inferior capsule.

Figure 3-54

Inferior-posterior labrum.

Figure 3-55

Posterior-inferior labrum.

Figure



Diagnostic Arthroscopy and Normal Anatomy

3-56

Posterior

labrum,

with

the

77

arthroscope

posterior.

from the arthroscope to the labrum. This requires that you withdraw the arthroscope until it is immediately anterior to the posterior capsule. As a novice, I would repeatedly pull the arthroscope completely out of the joint. My technique to minimize (but not eliminate) the problem is as follows: Rotate the objective lens of the arthroscope so that it is pointed to the 6-o’clock position. Pinch your index finger and thumb around the cannula where it exits the skin. This increased sensory feedback helps you control the distance the cannula moves and gives you immediate control. Gently withdraw the arthroscope as posteriorly as possible to obtain the best view of the biceps-labrum complex (Figs. 3-57 through 3-59). Examine the biceps tendon and use an instrument to draw the intra-articular portion into the joint and inspect it for inflammation or tearing. Carefully examine the anterior and posterior pulleys for

Figure

3-57 Pinch

arthroscope.

the

cannula

and

withdraw

the

78

Section One



Figure 3-58

The Basics

Rotate the arthroscope. Figure 3-60

signs of trauma that may indicate biceps tendon instability. Follow the biceps tendon to its joint exit. Adhesions may exist between the biceps tendon and the supraspinatus tendon; these may be either congenital or post-traumatic (Figs. 3-60 through 3-78). Rotate the arthroscope so that it is pointed to 6 o’clock. Follow the posterior labrum from superior to inferior and note any labrum separation, fraying, or tears. Continue inferiorly until you can see the posterior-inferior glenohumeral ligament. Internally rotate the arm and observe the normal tightening of this ligament. Introduce a probe from the anterior portal and evaluate the biceps-labrum complex. Often, a SLAP lesion is obvious, but sometimes probing is necessary. Abduct and externally rotate the shoulder to see whether the superior labrum peels off the glenoid (Figs. 3-79 through 3-85). Adhesions may exist between the biceps tendon and the rotator cuff; these too may be either congenital or posttraumatic (Figs. 3-86 and 3-87).

Figure 3-59

Biceps-labrum complex.

Figure 3-61

Biceps tendon synovitis.

Biceps tendon exiting from the glenohumeral

joint.

Figure 3-62

Biceps tendon entering the bicipital groove.

Chapter 3



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-66

Bordering ligament, anterior pulley.

Figure 3-63

Bicipital groove.

Figure 3-64

Bicipital groove.

Figure 3-67 Partial biceps tendon tear.

Bicipital groove, with synovial lining.

Figure 3-68 Partial biceps tendon tear.

Figure 3-65

79

80

Section One



The Basics

Figure 3-69

Partial biceps tendon tear.

Figure 3-70

Partial biceps tendon tear.

Figure 3-71

Partial biceps tendon tear.

Figure 3-72

Introduce the shaver.

Figure 3-73

Lateral to biceps.

Figure 3-74

Medial to biceps.

Chapter 3

Pull the extra-articular biceps tendon into the glenohumeral joint.

Figure 3-75

Pull the extra-articular biceps tendon into the glenohumeral joint.

Figure 3-76

Pull the extra-articular biceps tendon into the glenohumeral joint.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-78

Extra-articular biceps tendon synovitis.

Figure 3-79

Normal superior labrum.

Figure 3-77

Figure 3-80 Minor fraying of the superior labrum.

81

82

Section One



The Basics

Figure 3-81 Minor separation of the superior labrum.

Figure 3-84

SLAP lesion continuing into the anterior-superior

labrum.

Figure 3-82

Probe for separation.

Figure 3-83

SLAP lesion.

Figure 3-85

Normal anterior-superior labral foramen.

Figure 3-86

Biceps—rotator cuff adhesion.

Chapter 3

Figure 3-87



Diagnostic Arthroscopy and Normal Anatomy

Biceps—rotator cuff adhesion.

Move your hand and the camera toward the floor to point the arthroscope superiorly and view the rotator cuff tendons. Abduct and externally rotate the shoulder until you see the anterior supraspinatus that is marked anteriorly by the biceps tendon. The anterior margin of the supraspinatus forms the posterior biceps tendon pulley. Move the camera medially and inferiorly (so that the arthroscope tip moves laterally and superiorly) and follow the cuff insertion from its anterior to posterior margins. At the same time, abduct and rotate the humeral head so that the arthroscope follows the cuff insertion from anterior to posterior. Note the insertion of the supraspinatus into the footprint area. There should be no exposed bone between the articular margin of the humeral head and the supraspinatus tendon insertion. Partial articular surface tears can be diagnosed by observing the amount of exposed bone in millimeters between the remaining tendon and the articular margin. The infraspinatus does not insert at the articular margin, and exposed bone in this area is normal. The small holes in the humeral head near the posterior cuff are normal vascular channels. When you identify the posterior cuff insertion, tilt the arthroscope inferiorly and continue to externally rotate the shoulder. You can now see the posterolateral humeral head and document the presence or absence of a Hill-Sachs lesion. Withdraw the arthroscope slightly so that the lens does not scrape against the humeral head and allow it to return to the biceps tendon—labrum complex (Figs. 3-88 through 3-101). Inspect the cartilage on the humeral head and glenoid for signs of osteoarthrosis, such as eburnation and cobblestoning. The cartilage is normally thin in

Figure 3-88

Anterior supraspinatus.

Figure 3-89

Anterior supraspinatus.

83

Articular surface of a partial-thickness rotator cuff tear of the supraspinatus.

Figure 3-90

84

Section One

Figure 3-91



The Basics

Full-thickness supraspinatus tear.

Figure 3-94 Posterior supraspinatus.

Mid-supraspinatus.

Figure 3-95 Posterior supraspinatus.

Mid—posterior supraspinatus.

Figure 3-96 Infraspinatus.

Figure 3-92

Figure 3-93

Chapter 3

Figure 3-97

Capsular reflection.

Figure 3-98

Figure 3-99

Bare area.

Vascular channels.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-100

85

Bare area.

the central glenoid, and this should not be confused with osteoarthrosis (Figs. 3-102 through 3-107). Remove the arthroscope from the posterior cannula, reinsert it in the anterior cannula, and again inspect the posterior labrum, capsule, and posterior rotator cuff. Move the arm into abduction and external rotation, and evaluate the shoulder for internal impingement between the posterior-superior labrum and the posterior cuff and capsule. Observe the normal pear shape of the glenoid from this perspective. The glenoid widens inferiorly. Loss of this pear shape corresponds to bone loss in the anterior-inferior glenoid and may be seen in patients with glenohumeral instability (Figs. 3108 through 3-111). This completes the routine inspection of the glenohumeral joint. Withdraw both cannulas and proceed to the subacromial space.

Figure 3-101

Shallow Hill-Sachs lesion.

86

Section One



The Basics

Figure 3-102

Anterior glenoid cartilage loss.

Figure 3-105

Humeral head cartilage tear.

Figure 3-103

Anterior glenoid cartilage loss.

Figure 3-106

Full-thickness cartilage loss.

Figure 3-104

Osteoarthrosis of the glenoid.

Figure 3-107

Osteoarthrosis of the humeral head.

Chapter 3

Figure 3-108

Posterior-superior labrum.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-111

87

Posterior-inferior glenohumeral ligament.

DIAGNOSTIC SUBACROMIAL SPACE ARTHROSCOPY The diagnostic examination of the subacromial space is systematic to ensure that no lesions are overlooked. The plan described in Table 3-2 can be used as a guide. The subacromial space is a pseudoarticulation that permits gliding between the proximal humerus and the coracoacromial arch. Arthroscopic experience has allowed us to define the subacromial space, which has well-defined borders when cleared of the hypertrophic bursal tissue associated with chronic subacromial impingement. The arthroscopic subacromial space begins halfway back from the anterior acromion, and posterior entry requires the surgeon to penetrate a veil or curtain of bursal tissue that separates the anterior Figure 3-109

Posterior labrum and gutter.

Table 3-2 DIAGNOSTIC EXAMINATION OF THE SUBACROMIAL SPACE View from Posterior Portal Acromial undersurface Coracoacromial ligament Anterior bursa Supraspinatus insertion into greater tuberosity Subdeltoid adhesions Acromioclavicular joint View from Lateral Portal Posterior rotator cuff Posterior bursa Figure 3-110

Inferior-posterior labrum.

Rotator interval

88

Section One



The Basics

Figure 3-113

Palpate the anterior acromion with the

trocar tip.

Figure 3-112

Bursa anatomy.

from the posterior space. Anterior, posterior, and lateral gutters can be defined. The medial confines are below the acromioclavicular joint, and exposure of the lateral clavicle requires resection of thick fibrofatty and vascular tissue. The lateral wall lies beyond the greater tuberosity, and the anterior margin is the anterior acromial border (Fig. 3-112). It is often difficult to visualize the subacromial space owing to reactive bursitis and fibrosis. When you have difficulty visualizing the subacromial space, it is usually because the arthroscope is positioned too far posteriorly. It is helpful to position the arthroscope anteriorly in the subacromial space to minimize the effect of the bursal tissue located posteriorly within the space. Use the same posterior skin incision to enter the subacromial space. Place the trocar and cannula through the skin incision and palpate the posterior edge of the acromion. Slide immediately beneath the bone and advance the trocar and cannula anteriorly. The cannula should remain in contact with the acromion. With your other hand, palpate the anterior acromion and advance the trocar beyond the anterior acromion until you can feel the trocar tip. Withdraw the trocar until it is just posterior to the anterior acromion. Usually you can palpate the coracoacromial ligament. Maintain the cannula position while you remove the trocar and insert the arthroscope.

Rotate the arthroscope so that it is directed toward the acromion, and determine whether there are any alterations in the coracoacromial ligament or the acromion (Figs. 3-113 and 3-114). Now orient the arthroscope lens so that it is pointing directly down at the rotator cuff. If you maneuver the shoulder through a range of motion and rotate the arthroscope, you will obtain a view of the superior portion of the subscapularis, the supraspinatus, and the superior portion of the infraspinatus. If you desire a better view of the posterior rotator cuff or if you cannot see clearly, establish a lateral portal. Identify the precise location of the lateral portal with a spinal needle. Introduce the needle percutaneously until it is 1 to 2 cm posterior to the anterior acromion and located midway between the acromion and the rotator cuff. The lateral cannula should enter the subacromial space parallel to and immediately beneath the inferior surface of the acromion. The distance

Figure 3-114

Lateral cannula location too anterior.

Chapter 3

between the incision and the lateral acromial border varies, depending on the patient’s size; in general, place the lateral portal 2 to 3 cm distal to the lateral acromial border. If you still cannot see well, advance the arthroscope anteriorly to free it of any surrounding bursal tissue and then withdraw it posteriorly until the acromion is visualized. If visualization remains poor, I have found a triangulation technique helpful. Insert the cannula and trocar as described earlier. Create a lateral portal by incising the skin 1 to 2 cm posterior to the anterolateral acromial border. The distance between the incision and the lateral acromial border varies, depending on the patient’s size; in general, place the lateral portal 2 to 3 cm distal to the lateral acromial border. The lateral cannula should enter the subacromial space parallel to and immediately beneath the inferior surface of the acromion. Insert a cannula and trocar through the lateral portal and, with one hand holding each, position them so that they touch each other. Often you can sense bursal tissue interposed between the two cannulas. Rub them together to remove the bursal tissue until you feel the two cannulas making direct contact. Advance the lateral cannula medially until it is past the tip of the posterior trocar. Push the posterior trocar until it is in direct contact with the lateral cannula. Press both cannulas together, remove the trocar from the posterior cannula, and insert the arthroscope. You should now be looking directly at the lateral cannula. Remove the lateral trocar and insert a motorized soft tissue resector. Palpate the acromion above and the rotator cuff below with the resector tip

A



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-115

Subacromial space obscured.

to help with orientation. Use the resector to remove bursal tissue until you can see clearly. If the shaver is on the rotator cuff, direct the shaver blade superiorly to avoid causing damage. Direct the shaver blade inferiorly when you are working near the acromion. Be careful not to contact the cuff or the acromion with the resector, because this will alter the subacromial space anatomy (Figs. 3-115 through 3-120). Once you can see clearly, perform a diagnostic inspection of the subacromial space. Observe the acromion and the coracoacromial ligament for signs of impingement such as fraying or erythema. Rotate the arthroscope so that it looks directly at the rotator cuff; at the same time, move the arthroscope tip superiorly to maximize the distance between the

B Figure 3-116

89

A, Palpate the lateral cannula with the trocar tip. B, Visualize the lateral cannula.

90

Section One

Figure 3-117



The Basics

Withdraw the arthroscope slightly.

Figure 3-120

Withdraw the lateral cannula.

arthroscope and the rotator cuff. This improves your perception of the extent of any pathology. Signs of impingement include fraying, fibrillation, and partial tearing of the rotator cuff bursal surface. Advance the arthroscope anteriorly to view the anterior gutter. Rotate the arthroscope to observe the lateral gutter. Move the arthroscope to the lateral portal. This allows a better view of the subscapularis tendon and posterior rotator cuff. If bursa is covering the rotator cuff tendons, resect it until you can see the tendon fibers. This completes the diagnostic examination of the glenohumeral joint and subacromial space (Figs. 3-121 through 3-143). Figure 3-118

Figure 3-119

Introduce the shaver.

Visualize the shaver within the lateral cannula.

Figure 3-121

Rotator cuff.

Chapter 3

Figure 3-122

Figure 3-123

Figure 3-124

Anterior gutter.

Anterolateral gutter.

Musculotendinous junction.



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-125

Figure 3-126

Figure 3-127

Lateral gutter.

Coracoacromial ligament.

Coracoacromial ligament fraying.

91

92

Section One

Figure 3-128



The Basics

Coracoacromial ligament fraying.

Figure 3-129

Spinal needle.

Figure 3-130

Os acromiale.

Figure 3-131

Figure 3-132

Os acromiale.

Lateral subacromial adhesion.

Figure 3-133

Resect the adhesion.

Chapter 3

Figure 3-134

Partial-thickness rotator cuff tear in the bursal



Diagnostic Arthroscopy and Normal Anatomy

Figure 3-137

93

Full-thickness rotator cuff repair.

surface.

Coracoacromial ligament, with the arthroscope in the lateral cannula.

Partial-thickness rotator cuff tear in the bursal

Figure 3-138

Near full-thickness bursal, partial-thickness rotator cuff tear.

Figure 3-139

Figure 3-135

surface.

Figure 3-136

eral cannula.

Rotator cuff, with the arthroscope in the lat-

94

Section One



The Basics

Right shoulder

Figure 3-140 Rotator interval, with the arthroscope in the lateral cannula. A needle probes the anterior supraspinatus.

Figure 3-143

Rotator interval opened.

INCISIONS I include a section on incisions here to emphasize the many variations on the basic theme of posterior, lateral, and anterior portals. Although the incisions required for each procedure are discussed in the applicable chapters, these discussions are separated by many pages, and the small differences among them may go unnoticed. These small but critical variations among the incisions are better appreciated as the complexity of the operation increases.

Rotator Cuff Repair Viewing Portals Figure 3-141 Rotator interval, with the arthroscope in the lateral cannula. A needle probes superior subscapularis.

In addition to the portals already mentioned, a posterior-lateral viewing portal may be necessary. Some patients have an increased posterior slope to the acromion, so even if the surgeon enters the subacromial space immediately inferior to the posterolateral acromion, the angle of the arthroscope is too vertical. In other patients, the rotator cuff extends too far laterally; with the arthroscope in the normal posterior portal, a tear is difficult to visualize. Moving the arthroscope to a more lateral position improves the surgeon’s view. Many surgeons prefer the lateral portal as the routine viewing portal. My general preference is to view posteriorly or posterolaterally and to insert instruments laterally. However, with larger tears or small, complex tears, I do not hesitate to move the arthroscope to the lateral portal if doing so results in a better understanding of the tear’s geometry.

Instrument Portals

Figure 3-142

Needle palpates the rotator interval.

Additional anterior-lateral or posterior-lateral portals may be necessary. With large or massive rotator cuff tears that require many more sutures than usual,

Chapter 3



95

Diagnostic Arthroscopy and Normal Anatomy

4

1

2

3

2 3 1

Figure 3-144

Anterior incisions for rotator cuff repair. Figure 3-146

Posterior incisions for rotator cuff repair.

suture management is complex, and it is often necessary to move sutures out of the cannulas to insert instruments. Portals immediately lateral to the acromion (with the shoulder adducted) are needed to insert anchors medially for a double-row repair (Figs. 3-144 through 3-146).

Acromioclavicular Joint Resection

2

1

The necessary incisions are illustrated in Figures 3-147 and 3-148.

Glenohumeral Joint Reconstruction Viewing Portals The posterior portal is 2 cm inferior and medial to the posterolateral acromion. This allows parallel access to the glenohumeral joint in the superior third of the glenoid. This viewing portal provides access to the rotator interval and the anterior and inferior areas of the glenohumeral joint. If I need to move

Figure 3-147

Anterior incisions for acromioclavicular joint

resection.

7 6 1

5

2

2 4

1

3

Figure 3-148 Figure 3-145

3

Lateral incisions for rotator cuff repair.

resection.

Lateral incisions for acromioclavicular joint

96

Section One



The Basics

the arthroscope to the anterior-superior portal to view the posterior glenohumeral joint, I can insert instruments through the posterior portal and gain access to the posterior-inferior glenohumeral joint. However, if I need access to the inferior-posterior glenohumeral joint, I require a second posterior portal located more inferiorly. In this situation I make my initial posterior portal more superior. This leaves sufficient space to insert a second posterior portal more inferiorly that allows access to the inferior-posterior glenohumeral joint.

Instrument Portals I generally insert instruments through the anteriorinferior portal or the routine posterior portal (Fig. 3-149).

SLAP

Latarjet Viewing Portals The standard glenohumeral joint portal is used for the initial examination and identification of anterior lesions and for coracoid preparation. I use a lateral incision placed slightly anterior to the anterior acromion to better view the superior and inferior coracoid surfaces, the rotator interval, the anterior scapular neck, and the insertion of the coracoid through the subscapularis split. I use a more distal and anterior portal if the anterior scapular neck is not well visualized. This portal is also used for visualizing the anterior subscapularis during the longitudinal split. An anterior portal lateral to the coracoid is useful to view the superior surface of the coracoid and to position the drill holes (Fig. 3-150).

Viewing Portals

Instrument Portals

I use a routine posterior glenohumeral joint portal for the initial inspection. I use the anterior-superior portal to view the posterior-superior glenoid if I cannot see it clearly with the arthroscope in the posterior portal.

The anterior-lateral portal is used for lateral coracoid dissection, and the lateral-anterior portal is used for inferior and superior coracoid dissection. I use the superior coracoid portal (the haut portal of Lafosse) for pectoralis minor release and coracoid drilling.

Instrument Portals I establish an anterior-inferior portal for outflow and so that I can insert curved suture passers. If the anterior portion of the SLAP lesion is at the 10- to 11-o’clock position (for a right shoulder), I may pass a straight suture passer through the anterior-superior portal. If the SLAP lesion extends more posteriorly, I may insert the posterior suture anchor through the posterior portal.

Suprascapular Nerve Decompression at the Suprascapular Notch Viewing Portals I use a lateral portal in line with the posterior clavicle. The portal is 2 cm posterior to the anterior acromion (Figs. 3-151 and 3-152).

4 2

1

3 2

1 5

6

Figure 3-149

reconstruction.

Anterior incisions for glenohumeral joint Figure 3-150

Latarjet anterior incisions.

Chapter 3

4 2

Figure 3-151

1



Diagnostic Arthroscopy and Normal Anatomy

5

3

Lateral incisions for suprascapular nerve

decompression.

Instrument Portals

Figure 3-153

Anterior incisions combined.

The portal is just anterior to the anterior acromion. The lateral-superior portal (for nerve dissection and suprascapular ligament division) is 4 cm medial to the medial acromion. The medial-superior portal (for nerve retraction) is 6 cm medial to the medial acromion.

Suprascapular Nerve Decompression at the Spinoglenoid Notch Viewing Portals The lateral-posterior portal is 4 cm inferior to the posterior acromion. I also use a portal placed more anterior and lateral so that I can see the scapular spine and the spinoglenoid ligament more clearly. Figure 3-154

Lateral incisions combined.

5 4

2

1

3

Posterior and superior incisions for suprascapular nerve decompression.

Figure 3-152

Figure 3-155

Posterior incisions combined.

97

98

Section One



The Basics

Instrument Portals The medial-posterior portal is 4 cm medial to the lateral-posterior portal. I insert a soft tissue dissector to dissect the infraspinatus muscle from the infraspinatus fossa of the posterior scapula. I insert a scissors to divide the spinoglenoid ligament through a portal positioned along the lateral acromion.

Incision Overview It is interesting to see all the incisions side by side. This emphasizes the small but significant changes each surgeon makes to adapt to the particular demands of a specific operation (Figs. 3-153 through 3-155).

CHAPTER

4

Glenohumeral Instability

Orthopedic surgeons have a fundamental desire to find a simple solution to glenohumeral instability, leading to various operative approaches. Initially, surgeons observed that abduction and external rotation resulted in glenohumeral joint dislocation, and early operations sought to eliminate that dislocation by limiting the offending motion—external rotation. In many patients, this succeeded in controlling the dislocation, but some were unhappy with the loss of shoulder movement and function; others continued to have instability. Subsequently, the Bankart lesion came to be regarded as the essential lesion, so labrum repair predominated. Labrum repair operations were successful in some but not all patients, and the underlying rationale—that lesions of the labrum were the sole cause of instability—could not explain dislocations that occurred without such lesions. Further, as DePalma observed, many patients had degeneration of the labrum that appeared to be an aging phenomenon, yet few of these patients developed glenohumeral joint instability. Subsequently, patients with recurrent anterior dislocations without labrum detachment were treated with an anterior capsular tightening procedure. Again, many patients benefited, but others continued to suffer shoulder dislocation or subluxation. With the understanding that some shoulders are unstable in multiple directions (with or without labrum lesions), interest shifted to global capsular tightening. The capsular shift as described by Neer provided a solution to this challenging condition. More recently, the desire to control glenohumeral instability while retaining function for overhead sports has motivated the search for new techniques involving arthroscopy. The advantages of arthroscopic

stabilization include smaller skin incisions, more complete glenohumeral joint inspection, ability to treat all intra-articular lesions, access to all areas of the glenohumeral joint for repair, less soft tissue dissection, and maximal preservation of external rotation. Arthroscopy enables surgeons to inspect the entire glenohumeral joint and observe lesions in the unstable shoulder. Concurrently, clinical and basic science investigations have increased our understanding of the pathophysiology of glenohumeral instability. We now have the background, knowledge, and technical skill to solve the problems of glenohumeral instability, and the past decade has brought both exciting advances and better patient outcomes.

LITERATURE REVIEW Because current treatments are directly linked to the past, here I summarize the intellectual history of arthroscopic shoulder stabilization. Early arthroscopic repairs used a staple to advance the Bankart lesion superiorly and medially and were associated with failure rates up to 30%. When immobilization was extended, the failure rate approached 10% to 15%. Owing to potential complications from staples within the glenohumeral joint, other surgeons used a transglenoid suture repair of the Bankart lesion. Early publications reported initial success rates up to 100%, but these results deteriorated with longer follow-up. The two essential elements of these techniques are passage of sutures through the avulsed labrum and then passage through drill holes in the scapular neck. The sutures are tied posteriorly over soft tissue or bone.

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Later research and outcomes documented two flaws with these approaches: the medial location of the repaired labrum and failure to address capsular laxity. Neviaser first identified the anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion in shoulders with anterior-inferior glenohumeral instability. The detached labrum-ligament complex healed medially on the scapular neck, which allowed excessive humeral translation. It was apparent that the staple and transglenoid suture techniques described earlier repaired the labrum medially but created an ALPSA lesion. Savoie examined shoulders that had dislocated following arthroscopic stabilization and found that the labrum had been repaired 5 mm medial to the glenoid rim. He was the first to point out that the attachment site of the repaired ligaments was critical. Savoie subsequently modified his technique by moving the entry position of the anchor from the medial scapular neck to the glenoid articular surface and reported improved results with the new technique. Bone suture anchors enabled repair of the detached labrum directly to the glenoid rim. Wolf pioneered this approach for arthroscopic instability repairs. Improved outcomes occurred as surgeons learned to position the glenoid labrum correctly on the glenoid rim. Harryman and associates introduced the term concavity-compression to explain the important role of the labrum in glenohumeral instability. However, further investigation raised two questions: Was the Bankart lesion the only labrum lesion responsible for anterior-inferior instability? Could any labrum lesion or combination of labrum lesions produce glenohumeral instability alone, without the presence of any other lesion? Rodosky described the role of the biceps-labrum complex in anterior-inferior instability. Detachments of the superior labrum—tear of the superior labrum from anterior to posterior (SLAP lesion)—performed in the laboratory allowed increased anterior humeral head translation. Speer also used a cadaver model to determine that although a Bankart lesion allows increased humeral head translation, it alone does not result in humeral head dislocation. Capsular stretch or elongation, along with a Bankart lesion, is necessary for dislocation. Tibone emphasized that the rate of capsular stretch is an important variable because the speed of the injury may determine where the capsular ligament is damaged. In a laboratory study, Bigliani demonstrated that faster strain rates result in ligament injury, whereas slower strain rates result in a higher percentage of failures at the ligament insertion site. Bigliani also studied the tensile properties of the shoulder capsule in patients

with acute dislocation and found that some degree of capsular damage was usually present, even with a Bankart lesion. Baker arthroscopically inspected the shoulders of 45 patients within 10 days of acute dislocation and found that the capsule had been stretched or torn in all patients with or without an associated Bankart lesion. We are all indebted to Gross, who elegantly summarized much of this information. Most descriptions of arthroscopic technique have omitted treatment of the rotator interval. This area of the glenohumeral joint capsule is the soft tissue between the superior border of the subscapularis tendon and the anterior edge of the supraspinatus tendon and includes the superior glenohumeral ligament and a portion of the coracohumeral ligament. Neer and Rowe described the role of the rotator interval in open repair of shoulder instability. Rowe and Zarins inspected the superior aspect of the rotator cuff and found that 20 of 37 patients undergoing operation had a large opening in the capsule between the supraspinatus and subscapularis. Harryman’s laboratory studies advanced our understanding of the rotator interval. He found that opening the rotator interval increased inferior-posterior translation. Perhaps the most subjective (and therefore difficult) type of instability treatment is capsular tensioning. The orthopedic community greeted thermal treatment with great interest; however, clinical application outpaced basic scientific investigation. Recently we gained some appreciation of the thermal technique’s complexity, appropriate role, limitations, and complications. Thermal treatment has been associated with the devastating complications of capsular necrosis, capsular rupture, and chondrolysis. To what degree the application of heat causes these problems is unknown, but at present, the use of thermal capsulorrhaphy has largely been abandoned. I believe that the high failure rates previously reported for arthroscopic repairs were due to technical factors, such as medial repair of the anterior labrum, as well as failure to treat all lesions that contribute to glenohumeral instability. My colleagues and I have reported our early results, and we emphasize the following 11 ideas. 1. Glenohumeral instability occurs in several directions. 2. These directions are classified as anterior, posterior, bidirectional (anterior-inferior or posterior-inferior), and multidirectional (inferior, anterior, and posterior). 3. The classification of direction is somewhat arbitrary.

Chapter 4

4. The primary direction of instability is determined through a combination of patient history, physical examination, radiographic analysis, examination under anesthesia, and evaluation of the glenohumeral joint at the time of arthroscopic surgery. 5. Lesions are usually multiple. 6. Instability in any direction may be the result of various combinations of lesions. 7. The same combination of lesions may produce instability in different directions in different patients. 8. Instability correction requires that all lesions be identified and repaired. 9. It may be necessary to operate on areas of the glenohumeral joint on the side opposite the primary instability to balance the shoulder and prevent iatrogenic instability. 10. Glenohumeral instability should probably be considered a single entity defined as symptomatic excessive humeral head translation. 11. The clinical expression of this translation is variable in each individual. Orthopedic surgeons use patient history, physical examination, radiographic analysis, and operative findings to diagnose the clinical expression of glenohumeral instability. Unidirectional instabilities are well appreciated and are generally categorized as anterior or posterior. On physical examination, patients with multidirectional instability have symptoms of pain and apprehension when the shoulder is stressed in anterior, posterior, and inferior directions. Neer’s pioneering concepts were twofold: glenohumeral instability can occur in multiple directions, and correction of all three symptomatic directions is necessary. In my experience, however, there is a group of patients who are symptomatic in only two directions. There is little in the literature concerning bidirectional glenohumeral instability—that is, inferior instability with either an anterior or a posterior component—which is a separate entity from multidirectional instability and unidirectional anterior or posterior instability. Neer discussed instability in two directions in his paper on multidirectional instability. Altchek described his results with operation for multidirectional instability of the anterior and inferior types. Pollock and Bigliani specifically used the term bidirectional in their paper on recurrent posterior shoulder instability. In a search for a unifying approach to the many forms of glenohumeral instability, I found Pollock and Bigliani’s analysis most helpful. In their article on anterior-inferior shoulder instability, they discussed the complexities



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of instability classification and stressed the need to address all components of glenohumeral laxity to balance the shoulder. They were the first to report that an area of asymptomatic laxity must be treated to correct symptomatic instability in another direction, whereas previous articles had focused on correcting the laxity in the direction of the instability. The clinical expression of glenohumeral joint laxity is termed instability, and my philosophy is that the direction or directions of instability are, to a large degree, the result of laxity in various areas of the glenohumeral capsule and insertion tears of the labrum. Other factors undoubtedly play a role. Some of these factors require nonoperative treatment (muscular strengthening and neuromuscular conditioning), and others require modification of the surgical technique, such as when anterior glenoid bone loss dictates an operation such as the Latarjet procedure. Successful arthroscopic treatment requires that the surgeon identify the direction and degree of clinical instability preoperatively, identify the areas responsible for excessive translation arthroscopically, and then correct all necessary areas of the glenohumeral joint. A prime example of this approach is a patient with recurrent posterior glenohumeral subluxation. This patient likely has excessive laxity in the posterior-inferior capsule, but correction of that area alone will not necessarily control excessive humeral head translation. Even though the patient is not symptomatic in the direction of the rotator interval or the anterior-inferior glenohumeral ligament, tightening of both these areas is usually required. There are many similarities between arthroscopic rotator cuff repair and arthroscopic glenohumeral reconstruction, but there are also important fundamental differences. Arthroscopic rotator cuff repair has certain advantages over the traditional open approach, as described in Chapter 12. Fundamentally, however, the primary goal of both the arthroscopic and the open procedure is identical: to reattach the torn edge of the rotator cuff tendon to its normal point of anatomic insertion. Operations within the glenohumeral joint are technically less demanding than those within the tight confines of the subacromial space, but arthroscopic glenohumeral reconstruction is not a simple operation. Although the glenohumeral joint is better visualized and the surgeon has more space to manipulate instruments than within the subacromial space, the less demanding technical aspects of the procedure are offset by a greater deficit in knowledge. For example, there are no objective standards by which

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Glenohumeral Joint Surgery

Superior SLAP Cuff

Interval

Internal impingement Posterior

Anterior

PIGHL

AIGHL Inferior capsule Inferior

Figure 4-1 The circle concept of instability. AIGHL, anteriorinferior glenohumeral ligament; PIGHL, posterior-inferior glenohumeral ligament.

to judge ligament or capsular tension, so the surgeon can only estimate the amount of tightening needed. The most critical part of the procedure is the one that lacks objective guidelines. I have found it helpful to use a circle to conceptualize some of the factors involved in glenohumeral joint instability (Fig. 4-1). Think of the circle in the figure as a sagittal view of the right shoulder, with the arrow representing the direction of anteriorinferior translation. The most common form of shoulder instability occurs in the anterior-inferior direction, and our initial understanding was that the lesion was in the anterior-inferior portion of the shoulder. Depending on the surgeon’s country of origin, this lesion is termed the Bankart, Broca, or Perthes lesion. The search for this ‘‘essential’’ lesion dominated research for 50 years, and other surgeons presented their clinical and laboratory work questioning this idea. DePalma thought this explanation was inadequate because he had identified unstable shoulders without any labrum abnormality, as well as shoulders with labrum abnormalities that were stable. Nonetheless, the Bankart lesion became the focus of operative repair. This thinking persisted with few challenges until Neer and Foster’s article on multidirectional instability emphasized the importance of an inferior capsular lesion. Rowe and Zarins also described operative correction of a shoulder with anterior-inferior instability in which no Bankart lesion was found. Further investigation identified the importance of the inferior-posterior capsule and ligaments as additional static stabilizers, as well as the importance of the rotator cuff muscles as dynamic stabilizers. The role of the superior labrum

in anterior-inferior instability was described by Snyder and Rodosky. Harryman reminded us of the role the rotator interval plays in glenohumeral joint motion and translation. Morgan, Burkhart, and the Jobes pioneered our thinking on the influence of glenohumeral joint translation (if any) on internal impingement. Obviously, as we learn more about the glenohumeral joint structures in both normal and pathologic shoulders, surgical decision making becomes more complex.

DIAGNOSIS Patient History I collect sufficient data to rate patients according to the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Constant scoring system, the scoring system of Rowe, and the University of California at Los Angeles (UCLA) Shoulder Scale. Recently, my colleagues and I developed our own scoring system that allows us to compare patients with high as well as low levels of shoulder function without an excessive response burden. Before operation, all patients complete self-assessment questionnaires to document their levels of shoulder pain, satisfaction, and function. To increase diagnostic precision, I classify each shoulder by chronicity, degree, and traumatic onset. I document (according to the patient’s description) whether the instability is chronic or acute (< 6 weeks) and further classify the instability as recurrent dislocation, recurrent subluxation after a single dislocation, or recurrent subluxation without prior dislocation. I record whether the patient developed instability after a traumatic event of a magnitude sufficient to damage the glenohumeral ligaments (traumatic or atraumatic) and use guidelines similar to those described by Wirth. A traumatic cause is supported by an injury with the arm forcefully abducted, externally rotated, and extended; sudden sharp pain; the need for manipulative reduction; and residual aching in the shoulder for several weeks. Atraumatic instability is characterized by an insidious onset or following minor trauma and is associated with mild pain and a spontaneous reduction. All patients are questioned about arm position or activity that reproduces their symptoms. Additionally, I record the sports participation, if any, of each patient. I classify sports according to the method described by Allain. Type 1 sports are nonimpact and consist of breaststroke swimming, rowing, running, or sailing. Type 2 sports are high impact and

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105

include bicycle riding, snow skiing, soccer, and water skiing. Type 3 sports require overhead use of the arm with hitting movments, such as crawl-stroke swimming, golf, tennis, throwing, and weight lifting. Type 4 sports involve overhead hitting movements and sudden stops such as basketball, football, handball, ice hockey, judo, karate, kayaking, lacrosse, polo, rodeo, volleyball, wind surfing, and wrestling. I also record which shoulder is dominant.

Physical Examination I measure active ranges of motion according to the Constant rating system, which includes forward flexion, abduction, external rotation in abduction, and behind-the-back internal rotation. Passive elevation and external rotation (with the arm adducted), as well as external rotation and internal rotation with the arm abducted 90 degrees, are measured. I measure internal rotation at 90 degrees of abduction in the coronal as well as the scapular plane. Elevation strength is measured using a dynamometer with the arm elevated 90 degrees in the scapular plane and internally rotated, with the result recorded in pounds. The instability examination is performed on both shoulders. I compress (load) the humeral head into the glenoid during all maneuvers. I assess glenohumeral translation in eight directions: anterior-superior, anterior, anterior-inferior, inferior-anterior, inferior, inferior-posterior, posterior-inferior, and posterior. An essential element of the instability examination is patient relaxation; an effective examination is not possible if the patient’s muscles are tense. This may occur as a result of pain during the examination or fear that pain will follow a particular maneuver. If the patient is comfortable, I perform the examination with the patient standing; if relaxation is not adequate, I examine him or her seated or supine. I assess anterior-superior translation with the shoulder in 0 degrees of abduction and the arm externally rotated 90 degrees while I grasp the humeral head and move it anterosuperiorly. Anterior translation is assessed with an anterior force applied to the shoulder with the arm in 90 degrees of abduction; anterior-inferior translation is tested with the arm in the same position, but the direction of force is changed to anteroinferior (Fig. 4-2). I also perform the relocation test (Fig. 4-3). A particularly useful maneuver is the Rowe test to assess inferior-anterior translation. To perform this examination, have the patient stand and flex the trunk from the hips approximately 30 degrees. Instruct the patient to relax the arms and let them hang from the shoulder toward the floor. In this relaxed position, the shoulders

Figure 4-2

Dr. Rowe examines a patient for anterior

instability.

are effectively elevated 30 degrees (Fig. 4-4); the examiner then applies a distraction force. Inferior translation is assessed with an inferior force applied with the shoulder at 0 degrees of abduction (sulcus test). If the translation force is applied in an inferior-posterior direction, the surgeon can gain additional information. Posterior translation is examined with the arm elevated 90 degrees, adducted slightly, and rotated internally approximately 30 degrees. I translate the shoulder in a posterior-inferior direction and record the result. I then apply a posterior force and assess the translation. Typically, posterior translation produces minimal complaints, but as the shoulder is extended, the humeral head reduces, and the patient reports pain.

A

B Figure 4-3

A and B, Relocation test.

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30°

Figure 4-5

Figure 4-4

Patient position for the Rowe test.

I record the presence or absence of pain and apprehension for each instability maneuver and grade the amount of humeral head translation on the glenoid surface as 0 (stable or trace laxity), 1 (up to 50%), 2 (> 50% but not dislocatable), or 3 (dislocatable). The grading of instability is somewhat subjective but appears to be relatively consistent for each examiner. I record the presence of laxity in the contralateral shoulder and elbows and the patient’s ability to bring the thumb to the forearm, but I use no formal grading system for the degree of generalized ligament laxity. I simply record ligament laxity as present or absent. I exclude other sources of shoulder pain (rotator cuff lesions, acromioclavicular joint arthritis, thoracic outlet syndrome, brachial plexus lesions, glenohumeral arthritis) through the patient history, physical examination, and radiographic analysis.

Anterior-inferior dislocation.

glenohumeral instability consists of humeral head dislocation. Indirect radiographic signs of instability include calcification adjacent to the anterior glenoid, a bone Bankart lesion, anterior glenoid bone loss, or a HillSachs lesion. On magnetic resonance imaging and computed tomography, additional evidence of instability includes detachment of the glenoid labrum from the glenoid bone, capsular stripping from the glenoid, and ligament insufficiency (Figs. 4-5 through 4-14). If the diagnosis is in doubt, an arthroscopic examination and examination under anesthesia are helpful. I observe humeral head movement under direct arthroscopic visualization. The presence of intra-articular lesions may allow the surgeon to diagnose a predominant direction of instability or an unrecognized direction of instability. These lesions are located in the humeral head and glenoid (chondral or osteochondral defects), labrum (fraying or separation from the glenoid), and capsular ligaments (tear or laxity).

Radiographs Routine radiographs include anteroposterior glenoid, axillary, and supraspinatus outlet views. I recently added the Bernejeau view to my routine radiographs because I think it best demonstrates the presence or absence of anterior glenoid bone loss. I obtain Bernejeau views of both shoulders for comparison. Other radiographic imaging (magnetic resonance imaging, computed tomography, arthrography) is not routinely performed. Direct radiographic evidence of

Figure 4-6

Glenoid rim fracture.

Chapter 4

Figure 4-7



Glenohumeral Instability

Bone Bankart lesion. Figure 4-10 Bankart lesion.

Figure 4-8

Bone Bankart lesion (circled), axillary view.

Figure 4-9

SLAP lesion.

Figure 4-11

Hill-Sachs lesion.

Figure 4-12 Anterior capsular stripping.

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RA

SP

Figure 4-15 Figure 4-13

Contracted posterior-inferior capsule.

Glenoid rim fracture.

commonly occurs in patients with traumatic anteriorinferior glenohumeral instability (Figs. 4-15 and 4-16).

NONOPERATIVE TREATMENT Nonoperative treatment consists of avoidance of painful activities, nonsteroidal anti-inflammatory medication for pain if necessary, and a home physical therapy program designed to eliminate contractures and maintain or improve shoulder girdle strength and neuromuscular coordination. The goal is to improve the strength of those muscles responsible for glenohumeral stability. Therefore, patients perform resistive exercises of the internal rotators, external rotators, biceps, triceps, and scapular muscles with surgical tubing and light weights (maximum 5 pounds). Patients are instructed in exercises to improve neuromuscular coordination and proprioception. Areas of contracture are identified and corrected with specific stretching. Posterior contracture

Figure 4-14

(arrow).

OPERATIVE TREATMENT Indications The primary indication for operation is persistent shoulder pain due to glenohumeral instability that

Posterior humeral glenohumeral ligament tear Figure 4-16

Adduction stretch.

Chapter 4

has not responded to a minimum of 6 months of nonoperative treatment as described earlier. The only exceptions are patients who desire operative repair acutely (within 6 weeks after an initial traumatic dislocation). Fundamentally, I believe the decision to operate is the patient’s, and I present the natural history of an initial shoulder dislocation in the context of the particular situation. When a patient sustains an initial dislocation that occurs with sufficient energy that it can be classified as traumatic, surgical repair is an option. I consider nine factors: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Patient age Amount of trauma involved in the dislocation Reduction method Arm dominance Present activity level Desired activity level Patient’s sensation of instability Radiographic findings Timing during a sports season

Seven factors influence the decision in favor of acute repair: 1. Age younger than 20 years 2. Traumatic dislocation (as opposed to dislocations that occur with minimal force) 3. Reduction required (as opposed to spontaneous reduction) 4. Dominant arm 5. High activity level 6. Desire to continue that activity level 7. Sensation of instability while in a sling or with movement during sling removal or dressing A displaced bone fragment indicates that the labrum does not lie in its anatomic location and will heal with the attached soft tissue in a medial position. If the patient is currently participating in a team sport and the season is less than 2 months from completion, we discuss the patient’s desire to return to that sport or another seasonal sport. For example, a high school junior with an interest in football may elect to have his shoulder repaired so that he can play during his senior year. A patient who also participates in a spring sport may not want to risk missing baseball season, for example, particularly if that is his area of concentration. I explain the chance of recurrent instability in light of the patient’s particular situation and let the patient and family decide on operative or nonoperative care. My experience correlates with much of the recent literature. Patients who are younger than 20 years and participate in vigorous overhead activities have a high



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rate of redislocation. However, unless the patient falls into the select subgroup described earlier with factors influencing early repair, the chances of recurrent dislocation are less than 50%, and of those in whom redislocation occurs, only 50% request surgery. Historians will likely view our past treatment of traumatic shoulder dislocation as suboptimal. Essentially, there is a 25% recurrence rate (much higher in certain patients). Arthroscopic treatment has a 90% to 95% success rate, yet it is not routinely performed. Orthopedic surgeons operate on acute ligament injuries of the knee and ankle but rarely on the shoulder. I think that as our techniques and equipment continue to improve, and as our ability to identify patients at high risk of recurrent symptomatic dislocation increases, patients with acute shoulder dislocation will have greater access to surgical care.

Contraindications Absolute contraindications to surgery include glenohumeral instability with selective voluntary muscle contractions and questionable emotional stability. Patients who can activate their muscles and demonstrate glenohumeral subluxation or dislocation with the arm by the side seem to have a poor prognosis after operative care. Evaluating a patient’s emotional stability is, of course, subjective. Relative contraindications include failed prior instability surgery, poorquality ligaments, and large bone defects of the glenoid or humeral head. The solution in the last case is the Latarjet procedure, discussed later in this chapter (Fig. 4-17).

Figure 4-17 Three-dimensional computed tomographic reconstruction with anterior bone loss.

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Most Hill-Sachs lesions do not affect the operative result because, with restoration of soft tissue tension, the Hill-Sachs lesion does not engage the anterior glenoid. However, when the humeral head defect is large enough, there is insufficient surface area to allow adequate external rotation. If the patient regains external rotation, he or she may experience a sensation of catching as the Hill-Sachs lesion rides over the anterior rim. Earlier operations dealt with this issue by intentionally restricting external rotation, but such an approach limits function and may lead to asymmetric loading and arthrosis. I have found that arthroscopy is the most effective means of evaluating whether the Hill-Sachs lesion is large enough to require an open procedure such as a humeral head allograft or rotational osteotomy. For those rare patients with very large, engaging Hill-Sachs lesions, I recently began using a metallic cap (ArthroSurface) to fill in the defect and have been very pleased with the short-term results. Wolf has described his arthroscopic remplissage procedure, which involves advancement of the infraspinatus tendon and posterior capsule into the humeral head defect.

OPERATIVE APPROACH Here, I describe why I choose to repair various structures within the glenohumeral joint and when during the operation I do so. Because I consider glenohumeral instability to be a single entity with variable clinical expression, I do not present separate sections on the treatment of each direction of instability.

Operative Rationale The underlying principle of arthroscopic repair is to identify and repair all lesions that contribute to glenohumeral instability. This involves de´bridement, repair of ligament and labrum tears, capsular tensioning, and, if needed, repair of the rotator interval. My approach to a patient with glenohumeral instability is first to determine the direction or directions of instability by conducting a thorough history, physical examination, examination under anesthesia, and examination during glenohumeral arthroscopy. I then evaluate all the structures within the glenohumeral joint and decide which ones require operation. A patient with unidirectional anterior instability may require an anterior labrum repair, but if capsular stretching has occurred, anterior capsular imbrication may be necessary as well. Another patient with the

same direction and degree of translation may not be stabilized with these two maneuvers and may require a superior labrum repair. A patient with posteriorinferior instability may not be stabilized after posterior labrum and posterior capsule repair and may require tightening of the inferior capsule and anterior-inferior glenohumeral ligament. A rotator interval repair may be necessary. The decision making is complex, but it accurately reflects the reality of the clinical situation. The goals of de´bridement are to remove sources of mechanical irritation or functional instability. Only minor labrum flap tears (< 50% of the labrum thickness) are removed, and every attempt is made to repair the lesions. The purpose of ligament and labrum reattachment to bone is twofold. First, adequate capsular tension is impossible to achieve unless the labrum and ligament are securely attached to the glenoid. I repair all traumatic tears of the superior, anterior, posterior, and inferior labra because all these lesions contribute to glenohumeral instability. Second, anatomic repair of the ligament and labrum restores cavity-compression to the glenohumeral joint. Lippitt has demonstrated that compression of the humeral head into the glenoid by muscular force is an effective stabilizer to humeral translation, and resection of the labrum decreases stability by 20%. Reattaching the anterior-inferior ligament—labrum complex to the glenoid may not restore sufficient stability to the glenohumeral joint. Speer demonstrated only a small increase in humeral translation with a simulated Bankart lesion and concluded that capsular stretching or elongation is necessary to produce glenohumeral instability. Therefore, the final portion of the operation is to restore capsular tension. I classify capsular elongation as primary or secondary. Primary elongation refers to permanent deformation of the capsular fibers due to a single traumatic event or multiple episodes of instability. Secondary elongation occurs when there is a tear at the insertion site, thereby decreasing capsular tension. This may occur within the anterior-inferior capsule after a Bankart lesion or as a result of a superior labrum tear. The biceps-labrum complex contributes to anterior-inferior translation, and its detachment results in increased humeral translation. Thus, I repair all traumatic superior labrum detachments. Rotator interval and superior glenohumeral ligament tears also affect glenohumeral stability. I have observed at operation that repair of the rotator interval decreases inferior and posterior translation of the humeral head. If the

Chapter 4

repair also incorporates the superior portion of the middle glenohumeral ligament, anterior capsular tension is increased. Thus the surgeon can restore capsular tension by two methods: primary capsular elongation requires operation directly on the capsule, and secondary elongation responds to repair of insertion site tears. I correct primary capsular elongation by three techniques used singly or in combination: (1) advancement of the capsule to the labrum, (2) advancement of the capsule to the glenoid with suture anchors, and (3) capsular imbrication. The goal of this portion of the procedure is to restore ligament and capsule tension and to eliminate excessive humeral head translation, which I define as greater than 25%. To estimate the percentage of translation, I visually divide the humeral head into four segments and observe how much of the humeral head translates with relation to the glenoid. Any or all of the following areas may require tightening: middle glenohumeral ligament, anterior-inferior glenohumeral ligament, inferior capsule, posteriorinferior glenohumeral ligament, and posterior capsule. My preference is to advance the capsule to the intact or repaired labrum with braided sutures. Only if the labrum is small or absent is the capsule repaired to the glenoid rim with bone suture anchors. Drill holes for the suture anchors are placed through the glenoid articular surface approximately 1 to 2 mm from the peripheral glenoid rim. The detached labrum is sutured so that it contacts the scapular neck and extends onto the glenoid articular surface. This reestablishes the labrum ‘‘bumper’’ and re-creates an optimal surface for concavity-compression. I estimate the amount of tightening based on both the degree and the direction of translation, using guidelines similar to those described by Warner for open operations. A soft tissue grasper is used to apply traction to the various portions of the capsule while the arm is positioned in different degrees of abduction and external rotation and I apply translation forces. I try to establish tension in different parts of the capsule according to their role in glenohumeral stability. I estimate appropriate tension of the inferior capsule with the arm in 60 degrees of abduction and 60 degrees of external rotation, the middle glenohumeral ligament with the arm in 30 degrees of abduction and external rotation, and the rotator interval with the arm in 0 degrees of abduction and 30 degrees of external rotation (Figs. 4-18 through 4-22). Because I am technically unable to perform the repair with the arm in complete abduction or

Figure 4-18



Glenohumeral Instability

111

Inferior translation with the shoulder internally

rotated.

external rotation, I estimate the appropriate amount of tension, return the arm to 20 degrees of abduction and 30 degrees of external rotation, and then complete the arthroscopic repair. With the greater visualization afforded by the arthroscope, the surgeon can selectively repair damaged portions of the capsule. This is an advantage over open reconstructions for anterior instability. With the increased selectivity of arthroscopic repair comes the promise of improved patient outcomes, but also a new set of decisions to be made. This is less of a problem with tears of the labrum insertion, because the goal of returning the labrum to its anatomic location is relatively well understood. More difficult are decisions regarding ligament or capsule tightening; the surgeon has to decide what portions of the capsule should be tightened, how much

Figure 4-19

rotated.

Inferior translation with the shoulder externally

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Glenohumeral Joint Surgery

tightening is necessary, and by which technique tightening should occur.

Intraoperative Decision Making and Indications De´bridement

Figure 4-20

Inferior translation in abduction.

I de´bride only minor flap tears of the labrum. Flap tears greater than 50% are repaired with absorbable monofilament sutures. I find that labrum palpation with a probe is necessary to determine the presence of minor flap tears, cleavage tears that exist within the labrum substance, and minor separations of the labrum from the glenoid. Loose bodies are removed with surgical forceps.

Labrum Repair

Figure 4-21

Anterior translation.

The labrum is normally attached securely to the glenoid bone anteriorly, inferiorly, and posteriorly below the glenoid equator; I consider separations in these areas to be lesions. The anterior-superior labrum is usually not well attached to the glenoid (sublabral foramen), and separation in this area is considered normal. The superior labrum attachment is variable, and a mobile superior labrum without evidence of trauma is not classified as a SLAP lesion. When the superior labrum separation is a normal variant, the superior glenoid is covered with smooth cartilage, and the labrum shows no evidence of trauma. Signs of traumatic separation include tears within the substance of the superior labrum, cartilage loss with exposed bone at the site of labrum attachment, and an increase in superior labrum separation with abduction and external rotation of the arm. I repair the superior labrum anatomically and make no attempt to shift the superior labrum anteriorly or posteriorly. In contrast, during repair of the anterior, inferior, or posterior labrum, I will, if necessary, shift the labrum laterally so that it projects onto the glenoid surface and reestablishes the labrum as a bumper to aid in concavity-compression.

Capsular Tensioning

Figure 4-22 Posterior translation.

I estimate the location of the ligament repair site (and therefore the ligament tension) by grasping the ligament and placing it at different locations on the glenoid. Humeral head translation is performed with the torn ligament positioned at possible repair sites until humeral head translation is less than 25% of the glenoid diameter. Typically, 5 to 15 mm of lateral and superior ligament advancement is required. Arm position affects ligament and capsule tension, so I routinely maintain the shoulder in 20 degrees of abduction and 30 degrees of external rotation during

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113

this portion of the operation. I alter the arm position when operating on the dominant arm of a competitive, throwing athlete. In these patients, I determine the ligament repair site after I position the arm in 60 degrees of external rotation.

Rotator Interval If the shoulder demonstrates persistent excessive translation after de´bridement, labrum repair, and capsular tensioning, I turn my attention to the rotator interval. If the direction of translation is inferior or inferiorposterior, I place a monofilament suture through the soft tissue immediately adjacent to the anterior border of the supraspinatus and then through the soft tissue superior to the subscapularis tendon. I place the suture as far laterally as possible so as not to interfere with postoperative external rotation. While applying traction on this suture, I again assess humeral head translation. If the correction is adequate, the suture is tied. If the correction is inadequate, the suture is removed and placed in a more medial position until excessive translation is corrected. If the direction of persistent translation is inferior-anterior, the inferior limb of the suture is passed through the superior portion of the middle glenohumeral ligament to increase tension in that portion of the capsule.

OPERATIVE TECHNIQUE The patient receives an interscalene block to diminish postoperative pain and is then placed under general anesthesia. The anesthesiologist administers 1 g cephalosporin intravenously. I place the patient in the sitting position and examine both shoulders as described earlier. The shoulder joint is entered with a cannula and blunt trocar through a posterior skin incision placed 1.5 cm inferior and 2 cm medial to the posterolateral border of the acromion. I place the posterior portal in a more superior location than the soft spot. This allows me more access if I must introduce a second inferiorposterior portal later during the procedure. I perform a brief inspection and evaluate the rotator interval for evidence of trauma or laxity. This must be done before placement of the anterior portals because they will pass through the rotator interval and alter its appearance. An anterior portal site is identified with a spinal needle so that the cannula enters the shoulder joint immediately superior to the subscapularis tendon and 1 cm lateral to the glenoid. The more lateral the anteriorinferior cannula, the easier it is to place anchors perpendicular to the glenoid surface, but the more difficult it is to reach the inferior aspects of the glenohumeral joint. If

Figure 4-23 Portal sites for arthroscopic subacromial decompression and glenohumeral reconstruction, in the traditional soft spot.

the anterior-inferior cannula is placed more medially, it is easier to reach the inferior glenohumeral joint but more difficult to place suture anchors. I then inspect the glenohumeral joint completely. I reexamine the shoulder for translation while viewing it through the arthroscope and use a probe to examine the labrum for tears and palpate the capsule to evaluate ligament tension (Figs. 4-23 through 4-38). I then establish the anterior-superior portal with a spinal needle. The anterior-superior cannula is placed 1 cm superior and 5 mm lateral to the anterior-inferior cannula (Figs. 4-39 through 4-42).

Figure 4-24

Widened, thin rotator interval.

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Figure 4-25

Anterior portals.

At this point I remove the arthroscope and insert it through the anterior-superior cannula to inspect the posterior glenohumeral joint more completely, paying particular attention to the glenoid shape. Anterior glenoid bone loss can be observed by loss of the normal glenoid pear shape. If my observations with the

Figure 4-26

Anterior-inferior portal location.

Figure 4-27 Cannula in the anterior-inferior portal.

arthroscope positioned posteriorly lead me to conclude that the anterior ligaments are inadequate for surgical repair or my view with the arthroscope positioned anteriorly demonstrates a loss of anterior glenoid bone, I perform an arthroscopic Latarjet procedure (Figs. 4-43 through 4-46). I then return the arthroscope to the posterior cannula. All structures within the glenohumeral joint are examined systematically, and all lesions consistent with instability are recorded. These lesions are variable and may include tears of the rotator cuff (partial and complete), rotator interval, glenoid labrum, glenohumeral ligaments, and biceps tendon. I have noted, as

Figure 4-28

Superior labrum tear.

Chapter 4

Figure 4-29

Palpating for a superior labrum tear.

Figure 4-30

Poorly defined middle glenohumeral ligament.

Figure 4-31

Palpation of the anterior-inferior glenohumeral

ligament.

Figure 4-32

Figure 4-33



Glenohumeral Instability

Anterior cartilage loss.

Chisel exposing a small Bankart lesion.

Figure 4-34 Bankart lesion.

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Figure 4-35



Glenohumeral Joint Surgery

Palpation of the inferior capsule.

Figure 4-38

Shallow Hill-Sachs lesion.

Figure 4-39

Anterior-inferior cannula.

Figure 4-36 Loose body removal.

Figure 4-40 Figure 4-37

Humeral head cartilage lesion.

location.

Needle identifies the anterior-superior portal

Chapter 4

Introduce the anterior-superior cannula and palpate the rotator interval. Figure 4-41

Metal cannula and arthroscope moving to the anterior-superior portal.

Figure 4-42

Anterior Bankart lesion seen from the anteriorsuperior cannula.

Figure 4-44

Figure 4-45



Glenohumeral Instability

Posterior labrum fraying.

Posterior labrum split.

Figure 4-43

Figure 4-46

Posterior Bankart lesion.

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have others, that the glenohumeral ligaments can tear at either the glenoid or humeral head insertion. To evaluate the glenohumeral ligaments for midsubstance tears or plastic deformation, I assess them for laxity by directly observing and palpating them (with an arthroscopic probe) and applying translation stresses as I rotate the shoulder. I document the location on the glenoid and the extent (superior to inferior and medial to lateral) of labrum detachment. Labra that are frayed or have midsubstance tears are noted. The presence or absence of loose bodies is also recorded. The cartilage is inspected for damage to the glenoid and humeral head (Hill-Sachs lesion). I carefully examine the glenoid and use an arthroscopic probe inserted through the anterior-inferior cannula to measure the glenoid width. The inferior portion below the glenoid equator should have a greater anterior-posterior width than the glenoid superior to the equator. If it does not, there has been too much bone loss, and a bone graft is necessary to restore glenoid width. Previously, I performed this operation with the open Latarjet technique; more recently, based on the work of Lafosse, I have made the transition to an all-arthroscopic Latarjet. I then examine the Hill-Sachs lesion and record its location, dimensions, and orientation. A posterolateral location indicates anterior instability, and an anteromedial location is consistent with posterior instability. I note the lesion’s length, width, and depth and maneuver the shoulder until I can determine what amount of external rotation will allow the Hill-Sachs lesion to engage the glenoid rim. I center the humeral head by compressing it against the glenoid while performing this maneuver. Usually the Hill-Sachs lesion does not engage the glenoid rim without anterior translation. If the Hill-Sachs lesion engages the glenoid rim with the humeral head centered and the amount of external rotation is 40 degrees or less, I suture the posterior capsule into the humeral head defect (the remplissage of Wolf). This rarely occurs. If the external rotation is greater than 40 degrees, I continue with arthroscopic stabilization. To examine the orientation of the Hill-Sachs lesion, I position the arm so that the lesion is parallel to the anterior glenoid rim and observe the amount of abduction and external rotation. This is the position of the arm during the moment of dislocation and indicates which areas of the capsule are damaged. As a rule, the greater the amount of abduction needed to align the Hill-Sachs lesion with the anterior glenoid rim, the more damage there is to the inferior capsule. A smaller amount of abduction indicates more anterior capsule (middle glenohumeral ligament) damage (Figs. 4-47 and 4-48).

Figure 4-47

Hill-Sachs lesion, with the arm resting at the

patient’s side.

If a posterior repair is necessary, I perform this before superior, anterior, or inferior capsular repair. Repair in any of these areas dramatically limits access to the posterior, and especially the posterior-inferior, glenohumeral joint (Figs. 4-49 through 4-61).

Posterior Repair The principles of posterior repair are similar to those for anterior and inferior repair, but there are some specific distinctions. Because posterior repair is performed less frequently than anterior repair, the surgeon is

Figure 4-48 Hill-Sachs lesion, with the arm positioned until the lesion is parallel to the anterior glenoid rim.

Chapter 4

Figure 4-49

Figure 4-50

Glenohumeral Instability

Figure 4-52

Drill an inferior anchor hole.

Figure 4-53

Drill a superior anchor hole.

De´bride the posterior labrum.

Abrade the posterior glenoid with a round bur.

Figure 4-51



The posterior glenoid is prepared.

Figure 4-54

Insert the anchor.

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Figure 4-55



Glenohumeral Joint Surgery

Retrieve the braided suture. Figure 4-58

Figure 4-56 Pass through the labrum and retrieve the suture with a nylon loop through the anterior-inferior cannula.

Retrieve the braided suture from the anteriorinferior cannula to the posterior cannula.

Figure 4-59

Tie knots.

Tighten the inferior-posterior capsule.

Figure 4-57

Figure 4-60

Repair of the now-intact labrum.

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121

is technical: I cannot maneuver the posteriorly located drill to penetrate the articular cartilage at an appropriate angle. Second, in most posterior repairs, I suture the posterior capsule and incorporate enough capsule with the labrum to re-create the labrum bumper, even with anchors located in this position. The posterior labrum bumper is smaller than the one I create anteriorly, but this corresponds to the normal labrum anatomy. I locate the drill holes 2 to 3 mm posterior to the articular surface. The angle is parallel to the surface or slightly posterior to it. I insert the anchors and repair the labrum and capsule from inferior to superior. Figure 4-61

Completed repair.

not as familiar with the hand maneuvers needed to position instruments within the glenohumeral joint. I recognize that my movements will be slower and less fluid than when operating anteriorly, so I mentally allow myself some leeway during posterior operations.

Portal Placement To establish the posterior portal, I move the arthroscope to the anterior-superior cannula. I leave the anterior-inferior cannula in place to provide outflow, and I can insert the crochet hook through it to retrieve sutures. While I view the posterior capsule through the arthroscope, I remove the posterior metal cannula and insert a larger-diameter plastic cannula through the same skin incision. I advance it until the tip tents the capsule. I then move the tip inferiorly and advance it external to the capsule until it reaches the appropriate entry point. This point is located near the inferior glenoid for inferior-posterior capsular tensioning; it may be at the glenoid equator if the labrum is the only damaged structure.

Scapular Neck Preparation I use a 4-mm round bur. Because of the portal location, the bur enters the glenohumeral joint parallel to the glenoid surface. I advance it into the joint and move it superiorly and inferiorly over the desired distance. It helps to advance the arthroscope as far into the joint as possible and rotate it to obtain the best view of the posterior glenoid.

Drill Holes I leave the arthroscope in the anterior-superior cannula and insert the drill posteriorly. I place the posterior drill holes on the posterior scapular neck. In contrast, for an anterior repair, I position the drill holes on the glenoid articular surface. One reason for the difference

Suture Passing I use the Smith-Nephew or Spectrum crescent hook and pierce the posterior-inferior capsule and advance it superiorly. The instrument tip penetrates the capsule and is visible. I then proceed through the soft tissue superiorly, pierce the labrum, and advance the two free ends of the 2-0 nylon suture into the glenohumeral joint. Dr. Hammerman (my assistant) inserts a crochet hook through the anterior-inferior cannula, retrieves the sutures, and applies a hemostat. I remove the crescent hook from the joint. The anchor sutures exit the joint through the posterior cannula. We then reverse the loop with another monofilament suture so that the loop end comes out the anterior-inferior cannula and the two free ends exit the posterior cannula. I insert a crescent hook through the anteriorinferior cannula and retrieve one of the anchor suture strands. I place it through the looped end of the monofilament suture and pull it through the labrum and posterior cannula until it exits posteriorly. I tie the knot through the posterior cannula. I then repeat this sequence until the posterior repair is complete and then go on to capsular tensioning. If no posterior repair is needed, I return the arthroscope to the posterior cannula and continue with the glenohumeral reconstruction.

Anterior-Inferior Repair Bankart Bankart Release of Labrum and Capsule with Cautery Bankart Complications The repair sequence varies and depends on the specific combination of lesions identified. I follow a pattern of

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de´bridement, ligament or labrum reattachment, and capsular tensioning.

De´bridement De´bridement is performed to smooth frayed labrum fragments or to remove torn fragments. It is also performed, if necessary, to identify the depth of partialthickness rotator cuff tears. Loose bodies are removed, but doing so is usually frustrating because the inflow blows the pieces around the joint. I find it helpful to attach suction to the outflow cannula, let the flow of fluid bring the loose body to the mouth of the cannula, and then grasp it with a forceps.

Type B

Insertion Tears I then treat labrum and ligament insertion site tears. Technical considerations dictate the order of labrum repair. Posterior labrum tears are repaired first, followed by tears in the inferior, anterior, and superior labrum. As the labrum (and attached ligaments) is repaired, the ability to displace the humeral head and insert bone or soft tissue suture anchors or sutures is compromised. I repair the posterior labrum first because access to this lesion becomes difficult after superior or anterior labrum repair. Posterior, inferior, and superior labrum tears are usually easily identified and minimally displaced. This is not the case with anterior labrum tears. I classify three types of anterior labrum detachment: type A, in which the labrum is separated from the glenoid bone but remains at the level of the glenoid articular surface; type B, in which the labrum is separated and retracted medially; and type C, in which the labrum is retracted and has

Type A

Figure 4-62

Type A lesion.

Figure 4-63

Type B lesion.

healed medially on the glenoid (equivalent to an ALPSA lesion) (Figs. 4-62 through 4-64). Type B and C lesions require that the surgeon dissect the labrum from the glenoid and place it laterally on the glenoid articular surface. I perform this with a combination of a thermal probe, power bur, scissors, and blunt dissection. If the anterior-inferior or middle glenohumeral ligaments are retracted and adherent to the subscapularis, I release the ligaments before insertion site repair.

Type C

Figure 4-64 Type C lesion.

Chapter 4

I make an incision with a scissors along the superior border of the middle glenohumeral ligament and insert a blunt instrument (posterior to the capsule and anterior to the subscapularis tendon) to separate the two structures. If the labrum or capsule has healed medially, I insert a sharp chisel dissector along the scapular neck to peel these structures from the bone. I advance the arthroscope (located in the posterior cannula) as far anteriorly as possible and rotate it to obtain the best anterior view. If the view is not satisfactory, I transfer the arthroscope to the anteriorsuperior cannula. Once the capsule and labrum have been separated from the bone, I try to advance them laterally. If further mobilization is necessary, I insert arthroscopic scissors through the anterior-inferior cannula and divide the soft tissue attachment in the base of the V formed by the scapular neck posteriorly and the capsule anteriorly. I continue to divide the soft tissue until I can see the muscular fibers of the subscapularis (Figs. 4-65 through 4-68).



Glenohumeral Instability

Figure 4-66

Chisel to dissect the labrum from the glenoid.

Figure 4-67

Use scissors to mobilize the labrum and

capsule.

Figure 4-65

repair.

123

Location of two anterior cannulas for anterior Figure 4-68 Muscular fibers of the subscapularis.

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Glenohumeral Joint Surgery

Bankart, Bone Fragment Bankart Acute Dislocation Patients with traumatic unidirectional instability often have a piece of bone attached to the anterior labrum that was avulsed from the glenoid during dislocation. These fragments are often too small to be seen on radiographs, but they are easily seen and palpated during arthroscopy. I try to retain these fragments and incorporate them in the labrum repair to add bulk. The tip of the suture passer must pass underneath the fragment so that the fragment is lifted by the suture and reduced laterally. With larger bony Bankart lesions, it is more critical to retain the fragment. If the fragment is excised, the glenoid width decreases. Studies have shown that glenoid narrowing as small as 4 mm significantly compromises containment of the humeral head by the glenoid. In addition, if the fragment is excised, the glenohumeral ligaments will not be long enough. I prefer to repair the labrum and ligaments with the shoulder in external rotation. If there is insufficient ligament length, the surgeon is forced to perform the repair with the shoulder internally rotated, which makes it very difficult for the patient to regain adequate external rotation.

Figure 4-69 Abrade the anterior scapular neck.

Anterior Scapular Neck Preparation After labrum and ligament mobilization, the scapular neck is abraded to a depth of 1 mm. The abraded area begins at the level of the glenoid cartilage and extends 2 cm medially on the scapula. It is important not to abrade too deeply and risk compromising the glenoid width and creating the problems discussed earlier. This can be done with the arthroscope in the posterior portal and the bur in the anterior-inferior cannula, or the arthroscope can be moved to the anterior-superior cannula (Figs. 4-69 through 4-71).

Figure 4-70

Anterior view.

Drill Holes Drill holes for the suture anchors are placed through the glenoid articular surface approximately 1 to 2 mm from the lateral glenoid margin. I space the drill hole sites (typically three are used) proportionally along the anterior glenoid. I use the round bur to remove a small area of cartilage and mark the drill hole site. I do so for five reasons: 1. The cartilage in these patients is usually thick, and because the length of the drill is fixed, the greater the amount of cartilage present, the less distance the screw will insert in the bone.

Figure 4-71

Completed abrasion.

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125

2. If the drill hole is made in cartilage, it can be hard to identify. 3. I want to recess the screw as far as possible. 4. I can create a small shelf in the bone to decrease the acuity of the approach angle. 5. I want to maximize the area of labrum-bone contact because the labrum heals more securely to bone than to cartilage. Drill holes are created in the anterior and inferior glenoid with a power drill inserted through the anterior-superior cannula. To reach the most inferior portion of the glenoid, I ask the assistant to distract the humeral head laterally and posteriorly. Distraction is needed at three stages of the operation: placing the drill hole, passing the suture passer through the inferior capsule or labrum, and tying the suture. The assistant provides distraction during these brief times. During the remaining portions of the procedure, the arm rests in the arm holder without any distraction force. The surgeon’s ability to distract the glenohumeral joint is one reason why some surgeons prefer the lateral decubitus position. Continuous traction is not present in the sitting position. I find either approach acceptable and consider patient position a matter of surgeon preference. I place the drill holes through the anterior-superior cannula for two reasons: the angle of approach to the glenoid is easier, and it minimizes the number of times I must transfer sutures from the anterior-inferior to the anterior-superior cannula. The anterior-superior cannula is located slightly more superior and posterior to the anterior-inferior cannula and presents a less tangential approach to the articular glenoid surface. It is also easier to insert the anchors through the same cannula used for the drill because they enter the glenoid at the same angle as the drill. If I place the drill holes (and anchors) through the anterior-inferior cannula, I have to transfer the sutures to the anterior-superior cannula before inserting the suture passer. The suture passer must be inserted through the larger anterior-inferior cannula because the anterior-inferior aspect of the glenoid cannot be reached from the anterior-superior cannula. By avoiding having sutures in this cannula, I eliminate the possibility of the sharp tip of the suture passer cutting one of the sutures.

Figure 4-72

Insert the anchor through the anterior-superior

cannula.

the most inferior glenoid drill hole. The number of suture anchors varies, depending on the size of the labrum detachment, but I typically use three anchors. As Dr. Hammerman inserts each anchor, I distract the humeral head to allow him easier access to the drill hole. The anchor inserter has two vertical lines that mark the eyelet orientation. As he seats the anchor, he checks to see that the vertical lines (and eyelet) are oriented anterior-posterior rather than superior-inferior. This minimizes suture strand twisting and allows the suture to slide freely in the anchor during knot tying (Figs. 4-72 through 4-75).

Anchor Insertion I prefer to insert an anchor, pass the suture and tie it, and then go on to the next anchor rather than inserting all the anchors at one time. This minimizes the number of suture strands within the glenohumeral joint. I place the anchors inferiorly to superiorly. The first suture anchor is inserted through the anterior-superior cannula into

Figure 4-73

Anchor inserted on the glenoid surface.

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Figure 4-76

Advance the labrum onto the glenoid articular

surface.

Figure 4-74

Inserter orientation lines.

Suture Passing The most difficult suture to place is the most inferior, because access to the glenohumeral joint is generally quite limited. Suture passing is less difficult in patients with multidirectional instability because the inferior capsular laxity that accompanies this condition allows the surgeon greater access. The first decision I make is whether to repair only the detached labrum or to incorporate the inferior capsule with the repair to perform capsular imbrication. If capsular imbrication is not necessary and I want to repair the labrum alone, I use the suture passer to pierce the labrum at a point the brings the labrum to its normal anatomic insertion site on the glenoid. The torn labrum is usually displaced medially and inferiorly. Therefore, I must pierce the labrum with the suture passer so

Figure 4-75 Anchor and suture in the glenoid.

that when the knot is tied, the labrum is translated superiorly and laterally. This brings the labrum above the glenoid articular surface so that I can reestablish the labrum as a bumper and restore concavitycompression (Fig. 4-76). I often use the empty suture passer to grasp the labrum at various points and bring it to the glenoid until I am satisfied that the appropriate entry point has been established. Only then do I load the suture passer with the nylon passing suture for the final repair. I prefer to use the angled Smith-Nephew or Spectrum suture passer for this portion of the procedure. I use a right-angled instrument for right shoulders and a left-angled instrument for left shoulders. I normally incorporate some amount of capsule along with the labrum to correct capsular laxity. I find it easier to choose the correct spot in the capsule with the tip of the instrument before inserting the suture passer through the labrum. If the right-angled instrument is used in a left shoulder, the surgeon must pass it from the labrum to the capsule, and once the instrument has pierced the labrum, it is hard to manipulate and find the appropriate area of capsule (Figs. 4-77 and 4-78). The left-angled instrument allows me to pierce the capsule and advance it so that I can clearly see where the tip of the instrument exits the soft tissue near the glenoid. When I advance the nylon passing suture, it then lies on the glenoid, within reach of the crochet hook. Once the nylon suture is in the joint, I distract the humeral head, and Dr. Hammerman inserts a crochet hook through the anterior-superior cannula, retrieves the suture strands, and places a hemostat on the two free ends. The suture instrument is then removed from the anterior-inferior cannula. The loop end now exits from the anterior-inferior cannula, and the two free

Chapter 4

Figure 4-77

Left-angled instrument in the right shoulder.

Figure 4-79



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127

Piercing the capsule.

ends exit from the anterior-superior cannula (Figs. 4-79 through 4-83). This description is reversed for a right shoulder.

Loop Reversal Because I have passed the suture in the manner described earlier, if I place an anchor suture in the loop end, it will pass through the labrum in the wrong direction—from anterior to posterior. This loop around the labrum inhibits suture sliding and therefore threatens the security of the knot. I want the anchor suture to pass from the anchor through the labrum from posterior to anterior. Therefore, I use a monofilament suture to reverse the loop. The two free ends of the monofilament suture are placed through the loop of the nylon. By pulling on the two free nylon ends, the loop of monofilament is brought

Figure 4-80

Advance the capsule to the labrum.

Figure 4-81 Puncture the labrum and advance the nylon Figure 4-78

Right-angled instrument in the right shoulder.

suture.

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Figure 4-82



Glenohumeral Joint Surgery

Access to the nylon suture with the crochet hook.

into the anterior-inferior cannula, through the labrum and capsule, and out the anterior-superior cannula. The loop of monofilament suture is now in the same anterior-superior cannula that contains the suture anchor sutures (Fig. 4-84). Obviously, these steps can be avoided by initially passing the suture passer in the opposite direction. However, loop reversal takes about 10 seconds to accomplish, and the advantages of piercing the labrum from anterior to posterior far outweigh the inconvenience of this extra step. Because the SmithNephew instrument can be loaded with the loop end first, the surgeon can eliminate this portion of the procedure by using the AccuPass instrument. An exception to this technique occurs during repair of a shoulder with a large Bankart bone fragment. Because of the size of the bone, the suture cannot be

Figure 4-83

cannula.

Retrieve the suture through the anterior-superior

Figure 4-84

Reverse the loop direction with the Prolene

(blue) suture.

passed from the labrum or capsule toward the glenoid (lateral to medial). In this situation, I use a rightangled suture passer for a left shoulder, place the instrument tip under the bone fragment, and rotate the instrument so that I obtain an adequate amount of soft tissue. No loop reversal is needed.

Bankart Acute Dislocation Passing the Anchor Suture I insert a crochet hook through the anterior-inferior cannula and grab one of the suture anchor limbs. I remove the most posterior anchor suture limb out the anteriorinferior cannula. The anterior suture anchor limb and the monofilament loop are now in the anterior-superior cannula. Dr. Hammerman places 8 cm of the suture

Retrieve the posterior anchor suture strand out the anterior-inferior cannula.

Figure 4-85

Chapter 4

Figure 4-86 Pass the anterior anchor suture strand from the anterior-superior cannula, through the labrum and capsule, to the anterior-inferior cannula.

anchor limb through the loop. He then pulls the hemostat clamped to the two free ends of the monofilament suture in the anterior-inferior cannula and, while I provide humeral head distraction, pulls the suture from the anterior-superior cannula into the joint, through the labrum and capsule, and out the anteriorinferior cannula. He then removes the monofilament suture. Both suture anchor limbs are now out the anterior-inferior cannula, and I tie the knot (Figs. 4-85 and 4-86).

Knot Tying I first apply traction to both suture ends to eliminate any twists in the sutures. I then pass the loop suture grasper into the joint and encircle the suture that does not pass through the labrum. I select this suture because I want the other strand to be the post. This allows me to slide the knots and obtain better knot security. I then place a half-hitch throw and use the knot pusher to push the throw into the joint and bring the labrum to the glenoid. I throw another half hitch in the same direction and push it into the joint. I pull on the post strand while releasing any tension from the other suture anchor strand, slipping the knot and labrum until the labrum is in its desired location and the knot is tied firmly. I then throw a half hitch in the opposite direction and tighten it, reverse the post and tie another half hitch, and reverse the post again and tie another half hitch. This results in a secure knot (Figs. 4-87 and 4-88).

Figure 4-87



Glenohumeral Instability

129

Retrieve both limbs of the anchor suture.

Superior Labrum Repair SLAP Repair After the inferior and anterior labra are repaired, any tear of the labrum from the superior glenoid bone is identified. The superior glenoid bone is abraded with a power bur, and two suture bone anchors are inserted. The location of the suture anchors varies and depends on the anatomy of the lesion; I typically place one suture anchor one third of the tear length from the posterior margin and a second anchor one third of the tear length from the anterior margin. I prefer nonabsorbable No. 2 braided suture and currently use a plastic tap-in anchor exclusively. The details of this portion of the procedure are described in Chapter 5 (Fig. 4-89).

Figure 4-88

Final repair.

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Glenohumeral Joint Surgery

Figure 4-89

SLAP repair.

Figure 4-91 Spectrum pierces the middle glenohumeral ligament inferior to the tear.

Capsular Repair The better view obtained with arthroscopic inspection (compared to open surgery) has allowed me to become increasingly selective in performing capsular repair. I can identify and repair lesions restricted to only one of the glenohumeral ligaments without tightening the undamaged portions of the capsule. A typical example is a tear of the middle glenohumeral ligament. Once I identify the tear, I use braided, permanent sutures to repair it to the intact labrum. I insert the suture passer through the anterior-inferior cannula, pierce the torn capsule, and puncture the labrum at the site of desired repair. I then advance the suture and use a crochet hook to retrieve it out the anterior-superior cannula. I retrieve the suture limb and tie the strands through the large anteriorinferior cannula. These steps are repeated as needed (Figs. 4-90 through 4-102).

Figure 4-90

Middle glenohumeral ligament tear.

Advance the intact middle glenohumeral ligament superiorly.

Figure 4-92

Figure 4-93 Pierce the capsule.

Chapter 4

Figure 4-94

Figure 4-95

Pierce the labrum.

Advance the nylon suture.



Glenohumeral Instability

131

Figure 4-97 Remove the Spectrum and withdraw the suture limb out the anterior-inferior cannula.

Figure 4-98

Both suture limbs exit the anterior-inferior

cannula.

Figure 4-96

cannula.

Retrieve the suture limb out the anterior-superior

Test the tension in the repaired middle glenohumeral ligament.

Figure 4-99

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Determining Capsular Tension

Figure 4-100

Tie knots.

I have experimented with various techniques for determining the appropriate amount of capsular tension, including measuring the amount of translation in centimeters and measuring capsular tension with various types of strain gauges, but none has been successful. My current technique is to maximally tighten the capsule while varying the position of the shoulder. As in an open capsular shift procedure, it is possible to selectively tighten different areas of the capsule. I position the shoulder in elevation and internal rotation, grasp the posterior capsule with a forceps, and determine its maximum superior advancement on the glenoid. I then suture it in this position. I tighten the inferior capsule in 0 degrees of abduction and neutral rotation. I tighten the anterior capsule in 45 degrees of abduction and 45 degrees of external rotation. If persistent inferior or inferior-posterior translation remains, I proceed to a rotator interval repair. The repair sequence is to place the rotator interval sutures, test the capsular tension, and tie the rotator interval sutures.

Capsular Tightening

Figure 4-101

Figure 4-102

Repeat as needed.

Final middle glenohumeral ligament repair.

If capsular tightening is necessary, there are two options. One is to repair the labrum to its anatomic location and then use a second suture to advance the capsule to the now repaired labrum. A second option is to repair the labrum and tighten the capsule in one step. There are advantages and disadvantages to each approach. If the surgeon chooses the first option, two suture-passing steps are required. If the surgeon chooses the second option, the decision making is more complex and the amount of tightening possible is more limited. The goal is to advance the capsule superiorly and laterally as well as repair the labrum. Therefore, the surgeon must determine precisely where the suture passer should enter both the capsule and the labrum. Once the suture passer enters the capsule, the surgeon’s ability to maneuver the needle tip and pierce the labrum is limited. It is also difficult to achieve more than 1 cm of capsular tightening with this technique. This may be sufficient for most cases of traumatic unidirectional instability, but more capsular tightening may be necessary for bidirectional and multidirectional instability. I also lightly de´bride the capsule with an arthroscopic rasp because the synovial bleeding aids capsular healing (Figs. 4-103 through 4-105). I modify the repair technique when the labrum is intact but the glenohumeral ligament has been torn from the labrum. If the labrum is of sufficient size to allow suture placement within its substance, the ligament is repaired directly to the labrum with monofilament or braided suture. If the labrum is absent, the

Chapter 4

Figure 4-103

Use a whisker shaver to lightly abrade the

capsule.



Glenohumeral Instability

133

capsule is advanced onto the glenoid articular cartilage surface and repaired with suture anchors (as described earlier), creating a labrum bumper. If the labrum-ligament complex is attached to the glenoid but the ligament lacks sufficient tension to contain the humeral head, I operate directly on the capsule using the methods described earlier. The goal of this portion of the procedure is to restore ligament and capsule tension and to eliminate excessive humeral head translation. The capsule can be tightened by advancing it radially and suturing it to the labrum, or it can be translated superiorly 1 to 2 cm and then sutured. I load a braided suture into a Smith-Nephew suture passer, insert it through the anterior-inferior cannula, and pierce the capsule at the point where I want to advance to the glenoid. For sutures in the inferior labrum or capsule, the assistant provides distraction to the humerus as I reach down to grab the capsule. After the instrument has pierced the capsule, I advance the tip of the suture passer to the labrum and penetrate it. I advance the monofilament suture into the joint. I maintain distraction while Dr. Hammerman reaches into the joint with a crochet hook and retrieves the suture out the anterior-superior cannula. I then insert the crochet hook through the anterior-inferior cannula and retrieve the other suture limb. The monofilament suture is used to feed a braided suture into the glenohumeral joint. I then tie the knot. These steps are repeated as necessary. I examine the shoulder for translation, and if I have established adequate tension, the operation is concluded.

Capsular Shift Figure 4-104

Use a rasp to lightly abrade the capsule.

Bankart Capsular Shift

Multidirectional Instability

Figure 4-105

Use a rasp to lightly abrade the capsule.

In patients with multidirectional or bidirectional instability, the capsule may not tighten adequately with simple advancement or 1 to 2 cm of superior translation. If further capsular movement is necessary, I perform a capsular shift. To shift the anterior capsule superiorly, I divide the attachment of the middle glenohumeral ligament to the subscapularis. I use scissors to incise along the superior border of the middle glenohumeral ligament from a point overlying the subscapularis to the glenoid. I then use a blunt dissector to separate these two structures. I divide the capsular attachment to the glenoid with scissors, starting anteriorly and continuing until I reach the 6-o’clock position. I then incise

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the capsule radially approximately 2 cm. I use the blunt dissector to free the anterior and inferior capsule from the underlying subscapularis muscle. The capsule is now mobilized sufficiently to allow significant advancement superiorly and is sutured as described earlier. If a posterior capsular shift is necessary, I transfer the arthroscope to the anterior-superior cannula and divide the posterior capsule from the glenoid.

Rotator Interval Repair Interval Repair Rotator interval repair is the last step performed within the glenohumeral joint, because cannulas cannot be inserted anteriorly once this repair is completed. A suture passer through the anterior-inferior cannula is used to place a monofilament suture through the capsule superior to the subscapularis tendon. I advance the suture into the joint and withdraw it through the anterior-superior cannula. I then load a doubled 2-0 nylon suture into the suture passer, insert it through the anterior-superior cannula, and position it in the joint. I withdraw the anterior-superior cannula until it is external to the capsule. I then withdraw the suture passer external to the capsule and pierce the superior capsule. I advance this suture into the joint and withdraw the two free ends out the anterior-inferior cannula. The monofilament suture through the anterior-superior cannula is placed in the nylon loop. Traction on the two free ends of the nylon (exiting the anterior-inferior cannula) draws the suture through the superior capsule and out the anterior-inferior cannula. The knot is then tied, and an additional suture is placed if necessary. If a greater degree of tightening is required, the superior capsular tissue is sutured to the middle glenohumeral ligament (Figs. 4-106 through 4-114).

Pierce the middle glenohumeral ligament with a suture passer.

Figure 4-106

Figure 4-107

Advance the monofilament suture.

Figure 4-108 Insert a crochet hook through the anteriorsuperior cannula.

Figure 4-109

cannula.

Retrieve the suture out the anterior-superior

Chapter 4

Figure 4-110



Glenohumeral Instability

135

Puncture the superior glenohumeral ligament.

Figure 4-111 Advance the nylon suture and withdraw it out the anterior-inferior cannula.

Figure 4-113

Test the capsular tension.

Figure 4-114

Completed interval repair.

Rotator Cuff Lesions

Figure 4-112

Test the tension of the repair.

Overhead throwing athletes may have rotator cuff lesions that range from minor fraying to full-thickness tears. When these tears are partial-thickness grade 3 or full thickness, I repair them after I complete the glenohumeral joint reconstruction. I mark the area of the tear with a spinal needle or monofilament suture and reinsert the arthroscope into the subacromial space. Anterior lesions are usually small tears and are easily repaired. Posterior lesions are repaired with the arthroscope in the lateral portal, and instruments are passed through the anterior and posterior portals.

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Posterior Bankart with Posterior Rotator Cuff Repair

POSTOPERATIVE MANAGEMENT Postoperative management is similar for all patients. A soft pillow sling supports the arm in 15 degrees of abduction. If the primary direction of instability repair is anterior, I position the elbow anterior to the coronal plane of the shoulder with the arm internally rotated. If the primary direction is posterior, I position the elbow posterior to the coronal plane with the arm in 10 degrees of external rotation. I place the elbow of a patient with multidirectional instability in neutral rotation and 25 degrees of abduction. An ice-pack wrap decreases postoperative shoulder swelling and pain. I administer 1 g cephalosporin 8 hours postoperatively. Patients may choose to go home the afternoon of surgery or the next morning. Active range-of-motion exercises of the fingers, wrist, and elbow, as well as deltoid muscle isometric exercises, are started the morning after the operation and continued at home for 2 weeks. At 2 weeks, I obtain an anteroposterior radiograph to document the position of the humeral head. Patients are allowed to remove the sling for active elevation and external rotation exercises twice daily but wear the sling at all other times. If the patient had an anterior repair, I allow active elevation as tolerated. I instruct patients to limit external rotation to 20 degrees at week 2, 40 degrees at week 4, and 60 degrees at week 6. If the patient had a posterior repair (either as the only operation or along with an anterior or inferior repair), I restrict active elevation to

Table 4-1

90 degrees and internal rotation to neutral but allow unlimited external rotation. If the patient had a multidirectional instability operation, I instruct him or her to limit shoulder motion as much as possible. Generally, these patients have some degree of ligament laxity, and achieving full range of motion is not a problem. The sling is worn for 6 weeks, after which it is removed and the patient begins active range-of-motion (without restrictions), strengthening, and neuromuscular exercises. Patients continue rangeof-motion and strengthening exercises for 1 year.

RESULTS Operative Repair The lesions repaired at operation are variable, and most patients have more than one. My experience is summarized in Tables 4-1 through 4-3. These early reports are consistent with my findings in my last 1000 operations. The average number of bone or soft tissue anchors used is 2.4 (range, 0 to 5).

Postoperative Scores and Shoulder Rating Systems Shoulder rating systems reflected an improvement in shoulder status (see Table 4-3). Comparing the scores before surgery to those at final follow-up, paired t-tests revealed significant increases in total and subscale scores for the ASES, Constant, Rowe, and UCLA shoulder scores (P = .0001). Neither the Constant nor the ASES system provides guidelines that allow the

PREOPERATIVE PHYSICAL EXAMINATION FINDINGS: BIDIRECTIONAL

Abd/ER (IA)

0+

1+

2+

6

26

4

3+

Pain

0

31

Apprehension

14

Abd/ER (IP)

2

12

2

0

14

7

Abd/Down (IA)

3

19

14

0

25

12

Abd/Down (IP)

0

7

9

0

9

6

Sulcus (IA)

0

13

23

0

36

23

Suclus (IP)

0

9

7

0

16

9

Rowe (IA)

2

10

24

0

32

22

Rowe (IP)

0

8

8

0

16

10

24 6

11 6

1 1

0 3

2 4

0 4

Posterior (IA) Posterior (IP)

Abd/Down, abduction and downward force; Abd/ER, abduction and external rotation; IA, inferior-anterior; IP, inferior-posterior.

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137

Table 4-2 OPERATIVE FINDINGS BIDIRECTIONAL (n = 33) UNIDIRECTIONAL (n = 53)

Inferior-Anterior

31

16

7

10

48

9

0

10

Inferior-Posterior

MULTIDIRECTIONAL (n = 47)

Labrum repair Superior Anterior Type A

25

Type B

15

Type C

8

Inferior

2

2

0

2

Posterior

0

0

2

6

Anterior

46

25

5

47

Middle

41

33

11

47

Inferior

31

19

7

47

Posterior

0

0

9

47

Ligament suture imbrication

Thermal tightening Anterior

48

7

1

Middle

5

5

2

Inferior

11

17

9

Posterior Rotator interval repair

0

0

7

14

22

14

28

Table 4-3 FINAL RESULTS* ASES

Pre

CONSTANT

ROWE

UCLA

Post

Pre

Post

Pre

Post

Pre

Post

Unidirectional Instability Score

45.5

91.7

56.4

91.8

11.3

91.9

17.6

32.0

SD

18.6

13.7

13.3

11.3

5.7

20.8

4.8

4.7

Bidirectional Instability Score

45.5

94.0

57.0

92.4

20.3

92.1

18.6

32.7

SD

16.2

9.3

12.9

10.4

13.3

19.5

4.4

3.7

94.7 9.3

60 11.5

91.7 8.5

14.2 13

93.7 13.2

17.4 4.5

33.1 2.9

Multidirectional Instability Score SD

45.4 18.8

*All postoperative scores significant: P = .0001. ASES, American Shoulder and Elbow Surgeons Shoulder Index; Post, postoperative; Pre, preoperative; SD, standard deviation; UCLA, University of California at Los Angeles.

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surgeon to determine which scores reflect excellent or poor results. Ellman categorized UCLA shoulder scores of 29 to 35 as equivalent to good to excellent results and those less than 29 as fair to poor. In Rowe’s system, scores of 90 to 100 are excellent and 75 to 89 are good. In my experience with all three types of glenohumeral instability (traumatic unidirectional anterior, bidirectional, and multidirectional), about 90% of shoulders have achieved good to excellent results according to both the Rowe and UCLA scores. The details of these results are summarized in the following sections.

Range of Motion No patient lost more than 5 degrees of forward elevation. External rotation at 90 degrees of abduction averaged 88 degrees, compared with 83 degrees preoperatively. The gain in movement reflects the preoperative loss of external rotation that is typical in patients with traumatic anterior instability caused by medial healing of the Bankart lesion (ALPSA). Patients without ALPSA lesions have a similar loss of external rotation because they tend to limit that motion to avoid pain or instability.

Return to Sports Participation Among my patients with unidirectional traumatic anterior glenohumeral instability, 43 participated actively in sports before the onset of their shoulder problems: 0 patients participated in type 1, 5 in type 2, 30 in type 3, and 8 in type 4 sports. When stratified by level of participation, 7 patients participated at level 1 (high school team sports), 1 at level 2 (college team sports), and 35 at level 3 (recreational athletes). At final follow-up evaluation, 5 patients did not participate in sports owing to issues unrelated to their shoulders. The reasons most commonly cited were work or family commitments, graduation from high school or college (and the associated lack of team sports), and injuries to the knee or lumbar spine. The remaining 38 patients participated in sports: 1 in type 1, 6 in type 2, 26 in type 3, and 5 in type 4. The level of participation at final follow-up was 3 at level 1, 0 at level at 2, and 35 at level 3. Four patients with persistent shoulder instability had decreased their level of participation at final follow-up.

Ligament Laxity The final Rowe score was stratified according to the presence or absence of generalized ligament laxity. Patients without evidence of ligament laxity (n = 47)

had a final mean Rowe score of 94, and those with ligament laxity (n = 6) had a final score of 74. The difference was statistically significant (P = .02). The poorer results in patients with generalized ligament laxity may stem from technically inadequate repairs, or they may suggest that patients with anteriorinferior instability and generalized ligament laxity require an open capsular reconstruction to achieve adequate soft tissue tension.

Complications No major intraoperative or perioperative complications (permanent nerve injuries, wound infections) occurred. Two patients noted paresthesias in the musculocutaneous nerve distribution. All had resolved by the 6-week postoperative visit. One patient noted minor wound drainage that resolved within 1 week without the use of antibiotics. I did not observe any complications from suture anchors.

LATARJET As noted earlier, in some cases I have found the results of soft tissue reconstruction of the glenohumeral joint ligaments unsatisfactory. There are four situations in which no combination of labrum repair and capsular tensioning is successful: 1. 2. 3. 4.

Anterior-inferior glenoid bone loss Poor-quality ligaments Suboptimal patient compliance Extreme sports participation

An demonstrated in a cadaver experiment that anterior glenoid defects greater than 4 mm result in glenoid insufficiency that the surgeon cannot correct with soft tissue repair. I use 4 mm only as a guideline because An’s laboratory experiment did not take into account the variability of capsular advancement that can be achieved in a particular patient. I have found threedimensional computed tomography reconstruction or the Bernejeau view to be helpful radiographic aids; however, I rely more on my inspection of the glenoid shape at the time of arthroscopic examination. After I inspect the glenohumeral joint with the arthroscope in the posterior portal, I create an anterior portal and move the arthroscope there. This allows me to look down the anterior glenoid and observe the presence or absence of the normal pear shape. If I am unsure whether there is bone loss anteriorly, I insert a probe through the posterior cannula and note the distance from the glenoid bare spot to the anterior and posterior glenoid (Figs. 4-115 through 4-118).

Chapter 4

Figure 4-117 RT should

Figure 4-115

Magnetic resonance image shows anterior

bone loss.

Poor ligament quality may be due to prior surgery or multiple dislocations. The surgeon gains some information about ligament quality as the ligaments are palpated and maneuvered with surgical instruments. However, the assessment of ligament quality is subjective and therefore imprecise. The literature contains multiple articles listing poor-quality ligaments as an indication for open surgery, but usually this involves some type of ligament repair. I do not

Figure 4-116

Insufficient bone to contain the glenoid.



Glenohumeral Instability

139

Absent anterior capsule and glenohumeral

ligaments.

understand why surgeons who decide that the glenohumeral joint ligaments are insufficient for arthroscopic repair would proceed to do an open ligament repair. I am not aware of any experimental evidence that exposing inadequate glenohumeral ligaments to air or light causes these deficient ligaments to improve. It is my opinion that if the ligaments are inadequate, the surgeon must find some other operative method. Patient compliance with any postoperative regimen is variable, but in my experience, young patients with an active lifestyle may disregard some or all postoperative instructions and restrictions. Only a flawless preoperative character analysis and a prescient understanding of perioperative behavior would eliminate this as an issue. When I have doubts about the patient’s maturity, I sleep better knowing that my repair is held with two large bone screws rather than five No. 1 sutures. Certain sports or activities are so demanding that participation requires not a normal shoulder but a ‘‘better than normal’’ shoulder. The demands of

Figure 4-118

Insufficient bone to contain the glenoid.

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rock climbing, competitive kayaking, and weight lifting are so great that few patients return to these activities after conventional surgical repair (open or arthroscopic). I tell patients that a soft tissue repair is sufficient to allow them a return to almost all highdemand activities, but certain activities require a different approach. Failed prior surgery (open or arthroscopic) is the most common indication for the Latarjet procedure. I have successfully treated such patients with the Latarjet procedure as published and taught to me by Gilles Walch. More recently, I have successfully treated these patients with an arthroscopic Latarjet procedure as described and taught to me by Laurent Lafosse from Annecy, France (as of this writing, he has yet to publish his results). He is the pioneer in the arthroscopic approach, and I am grateful for the time he spent teaching me his techniques. Interestingly, the evolution of the Latarjet from an open to an arthroscopic procedure, its reception in the orthopedic community, and my transition from open to all-arthroscopic repair (described later) are eerily reminiscent of my experiences with arthroscopic subacromial decompression, arthroscopic distal clavicle resection, arthroscopic glenohumeral reconstruction, and arthroscopic rotator cuff repair. The Latarjet procedure involves placing the coracoid and the attached muscles through a longitudinal split in the subscapularis muscles and fixing it to the anterior-inferior glenoid with two screws. This accomplishes several objectives: the glenoid is enlarged, the potential space for the humeral head to move anterior and inferior to the glenoid is eliminated, and the coracoid prevents a portion of the subscapularis from moving superiorly as the shoulder is moved into a position of abduction and external rotation. The inferior surface of the coracoid matches the anterior-inferior scapular neck quite nicely. The coracoid is good-quality bone, and its fixation to the scapular neck is very secure. Because of this secure fixation, patients can discontinue the sling after 1 week for most activities of daily living. The coracoacromial ligament remains attached to the coracoid and is used to reinforce the anterior capsule. Several publications have documented excellent clinical results (Figs. 4-119 through 4-122). The Latarjet has a long and well-documented history of success, and experienced shoulder surgeons such as Gilles Walch and Christian Gerber use it almost exclusively to treat traumatic anteriorinferior glenohumeral instability. However, I am not certain why the operation is effective. Even the most perfect placement of the coracoid cannot create a

Coracoacromial ligament

Graft Glenoid bone loss

Screws Graft

Figure 4-119

Latarjet procedure.

surface that approaches the graceful concavity of the native glenoid. Is the inferior position of the lower subscapularis a dynamic or static block to anterior translation when the arm is abducted and externally rotated? What is the role of the transferred conjoined tendon? Braly and Tullos attempted to answer some of these questions in their classic article. It is obvious that the Latarjet controls glenohumeral joint instability by a different mechanism from those procedures that repair the labrum and capsule. Both operations are effective yet seem to approach the problem from diametrically opposite directions.

Figure 4-120

Radiograph of the Latarjet open technique.

Chapter 4

Figure 4-121

Radiograph of the Latarjet arthroscopic

technique.

Can both approaches be right? A similar (but more complex) problem was faced by physicists at the dawn of the 20th century when they tried to reconcile the behavior of light. In some experiments, light behaved as a wave; in others, it clearly acted as a particle—photons of energy. The great Danish physicist Niels Bohr reflected on this issue and concluded, ‘‘The opposite of a correct statement is a false statement. But the opposite of a profound truth may well be another profound truth.’’

Figure 4-122

technique.

Radiograph of the Latarjet arthroscopic



Glenohumeral Instability

141

My current thinking on this issue is that labrum and capsule repairs control glenohumeral joint instability by altering the static restraints to humeral head motion, whereas the Latarjet and Bristow procedures alter the dynamic factors. We know that both mechanisms are involved. For example, consider a patient with asymptomatic glenohumeral joint laxity. He is active in sports, and the stabilizing muscles are strong. When this patient enters law school, the demands of study cut into his exercise routine, and his muscles lose tone. When this individual attempts to get back in condition and begins a weight-lifting program, the shoulders sublux, and he presents to the orthopedic surgeon complaining of pain. The solution to this patient’s dilemma is not surgery but simply a strengthening program for the rotator cuff and the scapular stabilizing muscles. Now consider a second law school student who has no laxity and sustains a traumatic dislocation during a rugby match. Emergency room reduction is necessary. Owing to continued dislocations, this patient undergoes surgery during which a Bankart lesion is found and corrected. Both patients had glenohumeral joint instability, but one cause was dynamic and the other was loss of the static stabilizers. Although these polar opposites present clear choices, I am uncertain where the vast majority of patients fall. Perhaps both mechanisms exist in all patients, but the relative contributions of the dynamic and static stabilizers vary from one individual to another. Perhaps our surgical corrections should reflect that. Although there are some conditions for which a Latarjet-type procedure is definitely indicated (as outlined earlier), there are other situations (e.g., multidirectional, bidirectional, posterior instability) in which the more global correction afforded by arthroscopic soft tissue repair and balancing is required. At present, the orthopedic surgeon can correct most forms of anterior-inferior glenohumeral joint instability with either approach and achieve a successful result. There are a number of issues that deserve discussion regarding an arthroscopic approach: What are the potential advantages? Is it technically possible to reproduce the appropriate steps? What are the potential risks? How difficult is the technique? The criticism of the arthroscopic Latarjet is familiar to those of us who witnessed the transition from open subacromial decompression and rotator cuff repair to arthroscopic techniques. The criticism has a predictable pattern. Leading orthopedic surgeons on editorial boards and lecture panels inevitably proclaim that the

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developer of an arthroscopic technique cannot do the following: 1. 2. 3. 4. 5. 6.

Insert the arthroscope into the appropriate area. Visualize the relevant structures. Insert instruments to repair the lesions. Repair the lesions adequately. Perform the operation within a reasonable time. Achieve results equivalent to those of the open procedure. 7. Improve on the results of the open procedure. 8. Teach others to perform the operation. When Lafosse first presented his technique for arthroscopic Latarjet, all these criticisms were voiced, as they were in 1983 (arthroscopic subacromial decompression), 1985 (arthroscopic distal clavicle resection), 1987 (arthroscopic glenohumeral reconstruction), 1992 (arthroscopic rotator cuff repair), and 1995 (arthroscopic treatment of irreparable rotator cuff tears). The first question to answer was, why perform the operation arthroscopically? Although the results of the open Latarjet are excellent, they are not perfect. Perhaps an arthroscopic technique could improve the results owing to increased technical precision or treatment of lesions unrecognized during open repair (e.g., posterior ligament tears, SLAP lesions). I knew it was possible to insert the arthroscope and instruments into the subdeltoid space and visualize quite clearly the coracoid, conjoined tendon, and anterior subscapularis. The next step in the transition from open to arthroscopic repair involved detailing the individual steps performed during an open Latarjet: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Anterior skin incision Exposure of the deltopectoral groove Lateral retraction of the cephalic vein Separation of the deltoid from the pectoralis major Identification of the coracoid Identification of the coracoacromial ligament Division of the clavipectoral fascia along the lateral border of the conjoined tendon Release of the coracoacromial ligament from the acromion Release of the pectoralis minor from the medial coracoid Coracoid osteotomy Coracoid decortication Drilling of holes in the coracoid Subscapularis split Capsulotomy Preparation of the anterior scapula

16. Passage of the coracoid through the subscapularis split 17. Precise coracoid placement on the anterior scapula 18. Secure fixation with screws 19. Capsular repair with the coracoacromial ligament 20. Skin closure The next phase was to determine which of the steps was necessary and which could be performed with the arthroscopic technique. Steps 1 to 4 are not needed because the cannula passes directly into the requisite areas, and step 20 is self-evident. I reviewed videos of the surgical technique with Lafosse and saw that he could do all the necessary steps. My experience with other arthroscopic operations convinced me that I already knew how to perform steps 5 to 8, 11, and 15. I performed steps 9, 10, 12 to 14, and 16 to 19 in the cadaver laboratory. I had stopped repairing the capsule and coracoacromial ligament during my open Latarjet procedures and saw no need to perform it arthroscopically. At this point, I was convinced that I could perform an arthroscopic Latarjet. I then began to perform portions of the arthroscopic repair. I arthroscopically examined all patients who were to undergo an open Latarjet. I set a 1-hour time limit and performed different parts of the arthroscopic procedure: 1. Scapular neck preparation. I had already developed skill at anterior scapular neck preparation during my experience with arthroscopic glenohumeral joint stabilization. 2. Release of the rotator interval. Release of the rotator interval is commonly performed in the treatment of shoulder stiffness. I accomplish this with an electrocautery device and a power shaver. 3. Identification of the coracoid. I had performed a few coracoid osteotomies for coracoid impingement, so I was somewhat familiar with the method of coracoid exposure through the rotator interval. During operations for repair of the subscapularis, I routinely visualize the coracoid, so I was familiar with the view with the arthroscope placed in the lateral portal. 4. Release of the coracoacromial ligament. I typically visualize the coracoacromial ligament through the rotator interval during a contracture release to ensure that I resect all interval tissue. I did not find it difficult to follow the ligament laterally and release it from the acromion.

Chapter 4

5. Coracoid decortication. With the arthroscope in the posterior portal and a shaver inserted anteriorly, the coracoid can be identified by palpating it with the shaver. Soft tissue can be removed from the superior and lateral surfaces. I use electrocautery alone or a power shaver equipped with electrocautery. Once the lateral surface is clean, I begin to clean the inferior surface. I then use a power bur to remove a small thickness of cortical bone from the inferior surface. These first five steps were all accomplished with the arthroscope inserted through standard portals, the posterior glenohumeral joint, and the lateral subacromial locations. The next steps required that I learn and master the use of various anterior portals: 6. Division of the clavipectoral fascia. I move the arthroscope to an anterior-lateral portal, immediately lateral to the coracoid. This portal is in line with the anterior acromion and 3 to 5 cm lateral to the lateral acromion. The coracoid can be seen medially, and I orient myself to the location of the glenohumeral joint posteriorly, the subscapularis inferiorly, the pectoralis minor medially, and the lateral border of the conjoined tendon and clavipectoral fascia laterally. I use the previously created anterior portal and introduce an electrocautery instrument to divide the clavipectoral fascia immediately lateral to the border of the conjoined tendon. The area is well seen, and division is not difficult. 7. Release of the pectoralis minor. I advance the arthroscope deeper (more medially) until I see the pectoralis minor tendon. I insert a spinal needle percutaneously, immediately anterior to the midcoracoid, and make a small incision. Through this incision I insert the metal trocar and use it as a soft tissue dissector. The superior portion of the tendon (and the brachial plexus) is easily seen. The distal portion of the pectoralis minor tendon is harder to identify. I then remove the trocar, introduce the electrocautery, and begin releasing the pectoralis minor tendon from the medial coracoid. I continue distally until the tendon is released. 8. Drilling of holes in the coracoid. Up to this point, I have used conventional arthroscopic instruments, but some specialized instruments are now necessary. I insert a special drilling guide through the anterior coracoid incision and place it against the anterior coracoid. If the distal coracoid tip is not evident, I insert a spinal



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needle to mark its location. The drill guide must be positioned midway between the medial and lateral cortical borders. The proximal-distal position is determined by allowing sufficient coracoid bone distal to the distal screw hole so the screw will not cut out. The two drill holes are then made. 9. Coracoid osteotomy. I insert a 1=4-inch osteotome through the anterior incision and perform the osteotomy under direct vision. Once the coracoid is free, I insert a suture through the drill holes and leave the suture coming out through the anterior coracoid portal. 10. Subscapularis split. To help locate the correct site of the split (from superior to anterior), I pass a long switching stick into the glenohumeral joint from anterior to posterior. With the arthroscope in the anterolateral portal, I can see into the joint through the rotator interval and determine the location of the anteriorinferior glenoid. I advance the rod past this and into the subscapularis. I look anterior to the subscapularis and insert a retractor to move the coracoid (and neurovascular structures) medially. I continue to advance the rod through the subscapularis muscle. I insert electrocautery through the anterior coracoid portal and divide the subscapularis muscle medially and the tendon more laterally. When entering the joint laterally, there is a danger of scoring the humeral head; to minimize the chance of this occurring, I use the rod to push the capsule anteriorly and develop a little space between the capsule and the articular cartilage. 11. Passage of the coracoid through the subscapularis. Once I have created sufficient space for the coracoid, I advance the rod anteriorly until the rod tip tents the skin. The rod passes through the deltoid muscle. I incise the skin and advance the rod. The next step also involves a specialized tool. I insert a grasper through the inferior anterior-medial portal, grasp the sutures transfixing the coracoid, and bring them out this portal. The sutures are placed through the double-barrel inserter, and the coracoid is positioned against the end of the device. Temporary fixation screws secure the coracoid to this device. 12. Coracoid placement. With the inserter device and its attached coracoid, I find the transfixation rod and withdraw it posteriorly as I advance the coracoid through the subscapularis and into the glenohumeral joint.

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13. Coracoid fixation. At this point, I have an excellent view of the anterior glenoid. The coracoid is positioned at the site of the glenoid defect. I make sure the coracoid does not project laterally into the glenohumeral joint and contact the humeral head. I replace the temporary screws with longer permanent fixation screws. I then remove the inserter and inspect the completed repair. 14. I make no attempt to repair the subscapularis, because such tightening would restrict internal and external rotation. 15. The instruments are removed, and the small skin incisions are closed with subcuticular absorbable sutures. I place the patient in a shoulder immobilizer that can be removed for bathing, dressing, and pendulum exercises. At the 1-week visit, I remove the sling and allow the patient to use the arm for all routine activities of daily living. I obtain an anteroposterior radiograph. At the 6-week visit, I obtain a Bernejeau view to evaluate the position of the coracoid. I encourage active shoulder stretching and begin a home strengthening program. Once bone healing is seen on the Bernejeau or axillary view, I allow unrestricted activity.

DISCUSSION The wide variety of treated lesions, patient populations, operative techniques, length of follow-up, and scoring systems can complicate comparisons of results of arthroscopic and open operations. However, improvements in various parameters described in multiple investigations allow me to conclude that arthroscopic repair of glenohumeral instability using the techniques I have described can produce outcomes that are better than those achieved with prior arthroscopic treatments and equivalent to those of open repair. The spectrum of operative findings does not support the concept of any ‘‘essential lesion.’’ On the contrary, it appears that the cause of glenohumeral instability is multifactorial, and successful treatment requires that any operative approach be sufficiently flexible to deal with the variety of lesions found. The arthroscopic approach allows the surgeon to identify and treat all the lesions of shoulder instability. I believe that the success of arthroscopic treatment is based on our ability to perform an anatomic repair of anterior, superior, and inferior labrum tears; correct capsular elongation; and, if necessary, repair the rotator interval.

My goal is to repair the patient’s shoulder by whatever technique will be most effective. At present, my operative treatment of glenohumeral instability is arthroscopic. With the arthroscopic technique, I inspect the entire glenohumeral joint and avoid soft tissue dissection. No division of the subscapularis is required. Although I have no statistical evidence, my impression is that arthroscopic repair provides improved cosmesis, decreased postoperative pain, and more rapid gains in motion compared with open operative treatment of similar lesions. These techniques should be used only by an experienced orthopedic surgeon familiar with the normal and abnormal anatomy seen during both open and arthroscopic shoulder operations. A thorough understanding of the various conditions that produce shoulder pain is needed. An orthopedic surgeon who infrequently performs open glenohumeral instability repair should not attempt the arthroscopic procedure.

BIBLIOGRAPHY Abrams JS: Arthroscopic repair of posterior instability and reverse humeral glenohumeral ligament avulsion lesions. Orthop Clin North Am 34:475-483, 2003 Ahmad CS, Wang VM, Sugalski MT, et al: Biomechanics of shoulder capsulorrhaphy procedures. J Shoulder Elbow Surg 14(1 Suppl):12S-18S, 2005 Allain J, Goutalliler D, Glorion C: Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 80:841-852, 1998 Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 18:25-28, 1990 Bigliani LU, Kurziil PR, Schwartzbach CC, et al: Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 22:578-584, 1994 Bigliani LU, Pollock RG, Soslowsky LJ, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 10:187-197, 1992 Blasier RB, Soslowsky LJ, Palmer ML: Posterior glenohumeral subluxation: Active and passive stabilization in a biomechanical model. J Bone Joint Surg Am 79:433-440, 1997 Boileau P, Villalba M, He´ry JY, et al: Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 88:1755-1763, 2006 Braly WG, Tullos HS: A modification of the Bristow procedure for recurrent anterior shoulder dislocation and subluxation. Am J Sports Med 13:81-86, 1985 Burkhart SS, De Beer JF, Barth JR, et al: Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy 23:1033-1041, 2007

Chapter 4

Burkhart SS, Morgan CD: The peel-back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 14:637-640, 1998 Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 74:890-896, 1992 Caspari R, Savoie F: Arthroscopic reconstruction of the shoulder: The Bankart repair. In McGinty J (ed): Operative Arthroscopy, New York, Raven, 1991 DePalma A: Recurrent dislocation of the shoulder joint. Ann Surg 132:1052-1065, 1950 Ellman H, Gartsman GM: Arthroscopic Shoulder Surgery and Related Procedures, Philadelphia, Lea & Febiger, 1993 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of anterior-inferior glenohumeral instability: Two to five-year follow-up. J Bone Joint Surg Am 8:991-1003, 2000 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of bi-directional glenohumeral instability: Two- to five-year follow-up. J Shoulder Elbow Surg 10:28-36, 2001 Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of multidirectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy 17:236-243, 2001 Gartsman GM, Taverna E, Hammerman SM: Arthroscopic rotator interval repair in glenohumeral instability: Description of an operative technique. Arthroscopy 15:330-332, 1999 Gartsman GM, Taverna E, Hammerman SM: Arthroscopic treatment of acute traumatic anterior glenohumeral dislocation and greater tuberosity fracture. Arthroscopy 15:648-650, 1999 Gross RM: Open and Arthroscopic Glenohumeral Instability Repairs, New Orleans, American Academy of Orthopaedic Surgeons, 1998 Habermeyer P, Gleyze P, Rickert M: Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 8:66-74, 1999 Harryman DT, Sidles JA, Harris SL, Matsen FA: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 74:53-66, 1992 Hayashi K, Thabit G, Bogdanske JJ, et al: The effect of nonablative thermal probe energy on the ultrastructure of joint capsular collagen. Arthroscopy 12:474-481, 1996 Itoi E, Lee SB, Berglund LJ, et al: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am 82:35-46, 2000 Kartus C, Kartus J, Matis N, et al: Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks: A clinical and radiographic study with a seven to ten-year follow-up. J Bone Joint Surg Am 89:1442-1448, 2007 Kohn D: The clinical relevance of glenoid labrum lesions. Arthroscopy 3:223-230, 1987



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Lafosse L, Lejeune E, Bouchard A, et al: The arthroscopic Laterjet procedure for the treatment of anterior shoulder instability. Arthroscopy 23:1242el-5, 2007 Lippitt SB, Vanderhooft JE, Harris SL, et al: Glenohumeral stability from concavity-compression: A quantitative analysis. J Shoulder Elbow Surg 2:27-35, 1993 Lopez MJ, Hayashi K, Fanton GS, et al: The effect of radiofrequency energy on the ultrastructure of joint capsular collagen. Arthroscopy 14:495-501, 1996 McIntyre LF, Caspari RB, Savoie FH: The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 13:418-425, 1997 McIntyre LF, Caspari RB, Savoie FH: The arthroscopic treatment of posterior shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 13:426-432, 1997 McMahon PJ, Tibone JE: The anterior bond of the inferior glenohumeral ligament: biomechanical properties from tensile testing in the position of apprehension. J Shoulder Elbow Surg 7:467-471, 1998 Mologne TS, Provencher MT, Menzel KA, et al: Arthroscopic stabilization in patients with an inverted pear glenoid: Results in patients with bone loss of the anterior glenoid. Am J Sports Med 35:1276-1283, 2007 Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3:111-122, 1987 Morrey BF, Janes JM: Recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 58:252-256, 1976 Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am 62:897-908, 1980 Neviaser TJ: The anterior labroligament periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 9:17-21, 1993 Nottage WM: Thermal probe-assisted shoulder surgery. Arthroscopy 13:635-638, 1997 Pappas AM, Goss TP, Kleinman PK: Symptomatic shoulder instability due to lesions of the glenoid labrum. Am J Sports Med 11:279-288, 1983 Rhee YG, Ha JH, Cho NS: Anterior shoulder stabilization in collision athletes: Arthroscopic versus open Bankart repair. Am J Sports Med 34:979-985, 2006 Richards RR, An K-N, Bigliani LU, et al: A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 3:347-352, 1994 Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 22:121-130, 1994 Rowe CR, Zarins B: The Bankart procedure: Long-term endresult study. J Bone Joint Surg Am 60:1-16, 1978 Rowe CR, Zarins B: Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am 63:863-872, 1981 Savoie FH, Miller CD, Field LD: Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 13:201-209, 1997

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Speer K, Deng X, Borrero S, et al: Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 78:1819-1825, 1994 Ticker JB, Bigliani LU, Soslowsky LJ, et al: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 5:269-279, 1996 Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 4:352-364, 1995 Williams MM, Snyder SJ, Buford D Jr: The Buford complex— the ‘‘cord-like’’ middle glenohumeral ligament and absent anterosuperior labrum complex: A normal anatomic capsulolabral variant. Arthroscopy 10:241-247, 1994 Wirth MA, Groh GI, Rockwood CA Jr: Capsulorrhaphy through an anterior approach for the treatment of

atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am 80:1570-1578, 1998 Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 11:600-607, 1995 Wolf EM, Eakins CL: Arthroscopic plication for posterior shoulder instability. Arthroscopy 14:153-163, 1998 Wolf EM, Wilk RM, Richmond JC: Arthroscopic Bankart repair using suture anchors. Oper Tech Orthop A: 184-191, 1991 Zuckerman JD, Matsen FA: Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am 66:175-180, 1984

CHAPTER

5

Biceps Tendon Lesions

The biceps tendon represents a transition from the glenohumeral joint to the subacromial space. Biceps lesions occurring at the glenoid attachment are intimately involved in the treatment of glenohumeral instability, and biceps abnormalities in the region of the bicipital groove (subluxation and synovitis) are part of subacromial impingement. I often perform biceps tenodesis as part of the treatment for a rotator cuff tear. Biceps tenotomy is one option for the treatment of irreparable rotator cuff tears. There are seven basic mechanisms by which biceps lesions cause shoulder dysfunction proximally at the biceps-labrum complex: 1. Mechanical abnormalities such as labrum flap tears 2. Labrum pathology resulting in glenohumeral joint instability (e.g., loss of concavity-compression and the attachment site for the glenohumeral ligaments) 3. Part of the pathophysiology of cyst development 4. Lesions within the tendon substance, which may be painful due to intrinsic biceps tendinitis or a partial tear; with more extensive damage, an enlarged tendon may cause pain due to biceps entrapment 5. Entrapment with arm elevation—the hourglass biceps, as described by Boileau 6. Biceps tendon dislocation or subluxation; even a normal biceps tendon may become part of a pathologic process, such as that seen with rotator cuff and subscapularis tears 7. Biceps adhesions accompanying a proximal humerus fracture or after glenohumeral arthroplasty

PROXIMAL BICEPS LESIONS Superior labrum from anterior to posterior (SLAP) lesions offer an interesting and complex challenge to shoulder surgeons. Patients with SLAP lesions present with a wide spectrum of clinical complaints; the findings on physical examination differ, the clinical findings are nonspecific, and radiographic diagnosis is imprecise. Even at operation the findings are variable, and the decision whether to repair a SLAP lesion requires a thorough understanding of the patient’s clinical condition and shoulder pathophysiology.

Anatomy The anterior, inferior, and posterior labrum is firmly attached to the glenoid, and separation of any of these areas from the glenoid is pathologic. An exception to this is the normal sublabral hole that exists near the anterior-superior glenoid (Fig. 5-1). The superior labrum, in contrast, has wide variability in terms of its attachment to the glenoid. A normal superior labrum is not always attached, or it may have only a flimsy connection to the glenoid. If the glenoid underlying the superior labrum is covered with smooth cartilage and neither the superior labrum nor the glenoid demonstrates any evidence of trauma, I consider this superior labrum separation to be a normal anatomic variant and not a pathologic lesion (Fig. 5-2). Evidence of trauma includes fraying or tearing of the superior labrum or damage to the glenoid cartilage directly underneath the labrum separation. Superior labrum separation without evidence of trauma does not require repair.

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Figure 5-1



Glenohumeral Joint Surgery

Normal anterior-superior labral hole.

A SLAP lesion is an abnormal separation of the superior labrum from anterior to posterior. It was first described by Snyder, who noted four variations. In a type 1 lesion, the superior labrum is attached to the glenoid rim, but there is fraying of the leading edge of the labrum. In a type 2 lesion, the superior labrum is detached from the glenoid. A type 3 lesion is similar to type 2, but there is also a bucket-handle tear, whereas a type 4 lesion has a longitudinal split in the biceps tendon (Figs. 5-3 through 5-6). There are many variations of these four basic lesions. This is particularly true with regard to the glenohumeral ligaments. The middle and rarely the anterior-inferior glenohumeral ligaments may be attached to the glenoid only through the superior labrum. SLAP lesions have been identified in patients with full-thickness rotator cuff tears and in those with glenohumeral instability. A number of publications

Figure 5-2

Normal superior labrum separation.

Figure 5-3

SLAP type 1.

Figure 5-4

SLAP type 2.

Figure 5-5

SLAP type 3.

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Compress

External rotation

Figure 5-6

SLAP type 4.

have addressed this lesion’s frequency and our ability to diagnose it. Rodosky made an important contribution when he demonstrated the contribution of the superior labrum to anterior glenohumeral instability. Walch, Jobe, Morgan, and Burkhart have discussed the role of the superior labrum in internal impingement.

Figure 5-7

Shoulder compressed and rotated.

Rotator Cuff Disease Secondary Impingement

Mechanical Irritation Patients may present with symptoms of intermittent catching or locking of the shoulder during overhead sports or activities of daily living. The pain is sharp, severe, and localized vaguely as ‘‘deep within the shoulder joint.’’ Physical examination findings are variable. The examiner applying compression to the abducted shoulder and rotating the arm may reproduce pain (Fig. 5-7). Placing the internally rotated arm in adduction and having the patient resist a downward force (the O’Brien test) may be painful. The Speed test may be positive. A magnetic resonance imaging study without contrast occasionally demonstrates a detached superior labrum, but the addition of contrast material seems to improve its sensitivity (Fig. 5-8). An orthopedic surgeon with a high index of suspicion who excludes other more common causes of shoulder pain such as impingement, acromioclavicular joint arthrosis, and glenohumeral instability most commonly diagnoses SLAP lesions. There are no definitive patient complaints or physical examination findings that will always enable the surgeon to diagnose a labrum tear. I diagnose most SLAP lesions at arthroscopy.

SLAP lesions are infrequent in the classic outlet impingement of stage 2 rotator cuff disease. I suspect SLAP lesions in younger patients who present with impingement symptoms and a type 1 or type 2 acromion. Magnetic resonance images are normal, and the physical examination is usually consistent with impingement. Physical findings suggestive of a SLAP lesion are absent. In this setting, I carefully evaluate the superior labrum attachment at the time of arthroscopy.

Figure 5-8

Magnetic resonance imaging with contrast.

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The presence of normal cartilage covering the superior glenoid or the absence of trauma leads me to believe that the superior labrum separation is a normal anatomic variation that plays no role in the patient’s shoulder pain. In these individuals, I ignore the labrum and treat the patient for subacromial impingement. A more confusing situation exists in patients with classic outlet impingement, as diagnosed by history and physical examination, and a traumatic superior labrum separation (SLAP type 2). Once I have confirmed that the SLAP lesion is traumatic and not an anatomic variation, I begin to question the accuracy of my preoperative diagnosis of impingement. In patients younger than 40 years, I carefully check for subtle signs of anterior-inferior instability such as labrum fraying, fissures, or minor separations. In this clinical setting, the surgeon should be aware that the SLAP lesion might cause or exacerbate subtle anterior-inferior glenohumeral instability and that the ‘‘impingement’’ symptoms are secondary. It is usually impossible to determine whether (1) the SLAP lesion is the result of altered shoulder biomechanics that accompany chronic impingement, (2) the SLAP lesion has altered shoulder biomechanics enough to cause impingement, or (3) there is any relationship between the two. It is possible that two separate pathologic processes are involved. I am convinced, based on personal experience and the publications of Walch, that the long head of the biceps is not a major depressor of the humeral head, but perhaps more subtle processes are at work.

SLAP Lesion with Acute Rotator Cuff Tear With the increasing use of arthroscopy, surgeons now routinely inspect the glenohumeral joint and identify SLAP lesions. SLAP lesions are not seen during open rotator cuff repair, so their incidence has been underreported in publications dealing with open techniques. They occur more frequently in younger patients following significant trauma. A typical example is a worker who falls backward and lands on his elbow with the shoulder in extension. The humeral head is driven superiorly, and presumably the biceps tendon attachment is avulsed from the glenoid. I repair SLAP lesions that are noted in the setting of an acute full-thickness rotator cuff tear.

Chronic Full-Thickness Rotator Cuff Tear My experience is that SLAP lesions are found infrequently in patients with chronic full-thickness rotator cuff tears. Taverna and I found an incidence of 2.5% (5 of 200), and we could not determine whether the SLAP lesion preceded the rotator

cuff tear, followed the tear, or was an independent entity. One of the reasons for repairing the rotator cuff tendons is to restore their ability to center the humeral head during overhead elevation. It seems reasonable to repair another possible source of humeral head depression—the biceps-labrum complex. Here again, theory collides with reality. My goal after rotator cuff repair is to restore full passive range of motion, but if the SLAP lesion is repaired, I must restrict full external rotation so as not to disrupt the SLAP repair. Unless the SLAP lesion is significant, I prefer to repair only the rotator cuff. The average age of my patients who undergo arthroscopic rotator cuff repair is 62 years, and I am not concerned about the SLAP lesion and its effect on glenohumeral joint stability. I prefer to perform a tenodesis of the biceps tendon rather than a labrum repair. With the tenodesis, patients can perform my standard rehabilitation regimen after rotator cuff repair, without any concerns about external rotation. I alter their postoperative care by instructing patients not to perform elbow flexion against resistance for 3 weeks.

Glenohumeral Instability SLAP lesions contribute to glenohumeral instability directly and indirectly. Rodosky demonstrated in the laboratory that less force is required to translate the humerus on the glenoid when a SLAP lesion is present. Pagnani demonstrated in cadavers an increase in anterior-posterior and superior-inferior translation when a SLAP lesion is created. The presence of a SLAP lesion therefore contributes indirectly to glenohumeral instability, so it seems reasonable to repair a SLAP lesion along with other lesions found during a glenohumeral reconstruction. The SLAP lesion can also directly affect glenohumeral stability. The anatomy of glenohumeral ligament insertions is variable, and I have seen cases in which the middle and even anterior-inferior glenohumeral ligaments are attached not to the anteriorinferior glenoid but directly to the superior labrum. Superior labrum detachment removes the connection stabilizing the glenohumeral ligament and the glenoid. A SLAP lesion in such an individual is functionally a ‘‘Bankart’’ lesion, and I think superior labrum repair is indicated. Morgan and Burkhart presented a third type of relationship between SLAP lesions and glenohumeral instability. They postulate that repetitive overload stress in a throwing athlete creates a posteriorsuperior SLAP lesion. The ‘‘bumper’’ and ‘‘suctioncup’’ effects of the labrum are destroyed, and

Chapter 5

posterior-superior instability is the result. This type of instability can cause articular surface partialthickness rotator cuff tears and anterior-inferior glenohumeral instability. This is supported by Pagnani’s cadaver study, in which he found that an experimentally produced SLAP lesion resulted in increased anterior-posterior and superior-inferior translation. My experience supports repair of the SLAP lesion in this setting.



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Inte r

nal rotation

Anterior

The Throwing Athlete Tight posterior capsule producing avulsion SLAP

Diagnosis Patients with SLAP lesions may present with symptoms of mechanical abnormalities. They complain of locking or catching when they participate in athletics or vigorous activities of daily living. They also complain of painful catching or popping with passive shoulder compression and rotation. The relocation test may be positive (Fig. 5-9). The physician can perform a variety of clinical tests, but in my experience, they may not produce pain when a SLAP lesion is present, or they may produce pain when no SLAP lesion exists. Although such tests are helpful, the examiner must put them in the context of the patient’s clinical situation. Patients with SLAP lesions may present with findings typical of subacromial impingement or

A

Figure 5-10

Tight posterior capsule producing avulsion.

a full-thickness rotator cuff tear. Alternatively, the physical examination findings and patient complaints may be consistent with glenohumeral instability. In addition, patients may complain of posterior-superior subdeltoid pain when the arm is placed in abduction and external rotation during athletics or work. I pay close attention to posterior soft tissue contracture and evaluate the shoulder’s internal rotation in neutral extension as well as in the scapular plane. Internal rotation may be quite limited. The source of the underlying soft tissue contracture is unclear; some patients have significant loss of internal rotation yet also have excessive posterior glenohumeral translation. This suggests that in some patients, the posterior capsule may be contracted, whereas others have a normal or lax capsule with contracture of the posterior rotator cuff. Morgan and Burkhart believe that the posterior contracture is primary. With forceful internal rotation, the tight posterior capsule causes traction on the superior labrum and produces an avulsion injury (Fig. 5-10). Although this hypothesis is reasonable, it does not explain those patients with SLAP lesions and normal internal rotation or those with internal rotation loss but no SLAP lesion. Clearly, our knowledge on this topic is incomplete.

Nonoperative Treatment

B Figure 5-9

A and B, Relocation test.

Nonoperative treatment is directed at correctable, underlying causes of shoulder pain. Limitations of passive range of motion are corrected with appropriate stretching exercises. Impingement is treated with activity modification and selective rest of the shoulder. Glenohumeral instability is treated with exercises

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to strengthen the glenohumeral stabilizing muscles and to improve neuromuscular coordination, as described in Chapter 4. Pay particular attention to scapular kinematics and stress rehabilitation in this area. Read the works of Kibler.

Indications and Contraindications for Surgery SLAP lesions that produce mechanical symptoms of locking or catching are the least likely to respond to rehabilitation, and operation is indicated if symptoms are present for 3 to 6 months. In patients with SLAP lesions that coexist with glenohumeral instability or rotator cuff disease, indications are based on the underlying condition. All SLAP lesions are technically reparable, but there are some SLAP lesions that should not be repaired. Because SLAP repair requires postoperative immobilization, I do not repair SLAP lesions that are found during operation for adhesive capsulitis or chronic rotator cuff tears.

Operative Technique SLAP Repair Before a surgeon repairs a SLAP lesion, two questions must be answered: Is the superior labrum separation from the glenoid a lesion, or is it an anatomic variant? What is the relationship between the labrum separation and the patient’s clinical presentation? Before undergoing general anesthesia, patients receive an interscalene block to diminish postoperative pain. Patients are placed in the sitting position. The range of motion for external and internal rotation with the arm in 90 degrees abduction and the range of motion for external rotation with the arm in 0 degrees abduction are recorded. I examine the shoulder for anterior, inferior, and posterior translation and record the results. The shoulder is then prepared and draped routinely. The bony outlines of the acromion and coracoid process are palpated and marked with a surgical marking pen. The shoulder joint is entered with a cannula and blunt trocar through a posterior skin incision placed approximately 1.5 cm inferior and 2 cm medial to the posterolateral border of the acromion. The arthroscope is inserted into the glenohumeral joint. An anteriorinferior portal is identified with a spinal needle so the cannula enters the shoulder immediately superior to the subscapularis tendon and 1 cm lateral to the

Figure 5-11

Anterior portal sites.

glenoid. The arthroscope is then inserted through the anterior portal, and the posterior structures are inspected. The arthroscope is then reinserted posteriorly (Figs. 5-11 through 5-17). All structures within the glenohumeral joint are examined systematically. Lesions are variable and include tears of the rotator cuff (partial and complete), rotator interval lesions, biceps tendon fraying, and glenohumeral ligament tears. I specifically examine the labrum below the glenoid equator, anteriorly

Anterior Anterolateral

Figure 5-12

necessary.

Superior portal placed more laterally, if

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153

Figure 5-13 Skin markings.

Figure 5-15

Anterior-inferior cannula entering the joint.

Figure 5-16

Anterior-inferior cannula entering the joint.

Figure 5-17

Anterior-inferior cannula entering the joint.

and posteriorly, for signs of fraying and detachment. Attention is then turned to the superior labrum. An arthroscopic probe is useful to assess the labrum attachment accurately because fibrous healing may have occurred after trauma. A normal labrum cannot be separated with the probe.

SLAP 1 Lesions I do not regard the minor fraying at the free edge of the labrum as pathologic and therefore do not perform any de´bridement.

Figure 5-14 Cannula orientation.

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SLAP 2 Lesions If a SLAP 2 lesion is identified, an anterior-superior portal is created. A spinal needle is inserted at the anterolateral acromial corner and enters the joint lateral to the biceps tendon. The second cannula is introduced. It is critical to position the anterior-superior cannula precisely. To obtain a proper angle for the bur and drill, this cannula must be placed as far lateral and superior as possible. I always use a spinal needle to identify both the entry point and the angle for this cannula. The spinal needle should enter the joint very close to where the biceps exits from the glenohumeral joint and should approach the superior glenoid perpendicularly (Figs. 5-18 through 5-23). I prefer suture anchor repair rather than the tack technique. I am more comfortable with the fixation afforded by the anchors and the superior holding power of the sutures as they surround the labrum. Often the superior labrum is robust, and the amount of tack inserted into the superior glenoid seems marginal. There are two drawbacks to the suture anchor method: knot tying is necessary, and the posterior anchors can be difficult to insert. Knot tying is a skill that can be mastered with practice. The surgeon can usually place an anchor posterosuperiorly on the glenoid through the anterolateral portal. If it is not

Figure 5-19 Spinal needle identifying the site for the anterior-superior cannula.

Figure 5-20 Anterior-superior cannula entering through the rotator interval.

Angle for spinal needle insertion to determine the site of the anterior-superior cannula.

Figure 5-18

Figure 5-21 Cannula orientation.

Chapter 5

Figure 5-24

Figure 5-22 Cannula orientation.

possible to insert the posterior anchor through the anterior-superior portal, I move the arthroscope to the anterior-superior portal and insert the posterior anchor through the posterior portal. I use a 4-mm power bur to abrade the glenoid beneath the detached superior labrum to expose cancellous bone. I usually insert it through the anterior-superior portal because this provides the best angle of approach. On occasion, the superior labrum is very meniscoid, with the labrum margin extending

Figure 5-23 Cannula orientation.



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155

Preparation to expose cancellous bone.

down the glenoid and obscuring my view of the superior glenoid. In this situation, I insert the bur through the anterior-inferior portal, and Dr. Hammerman (my assistant) inserts a probe through the anterior-superior portal and retracts the labrum superiorly. This reveals the superior glenoid surface. Cancellous bone is exposed from the anterior to the posterior margins of the superior labrum detachment (Fig. 5-24). Holes for the suture anchors are then made with a power drill. The drill is inserted through the anteriorsuperior cannula, and the two holes are spaced evenly along the length of the defect. I drill the anterior hole first and then the posterior hole. Owing to the curvature of the glenoid, the posterior hole is more oblique than the anterior hole. As the posterior drill hole is moved posteriorly along the glenoid rim, it becomes more oblique. It is a matter of surgical judgment how much obliquity is permissible. The greater angle of approach causes the screw to be located more superficially in the bone. If the angle is unacceptable, there are two options: move the cannula more posteriorly so that it approaches the glenoid less acutely, or change the curvature of the superior glenoid rim. If the superior labrum separation extends more posteriorly than normal, anchor placement is made easier with a technique modification. Both the superior portal of Neviaser and a posterior-superior portal pass through the substance of the rotator cuff tendons and might lead to tendon rupture. Thus, when the SLAP lesion extends farther posteriorly than normal, I try to move the anterior-superior portal posteriorly. I use a spinal needle placed 1 cm posterior to the anterior acromial border. If the drill angle is still too acute, I insert a 4-mm round bur through the anteriorsuperior portal and remove a small amount of

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Bur creating shelf

Figure 5-25 Drill at the normal angle of approach.

Abrade the superior surface of the glenoid to allow the drill to penetrate.

Figure 5-27

glenoid bone to create a ‘‘shelf’’ whose face is now more perpendicular to the drill (Figs. 5-25 through 5-28). The posterior anchor is inserted through the anterior-superior cannula, and the two anchor sutures remain in this cannula. A Smith-Nephew AccuPass instrument is inserted through the anterior-inferior portal. The right-angled instrument is passed from the superior aspect of the detached labrum to the inferior aspect. Passing the suture from inferior to superior may result in detachment of the bucket handle as pressure is placed on the suturing device; it also causes the nylon sutures to exit the suture passer and move superiorly, making them harder to retrieve. Passing the sutures from superior to inferior places less stress on the labrum; the sutures exit the labrum and move inferiorly, making their retrieval easier. The nylon suture is advanced fully into the glenohumeral

joint, and the suture instrument is withdrawn. A crochet hook is used to retrieve both suture ends. Insert the crochet hook through the anterior-superior cannula. To avoid tangling the sutures, pass the crochet hook underneath (medial to) the sutures coming from the anterior-inferior cannula. The loop portion of the nylon suture protrudes from the anterior-superior cannula, and the two free ends from the anteriorinferior cannula. I prefer to repair the labrum with the suture knot on the superior surface of the labrum rather then bury the knot and interpose it between

Drilling into shelf

Figure 5-26

Drill at a tangential angle.

Figure 5-28

Anchor insertion.

Chapter 5

Figure 5-29

Spectrum suture passer.

the detached superior labrum and its repair site. Place a hemostat on the two free ends of the sutures. Use a crochet hook to retrieve one of the anchor’s suture strands and bring it out the anterior-inferior cannula. The remaining anchor suture (in the anterior-superior cannula) is placed through the looped nylon and pulled through the labrum and out the anterior-inferior cannula. Both sutures from the posterior anchor now exit the anterior-inferior cannula (Figs. 5-29 through 5-38). Occasionally, the braided suture anchor sutures do not pull smoothly through the labrum. Using additional force would cause the nylon passing sutures to tear. I prefer to use the technique developed by Hammerman. He threads the two free ends of the nylon suture through the knot tying instrument and then advances the tip of the instrument near the

Figure 5-30

Spectrum suture passer.



Biceps Tendon Lesions

157

Retrieve the nylon suture through the anteriorsuperior cannula.

Figure 5-31

Figure 5-32

Figure 5-33

Bring the nylon suture underneath.

Reverse the direction of the loop.

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Glenohumeral Joint Surgery

Move one suture strand from the anteriorsuperior cannula to the anterior-inferior cannula.

Figure 5-34

Figure 5-35 Pass the anchor suture through the labrum.

Figure 5-36

Tie the knot.

Figure 5-37

Past-point.

labrum. Rather then pull the nylon sutures, he uses the knot tying instrument to push the sutures through the labrum. Because the instrument is adjacent to the point where the sutures exit from the labrum, he is able to exert significant force without danger of suture breakage (Figs. 5-39 and 5-40). The second anchor is inserted into the anterior drill hole through the anterior-superior cannula. I insert the anterior anchor before I tie the posterior sutures because the anterior hole is obscured after the posterior sutures are tied. The posterior anchor sutures are tied with an arthroscopic knot tying instrument through the anterior-inferior cannula, and the sutures are cut with arthroscopic scissors. The anterior anchor suture is then placed through the anterior portion of the detached superior labrum as described earlier,

Figure 5-38

Completed repair.

Chapter 5

Figure 5-39

Anchor suture caught in the labrum.

and the sutures are tied and cut. For small labrum lesions, a single anchor (loaded with two sutures) will suffice for repair. The technique is similar to that described for two anchors.

SLAP 3 Lesions If the bucket handle is less than one third of the labrum width, it is excised, and I repair the major portion of the superior labrum to the glenoid, as described earlier. If the bucket handle is one third or greater, I repair the detached portion. The posterior anchor is inserted, and one limb of the suture anchor suture is passed through the major portion of the labrum, as described earlier. Both suture strands, which are now in the anterior-inferior cannula, are retrieved out the anterior-superior cannula with a

Figure 5-41



Biceps Tendon Lesions

159

SLAP type 3.

crochet hook. Failure to perform this step may result in the suture instrument cutting the suture during the next portion of the operation. Place a hemostat on one of the suture limbs to identify which suture limb passes through the bucket-handle fragment. The AccuPass instrument is then inserted through the anterior-inferior cannula and pierces the bucket handle from lateral to medial so as not to avulse the fragment. The loop end of the nylon suture is retrieved out the anterior-superior cannula with a crochet hook. The first suture (already passed through the labrum) is transferred from the anterior-superior cannula to the anterior-inferior cannula to minimize tangling. The second posterior anchor suture is then passed from the anterior-superior cannula, through the labrum, and out the anterior-inferior cannula. The sutures are tied and cut. This technique is repeated with the anterior anchor sutures to repair the anterior portion of the superior labrum and the anterior portion of the bucket-handle tear (Figs. 5-41 through 5-44).

SLAP 4 Lesions

Figure 5-40

Advance into the joint with a knot pusher.

If the longitudinal tear in the biceps tendon is less than one third of the tendon diameter, I excise the torn fragment. If the fragment is one third or greater, I repair the torn fragment to the major portion of the biceps tendon. The superior labrum is repaired first, as described earlier. The AccuPass instrument is used to place a No. 1 PDS suture through the torn fragment and then through the major portion of the biceps tendon. The suture is then tied. One or two sutures are sufficient to accomplish the repair (Figs. 5-45 through 5-50).

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Figure 5-42



Glenohumeral Joint Surgery

First anchor suture strand through a major

Figure 5-45 SLAP type 4.

Second anchor suture strand through a minor

Figure 5-46

Biceps repair.

Completed repair.

Figure 5-47

Biceps repair.

fragment.

Figure 5-43

fragment.

Figure 5-44

Chapter 5



Biceps Tendon Lesions

161

Postoperative Treatment

Figure 5-48

Biceps repair.

The patient is placed in a sling that is worn at all times except while bathing. At 2 weeks, active range of motion is allowed in all planes except external rotation in abduction. The sling is worn until week 4, at which time passive range of motion is started, with an emphasis on posterior capsule stretching. Six weeks after surgery, external rotation in abduction is allowed, and stretching continues. The patient is started on a progressive strengthening program using surgical tubing for the deltoid, rotator cuff, scapular muscles, biceps, and triceps. Upper extremity sports are allowed 3 months after surgery, with the exception of throwing. Throwing begins 4 months after operation with lowvelocity, short-distance throwing, with the athlete concentrating on proper throwing mechanics. Distance and velocity are gradually increased until 7 months after operation, at which point I allow the patient to resume competitive throwing.

BICEPS LESIONS DISTAL TO THE SLAP LESION

Figure 5-49

Biceps repair.

Biceps tendinitis and partial tears are occasionally isolated causes of significant shoulder pain, but they are more commonly found in conjunction with subacromial impingement and rotator cuff tears. Although arthroscopic subacromial decompression and rotator cuff repair have been thoroughly described, arthroscopic biceps treatment has rarely been mentioned. Since 2001, there has been a significant shift in our thinking, and I now treat biceps lesions more frequently. Biceps lesions requiring arthroscopic treatment include tendinitis, partialthickness tears, hypertrophy, and subluxation (Figs. 5-51 and 5-52).

Literature Review

Figure 5-50

Biceps repair.

Since the publication of the first edition of this book, the literature on the arthroscopic treatment of biceps lesions has become more robust. These presentations focus on two issues: should the surgeon perform a tenodesis or a tenotomy, and if a tenodesis is performed, what is the preferred technique? Hawkins and Walch have questioned the value of any tenodesis operation. Their results suggest that equal or better results can be achieved with tenotomy. Tenotomy is faster, is easier to perform, does not appear to affect elbow flexion strength, and does not normally result in a cosmetic deformity. Some patients express concern about the possible cosmetic deformity, particularly men who lift weights.

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Diagnosis

Figure 5-51

Biceps synovitis.

If a patient has any concerns about the appearance of the arm, I perform a tenodesis. If the patient participates in overhead or throwing sports, I prefer tenodesis. My results with tenodesis have been favorable, but many patients complain of pain around the site of tenodesis for months. When patients ask about my preference, I usually tell them that if it were my shoulder, I would have a tenotomy. For those surgeons who prefer tenodesis, there are three basic methods of fixation. My colleagues and I have described our technique with suture anchors, and Boileau has described his experience with a bioabsorbable screw. Elkousy and Rodosky published an elegant technique for soft tissue fixation with sutures. I have no experience with the Boileau screw, but in my hands, both the soft tissue suture technique and the suture anchor technique are very effective.

I make the diagnosis of a biceps tendon lesion based on a combination of patient history, physical examination, radiographic imaging, and findings at arthroscopic surgery. The patient history and physical examination may point to a problem in the biceps tendon, but that information is usually nonspecific. Patients often indicate the biceps area as the source of their pain. This seems to be much more specific than the diffuse area of pain described with a rotator cuff tear. Of course, such localization by the patient does not eliminate the possibility that the biceps is normal and the lesion is in the anterior supraspinatus or superior subscapularis. Patients often describe pain with activities that involve internal rotation, such as pressing an object together with both arms, reaching out to the side to close a car door, or reaching up behind the back. Some specifically describe the feeling of something rolling into and out of place or the sensation of slipping. Sometimes the pain is felt more acutely within the substance of the biceps muscle. These complaints are nonspecific and are also reported by patients with subacromial impingement syndrome and other more serious forms of rotator cuff disease. In patients who appear to have a mechanical block to full elevation yet maintain normal external rotation, I am suspicious of biceps tendon entrapment due to tendon hypertrophy. The primary (Neer) and secondary (Hawkins) impingement signs may also produce pain on physical examination. I have not found the Yergason test helpful and prefer the Speed test. Patients commonly describe painful popping or catching in the anterior shoulder area. A lidocaine injection into the area of the proximal biceps tendon sheath may be helpful in differentiating subacromial impingement from biceps tendinitis, but I often find it more useful to determine the degree to which the biceps lesion is producing pain. The definitive diagnosis is usually made on magnetic resonance imaging or at the time of arthroscopic surgery. When reviewing the magnetic resonance image, I pay particular attention to the subscapularis, because biceps subluxation and tendinitis can be associated with partial-thickness tears of the articular surface of the subscapularis (Figs. 5-53 through 5-56).

Indications for Treatment

Figure 5-52

Biceps partial tear.

Partial-thickness biceps tendon tears within the glenohumeral joint are not uncommon; they may occur subsequent to a traumatic event, or they may be the result of chronic subacromial impingement. When the tear is less than 30% of the tendon width, the frayed edges are de´brided. If the tear is greater than 30% of the tendon width, I perform a tenodesis. When the tendon is

Chapter 5

Figure 5-53

Biceps Tendon Lesions

163

Subscapularis partial tear. Figure 5-55

subluxed medially, I prefer biceps tenodesis or tenotomy, usually in combination with a subscapularis repair. If a biceps lesion is found in the area of the bicipital groove during subacromial decompression for a fullthickness rotator cuff tear, the surgeon has four options: ignore the biceps lesion or perform stabilization, tenodesis, or tenotomy (Table 5-1). Because there is no scientific evidence to guide us, treatment is determined by personal preference. I have experience with all four options but have seen the best results with tenodesis in younger patients who have good-quality rotator cuff tendons and tenotomy in older patients who have poorer quality biceps and rotator cuff tendons.

Figure 5-54



Subscapularis partial tear.

Subscapularis partial tear.

I usually treat full-thickness tears of the biceps tendon nonoperatively, but some patients are very concerned about the injury and request repair (Fig. 5-57). Because the remnant stump within the glenohumeral joint may cause mechanical symptoms, I perform an arthroscopic de´bridement of the biceps tendon back to the level of the superior labrum. The bicipital sheath is accessible arthroscopically from the level of the rotator interval to the insertion of the pectoralis major tendon. I identify the sheath and open it, find the tendon, and repair it with a suture anchor as far proximal as possible to restore resting tension in the muscle.

Figure 5-56

Subscapularis partial tear.

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Table 5-1 INDICATIONS FOR TREATMENT Biceps Lesion

Treatment

Inflamed

Tenosynovectomy

Partially torn < 30%

De´bride

Partially torn > 30% Biceps quality good, cuff repair good

Tenodesis

Biceps quality good, cuff repair poor

Tenodesis or tenotomy

Biceps quality poor, cuff repair good

Tenotomy

Biceps quality poor, cuff repair poor

Tenotomy

Operative Technique Intra-articular Biceps Tendinitis I use a standard posterior portal and enter the glenohumeral joint. I visualize the biceps tendon and areas of fraying, inflammation, or partial tear. An anterior portal is established, and a probe is introduced to pull the tendon and bring its extra-articular portion into view (Figs. 5-58 and 5-59). If the fraying or inflammation is localized to the intra-articular portion of the biceps tendon, a shaver is introduced through the anterior portal, and de´bridement is performed. If a portion of the biceps tendon lesion lies within the bicipital groove, external to the glenohumeral joint, I prefer to use a subacromial approach to treat the lesion.

Figure 5-57

Patient with complete biceps tear.

Figure 5-58

Figure 5-59

Shaver retracting the biceps tendon.

Extra-articular biceps pulled into view.

Chapter 5

Partial Tear of the Intra-articular Biceps Tendon This lesion is immediately observed upon entry into the glenohumeral joint. I establish an anterior portal with an 8-mm cannula. If the biceps tear is the only lesion within the glenohumeral joint, I prefer to repair it with a one-cannula technique. I use an AccuPass right-angled instrument loaded with monofilament suture and pierce the entire tendon from the area of the tear flap toward the more normal tendon. I advance 15 to 20 cm of the suture into the joint and then withdraw the instrument. I grasp the free end of the suture with a crochet hook and withdraw it through the anterior cannula. I tie the suture and repeat these steps with additional sutures as necessary, depending on the length of the tear area. Other instruments can be used to repair the biceps tendon, but they require two cannulas because one instrument is used to pass the suture and another instrument is needed to retrieve the suture.

Subacromial Techniques TENDINITIS AND PARTIAL-THICKNESS TEARS WITH INTACT ROTATOR CUFF I use a standard posterior portal and

enter the glenohumeral joint. The biceps tendon is visualized, and areas of fraying, inflammation, or partial tear are noted. I establish an anterior portal and introduce a probe so that I can pull on the tendon to bring the extra-articular portion into view. I introduce a spinal needle percutaneously near the anterolateral acromial border and pierce the tendon just proximal to its exit from the joint. The needle is advanced until it is lodged in bone so that it does not



Biceps Tendon Lesions

move when I remove the arthroscope from the glenohumeral joint and reinsert it into the subacromial space (Fig. 5-60). After removing the arthroscope from the joint and redirecting it into the subacromial space, I locate the spinal needle and establish a lateral portal. I use a scissors or motorized shaver to divide the flimsy capsular tissue of the rotator interval and expose the biceps tendon and the bicipital groove. I then insert an arthroscopic probe through the anterior portal, lift the biceps tendon from its groove, and inspect it. If the tendon is intact and of good quality but inflamed, I perform a tenosynovectomy using a power shaver. If the biceps is partially torn, I perform a tenodesis using the technique described next. BICEPS TENODESIS—SUTURE ANCHOR TECHNIQUE The biceps tenodesis is performed after the subacromial decompression but before the arthroscopic rotator cuff repair. Standard anterior and lateral portals are used. I move the outflow to the posterior portal and the arthroscope to the lateral portal. If the bicipital groove is flattened, as is common in chronic cuff tears, I retract the tendon medially and use a 4-mm round bur to deepen the bicipital groove. If the shape of the groove appears normal, I insert a bur and abrade the cortical margins of the groove for a distance of 2 cm. I then insert an anchor into the center of the deepened groove. The anchor can be inserted through the anterior cannula, but often the angle is too oblique. If this is the case, I insert the anchors through a percutaneous stab wound. I use a spinal needle and

Biceps long head tendon

A

165

B Figure 5-60 A, Spinal needle piercing the biceps tendon. B, Biceps fraying in the groove.

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pierce the anterior shoulder until the needle tip is within the bicipital groove and the angle of approach is satisfactory for anchor placement. I then incise the skin at this location and insert the suture anchor. The anchor sutures are exiting the anterior cannula, the arthroscope is in the lateral cannula, and the Elite suture punch (my preferred instrument for this technique) is inserted through the posterior cannula. One of the anchor sutures is moved from the anterior cannula to the lateral cannula with a loop grasper or crochet hook. The suture is loaded on the Elite punch, which passes through the posterior cannula into the subacromial space and pierces the biceps tendon. This suture is retrieved out the anterior cannula. The second suture from that same anchor is placed in a similar fashion, completing the mattress suture. These steps are repeated for both suture limbs of the second anchor. The sutures are usually tied from the posterior cannula. If the surgeon prefers a Caspari suture punch, it is loaded with doubled 2-0 nylon suture and inserted through the lateral cannula to pierce the biceps tendon. The 2-0 nylon suture is advanced and drawn out the anterior cannula. One limb of the first anchor suture is brought from the anterior cannula (or stab wound) to the lateral cannula and passed through the biceps tendon using the nylon loop. This process is repeated with the second limb of the same color anchor suture, which is placed 5 mm from the first suture. A mattress suture has now been placed through the biceps tendon. This process is repeated with sutures from the second anchor, and the sutures are tied. I excise the intra-articular portion of the biceps tendon and repair the rotator cuff tear with arthroscopic technique (Figs. 5-61 through 5-70).

Figure 5-62

Identifying the biceps tendon.

If the subscapularis is also torn, I first perform the biceps tenodesis with the suture anchor technique just described and then repair the subscapularis. If the supraspinatus is torn, the order of repair is biceps tenodesis, subscapularis repair, and finally supraspinatus repair.

Abrading flattened bone surface, creating a new groove

Dividing rotator interval

Figure 5-61 Division of the rotator interval, exposing the biceps tendon.

Figure 5-63

Abrading the repair site.

Chapter 5

Percutaneously placing anchor screws

Anchor screws

A



Biceps Tendon Lesions

167

Percutaneously placing anchor screws

A

B B Figure 5-64

Figure 5-66

A and B, Suture placement.

A and B, Anchor insertion.

A

B Figure 5-67 Figure 5-65

Anchor insertion.

tendon.

A and B, Suture spacing along the biceps

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Anchor sutures tied

A Excising biceps tendon

A Rotator interval sutured

B Figure 5-69

A and B, Excise the intra-articular biceps

stump.

B Figure 5-68

A and B, Sutures tied.

Abrading bone surface medial to the lesser tuberosity

A

Subscapularis tendon sutured medial to biceps tendon

B Anchors set in place

C Figure 5-70

A-C, Subscapularis repair, if necessary.

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169

Biceps Tenodesis—Extra-Articular Technique  Place the patient in the upright beach-chair position with the acromion parallel to the floor.  Perform routine diagnostic glenohumeral joint arthroscopy from the posterior portal.  Insert a spinal needle lateral to the coracoid tip and into the glenohumeral joint through the rotator interval.  Remove the spinal needle and make a small stab incision using a scalpel.  Insert a blunt metal trocar through the anterior incision and into the glenohumeral joint to facilitate passage of the mechanical shaver.  Remove the trocar and insert the shaver percutaneously into the joint.  Use the shaver as a probe to pull the biceps tendon into the joint to visualize and document the extra-articular proximal biceps tendon.  Resect the lateral rotator interval tissue overlying the biceps tendon at its entry into the joint (a triangle of tissue bounded posteriorly by the anterolateral supraspinatus tendon and anteriorly by the superolateral subscapularis).  Remove the shaver.  Insert a spinal needle at the anterolateral corner of the acromion through the opening in the rotator interval and pierce the biceps tendon.  Insert an arthroscopic scissors into the joint through the anterior stab incision and transect the long head of the biceps tendon at its proximal insertion. The transection should be at the level of the superior labrum. Try to avoid leaving a medial stump of biceps tendon. (Insert the shaver to de´bride a medial biceps tendon stump, if necessary.)  Remove the arthroscope from the joint.  Insert the metal cannula and trocar posteriorly into the subacromial space.  Insert the arthroscope.  Make a small stab incision at the midlateral position approximately 1 cm distal to the lateral acromial border.  Insert a blunt metal trocar into the subacromial space and locate it using the arthroscope.  Remove the trocar and replace it with the shaver.  Clear the subacromial bursa as needed for clear visualization of the bursal surface of the rotator cuff. (Achieve adequate visualization of the anterior and lateral subacromial space and the previously placed spinal needle.)  Remove the shaver and replace it with a metal cannula and trocar.  Remove the arthroscope from the posterior portal and insert it laterally.  Enlarge the posterior incision and insert an 8-mm cannula. Move the outflow from the arthroscope to the 8-mm cannula.  Position the shoulder in approximately 60 degrees of anterior elevation and neutral rotation using the McConnell arm positioning device.  With the arthroscope in the lateral portal, visualize the biceps tendon through the opening in the rotator interval. Insert the shaver through the anterior incision to enlarge the interval window if necessary, further exposing the biceps tendon.

 Insert a nonlocking grasper through the posterior cannula, remove the spinal needle piercing the biceps tendon, and deliver the tendon into the subacromial space through the opening in the rotator interval using the grasper.  Insert a locking grasper through the anterior incision and grasp the proximal end of the biceps tendon (this instrument maintains control of the tendon for the remainder of the procedure). Remove the posterior grasper.  Insert a spinal needle percutaneously approximately 1 cm distal to the anterolateral tip of the acromion, directed toward the bicipital groove.  Make a small skin incision and insert a 5-mm cannula. (Insert the cannula until it touches the humerus, and then pull it backward. This maneuver aids in retraction of the subdeltoid fascia for visualization.)  Use the locking grasper to pull the biceps tendon medially, introduce the shaver through the 5-mm cannula, and resect approximately 1 to 1.5 cm of tissue overlying the biceps tendon from proximal to distal.  Expose the bicipital groove by ‘‘pushing’’ the biceps tendon laterally using the locking grasper. Use the shaver to remove soft tissue from the bicipital groove (keep the blades pointed toward the humerus medially, and the guard will protect the biceps tendon laterally).  Insert a small round bur through the 5-mm cannula, and carve away the exposed bicipital groove to bleeding bone. (Do not go completely through to cancellous bone, because the anchor fixation may be compromised.)  Pass a double-loaded Arthrex FT (full-thread) anchor through the 5-mm cannula, and insert it into the base of the bicipital groove. (A small amount of internal or external rotation and elevation of the shoulder may be required to insert the anchor perpendicular to the bone.) The base of the anchor is seated at the level of the remaining cortical bone.  Remove the 5-mm cannula and then replace it, with the sutures exiting outside the cannula.  Use the locking grasper to pull the biceps tendon back to a medial position. The assistant holding the grasper should lower his or her hand to hold the tendon superior to the groove, which assists in suture passing.  Complete suture passing and knot tying through the posterior cannula. Sutures are passed through the biceps tendon in a mattress configuration from distal to proximal.  Pass a crochet hook from posterior through the 8-mm cannula to retrieve one limb of the solid (blue) suture.  Use an Elite Pass to pass this suture through the biceps tendon as distal along the tendon as possible. (Use the locking grasper to pull the tendon medially during passage of the most lateral suture.)  Retrieve the suture using a grasper through the 5-mm cannula.  Retrieve the second limb of blue suture and pass it in the same fashion. The sutures should be passed through the biceps approximately 1 cm apart and at differing angles to each other.  Retrieve the tiger-stripe sutures and pass them through the biceps tendon from the posterior cannula, proximal to the blue sutures, using the same technique. Continued

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 Make sure the shoulder is externally rotated slightly (approximately 15 degrees) for suture retrieval and knot tying.  Retrieve the two lateral sutures (blue) through the posterior cannula.  Use a loop grasper to ensure that the sutures are not crossed.  Tie the sutures using arthroscopic square knots.  Cut the sutures with fiber-wire scissors, leaving a small tail.

Biceps Tenodesis Glenohumeral Joint Biceps Tenodesis in Bicipital Groove Biceps Tenodesis Near Pectoralis Major BICEPS TENODESIS—INTRA-ARTICULAR TECHNIQUE Standard shoulder arthroscopy equipment is required for this procedure, including 5- and 8-mm arthroscopic cannulas, a tissue-penetrating suture passer, and No. 1 Ethibond braided polyester suture. I prefer to put patients in the beach-chair position; however, this technique can also be performed with the patient in the lateral decubitus position. I inspect the glenohumeral joint through a standard posterior portal and then place an anterior cannula through the rotator interval superior to the subscapularis tendon. The anterior glenohumeral joint cannula is the ‘‘working’’ cannula and should be 8 mm in size. The biceps tendon is evaluated from its glenoid origin medially and followed into the bicipital groove laterally; instability, inflammation, degeneration, and tears are noted. The shoulder is elevated with the elbow extended as described by Boileau to examine tendon gliding and evaluate for possible biceps entrapment—the hourglass biceps (Fig. 5-71). A probe is placed through the anterior cannula to pull the biceps into the joint, improving distal tendon visualization. Sutures used to complete the tenodesis are passed through an accessory anterior cannula. Proper accessory cannula placement is ensured by using a spinal needle. The needle is inserted through the anterolateral shoulder into the subacromial space and then into the glenohumeral joint, penetrating the anterior border of the supraspinatus. The needle is removed, and a small skin incision is made to allow placement of a 5-mm cannula. A metal trocar is

 Retrieve, tie, and cut the tiger-striped sutures in the same fashion.  Pass a grasper from posterior through the 8-mm cannula to grip the proximal biceps tendon stump.  Remove the locking grasper.  Pass arthroscopic scissors through the 5-mm cannula to transect the remaining biceps tendon proximal to the tenodesis sutures.  Remove the tendon stump from posterior through the 8mm cannula, completing the procedure.

inserted through the skin incision into the subacromial space. The trocar is swept in a circular manner to release any adhesions between the rotator cuff tissue and the subacromial bursa. The mechanical release of adhesions is important to ensure that the mattress suture is pulled against the interval tissue after knot tying and is not caught within the bursa, which could loosen the tenodesis suture. The 5-mm cannula is then advanced into the subacromial space and pushed against, but not through, the rotator interval tissue superior to the biceps tendon. A grasper is inserted through the 8-mm anterior cannula to secure the biceps tendon and pull it proximally into the glenohumeral joint. A No. 1 Ethibond braided polyester suture is loaded onto a Cuff-Stitch (Smith-Nephew Endoscopy, Andover, Mass) through the convex side of the device, leaving a 4-cm length of suture on the concave side. The Cuff-Stitch is passed down the smaller cannula and through the anterior supraspinatus until the tip of the suture passer pierces the biceps tendon. A grasper is used to retrieve the suture from the concave side of the Cuff-Stitch inside the joint and pull the end out through the 8-mm working portal. The Cuff-Stitch is removed from the cannula, allowing the suture to slide within the eyelet without completely unloading the device, until approximately 4 cm of suture remains. A second pass is made down the 5-mm cannula through the supraspinatus and the biceps tendon. The suture is retrieved again from the concave side of the Cuff-Stitch, unloading the device, and is pulled out the larger portal. If desired, a second tenodesis suture can be passed by repeating these steps. The suture is now transtendinous and pierces the biceps tendon in a mattress configuration. A loop grasper is used to ensure that the sutures are not crossed within the cannula, and a knot pusher facilitates the tying of arthroscopic knots, through the 8-mm cannula, to tenodese the biceps. I prefer arthroscopic square knots. The suture strands are cut with a sliding suture scissors, and the intra-articular portion of the biceps tendon is excised with arthroscopic scissors. I use a power shaver to smooth the cut edges. The tenodesis is now complete, and any

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171

Biceps long head tendon entrapment

A

B

C

D Figure 5-71

A-D, Hourglass biceps of Boileau.

associated procedures can be carried out without interference from the biceps tendon. Following the procedure, the cannulas and scope are removed from the joint, fluid is expressed, and portals are closed in a standard fashion, my preference being subcuticular

3-0 absorbable monofilament suture. Sterile dressings are applied, and the arm is secured in a sling. The step-by-step technique for intra-articular biceps tenodesis is described here:

 Position the patient in the beach-chair position with the acromion parallel to the floor.  Perform a diagnostic arthroscopy from a standard posterior portal.  Insert a spinal needle lateral to the coracoid and into the glenohumeral joint—penetrating the rotator interval.  Remove the needle, incise the skin, and insert an 8mm cannula.  Evaluate the biceps tendon from its insertion medially to its passage laterally into the bicipital groove.  Elevate the shoulder with the elbow extended to examine the biceps tendon gliding, and evaluate for biceps entrapment (i.e., hourglass biceps).

 Insert a probe through the anterior cannula to pull the biceps tendon into the joint, improving distal tendon visualization.  Insert a spinal needle just distal to the anterolateral acromion into the glenohumeral joint, penetrating the anterior border of the supraspinatus.  Remove the spinal needle and make a skin incision to accommodate a 5-mm cannula.  Insert a blunt metal trocar percutaneously into the subacromial space.  Sweep the trocar in a circular manner to release any adhesions between the rotator cuff tissue and the subacromial bursa. Continued

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 Insert the 5-mm cannula and advance it against, but not through, the rotator interval tissue superior to the biceps tendon.  Insert a suture grasper into the joint through the 8-mm anterior cannula. Secure the biceps tendon, and pull it medially into the glenohumeral joint.  Load a No. 1 Ethibond braided polyester suture onto a Cuff-Stitch through the convex side of the device, leaving a 4-cm length of suture on the concave side.  Pass the Cuff-Stitch through the 5-mm cannula, through the anterior margin of the supraspinatus tendon, and pierce the biceps tendon.  Use the grasper holding the biceps to retrieve the suture from the concave side of the Cuff-Stitch, inside the joint, and pull the end out through the 8mm working portal.  Remove the Cuff-Stitch from the cannula, allowing the suture to slide within the eyelet without completely unloading the device, until approximately 4 cm of suture remains.

Tenotomy My primary indication for biceps tenotomy is a poorquality biceps tendon that will not hold sutures. Patients should be informed of this possibility before the operation. I have no hard-and-fast rules for moving from tenodesis to tenotomy, but I tend to perform tenotomy more frequently if the patient is older or less active or if the nondominant arm is involved. Larger patients with less muscle definition note no cosmetic deformity. For those patients with an irreparable rotator cuff tear, tenotomy has major benefits in terms of pain relief and no adverse effects.

Figure 5-72

Pass the suture through the biceps tendon.

 Pass the Cuff-Stitch down the 5-mm cannula a second time through the supraspinatus and the biceps tendon.  Unload the Cuff-Stitch by retrieving the suture from the concave side of the device with a suture grasper and pulling it out the 8-mm cannula.  If a second tenodesis suture is desired, repeat the previous seven steps.  Insert a loop grasper through the 8-mm cannula to ensure that the sutures are not crossed.  Secure the tenodesis with arthroscopic square knots tied through the anterior 8-mm cannula.  Cut the suture strands using arthroscopic sliding suture scissors.  Excise the intra-articular portion of the biceps tendon with arthroscopic scissors.  Use a power shaver to smooth the cut ends of the biceps.  The tenodesis is complete. Any associated procedures can be completed without interference of the biceps tendon (Figs. 5-72 through 5-77).

If the rotator cuff is intact, I establish two intraarticular anterior portals. I insert an arthroscopic forceps through the anterior-inferior cannula, grasp the biceps tendon, and pull the tendon into the glenohumeral joint as far as I can. I hold the tendon in this position, insert a scissors through the anteriorsuperior portal, and divide the tendon as far distal as possible. I then grasp the remaining stump of tendon distally and incise it near the superior labrum. The tendon stump is retrieved out through the anteriorinferior cannula. If the rotator cuff is torn, I perform a tenotomy before repairing the rotator cuff. The arthroscope is

Figure 5-73

Retrieve the suture out the anterior cannula.

Chapter 5

Figure 5-74

Pass the suture through the biceps tendon a

Figure 5-77



Biceps Tendon Lesions

173

Completed tenodesis.

second time.

positioned in the posterior portal. My assistant places a grasper through the anterior portal and retracts the edge of the torn supraspinatus superiorly so that I can see the biceps-labrum junction. I insert a scissors through the lateral cannula and divide the biceps tendon at the glenoid attachment. The assistant uses the grasper in the anterior cannula to pull the divided biceps tendon into the subacromial space. I use a scissors placed through the lateral cannula to divide the tendon distally. Because the anterior cannula is usually too small to accommodate the biceps tendon, I insert a grasper through the lateral cannula and bring the tendon through the larger cannula or bring the tendon and cannula out together.

Figure 5-75

Tie the suture.

Postoperative Treatment Postoperative treatment for biceps tendon repair and tenodesis are identical. I discourage active elbow flexion for 3 weeks. I then allow active elbow flexion and extension but do not allow flexion against resistance for 6 weeks after the operation. If I perform a tenotomy, there are no changes in the normal postoperative rehabilitation regimen for the primary operation, rotator cuff repair, arthroscopic subacromial decompression, or de´bridement of an irreparable rotator cuff tear.

DISCUSSION

Figure 5-76

Cut the tendon.

Surgeons now recognize that the biceps has an important role in the cause of shoulder pain and are performing more biceps tendon operations. Whether this represents an actual increase in our knowledge base or is simply a cyclical variation remains to be

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seen. It is not known which tenodesis technique is superior or whether any of these techniques provide better results than simple tenotomy. Surgeons must rely on their own experience, training, and judgment until science can guide us.

BIBLIOGRAPHY Ahmad CS, DiSipio C, Lester J, et al: Factors affecting dropped biceps deformity after tenotomy of the long head of the biceps tendon. Arthroscopy 23:537-541, 2007. Ahrens PM, Boileau P: The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 89:1001-1009, 2007. Armstrong A, Teefey SA, Wu T, et al: The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg 15:7-11, 2006. Barber A, Field LD, Ryu R: Biceps tendon and superior labrum injuries: Decision-marking. J Bone Joint Surg Am 89: 1844-1855, 2007. Boileau P, Ahrens PM, Hatzidakis AM: Entrapment of the long head of the biceps tendon: The hourglass biceps—a cause of pain and locking of the shoulder. J Shoulder Elbow Surg 13:249-257, 2004. Boileau P, Baque´ F, Valerio L, et al: Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am 89:747-757, 2007. Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Tech Shoulder Elbow Surg 2: 153-165, 2001. Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Arthroscopy 18:1002-1012, 2002. Boileau P, Neyton L: Arthroscopic tenodesis for lesions of the long head of the biceps. Oper Orthop Traumatol 17: 601-623, 2005. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I. Pathoanatomy and biomechanics. Arthroscopy 19:404-420, 2003. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part II. Evaluation and treatment of SLAP lesions in throwers. Arthroscopy 19:531-539, 2003. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III. The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19:641-661, 2003. Checchia SL, Doneux PS, Miyazaki AN, et al: Biceps tenodesis associated with arthroscopic repair of rotator cuff tears. J Shoulder Elbow Surg 14:138-144, 2005. Choi CH, Kim SK, Jang WC, Kim SJ: Biceps pulley impingement. Arthroscopy 20(Suppl 2):80-83, 2004.

Dines DM, Warren RF, Inglis AE: Surgical treatment of lesions of the long head of the biceps. Clin Orthop Relat Res 164:165-171, 1982. Gartsman GM, Hammerman SM: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16:550-552, 2000. Gartsman GM, Khan M, Hammerman SM: Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg Am 80:832-840, 1998. Gartsman GM, Taverna E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997. Gill HS, El Rassi G, Bahk MS, et al: Physical examination for partial tears of the biceps tendon. Am J Sports Med 35:1334-1340, 2007. Glueck DA, Mair SD, Johnson DL: Shoulder instability with absence of the long head of the biceps tendon. Arthroscopy 19:787-789, 2003. Hitchcock HH, Bechtol CO: Painful shoulder: Observation on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am 30:263-273, 1948. Holtby R, Razmjou H: Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: Comparison with arthroscopic findings. Arthroscopy 20:231-236, 2004. Jobe CM: Posterior superior glenoid impingement: Expanded spectrum. Arthroscopy 11:530-536, 1995. Kelly AM, Drakos MC, Fealy S, et al: Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results. Am J Sports Med 33:208-213, 2005. Kibler WB: Scapular involvement in impingement: Signs and symptoms. Instr Course Lect 55:35-43, 2006. Kibler WB, Press J, Sciascia A: The role of core stability in athletic function. Sports Med 36:189-198, 2006. Kibler WB, Uhl TL, Maddux JW, et al: Qualitative clinical evaluation of scapular dysfunction: A reliability study. J Shoulder Elbow Surg 11:550-556, 2002. Kim SH, Yoo JC: Arthroscopic biceps tenodesis using interference screw: End-tunnel technique. Arthroscopy 21:1405, 2005. Klepps S, Hazrati Y, Flatow E: Arthroscopic biceps tenodesis. Arthroscopy 18:1040-1045, 2002. Kohn D: The clinical relevance of glenoid labrum lesions. Arthroscopy 3:223-230, 1987. Kuhn JE, Lindholm SR, Huston LJ, et al: Failure of the biceps superior labral complex: A cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy 19:373-379, 2003. Lafosse L, Reiland Y, Baier GP,et al: Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: A new classification based on arthroscopic observations. Arthroscopy 23:73-80, 2007. Lunn JV, Castellanos-Rosas J, Walch G: Arthroscopic synovectomy, removal of loose bodies and selective biceps tenodesis for synovial chondromatosis of the shoulder. J Bone Joint Surg Br 89:1329-1335, 2007.

Chapter 5

Maffet MW, Gartsman GM, Moseley B: Superior labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 23:93-98, 1995. Maier D, Jaeger M, Suedkamp NP, Koestler W: Stabilization of the long head of the biceps tendon in the context of early repair of traumatic subscapularis tendon tears. J Bone Joint Surg Am 89:1763-1769, 2007. Mazzocca AD, Bicos J, Santangelo S,et al: The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 21:1296-1306, 2005. Mazzocca AD, Rios CG, Romeo AA, Arciero RA: Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 21:896, 2005. Morgan CD, Burkhart SS, Palmeri M, Gillespie M: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 14:553-565, 1998. Motley GS, Osbahr DC, Holovacs TF, Speer KP: An arthroscopic technique for confirming intra-articular subluxation of the long head of the biceps tendon: The ramp test. Arthroscopy 18:E46, 2002. Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am 54:41-50, 1972. O’Donoghue DH: Subluxing biceps tendon in the athlete. Clin Orthop Relat Res 164:26-34, 1982. Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 18:483-487, 2002. Pagnani MJ, Deng XH, Warren RF, et al: Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 77:1003-1010, 1995. Post M, Benca P: Primary tendinitis of the long head of the biceps. Clin Orthop Relat Res 246:117-124, 1989.



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Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 22:121-130, 1994. Rodosky MW, Rudert MF, Harner CH, et al: Significance of a superior labral lesion of the shoulder: A biomechanical study. Trans Orthop Res Soc 15:276, 1990. Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 19:1137-1141, 2003. Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 4: 243-248, 1995. Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 6:274-279, 1990. Tuoheti Y, Itoi E, Minagawa H, et al: Attachment types of the long head of the biceps tendon to the glenoid labrum and their relationships with the glenohumeral ligaments. Arthroscopy 21:1242-1249, 2005. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL: The origin of the long head of the biceps from the scapula and glenoid labrum: An anatomical study of 100 shoulders. J Bone Joint Surg Br 76:951-954, 1994. Walch G, Boileau P, Noel E, et al: [Surgical treatment of painful shoulders caused by lesions of the rotator cuff and biceps, treatment as a function of lesions: Reflections on the Neer’s concept]. Rev Rhum Mal Osteoartic 58:247-257, 1991. Walch G, Noel E, Donell ST: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1:238-245, 1992. Walch G, Nove-Josserand L, Boileau P, Levigne C: Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg 7:100-108, 1998.

CHAPTER

6

Stiffness

There are four basic conditions that produce shoulder stiffness and are amenable to arthroscopic treatment: idiopathic adhesive capsulitis, diabetic stiff shoulder, and post-traumatic and postoperative stiffness. I discuss the treatment of the stiff, osteoarthritic shoulder in Chapter 7. Idiopathic adhesive capsulitis is widely believed to be a painful but self-limited condition that resolves after 1 to 2 years. Recent reports suggest that although many patients improve, they have significant limitations of movement and function. Additionally, those who suffer from disabling pain are unwilling to wait for their condition to resolve and inquire about operative treatment. Shoulder stiffness in diabetic patients seems to cause greater pain and is more refractory to nonoperative treatment than is idiopathic stiffness. The impairment from post-traumatic stiffness is directly related to the severity of the trauma. Postoperative stiffness can be the result of excessive scarring in the area of surgery (subacromial adhesions after rotator cuff repair, anterior glenohumeral capsule contracture after a Bankart procedure), but I have also seen profound glenohumeral joint contracture after surgery that does not violate the capsule (Figs. 6-1 through 6-3). One advantage of the arthroscopic technique is that it enables the release of intra-articular, subacromial, and subdeltoid adhesions without dividing the subscapularis. Active range of motion can be started immediately after surgery without concern for tendon dehiscence.

176

LITERATURE REVIEW Arthroscopic treatment is generally successful, with the degree of improvement related to the patient’s underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results. Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great

Figure 6-1

Postsurgical stiffness after rotator cuff repair.

Chapter 6



Stiffness

177

DIAGNOSIS

Figure 6-2

Postsurgical stiffness after a Bristow procedure.

as that seen in patients with idiopathic adhesive capsulitis.

CLINICAL PRESENTATION Patients with all types of adhesive capsulitis present with painful, limited shoulder motion. Pain at night interferes with sleep. Routine activities of daily living that require reaching overhead or behind the back are difficult and painful. Rapid movements cause especially severe pain. Most patients either recall a trivial antecedent injury or cannot identify an inciting event. Patients demonstrate restricted passive and active motion, with motion usually less than 50% that of the contralateral shoulder. Radiographs are usually normal, but mild osteopenia due to disuse is typical.

Figure 6-3 Post-traumatic and postsurgical stiffness after open reduction and internal fixation.

A number of other shoulder conditions that produce painful, limited motion can be eliminated by patient history, physical examination, and radiographic evaluation. Patients with rotator cuff tears present with passive motion greater than active motion, weakness on manual muscle testing, and abnormal magnetic resonance images or arthrograms. In patients with osteoarthrosis, plain radiographs depict loss of the glenohumeral joint space (Fig. 6-4). Patients with posttraumatic stiffness may have malunited fractures, and those with postoperative stiffness may have internal fixation devices that interfere with motion. It is important to obtain a thorough history that ascertains prior trauma or shoulder difficulties. Patients should also be asked about diabetes and thyroid dysfunction. Evaluate and record passive range of motion in elevation, abduction, and external rotation (in adduction with the arm at the side and in maximal allowable abduction). Measure internal rotation as the vertebral level to which the patient can reach with the extended thumb. Behind-the-back internal rotation is usually decreased, but it is occasionally close to normal because internal rotation measured in this manner includes not only glenohumeral movement but also scapulothoracic motion. With prolonged shoulder stiffness, scapulothoracic motion may increase to compensate for the loss of glenohumeral rotation. For this reason, I use a more sensitive technique that eliminates scapulothoracic motion: I stabilize the scapula with one hand and abduct the arm with the other. I then record external and internal rotation in this maximally abducted position and compare it with the contralateral shoulder. I assess muscle strength in elevation

Figure 6-4

Osteoarthrosis.

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Glenohumeral Joint Surgery

and external rotation and obtain anteroposterior, axillary, and supraspinatus (scapular) outlet plain radiographs.

INDICATIONS FOR SURGERY As a general principle, I consider operation if the patient has persistent pain and stiffness after 6 months of appropriate nonoperative care. I define severe stiffness as 0 degrees of external rotation and less than 30 degrees of abduction; moderate stiffness is defined as a decrease of 30 degrees in either plane compared with the contralateral shoulder. Although it is clinically significant to the patient, I do not consider loss of internal rotation in any plane an indication for arthroscopic release. One exception is throwing athletes; in these patients, posterior contracture and decreased internal rotation may be the only lesion. I discuss the management of this special group in Chapter 5. If stiffness persists, but pain has diminished after 6 months, I continue nonoperative care for an additional 2 months in case the decrease in pain indicates that the stiffness is about to resolve or ‘‘thaw’’ spontaneously. If there is no improvement in the range of motion 2 months later, I consider operation. I have found external rotation to be the most important predictor of success or failure of nonoperative treatment. If external rotation remains at neutral or worse 4 to 6 months after the start of nonoperative treatment, I do not recommend further nonoperative management and consider operation. In my opinion, the persistent loss of external rotation to such a degree indicates a stiff shoulder that will not respond to nonoperative care, making earlier operative intervention advisable.

Figure 6-5

Myositis ossificans.

joint release. Patients with mildly malunited fractures of the greater tuberosity or proximal humerus can be treated arthroscopically, but those with badly malunited fractures or internal fixation require open release, removal of hardware, and fracture osteotomy, as indicated (see Fig. 6-3). Patients in the inflammatory or contracting phase of idiopathic adhesive capsulitis should not undergo operation because the surgery may accelerate the contracture. I measure range of motion sequentially and wait until the motion has stabilized. Myositis ossificans is a contraindication to arthroscopic release (Fig. 6-5).

OPERATIVE TECHNIQUE Contracture Release

CONTRAINDICATIONS TO SURGERY Contraindications to arthroscopic treatment apply mainly to patients with postoperative and posttraumatic stiffness. Patients who have had instability surgery with subscapularis takedown or shortening may develop profound soft tissue contracture. The contracture in these patients is typically extraarticular between the subscapularis and the conjoined tendon. I can often identify adhesions between the subscapularis and the conjoined tendon when the arthroscope is placed in the lateral subacromial portal. If this area cannot be well visualized, open release may be a necessary addition to an arthroscopic glenohumeral

Examination under Anesthesia After the induction of anesthesia, examine both shoulders for range of motion in elevation, abduction, and external rotation in adduction. Place the shoulder in maximal abduction, and record internal and external rotation.

Manipulation I attempt gentle closed manipulation (Figs. 6-6 through 6-11). It is difficult to quantify gentle, but I apply only a small amount of force to the shoulder in elevation and then in abduction. If the shoulder

Chapter 6

Figure 6-6

Elevation.

Figure 6-8



Stiffness

External rotation.

responds to closed manipulation, it should move with minimal force. If I think that motion is improving with abduction and elevation, only then do I attempt to externally rotate the shoulder. I externally rotate the shoulder in maximal abduction and then in adduction. If motion continues to improve, I begin internal rotation stretching—first internally rotating the shoulder in maximal abduction and, if the motion improves, then stretching the shoulder in cross-body adduction and finally behind-the-back internal rotation. The specific order of motion is important because external rotation and internal

Figure 6-7

Abduction.

Figure 6-9

External rotation of 90 degrees.

Figure 6-10

Internal rotation of 90 degrees.

179

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Glenohumeral Joint Surgery

Superior Superior entry

Inferior entry

Inferior

Figure 6-12 Location of joint entry. Figure 6-11

Adduction.

rotation involve torsion stresses and may cause a spiral fracture to the humerus. If the shoulder does not respond to abduction and elevation, I do not attempt any rotational movements and proceed directly to arthroscopy. If the shoulder responds to manipulation but full movement is not achieved, I perform arthroscopy and release the remaining adhesions. If full range of motion is obtained after manipulation, I insert the arthroscope and confirm that the capsule is completely released. I have observed a number of shoulders with full range of motion after manipulation but with persistent capsular contracture; in these cases, the manipulation released only the extra-articular adhesions.

Joint Entry Entry into the stiff shoulder is always difficult because, by definition, the joint volume is reduced. Forceful entry may damage the articular surfaces of either the glenoid or the humeral head. The joint is difficult to enter with a spinal needle because of the tight, thickened posterior capsule; in addition, the generalized capsular stiffness limits the amount of fluid that can be injected. I have had better success with a standard metal cannula and a rounded trocar, which are larger and stiffer than a spinal needle. With these instruments, I can palpate the posterior glenohumeral joint line with greater ease. The entry position is critical. Joint entry through the traditional soft spot (at the level of the glenoid equator) increases the risk of cartilage surface damage. At this level, the glenohumeral joint

space is narrowest, making trocar entry difficult. I prefer to enter the joint superiorly, in an area bounded by the superior glenoid, the rotator cuff, and the humeral head, where the joint space is wider (Fig. 6-12). I incise the skin and insert the cannula and trocar until I can palpate bone. I then rotate the shoulder internally and externally to determine whether the trocar tip rests on the humeral head (movement detected) or glenoid (no movement). I lower my hand (and elevate the trocar tip) until I can palpate the superior glenoid rim. Only then do I attempt to enter the joint. If I cannot clearly palpate the interval between the humeral head and the glenoid, a plastic cannula and trocar may allow more forceful joint entry with a decreased risk of bone damage (Fig. 6-13). Once the arthroscope is in the glenohumeral joint, it is directed at the rotator interval. I insert a spinal needle anteriorly, lateral to the coracoid process, until I can see the needle enter the joint. I incise the skin and insert a plastic 5-mm cannula and trocar.

Rotator Interval The first step in the operation is to release the rotator interval (Figs. 6-14 and 6-15). I use a motorized soft tissue resector to do so. Insert the resector through the cannula into the joint; then back the cannula out of the joint, leaving the resector tip in the rotator interval. Soft tissue is excised from an area bounded by the biceps tendon medially, the superior border of the subscapularis tendon inferiorly, and the

Chapter 6

Figure 6-15



Stiffness

181

Synovitis of the rotator interval.

humeral head is properly located. If full range of motion is not achieved, or if motion has improved but the capsule is not completely divided, go to the next step. Figure 6-13

Palpate the bone to determine the entry point.

humeral head laterally. The coracoacromial ligament should be clearly visible as a shiny structure at the anterior border of the acromion. Reinsert the cannula into the joint and remove the resector. Withdraw the arthroscope from the posterior cannula in the joint, leaving the cannula in place, and attempt a closed manipulation as described earlier. If full range of motion is obtained, reinsert the arthroscope posteriorly and verify that the capsule is divided and that the

Figure 6-14 Contracted rotator interval.

Anterior Capsule Identify the point where the middle glenohumeral ligament crosses the subscapularis tendon. It is important to separate the subscapularis tendon from the middle glenohumeral ligament. I find electrocautery helpful to gradually divide the fibers of the middle glenohumeral ligament until the tendinous portion of the superior subscapularis is visualized. I then insert a blunt dissector anterior to the middle glenohumeral ligament to separate the two structures. I use a Harryman soft tissue punch (Smith-Nephew Endoscopy, Andover, Mass) to remove a 5- to 10-mm strip of anterior capsule. This includes the middle glenohumeral ligament and the superior portion of the anterior-inferior glenohumeral ligament. Electrocautery can also be used for this portion of the procedure (Figs. 6-16 through 6-22). I always use a blunt dissector to release any adhesions anterior and posterior to the subscapularis (Figs. 6-23 and 6-24). No harm is done if the surgeon resects the superior tendinous border of the subscapularis, particularly in the area of the coracohumeral ligament. Usually a small amount of increased lateral humeral head displacement is possible. I then advance the arthroscope anteriorly and inferiorly so that I have a better view of the posterior portion of the anteriorinferior glenohumeral ligament and the inferior capsule. I advance the punch, placing the bottom,

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Glenohumeral Joint Surgery

Figure 6-16

Contracted anterior capsule.

Figure 6-18 Divide the superior portion of the middle glenohumeral ligament.

blunt jaw exterior to the capsule, and divide the capsule from anterior to posterior as far from the glenoid labrum as possible (Figs. 6-25 through 6-32). The level at which I stop the inferior-anterior release depends on the amount of axillary pouch contracture. A tight pouch limits the degree to which I can safely advance the punch without applying excessive distraction to the glenohumeral joint. This is usually at about the 5-o’clock position for a right shoulder. To access and safely release the axillary pouch, I treat the posterior and inferior-posterior areas of the capsule. I keep the punch and capsular resection adjacent to the glenoid and try to maintain Figure 6-19 Cauterize the middle glenohumeral ligament covering the subscapularis.

Identify the superior portion of the middle glenohumeral ligament.

Figure 6-17

Figure 6-20 Cauterize the middle glenohumeral ligament covering the subscapularis.

Chapter 6

Figure 6-21 Cauterize the middle glenohumeral ligament covering the subscapularis.



Stiffness

183

Figure 6-23

Blunt dissector anterior to the subscapularis.

Figure 6-24

Blunt dissector posterior to the subscapularis.

the arm in slight abduction and external rotation to protect the axillary nerve. I remove the soft tissue punch and cannula from the anterior portal and insert a metal cannula and trocar in their place. I remove the arthroscope from the posterior portal and insert it anteriorly. Under direct vision, I insert the small plastic cannula and trocar posteriorly. The glenohumeral joint is usually too contracted to allow the insertion of a larger-diameter cannula. I insert a motorized shaver and resect 5 to 10 mm of posterior capsule, beginning superiorly and moving inferiorly. Once I have resected the posterior capsule, I can easily insert a large-diameter

Figure 6-22 Cauterize the middle glenohumeral ligament covering the subscapularis.

Figure 6-25

Contracted inferior capsule.

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Section Two

Figure 6-26



Glenohumeral Joint Surgery

Capsular punch in the anterior-inferior capsule.

Figure 6-29

Complete the posterior capsule resection with

a punch.

cannula that will accommodate the capsular resection punch. I insert the punch and resect a 10-mm strip of the posterior-inferior capsule 5 to 10 mm from the glenoid labrum to avoid any damage to it. The last step in the intra-articular portion of the procedure is complete release of the inferior capsule. Often, surgical division is not necessary because the last portion of the capsule can be released through manipulation. The use of manipulation avoids the placement of instruments near the axillary nerve. After I manipulate the shoulder, I insert the arthroscope to inspect the gap between the resected Figure 6-27

Shaver resecting the posterior capsule.

Return the arthroscope to the posterior portal and complete the inferior capsule resection.

Figure 6-30 Figure 6-28

Insert the large cannula posteriorly.

Chapter 6

Figure 6-33 Figure 6-31



Stiffness

185

Remove subacromial adhesions, if present.

Inferior capsule resection.

edges of the capsule and to confirm that the humeral head is normally located. If I cannot gain full range of motion with manipulation, I insert the arthroscope posteriorly and the cannula and punch anteriorly and resect the inferior capsule.

cuff or coracoacromial ligament fraying. By definition, a patient with adhesive capsulitis cannot move his or her shoulder into the positions consistent with the clinical diagnosis of impingement. The raw acromial bone surface produced after acromioplasty creates the opportunity for postoperative adhesions and should be avoided.

Subacromial Space I introduce the arthroscope into the subacromial space. If the subacromial space is not clearly seen, I insert a motorized soft tissue resector and remove bursa and adhesions (Fig. 6-33). I do not advise an acromioplasty even if there is arthroscopic evidence of impingement, such as rotator

Figure 6-32

Inferior capsule resection.

POSTOPERATIVE CARE I use pharmacologic techniques to reduce postoperative inflammation and adhesion formation. After I confirm the diagnosis of capsular contracture arthroscopically, but before I begin soft tissue resection, the anesthesiologist gives the patient 100 mg hydrocortisone sodium succinate intravenously. I do not use intra-articular cortisone at the conclusion of the procedure because operative resection of the capsule causes the steroid to extravasate and lose its effectiveness. In patients with post-traumatic or postsurgical stiffness and subacromial adhesions requiring release, I inject 100 mg hydrocortisone sodium succinate (Solu-Cortef) into the subacromial space at the conclusion of the operation. Postoperatively, I place the patient on a methylprednisolone (Medrol) Dosepak. I do not use steroids in diabetic patients. I admit patients to the hospital overnight. I do not place the arm in a sling or immobilizer. A pillow is placed under the axilla to keep the arm away from the chest, and the patient and nursing staff are encouraged to avoid placing the patient’s arm in internal rotation. Beginning on the afternoon of surgery, I use a continuous passive motion chair to maintain the full range of motion gained at surgery. I find it extremely helpful

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to visit the patient on the afternoon of surgery and demonstrate that he or she now has full range of motion. This is easily done because the patient’s shoulder is still anesthetized from the interscalene block. This visual demonstration of full movement impresses on the patient that the operation was successful. I emphasize that complete recovery depends on adherence to the postoperative rehabilitation program. Upon discharge from the hospital, the patient uses the continuous passive motion chair four times a day for 1 hour each session. This continues for 2 weeks. I then see the patient in the clinic, and if movement is satisfactory, chair use is discontinued. Passive elevation while supine and external rotation with the aid of a dowel or pulley are continued. The patient is encouraged to use the arm for all activities and motions that are comfortable. I see the patient again at 6 weeks, 3 months, and 6 months after surgery. If the patient has not achieved full range of motion by 3 months, I offer a repeat contracture release. At this point, however, usually only a gentle closed manipulation is necessary.

BIBLIOGRAPHY Berghs BM, Sole-Molins X, Bunker TD: Arthroscopic release of adhesive capsulitis. J Shoulder Elbow Surg 13: 180-185, 2004. Buchbinder R, Green S, Youd JM: Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev (online) 1:CD004016, 2003. Buchbinder R, Green S, Youd JM, Johnston RV: Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev (online) 4:CD006189, 2006. Ponti A, Vigano` MG, Taverna E, Sansone V: Adhesive capsulitis of the shoulder in human immunodeficiency virus-positive patients during highly active antiretroviral therapy. J Shoulder Elbow Surg 15:188-190, 2006. Diwan DB, Murrell GA: An evaluation of the effects of the extent of capsular release and of postoperative therapy on the temporal outcomes of adhesive capsulitis. Arthroscopy 21:1105-1113, 2005. Green S, Buchbinder R, Hetrick S: Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev (online) 2:CD004258, 2003. Green S, Buchbinder R, Hetrick S: Acupuncture for shoulder pain. Cochrane Database Syst Rev (online) 2:CD005319, 2005. Griggs SM, Ahn A, Green A: Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 82:1398-1407, 2000. Harryman DT II: Shoulders: Frozen and stiff. Instr Course Lect 42:247-257, 1993.

Harryman DT II: Arthroscopic management of shoulder stiffness. Oper Tech Sports Med 5:264-274, 1997. Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 13:133-147, 1997. Harzy T, Benbouazza K, Amine B, et al: Idiopathic hypoparathyroidism and adhesive capsulitis of the shoulder in two first-degree relatives. Rev Rhum 71:234-236, 2004. Ide J, Takagi K: Early and long-term results of arthroscopic treatment for shoulder stiffness. J Shoulder Elbow Surg 13:174-179, 2004. Jerosch J, Filler TJ, Peuker ET: Which joint position puts the axillary nerve at lowest risk when performing arthroscopic capsular release in patients with adhesive capsulitis of the shoulder? Knee Surg Sports Traumatol Arthrosc 10:126-129, 2002. Levine WN, Kashyap CP, Bak SF, et al: Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg 16:569-573, 2007. Loew M, Heichel TO, Lehner B: Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg 14:16-21, 2005. Mullett H, Byrne D, Colville J: Adhesive capsulitis: Human fibroblast response to shoulder joint aspirate from patients with stage II disease. J Shoulder Elbow Surg 16:290-294, 2007. Ogilvie-Harris DJ, Myerthall S: The diabetic frozen shoulder: Arthroscopic release. Arthroscopy 13:1-8, 1997. Quraishi NA, Johnston P, Bayer J, et al: Thawing the frozen shoulder: A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br 89:1197-1200, 2007. Richards DP, Glogau AI, Schwartz M, Harn J: Relation between adhesive capsulitis and acromial morphology. Arthroscopy 20:614-619, 2004. Scarlat MM, Harryman DT II: Management of the diabetic stiff shoulder. Instr Course Lect 49:283-293, 2000. Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am 74:738-746, 1992. Warner JJP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg 5:130-140, 1997. Warner JJP, Answorth A, Marks PH, Wong P: Arthroscopic release for chronic refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am 78:1808-1816, 1996. Warner JJP, Greis PE: The treatment of stiffness of the shoulder after repair of the rotator cuff. J Bone Joint Surg Am 79:1260-1269, 1997. Warner JJP, Goitz JJ, Groff YJl: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 79:1151-1158, 1997. Wolf JM, Green A: Influence of comorbidity on self-assessment instrument scores of patients with idiopathic adhesive capsulitis. J Bone Joint Surg Am 84:1167-1173, 2002. Yamaguchi K, Sethi N, Bauer GS: Postoperative pain control following arthroscopic release of adhesive capsulitis: A short-term retrospective review study of the use of an intra-articular pain catheter. Arthroscopy 18:359-365, 2002.

CHAPTER

7

Arthrosis

Arthroscopic treatment of glenohumeral arthrosis is a controversial subject with little scientific evidence to guide orthopedic surgeons. At present, the surgical options are limited, but with increased knowledge and technology, this will inevitably change. Surgeons encounter diverse lesions, including minor areas of chondromalacia in patients with glenohumeral instability, loose bodies in osteochondromatosis, areas of full-thickness cartilage loss, and osteophytes in patients with avascular necrosis, rheumatoid arthritis, or osteoarthrosis.

DIAGNOSIS The diagnosis of osteoarthrosis, rheumatoid arthritis, or avascular necrosis is made clinically with a combination of patient history, physical examination, laboratory tests, and plain radiographs. I do not use arthroscopy to evaluate the glenohumeral joint and stage the disease. There are situations in which cartilage lesions are unsuspected, and I find them during arthroscopic treatment for impingement, rotator cuff tear, or glenohumeral instability. These unsuspected lesions are usually small, and treatment is directed at removing loose bodies and de´briding unstable cartilage flaps. The role of microfracture and marrow stimulation is unproved at this time.

response and physical therapy to maintain or improve shoulder range of motion and strength.

INDICATIONS FOR SURGERY Surgical indications vary with the underlying disease process. Arthroscopic synovectomy may be beneficial in the treatment of early rheumatoid arthritis. Synovectomy may retard the disease process and produce results similar to those seen in the rheumatoid knee, elbow, and wrist (Fig. 7-1). The earliest stage of avascular necrosis may be amenable to arthroscopic de´bridement and humeral head drilling. Before subchondral and articular surface collapse (stage 1 and early stage 2 disease), core decompression may produce outcomes similar to those

NONOPERATIVE TREATMENT Nonoperative treatment is largely palliative and consists of medication to diminish the inflammatory

Figure 7-1

Rheumatoid arthritis.

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Figure 7-2

Avascular necrosis. Figure 7-4

in the hip. The potential for success may be greater than in the hip because the glenohumeral joint is non—weight bearing (Fig. 7-2). De´bridement of cartilage flap tears may help a patient with chondromalacia whose symptoms are caused by mechanical locking and catching (Figs. 7-3 through 7-5). Loose bodies in osteochondromatosis may cause mechanical symptoms, and pain relief can be substantial following their removal. The surgeon should carefully inspect the subcoracoid space and the bicipital sheath, where loose bodies may be overlooked. The biceps sheath should be inspected distally to the level of the pectoralis major tendon insertion. Osteoarthrosis is probably the most common clinical cause of glenohumeral incongruity seen in the

Figure 7-3

De´bridement of cartilage fragments.

De´bridement of a cartilage lesion.

office. The source of pain in osteoarthrosis is multifactorial and consists of joint surface irregularity, mechanical disturbances from loose or displaced labrum fragments, loose bodies, and joint contracture (Figs. 7-6 through 7-9). Arthroscopic lavage reportedly achieves temporary, limited pain relief owing to either the placebo effect or alterations in the chemical composition of the glenohumeral joint fluid. Patients return to their baseline states relatively quickly, however, and I do not perform or advise such procedures. If a surgeon wishes to treat a patient with glenohumeral arthrosis arthroscopically, the approach must be comprehensive and include removal of loose bodies and labrum fragments, release of soft tissue contracture, and restoration of joint surface congruity, including de´bridement of glenoid and humeral head osteophytes if necessary.

Figure 7-5

Glenoid cartilage defect.

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Joint contracture Capsule Coracohumeral lig.

Surface irregularity Loose bodies

Mechanical Labrum fragments

Figure 7-9

Figure 7-6

Osteoarthrosis.

Sources of pain in osteoarthrosis.

Unless the surgeon is capable of dealing with all these elements, an arthroscopic approach is unwarranted. The surgeon must also carefully explain the investigational nature of the procedure to the patient. Within these confines, the indications for arthroscopic treatment are lmited.

CONTRAINDICATIONS TO SURGERY

Figure 7-7

Loose bodies.

Contraindications to the arthroscopic treatment of arthrosis also vary with the underlying disease process. Synovectomy does not benefit a patient with articular incongruity. Core decompression cannot be expected to reverse bone collapse. De´bridement of a small labrum tear will not help a patient with osteoarthrosis. I have treated many patients with pain and stiffness from osteoarthritis who have undergone manipulation—an approach that should be abandoned. Orthopedic surgeons must appreciate that although idiopathic adhesive capsulitis and osteoarthritis both produce pain and decreased range of motion, they have different causes and require different treatments. Arthrosis patients have capsular contractures, as do patients with adhesive capsulitis, but extra-articular adhesions and articular incongruity are important additional causes of their shoulder stiffness.

CHONDRAL LESIONS

Figure 7-8

Osteoarthrosis at arthroscopy.

My approach is conservative for chondral lesions. I remove loose pieces and flap tears but do not drill or microfracture the bone surface. I gently abrade areas of cortical bone.

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OSTEOARTHRITIS Glenohumeral Joint Arthrosis Microfracture After the administration of anesthesia, I examine the shoulder for range of motion but do not attempt a closed manipulation. I establish standard posterior and anterior portals and perform a complete glenohumeral joint inspection, observing in particular the presence and extent of cartilage loss, labrum flap tears, rotator cuff fraying or tearing, and capsular contracture. Entry into the glenohumeral joint is always difficult owing to the loss of joint space from absent articular cartilage and soft tissue contracture. I insert the posterior cannula and trocar first and place the entry point more superior than normal, just inferior to the posterior acromion and about 2 cm medial to the posterolateral corner of the acromion. The superior portal allows easier access to the glenohumeral joint at the level of the superior glenoid, so the trocar does not have to enter the joint between the humeral head and glenoid (Fig. 7-10). If the glenohumeral joint is particularly tight, I enter the joint with a plastic cannula and trocar so as not to penetrate the scapula or the humeral head. I prefer a plastic cannula and trocar to minimize articular damage, but often the capsule is so thick that the plastic trocar cannot penetrate it. The anterior capsule is also difficult to penetrate, and it is sometimes necessary to use only the metal trocar (without the cannula) to create an entrance to the glenohumeral

Figure 7-11

Rotator interval de´bridement.

joint. I use a standard shaver to de´bride the rotator interval and any labrum tears (Fig. 7-11). I then perform a complete capsule release anteriorly, posteriorly, and inferiorly. I pay particular attention to the subscapularis because my experience with shoulder arthroplasty has convinced me how critical it is to restore subscapularis muscle excursion. The middle glenohumeral ligament is adherent to the posterior (articular) surface of the subscapularis, and I use cautery to identify the plane between the two structures (Fig. 7-12). A scissors is useful to divide firm bands of scar tissue. I then use a blunt dissector to sweep any adhesions off the subscapularis muscle. The next step is to release adhesions from the anterior surface of the subscapularis, for which the blunt dissector is particularly useful (Fig. 7-13).

Superior Superior entry

Inferior entry

Inferior

Figure 7-10 There is more space for the trocar at the superior aspect of the glenohumeral joint.

Cautery to define the plane between the subscapularis and middle glenohumeral ligament.

Figure 7-12

Chapter 7

Soft tissue dissection anterior and posterior to the subscapularis.

Figure 7-13

The anterior and posterior capsule releases are similar to those I perform for adhesive capsulitis, but the inferior release is different. With adhesive capsulitis, the inferior capsule can often be released by shoulder manipulation after the division of the anterior and posterior capsule. Patients with arthrosis have an extremely thick inferior capsule, however, and such an approach is not successful. The inferior capsule must be divided with a capsular resector. This requires the surgeon to release the anterior-inferior capsule from an anterior approach and the posterior-inferior capsule from a posterior approach (Figs. 7-14 through 7-16). The third area of subscapularis release involves the connections between the subscapularis and the coracoid. This portion of the operation is performed with the

Figure 7-14

Anterior-inferior capsule release.

Figure 7-15



Arthrosis

191

Inferior-posterior capsule release.

arthroscope in the glenohumeral joint after the rotator interval has been opened. The coracohumeral ligament is thick and contracted, limiting subscapularis excursion. This area is not normally seen during routine glenohumeral joint arthroscopy but can be visualized arthroscopically with the technique described later. After I excise the contracted tissue, open the rotator interval, and remove adhesions from the anterior and posterior surfaces of the subscapularis, the coracoid process comes into view. With a scissors or blunt dissector I release any connections between the superior surface of the subscapularis and the coracoid (Fig. 7-17). This completes the soft tissue release. Next, I turn my attention to the bone surfaces of the glenoid and the humeral head.

Figure 7-16 Posterior capsule release.

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Figure 7-17 Coracohumeral ligament release. Figure 7-18 Bur in the posterior portal as viewed from the anterior portal.

The degree and type of glenoid wear can be seen on preoperative imaging studies. There are two types of glenoid abnormalities that are amenable to arthroscopic treatment. The first occurs when the glenoid conforms to the humeral head but the space is diminished. My goal is to increase the space between the two structures. In the second type of glenoid abnormality, there is posterior glenoid erosion or a step-off, usually resulting from chronic anterior contracture and posterior humeral head subluxation. I inspect the radiographs to determine both glenohumeral congruency and glenoid bone stock. To create more space between the humeral head and a conforming glenoid, I place the arthroscope posteriorly and the round bur through the anterior cannula. I begin removing bone 10 mm from the superior glenoid and remove a 1-mm strip from anterior to posterior. I then remove bone from that strip to the superior glenoid margin, taking care not to damage the biceps-labrum anchor. I complete the glenoid bone removal by leveling the glenoid from superior to inferior. It is usually necessary at some point to move the arthroscope anteriorly and the bur posteriorly to reach all areas of the glenoid and create a level surface. Matsen introduced the phrase ream and run for such treatment when he inserts a prosthetic hemiarthroplasty (Fig. 7-18). To form a conforming glenoid surface when there is a posterior step-off, I follow the same general technique as just described, beginning with the arthroscope in the posterior cannula and the power bur in the anterior cannula. I then remove the anterior surface from superior to inferior to eliminate the step-off and create a smooth, uniform surface (Figs. 7-19 through 7-23).

After operation, patients begin continuous passive motion in a motorized chair. They undergo 1-hour sessions in the chair four times a day for 2 weeks. During this time, active range of motion and activities are encouraged as much as pain allows. I continue to

A Remnant cartilage being abraded

Bone to be abraded

B Figure 7-19

abrasion.

A and B, Posterior step-off and area of bone

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A A

C

B Figure 7-20 A and B, Area of bone abrasion.

B Figure 7-22

A-C, Abrasion arthroplasty.

emphasize range of motion at each patient visit and start strengthening when manual muscle testing is painless. To monitor disease progression, plain anteroposterior and axillary radiographs are obtained every 3 months for the first year, every 6 months for the next year, and then yearly.

A Area to be abraded 2 mm

B Figure 7-21

Depth of bone abrasion.

Figure 7-23

A and B, Completed abrasion arthroplasty.

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The results in this carefully selected and counseled group of patients are preliminary, but so far, they have been gratifying. Approximately 50% report satisfaction with the procedure and experience a significant decrease in pain and an increase in motion and function. It is unknown whether the bone removal will compromise glenohumeral joint integrity to such an extent that humeral head medialization will occur. This has been reported by some surgeons. New approaches to arthritis in young patients are being developed and revolve around the interposition of material between the humeral head and the glenoid. These materials are either biologic (fascia lata and meniscal allograft) or synthetic (biologic ingrowth materials). Both types have vocal champions, but little science and experience are available to guide orthopedic surgeons. My technique for inserting the interposition is described in the steps described in the box. Joe de Beer has the largest experience with this type of operation.

RHEUMATOID ARTHRITIS As in other joints, synovectomy of the rheumatoid shoulder is most beneficial when carried out early in the disease process, before cartilage and bone have been destroyed and the rotator cuff eroded. The patient is staged according to the Steinbrocker radiographic and functional classification (Table 7-1). Subsequent patient evaluation allows the surgeon to reassess the disease progression. Patients in radiographic stages I and II and functional classes I and II have the best chance of benefiting from arthroscopic synovectomy and de´bridement. I enter the glenohumeral joint through a standard posterior portal and establish an anterior-inferior and then an anterior-superior cannula. Because of the bleeding that often occurs with rheumatoid synovectomy, the anterior-superior cannula is helpful for outflow. A pump is essential. I use a grasping forceps to remove large pieces of loose cartilage or soft tissue and a motorized resector to de´bride labrum flap tears.

Arthroscopic Graft Jacket Placement Graft Preparation  Follow the manufacturer’s directions for hydrating the graft (which may require up to 30 minutes).  Secure the graft jacket (after hydration) to the SMH Graft-Jacket Racket using No. 1 Ethibond sutures. (The appropriate graft jacket size is determined at the initial arthroscopy.)

Procedure Protocol                  

Position the patient in the beach-chair position. Prepare and drape the patient for a routine shoulder arthroscopy. Affix the Tornier proximal humeral fracture jig to the patient’s arm using a Coban-type wrap. Fix the Graft-Jacket Racket to the fracture jig, and position the device anterior and inferior to the shoulder. Perform a diagnostic arthroscopy from the posterior portal. Establish an anterior-inferior portal using a 10-mm cannula. Measure the size of the glenoid using the calibrated probe. (The hydrated graft jacket can now be cut to size and secured to the holder.) Open the rotator interval using a motorized shaver. Perform an abrasion arthroplasty of the glenoid surface with a round bur through the anterior portal. Insert a metal cannula into the anterior-superior position. Remove the arthroscope from the posterior cannula and insert it into the anterior-superior cannula to visualize the posterior-inferior glenoid. Complete the abrasion arthroplasty of the posterior-inferior glenoid with the small bur through the posterior portal. Insert a spinal needle percutaneously from the lateral position into the glenohumeral joint and through the supraspinatus tendon under arthroscopic visualization. Remove the needle, incise the skin, and insert a metal cannula and trocar into the joint. The arthroscope is now moved to this ‘‘trans-cuff’’ portal for visualization of the anterior and posterior glenoid. Remove the metal cannula and insert an 8-mm cannula into the anterior-superior portal. Insert an orange 5-mm cannula into the posterior portal. Insert a double-loaded bioabsorbable suture anchor through an accessory posterior-inferior portal (localized with a spinal needle) into the glenoid at the posterior-inferior quadrant (7-o’clock position on a right shoulder, and 5 o’clock on a left).

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Suture Passing                               

Use a crochet hook to pull the most inferior white suture out the anterior-inferior cannula. Pass the suture through the graft jacket at the corresponding position using a suture passer. Pull one limb of green suture through the anterior-inferior cannula. Pass this suture through the graft just superior and medial to the white strand using the Elite Pass. Tie a knot in the green suture, securing it to the graft jacket. Use a crochet hook to pull the superior white suture limb out the anterior-inferior cannula. Pass the strand through the graft using the Elite Pass. Secure the two white suture strands using a hemostat. The remaining strand of green suture should not be passed and should exit through the accessory portal. Insert a second double-loaded suture anchor in the posterior-superior quadrant (10 o’clock on a right shoulder, and 2 o’clock on a left) through an accessory portal (localized with a spinal needle) and repeat the previous nine steps. Insert a third suture anchor into the glenoid at the 12-o’clock position. Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula. Pass the suture through the graft jacket using the Elite Pass at the corresponding position. Pull one limb of green suture out the anterior-inferior cannula. Pass the suture through the graft inferior and medial to the previously passed white strand. Tie a knot in the green suture, securing it to the graft jacket. Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula. Pass the suture through the graft using the Elite Pass. Secure the white strands together using a hemostat. Pull the remaining green suture strand out the anterior-inferior cannula. Insert a fourth anchor into the anterior-superior quadrant of the glenoid (5 o’clock on a right shoulder, and 10 o’clock on a left) and repeat the previous nine steps. Insert a fifth anchor into the anterior-inferior quadrant of the glenoid (5 o’clock on a right shoulder, and 7 o’clock on a left). Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula. Pass the suture through the graft jacket using the Elite Pass at the corresponding position. Pull one limb of green suture out the anterior-inferior cannula. Pass the suture through the graft inferior and medial to the previously passed white strand. Tie a knot in the green suture, securing it to the graft jacket. Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula. Pass the suture through the graft using the Elite Pass. Secure the white strands together using a hemostat. Allow the remaining green suture to stay within the anterior-superior cannula.

Preparing to Insert the Graft Jacket     

Pass all sutures through the graft and secure with hemostats. Remove the diaphragm from the anterior-superior cannula. Roll the graft jacket into a cylinder from superior to inferior. Keep all white sutures taut while passing the graft. Use a grasper to ‘‘push’’ the graft through the 10-mm cannula, and use the posterior green sutures exiting the accessory portals as traction sutures to ‘‘pull’’ the graft into the joint.  Once the graft enters the joint, pull the anterior green sutures taut to flatten the graft.

Tying the Posterior-Inferior Sutures  Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the posterior-inferior accessory portal.  Tie the white sutures using arthroscopic square knots and cut.  Cut the green suture at the level of the graft.

Tying the Posterior-Superior Sutures  Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the posterior-superior accessory portal.  Tie the white sutures using arthroscopic square knots and cut.  Cut the green suture at the level of the graft.

Continued

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Arthroscopic Graft Jacket Placement—cont’d Tying the Superior (12 o’clock) Suture    

Use a loop grasper to pull the white sutures out through the anterior-superior cannula. Pass the loop grasper a second time to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Tying the Anterior-Superior Sutures    

Use a loop grasper to pull the white sutures out through the anterior-superior cannula. Pass the loop grasper a second time to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Tying the Anterior-Inferior Sutures    

Allow the sutures to remain in the anterior-inferior cannula. Use a loop grasper to ensure the sutures are not crossed. Tie the white sutures using arthroscopic square knots and cut. Cut the green suture at the level of the graft.

Completing the Procedure  Remove the arthroscope.  Close the portals using 3-0 Monocryl sutures.  Apply sterile dressing.

Because the synovium is vascular, I prefer to use the thermal coagulation probe to ‘‘paint’’ all areas of proliferative synovitis before resection (Fig. 7-24). The whisker resector allows me to perform a thorough synovectomy without violating the glenohumeral joint capsule (Fig. 7-25). The Electroblade shaver, with its built-in cautery system, is extremely valuable in these situations. I prefer to start the synovectomy inferiorly and move to the anterior and then superior aspects of the joint. I move the arthroscope anteriorly and the resector posteriorly to complete the removal of soft tissue in the posterior-inferior and posterior regions. After carefully inspecting the subscapularis recess for additional synovitis or loose bodies, I remove the arthroscope and, through the same posterior incision, insert it into the subacromial space. Bursal proliferation is often profound. I remove the hypertrophic bursa and perform an arthroscopic subacromial decompression and acromioclavicular joint resection if indicated by clinical examination. Postoperative rehabilitation is identical to that described for the treatment of osteoarthritic glenohumeral joints.

AVASCULAR NECROSIS Arthroscopic treatment of avascular necrosis is limited to those individuals with stage 1 or early stage 2 disease, before any collapse has occurred. I place the guide pin from a hip compression set on the anterior shoulder and, with the use of fluoroscopic imaging, adjust the angle and direction of the pin until it is correctly positioned. I then mark the pin location on the lateral deltoid and incise the skin with a scalpel. To avoid injury to the axillary nerve, I use a hemostat to spread the deltoid fibers until I reach the lateral humeral cortex. A drill guide is placed into the wound until it rests on the humerus. I use biplane radiographic imaging to insert a guide pin in the center of the humeral head to within 3 mm of the articular surface. I place a cannulated drill over this and, under radiographic control, perform a single core decompression. Postoperatively, patients are allowed unlimited active and passive range of motion but no sports or heavy lifting for 3 months. I follow patients with serial radiographs or magnetic resonance imaging studies as needed.

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Table 7-1 STEINBROCKER RADIOGRAPHIC AND FUNCTIONAL CLASSIFICATION OF RHEUMATOID ARTHRITIS Radiographic Classification Stage I

No destructive change; osteoporosis and soft tissue change only

Stage II

Mild to moderate erosive change or joint space reduction

Stage III

Joint markedly narrowed (<1 mm); extensive erosion and subluxation

Stage IV

Fibrosis or bony ankylosis

Figure 7-25

Whisker resector.

Functional Classification Class I

Full function

Class II

Adequate function despite pain and limited motion

BIBLIOGRAPHY

Class III

Very limited function

Class IV

Wholly incapacitated

Baillon JM, Hutsebaut K: Place de l’arthroscopie dans l’osteonecrose de l’epaule. Acta Orthop Belg 65(Suppl 1):104, 1999. Bhatia DN, van Rooyem KS, du Toit DF, de Beer JF: Arthroscopic technique of interposition arthroplasty of the glenohumeral joint. Arthroscopy 22:570, 2006. Bishop JY, Flatow EL: Management of glenohumeral arthritis: A role for arthroscopy? Orthop Clin North Am 34:559-566, 2003. Cameron ML, Kocher MS, Briggs KK, et al: The prevalence of glenohumeral osteoarthrosis in unstable shoulders. Am J Sports Med 31:53-55, 2003. Clinton J, Franta AK, Lenters TR, et al: Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis. J Shoulder Elbow Surg 16:534-538, 2007. Hayes JM: Arthroscopic treatment of steroid induced osteonecrosis of the humeral head. Arthroscopy 5:218-221, 1989. L’Insalata JC, Pagnani MJ, Warren RF, Dines DM: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 5:355-361, 1996. Matsen FA, Bicknell RT, Lippitt SB: Shoulder arthroplasty: The socket perspective. J Shoulder Elbow Surg 16:S241S247, 2007. McCarty LP, Cole BJ: Nonarthroplasty treatment of glenohumeral cartilage lesions. Arthroscopy 21:1131-1142, 2005. Mont M, Maar DC, Urquhart MW, et al: Avascular necrosis of the humeral head treated by core decompression. J Bone Joint Surg Br 75:785-788, 1993. Nakagawa Y, Ueo T, Nakamura T: A novel surgical procedure for osteonecrosis of the humeral head: Reposition of the joint surface and bone engraftment. Arthroscopy 15:433-438, 1999.

Response Grade I

Complete remission

Grade II

Major improvement

Grade III Grade IV

Minor improvement No improvement or progression

Figure 7-24

Rheumatoid synovium.

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Parsons IM, Weldon EJ, Titelman RM, Smith KL: Glenohumeral arthritis and its management. Phys Med Rehabil Clin N Am 15:447-474, 2004. Pennington WT, Bartz BA: Arthroscopic glenoid resurfacing with meniscal allograft: A minimally invasive alternative for treating glenohumeral arthritis. Arthroscopy 21: 1517-1520, 2005. Scheibel M, Bartl C, Magosch P, et al: Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder. J Bone Joint Surg Br 86:991-997, 2004.

Siebold R, Lichtenberg S, Habermeyer P: Combination of microfracture and periosteal-flap for the treatment of focal full thickness articular cartilage lesions of the shoulder: A prospective study. Knee Surg Sports Traumatol Arthrosc 11:183-189, 2003. Sperling JW, Steinman SP, Cordasco FA, et al: Shoulder arthritis in the young adult: Arthroscopy to arthroplasty. Instr Course Lect 55:67-74, 2006. Weinstein DM, Bucchieri JS, Pollock RG, et al: Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 16:471-476, 2000.

CHAPTER

8

Periarticular Cysts

With the increased use of magnetic resonance imaging (MRI), we now diagnose more patients with periarticular shoulder cysts who are referred for care. It is unknown whether this represents a true increase in the incidence of cysts or merely reflects the sensitivity of MRI (Figs. 8-1 through 8-3).

LITERATURE REVIEW Surgeons agree that labrum tears result in cyst formation. The proposed cause is similar to wrist ganglions. It is postulated that a labrum tear allows joint fluid to leak and form an extra-articular accumulation. Communication between the glenohumeral joint and the cyst has been demonstrated, but there is no evidence for this proposed cause. Iannotti described his approach to cyst treatment, which consists of arthroscopic cyst decompression and labrum repair to treat patients with suprascapular neuropathy.

activity. Symptoms from a periarticular cyst may be the result of rotator cuff pathology, labrum pathology, or suprascapular nerve compression, or some combination. Labrum detachment may cause rotator cuff symptoms as a result of contact against the posteriorsuperior glenoid, and the patient may complain of posterior-superior shoulder pain while throwing or performing other activities that require the arm to be placed in abduction and external rotation (Fig. 8-4). Mechanical labrum symptoms include sensations of locking, catching, or popping. Pain may prevent full muscular contraction and can result in weakness during lifting. Pressure from the cyst on the suprascapular nerve can cause pain or a burning discomfort in the scapular or trapezius muscle region (Fig. 8-5).

DIAGNOSIS Patients present with shoulder pain or weakness, or both. These nonspecific symptoms do not point the examiner toward the diagnosis of a periarticular cyst. The surgeon should be suspicious when the findings are at odds with the typical presentation of patients with rotator cuff impingement or glenohumeral instability—for example, a patient younger than 40 years who presents with rotator cuff symptoms absent any significant trauma or any history of repetitive shoulder

Figure 8-1

Superior location, coronal view.

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Figure 8-4 Figure 8-2

SLAP lesion.

Transverse view.

Nerve compression can also result in weakness. This weakness may be difficult to detect because, over time, compensatory hypertrophy can develop in the teres minor muscle (Fig. 8-6). Although patients with advanced nerve compression may complain of weakness, in my experience, they usually present with more subtle findings. Suprascapular nerve compression initially causes mild weakness of the supraspinatus and infraspinatus. When patients perform overhead activities or movements, the weakened rotator cuff does not stabilize the humeral head adequately, and slight superior subluxation occurs. This results in complaints very similar to those accompanying subacromial impingement. None of these symptoms is diagnostic of a cyst, but they usually prompt the physician to order MRI. Rotator cuff

findings may be nonspecific or consistent with a partialthickness rotator cuff tear. Superior or posterior-superior labrumdetachmentisnoted.Acystisseenintheposteriorsuperior shoulder.Thesizecan bevariablebut istypically 1 to 2 cm in diameter. The cyst may or not be seen communicating with the labrum tear. The cyst may be juxta-articular or located more superiorly near the suprascapular notch. The surgeon should also be aware that the cyst may not be producing any symptoms at all and may be an incidental finding. Whenever rotator cuff symptoms occur in a patient younger than 50 years, the surgeon should order MRI with contrast enhancement; without contrast, the labrum lesion is not as easily seen.

A

B Periarticular cyst

Spinoglenoid ligament

C Figure 8-3

Posterior cyst.

D Figure 8-5

A-D, Suprascapular nerve compression.

Chapter 8

Atrophy of the supraspinatus and infraspinatus; hypertrophy of the teres minor.

Figure 8-6

NONOPERATIVE TREATMENT Treatment is directed at the underlying cause of the patient’s symptoms. I treat rotator cuff symptoms with selective rest, activity modification, nonsteroidal antiinflammatory medication, and a home rehabilitation program focused on stretching the posterior shoulder structures and strengthening the shoulder stabilizing muscles. Mechanical labrum symptoms may be the result of subtle glenohumeral instability, so I have patients focus on exercises to improve the shoulder stabilizers. If the cyst is located near the posterior-superior glenoid, I order electrodiagnostic testing to detect the presence or absence of suprascapular nerve involvement as well as provide information about the cyst’s extent and location. Abnormalities of both the supraspinatus and infraspinatus point to a proximal lesion, usually at the suprascapular notch. Abnormalities limited to the infraspinatus are consistent with a more distal lesion, often at the spinoglenoid ligament.

INDICATIONS FOR SURGERY For perilabral cysts without suprascapular nerve involvement, I recommend arthroscopic labrum repair and cyst decompression as the treatment of choice. The rationale of arthroscopic treatment is that the labrum tear allows the leakage of joint fluid extraarticularly, which forms the cyst. With labrum repair, the joint seal is reestablished, and the cyst will not re-form. Labrum repair also cures the pain caused by the labrum tear and the subsequent alteration in glenohumeral joint biomechanics. There is



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201

also anecdotal evidence that labrum repair without cyst decompression may be successful. A number of reports document disappearance of the cyst on MRI after labrum repair. Indications depend on the cyst location and associated conditions such as rotator cuff involvement and significant tearing of the labrum. The anatomic alterations within the glenohumeral joint are often aggravated by subtle glenohumeral instability, and a 3- to 6-month period of home rehabilitation to strengthen the shoulder stabilizers is advised before operation is considered. If the physical examination and electrodiagnostic testing indicate that the cyst is associated with nerve compression, the indications are different. In this situation, surgical intervention is considered more urgently, rather than after extensive rehabilitation. Suprascapular notch cysts are treated by arthroscopic suprascapular notch decompression followed by glenohumeral joint evaluation, cyst decompression, and labrum repair if needed. Infraspinatus involvement without supraspinatus involvement is consistent with a more distal lesion, in which case I decompress the nerve at the level of the spinoglenoid ligament.

Suprascapular Nerve Decompression at the Suprascapular Notch Suprascapular Nerve Decompression—Cadaver

OPERATIVE TECHNIQUE Suprascapular Nerve Decompression at the Suprascapular Notch (Lafosse Technique) The patient is placed in the sitting position, and the shoulder is prepared and draped routinely. I perform the nerve exploration and decompression before the glenohumeral joint surgery because any soft tissue swelling makes the nerve portion of the operation much more difficult. No arm traction is needed. The suprascapular nerve originates from the upper trunk of the brachial plexus and travels deep to the trapezius muscle. The suprascapular nerve passes deep to the suprascapular ligament, and the suprascapular artery normally (but not always) passes superficial to the ligament. The nerve divides just proximal to the notch. The medial branch continues on to supply the supraspinatus muscle, and the lateral

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Figure 8-7

Glenohumeral Joint Surgery

Lateral portal locations.

branch descends around the lateral margin of the scapular spine and passes deep to the spinoglenoid ligament at the spinoglenoid notch. I use five portals. The first is a standard posterior portal that I use to view the subacromial space. The second is a lateral portal located anterior to the midline of the aromion, and the third is placed anterior to the anterolateral acromial border. The fourth is located approximately 2 cm medial to the standard Neviaser portal. I establish the fourth portal near the end of the procedure under direct vision with an outside-in technique. The fifth portal is placed medial to the fourth portal. I insert a trocar through portal 5 to retract the nerve and then divide it with a Kerrison rongeur placed through portal 4 (Figs. 8-7 and 8-8). I introduce the arthroscope into the posterior portal and a shaver laterally. I excise bursa until I obtain a good view of the coracoacromial ligament and the anterior border of the supraspinatus muscle. I trace the coracoacromial ligament to the coracoid and identify the coracoid by palpating it with the tip of

Figure 8-8

Medial portal locations.

the shaver. I usually move the arthroscope to the lateral portal and use the instruments through either the posterior portal or the anterolateral portal. I then follow the coracoid to its base and identify the origin of the coracoclavicular ligaments. The trapezoid is identified most laterally, and the conoid is seen more medially. Just medial to the conoid ligament is the yellowish perineural fat. Electrocautery can be performed safely as long as it is kept superior, above the level of the supraspinatus muscle (and the transverse scapular ligament and suprascapular nerve). The lateral insertion of the suprascapular ligament can be seen just medial to the conoid ligament. I can normally view the suprascapular artery pulsating above the ligament. I then establish the fourth (medial) portal by palpating the area until I am directly over the notch; I insert a spinal needle to confirm that I have located the portal precisely. I then carefully incise only the skin (to avoid any superficial cutaneous nerve branches) and insert a blunt trocar. I dissect the soft tissue and fat away from the notch until I can clearly see the ligament and the nerve. I insert the trocar lateral to the nerve and retract the nerve medially. I make a small stab incision in the skin directly over the lateral portion of the ligament, insert a 1-mm Kerrison rongeur, and divide the ligament. I remove the rongeur and probe the notch to make sure the nerve is thoroughly decompressed and intact. If other lesions exist (e.g., labrum, biceps tendon, or rotator cuff tears), I enter the glenohumeral joint posteriorly and establish a routine anterior-inferior portal. The labrum tear is usually located in the superior or posterior-superior glenoid. I move the arthroscope to the anterior portal and carefully inspect the posterior-superior aspect of the rotator cuff for signs of damage. If a grade 2 or 3 lesion is found, I mark the area with a monofilament suture and (after labrum repair) inspect that area while viewing from the subacromial space. I perform a rotator cuff repair if there is also partial tearing on the bursa side. If the rotator cuff is normal, I proceed with the labrum repair. The details of the repair are identical to those described in Chapter 5. The cyst is usually located deep to the capsule and posterior to the biceps tendon. I remove this area with a power shaver until I can see the cyst. I remove the cyst with a power shaver and make no attempt to repair the superior joint capsule (Figs. 8-9 through 8-18). If the labrum is separated only slightly, I use a soft tissue chisel instrument to dissect underneath the labrum. In Iannotti’s experience, opening this area often leads directly to the cyst, and cystic fluid can be expressed into the joint.

Chapter 8

Figure 8-9



Periarticular Cysts

Chisel dissecting underneath the superior labrum. Figure 8-11

Suprascapular nerve below the supraspinatus

muscle.

There are often soft tissue connections between the superior glenohumeral joint capsule and the posteriorsuperior labrum. These may represent the pathway for synovial fluid to leak from the joint to the cyst. Some surgeons cauterize this area to obliterate the connection; others de´bride the area to open the connection and ‘‘decompress’’ the cyst. Until there is ample scientific evidence to guide treatment, surgeon preference is the deciding factor. I believe that labrum repair and cyst excision are the only intra-articular treatments required. I am concerned about thermal application and extensive soft tissue resection of the posterior-superior capsule owing to the proximity of the suprascapular nerve, which lies approximately 1 to 2 cm medial to the glenoid rim. I carefully de´bride any soft tissue connections but keep the shaver near the glenoid.

Figure 8-10

meral joint.

203

Figure 8-12

SLAP lesion.

Figure 8-13

SLAP repair.

Opening the cystic connection to the glenohu-

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Figure 8-14



Glenohumeral Joint Surgery

Suprascapular ligament above the needle.

Figure 8-17

Kerrison rongeur dividing the ligament.

Variations of Technique Other options for the treatment of an extra-articular cyst include open cyst excision and injection of cortisone into the cyst, usually under MRI guidance. The latter has been reported to cause cyst dissolution and may be performed pre- or postoperatively. Open cyst excision is associated with a higher morbidity than arthroscopic treatment.

Postoperative Care Postoperative care is identical to that for the superior labrum from anterior to posterior (SLAP) lesion repair described in Chapter 5. Repeat MRI and electrodiagnostic testing may be performed 3 months after operation. Figure 8-15

Suprascapular ligament below the needle.

Figure 8-16 Suprascapular nerve underneath the ligament.

Figure 8-18

Suprascapular nerve after ligament division.

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205

Suprascapular Nerve Decompression at the Spinoglenoid Ligament Suprascapular Nerve Decompression at the Spinoglenoid Ligament I use the standard sitting position and establish routine posterior and anterior portals. I view through the posterior portal and insert a spinal needle lateral to the acromion and angle it so that it enters the glenohumeral joint through the muscular (rather than the tendinous) portion of the supraspinatus. I move the arthroscope to the lateral, trans—rotator cuff portal and insert a power shaver through the posterior portal. I resect the glenohumeral joint capsule superior to the glenoid and posterior to the biceps-labrum junction. I remove enough capsule to visualize the fibers of the supraspinatus muscle. I then insert an elevator through the anterior portal and elevate the supraspinatus muscle from the supraspinatus fossa. This allows me to see the cyst, and I resect a portion of it with a power shaver. Once I have decompressed the cyst, I look for the nerve approximately 2.5 to 3 cm medial to the glenoid rim. It is located on the supraspinatus fossa and passes underneath the spinoglenoid ligament at the level of the scapular spine. I resect the ligament and then trace the nerve proximally and distally to verify that there are no other areas of nerve entrapment. I now use the technique described by Plancher (Figs. 8-19 and 8-20). I use two posterior incisions—one located 4 cm medial to the posterolateral acromion and a second 4 cm medial to the acromion. Through the more medial incision, I insert a soft tissue dissector to free the

Posterior portal locations to access the spinoglenoid notch.

Figure 8-19

Figure 8-20 Spinoglenoid ligament.

infraspinatus muscle from the scapula. I insert the arthroscope through the lateral incision. Often, a third incision placed more laterally is used to insert a scissors to divide the spinoglenoid ligament.

BIBLIOGRAPHY Antoniou J, Tae SK, Williams GR, et al: Suprascapular neuropathy: Variability in the diagnosis, treatment, and outcome. Clin Orthop Relat Res 386:131-138, 2001. Barwood SA, Burkhart SS, Lo IK: Arthroscopic suprascapular nerve release at the suprascapular notch in a cadaveric model: An anatomic approach. Arthroscopy 23:221-225, 2007. Bhatia DN, de Beer JF, van Rooyen KS, du Toit DF: Arthroscopic suprascapular nerve decompression at the suprascapular notch. Arthroscopy 22:1009-1013, 2006. Chochole MH, Senker W, Meznik C, Breitenseher MJ: Glenoid-labral cyst entrapping the suprascapular nerve: Dissolution after arthroscopic debridement of an extended SLAP lesion. Arthroscopy 13:753-755, 1997. Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 12:739-745, 1996. Lafosse L, Tomasi A, Corbett S, et al: Arthroscopic release of suprascapular nerve entrapment at the suprascapular notch: Technique and preliminary results. Arthroscopy 23:34-42, 2007. Levy P, Roger B, Tardieu M, et al: [Cystic compression of the suprascapular nerve: Value of imaging. Apropos of 6 cases and review of the literature]. J Radiol 78:123-130, 1997. Lichtenberg S, Magosch P, Habermeyer P: Compression of the suprascapular nerve by a ganglion cyst of the spinoglenoid notch: The arthroscopic solution. Knee Surg Sports Traumatol Arthrosc 12:72-79, 2004.

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Millett PJ, Barton RS, Pacheco IH, Gobezie R: Suprascapular nerve entrapment: Technique for arthroscopic release. Tech Shoulder Elbow Surg 7:89-94, 2006. Plancher KD, Luke TA, Peterson RK, Yacoubian SV: Posterior shoulder pain: A dynamic study of the spinoglenoid ligament and treatment with arthroscopic release of the scapular tunnel. Arthroscopy 23:991-998, 2007.

Westerheide KJ, Dopirak RM, Karzel RP, Snyder SJ: Suprascapular nerve palsy secondary to spinoglenoid cysts: Results of arthroscopic treatment. Arthroscopy 22:721-727, 2006. Youm T, Matthews PV, El Attrache NS: Treatment of patients with spinoglenoid cysts associated with superior labral tears without cyst aspiration, debridement, or excision. Arthroscopy 22:548-552, 2006.

CHAPTER

9

Sepsis

Glenohumeral joint sepsis is an unusual indication for shoulder arthroscopy. In my experience, the arthroscope has greatly facilitated the management of this difficult condition. Treatment goals include performing fluid cultures and tissue biopsies to identify the infecting organism or organisms and determining the extent of tissue involvement, followed by joint irrigation and de´bridement in a manner that minimizes morbidity and allows early functional recovery. Serial needle aspirations cannot remove all joint debris or reach all loculations and infected clots. Arthrotomy enables thorough irrigation and de´bridement, but with increased soft tissue injury compared with arthroscopic treatment.

LITERATURE REVIEW Most series on sepsis in various joints report the incidence of shoulder involvement as 3% to 12%. The most common organisms isolated are Staphylococcus aureus (61%) and Staphylococcus epidermidis (17%), but polymicrobial infections are frequent (67%). In his series, Gelberman noted that all patients had significant underlying medical conditions such as alcoholism, liver disease, malignancy, heroin addiction, or renal failure. Patients with acquired immunodeficiency syndrome (AIDS) and patients who have undergone shoulder replacement may also present with septic shoulders. The rise of methicillin-resistant S. aureus (MRSA) and Propionibacterium acnes is of concern. The latter is very difficult to detect with laboratory analysis.

DIAGNOSIS All studies on shoulder pyarthrosis have noted a delay in establishing a diagnosis because the clinical findings may be subtle. Patients are often afebrile and may complain of nonspecific shoulder discomfort. The white blood cell count may be normal, and the increase in the erythrocyte sedimentation rate is often not dramatic. I find the C-reactive protein test to be more sensitive. The literature on this subject confirms that glenohumeral joint infections are very difficult to diagnose, and any or all tests may be negative despite an ongoing infection. If glenohumeral sepsis is a possibility, I advise arthroscopic evaluation; the risks of a negative arthroscopy are small when compared to the dire consequences of a missed septic arthritis. I obtain a consultation with an infectious disease specialist once I suspect the diagnosis of infection; such assistance is invaluable in the postoperative period. I have a general surgeon insert a catheter for long-term parenteral antibiotics after the patient is anesthetized in the operating room and before I begin the arthroscopic operation. I do not administer antibiotics until I have obtained the appropriate specimens.

OPERATIVE TECHNIQUE I establish a routine posterior portal and insert culture swabs into the joint before instilling fluid so that I can obtain specimens for aerobic and anaerobic analysis. After the arthroscope is inserted posteriorly, I create an

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Glenohumeral Joint Surgery

Figure 9-1 Infection after an arthroscopic Bankart procedure. Note the remaining glenoid articular cartilage.

Figure 9-3

De´bridement and synovectomy.

anterior-inferior portal and insert a large cannula. I use a tissue-grasping forceps to obtain soft tissue specimens, which are sent to the laboratory for frozen section, Gram stain, and culture and sensitivity testing. I find it helpful to alert the pathologist in advance of the procedure to obtain a rapid reading of the Gram stain. I use a motorized tissue resector to perform a synovectomy and de´bridement of all involved areas throughout the glenohumeral joint. In my experience, only a remnant of the rotator cuff is usually present (Figs. 9-1 through 9-8). I irrigate the joint copiously with 6 L of irrigation fluid. I then create an anterior-superior portal and move the arthroscope to that location. I insert a hip suction tube through the posterior cannula and bring Figure 9-4

Figure 9-2

Anchor remnant.

Bone defects in the area of anchors.

Figure 9-5

Insert the tubing anteriorly.

Chapter 9



Sepsis

209

it out the anterior-inferior cannula; I then repeat the process to insert a second suction drain. I move the arthroscope posteriorly and use a crochet hook to move one of the drains from the anterior-inferior cannula to the anterior-superior cannula. Throughand-through irrigation can be established with this technique. I inspect the subacromial space and perform de´bridement and drain insertion as necessary. If the patient responds, I remove the drains 48 hours after surgery. The operation is repeated as necessary until the infection is controlled.

BIBLIOGRAPHY Figure 9-6

Figure 9-7

Figure 9-8

Drainage tube in the joint.

Drainage tube advanced in the joint.

Drainage tube exiting the posterior portal.

Bertone C, Rivera F, Avallone F, et al: Pneumococcal septic arthritis of the shoulder: Case report and literature review. Panminerva Med 44:151-154, 2002. Cleeman E, Auerbach JD, Klingenstein GG, Flatow EL: Septic arthritis of the glenohumeral joint: A review of 23 cases. J Surg Orthop Adv 14:102-107, 2005. Costantino TG, Roemer B, Leber EH: Septic arthritis and bursitis: Emergency ultrasound can facilitate diagnosis. J Emerg Med 32:295-297, 2007. Esenwein SA, Ambacher T, Kollig E, et al: [Septic arthritis of the shoulder following intra-articular injection therapy: Lethal course due to delayed initiation of therapy]. Unfallchirurg 105:932-938, 2002. Gordon EJ, Hutchful GA: Pyarthrosis simulating ruptured rotator cuff syndrome. South Med J 75:759-762, 1982. Hammel JM, Kwon N: Septic arthritis of the acromioclavicular joint. J Emerg Med 29:425-427, 2005. Jeon IH, Choi CH, Seo JS, et al: Arthroscopic management of septic arthritis of the shoulder joint. J Bone Joint Surg Am 88:1802-1806, 2006. Kitsis CK, Marino AJ, Krikler SJ, Birch R: Late complications following clavicular fractures and their operative management. Injury 34:69-74, 2003. Lluı´s M, Rovira E: [Image of the week: Septic arthritis and sepsis by MRSA of cutaneous region]. Med Clin (Barc) 126:720, 2006. Master R, Weisman MH, Armbuster TG, et al: Septic arthritis of the glenohumeral joint: Unique clinical and radiographic features and a favorable outcome. Arthritis Rheum 20:1500-1506, 1977. Mehta P, Schnall SB, Zalavras CG: Septic arthritis of the shoulder, elbow, and wrist. Clin Orthop Relat Res 451: 42-45, 2006. Morihara T, Arai Y, Horii M, et al: Arthroscopic treatment for septic arthritis of the shoulder in an infant. J Orthop Sci 10:95-98, 2005. Murdoch DM, McDonald JR: Mycobacterium avium-intracellulare cellulitis occurring with septic arthritis after joint injection: A case report. BMC Infect Dis 7:9, 2007. Parisien JS, Shaffer B: Arthroscopic management of pyarthrosis. Clin Orthop Relat Res 275:243-247, 1992.

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Rolf O, Stehle J, Gohlke F: [Treatment of septic arthritis of the shoulder and periprosthetic shoulder infections: Special problems in rheumatoid arthritis]. Orthopade 36:700-707, 2007. Ross JJ, Shamsuddin H: Sternoclavicular septic arthritis: Review of 180 cases. Medicine 83:139-148, 2004. Seitz WH, Damacen H: Staged exchange arthroplasty for shoulder sepsis. J Arthroplasty 17:36-40, 2002. Smith AM, Sperling JW, Cofield RH: Outcomes are poor after treatment of sepsis in the rheumatoid shoulder. Clin Orthop Relat Res 439:68-73, 2005. Ward WG, Eckardt JJ: Subacromial/subdeltoid bursa abscesses: An overlooked diagnosis. Clin Orthop Relat Res 288:189-194, 1993.

Ward WG, Goldner RD: Shoulder pyarthrosis: A concomitant process. Orthopedics 17:591-595, 1994. Weishaupt D, Schweitzer ME: MR imaging of septic arthritis and rheumatoid arthritis of the shoulder. Magn Reson Imaging Clin N Am 12:111-124, 2004. ¨ ller EJ, Ambacher T, et al: Arthrodesis of the Wick M, Mu shoulder after septic arthritis: Long-term results. J Bone Joint Surg Br 85:666-670, 2003. Yu KH, Luo SF, Liou LB, et al: Concomitant septic and gouty arthritis—an analysis of 30 cases. Rheumatology (Oxford) 42:1062-1066, 2003.

CHAPTER

10

Impingement Syndrome

Rotator cuff tendon lesions of the subacromial space include tendinosis (impingement syndrome), partialthickness tears, reparable full-thickness tears, massive tears, irreparable tears, and cuff arthropathy. I also include acromioclavicular joint pathology in this category. Patients often present to the orthopedic surgeon’s office with impingement syndrome, which is a common indication for arthroscopic surgery.

CLINICAL PRESENTATION Stage 2 impingement (chronic rotator cuff tendinosis) is a clinical syndrome. The patient complains of subdeltoid pain with radiation down the lateral arm to the area of the deltoid insertion or down the front of the arm into the biceps muscle. Pain occurs as the arm passes through the arc of 70 to 100 degrees of abduction. Nighttime pain interferes with sleep. Physical examination normally demonstrates full passive range of motion. Small limitations in elevation and behindthe-back internal rotation are due to the patient’s pain rather than true passive glenohumeral joint contracture. Active abduction and behind-the-back internal rotation are painful. The patient often reports pain while actively lowering the arm after the examiner raises it passively. The primary (Neer) and secondary (Hawkins) impingement signs are positive, and pain is

relieved with a subacromial lidocaine injection (impingement test).

LITERATURE REVIEW A number of reports in the orthopedic surgery literature describe the arthroscopic management of stage 2 rotator cuff disease. Several authors have reported 70% to 90% success rates with arthroscopic acromioplasty. All authors stress that arthroscopic surgery is successful when impingement is due to extrinsic compression on the tendon by the structures of the coracoacromial arch. It is not successful when impingement is intrinsic, as may be seen with the increased demand on rotator cuff tendons in patients with glenohumeral subluxation. Other studies have compared the open and arthroscopic techniques. Matsen and colleagues found that although the open technique produced a slightly higher success rate, the return to function was superior with arthroscopic treatment. Norlin found that the arthroscopic technique produced better results and a more rapid return of function. Van Holsbeeck and associates reported marginally better results with the open technique but advised arthroscopic decompression for patient convenience and satisfaction. Recent literature has focused on the dynamic cause of some cases

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Subacromial Space Surgery

of impingement syndrome. It is well known that alterations in scapular biomechanics can cause subacromial pain. Treatment in these individuals is not surgical but involves a comprehensive physical therapy program. The best work on this topic is by Kibler.

DIAGNOSIS The classic history of stage 2 impingement is shoulder pain during activities that place the shoulder in 70 to 100 degrees of elevation or abduction. Typical activities include reaching overhead (e.g., for items on a high shelf), behind the back (e.g., to fasten a brassiere or belt), or to the side (e.g., to insert an ATM card, use a seatbelt, or access an alarm clock). Pain is localized to the subacromial region and radiates to the deltoid insertion and often anteriorly into the biceps. Nighttime pain is noted regularly. The role of trauma is variable; some patients present with symptoms after major injury, but in many others, the pain occurs after repetitive activities without trauma or antecedent injury. Physical examination demonstrates a full or nearly normal range of passive motion. Occasionally, I find local tenderness in the area of the supraspinatus insertion. I prefer to stand behind the patient, position the shoulder in slight extension, and place my index finger in the area of the rotator cuff insertion. Sometimes when I rotate the shoulder I can imagine a defect in this area consistent with a full-thickness rotator cuff tear. Acromioclavicular joint tenderness should alert the examiner that this joint might be the primary source of pathology. Acromioclavicular joint arthritis can mimic stage 2 impingement. Joint inflammation may cause irritation to the supraspinatus tendon as it passes underneath the acromioclavicular joint. Additionally, acromioclavicular joint arthritis can coexist with primary impingement. I carefully examine patients younger than 40 years for the presence of glenohumeral instability. In these patients, subacromial pain may be the result of traction on the rotator cuff rather than true stage 2 impingement. Three impingement signs consistent with stage 2 impingement have been described and are recorded as positive when subacromial pain is produced. The primary (Neer) sign occurs when the examiner places the shoulder in maximal elevation. To demonstrate the secondary (Hawkins) sign, the shoulder is elevated 80 degrees and then maximally internally rotated. The tertiary sign (painful arc) consists of subacromial pain with the shoulder in 90

degrees of abduction. The location of the pain should be carefully noted. A patient with soft tissue pain from rhomboid-trapezius spasm may have increased pain during each of these maneuvers, but the pain is not localized to the subacromial region. After the physical examination, the surgeon may perform an impingement test. This test consists of injecting local anesthetic into the subacromial space and then attempting to elicit the impingement signs again. If the pain is eliminated or substantially reduced, the test is recorded as positive. The physician must be aware that a positive test result only confirms that the structures producing pain lie within the subacromial space; it is not, by itself, diagnostic of impingement syndrome. My preferred technique for subacromial injection is posterior. This is how I enter the subacromial space during shoulder arthroscopy, so I am familiar with this approach. Other surgeons are equally successful with lateral or anterior approaches. The diagnosis of impingement syndrome is clinical, and arthroscopy does not routinely play a role. A number of conditions that mimic the clinical presentation of impingement are best diagnosed with arthroscopic techniques. Glenohumeral instability, articular surface partial rotator cuff tears, labrum tears, small areas of degenerative arthritis, posterior glenoid—rotator cuff impingement, and lesions of the rotator interval are examples. Glenohumeral instability may result in secondary traction tendinitis, with positive impingement signs as well as a positive impingement test. Successful surgical management of this condition does not involve shoulder decompression but rather treatment of the underlying glenohumeral instability. Other conditions that may mimic stage 2 impingement syndrome but cannot be diagnosed with arthroscopic technique include acromioclavicular joint arthritis, cervical spine disease, and suprascapular neuropathy. There is little scientific support for the concept that acromial morphology is significant. Many think the type 3 acromion is actually ossification of the coracoacromial ligament that is medially positioned and plays no role in subacromial impingement. Historically, plain radiograph bone findings consistent with subacromial impingement include type 3 acromion, anterior acromial sclerosis, anterior medial spurs (ossification of the coracoacromial ligament), and inferior spurring of the distal clavicle. Magnetic resonance imaging findings include tendinosis, bursitis, and lateral acromial downsloping. In summary, subacromial impingement that responds to arthroscopic subacromial decompression is based

Chapter 10

Figure 10-1 Type 3 acromion, scapular outlet view.

Figure 10-3



Impingement Syndrome

215

Coracoacromial ligament ossification.

INDICATIONS FOR SURGERY on extrinsic factors such as abnormal acromial shape, sloping, or spurs within the coracoacromial ligament or acromioclavicular joint. Subacromial ‘‘impingement’’ findings that do not respond to arthroscopic subacromial decompression are those of intrinsic rotator cuff tendinopathies and those secondary to glenohumeral joint instability (Figs. 10-1 through 10-3).

Figure 10-2 Anterolateral acromial spur.

The indications for arthroscopic treatment include pain or weakness that interferes with work, sports, or activities of daily living and is unresponsive to appropriate nonoperative treatment. The usual nonoperative regimen consists of oral anti-inflammatory medication, cortisone injections into the subacromial space (two or three, spaced 2 months apart), activity modification, selective rest, and a rehabilitation program. The rehabilitation program is designed to restore or maintain movement and to improve strength in the deltoid, scapular stabilizers, and rotator cuff muscles. The recommended duration of this nonoperative approach varies, but it seems reasonable to consider surgery if the patient’s pain continues for 12 months or is increasing in severity after 6 months. Additionally, an unusual indication for operative treatment is a superiorly displaced, healed greater tuberosity fracture. Arthroscopic subacromial decompression treats the deformity by increasing clearance for the malunited bone. The concept of acromioplasty itself is controversial, with some surgeons believing that acromioplasty is unnecessary. It is Matsen’s opinion that contact between the rotator cuff and acromial undersurface is normal and that acromial spurs are the result of—not cause of—a primary tendon abnormality. He treats patients demonstrating stage 2 impingement with de´bridement of abnormal bursa and adhesions and then initiates a vigorous rehabilitation program. Nirschl’s view is that impingement is an intrinsic tendinopathy and that acromioplasty is not needed. Conversely, numerous articles have reported good results with acromioplasty. At present, there is little scientific evidence to guide orthopedic surgeons,

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who must consider these conflicting opinions within the context of their own experience. We await welldesigned, prospective, randomized studies to evaluate this issue. I discuss the need for acromioplasty in relation to rotator cuff repair in Chapter 12. Acromioclavicular joint arthritis may coexist with subacromial impingement. If the patient is symptomatic from the arthritis, as determined by the preoperative clinical examination, acromioclavicular joint resection is performed. Resection can be accomplished through the subacromial approach, although some surgeons prefer a direct approach into the acromioclavicular joint itself.

CONTRAINDICATIONS TO SURGERY Pain occurring during abduction can have a number of other causes besides the extrinsic mechanical factors of subacromial impingement, including early rheumatoid arthritis, post-traumatic arthritis, and avascular necrosis. However, these are unusual conditions with clear radiographic findings. An unusual situation is a patient with chondromalacia from early osteoarthrosis. In this case, the plain radiographic findings are normal, and the true cause of the patient’s pain is discovered during arthroscopic examination. There are three common clinical entities that may lead to an erroneous diagnosis: glenohumeral instability, adhesive capsulitis, and musculoskeletal pain syndromes. Fortunately, the surgeon can identify all with appropriate evaluation. Probably the most common error is operating on patients with intrinsic tendinopathy secondary to glenohumeral instability. The repetitive overload of the rotator cuff tendons as they attempt to stabilize the glenohumeral joint causes inflammation and swelling of the tendons. Although the instability may be subtle, the pain from rotator cuff and bursa inflammation may be severe, causing the patient to present for evaluation and treatment. Impingement signs and the impingement test are positive. These patients are usually younger than 40 years and have normal plain radiographs. In this setting, I proceed very cautiously and advise a prolonged period of nonoperative care. Arthroscopic subacromial decompression without correction of the underlying glenohumeral joint lesions will fail. I devote more time to the relationship between rotator cuff lesions and glenohumeral instability in the section on internal impingement and partial-thickness rotator cuff tears (see Chapter 11). The second most common error occurs when the patient has adhesive capsulitis. The diagnosis of adhesive capsulitis is straightforward when the disease

is at its peak, but patients in the very early or late phase may have only a small loss of external rotation that can be missed if the examiner fails to measure both shoulders. I carefully measure external rotation in maximal abduction and compare the side-to-side difference, which may be the first finding. The loss of external rotation does not allow the greater tuberosity to rotate away from the acromion during elevation and may mimic the clinical findings of impingement. Posterior capsule tightness can lead to obligatory anterior-superior humeral head translation and cause contact between the rotator cuff and the coracoacromial arch. The loss of internal rotation is most noticeable with the shoulder abducted 80 to 90 degrees. Musculoskeletal pain syndromes commonly cause pain in the scapular muscles, and this too can be confused with subacromial impingement. The impingement signs may be positive, but the pain is located in the scapular muscles or trapezius rather than in the classic locations. A rare cause of impingement pain is suprascapular nerve entrapment. This may be caused by a cyst within the suprascapular notch or in the area of the spinoglenoid ligament. Entrapment can also exist in the absence of a cyst because the suprascapular nerve is particularly vulnerable in these two locations. Realistically, the diagnosis is one of exclusion, made after other more common lesions have been ruled out, but the surgeon should be suspicious when there is burning pain in the midtrapezius region, weakness out of proportion to pain, significant atrophy in the supraspinatus or infraspinatus fossa, or a cyst noted on magnetic resonance imaging in the region of the nerve.

ARTHROSCOPIC FINDINGS Most surgeons examine the glenohumeral joint for unsuspected lesions before arthroscopic subacromial decompression. Subtle Bankart or superior labrum from anterior to posterior (SLAP) lesions, labrum fraying, early adhesive capsulitis, and small areas of cartilage loss are some examples. Imaging studies may underestimate the extent of rotator cuff damage. Subacromial findings in stage 2 impingement are variable. The space may be clear, or a dense, fibrous bursal reaction may be found. Impingement syndrome may exist even in the presence of a clear, well-defined subacromial space. In some individuals, contact between the rotator cuff and the acromion produces pain but does not incite an inflammatory bursitis reaction. Tendon erosion, fraying, or partial-thickness tears may be found on the superior

Chapter 10

(bursal) surface of the cuff. Erosions on the acromial undersurface near the anterior edge are frequently noted, as are small areas of inflammation. The surgeon may also observe coracoacromial ligament fraying. Although these findings are suggestive of subacromial impingement, they are not necessarily diagnostic.

TREATMENT Arthroscopic treatment of stage 2 impingement involves examination under anesthesia to document range of motion and translation, followed by inspection of the glenohumeral joint and treatment, if indicated, of any coexisting intra-articular lesions. Subacromial treatment includes excision of sufficient pathologic bursa to accomplish three goals: inspect the surface of the tendons, remove the space-occupying lesion, and remove an inflamed, pain-producing structure. If the bursa is not pathologically thickened or if it does not obscure my view to the rotator cuff tendon insertion, I do not resect the bursa. In most cases, treatment of the coracoacromial ligament involves resection from the lateral acromial border to the medial acromial border. Some surgeons prefer to divide, rather than resect, the ligament. As noted earlier, some may elect not to perform acromioplasty or coracoacromial ligament resection, limiting treatment to bursectomy. I perform an inferior acromioplasty to convert the acromion to a flat (type 1) structure. This can be accomplished with a power bur placed in either the lateral or the posterior portal, depending on the surgeon’s preference. The acromioclavicular joint may contribute to impingement syndrome through the formation of inferior acromioclavicular joint osteophytes. Inferior osteophytes may project downward into the rotator cuff tendons and cause or exacerbate impingement. The presence of these osteophytes is documented on plain radiographs or magnetic resonance imaging. The osteophyte can be removed arthroscopically.



Impingement Syndrome

or glenohumeral instability may mimic subacromial impingement. I have seen a patient rapidly lose motion between the last office examination and the examination under anesthesia at surgery.

Positioning Patient positioning is a matter of surgeon preference. Although many surgeons are more comfortable with patients in the lateral decubitus position, I prefer to have them in the sitting position. The arm is allowed to rest naturally by the patient’s side. In my experience, traction is not necessary during this procedure or any operation within the subacromial space.

Landmarks I mark the surface anatomy of the clavicle, acromion, coracoid process, and scapular spine with a surgical marking pen. I mark the inferior surfaces of the bone, because it is from these points that distances are measured (Fig. 10-4).

Glenohumeral Joint Entry and Findings I enter the glenohumeral joint posteriorly, as described in Chapter 3, and perform a complete inspection of the glenohumeral joint while viewing from the posterior portal. I then create an anterior portal, move the arthroscope anteriorly, and complete the diagnostic portion of the examination. There are usually few intra-articular signs of subacromial impingement. There may be fraying or erythema of the anterior supraspinatus. I carefully observe for findings that may mimic stage 2 subacromial impingement. These include a SLAP lesion (internal impingement), Bankart lesion

OPERATIVE TECHNIQUE Arthroscopic Subacromial Decompression Examination under Anesthesia I prefer a combination of general anesthesia and interscalene block. I examine both shoulders for range of motion and translation. As previously mentioned, early (or late resolving) adhesive capsulitis

217

Figure 10-4

Skin markings.

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Section Three

Figure 10-5



Subacromial Space Surgery

Partial-thickness rotator cuff tear.

Figure 10-7

Nondisplaced Bankart lesion.

(anterior-inferior glenohumeral instability), contracted inferior capsule recess (adhesive capsulitis), or rotator interval tear (anterior-superior glenohumeral instability) (Figs. 10-5 through 10-11). I use an arthroscopic probe and palpate the glenohumeral ligaments to ensure that they are securely attached to both the glenoid rim and the humeral head. I have not found it necessary to de´bride minor areas of frayed labrum. I remove the instruments and cannulas and proceed to the subacromial space.

Subacromial Entry and Findings I enter the subacromial space posteriorly and create a lateral working portal as described in Chapter 3. I verify my spatial orientation by rehearsing the movements required during the operation. I touch the shaver tip to

Figure 10-6

Fraying of the labrum.

Figure 10-8

Figure 10-9

SLAP lesion.

Humeral head cartilage lesion.

Chapter 10

Figure 10-12 Figure 10-10



Impingement Syndrome

Palpate the trocar.

Contracted rotator interval.

the acromion (lower my hand), rotator cuff (raise my hand), anterior acromion (bring my hand toward myself), and posterior acromion (move my hand away from myself) (Figs. 10-12 through 10-20). Findings of subacromial impingement include erythema or fraying of the coracoacromial ligament or the bursal cuff surface. There is usually a proliferative bursitis, although sometimes the subacromial space is clear. Adhesions may be present between the rotator cuff and the acromion or deep surface of the deltoid fascia. I sweep the cannula and trocar medially and laterally to release any significant adhesions (Fig. 10-21).

Figure 10-11

Contracted anterior capsule.

Figure 10-13

Palpate the acromion.

Figure 10-14

Palpate the acromion.

219

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Section Three

Figure 10-15



Subacromial Space Surgery

Palpate the rotator cuff. Figure 10-18

Palpate the rotator cuff.

Figure 10-19

Move posteriorly.

Palpate the coracoacromial ligament.

Figure 10-20

Move posteriorly.

Figure 10-16

Figure 10-17

Palpate the coracoacromial ligament.

Chapter 10

Figure 10-22 Figure 10-21



Impingement Syndrome

221

Posterior bursal curtain.

Blunt dissection of subacromial adhesions.

Bursectomy If bursitis obscures the view, I remove it by turning the shaver tip away from the arthroscope (to avoid accidental damage to the lens) and positioning it midway between the acromion and the rotator cuff. I increase the suction slightly and begin shaving. As I remove the bursa, the subacromial space clears, and I can see the shaver tip. I gradually increase the suction on the shaver and continue to remove bursa. Do not shave medially; that area does not contribute to subacromial impingement, and inadvertent medial shaving of the well-vascularized bursa can cause bleeding that is difficult to control and rupture the muscle fibers of the rotator cuff. Once the bursa is removed from the lateral, tendinous portion of the rotator cuff, I look for adhesions anteriorly or laterally and remove these with scissors or a motorized resector until a complete view of the supraspinatus is possible (Figs. 10-22 through 10-28).

Figure 10-23

Bursa obscuring the view of the subacromial

space.

Coracoacromial Ligament When performing a subacromial decompression, a critical step is to identify the anterolateral acromion, which is usually covered by the coracoacromial ligament. Electrocautery is useful for this portion of the procedure. I palpate the bone surface with the electrocautery tip (without power) and locate the anterior and then the lateral acromial borders. With the electrocautery tip placed against the acromion approximately 1 cm posterior to the anterior bone margin and 1 cm medial to the lateral bone margin, I ablate soft tissue until the bone is visible. I move

Figure 10-24

Musculotendinous junction (arrow).

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Section Three



Figure 10-25

Subacromial Space Surgery

Subacromial adhesion.

Partial-thickness tear of the bursal surface of the rotator cuff.

Figure 10-28

anteriorly and laterally and remove more soft tissue and coracoacromial ligament until I can clearly see the anterolateral acromial border. I then sweep the coracoacromial ligament from the anterior-inferior acromion until it falls inferiorly. This usually completes the coracoacromial ligament release. Another technique is to use the power bur or shaver and gradually peel the soft tissue away from the acromion. This makes resection of the coracoacromial ligament less risky because it is now a safe distance from the small branches of the thoracoacromial artery. If the surgeon believes that coracoacromial ligament release is preferable to resection, only the lateral portion of the ligament is resected; the medial portion is left intact (Figs. 10-29 through 10-37). Figure 10-26

Resect the adhesion.

Acromioplasty

Figure 10-27

Fraying of the bursal surface of the rotator cuff.

Using preoperative radiographs, I estimate the amount of bone removal necessary. Anteroposterior radiographs may demonstrate anterolateral sclerosis and thickening. An apical tilt view may demonstrate ossification of the coracoacromial ligament with medial bony projections. The outlet view provides information about anterior acromial thickness. Smaller individuals require less bone removal than do larger individuals. Preoperative radiographic assessment of bone thickness and estimation of the amount of bone removal needed to achieve a flat, type 1 acromion can help the surgeon avoid excessive bone removal or acromial fracture. Before acromioplasty, the inferior bone surface should be free of soft tissue. I place the bur at the anterolateral bone margin and remove anterior-inferior bone until the deltoid fascia is seen and the appropriate

Chapter 10

Figure 10-29

Figure 10-30



Impingement Syndrome

Erythema of the coracoacromial ligament.

Figure 10-32

Coracoacromial ligament release.

Fraying of the coracoacromial ligament.

Figure 10-33

Coracoacromial ligament release.

Coracoacromial ligament release.

Figure 10-34

Identify the anterolateral corner.

Figure 10-31

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Figure 10-35



Subacromial Space Surgery

Identify the anterior acromion.

amount of bone (as estimated from preoperative radiographs) is removed. I remove bone until the inferior acromial surface is flat and parallel to the floor. Only then do I continue medially. I remove bone from inferior to superior. Because the acromion increases in thickness from lateral to medial, more bone is removed medially. I remove bone until a flat surface is achieved based on my view with the arthroscope in the posterior portal and angled upward. There are two additional ways to check the acromioplasty. With the arthroscope in the posterior portal, place the tip up against the bone and rotate the arthroscope’s objective lens downward. This maneuver angles the beam parallel to the acromial undersurface, and any bone projecting downward requires removal. The second method is to move the arthroscope to the lateral portal. Introduce the cannula or shaver, place it against the acromial undersurface, and check for a flat bone surface (Figs. 10-38 through 10-43).

Hemostasis

Figure 10-36

Identify the medial acromion.

Bleeding control is vital during an arthroscopic subacromial decompression. I avoid de´bridement of the medial subacromial space where the bursa is well vascularized and the rotator cuff is muscular. The acromial branch of the thoracoacromial artery, located anterior to the coracoacromial ligament, is another source of bleeding. One technique that decreases the likelihood of excessive bleeding is to use thermal cautery for subperiosteal dissection of the coracoacromial ligament and for division of the ligament. When bleeding is encountered, I immediately try to control it rather than proceeding with the operation. I stop the outflow, advance the arthroscope with its

Figure 10-38 Figure 10-37

Soft tissue dissection with a shaver.

undersurface.

Bur oriented parallel to the acromion

Chapter 10

Figure 10-42 Figure 10-39



Impingement Syndrome

225

Arthroscope rotated up toward the acromion.

Begin resection of the anterolateral acromial

corner.

inflow fluid stream as close to the site of bleeding as possible, and increase the pump pressure to tamponade the vessel. I bring the coagulation instrument into the space near the site of bleeding, gradually decrease the pump pressure until the bleeding source is identified, and coagulate the area. This step is a little easier if a combination shaver-electrocautery unit is used.

Where to Start and When to Stop Because this topic is so important, I explain in detail how to perform an arthroscopic subacromial decompression. Orthopedic surgeons have two basic questions: 1. Exactly where do I begin the acromioplasty? 2. How do I know when I have completed it successfully? Figure 10-40

Resect bone more medially.

B

A C Figure 10-41

A-C, Pattern of bur movement.

Figure 10-43

View of the acromion.

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The answer is complex, but it begins with an understanding of acromial shape as it exists preoperatively and how it should appear after arthroscopic subacromial decompression. A basic problem is that we try to evaluate a three-dimensional structure such as the acromion with two-dimensional imaging. Therefore, multiple radiographic views are needed. An anteroposterior view gives the surgeon information about acromial thickness, anterior edge sclerosis, lateral slope, and medial ossification of the coracoacromial ligament. From this view, the surgeon gains an impression of how to perform the bone resection. Medial ossification of the coracoacromial ligament alerts the surgeon that more anterior and medial bone removal is needed, whereas a lateral slope dictates more lateral bone removal than usual. The axillary view provides information about the presence of an os acromiale. The lateral or scapular outlet view demonstrates acromial thickness, slope, and shape; it also guides the surgeon in determining how much anterior bone to remove. A thicker acromion requires more bone removal than a thin one, and this can be estimated from the radiograph or magnetic resonance image. Draw a line along the flat posterior portion of the acromion and extend it anteriorly past the anterior acromial edge. Bone inferior to that line must be removed to create a flat, type 1 acromion. A type 2 acromion can compromise the subacromial space and result in impingement, particularly if the slope is more inferior than normal. After studying these three radiographic views, the surgeon should understand the preoperative acromion in three dimensions. Next, the surgeon must understand how the acromion should look after operation. The anteroposterior radiograph should show a thinner acromion with removal of anterior sclerosis and medial ossification. Lateral tilt, if present preoperatively, should be eliminated. The axillary view shows a more radiolucent acromion, consistent with bone removal. Probably the most helpful postoperative radiograph is the scapular outlet view. By comparing the pre- and postoperative radiographs, the surgeon can judge the adequacy of bone removal. Moving these concepts directly to the operating room requires that the surgeon first establish a clear view of the subacromial space. This requires bursectomy and hemostasis. The soft tissue must then be removed from the acromial undersurface so that the bone is visible. The next step is to identify the anterior and lateral acromial borders clearly, as described earlier. Only when these steps have been accomplished can the surgeon reliably perform an arthroscopic acromioplasty. I usually view the acromion with the arthroscope rotated

Figure 10-44 Arthroscope rotated toward the rotator cuff. The beam is parallel to the acromion undersurface.

superiorly, but at this point I tilt the arthroscope, advance it so that it touches the acromion, and then rotate it so that the beam is parallel to the undersurface (Figs. 10-44 and 10-45). Bone projecting downward must be removed, and I estimate how many millimeters this represents. I place the acromionizer bur against the acromion, which provides a yardstick by which to judge the amount of bone removal needed. I then return the arthroscope to its original position and rotation and identify the anterolateral acromial corner by both inspection and palpation. Only when this area is clear and I can view the deltoid fascia anteriorly and laterally do I begin the coracoacromial ligament resection. I use electrocautery to divide the coracoacromial ligament from the anterolateral acromion. I move medially and dissect the coracoacromial ligament from the anterior acromion and let it fall toward the rotator cuff.

Figure 10-45

View of the acromion.

Chapter 10

If I encounter bleeding during this portion of the procedure, I cauterize the vessel immediately. It may be tempting to continue the operation if there is only minor bleeding; however, this small compromise in picture clarity gradually worsens, and if further bleeding occurs, it may be hard to find the offending vessels. Once I have released the coracoacromial ligament attachment, I insert the soft tissue resector and remove the ligament until I reach the level of the medial acromion. I then insert the acromionizer and begin at the anterolateral corner of the acromion, increasing the suction until I have a clear view; too much suction, however, will collapse the subacromial space. As I rotate the bur away from the arthroscope, I start the bur spinning before I touch the bone. If the acromionizer is resting on the bone when it is started, the bur tends to jump and can inadvertently strike the arthroscope lens. I hold the bur about 2 mm from the bone, engage the power, and then gently touch the bone. I apply gentle pressure and move the bur anteriorly, away from the arthroscope. Once I see and feel it break through the anterior cortex, I stop the bur and confirm that the deltoid fascia is visible. I then continue to work in this area and resect more bone superiorly until the anterolateral acromion is converted to a flat, type 1 shape. I rotate the arthroscope’s objective lens 180 degrees to confirm this. I then move medially and resect enough bone until this area is parallel to the anterolateral resection. I continue medially until I reach the medial margin of the acromion, where it forms the lateral border of the acromioclavicular joint. As I resect bone medially, I advance the arthroscope and rotate it inferiorly and medially, always attempting to keep the area of bone resection centered in the picture. I usually resect the medial border of the acromion until the soft tissue of the acromioclavicular joint is visible. I have not had any significant problems with late acromioclavicular joint instability or pain with this approach. I then move the arthroscope to the lateral portal to ensure that I have created a type 1 acromion. The acromioplasty can be examined by inserting an instrument or probe and placing it flat against the acromial undersurface. Another technique presented by Hawkins is to enlarge the lateral portal enough to introduce the tip of a finger and palpate the acromion. This is a good technique to use when learning to perform arthroscopic subacromial decompression.



Impingement Syndrome

Resected bone

Figure 10-46

Orientation drawing for the cutting block

technique.

scapular outlet view, draw a line from the inferior margin of the posterior acromion to the inferior margin of the anterior acromion. Draw a second line from the inferior margin of the posterior acromion parallel to the inferior acromion. This should provide an estimate of the amount of bone to be removed. After the soft tissue is removed from the acromial undersurface, move the arthroscope to the lateral portal and place the acromionizer bur in the posterior cannula. Advance the bur anteriorly and place it up against the acromial undersurface. Move the bur laterally and medially as you advance it anteriorly and remove bone. The alignment of the instrument shaft against the now flat acromion ensures that a type 1 acromion is present (Figs. 10-46 through 10-50). There is the danger of bone transection with the cutting block technique in individuals with thin or angulated acromions. Appropriate analysis of the preoperative scapular outlet view should allow

Variations of Technique A variation of the standard acromioplasty is the posterior ‘‘cutting block’’ technique. On the preoperative

227

Figure 10-47

Shave posteriorly.

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Section Three



Subacromial Space Surgery

Resected bone

Figure 10-48

Advance the bur. Figure 10-51 Curved acromion poses a risk during the cutting block technique.

the surgeon to select the correct technique (Figs. 10-51 and 10-52).

Os Acromiale

Figure 10-49

Test the resection with the trocar.

An anatomic variation that the surgeon may encounter is the os acromiale (Fig. 10-53). The os represents a failure of the acromion to ossify completely and can best be diagnosed on the axillary radiograph. Three different treatments have been proposed: ignore the fragment, excise it, or perform internal fixation. The literature reports good results with each method. I do not advocate excision unless the anterior fragment is very small. I perform internal fixation only if there is palpation tenderness over the fragment on the preoperative

Resected bone

Figure 10-50

lateral portal.

Completed acromioplasty viewed from the

Figure 10-52 Thin acromion poses a risk during the cutting block technique.

Chapter 10

Figure 10-53

Os acromiale.

physical examination. I have found that the os is generally asymptomatic, so I perform a routine acromioplasty.

POSTOPERATIVE MANAGEMENT After arthroscopic decompression for stage 2 impingement, active motion can be started immediately without fear of deltoid detachment. The physical therapist instructs the patient in passive range of motion in elevation and external rotation with a dowel rod. Active range of motion in all planes is encouraged. Strengthening can begin about 3 months after surgery or sooner, once resisted manual testing of the operated shoulder muscles is painless.

CAUSES OF FAILURE Failure of Thought



Impingement Syndrome

229

with a loss of external rotation does not allow the greater tuberosity to rotate and clear the acromion. Passive range of motion during examination under anesthesia demonstrates a loss of motion compared with the contralateral side. The inferior recess and the rotator interval may appear contracted or inflamed on arthroscopic inspection. Chondromalacia or early osteoarthrosis that is not detectable on plain radiographs can be diagnosed during the glenohumeral arthroscopic inspection. Acromioclavicular joint arthritis or osteolysis may cause enough local synovitis to irritate the rotator cuff and result in a clinical presentation similar to impingement. Physical examination demonstrates local tenderness over the acromioclavicular joint and acromioclavicular joint pain with adduction and behind-the-back internal rotation. Surgeons should be suspicious of the impingement diagnosis in patients younger than 40 years. Glenohumeral instability may cause a traction tendinitis that mimics impingement. At surgery, the surgeon may observe an obvious Bankart lesion but should search for more subtle lesions. In patients younger than 40 years, I carefully examine the glenohumeral joint for labrum fraying, consistent with excessive glenohumeral translation. Rotator interval tears and SLAP lesions may also cause glenohumeral instability. Correction of the underlying instability is necessary.

Technical Failure Inadequate Decompression At reoperation, the most common cause of failure is inadequate acromioplasty or coracoacromial ligament release. The surgeon should pay close attention to the anterolateral acromial corner and must visualize this area clearly to ensure adequate bone removal.

Unrealistic Expectations

Excessive Decompression

The causes of failure after arthroscopic subacromial decompression are identical to those seen after open acromioplasty. Patients should understand that it may take 6 to 12 months to recover fully from the operation. Patients are often referred to me because they have pain 1 to 2 months after arthroscopic subacromial decompression, and both they and their surgeons are concerned about failure. Counseling patients to have realistic expectations is invaluable.

Excessive decompression usually occurs in small women with thin acromions. When the surgeon fails to study the preoperative scapular outlet view, the small bone size is not appreciated. A standard acromioplasty performed with the acromionizer bur in the lateral portal may excessively thin the acromion, causing an intraoperative fracture or fracture during early postoperative rehabilitation. An arthroscopic subacromial decompression performed with the cutting block technique with the acromionizer bur in the posterior portal may result in a complete anterior acromionectomy if the surgeon does not study the scapular outlet view carefully and appreciate the relative thinness or curvature of the acromion.

Improper Diagnosis Shoulder pain as the arm passes through the painful arc is common in a number of conditions other than impingement syndrome. Early adhesive capsulitis

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Subacromial Space Surgery

Lateral Acromial Resection Lateral resection occurs because of a misunderstanding of the pathophysiology of subacromial impingement or a technical error. Lateral subdeltoid pain when the arm is abducted may prompt some surgeons to resect the lateral acromion incorrectly. Poor visualization or disorientation may cause the surgeon to mistake the lateral acromion for the anterior acromion.

COMPARISON OF OPEN AND ARTHROSCOPIC APPROACHES To today’s readers, the following comparison is almost anachronistic, but I include it to anchor this portion of the text in history. The battle is finished, and arthroscopy is the victor. Arthroscopy has certain theoretical advantages over conventional open surgery. The skin incisions are smaller, and the cosmetic result is better. Both arthroscopic and open procedures can be performed on an outpatient basis, which is more convenient for patients and less expensive for third-party payers. Most patients can perform activities of daily living and can return to sedentary jobs within days. Because the deltoid is not detached from the acromion, active range-ofmotion exercises can be started as soon as tolerated. Perhaps more important is the fact that the glenohumeral joint can be inspected. Although clinically important intra-articular lesions are not common, glenohumeral instability, labrum tears, partial-thickness articular surface rotator cuff tears, biceps tendon lesions, and arthritic changes in the glenoid or humeral head can be identified. These might well be overlooked with a conventional open approach; their accurate diagnosis and eventual treatment can clearly be of benefit in achieving the optimal functional result for the patient. Arthroscopic subacromial decompression can be a difficult skill for many individuals to master, and it is certainly harder to teach than open acromioplasty. Better hand-eye coordination is required, and triangulating and manipulating power instruments within millimeters of each other can be challenging. The cost difference between outpatient arthroscopic surgery and inpatient open procedures may not be as great as perceived by patients, surgeons, and insurance carriers. Certainly the cost of a hospital stay is avoided with arthroscopic surgery, but this is at least partially offset by the increased cost of the arthroscopic setup. The price of disposable instruments, tubing, and fluid is an important consideration. The operating room, recovery room, and surgeon’s and anesthesiologist’s

fees constitute the largest portion of the expense. These charges are similar for both arthroscopic and open acromioplasty. It seems logical to conclude that the arthroscopic approach allows patients to return to work more rapidly—at least to jobs that do not require heavy labor. This should have a substantial impact on cost analyses that take into account days lost from work; however, studies that systematically address this issue have not been performed. Further, it appears that even in this area, the differences may be only slight. Many patients who do not perform manual labor can return to work once the pain is adequately controlled. The ability to return to work seems to be less heavily influenced by the surgical findings. Deltoid management differs between the open and arthroscopic approaches. The open approach requires a small amount of deltoid detachment and reattachment; therefore, the deltoid must be protected and allowed to heal to avoid the debilitating complication of deltoid dehiscence. In contrast, the arthroscopic technique allows immediate active motion. Advocates of open techniques state that very little deltoid removal is required and that there are reliable techniques to secure the deltoid’s reattachment. Advocates of the arthroscopic approach argue that deltoid detachment is avoided; however, the arthroscopic technique also has the potential for deltoid injury. The deltoid fascial origin can be disrupted if an overly aggressive anterior or anterolateral acromioplasty is performed. At this time, the debate between open and arthroscopic approaches has largely been put to rest. Arthroscopy is the accepted method of treatment. Impingement syndrome can be treated successfully with arthroscopic subacromial decompression. Arthroscopy allows complete inspection of the glenohumeral joint, enabling the surgeon to diagnose and treat coexisting intra-articular lesions. The surgeon can perform a thorough bursectomy, coracoacromial ligament resection, and acromioplasty without the need for deltoid detachment.

CORACOID IMPINGEMENT Coracoid Impingement Another cause of anterior shoulder pain is coracoid impingement. This unusual lesion is diagnosed by the patient’s description of anterior shoulder pain with adduction of the internally rotated arm. There is tenderness over the coracoid process, and pain is increased

Chapter 10



Impingement Syndrome

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BIBLIOGRAPHY

Figure 10-54

Coracoid impingement on magnetic resonance

imaging.

when the examiner passively adducts the internally rotated shoulder. An injection of local anesthetic near the coracoid relieves the pain. Radiographs may be normal, but the axillary view may demonstrate a pronounced lateral curvature or elongation of the coracoid process. Occasionally, magnetic resonance imaging demonstrates compression of the subscapularis against the coracoid (Fig. 10-54). If conservative treatment is not successful, operation is indicated. I inspect the glenohumeral joint first. Intra-articular findings may include fraying of the subscapularis tendon insertion. Coracoid recession can be performed with either an intra-articular or a subacromial approach. I insert a cannula anteriorly through the rotator interval and use a shaver to resect the interval tissue. The coracoid can be observed medially, just superior to the subscapularis tendon. A bur can be introduced through the cannula or inserted percutaneously just anterior to the anterior acromion to perform the bone resection. If I perform a subacromial coracoid recession, I remove the arthroscope and redirect it into the subacromial space. I create lateral and anterior portals and move the arthroscope to the lateral portal. I introduce the shaver through the anterior portal and perform a thorough bursectomy. I can then identify the subscapularis, the acromion, and the coracoacromial ligament. I advance the arthroscope and follow the coracoacromial ligament to the region of the coracoid process. I introduce a shaver through the anterior portal and palpate the coracoid process. I remove enough soft tissue so that I can see the coracoid bone and then insert a round bur to recess the coracoid distally and laterally until I have created sufficient space. I place the arm in adduction and internal rotation and test the adequacy of the bone resection. Postoperative management is similar to that described earlier.

Altchek DW, Carson EW: Arthroscopic acromioplasty: Current status. Orthop Clin North Am 28:157-168, 1997. Axelsson K, Nordenson U, Johanzon E, et al: Patient-controlled regional analgesia (PCRA) with ropivacaine after arthroscopic subacromial decompression. Acta Anaesthesiol Scand 47:993-1000, 2003. Barber FA: Long-term results of acromioclavicular joint coplaning. Arthroscopy 22: 125-129, 2006. ¨ K, Hermodsson Y, et al: High patient Bengtsson M, Lunsjo satisfaction after arthroscopic subacromial decompression for shoulder impingement: A prospective study of 50 patients. Acta Orthop Scand 77:138-142, 2006. Board TN, Srinivasan MS: The effect of irrigation fluid temperature on core body temperature in arthroscopic shoulder surgery. Arch Orthop Trauma Surg 128:531-533, 2007. Bonsell S: Detached deltoid during arthroscopic subacromial decompression. Arthroscopy 16:745-748, 2000. Braman J, Flatow E: Arthroscopic decompression and physiotherapy have similar effectiveness for subacromial impingement. J Bone Joint Surg Am 87:2595, 2005. Budoff JE, Nirschl RP, Guidi EJ: Debridement of partialthickness tears of the rotator cuff without acromioplasty: Long-term follow-up and review of the literature. J Bone Joint Surg Am 80:733-748, 1998. Caspari RB, Thal R: A technique for arthroscopic subacromial decompression. Arthroscopy 8:23-30, 1992. Chao D, Young S, Cawley P: Postoperative pain management for arthroscopic shoulder surgery: Interscalene block versus patient-controlled infusion of 0.25% bupivacaine. Am J Orthop 35:231-234, 2006. Checroun AJ, Dennis MG, Zuckerman JD: Open versus arthroscopic decompression for subacromial impingement: A comprehensive review of the literature from the last 25 years. Bull Hosp Jt Dis 57:145-151, 1998. Deshmukh AV, Perlmutter GS, Zilberfarb JL, Wilson DR: Effect of subacromial decompression on laxity of the acromioclavicular joint: Biomechanical testing in a cadaveric model. J Shoulder Elbow Surg 13:338-343, 2004. De Wachter J, van Glabbeek F, van Riet R, et al: Surrounding soft tissue pressure during shoulder arthroscopy. Acta Orthop Belg 71:521-527, 2005. Dom K, van Glabbeek F, van Riet RP, et al: Arthroscopic subacromial decompression for advanced (stage II) impingement syndrome: A study of 52 patients with five years follow-up. Acta Orthop Belg 69:13-17, 2003. Ellman H, Harris E, Kay SP: Early degenerative joint disease simulating impingement syndrome: Arthroscopic findings. Arthroscopy 8:482-487, 1992. Ellman H, Kay SP: Arthroscopic subacromial decompression for chronic impingement: Two- to five-year results. J Bone Joint Surg Br 73:395-398, 1991. Fealy S, April EW, Khazzam M, et al: The coracoacromial ligament: Morphology and study of acromial enthesopathy. J Shoulder Elbow Surg 14:542-548, 2005.

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Funk L, Levy O, Even T, Copeland SA, et al: Subacromial plica as a cause of impingement in the shoulder. J Shoulder Elbow Surg 15:697-700, 2006. Gartsman GM: Arthroscopic acromioplasty for lesions of the rotator cuff. J Bone Joint Surg Am 72:169-180, 1990. Gartsman GM, Bennett JB, Blair ME, et al: Arthroscopic subacromial decompression: An anatomic study. Am J Sports Med 16:48-50, 1988. Guyette TM, Bae H, Warren RF, et al: Results of arthroscopic subacromial decompression in patients with subacromial impingement and glenohumeral degenerative joint disease. J Shoulder Elbow Surg 11:299-304, 2002. Harvey GP, Chelly JE, Al Samsam T, Coupe K: Patient-controlled ropivacaine analgesia after arthroscopic subacromial decompression. Arthroscopy 20:451-455, 2004. Hawkins RJ, Plancher KD, Saddemi SR, et al: Arthroscopic subacromial decompression. J Shoulder Elbow Surg 10:225-230, 2001. Hovis WD, Dean MT, Mallon WJ, Hawkins RJ: Posterior instability of the shoulder with secondary impingement in elite golfers. Am J Sports Med 30:886-890, 2002. Husby T, Haugstvedt JR, Brandt M, et al: Open versus arthroscopic subacromial decompression: A prospective, randomized study of 34 patients followed for 8 years. Acta Orthop Scand 74:408-414, 2003. Karkabi S, Besser M, Zinman C: Arthroscopic subacromial decompression performed under local anesthesia. Arthroscopy 21:1404, 2005. Kay SP, Dragoo JL, Lee R: Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression. Arthroscopy 19:805-809, 2003. Kharrazi FD, Busfield BT, Khorshad DS: Acromioclavicular joint reoperation after arthroscopic subacromial decompression with and without concomitant acromioclavicular surgery. Arthroscopy 23:804-808, 2007. Kibler WB: Scapular involvement in impingement: signs and symptoms. Instr Course Lect 55:35-43, 2006. Kim SH, Ha KI: Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 16:695-700, 2000. Lim JT, Acornley A, Dodenhoff RM: Recovery after arthroscopic subacromial decompression: Prognostic value of the subacromial injection test. Arthroscopy 21:680-683, 2005. Lo IK, Burkhart SS: Arthroscopic coracoplasty through the rotator interval. Arthroscopy 19:667-671, 2003. Lo IK, Parten PM, Burkhart SS: Combined subcoracoid and subacromial impingement in association with anterosuperior rotator cuff tears: An arthroscopic approach. Arthroscopy 19:1068-1078, 2003. Machner A, Merk H, Becker R, et al: Kinesthetic sense of the shoulder in patients with impingement syndrome. Acta Orthop Scand 74:85-88, 2003. Mair SD, Viola RW, Gill TJ, et al: Can the impingement test predict outcome after arthroscopic subacromial decompression? J Shoulder Elbow Surg 13:150-153, 2004. Matthews LS, Blue JM: Arthroscopic subacromial decompression—avoidance of complications and enhancement of results. Instr Course Lect 47:29-33, 1998.

McCallister WV, Parsons IM, Titelman RM, Matsen FA 3rd: Open rotator cuff repair without acromioplasty. J Bone Joint Surg 87:1278-1283, 2005. McClelland D, Paxinos A, Dodenhoff RM: Rate of return to work and driving following arthroscopic subacromial decompression. Aust N Z J Surg 75:747-749, 2005. McKeon B, Baltz MS, Curtis A, Scheller A: Fluid temperatures during radiofrequency use in shoulder arthroscopy: A cadaveric study. J Shoulder Elbow Surg 16:107-111, 2007. Morrison DS, Frogameni AD, Woodworth P: Non-operative treatment of subacromial impingement syndrome. J Bone Joint Surg Am 79:732-737, 1997. Muddu BN, Umaar R, Kim WY, et al: Whiplash injury of the shoulder: Is it a distinct clinical entity? Acta Orthop Belg 71:385-387, 2005. Mullett H, Benson R, Levy O: Arthroscopic treatment of a massive acromioclavicular joint cyst. Arthroscopy 23:446.e1-446.e4, 2007. Nisar A, Morris MW, Freeman JV, et al: Subacromial bursa block is an effective alternative to interscalene block for postoperative pain control after arthroscopic subacromial decompression: A randomized trial. J Shoulder Elbow Surg 17:78-84, 2007. Norlin R: Arthroscopic subacromial decompression versus open acromioplasty. Arthroscopy 5:321-323, 1989. O’Neill PJ, Cosgarea AJ, Freedman JA, et al: Arthroscopic proficiency: A survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy 18:795-800, 2002. Ortiguera CJ, Buss DD: Surgical management of the symptomatic os acromiale. J Shoulder Elbow Surg 11:521-528, 2002. Park JY, Hyun JK, Seo JB: The effectiveness of digital infrared thermographic imaging in patients with shoulder impingement syndrome. J Shoulder Elbow Surg 16:548-554, 2007. Prickett WD, Teefey SA, Galatz LM, et al: Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively. J Bone Joint Surg Am 85:1084-1089, 2003. Sampson TG, Nisbet JK, Glick JM: Precision acromioplasty in arthroscopic subacromial decompression of the shoulder. Arthroscopy 7:301-307, 1991. Sivan M, Venkateswaran B, Mullett H, et al: Peripheral paresthesia in patients with subacromial impingement syndrome. Arch Orthop Trauma Surg 127:609-612, 2007. Soyer J, Vaz S, Pries P, Clarac JP: The relationship between clinical outcomes and the amount of arthroscopic acromial resection. Arthroscopy 19:34-39, 2003. Taverna E, Battistella F, Sansone V, et al: Radiofrequency-based plasma microtenotomy compared with arthroscopic subacromial decompression yields equivalent outcomes for rotator cuff tendinosis. Arthroscopy 23:1042-1051, 2007. Tillander B, Norlin R: Intraoperative measurements of the subacromial distance. Arthroscopy 18:347-352, 2002. T’Jonck L, Lysens R, De Smet L, et al: Open versus arthroscopic subacromial decompression: Analysis of one-year results. Physiother Res Int 2:46-61, 1997. Urba´nek L, Karjagin V: [Arthroscopic subacromial decompression—personal experience and results]. Acta Chir Orthop Traumatol Cech 71:45-49, 2004.

CHAPTER

11

Partial-Thickness Rotator Cuff Tears

Partial-thickness rotator cuff tears constitute an interesting and difficult group of shoulder lesions. In large part the difficulty stems from terminology: we use the phrase partial-thickness rotator cuff tear to describe the anatomic end result of several different pathophysiologic pathways. If we consider rotator cuff disease to be an intrinsic tendinopathy and part of the natural aging process, partial-thickness rotator cuff tears represent a transition from tendinosis to tendon rupture. If we view rotator cuff changes as lesions caused by extrinsic compression forces, partial-thickness rotator cuff tears are the result of more compression than that which results in tendinosis and less compression than that which results in full-thickness tears. If we accept the hypothesis that partial-thickness rotator cuff tears are the result of compression between the humeral head and the acromion, do these compression forces cause partial-thickness tears in patients with internal impingement? Perhaps the rotator cuff tears we see in younger patients are due to excessive eccentric muscular contraction. Because it appears that the same anatomic lesion (partial-thickness rotator cuff tear) can be caused by different mechanisms, the surgeon must determine the cause and treat the tear accordingly.

LITERATURE REVIEW In a group of throwing athletes (average age, 22 years) treated with arthroscopic de´bridement without decompression, Andrews reported 85% good or excellent results. Snyder found 47 partial tears in a group

of 600 patients undergoing shoulder arthroscopy and advocated de´bridement without decompression if the tear was confined to the articular surface; arthroscopic subacromial decompression was added if the tear extended to both the articular and bursal surfaces. In our series of partial-thickness rotator cuff tears, Milne and I reported that outlet impingement tears of less than 50% of the tendon thickness respond well to arthroscopic subacromial decompression, whereas tears greater than 50% require repair. Partial-thickness rotator cuff tears in patients with glenohumeral instability require instability correction and then rotator cuff repair or arthroscopic subacromial decompression, depending on the extent of the individual lesions.

DIAGNOSIS Patients with partial-thickness rotator cuff tears may present with signs and symptoms typical of rotator cuff disease. When the shoulder is elevated through the painful arc during activities of daily living, pain is localized deep to the lateral deltoid muscle (subdeltoid pain). Night pain is also a regular feature. Examination demonstrates normal active and passive range of motion with positive impingement signs. Subacromial anesthetic injection relieves the pain. A critical feature of the examination is the amount of pain and weakness observed when resisted manual muscle testing is performed. Significant pain and weakness with resisted external rotation or elevation

233

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are relative indications for early operative intervention. Plain radiographs appear similar to those of patients with impingement syndrome or full-thickness tears. Most commonly, the diagnosis is made with magnetic resonance imaging (MRI). I have found that the use of intra-articular gadolinium increases the sensitivity of MRI in patients with partial-thickness rotator cuff tears, particularly in those who must have open MRI. Diagnostic ultrasonography has also been very helpful in my practice, especially in cases of intrasubstance partial-thickness rotator cuff tears (Figs. 11-1 through 11-3). Often, a partial-thickness tear is found at the time of arthroscopic examination of the glenohumeral joint. Figure 11-1

Partial-thickness rotator cuff tear, coronal view.

NONOPERATIVE TREATMENT In the absence of significant subacromial space compromise from a type 3 acromion, nonoperative treatment is indicated and is identical to that prescribed for patients with impingement syndrome. Patients are instructed to avoid painful positions and activities. Nonsteroidal anti-inflammatory medication may relieve pain at night. If there is a loss of passive motion, appropriate stretching exercises are indicated. Home exercises to strengthen the scapular stabilizing muscles may help.

INDICATIONS FOR SURGERY

Figure 11-2

Partial-thickness rotator cuff tear, sagittal view.

If pain persists for 9 to 12 months or increases after 6 months of nonoperative treatment, operative intervention is considered.

OPERATIVE TECHNIQUE Operative Findings

Ultrasonography of partial-thickness rotator cuff tear (arrow).

Figure 11-3

The findings in patients with partial-thickness rotator cuff tears are related to both the severity of the tear and the presence of other lesions within the joint. Most tears are located on the articular surface; approximately 75% of these are in the supraspinatus tendon, 20% are in the infraspinatus tendon, and 5% are in the teres minor tendon. The depth or severity of the tendon tear is grade 1 (less than one fourth of the tendon thickness) in 45% of cases, grade 2 (less than half the tendon thickness) in 40%, and grade 3 (more than half the tendon thickness) in 15% (Figs. 11-4 through 11-7). Chondral defects on the articular surface of the humeral head or the glenoid or the presence of

Chapter 11

Figure 11-4

Grade 1 supraspinatus tear.



Partial-Thickness Rotator Cuff Tears

Figure 11-7

235

Grade 3 supraspinatus tear.

labrum tears or separations is suggestive of glenohumeral instability and should prompt the surgeon to consider whether the partial-thickness rotator cuff tear coexists with other clinical diagnoses (Figs. 11-8 and 11-9).

Intraoperative Decision Making

Figure 11-5

Grade 2 supraspinatus tear.

Figure 11-6

Grade 3 supraspinatus tear.

Three options are available for the arthroscopic treatment of partial-thickness rotator cuff tears: (1) de´bridement of the partial-thickness tear alone, (2) de´bridement of the tear with subacromial decompression, and (3) arthroscopic repair of the partial-thickness tear combined with subacromial decompression. I consider four factors when I treat patients with partial-thickness rotator cuff tears: (1) tear size and

Figure 11-8

Chondral defect of the humeral head.

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Figure 11-9

Subacromial Space Surgery

Small Bankart lesion.

depth, (2) the patient’s desired activity level, (3) bone structure, and (4) cause of the tear. No one factor by itself determines treatment; the clinician must analyze the effects of all these factors to decide on the appropriate management. I have found the following guidelines helpful in the treatment of these troublesome lesions. The most critical decision is whether the tear can be treated by arthroscopic decompression alone or whether this must be accompanied by tendon repair. There is no general agreement on how the tear’s dimensions (length and width) should influence surgical decision making. Most authors recommend surgical repair if the tear extends to a depth of 50% or more of the tendon substance. If, while viewing from within the glenohumeral joint, the synovial tendon surface inserts at the level of the articular cartilage but there is a partial tear more proximally, I de´bride the area until I observe normal tendon fibers. I then use the known dimensions of the shaver to estimate the depth of the lesion. I assume that the normal tendon thickness is 6 to 8 mm and use that to estimate the tear depth. This applies to either the supraspinatus or the infraspinatus. If the supraspinatus tendon does not insert at the level of articular cartilage and there is exposed bone, I use Nottage’s guidelines and estimate a 10% tear for every millimeter of exposed bone. For example, 5 mm or more of exposed bone means a tear greater than 50%, in which case I usually repair the lesion. The method works only for the supraspinatus because the infraspinatus does not insert at the level of the articular cartilage, and an area of exposed bone

between the tendon insertion and the hyaline cartilage of the humeral head is normal. Sedentary patients with partial tears are more likely to do well with decompression alone; active patients are more likely to benefit from tendon repair. Patients with structural bone abnormalities (e.g., hooked acromion, inferior acromioclavicular joint osteophytes, anterior acromial spurs) are more likely to benefit from decompression. Patients with glenohumeral instability require correction of the lesions responsible for excessive translation. These factors are then considered in light of patient preference. Some patients prefer tendon repair if it can more reliably lead to a cure; others may choose de´bridement or decompression because that approach involves fewer lifestyle inconveniences. At each end of the decision-making spectrum, treatment is less controversial: active individuals with normal bone shape and tears involving more than 50% of the tendon thickness are best treated with surgical repair, whereas sedentary patients with acromial spurring and tears involving less than 50% of the tendon thickness can be treated successfully with arthroscopic decompression alone. For those in the middle, treatment is less well defined. Surgeon experience and patient preference, rather than scientific data, appear to dictate the treatment approach. The vast majority of partial-thickness tears appear on the articular surface of the rotator cuff tendon and are not visible during the inspection of the bursal surface that occurs during an open procedure. It therefore seems that the incidence of partial-thickness tears has been underestimated in the literature dealing with open shoulder surgery. Inspection of the cuff’s articular surface is better performed arthroscopically because the entire cuff can be easily evaluated and the location, size, and depth of the tear can be appreciated. The tear can be marked with a suture so that the surgeon can locate the lesion during subsequent subacromial inspection.

Articular Surface Partial-Thickness Tears Partial-Thickness Rotator Cuff Tear When an articular surface partial-thickness rotator cuff tear is noted during the diagnostic examination, the surgeon should establish an anterior portal and introduce a motorized shaver. Remember that the synovial lining, not the tendon, is visualized during this initial inspection. Using the shaver, perform a limited de´bridement to clearly establish the length, width, and depth of the tear. Some surgeons believe that a partialthickness rotator cuff tear is always an intrinsic

Chapter 11

Figure 11-10

tendinopathy and that de´bridement stimulates a healing response. I am not comfortable with such a general approach, so I first de´bride the partial tear to determine its size. If, based on the criteria discussed earlier, I decide that repair is necessary, I may use the shaver to complete the tear until the shaver enters the subacromial space. Usually I perform a limited de´bridement and, while viewing from the glenohumeral joint, percutaneously insert a spinal needle into the area of the partial tear. Generally, the needle is inserted near the anterolateral corner of the acromion because most articular surface partial-thickness rotator cuff tears are located in the anterior portion of the supraspinatus. If the tear is more posterior, the needle insertion point must be more posterior. I note how far the tear extends anteriorly, posteriorly, medially, and laterally from the needle. I then insert an absorbable monofilament suture through the needle and remove the needle (Figs. 11-10 through 11-17).

Figure 11-11

Partial-Thickness Rotator Cuff Tears

237

Percutaneous spinal needle insertion. Figure 11-12

needle.



Pass the monofilament suture through the

Needle through a partial-thickness rotator cuff

tear.

Figure 11-13

Figure 11-14

meral joint.

Insert the suture through the needle.

Advance sufficient suture into the glenohu-

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Anterior and posterior suture for a larger partial-thickness rotator cuff tear in the subacromial space.

Figure 11-15

Figure 11-16

Rotator cuff repair.

I remove the arthroscope from the glenohumeral joint and insert it into the subacromial space. If I can see the monofilament suture, I create a lateral portal so that the cannula enters the subacromial space near the suture. If I cannot see clearly because of proliferative bursitis, I insert a spinal needle percutaneously so that it enters the subacromial space in the approximate area of the tear. I have a general idea of the tear’s location and size based on my examination of the rotator cuff tendon from the glenohumeral joint. I insert the cannula and shaver and carefully remove bursal tissue beginning medial to the tear location until I can see the marking suture. By palpating the area of partial tear, one can appreciate the difference in tendon quality compared with normal tendon. I place the shaver near the point where the marking suture exits the tendon and remove the suture while holding the shaver firmly against the tendon. I de´bride the tendon near its insertion into the greater tuberosity until I enter the joint. I use the shaver to palpate underneath the tendon and determine the area of detachment. I remove the smallest amount of tendon possible because excessive de´bridement shortens the tendon. If the surgeon then attempts to repair the tendon to its anatomic insertion site, the repair will be under too much tension, which can lead to postoperative stiffness. I try to limit the de´bridement to 5 mm or less. If more de´bridement is necessary because of tendon damage, I recommend that the surgeon not repair the tendon edge laterally at its anatomic insertion site but do so more medially. This preserves the normal resting muscle length of the torn cuff tendon and decreases the incidence of tendon rupture and postoperative stiffness resulting from a repair under too much tension. A more medial repair requires that the bone suture anchors be positioned medial to their normal position. Once the articular surface partial-thickness rotator cuff tear is converted to a full-thickness tear, the surgeon can perform a standard rotator cuff repair.

Variations of Technique: Posterior Lesions

Figure 11-17

Rotator cuff repair, lateral view.

Partial-thickness rotator cuff tears are most often located on the articular surface of the anterior supraspinatus tendon. However, some lesions are located posteriorly, either in the posterior supraspinatus tendon or in the infraspinatus tendon. Because this area of the rotator cuff does not contact the anterior acromion during elevation, these lesions cannot be explained by the classic theory of outlet impingement. MRI studies have demonstrated that there is physiologic

Chapter 11

contact between the posterior rotator cuff and the posterior-superior glenoid during maximal abduction and external rotation. Therefore, contact that the surgeon observes between the rotator cuff and the glenoid on MRI or during arthroscopy is not necessarily pathologic. What is not clear at this time is why this contact causes no pain in some individuals but produces significant symptoms in others. If the patient’s complaints and physical examination findings demonstrate pain with abduction and external rotation localized to the posterior glenoid margin, the surgeon must search for a cause. Walch and Jobe have discussed the nature of posterior articular surface rotator cuff tears and have introduced the term internal impingement. There is no single explanation of the cause of internal impingement at this time. One theory is that anterior-inferior glenohumeral instability occurs as a primary event. The resulting excessive translation causes a traction lesion on the posterior rotator cuff tendon as the rotator cuff is called on to stabilize the humeral head. Another theory is that excessive anterior translation increases the frequency and degree of the normal physiologic contact so that, over time, compressive pathologic tendon and labrum lesions occur when the arm is placed in abduction and external rotation. Another line of reasoning is that internal impingement is caused by superior-posterior instability. The posterior contracture that occurs in throwing athletes causes traction on the posterior-superior labrum. Owing to a traumatic event or repetitive microtrauma, the biceps tendon—glenoid labrum anchor is detached. The loss of superior-posterior stabilization allows superior-posterior migration of the humeral head and rotator cuff. The resulting traction produces a rotator cuff tear. Some surgeons believe that instability is not necessary for the development of internal impingement and that simple repetitive compression of the posterior rotator cuff between the humeral head and glenoid is sufficient to cause damage. Another view is that a decrease in the normal 25 to 35 degrees of humeral retroversion leads to increased contact between the humeral head and the superior-posterior glenoid. This situation is similar to that confronting orthopedic surgeons in their search for an ‘‘essential’’ lesion to explain anterior-inferior glenohumeral instability. We have learned that anterior-inferior glenohumeral instability can result from a number of different causes. My own view is that all the causes just described can produce internal impingement, but in an individual patient, one of them will be predominant. It is the surgeon’s task to identify which cause is responsible for the patient’s pain. The analysis and diagnosis are

Figure 11-18



Partial-Thickness Rotator Cuff Tears

239

Posterior partial-thickness rotator cuff tear.

difficult, but once the cause of internal impingement is determined, the treatment is relatively straightforward (Figs. 11-18 through 11-21). The preoperative evaluation should document the direction and degree of translation compared with the uninvolved shoulder. I test the amount of internal rotation with the arm in 90 degrees of abduction in both the coronal and scapular planes. Radiography and MRI are usually necessary to determine the degree of rotator cuff involvement and the amount of humeral retroversion. During the arthroscopic evaluation I determine the direction and degree of humeral head translation and search for any signs that this translation is pathologic, such as labrum detachment. I carefully evaluate all areas of the labrum for detachment, fraying, or tearing. I assess the competency of the glenohumeral ligaments and the rotator interval. I move the arthroscope to the anterior portal to

Figure 11-19

View from the subacromial space.

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Bursal Surface Partial-Thickness Tears Although articular surface tears have various causes and require individualized treatment, bursal surface partialthickness rotator cuff tears are almost always the result of chronic subacromial impingement. The surgeon should convert these lesions to full-thickness tears and repair them with a standard technique. Yamaguchi has used diagnostic ultrasonography to demonstrate a very high rate of healing of these lesions after surgical repair.

POSTOPERATIVE TREATMENT Figure 11-20

Rotator cuff repair, posterior view.

examine the posterior rotator cuff and evaluate the contact between the cuff and the superior-posterior glenoid when I place the arm into abduction and external rotation. Gentle de´bridement may demonstrate a minor lesion of the synovial lining or tendon, or it may reveal a near full-thickness tendon tear. I continue the posterior examination to evaluate the status of the posterior-inferior glenohumeral ligament. If the primary shoulder problem is instability, I perform an arthroscopic correction. If the partialthickness rotator cuff tear is minor, it is reasonable to treat it with de´bridement alone. If the partial-thickness rotator cuff tear is grade 2 or 3, I mark it with a needle and suture and view the lesion from the subacromial space. I then complete the tear and repair it with a standard technique.

Figure 11-21

Rotator cuff repair, lateral view.

Patients whose partial-thickness rotator cuff tears are treated with de´bridement alone undergo rehabilitation similar to that of patients treated with arthroscopic decompression for subacromial impingement. A modification is made for strengthening, however. I do not strengthen the involved muscle for at least 3 months, or until manual muscle testing does not produce pain. At that point, the muscle can be rehabilitated routinely. If a partial-thickness rotator cuff tear is converted to a full-thickness tear, rehabilitation proceeds as described for rotator cuff tears.

BIBLIOGRAPHY Andrews JR, Broussard TS, Carson WG: Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: A preliminary report. Arthroscopy 1:117-122, 1985. Bey MJ, Ramsey ML, Soslowsky LJ: Intratendinous strain fields of the supraspinatus tendon: Effect of a surgically created articular-surface rotator cuff tear. J Shoulder Elbow Surg 11:562-569, 2002. Cordasco FA, Backer M, Craig EV, et al: The partial-thickness rotator cuff tear: Is acromioplasty without repair sufficient? Am J Sports Med 30:257-260, 2002. Esch JC: Arthroscopic subacromial decompression: Results according to the degree of rotator cuff tear. Arthroscopy 4:241-249, 1988. Fukuda H: Partial-thickness rotator cuff tears: A modern view on Codman’s classic. J Shoulder Elbow Surg 9:163-168, 2000. Gartsman GM, Milne J: Partial articular surface tears of the rotator cuff. J Shoulder Elbow Surg 4:409-416, 1995. Snyder S: Partial thickness rotator cuff tears: Results of arthroscopic treatment. Arthroscopy 7:1-7, 1991. Spencer EE, Dunn WR, Wright RW, et al: Interobserver agreement in the classification of rotator cuff tears using magnetic resonance imaging. Am J Sports Med 36:99-103, 2008. Vinson EN, Helms CA, Higgins LD: Rim-rent tear of the rotator cuff: A common and easily overlooked partial tear. AJR Am J Roentgenol 189:943-946, 2007. Wolff AB, Sethi P, Sutton KM, et al: Partial-thickness rotator cuff tears. J Am Acad Orthop Surg 14:715-725, 2006.

CHAPTER

12

Full-Thickness Rotator Cuff Tears

An arthroscopic rotator cuff repair consists of the following elements: glenohumeral joint inspection, subacromial space inspection, partial bursectomy, assessment of rotator cuff tendon reparability, identification of tear geometry, coracoacromial ligament resection, acromioplasty, greater tuberosity repair site preparation, anchor placement, suture placement, and knot tying. Each of the individual elements can be accomplished arthroscopically; however, performing them in a single operation requires strict adherence to a systematic operative technique.

LITERATURE REVIEW Since the mid-1990s, the repair of full-thickness rotator cuff tears has undergone a transition from open techniques to combined open and arthroscopic methods (mini-open repair) to exclusively arthroscopic repairs. During this time, orthopedic surgeons have documented the successful arthroscopic treatment of the entire spectrum of rotator cuff lesions, including stage 2 impingement and partial- and full-thickness tears. Initially, the issue was one of efficacy—whether an expert surgeon could technically reproduce all the elements of an open rotator cuff repair arthroscopically. Despite a modest amount of skepticism, the orthopedic community recognized that this was possible. The next step was to determine whether other surgeons could reproduce the operation—the effectiveness issue. This too was resolved (after some interesting

sturm und drang) in favor of arthroscopic rotator cuff repair. Analyses of the clinical results paralleled these technical issues but necessarily followed them as we awaited patient follow-up. As reports demonstrated patient outcomes as good as or better than those obtained with open repair, the general consensus emerged that arthroscopic rotator cuff repair was a successful operation. A great degree of attention was focused (and continues to be focused) on the technical aspects of the operation, such as anchor types, suture patterns, suture materials, and instruments. More recently, studies focused on healing rates after arthroscopic rotator cuff repair, using methods such as magnetic resonance imaging (MRI), contrast-enhanced MRI or computed tomography, and diagnostic ultrasonography. These studies present a wide spectrum of healing rates ranging from 90% for isolated supraspinatus tears to 0% for large and massive tears. Appropriately, this is an area of intense focus. Most interesting is the interpretation of why healing rates are so low. At least one editorial has attributed low healing rates to arthroscopic repair techniques. Although I certainly agree that all our techniques could benefit from improvement, I was struck by the lack of intellectual rigor on this issue. Those who fault arthroscopic repair argue that arthroscopic healing rates are inferior to the good clinical results of open rotator cuff repair. This, however, is a breakdown in intellectual reasoning because it is a classic ‘‘apples to oranges’’ comparison. Critics do not compare the clinical results of arthroscopic rotator cuff repair to the clinical results of

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open repair, nor do they compare the MRI or ultrasound healing rates of arthroscopic repair to the healing rates of open repair (although this would be valuable information). Instead, there is an oblique linking of two related but not truly comparable concepts: clinical outcome and anatomic healing. The thinking appears to be that the good clinical results of open rotator cuff repair were the result of a high anatomic tendon-to-bone healing rate. However, there is no evidence that this is true. Early arthrogram studies demonstrated a high percentage of patients with dye linkage, and Harryman’s classic ultrasound work demonstrated that 80% of isolated supraspinatus tears and less than 50% of large tears were healed. Somehow these studies were dismissed as aberrant because everyone knew that their own results were inconsistent with such high failure rates. Again, intellectual confusion occurred. Surgeons knew that their clinical results were good and therefore assumed that their anatomic results must be good as well, all scientific evidence to the contrary. It was as if we could not believe that Harryman’s healing rates applied to our own efforts. Further, our misplaced confidence in anatomic healing affected patients’ rehabilitation regimens. Because we knew the repair was secure and would heal, the most important obstacle became return of motion; thus the prevailing dogma was early passive range of motion. These notions were called into question by the work of Deutsch, who demonstrated better rotator cuff repair healing with a rehabilitation program that moved more slowly than previous protocols called for. He reasoned that large ranges of motion could cause a loss of contact between the tendon and the footprint and result in diminished healing rates. There has been little confirmation of Deutsch’s findings, but based on his good results and his superb thought process, I have changed my rehabilitation protocol to reflect his views. I suspect that today, MRI and ultrasound studies would demonstrate an equal amount of healing in open and arthroscopic repair groups. The real lesson for me has been that although my patients do well clinically, I should try to increase the rate of anatomic healing. I have attempted to do this (where possible) by changing my repair construct (double-row suture bridge), rehabilitation program (limited, gentle, passive range of motion), and outcome analysis (diagnostic ultrasonography to evaluate repair integrity). I am closely following the exciting science of biologic and synthetic measures to increase tendon healing to bone, as well as the impressive laboratory work being done in genetic manipulation.

DIAGNOSIS The clinical presentation of patients with full-thickness rotator cuff tears is similar to that of patients with stage 2 impingement, although complaints of weakness, particularly with overhead activity, may be greater. Plain radiographs are essential to evaluate the shoulder for glenohumeral arthritis, superior migration of the humeral head, acromioclavicular joint arthritis, inferior acromioclavicular joint spurs, and acromial shape. MRI provides information about the size and retraction of the rotator cuff tear and, more important, the degree of atrophy in the rotator cuff muscles (Figs. 12-1 through 12-5). The findings of the clinical examination are most commonly correlated with those of radiologic studies (arthrography, MRI, diagnostic ultrasonography) to make the diagnosis. Arthroscopy can also be used to diagnose the presence and size of a complete rotator cuff tear, although no authors have suggested that this be done routinely. The arthroscope is most useful in diagnosing complete tears in patients who have falsenegative imaging studies. False-negative results occur most frequently with arthrography, particularly if the synovial lining remains intact, or with MRI if the tear is smaller than 1 cm. I have found the injection of contrast material (gadolinium) to be helpful in increasing MRI’s accuracy, particularly in patients with partial-thickness rotator cuff tears.

Figure 12-1

Type 3 acromion.

Chapter 12



Figure 12-4

Figure 12-2 Anterolateral acromial spur.

NONOPERATIVE TREATMENT The basic elements of nonoperative treatment are similar to those for patients with stage 2 impingement. They consist of selective rest and activity modification (avoidance of painful activities and

Figure 12-3

Ossification of the coracoacromial ligament.

Full-Thickness Rotator Cuff Tears

243

Full-thickness rotator cuff tear.

positions), nonsteroidal anti-inflammatory medication to reduce pain, and a home rehabilitation program designed to correct deficits of motion (with passive stretching) and to strengthen the uninvolved shoulder muscles. The presence of a full-thickness rotator cuff tear is not an absolute indication for operation. I believe that some patients—those with good-quality rotator cuff tendons, a specific injury that caused the onset of their symptoms, and little tendon retraction on MRI—can be treated nonoperatively. I observe their progress monthly for a 3-month period and assess healing (or nonhealing) with diagnostic ultrasonography. At that point, if their pain is controlled and they have good function, we discuss their options. I inform them that our current understanding of full-thickness rotator cuff tears is that best

Figure 12-5

Supraspinatus atrophy.

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results are achieved with prompt surgical repair. Delay in repair results in muscle atrophy that can have no positive impact on the ultimate outcome. If a patient has significant pain or functional impairment, the decision for operation is straightforward. However, for those who have minimal symptoms or those whose symptoms have gone from severe to minimal, it is difficult to commit to a rotator cuff repair and the subsequent period of recovery when they perceive no real shoulder problem. There is no simple answer to this dilemma other than to discuss honestly the current level of scientific knowledge and counsel patients as they make their decisions. I relate my experiences with patients who have returned at a later date and undergone successful operation, as well as those who eventually return with irreparable lesions. The decision is easier in patients who already have significant tendon retraction and muscle atrophy; in these patients, nonoperative treatment is less risky because the rate of tendon healing after operation is low, and pain relief is the goal. I recommend Yamaguchi’s chapter in Arthroscopic Rotator Cuff Surgery, edited by Abrams and Bell.

INDICATIONS FOR SURGERY The indications for arthroscopic rotator cuff repair are identical to those for open repair. The surgeon should not alter or ‘‘broaden’’ the indications in the mistaken view that arthroscopic repair is a minor procedure. Although the skin incisions are smaller and the deltoid is left attached, arthroscopic repair incorporates all the elements of open repair. I have repaired all sizes and shapes of rotator cuff tears arthroscopically and have not performed any open repairs in my last 2000 operations. I find it helpful to present patients with printed information outlining the postoperative rehabilitation and activity limitations. I have them read this material in the office and then discuss any questions and concerns they may have. Because patient retention of this information is generally poor, I offer this (and other relevant information) on a website.

CONTRAINDICATIONS TO SURGERY Patients who are unable to tolerate either the open surgery itself or the postoperative rehabilitation are not candidates for arthroscopic rotator cuff repair. Poor tendon quality, musculotendinous retraction, and muscular atrophy are not improved with arthroscopy.

OPERATIVE TECHNIQUE Rotator Cuff Repair, Single Row—Animation Rotator Cuff Repair, Single Row—Model Rotator Cuff Repair, Single Row Rotator Cuff Repair, Longitudinal Repair—Model Rotator Cuff Repair, Longitudinal Repair Rotator Cuff Repair, Horizontal Cleavage Tear—Model Anesthesia I use interscalene block anesthesia supplemented with general anesthesia. Regional anesthesia allows the use of less anesthetic agent, minimizes postoperative side effects, and provides excellent pain relief in the postoperative period. General anesthesia eliminates movement due to patient discomfort on the operating table.

Positioning I prefer to have the patient in the sitting position. The orientation of the shoulder is similar to that during open procedures, and this position allows easy access to the anterior, lateral, and posterior aspects of the shoulder. I pay particular attention to the inclination of the acromion, which should be horizontal. The amount of posterior acromial slopes varies from patient to patient, and failure to position the patient so that the acromion is parallel to the floor results in the surgeon directing the arthroscope more vertically and having to work ‘‘uphill.’’ Patient positioning is greatly facilitated by the use of the Schloein patient positioner (Orthopedic Systems Inc., Union City, Calif), and the arm is controlled with a McConnell arm holder (McConnell Orthopedics, Greenville, Tex) or a Spyder arm positioner (Smith-Nephew Endoscopy, Andover, Mass). The Schloein speeds patient positioning and allows excellent access to the

Chapter 12

Figure 12-6



Full-Thickness Rotator Cuff Tears

245

Acromion parallel to the floor.

posterior shoulder without translating the patient off the side of the operating table. The Spyder or the McConnell allows the surgeon to position the arm without help from the assistant and is invaluable in maintaining proper arm rotation so that the repair site is directly underneath the operating cannula (Figs. 12-6 and 12-7).

Portals I routinely use three portals: posterior, lateral, and anterior. The posterior portal is 1.5 cm medial and 1.5 cm inferior to the posterolateral acromial border, the lateral portal is 2 cm posterior to the anterior acromial border and approximately 2 to 4 cm lateral to the acromion, and the anterior portal is 2 cm anterior to the anterolateral acromion. The posterior portal is made superior to the traditional point of entry in the ‘‘soft spot’’ so that the arthroscope enters the subacromial space parallel to and just underneath the acromial undersurface. This maximizes the distance between the arthroscope and the rotator cuff tear and improves

Figure 12-8 The soft spot is inferior and medial to my preferred glenohumeral joint entry site.

the surgeon’s ability to determine tear size and geometry. The lateral portal should allow the cannula to enter midway between the humeral head and the acromion. This location facilitates acromioplasty and enables the surgeon to tilt the cannula inferiorly toward the humeral head for easy placement of suture anchors in the greater tuberosity for rotator cuff repair. The anterior cannula is used for outflow and retrieving sutures but can also be used for insertion of an anterior anchor. This cannula is inserted after the acromioplasty. I identify the precise location with a spinal needle so that the center of the cannula is parallel with the tendon repair location. If the cannula is too medial, it is difficult to retrieve sutures from the anchors owing to interference from the patient’s head. Conversely, suture retrieval from the bursal rotator cuff surface is difficult if the anterior cannula is located too laterally. Other portals are used as needed (Figs. 12-8 through 12-11).

Glenohumeral Joint

Figure 12-7

McConnell arm holder base.

I first determine the range of motion and stability of the shoulder with an examination under anesthesia and then perform an arthroscopic glenohumeral joint inspection. Intra-articular lesions are not visualized during open repair, precluding an adequate comparison with arthroscopic findings. Most arthroscopic studies report abnormalities such as focal synovitis, partial biceps tendon tears, arthritic changes in the humeral head or glenoid, labrum tears, and loose bodies. It is uncertain whether these intra-articular lesions arise because of the cuff tear or are merely

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Figure 12-9

Lateral portal. Figure 12-12

Loss of space between the biceps and the

supraspinatus.

Figure 12-10

Accessory lateral portals.

part of the normal aging process. Arthroscopic findings in older patients with irreparable tears include arthritic changes, synovitis, and biceps tendon tears. Not surprisingly, these findings occur with a higher frequency than in patients with partial or complete rotator cuff tears that are reparable. Overall, glenohumeral joint abnormalities occur in 12.5% of patients and include osteoarthrosis, biceps tendon tears (partial or complete), labrum tears, labrum separations (superior labrum from anterior to posterior [SLAP] lesions), synovitis, and capsular contracture. During arthroscopy of the glenohumeral joint, absence of the normal space between the biceps tendon and the supraspinatus indicates a complete rotator cuff tear (Fig. 12-12). On completion of the glenohumeral joint inspection, I remove the arthroscope from the joint.

Subacromial Space

Figure 12-11

Anterior portals.

I redirect the cannula and trocar through the same posterior skin incision into the subacromial space and palpate the acromial undersurface with the cannula. I then sweep the cannula medially and laterally to make certain that no portion of the rotator cuff is adherent to the acromion (Figs. 12-13 through 12-15). The arthroscope is then inserted, and usually the space is easily seen. The camera is oriented so that the acromion appears horizontal and parallel to the floor; I try to maintain this orientation throughout the procedure. I also try to maintain the maximal distance between the arthroscope and the tendon lesion, which helps me appreciate the extent of the tendon tear (Fig. 12-16).

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247

1

2

Figure 12-13

Subacromial space entry. 2001 after Hengst

Figure 12-16 Maintain distance between the arthroscope lens and the rotator cuff.

Figure 12-14

Palpate the anterior acromion and trocar tip.

Figure 12-15

Sweep the cannula.

The lateral portal is identified with a spinal needle inserted percutaneously and directed so that it is 2 cm posterior to the anterior acromial border and positioned midway between the acromion and the greater tuberosity. The goal is to have the lateral cannula positioned in the center of the rotator cuff tear in the anterior-posterior plane and midway between the acromion and the rotator cuff insertion site. I move the spinal needle until the position is perfect and then I make a stab wound and insert the lateral cannula. The first goal is clear visualization of the subacromial space. Bursae that obscure visualization are removed with a power shaver (Figs. 12-17 and 12-18); however, the surgeon should be careful not to alter the appearance of the rotator cuff or acromion. Bursal tissue is involved in the healing response, and complete bursectomy is unwarranted. Avoid removing any bursa medial to the rotator cuff musculotendinous junction, because this area is very vascular. Once the bursa is removed, the acromion and coracoacromial ligament are examined for signs of impingement such as erythema, fraying, and fibrillation (Figs. 12-19 and 12-20). I then establish an anterior portal and insert a cannula. This improves fluid outflow and visualization (Figs. 12-21 through 12-25).

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Insert the needle for the lateral cannula parallel to the acromion.

Figure 12-17

Figure 12-20

Figure 12-21 Figure 12-18

Figure 12-19

Bursectomy.

Coracoacromial ligament erythema.

Coracoacromial ligament fraying.

Establish the anterior portal location with a

spinal needle.

Figure 12-22

Anterior needle too lateral.

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Full-Thickness Rotator Cuff Tears

Figure 12-26 Figure 12-23

249

Introduce the measuring probe.

Anterior needle too medial.

Tear Classification

Figure 12-24

Anterior needle parallel to the rotator cuff edge.

Figure 12-25

Anterior cannula.

The arthroscope is rotated so that it points directly down at the rotator cuff tear. With small to mediumsized tears, their size and geometry are easily appreciated. Tear size is measured by comparing it to the known diameter of the lateral cannula or measuring it with an arthroscopic probe. The length of the tear from anterior to posterior, as well as the amount of medial retraction, is noted (Figs. 12-26 through 12-31). Straight medial retraction or retraction in an elliptical shape is the most common finding. As tear size increases, the surgeon is less able to appreciate tear geometry. In a right shoulder, reverse L-shaped tears with a longitudinal component along the rotator interval allow the tear to rotate posteriorly. L-shaped tears have a longitudinal limb posteriorly, often at the

Figure 12-27

Measure the rotator cuff tear.

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Transverse tear

Figure 12-28

Transverse tear. Figure 12-31

Figure 12-29

Transverse tear.

Elliptical tear.

junction of the supraspinatus and infraspinatus, in addition to the lateral, transverse detachment at the greater tuberosity (Figs. 12-32 through 12-36). Longitudinal tears may occur in the area of the rotator interval and occasionally within the substance of the supraspinatus. Only when tear geometry is appreciated can the surgeon perform an effective repair. I use a tissue grasper to pull on the tear edge, attempting to determine the repair site location. Varying both the direction of pull and the arm positions of elevation, abduction, and rotation is often required. Typically, the arm is positioned in 20 degrees of elevation, 15 degrees of abduction, and 10 degrees of internal rotation (Figs. 12-37 through 12-44). The arm is maintained in this position with a mechanical arm holder (e.g., Spyder or McConnell). Only when I determine that the tear is reparable do I

Elliptical tear L-shaped tear

e appe shha L–s

Figure 12-30

Elliptical tear.

Figure 12-32

L-shaped tear.

L-shaped repair.

Figure 12-33

Figure 12-36

Reverse L-shaped tear repair.

e aappe -–sshh L e

s ver Re

Reverse L-shaped tear

Figure 12-34

Reverse L-shaped tear.

Figure 12-35

Reverse L-shaped tear.

Figure 12-37 Insert the grasper through the lateral cannula to test tendon mobility.

Figure 12-38 Insert the grasper through the lateral cannula to test tendon mobility.

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Figure 12-39 Insert the grasper through the anterior cannula to test tendon mobility.

consider whether a subacromial decompression is appropriate. I prefer to avoid a subacromial decompression because I have found that in patients with a type 2 acromion, it has no beneficial effect on the outcome of the rotator cuff repair. If the tear is irreparable or is unlikely to be durable, subacromial decompression is unwise because it will destroy the static stabilizing effect of the coracoacromial arch (acromion and coracoacromial ligament) and allow anterior-superior subluxation or escape of the humeral head. With larger or retracted tears, it is helpful to move the arthroscope to the lateral portal to gain an additional perspective.

Externally rotate the arm until the tear is reduced and directly under the lateral cannula.

Figure 12-40

Figure 12-41 Abduct and externally rotate the arm until the tear is reduced and directly under the lateral cannula.

Coracoacromial Ligament If a full-thickness rotator cuff tear is reparable and the result of chronic impingement, and if I determine that subacromial decompression is needed, I divide the coracoacromial ligament at its lateral insertion point on the acromion. I prefer to use electrocautery owing to the rather inconvenient location of blood vessels in

Figure 12-42 Abduct the arm until the tear is reduced and directly under the lateral cannula.

Chapter 12



Figure 12-45

Figure 12-43 Extend the arm until the tear is reduced and directly under the lateral cannula.

this area. Once the lateral margin of the ligament has been released, I use a power shaver to resect the ligament to the medial acromial border (Figs. 12-45 and 12-46).

Acromioplasty I (and others) do not find the routine use of acromioplasty beneficial. However, these few reports must be

Elevate the arm until the tear is reduced and directly under the lateral cannula.

Full-Thickness Rotator Cuff Tears

253

Identify the anterolateral acromion.

balanced against the long-standing and widespread use of acromioplasty with generally good results. My own sense is that we do not yet have a complete picture, and additional studies will more accurately define the role of acromioplasty in rotator cuff repair surgery. The goal of acromioplasty is to increase the size of the subacromial space. I therefore perform acromioplasty if the subacromial space is tight and I cannot visualize the area adequately or maneuver my instruments effectively. I make this decision at the time of operation irrespective of the acromial type. A type 2 or 3 acromion is converted to a flat, type 1 acromion. Unless the bone is extremely thick, there is no need to perform acromioplasty for a type 1 acromion. I do not try to alter the medial-lateral or anterior-posterior dimensions of the acromion. If the acromion has a lateral slope as identified on MRI or plain radiographs, the inferior aspect of the lateral acromion is thinned.

Figure 12-44

Figure 12-46

Cauterize the inferior acromion.

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Figure 12-47



Subacromial Space Surgery

Completed acromioplasty.

I start the acromioplasty laterally and resect bone until the inferior portion of the medial acromion is removed and the soft tissue of the acromioclavicular joint is visible (Fig. 12-47).

Figure 12-48

Completed acromioclavicular joint resection.

to control owing to the medial location of the bleeding vessels. Anterior adhesions to the coracoid are usually very thick and require release with electrocautery. This is particularly true in the area of the coracohumeral ligament (Figs. 12-49 through 12-51).

Acromioclavicular Joint After I remove the medial acromion and the acromioplasty is completed, the acromioclavicular joint comes into view. In my opinion, clavicular coplaning (removing the inferior one third of the distal clavicle with a power bur) is not effective. Only if the patient has symptoms consistent with acromioclavicular joint arthritis based on the preoperative history (pain localized to the acromioclavicular joint with cross-body adduction or behind-the-back internal rotation) and examination (acromioclavicular joint tenderness on palpation) do I perform an acromioclavicular joint resection (Fig. 12-48).

Repair Site Preparation The next step is preparation of the bone surface at the repair site. A 4-mm round bur is used to prepare a cancellous bed for the tendon. I remove 1 mm (or less) of cortical bone until the cancellous bone is visible. I consider this portion of the procedure a decortication (Figs. 12-52 through 12-54). I do not place the tendon in a trough. The site of bone preparation is based on tendon mobility. If an anatomic repair is possible, the bone is prepared from

Cuff Mobilization Adhesions may form within the subacromial space between the rotator cuff and the acromion or between the rotator cuff and the deltoid, interfering with tendon mobilization. Adhesions to the coracoid or a coracohumeral ligament contracture may restrict rotator cuff tendon excursion and thereby give the false impression of irreparability. Posterior adhesions usually are not dense and can often be released by inserting a metal trocar and cannula through the lateral portal, placing it superior to the anterior tear edge and sweeping it posteriorly directly beneath the acromion. Occasionally, electrocautery is used to divide adhesions if they are particularly thick. It is unwise to attempt to remove dense adhesions with a power shaver; bleeding often results, and it is difficult

Figure 12-49

Subacromial adhesion.

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Full-Thickness Rotator Cuff Tears

Figure 12-52 Figure 12-50

Prepare the repair site.

Subdeltoid cuff adhesion.

the articular margin of the humeral head to the greater tuberosity. The tendon tear length determines the anterior-to-posterior dimension of the bone preparation site. The width is the distance from the articular cartilage of the humeral head to the medial margin of the greater tuberosity, generally 1 to 2 cm. If anatomic repair is not possible without excessive tendon tension, I move the repair site. I prefer to repair the tendon up to 10 mm medially without tension rather than repair it anatomically under excessive tension.

Repair site decortication

Figure 12-53

Width and depth of the repair site.

Releasing coracohumeral ligament

Figure 12-51

255

Coracohumeral ligament release.

Figure 12-54

Bone abrasion.

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Anchor Selection Anchor Design The ideal suture anchor has the following characteristics: (1) it allows firm fixation in the greater tuberosity, (2) the surgeon can select the type of suture loaded on the anchor, (3) the anchor can be inserted manually without the need for predrilling or power instruments, (4) the suture slides through the anchor, (5) the anchor is removable from the bone in case of suboptimal placement or suture breakage, (6) the anchor is attached securely to the inserting device so that it does not become dislodged during placement within the tight confines of the subacromial space, (7) the anchor can penetrate the bone at an acute angle, and (8) it is biodegradable without any adverse effects. No currently available suture anchor meets all these criteria. Each anchor has relative advantages and disadvantages, and the choice is based on the surgeon’s personal preference. At present, I use 5-mm metallic anchors (SmithNephew Endoscopy, Andover, Mass) for rotator cuff repair. These anchors have excellent pullout strength. The handle design and shaft length of the inserter are appropriate. The anchors are firmly attached to the inserter shaft so that they do not dislodge as the surgeon manipulates the anchors within the subacromial space. The anchors have a trocar tip so that predrilling is not necessary. I prefer not to predrill during rotator cuff repair because the area lateral to the tuberosity is covered with soft tissue, making it difficult to find the screw hole. I also like an anchor I can insert with one hand while I hold the arthroscope with the other. With tap-in anchors, the assistant has to hold the arthroscope while the surgeon positions the anchor with one hand and uses the mallet with the other. The Smith-Nephew anchor has two preloaded No. 2 Ultrabraid sutures; one suture is striped, and the other is white, which helps me select the appropriate suture during the repair. The anchor eyelet is large enough to allow the sutures to slide freely during knot tying (Figs. 12-55 through 12-60).

Figure 12-55

Insert the anchor with fingertip pressure.

I do not like the tissue reactions observed with currently available bioabsorbable anchors, but I am confident that further research will alleviate this problem. I have had difficulty inserting plastic nonabsorbable anchors owing to anchor deformation with less than optimal insertion. I have no experience with allograft bone anchors, which offer the advantage of bone graft to the proximal humerus.

Anchor Material Anchors are available in four different materials: metal, nonabsorbable plastic, bioabsorbable plastic, and allograft bone. I prefer metal anchors because they offer secure fixation and lower cost. I also like that they are radiopaque, which allows me to visualize anchor pullout or migration on plain radiographs. The disadvantage of metal anchors is that they compromise postoperative MRI, even when special digital subtraction techniques are used.

Anchor is inserted perpendicular to the greater tuberosity.

Figure 12-56

Chapter 12

Slide the cannula to the greater tuberosity if soft tissue is interfering.

Figure 12-57



Full-Thickness Rotator Cuff Tears

257

Figure 12-60 The horizontal mark indicates depth, and the longitudinal mark indicates eyelet orientation.

Suture Selection Because the identification and management of sutures within the subacromial space can be difficult, it is advantageous to use different colored sutures. The anchor is preloaded with one white and one striped suture. This allows the surgeon to easily identify which suture corresponds to each suture anchor. I prefer braided, nonabsorbable No. 2 Ultrabraid.

Anchor Placement

Figure 12-58

Anchor trocar tip penetrates bone without

predrilling.

Figure 12-59

Insert the anchor distally.

The number of anchors depends on the length and geometry of the rotator cuff tear. For all but the smallest tears, I use two anchors. I place the anchors lateral to the greater tuberosity for the following reasons: 1. The anchor is placed in bone with an intact cortical surface, compared with the prepared cancellous bed of the repair site. 2. Bone density is greater in this distal location than in more proximal bone. 3. The angle of anchor insertion between the anchor and the bone is minimized, allowing a ‘‘straight-in’’ anchor insertion. 4. The anchor can be inserted through the cannula without the need for a percutaneous insertion. 5. A lateral anchor position places the vector of tendon pull approximately 90 degrees to the longitudinal axis of the anchor, minimizing anchor pullout (Fig. 12-61). 6. The tendon can be repaired anatomically (Fig. 12-62). If the anchors are positioned medially on the tuberosity, the ultimate healing site is also moved medially.

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Subacromial Space Surgery

The Smith-Nephew anchor inserter has two marks near the anchor end. The circumferential, transverse mark indicates the appropriate depth of insertion. I insert the anchor until this line is beneath the bone cortex. The longitudinal lines on the inserter shaft indicate anchor eyelet orientation. The eyelet opening lies in the plane perpendicular to the plane that incorporates the two longitudinal lines. Proper eyelet orientation is critical so that the sutures slide freely during knot tying. Theoretically, the eyelet should be parallel to the tendon edge, allowing the sutures to slide most easily. The problem during surgery is that selecting the appropriate suture limb is both technically challenging and complicated by the anchor eyelet’s subcortical location and obscuring bursa. If the surgeon selects the suture limb nearest the tendon edge for passage through the tendon, the suture slides freely while tying; if the opposite limb is selected, the suture strands cross after passage through the tendon, causing resistance to sliding. To eliminate this problem, I orient the eyelet perpendicular to the tendon edge. With the eyelet in this position, it does not matter which suture limb I select for passage; the eyelet is large enough so that either suture limb will slide freely. Some newer anchors solve this problem by allowing the eyelet to rotate freely. Some surgeons prefer to insert all anchors in the bed of the sulcus to repair the tendon more directly to the repair site. Others prefer a ‘‘double-row’’ technique with anchors inserted laterally to repair the tendon anatomically and an additional row of anchors inserted medially for tendon-bone approximation. A recent addition to rotator cuff repair techniques is the suture bridge repair. This technique uses two medial anchors and two lateral anchors with the sutures in a crossing pattern. (The double-row and suture bridge techniques are discussed in more detail later in this chapter.)

90

°a

ng

le

pu

ll

Figure 12-61

Right angle between the tendon and the

anchor.

tuberosity. I apply slight pressure until the trocar tip punctures the cortex. I then rotate the handle and let the anchor threads advance the anchor without pushing inward. I do not apply pressure to the anchor handle; the osteoporotic bone in some patients would allow the anchor to plunge into the humerus. After I insert each anchor, I pull on the suture strands to test anchor fixation. Ideally, one should be able to translate the humeral head (and the patient) laterally when pulling on the sutures. This step ensures that the anchors are well inserted. After the anchors are inserted, I pass the anchor sutures through the tendon. Passing the sutures independently of the anchor makes it easier to determine the precise location of suture penetration through the tendon.

Single-Row Repair I repair the rotator cuff tear with the patient’s arm in relative adduction. If the tendon cannot advance to its anatomic insertion point with the arm in adduction, I repair the tendon medially (Figs. 12-63 and 12-64). I have found that function is not compromised by moving the tendon insertion site up to 10 mm medially. I do not believe that you can repair the tendon in abduction, brace it postoperatively, gradually lower the arm, and have the repair ‘‘stretch.’’ I place the most anterior anchor first and proceed posteriorly with additional anchors as needed. I position the anchor trocar tip against the humeral cortex approximately 5 to 7 mm distal to the greater

Anatomic anchor repair

Figure 12-62

Anatomic repair.

Chapter 12

An alternative technique is to insert an anchor, pass the sutures, and tie the knots before proceeding to the next anchor. If the surgeon is comfortable with this technique, it may produce good results. I find this approach difficult for two reasons. First, with large tears, it is often difficult to judge which suture goes where, and errors in anatomic repair are more likely. Second, with smaller tears, if the knots are tied and a portion of the tendon is repaired, it is possible to disrupt the repair when using suture passing instruments for the remainder of the repair. After I insert each anchor, the assistant inserts a crochet hook through the anterior cannula, pulls the four suture strands out the cannula, and clamps them with a hemostat so that each group of sutures is kept together. It is helpful to use a different sized hemostat for each group of four sutures to designate which anchor they originate from.

Suture Placement Once suture anchor placement has been completed, the braided sutures are passed through the torn tendon. The soft tissue grasper is passed through the lateral cannula, and the precise location of the tendon repair as well as the location and spacing of each suture are estimated. I space the sutures evenly from the anterior and posterior margins of the tear and place them approximately 5 to 8 mm from the tendon edge. I insert the anchors from anterior to posterior and then pass the sutures through the tendon from anterior to posterior.

Suture Passing Elite Suture Passer Technique I insert a crochet hook through the lateral cannula, retrieve the most anterior suture, and bring it out the lateral cannula. My assistant loads the suture in the jaws of the Elite instrument. I insert the Elite through the lateral cannula and place the most anterior suture in the rotator cuff tendon as medially as possible. The precise location of the suture varies based on the location of the musculotendinous junction, which extends quite laterally in some patients. Passing sutures through the muscular portion is difficult because the needle or the suture may be hard to identify and retrieve. This requires a different type of insertion technique or a more lateral suture placement. My assistant inserts a suture grasper through the anterior cannula and grasps the suture as it exits from the rotator cuff. After my assistant assures me that the suture is grasped securely, I open the jaws of the Elite instrument and remove it out the lateral



Full-Thickness Rotator Cuff Tears

259

Medial repair site with retracted tendon

Figure 12-63

Retracted rotator cuff tear.

cannula. Only then does my assistant remove the suture out the anterior cannula. If we both remove our instruments simultaneously, errors in suture management may occur. It is important to perform one step at a time. The sutures are then placed from anterior to posterior using the previously described technique (Figs. 12-65 through 12-77).

Caspari Suture Punch Technique The Caspari suture punch does not accept braided suture, so I use a 2-0-nylon suture, looped in half, as a suture relay. I prefer this over a wire shuttle because of its lower cost and ready availability. The two free ends are passed into the suture punch, and the loop end exits from the handle. I insert the Caspari punch through the lateral cannula and grasp the tendon at the point that I believe should be translated to the anterior anchor. I close the Caspari jaws slightly but do not puncture the tendon—the instrument functions as a tissue grasper. I then pull the tendon toward the anterior anchor and determine whether this is indeed an anatomic repair.

Medial anchor repair

Figure 12-64

Medial repair.

260

Section Three



Subacromial Space Surgery

Disrupted suture

Caspari disrupting repair of previously tied suture

Figure 12-65

Suture instrument can disrupt the repair.

Figure 12-68

Test cuff mobility.

Often, some change in humeral position is necessary. Once I have identified the appropriate site for the first suture, I close the jaws until I can see the needle tip of the suture passer exit from the tendon. The tendon is grasped and punctured, and the two paired suture ends are advanced into the subacromial space. This seemingly simple step can prove quite difficult because of tendon thickness and bursae overlying the tendon surface. The needle on the Caspari punch is 4 mm, and if the tendon thickness is greater than 5

Figure 12-66

Double-row technique.

Figure 12-67

Abrade repair site.

Figure 12-69

Insert anterior anchor.

Chapter 12

Figure 12-70

Full-Thickness Rotator Cuff Tears

261

Retrieve sutures.

to 6 mm, it is hard to pass the needle tip completely through the tendon. My solution to this problem was to ask the manufacturer Linvatec to modify the needle tip and increase its length to 6 mm. This small change helped me greatly, and the modified instrument is now available to any surgeon. Another technique I use is to twist the Caspari punch while pulling on the tendon so that I force the needle through the tendon. If I can see a thin layer of bursa or tendon covering the needle tip but I cannot advance the nylon sutures, my assistant inserts a crochet hook

Figure 12-71



Insert posterior anchor.

Figure 12-72

Pass posterior sutures out anterior cannula.

through the anterior cannula to sweep away the bursa and provide counterpressure. This allows the needle tip to penetrate the tendon fully. The crochet hook is used to retrieve the free ends of the nylon suture out the anterior cannula, and a hemostat is applied to the suture ends. The hemostat prevents the nylon sutures from being pulled

Figure 12-73

Retrieve anterior suture out lateral cannula.

262

Section Three



Subacromial Space Surgery

Figure 12-76

Figure 12-74

Pass first anterior suture through tendon.

inadvertently through the anterior cannula as the Caspari punch is withdrawn laterally. The suture punch is removed through the lateral cannula, leaving the loop protruding out the lateral cannula. The hemostat on the anterior anchor sutures is removed. The crochet hook is then used to retrieve one of the anterior suture anchor strands and bring it out the lateral cannula. To find the appropriate

Figure 12-75

All four suture strands passed.

The final anterior suture.

anchor, advance and rotate the arthroscope so that it points toward the anchor. Insert the crochet hook through the lateral cannula and identify the anterior anchor. Hook a limb of the green suture first and gently pull on it. If you have the correct suture, it will slide freely because the hemostat has been removed. If there is resistance, either you have selected the wrong suture (from a more posterior anchor) or it is entangled in the other sutures. Have your assistant tug on the correct suture exiting out the anterior cannula to ensure you have made the right choice. Another technique at this point in the operation is to have your assistant place the correct

Figure 12-77

Completed repair.

Chapter 12

suture in the knot pusher and pass it down the anterior cannula and into the subacromial space until you can visualize it. To ensure that the nylon loop and the braided suture have not become entangled, a suture retrieval forceps is passed through the lateral cannula and into the subacromial space, and both strands of nylon suture are enclosed within the forceps’ jaws. The braided suture should remain external to the forceps. The forceps’ jaws are kept closed around the two nylon suture strands, and the forceps is removed from the cannula. This is a critical step and should be repeated for each suture. The free end of the braided suture is placed within the loop of the 2-0 nylon external to the lateral cannula. Traction is placed on the two ends of the nylon suture anteriorly, and the braided suture is pulled from the lateral cannula, into the subacromial space, through the tendon, and out the anterior cannula. At this point, a simple suture has been placed through the anterior rotator cuff. Repeat these steps as necessary for the remaining anterior suture anchor strand and for additional, more posterior, suture anchor strands. Some surgeons find it helpful to apply a hemostat to each pair of suture strands immediately after passage through the tendon. This makes it impossible to pull the suture out from the tendon or from the anchor inadvertently. This is a critical step in suture management for inexperienced surgeons (Figs. 12-78 through 12-103).

Knot Tying Knot tying generally begins posteriorly and proceeds anteriorly, although the surgeon may modify this based on tear geometry. Using a crochet hook, each pair of posterior anchor sutures is transferred from

Figure 12-78

Crochet hook for suture retrieval.



Full-Thickness Rotator Cuff Tears

Figure 12-79

263

Insert crochet hook.

the anterior cannula to the lateral cannula and tied individually. The anterior sutures are retrieved from the anterior cannula, brought out the lateral cannula, and tied in a similar fashion. I have tried various suture techniques (mattress, modified Mason-Allen) but find them cumbersome and time-consuming. Mattress sutures double the number of passes through the tendon and, because of their medial location, cause the tendon edge to flip up. I prefer to use simple sutures to repair rotator cuff tears of all sizes and have not experienced problems with suture pullout. Simple sutures pass over the tendon edge and hold it firmly against the bone. When teaching knot tying, I consistently observe surgeons placing too much tension on their knots,

Figure 12-80

Sweep sutures.

264

Section Three



Subacromial Space Surgery

Figure 12-84 Figure 12-81

Load 2-0 nylon into the Caspari suture punch.

Retrieve the anchor sutures out the anterior

cannula.

Insert the Caspari suture punch through the lateral cannula.

Figure 12-85 Figure 12-82

Retrieve the anchor sutures out the anterior

cannula.

Figure 12-83

Load 2-0 nylon into the Caspari suture punch.

Figure 12-86

Puncture the tendon.

Chapter 12

Figure 12-90 Figure 12-87

Retrieve two free ends of nylon out the ante-



Full-Thickness Rotator Cuff Tears

265

Bring the looped end of nylon out the lateral

cannula.

rior cannula.

Figure 12-88

Retrieve two free ends of nylon out the ante-

Figure 12-91

Apply a hemostat.

Figure 12-92

rior cannula.

Figure 12-89

Retrieve one limb of anchor suture from the anterior cannula.

Withdraw the suture out the lateral cannula.

266

Section Three

Figure 12-93



Subacromial Space Surgery

Use a looped grasper to check for suture

tangles.

Figure 12-96 Pull on the nylon sutures exiting the anterior cannula, then pull, then anchor suture down the lateral cannula into the subacromial space.

Crochet hook pulling nylon out anterior cannula

Figure 12-94

Insert 7.5 cm of anchor suture through the

nylon loop.

Figure 12-97 Pull on the nylon sutures exiting the anterior cannula, then pull suture from the subacromial space through the tendon and out anterior cannula.

Figure 12-98 Figure 12-95

Close-up of anchor suture through nylon loop.

tendon.

Pull the anchor suture through the rotator cuff

Chapter 12

Figure 12-99

Remove slack in the anchor sutures.



Full-Thickness Rotator Cuff Tears

Figure 12-102

267

Slide it under the tendon.

usually because of inexperience with arthroscopic knot tying. I tie the first anchor suture with only enough tension to advance the tendon edge to the desired repair site. At this point, the tendon is normally reduced, and the subsequent sutures must be tied with just enough tension to approximate the tendon edge. Excessive tension will strangulate the tissue or cause the suture to pull through the tendon (Figs. 12-104 through 12-112).

Figure 12-100

Figure 12-101

Alternative technique when space is tight.

Rotate the Caspari suture punch 90 degrees.

Figure 12-103

Advance the nylon suture.

268

Section Three



Subacromial Space Surgery

Figure 12-107

Retrieve two suture limbs from the anterior cannula to the lateral cannula.

Figure 12-104

Figure 12-105

Figure 12-106

Check for tangles.

Thread the knot pusher.

Advance the knot pusher down the lateral

cannula.

Figure 12-108

Figure 12-109

Overhead throw.

Second overhand throw.

Chapter 12



Full-Thickness Rotator Cuff Tears

269

Arthroscopic Knot Tying Double-Row Repair Standard Double Row This repair normally requires two medial anchors and two lateral anchors. The medial anchor sutures are placed in a mattress fashion, and the lateral anchor sutures are placed as simple sutures. To place the medial anchors, I take the patient’s arm out of the arm holder and place it in adduction. I identify the appropriate insertion site with a spinal needle. This is commonly located adjacent to the lateral acromial edge. I then make a small skin incision and insert a metal cannula and trocar. I place the first anchor Figure 12-110

Slip the second throw.

Posterior

Anterior 1

2

3

4 Suture tying tension scale 1-10

Figure 12-111

Suture number

Tension amount

1

4/10

2

2/10

3

1/10

4

1/10

Suture tension.

Knot tension scale 1-10 Throw number

Tension amount

5

1

3/10

4 3

2

3/10

3

3/10

4

5/10

5

6/10

2 1

Figure 12-112

Knot tension.

270

Section Three



Subacromial Space Surgery

33% posterior to the anterior tendon margin and immediately lateral to the articular cartilage. The sutures are retrieved out the anterior cannula. I then place a second medial anchor 33% anterior to the posterior tendon margin with the same technique. Usually a small amount of internal rotation is needed to access the more posterior anchor. I then retrieve the most anterior suture out the lateral cannula, pass it through the tendon, and take it out anteriorly. I then perform a mattress suture by taking the second suture from the same anchor and passing it through the tendon approximately 7 mm posteriorly to the anterior suture. I repeat these steps to place a mattress suture with the posterior medial anchor sutures. I then remove the cannula and place the sutures external to the cannula. I place the lateral anchors (usually two or three) as described earlier for the simple repair. I tie the lateral anchor sutures first, followed by the anterior medial anchor sutures. I prefer to tie these from the anterior cannula so that the line of pull of the suture throws achieves the best compression. These sutures are cut, and then the posterior medial anchor sutures are tied (Figs. 12-113 and 12-114).

Figure 12-114

Double-row technique.

Double-Row Repair Suture Bridge The medial anchors and mattress sutures are placed as described earlier and tied. I retrieve one suture from the posterior anchor and one suture from the anterior anchor out the lateral cannula. The sutures are placed in the push-lock anchor and inserted into the proximal humerus. The location is 10 to 15 mm distal to the greater tuberosity and in line with the anterior medial anchor. I adjust tension on the rotator cuff by pulling separately on the two suture strands. Once I am satisfied with the reduction, I use a mallet to tap on the impactor and lock the suture repair. I repeat the process for the posterior sutures and anchor. No tying of the lateral sutures is needed (Figs. 12-115 through 12-118).

Double row anchors

Figure 12-113

Double-row technique.

Figure 12-115

Double-row technique (suture bridge).

Chapter 12

Figure 12-116

Double-row technique (suture bridge).

Figure 12-118



Full-Thickness Rotator Cuff Tears

271

Double-row technique (suture bridge).

Rotator Cuff Repair, Bridge Technique—Model Rotator Cuff Repair, Bridge Technique Rotator Cuff Repair, Lateral View Horizontal Cleavage Tears

Figure 12-117

Double-row technique (suture bridge).

If the distal edge of the articular-sided layer is even with the distal edge of the more superficial bursalsided layer, I repair the two layers together anatomically and incorporate both in the repair. First I place a suture through the deeper layer using the Elite suture punch and the technique previously described. I apply a hemostat to the corresponding limb of suture that was not passed through the deep layer. I repeat the process and pass the suture through the superficial layer of the tendon. Normally, I cannot pass the suture through both tendon layers with one pass. If the deep layer is retracted medially (as is often the case) and will not advance laterally, I repair it in situ with a mattress suture. Because the Elite punch usually does not allow me to reach far enough medially to the superficial layer, I use the Cuff-Stitch to insert this suture. After the repair is completed, I remove the patient’s arm from the arm holder and move it through a range of motion. This allows me to document the security of the repair and examine the amount of clearance between the rotator cuff and the acromion.

272

Section Three

Figure 12-119



Subacromial Space Surgery

Continuous passive motion chair.

Each incision is closed with a single subcutaneous, inverted 3-0 Monocryl suture and Steri-strips. An absorbent sterile dressing is placed over the shoulder.

POSTOPERATIVE TREATMENT I remove the dressing the morning after the operation and allow the patient to shower without any protection of the surgical wounds. The patient’s arm is placed in a sling except for exercises (Figs. 12-119 through 12-121). The safe limits of movement are determined at the time of surgery and documented. I have the patient perform 2 minutes of pendulum exercises five times a day. Many patients like to use a continuous passive motion chair for 2 weeks. I evaluate the patient in the clinic after 2 weeks and obtain an anteroposterior radiograph to evaluate the anchor position. I discontinue the continuous passive motion chair (if used) and have the patient

Figure 12-120

Ice pack.

Figure 12-121

Shoulder immobilizer.

continue the pendulum exercises. The patient continues to wear the sling and is cautioned to avoid active range of motion with the operated shoulder. I next see the patient 6 weeks after surgery. Passive range of motion continues, but active elevation and external rotation are allowed. I instruct the patient in supine, active-assisted range-of-motion exercises. Strengthening is instituted after 3 months, and the rehabilitation continues for 12 months. The rehabilitation program is described in more detail in Chapter 19.

RESULTS In my experience, arthroscopic results are equal to those of open or mini-open repairs. I found that the average postoperative University of California at Los Angeles (UCLA) score was 31 of 35, and 84% of patient outcomes were rated good to excellent. Moreover, the UCLA, American Shoulder and Elbow Surgeons, and Constant rating systems all demonstrated an improvement in shoulder function (Tables 12-1 through 12-5). When the results were analyzed in terms of patient self-reporting, I found improvement in all the parameters of the SF-36 Health Survey. Inanearlyreportonarthroscopicrotatorcuffrepair,my colleagues and I analyzed patients with glenohumeral lesions (major labrum tears, Bankart and SLAP lesions, and osteoarthrosis) as a subgroup. Mean preoperative UCLA scores were 23.7 for the normal group and 10.9 for the group with major glenohumeral lesions. Postoperative UCLA scores were 31.2 for the normal group and 29.9 for the group with major glenohumeral lesions, differences that were not statistically significant.

Chapter 12

Table 12-1 RESULTS OF ARTHROSCOPIC REPAIR BY RATING SYSTEM System

Preoperative

Postoperative

UCLA total

12.4

± 4.2

31.1*

± 3.2

Pain

2.4

± 1.7

8.6*

Function

3.7

± 2.2

Flexion

3.6

± 2.2



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273

Table 12-2 RESULTS OF ARTHROSCOPIC REPAIR ON ASES ACTIVITIES OF DAILY LIVING* Activity

Preoperative

Postoperative

± 1.6

Put on coat

1.55

± 0.76

2.93

± 0.30

8.9*

± 1.2

Sleep

0.96

± 0.95

2.62

± 0.70

4.9*

± 0.3

Reach up back

1.01

± 0.79

2.70

± 0.46

2.39

± 0.84

2.97

± 0.16

Strength

2.3

± 1.0

4.1*

± 0.9

Toilet

Satisfaction

0.4

± 0.5

4.6*

± 0.9

Comb hair

1.59

± 0.96

2.89

± 0.36

30.7

± 15.7

87.6*

± 12.8

Reach high shelf

0.96

± 0.95

2.67

± 0.58

7.7

± 1.7

1.4*

± 1.6

0.53

± 0.78

2.22

± 0.99

Function

11.4

± 5.7

26.8*

± 8.0

Lift 10 pounds above shoulder

Constant (absolute)

41.7

± 12.8

83.6*

± 9.0

Throw overhead

0.55

± 0.80

2.34

± 0.90

Constant (age adjusted)

43.3

± 11.6

84.0*

± 7.5

Work Sports

1.33 0.52

± 1.05 ± 0.82

2.81 2.67

± 0.99 ± 0.73

ASES total Pain

Pain

3.58

± 2.62 12.91*

± 2.34

Function

3.37

± 1.94 18.78*

± 1.53

Elevation

7.62

± 2.45

9.78*

± 0.63

Abduction

6.15

± 2.62

9.56*

± 1.13

External rotation

6.82

± 2.16

9.53*

± 1.18

Internal rotation Strength

6.66

± 2.12

9.08*

± 1.18

7.51

± 4.69 14.00*

± 5.41

*All changes were significant (P = .0001); Wilcoxon signed rank test used for differences between preoperative and postoperative scores. ASES, American Shoulder and Elbow Surgeons.

*P = .0001. ASES, American Shoulder and Elbow Surgeons; UCLA, University of California at Los Angeles.

Table 12-3 RESULTS OF ARTHROSCOPIC REPAIR ON RANGE OF MOTION* Passive Range of Motion

Preoperative

Postoperative

Elevation

135

± 22

149

±4

External rotation

66

± 12

78

± 10

Internal rotation

L1

± 4 levels

T9

± 3 levels

*Differences significant (P = .0001); Wilcoxon signed rank test used to test for significance.

274

Section Three



Subacromial Space Surgery

This comparison indicates that the identification and treatment of intra-articular lesions result in outcomes similar to those in patients without intra-articular lesions.

Table 12-4 RESULTS OF ARTHROSCOPIC REPAIR ON PHYSICAL AND MENTAL FUNCTION Criterion

Preoperative Postoperative

COMPLICATIONS

Physical function

57.2 ± 25.7 76.6

± 27.1

Role, physical

24.6 ± 37.4 75.7

± 40.4

Bodily pain

27.7 ± 19.7 68.2

± 24.1

General health

70.8 ± 28.7 72.4

± 21.8

Vitality

50.6 ± 24.2 62.8

± 18.4

Social functioning

57.5 ± 31.2 84.0

± 25.5

Role, emotional

62.1 ± 43.8 82.4

± 34.3

Mental health

70.3 ± 22.2 78.2

± 19.3

Physical component summary

34.1

± 9.1 46.6

± 10.8

Mental component summary

48.7 ± 13.1 52.6

± 9.4

The most common complications following arthroscopic rotator cuff repair are stiffness and tendonbone discontinuity. Although the terms tendon retear or disruption of the repair are commonly used, I am not convinced that the tendon ever healed. What we can observe directly is that the patient has a problem with pain or weakness; an imaging study demonstrates tendon-bone discontinuity, and the interpretation is that the tendon has torn. However, there is little evidence that a healed tendon has torn. This is more than a semantic difference. If a repaired tendon heals and then tears at a later date, our efforts are directed at postoperative issues. If the problem is one of failure of the tendon to heal after the initial operation, we must direct our efforts in another direction.

 Differences in preoperative and postoperative SF-36 Health Survey scores significant (P = .0015) for all scores except general health and mental component summary.

Stiffness If stiffness persists 6 months after operation, I perform an arthroscopic contracture release as described in Chapter 6. The area of contracture is frequently within the glenohumeral joint, indistinguishable from idiopathic adhesive capsulitis. Quite often, the subacromial space is pristine, without any evidence of adhesions in the area of prior surgery. A major cause of shoulder stiffness after rotator cuff repair is that some repairs are placed under too much

Table 12-5

RESULTS OF ARTHROSCOPIC REPAIR UCLA

STRENGTH

Criterion

Preop

Postop

Preoperative UCLA

1.00

0.081

Postoperative UCLA

0.081

Preoperative strength Postoperative strength

Preop

TENDON TEAR

Postop

Length

Width

Size

Age

0.417

0.067

0.067

—0.049

0.015

1.00

0.309

0.515

—0.161

—0.092

—0.122

—0.04

0.417

0.309

1.00

0.456

—0.244

—0.131

—0.199

—0.448

0.067

0.515

0.457

1.00

—0.407

—0.310

—0.373

—0.368

0.067

—0.161

—0.244

—0.407

1.00

0.676

0.906

0.336

—0.049

—0.092

—0.133

—0.310

0.676

1.00

0.912

0.292

Size

0.015

—0.123

—0.199

—0.373

0.906

0.912

1.00

0.346

Age

—0.157

—0.043

—0.449

—0.368

0.336

0.292

0.346

1.00

—0.157

Tendon Tear Length Width

UCLA, University of California at Los Angeles.

Chapter 12

tension. I would rather repair the tendon edge medially than have it positioned ‘‘anatomically’’ under excessive tension.

Tendon-Bone Discontinuity If the patient has persistent pain and weakness, the surgeon may perform gadolinium-enhanced MRI. Unfortunately, this often results in a false-positive study due to artifact from the prior surgery. My preferred evaluation technique is diagnostic ultrasonography, which is simple, rapid, and unaffected by the presence of metallic anchors. Persistent pain and weakness 6 months after surgery are relative indications for revision operation. If a tear is identified at reoperation, it is repaired again. Occasionally, adhesions in the subacromial space produce a tethering effect and are responsible for the pain. These adhesions are usually easily removed. Most patients elect to have the second surgery; however, some who are improved and have good function but still have moderate pain accept their condition and decline further surgery. In my first 2000 arthroscopic rotator cuff repairs, 3.5% of patients had significant postoperative stiffness that required surgery.

Anchor Retrieval Occasionally the surgeon must remove an anchor after it has been inserted. Either the anchor is malpositioned or the surgeon has pulled the suture out of the anchor or broken the suture during knot tying. One option is to insert another anchor and ignore the empty anchor. If the surgeon wishes to remove the anchor, there are several techniques. If the sutures are still in the anchor, use the wire loop to replace the sutures in the inserter. Advance the inserter gently into the screw hole until it engages the anchor. Keep traction on the sutures so that the inserter maintains contact with the anchor, and unscrew it. If there are no sutures in the anchor, the situation is more difficult. If the bone quality is poor, there will be no resistance as the inserter is advanced to try to engage the anchor. In this case, I prefer to leave the anchor in position and simply insert another one. If the bone quality is good, place the inserter in the bone hole until it engages the anchor; unscrew it until it is halfway out the hole but the threads still engage the bone and the anchor is not loose and then insert the loop grabber through the anterior portal and encircle the anchor with thread. I use the inserter to unscrew the anchor completely out of the bone while the assistant holds on to the anchor by its threads. I then remove the inserter and the assistant rotates the anchor so that it is parallel to the lateral cannula. I insert a toothed grasper through the lateral cannula and grasp the anchor by



Full-Thickness Rotator Cuff Tears

275

the eyelet. The assistant loosens his grasp on the loop grabber, and I remove the anchor through the lateral cannula. Occasionally, the anchor dislodges from the grasper as it is pulled through the rubber dam of the lateral cannula. This may result in a loose anchor that floats in the subacromial space. I generally avoid this complication by removing the lateral cannula with the anchor and grasper inside it.

DISCUSSION Arthroscopic rotator cuff repair is performed in many centers around the world. The individuals who have taken this procedure from theory to practice are expert arthroscopic technicians with a thorough understanding of rotator cuff repair fundamentals. Whether arthroscopic cuff repair has good long-term results comparable to those of open procedures remains to be seen, and I await the publication of studies with sufficient numbers of patients and long-term followup. A separate issue is whether this technique has wide applicability among surgeons of varying arthroscopic skills. Each individual surgeon must consider the relative benefits of arthroscopic repair and decide whether the difficulty of the procedure, compared with the open technique, makes it worthwhile. For orthopedic surgeons considering making the transition from open to arthroscopic technique, caution is appropriate. The surgeon must not only master each of the individual elements described here but also perform them in a precise and timely fashion. The surgeon must have a reasonable volume of patients with rotator cuff tears and be proficient at arthroscopic subacromial decompression. Experience is required to recognize the tendon tear patterns and shapes as viewed through the arthroscope. Tendon mobilization of retracted tears can be difficult. Suture anchors must be placed accurately so that the repaired tendon rests in the desired location. The orthopedist must manage multiple strands of suture material within the tight confines of the subacromial space and tie secure knots with the use of arthroscopic tools.

BIBLIOGRAPHY Abboud JA, Silverberg D, Pepe M, et al: Surgical treatment of os acromiale with and without associated rotator cuff tears. J Shoulder Elbow Surg 15:265-270, 2006. Abrams JS, Bell RH: Arthroscopic Rotator Cuff Surgery. Secaucus, New Jersey, Springer Science. Adams JE, Zobitz ME, Reach JS, et al: Rotator cuff repair using an acellular dermal matrix graft: An in vivo study in a canine model. Arthroscopy 22:700-709, 2006.

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Anderson K, Boothby M, Aschenbrener D, van Holsbeeck M: Outcome and structural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: Minimum 2-year follow-up. Am J Sports Med 34:1899-1905, 2006. Beall DP, Williamson EE, Ly JQ, et al: Association of biceps tendon tears with rotator cuff abnormalities: Degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol 180:633-639, 2003. ¨ n U, et al: Superior excursion of the Bezer M, Yildirim Y, Akgu humeral head: A diagnostic tool in rotator cuff tear surgery. J Shoulder Elbow Surg 14:375-379, 2005. Blevins FT, Warren RF, Cavo C, et al: Arthroscopic assisted rotator cuff repair: Results using a mini-open deltoid splitting approach. Arthroscopy 12:50-59, 1996. Boes MT, McCann PD, Dines DM: Diagnosis and management of massive rotator cuff tears: The surgeon’s dilemma. Instr Course Lect 55:45-57, 2006. Boileau P, Brassart N, Watkinson DJ, et al: Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 87:1229-1240, 2005. Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 16:82-90, 2000. Fealy S, Adler RS, Drakos MC, et al: Patterns of vascular and anatomical response after rotator cuff repair. Am J Sports Med 34:120-127, 2006. Gartsman GM: Arthroscopic assessment of rotator cuff tear reparability. Arthroscopy 12:546-549, 1996. Gartsman GM: Arthroscopic management of rotator cuff disease. J Am Acad Orthop Surg 6:259-288, 1998. Gartsman GM, Brinker MR, Khan M, Karahan M: Early effectiveness of arthroscopic repair for patients with fullthickness tears of the rotator cuff. J Bone Joint Surg Am 80:33-40, 1998. Gartsman GM, Brinker MR, Khan M, Karahan M: Self-assessment of general health status in patients with five common shoulder conditions. J Shoulder Elbow Surg 7:228-237, 1998. Gartsman GM, Khan M, Hammerman SM: Arthroscopic repair of full-thickness rotator cuff tears. J Bone Joint Surg Am 8:832-840, 1998. Gartsman GM, O’Connor DP: Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: A prospective, randomized study of one-year outcomes. J Shoulder Elbow Surg 13:424-426, 2004. Gartsman GM, Taverna E: The incidence of glenohumeral joint abnormalities associated with full- thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997. Gill TJ, McIrvin E, Kocher MS, et al: The relative importance of acromial morphology and age with respect to rotator cuff pathology. J Shoulder Elbow Surg 11:327-330, 2002. Gimbel JA, Mehta S, Van Kleunen JP, et al: The tension required at repair to reappose the supraspinatus tendon to bone rapidly increases after injury. Clin Orthop Relat Res 426:258-265, 2004. Gleyze P, Thomazeau H, Flurin PH, et al: [Arthroscopic rotator cuff repair: A multicentric retrospective study of 87 cases with anatomical assessment]. Rev Chir Orthop Reparatrice Appar Mot 86:566-574, 2000.

Goutallier D, Postel JM, Gleyze P, et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 12:550-554, 2003. Grana WA, Teague B, King M, Reeves RB: An analysis of rotator cuff repair. Am J Sports Med 22:585-588, 1994. Harryman DT, Hettrich CM, Smith KL, et al: A prospective multipractice investigation of patients with full-thickness rotator cuff tears: The importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status. J Bone Joint Surg Am 85:690-696, 2003. Harvie P, Ostlere SJ, Teh J, et al: Genetic influences in the aetiology of tears of the rotator cuff: Sibling risk of a full-thickness tear. J Bone Joint Surg Br 86:696-700, 2004. Hirose K, Kondo S, Choi HR, et al: Spontaneous healing process of a supraspinatus tendon tear in rabbits. Arch Orthop Trauma Surg 124:374-377, 2004. Ide J, Maeda S, Takagi K: A comparison of arthroscopic and open rotator cuff repair. Arthroscopy 21:1090-1098, 2005. Ide J, Tokiyoshi A, Hirose J, Mizuta H: Arthroscopic repair of traumatic combined rotator cuff tears involving the subscapularis tendon. J Bone Joint Surg Am 89:23782388, 2007. Kandemir U, Allaire RB, Jolly JT, et al: The relationship between the orientation of the glenoid and tears of the rotator cuff. J Bone Joint Surg Br 88:1105-1109, 2006. Kim E, Jeong HJ, Lee KW, Song JS: Interpreting positive signs of the supraspinatus test in screening for torn rotator cuff. Acta Med Okayama 60:223-228, 2006. Kim SH, Ha KI, Park JH, et al: Arthroscopic versus mini-open salvage repair of the rotator cuff tear: Outcome analysis at 2 to 6 years’ follow-up. Arthroscopy 19:746-754, 2003. Klepps S, Bishop J, Lin J, et al: Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med 32:1716-1722, 2004. Kobayashi M, Itoi E, Minagawa H, et al: Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits. J Shoulder Elbow Surg 15:371-377, 2006. Kuhn JE, Dunn WR, Ma B, et al: Interobserver agreement in the classification of rotator cuff tears. Am J Sports Med 35:437-441, 2007. ¨ la¨ K, Niemitukia L, Jaroma H, Va¨a¨ta¨inen U: Long-term Kyro MRI findings in operated rotator cuff tear. Acta Radiol 45:526-533, 2004. La¨hteenma¨ki HE, Hiltunen A, Virolainen P, Nelimarkka O: Repair of full-thickness rotator cuff tears is recommended regardless of tear size and age: A retrospective study of 218 patients. J Shoulder Elbow Surg 16:586-590, 2007. La¨hteenma¨ki HE, Virolainen P, Hiltunen A, et al: Results of early operative treatment of rotator cuff tears with acute symptoms. J Shoulder Elbow Surg 15:148-153, 2006. Lee E, Bishop JY, Braman JP, et al: Outcomes after arthroscopic rotator cuff repairs. J Shoulder Elbow Surg 16:1-5, 2007. Lo IK, Boorman R, Marchuk L, et al: Matrix molecule mRNA levels in the bursa and rotator cuff of patients with full-thickness rotator cuff tears. Arthroscopy 21:645-651, 2005.

Chapter 12

Longo UG, Franceschi F, Ruzzini L, et al: Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med 36:533-538, 2007. MacMahon PJ, Taylor DH, Duke D, et al: Contribution of full-thickness supraspinatus tendon tears to acquired subcoracoid impingement. Clin Radiol 62:556-563, 2007. Matthews TJ, Hand GC, Rees JL, et al: Pathology of the torn rotator cuff tendon: Reduction in potential for repair as tear size increases. J Bone Joint Surg Br 88:489-495, 2006. Matthews TJ, Smith SR, Peach CA, et al: In vivo measurement of tissue metabolism in tendons of the rotator cuff: Implications for surgical management. J Bone Joint Surg Br 89:633-638, 2007. Mazoue´ CG, Andrews JR: Repair of full-thickness rotator cuff tears in professional baseball players. Am J Sports Med 34:182-189, 2006. Meyer DC, Fucentese SF, Koller B, Gerber C: Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg 13:333-337, 2004. Middleton WD, Teefey SA, Yamaguchi K: Sonography of the rotator cuff: Analysis of interobserver variability. AJR Am J Roentgenol 183:1465-1468, 2004. Milano G, Grasso A, Salvatore M, et al: Arthroscopic rotator cuff repair with and without subacromial decompression: A prospective randomized study. Arthroscopy 23:81-88, 2007. Moon YL, Kim SJ: Bursoscopic evaluation for degree of rotator cuff tear using an air-infusion method. Arthroscopy 20:e105-e107, 2004. Motamedi AR, Urrea LH, Hancock RE, et al: Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears. J Shoulder Elbow Surg 11:6-10, 2002. Murray TF, Lajtai G, Mileski RM, Snyder SJ: Arthroscopic repair of medium to large full-thickness rotator cuff tears: Outcome at 2- to 6-year follow-up. J Shoulder Elbow Surg 11:19-24, 2002. Nove´-Josserand L, Edwards TB, O’Connor DP, Walch G: The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration. Clin Orthop Relat Res 433:90-96, 2005. Nyffeler RW, Werner CM, Sukthankar A, et al: Association of a large lateral extension of the acromion with rotator cuff tears. J Bone Joint Surg Am 88:800-805, 2006. O’Holleran JD, Kocher MS, Horan MP, et al: Determinants of patient satisfaction with outcome after rotator cuff surgery. J Bone Joint Surg Am 87:121-126, 2005. Osbahr DC, Murrell GA: The rotator cuff functional index. Am J Sports Med 34:956-960, 2006. Ozbaydar MU, Tonbul M, Tekin AC, Yalaman O: [Arthroscopic rotator cuff repair: Evaluation of outcomes and analysis of prognostic factors]. Acta Orthop Traumatol Turc 41:169-174, 2007. Park JY, Lee WS, Lee ST: The strength of the rotator cuff before and after subacromial injection of lidocaine. J Shoulder Elbow Surg 17(1 suppl):8S-11S, 2008. Perry SM, Gupta RR, Van Kleunen J, et al: Use of small intestine submucosa in a rat model of acute and chronic rotator cuff tear. J Shoulder Elbow Surg 16(5 Suppl):S179-S183, 2007.



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Prasad N, Odumala A, Elias F, Jenkins T: Outcome of open rotator cuff repair: An analysis of risk factors. Acta Orthop Belg 71:662-666, 2005. Reilly P, Amis AA, Wallace AL, Emery RJ: Supraspinatus tears: Propagation and strain alteration. J Shoulder Elbow Surg 12:134-138, 2003. Reilly P, Macleod I, Macfarlane R, et al: Dead men and radiologists don’t lie: A review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl 88:116-121, 2006. Ruotolo C, Fow JE, Nottage WM: The supraspinatus footprint: An anatomic study of the supraspinatus insertion. Arthroscopy 20:246-249, 2004. Sallay PI, Hunker PJ, Lim JK: Frequency of various tear patterns in full-thickness tears of the rotator cuff. Arthroscopy 23:1052-1059, 2007. Saupe N, Pfirrmann CW, Schmid MR, et al: Association between rotator cuff abnormalities and reduced acromiohumeral distance. AJR Am J Roentgenol 187:376-382, 2006. Scibek JS, Mell AG, Downie BK, et al: Shoulder kinematics in patients with full-thickness rotator cuff tears after a subacromial injection. J Shoulder Elbow Surg 17:172-181, 2007. Shen PH, Lien SB, Shen HC, et al: Long-term functional outcomes after repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images. J Shoulder Elbow Surg 17(1 suppl):1S-7S, 2007. Smith AM, Sperling JW, Cofield RH: Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg Am 87:1782-1787, 2005. Snyder SJ: Technique of arthroscopic rotator cuff repair using implantable 4-mm Revo suture anchors, suture shuttle relays, and no. 2 nonabsorbable mattress sutures. Orthop Clin North Am 28:267-275, 1997. Sperling JW, Cofield RH, Schleck C: Rotator cuff repair in patients fifty years of age and younger. J Bone Joint Surg Am 86:2212-2215, 2004. Sørensen AK, Bak K, Krarup AL, et al: Acute rotator cuff tear: Do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma. J Shoulder Elbow Surg 16:174-180, 2007. Tauro JC: Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy 14:45-51, 1998. Tauro JC: Stiffness and rotator cuff tears: Incidence, arthroscopic findings, and treatment results. Arthroscopy 22:581-586, 2006. Teefey SA, Middleton WD, Payne WT, Yamaguchi K: Detection and measurement of rotator cuff tears with sonography: Analysis of diagnostic errors. AJR Am J Roentgenol 184:1768-1773, 2005. Temple JD, Sethi PM, Kharrazi FD, Elattrache NS: Direct biceps tendon and supraspinatus contact as an indicator of rotator cuff tear during shoulder arthroscopy in the lateral decubitus position. J Shoulder Elbow Surg 16:327-329, 2007. Tuoheti Y, Itoi E, Yamamoto N, et al: Contact area, contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair. Am J Sports Med 33:1869-1874, 2005.

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disease: A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 88:1699-1704, 2006. Yu J, McGarry MH, Lee YS, et al: Biomechanical effects of supraspinatus repair on the glenohumeral joint. J Shoulder Elbow Surg 14(1 Suppl):65S-71S, 2005. Zilber S, Carillon Y, Lapner PC, et al: Infraspinatus delamination does not affect supraspinatus tear repair. Clin Orthop Relat Res 458:63-69, 2007. Zvijac JE, Levy HJ, Lemak LJ: Arthroscopic subacromial decompression in the treatment of full thickness rotator cuff tears: A 3- to 6-year follow-up. Arthroscopy 10:518-523, 1994.

CHAPTER

13

Massive Rotator Cuff Tears

I define a massive rotator cuff tear as one involving at least two rotator cuff tendons and measuring 5 cm in length from anterior to posterior. It is difficult for surgeons to determine whether a massive, retracted rotator cuff tear is reparable. This is true for both arthroscopic and conventional open techniques. If the tendon is mobile and can be advanced to its anatomic location or medialized within 10 mm of its anatomic location without shoulder abduction, the tear is reparable. If, on initial inspection, the tendon does not meet these criteria, it is not necessarily irreparable. Subacromial, subdeltoid, and intraarticular adhesions may limit cuff excursion. With an arthroscopic technique, the surgeon can release these adhesions and determine definitively whether the tear is reparable. I am frequently asked how I can repair massive tears arthroscopically. The answer, like the technique, is both simple and complex. The simple part is my attitude. I understand that massive tears will require more de´bridement and soft tissue releases before I can determine reparability. It will take multiple movements of the arthroscope to different cannulas to get a full picture of the tear geometry, and suture management will prove challenging. I know that I must move slowly to avoid making technical errors that will prolong an already complicated operation. I also accept the reality that I will make technical errors during the operation and that I must be patient, correct the problem, and move on. The complex part is actually doing all these things. If you are at the stage where you are about to undertake the repair of a massive rotator cuff tear, you already have the necessary technical skill. It is helpful to spend some time detailing the challenges that lie

ahead. You may find it helpful to review exercise 3 outlined in Chapter 1. Large or massive retracted rotator cuff tears differ from smaller tears in six aspects: 1. 2. 3. 4. 5. 6.

Quantity of sutures and anchors Tear geometry Variability of repair sequence Suture management Tendon-to-tendon repair Muscle quality

The most straightforward aspect is quantity of sutures and anchors. Larger tears require more anchors, more sutures, and more time to complete. Tear geometry is difficult to identify. Larger tears often assume distorted shapes because the tendons have detached, rotated, and come to rest far from their insertion sites. The tendon has deformed plastically. It is often difficult to understand how points on the retracted tendon attach to corresponding points on the humeral head. Identifying this relationship requires an understanding of the geometry of the tear and thus the geometry of the repair (Fig. 13-1). This is difficult enough when then tendon is mobile but becomes increasingly complex when the tear is retracted and fixed. Only with thorough soft tissue releases can the surgeon maneuver the tendon and determine the precise repair site. The surgeon must often alter the normal repair technique of placing anchors from anterior to posterior and tying knots from posterior to anterior. The repair may require knot tying from anterior to posterior, or the surgeon may have to repair the most anterior and posterior margins first and repair the central portion last.

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LITERATURE REVIEW

Figure 13-1 Massive rotator cuff repair.

In addition, suture management is complex. As the number of anchors and sutures increases, the technical difficulty seems to increase geometrically. Strict adherence to two principles is vital: keep the working cannula free of sutures, and transfer suture strands so they do not cross the area of tendon repair. It is often necessary to combine a longitudinal tendon-to-tendon repair with a transverse tendon-tobone repair. This may require the use of different suturing techniques, sutures, instruments, viewing portals, and knot tying methods (Fig. 13-2). Finally, massive rotator cuff tears are diseases of tendon and muscle. These large tendon tears are usually chronic and are accompanied by significant muscle atrophy. The surgeon must be aware that heroic efforts to repair tendons will not produce a successful result if the corresponding muscles are not functional.

Cordasco and Bigliani reported on the open repair of massive rotator cuff tears. In their series, 85% of patients (52 of 61) had satisfactory results, and 92% (56 of 61) had satisfactory pain relief; they experienced mean gains of 76 degrees in forward elevation and 30 degrees in external rotation. Burkhart reported similar results with the arthroscopic treatment of massive tears. Burkhart has also contributed greatly to our understanding of the biomechanics of massive rotator cuff tears and their repair. I find the concept of margin convergence particularly useful. The first principle of margin convergence is that partial repair of a massive tear can reduce the patient’s pain and improve function. Complete anatomic repair, though desirable, may not be possible in patients with massive rotator cuff tears; however, a good outcome can be achieved with a partial repair. The second principle is that if the surgeon can establish anterior and posterior stability to the shoulder, good function is possible even if the supraspinatus is not reparable. Anterior stability may be achieved through a subscapularis repair and posterior stability through an infraspinatus repair. The healing rate of large and massive tears has been reported by a number of authors, with healing rates ranging from 0% to 80%. There appears to be a higher healing rate with modern double-row fixation techniques. Warner (see Costouros et al.) discussed the possibility that abnormalities of the suprascapular nerve may be partially responsible for pain in patients with retracted tears. It is not unreasonable to assume that tendon retraction and the resulting distortion of the suprascapular nerve could be a source of pain.

OPERATIVE TECHNIQUE Soft Tissue Releases for Massive Rotator Cuff Tear Visualization

Figure 13-2

Tendon-to-tendon repair.

I inspect the glenohumeral joint and obtain full passive range of motion through gentle manipulation or contracture release. If the surgeon cannot position the arm in full (or nearly full) elevation and external rotation, the rotator cuff repair may be difficult or impossible, and the postoperative recovery will certainly be challenging (Fig. 13-3). I remove the arthroscope and redirect it into the subacromial space. I introduce the trocar and cannula through the subcutaneous tissue until I can

Chapter 13

Figure 13-3

Contracture release.

Figure 13-5

palpate the posterior acromion. I then advance the cannula and trocar along the inferior acromial surface so that I enter the subacromial space superior to any rotator cuff tendon adherent to the acromion while creating the maximal distance between the arthroscope lens and the rotator cuff tear (Figs. 13-4 through 13-6). I establish a lateral portal and use a motorized shaver to remove any bursal tissue that impedes a clear view of the tendon tear. Surprisingly, the subacromial space is often well visualized in massive full-thickness tears. The thick subacromial bursitis that characterizes stage 2 impingement is usually absent. When a bursa is present, it is usually located posteriorly; I remove it by inserting the arthroscope posteriorly and the soft tissue shaver laterally. I continue removing the bursa until I can see the rotator cuff tear clearly. If I cannot obtain a clear view of the



Massive Rotator Cuff Tears

281

Rotator cuff adherent to the acromion (arrow).

VIEW THROUGH ARTHROSCOPE

1

2

A 1 2

B Figure 13-4

Palpate the inferior acromion.

Figure 13-6 A and B, The appearance of the rotator cuff repair changes with perspective.

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Figure 13-7



Subacromial Space Surgery

Thickened posterior bursa.

tendon, I move the arthroscope to the lateral portal and insert the shaver posteriorly (Fig. 13-7). At this point I have the option of continuing the repair with the arthroscope laterally or moving it to its normal posterior position. My preference is to work with the arthroscope in the posterior portal. I rotate the arthroscope so that it is pointed directly down at the rotator cuff tear (Figs. 13-8 and 13-9).

Tear Classification With small to medium tears, the size and tear geometry are easily appreciated, but this is not often the case with massive tears. There are 13 factors that distinguish the arthroscopic treatment of massive rotator cuff tears from the treatment of smaller lesions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Tear size Muscle contraction Muscle quality Tendon retraction Tendon substance loss Tendon quality Tendon rotation Subdeltoid and subacromial adhesions Coracohumeral ligament contracture Capsular contracture Greater tuberosity prominence Superior humeral head migration Repair without acromioplasty

Fundamentally, rotator cuff repair is a question of what goes where. The size and retraction of massive tears often make implementing the appropriate repair steps difficult. Even when the surgeon understands the tear geometry, mobilizing the tendon is difficult.

Figure 13-8

Arthroscope directed upward toward the

acromion.

Because most of these lesions are chronic, muscle contracture limits the excursion of the tendon edge even when the surgeon has performed the appropriate releases. Even if an anatomic repair is possible, the chronic nature of the lesion affects the muscle quality so that it does not function naturally. There is also the issue of tendon substance loss. Frequently, the surgeon identifies the musculotendinous junction and finds that there is very little tendon remaining for repair. The advanced age of these patients and the long-standing duration of the lesion also adversely affect tendon quality and repair security. With smaller tears, the tendon retracts medially. With larger tears, the tendon not only retracts medially but also rotates posteriorly or anteriorly, further complicating the repair. Adhesions between the rotator cuff and the deltoid or the acromion limit mobilization. Contracture of the coracohumeral

Figure 13-9 Arthroscope directed downward toward the rotator cuff tear.

Chapter 13

ligament and the glenohumeral joint capsule can also be significant. The greater tuberosity may enlarge and encroach on the subacromial space, making the choice of repair site difficult. Superior migration of the humeral head in some patients with massive rotator cuff tears diminishes the size of the subacromial space and complicates the task of maneuvering instruments during the repair. Because of these factors, I am not convinced that, even with an anatomic repair, the rotator cuff will function normally and centralize the humeral head into the glenoid during arm elevation. I consider such patients to have anatomically intact but functionally insufficient rotator cuffs. If the passive superior restraints of the coracoacromial arch are removed with acromioplasty and coracoacromial ligament resection, the humeral head will escape the confines of the coracoacromial arch and subluxate anteriorly, medially, and superiorly. Elevation will be limited and painful. Subacromial decompression with a nonfunctional rotator cuff repair (or an irreparable tear) transforms the patient from one who has pain during elevation to one who has pain and no ability to elevate the arm. For these reasons, I do not perform an acromioplasty or coracoacromial ligament resection during repair of a massive rotator cuff tear. This further limits the maneuverability of instruments in the subacromial space. I measure with a marked probe the length of the tear from anterior to posterior and the amount of medial retraction. Straight medial retraction or retraction in an ellipse are the most common findings (Figs. 13-10 and 13-11). As tear size increases, the surgeon’s ability to appreciate tear geometry is reduced. The following



Massive Rotator Cuff Tears

Elliptical

Figure 13-11

Elliptical tear.

descriptions apply to a right shoulder and are reversed for a left shoulder. L-shaped tears have a longitudinal limb posteriorly, often at the junction of the supraspinatus and infraspinatus, in addition to lateral detachment at the greater tuberosity. Reverse L-shaped tears—with a longitudinal component along the rotator interval—allow the tear to rotate posteriorly. Longitudinal tears may be present in the area of the rotator interval and occasionally within the substance of the supraspinatus (Figs. 13-12 through 13-15). Vshaped tears have the longitudinal component in addition to lateral detachment. When I identify a massive tear that will not reduce with straight lateral traction, I have found that the best way to reduce the tendon is to insert an

Transverse tear

L-shaped tear

e

hap

L-s

Figure 13-10

Transverse tear.

283

Figure 13-12

L-shaped tear.

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Subacromial Space Surgery

pe

ha

se ver Re

L-s

Reverse L-shaped tear

Figure 13-14 Figure 13-13

Reverse L-shaped tear.

L-shaped tear.

Cuff Mobilization

instrument through the anterior cannula, grasp the posterior portion of the tendon, and pull it anterolaterally (Figs. 13-16 and 13-17). This is usually more effective than pulling the anterior limb posteriorly or performing soft tissue releases. I use a grasper and pull on the tear edge, attempting to determine its anatomic location while varying elevation and rotation until a best fit is obtained. Only when the tear geometry is appreciated can an effective repair be done. The McConnell arm holder is then secured to maintain the arm position (Figs. 13-18 and 13-19).

A

If adhesions have formed within the subacromial space between the rotator cuff and acromion or between the rotator cuff and deltoid, interfering with tendon mobilization, they must be released. I usually release anterior and lateral adhesions with a motorized shaver. Occasionally I use electrocautery to divide adhesions if they are particularly thick (Figs. 13-20 and 13-21). Posterior adhesions usually are not dense and can often be released by inserting a metal trocar and cannula through the lateral portal. Place the trocar superior to the anterior tear edge and sweep it posteriorly directly beneath the arthroscope (Fig. 13-22). It is unwise to

B Figure 13-15

A, Reverse L-shaped tear. B, Repair.

Figure 13-19 Figure 13-16

External rotation.

Grasp the retracted tendon edge.

Figure 13-17

Advance the tendon edge. Figure 13-20

Adhesions of the rotator cuff and deltoid

fascia.

Figure 13-18

Internal rotation.

Figure 13-21

Adhesions of the rotator cuff and acromion.

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Releasing coracohumeral ligament

Figure 13-22

Sweep and disrupt the subacromial adhesions. Figure 13-24

remove these adhesions with a power shaver; hard-to-control bleeding often results owing to the posteromedial location of the bleeding vessels. Therefore, I release any remaining adhesions in this area with electrocautery. Adhesions to the coracoid or a coracohumeral ligament contracture may give the false impression of irreparability. Adhesions to the coracoid are usually very thick and require resection with electrocautery. This is particularly true in the area of the coracohumeral ligament. This ligament is not clearly visualized and is best appreciated by applying lateral traction to the tendon edge and observing a ridge of tissue that prevents mobilization. I grasp the tendon edge with a soft tissue grasper inserted through the lateral portal, insert the electrocautery through the anterior portal, and divide the ligament (Figs. 13-23 and 13-24).

Coracohumeral ligament release.

Coracohumeral ligament contracture is often accompanied by a contracture of the rotator interval. I palpate or visualize the superior border of the subscapularis and use a scissors to divide the interval from the lateral tendon border to the coracoid (Figs. 13-25 through 13-27). Occasionally, division of the intra-articular joint capsule is helpful. Using arthroscopic scissors, I release the capsule adjacent to the glenoid beginning posterior to the biceps-labrum attachment (Figs. 13-28 and 13-29). This slightly increases tendon excursion. The suprascapular nerve is located approximately 1 to 2 cm medial to the glenoid, and the surgeon must be careful during medial dissection to avoid injuring this vital structure. This area is well visualized and accessible with the arthroscope in the subacromial space in patients with massive tears. This is not the case with

Interval release Adhesions to coracohumeral ligament and supraspinatus, causing contracture

Pulling supraspinatus tendon

Coracohumeral ligament contracture limits rotator cuff mobility.

Figure 13-23

Figure 13-25

Interval release.

Figure 13-26

Figure 13-27

Interval slide.

Interval slide.

the inferior capsule and, to a lesser extent, the anterior capsule. Subacromial and subdeltoid adhesions limit the tendon’s ability to advance to the humeral head, and inferior capsular contracture can limit the ability of the humeral head to meet the tendon. These capsular contractures prevent the humeral head movement required for tendon-bone apposition. Usually I identify and correct the inferior contracture during the glenohumeral joint portion of the operation. I release inferior capsule contracture, as necessary, as described in Chapter 6. If I cannot adequately release the anterior contracture with the arthroscope in the subacromial space, I remove the arthroscope and redirect it into the glenohumeral joint, release the anterior

Superior capsule release

Figure 13-28

Superior capsule release.

Figure 13-29

Superior capsule release.

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Medial repair site with retracted tendon

Figure 13-32 Figure 13-30

Prominent greater tuberosity.

contracture, and then reposition the arthroscope in the subacromial space. Fenlin has taught us that the greater tuberosity is often abnormal in patients with chronic, massive rotator cuff tears. These abnormalities, which include osteophytes or reactive enlargement of the greater tuberosity, compromise the space available for instruments during the surgical repair and impinge against the acromion during arm elevation postoperatively. Because I do not perform acromioplasty in this setting, I recess the greater tuberosity by inserting the bur through the lateral cannula and removing the abnormal bony overgrowth until I obtain adequate clearance between the proximal humerus and the acromion (Figs. 13-30 and 13-31). Tendon reparability is based not only on tendon mobility but also on tissue quality and its ability to hold sutures and thus be used in the repair. I gain a sense of tendon quality while grasping and

Figure 13-31

Medial bone preparation.

Greater tuberosity recession.

manipulating the tendon to determine the repair geometry. This can affect the decision whether an anatomic repair is possible. If anatomic repair is not possible without excessive tendon tension, I repair the tendon medially and adjust the bone decortication site accordingly. The tendon edge can be repaired as much as 10 mm medial to its anatomic insertion without a significant loss of overhead elevation. In this situation, it is helpful to remove a 5-mm strip of humeral head articular cartilage. This exposes a greater surface of decorticated bone to the repaired tendon and may aid tendon healing. Medial repairs require the surgeon to change the method of anchor insertion. An anatomic repair is best obtained with lateral anchor placement, but this is not possible with a medial repair. I identify the proper site and insertion angle with a spinal needle inserted percutaneously. The skin entry point is usually immediately lateral to the acromion. I make a stab wound and insert the anchors percutaneously (Figs. 13-32 through 13-35).

Figure 13-33

Percutaneous anchor insertion.

Chapter 13



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289

Anterior and posterior repair with central portion unrepaired

Anterior

Medial anchor repair

Posterior

Figure 13-34

Medial repair.

If I cannot repair the tendon without further medialization, I repair the anterior and posterior margins anatomically and do not repair the central portion of the tear. A tendon repaired under appropriate tension in this manner is superior to an anatomic, watertight repair under excessive tension (Fig. 13-36). I do not repair the tear with the arm abducted. When the arm is brought back to the patient’s side, the repair will be under excessive tension and will fail.

Figure 13-36

Anterior and posterior margin repair.

next anchor. For example, it may be helpful to place the most anterior anchor and two sutures and tie them first. Then place the most posterior anchor and sutures and tie these. This converts a massive tear into a normal-sized transverse tear (Fig. 13-37).

Suture Management The procedure that follows is complex, but it is possible. Write down all the steps and rehearse them with a

Repair Sequence It is often necessary to vary the repair sequence when faced with a large or massive rotator cuff tear. Because the tear is so large, it is possible to place anchors, insert sutures, and tie them before proceeding to the

Figure 13-35

Medial repair.

Figure 13-37

Anterior portion of the tear is repaired first.

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practice board and the exercises outlined in Chapter 1. Watch the videos that deal with large rotator cuff repairs. When three to four anchors are needed for the repair, it is helpful to alter the usual suture management technique. Six to eight sutures within the subacromial space are difficult to handle. After I insert the anterior anchor, I withdraw the sutures through the anterior cannula as usual. I insert the next anchor posteriorly and withdraw these sutures out the anterior cannula. I internally rotate the arm and place the third anchor. At this point, if the sutures are pulled through the anterior cannula there will be six sutures (12 strands) through this cannula, making management difficult. Additionally, if the posterior sutures are through the anterior cannula, passing the anterior sutures through the tendon will be difficult because the posterior sutures cross the tendon edge and may block access to the cuff tear. One option is to insert and then tie the anterior sutures before placing additional sutures or anchors, but often the tendon tear is not quite large enough. Also, if the anterior sutures are tied, it is difficult to place more sutures without

manipulating the tendon and possibly disrupting the repair. I modify the technique as follows: I insert the anterior anchor and withdraw the four suture strands out the anterior cannula. I insert the next anchor more posteriorly. I make a percutaneous stab wound anterolaterally, reach into the subacromial space with the loop grabber, and withdraw the four suture strands from the second anchor. I insert the most posterior anchor, make a percutaneous stab wound posterolaterally, and pull the posterior anchor sutures through this incision. The subacromial space is now relatively clear of sutures, and tendon repair can proceed naturally without sutures crossing the tendon edge (Figs. 13-38 through 13-49). The next step is to pass the sutures through the tendon. I insert the suture punch through the lateral portal, grasp the most anterior portion of the cuff that corresponds to the anterior anchor, and pass the first suture through the rotator cuff tendon. I retrieve the suture out the anterior cannula. I repeat this with the second anterior suture. I then insert a crochet hook through the lateral cannula and pull one limb

Anterior and middle anchor sutures in anterior cannula

A Inte r

na lr

ati ot on

Internally rotate humerus, place 3rd anchor by percutaneous stab wound

B Figure 13-38

A and B, Internally rotate the shoulder to place the posterior anchors.

Chapter 13

Figure 13-39

Lateral portal sites.

Figure 13-42



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291

Posterolateral stab wound site.

Loop grabber pulling middle anchor sutures through AL stab wound

Figure 13-43

Small loop grasper.

Withdraw the middle anchor sutures through an anterolateral (AL) stab wound.

Figure 13-40

Figure 13-41

wound.

Sutures withdrawn out an anterolateral stab

Figure 13-44

stab wound.

Insert the grasper through the posterolateral

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Figure 13-48 Figure 13-45

Figure 13-46

Withdraw the sutures out the stab wound.

Grasp the white sutures.

Withdraw the sutures out the stab wound.

of the middle anchor sutures from the anterolateral stab wound and insert it through the tendon as described earlier. This suture can be withdrawn through the anterior cannula or through the anterolateral stab wound. Repeat these steps for the second suture of the middle anchor. To place the posterior anchor sutures, I insert the crochet hook through the lateral cannula and grasp one of the posterior anchor suture strands exiting from the posterolateral percutaneous stab wound. I place the suture through the most posterior portion of the rotator cuff tendon with the suture punch and withdraw it out the anterior cannula. I then reach through the posterolateral stab wound, retrieve that strand of anchor suture, and take it back out the posterolateral stab wound. If I left it in the anterior cannula, it would cross the area of the rotator cuff where I want to place the next suture. I then use the suture punch to place the second posterior anchor suture,

Loop grabber pulling posterior anchor sutures through PL stab wound

Figure 13-49 Figure 13-47

Grasp the green sutures.

posterolateral.

Repair area free of crossing sutures. PL,

Chapter 13

pass the anchor suture as previously described, and bring it out the anterior cannula. I leave this suture in the anterior cannula because I am now ready to start tying sutures. I usually begin posteriorly and insert a crochet hook through the lateral cannula and retrieve the two suture limbs from the posterior anchor that exit the posterolateral stab wound. These are the suture limbs located in the most posterior portion of the torn tendon. I tie this one first because it is usually under the least amount of tension. I then retrieve the second set of posterior anchor sutures from the anterior cannula and cut and tie these. The rotator cuff tear is now smaller, and there are fewer sutures to manage. I tie the remaining sutures.



Massive Rotator Cuff Tears

Figure 13-50

Margin convergence.

Figure 13-51

Margin convergence.

Figure 13-52

Margin convergence.

Margin Convergence Rotator Cuff Repair, Margin Convergence Margin convergence involves a tendon-to-tendon repair beginning medially at the tear apex. I move the arthroscope to the lateral portal to gain a better understanding of tear geometry and establish anterior and posterior portals. I begin medially and place a suture approximately 5 mm lateral to the tear apex, place tension on the suture, and observe the change in tear size. I continue placing sutures from medial to lateral until I cannot approximate the tear any further. At this point, if the lateral tendon margin is lateral to the articular cartilage, tendon-to-bone repair with suture anchors is appropriate (Figs. 13-50 through 13-55). Certain modifications in repair technique are required. It is easier to repair the tendon by inserting the suturing instrument posteriorly, withdrawing the suture posteriorly, and then tying from either the posterior or the anterior portal, depending on the surgeon’s preference. I use the Smith-Nephew crescent Cuff-Stitch to place a braided suture. I place the instrument through the posterior portal and pierce the posterior limb of the rotator cuff. I then insert an instrument such as the Arthropierce through the anterior cannula and pierce the anterior limb of the rotator cuff. I grasp the suture, withdraw the instrument back through the anterior cannula, and pull the suture through the anterior tendon. Another option is the Spectrum crescent suture passer. Place this instrument through the anterior cannula and pierce the anterior tendon limb. Feed the posterior suture into the end of the anterior suture passer. Use the wheel to pull the suture through the anterior

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instrument. Withdraw both the instrument and the suture through the anterior cannula. I use a crochet hook to pull both suture limbs out the posterior cannula and tie the knot (Figs. 13-56 through 13-58).

Suture Tying

Figure 13-53

Margin convergence.

If four sutures are placed in the longitudinal tear, the tying sequence is as follows: Place the first (most medial) suture. Place the second suture and then tie the first. Place the third suture and tie the second suture. Place the fourth suture and tie the third suture. Tie the fourth suture (see Figs. 13-50 through 13-53).

Subscapularis Tears Subscapularis tears are often identified in patients with massive supraspinatus and infraspinatus tears. The subscapularis tears may be partial or full thickness. Full-thickness lesions are usually confined to

Figure 13-54

Figure 13-55

Margin convergence, medial anchor repair.

Margin convergence, anatomic anchor repair.

Figure 13-56

Cuff-Stitch.

Figure 13-57

Cuff-Stitch.

Chapter 13

Figure 13-58

Spectrum suture passer.

the superior portion of the subscapularis and are easily repaired with a standard arthroscopic rotator cuff repair technique. More substantial lesions require that the surgeon move the arthroscope to the lateral portal and introduce instruments through the anterior and posterior portals. However, the repair techniques are similar to those discussed in the treatment of full-thickness supraspinatus tears.

Subscapularis Repair

POSTOPERATIVE MANAGEMENT The postoperative management is similar to that for patients who undergo routine rotator cuff repair, as described in Chapter 19. Rotator cuff surgery in patients with massive tears is complex and technically demanding, but patient satisfaction is high because pain relief is excellent and function is satisfactory.

BIBLIOGRAPHY Burkhart SS: Partial repair of massive rotator cuff tears: The evolution of a concept. Orthop Clin North Am 28:125-132, 1997. Burkhart SS: The principle of margin convergence in rotator cuff repair as a means of strain reduction at the tear margin. Ann Biomed Eng 32:166-170, 2004. Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence: A method of reducing strain in massive rotator cuff tears. Arthroscopy 12:335-338, 1996.



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Burkhart SS, Barth JR, Richards DP, et al: Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration. Arthroscopy 23:347-354, 2007. Burkhart SS, Danaceau SM, Pearce CE Jr: Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique—margin convergence versus direct tendon-to-bone repair. Arthroscopy 17:905-912, 2001. Burkhart SS, Tehrany AM: Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 18:454-463, 2002. Cordasco FA, Bigliani LU: The rotator cuff: Large and massive tears. Technique of open repair. Orthop Clin North Am 28:179-193, 1997. Costouros JG, Porramatikul M, Lie DT, Warner JJ: Reversal of suprascapular neuropathy following arthroscopic repair of massive supraspinatus and infraspinatus rotator cuff tears. Arthroscopy 23:1152-1161, 2007. DiGiovanni J, Marra G, Park JY, Bigliani LU: Hemiarthroplasty for glenohumeral arthritis with massive rotator cuff tears. Orthop Clin North Am 29:477-489, 1998. Fenlin JM Jr, Chase JM, Rushton SA, Frieman BG: Tuberoplasty: Creation of an acromiohumeral articulation—a treatment option for massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 11:136-142, 2002. Galatz LM, Ball CM, Teefey SA, et al: The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 86:219-224, 2004. Gartsman GM, Khan M, Hammerman SM: Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 80:832-840, 1998. Gerber C, Schneeberger AG, Hoppeler H, Meyer DC: Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: A study in thirteen patients. J Shoulder Elbow Surg 16:691-696, 2007. Keen J, Nyland J, Kocabey Y, Malkani A: Shoulder and elbow function 2 years following long head triceps interposition flap transfer for massive rotator cuff tear reconstruction. Arch Orthop Trauma Surg 126:471-479, 2006. Richards DP, Burkhart SS, Lo IK: Subscapularis tears: Arthroscopic repair techniques. Orthop Clin North Am 34:485-498, 2003. Sano H, Nakajo S: Repeated hemarthrosis with massive rotator cuff tear. Arthroscopy 20:196-200, 2004. Vad VB, Southern D, Warren RF: Prevalence of peripheral neurologic injuries in rotator cuff tears with atrophy. J Shoulder Elbow Surg 12:333-336, 2003. Zingg PO, Jost B, Sukthankar A, et al: Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am 89:1928-1934, 2007.

CHAPTER

14

Irreparable Rotator Cuff Tears

The biggest problem with the arthroscopic treatment of massive rotator cuff tears is the possibility of misdiagnosis. Often, a massive tear is retracted and appears irreparable, but after soft tissue release, the defect is reparable. I overcame this problem through practice: I estimated both the size and the reparability of tears arthroscopically; then I opened the shoulder for comparison until I became confident of the accuracy of my arthroscopic diagnoses. If the lesion is truly irreparable, arthroscopic treatment allows a thorough de´bridement while retaining all the advantages of arthroscopic surgery, including glenohumeral joint inspection and correction of

B

A Figure 14-1

296

intra-articular abnormalities, preservation of the deltoid insertion, and a complete inspection and manipulation of the rotator cuff without the need for acromioplasty, coracoacromial ligament resection, or subscapularis detachment. Perhaps the most difficult patients to treat are those whose irreparable tears were diagnosed after open acromioplasty and coracoacromial ligament resection were performed. Loss of the static restraint of the coracoacromial arch allows anterior superior escape of the humeral head. Relatively painful shoulder elevation is converted to very painful shoulder shrugging—the classic pseudoparalytic shoulder (Fig. 14-1).

A and B, Irreparable rotator cuff tear.

Chapter 14

LITERATURE REVIEW When a massive, irreparable defect in the rotator cuff tendons is identified at surgery, the surgeon has various treatment options to choose from. Local tissue transfer from the remaining intact rotator cuff, use of the upper portion of the subscapularis, incorporation of the intra-articular portion of the biceps tendon, supraspinatus advancement, deltoid muscle flap, synthetic materials, and tendon allograft have been proposed. A latissimus dorsi transfer has been described by Gerber and others, but there are questions about the morbidity of this procedure as well as the dynamic function of the graft. For patients in whom overhead work and stronger external rotation are vital, the relatively modest gains afforded by latissimus dorsi transfer can be of major importance. Subscapularis transfer and biceps incorporation are rarely performed. Synthetic grafts are currently a source of great interest, but little science is available to guide the orthopedic surgeon. Because irreparable tendon tears are almost always accompanied by profound muscle atrophy and fatty infiltration, it seems unlikely that synthetic tendon connected to nonviable muscle will function. One of the most widely used open procedures was described by Rockwood, who de´brided the edges of the necrotic tendon, thoroughly decompressed the subacromial space by performing an anterior and inferior acromioplasty, resected the coracoacromial ligament, and removed the subacromial bursa. The deltoid was meticulously repaired. Postoperatively, the patient was started on an immediate rehabilitation program. Rockwood obtained good results using this technique, with patients achieving pain relief and marked improvement in function. My own experience was not as positive. My success rate was lower, and I found that after this procedure some of my patients experienced an improvement in pain but a loss of strength. Since these reports appeared, Nirschl has taught us to avoid acromioplasty in these patients. Preserving the coracoacromial arch helps keep the humeral head centered in the glenohumeral joint and prevents the disastrous complication of anterior superior humeral head subluxation. Less has been written about the arthroscopic treatment of patients with irreparable tears. Ellman and I have both achieved good pain relief with arthroscopic treatment in a limited number of patients; reasonable pain relief has been documented in most patients at up to 5 years’ follow-up. We emphasize thorough de´bridement and synovectomy, accompanied by the removal of any downward-protruding acromial or acromioclavicular joint spurs. Burkhart reported that among



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297

25 patients with massive irreparable tears, 88% had good or excellent results after arthroscopic treatment; those results have not deteriorated with the passage of time. Many older individuals have relatively good active and passive motion; pain is their primary complaint. Arthroscopic de´bridement and biceps tenotomy can provide good pain relief with little morbidity. For individuals who need more motion or strength, I advise reverse shoulder arthroplasty.

DIAGNOSIS Physical examination usually demonstrates normal or near-normal passive range of motion; however, there may be limits because of capsular contractures. Active range of motion is decreased. Supraspinatus and infraspinatus atrophy may be observed. Manual muscle testing demonstrates grade 3 or lower strength with external rotation and elevation. The patient’s subscapularis function should be evaluated using either the belly-press test or the lift-off test with the arm internally rotated to the back. Plain radiographs may show the humeral head centered in the glenoid, but superior migration may be present. Magnetic resonance imaging (MRI), which some surgeons do not use routinely in older patients, is often of great value in this clinical setting. The amount of tendon retraction is more clearly defined on MRI than on arthrography and, perhaps more important, the degree of atrophy and fatty degeneration or substitution in the rotator cuff muscles can be appreciated (Fig. 14-2). If the patient’s rotator cuff strength is grade 3 or less and MRI demonstrates humeral head superior migration, retraction of the tendon to the glenoid rim, and severe muscular atrophy, the cuff defect is almost certainly irreparable. The status of the subscapularis requires close attention. Patients with irreparable, retracted subscapularis tears can be treated with arthroscopic de´bridement. However, Burkhart has shown that patients with reparable subscapularis tears benefit from subscapularis repair even in the presence of superior humeral head migration (Fig. 14-3).

NONOPERATIVE TREATMENT Nonoperative treatment consists of activity modification, nonsteroidal anti-inflammatory medications, cortisone injections, and a physical therapy program designed to maintain or improve shoulder range of motion and strengthen the deltoid, scapular rotators, biceps, and intact rotator cuff muscles.

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A

B

Figure 14-2 A, Fatty infiltration of the supraspinatus, coronal view. B, Fatty infiltration of the supraspinatus and infraspinatus,

sagittal view.

I continue nonoperative treatment for at least 6 months. A surprising number of patients have reduced pain as the inflammation decreases and regain adequate function with muscle strengthening exercises. Stretching can often improve capsular contracture and further diminish pain.

INDICATIONS FOR SURGERY Indications for operation include pain interfering with work or activities of daily living or nighttime pain unresponsive to the nonoperative treatment outlined earlier. Patients should have a well-preserved glenohumeral joint space on plain radiographs and relatively pain-free passive external rotation with the arm at the side. The presence of an intact biceps that could serve as a pain generator and might respond to

tenotomy is helpful. The presence of a dislocated biceps, usually medial, is often very painful and responds well to biceps tenotomy.

CONTRAINDICATIONS TO SURGERY Because the goal of this procedure is pain relief, patients who require strength for overhead work usually will not be satisfied with the results of de´bridement. In my practice, this is an unusual situation, because most of my patients with this condition are older and less active. Patients with painful passive external and internal rotation and advanced glenohumeral joint arthritis are not candidates for arthroscopic de´bridement. I prefer to treat these patients, or those with true rotator cuff arthropathy, with reverse arthroplasty.

OPERATIVE TECHNIQUE Irreparable Rotator Cuff Tear Examine the shoulder for range of motion and compare it with the contralateral shoulder. Perform a gentle manipulation to correct losses of motion in abduction, elevation, and external and internal rotation.

Glenohumeral Joint

Figure 14-3

Subscapularis tear.

A standard posterior portal is used to enter and inspect the glenohumeral joint. Because there is no infraspinatus tendon, the joint is entered easily. Patients with irreparable rotator cuff tears are often older,

Chapter 14

Figure 14-4

Anterior-inferior capsule release.

and multiple glenohumeral abnormalities are identified. I ignore areas of minor labrum fraying or cartilage thinning on the glenoid or humeral head, which are not likely to be responsible for the patient’s pain. If I find labrum flap tears that could cause mechanical abnormalities, a glenoid surface abnormality such as a step-off, or a capsular contracture, I create an anterior portal with a spinal needle. I place the anterior portal more laterally than usual. If the anterior portal is placed normally (more medially and inferiorly) so that it enters the glenohumeral joint adjacent to the superior border of the subscapularis tendon, it will not be useful for the subacromial portion of this procedure, and an additional portal will be needed. I de´bride labrum flap tears with a motorized shaver and correct areas of contracture as described in Chapter 6 (Fig. 14-4). I then remove all instruments and cannulas from the glenohumeral joint.



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I use the same posterior skin incision to enter the subacromial space. After the trocar passes through the skin and subcutaneous tissue, but before it enters the deltoid muscle, I translate the cannula and trocar superiorly until the trocar tip touches the posterior acromion. I then direct the cannula and trocar until they are parallel to the acromion. I advance the cannula and trocar, palpate the acromion’s inferior surface, and then slide along the inferior surface until the trocar tip is 1 cm posterior to the anterior edge of the acromion. This has three beneficial effects: (1) the trocar tip can be used to dissect any rotator cuff tendon that is adherent to the acromion; (2) the cannula is positioned parallel to the inferior surface of the acromion, not directed superiorly; and (3) the arthroscope is positioned at the maximal distance from the humeral head, which improves my perspective of the size and shape of the rotator cuff lesion. I remove the trocar, insert the arthroscope, and establish a lateral working portal. I perform a bursectomy to view the rotator cuff defect clearly and then insert a cannula for outflow through the anterior portal (Figs. 14-5 and 14-6). I insert a grasper through the lateral portal and pull on the tendon edges to determine their quality and mobility (Figs. 14-7 and 14-8). I usually move the arthroscope to the lateral portal and obtain a different view of the rotator cuff tear. Some surgeons prefer to view laterally and insert the instruments from the posterior portal, whereas others prefer to leave the arthroscope in the posterior portal and insert the instruments laterally. I use whichever portal gives me the best view of the subacromial space (Fig. 14-9). If the tear is massive and MRI or physical examination does not demonstrate significant atrophy, I perform soft tissue releases and consider repair

Subacromial Space It may seem unnecessary to remove the cannula and reinsert it because with an irreparable tear, the surgeon can view both the glenohumeral joint and the subacromial space. However, I have found that there is a subtle but critical difference in the angle of the two views. When I enter the glenohumeral joint, I tilt the arthroscope slightly inferiorly, which allows a better view of the structures within the joint. When directing the arthroscope superiorly to view the subacromial space, the arthroscope is too close to the humeral head, and its angle of approach tends to distort the view.

Figure 14-5

Rotator cuff adherent to the acromion (arrow).

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Figure 14-6



Subacromial Space Surgery

Cannula parallel to the acromion. Figure 14-9

Figure 14-7

Traction on the rotator cuff tendon, posterior

view.

Figure 14-8

view.

Lateral view.

(Figs. 14-10 through 14-15). In these patients, the posterior bursa can be quite hypertrophic and may appear to be the posterior tendon. I palpate and de´bride with a shaver to separate the bursa from the tendon (Fig. 14-16). I carefully examine the subscapularis. De´bridement of irreparable supraspinatus tears combined with arthroscopic subscapularis repair often leads to surprisingly good shoulder function (see Chapter 13). If the rotator cuff tendons are absent or excessive tension would be necessary to effect a repair, I proceed to de´bridement. I use a motorized shaver to remove rotator cuff remnants from the greater tuberosity. If the greater tuberosity is prominent, I smooth it with a bur. I inspect the anterior, lateral, and posterior gutters for adhesions that can restrict motion between the deltoid

Traction on the rotator cuff tendon, posterior Figure 14-10

Superior capsule release.

Chapter 14

Figure 14-11

Medial adhesions of the rotator cuff tendon.

Figure 14-12

Figure 14-13

Coracohumeral ligament release.

Coracohumeral ligament release.

Figure 14-14



Irreparable Rotator Cuff Tears

Coracohumeral ligament release.

Figure 14-15

Figure 14-16

Excessive tension.

Thickened posterior bursa.

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Figure 14-17

Tuberosityplasty.

Figure 14-19

and the rotator cuff and remove them with arthroscopic scissors, electrocautery, or a power shaver (Figs. 14-17 and 14-18). As Nirschl and Flatow reported, removal of the coracoacromial arch in patients with no functioning rotator cuff can result in a devastating complication; superomedial humeral head dislocation. The coracoacromial ligament is not resected, and I do not perform an acromioplasty. An important source of pain in patients with irreparable rotator cuff tears can be the biceps tendon. I consider tenotomy if the biceps tendon quality is poor, there is a partial tear, or it is dislocated

Figure 14-18

Tuberosityplasty.

Medial dislocation of the biceps.

medially. Another relative indication for biceps tenotomy is a lack of tendon excursion. I grasp the tendon with a tendon grasper inserted through the lateral cannula and try to translate it. Often the tendon is adherent to bone or soft tissue distal to the bicipital groove and does not glide. My interpretation of this finding is that the biceps has effectively undergone tenodesis, and the intra-articular portion can be sacrificed without any apparent negative effects. I discuss the option of tenotomy with patients preoperatively and caution them about the potential for deformity. I have been pleased with the amount of pain relief tenotomy provides (Figs. 14-19 through 14-25).

Figure 14-20

Test biceps excursion.

Chapter 14

Figure 14-21

Figure 14-22



Irreparable Rotator Cuff Tears

303

Test biceps excursion.

Figure 14-24

Biceps tendon removed.

Figure 14-25

Biceps stump de´brided.

Distal biceps tendon release.

POSTOPERATIVE MANAGEMENT

Figure 14-23

Proximal biceps tendon release.

The various exercises for rehabilitation are illustrated in Chapter 19. I start patients on immediate passive range of motion with a continuous passive motion chair, dowel, or pulley. Active range of motion for routine activities of daily living can be started once the patient recovers from the interscalene block. I do not place the arm in a sling. Once passive range of motion has been recovered, the patient can

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begin active-assisted range-of-motion exercises. I place the patient supine on the examining table and passively elevate the shoulder to 90 degrees. If the patient can maintain this position with active muscle stabilization, I determine whether he or she has enough control to lower the arm independently. If so, I ask the patient to actively raise the arm. If the patient cannot perform the active and active-assisted exercises supine (with the scapula supported and gravity eliminated), I do not allow him or her to work on standing, active, overhead elevation. The patient works supine until good arm control has been achieved; only then does he or she progress to the next stage. Standing active range of motion also has three phases. First, I have the patient elevate the arm passively and try to maintain it in elevation actively. I advise the patient to keep the contralateral hand under the operated forearm; this provides some emotional support, because most patients have not had the arm in this position for some time. Also, if the patient cannot control the operated shoulder, the normal hand is there to prevent it from falling to the side. Once the patient can hold this position comfortably for 30 seconds (the patient performs the exercise in front of a clock with a second hand), I have the patient raise the arm passively, hold it there for 5 seconds, and then lower it slowly. Again, the contralateral hand is there for support as needed. Once the patient is comfortable with phase two, active elevation can begin. The patient begins by assisting the operated arm with fingertip pressure from the normal arm until full elevation is achieved. I gradually have the patient decrease the use of the normal arm until full, slow, controlled active elevation is possible. Once postoperative pain has diminished, patients also begin a strengthening program and use light surgical tubing to strengthen the deltoid, internal rotators, and scapular stabilizing muscles. It is critical to provide encouragement to these patients and inform them that it will take many months to achieve the goals of the operation.

COMPLICATIONS The most devastating complication is superomedial humeral head instability and subluxation. I avoid this problem by leaving the coracoacromial ligament intact and not performing an anterior acromionectomy or anterior-inferior acromioplasty. Treatment may require a reverse shoulder prosthesis.

BIBLIOGRAPHY Aluisio FV, Osbahr DC, Speer KP: Analysis of rotator cuff muscles in adult human cadaveric specimens. Am J Orthop 32:124-129, 2003. Boileau P, Baque´ F, Valerio L, et al: Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am 89:747-757, 2007. Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Arthroscopy 18:1002-1012, 2002. Burkhart SS: Arthroscopic treatment of massive rotator cuff tears: Clinical results and biomechanical rationale. Clin Orthop Relat Res 267:45-56, 1991. Burkhart S, Nottage WM, Ogilvie-Harris DJ, et al: Partial repair of irreparable rotator cuff tears. Arthroscopy 10:363-370, 1994. Codsi MJ, Hennigan S, Herzog R, et al: Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: Surgical technique. J Bone Joint Surg Am 89(Suppl 2):1-9, 2007. Costouros JG, Espinosa N, Schmid MR, Gerber C: Teres minor integrity predicts outcome of latissimus dorsi tendon transfer for irreparable rotator cuff tears. J Shoulder Elbow Surg 16:727-734, 2007. Dines DM, Moynihan DP, Dines JS, McCann P: Irreparable rotator cuff tears: What to do and when to do it; the surgeon’s dilemma. Instr Course Lect 56:13-22, 2007. Duralde XA, Bair B: Massive rotator cuff tears: The result of partial rotator cuff repair. J Shoulder Elbow Surg 14:121-127, 2005. Edwards TB, Walch G, Nove´-Josserand L, et al: Arthroscopic debridement in the treatment of patients with isolated tears of the subscapularis. Arthroscopy 22:941-946, 2006. Ellman H, Kay SP, Wirth M: Arthroscopic treatment of fullthickness rotator cuff tears: 2- to 7-year follow-up study. Arthroscopy 9:195-200, 1993. Fenlin JM, Chase JM, Rushton SA, Frieman BG: Tuberoplasty: Creation of an acromiohumeral articulation—a treatment option for massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 11:136-142, 2002. Funakoshi T, Majima T, Iwasaki N, et al: Application of tissue engineering techniques for rotator cuff regeneration using a chitosan-based hyaluronan hybrid fiber scaffold. Am J Sports Med 33:1193-1201, 2005. Gartsman GM: Arthroscopic assessment of rotator cuff tear reparability. Arthroscopy 12:546-549, 1996. Gartsman GM: Massive, irreparable tears of the rotator cuff: Results of operative debridement and subacromial decompression. J Bone Joint Surg Am 79:715-721, 1997. Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am 88:113-120, 2006. Halder AM, O’Driscoll SW, Heers G, et al: Biomechanical comparison of effects of supraspinatus tendon detachments, tendon defects, and muscle retractions. J Bone Joint Surg Am 84:780-785, 2002.

Chapter 14

Iannotti JP, Hennigan S, Herzog R, et al: Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: Factors affecting outcome. J Bone Joint Surg Am 88:342-348, 2006. Jost B, Puskas GJ, Lustenberger A, Gerber C: Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears. J Bone Joint Surg Am 85:1944-1951, 2003. Klinger HM, Steckel H, Ernstberger T, Baums MH: Arthroscopic debridement of massive rotator cuff tears: Negative prognostic factors. Arch Orthop Trauma Surg 125:261-266, 2005. Konrad GG, Sudkamp NP, Kreuz PC, et al: Pectoralis major tendon transfers above or underneath the conjoint tendon in subscapularis-deficient shoulders: An in vitro biomechanical analysis. J Bone Joint Surg Am 89:2477-2484, 2007. Ma HL, Hung SC, Wang ST, Chen TH: The reoperation of failed rotator cuff repairs. J Chin Med Assoc 66:96-102, 2003. Moore DR, Cain EL, Schwartz ML, Clancy WG: Allograft reconstruction for massive, irreparable rotator cuff tears. Am J Sports Med 34:392-396, 2006. Morelli M, Nagamori J, Gilbart M, Miniaci A: Latissimus dorsi tendon transfer for massive irreparable cuff tears: An anatomic study. J Shoulder Elbow Surg 17:139-143, 2007. Mura N, O’Driscoll SW, Zobitz ME, et al: Biomechanical effect of patch graft for large rotator cuff tears: A cadaver study. Clin Orthop Relat Res 415:131-138, 2003.



Irreparable Rotator Cuff Tears

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Nirschl RP: Rotator cuff surgery. Instr Course Lect 38:447462, 1989. Pearle AD, Kelly BT, Voos JE, et al: Surgical technique and anatomic study of latissimus dorsi and teres major transfers. J Bone Joint Surg Am 88:1524-1531, 2006. Postacchini F, Gumina S: Results of surgery after failed attempt at repair of irreparable rotator cuff tear. Clin Orthop Relat Res 397:332-341, 2002. Walch G, Edwards TB, Boulahia A, et al: Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: Clinical and radiographic results of 307 cases. J Shoulder Elbow Surg 14:238-246, 2005. Werner CM, Zingg PO, Lie D, et al: The biomechanical role of the subscapularis in latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg 15:736-742, 2006. Wirth MA, Rockwood CA: Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am 79:722-731, 1997. Zingg PO, Jost B, Sukthankar A, et al: Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am 89:1928-1934, 2007.

CHAPTER

15

Acromioclavicular Joint

Acromioclavicular joint pain is a common shoulder condition that can result from a specific injury, from repetitive minor trauma, or as part of the aging process. When the source of pain is articular incongruity, the lesion is amenable to arthroscopic treatment (Fig. 15-1). Articular incongruity may be seen in post-traumatic arthritis, type 2 acromioclavicular dislocation with less than 25% subluxation, primary osteoarthritis, rheumatoid arthritis, septic arthritis, and osteolysis of the distal clavicle. In my experience, individuals with type 3 to type 6 acromioclavicular dislocations are not suitable candidates for arthroscopic surgery because their pain is due to acromioclavicular joint

Figure 15-1

306

Acromioclavicular joint arthritis.

instability. I treat these patients with open reconstruction of the coracoclavicular ligaments (Fig. 15-2).

LITERATURE REVIEW My colleagues and I have demonstrated that an adequate acromioclavicular resection can be performed arthroscopically in a laboratory setting and that satisfactory results can be obtained in a clinical setting. Snyder (see Buford et al) and Flatow reported good results in 90% of patients. Neviaser demonstrated the efficacy of resecting only the medial acromion without resecting the distal clavicle. Both the direct approach to

Figure 15-2

Type 5 acromioclavicular joint dislocation.

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Acromioclavicular Joint

307

the acromioclavicular joint and the indirect approach through the subacromial bursa appear to be equally effective. Arthroscopic reconstruction of the acromioclavicular joint for dislocation has been reported. Owing to the short-term nature of the results, I still prefer open operative reconstruction.

DIAGNOSIS Patients complain of pain in the area of the acromioclavicular joint during cross-body adduction (washing the opposite axilla or reaching for a seatbelt) or behindthe-back internal rotation (fastening a bra or pulling a belt through its loops). Weight lifters experience pain during a flat or inclined bench press. Physical examination demonstrates normal active and passive range of motion, with the exception of limited adduction or internal rotation. There is pain on direct palpation of the anterior or superior aspect of the acromioclavicular joint. Selective injections (described later) are a useful adjunct. Plain anteroposterior radiographs demonstrate joint space narrowing, joint incongruity, inferior osteophytes, or distal osteolysis. A 15-degree apical tilt view may show the acromioclavicular joint more clearly. Magnetic resonance imaging (MRI) commonly demonstrates acromioclavicular joint arthritis in patients older than 40 years. The radiologist almost always mentions changes that are interpreted as acromioclavicular arthritis. The surgeon should be careful to interpret such studies in light of an appropriate patient history and physical examination (Fig. 15-3). Some patients with superior labrum from anterior to posterior (SLAP) lesions have a presentation similar

Figure 15-4

SLAP lesion.

to that of patients with acromioclavicular arthritis. Patients localize their pain deep to the acromioclavicular joint and have pain with adduction and behind-the-back internal rotation. Specific acromioclavicular tenderness to palpation is absent. Adduction is similar to the movement performed during the O’Brien test and may misdirect the surgeon (Fig. 15-4).

NONOPERATIVE TREATMENT Nonoperative treatment is usually successful and consists of avoidance of painful positions and activities and nonsteroidal anti-inflammatory medication. Because the pain from this condition is rarely disabling, I counsel patients to wait 6 to 12 months before they consider surgery.

Injection

Figure 15-3 Magnetic resonance image showing acromio-

clavicular joint arthritis.

Lesions of the acromioclavicular joint and subacromial space are difficult to differentiate. Acromioclavicular arthritis can cause irritation of the underlying cuff, and the altered shoulder mechanics that accompany rotator cuff disease may aggravate an otherwise normal acromioclavicular joint. Selective acromioclavicular joint injection has two possible benefits: it may help the surgeon diagnose the primary source of pain, and it may be therapeutic if the cortisone diminishes joint inflammation. I use a 25-gauge shortbarrel needle; a longer needle can inadvertently penetrate the inferior acromioclavicular joint capsule and enter the subacromial space. Palpate the sulcus between the distal clavicle and medial acromion. Because the acromioclavicular joint may slope or tilt

308

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Subacromial Space Surgery

in different directions, study the anteroposterior radiograph to determine the joint inclination. Clean the skin overlying the superior aspect of the joint with an antibacterial preparation. Advance the needle through the skin while maintaining gentle pressure on the plunger. When the joint is entered, you will feel the change in resistance. Inject 1 to 2 mL of 2% plain lidocaine and 1 mL of methylprednisolone (Depo-Medrol). Figure 15-6

INDICATIONS FOR SURGERY Surgery is indicated when acromioclavicular joint arthritis has been identified as the source of shoulder pain by patient history, physical examination, plain radiographs and, when appropriate, MRI. Patients whose pain interferes with activities of daily living, work, or sports and who have not responded to a minimum of 6 months’ conservative care are good candidates for arthroscopic acromioclavicular joint resection. Patients with MRI evidence of acromioclavicular joint arthritis but whose pain is not localized to the acromioclavicular joint are not candidates for acromioclavicular joint resection.

Acromioplasty.

medial acromion and distal clavicle so that physical contact is eliminated during shoulder motion. Traditionally, open resection involves the removal of 1 to 1.5 cm of distal clavicle. Arthroscopic acromioclavicular resection removes 5 to 8 mm of distal clavicle and 5 mm of medial acromion (Figs. 15-5 through 1511). Patient positioning and diagnostic glenohumeral arthroscopy are performed routinely. However, I move the posterior incision 2 to 3 mm laterally from its

OPERATIVE TECHNIQUE Acromioclavicular Joint Resection The two goals of arthroscopic acromioclavicular joint resection are to remove the abnormal distal portion of the clavicle and to create enough space between the

A 5-10 mm

5-10 mm

A

B Figure 15-5

A and B, Area of desired bone removal.

B Figure 15-7 A and B, Resect the anterior portion of the medial acromion.

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309

A 7-10 mm 5 mm

Figure 15-10

Resect the distal clavicle.

B Figure 15-8

A and B, Complete medial acromion resection.

A A

B

C

B Figure 15-9

A-C, End-on view showing the sequence of distal clavicle resection.

Figure 15-11

A and B, Expose the distal clavicle.

310

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Subacromial Space Surgery

normal location. This allows me to angle the arthroscope medially and obtain a better view of the distal clavicle when I enter the subacromial space. The instruments are then removed, and attention is turned to the subacromial space. The cannula and trocar are inserted through the posterior incision into the subacromial space. The arthroscope is inserted, and a subacromial inspection is performed. If the space is not seen clearly, bursectomy is performed as described in Chapter 10. If arthroscopic subacromial decompression is required, the procedure is performed as described in Chapter 10. I modify arthroscopic subacromial decompression when I combine it with acromioclavicular resection. I completely resect the medial acromial wall adjacent to the acromioclavicular joint from anterior to posterior. If arthroscopic subacromial decompression is not necessary, I establish a lateral portal for instrumentation. I use a soft tissue resector to remove any bursa that obscures the view of the medial acromion and use electrocautery to coagulate the soft tissue and vessels on the acromion. The cutting or ablation setting on the electrocautery device can effectively expose acromial bone. I use a soft tissue resector until the medial acromial surface is free from soft tissue. I then insert a power bur through the lateral portal and remove the medial acromion until soft tissue or distal clavicle is visible (Figs. 15-12 through 15-16). I then establish an anterior portal directly anterior to the acromioclavicular joint. Precision is critical, so I use a spinal needle to localize the cannula site. The anterior portal must be located in the center of

Use cautery to expose the bone surface and cauterize blood vessels.

Resect the inferior aspect of the medial acromion with the bur in the lateral portal.

Figure 15-13

Figure 15-14

Arthroscope rotated medially.

Figure 15-12

Figure 15-15

Distal clavicle viewed from the posterior portal.

Chapter 15

Figure 15-18 Figure 15-16



Acromioclavicular Joint

311

Needle localizing the anterior portal.

Distal clavicle viewed from the lateral portal.

the acromioclavicular joint. If the location is too lateral, it is difficult to remove the distal clavicle; if it is too medial, it is difficult to remove the medial acromion (Figs. 15-17 through 15-19). If I have a good view of the distal clavicle with the arthroscope positioned in the posterior cannula, there is no need to change its location. In most cases, I can angle the cannula medially and rotate the arthroscope to obtain a good view. I usually perform the medial acromial resection and the initial portion of the distal clavicle resection with the arthroscope in the posterior portal. In most patients, I routinely move the arthroscope to the lateral portal to finish the posterior portion of the distal clavicle resection. I cauterize the soft tissue at the anterior, inferior, and posterior borders of the distal clavicle.

Figure 15-17

Location of the anterior portal.

This decreases the likelihood of bleeding during bone and soft tissue removal (Figs. 15-20 and 15-21). I tilt the arthroscope superiorly and rotate the camera until I have the best view of the anterior portion of the medial acromion. I use the bur to remove the superior surface of the medial acromion from anterior to posterior, being careful not to violate the superior capsule of the acromioclavicular joint. At this point, I have removed 4 to 5 mm of bone from the medial acromion. I then withdraw the arthroscope and rotate it so that I am looking directly at the distal clavicle. I remove one bur width of distal clavicle from anterior to posterior and begin removing bone from the anterior half of the distal clavicle. I remove bone equal to the depth of the acromionizer (5 mm) or the metal guard around the bur (7.2 mm). Then I usually move the arthroscope to the lateral portal

Figure 15-19

Needle in the anterior portal.

312

Section Three

Figure 15-20



Subacromial Space Surgery

Cautery of the anterior clavicle.

Figure 15-22

Resect the superior portion of the medial

acromion.

and the outflow cannula to the posterior portal. This allows an end-on view of the distal clavicle. I move the bur posteriorly and remove the same amount of bone from the posterior half of the distal clavicle until the clavicle surface is flat. I rotate and tilt the arthroscope until I can see the posterior border of the distal clavicle and the posteromedial acromion. I inspect the posterior aspect of the acromioclavicular joint and remove any remaining posteromedial acromion that may cause impingement during shoulder extension or abduction. At this point, 10 to 15 mm of bone has been removed (5 mm of medial acromion, and 5 to 10 mm of distal clavicle). I advance the cannula or shaver (an instrument with a known size) into the resected area to ensure that there is adequate space between the distal clavicle and the acromion. I also advise surgeons to insert the arthroscope into the anterior cannula and view the acromioclavicular joint directly (Figs. 15-22 through 15-33).

Figure 15-23

Resect the superior portion of the medial acromion with the arthroscope rotated superiorly.

Figure 15-24 Figure 15-21

Cautery of the inferior clavicle.

Resect the superior portion of the medial

acromion.

Chapter 15

Resect the superior portion of the medial acromion with the arthroscope rotated superiorly.

Figure 15-25

Figure 15-26

Superior capsule of the acromioclavicular joint.

Figure 15-27

Remove 4 to 5 mm of bone in the medial

acromion.

Acromioclavicular Joint

Figure 15-28

Anterior clavicle resection.

Figure 15-29

Anterior clavicle resection.

Figure 15-30

contact.



313

Evaluate the posteromedial acromion for

314

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Subacromial Space Surgery

Cannula Position Cannula position is critical, and small errors can significantly prolong operative time and diminish the quality of the resection.

Posterior Portal

Figure 15-31

Outside view of the bur in the anterior cannula.

If the posterior portal is placed in the ‘‘soft spot,’’ it is too medial and inferior to allow a good view of the distal clavicle. My standard portal location for an arthroscopic subacromial decompression is 1 cm inferior and 1 cm medial to the posterolateral acromial margin. For an acromioclavicular joint resection, I move the posterior portal 2 to 3 mm laterally. This allows me to angle the arthroscope medially and obtain a better view of the distal clavicle.

Lateral Portal If the lateral portal is too anterior, the anterior clavicle and acromion are not well visualized, which can lead to inadequate bone resection. If the lateral cannula is too superior, the superior aspect of the distal clavicle and medial acromion cannot be seen.

POSTOPERATIVE MANAGEMENT

Figure 15-32

Measure the amount of bone resection.

An ice pack decreases swelling, inflammation, and pain postoperatively. It is worn for 1 hour, four times a day, for the first 2 weeks. Active and passive range of motion is started on the first postoperative day. Strengthening is started when examination demonstrates pain-free manual muscle testing. Work and sports are allowed as tolerated by the patient. Maximal improvement occurs 6 to 12 months after operation.

COMPLICATIONS Acromioclavicular instability is a concern after acromioclavicular resection. I limit distal clavicle resection to 10 to 15 mm to avoid violating the coracoclavicular ligaments. When I remove the superior distal clavicle osteophyte, I pay particular attention to the superior soft tissue envelope and do not resect any superior acromioclavicular ligament.

BIBLIOGRAPHY

Figure 15-33

resection.

Check the final acromioclavicular joint

Berg EE, Ciullo JV: The SLAP lesion: A cause of failure after distal clavicle resection. Arthroscopy 13:85-89, 1997. Boehm TD, Barthel T, Schwemmer U, Gohlke FE: Ultrasonography for intraoperative control of the

Chapter 15

amount of bone resection in arthroscopic acromioclavicular joint resection. Arthroscopy 20(Suppl 2):142-145, 2004. Buford D Jr, Mologne T, McGrath S, et al: Midterm results of arthroscopic co-planing of the acromioclavicular joint. J Shoulder Elbow Surg 9:498-501, 2000. Charron KM, Schepsis AA, Voloshin I: Arthroscopic distal clavicle resection in athletes: A prospective comparison of the direct and indirect approach. Am J Sports Med 35:53-58, 2007. Chernchujit B, Tischer T, Imhoff AB: Arthroscopic reconstruction of the acromioclavicular joint disruption: Surgical technique and preliminary results. Arch Orthop Trauma Surg 126:575-581, 2006. Clavert P, Leconiat Y, Dagher E, Kempf JF: [Arthroscopic surgery of the acromioclavicular joint]. Chirurgie Main 25(Suppl 1):S36-S42, 2006. Debski RE, Fenwick JA, Vangura A, et al: Effect of arthroscopic procedures on the acromioclavicular joint. Clin Orthop Relat Res 406:89-96, 2003. Elser F, Chernchujit B, Ansah P, Imhoff AB: [A new minimally invasive arthroscopic technique for reconstruction of the acromioclavicular joint]. Unfallchirurg 108:645649, 2005. Flatow EL, Duralde XA, Nicholson GP, et al: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 4:41-50, 1995. Freedman BA, Javernick MA, O’Brien FP, et al: Arthroscopic versus open distal clavicle excision: Comparative results at six months and one year from a randomized, prospective clinical trial. J Shoulder Elbow Surg 16:413-418, 2007. Gartsman GM: Arthroscopic resection of the acromioclavicular joint. Am J Sports Med 21:71-77, 1993. Gartsman GM: Extra-articular uses of the arthroscope—acromioclavicular arthroplasty. Clin Sports Med 12:111-121, 1993. Gartsman GM, Combs AH, Davis PF, et al: Arthroscopic acromioclavicular joint resection: An anatomical study. Am J Sports Med 19:1:2-5, 1991. Kay SP, Dragoo JL, Lee R: Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression. Arthroscopy 19:805-809, 2003.



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Kharrazi FD, Busfield BT, Khorshad DS: Acromioclavicular joint reoperation after arthroscopic subacromial decompression with and without concomitant acromioclavicular surgery. Arthroscopy 23:804-808, 2007. Lafosse L, Baier GP, Leuzinger J: Arthroscopic treatment of acute and chronic acromioclavicular joint dislocation. Arthroscopy 21:1017, 2005. Lervick GN: Direct arthroscopic distal clavicle resection: A technical review. Iowa Orthop J 25:149-156, 2005. Levine WN, Soong M, Ahmad CS, et al: Arthroscopic distal clavicle resection: A comparison of bursal and direct approaches. Arthroscopy 22:516-520, 2006. Mullett H, Benson R, Levy O: Arthroscopic treatment of a massive acromioclavicular joint cyst. Arthroscopy 23:446.e1-446.e4, 2007. Nourissat G, Kakuda C, Dumontier C, et al: Arthroscopic stabilization of Neer type 2 fracture of the distal part of the clavicle. Arthroscopy 23:674.e1-674.e4, 2007. Nuber GW, Bowen MK: Arthroscopic treatment of acromioclavicular joint injuries and results. Clin Sports Med 22:301-317, 2003. Pennington WT, Hergan DJ, Bartz BA: Arthroscopic coracoclavicular ligament reconstruction using biologic and suture fixation. Arthroscopy 23:785.e1-785.e7, 2007. Petchell JF, Sonnabend DH, Hughes JS: Distal clavicular excision: A detailed functional assessment. Aust N Z J Surg 65:262-266, 1995. Rolla PR, Surace MF, Murena L: Arthroscopic treatment of acute acromioclavicular joint dislocation. Arthroscopy 20:662-668, 2004. Stein BE, Wiater JM, Pfaff HC, et al: Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. J Shoulder Elbow Surg 10:204-208, 2001. Tennent TD, Beach WR: An improved technique for arthroscopic resection of the acromioclavicular joint. Arthroscopy 19:E119-E120, 2003. Tytherleigh-Strong G, Gill J, Sforza G, et al: Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection. Arthroscopy 17:E36, 2001.

CHAPTER

16

Calcific Tendinitis

One of the most painful acute conditions affecting the shoulder is calcific tendinitis. Patients experience a sudden, atraumatic onset of severe pain that is present at rest and increases with any shoulder movement. The pain is often severe enough to cause the individual to present at a local emergency room or to demand immediate evaluation in the orthopedist’s office. Patients often appear to be in distress and cradle the affected arm.

LITERATURE REVIEW The cause of acute calcific tendinitis is not precisely known, but Uhthoff’s analysis of the condition is the best. He considers calcific tendinitis a self-healing tendinopathy with a precalcifying phase during which a reduction in oxygen tension transforms a portion of the tendon into fibrocartilage. In this phase, chondrocytes mediate the deposition of calcium. Following the formative phase, the calcium may exist for an indefinite period and produce no symptoms. At some point, phagocytic cells accumulate around these calcium foci, and vascular proliferation occurs. The resorptive phase begins when these new vascular channels provide a pathway for resorption and restore normal perfusion and oxygen tension to the tissues. The acute pain begins with the resorptive phase. After the calcification is resorbed, the tendon is capable of normal function. Ellman reported on a multicenter study of 131 patients treated arthroscopically. The average Constant functional score was 69.4 of a possible 75. There was no correlation with patient age, size of the

316

calcification, or duration of symptoms. Acromioplasty was not shown to be of any benefit. In contrast, Mole and colleagues reported that acromioplasty improved the outcome in their patients.

DIAGNOSIS The diagnosis of calcific tendinitis is radiographic. Plain radiographs show single or multiple calcium deposits usually located in the supraspinatus tendon (65%). They also can occur in the infraspinatus (30%) or, more rarely, the subscapularis tendon (5%). The size, density, and location of the deposit must be evaluated closely to distinguish this condition from the dystrophic calcific densities that occur incidentally in rotator cuff tendinosis. These findings are summarized in Table 16-1 and shown in Figures 16-1 through 16-4. The shoulder is often swollen, and the overlying skin is sensitive to touch. The slightest pressure applied over the supraspinatus insertion may elicit severe pain. Active and passive range of motion is painful and restricted. Another cause of acute shoulder pain is cervical radiculopathy, and the surgeon should attempt to elicit a history of radicular pain or paresthesia and carefully examine the patient for neck pain with neck motion. A review of the radiographs confirms the diagnosis. Owing to the persistent, severe pain, patients often present with a magnetic resonance image taken to evaluate the rotator cuff tendons. Diagnostic ultrasonography is an easy and effective method of diagnosis (Figs. 16-5 and 16-6).

Chapter 16



Calcific Tendinitis

317

Table 16-1 RADIOGRAPHIC FEATURES OF CALCIUM DEPOSITS

Feature

Calcific Tendinitis

Rotator Cuff Tendinosis

Size

5-15 mm

<5 mm

Location

10-15 mm medial to greater tuberosity

Adjacent to tuberosity

Density Character

Less opaque Soft

Dense Hard

Calcific tendinitis in the subscapularis, with the shoulder externally rotated.

Figure 16-3

Figure 16-1

Calcific tendinitis, with the shoulder externally Calcific tendinitis in the subscapularis, with the shoulder internally rotated.

rotated.

Figure 16-2

rotated.

Figure 16-4

Calcific tendinitis, with the shoulder internally

Figure 16-5

imaging.

Calcific tendinitis on magnetic resonance

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INDICATIONS FOR SURGERY I have not operated on any patients for an initial acute attack of calcific tendinitis because the nonoperative treatment described earlier is generally successful. The indication for operation is repeated episodes of acute calcific tendinitis. I do not require a specific number of attacks before I consider operation; after the second episode, I offer arthroscopic surgery as a treatment option. Patients’ ability to tolerate episodes of severe pain varies greatly. Some patients choose not to have surgery for yearly attacks, whereas others welcome the opportunity for surgical correction.

OPERATIVE TECHNIQUE Calcific Tendinitis On ultrasonography, a hypoechoic (black) area is seen in the tendon (arrow).

Figure 16-6

NONOPERATIVE TREATMENT Patients presenting with an attack of acute calcific tendinitis are likely in the resorptive phase, and the condition is self-resolving. Therefore, nonoperative care is supportive and consists of an explanation of the condition’s natural history, narcotic analgesics, rest, and ice. The application of heat increases blood flow to an inflamed area but also increases pain and is therefore contraindicated. I believe that nonsteroidal anti-inflammatory medications decrease the ability to resorb calcium, so I do not prescribe them, nor do I inject cortisone into the subacromial space. Occasionally, I inject a local anesthetic (bupivacaine 0.25%) into the subacromial space to provide temporary pain relief, but I make no attempt to needle the calcium deposit. Once the severe pain has subsided, I instruct patients in gentle stretching exercises and allow them to resume activities as tolerated. If the attack of calcific tendinitis is prolonged and muscular atrophy develops, I prescribe a series of home exercises with surgical tubing to improve the strength of the shoulder girdle muscles. Mole and colleagues studied the effects of treatment on calcium deposits and found that supportive treatment led to a 0% disappearance rate at 4 years, extracorporeal shock waves to a 35% disappearance rate at 1 year, and needling to a 60% disappearance rate at 1 year. Prospective, randomized studies have not documented the benefits of extracorporeal shock-wave treatment.

The location of the deposit is determined by reviewing radiographs taken with the arm in different positions. On the anteroposterior radiograph, deposits in the supraspinatus tendon move medially when the arm is internally rotated. Lesions in the infraspinatus move laterally as the arm is moved into internal rotation. It is also important to note how far medially the calcium is located from the greater tuberosity. Study the axillary radiograph to determine the location of the calcific deposit. Calcium excision usually produces a vigorous inflammatory response, and many patients experience an acute attack in the postoperative period. For this reason, unless there are medical contraindications such as diabetes or hypertension, I have the anesthesiologist administer 100 mg of methylprednisolone (Solu-Medrol) intravenously before the operation and place the patient on a Medrol Dosepak after surgery. Interscalene block anesthesia is extremely helpful in the treatment of these patients. I establish a routine posterior glenohumeral joint portal and perform a complete glenohumeral joint inspection. I inspect the rotator cuff articular surface for areas of erythema or increased vascularity because these areas may correspond to the location of the calcium deposit (Fig. 16-7). When there is an abnormality, it is commonly located in the anterior rotator cuff, within the supraspinatus tendon. However, in patients with chronic calcific tendinitis, the articular cuff surface is usually normal. If the rotator cuff and the remainder of the glenohumeral joint appear normal, I immediately proceed to the subacromial space. I insert the arthroscope into the subacromial space through the posterior portal and establish a lateral

Chapter 16

Figure 16-9

Erythema on the articular surface of the

Figure 16-7



Calcific Tendinitis

319

Knife used to incise the bursal covering of

calcium.

supraspinatus.

subacromial portal. I insert a motorized shaver and perform a bursectomy so that I can see clearly within the subacromial space. Calcium deposits may appear as whitish discolorations or bulges in the tendon (Fig. 16-8). If the tendon appears normal and no deposit is seen, I insert a blunt trocar through the lateral cannula and palpate the tendon for areas of increased hardness. It is important not to confuse the firm feeling of the supraspinatus insertion into the greater tuberosity with a calcium deposit. If I cannot detect any calcium through inspection or palpation, I insert a spinal needle and puncture the tendon in multiple areas of the suspected lesion. If no abnormal areas are identified with this approach, I insert a spinal needle into the most likely

Figure 16-8

space.

Calcium deposit viewed from the subacromial

area of the tendon and use intraoperative radiographs or fluoroscopy. Once the calcium deposit is identified, I begin the process of calcium removal. I insert an arthroscopic scissors or knife through the lateral portal and incise the deposit (Figs. 16-9 and 16-10). The consistency of the calcium deposit is variable. It may feel as hard as bone, similar to toothpaste, or granular. Pressure on the tendon may express the calcium, in which case it can be seen filling the subacromial space. I increase the rate of pump flow (not pump pressure) to maintain visualization. Commonly, a portion of the calcium remains adherent to the tendon fibers or interspersed within the tendon substance. I insert a motorized shaver and gently remove calcium while maintaining tendon integrity.

Figure 16-10

calcium.

Knife used to incise the bursal covering of

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Subacromial Space Surgery

I do not perform an acromioplasty because I believe the exposed bone surface increases the risk of postoperative stiffness.

POSTOPERATIVE MANAGEMENT

Figure 16-11

Shaver removing calcium.

The shaver tip can also be used as a probe to apply pressure to the calcium deposit (Fig. 16-11). If the deposit is hard or bonelike, I use the shaver to remove as much calcium as possible without excising tendon fibers. I prefer to leave some calcium rather than sacrifice tendon integrity. Once the deposit is opened and most of the calcium removed, the resorption process is unimpeded. The postoperative radiograph almost always demonstrates a complete absence of calcium. If a defect exists in the tendon after calcium removal, I do not repair the tendon (Fig. 16-12). The protected motion required after rotator cuff repair combined with the intense inflammatory response after calcium excision often result in profound shoulder stiffness. I have never had to repair a supraspinatus defect that went on to become a full-thickness tear.

Figure 16-12

Rotator cuff defect after calcium removal.

I have patients start passive range of motion in elevation and external rotation on the afternoon of surgery. Patients find the continuous passive motion chair an effective treatment. They are encouraged to use the shoulder actively and perform routine activities of daily living within the limits of their discomfort. I do not allow patients to use a sling. I see patients in the office 2 weeks after the operation and obtain an anteroposterior radiograph to evaluate the change in the calcium deposit. I have patients stop continuous passive motion and use supine dowel passive range of motion in the same planes. I see patients in the office 2 months after operation, and if they have no pain with resisted muscle testing, they start a home strengthening program with rubber tubing.

BIBLIOGRAPHY Ark JW, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 8:183-188, 1992. Arrigoni P, Brady PC, Burkhart SS: Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement. Arthroscopy 22:1139.e11139.e3, 2006. Ellman H: Shoulder arthroscopy: Current indications and techniques. Orthopedics 11:45-51, 1988. Gotoh M, Higuchi F, Suzuki R, Yamanaka K: Progression from calcifying tendinitis to rotator cuff tear. Skeletal Radiol 32:86-89, 2003. Hurt G, Baker CL Jr: Calcific tendinitis of the shoulder. Orthop Clin North Am 34:567-575, 2003. Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 7:30-37, 1998. Krasny C, Enenkel M, Aigner N, et al: Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. J Bone Joint Surg Br 87:501-507, 2005. Mole D, Kempf JF, Gleyze P: Calcifications of the rotator cuff. Rev Orthop 79:532-541, 1993. Noel E: Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed 64:619-628, 1997. Nutton RW, McBirnie JM, Phillips C: Treatment of chronic rotator-cuff impingement by arthroscopic subacromial decompression. J Bone Joint Surg Br 79:73-76, 1997.

Chapter 16

Rotini R, Bungaro P, Antonioli D, et al: Algorithm for the treatment of calcific tendinitis in the rotator cuff: Indications for arthroscopy and results in our experience. Chir Organi Mov 90:105-112, 2005. Seil R, Litzenburger H, Kohn D, Rupp S: Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 22:521-527, 2006. Sirveaux F, Gosselin O, Roche O, et al: [Postoperative results after arthroscopic treatment of rotator cuff calcifying tendonitis, with or without associated glenohumeral exploration]. Rev Chir Orthop Reparatrice Appar Mot 91:295-299, 2005.



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Sorensen L, Teichert G, Skjodt T, Dichmann OL: Preoperative ultrasonographic-guided marking of calcium deposits in the rotator cuff facilitates localization during arthroscopic surgery. Arthroscopy 20(Suppl 2):103-104, 2004. Uhthoff HK, Loehr JW: Calcific tendinopathy of the rotator cuff: Pathogenesis, diagnosis, and management. J Am Acad Orthop Surg 5:183-191, 1997.

CHAPTER

17

Fractures

Arthroscopic techniques are rarely used in the treatment of shoulder fractures; however, arthroscopy may be beneficial in some cases of greater tuberosity fracture, fracture of the glenoid rim, and displaced intra-articular humeral head malunion. Displaced greater tuberosity fractures and greater tuberosity nonunions can be treated arthroscopically. These may be isolated two-part fractures or fractures that accompany an anterior glenohumeral joint dislocation. I have used arthroscopy to identify significant partial-thickness rotator cuff tears as the source of pain in patients who exhibited satisfactory bone union after a greater tuberosity fracture. Isolated, displaced lesser tuberosity fractures can be managed arthroscopically; usually this is combined with a

subscapularis repair. Small glenoid rim fractures associated with glenohumeral instability are covered in Chapter 4. Larger glenoid fractures that are displaced and associated with humeral head instability or with a significant (> 5 mm) step-off can be treated arthroscopically (Fig. 17-1). Rarely, the malunion of an intra-articular fracture blocks glenohumeral joint motion. In this case, I use a bur to smooth the prominence, combined with a soft tissue release to help restore motion. There have been a few reports of the arthroscopic treatment of proximal humerus fractures (usually combined with an open approach owing to inadequate reduction), but I have no experience with the arthroscopic treatment of these fractures.

LITERATURE REVIEW

Figure 17-1

322

Glenoid rim fracture.

The majority of fracture cases involve glenoid rim fractures. Smaller fragments are incorporated with suture fixation during a Bankart repair, and larger fragments can be fixed with cannulated screws. Hardy (see Bauer et al) from France has had good experience in the management of glenoid fractures arthroscopically. Acute greater tuberosity fractures occur both with and without glenohumeral dislocation; the association between greater tuberosity fracture and acute anterior-inferior glenohumeral dislocation is well known. Operative treatment for displaced greater tuberosity fractures using an open surgical approach has been described. My colleagues and I have documented our experience with arthroscopic repair for acute greater tuberosity

Chapter 17

fractures associated with glenohumeral dislocation as well as for greater tuberosity nonunion.

DIAGNOSIS Persistent pain after an acute shoulder dislocation may be caused by a greater tuberosity fracture that was undiagnosed initially. Patients are usually able to describe the dislocation, but it is surprising how often a fracture goes unrecognized after dislocation and spontaneous reduction. The diagnosis of a greater tuberosity fracture is usually made on plain radiographs. Accurate anteroposterior and axillary films are mandatory. Magnetic resonance imaging performed to determine the status of the rotator cuff may demonstrate a nondisplaced greater tuberosity fracture.

NONOPERATIVE TREATMENT Nonoperative treatment is the mainstay for nondisplaced greater tuberosity fractures and for almost all fractures with less than 5 mm of displacement. If pain or weakness persists longer than 3 months after injury, magnetic resonance imaging may demonstrate an associated partial- or full-thickness rotator cuff tear. Because greater tuberosity fractures usually heal quite readily, persistent pain may also signal nonunion. Tomograms or computed tomograms can demonstrate nonunion.



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323

fracture, the treating orthopedist referred the patient to our office. The patient’s medical history revealed no significant shoulder problems before the injury. Physical examination was limited by pain from the shoulder injury but demonstrated normal neurovascular status. Plain radiographs demonstrated prereduction and postreduction views of the dislocation and a displaced greater tuberosity fracture. Because the patient wished to pursue his avocation of competitive polo, we advised operative arthroscopic treatment.

Nonunion A 63-year-old woman fell and sustained a minimally displaced greater tuberosity fracture. Despite appropriate nonoperative treatment, the fracture progressed to nonunion. Physical examination demonstrated painful, limited active shoulder motion in elevation and abduction. Plain radiographs showed a nonunion. Based on the patient’s clinical presentation, we advised operative arthroscopic treatment.

CONTRAINDICATIONS TO SURGERY Insufficient bone stock, significant displacement, or tuberosity retraction may preclude the reduction and fixation of a greater tuberosity fracture using arthroscopic techniques.

OPERATIVE TECHNIQUE INDICATIONS FOR SURGERY Glenoid fractures that are displaced and associated with glenohumeral joint instability should be fixed, if possible. Minimally displaced greater tuberosity fractures may be treated nonoperatively; however, recent evidence suggests that as little as 5 mm of superior displacement may produce shoulder dysfunction. Patients can usually tolerate greater degrees of posterior rotation than superior migration of the fractured tuberosity. Two typical clinical situations are described here, representing examples of cases in which arthroscopic treatment is indicated.

Acute Fracture A 46-year-old, right-hand-dominant man sustained an anterior-inferior glenohumeral dislocation and a greater tuberosity fracture while playing polo. The dislocation was reduced in the emergency room, but owing to the displacement of the greater tuberosity

After the successful induction of general anesthesia supplemented with interscalene block, the patient is placed in the sitting position, and the arm is prepared and draped. Make a standard entry into the glenohumeral joint, inspect the joint for any associated injuries, and repair them as indicated. Remove the arthroscope and insert it into the subacromial space. Identify the lateral portal site with a spinal needle and insert a large, self-sealing cannula and trocar. Introduce an arthroscopic probe and identify the fracture site. Probe palpation can detect any movement in the greater tuberosity; soft tissue covering the fracture site usually makes it impossible to view the bone directly. If the fracture is acute, hemorrhage will also be visualized around the fracture area. Establish an anterior portal and introduce a cannula. Use a curette or power shaver to remove the soft tissue covering the fracture site laterally, and lift up the fragment to expose the fracture bed. Lightly abrade the fracture (or nonunion) site with a power bur. Reduce the greater tuberosity using a trocar (placed through

324

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Subacromial Space Surgery

Reducing fracture

Probe moving fracture

Figure 17-4

Reduce the fracture with a probe or Kirschner

wire. Figure 17-2

Identify the fracture site.

the anterior portal). Either through the lateral cannula or percutaneously, insert a Kirschner wire through the tuberosity fragment and into the humeral head. I use a partially threaded, cannulated 6.5-mm screw inserted over the guide wire to obtain firm, compressive fixation of the tuberosity. Reinsert the arthroscope into the glenohumeral joint and verify that the screw has not penetrated the humeral articular surface. Check the reduction and screw placement with an intraoperative radiograph or fluoroscopic imaging (Figs. 17-2 through 17-6).

K-wire through fragment

Figure 17-5

Temporary fixation with Kirschner wire (K-wire).

Curetting fracture bed

Screw securing fractured tuberosity to humerus

Figure 17-3

Curette the fracture bed.

Figure 17-6

Permanent screw fixation.

Chapter 17

POSTOPERATIVE MANAGEMENT Postoperative management is similar to that for a fullthickness rotator cuff tear. Place the patient’s arm in a sling for 6 weeks. Start passive range of motion in elevation and external rotation the afternoon following surgery and continue for 6 weeks. At the 2-week, 6-week, and 3-month visits, obtain radiographs to verify healing and the position of both the bone fragment and the screw. Active range of motion is started at week 6 and strengthening at 3 months. If the patient complains of pain in the area of the screw head, I remove the screw once fracture consolidation is demonstrated on radiographs.

Malunion of the Humeral Head

BIBLIOGRAPHY Barth JR, Burkhart SS: Arthroscopic capsular release after hemiarthroplasty of the shoulder for fracture: A new treatment paradigm. Arthroscopy 21:1150, 2005. Bauer T, Abadie O, Hardy P: Arthroscopic treatment of glenoid fractures. Arthroscopy 22:569.e1-569.e6, 2006. Boileau P, Ahrens P: The TOTS (temporary outside traction suture): A new technique to allow easy suture placement and improve capsular shift in arthroscopic Bankart repair. Arthroscopy 19:672-677, 2003. Bonsell S, Buford DA Jr: Arthroscopic reduction and internal fixation of a greater tuberosity fracture of the shoulder: A case report. J Shoulder Elbow Surg 12:397-400, 2003. Cameron SE: Arthroscopic reduction and internal fixation of an anterior glenoid fracture. Arthroscopy 14:743-746, 1998. Carrera EF, Matsumoto MH, Netto NA, Faloppa F: Fixation of greater tuberosity fractures. Arthroscopy 20:e109-e111, 2004. Dawson FA: Four-part fracture dislocation of the proximal humerus: An arthroscopic approach. Arthroscopy 19:662-666, 2003.



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Flatow EL, Cuomo F, Maday MG, et al: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 73:1213-1218, 1991. Fujii Y, Yoneda M, Wakitani S, Hayashida K: Histologic analysis of bony Bankart lesions in recurrent anterior instability of the shoulder. J Shoulder Elbow Surg 15:218-223, 2006. Gartsman GM, Taverna E: Arthroscopic treatment of rotator cuff tear and greater tuberosity fracture nonunion. Arthroscopy 12:242-244, 1996. Gartsman GM, Taverna E, Hammerman SM: Arthroscopic treatment of acute traumatic anterior glenohumeral dislocation and greater tuberosity fracture. Arthroscopy 15:648-650, 1999. Hinov V, Wilson F, Adams G: Arthroscopically treated proximal humeral fracture malunion. Arthroscopy 18:1020-1023, 2002. Kim SH, Ha KI: Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. Arthroscopy 16:695-700, 2000. Krackhardt T, Schewe B, Albrecht D, Weise K: Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy 22:227.e1-227.e6, 2006. Porcellini G, Campi F, Paladini P: Arthroscopic approach to acute bony Bankart lesion. Arthroscopy 18:764-769, 2002. Porcellini G, Campi F, Paladini P: Articular impingement in malunited fracture of the humeral head. Arthroscopy 18:E39, 2002. Sugaya H, Kon Y, Tsuchiya A: Arthroscopic repair of glenoid fractures using suture anchors. Arthroscopy 21:635, 2005. Taverna E, Sansone V, Battistella F: Arthroscopic treatment for greater tuberosity fractures: Rationale and surgical technique. Arthroscopy 20:53-e57, 2004. Varghese J, Thilak J, Mahajan CV: Arthroscopic treatment of acute traumatic posterior glenohumeral dislocation and anatomic neck fracture. Arthroscopy 22:676.e1-676.e2, 2006.

CHAPTER

18

Diagnostic Ultrasonography

Ultrasonography is my routine method for diagnosing rotator cuff disorders. Magnetic resonance imaging (MRI) tends to overestimate the severity of rotator cuff lesions, and it is expensive and time-consuming. Compared with MRI, ultrasonography is a much more pleasant experience for patients with claustrophobia. For patients in whom MRI is contraindicated (those with cardiac pacemakers or metal clips in the brain or around the carotid artery), diagnostic ultrasonography is essential (Fig. 18-1). I still use MRI for patients with osseous or ligamentous lesions of the glenohumeral joint because I cannot visualize these areas with ultrasonography. Ultrasonography is also helpful in the management of patients after rotator cuff repair; it allows me to directly evaluate the repair. I began using diagnostic ultrasonography in my office in 2004 and have been very pleased with the results. I use it primarily to diagnose lesions of the infraspinatus, supraspinatus, subscapularis, and biceps tendons. These lesions include tendinitis, partial- and full-thickness rotator cuff tears, calcific tendinitis, and bursitis. I do not use ultrasonography to diagnose intra-articular lesions. I perform the examination myself, although others may choose to have a radiologist or a trained technician do so. I think the treating orthopedic surgeon has the most comprehensive knowledge of shoulder anatomy and the best idea of the clinical lesions that might be found in patients undergoing ultrasound examinations. I also enjoy the few extra minutes of hands-on time with patients, and they enjoy seeing moving images on a screen. I had heard about surgeons using diagnostic ultrasonography from others such as Rick Matsen, Dean

326

Ziegler, Ken Yamaguchi, and Joe de Beers. I also found a helpful website from the University of Michigan (http://www.med.umich.edu/rad/muscskel/ mskus/index.html). In addition, representatives of the manufacturers of diagnostic ultrasound equipment (e.g., Siemens, General Electric, Sonosite, Aloka) were extremely helpful. All this was well and good, but I still did not how to actually perform a diagnostic ultrasound examination. I finally linked up with Gary Pattee, who was kind enough to share his

Figure 18-1

Indication for ultrasonography.

Chapter 18

Figure 18-2



Diagnostic Ultrasonography

327

Demonstration of an ultrasound examination.

wealth of experience and, most important, show me how to perform the examination. Like so many things, it helps to have an expert at your side when you are learning something new (Fig. 18-2). Armed with a little knowledge and a great deal of enthusiasm, I converted a small storage closet in my clinic area to a diagnostic ultrasonography room and purchased an ultrasound machine (Figs. 18-3 and 18-4). There are also excellent portable machines that you can bring right into the examining room so that no extra space is required. If you are familiar with

Figure 18-4

Ultrasound machine.

shoulder anatomy as seen during open and arthroscopic surgery and have some experience with shoulder MRI, you will find diagnostic ultrasonography a fairly simple technique to master. One criticism I have heard is that the accuracy of diagnostic ultrasonography is very user-dependent, but so are many other activities. I began performing diagnostic ultrasonography on as many patients as possible so that I could compare the results with current MRI studies. Gradually, as I became more experienced, my confidence increased. After about 100 diagnostic ultrasound examinations, I felt very comfortable with the technique. I also had the advantage of directly observing the lesions diagnosed with ultrasonography at shoulder arthroscopy, and I found it very helpful to bring the ultrasound images into the operating room for comparison.

Ultrasound

Figure 18-3

Ultrasonography suite.

My purpose here is to present the technique I use daily in my office practice. First, I walk the patient to the ultrasonography room and have him or her put on a gown so that I have access to both shoulders. I enter the patient’s name on the information screen and start the examination. After applying gel to both the patient and the probe, I start anteriorly and identify the bicipital groove and subscapularis tendon. I then rotate the

328

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Subacromial Space Surgery

Figure 18-7 Placement of the ultrasound probe to obtain a longitudinal view of the biceps tendon.

Placement of the ultrasound probe to view the transverse axis of the bicipital groove.

Figure 18-5

probe and obtain a longitudinal view of the biceps tendon. I move to the posterior shoulder and examine the infraspinatus and posterior labrum. I conclude the examination with views of the supraspinatus tendon. I apply the probe and maneuver the shoulder into extension to move the supraspinatus farther away from the acromion. I can then abduct the arm slightly and observe the normal glide between the supraspinatus and the deltoid, as well as observe any impingement—the dynamic impingement test. I then have the patient place his or her hand behind the body in the small of the back. I place the probe over the supraspinatus, apply compression, and see whether I can demonstrate a gap in the tendon substance. If the situation calls for it, I then examine the opposite shoulder, but I do not do this routinely (Figs. 18-5 through 18-32). Figure 18-8

Figure 18-9 Figure 18-6

Bicipital groove transverse axis.

tendon.

Biceps tendon longitudinal view.

Magnetic resonance imaging of the biceps

Chapter 18



329

Diagnostic Ultrasonography

Placement of the ultrasound probe to view the long axis of the subscapularis.

Figure 18-10

Figure 18-13

Subscapularis transverse axis.

I ask the patient to dress and meet me back in the examination room. I document the diagnostic ultrasound findings on a template and add it to the patient’s record. I do not routinely print the images on paper. I eventually transfer them to a CD and place them on a separate hard drive for safekeeping. I review the images at the time of surgery.

Figure 18-11

Subscapularis long axis.

Placement of the ultrasound probe to view the transverse axis of the subscapularis.

Figure 18-12

Figure

18-14

subscapularis.

Magnetic

resonance

imaging

of

the

330

Section Three



Subacromial Space Surgery

Placement of the ultrasound probe to view the long axis of the supraspinatus (with the patient’s arm behind the back).

Figure 18-15

Figure 18-16

the back).

Placement of the ultrasound probe to view the transverse axis of the supraspinatus.

Figure 18-17

Supraspinatus long axis (with the arm behind Figure 18-18

Supraspinatus transverse axis.

Chapter 18

Placement of the ultrasound probe to view the long axis of the infraspinatus.

Figure 18-19

Figure 18-20

Infraspinatus long axis.



Diagnostic Ultrasonography

331

Placement of the ultrasound probe to view the posterior labrum.

Figure 18-21

Figure 18-22

Posterior labrum (arrows).

332

Section Three

Figure 18-23



Subacromial Space Surgery

Articular surface partial rotator cuff tear.

Articular surface partial rotator cuff tear with extension (arrow).

Figure 18-24

Figure 18-25

Figure 18-26

operation.

Full-thickness supraspinatus tear (arrows).

Healed rotator cuff repair 6 months after

Chapter 18

Figure 18-29 Figure 18-27



Diagnostic Ultrasonography

333

Complete biceps tear, transverse view.

Fluid after subacromial injection (arrows).

Figure 18-28

Calcific tendinitis (arrows).

Figure 18-30

Complete biceps tear, longitudinal view.

334

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Figure 18-31

Figure 18-32

Biceps cyst.

Thickened biceps.

BIBLIOGRAPHY Ambacher T, Kirschniak A, Holz U: Intraoperative localization of calcification in the supraspinatus via a percutaneous marking suture after preoperative ultrasound. J Shoulder Elbow Surg 16:146-149, 2007. Arkun R: [Diagnostic imaging of the rotator cuff]. Acta Orthop Traumatol Turc 37(Suppl 1):13-26, 2003. Cullen DM, Breidahl WH, Janes GC: Diagnostic accuracy of shoulder ultrasound performed by a single operator. Australas Radiol 51:226-229, 2007.

Fealy S, Adler RS, Drakos MC : Patterns of vascular and anatomical response after rotator cuff repair. Am J Sports Med 34:120-127, 2006. Fealy S, Rodeo SA, MacGillivray JD, et al: Biomechanical evaluation of the relation between number of suture anchors and strength of the bone-tendon interface in a goat rotator cuff model. Arthroscopy 22:595-602, 2006. Ferri M, Finlay K, Popowich T, et al: Sonography of fullthickness supraspinatus tears: Comparison of patient positioning technique with surgical correlation. AJR Am J Roentgenol 184:180-184, 2005. Galatz LM, Ball CM, Teefey SA, et al: The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 86:219-224, 2004. Goldberg JA, Bruce WJ, Walsh W, Sonnabend DH: Role of community diagnostic ultrasound examination in the diagnosis of full-thickness rotator cuff tears. Aust N Z J Surg 73:797-799, 2003. Husby T, Haugstvedt JR, Brandt M, et al: Open versus arthroscopic subacromial decompression: A prospective, randomized study of 34 patients followed for 8 years. Acta Orthop Scand 74:408-414, 2003. Iannotti JP, Ciccone J, Buss DD, et al: Accuracy of officebased ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am 87:1305-1311, 2005. Kartus J, Kartus C, Rostga˚rd-Christensen L, et al: Long-term clinical and ultrasound evaluation after arthroscopic acromioplasty in patients with partial rotator cuff tears. Arthroscopy 22:44-49, 2006. Kayser R, Hampf S, Seeber E, Heyde CE: Value of preoperative ultrasound marking of calcium deposits in patients who require surgical treatment of calcific tendinitis of the shoulder. Arthroscopy 23:43-50, 2007. ¨ ner A, et al: Sonographic verKluger R, Mayrhofer R, Kro sus magnetic resonance arthrographic evaluation of fullthickness rotator cuff tears in millimeters. J Shoulder Elbow Surg 12:110-116, 2003. McIntyre LF, Norris M, Weber B: Comparison of suture welding and hand-tied knots in mini-open rotator cuff repair. Arthroscopy 22:833-836, 2006. Middleton WD, Payne WT, Teefey SA, et al: Sonography and MRI of the shoulder: Comparison of patient satisfaction. AJR Am J Roentgenol 183:1449-1452, 2004. Middleton WD, Teefey SA, Yamaguchi K: Sonography of the rotator cuff: Analysis of interobserver variability. AJR Am J Roentgenol 183:1465-1468, 2004. Milosavljevic J, Elvin A, Rahme H: Ultrasonography of the rotator cuff: A comparison with arthroscopy in onehundred-and-ninety consecutive cases. Acta Radiol 46:858-865, 1987. Moon YL, Kim SJ: Bursoscopic evaluation for degree of rotator cuff tear using an air-infusion method. Arthroscopy 20:105-107, 2004. Moosmayer S, Smith HJ: Diagnostic ultrasound of the shoulder—a method for experts only? Results from an orthopedic surgeon with relative inexperience compared to operative findings. Acta Orthop 76:503-508, 2005.

Chapter 18

Morag Y, Jacobson JA, Lucas D, et al: US appearance of the rotator cable with histologic correlation: Preliminary results. Radiology 241:485-491, 2006. Pan PJ, Chou CL, Chiou HJ, et al: Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: A functional and sonographic study. Arch Phys Med Rehabil 84:988-993, 2003. Prickett WD, Teefey SA, Galatz LM, et al: Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively. J Bone Joint Surg Am 85:1084-1089, 2003. Reilly P, Macleod I, Macfarlane R, et al: Dead men and radiologists don’t lie: A review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl 88:116-121, 2006. Rudzki JR, Adler RS, Warren RF, et al: Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: Age- and activity-related changes in the intact asymptomatic rotator cuff. J Shoulder Elbow Surg 17(1 Suppl):96S-100S, 2007. Schneider TL, Schmidt-Wiethoff R, Drescher W, et al: The significance of subacromial arthrography to verify partial bursal-side rotator cuff ruptures. Arch Orthop Trauma Surg 123:481-484, 2003. Seil R, Litzenburger H, Kohn D, Rupp S: Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon. Arthroscopy 22:521-527, 2006. Sofka CM, Adler RS: Original report: Sonographic evaluation of shoulder arthroplasty. AJR Am J Roentgenol 180:1117-1120, 2003. Sørensen AK, Bak K, Krarup AL, et al: Acute rotator cuff tear: Do we miss the early diagnosis? A prospective study



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showing a high incidence of rotator cuff tears after shoulder trauma. J Shoulder Elbow Surg 16:174-180, 2007. Strobel K, Hodler J, Meyer DC, et al: Fatty atrophy of supraspinatus and infraspinatus muscles: Accuracy of US. Radiology 237:584-589, 2005. Taverna E, Battistella F, Sansone V, et al: Radiofrequencybased plasma microtenotomy compared with arthroscopic subacromial decompression yields equivalent outcomes for rotator cuff tendinosis. Arthroscopy 23:1042-1051, 2007. Teefey SA, Middleton WD, Payne WT, Yamaguchi K: Detection and measurement of rotator cuff tears with sonography: Analysis of diagnostic errors. AJR Am J Roentgenol 184:1768-1773, 2005. Teefey SA, Rubin DA, Middleton WD, et al: Detection and quantification of rotator cuff tears: Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am 86:708-716, 2004. Verma NN, Dunn W, Adler RS, et al: All-arthroscopic versus mini-open rotator cuff repair: A retrospective review with minimum 2-year follow-up. Arthroscopy 22:587-594, 2006. Wu HP, Dubinsky TJ, Richardson ML: Association of shoulder sonographic findings with subsequent surgical treatment for rotator cuff injury. J Ultrasound Med 22:155-161, 2003. Ziegler DW: The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders. J Shoulder Elbow Surg 13:291-297, 2004.

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Rehabilitation

I prefer to instruct patients in a rehabilitation program without the aid of a physical therapist. It takes little time, assures me that the exercises are appropriate, and is much appreciated by the patients. It is important to be realistic about goals. I constantly ask myself, exactly what do I want the patient to accomplish with therapy? Possible goals are to improve movement, strength, or coordination. I keep the exercises simple and minimize the time required to perform them. If a patient has difficulty understanding my instructions or expresses a desire for more intensive therapy in a facility, I direct the patient to a well-qualified physical therapist.

PENDULUM

One minute (Figs. 19-1 and 19-2).

ELEVATION Stretch in elevation, hold for 20 seconds, relax for 20 seconds, stretch for 20 seconds (Fig. 19-3).

Stretch in external rotation, hold for 20 seconds, relax for 20 seconds, stretch for 20 seconds (Fig. 19-4).

EXTERNAL ROTATION

CROSS-BODY ADDUCTION Stretch in cross-body adduction, hold for 20 seconds, relax for 20 seconds, stretch for 20 seconds. Keep the elbow straight (Fig. 19-5).

Passive Range of Motion Exercises Active Range of Motion Exercises Strengthening Exercises

ADHESIVE CAPSULITIS Patients should avoid any stretching exercises while the shoulder is still very painful. Rest and pain control are paramount. Once the situation has stabilized, patients should perform the following exercises four times a day. The total amount of exercise time should not exceed 20 minutes a day. I never have patients stretch in abduction or behind-the-back internal rotation. The exercises should never be painful. Gentle stretching is the key.

336

A

B Figure 19-1

A and B, Pendulum.

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Figure 19-4

Figure 19-2

Figure 19-3



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External rotation stretch.

Pendulum (cradled).

Elevation stretch.

Figure 19-5

Cross-body adduction stretch.

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IMPINGEMENT SYNDROME Acute and chronic inflammation leads to musculotendinous shortening, so stretching in adduction is most important. I want patients to rest the supraspinatus but improve strength in the scapular rotators and the subscapularis. I have patients avoid strengthening of the supraspinatus (because it is painful) and of the deltoid because its action (if unopposed by a normal rotator cuff) is to promote superior humeral head elevation. If external rotation or biceps contraction is painful on physical examination, I eliminate those exercises from the program. The key idea here is less pain, more gain.

Motion PENDULUM

One minute (see Fig. 19-1).

CROSS-BODY ADDUCTION Stretch in cross-body adduction, hold for 20 seconds, relax for 20 seconds, stretch for 20 seconds. Keep the elbow straight (see Fig. 19-5).

Figure 19-6

Biceps strengthening.

Figure 19-7

Triceps strengthening.

Strength I like to start with biceps and triceps strengthening because these exercises are usually painless and help build patient confidence and diminish fear. I use surgical tubing for resistance and have patients progress as tolerated. These exercises are performed three times per week. BICEPS TRICEPS

Ten repetitions (Fig. 19-6). Ten repetitions (Fig. 19-7).

INTERNAL ROTATION

Ten repetitions (Fig. 19-8).

EXTERNAL ROTATION

Ten repetitions (Fig. 19-9).

SCAPULAR ELEVATION SCAPULAR RETRACTION

Ten repetitions (Fig. 19-10). Ten repetitions (Fig. 19-11).

FULL-THICKNESS ROTATOR CUFF TEARS The goal is to improve or maintain range of motion and improve the strength of the uninvolved muscles.

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Figure 19-8

Internal rotation strengthening.

Figure 19-9

External rotation strengthening.



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Motion PENDULUM

One minute (see Fig. 19-1).

CROSS-BODY ADDUCTION Stretch in cross-body adduction, hold for 20 seconds, relax for 20 seconds, stretch for 20 seconds. Keep the elbow straight (see Fig. 19-5).

Strength Again, start with biceps and triceps strengthening to build patient confidence. Use surgical tubing for resistance, and have the patient progress as tolerated. These exercises are performed three times per week. BICEPS TRICEPS Figure 19-10

Ten repetitions (see Fig. 19-6). Ten repetitions (see Fig. 19-7)

Scapular elevation strengthening. INTERNAL ROTATION

Ten repetitions (see Fig. 19-8).

EXTERNAL ROTATION

Ten repetitions (see Fig. 19-9).

SCAPULAR ELEVATION

Ten repetitions (see Fig. 19-10).

SCAPULAR RETRACTION Ten repetitions (see Fig. 19-11).

MASSIVE OR IRREPARABLE ROTATOR CUFF TEARS

Figure 19-11

Scapular retraction strengthening.

The goal is to improve or maintain range of motion and improve the strength of the uninvolved muscles. In these patients, who are generally older, the normal muscles must be trained to substitute for the absent muscles. Realistic goals must be agreed on, and patients should understand that this can be a 6month process. Patients begin with pendulum exercises as a warmup (see Fig. 19-1). They then progress to active assisted range-of-motion exercises and finally strengthening exercises (as previously described). At first, they do the exercises supine, lying on a bed or on the floor. The supine position minimizes the effects of gravity. I also have them decrease arm weight by bending the elbow. Patients do these exercises four times a day. They are allowed to move on to the next stage only when they are comfortable performing the current level of exercise.

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but keep the elbow flexed to 90 degrees. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-12).

Supine Exercises Stage 1 Bend the elbow 90 degrees. Use the opposite arm to help elevate it until it is perpendicular to the floor. Encourage the patient to gradually increase the use of the damaged shoulder and decrease the contribution of the good shoulder until the former is doing all the work. Hold for 5 seconds. Keep the opposite arm nearby to help if necessary. Lower the arm actively,

Stage 2 Bend the elbow 45 degrees. Actively elevate the arm until it is perpendicular to the floor. Hold for 5 seconds. Lower the arm actively, but keep the elbow flexed to 45 degrees. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-13).

D

A

B

E

C F

Figure 19-12

A through F, Stage 1 supine active elevation.

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Stage 3 Keep the elbow straight. Actively elevate the arm until it is perpendicular to the floor. Hold for 5 seconds. Lower the arm actively, but keep the elbow straight. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-14).

Stage 4 Holding a 1-pound weight in the hand, bend the elbow 90 degrees. Use the opposite arm to help elevate the arm

until it is perpendicular to the floor. Encourage the patient to gradually increase the use of the damaged shoulder and decrease the contribution of the good shoulder until the former is doing all the work. Hold for 5 seconds. Keep the opposite arm nearby to help if necessary. Lower the arm actively, but keep the elbow flexed to 90 degrees. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-15).

D

A

45˚

B E

C F

Figure 19-13

A through F, Stage 2 supine active elevation.

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343

Stage 5

A

Holding a 1-pound weight in the hand, bend the elbow 45 degrees. Actively elevate the arm until it is perpendicular to the floor. Hold for 5 seconds. Lower the arm actively, but keep the elbow flexed to 45 degrees. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-16).

Stage 6 Holding a 1-pound weight in the hand and keeping the elbow straight, actively elevate the arm until it is perpendicular to the floor. Hold for 5 seconds. Lower the arm actively, but keep the elbow straight. Gradually build up to 30 seconds without any use of the opposite arm (Fig. 19-17). Only when patients have reached this level do I have them begin standing exercises.

B

Standing Exercises I call this part of the rehabilitation program threephase active elevation. Dr. Charles Rockwood instructed me in these exercises. Figure 19-14

A and B, Stage 3 supine active elevation.

A

D

B E

C F

Figure 19-15

A through F, Stage 4 supine strengthening.

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A

D

45˚

B E

C

F

Figure 19-16

A through F, Stage 5 supine strengthening.

The program consists of three stages: (1) passive elevation and then actively holding the arm overhead, (2) passive elevation and then actively lowering the arm, and (3) active elevation. Patients must satisfactorily complete each stage before advancing. This gentle and graduated program provides enough stress to strengthen the rotator cuff tendons and muscles but does so in a safe and controlled manner. It starts with the easiest activity—holding the arm directly overhead after raising it passively—then progresses to actively lowering the arm, which is helped by gravity, and finally the most difficult action—raising the arm against gravity.

A

B

Stage 1

Figure 19-17

A and B, Stage 6 supine strengthening.

Patients grasp the affected arm by the wrist and passively raise the operated shoulder to maximal elevation. They then remove the hand from the wrist but keep it nearby to catch the arm in case the muscles fatigue and the arm drops. Patients start by actively maintaining the shoulder in maximal elevation for 5 seconds and then progress at their own pace until they

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can hold the elevated position for 30 seconds. I recommend that they do these exercises in front of a clock with a second hand so that they can monitor the time precisely. Once they can hold the position for 30 seconds, they increase the number of repetitions until they can do 10 repetitions three times daily (Fig. 19-18). When this is accomplished, they move to stage 2.

Hold for 30 seconds

Stage 2 Patients passively elevate the operated shoulder, hold it for 10 seconds, and then actively lower it in a slow, controlled fashion. Again, the contralateral hand is placed 4 inches below the forearm of the operated side so that if the arm falls due to muscle fatigue it can be protected (Fig. 19-19). After the patient can do 10 repetitions of this exercise, they move to stage 3.

B

Stage 3

A A and B, Standing passive elevation, holding the arm overhead actively.

Figure 19-18

Patients actively elevate the operated shoulder. With slight pressure from the nonoperated hand, they begin active assisted elevation. They gradually decrease the pressure from the contralateral hand until they can actively elevate the operated arm in a slow, controlled fashion (Fig. 19-20). Throughout this process, I stress

Hold for 10 seconds

10 seconds

B A Figure 19-19

A and B, Standing passive elevation, lowering the arm actively.

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that recovery takes months rather than weeks and that gradual progress is the goal. Once patients can actively elevate the arm (or 3 months after operation), they return to the office for instruction in strengthening exercises using rubber tubing (see Figs. 19-6 through 19-11).

Raise hand above head, lower slowly, repeat as many times you can

ROTATOR CUFF REPAIR Patients wear a sling for protection and remove it for exercising, bathing, and dressing. They can remove the sling and position the arm for comfort while seated or in bed, but I recommend that they always wear the sling when out in public. I encourage active elbow extension and flexion; if patients are comfortable doing so, they can actively internally and externally rotate the shoulder with the elbow held against the side. They are cautioned to avoid active abduction and elevation.

A

B

Figure 19-20

Day of Surgery to Week 6

lowering.

Patients perform pendulum exercises four times a day (see Fig. 19-1), as well as active elbow flexion and extension. They are encouraged to open and close the fingers to minimize hand swelling.

BICEPS

Weeks 6 to 12 Patients stop wearing a sling. They are allowed to move the arm without any weight in the hand. They can hold and drink a glass of iced tea but cannot pass someone a pitcher filled with tea. Patients begin with pendulum exercises as a warmup (see Fig. 19-1). They progress through the six stages of supine exercises and the three stages of standing exercises as outlined earlier for massive or irreparable rotator cuff tears (see Figs. 19-12 through 19-20).

Week 12 Activities can be engaged in as tolerated, and a strengthening program is started. I like to begin with biceps and triceps strengthening because these exercises are usually painless and help build patient confidence and diminish fear. Patients use surgical tubing for resistance and progress at their own pace. These exercises are performed three times per week. I rarely have patients perform isolated supraspinatus strengthening.

TRICEPS

A and B, Standing active elevation and

Ten repetitions (see Fig. 19-6). Ten repetitions (see Fig. 19-7).

INTERNAL ROTATION

Ten repetitions (see Fig. 19-8).

EXTERNAL ROTATION

Ten repetitions (see Fig. 19-9).

SCAPULAR ELEVATION

Ten repetitions (see Fig. 19-10).

SCAPULAR RETRACTION Ten repetitions (see Fig. 19-11).

GLENOHUMERAL JOINT INSTABILITY Recurrent Subluxation or Dislocation If the injury is acute, I advise rest until the pain subsides. I then allow gentle active range of motion as tolerated. I recommend the avoidance of all stretching in the acute phase. I have found that many patients with recurrent anterior instability have developed a posterior shoulder contracture that aggravates the underlying instability. If they have posterior structure tightness, I have them stretch the posterior capsule with cross-body adduction as well as with abduction internal rotation with the scapula stabilized. Patients with anterior instability should avoid stretching in abduction and

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external rotation, and those with posterior or multidirectional instability should avoid elevation and cross-body adduction. I start strengthening of the shoulder stabilizing muscles (external rotators, internal rotators, and scapular stabilizers) as soon as possible.

Stretch CROSS-BODY ADDUCTION Hold for 30 seconds, repeat three times (see Fig. 19-5). Figure 19-21 ABDUCTION INTERNAL ROTATION

Hold for 30 seconds,

Abduction internal rotation stretch.

repeat three times (Fig. 19-21). Hold for 30 seconds, repeat three times (see Fig. 19-21).

ABDUCTION INTERNAL ROTATION

Strength BICEPS

Ten repetitions (see Fig. 19-6).

Strength TRICEPS

Ten repetitions (see Fig. 19-7).

BICEPS

Ten repetitions (see Fig. 19-6).

INTERNAL ROTATION

Ten repetitions (see Fig. 19-8).

TRICEPS

EXTERNAL ROTATION

Ten repetitions (see Fig. 19-9).

INTERNAL ROTATION

Ten repetitions (see Fig. 19-8).

EXTERNAL ROTATION

Ten repetitions (see Fig. 19-9).

SCAPULAR ELEVATION SCAPULAR

Ten repetitions (see Fig. 19-10).

RETRACTION

Ten

repetitions

(see

Fig.

Ten repetitions (see Fig. 19-7).

SCAPULAR ELEVATION

Ten repetitions (see Fig. 19-10).

19-11). SCAPULAR RETRACTION

After Glenohumeral Joint Instability Surgery

SHOULDER ELEVATION

Ten repetitions (see Fig. 19-11). Ten repetitions (Fig. 19-22).

Immobilization The period of sling use depends on the details of the operation and the reliability of the patient. For operations that involve ligament or capsule repairs, I have patients protect the shoulder for 6 weeks. For an operation such as the Latarjet, which has stronger initial fixation, I have patients wear the sling for 7 to 10 days until the first office visit. During sling use, patients can remove it as needed for active range of motion of the fingers, wrist, and elbow. Pendulum exercises are allowed if they can be done comfortably. When the sling is removed, patients are allowed active range of motion in external rotation and cross-body adduction. Active elevation is allowed except in patients with posterior instability. At about 2 months, patients can begin passive stretching and strengthening, as follows.

Stretch CROSS-BODY ADDUCTION Hold for 30 seconds, repeat three times (see Fig. 19-5).

Figure 19-22

Shoulder elevation strengthening.

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ROTATOR CUFF TEARS IN PARAPLEGICS My experience repairing rotator cuff tears in paraplegic patients has been positive, which differs from some reports in the literature. Rotator cuff repair, biceps tenodesis, and tenotomy are performed identically, regardless of whether the patient uses a wheelchair. Surgical indications are slightly different, but preoperative planning and postoperative rehabilitation differ greatly. My overall approach to this group of patients is to satisfy their needs, and in most cases, this involves nonoperative treatment. Because the upper extremities are the sole means of locomotion for patients in wheelchairs, they are apprehensive about any surgery. However, years of wear and tear can lead to pain that interferes with sleeping and transferring. In my practice, these are the two most common surgical indications. Patients are required to transfer to and from bed, on and off the toilet, and into and out of the car, and any infirmity that adversely affects these activities adversely affects their independence. Operations that require little postoperative protection are ideal. Arthroscopic subacromial decompression, acromioclavicular joint resection, and biceps tenotomy are examples. However, if the pain and loss of strength from a full-thickness rotator cuff tear are debilitating, repair is indicated. A detailed discussion with patients is necessary, and they must be advised of the options and the likely outcome of each option. For example, some patients with fullthickness rotator cuff tears choose de´bridement alone. Those who choose rotator cuff repair must be advised that immediate weight bearing will almost certainly disrupt the repair; therefore, patients must make arrangements for assistance after operation. This may include increased help from a family member, professional assistance at home, a shortterm stay at a rehabilitation facility, or a longer stay at a rehabilitation facility until the tendon has completely healed. All are reasonable options, depending on the individual and his or her particular situation. Some patients plan their recovery in terms of their finances, because a full-time home-care aide can cost $20,000 to $30,000. The surgeon should also be aware that there are many devices available to help paraplegics transfer more easily, and these can be extremely helpful in the postoperative period. I asked several of my paraplegic patients to contribute helpful information they learned from their experiences, in the hope that these pointers will benefit both surgeons and their patients.

Mobility One patient used a motorized scooter until the operated shoulder had healed well enough to return to braces and crutches. This patient said, ‘‘Before I had the scooter modified for lifting into my van, the chair seat could rotate 360 degrees. The seat still rotates over 180 degrees, and the arms on each side lift up. This has given me additional maneuverability for transferring. And the chair can be locked into any position within the 360 degrees.’’ After sufficient healing had taken place, and with the doctor’s permission, this patient used a crutch under the operated arm as a lever or wedge to help stand up and then walked ‘‘fourpoint’’ with braces and crutches.

Bathroom Basics Patients advise the use of a hand-held shower nozzle with an on-off switch at the handle (these can be found online). A bathtub chair makes maneuvering easier and can be used in either the tub or the shower. Consider a drop-arm commode if the bathroom is not easily accessible. Wipe with sanitizing wipes to prevent bladder infections.

Bedroom Basics The patient who used the scooter also found a hospital bed helpful. This patient said, ‘‘I had to get what is called a Hi/Lo bed (or an Alzheimer’s bed) so that I could raise or lower it to the level of my scooter. Actually, when moving from the bed to the scooter, I raised the bed higher than the scooter so I had gravity to help a little in the transfer, and I did the opposite getting into bed. It worked better for me to have only one bed rail (on the operated side). The second rail on the other side got in the way of a good transfer from bed to scooter.’’ This patient also noted that polyester sateen sheets make sliding on the bed easier. However, the downside is that they are very slippery and tend to slide onto the floor. Also, they are hotter than cotton sheets.

Transferring Tips Patients advise that, when possible, bring the scooter or wheelchair right up next to the bed or commode and do a direct transfer rather than using a transfer board. Plastic bags can facilitate the effort. A 30-inch transfer board is necessary to transfer into a car; a longer, plastic transfer board with a disc seat that glides along the

Chapter 19

length can be used to transfer onto a bathtub chair in the shower stall. Patients recommend that braces not be worn while you are recuperating and unable to stand and walk; they are just additional weight that you must lift and scoot when transferring.

Insurance Several patients had pointers about dealing with insurance. One patient recommended getting a case manager—preferably someone who is knowledgeable about paraplegia and how an individual’s everyday activities can be affected by a shoulder problem and recovery from surgery. The patient and case manager



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should then begin planning for the patient’s postoperative care so that insurance covers as much as possible. As one patient noted, ‘‘Having to be in a sling for several weeks after surgery and then no weight bearing for 2 months is very different for someone who does not have the use of their legs. There is a definite need for assistance after surgery. You will not be able to function by yourself.’’ Also remember to arrange with the insurance case manager for an ambulance to transport you from the hospital to the rehabilitation hospital. Do not assume that this will automatically be approved. One patient found a letter very helpful in his negotiations with his insurance carrier (see Box):

Letter to Insurance Carrier To whom it may concern: My patient John Smith currently has a full-thickness tear of the supraspinatus tendon in his left shoulder. This medical issue is causing severe pain and weakness in that shoulder. This is complicated by his spinal cord injury that resulted in paraplegia. Mr. Smith suffered a complete lesion in his spinal cord in 1999 and underwent rehabilitation at the Institute for Rehabilitation and Research here at the Houston Medical Center. Unfortunately, this tear jeopardizes everything Mr. Smith has accomplished and hopes to continue to achieve. He relies mainly on his shoulders in transferring multiple times a day to the car, bed, toilet, shower, and so on, and using his wheelchair to live independently, and this injury is causing him significant pain and weakness and threatening his independence. For someone who does not have a spinal cord injury and has no ambulatory problems, this would be less of an issue. However, for Mr. Smith, this injury is a critical problem. The long-term prognosis is that his shoulder will continue to get worse with regard to pain and weakness, which will severely limit his ability to maintain his preinjury function. My recommendation is to do shoulder surgery to repair the tendon, which will lessen the pain and weakness he is now experiencing and provide him a better long-term prognosis. The point of this letter is to alert you that Mr. Smith’s immediate postoperative care and recovery will require him to be admitted to a rehabilitation center. The normal recovery period for this type of surgery is 3 months. The shoulder is kept in a sling for 6 weeks, with no weight bearing (transferring) for at least 8 to 12 weeks. All patients having this type of surgery require daily therapy to keep the arm moving and achieve a better long-term result. Mr. Smith’s therapy will be even more aggressive owing to his dependence on his shoulder for independent living—another reason for him to be treated at a rehabilitation hospital. Given Mr. Smith’s situation and these postoperative restrictions, a rehabilitation hospital such as the Institute for Rehabilitation and Research is crucial to achieve a good outcome and to prevent the known complications that paraplegics are subject to. For instance, the trained staff there can help prevent bed sores and decubitus ulcers by turning Mr. Smith every 2 hours, as well as assist in his bowel and bladder program, which he will not be able to manage by himself. It is my strong recommendation that he receive between 2 and 3 months of care in a high-quality rehabilitation hospital. If you have any further questions, please do not hesitate to call me or my assistant Evelyn at 713-555-2000. Sincerely, Dr. G. M. Gartsman

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Postoperative Care The best plan is to arrange for care at a rehabilitation hospital or an assisted living facility for several weeks after the surgery. That way, rehabilitation of the operated shoulder, as well as daily routines of bladder, bowel, and skin care, will be handled professionally. However, as one patient discovered, such plans do not always work out as expected. He said, ‘‘I was able to get approval from the insurance company for 2 months at the rehabilitation hospital, but I ended up staying there for only 2 weeks. The rehabilitation professionals at the facility felt that training me to do transfers and assist with other medical care concerns, with probable assistance at home, was all that was necessary. What occurred in my situation was that the rehabilitation protocols of my rehabilitation physician and the actual admitting physician (not the operating orthopedic surgeon), were different. Still, my 2-week stay at the rehabilitation hospital was beneficial.’’ An alternative plan is to go home after surgery and use the assistance of a family member or an attendant. However, a family member’s level of training may not be adequate, so it is probably better to hire a skilled attendant or nurse. After his 2 weeks in the rehabilitation facility, the patient mentioned earlier arranged to have home care for the remaining 6 to 8 eight weeks of his recovery. He noted that finding the right individuals for the job is key. Although most insurance policies cover about 16 to 20 hours of actual nursing care at home, this is not the type of care required. He said, ‘‘You are looking for someone to help with dressing, bathing, eating, cooking, and cleaning. You also need assistance with daily transfers from your bed to your wheelchair. This is different from the medical care given by a registered nurse. It is also nice to have someone available to take you to doctor’s appointments and assist with physical therapy at home.’’ This patient recommends asking at the rehabilitation hospital whether any nurses or skilled technicians there are looking for additional work. His main

caregiver was a skilled technician who was not a licensed vocational nurse, but the work she did at the hospital was basically the same type of help he required at home. He then asked her to find other individuals to make up a team of caregivers who could handle the 24-hour-a-day care he required. She was able to find three people who provided home care for 6 weeks before the patient returned to work. This patient happened to live in Texas, which has a Department of Assistive and Rehabilitative Services that covers this type of care. The overall cost can be anywhere from $15 to $25 an hour and can total $20,000 to $30,000 by the time a patient is fully recovered. This agency also covered the cost of some equipment that insurance did not, such as a shower bench and toilet chair. In addition, the department covered the rental of a van with a lift for several months after the patient returned to work. He said, ‘‘I could not use my car for transfers and load my wheelchair. I had to continue to let the shoulder heal for 2 months after returning to work. I did eventually go back to using my car about 4 months after surgery, but the van may be a good alternative in a few years just because of age and other disability considerations.’’ As far as his satisfaction with the outcome, this patient said, ‘‘After 9 months, I have gotten good results from the surgery, but I still lack some strength and confidence. Today I am using the arm and shoulder again in all daily transfers as well as driving. There is some strength loss, but it is not severe—probably about 10% at this point, and even that should come back over time. I would recommend that you follow doctor’s orders and keep doing your exercises to keep the arm as strong as possible and stretched out. I have noticed some pain and functional issues if it is not exercised regularly. I am back at work and doing well with all my job responsibilities. However, I would recommend that you refrain from picking up more than 10 to 20 pounds when it requires a lift away from the body. You need your shoulders and arms to be strong for daily activities, particularly as you get older with a disability.’’

Index A Abduction acromioclavicular joint pain with, 311–312 in diagnostic glenohumeral arthroscopy, 67 with external rotation, 68f with internal rotation, 68f, 69f in glenohumeral instability, 105 inferior translation with, 111, 112f in impingement syndrome diagnosis, 213, 214 in lateral decubitus position, 50 in proximal biceps tendon lesion diagnosis, 151 in rotator cuff tears full-thickness, 250, 258 massive, 279, 289 in stiffness treatment, 177–180, 179f, 180f, 182–183 Abduction internal rotation stretch, for glenohumeral instability, with recurrent dislocation, 347, 347f Abrasion arthroplasty for distal biceps tendon lesions, 165–166, 166f for fracture fixation, 323–324 for full-thickness rotator cuff repair, 254, 255f for glenohumeral instability, 119f of glenoid, for glenohumeral arthrosis, 192, 192f, 193f Absorbent mat, in operating room setup, 47, 48f AccuPass instrument, for suture management deploying braided suture, 53, 54f deploying nylon loop, 54f description of, 54f, 57 handling, 43 in biceps tendon lesions repair distal, 165 proximal, 156–157, 159 loading and employing, 7–10, 10f thumb position for, 7–10, 10f, 43

Acromial corner anterolateral, in acromioplasty, 222–224, 225f posterolateral, in diagnostic arthroscopy, 64, 65f Acromioclavicular joint arthritic conditions of, 214, 216, 306–308, 306f, 307f SLAP lesions vs., 307, 307f arthroscopic resection of, 308 arthroscope rotation in, 310f, 311–312, 312f bone measurement in, 308f, 311–312, 314f burs in, 310–312, 314f cannula and trocar in, 310–312, 314, 314f clavicle in anterior resection, 311–312, 313f cautery of, 312f distal perspectives, 66, 66f, 306 distal procedures, 310–312, 310f, 311f end-on view of, 309f, 311–312 electrocautery in, 310, 310f, 311, 312f for impingement syndrome, 216 in rotator cuff repair full-thickness, 254, 254f of paraplegics, 348 incisions for, 95, 95f superior-lateral indications, 66, 66f indications for, 308 medial acromion in, 311–312, 312f, 313f open resection vs., 3, 306–308 patient position for, 49 portals in, 310, 310f, 311f, 314 posteromedial acromion in, 311–312, 313f spinal needle in, 310–311, 311f superior capsule in, 311–312, 313f complications of, 314 diagnosis of, 307, 307f dislocations of, 306, 306f

Acromioclavicular joint (Continued) in impingement syndrome, 214, 216, 217, 311–312 injection of, 307–308 instability of, after resection, 314 literature review of, 306 nonoperative treatment of, 307 open resection of arthroscopic resection vs., 3, 306–308 clavicle in distal perspectives, 66, 66f, 306 distal procedures, 308, 308f, 309f medial acromion in, 308, 308f, 309f technique for, 308, 308f, 309f postoperative management of, 314 reconstruction of. See Acromioplasty. Acromion in acromioclavicular joint resection medial resection of arthroscopic, 311–312, 312f open, 308, 308f, 309f posteromedial resection of, 311–312, 313f in diagnostic arthroscopy, 68–69, 89–90 anterior, 87–88, 88f inferior, 89 in impingement treatment cutting block technique and, 227, 227f, 228f, 229 decompression and, 225, 226f palpation of, 218–219, 219f technical failure and, 229 in rotator cuff repair irreparable, 299, 299f, 300f massive, 280–281, 281f, 282f cuff mobilization and, 284, 285f, 286f, 288 in sitting position, 50–51, 52f checking for, 51f, 52f reconstruction of. See Acromioplasty.

Page numbers followed by f indicate figures; t, tables; b indicate boxes.

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352

Index

Acromion (Continued) spur of, in full-thickness rotator cuff tears, 242, 243f type 1 in full-thickness rotator cuff tears, 253–254 in impingement syndrome, 226, 227 type 2 in full-thickness rotator cuff tears, 253–254 in impingement syndrome, 226 type 3 in full-thickness rotator cuff tears, 242f, 253–254 in impingement syndrome, 214, 215f in partial-thickness rotator cuff tears, 234 Acromionizer bur, 61f Acromioplasty arthroscopic vs. open, 3, 306–308 cutting block technique for, 227, 227f, 228f bone transection risk with, 227–229, 228f for acromioclavicular joint conditions, 308–310. See also Acromioclavicular joint. for impingement syndrome, 215–216, 222, 224f, 225f technical failure of, 229 where to start/when to stop, 225, 226f in rotator cuff repair full-thickness, 253, 254f irreparable, 297, 304 indications for, 308 open technique for, irreparable rotator cuff tears following, 296 os acromiale and, 228, 229f power instruments for, 60 Active elevation, for massive or irreparable rotator cuff tears, 343–344 lowering arm, 345, 346f three-phase. See Three-phase active elevation. Activities of daily living postoperative, with Latarjet procedure, 144 rotator cuff tears and, 273t, 298, 303–304 in paraplegics, 348, 350 Activity modification for glenohumeral instability, 108 for impingement syndrome, 215 for periarticular cysts, 201

Activity modification (Continued) for proximal biceps tendon lesions, 151–152 for rotator cuff tears full-thickness, 243 irreparable, 297 Adduction acromioclavicular joint pain with, 254, 307 cross-body stretch in for adhesive capsulitis, 336, 337f for full-thickness rotator cuff tears, 255–256, 337f for glenohumeral instability, 108, 108f postoperative, 337f, 347 with recurrent dislocation, 337f, 347 for impingement syndrome, 337f, 338 in diagnostic glenohumeral arthroscopy, 67, 178–180 in full-thickness rotator cuff tears, 254, 258 in proximal biceps tendon lesion diagnosis, 149 Adhesions biceps tendon lesions related to, 147, 170–171 in diagnostic arthroscopy of glenohumeral joint, 77–78, 82f, 83f of subacromial space, 92f in glenohumeral arthrosis, 189, 190, 191 in impingement syndrome, subacromial, 215–216, 219, 221f bursectomy and, 219–221, 222f in rotator cuff tears full-thickness, 254, 255f irreparable, 254, 279, 299–302, 299f, 301f massive, 254, 279, 281f, 282–288 in stiffness treatment as indication, 176, 178–180, 185, 185f postoperative, 185 Adhesive capsulitis idiopathic, 176–178 glenohumeral arthrosis vs., 189–191 impingement syndrome vs., 216, 217, 229 subacromial impingement vs., 217–218, 219f rehabilitation program for, 336, 336f, 337f Aging process in acromioclavicular joint, 306 in rotator cuff disease, 233

Airway management, in anesthesia,, 48, 48f, 49f AL (anterolateral) stab wound, for massive rotator cuff repair, 290–292, 291f Allografts bone anchors as, in full-thickness rotator cuff repair, 256 tendons as, in irreparable rotator cuff repair, 297 ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion, in glenohumeral instability, 102, 138 American Shoulder and Elbow Surgeons (ASES) Shoulder Index of full-thickness rotator cuff repair results, 272, 273t of glenohumeral instability, 104 Analgesics for adhesive capsulitis, 336 for calcific tendinitis, 318 immediate postoperative, 48 Anatomy models for arthroscopic shoulder surgery training, 5 two dimensional model of glenohumeral reconstruction, 6f of rotator cuff repair, 6f Anchor sutures for distal biceps tendon lesions, 162, 165–166, 166f, 167f, 168f in full-thickness rotator cuff repair design perspectives, 255–256 double-row technique, 258, 260f, 267–269, 270f material perspectives, 256 placement of, 257 postoperative retrieval of, 275 selection of, 255–256, 256f, 257f single-row technique, 258, 258f in glenohumeral instability repair, 63, 113, 119f, 121, 125f anterior-inferior insertions, 125, 125f, 126f historical approaches to, 102 passing technique for, 128, 128f, 129f in massive rotator cuff repair, 279, 288, 288f, 294, 294f, 295f management of, 280, 289, 290f, 291f, 292f sequence for, 289, 289f in operating room setup, 63 in SLAP lesions repair for type 3, 159, 160f posterior, for type 2, 154, 156f, 158f, 159f

Index

Anchor sutures (Continued) percutaneous insertion of, 12 plastic, in full-thickness rotator cuff repair, 256 remnant of, in sepsis treatment, 208–209, 208f skills for, 12 Anesthesia examination under clinical data compared to, 44 for impingement syndrome, 217 in operating room, 44 in stiffness treatment, 178 for calcific tendinitis treatment, 318 for full-thickness rotator cuff repair, 244 general, 48 in operating room setup, 48 local. See Local anesthetic. regional, 48 Anterior acromion in diagnostic arthroscopy, 87–88, 88f Anterior capsule in diagnostic glenohumeral arthroscopy, 75, 76f in impingement syndrome, contracted recess vs., 217–218, 219f in stiffness treatment, 181, 182f blunt dissection of, 181, 183f cauterization of, 181, 182f, 183f contracture of, 178–180, 182–183, 182f, 183f release technique for, 178 glenohumeral ligament and, 181, 182f resection methods for, 181–185, 184f, 185f release of in glenohumeral arthrosis treatment, 190–191, 191f in rotator cuff repair irreparable, 299, 299f massive, 286–287 Anterior glenohumeral ligament in diagnostic arthroscopy, 75, 76f in glenohumeral instability, 102, 103, 115f circle concept of, 104, 104f Anterior gutter, in diagnostic subacromial arthroscopy, 87–88, 90, 91f Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, in glenohumeral instability, 102, 138 Anterior labrum, detachment classification of, 122–124, 122f

Anterior portal combined views of, 98, 97f for acromioclavicular joint resection, 95f, 310–311, 311f for biceps tendon lesion repair distal, 164, 165, 172 proximal, 152, 152f for diagnostic glenohumeral arthroscopy, 66, 67f, 70t inside-out technique, 70–72 outside-in technique, 72 for fracture fixation, 323–324 for glenohumeral arthrosis treatment, 190 for glenohumeral instability treatment, 113–114, 113f, 114f, 116f, 117f for glenohumeral joint reconstruction, 95–96, 96f for Latarjet lesions/repair, 96, 96f for rotator cuff repair, 94–95, 95f full-thickness, 245, 246f, 247, 248f, 249f irreparable, 299 massive, 286, 293–295 for SLAP lesion repair, 66–67 for SLAP lesions, 96 for suprascapular nerve decompression at the spinoglenoid notch, 97 at the suprascapular notch, 96–97 for periarticular cysts, 202–203, 202f Anterior shoulder, sitting position for access to, 50–51, 53f Anterior translation, in glenohumeral instability, 110–111, 112f Anterior-inferior repair of glenohumeral instability anchor insertion for, 125, 125f, 126f anterior scapular neck preparation in, 124, 124f Bankart lesions and, 104, 121 bone fragments and, 123–124 de´bridement in, 122 drill holes for, 124 glenohumeral ligament release in, 122–123, 123f insertion tears and, 122, 122f knot tying in, 129, 129f loop reversal in, 127, 128f passing the anchor suture in, 128, 128f, 129f principles of, 121 suture passing in, 125–126, 126f, 127f, 128f

353

Anterior-posterior longitudinal tears, full-thickness, of rotator cuff, 247–249, 251f, 252f, 253f Anterolateral (AL) stab wound, for massive rotator cuff repair, 290–292, 291f Antibiotics for sepsis treatment, 207 postoperative, for glenohumeral instability treatment, 136, 138 Anti-inflammatory medication. See also specific drug, e.g., Cortisone. for impingement syndrome, 215 Arm, contralateral, in sitting position, 50–51, 52f Arm holders, for sitting position, 50, 52f in rotator cuff repair full-thickness, 244–245, 245f, 250–252 massive, 283–284 Arthrex Suture Bridge, 63 Arthritis advanced glenohumeral joint, irreparable rotator cuff tears and, 298 full-thickness rotator cuff tears and, 245–246, 254 in acromioclavicular joint, 214, 306–308, 306f, 307f in impingement syndrome, 216 SLAP lesions vs., 307, 307f osteoarthritis, in glenohumeral arthrosis, 190 rheumatoid, in glenohumeral arthrosis, 187, 187f, 194, 197f classification of, 194, 197t Arthropierce suture passer, 56f, 57 Arthroscope hand positions for using, 11f handling of, 42 in operating room setup, 52–53 rotation techniques for, 11f, 43 surgeons’ views of, 3, 4f Arthroscopic graft jacket placement, for glenohumeral joint arthrosis, 194–196, 196b Arthroscopic lavage, for glenohumeral arthrosis, 188–189 Arthroscopic pump, in operating room setup, 47, 47f, 62 Arthroscopic shoulder surgery acromioplasty in, 3, 306–307, 308 equipment for, 52–53 indications for. See specific pathology, e.g., Stiffness.

354

Index

Arthroscopic shoulder surgery (Continued) instrument handling for, 42 intellectual history of, 101 intellectual skills for, 3, 41 evaluating need for, 3–4 open repair vs. See Open shoulder surgery. portals for. See Instrument portals. technical skills for, 4 evaluating need for, 3–4 knot tying as, 19, 29, 31–41 suture anchors in, 12 suture management as, 12 sutures through tendons in, 12 transition from open repair gaining experience in, 3, 4, 8–9, 41 stages and plan for, 41 Arthroscopy Association of North America, arthroscopic shoulder surgery training program of, 4, 5 Arthroscopy, diagnostic. See Diagnostic arthroscopy. Arthrosis. See Glenohumeral joint arthrosis. ArthroSurface cap, for glenohumeral instability, 110 Arthrotomy, for sepsis, 207 Articular surface partial-thickness rotator cuff tear operative treatment of, 236–238, 237f, 238f ultrasonography of, 326, 332f ASES (American Shoulder and Elbow Surgeons) rating system of full-thickness rotator cuff repair results, 272, 273t of glenohumeral instability, 104 Aspiration. See Needle aspiration. Assisted living facility, for rotator cuff repair rehabilitation, in paraplegics, 350 Athletes. See Sports; Throwing athlete. Atrophy, of muscles, with rotator cuff tears full-thickness, 242–244, 243f supraspinatus muscle/tendon tear and, 242, 243f irreparable, 297, 299–300 Avascular necrosis, in glenohumeral joint arthrosis, 188f, 194 Avulsion injury of labrum, in glenohumeral instability, 101, 102 SLAP lesions resulting from, 151, 151f Axillary nerve, in stiffness treatment, 182–183, 184

Axillary pouch, in stiffness treatment, 182–183 Axillary recess, in diagnostic glenohumeral arthroscopy, 75, 76f

B Back table, in operating room setup, 48, 48f Bags fluid, in operating room setup, 47, 47f for lateral decubitus positioning, 49–50, 50t Bankart lesions accurate assessment of, 5–8 in glenohumeral instability, 101, 115f anterior-inferior repair of, 104, 121 capsular shift of, 105 historical treatment of, 101 posterior repair of, 118 radiographs of, 107f SLAP variations of, 102, 104f, 107f, 129 repair of, 129, 130f with bone fragment, 123–124 with complications, 121 in partial-thickness rotator cuff tears, 234–235, 236f subacromial impingement vs., 217–218, 218f, 229 Bankart repair AccuPass technique for, 15–16, 16b Caspari suture punch technique for, 14–15, 15b infection after, 208f portals for, 52–53 posterior, 66 simulation of, 17–19, 27f, 28f, 29f soft tissue management in, 57 stiffness following, 176 Beach-chair position, 50, 50t, 51f Beanbag, vacuum, for lateral decubitus position, 49–50, 50t Belly-press test, for irreparable rotator cuff tears, 297 Bernejeau view, of coracoid ligament, post-Latarjet procedure, 144 Biceps strengthening for glenohumeral instability postoperative, 338f, 347 with recurrent dislocation, 338f, 347 for impingement syndrome, 338, 338f for rotator cuff repair, 338f, 346 for rotator cuff tears, fullthickness, 256–257, 338f

Biceps stump, intra-articular, in distal biceps tendon lesion repairs, 168f, 303f Biceps synovitis, 162f Biceps tendinitis, 147 description of, 161, 162f diagnosis of, 162, 163f literature review of, 161 operative technique for and partial-thickness tears with intact rotator cuff, 162f, 165, 165f intra-articular, 164, 164f overview discussion on, 161, 173 postoperative treatment for, 173 Biceps tendon cyst of, ultrasonography of, 334f dislocation of, 147, 302, 302f in irreparable rotator cuff tears, 302, 302f entrapment of, 147 hourglass, of Bolieau, 171f in diagnostic glenohumeral arthroscopy, 70, 75–78 extra-articular views of, 81f normal anatomy of, 78f, 79f shaver views of, 80f, 81f tears of, 79f, 80f in glenohumeral arthrosis, 188 in stiffness treatment, 180–181 lesions of distal, 161. See also Distal biceps tendon lesions. dysfunctional mechanisms of, 147 overview discussion on, 147, 173 proximal, 147. See also Proximal biceps tendon lesions. MRI of, 328f distal lesions, 162, 163f proximal lesions, 149–150, 149f test excursion of, in irreparable rotator cuff tears, 302, 302f ultrasonography of, 326, 328f thickened, 334f Biceps tendon tears, 147 complete, ultrasonography of, 333f diagnosis of, 79f, 80f full-thickness, 163, 164f in rotator cuff tears full-thickness, 245–246, 246f irreparable, 296, 297, 298, 302 partial intra-articular, 164–165 partial-thickness, 162–163 with intact rotator cuff, 162f, 165, 165f Biceps tenodesis, 165 extra-articular technique in, 161 indications for, 161–163, 165 intra-articular technique in, 170, 171f, 172f, 173f

Index

Biceps tenodesis (Continued) literature review of, 161 suture anchor technique in, 165–166, 166f, 167f, 168f Biceps tenotomy, for irreparable rotator cuff tears, 161–163, 172–173, 298, 302, 303f in paraplegics, 348 Biceps-labrum complex in diagnostic glenohumeral arthroscopy, 70, 75–78, 78f in glenohumeral instability, 102, 110–111 in massive rotator cuff repair, 286–287 lesions causing dysfunction in, 147, 172–173 Biceps—rotator cuff, adhesions of, 78, 82f, 83f Bicipital groove in irreparable rotator cuff tears, 302 ultrasonography of, 327–328, 328f Bicipital sheath, in glenohumeral arthrosis, 188 Biopsy(ies), tissue, for sepsis diagnosis, 207–208 BioRaptor anchor, 63 Bleeding control of in acromioclavicular joint resection, 311, 312f in impingement treatment, 219–221, 224, 226–227 in rotator cuff repair full-thickness, 252–254, 253f massive, 284–286 electrocautery for, 62, 62f. See also Electrocautery. fluid management for, 62 with acute fractures, 323–324 Blunt dissection in glenohumeral arthrosis treatment, 190, 191, 191f in stiffness treatment, 181, 183f of subacromial adhesions, for impingement syndrome, 219, 221f Blunt dissector, 57, 57f, 58f with measuring guide markings, 58f Bolieau, hourglass biceps of, 171f Bolieau screw fixation, for distal biceps tendon lesions, 162 Bone exposure of cancellous, in SLAP 2 lesions repair, 155, 155f fragments of, in glenohumeral instability, 123–124

Bone (Continued) landmarks of, for diagnostic glenohumeral arthroscopy, 64, 65f palpation of. See Palpation. surface, decortication of, in full-thickness rotator cuff repair, 254, 255f Bone anchors, allograft, in full-thickness rotator cuff repair, 256 Bone marrow stimulation, in glenohumeral arthrosis, 187 Braces, for paraplegics, with rotator cuff tears, 348–349 Braided suture deployment instrument for, 53, 54f in full-thickness rotator cuff repair, 259, 263 in glenohumeral instability repair, 111, 120f, 121, 129, 130, 132–133 in operating room setup, 60 passing through tendons, 12 Breathing tubes, for anesthesia endotracheal, 48, 51f laryngeal, 48, 48f, 49f Bridge repair, suture Arthrex material for, 63 of full-thickness rotator cuff tears, 270, 270f, 271f Bristow procedure, stiffness following, 176f Broca lesions, 104. See also Bankart lesions. Bucket-handle tears, in SLAP 3 lesions, 159 Burs, 60 acromionizer, 61f in acromioclavicular joint resection, 310–312, 314f in distal biceps tendon lesion repairs, 165–166 in fracture fixation, 323–324 in glenohumeral arthrosis treatment, 192, 192f in glenohumeral instability repair, 122, 124 in impingement treatment, 221–224, 224f, 229 coracoid, 231 pattern of movement for, 224, 225f, 226–227 variations of technique, 227, 228f in rotator cuff repair full-thickness, 254, 255f irreparable, 299–302, 301f massive, 288

355

Burs (Continued) in SLAP 2 lesions repair, 155, 156f oval, 61f round, 60f, 61f Bursa in diagnostic subacromial arthroscopy, 89–90, 93f in full-thickness rotator cuff repair, 247, 259–261 in glenohumeral joint arthrosis treatment, 196 in impingement syndrome, 215–216, 219, 224–225 Bursal curtain, posterior, in impingement syndrome, 221f Bursal surface partial-thickness tears, 240 Bursectomy for impingement syndrome coracoid, 231 subacromial, 219–221, 221f, 222f, 226–227 in acromioclavicular joint resection, 310 in calcific tendinitis treatment, 318–319, 319f in rotator cuff repair full-thickness, 247, 248f irreparable, 299 Bursitis in massive rotator cuff repair, 281–282 in subacromial space, 88 impingement syndrome and, 219–221 ultrasonography of, 326

C Calcific tendinitis diagnosis of, 316, 317f, 317t, 318f literature review of, 316 nonoperative treatment of, 318 operative technique for, 318, 319f, 320f indications for, 318 pain with, 316 postoperative treatment of, 320 ultrasonography of, 326, 333f Calcification process, in calcific tendinitis, 316 Cancellous bone, exposure of, in SLAP 2 lesions repair, 155, 155f Cannula(s) 5.5-mm, 61–62, 62f 8-mm, 61–62, 62f eight-mm, 61–62, 62f for diagnostic arthroscopy of glenohumeral joint, 68–72, 73f, 75–77, 77f

356

Index

Cannula(s) (Continued) of subacromial space, 88–89, 89f, 90f in acromioclavicular joint resection, 310–312, 314, 314f in calcific tendinitis treatment, 319 in distal biceps tendon lesion repairs, 165–166, 170–173, 172f in fracture fixation, 323–324 in glenohumeral arthrosis treatment, 190, 194 in glenohumeral instability repair, 113–118, 114f, 116f, 117f, 123f in operating room setup, 61 in rotator cuff repair full-thickness, 245–247, 247f, 248f, 249f, 254, 259, 261–263, 268f, 269–270 arm maneuvering for, 252f, 253f irreparable, 299, 300f, 302 massive, 280–281, 284–286, 290–292 partial-thickness, 237–238 in sepsis treatment, 207–209 in SLAP lesions repair anterior-inferior, 152, 153f, 156–157, 158f, 159 anterior-superior, 154, 154f, 155f, 156–157, 157f, 158f, 159 in stiffness treatment, 180, 180–181, 183–185, 184f Capsular elongation, in glenohumeral instability, 110–111 arthroscopic treatment of, 110 historical treatment of, 102 radiographs of, 106, 106f, 107f, 108f Capsular repair of glenohumeral instability, 129–130, 130f, 131f, 132f Capsular resection punch, 57, 58f in glenohumeral arthrosis treatment, 190–191 Capsular shift, in glenohumeral instability Bankart lesions and, 105 operative treatment of, 101, 105 Capsular tensioning/tightening, in glenohumeral instability, 102, 110–112, 121, 130–132, 134, 135f Capsule anterior. See Anterior capsule. inferior. See Inferior capsule.

Capsule (Continued) posterior. See Posterior capsule. superior. See Superior capsule. Capsulitis, idiopathic adhesive, 176, 177, 178, 178f glenohumeral arthrosis vs., 189, 190–191 impingement syndrome vs., 216, 217, 229 subacromial impingement vs., 217–218, 219f Cartilage, in diagnostic arthroscopy, 83–85, 86f Cartilage lesions in glenohumeral arthrosis, 187, 188f arthroscopic treatment of, 189 de´bridement of, 187–189, 188f in glenohumeral instability, 115f, 116f, 118 in impingement syndrome, 218, 218f in partial-thickness rotator cuff tears, 234–236, 235f, 236f Caspari Suture Punch description of, 8f, 54f, 56 handling of, 43 in full-thickness rotator cuff repair, 259, 263f, 264f, 265f, 266f, 267f loading and employing, 8f, 9f, 10f thumb position for, 9f tip of, 54f Catching, of shoulder with biceps tendon lesions, 147, 149, 149f, 151 with glenohumeral arthrosis, 188 Catheter, long-term, for sepsis treatment, 207 Cauterization. See Electrocautery. Cervical radiculopathy, shoulder pain related to, 316 Cervical spine support for lateral decubitus position, 49–50 for sitting position, 52f anterior alignment check, 52f positioning of, 51f Chin strap, for securing cervical spine, 52f Chisel dissectors, 57, 57f in glenohumeral instability repair, 122–123, 123f Chondral defects. See Cartilage lesions. Chronicity, of glenohumeral instability, 104

Circle concept, of glenohumeral instability, 104, 104f Clavicle, distal in acromioclavicular joint resection anterior resection, 311–312, 313f arthroscopic procedures, 310–312, 310f, 311f cautery of, 312f end-on view of, 309f, 311–312 open procedures, 308, 308f, 309f perspectives of, 66, 66f, 306 osteolysis of, 306 Clavipectoral fascia, in Latarjet procedure, for glenohumeral instability, 143 Cleavage tears, horizontal, of rotator cuff, 271 Clinical data display in operating room, 44 electronic, 63 for proximal biceps tendon lesion diagnosis, 151 Clinical programs, for arthroscopic shoulder surgery training, 3, 4, 5 Coagulation instruments, for bleeding control, 62, 62f Cognitive factors, of impingement treatment failure, 229 Compression in diagnostic ultrasonography, 327–328 in proximal biceps tendon lesion diagnosis, 149, 149f rotator cuff tears related to, 233, 239 Computed tomography of full-thickness rotator cuff tears, 241–242 of glenohumeral instability, 106 for three-dimensional reconstruction, 109, 109f of greater tuberosity fractures, 323 Concavity-compression, of labrum, in glenohumeral instability, 102, 110, 111, 125–126 Conservative treatment of acromioclavicular joint conditions, 307 of calcific tendinitis, 318 of glenohumeral arthrosis, 187 of glenohumeral instability, 103, 108, 108f of greater tuberosity fractures, 323 of impingement syndrome, 215

Index

Conservative treatment (Continued) of periarticular cysts, 201, 202 of proximal biceps tendon lesions, 151 of rotator cuff tears full-thickness, 242–243 in paraplegics, 348 irreparable, 297 partial-thickness, 234 Constant scoring system, for glenohumeral instability, 104 postoperative results of, 136–138, 137t Continuous passive motion chair for calcific tendinitis, 320 in glenohumeral arthrosis treatment, 192–193 in rotator cuff repair full-thickness, 272, 272f irreparable, 303–304 in stiffness treatment, 185–186 Contraction(s) excessive eccentric muscle, rotator cuff tears related to, 233 of rotator interval, 72f Contracture(s) in full-thickness rotator cuff tears capsular, 245–246 coracohumeral ligament, 254, 255f postoperative, 274 in glenohumeral arthrosis, 188–189, 189f in glenohumeral instability, 108, 108f in impingement syndrome, anterior capsule recess vs., 217–218, 219f in irreparable rotator cuff tears, capsular, 297, 298 in massive rotator cuff tears, 282–283 release of, 280, 281f, 286–288, 286f in proximal biceps tendon lesions, 151 stiffness related to, 178 of anterior capsule, 178–180, 182–183, 182f, 183f release technique for, 178 Contralateral arm/elbow, in sitting position, 50–51, 52f Coordination training, for glenohumeral instability, 108 Coracoacromial ligament fraying of, 91f, 92f, 223f

Coracoacromial ligament (Continued) in diagnosis arthroscopy, 89–90, 91f, 92f, 93f in glenohumeral instability, 102 in impingement syndrome, 89–90, 221, 226 palpation of, 219, 220f release technique for, 221–222, 223f, 224f in Lafosse technique, 202–203 in rotator cuff tears full-thickness, 248f, 252, 253f irreparable, 296, 297, 301f, 302, 304 massive, 283 in stiffness treatment, 180–181 ossification of in full-thickness rotator cuff tears, 242, 243f in impingement syndrome, 214, 215f release of, in glenohumeral instability, 142 Coracohumeral ligament, contractures of in full-thickness rotator cuff tears, 254, 255f in massive rotator cuff tears, 282–283 release of, 286, 286f Coracoid impingement, 230, 231f in glenohumeral instability, 142 Coracoid ligament arthroscopic preparation of, portals for, 96 contractures of, in massive rotator cuff tears, 286 in diagnostic glenohumeral arthroscopy, 68–69 in glenohumeral instability Latarjet procedure and, 140f, 142, 143, 144 postoperative evaluation of, 144 release of, in glenohumeral arthrosis treatment, 191, 192f Coracoid osteotomy, in glenohumeral instability, 142, 143 Core decompression, for glenohumeral arthrosis, 189, 196 Cortisone, injection of for acromioclavicular joint inflammation, 307–308 for calcific tendinitis, 318 for impingement syndrome, 215 for irreparable rotator cuff tears, 297 in periarticular cyst treatment, 205 in stiffness treatment, 185 C-reactive protein, in sepsis, 207

357

Crochet hook, for suture management, 58, 58f fine-toothed, 58f in glenohumeral instability repair, 121, 126–127, 130, 133, 134f in rotator cuff repair full-thickness, 259–269 massive, 290–294 in SLAP lesions repair, 156–157, 159 Cross-body adduction stretch for adhesive capsulitis, 336, 337f for full-thickness rotator cuff tears, 255–256, 337f for glenohumeral instability, 108, 108f postoperative, 337f, 347 with recurrent dislocation, 337f, 347 for impingement syndrome, 337f, 338 Cuff mobilization, in rotator cuff repair full-thickness, 254, 254f, 255f massive, 284, 285f, 286f, 287f, 288f, 289f Cuff-Stitch suture passers, 53, 56–57 in distal biceps tendon lesion repairs, 170–171 in rotator cuff repair full-thickness, 271 massive, 293–294, 294f, 295f left-angled, 56f right-angled, 56f straight, 55f Cultures, for sepsis diagnosis joint fluid, 207–208 tissue, 207–208 Curette, in fracture fixation, 323–324, 324f Cutting block technique, for acromioplasty, 227, 227f, 228f bone transection risk with, 227–229, 228f Cyst(s) as biceps tendon lesions, 147 ultrasonography of, 334f periarticular. See Periarticular cysts.

D De´bridement in glenohumeral arthrosis after synovectomy, 194 of cartilage lesions, 187–189, 188f of rotator interval, 190, 190f, 191 in glenohumeral instability repair, 110, 112, 119f, 122

358

Index

De´bridement (Continued) anterior-inferior, 122 in impingement syndrome, 215–216, 218, 224–225 in intra-articular tendinitis treatment, 164 in periarticular cyst treatment, 203–205 irrigation and, in sepsis treatment, 207–209, 208f of rotator cuff tears in paraplegics, 348 irreparable, 296–300, 303f partial-thickness, 235 of articular surface, 236–238 of posterior tears, 239–240 with subacromial decompression, 235, 236 Decompression, core, for glenohumeral arthrosis, 189, 196 Decortication of bone surface, in full-thickness rotator cuff repair, 254, 255f of coracoid, in glenohumeral instability, 143 Dedicated team, in operating room setup, 63, 63f Deltoid adhesions of, in rotator cuff tears full-thickness, 254, 255f irreparable, 300–302 massive, 284, 285f, 287–288 in impingement treatment arthroscopic vs. open, 230 ultrasonography of, 327–328 in irreparable rotator cuff repair, 297 Diabetic stiff shoulder, 176–177 Diagnostic arthroscopy incision variations for, 90–94 in acromioclavicular joint resection, 95 in glenohumeral joint resection, 95 in Latarjet lesions, 96 in rotator cuff repair, 94 in SLAP lesions, 96 in suprascapular nerve decompression at the spinoglenoid notch, 97 at the suprascapular notch, 96 overview of, 97f, 98 normal anatomy and, 64 of glenohumeral joint, 64, 66f, 69–70 of subacromial space, 86–87, 88f of glenohumeral joint, 64 anterior portals in, 66, 67f

Diagnostic arthroscopy (Continued) bone landmarks for, 64, 65f lateral portals in, 66–67, 67f medial portals in, 66–67, 66f orientations for, 70, 71f posterior portals in, 64, 65f posterolateral acromial corner in, 64, 65f procedure for, 67, 70t rotation of arthroscope in, 72–75, 75f, 78, 78f superior portals in, 66, 66f trocar entry for, 64, 72, 73f of subacromial space, 86–87, 87t anterior acromion in, 87–88, 88f anterior gutter in, 87–88, 90, 91f bursa in, 89–90, 93f inferior acromion in, 89 lateral gutter in, 87–88, 90, 91f lateral portal in, 88–89, 88f, 90f orientations for, 87–89 posterior entry for, 87–88 triangulation technique for, 89, 89f patient positioning for, 49 portals for. See Viewing portals. surgeon training on, 5–9 Directionality, of glenohumeral instability, 103, 132 postoperative ratings of, 136–138, 136t, 137t Dislocation of acromioclavicular joint, 306, 306f of biceps tendon, 147, 302, 302f in irreparable rotator cuff tears, 302, 302f of glenohumeral joint greater tuberosity fractures and, 322–323 mechanisms causing, 101, 102, 103 persistent pain with, 323 rehabilitation for recurrent, 346 strength exercises in, 338f, 339f, 340f, 347 stretch exercises in, 337f, 347, 347f traumatic, 109–111 Distal biceps tendon lesions, 161 biceps tenodesis for, 161–163, 165 extra-articular technique in, 161 intra-articular technique in, 170, 171f, 172f, 173f suture anchor technique in, 165–166, 166f, 167f, 168f description of, 161, 162f diagnosis of, 162, 163f

Distal biceps tendon lesions (Continued) literature review of, 161 operative technique for, 163–164 biceps tenodesis as, 161–163, 165 indications for, 162, 164f, 164t intra-articular tendinitis and, 164, 164f irreparable rotator cuff tear and, 172–173 partial tear of intra-articular tendon and, 164–165 spinal needles in, 165–166, 165f, 170–171 subacromial approaches in, 165 tendinitis and partial-thickness tears with intact rotator cuff, 162f, 165, 165f tenotomy as, 161–162, 172–173 indications for, 162–163, 302, 303f overview discussion on, 161, 173 postoperative treatment for, 173 synovitis and, 162f the throwing athlete and, 161–162 Distraction, intraoperative, patient position for, 49, 50 Double-row repair, of rotator cuff tears full-thickness, 258, 260f, 267–269, 270f suture bridge technique, 270, 270f, 271f massive, 280 Drainage tube, in sepsis treatment, 208–209, 208f, 209f Drapes, placement during patient positioning, 50, 51 Drill holes, in glenohumeral instability repair anterior-inferior, 124 of glenoid bone, 124–125, 125f posterior, 121 Drills in glenohumeral arthrosis treatment, 196 in SLAP 2 lesions repair, 155, 156f Drive-through sign, in diagnostic glenohumeral arthroscopy, 75 Dynamic impingement test, 327–328

E Eccentric muscle contraction, excessive, rotator cuff tears related to, 233 Education on arthroscopic shoulder surgery AANA programs for, 3, 4, 5

Index

Education (Continued) anatomy models for, 5 clinical programs for, 3, 4, 5 diagnostic, 5–9 textbooks for, 41 video programs for, 5, 16–17 on glenohumeral instability treatment, 5–8, 5f on rotator cuff repair, 5–8 Elbow, contralateral, in sitting position, 50–51, 52f Elbow exercises, for rotator cuff repair, 346 Electroblade shaver, 60, 60f for electrocautery, 62, 62f in glenohumeral joint arthrosis treatment, 196 Electrocautery for bleeding management, 62, 62f in acromioclavicular joint resection, 310, 310f, 311, 312f in impingement treatment, 221–222, 226–227 in Latarjet procedure, in glenohumeral instability, 142, 143 in periarticular cyst treatment, 202–205 in rotator cuff repair full-thickness, 252–253, 253f irreparable, 300–302 massive, 284–286 instruments for, 62, 62f of anterior capsule, in stiffness treatment, 181, 182f, 183f Electrodiagnostic testing, for periarticular cysts, 201, 202, 205 Electrosurgical grounding pad, 49–50 Elevation in diagnostic glenohumeral arthroscopy, 67, 68f in impingement syndrome, 213, 214 in rotator cuff tears full-thickness, 250, 272 irreparable, 296, 297, 304 massive, 280, 283–284 partial-thickness, 233–234 in stiffness treatment, 177–180, 179f Elevation exercises/strengthening active vs. passive. See Active elevation; Passive elevation. for massive or irreparable rotator cuff tears standing active, 343–344 lowering arm, 345, 346f

Elevation exercises/strengthening (Continued) standing passive, 343–344 holding arm overhead, 344, 345f lowering arm, 345, 345f supine active stage 1, 341, 341f stage 2, 341, 342f stage 3, 342, 343f postoperative, for glenohumeral instability, 136 scapular for full-thickness rotator cuff tears, 259, 340f for glenohumeral instability postoperative, 340f, 347 with recurrent dislocation, 340f, 347 for impingement syndrome, 338, 340f for rotator cuff repair, 340f, 346 shoulder, for glenohumeral joint surgery, 347, 347f Elevation stretch, for adhesive capsulitis, 336, 337f Elite Pass instrument for suture management for suture management description of, 53–57, 53f handling of, 43 in distal biceps tendon lesion repair, 165–166 in full-thickness rotator cuff repair, 259, 259f, 260f, 261f, 262f in stiffness treatment, 181–185, 184f punch needle, 7f loading and employing, 7f, 8f with needle deployed, 54f Elliptical tears, of rotator cuff full-thickness, 249–250, 250f massive, 283f Emotional stability, as glenohumeral instability treatment factor, 109 End-cutting scissors, 58, 60f Endotracheal tube, for anesthesia, 48 securing in sitting position, 51f Entry. See also specific portal, e.g., Anterior portal. for glenohumeral arthrosis treatment, 190, 190f for impingement treatment glenohumeral joint and, 217, 218f, 219f subacromial space and, 218–219, 219f, 220f

359

Entry (Continued) in diagnostic glenohumeral arthroscopy, 64, 67–68, 72, 73f in stiffness treatment, 180, 180f Epinephrine, intraoperative, 62 Equipment, in operating room setup, 52–53 anchors as, 63 arthroscope as, 52–53 cannulas as, 61 fluid management and, 62 hand instruments as, 56 photography and, 63 positioning of, 47, 47f, power instruments as, 60 soft tissue management and, 57 suture management and, 57–58 suture passers as, 53 sutures as, 58–60 thermal instruments as, 62 transfer rods as, 63 video recording and, 63 Erythema in calcific tendinitis, 316, 318, 319f in full-thickness rotator cuff tears, 247, 248f Erythrocyte sedimentation rate, in sepsis, 207 Ethibond suture, in operating room setup, 60 Examination for glenohumeral instability, 67, 103, 105, 105f, 106f for impingement syndrome, 214, 229, 230 of acromioclavicular joint, 307 of biceps tendon lesions distal, 162 proximal, 149f, 151, 161 of glenohumeral joint, 67, 68f, 69f, 187 of rotator cuff tears full-thickness, 242 irreparable, 299–300, 297 partial-thickness, 233–234 under anesthesia clinical data compared to, 44 for impingement syndrome, 217 in operating room, 44 in stiffness treatment, 178 Exercises. See Elevation exercises/ strengthening; Strengthening exercises; Stretching exercises. rehabilitative. See Rehabilitation. Extension, active elbow, for rotator cuff repair, 346

360

Index

External rotation in calcific tendinitis, 317f, 320 in diagnostic glenohumeral arthroscopy, 67, 68f in abduction with anterior stress, 68f sulcus test in, 69f in glenohumeral instability, 101, 105 for labrum repair, 123–124 inferior translation with, 111, 111f in proximal biceps tendon lesion diagnosis, 151, 152 in rotator cuff tears full-thickness, postoperative, 272 irreparable, 300f massive, 280, 285f in sitting position, 50 in stiffness treatment, 177–180, 179f, 182–183 External rotation strengthening for full-thickness rotator cuff tears, 259, 339f for glenohumeral instability, 136 postoperative, 339f, 347 with recurrent dislocation, 339f, 347 for impingement syndrome, 338, 339f for rotator cuff repair, 339f, 346 External rotation stretch, for adhesive capsulitis, 336, 337f Extra-articular biceps tendon, in diagnostic glenohumeral arthroscopy, 81f Extra-articular biceps tenodesis, 161 Extracorporeal shock-wave treatment, of calcific tendinitis, 318 Eyelets in arthroscopic shoulder surgery for suturing practice, 16 laser alignment for insertion, 5f suture to tendon, 5f, 6f in full-thickness rotator cuff repair, 256, 257f, 258

F Fibrosis, in subacromial space, 88 Finger exercises, for rotator cuff repair, 346 Fixation techniques for glenoid rim fractures, 322–323 internal, stiffness following, 177f K-wire, for fractures, 323–324, 324f screw. See Screw fixation. suture, of glenoid rim fractures, 322–323

Flexion active elbow, for rotator cuff repair, 346 in lateral decubitus position, 50 Fluid bags for lateral decubitus position, 49–50 in operating room setup, 47, 47f Fluid management for bleeding, 62 operating room setup for, 62 Foot pedals, in operating room setup, 47, 48f Force testing for biceps tendon lesions distal, 162 proximal, 149, 149f, 151, 151f for diagnostic glenohumeral arthroscopy, 67, 69f for glenohumeral instability, 105 for impingement syndrome, 213, 214 for stiffness treatment, 178–180 Forceps, suture retrieval in full-thickness rotator cuff repair, 263 in glenohumeral instability repair, 132 Four-suture, two-anchor rotator cuff repair, 17–19 simulation of, 19f, 20f, 21f, 22f Fracture(s) acute, 323–324 arthroscopy benefits for, 322 diagnosis of, 323 glenoid rim. See Glenoid rim fractures. greater tuberosity. See Greater tuberosity. humeral head, 322 fixation of, 323–324, 324f literature review of, 322 microfracture, in glenohumeral arthrosis, 187, 189 nonoperative treatment of, 323 nonunion of, 322–323 operative technique for, 323, 324f contraindications for, 323 indications for, 323 postoperative management of, 325 Fraying in full-thickness rotator cuff tears, 247, 248f in glenohumeral instability, of labrum, 117f in impingement syndrome of coracoacromial ligament, 223f of labrum, 216–218, 218f of rotator cuff bursa, 222f of supraspinatus, 217–218

Fraying (Continued) of coracoacromial ligament, 223f in diagnosis arthroscopy, 91f, 92f Full-thickness rotator cuff tears adhesions with, 254, 255f chronic, SLAP lesions with, 150 classification of, 247–249, 249f complications of, 274 diagnosis of, 242, 242f, 243f diagnostic arthroscopy of, vs. partial-thickness, 93f discussion on, 275 literature review of, 241 MRI of, 241–242, 242f, 243f nonoperative treatment of, 242–243 operative technique for, 244 acromioclavicular joint resection in, 254, 254f acromioplasty in, 253, 254f anchor placement in, 257 anchor selection in, 255–256, 256f, 257f anesthesia in, 244 anterior-posterior longitudinal tears, 247–249, 251f, 252f, 253f arthroscopic results of, 272 activities of daily living and, 273t by criteria, 274t by rating system, 273t physical and mental function and, 274t range of motion and, 273t arthroscopic vs. open, 244, 272, 275 components of, 241, 244 contraindications for, 244 coracoacromial ligament in, 248f, 252, 253f coracohumeral ligament in, 254, 255f cuff mobilization in, 254, 254f, 255f elliptical tears, 249–250, 250f glenohumeral joint in, 245, 246f horizontal cleavage tears, 271 indications for, 244 knot tying in, 263, 268f, 269f L-shaped tears, 249–250, 250f, 251f mattress suture in, 263–271 medium tears, 247–249 patient positioning in, 244, 245f portals in, 245, 245f, 246f repair site preparation in, 254, 255f

Index

Full-thickness rotator cuff tears (Continued) reverse L-shaped tears, 249–250, 251f small tears, 247–249 subacromial decompression in, 250–253 subacromial space in, 246, 247f suture passing in, 259 bridge variation, 270, 270f, 271f Caspari suture punch technique, 259, 263f, 264f, 265f, 266f, 267f Elite suture passer technique, 259, 259f, 260f, 261f, 262f suture placement in, 259 double-row repair, 258, 260f, 267–269, 270f single-row repair, 258, 258f suture selection in, 256–257 suture tension in, 263–269, 269f tear classification in, 247–249 transverse tears, 249–250, 250f postoperative treatment for, 272, 272f rehabilitation program for motion exercises in, 336f, 337f, 340 strength exercises in, 243, 272, 338f, 339f, 340, 340f Functional classification, Steinbrocker, of rheumatoid arthritis, 194, 197t Functional status in full-thickness rotator cuff repair results, 272, 274t of paraplegics, with rotator cuff tears, 348, 350

G General anesthesia, in operating room setup, 48 Geometry, of rotator cuff tears, 5–9, 247–249 massive, 279, 280f, 282–284, 288, 293 Glenohumeral instability Bankart lesions with, 101, 115f, 117f anterior-inferior repair of, 104, 121 capsular shift of, 105 historical treatment of, 101 posterior repair of, 118 radiographs of, 107f SLAP variations of, 102, 104f, 107f, 129

Glenohumeral instability (Continued) repair of, 129, 130f with bone fragment, 123–124 with complications, 121 capsular elongation with, 110–111 arthroscopic treatment of, 110 historical treatment of, 102 radiographs of, 106, 106f, 107f, 108f cartilage lesions with, 115f, 116f circle concept of, 104, 104f clinical expression of, 103 degree of, 104 diagnosis of, 104 patient history in, 103, 104 physical examination in, 67, 103, 105, 105f, 106f radiographs in, 103, 106, 106f, 107f, 108f directionality of, 103, 132 glenohumeral ligament in, 113, 115f, 130, 130f, 131f, 135f greater tuberosity fractures and, 322–323 Hill-Sachs lesion with, 107f, 110, 116f, 118, 118f treatment considerations of, 110 impingement syndrome vs., 214, 216–218, 229 labrum signs of, 72–73, 103, 114f, 115f, 117f historical treatment of, 101, 102, 104 operative treatment of, 101, 110, 112 literature review on, 101 nonoperative treatment of, 103, 108, 108f operative treatment of, 108 anchors for, 63, 113, 119f, 121, 125f historical approaches to, 102 passing technique for, 128, 128f, 129f anterior portals for, 113–114, 113f, 114f, 116f, 117f, anterior-inferior repair in, 121. See also Anterior-inferior repair of glenohumeral instability. approaches to, 101, 110 arthroscopic vs. open, 3, 101, 110 cannula and trocar in, 113–118, 114f, 116f, 117f, 123f capsular repair in, 129–130, 130f, 131f, 132f capsular shift and, 101, 105 capsular tensioning in, 102, 111–112, 121

361

Glenohumeral instability (Continued) contraindications for, 109, 109f de´bridement in, 110, 112, 119f, 122 decision making for, 109–111 intraoperative, 112 discussion on, 144 failure rates with, 102–103 glenoid drill holes for, 124–125, 125f indications for, 108 inspection in, 113–114 key points for, 102–103 knot tying in, 120f, 125, 128–129 anterior-inferior repair, 129, 129f labrum repair in, 101, 110, 112 Latarjet procedure in, 113–114, 117f. See also Latarjet procedure. posterior repair in, 121. See also Posterior repair of glenohumeral instability. postoperative management of, 136 rationale in, 110, 111f, 112f results of, 136 complications in, 138 ligament laxity in, 138 preoperative findings vs., 136, 136t range of motion in, 138 return to sports participation in, 138 scores and rating systems for, 136, 137t technique findings with, 136, 137t rotator interval in, 111, 113, 113f, 117f repair of, 134, 134f, 135f scapular neck preparation for, 121, 142 superior labrum repair in, 129 capsular repair and, 130, 130f, 131f, 132f capsular tension determination and, 130–132 capsular tightening and, 132, 133f principles of, 129, 130f surgeon training on, 5–8, 5f technique for, 113 overhead sports and, 101, 104–105, 134–135 periarticular cysts causing, 200, 202 recurrent, 109 rehabilitation for, 346 postoperative, 136, 144, 347 immobilization in, 347

362

Index

Glenohumeral instability (Continued) strength exercises in, 136, 338f, 339f, 340, 340f, 347, 347f stretch exercises in, 337f, 347, 347f with recurrent subluxation or dislocation, 346 strength exercises in, 338f, 339f, 340f, 347 stretch exercises in, 337f, 347, 347f rotator cuff tears and arthroscopic treatment of, 103–104 in throwing athletes, 134–135 irreparable, 304 partial-thickness, 234–236, 239 rotator intervals in, 70, 71f, 72f, 111, 113, 113f, 117f historical treatment of, 102 repair of, 134, 134f, 135f SLAP lesions contributing to, 147, 150–151 Bankart type, 102, 104f, 107f, 129 repair of, 129, 130f Glenohumeral joint cysts of. See Periarticular cysts. diagnostic arthroscopy of, 64 anterior portals in, 66, 67f bone landmarks for, 64, 65f lateral portals in, 66–67, 67f medial portals in, 66–67, 66f orientations for, 70, 71f posterior portals in, 64, 65f posterolateral acromial corner in, 64, 65f procedure for, 67, 70t rotation of arthroscope in, 72–75, 75f, 78, 78f superior portals in, 66, 66f trocar entry for, 64, 72, 73f dislocation of greater tuberosity fractures and, 322–323 mechanisms causing, 101–103 persistent pain with, 323 rehabilitation for recurrent, 346 strength exercises in, 338f, 339f, 340f, 347 stretch exercises in, 337f, 347, 347f traumatic, 109–111 entry into, for impingement treatment, 217, 218f, 219f in calcific tendinitis treatment, 318 in rotator cuff repair full-thickness, 245, 246f irreparable, 296, 298, 299f

Glenohumeral joint (Continued) partial-thickness, 236–237, 237f infection of. See Sepsis. normal anatomy of, 64, 66f, 69–70 physical examination of, 67, 68f, 69f release of, in stiffness treatment, 178, 183–184 translation of, SLAP lesions resulting from, 150–151 Glenohumeral joint arthrosis advanced, irreparable rotator cuff tears and, 298 avascular necrosis in, 188f, 194 diagnosis of, 187 nonoperative treatment of, 187 operative treatment of arthroscope placement in, 190, 192 capsular release in, 190–191, 190f, 191f, 192f cartilage flap tears in, 187, 188, 188f chondral lesions in, 187, 188f, 189 de´bridement of, 187–189, 188f continuous passive motion after, 192–193 contraindications for, 189 entry in, 190, 190f glenoid management in, 192, 192f, 193f graft jacket placement in, arthroscopic, 194–196b indications for, 187, 187f, 188f, 189f new approaches in, 194 results of, 193–194, 197t osteoarthritis in, 190 rehabilitation for, 347 immobilization in, 347 strength exercises in, 338f, 339f, 340, 340f, 347, 347f stretch exercises in, 337f, 347, 347f rheumatoid arthritis in, 187, 187f, 194, 197f classification of, 197t Glenohumeral joint reconstruction incisions for, 95 instrument portals, 96, 96f viewing portals, 95 patient position for, 49, 50 power instruments for, 60 rehabilitation for, 347 immobilization in, 347 strength exercises in, 338f, 339f, 340, 340f, 347, 347f

Glenohumeral joint reconstruction (Continued) stretch exercises in, 337f, 347, 347f soft tissue management in, instruments for, 57, 58 two dimensional model of, 6f Glenohumeral joint space, 66f Glenohumeral ligament(s). See also specific ligament, e.g., Anterior glenohumeral ligament. in glenohumeral instability, 102, 113, 115f, 130, 130f, 131f, 132–134, 135f anterior-inferior release of, 122–123, 123f laxity of, 138, 139 in impingement syndrome, 218 in posterior rotator cuff tears, 239–240 in stiffness treatment, 181–182, 182f cauterization of, 181, 182f, 183f normal anatomy of, 72–73, 73f, 74f partial tears in, 71f release of in glenohumeral arthrosis treatment, 190 in glenohumeral instability repair, 122–123, 123f rotator intervals in, 70, 71f Glenoid bone cartilage defect of, 187–188, 188f in diagnostic glenohumeral arthroscopy, 68–69, 78, 83–85 osteoarthrosis of, 86f in glenohumeral arthrosis assessment of, 86f degree and types of wear, 192 operative correction of, 192, 192f, 193f in glenohumeral instability repair drill holes and, 124–125, 125f loss of, 113–114, 118, 138, 139f posterior, 118, 119f in SLAP 2 lesions repair, 155–156, 155f, 156f in stiffness treatment, 180, 182–183 posterior-superior, in SLAP lesions, portals for, 96 Glenoid labrum-ligament complex anatomy of, normal, 147, 148f in diagnostic glenohumeral arthroscopy, 70, 72–73 abnormal findings of, 78, 81f, 82f

Index

Glenoid labrum-ligament complex (Continued) normal findings of, 73–75, 77f, 81f, 82f posterior anatomy of, 83–85, 87f in glenohumeral instability, 102, 133 in stiffness treatment, 181–182, 184 pathology of, with biceps tendon lesions, 147 Glenoid rim fractures, in glenohumeral instability, 322, 322f literature review of, 322 operative technique for, 323, 324f indications for, 323 radiographs of, 106, 106f, 108f Graft jacket, arthroscopic placement of, for glenohumeral arthrosis, 194–196b Grafts/grafting, in rotator cuff repair full-thickness, 256 irreparable, 297 Gram stain, tissue, for sepsis diagnosis, 207–208 Graspers soft tissue, 57, 57f in knot tying, 30–31 in rotator cuff repair full-thickness, 250, 251f, 252f, 259 massive, 283–284, 285f, 286, 291f in sepsis treatment, 207–208 less aggressive, 57, 57f suture, 58 in full-thickness rotator cuff repair, 266f large, 59f small, 59f with jaws open, 59f Greater tuberosity fractures of diagnosis of, 322–323 in glenohumeral instability, 322–323 literature review of, 322–323 nonoperative treatment of, 323 operative technique for, 323, 324f indications for, 323 in rotator cuff repair full-thickness, 256, 256f, 257f irreparable, 300–302, 302f massive, 282, 287–288, 288f Grounding pad, electrosurgical, 49–50

H Hair removal, in shoulder preparation, 48

Hammerman technique, for SLAP 2 lesions repair, 155, 157–159 Hand instruments, in operating room setup, 56 Harryman soft tissue punch, in stiffness treatment, 181 Haut portal of Lafosse, 96 Hawkins impingement sign, 213, 214 in distal biceps tendon lesions, 162 Health insurance, for rotator cuff repair, in paraplegics, 349, 349b Heat therapy, for calcific tendinitis, 318 Hemiarthroplasty, prosthetic, ream and run insertion of, 192, 192f Hemorrhage. See Bleeding. Hemostasis in acromioclavicular joint resection, 311, 312f in full-thickness rotator cuff repair, 252–254, 253f in impingement treatment, 219–221, 224, 226–227 Hemostat, for suture management in full-thickness rotator cuff repair, 259, 261–263, 265f, 271 in glenohumeral instability repair, 126–127 Hill-Sachs lesion in diagnostic arthroscopy, 83, 85f in glenohumeral instability, 107f, 110, 116f, 118, 118f treatment considerations of, 110 History taking for acromioclavicular joint conditions, 307 for biceps tendon lesions distal, 162 proximal, 151 for glenohumeral instability, 103, 104 for glenohumeral joint pathology, 187 for impingement syndrome, 214 Home-based rehabilitation for calcific tendinitis, 320 for glenohumeral instability, 108, 136, 144 for periarticular cysts, 201, 202 for rotator cuff tears full-thickness, 243, 244 in paraplegics, 348, 350 Home-care aide, for paraplegics, with rotator cuff tears, 348, 350 Hook. See Crochet hook. Horizontal cleavage tears, fullthickness, of rotator cuff, 271

363

Hourglass biceps of Bolieau, 171f Humeral head cartilage lesions of, 86f in partial-thickness rotator cuff tears, 234–236, 235f, 236f subacromial impingement vs., 218, 218f compression of, in partialthickness rotator cuff tears, 233, 239 fractures of displaced intra-articular, 322 fixation of, 323–324, 324f Hill-Sachs lesions of, 83, 85f in diagnostic glenohumeral arthroscopy, 68–69, 72–73, 83 cartilage tear of, 86f normal anatomy of, 83, 83f, 85f osteoarthrosis of, 83–85, 86f in glenohumeral arthrosis, 187–189, 192 operative correction of, 192, 192f in glenohumeral instability assessment of, 105, 106 treatment considerations of, 110 in rotator cuff tears full-thickness, 242, 250–252 irreparable, 296–299, 298f, 304 massive, 279, 282, 283, 287–288 in SLAP lesions, 150 in stiffness treatment, 180–182, 184–185 translation of, in glenohumeral instability, 102, 103, 110 Hydrocortisone, in stiffness treatment, 185

I Ice therapy for calcific tendinitis, 318 postoperative for acromioclavicular joint resection, 314 for full-thickness rotator cuff repair, 272, 272f for glenohumeral instability, 136 Idiopathic adhesive capsulitis, 176–178 glenohumeral arthrosis vs., 189–191 impingement syndrome vs., 216, 217, 229 rehabilitation program for, 336, 336f, 337f subacromial impingement vs., 217–218, 219f

364

Index

Immobilization. See Sling immobilization. Impingement sign(s) Hawkins vs. Neer, 213, 214 in distal biceps tendon lesions, 162 in partial-thickness rotator cuff tears, 233–234 Impingement syndrome acromioclavicular joint and, 214, 216, 217, 311–312 arthroscopic findings in, 216 arthroscopic treatment of, 217 acromioclavicular joint in, 214, 217 acromioplasty in, 222, 224f, 225f bursectomy in, 219–221, 221f, 222f, 231 contraindications for, 216 coracoacromial ligament in, 221, 223f, 224f, 226 examination under anesthesia for, 217 failure of, 229 technical, 229 thought-related, 229 glenohumeral joint entry and, 217, 218f, 219f hemostasis in, 219–221, 224, 226–227 indications for, 215 open approach vs., 230 os acromiale in, 228, 229f positioning for, 217 postoperative management of, 229 skin markings for, 217, 217f subacromial entry in, 218–219, 219f, 220f subacromial findings in, 216–217, 219, 221f variations of, 227, 227f, 228f where to start/when to stop, 225, 226f clinical presentation of, 213 coracoid, 230, 231f in glenohumeral instability, 142 diagnosis of, 214, 215f improper, 229 ultrasonography in, 327–328 differential diagnosis of, 214, 216 electrocautery for, 221–222, 226–227 glenohumeral instability vs., 214, 216–218, 229 internal rotator cuff tears related to, 233, 239 subacromial vs., 217–218, 218f literature review of, 213 nonoperative treatment of, 215

Impingement syndrome (Continued) of rotator cuff outlet, 149, 151–152, 238–239 secondary distal, 162 proximal, 149, 151–152 stage 2, 213 rehabilitation program for, 215–216, 229, 337–338 motion exercises in, 336f, 337f, 338 strength exercises in, 338, 338f, 339f, 340f subacromial, 162–163, 214–215, 215f stage 2, conditions mimicking, 217–218, 218f, 219f treatment of, 216, 219, 221f See also Subacromial decompression. Impingement test dynamic, 327–328 for glenohumeral instability, 216 for impingement syndrome, 213, 214 Incisions. See also specific approach, e.g., Anterior portal. combined views of, 97f, 98 for instruments. See Instrument portals. for viewing. See Viewing portals. Infection, septic diagnosis of, 207 literature review of, 207 operative technique for, 207 treatment goals for, 207 Infectious disease consultation, for sepsis, 207 Inferior acromion in diagnostic arthroscopy, 89 Inferior capsule contracted recess of, impingement syndrome vs., 217–218, 219f in diagnostic glenohumeral arthroscopy, 75, 76f, 77f in glenohumeral instability, 116f in stiffness treatment, 181–184, 183f, 184f, 185f release of in glenohumeral arthrosis treatment, 190–191, 191f in rotator cuff repair irreparable, 299, 299f massive, 286–288 Inferior glenohumeral ligament in diagnostic arthroscopy, 75, 76f, 78 in glenohumeral instability, 102, 103

Inferior glenohumeral ligament (Continued) circle concept of, 104, 104f Inferior portal for glenohumeral arthrosis treatment, 190, 190f for glenohumeral instability treatment, 113, 114f for glenohumeral joint reconstruction, 66–67, 67f, 95–96 for SLAP lesions, 96 Inferior translation, in glenohumeral instability, 110–111, 111f in abduction, 111, 112f Inflammation impingement syndrome vs., 216–217 in acromioclavicular joint, 307–308 in distal biceps tendon lesions, 164, 164t in stiff shoulder, 178 postoperative, 185 with calcium excision, 318, 320 Infraspinatus muscle/tendon calcific tendinitis of, 316, 318 in diagnostic arthroscopy, 84f periarticular cysts impact on, 200, 201, 201f, 202 tears of irreparable rotator cuff tears and, 297, 298f massive rotator cuff tears and, 294–295 partial-thickness rotator cuff tears and, 234, 236 repair of, 235 ultrasonography of, 326, 327–328, 331f Injections anesthetic. See Local anesthetic. anti-inflammatory. See specific drug, e.g., Cortisone. subacromial, fluid after, ultrasonography of, 333f Insertion tears, in glenohumeral instability repair, 122, 122f Inspection in glenohumeral instability repair, 113–114 for Latarjet procedure, 138, 139f of rotator cuff articular surface, arthroscopic vs. open, 236 Instability, of glenohumeral joint. See Glenohumeral instability. Instrument cart, in operating room setup, 47, 47f

Index

Instrument portals in glenohumeral joint reconstruction, 96, 96f in Lafosse technique, 202 in Latarjet lesions/repair, 96 in rotator cuff repair, 94, 95f in SLAP lesion repair, 96 in suprascapular nerve decompression at the spinoglenoid notch, 97–98 at the suprascapular notch, 96–97 Instruments handling of, 42 in operating room setup hand, 56 power, 60 thermal, 62 Insurance issues, of rotator cuff repair, in paraplegics, 349, 349b Intellectual skills, for arthroscopic shoulder surgery, 3, 41 evaluating need for, 3–4 Internal fixation, open reduction and, stiffness following, 177f Internal impingement rotator cuff tears related to, 233, 239 subacromial vs., 217–218, 218f Internal rotation in acromioclavicular joint pain, 307 in calcific tendinitis, 317f in diagnostic glenohumeral arthroscopy, 67 in abduction in coronal plane, 68f in abduction in scapular plane, 69f sulcus test in, 69f in glenohumeral instability, inferior translation with, 111, 111f in proximal biceps tendon lesion diagnosis, 147, 151, 151f, 152 in rotator cuff repair irreparable, 297 massive, 285f in stiffness treatment, 177–180 Internal rotation strengthening for full-thickness rotator cuff tears, 259, 339f for glenohumeral instability postoperative, 339f, 347 with recurrent dislocation, 339f, 347 for impingement syndrome, 338, 339f for rotator cuff repair, 338f, 346

Internal rotation stretch, abduction, for glenohumeral instability, with recurrent dislocation, 347, 347f Interscalene block, 48, 60 for calcific tendinitis treatment, 318 for fracture fixation, 323–324 for full-thickness rotator cuff repair, 244 Intra-articular biceps stump, in distal lesion repairs, 156f, 168f Intra-articular biceps tendinitis, 164, 164f Intra-articular biceps tendon partial tear, 164–165 Intra-articular biceps tenodesis, 170, 171f, 172f, 173f Intra-articular lesions in glenohumeral instability, 106 treatment of, 101 of rotator cuff tendon in full-thickness tears, 245–246 in irreparable tears, 296, 297 in massive tears, 286–287 ultrasonography of, 326, 332f Irreparable rotator cuff tears adhesions in, 254, 279, 299–302, 299f, 301f diagnosis of, 279, 288, 296, 297, 298f after open surgery, 296 in glenohumeral instability, 304 literature review of, 297 nonoperative treatment of, 297 operative technique for arthroscopic perspectives of, 296, 296f biceps tenotomy in, 161–163, 172–173, 297, 298, 302, 302f, 303f complications of, 303 contraindications for, 298 examination for, 298 glenohumeral joint in, 296, 298, 299f indications for, 298 subacromial space in, 299, 299f, 300f, 301f, 302f postoperative management for, 303 rehabilitation program for, 340 goal of, 340 standing exercises in, 343 stage 1, 344, 345f stage 2, 345, 345f stage 3, 345, 346f stages of, 343–344 supine exercises in, 341 stage 1, 341, 341f stage 2, 341, 342f

365

Irreparable rotator cuff tears (Continued) stage 3, 342, 343f stage 4, 342, 343f stage 5, 343, 344f stage 6, 343, 344f warm-up for, 336f, 340 Irrigation and de´bridement, in sepsis treatment, 207–209, 208f

J Joint entry. See Entry. Joint fluid cultures of, for sepsis diagnosis, 207–208 subacromial, after injections, 333f

K Kerrison rongeur, in periarticular cyst treatment, 202–203, 205f Kidney rest, for lateral decubitus position, 49–50 Kinematics, of scapula, in biceps tendon lesion rehabilitation, 151–152 KINSA knotless anchor system, 63 Kirschner wire fixation, for fractures, 323–324, 324f Knife, in calcific tendinitis treatment, 319–320, 319f Knot pusher for one-handed knot, 35f simulation of, 35f, 36f, 37f, 38f, 39f, 40f, 41f for suture management, 58, 59f handling of, 43 in full-thickness rotator cuff repair, 262–263, 268f in SLAP lesions repair, 159f Knot tension, in full-thickness rotator cuff repair, 263–269, 269f Knot tying board for, 6f, 9f in distal biceps tendon lesion repairs, 170–171, 173f in glenohumeral instability repair, 120f, 125, 128–129 anterior-inferior, 129, 129f in rotator cuff repair full-thickness, 263, 268f, 269f massive, 279, 294, 294f, 295f in SLAP 2 lesions repair, 154–159, 158f overhand, 29 one-handed, 30, 31f, 32f, 33f, 34f, 35f using a knot pusher, 35f, 36f, 37f, 38f, 39f, 40f, 41f two-handed, 29–30, 30f, 31f

366

Index

Knot tying (Continued) skills for, 19, 29, 31–41 sliding, 31–41

L Labrum anterior, detachment classification of, 122, 122f, 123–124 biceps. See Biceps-labrum complex. fragments of, in glenohumeral arthrosis, 188–189, 189f, 194 fraying of in glenohumeral instability, 117f in impingement syndrome, 216–218, 218f glenoid. See Glenoid labrumligament complex. in glenohumeral instability, diagnostic signs of, 72–73, 103, 114f, 115f, 117f historical treatment of, 101, 102, 104 operative treatment of, 101, 110, 112 pathology of, with biceps tendon lesions, 147 anchor sutures for, 156–159, 158f, 159f normal anatomy vs., 147, 148f proximal, 152, 153 periarticular cysts impact on, 200 posterior in glenohumeral instability, 113–118, 117f, 119f, 122 ultrasonography of, 327–328, 331f splitting of, in glenohumeral instability, 117f superior. See Superior labrum. Labrum reattachment/repair anchors for, 63 for periarticular cysts, 202–205 in glenohumeral instability repair, 101, 110, 112 Labrum tears, 200, 202 in glenohumeral instability, 103, 114f, 115f historical treatment of, 101, 102 repair of, 101, 110, 112 in rotator cuff tears full-thickness, 245–246 irreparable, 298–299 Lafosse technique incisions for, 96 instrument portals, 96–97 viewing portals, 96, 97f

Lafosse technique (Continued) indications for. See Suprascapular nerve decompression at the suprascapular notch. Laryngeal mask air tube, 48, 48f secured in place with tape, 49f Latarjet procedure for glenohumeral instability, 113–114, 117f coracoid ligament in, 142–144 effectiveness factors of, 140–141 electrocautery in, 142, 143 indications for, 103, 138, 140, 141 inspection in, 138, 139f ligament quality and, 139 open transition to arthroscopic, 142–144 open vs. arthroscopic, 140f, 141–142, 141f patient compliance with, 139 postoperative care for, 144 radiography in, 139f, 140f, 141f Bernejeau view of coracoid ligament, 144 spinal needles in, 143 sports and, 139–140 subscapularis tendon/muscle in, 143, 144 technique for, 140, 140f incisions for, 96 instrument portals, 96 viewing portals, 96, 96f Lateral decubitus position, operating room setup and, 49, 50t Lateral gutter, in diagnostic subacromial arthroscopy, 87–88, 90, 91f Lateral portal combined views of, 97f, 98 for acromioclavicular joint resection, 66, 66f, 95f, 310–312, 310f, 311f, 314 for acromioplasty, 224, 227, 228f, 229 for calcific tendinitis treatment, 318–320 for diagnostic glenohumeral arthroscopy, 66–67, 67f for fracture fixation, 323–324 for impingement treatment, 218–219 for Latarjet lesions/repair, 96 for rotator cuff repair, 94–95, 95f full-thickness, 245, 246f, 247, 250–252, 254 massive, 281–282, 282f, 286, 291f, 293, for subacromial decompression, 66, 67f

Lateral portal (Continued) for suprascapular nerve decompression at the spinoglenoid notch, 97, 98 at the suprascapular notch, 96–97, 97f for periarticular cysts, 202–203, 202f Lavage, arthroscopic, for glenohumeral arthrosis, 188–189 Left-angled instrument, for suture management, in glenohumeral instability repair, 126–127, 127f Leg pads, for sitting position, 52f Lidocaine injection, for impingement syndrome, 213, 214 Lift-off test, for irreparable rotator cuff tears, 297 Ligament laxity, in glenohumeral instability, 138 Latarjet procedure and, 139 postoperative, 138 Ligaments. See specific ligament, e.g., Glenohumeral ligament(s). Linvatec shuttle relay, for suture transfer, 53 Local anesthetic for acromioclavicular joint injection, 307–308 for calcific tendinitis, 318 for impingement syndrome, 213, 214 for impingement test, 213, 214 Locking, of shoulder with biceps tendon lesions, 147, 149, 149f, 151 with glenohumeral arthrosis, 188 Longitudinal repair, tendon-totendon, of rotator cuff tears massive, 280, 280f, 293–294 Longitudinal (L-shaped) tears, of rotator cuff, 249–250, 250f, 251f anterior-posterior, 247–249, 251f, 252f, 253f massive, 283, 283f, 284f reverse, 249–250, 251f Loop reversal, in glenohumeral instability repair, 127, 128f Loop suture, nylon deployment instrument for, 53, 54f in glenohumeral instability repair, 126, 127–128, 127f, 128f, 135f

Index

Loop suture, nylon (Continued) reversal of, 127, 128f in SLAP 2 lesions repair, 156–157, 157f Loose bodies in full-thickness rotator cuff tears, 245–246 in glenohumeral arthrosis, 187, 188, 189f de´bridement of, 187–189, 188f in glenohumeral instability repair, 116f L-shaped tears. See Longitudinal (L-shaped) tears.

M Magnetic resonance imaging (MRI) contraindications for, 326 display in operating room, 44, 46f of acromioclavicular joint conditions, 307, 307f, 308 of biceps tendon lesions, 328f distal, 162, 163f proximal, 149–150, 149f of calcific tendinitis, 316, 317f of coracoid impingement treatment, 230, 231f of glenohumeral instability, 106 of greater tuberosity fractures, 323 of periarticular cysts, 199, 199f, 200, 200f postoperative, 205 of rotator cuff tears full-thickness, 241–242, 242f, 243f irreparable, 297, 298f, 299–300 partial-thickness, 233–234, 234f, 238–239 of stiff shoulder, 177 of subscapularis tendon, 329f ultrasonography vs., 326, 327 Mallet, in full-thickness rotator cuff repair, 256 Malunion, of humeral head fractures, 322 Manipulation for glenohumeral arthrosis, 189 in rotator cuff repair massive, 280 in stiffness treatment, 178, 179f, 180f Manual muscle testing, for irreparable rotator cuff tears, 297 Margin convergence, in massive rotator cuff repair, 293, 293f, 294f

Marking suture, on articular surface, for rotator cuff tears, 236, 238 Markings, preoperative. See Skin markings. Mason-Allen sutures, modified, in full-thickness rotator cuff repair, 263–269 Massive rotator cuff tears adhesions with, 254, 279, 281f, 282–288 classification of, 283 definition of, 279 geometry of, 279, 280f, 283–284, 288, 293 literature review of, 280 operative technique for, 280 cuff mobilization in, 284, 285f, 286f, 287f, 288f, 289f elliptical tears, 283f L-shaped tears, 283, 283f, 284f margin convergence in, 293, 293f, 294f muscle disease and, 280, 282–283 repair sequence in, 289, 289f reverse L-shaped tears, 283, 284f simple vs. complex arthroscopic, 279, 280 appearance perspectives of, 280–281, 281f subscapularis tears in, 286, 294 suture management in, 280, 289, 290f, 291f, 292f suture tying in, 279, 294, 294f, 295f tear classification, 282 tendon-to-tendon longitudinal repair, 280, 280f, 293–294 transverse tears, 283f visualization in, 280, 281f, 282f postoperative management for, 295 rehabilitation program for, 340 goal of, 340 standing exercises in, 343 stage 1, 344, 345f stage 2, 345, 345f stage 3, 345, 346f stages, 343–344 supine exercises in, 341 stage 1, 341, 341f stage 2, 341, 342f stage 3, 342, 343f stage 4, 342, 343f stage 5, 343, 344f stage 6, 343, 344f

367

Massive rotator cuff tears (Continued) warm-up for, 336f, 340 smaller tears vs., 279, 282 Mat, absorbent, in operating room setup, 47, 48f Mattress suture in distal biceps tendon lesion repair, 165–166, 170–171 in full-thickness rotator cuff repair, 263–270, 271 Mayo stand, in operating room setup, 48, 48f McConnell arm holder, for sitting position, 50, 52f in rotator cuff repair full-thickness, 244–245, 245f, 250–252 massive, 283–284 Measuring probe for bone resection, in acromioclavicular joint, 308f, 311–312, 314f for tear classification, in rotator cuff repair full-thickness, 247–249, 249f massive, 283 Mechanical abnormalities, with biceps tendon lesions, 147, 151 Mechanical arm holders, for sitting position, 50–51 in rotator cuff repair full-thickness, 244–245, 245f, 250–252 massive, 283–284 Mechanical irritation tests, for biceps tendon lesions distal, 162 proximal, 149, 149f, 151, 151f Medial acromion resection, in acromioclavicular joint resection arthroscopic, 311–312, 312f, 313f open, 308, 308f, 309f Medial portal for diagnostic glenohumeral arthroscopy, 66–67, 66f for suprascapular nerve decompression at the spinoglenoid notch, 98 at the suprascapular notch, 96–97 for periarticular cysts, 202–203, 203f Medial repair, of massive rotator cuff tears, 288, 289f Mental functioning, in fullthickness rotator cuff repair results, 272, 274t Metallic anchors, in full-thickness rotator cuff repair, 256

368

Index

Metallic caps, for glenohumeral instability, 110 Methicillin-resistant S. aureus (MRSA), in sepsis, 207 Methylprednisolone, injection of for acromioclavicular joint inflammation, 307–308 preoperative, for calcific tendinitis, 318 Microfracture, in glenohumeral arthrosis, 187, 189 Microorganisms, in sepsis, 207 Middle glenohumeral ligament, in glenohumeral instability, 115f, 118, 118f capsular repair consideration of, 130, 130f, 131f, 132f rotator interval repair consideration of, 134, 134f Models, anatomic for arthroscopic shoulder surgery training, 5 two dimensional model of glenohumeral reconstruction, 6f of rotator cuff repair, 6f Monocryl suture in full-thickness rotator cuff repair, 271 in operating room setup, 60 Monofilament suture in glenohumeral instability repair, 127–129, 134, 134f in partial-thickness rotator cuff repair, 236–237, 237f Motion exercises for full-thickness rotator cuff tears, 336f, 337f, 340 for impingement syndrome, 336f, 337f, 338 MRI. See Magnetic resonance imaging (MRI). MRSA (methicillin-resistant S. aureus), in sepsis, 207 Muscle contraction, excessive eccentric, rotator cuff tears related to, 233 Muscle flaps, in irreparable rotator cuff repair, 297 Muscle testing, manual, for irreparable rotator cuff tears, 297, 303–304 Muscle transfers, in irreparable rotator cuff repair, 297 Muscles. See also specific muscle, e.g., Supraspinatus muscle/tendon. atrophy of, with rotator cuff tears full-thickness, 242–244, 243f irreparable, 297, 299–300

Muscles (Continued) disease of, with massive rotator cuff tears, 280, 282–283 Musculoskeletal pain syndromes, impingement syndrome vs., 216 Musculotendinous junction in diagnostic subacromial arthroscopy, 91f in impingement syndrome, 219–221, 221f in massive rotator cuff tears, 282–283 Myositis ossificans, 178, 178f

N Necrosis, avascular, in glenohumeral joint arthrosis, 188f, 194 Needle aspiration, serial, for sepsis, 207 Needles Elite suture punch. See Elite Pass instrument. spinal. See Spinal needles. Neer impingement sign, 213, 214 in distal biceps tendon lesions, 162 Nerve decompression, suprascapular. See Suprascapular nerve decompression. Nerve entrapment, suprascapular, impingement syndrome vs., 216 Neuromuscular exercises, for glenohumeral instability, 136 Nonoperative treatment of acromioclavicular joint conditions, 307 of calcific tendinitis, 318 of glenohumeral arthrosis, 187 of glenohumeral instability, 103, 108, 108f of greater tuberosity fractures, 323 of impingement syndrome, 215 of periarticular cysts, 201, 202 of proximal biceps tendon lesions, 151 of rotator cuff tears full-thickness, 242–243 in paraplegics, 348 irreparable, 297 partial-thickness, 234 Nonsteroidal anti-inflammatory drugs for acromioclavicular joint conditions, 307 for calcific tendinitis, 318 for glenohumeral instability, 108

Nonsteroidal anti-inflammatory drugs (Continued) for periarticular cysts, 201 for rotator cuff tears full-thickness, 243 irreparable, 297 partial-thickness, 234 Nonunion, of greater tuberosity fractures, 322–323 Nursing care, home-based, for rotator cuff repair rehabilitation, in paraplegics, 350 Nylon suture in full-thickness rotator cuff repair, 259, 261–262, 263, 264f, 265f, 266f, 268f in operating room setup, 60 loop deployment instrument for, 53, 54f in glenohumeral instability repair, 126, 127–128, 127f, 128f, 135f reversal of, 127, 128f in SLAP 2 lesions repair, 156–157, 157f

O O’Brien test for acromioclavicular joint assessment, 307 for proximal biceps tendon lesions, 149 One-anchor, two-suture rotator cuff repair, 12–14, 17–19 simulation of, 17f, 18f One-handed knot, 30 simulation of, 32f, 33f, 34f, 35f using a knot pusher, 35f, 36f, 37f, 38f, 39f, 40f, 41f Open reduction and internal fixation, stiffness following, 177f Open shoulder surgery acromioplasty in, 3, 306–307, 308 arthroscopic repair vs., 3 conversion to, patient position and, 50 for glenohumeral instability, 3, 101, 110 for impingement syndrome, 230 for rotator cuff tears full-thickness, 244, 272, 275 glenohumeral instability and, 103–104 massive, 279 partial-thickness, 236 irreparable rotator cuff tears following, 296

Index

Open shoulder surgery (Continued) resection as. See specific anatomy or pathology, e.g., Acromioclavicular joint. transition to arthroscopy focus on details, 5–8, 41 gaining skill experience, 3–5, 8–9, 41 Operating room setup absorbent mat in, 47, 48f anesthesia in, 48 arthroscopic pump in, 47, 47f, 62 back table in, 48, 48f clinical data in, 44 dedicated team in, 63, 63f equipment in, 52–53 anchors as, 63 arthroscope as, 52–53 cannulas as, 61 fluid management, 62 hand instruments as, 56 photography and, 63 positioning of, 47, 47f power instruments as, 60 soft tissue management and, 57 suture management and, 57–58 suture passers as, 53 sutures as, 58–60 thermal instruments as, 62 transfer rods as, 63 video recording and, 63 fluid bags in, 47, 47f foot pedals in, 47, 48f instrument cart in, 47, 47f Mayo stand in, 48, 48f patient positioning and, 49 importance of detail, 49 lateral decubitus position, 49, 50t sitting position, 50, 50t patient record in, 44, 44f, 45f radiographic display in, 44, 46f room layout for, 47, 47f shoulder preparation table in, 48 ultrasonography in, 327 Operative site, preoperative verification of, 48–49, 49f Orthopedic Learning Center, 4, 5 Os acromiale in diagnostic subacromial arthroscopy, 92f in impingement syndrome, 228, 229f Ossification, of coracoacromial ligament, in impingement syndrome, 214, 215f Osteoarthritis, in glenohumeral arthrosis, 190

Osteoarthrosis of glenohumeral joint. See Glenohumeral joint arthrosis. of glenoid bone, 83–85, 86f of humeral head, 83–85, 86f stiff shoulder related to, 176, 177, 177f Osteolysis, of distal clavicle, 306, 314 Osteophytes in distal clavicle, 217, 306, 314 in glenohumeral arthrosis, 188–189 Osteotomy, coracoid, in glenohumeral instability, 142, 143 Outlet impingement syndrome, of rotator cuff, 149, 151–152, 238–239 Oval bur, 61f Overhand knot, 29 one-handed, 30 simulation of, 31f, 32f, 33f, 34f, 35f using a knot pusher, 35f, 36f, 37f, 38f, 39f, 40f, 41f two-handed, 29–30, 30f, 31f Overhead sports distal biceps tendon lesions and, 161–162 glenohumeral instability and, 104–105 treatment of, 101, 134–135 rotator cuff lesions and, 134–135 SLAP lesions and, 150–151 Overload stress, repetitive impingement syndrome vs., 216 SLAP lesions related to, 150–151 Oxygen tension, in calcific tendinitis, 316

P Pain acromioclavicular joint conditions causing, 306, 307 treatment considerations, 307, 308 biceps tendon lesions causing distal to SLAP lesion, 161, 162 proximal, 147, 149, 149f, 151 calcific tendinitis causing, 316 cervical radiculopathy causing, 316 glenohumeral arthrosis causing, 188, 189f postoperative, 192–194 glenohumeral instability causing, 105–109 impingement syndrome causing, 213, 214, 216, 230

369

Pain (Continued) treatment failure and, 229, 230 periarticular cysts causing, 200 rotator cuff tears causing full-thickness, 254, 275 irreparable, 296–298, 302, 304 massive, 280, 294–295 partial-thickness, 233–234 shoulder dislocation causing, 323 stiff shoulder causing, 177 with arthroscopic vs. open shoulder repair, 3 Pain management for adhesive capsulitis, 336 for calcific tendinitis, 318 immediate postoperative, 48 Pain syndromes, impingement syndrome vs., 216 Palliative treatment, of glenohumeral arthrosis, 187 Palpation in acromioclavicular joint assessment, 307 in diagnostic arthroscopy of glenohumeral joint, 68–69, 70f of subacromial space, 89, 89f in rotator cuff repair full-thickness, 247f, 254 massive, 280–281, 281f, 286 in SLAP repair, 152 in stiffness treatment, 180, 181f probe, in fracture fixation, 323–324, 324f Paraplegics, rotator cuff tears in, 348 nonoperative treatment of, 348 operative treatment of bathroom basics and, 348 bedroom basics and, 348 indications for, 348 insurance issues with, 349, 349b mobility concerns, 348 preoperative planning for, 348 postoperative rehabilitation for, 348, 350 transferring and, 348 Partial-thickness rotator cuff tears description of, 233 diagnosis of, 233, 234f diagnostic arthroscopy of, vs. full-thickness, 93f in glenohumeral instability, 234–236, 239 in impingement syndrome, 219–221, 222f literature review of, 233 MRI of, 233–234, 234f, 238–239

370

Index

Partial-thickness rotator cuff tears (Continued) nonoperative treatment of, 234 operative treatment of decision making in, 235 findings in, 234, 235f, 236f in articular surface tears, 236–238, 237f, 238f in bursal surface tears, 240 indications for, 234 posterior lesions, 238, 239f, 240f sutures in, 236–237, 237f, 238f variations of, 238, 239f, 240f postoperative treatment of, 240 ultrasonography of, articular surface, 326, 332f Passive elevation, for massive or irreparable rotator cuff tears, 343–344 holding arm overhead, 344, 345f lowering arm, 345, 345f Passive motion chair. See Continuous passive motion chair. Past-point, in SLAP 2 lesions repair, 158f Patient expectations, for impingement treatment, 229 Patient history. See History taking. Patient positioning for full-thickness rotator cuff repair, 244–245, 245f for impingement treatment, 217 in operating room setup, 49 beach-chair, 50, 50t, 51f importance of detail, 49 lateral decubitus, 49, 50t Schloein device for, 50, 244–245 sitting, 50, 50t, 51f Spyder Arm device for, 50, 250–252 Trendelenburg, 50–51 Patient record, in operating room setup, 44, 44f, 45f electronic, 63 PDS suture, in operating room setup, 60 Pectoralis minor in Latarjet procedure, in glenohumeral instability, 143 release of, portals for, 96 Pedals, foot, in operating room setup, 47, 48f Pendulum exercises for adhesive capsulitis, 336, 336f, 337f

Pendulum exercises (Continued) for full-thickness rotator cuff tears, 255–256, 336f for impingement syndrome, 336f, 338 for rotator cuff repair full-thickness, 272 surgical day to week 6, 336f, 346 weeks 6 to 12, 336f, 346 postoperative for full-thickness rotator cuff repair, 272 for glenohumeral instability, 144 Periarticular cysts diagnosis of, 200 electrocautery for, 202–205 electrodiagnostic testing for, 201, 202, 205 in glenohumeral instability, 200, 202 incidence of, 199 literature review of, 200 MRI of, 199, 199f, 200, 200f, 205 nonoperative treatment of, 201 suprascapular nerve compression with, 200, 201f surgical treatment of indications for, 202 suprascapular nerve decompression at the spinoglenoid ligament, 205–206, 205f, 206f suprascapular nerve decompression at the suprascapular notch, 202 miscellaneous tear repair with, 203–205 portals for, 202–203, 202f, 203f postoperative care for, 205 variations of, 205 teres minor muscle hypertrophy and, 200, 201f Perthes lesions, 104. See also Bankart lesions. Phagocytosis, in calcific tendinitis, 316 Photographs, intraoperative, equipment for, 63 Physical examination. See Examination. Physical functioning in full-thickness rotator cuff repair results, 272, 274t of paraplegics, with rotator cuff tears, 348, 350 Physical therapy. See also Rehabilitation. for glenohumeral arthrosis, 187 for glenohumeral instability, 108 referral, for rehabilitation, 336

Pillows, for patient positioning, 49–51 PL (posterolateral) stab wound, for massive rotator cuff repair, 290, 291f, 292–293, 292f Plastic anchors, in full-thickness rotator cuff repair, 256 Portals. See also specific approach, e.g., Anterior portal; specific pathology, e.g., Glenohumeral instability. combined views of, 97f, 98 for instruments. See Instrument portals. for viewing. See Viewing portals. Posterior capsule in diagnostic glenohumeral arthroscopy, 75, 76f in SLAP lesion diagnosis, 151, 151f in stiffness treatment, 182–184, 184f release of, in glenohumeral arthrosis treatment, 190–191, 191f Posterior glenohumeral ligament in diagnostic arthroscopy, 78 in glenohumeral instability, 103, 108f circle concept of, 104, 104f Posterior glenoid, in glenohumeral instability repair, 118, 119f Posterior labrum in glenohumeral instability, 113–118, 117f, 119f, 122 ultrasonography of, 327–328, 331f Posterior portal combined views of, 97f, 98 for acromioclavicular joint resection, 310f, 314 for acromioplasty, 222–224 for diagnostic glenohumeral arthroscopy, 70t for glenohumeral arthrosis treatment, 190 for glenohumeral instability treatment, 121 for glenohumeral joint reconstruction, 95–96 for rotator cuff repair, 94–95, 95f full-thickness, 245 irreparable, 298–299 massive, 282, 282f, 293–295 for SLAP lesions, 96, 155–156 for subacromial decompression, 64–65, 65f for suprascapular nerve decompression

Index

Posterior portal (Continued) at the spinoglenoid notch, 97, 98, 205f, 206 at the suprascapular notch, 96, 97f for periarticular cysts, 202–203 Posterior portals for diagnostic glenohumeral arthroscopy, 64, 65f for SLAP lesion repair, 66 Posterior repair of glenohumeral instability, 121 Bankart lesions and, 118 drill holes for, 121 portal placement for, 114–118, 121 scapular neck preparation for, 121 step-by-step, 118, 119f, 120f, 121f principles of, 121 suture passing for, 120f, 121 Posterior shoulder, sitting position for access to, 50–51, 53f Posterior step-off erosion, of glenoid bone, 192, 192f in irreparable rotator cuff repair, 299 operative correction of, 192, 193f Posterior translation, in glenohumeral instability, 111, 112f Posterior-inferior glenohumeral joint, portals for, 95–96, 96f Posterior-superior glenoid, in SLAP lesions, portals for, 96 Posterolateral acromial corner, in diagnostic arthroscopy, 64, 65f Posterolateral (PL) stab wound, for massive rotator cuff repair, 290, 291f, 292–293, 292f Posteromedial acromion, in acromioclavicular joint resection, 311–312, 313f Postoperative care. See specific procedure or surgery. Power instruments. See also Burs. for glenohumeral joint reconstruction, 60 in operating room setup, 60 Preparation table, shoulder, 48 Prolene suture, in operating room setup, 60 Propionibacterium acnes, in sepsis, 207 Proprioception training, for glenohumeral instability, 108 Prosthetic hemiarthroplasty, ream and run insertion of, 192, 192f

Prosthetics, for glenohumeral instability, 110 Proximal biceps tendon lesions, 147 anatomy of, 147, 148f diagnosis of, 151, 151f glenohumeral instability and, 147, 150–151 mechanical irritation and, 149, 151, 151f nonoperative treatment of, 151 operative technique for anterior portals in, 152, 152f cannula in anterior-inferior, 152, 153f, 156–157, 158f, 159 anterior-superior, 154, 154f, 155f, 156–157, 157f, 158f, 159 contraindications for, 152 indications for, 152 labrum assessment in, 152, 153 skin markings in, 152, 153f SLAP 1 lesions and, 153–154 SLAP 2 lesions and, 154, 154f, 155f, 156f, 157f, 158f, 159f SLAP 3 lesions and, 159, 159f, 160f SLAP 4 lesions and, 159, 160f, 161f superior portals in, 152, 152f overview discussion on, 147, 173 physical examination for, 149f, 151, 161 postoperative treatment of, 161 rotator cuff disease and, 149 irreparable, 302, 303f SLAP lesions as, 147–148 the throwing athlete and, 150–151 Pseudoparalytic shoulder, 296, 296f Pump, arthroscopic, in operating room setup, 47, 47f, 62 Punch needle Elite instrument for. See Elite Pass instrument. soft tissue, in stiffness treatment, 181–185, 184f

Q QuickT anchor, 63

R Radiculopathy, cervical, shoulder pain related to, 316 Radiographic classification, Steinbrocker, of rheumatoid arthritis, 194, 197t Radiographic display, in operating room, 44, 46f

371

Radiography in impingement syndrome, 216, 217, 222–224, 226, 229, 230 of acromioclavicular joint conditions, 307–308 of biceps tendon lesions distal, 162, 163f proximal, 149–150, 149f of calcific tendinitis, 316, 317f, 317t, 318f postoperative, 320 of coracoid ligament, post-Latarjet procedure, 144 of glenohumeral arthrosis, 187–189, 187f, 188f, 189f, 192 avascular necrosis in, 196 of glenohumeral instability diagnostic, 103, 106, 106f, 107f, 108f Latarjet procedure and, 139f, 140f, 141f of greater tuberosity fractures, 323 postoperative, 323–325 of Latarjet procedure, for glenohumeral instability, 140f, 141, 141f of rotator cuff tears full-thickness, 242, 272 irreparable, 297 partial-thickness, 233–234 of stiff shoulder, 177–178, 177f Range of motion in acromioclavicular joint conditions, 307, 311–312 in diagnostic glenohumeral arthroscopy, 67 in diagnostic ultrasonography, 326 in glenohumeral arthrosis postoperative, 192–194, 196 preoperative, 187, 189, 190 in glenohumeral instability, 103, 132 postoperative ratings of, 136–138, 136t, 137t in impingement syndrome, 213, 217, 229, 230 in stiff shoulder postoperative, 64, 176–177, 185–186 preoperative, 177–180 proximal biceps tendon lesions and, 149, 151, 152 rotator cuff tears and full-thickness, 250 arthroscopic repair results, 273t irreparable, 297, 303–304 massive, 279, 280, 283

372

Index

Range of motion (Continued) partial-thickness, 233–234 Range of motion therapy. See Rehabilitation. Rasp, in glenohumeral instability repair, 132, 133f Rating systems, for full-thickness rotator cuff repair results, 272, 273t Ream and run insertion, of prosthetic hemiarthroplasty, 192, 192f Record, patient, in operating room setup, 44, 44f, 45f electronic, 63 Regional anesthesia, in operating room setup, 48 Rehabilitation for adhesive capsulitis, 336, 336f, 337f for fracture fixation, 325 for glenohumeral instability, 346 postoperative, 136, 144, 347 immobilization in, 347 strength exercises in, 136 338f, 339f, 340f, 347, 347f stretch exercises in, 337f, 347, 347f with recurrent subluxation or dislocation, 346 strength exercises in, 338f, 339f, 340f, 347 stretch exercises in, 337f, 347, 347f for impingement syndrome, 215–216, 229, 337–338 motion exercises in, 336f, 337f, 338 strength exercises in, 338, 338f, 339f, 340f for rotator cuff repair, 240, 346 full-thickness, 272 in paraplegics, 348, 350 irreparable, 297, 303–304 sling in, 346 surgical day to week 6, 336f, 346 week 12, 338f, 339f, 340f, 346 weeks 6 to 12, 336f, 341f, 342f, 343f, 344f, 345f, 346, 346f for rotator cuff tears full-thickness motion exercises in, 336f, 337f, 340 strength exercises in, 243, 272, 338f, 339f, 340, 340f massive or irreparable, 340 goal of, 340 standing exercises in, 343 stage 1, 344, 345f stage 2, 345, 345f

Rehabilitation (Continued) stage 3, 345, 346f stages of, 343–344 supine exercises in, 341 stage 1, 341, 341f stage 2, 341, 342f stage 3, 342, 343f stage 4, 342, 343f stage 5, 343, 344f stage 6, 343, 344f warm-up for, 336f, 340 goals for, 336 home-based. See Home-based rehabilitation. physical therapy referral for, 336 postoperative for acromioclavicular joint resection, 314 for arthroscopic vs. open shoulder repair, 3 for biceps tendon lesions distal, 173 proximal, 151–152 for calcific tendinitis, 320 for glenohumeral arthrosis, 192–193, 196 for glenohumeral instability, 136, 144, 347 for rotator cuff repair, 240, 346 in stiffness treatment, 64, 185–186 Rehabilitation hospital, for rotator cuff repair, in paraplegics, 350 Relocation test for glenohumeral instability, 105, 105f for proximal biceps tendon lesions, 151, 151f Remplissage procedure, for glenohumeral instability, 110, 118 Repetitive overload stress impingement syndrome vs., 216 SLAP lesions related to, 150–151 Resection, arthroscopic vs. open. See specific anatomy or pathology, e.g., Acromioclavicular joint. Resection punch, capsular, 57, 58f Resistive exercises, for glenohumeral instability, 108 Resorptive phase, of calcific tendinitis, 316, 318 Rest therapy for adhesive capsulitis, 336 for biceps tendon lesions distal, postoperative, 173 proximal, 151–152 for calcific tendinitis, 318 for full-thickness rotator cuff tears, 243

Rest therapy (Continued) for impingement syndrome, 215 for periarticular cysts, 201 Retraction strengthening, scapular for full-thickness rotator cuff tears, 259, 340f for glenohumeral instability postoperative, 340f, 347 with recurrent dislocation, 340f, 347 for impingement syndrome, 338, 340f for rotator cuff repair, 340f, 346 Return to sports, after glenohumeral instability treatment, 138 Reverse L-shaped tears, of rotator cuff full-thickness, 249–250, 251f massive, 283, 284f Rheumatoid arthritis, in glenohumeral arthrosis, 187, 187f, 194, 197f classification of, 194, 197t Right-angled instrument, for suture management, in glenohumeral instability repair, 126–127, 127f, 128 Ringer’s solution, for intraoperative fluid management, 62 Rods, transfer, in operating room setup, 63 Room layout, for operating room, 47, 47f Rotation external. See External rotation. for proximal biceps tendon lesion diagnosis, 149, 149f in full-thickness rotator cuff tears, 250 internal. See Internal rotation. shoulder fractures and, 323 Rotation strengthening for full-thickness rotator cuff tears external, 259, 339f internal, 259, 339f for glenohumeral instability external postoperative, 339f, 347 with recurrent dislocation, 339f, 347 internal postoperative, 339f, 347 with recurrent dislocation, 339f, 347 for impingement syndrome external, 338, 339f internal, 338, 339f for rotator cuff repair external, 339f, 346 internal, 339f, 346

Index

Rotator cuff disease as intrinsic aging, 233 impingement syndrome vs., 216 ultrasonography of, 326 with biceps tendon lesions distal, 162 proximal, 147–149 Rotator cuff repair anchors for, 63 arthroscopic full-thickness, 93f portals for, 245, 245f, 246f glenohumeral instability and, 103–104 gradual transition to open, 41 open vs., 3 partial-thickness, 235 articular surface in, 236–238, 237f, 238f bursal surface, 240 variations of, 238, 239f, 240f stages for, 41, 42 Caspari technique for, 13–14b elements of, 11–12 Elite Pass technique for, 12-13 geometry of, 8–9 healed, ultrasonography of, 332f in paraplegics bedroom basics and, 348 indications for, 348 insurance issues with, 349, 349b mobility concerns, 348 postoperative rehabilitation for, 348, 350 preoperative planning for, 348 transferring and, 348 incisions for, 94 instrument portals, 94, 95f viewing portals, 94 Joe W. King invitational course on, 5f one-anchor, two-suture technique for, 12-14, 17–19, 17f, 18f open arthroscopic vs., 3 conversion to, patient position and, 50 hand instruments for, 56–57, 58 power instruments for, 60 rehabilitation for, 240, 346 full-thickness, 272 in paraplegics, 348, 350 irreparable, 297, 303–304 sling in, 346 surgical day to week 6, 336f, 346 week 12, 338f, 339f, 340f, 346 weeks 6 to 12, 336f, 341f, 342f, 343f, 344f, 345f, 346, 346f

Rotator cuff repair (Continued) stiffness following, 176, 176f surgeon training on, 5–8 three-anchor, six-suture technique for, 17–19, 22f, 23f, 24f, 25f, 26f, 27f two dimensional model of, 6f two-anchor, four-suture technique for, 17–19, 19f, 20f, 21f, 22f with periarticular cyst treatment, 203 Rotator cuff tears accurate assessment of, 5–9 acute, SLAP lesions with, 150 arthroscopic scope limits prior to open repair, 41 biceps tendon lesions related to, 147–150 classification of full-thickness, 247–249, 249f massive, 279, 283 clinical presentation of, 177 diagnostic arthroscopy of, 79–83, 83f partial- vs. full-thickness, 93f full-thickness. See Full-thickness rotator cuff tears. greater tuberosity fractures with, 322, 323 in glenohumeral instability arthroscopic treatment of, 103–104 in throwing athletes, 134–135 irreparable, 304 partial-thickness, 234–236, 239 in paraplegics, 348 nonoperative treatment of, 348 operative treatment of bathroom basics and, 348 bedroom basics and, 348 indications for, 348 insurance issues with, 349, 349b mobility concerns, 348 preoperative planning for, 348 postoperative rehabilitation for, 348, 350 transferring and, 348 in throwing athlete, 134–135 irreparable. See Irreparable rotator cuff tears. massive. See Massive rotator cuff tears. partial-thickness. See Partialthickness rotator cuff tears. subacromial impingement vs., 217–218, 218f, 219f ultrasonography of, 326, 332f

373

Rotator cuff tendon articular surface of arthroscopic vs. open inspection of, 236 partial-thickness tears of, 236–238, 237f, 238f ultrasonography of lesions of, 326, 332f calcific deposits in, 316, 317t, 320, 320f chronic tendinosis of, 213. See also Impingement syndrome. diagnostic arthroscopy of, 90, 90f, 93f intact, biceps tendinitis and partial-thickness tears with, 162f, 165, 165f palpation of, in impingement treatment, 219, 220f periarticular cysts impact on, 200 remnant of, in sepsis treatment, 208–209, 208f secondary impingement syndrome of, with biceps tendon lesions distal, 162 proximal, 149, 151–152 Rotator interval contractions of, 181f de´bridement of, in glenohumeral arthrosis, 190, 190f, 191 in diagnostic glenohumeral arthroscopy abnormal, 70, 71f, 72f normal, 70, 71f in diagnostic subacromial arthroscopy needle palpation of, 94f needle probing of, 94f opened, 94f in distal biceps tendon lesion repairs, 165–166, 166f in glenohumeral instability, 70, 71f, 72f, 111, 113, 113f, 117f historical treatment of, 102 repair of, 134, 134f, 135f in stiffness treatment, 180, 181f release of, in massive rotator cuff repair, 286, 286f, 287f synovitis of, 72f, 181f widening of, 72f Round bur, 60f, 61f Rowe scoring system, for glenohumeral instability, 104 ligament laxity in, 138 postoperative results, 136–138, 137t

374

Index

Rowe test, for glenohumeral instability, 105, 105f, 106f

S Scapula, kinematics of, in biceps tendon lesion rehabilitation, 151–152 Scapular elevation strengthening for full-thickness rotator cuff tears, 259, 340f for glenohumeral instability postoperative, 340f, 347 with recurrent dislocation, 340f, 347 for impingement syndrome, 338, 340f for rotator cuff repair, 340f, 346 Scapular neck preparation, in glenohumeral instability repair anterior, 124, 124f Latarjet technique, 142 posterior, 121 Scapular retraction strengthening for full-thickness rotator cuff tears, 259, 340f for glenohumeral instability postoperative, 340f, 347 with recurrent dislocation, 340f, 347 for impingement syndrome, 338, 340f for rotator cuff repair, 340f, 346 Scapulothoracic motion, in stiff shoulder, 177–178 Schloein patient positioner, 50, 244–245 Scissors for suture management, 58, 59f end-cutting, 58, 60f in calcific tendinitis treatment, 319–320 in glenohumeral arthrosis treatment, 190, 191 in glenohumeral instability repair, 122–123, 123f in rotator cuff repair irreparable, 300–302 massive, 286–287 Scoring systems, for glenohumeral instability, 104 postoperative results of, 136–138, 137t Screw fixation Bolieau, for distal biceps tendon lesions, 162 of glenoid rim fractures, 322–323 of greater tuberosity fractures, 323–324, 324f postoperative management of, 325

Second throw in knot tying, slipping technique for, 30–31 Secondary impingement syndrome, of rotator cuff distal, 162 proximal, 149, 151–152 Sepsis diagnosis of, 207 literature review of, 207 operative technique for, 207 treatment goals for, 207 SF-36 Health Survey, on fullthickness rotator cuff repair results, 272, 274t Shaver, 60, 60f in biceps tendinitis treatment intra-articular, 164, 164f with partial-thickness tears, 165 in calcific tendinitis treatment, 318–320, 320f in diagnostic arthroscopy of glenohumeral joint, 80f, 81f of subacromial space, 89, 90f in fracture fixation, 323–324, 324f in glenohumeral arthrosis treatment, 190 in impingement treatment, 218–222, 227f, 231 in periarticular cyst treatment, 202–203, 205–206 in rotator cuff repair full-thickness, 252–254 irreparable, 299–302 massive, 280–282, 284–286 partial-thickness, 236–238 in stiffness treatment, 183–184, 184f Shaving, in shoulder preparation, 48 Sheet roll, soft, for lateral decubitus position, 49–50 Shoulder anterior, sitting position for access to, 50–51, 53f posterior, sitting position for access to, 50–51, 53f pseudoparalytic, 296, 296f stiff. See Stiffness. Shoulder arthroscopy models, anatomic, 5, 7f Shoulder elevation strengthening, for glenohumeral joint surgery, 347, 347f Shoulder immobilizer, in full-thickness rotator cuff repair, 272, 272f Shoulder pain. See Pain. Shoulder preparation table, 48 Shoulder surgery arthroscopic. See Arthroscopic shoulder surgery. open. See Open shoulder surgery.

Single-row repair, of full-thickness rotator cuff tears, 258, 258f Sitting position, 50, 50t, 51f Six-suture, three anchor rotator cuff repair, 17–19 simulation of, 22f, 23f, 24f, 25f, 26f, 27f Skilled technicians, for rotator cuff repair rehabilitation, in paraplegics, 350 Skin markings anesthesiologist role in, 48–49, 49f for impingement treatment, 217, 217f for proximal biceps tendon lesion repair, 152, 153f Skin preparation/scrub, 50 products for, 48 SLAP lesions acromioclavicular arthritis vs., 307, 307f biceps tendon anatomy and, 147, 148f description of, 147–148 diagnosis of, 78, 82f proximal, 151, 151f, glenohumeral instability related to, 147, 150–151 Bankart type, 102, 104f, 107f, 129 repair of, 129, 130f in full-thickness rotator cuff tears, 245–246 incisions for, 96 instrument portals, 96 viewing portals, 96 mechanical irritation and, 149, 151, 151f nonoperative treatment of, 151 operative technique for anterior portals in, 66–67, 152, 152f cannula in anterior-inferior, 152, 153f, 156–157, 158f, 159 anterior-superior, 154, 154f, 155f, 156–157, 157f, 158f, 159, contraindications for, 152 indications for, 152 labrum assessment in, 152, 153 posterior portals in, 66 power instruments for, 60 skin markings in, 152, 153f superior portals in, 152, 152f periarticular cysts and, 200f, 205 treatment approaches to, 203–205, 204f physical examination for, 149f, 151, 161

Index

SLAP lesions (Continued) postoperative treatment of, proximal, 161 rotator cuff disease and, 149, 150 soft tissue management in, 57 subacromial impingement vs., 217–218, 218f the throwing athlete and, 150–151 type 1 description of, 147–148, 148f operative technique for, 153–154 rotator cuff disease with, 149–150 type 2 description of, 147–148, 148f operative technique for, 154, 154f, 155f, 156f, 157f, 158f, 159f rotator cuff disease with, 150 type 3 description of, 147–148, 148f operative technique for, 159, 159f, 160f type 4 description of, 147–148, 149f operative technique for, 159, 160f, 161f types of, 147–148, 148f, 149f variations of, 148–149 Sliding knot, 31–41 Sling immobilization in rotator cuff repair, 346 full-thickness, 272, 272f postoperative, glenohumeral instability surgery, 136, 144, 347 Slipping second throw in suture management, 30–31 Smith-Nephew anchor inserter, in rotator cuff repair full-thickness, 256, 258 massive, 293–294 Smith-Nephew Endoscopy power instruments for, 60 suture passers for, 53, 56, 156–157 Smith-Nephew suture passer, in glenohumeral instability repair, 126, 128, 133 Soft spot in acromioclavicular joint resection, 314 in diagnostic glenohumeral arthroscopy, 64–65 in full-thickness rotator cuff repair, 245, 245f in glenohumeral instability repair, 113, 113f Soft tissue contracture. See Contracture(s).

Soft tissue grasper, 57, 57f in knot tying, 30–31 in rotator cuff repair full-thickness, 250, 251f, 252f, 259 massive, 283–284, 285f, 286, 291f in sepsis treatment, 207–208 less aggressive, 57, 57f Soft tissue management, equipment for, 57 Soft tissue punch, in stiffness treatment, 181–185, 184f Soft tissue release, in irreparable rotator cuff repair, 299 Soft tissue resector in diagnostic subacromial arthroscopy, 89 in sepsis treatment, 207–208 in stiffness treatment, 180–181, 185 Spectrum suture passer description of, 55f handling, 43 in glenohumeral instability repair, 126 in massive rotator cuff repair, 293–294, 295f in SLAP 2 lesions repair, 157f Speed test, for biceps tendon lesions distal, 162 proximal, 149 Spinal needles for lateral portal identification, 66 in acromioclavicular joint resection, 310–311, 311f in calcific tendinitis treatment, 319 in diagnostic arthroscopy of glenohumeral joint, 72 of subacromial space, 88–89, 92f in distal biceps tendon lesion repairs, 165–166, 165f, 170–171 in fracture fixation, 323–324 in glenohumeral instability repair, 113, 116f in Latarjet procedure, for glenohumeral instability, 143 in periarticular cyst treatment, 202–203 in rotator cuff repair full-thickness, 247, 248f, 249f irreparable, 299 massive, 288 partial-thickness, 236–237, 237f in SLAP 2 lesions repair, 154, 154f, 155–156 in stiffness treatment, 180

375

Spinoglenoid ligament, periarticular cysts impact on, 201, 201f, 206f suprascapular nerve decompression for, 205–206, 205f Spinoglenoid notch, nerve decompression at. See Suprascapular nerve decompression at the spinoglenoid ligament. Sports in glenohumeral instability classification of, 104, 109 Latarjet procedure and, 139–140 return to postoperatively, 138 overhead. See Overhead sports. Spurs, acromial, in full-thickness rotator cuff tears, 242, 243f Spyder Arm Positioner, for sitting position, 50, 250–252 in full-thickness rotator cuff repair, 244–245 Stage 2 impingement syndrome of rotator cuff, 213 subacromial space and. See Impingement syndrome. Stages/staging for massive or irreparable rotator cuff tears rehabilitation. See Rehabilitation. for rotator cuff repair, 41, 42 of open to arthroscopic shoulder surgery transition, 41 Stand, Mayo, in operating room setup, 48, 48f Standing exercises for massive or irreparable rotator cuff tears, 343 goal of, 340 stage 1, 344, 345f stage 2, 345, 345f stage 3, 345, 346f warm-up for, 336f, 340 for rotator cuff repair, 345f, 346, 346f Staphylococcus aureus, in sepsis, 207 Staphylococcus epidermidis, in sepsis, 207 Steinbrocker classification, of rheumatoid arthritis, 194, 197t Step-off erosion, posterior, of glenoid bone, 192, 192f in irreparable rotator cuff repair, 299 operative correction of, 192, 193f Steroids, intra-articular. See Cortisone; Methylprednisolone.

376

Index

Stiffness arthroscopic surgery for contraindications to, 178, 178f indications for, 178 technique for, 178 clinical presentation of, 177 conditions producing, 176 postoperative, 176, 176f, 177f diabetes-related, 176–177 diagnosis of, 177, 177f following full-thickness rotator cuff repair, 274 glenohumeral ligament rotator intervals and, 70, 71f, 72f literature review of, 176 operative technique for, 178 anterior capsule in, 181, 182f blunt dissection of, 181, 183f cauterization of, 181, 182f, 183f contracture of, 178–180, 182–183, 182f, 183f glenohumeral ligament and, 181, 182f resection methods for, 181–185, 184f, 185f contracture release, 178 examination under anesthesia in, 178 joint entry in, 180, 180f, 181f manipulation in, 178, 179f, 180f rotator interval in, 180, 181f subacromial space in, 185, 185f postoperative care for, 185 Strain gauge, for glenohumeral instability treatment, 132 Strain rate, in glenohumeral instability, 102 Strengthening exercises biceps. See Biceps strengthening. elevational. See Elevation exercises/strengthening. for acromioclavicular joint resection, 314 for calcific tendinitis, 320 for fracture fixation, 325 for glenohumeral arthrosis, 187 for glenohumeral instability, 108, 136 postoperative, 136, 338f, 339f, 340, 340f, 347, 347f with recurrent subluxation or dislocation, 338f, 339f, 340f, 347 for impingement syndrome, 338, 338f, 339f, 340f for periarticular cysts, 201, 202

Strengthening exercises (Continued) for proximal biceps tendon lesions, 151–152 for rotator cuff repair, 338f, 339f, 340f, 346 for rotator cuff tears full-thickness, 243, 272, 338f, 339f, 340, 340f irreparable, 297, 298, 304 massive or irreparable, supine stage 4, 342, 343f stage 5, 343, 344f stage 6, 343, 344f partial-thickness, 234, 240 retractional. See Retraction strengthening. rotational. See Rotation strengthening. scapular. See Scapular elevation strengthening; Scapular retraction strengthening. shoulder elevation, for glenohumeral joint surgery, 347, 347f triceps. See Triceps strengthening. Stress, repetitive overload impingement syndrome vs., 216 SLAP lesions related to, 150–151 Stress testing for biceps tendon lesions distal, 162 proximal, 149, 149f, 151, 151f for diagnostic glenohumeral arthroscopy, 67, 69f Stretching exercises for adhesive capsulitis, 336, 337f for glenohumeral instability postoperative, 337f, 347, 347f with recurrent subluxation or dislocation, 337f, 347, 347f for proximal biceps tendon lesions, 151–152 for rotator cuff tears full-thickness, 243 partial-thickness, 234 Subacromial approach to coracoid impingement treatment, 231 to distal biceps tendon lesions, 164, 165 to glenohumeral arthrosis treatment, 196 Subacromial decompression arthroscopic vs. open, 3 for impingement syndrome, 216, 217, 219, 221f where to start/when to stop, 225, 226f in acromioclavicular joint resection, 310

Subacromial decompression (Continued) in glenohumeral instability repair, 113, 113f in rotator cuff repair full-thickness, 250–253 irreparable, 297 massive, 283–286, 286f of paraplegics, 348 partial-thickness with de´bridement, 235 with tendon repair, 235 lateral portal for, 66, 67f patient position for, 49 posterior portal for, 64–65, 65f power instruments for, 60 Subacromial impingement, 162–163, 214–215, 215f stage 2, conditions mimicking, 217–218, 218f, 219f treatment of. See Subacromial decompression. Subacromial injection, fluid after, ultrasonography of, 333f Subacromial space calcific tendinitis and, 318–320, 319f diagnostic arthroscopy of, 86–87, 87t anterior acromion in, 87–88, 88f anterior gutter in, 87–88, 90, 91f bursa in, 89–90, 93f inferior acromion in, 89 lateral gutter in, 87–88, 90, 91f lateral portal in, 88–89, 88f, 90f orientations for, 87–89 posterior entry for, 87–88 triangulation technique for, 89, 89f in impingement syndrome, 185 arthroscopic findings in, 216–217, 219, 221f diagnosis of, 214–215, 215f entry into, 218–219, 219f, 220f glenohumeral ligament rotator interval in, 70, 71f treatment considerations of, 216, 217, 219, 221f in rotator cuff repair full-thickness, 246, 247f, 257, 274 irreparable, 299, 299f, 300f, 301f, 302f massive, 280–284, 286–287, 290 partial-thickness, 236–237, 238f, 239f in stiffness treatment, 185, 185f normal anatomy of, 86–87, 88f suture management in, 58

Index

Subcoracoid space, in glenohumeral arthrosis, 188 Subluxation, of glenohumeral joint mechanisms causing, 101, 103 rehabilitation for recurrent, 346 strength exercises in, 338f, 339f, 340f, 347 stretch exercises in, 337f, 347, 347f Subscapularis tendon/muscle calcific tendinitis of, 317f in diagnostic arthroscopy, 72–73, 74f, 90, 96 recess of, 75f with tears, 75f in glenohumeral arthrosis treatment, release of, 190, 190f, 191, 191f, 192f in glenohumeral instability, 102 treatment considerations of, 122–123, 123f, 133 in Latarjet procedure, for glenohumeral instability, 143, 144 in stiffness treatment, 178, 180–181 MRI of, 329f tears of biceps tendon lesions related to, 147 partial, 162, 163f repair of, 162–163, 166, 168f in rotator cuff tears irreparable, 300 massive, 286, 294 ultrasonography of, 326–328 long axis view, 329f transverse axis view, 329f Sulcus test for diagnostic glenohumeral arthroscopy, 69f for glenohumeral instability, 105, 105f Superior capsule in acromioclavicular joint resection, 311–312, 313f release of, in rotator cuff repair irreparable, 300f massive, 286–287, 287f Superior glenohumeral ligament, in glenohumeral instability, 134, 135f Superior labrum abnormal separation of, 147–151. See also SLAP lesions. in glenohumeral instability, 113, 114f, 115f, 122 repair of, 129 capsular repair and, 130, 130f, 131f, 132f

Superior labrum (Continued) capsular tension determination and, 130–132 capsular tightening and, 132, 133f principles of, 129, 130f Superior labrum from anterior to posterior lesions. See SLAP lesions. Superior portal for acromioclavicular joint resection, 66, 66f for diagnostic glenohumeral arthroscopy, 66, 66f for glenohumeral arthrosis treatment, 190, 190f for glenohumeral instability treatment, 113–114, 116f, 117f for glenohumeral joint reconstruction, 66–67, 67f, 95–96 for proximal biceps tendon lesion repair, 152, 152f for SLAP lesions, 96, 155–156 for suprascapular nerve decompression, at the suprascapular notch, 96–97, 97f Supine exercises for massive or irreparable rotator cuff tears, 341 goal of, 340 stage 1, 341, 341f stage 2, 341, 342f stage 3, 342, 343f stage 4, 342, 343f stage 5, 343, 344f stage 6, 343, 344f warm-up for, 336f, 340 for rotator cuff repair, 336f, 341f, 342f, 343f, 344f, 346 Supportive treatment. See Conservative treatment. Suprascapular ligament, in periarticular cyst treatment, 202–203, 204f Suprascapular nerve compression of, with periarticular cysts, 200, 201f entrapment of, impingement syndrome vs., 216 in massive rotator cuff repair, 280, 286–287 pathway of, 202–205, 204f Suprascapular nerve decompression at the spinoglenoid ligament, for periarticular cysts, 205–206, 205f, 206f Suprascapular nerve decompression at the spinoglenoid notch

377

Suprascapular nerve decompression at the spinoglenoid notch (Continued) for periarticular cysts, 205–206, 205f, 206f incisions for, 97 instrument portals, 97–98 viewing portals, 97 Suprascapular nerve decompression at the suprascapular notch for periarticular cysts, 202 miscellaneous tear repair with, 203–205 portals for, 202–203, 202f, 203f postoperative care for, 205 variations of, 205 incisions for, 96 instrument portals, 96–97 viewing portals, 96, 97f Suprascapular notch, nerve decompression at. See Suprascapular nerve decompression at the suprascapular notch. Supraspinatus muscle/tendon calcific tendinitis of, 316, 318–320 in diagnostic arthroscopy normal anatomy of, 79–83, 83f, 84f tears of, 79–83, 83f, 84f in glenohumeral instability, 102 periarticular cysts impact on, 200–202, 201f surgical considerations of, 202–203, 204f, 205–206 tears of full-thickness, 332f full-thickness rotator cuff tears and, 245–246, 246f, 249–250 atrophy with, 242, 243f irreparable rotator cuff tears and, 297, 298f, 300 massive rotator cuff tears and, 294–295 partial-thickness rotator cuff tears and grades of, 234, 235f, 236 repair of anterior, 235 repair of posterior, 238 repair of, 166 ultrasonography of, 326–328, 332f long axis view, 330f transverse axis view, 330f Surgeon training. See Education. Surgical drains, in sepsis treatment, 208–209, 208f, 209f Suspension, intraoperative, patient position for, 49, 50

378

Index

Suture(s) anchor. See Anchor sutures. braided. See Braided suture. in distal biceps tendon lesion repairs, 162, 165–166, 167f, 168f, 170–171, 172f, 173f in full-thickness rotator cuff repair mattress, 263–271 placement of, 259 bridge technique for, 270, 270f, 271f double-row repair, 258, 260f, 267–269, 270f single-row repair, 258, 258f selection of, 256–257 tension of, 263–269, 269f in glenoid rim fracture fixation, 322–323 in operating room setup, 58–60, 63 in partial-thickness rotator cuff repair, 236–237, 237f, 238f loop. See Loop suture. marking, on articular surface, in rotator cuff repair, 236, 238 mattress in distal biceps tendon lesion repair, 165–166, 170–171 in full-thickness rotator cuff repair, 263–271 modified Mason-Allen, in fullthickness rotator cuff repair, 263–269 Monocryl, in full-thickness rotator cuff repair, 271 monofilament in glenohumeral instability repair, 127–129, 134, 134f in partial-thickness rotator cuff repair, 236–237, 237f nylon. See Nylon suture. traction, in knot tying, 30–31 Ultrabraid, in full-thickness rotator cuff repair, 256, 257 Suture bridge technique Arthrex material for, 63 in full-thickness rotator cuff repair, 270, 270f, 271f Suture graspers, 58 in full-thickness rotator cuff repair, 266f large, 59f small, 59f with jaws open, 59f

Suture management equipment for, 57–58 in soft tissue. See Soft tissue grasper; Soft tissue punch. in tendons, skills for, 12 skills for, 12 practice importance to, 16–19 tying in. See Knot tying. Suture passers arthropierce, 56f, 57 Cuff-Stitch instrument for. See Cuff-Stitch suture passers. Elite instrument as. See Elite Pass instrument. in glenohumeral instability repair, 125–127, 132, 133 in massive rotator cuff repair, 293–294, 294f, 295f in operating room setup, 53 Smith-Nephew, in glenohumeral instability repair, 126, 128, 133 Spectrum instrument for. See Spectrum suture passer. tips for, 55f, 56f Suture passing in full-thickness rotator cuff repair, 259 bridge variation, 270, 270f, 271f Caspari suture punch technique, 259, 263f, 264f, 265f, 266f, 267f Elite suture passer technique, 259, 259f, 260f, 261f, 262f in glenohumeral instability repair anterior-inferior, 125–126, 126f, 127f, 128f for anchors, 128, 128f, 129f posterior, 120f, 121 Suture tension, in full-thickness rotator cuff repair, 263–269, 269f Synovectomy for glenohumeral arthrosis, 187, 189 rheumatoid staging in, 194, 197t technique for, 194–196, 197f in irreparable rotator cuff repair, 296, 297 in sepsis treatment, 207–208, 208f power instruments for, 60 Synovitis biceps, 162f focal, in full-thickness rotator cuff tears, 245–246 of rotator interval, 72f, 181f Synthetic grafts, in irreparable rotator cuff repair, 297

T Table back, in operating room setup, 48, 48f shoulder preparation, 48 Tack technique, in SLAP 2 lesions repair, 154–155 Team, dedicated, in operating room setup, 63, 63f Tear(s) biceps tendon. See Biceps tendon tears. bucket-handle, in SLAP 3 lesions, 159 bursal surface partialthickness, 240 insertion, in glenohumeral instability repair, 122, 122f labrum. See Labrum tears. rotator cuff. See Rotator cuff tears. Technical failure, in impingement treatment, 229 Technical skills, for arthroscopic shoulder surgery, 4 evaluating need for, 3–4 knot tying as, 19, 29, 31–41 suture anchors in, 12 suture management as, 12 sutures through tendons in, 12 Tendinitis biceps. See Biceps tendinitis. calcific. See Calcific tendinitis. traction, impingement syndrome vs., 229 ultrasonography of, 326 Tendinopathy impingement syndrome vs., 216 intrinsic, 233 self-healing, 316 Tendinosis, of rotator cuff, chronic, 213. See also Impingement syndrome. Tendon allografts, in irreparable rotator cuff repair, 297 Tendon-bone discontinuity, following full-thickness rotator cuff repair, 274, 275 Tendons. See also specific tendon, e.g., Biceps tendon. sutures through, skills for, 12 Tendon-to-tendon longitudinal repair, of rotator cuff tears massive, 280, 280f, 293–294 Tenodesis. See Biceps tenodesis. Tenotomy. See Biceps tenotomy. Teres minor muscle/tendon hypertrophy of, with periarticular cysts, 200, 201f

Index

Teres minor muscle/tendon (Continued) tears of, in partial-thickness rotator cuff tears, 234 Textbooks, for arthroscopic shoulder surgery training, 41 Thermal capsulorrhaphy, for glenohumeral instability, 102 Thermal instruments, in operating room setup, 62 Three-anchor, six-suture rotator cuff repair, 17–19 simulation of, 22f, 23f, 24f, 25f, 26f, 27f, Three-phase active elevation, for massive or irreparable rotator cuff tears, 343 goal of, 340 stage 1, 344, 345f stage 2, 345, 345f stage 3, 345, 346f warm-up for, 336f, 340 Throwing athlete distal biceps tendon lesions in, 161–162 glenohumeral instability in, 104–105 treatment of, 101, 134–135 rotator cuff lesions and, 134–135 SLAP lesions in, 150–151 Tips, for suture passers, 55f, 56f Tissue biopsy, for sepsis diagnosis, 207–208 Traction device, for lateral decubitus position, 50 Traction suture, in knot tying, 30–31 Traction tendinitis, impingement syndrome vs., 229 Transfer flaps, muscle/tendon, in irreparable rotator cuff repair, 297 Transfer rods, in operating room setup, 63 Transfers, wheelchair, of paraplegics, with rotator cuff tears, 348 Translation, glenohumeral impingement syndrome vs., 229 in glenohumeral instability, 102, 103 assessment of, 105, 111 treatment considerations of, 110, 111–112, 111f, 112f proximal biceps tendon lesions resulting from, 150–152 with posterior rotator cuff tears, 239–240 Transverse tears, of rotator cuff full-thickness, 249–250, 250f massive, 283f

Trauma acromioclavicular joint conditions caused by, 306 biceps tendon lesions caused by, 147, 150 avulsion injury in, 151, 151f in glenohumeral instability, 109 onset of, 104 treatment considerations of, 110–111 stiff shoulder related to, 176–178 Trendelenburg position, for sitting position, 50–51 Triangulation technique, for diagnostic subacromial arthroscopy, 89, 89f Triceps strengthening for full-thickness rotator cuff tears, 258, 338f for glenohumeral instability postoperative, 338f, 347 with recurrent dislocation, 338f, 347 for impingement syndrome, 338, 338f for rotator cuff repair, 338f, 346 Trocar in acromioclavicular joint resection, 310 in biceps tendon lesions repair, 152, 170–171 in calcific tendinitis treatment, 319 in diagnostic arthroscopy of glenohumeral joint, 64, 67–68 bone palpation with, 68–69, 70f in portal establishment, 70–72, 73f of subacromial space, 88, 89 in fracture fixation, 323–324 in glenohumeral arthrosis treatment, 190 in glenohumeral instability repair, 113–118, 114f, 116f, 117f, 123f in impingement treatment, 219, 219f, 228f in periarticular cyst treatment, 202–203 in rotator cuff repair full-thickness, 246, 247f, 254, 258, 269–270 irreparable, 299 massive, 280–281, 284–286 in stiffness treatment, 180, 183–184 Tuberosityplasty, in rotator cuff repair full-thickness, 256, 256f, 257f

379

Tuberosityplasty, in rotator cuff repair (Continued) irreparable, 300–302, 302f massive, 282, 287–288, 288f TwinFix anchors, 63 Two-anchor, four-suture rotator cuff repair, 17–19 simulation of, 19f, 20f, 21f, 22f Two-handed knot, 29–30 simulation of, 30f, 31f Two-suture, one-anchor rotator cuff repair, 12-14, 17–19 simulation of, 17f, 18f Type 1 acromion, in impingement syndrome, 226, 227 Type 2 acromion, in impingement syndrome, 226 Type 3 acromion in impingement syndrome, 214, 215f in partial-thickness rotator cuff tears, 234

U UCLA score. See University of California at Los Angeles (UCLA) Shoulder Scale. Ultrabraid sutures in full-thickness rotator cuff repair, 256, 257 in operating room setup, 60 Ultrasonography, diagnostic accuracy of, 327 documentation of, 328–329 indications for, 326, 326f MRI vs., 326 of calcific tendinitis, 316, 318f of rotator cuff tears full-thickness, 241–244 partial-thickness, 233–234, 234f office suite for, 327, 327f performing, 326–327 portable machine for, 327, 327f technique for, 327–328 demonstration of, 326–327, 327f University of California at Los Angeles (UCLA) Shoulder Scale of full-thickness rotator cuff repair results, 272, 273t, 274t of glenohumeral instability, 104 postoperative results of, 136–138, 137t

V Vacuum beanbag, for lateral decubitus position, 49–50, 50t Vascular proliferation, in calcific tendinitis, 316, 318, 319f

380

Index

Video programs, for arthroscopic shoulder surgery training, 5, 16–17 Video recording, intraoperative, 63 Viewing portals in diagnostic glenohumeral arthroscopy, 70t in glenohumeral joint reconstruction, 95 in Lafosse technique, 96, 97f, 202 in Latarjet lesions/repair, 96, 96f in rotator cuff repair, 94 in SLAP lesion repair, 96 in suprascapular nerve decompression at the spinoglenoid notch, 97 at the suprascapular notch, 96, 97f Visualization, of massive rotator cuff tears, 280, 281f, 282f

W Warm-up exercises, for massive or irreparable rotator cuff tear rehabilitation, 336f, 340 WBC (white blood cell) count, in sepsis, 207 Weakness impingement syndrome causing, 215, 216 periarticular cysts causing, 200 rotator cuff tears causing full-thickness, 242–244, 243f postoperative, 274, 275 partial-thickness, 233–234 Weight bearing, by paraplegics, with rotator cuff tears, 348, 349 Weight lifting, acromioclavicular joint pain with, 307

Wheelchair transfers, of paraplegics, with rotator cuff tears, 348 Whisker resector, in glenohumeral joint arthrosis treatment, 196, 197f Whisker shaver, in glenohumeral instability repair, 133f White blood cell (WBC) count, in sepsis, 207 Wire fixation, Kirschner, for fractures, 323–324, 324f Wissinger rod, 63, 63f, 70–72 handle of, 63f tip of, 63f Wrist pad, for lateral decubitus position, 50

Y Yergason test, for distal biceps tendon lesions, 162