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Key Techniques in Orthopaedic Surgery

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letes, consider positioning the arm with slightly
greater external rotation and abduction.
1 6 S H O U L D E R A N D A R M
individuals. Place a self-retaining retractor under
the deltoid and pectoralis.
13. Open the clavipectoral fascia. Identify the lateral
edge of the conjoined tendon.
14. Identify the subscapularis tendon, long head of the
biceps tendon and lesser tuberosity. Internal and
external rotation helps define the subscapularis
tendon.
15. Palpate the axillary nerve by sliding your finger
down the subscapularis tendon and internally rotate
the arm when you reach the inferior border of the
subscapularis. This is known as the “tug test.”
16. Protect the axillary nerve with a retractor.
17. Identify the rotator interval. The superior edge of
the subscapularis is at the rotator interval and the
anterior humeral circumflex vessels (“three sis-
ters”) mark the inferior edge. Expose and cauterize
these vessels.
18. With the arm externally rotated, divide the sub-
scapularis tendon in its midportion. Typically this is
at a point 1 to 1.5 cm medial to the lesser tuberos-
ity. Carry the dissection down to but not through
the shoulder capsule. The fibers of the tendon run
transversely. The tendon can be divided completely
or partially (Fig. 3–2).
19. Place stay sutures along the edge of the tendon
(Fig. 3–3).
20. Define the plane between the subscapularis and cap-
sule. Using a Cobb elevator, separate the muscle and
capsule medially and tendon and capsule laterally.
21. Evaluate the rotator interval. It will need to be
closed later if it is widened or electively opened.
Procedure
22. Perform an arthrotomy. This can be done either lat-
erally (humeral) or medially (glenoid) (Fig. 3–4).
23. Carry the arthrotomy down to the humeral attach-
ment. Use a periosteal elevator to elevate the cap-
sule off the anterior glenoid.
24. For a lateral arthrotomy, elevate the capsule off the
humerus inferiorly in a similar fashion. Do not
incise the capsule too inferiorly, that is, through the
axillary pouch. This will result in an ineffective shift
of the inferior capsule.
25. If there is excessive inferior capsular redundancy, 
it may be necessary to make a “T” incision. This
allows a superior shift of the inferior capsule. The
1 7
Deltoid
muscle
Acromion
Coracoid
process
Cephalic
vein
Pectoralis
major muscle
Cautery
(Partial)
Axillary
nerve
(Complete)
Coracoid
process
Capsule
Subscapularis
tendon
Biceps tendon
Figure 3–1 Skin incision and subcutaneous
exposure.
Figure 3–2 Deep exposure depicting a complete
or a partial tenotomy of the subscapularis
tendon.
Figure 3–3 Axial view of the cut subscapularis
tendon and underlying capsule.
1 8
Coracohumeral ligament
2
1
Sub-
scapularis
tendon (art)
3
Subscapularis
tendon (art)
Drill holes
for suture
anchors
Glenoid
fossa
Anchor
A
B
Figure 3–4 Capsular incisions. (1) “T” based off
the humeral side (lateral shift). (2) “T” based 
off the glenoid side (medial shift). (3) Medial
arthrotomy without a shift.
Figure 3–5 (A) Correct position for transosseous
drill holes for a repair of a Bankart lesion. 
(B) Axial view of the correct position for
intraosseous anchors.
49. Close the skin with staples or a running subcuticu-
lar stitch and steristrips.
50. Apply a sterile compressive dressing.
51. Place the arm in a sling device. Transfer the patient
to the recovery room.
Suggested Readings
Bigliani, Louis U, eds. The Unstable Shoulder. Rosemont,
IL: American Academy of Orthopaedic Surgery, 1996.
Craig, EV, ed. The shoulder. Master Techniques in
Orthopedic Surgery. New York, NY: Raven, 1995.
Rowe CR, Patel D, Southmayd WW. The Bankart
procedure. J Bone Joint Surg 1978;60A:1–16.
3 O P E N A N T E R I O R S H O U L D E R S TA B I L I Z AT I O N 1 9
Closure
40. Thoroughly irrigate the wound with antibiotic
irrigation.
41. Ensure adequate hemostasis has been achieved.
42. A drain is usually not necessary.
43. Remove all retractors. Repeat the “tug-test” to verify
continuity and mobility of the axillary nerve.
44. If necessary, close the rotator interval.
45. Reapproximate the subscapularis tendon with the
arm in slight external rotation to avoid loss of exter-
nal rotation. Nonabsorbable suture is preferred.
46. If the pectoralis was released, reapproximate it with
a single, nonabsorbable suture.
47. Close the deltopectoral interval with absorbable
sutures. Protect the cephalic vein.
48. Close the subcutaneous tissue with absorbable suture.
Indications
1. Loose body
2. Foreign body
3. Labral tear
4. Impingement syndrome
5. Instability
6. Acromioclavicular arthritis
7. Infection
8. Diagnostic dilemma
Contraindications
1. Acute adjacent soft tissue injury resulting in risk of
neurovascular compromise from fluid extravasation
(relative)
Preoperative Preparation
1. Shoulder radiographs including true anteroposterior
(Grashe), outlet or “Y,” and axillary views; Stryker-
notch view is also obtained for patients with insta-
bility symptoms.
2. Consider magnetic resonance imaging (MRI) to con-
firm diagnoses.
3. Document preoperative neurovascular examination
of upper extremity.
Special Instruments, Position, 
and Anesthesia
1. Beach chair position on full-body beanbag.
a. Keep head midline with neck in neutral or
slightly flexed position.
b. Protract the scapula, which exposes the medial
border of the scapula. Drape the shoulder free
from the medial border of the scapula posteriorly
to the midline of the clavicle anteriorly (Fig. 4–1).
2. Alternatively, consider using the modified lateral
decubitus position which aligns the glenoid surface
horizontal. The arm is slightly forward flexed and
abducted 50 degrees with 10 to 15 lb of longitudi-
nal suspension applied from a traction tower.
3. All pressure points should be padded, particularly
the peroneal nerve.
4. The procedure can be performed with general
and/or scalene block anesthesia.
5. Routine arthroscopy equipment is required for diag-
nostic arthroscopy. Additional specialized instru-
mentation is necessary for each operative procedure.
Open shoulder instrumentation should be available.
Tips and Pearls
1. Perform a physical examination under anesthesia to
assess shoulder stability and range of motion.
C H A P T E R 4
Shoulder Arthroscopy
Daniel D. Buss and John R. Green III
2 0
 
2 1
Acromion anterior
inferior surface
Subacromial
bursitis
Humeral head
Anterior hooked
acromion
Excoricated
coracoacromial
ligament
B.t
Co,
Humerus
Superior
glenoid
tubercle
Acromion
Coracoid
process
Clavicle
4
Co.
5
6
Biceps
brachii
tendon
Humerus
2
1
Acromioclavicular
joint
3
Figure 4–1 Patient position. Superior view of 
the shoulder in the beach chair position before
draping. Note the exposure and scapular
protraction.
Figure 4–2 Portals and vectors. Closeup superior view of shoulder
demonstrating portal placement in relation to bony landmarks. 
1—posterior portal, 2—lateral portal, 3—superolateral portal, 
4—anterior superior portal, 5—anterior inferior portal, 6—5 o’clock
portal.
Figure 4–3 (A) Arthroscopic view of subacromial space demonstrating
anterior hooked acromion, excoriated coracoacromial ligament, and
subacromial bursitis.
2 2
B
C
A B
Flat acromial undersurface
Recession of
coracoacromial
ligament
Removal
of bursa
Hum
era
l
head
Acromion
Coracoid Needle in torn ligament
Middle glenohumeral ligament
Tear
Glenoid
Scope
view
Inferior
glenohumeral 
ligament
Hu
me
ral
hea
d
Figure 4–3 (Continued) (B) Arthroscopic view of vector into subacromial
space. (C) Arthroscopic view of subacromial space after decompression.