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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.