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Key-Techniques-in-Orthopaedic-Surgery

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Note the flattening of the undersurface of the acromion, recession of 
the coracoacromial ligament, and removal of the subacromial bursa.
Figure 4–4 (A) Arthroscopic view of Bankart lesion. (B) Arthroscopic
view of vector into glenohumeral joint.
4 S H O U L D E R A RT H R O S C O P Y 2 3
2. Drawing landmarks on the skin can help facilitate
accurate portal placement.
3. Routine intravenous antibiotics should be adminis-
tered prior to incision.
4. Confirm placement of the posterior portal with an
18-gauge 31⁄2-in spinal needle. Distend the gleno-
humeral joint with 20 cc of 0.5% bupivicaine with
epinephrine.
5. Infiltrate the portal sites with 0.5% bupivicaine
with epinephrine.
6. Consider relative hypotensive anesthesia because
this decreases intraoperative bleeding, thereby per-
mitting lower fluid pressures which helps minimize
fluid extravasation.
What To Avoid
1. Avoid chondral injury by using blunt obturators to
enter the joint under careful control. Do not plunge!
2. Avoid inadvertent rotator cuff tendon tears during
posterior portal placement by internal rotation of
the humerus.
3. Minimize risk of neurovascular injury by placing
the anterior portal lateral to the coracoid and keep-
ing the humerus adducted when creating anterior
portals.
Postoperative Care Issues
1. Use a sling with a 6-in elastic bandage wrapped
around the body. The elastic bandage can be re-
moved when the scalene block has worn off.
2. After arthroscopic shoulder decompression, the sling
is removed after 2 days, and early active, active-
assisted, and passive range-of-motion exercises are
begun. In addition, isotonic rotator cuff strengthen-
ing and scapular stabilization exercises are also
begun. The goal is full, active, pain-free range of
motion 4 weeks after surgery.
3. After an arthroscopic Bankart repair, the sling is
worn for 4 weeks. During this time, elbow range-of-
motion exercises, squeezing a tennis ball for grip,
co-contracture of the biceps and triceps, and pen-
dulum exercises are instituted. At 4 weeks, isometric
rotator cuff strengthening and active, active-assisted,
and passive range-of-motion exercises are begun.
External rotation is limited to 20 degrees until 
6 weeks after surgery. At 6 weeks, the patient begins
isotonic strengthening exercises. Heavy lifting and
throwing programs are deferred until 4 months
after surgery.
Operative Technique
1. Position the patient supine on the table. Place
blankets or pillows under the patient’s thighs. Flex
the waist approximately 35 degrees, the knees
approximately 40 degrees, and the back approxi-
mately 40 degrees.
2. With the head and neck in neutral position, con-
tour the beanbag around the patient and deflate
the bag.
3. Position the patient so the operative shoulder is
pulled to the bed’s edge to allow adequate access.
Secure the patient to the bed.
4. Prepare and drape the limb in the hospital’s stan-
dard sterile fashion.
5. Draw the bony landmarks, including the acromion,
clavicle, spine of the scapula, and coracoid tip, on
the skin.
Diagnostic arthroscopy—posterior portal
6. Place the posterior portal in the “soft spot” between
the infraspinatus, teres minor, and edge of deltoid.
This is located 2 to 3 cm inferior and 1 to 2 cm
medial to the posterolateral corner of the acromion.
Localize the plane of the glenoid with an 18-gauge
spinal needle. Enter the joint using a blunt obturator
(Fig. 4–2).
7. Establish intra-articular orientation with the arthro-
scope looking straight inferior (the light cord facing
straight up) by viewing the biceps tendon’s insertion
into the superior labrum and the plane of the gle-
noid. The inflow is through the arthroscope sheath.
8. Insert the arthroscope deeper into the shoulder to
visualize the subscapularis tendon.
9. Rotate the arthroscope medially to view the sub-
scapularis recess.
10. Rotate the arthroscope laterally to follow the sub-
scapularis tendon. Visualize the undersurface of the
biceps tendon, the superior glenohumeral ligament
upon the procedure being performed. A more supe-
rior position is desirable for stabilizing a superior
labral tear or debriding a partial thickness rotator
cuff tear, while a more inferior position is beneficial
for performing an anterior capsulolabral repair, and
a more medial position is advantageous for excising
the distal clavicle excision (Fig. 4–2).
19. Evaluate the area between the subscapularis tendon
and the supraspinatus tendon (rotator interval).
Under direct vision insert an 18-gauge 31⁄2-in spinal
needle into this triangle passing the needle tip
below the biceps tendon. The external entry point is
generally midway between the coracoid and the
anterior acromion. If an anterior portal is indicated,
insert a cannula with a blunt obturator at the same
angle as the spinal needle. If there is no indication
for an anterior portal, use this needle to probe the
superior labral attachment (Fig. 4–2). Alternatively,
an anterior portal may also be made from inside-out.
Drive the arthroscope anteriorly against the capsule
in the triangle formed by the humeral head, glenoid,
and biceps tendon. Remove the arthroscope from its
sheath and insert a Wissinger rod or switching stick
through the cannula so it can be palpated under the
skin. Incise the tented skin with a scalpel. Pass a can-
nula over the rod into the joint (Fig. 4–2).
Diagnostic arthroscopy—subacromial space
20. Approach the subacromial space using the same
skin incision as the posterior portal for the gleno-
humeral arthroscopy. With a blunt obturator in
place, withdraw the arthroscopic sheath from the
glenohumeral joint. Direct it superiorly in the sub-
cutaneous tissue along the undersurface of the
acromion until it rests against the coracoacromial
ligament. Err on the side of scraping superiorly
against the inferior acromion rather than inferiorly
against the rotator cuff. Withdraw the cannula 1 cm,
insert the arthroscope, and turn on the inflow
through the arthroscopic sheath.
21. Initial visualization can sometimes be difficult in
the presence of subacromial bursa pathology. In
this situation, pass a switching stick through the
arthroscopic cannula and out the anterior portal.
Pass a second cannula over the rod anteriorly into
the subacromial space. This cannula passes just
2 4 S H O U L D E R A N D A R M
crossing between the subscapularis tendon and the
long head of the biceps tendon, and the transverse
ligament securing the biceps tendon in the bicipital
groove.
11. Retract the arthroscope and examine the anterior
labrum. Externally rotate the humerus to accentuate
and visualize the middle glenohumeral ligament.
12. “Drive through” the joint into the axillary recess by
inserting the arthroscope deeper while rotating it to
look inferiorly. Inspect the anterior band of the
inferior glenohumeral ligament. The arthroscope’s
tip should be anterior to the articular surface to
minimize the risk of abrasion.
13. Rotate the arthroscope to look superior. Raise the
camera to view the inferior labrum and the humeral
insertion of the anterior band of the inferior gleno-
humeral ligament.
14. Follow the labrum posteriorly, externally rotate the
humerus to improve visualization.
15. Continue following the labrum superiorly. Examine
the superior glenohumeral recess with the humerus
abducted 20 to 30 degrees.
16. Follow the superior surface of the biceps tendon
laterally. Forward flex the patient’s arm slightly
and begin abducting and externally rotating the
humerus. Examine the supraspinatus tendon’s
insertion on to the greater tuberosity.
17. Visualize the insertion of the entire rotator cuff
from greater tuberosity to axillary recess by slowly
internally rotating the humerus and withdrawing
the arthroscope. The bare area on the posterolateral
humeral head is seen adjacent