arthroscopic shoulder procedures - ahn space lidocaine with epi injection systolic blood pressure...

Arthroscopic Shoulder

Procedures

David C. Neuschwander MD

Allegheny Health Network

Orthopedic Associates of

Pittsburgh

Shoulder Instability

Anterior Instability

Posterior Instability

Glenohumeral Joint Stability

Dependent upon the bony geometry and soft

tissues about the shoulder

Success rates of Open Anterior stabilization

procedures 90-95%

Despite low recurrence rates with open

procedures, there can be important losses

in external rotation, surgical morbidity and

difficult rehab

Shoulder Arthroscopy

Has a learning curve which is specific to

each procedure

Needs to duplicate the techniques which

have been done with an open technique

Measures to Limit Bleeding

Subacromial space lidocaine with epi

injection

Systolic blood pressure about 100 if

tolerated medically

Use of arthroscopic pump

Epi in fluid

Initial Evaluation

Scalene block or General Anesthesia

Assess range of motion and stability testing

Portal placement (Poster, Anterior) for evaluation of GH joint

Subacromial space portal placement (posterior, anterior, and lateral)

Use of accessory portals and anchor portals as necessary


Preop

Clinical

Exam

Assess Tissue Quality

Determine if the

tissue has moved

medially along the

glenoid neck

Determine how far the

tissue can be moved

to get desired effect

on the tension of the

repair

Anchor Placement

Along the glenoid

face-neck junction

Placed 5-7 mm apart

Recreate the “bumper

effect”


Postop

Exam


Initial Shoulder

Arthroscopic

Evaluation


Anterior Superior

Lateral Portal


Anchor Hole

Placement


Knot Tying


Final Evaluation


Another Case

Anterior Soft

Tissue

Bankart

Lesion


Anterior

Capsule

T Split


Preop

Arthroscopic

Exam


Initial

Probe

Eval


Elevate

Anterior

Labrum


Place

Anchor


Tie

Knot


Replace

Blue

Suture


Knot

Tying


Test

Stability


Evaluate

Final

Repair

Another Case

Retracted Anterior Labrum

Elevate Anterior Labrum

Shoulder Instability and

Rotator Cuff Repairs

March 29, 2014

Viewed From Posteriorly

Viewed Anteriorly

Benefits of Arthroscopic Technique

Less loss of external rotation (not have to

take down subscapularis)

Less difficulty regaining postoperative

motion

Better able to treat associated pathology

Refined Arthroscopic Technique

Anchors placed on the anterior glenoid

face-neck junction to recreate labral

“bumper” that deepens glenoid concavity

Plication sutures

Rotator Interval closure

Analysis of Athroscopic Instability

Failures

Too short a period of immobilization (< 3

weeks)

Use of too few anchors

Anterior placement of anchors on glenoid

neck rather than edge of the articular

surface

Participation in contact sports

Young Age

Analysis of Arthroscopic Failures

Glenohumeral Ligament Quality

Generalized ligamentous laxity

Engaging Hill-Sachs lesion

Bony Bankart (inverted pear shaped

glenoid)

Capsular attenuation

Posterior Shoulder Instability

2-10% of all instability cases

50% due to trauma

Athletes usually have subluxation rather

than dislocation

Most common in overhead throwers,

tennis players, butterfly and freestyle

swimmers, weightlifters, and football

lineman

History

Symptoms with forward flexion, adduction,

and internal rotation

Throwers (follow-through)

Swimmers (pull-through)

Location of pain variable

Often describe crepitation or click


Improvements in diagnosis and treatment

of athletes and other individuals has

shown posterior instability to be more

common than once thought


Symptoms

Pain, weakness and loss of function with

the arm in a forwardly flexed position

Many patients improve with conservative

treatment

Physical Exam

Posterior Joint Line Tenderness

Load and shift test (sitting and supine)



Loose Body


Viewed From Anterior

Portal

Viewed From Posterior

Portal

Viewed Posteriorly Viewed Anteriorly

Knot Tying

Anchor Placement Evaluate Knot Security

Suture Anchor for Anterior

Labral Tear

Final Repair

Final Repair Viewed from

Anterior Portal

Loose Body

Rotator Cuff

Rotator Cuff

Tendinitis

Partial Thickness Tears

Full Thickness Tears

Rotator Cuff Tendons

Supraspinatus

Infraspinatus

Teres Minor

Subscapularis

Operative Procedure

Visualization

Preparation

Execution

Visualization

Glenohumeral Evaluation

Humeral Head and Glenoid

Labrum

Biceps Tendon

Rotator Cuff ( all 4 Tendons)

Subacromial Space Evaluation

Bursal Side of Rotator Cuff

Preparation

Remove Thickened Bursal Tissue

Remove Thickened CA Ligament

Remove Acromial Spur

Evaluate Rotator Cuff Tear

Size

Tendons Involved

Configuration of Tear

Execution

Undertake Rotator Cuff Repair

Side to Side Rotator Cuff Repair

Second Suture

Reevaluate Tear

Single Row Repair

Single Row Repair

Single Row Repair

Single Row Repair

Single Row Evaluation

Double Row Repair

Evaluate Tear

Medial Row Anchor

Footprint Cuff Insertion

Thank You

Anterior Labral Bumper Effect

Arthroscopic Shoulder

Procedures

arthroscopic shoulder procedures - ahn space lidocaine with epi injection systolic blood pressure...

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