SHOULDER ARTHROSCOPY

DEFINITION

INDICATIONS

1. Instability Lesions

• Labral lesions (Bankart lesion - anteroinferior labral tear)
• Osteochondral lesions (Hill-Sachs lesion - posterior humeral head impaction fracture)
• HAGL (Humeral Avulsion of Glenohumeral Ligament)
• SLAP (Superior Labrum Anterior to Posterior) tears
• Multidirectional instability

2. Degenerative / Traumatic Conditions

• Partial or complete rotator cuff rupture (repair or debridement)
• Subacromial impingement syndrome (acromioplasty, bursectomy)
• Calcific tendinitis (tendinosis calcarea)
• Biceps tendon pathology (tenotomy / tenodesis)
• Acromioclavicular joint pathology

3. Inflammatory Conditions

• Synovitis / synovialitis
• Adhesive capsulitis (frozen shoulder) - capsular release
• Septic arthritis - irrigation and debridement
• Loose body removal

PRE-OPERATIVE ASSESSMENT

• AP view with arm in external rotation
• True AP (Grashey view) with arm in internal rotation
• Scapular outlet view
• Axillary lateral view
• Special: West Point, Bergeneau, Stryker notch views (for bony defects in instability)

• MRI: Evaluates soft-tissue structures, best for rotator cuff pathology
• MRA (Magnetic Resonance Arthrography): Best for capsulolabral pathology, SLAP tears, HAGL lesions
• 3D CT: Quantifies bony defects (glenoid bone loss, Hill-Sachs) and guides decision-making

PATIENT POSITIONING & ANAESTHESIA

1. Beach-Chair Position (Semi-Fowler)

• Patient sits upright with back flexed at 60°
• Shoulder overhangs the edge of the table
• Advantages:
  • Allows full arm rotation and abduction during surgery
  • No repositioning needed if conversion to open required
  • Easier orientation (normal anatomical position)
  • Arm traction weights can be applied for joint distraction
• Disadvantage: Slightly less joint distraction than lateral decubitus

2. Lateral Decubitus Position

• Patient placed on their side with the operative shoulder up
• Arm placed in traction (5-10 lbs) at 45° abduction and 15° forward flexion
• Advantages: Superior glenohumeral joint distraction, excellent inferior recess access
• Disadvantage: Repositioning required if open conversion needed; higher brachial plexus stretch risk

ARTHROSCOPIC PORTALS

Standard Portals (Miller's Review)

Additional Portals

Neurovascular Hazards at Each Portal (Miller's Review)

• Posterior portal: Axillary nerve (inferior), suprascapular nerve, suprascapular artery
• Anterior portals: Cephalic vein, axillary artery, axillary nerve
• Superior portals: Suprascapular artery, suprascapular nerve
• The axillary nerve is approximately 12 mm distal to the 6 o'clock position of the glenoid

TECHNIQUE (Campbell's Technique 57.1)

1. Joint insufflation: Insert 18-gauge spinal needle through posterior soft spot, directed toward coracoid tip. Inject 30-40 mL saline for joint distention - this distracts the humeral head from glenoid, making trocar entry safer and reducing chondral injury risk.
2. Posterior portal creation: Incise skin only (No. 11 blade, epidermis + dermis only - avoid deep deltoid penetration to prevent bleeding). Insert cannula + blunt trocar directed anteromedially toward coracoid.
3. Trocar navigation: Palpate bony scapular neck and glenoid with the blunt tip. Slide trocar laterally to locate the glenoid rim (felt as a small ridge). Entry site just lateral to this ridge ensures passage through muscular rotator cuff, not the tendinous portions.
4. Local anaesthetic injection: 20 mL diluted epinephrine (1:100,000) injected into portal sites and subacromial space to minimize bleeding. Verify no vessel is being injected before injection.
5. Arthroscope insertion: 30°-angled arthroscope introduced through posterior (dorsal) portal. Joint is washed with irrigant fluid.
6. Diagnostic survey: Systematic evaluation of all intraarticular structures (see below).
7. Anterior portal creation: Using inside-out or outside-in technique under direct vision, create anterior working portal for instruments.
8. Therapeutic procedure: Based on findings.

ARTHROSCOPIC ANATOMY & DIAGNOSTIC SURVEY

• Articular surface of humeral head (Hill-Sachs, chondral damage)
• Glenoid fossa articular surface (chondral lesions)
• Superior labrum and biceps anchor (SLAP lesions)
• Anterior labrum and inferior glenohumeral ligament (Bankart lesion)
• Posterior labrum and capsule
• Middle glenohumeral ligament (Buford complex)
• Subscapularis tendon (partial tears, HAGL)
• Rotator interval
• Supraspinatus and infraspinatus footprints (rotator cuff tears)
• Synovium, axillary recess

• Bursal surface of rotator cuff
• Coracoacromial ligament
• Undersurface of acromion (acromial morphology - Types I, II, III)
• AC joint

CONTROL OF BLEEDING / FLUID MANAGEMENT

• Add 1 mL of 1:1000 epinephrine per 3000 mL irrigant bag (if no cardiac contraindications)
• Hypotensive anaesthesia: SBP 90-100 mmHg is most effective
• Maintain systolic-to-pump pressure gradient of ~40 mmHg

• More problematic in shoulder than knee arthroscopy (increased depth of tissues)
• Monitor for neck/airway swelling
• Preserve muscle fascial layers to prevent extravasation
• Use lowest effective pump pressure

FLOWCHART

COMMON PROCEDURES PERFORMED

COMPLICATIONS

General Complications

Portal-Specific Risks

• Posterior portal: Suprascapular nerve (too medial) + axillary nerve (too inferior/lateral)
• Anterior portals: Cephalic vein, axillary artery
• Superior/Neviaser portal: Suprascapular artery and nerve

ADVANTAGES OF ARTHROSCOPY OVER OPEN SURGERY

SUMMARY MNEMONICS

• Posterior (primary viewing)
• Anterior (instruments)
• Lateral (subacromial)
• Special (Neviaser, Wilmington, 5 o'clock, 7 o'clock)

• Instability (Bankart, SLAP, MDI)
• Degenerative (rotator cuff, impingement, calcific tendinitis)
• Adhesive + inflammatory (capsulitis, synovitis, septic)

• Fluid extravasation
• Neuropathy (axillary, suprascapular)
• Infection
• Iatrogenic chondral injury
• Thromboembolism