Anterior portals in shoulder arthroscopy

The superolateral portal for arthroscopy of the shoulder

With the advent of arthroscopic procedures for the treatment of a variety of clinical conditions affecting the shoulder has come the need for better techniques for visualization of structural pathology, and better techniques for visualization of intracapsular structures during operative procedures. We present a new portal for shoulder arthroscopy that is safe to insert, providing a panoramic view of the glenohumeral joint (especially anteriorly), and allowing unobstructed observation of large instruments passed through more traditional anterior portals nearby. The superolateral portal is particularly suited for use in anterior stabilization procedures of the shoulder, where it can be used for direct visualization of the anterior glenoid neck, thus permitting the surgeon to perform such tasks as debridement or mobilization of tissues, and placement of tacks or sutures.

Arthroscopic Bankart suture repair

The purpose of this paper was to report our experience with an arthroscopic technique of repair for the Bankart lesion following shoulder instability. Twenty-seven patients (average age, 21.7 years) were followed for an average of 36 months after arthroscopic suture stabilization of anterior shoulder instability. Patients were excluded if instability was multidirectional or voluntary and if there was radiographic evidence of a significant loss of glenoid bone stock. Clinical evaluation using a functional grading system showed that 10 patients were rated as excellent, 5 good, and 12 poor. Fourteen patients returned to their previous level of activity. There were 12 patients rated as failed; all had recurrent instability of the shoulder. Success was associated with a period of immobilization of 3 weeks or longer and a history of acute injury, especially subluxation. Failures were associated with shorter immobilization periods after surgery and in patients who had recurrent dislocations. The younger patient, who may not have complied with the immobilization protocol, also seemed to be associated with failure. Contact sports seems to leave a patient at high risk for recurrence. We recommend caution in the use of arthroscopic procedures for the competitive athlete in whom a second surgery and rehabilitation might mean loss of more sports participation.

Anatomy of the supraclavicular fossa portal in shoulder arthroscopy

Because of the need for a third portal for operative procedures during glenohumeral joint arthroscopy, we studied the anatomy of the supraclavicular fossa portal with the humerus in various degrees of abduction and the trochar placed at various angles. Our purpose was to establish a "safe zone" of introduction that would avoid damage to the tendinou portion of the rotator cuff. Eight shoulder specimens were studied. Sharp- and blunt-tipped 4-mm trocars were used to enter the joint. The trapezius was penetrated at all angles of humeral abduction and trocar angulation. The trocar penetrated the tendinous portion of the rotator cuff in all specimens at 90 degrees of abduction, seven of eight specimens at 70 degrees, six of eight specimens at 60 degrees, and three of eight specimens at 45 degrees of abduction. No penetration of the musculotendinous portion occurred when the arm was in 30 degrees of abduction or at the side. When it is necessary to use the supraclavicular portal, traction should be released and the humerus should be brought down to at least 45 degrees. The trocar should be introduced laterally at 30 degrees and angled slightly posteriorly to avoid the tendinous portion of the rotator cuff.