Glenohumeral arthroscopy portals established using an outside-in technique: neurovascular anatomy at risk

Risk of Cephalic Vein Injury During the Creation of an Anterior Portal in Shoulder Arthroscopy

Background

There is a risk of cephalic vein injury during shoulder arthroscopy. However, limited data regarding its anatomic course are available.

Purpose

To analyze the positional relationship and factors affecting the distance between the coracoid tip and cephalic veins.

Study design

Case series; Level of evidence, 4.

Methods

A total of 80 contrast-enhanced computed tomography images from 80 patients (mean age, 49.6 ± 20.3 years; 61 men) were retrospectively analyzed. The distance between the center of the coracoid tip and the vertical line through the cephalic vein was measured in the axial (D1) and sagittal (D2) planes. The distance between 1 cm lateral to the center of the coracoid tip and the vertical line through the cephalic vein was measured in the sagittal plane (D3). Each distance was compared according to patient sex and laterality. Associations between each distance and the patient's age, height, weight, and body mass index were investigated.

Results

The mean D1 was 18.4 ± 7.3 mm in 59 patients. The mean D2 was 23.4 ± 11.6 mm, and it was within 10 mm in 10 patients (12.5%). The mean D3 was 33.7 ± 12.2 mm. There was no significant difference in D1, D2, and D3 according to patient sex or laterality. A positive correlation was observed only between D3 and patient height (r = 0.320; P = .034).

Conclusion

The cephalic vein was found to travel a mean of 23.4 mm distal and 33.7 mm distal to 1 cm lateral to the coracoid tip. Therefore, Care should be taken to avoid cephalic vein injury when creating an anterior inferior portal or 5-o'clock portal around these areas.

The safety and efficacy of 2 anterior-inferior portals for arthroscopic repair of anterior humeral avulsion of the glenohumeral ligament: cadaveric comparison

BACKGROUND

Humeral avulsion of the glenohumeral ligament (HAGL) lesions are associated with shoulder instability. Arthroscopic repair of anterior HAGL lesions typically requires the placement of an anterior-inferior (5-o'clock) portal, with different variations of this portal described. The purpose of this study was to determine the efficacy of described anterior-inferior shoulder arthroscopy portals for arthroscopic anterior HAGL repair, as well as evaluate the safety of these portals with respect to the surrounding neurovascular structures. Additionally, we sought to evaluate the effect of arm adduction vs. standard abduction during anterior-inferior portal creation.

METHODS

HAGL lesions were created and repaired using an all-arthroscopic technique in 12 cadaveric shoulders (matched pairs). Half of the repairs were performed using a standard 5-o'clock portal, whereas the other half of the matched pairs were repaired using a medialized 5-o'clock portal. Repairs were timed, and the number of anchor pullouts was recorded. The shoulders were subsequently dissected to measure the proximity of the portal to the cephalic vein, musculocutaneous nerve, axillary nerve, and lateral cord of the brachial plexus.

RESULTS

The average time for HAGL repair was 18.0 ± 4.6 minutes. Repair times using the medial 5-o'clock portal (19.0 ± 3.3 minutes) vs. standard 5-o'clock portal (16.2 ± 5.8 minutes) were not significantly different (P = .37). From abduction to adduction, the cephalic vein distance from the standard 5-o'clock portal increased from 4.1 ± 4.7 mm to 5.2 ± 5.4 mm (P = .02); musculocutaneous nerve distance, from 14.4 ± 9.8 mm to 18.1 ± 10.8 mm (P = .005); axillary nerve distance, from 19.2 ± 9.6 mm to 19.8 ± 9.2 mm (P = .12); and distance of the lateral cord of the brachial plexus, 13.8 ± 6.6 mm to 16.7 ± 6.4 mm (P = .0006).

CONCLUSIONS

The arm abduction angle significantly affects the distance of the cephalic vein, musculocutaneous nerve, and lateral cord of the brachial plexus from the anterior-inferior portal, regardless of which portal-standard or medial 5-o'clock portal-is chosen. This portal should be created with the arm in adduction. Arthroscopic HAGL repair can be performed safely, although accurate anchor placement remains a challenge. There was no advantage to use of the medial 5-o'clock portal. With a curved guide, the standard 5-o'clock portal allows for reproducible anchor placement and is recommended for anterior HAGL repairs.

Vascular Complications in Sports Surgery: Diagnosis and Management

Orthopedic sports surgery of the knee and shoulder is generally considered to be safe and effective. Vascular complications can occur during or after arthroscopy of either joint. A thorough understanding of anatomy, particularly when placing portals in non-routine locations, is extremely important. Prompt recognition of any vascular complication is of significant importance. This review will discuss the potential vascular complications for both knee and shoulder sports surgery, review the relevant anatomy, and discuss the treatment and expected outcome of each.

Arthroscopy Limits on Anterior Shoulder Instability

Much is discussed about the limits of the treatment of anterior shoulder instability by arthroscopy. The advance in understanding the biomechanical repercussions of bipolar lesions on shoulder stability, as well as in the identification of factors related to the higher risk of recurrence have helped us to define, more accurately, the limits of arthroscopic repair. We emphasize the importance of differentiation between glenoid bone loss due to erosion (GBLE) and glenoid edge fractures, because the prognosis of treatment differs between these forms of glenoid bone failure. In this context, we understand that there are three types of bone failure: a) bone Bankart (fracture); b) combined; and c) glenoid bone loss due to anterior erosion (GBLE), and we will address the suggested treatment options in each situation. Until recently, the choice of surgical method was basically made by the degree of bone involvement. With the evolution of knowledge, the biomechanics of bipolar lesions and the concept of glenoid track , the cutoff point of critical injury, has been altered with a downward trend. In addition to bone failures or losses, other variables were added and made the decision more complex, but a little more objective. The present update article aims to make a brief review of the anatomy with the main lesions found in instability; to address important details in arthroscopic surgical technique, especially in complex cases, and to bring current evidence on the issues of greatest divergence, seeking to guide the surgeon in decision making.

Defining the proximity of the axillary nerve from defined anatomic landmarks: an in vivo magnetic resonance imaging study

BACKGROUND

The location of the axillary nerve in the shoulder makes it vulnerable to traumatic or iatrogenic injury. Cadaveric studies have reported the location of the axillary nerve but are limited because of tissue compression, dehydration, and decay. Three-Tesla (T) magnetic resonance imaging (MRI) allows high anatomic resolution of neural structures. The aim of our study was to better define the location of the axillary nerve from defined bony surgical landmarks in vivo, using MRI scan.

METHODS

Using MRI, we defined a number of anatomic points and measured the distance from these to the perineural fat surrounding the axillary nerve using simultaneous tracker lines on both images. Two observers were used.

RESULTS

A total of 187 consecutive 3-T MRI shoulder scans were included. Mean age was 57.9 years (range 18-86). The axillary nerve was located at a mean of 14.1 mm inferior from the bony glenoid at the anterior border, 11.9 mm from the midpoint, and 12.0 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P < .001), and between the anterior and posterior borders (P < .001). The axillary nerve was located at a mean of 12.6 mm medial to the humeral shaft at the anterior border, 9.9 mm at the midpoint, and 8.6 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P = .008) and between the anterior and posterior borders (P = .002). The mean distance of the axillary nerve from the anterolateral edge of the acromion was 53.3 mm (95% confidence interval [CI] 52.3, 54.2; range 33.9-76.3). The mean distance of the axillary nerve from the inferior edge of the capsule was 2.7 mm (95% CI 2.9, 3.1; range 0.3-9.9). There was a positive correlation between humeral head diameter and axillary nerve distance from the inferior glenoid (R² = 0.061, P < .001). There was a positive correlation between humeral head diameter and distance from the anterolateral edge of the acromion (R² = 0.140, P < .001).

CONCLUSION

Our study has defined the proximity of the axillary nerve from defined anatomic landmarks. The proximity of the axillary nerve to the inferior glenoid and medial humeral shaft changes as the axillary nerve passes from anterior to posterior. The distance of the axillary nerve from the anterolateral edge of the acromion remains relatively constant. Both sets of distances may be affected by humeral head size. The study has relevance to the shoulder surgeon when considering "safe zones" during arthroscopic or open surgery.

The Saber Technique for Biceps Tenotomy

Long head of the biceps (LHB) pathology is a prevalent cause of shoulder pain. Arthroscopic tenotomy and tenodesis are performed for treatment at increasing frequency. When LHB pathology is the only glenohumeral intra-articular pathology that needs to be addressed, and an LHB tenotomy or subpectoral LHB tenodesis is planned, it is unnecessary and potentially harmful to establish an anterior rotator interval portal. The objective of this Technical Note is to describe a minimally invasive technique for LHB tenotomy at the supraglenoid tubercle without the need for establishing an accessory portal.

Angle of approach to the superior rotator cuff of arthroscopic instruments depends on the acromial morphology: an experimental study in 3D printed human shoulders

Background

Portal placement is a key factor for the success of arthroscopic procedures, particularly in rotator cuff repair. We hypothesize that the acromial anatomy may strongly determine the position of the shoulder bony landmarks and limit the surgeon’s freedom to position the arthroscopic approaches in direction towards the acromion. The purpose of this study was to analyze the relation between different acromial shapes and the freedom of movement of arthroscopic instruments relative to the rotator cuff from standardized arthroscopic portals in a laboratory study on 3D shoulder models.

Methods

3D models of shoulders with a broad range of different acromial shapes were printed using CT and MRI scans. Angles from the portals to defined points on the rotator cuff and the supraglenoid tubercle were measured. In conventional radiographs, the critical shoulder angle, the scapular body acromial angle, and the glenoid acromial angle were measured and compared with the measured angles to the rotator cuff.

Results

There was a large variation of angles of approach of instruments to the rotator cuff between the seven shoulders for each portal. From the joint line portal and the posterior edge portal, the biggest angles were measured to the posterior cuff. From the intermediate portal, the angles were largest to the intermediate rotator cuff and from the anterior portals to the anterior cuff. To the supraglenoid tubercle, best access was from anterior. For all portals, there was a big correlation between the glenoid acromial angle and the scapular body acromial angle with the angles of approach to the tendon and especially to the supraglenoid tubercle.

Conclusion

The access to the rotator cuff from almost every portal is influenced by the acromial shape. As hypothesized, a small (small GAA) and flat (big SBAA) acromion provide an easier approach to the rotator cuff from almost every portal. Therefore, it may severely influence the instruments maneuverability.

Arthroscopic subscapularis augmentation combined with capsulolabral reconstruction is safe and reliable

PURPOSE

The study aimed to compare modified arthroscopic subscapularis augmentation (MASA) with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction (Group A) or Bankart repair (Group B) for recurrent anterior shoulder instability (RASI).

METHODS

A retrospective series of 49 patients underwent primary surgery for RASI with glenoid bone loss (GBL) < 25%. Outcomes included the Oxford Shoulder Instability Score (OSIS), Visual Analogue Scale (VAS) score, Rowe score, and American Shoulder and Elbow Surgeons (ASES) functional outcome scale score. Recurrent instability, sports activity level, and range of motion (ROM) were also analysed.

RESULTS

No significant differences were observed at baseline. Forty-six patients were available for more than 2 years of follow-up. At the last follow-up after surgery, the patients in both groups had experienced significant improvements in all outcome scores (P < 0.05 for all), and obvious decreases in forward flexion and external rotation were noted in both groups (P < 0.05 for all). Group A had superior ASES scores, VAS scores, and OSISs (P < 0.05) but did not experience significant differences in either the Rowe score or ROM compared to Group B. Group A had lower rates of recurrent instability and superior outcomes for the return to sports activities. One patient in Group A had subluxation, and 4 patients in Group B had dislocation or subluxation. No patients in either group experienced neurovascular injury, joint stiffness, or surgical wound infection.

CONCLUSION

For RASI with GBL < 25%, MASA with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction was a safe technique that produced better outcomes in terms of ASES scores, VAS scores, OSISs, the return to sports, and postoperative recurrent instability and did not decrease the ROM compared to that achieved by arthroscopic Bankart repair.

LEVEL OF EVIDENCE

III.

Rotator Cuff Sparing Arthroscopic SLAP Repair With Knotless All-Suture Anchors

Arthroscopic repair of SLAP tears is a common shoulder procedure, especially in overhead athletes. Repair techniques have evolved over the last 20 years, and the optimal technique remains elusive. In many cases, a transrotator cuff portal placed lateral to the acromion is used to access the superior glenoid. However, violating the rotator cuff is not desirable in an overhead athlete, and this approach can be associated with an increased risk of postoperative morbidity. The purpose of this Technical Note is to describe our preferred surgical technique with a rotator cuff-sparing approach for arthroscopic SLAP repair with all-suture anchors.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligaments Based on Location

Humeral avulsion of the glenohumeral ligament (HAGL) can be a difficult problem to treat. HAGL lesions can be particularly challenging to repair when approached arthroscopically. Because of the technical difficulties of HAGL repair, the surgeon must be strategic to successfully address these lesions arthroscopically. The purpose of this article is to propose a surgical technique that can be used in the arthroscopic treatment of HAGL lesions based on their location.

Deep Brachial Artery Pseudoaneurysm Following Arthroscopic Shoulder Debridement

Vascular injuries resulting from arthroscopic surgeries are rare with a reported incidence of 0.005% of elective orthopedic procedures. We report a case of a 49-year-old male who developed a deep brachial artery pseudoaneurysm following an arthroscopic shoulder debridement and lysis of adhesions. He was successfully embolized with resolution of the pseudoaneurysm within 6 weeks of treatment. A review of the literature demonstrates that pseudoaneurysm formation after arthroscopic procedures is rare and pseudoaneurysms of the deep brachial artery have yet to be reported.

Editorial Commentary: Shoulder Anatomy, Finding the Axillary Nerve: Measure Twice, Cut Once

Most descriptions of shoulder anatomy note that the axillary nerve lies approximately 5 cm below the anterolateral corner of the acromion, and the nerve has been reported to range from 2 to 7 cm from the acromial edge, depending on the patient and measuring technique. The safe trans-deltoid operable area has been described as up to 4 cm below the acromion. A useful clinical guide I use is that the inferior extent of the subacromial bursa ends above the axillary nerve.

Editorial Commentary: Our Mentors Were Right, New Is Not Always Better: The Posterolateral Shoulder Trans-Rotator Cuff Portal Is Safe for SLAP Repairs

Shoulder SLAP repair anchors have traditionally been placed through a posterolateral trans-rotator cuff "Port of Wilmington" portal. Alternative anterolateral portals have been proposed to place superior glenoid anchors that seemingly avoid traversing the rotator cuff via the rotator interval but put the suprascapular nerve at risk. A recent cadaveric study demonstrated that the traditional posterolateral portal safely traversed the infraspinatus muscle belly in all specimens, which was in contrast to the anterolateral portal that traversed the supraspinatus tendon in all specimens. In addition, 80% of anchors placed through the anterolateral portal perforated the posterior glenoid in proximity to the suprascapular nerve. As originally suggested nearly 20 years ago, the posterolateral Port of Wilmington trajectory is safe on both the rotator cuff and glenoid side for SLAP repairs.

Single Working Portal Technique for Knotless Arthroscopic Bankart Repair

Arthroscopic Bankart repair is widely accepted as the method of choice in restoring the labrum to the glenoid rim. It has been shown to have comparable outcomes with open stabilization. This usually involves the use of 2 portals anteriorly: one anterosuperior accessory portal and another anteroinferior working portal. The aim of this Technical Note is to present a simple and reproducible technique for Bankart repair using a single working portal anteriorly without an accessory portal.

Controversies In The Surgical Management Of Shoulder Instability: Associated Soft Tissue Procedures

Background:

The glenohumeral joint is a ball-and-socket joint that is inherently unstable and thus, susceptible to dislocation. The traditional and most common anatomic finding is the Bankart lesion (anterior-inferior capsule labral complex avulsion), but there is a wide variety of anatomic alterations that can cause shoulder instability or may be present as a concomitant injury or in combination, including bone loss (glenoid or humeral head), complex capsule-labral tears, rotator cuff tears, Kim´s lesions (injuries to the posterior-inferior labrum) and rotator interval pathology.

Methods:

A review of articles related to shoulder anatomy and soft tissue procedures that are performed during shoulder instability arthroscopic management was conducted by querying the Pubmed database and conclusions and controversies regarding this injury were exposed.

Results:

Due to the complex anatomy of the shoulder and the large range of movement of this joint, a wide variety of anatomic injuries and conditions can lead to shoulder instability, specially present in young population. Recognizing and treating all of them including Bankart repair, capsule-labral plicatures, SLAP repair, circumferential approach to pan-labral lesions, rotator interval closure, rotator cuff injuries and HAGL lesion repair is crucial to achieve the goal of a stable, full range of movement and not painful joint.

Conclusion:

Physicians must be familiarized with all the lesions involved in shoulder instability, and should be able to recognize and subsequently treat them to achieve the goal of a stable non-painful shoulder. Unrecognized or not treated lesions may result in recurrence of instability episodes and pain while overuse of some of the techniques previously described can lead to stiffness, thus the importance of an accurate diagnosis and treatment when facing a shoulder instability.

All-Endoscopic Brachial Plexus Complete Neurolysis for Idiopathic Neurogenic Thoracic Outlet Syndrome: A Prospective Case Series

PURPOSE

To describe an all-endoscopic technique for infra- and supraclavicular brachial plexus (BP) neurolysis and to assess its functional outcomes for patients suffering from nonspecific neurogenic thoracic outlet syndrome (NTOS).

METHODS

Between January 2010 and January 2013, 36 patients presenting an idiopathic nonspecific NTOS benefited from an endoscopic decompression in our institution. The inclusion criteria were a typical clinical NTOS and failure of a 6-month well-conducted nonsurgical treatment. Preoperative findings about other shoulder conditions and complementary procedures were exclusion criteria. Interscalene, costoclavicular, and retropectoralis minor spaces were released endoscopically. The primary endpoint was the Disability of the Arm, Shoulder and Hand (DASH) score improvement 6 months after the surgery. Postoperative criteria such as pain relief, paresthesia, upper limb weakness, and provocative tests were also assessed.

RESULTS

Of 36 patients, 10 were excluded and 5 were lost during follow-up. The data of the 21 remaining patients were analyzed after 6 months. Pre- and postoperative mean DASH scores were, respectively, 70 (range 36-98) and 34 (range 2-91). The average improvement was 36 (range -20 to 80), with P = .0002. Pain and paresthesia were relieved in 80% to 90% of the cases. No complication was reported.

CONCLUSIONS

Although requiring arthroscopic skills and expert knowledge of the anatomy, our technique seems to be safe and reproducible, and it provides significant functional improvements in the selected patients with nonspecific NTOS, with an average postoperative DASH score improvement of 36%.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Shoulder Arthroscopy in the Lateral Decubitus Position

Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. The lateral decubitus position allows for excellent exposure to all aspects of the glenohumeral joint and is therefore frequently employed in procedures such as stabilization, in which extensive visualization of the inferior and posterior aspects of the joint is required. Improved visualization is imparted due to applied lateral and axial traction on the operative arm, which increases the glenohumeral joint space. To perform arthroscopy surgery in the lateral decubitus position successfully, meticulous care during patient positioning and setup must be taken. In this Technical Note, we describe the steps required to safely, efficiently, and reproducibly perform arthroscopic shoulder surgery in the lateral decubitus position.

Clinical Safety of the 5 O'clock Portal in Shoulder Arthroscopy: A Prospective Study

Background

The present study aimed to determine the rate of clinically significant neurovascular complications associated with the routine use of the 5 o'clock portal during arthroscopic Bankart repair.

Methods

Forty-eight consecutive patients underwent arthroscopic Bankart repair with the use of the 5 o'clock portal. These patients were followed at 2 weeks and 6 weeks postoperatively for subjective signs of neurovascular injury (i.e. numbness and tingling) as well as objective signs (i.e. intraoperative bleeding, radial pulse, capillary refill, sensation, motor strength, haematoma and oedema).

Results

Two out of 48 patients (4.2%) experienced transient neurological symptoms in an ulnar nerve distribution, which resolved by 6 weeks. There was no occurrence of clinically significant injury to the axillary nerve, axillary artery, musculocutaneous nerve, lateral cord of the brachial plexus or cephalic vein.

Conclusions

No clinically detectable neurovascular injuries were associated with the use of the 5 o'clock shoulder portal during Bankart repair.

Thawing frozen shoulder by steroid injection

BACKGROUND

Frozen shoulder is not an uncommon disorder, and steroid injection into the glenohumeral (GH) joint is one of the most well-known approaches for the frozen shoulder. However, their results have been varied with beneficial effects or no additional advantage. With the understanding about the pathological changes taking place in frozen shoulder and the biomechanics involved, we wanted to evaluate the short- and long-term efficacy of steroid injection by a novel three-site (NTS) injection technique and compare it with the single-site injection (SSI).

MATERIAL AND METHODS

This was a prospective study with 85 patients including all stages and randomized into two groups. SSI group received steroid injection through posterior approach. NTS group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid). Second sitting was repeated after 3 weeks. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score at initial, 3 week, 6 week and 6 month.

RESULTS

NTS group patients had significant pain relief and early improvement in activities of daily living ( p < 0.005). Both groups had improvement in shoulder movements but with NTS group, early near-normal scores were attained and sustained after 6 months. About 43% in SSI group could not attain near-normal levels and had relapses.

CONCLUSION

The three-site approach to steroid instillation in frozen shoulder is a safe method and provides early recovery and better improvement in shoulder function with less relapses.

A Biomechanical Analysis of Anchor Placement for Bankart Repair: Effect of Portal Placement

During arthroscopic Bankart repair, penetration of suture anchors through the far cortex can compromise the initial biomechanical characteristics of anchor stability and repair integrity. This study compared the placement of suture anchors through a low anterior-inferior rotator interval portal (AI) vs a trans-subscapularis portal to evaluate the rate of anchor perforation as well as biomechanical strength. Ten matched pairs of cadaveric shoulders were randomized to an AI or a trans-subscapularis portal for placement of suture anchors at the 3 o'clock and 5:30 positions. The following measurements were obtained: (1) distance from the portal to the cephalic vein; (2) presence and length of anchor penetration through the inferior glenoid; and (3) ultimate failure strength of the anchors. The distance from the portal to the cephalic vein was significantly greater with the AI vs the trans-subscapularis portal across all specimens (29.9 vs 11.2 mm, P<.05). The rate of anchor penetration was significantly increased in the AI group vs the trans-subscapularis group at the 5:30 position (60% vs 10%, P=.014) but not at the 3 o'clock position (P=.33). Mean pullout strength of the anchors at the 5:30 position trended higher in the trans-subscapularis group, but the difference was not significant (132.8 vs 112.6 N, P=.18). The cephalic vein is closer to the trans-subscapularis portal than to the AI, but is at a safe distance. Both the rate and the degree of glenoid suture anchor penetration were lower with the trans-subscapularis portal compared with the AI at the 5:30 position. Placing anchors through the trans-subscapularis portal provides a safe alternative method, with improved positioning of the inferiormost anchor compared with the traditional AI.

The Use of Accessory Portals in Bankart Repair With Posterior Extension in the Lateral Decubitus Position

The Bankart lesion, in which the anteroinferior labrum is detached from the glenoid, is the critical anatomic lesion in the majority of patients with anterior glenohumeral instability. Some patients with anterior glenohumeral instability will have Bankart lesions with posterior extension beyond the 6-o'clock position, and achieving anatomic labral repair in these cases can present a technical challenge. In our experience, the lateral decubitus position and use of accessory portals allow superior visualization of the inferior half of the glenohumeral joint for glenoid and labral preparation, anchor placement, and suture management. The use of double-loaded suture anchors at the inferior glenoid provides multiple points of fixation at this challenging location while limiting the number of anchors required. The purpose of this article is to present a simple and reproducible technique for arthroscopic repair of Bankart lesions with posterior extension, emphasizing the use of accessory 5-o'clock trans-subscapularis and 7-o'clock portals.

A multicenter study to evaluate subscapularis muscle function using 5:30 o'clock portal for antero-inferior shoulder stabilization

INTRODUCTION

The purpose of this study was to compare the outcome after arthroscopic antero-inferior shoulder stabilization with and without using a 5:30 o'clock portal.

MATERIALS AND METHODS

Sixty-two patients [age (mean ± SD), 28.05 ± 8.25 years] with a mean follow-up of 15.23 ± 5.02 months were included in this study. Thirty-one patients underwent arthroscopic antero-inferior shoulder stabilization using the 5:30 o'clock portal in center A (group I) and were compared to 31 matched patients managed with the 3 o'clock portal in center B (group II). Physical examination, standard shoulder scores, ultrasound assessment and subscapularis strength measurement were used to evaluate postoperative shoulder function.

RESULTS

Good to excellent results were seen in both groups. No significant differences were seen when comparing ASES, Constant and Rowe Score of both groups. Patients of group II achieved a significant higher score in the SST than patients of group I. (p < 0.05) Patients of group I had a significantly lesser loss of passive external rotation in 0° and 90° of abduction. (p = 0.04; p = 0.056) Ultrasound evaluation and strength measurement showed no significant differences in subscapularis muscle integrity or function neither between the involved and uninvolved shoulder nor between both groups.

CONCLUSION

Arthroscopic anterior-inferior shoulder stabilization results in excellent clinical results. When considering portal placement, the deep trans-subscapularis portal allows a more precise suture anchor placement at the inferior glenoid rim and capsular shift with a significant improved external rotation but does not negatively affect the subscapularis function in terms of internal rotation strength or structural integrity.

LEVEL OF EVIDENCE

III.

Results of Arthroscopic Bankart Lesion Repair in Patients with Post-Traumatic Anterior Instability of the Shoulder and a Non-Engaging Hill-Sachs Lesion with a Suture Anchor after a Minimum of 6-Year Follow-Up

Background

Shoulder instability is an important clinical problem. Arthroscopic surgery is an established treatment modality in shoulder instability, but it continues to be associated with a high rate of recurrences and complications. The purpose of the study was to analyze late outcomes of arthroscopic repair of Bankart lesions in patients with post-traumatic anterior shoulder instability and non-engaging Hill-Sachs lesion, with special focus on the incidence and causes of recurrences and complications.

Material/Methods

We investigated 92 patients (92 shoulders) who underwent surgery on account of post-traumatic anterior shoulder instability. The duration of follow-up ranged from 6 to 12.5 years (mean: 8.2 years). All patients were operated on in the lateral decubitus position using FASTak 2.8-mm suture anchors (FASTak, Arthrex, Naples, Florida). Treatment outcomes were evaluated using the Rowe and University of California at Los Angeles rating system (UCLA).

Results

According to Rowe scores, there were 71 (81.5%) excellent, 12 (12.6%) good, 5 (5.3%) satisfactory, and 2 (2.1%) poor results. Rowe scores improved in a statistically significant manner (p=0.00) post-surgery, to a mean of 90 (range: 25–100). Treatment outcomes measured as UCLA scores improved in a statistically significant manner (p=0.00), reaching post-operative levels of 12–35 (mean: 33.5). There were 9 recurrences, 1 case of axillary nerve praxia, and 1 case of anchor loosening.

Conclusions

With rigorous criteria for qualifying patients for surgery, arthroscopic treatment of post-traumatic anterior shoulder instability produces good outcomes and low recurrence and complication rates irrespective of the number of previous dislocations, age, or sex.

Shoulder arthroscopy: the basics

Shoulder arthroscopy is a commonly performed and accepted procedure for a wide variety of pathologies. Surgeon experience, patient positioning, knowledge of surgical anatomy, proper portal placement, and proper use of instrumentation can improve technical success and minimize complication risks. This article details the surgical anatomy, indications, patient positioning, portal placement, instrumentation, and complications for basic shoulder arthroscopy.

Trans-subscapularis portal versus low-anterior portal for low anchor placement on the inferior glenoid fossa: a cadaveric shoulder study with computed tomographic analysis

PURPOSE

The purpose of this study was to evaluate the accuracy of inserting a glenoid anchor at the 5:30 clockface position using a trans-subscapularis (TSS) portal versus a low anterior (LA) portal.

METHODS

Five surgeons (T.D., J.C., C.V., D.J.O-H., J.S.T.) placed a single anchor in 20 fresh-frozen cadaveric shoulders. In each of 2 shoulders, surgeons used an LA portal to insert the anchor, whereas in 2 shoulders a TSS portal was used. Surgeons were directed to place the anchor at the 5:30 position at an angle 45° to the glenoid surface (axial plane) and passing perpendicular to the glenoid rim in the coronal plane. Shoulders were then dissected and computed tomographic (CT) scans obtained. Anchor position relative to the clockface was documented by 2 blinded assessors, as was the angle of insertion in the axial and coronal planes. Statistical significance was calculated with a Student t test for paired samples (confidence interval [CI], 95%; significance, P < .05).

RESULTS

The average deviation from the 5:30 position was 48 minutes (standard deviation [SD], 31 minutes) for the LA portal (average position, 4:42 o'clock) versus 28.5 minutes (SD, 19 minutes) for the TSS group (average position, 5:02 o'clock) (P = .15). The average angle of anchor insertion in the axial plane was 67.2° (SD, 19°) for the LA portal versus 62.8° (SD, 14°) for the TSS portal (P = .49), whereas the average angle of insertion in the coronal plane was 31.3° (SD, 14°) of inferior angulation in the LA group and 14.3° (SD, 8°) of inferior angulation in the TSS group (P = .009). Of the anchors inserted, 9 of 20 (45%) showed evidence of far-cortical perforation. No difference in cortical perforation was seen between the 2 portals, with perforation more likely with anchors inserted greater than 45° in the axial plane (8 of 20) than with those inserted less than 45° (1 of 20) (P = .02).

CONCLUSIONS

The use of a TSS portal improves the angle of approach to the inferior glenoid rim in comparison with an LA portal, reducing the acuity of the angle of insertion in the coronal plane.

CLINICAL RELEVANCE

The TSS portal is an option for surgeons performing arthroscopic Bankart repair using anchors low on the glenoid rim.

Circumferential rotator cuff repair with the n+4 portal, subclavian portal, and high posteromedial portal

Passing suture during a rotator cuff repair requires proper orientation and purchase of the rotator cuff tendon. Our technique uses a new portal to improve access to the supraspinatus and infraspinatus and uses additional portals for a circumferential repair of the tear, thereby restoring the footprint. Using a penetrating suture passer through the anterior, posterior, and superomedial portals allows 270° of coverage. The lateral anchors complete the circumferential repair. Sutures from the medial anchors are passed in a retrograde fashion using 3 small incisions with no cannula. A spinal needle is used to localize the orientation of each portal. The N+4 portal is the workhorse portal, allowing access to the supraspinatus and infraspinatus. The suture retriever enters the trapezius 5 cm from the medial border of the acromion and 1 cm anterior to the spine of the scapula. It enters the subacromial space on top of the supraspinatus. This provides protection to the suprascapular nerve in the supraspinatus fossa. The cuff is lifted with a grasper to allow perpendicular passage of suture. The suture is retrieved for tying. The tissue purchase and location of suture placement help restore the footprint of the supraspinatus and infraspinatus. Additional sutures are passed anteriorly through the subclavian portal and posteriorly through the high posteromedial portal. The repair is completed with lateral-row anchors as needed.

Glenoid Rim Anatomy: Risk for Glenoid Vault Perforation During Labral Repair

Background:

Injuries to the glenoid labrum frequently require repair with anchors. Placing anchor devices arthroscopically can be challenging, and anchor malpositioning can complicate surgical outcomes.

Purpose:

To determine the safe insertion range and optimal insertion angle of glenoid labral anchors at various positions on the glenoid rim and to establish surgical guidelines that minimize risk of anchor perforation.

Study Design:

Descriptive laboratory study.

Methods:

Three-dimensional computed tomography scans of 30 normal cadaveric specimens were obtained. A virtual model of a generic labral anchor was inserted into the rim of the glenoid at the clockface positions represented by 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00, and 10:30. At each position, the safe insertion range was the maximal range measured, and the optimal insertion angle was identified as the angle between the bisector of the safe insertion range and the glenoid face.

Results:

Progressing in the clockwise direction, beginning at the 12:00 position, the safe insertion ranges (mean ± SD ) were 55.9° ± 10.6°, 63.6° ± 17.6°, 47.7° ± 9.1°, 46.1° ± 8°, 73.9° ± 9.7°, 40.9° ± 6.5°, 40.4° ± 7.4°, and 39.9° ± 7.1°, respectively. The optimal insertion angles were 47.9° ± 7.6°, 53.1° ± 10.9°, 35.0° ± 4.4°, 42.4° ± 4.9°, 60.9° ± 8.4°, 36.6° ± 5.9°, 31.2° ± 4.9°, 34.8° ± 4.6°, respectively.

Conclusion:

Optimal insertion angles and safe insertion ranges varied significantly with respect to the position on the glenoid face. The safe insertion range and optimal insertion angle were found to be wider at the anterior glenoid as compared with the posterior glenoid. A posterolateral insertion angle was safer than an anterior insertion angle at the 10:30 position.

Clinical Relevance:

Proper arthroscopic technique resulting in anchor insertion at the correct angle, depth, and location will prevent anchor-related glenohumeral complications such as glenoid perforation, cartilage damage, persistent pain, decreased range of motion, and failure of the reconstruction.

Complications of shoulder arthroscopy

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Pseudoaneurysm after arthroscopic subacromial decompression and distal clavicle excision

Arthroscopic shoulder surgery is considered a safe and effective method of treating a variety of shoulder pathologies and is associated with a low complication rate. The type and rate of complications can vary, depending on the procedure, positioning, surgical time, and anesthesia. Fortunately, neurovascular injuries occur infrequently. Numerous studies have described the proximity of neurovascular structures to portals placed in shoulder arthroscopy, in both the beach chair and the lateral decubitus positions. Accurate portal placement is important to avoid damage to adjacent neurovascular structures. Inaccurate placement of portals can lead to inadvertent damage to these structures and create more difficulty with visualization and angle of instrumentation, possibly compromising the success of the procedure. This article describes a 50-year-old man who underwent arthroscopic subacromial decompression and distal clavicle excision for persistent subacromial impingement and acromioclavicular arthritis. During postoperative follow-up, the patient had a small, bulging area located near the anterior portal site. Examination showed a well-healed anterior portal site with a small (approximately 2×2 cm), nontender, immobile mass located within the deep soft tissues just below the anterior portal incision. Ultrasound evaluation showed a pseudoaneurysm of a branch off the axillary artery. The patient underwent successful embolization of the pseudoaneurysm, with complete resolution of symptoms.

Inferior suture anchor placement during arthroscopic Bankart repair: influence of portal placement and curved drill guide

BACKGROUND

During arthroscopic Bankart repair, inferior anchor placement is critical to a successful outcome. Low anterior anchors may be placed with a standard straight guide via midglenoid portal, with a straight guide with trans-subscapularis placement, or with curved guide systems. Purpose/

HYPOTHESIS

To evaluate glenoid suture anchor trajectory, position, and biomechanical performance as a function of portal location and insertion technique. It is hypothesized that a trans-subscapularis portal or curved guide will improve anchor position, decrease risk of opposite cortex breach, and confer improved biomechanical properties.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty cadaveric shoulders were randomized to 1 of 3 groups: straight guide, midglenoid portal (MG); straight guide, trans-subscapularis portal (TS); and curved guide, midglenoid portal (CG). Three BioRaptor PK 2.3-mm anchors were inserted arthroscopically, with an anchor placed at 3, 5, and 7 o'clock. Specimens were dissected with any anchor perforation of the opposite cortex noted. An "en face" image was used to evaluate actual anchor position on a clockface scale. Each suture anchor underwent cyclic loading (10-60 N, 250 cycles), followed by a load-to-failure test (12.5 mm/s). Fisher exact test and mixed effects regression modeling were used to compare outcomes among groups.

RESULTS

Anchor placement deviated from the desired position by 9.9° ± 11.4° in MG specimens, 11.1° ± 13.8° in TS, and 13.1° ± 14.5° in CG. After dissection, opposite cortex perforation at 5 o'clock occurred in 50% of MG anchors, 0% of TS, and 40% of CG. Of the 90 anchors tested, 17 (19%) failed during cyclic loading, with a similar failure rate across groups (P = .816). The maximum load was significantly higher for the 3-o'clock anchors when compared with the 5-o'clock anchors, regardless of portal or guide (P = .021). For the 5-o'clock position, there were significantly fewer "out" anchors in the TS group versus the CG or MG group (P = .038). There was no statistically significant difference in maximum load among groups at 5 o'clock.

CONCLUSION

Accuracy in suture anchor placement during arthroscopic Bankart repair can vary depending on both portal used and desired position of anchor. The results of the current study indicate that there was no difference in ultimate load to failure among anchors inserted via a midglenoid straight guide, midglenoid curved guide, or percutaneous trans-subscapularis approach. However, midglenoid portal anchors drilled with a straight or curved guide and placed at the 5-o'clock position had significant increased risk of opposite cortex perforation compared with trans-subscapularis percutaneous insertion, with no apparent biomechanical detriment.

CLINICAL RELEVANCE

The findings from this study will facilitate improved understanding of risks and benefits of several techniques for arthroscopic shoulder instability treatment with regard to suture anchor fixation.

The global percutaneous shuttling technique tip for arthroscopic rotator cuff repair

Most arthroscopic rotator cuff repairs utilize suture passing devices placed through arthroscopic cannulas. These devices are limited by the size of the passing device where the suture is passed through the tendon. An alternative technique has been used in the senior author’s practice for the past ten years, where sutures are placed through the rotator cuff tendon using percutaneous passing devices. This technique, dubbed the global percutaneous shuttling technique of rotator cuff repair, affords the placement of sutures from nearly any angle and location in the shoulder, and has the potential advantage of larger suture bites through the tendon edge. These advantages may increase the area of tendon available to compress to the rotator cuff footprint and improve tendon healing and outcomes. The aim of this study is to describe the global percutaneous shuttling (GPS) technique and report our results using this method. The GPS technique can be used for any full thickness rotator cuff tear and is particularly useful for massive cuff tears with poor tissue quality. We recently followed up 22 patients with an average follow up of 32 months to validate its usefulness. American Shoulder and Elbow Surgeons scores improved significantly from 37 preoperatively to 90 postoperatively (P<0.0001). This data supports the use of the GPS technique for arthroscopic rotator cuff repair. Further biomechanical studies are currently being performed to assess the improvements in tendon footprint area with this technique.

The low-anterolateral portal for arthroscopic biceps tenodesis: description of technique and cadaveric study

PURPOSE

Arthroscopic biceps tenodesis surgery is an important procedure for the correction of biceps tendonitis or in conjunction with rotator cuff repair with biceps symptoms. Recent trends have developed in placing the biceps tendon lower in the bicipital groove for a tenodesis. However, a more distal biceps tenodesis location is technically challenging when carried out arthroscopically with standard posterior and lateral portals. We aimed to establish the safety of a low-anterolateral portal location for direct access to the lowest aspect of the bicipital groove.

METHODS

An anatomical study design was used to examine portal to neurovascular structural measurements in 23 cadaveric shoulders. These shoulders had undergone low-anterolateral portal placement over the inferior most aspect of the bicipital groove as determined by palpation and direct arthroscopic visualization. No arthroscopic irrigation was performed. Following this, the shoulders underwent open dissection with the cannula in place to evaluate for any potential damage to any portion of the axillary nerve.

RESULTS

All of the resultant portals in this study provided direct access to the inferior most aspect of the bicipital groove, and the dissection revealed that the portal was touching a small distal axillary nerve branch on the undersurface of the anterior deltoid in nearly half of the shoulders.

CONCLUSIONS

The placement of a low-anterolateral portal for arthroscopic biceps tenodesis at the distal bicipital groove does not produce significant neurovascular damage; the portal trajectory comes close to distal anterior branches of the axillary nerve. Given these findings, this portal should be placed bluntly to best protect these underlying neurovascular structures.

Complications of arthroscopic shoulder surgery

Shoulder arthroscopic procedures have become common in today's orthopedic practice. The safety of shoulder arthroscopy though well established, is not without complications both minor and significant. The true incidence of complications is difficult to identify in the current literature. However, as with all procedures, complications associated with shoulder arthroscopy do occur. General complications (ie, infection), those specific to shoulder arthroscopy (ie, positioning) and those associated with specific procedures (ie, failure) all have been recognized. The purpose of this article is to review the current literature regarding complications in shoulder arthroscopy, provide insight into the risk factors and types of complications and to provide guidelines on the prevention and management of complications if and when they occur.

A novel technique for advancing the inferior labrum in a bankart repair

Passing suture during a Bankart repair can be a difficult task. A key component of a Bankart repair involves shifting the anteroinferior capsule and labrum superiorly. This technical note describes a new technique of reaching the inferior aspect of the Bankart lesion from posterior. Typical suture passers push the tissue further away. Using a SutureLasso through the low posterolateral portal allows one to push the tissue from inferior toward the suture anchor, making it simpler to advance the capsulolabral complex. Three suture anchors are used in the anteroinferior quadrant. The lowest suture anchor is the critical anchor for advancing the capsule and labrum. The SutureLasso is placed into the axillary recess through the low posterolateral portal, and the nitinol wire is advanced through the capsule and labrum, retrieving the suture and pulling it back through the tissue for tying with a sliding locking knot. This ensures good superior advancement of the tissue and helps obtain an optimal arthroscopic result in Bankart repair. Additional anchors are placed, and suture passage for the middle and superior anchors is then completed from anterior. The advancement and restoration of the tissue tightness provide the optimal components for an excellent result.

The arthroscopic "subdeltoid approach" to the anterior shoulder

Surgical management of shoulder pathologies has evolved tremendously during the past 3 decades, such that many lesions previously treated with open techniques are now addressed arthroscopically. Despite this movement, many surgeons and outcome studies continue to prefer open repairs as the gold standard, criticizing--with good reason--the reliability, reproducibility, and extended operative time of arthroscopic repairs, particularly with respect to anterior stabilizations and subscapularis repairs. With this in mind, we present the arthroscopic "subdeltoid approach," a novel standardized exposure technique for extracompartmental anterior shoulder arthroscopy. We define the subdeltoid space as the fascial plane bound superiorly by the acromion and coracoacromial ligament, medially by the coracoid and the conjoint tendon, inferiorly by the musculotendinous insertion of the pectoralis major to the humerus, and laterally by the lateral border of the humerus. When coupled with existing arthroscopic tools, this space dramatically enhances our ability to apply open techniques to some of the more challenging anterior shoulder pathoanatomy and expand the indications and efficacy of arthroscopy. This exposure technique has been used in more than 300 cases during the past decade to treat a myriad of shoulder pathologies, without any longstanding postoperative complications.

A new technique of arthroscopic fixation using double anchors for SLAP lesions

PURPOSE

The aim of this study was to evaluate the clinical and structural outcome of the new fixation technique of type-II SLAP repair using double anchors compared with conventional method.

METHODS

Twenty-eight patients with 29 shoulders, who were followed up for at least 1 year after surgery, were enrolled. Fourteen shoulders were treated using the new technique (group 1), and 15 shoulders using the conventional technique (group 2). The clinical outcomes were evaluated using two different functional scores, the pain VAS and range of motion. The postoperative labral integrity was determined by magnetic resonance imaging at 1 year after surgery.

RESULTS

At postoperative 6 months, all functional scores of group 1 were superior to group 2, particularly in pain VAS and Constant Scoring System. All ranges of motion in group 1 showed a better result than in group 2, particularly in forward flexion and external rotation at 90° abduction (88° ± 4.8 in group 1 and 84° ± 9.2 in group 2, P = 0.03). At postoperative 12 months and the last visit, all functional scores in group 1 were superior to those in group 2 and all external rotations at 90° of abduction in group 1 showed significantly better results than those of group 2. All patients in group 1 showed complete healing of the repaired SLAP lesion but one patient in group 2 showed partial detachments on the MRI.

CONCLUSIONS

This new technique provides anatomical restoration of a SLAP lesion and yields successful clinical and structural outcomes at a short-term follow-up.

LEVEL OF EVIDENCE

Randomized controlled trials, level II.

Arthroscopically assisted fixation of glenoid fractures: a cadaver study to show potential applications of percutaneous screw insertion and anatomic risks

BACKGROUND

Displaced glenoid fractures require reduction and internal fixation to avoid chronic instability or degenerative changes. Arthroscopically assisted percutaneous fixation has been performed successfully for such fractures, avoiding extensive surgical dissection. To assess the application of this new technique, our cadaveric study was designed to show 1) the safe zones of percutaneous screw insertion and 2) the position of bony obstructions to the glenoid.

METHODS

In 18 cadaver shoulders, we performed arthroscopically assisted percutaneous wire insertion into the glenoid using anterior, superior, and posterior approaches. After dissection, distances from wires to the relevant neurovascular structures were recorded, and 95% confidence intervals were calculated. A safe distance was defined as 15 mm. The entry point of each wire and angle of insertion relative to the glenoid clock face was also recorded.

RESULTS

Superior and posterior percutaneous approaches appear to be safe, with minimal risk to the suprascapular vessels and axillary nerve, respectively. The anterior approach injured the cephalic vein in 30% of specimens, and there was a clinically significant risk to the musculocutaneous nerve and inferior branch of the suprascapular nerve. The superior portion of the glenoid is accessible by percutaneous screw insertion between the clock times 7:40 and 2:50, apart from positions occupied by the coracoid (1:05-2:00) and acromion (9:35-10:55).

CONCLUSIONS

Arthroscopic fixation of complex glenoid fractures has had good outcomes in clinical case studies. This cadaveric study shows that percutaneous screw insertion is safe via superior and posterior approaches and feasible for a range of fracture configurations.

Humeral avulsion of glenohumeral ligaments

Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra-articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini-open techniques involve limited incision in the lower one half of the subscapularis.

Anatomical considerations of subcoracoid neurovascular structures in anterior shoulder reconstruction

Anterior shoulder surgery, using open or arthroscopic technique, places subcoracoid neurovasculature at risk. This study examines the relationships of the brachial plexus and axillary artery to four bony landmarks and provides clinical correlations for anterior shoulder surgery. The musculocutaneous nerve (MN), posterior cord (PC), lateral cord (LC), and axillary artery (AA) were identified in 27 shoulders. Minimum distances (mm) were measured between neurovasculature and the coracoid tip, anterior midglenoid, inferior surface of the midclavicle, and anteromedial aspect of the acromioclavicular joint. Average distances from the coracoid to the MN, PC, LC, and AA were 69.7 ± 31.6, 50.5 ± 9.2, 41.8 ± 9.4, and 60.0 ± 8.0 mm, respectively; from the glenoid equator to the MN, PC, LC, and AA were 61.5 ± 38.5, 37.0 ± 6.1, 35.2 ± 8.7, and 45.2 ± 7.1 mm, respectively; from the midclavicle to the MN, PC, LC, and AA were 114.1 ± 33.9, 62.0 ± 13.6, 56.0 ± 19.7, and 69.9 ± 7.8 mm, respectively; and from the AC joint to the MN, PC, LC, and AA were 112.7 ± 36.5, 87.9 ± 10.6, 84.0 ± 12.0, and 100.9 ± 1.0 mm, respectively. The lateral cord was the closest structure to each bony landmark. The musculocutaneous nerve was the furthest structure from each bony landmark. Open procedures using a deltopectoral approach with the shoulder in the anatomical position, such as the Neer capsular shift and Warner capsular reconstruction, can use these results to prevent direct or retraction injuries. Results indicate a potential safe zone of 30 mm in diameter around the anteromedial coracoid tip for anteroinferior portal placement.

Complications in shoulder arthroscopy

Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.¹⁻⁷ These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them. This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.

ANATOMICAL RELATIONSHIP OF THE SUPRASCAPULAR NERVE TO THE CORACOID PROCESS, ACROMIOCLAVICULAR JOINT AND ACROMION

OBJECTIVE

To establish the anatomical relationship of the suprascapular nerve (SSN) located in the suprascapular notch, to the medial border of the base of the coracoid process, the acromial joint surface of the acromioclavicular joint and the anterolateral border of the acromion.

METHODS

We dissected 16 shoulders of 16 cadavers (9 males and 7 females). The distances from the suprascapular nerve (at its passage beneath the transverse ligament) to certain fixed points on the medial border of the base of the coracoid process, the acromial joint surface of the acromioclavicular joint, and the anterolateral border of the acromion were measured with the aid of calipers and correlated with age and sex. Cadavers with previous surgical interventions were excluded.

RESULTS

The mean measurements from the notch of the suprascapular nerve were: 3.9 cm to the medial border of the base of the coracoid process (ranging from 3.1 cm to 5.2 cm); 4.7 cm to the acromioclavicular joint (ranging from 3.9 cm to 5.2 cm); and 6.1 cm to the anterolateral border of the acromion (ranging from 5.7 cm to 6.8 cm).

CONCLUSION

Accurate anatomical knowledge of the nerves of the anterior region of the shoulder is essential in order to avoid iatrogenic injuries and to achieve satisfactory results in surgical treatment for shoulder diseases, whether performed as open or arthroscopic procedures.

Four-quadrant approach to capsulolabral repair: an arthroscopic road map to the glenoid

Advancing technology, improved instrumentation, and a desire to address intra-articular pathology with a minimally invasive approach have driven the expansion of arthroscopic shoulder surgery in the past 2 decades. Proponents cite greatly improved visualization, lack of the need to perform a capsulotomy, fewer subscapularis issues postoperatively, and improved access to the entire glenohumeral joint. Our understanding and recognition of glenohumeral joint pathology have improved, and our ability to appropriately treat it has also improved. Aside from the anteroinferior and superior capsulolabral injury, orthopaedic surgeons have encountered and are able to address combined lesions, posterior labral tears, 270 degrees to 360 degrees labral tears, capsular laxity, humeral avulsion of the glenohumeral ligaments, associated glenoid or humeral bone loss, and partial-thickness rotator cuff tears. To adequately address the extent of pathology encountered in a shoulder instability case, access to the inferior, posteroinferior, and posterior aspects is necessary. In this technical article we present a simplified approach using safe access points by dividing the glenohumeral joint into 4 quadrants that allows for ease of instrumentation and implant placement. This will provide a blueprint for the treatment of capsulolabral injuries. In addition to portal selection and location, we will discuss several instruments we believe are advantageous in tissue manipulation and suture management.

A cadaveric analysis of the arthroscopic fixation of anterior and posterior SLAP lesions through a novel lateral transmuscular portal

PURPOSE

To compare the most commonly used portals with a novel, lateral transmuscular portal for the treatment of anterior and posterior SLAP lesions.

METHODS

Six paired cadaveric shoulders underwent arthroscopy to assess 3 different instrumentation portals: the anterior-superior lateral (AL) portal, the Neviaser (N) portal, and the Rothman-lateral (RL) transmuscular portal. After each portal was established, 5-mm cannulas were inserted followed by guidewire-assisted placement of implant fixation instruments. Each shoulder was then dissected to assess the relation of the instruments to the surrounding anatomic structures.

RESULTS

When the AL portal was used, instrumentation consistently passed through the rotator interval. When the N and RL portals were used, instrumentation penetrated the rotator cuff muscle belly at a mean distance of 25.75 and 7.67 mm, respectively, from the tendon. The mean angles of entry into the glenoid rim with respect to the glenoid articular surface were 32 degrees, 38 degrees, and -6 degrees for the AL, RL, and N portals, respectively. There was no violation of subchondral bone; however, 2 specimens showed weakened articular surfaces with use of the N portal. The RL portal was the only portal that allowed placement of instrumentation into all 3 zones of the superior glenoid rim (anterior superior, direct superior, and posterior superior) without violation of the subchondral bone and at the recommended 30 degrees to 45 degrees angle of entry.

CONCLUSIONS

The RL portal provides a safe and efficient method of arthroscopic fixation and knot tying of anterior and posterior SLAP lesions by use of a single instrumentation portal.

CLINICAL RELEVANCE

This novel, lateral transmuscular portal allows optimal angles of implant placement in all areas of the superior glenoid and provides a direct, simplified approach for arthroscopic knot tying.

Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: anterior and posterior techniques

Humeral avulsion of the inferior glenohumeral ligament complex is an unusual pathology, often implicated in traumatic shoulder instability. Traditional open techniques involve at least partial detachment of the subscapularis, and arthroscopic techniques are limited by neurovascular boundaries. The technique described here presents an anterior and posterior arthroscopic approach that can be used individually or in combination to treat different types of humeral avulsion of the inferior glenohumeral ligament lesions. The anterior approach is based on anatomic guidelines described in the literature. The posterior approach is based on the arthroscopic and cadaveric anatomic studies described by one of the authors (D.N.B.); use of the recently described axillary pouch portal (Bhatia portal) permits safe arthroscopic instrumentation access in the entire inferior glenohumeral recess and provides adequate access to the posteroinferior aspect of the humeral head. The differential mattress stitch technique ensures secure fixation of the avulsed ligaments and eliminates excessive capsular redundancy. Technical tips to avoid complications are discussed, and a detailed rehabilitation protocol is presented.

Trans-rotator cuff portal is safe for arthroscopic superior labral anterior and posterior lesion repair: clinical and radiological analysis of 58 SLAP lesions

BACKGROUND

There are numerous accessory portals for the arthroscopic repair of superior labral anterior and posterior lesions. Many surgeons are reluctant to make a portal through the cuff because of concern about iatrogenic injury to the cuff.

HYPOTHESIS

An arthroscopic superior labral anterior and posterior lesion repair procedure using the trans-rotator cuff portal may yield favorable clinical and radiological outcomes, and cuffs may heal properly.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty-eight consecutive patients undergoing superior labral anterior and posterior lesion repair using the trans-rotator cuff portal, who had available both functional and radiological outcomes after 1 year of the operation, were enrolled. We evaluated the structural outcomes for the labrum and cuff using computed tomographic arthrography and measured various clinical outcomes (the supraspinatus power, visual analog scale for pain and satisfaction, American Shoulder and Elbow Surgeons shoulder evaluation form, University of California-Los Angeles shoulder score, Constant score, and Simple Shoulder Test) at the final visit.

RESULTS

All functional outcomes were improved significantly (P < .001). On computed tomographic arthrography, labral healing to the bony glenoid was achieved in all patients. Subacromial leakage of contrast media was observed in 3 patients (5.2%) through the muscular portion without any retraction or gap of the tendon. Two of 3 had preoperative cuff pathologic changes, and they were older than 45 years of age. Partial articular cuff tears were observed in 6 patients (10.3%), and 4 had the lesion preoperatively. There were no statistical differences in functional scores according to the presence of preoperative lesion, postoperative leakage, or partial cuff tear.

CONCLUSION

The data demonstrate favorable outcomes for arthroscopic superior labral anterior and posterior lesion repair using the trans-rotator cuff portal. We suggest that the trans-rotator cuff portal is an efficient and safe portal for superior labral anterior and posterior lesion repair, although there are some valid concerns of damaging the cuff in patients with a superior labral anterior and posterior lesion with concurrent cuff disorders, as well as in older patients.

An anatomic study of inferior glenohumeral recess portals: comparative anatomy at risk

PURPOSE

The purpose of this study was to describe the musculotendinous relations and neurologic structures at risk during establishment of posterior portals for access to the inferior glenohumeral recess (IGHR).

METHODS

Three 18-gauge spinal needles were used to establish 2 posteroinferior portals and 1 axillary pouch portal in 14 embalmed cadaveric shoulders, without joint distention and arthroscopic visualization. At dissection, musculotendinous structures traversed by the needles were recorded, and distances from the (1) axillary nerve (at the deltoid undersurface, quadrangular space, and capsule), (2) nerve to teres minor (at the inferior border of the teres minor muscle and at the capsule), and (3) suprascapular nerve were measured. Additional parameters studied included the vertical distances between the acromion and IGHR and between the acromion and axillary nerve. Statistical analysis (multiple comparisons procedure) was performed to compare relative portal safety.

RESULTS

The mean distance of the axillary pouch portal to the 3 nerves, at each level, was greater than that of the posteroinferior portals. In 1 specimen (7.1%), the posteroinferior portal tracts were in close proximity (within 2 mm) to the axillary nerve and its branch to the teres minor. The distance of the axillary pouch portal to the nerves was significantly greater (P < .05) at every level, except at the deltoid undersurface.

CONCLUSIONS

Our study suggests that posterior portal techniques described for access to the IGHR are safe; the risk of axillary nerve injury with posteroinferior portals is low, though possible. The axillary pouch portal is relatively farther away from the neurologic structures and provides safer access to the same region.

CLINICAL RELEVANCE

Arthroscopic procedures that require access to the IGHR can be safely performed with posteroinferior and axillary pouch portals. The axillary pouch portal may be used preferentially for this access because it is placed farthest from the neurologic structures.

Effects of the adducted or abducted position of the arm on the course of the musculocutaneous nerve during anterior approaches to the shoulder

Nerve injury is a common complication during anterior shoulder surgery. The purpose of the study was to evaluate the musculocutaneous nerve (MN) anatomically and to clarify the relationship of the MN to the glenoid labrum and coracoid process in different arm positions. The study was carried out on 40 shoulders of 20 adult cadavers fixed in 10% formaldehyde. The minimum distance of the MN at the entrance point of the nerve into the coracobrachialis to the anteromedial aspect of the coracoid tip and the distance between the MN and the top, middle, and inferior points of the glenoid labrum were measured. All measurements were performed with a digital caliper while the arm was in a neutral position, 45 degrees and 90 degrees of abduction, 90 degrees of abduction-internal rotation and 90 degrees of abduction-external rotation to evaluate whether arm position effects the results statistically or not. The results demonstrated that the position of the arm significantly changes the distance between the coracoid process (CP) and the MN or its cord. The change in distance between the glenoid labrum and the MN or its cord was also statistically significant. The distance between the CP and MN was greatest when the arm was abducted to 45 degrees (mean 3.4 cm) and least when the arm was positioned to 90 degrees of abduction-internal rotation (mean 2.0 cm). While the distance between the MN and the coracoid process was least at 90 degrees of abduction and internal rotation, the distance between the MN and glenoid labrum was lest with 90 degrees of abduction and external rotation. The distance between the glenoid labrum and MN was greatest with 45 degrees of abduction. The results of this study might be of use in avoiding the MN especially during Bristlow operations and certain rotator cuff procedures. Transferring the coracoid process during Bristow operations or placing arthroscopic portals when the arm is abducted to 45 degrees appears to be the safest position in terms of MN injury. Based on our results, when the arm needs to be abducted to 90 degrees during operation, externally rotating it may decrease the tension on the brachial plexus thus increasing the distance between the MN and the portals or retractors.

The axillary pouch portal: a new posterior portal for visualization and instrumentation in the inferior glenohumeral recess

Arthroscopic access to the inferior glenohumeral recess is necessary in several surgical procedures on the shoulder. Posteroinferior portals described for access to this region may pose a theoretic risk to the posterior neurovascular structures (outside-in technique) and to the articular cartilage (inside-out technique). The first author (D.N.B.) has devised a new posterior portal that permits direct linear access to the entire inferior glenohumeral recess. The portal is placed higher and more lateral compared with the previously described portals; this places it further away from the posterior neurovascular structures and facilitates linear access to the axillary pouch. The portal is created via an outside-inside technique, with a spinal needle to ascertain the correct portal site and angulation. The portal is placed at a mean distance of 20.45 +/- 4.9 mm (range, 15 to 35 mm) directly inferior to the lower border of the posterolateral acromial angle and 21.3 +/- 2 mm (range, 20 to 25 mm) lateral to the posterior viewing portal. The spinal needle or cannula is angulated medially at a mean of 30.6 degrees +/- 4.7 degrees (range, 25 degrees to 40 degrees ) in the axial plane and slightly inferiorly (mean, 2 degrees ; range, 20 degrees superiorly to 20 degrees inferiorly). Use of 30 degrees and 70 degrees arthroscopes through the axillary pouch portal facilitates visualization of the entire recess and of the humeral attachment of the inferior glenohumeral ligament complex for evaluation of humeral avulsion of the glenohumeral ligament lesions. The portal also permits instrumentation in combination with the standard posterior or anterosuperior viewing portal for removal of loose bodies, synovectomy, capsular shrinkage, capsulotomy, and anchor placement in the posteroinferior glenoid rim.