Anatomic risks of shoulder arthroscopy portals: anatomic cadaveric study of 12 portals

Arthroscopic Bankart repair using a single anterior working portal technique: a systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and outcomes of arthroscopic Bankart repair using a single anterior working portal and determine whether they are comparable to the standard two-portal technique.

METHODS

A search following PRISMA guidelines was performed in July 2024 in the PubMed, Embase, Scopus, and Cochrane Library databases. Studies evaluating outcomes of patients undergoing arthroscopic Bankart repair using a single anterior portal technique were included. A meta-analysis comparing outcomes was performed using a random-effects model. A P-value < 0.05 was considered statistically significant.

RESULTS

Seven studies in patients undergoing Bankart repair with a single anterior portal were included (311 patients, 84.6% male, mean age 27.8 years, mean follow-up 37.4 months). Five of seven studies compared outcomes of a single anterior portal versus the standard two-portal technique. The duration of surgery was significantly shorter in the single anterior portal group (P < 0.00001). The postoperative Oxford Instability Score (P = 0.84), Rowe score (P = 0.26), American Shoulder and Elbow Surgeons score (P = 0.73), Constant-Murley score (P = 0.92), and Visual Analog Scale Pain score (P = 0.07) were similar between both groups. The postoperative degree of shoulder abduction (P = 0.84) and external rotation (P = 0.64) were similar between both groups. The risk of redislocation (P = 0.98) was similar between both groups.

CONCLUSION

Patients undergoing arthroscopic Bankart repair with a single anterior portal had significantly lower operative times and comparable PROs, ROM, and risk of redislocation relative to patients undergoing repair with a standard two-portal technique.

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.

Shoulder and Knee Arthroscopy Access Point: Prospective Comparison of Sonographic and Palpatory Detection - Which Method is Better for Novices?

Purpose  Arthroscopy is one of the most common interventions in orthopedics. Hence it is important to train users early in order to ensure the safest possible identification of access portals (AP). This prospective study aimed to compare a palpatory (PalpMethod) with a sonographic (SonoMethod) method for AP location in the shoulder and knee joints. Materials and Methods  The study included trainee doctors (n=68) attending workshops (lasting approx. 90 minutes). In these workshops a teaching video initially demonstrated the PalpMethod and SonoMethod of AP identification. An experienced operator first marked the access portals on the test subject with a UV pen (determined ideal point [DIP]). Adhesive film was then affixed to the puncture regions. Subsequently participants marked on shoulders and knees first the point determined by palpation, then the point determined by sonography. Analysis involved DIP visualization with a UV lamp and employed a coordinate system around the central DIP. In addition, participants completed an evaluation before and after the workshop. Results  The analysis included 324 measurements (n=163 shoulders and n= 161 knees). The majority of participants had not previously attended any courses on manual examination (87.9%) or musculoskeletal ultrasound (93.9%). Overall, the markings participants made on the shoulder using the SonoMethod were significantly closer to the DIP than those made by the PalpMethod (Palp 18.8mm ± 14.5mm vs. Sono 11.2mm ± 7.2mm; p<0.001). On the knee, however, the markings made by the PalpMethod were significantly closer to the DIP overall (Palp 8.0mm ± 3.2mm vs. Sono 12.8mm ± 5.2mm; p<0.001). Conclusion The results show that the SonoMethod produces more accurate markings on the shoulder, while the PalpMethod is superior for the knee.

Improving visualization in shoulder arthroscopy

Arthroscopic shoulder procedures are one of the most common procedures used to restore function through minimally invasive techniques. With the demand for shoulder arthroscopic procedures comes the need for safe, effective, and efficient surgery that maximizes patient outcomes while minimizing complications. Many variables contribute to visualization in shoulder arthroscopy including vascular anatomy, blood pressure control, arthroscopic pump systems, turbulence control, epinephrine, and tranexamic acid. Furthermore, patient positioning can have a dramatic effect on visualization with both the beach chair position and lateral decubitus positioning having various strengths and weaknesses depending on the intended procedure being performed. The purpose of this review is to examine the benefits and complications reported in the literature for improving visualization in shoulder arthroscopy.

Operative Fixation of a Humeral Shaft Periprosthetic Fracture After IlluminOss: A Case Report

CASE

An 82-year-old man sustained a periprosthetic fracture after IlluminOss photodynamic bone stabilization system (PBSS) stabilization for an impending pathologic fracture. Nonoperative management was unsuccessful, and he subsequently underwent operative fixation, which featured lag screw fixation of the spiral distal humeral shaft fracture and osteotomy followed by plate fixation of the pathologic humeral shaft fracture.

CONCLUSION

This is the first article to report this complication with IlluminOss PBSS stabilization and details regarding revision surgery.

Limited Arthroscopic Deltoid Fasciectomy Increases Subacromial Visualization and Characterization of Rotator Cuff Tears

Adequate arthroscopic visualization in the subacromial space is a necessity to appropriately characterize rotator cuff tears and to subsequently develop a suture construct that best reduces the cuff tear with the least tissue tension possible for optimal healing. The purpose of this article and corresponding video is to demonstrate a technique for carrying out a limited deltoid fasciectomy, resulting in enhanced visualization of the rotator cuff through the lateral viewing portal.

Results of arthroscopic treatment for anteroinferior shoulder instability using a single anterior working portal using birdbeak

BACKGROUND

The shoulder joint is the joint with the most dislocations in all joints. The arthroscopic surgery method is considered the gold standard because it creates less soft tissue damage, shorter hospitalization and surgery time, and less restriction of movement after surgery in shoulder instability. Anterior single portal technique has become popular recently. In this study, it was aimed to evaluate the results of the anterior single portal repair technique using "birdbeak". We try to evaluate if this technique is a reliable technique and has the same or more advantages of two portal arthroscopic surgery and make the surgery easier for surgeons.

METHODS

In the total of 40 patients who underwent arthroscopic surgery for traumatic recurrent anterior shoulder dislocation between January 2017 and February 2020, this study included 19 patients with the surgical technique of arthroscopic isolated anterior labrum tear repair using a birdbeak from the anterior single working portal. Clinical results were evaluated with the Simple Shoulder Test (SST), Rowe Score for Instability (RWS) and Oxford Shoulder Instability Score (OSIS) tests before and after surgery. The relationship between the time to surgery after the first dislocation and clinical outcomes was also examined in the study. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to control the assumption of normality. In addition, Pearson correlation and Spearman correlation analyzes were used to test the relationship between the variables.

RESULTS

The mean follow-up period of the 19 patients included in this study was 33.1 months. The mean time to surgery after the first dislocation was 18.4 months. The mean preoperative number of dislocations was 5.3. The mean number of anchors used in the repair was 2.1. No recurrent dislocations were observed after surgery. A significant difference was observed between preoperative and postoperative SST, RWS and OSIS scores (respectively, p = 0.000 < 0.001, p = 0.000 < 0.001, p = 0.000 < 0.001). There was no statistically significant relationship between the time elapsed after the first dislocation and the postoperative SST, RWS, OSIS scores (respectively, p = 0.43 > 0.05, p = 0.39 > 0.05, p = 0.31 > 0.05).

CONCLUSION

It has been observed that the repair technique applied using the "birdbeak" from the anterior single working portal is a successful treatment, and further studies are required due to the limited literature.

Arthroscopic Anterior Glenoid Bone Grafting for Shoulder Instability Using an Interconnected Suture Anchor Technique

Anterior bone grafting is an established and frequently used treatment option for recurrent anterior shoulder instability in combination with significant glenoid bone loss. Several open and arthroscopic fixation techniques have been presented to this field in recent years. Some of these techniques are associated with different peri- and postoperative problems or complications. Therefore, the technical gold standard for anterior bone grafting has not been determined, resulting in an ongoing evolvement of bone-grafting techniques. Arthroscopic, metal-free fixation procedures were introduced to the field bone grafting to overcome previous problems of screw fixation. These metal-free techniques frequently include surgically challenging transglenoidal drilling and are placing anterior soft tissues and neurovascular structures at risk. We therefore present an arthroscopic anterior, PEEK (polyether ether ketone)-anchor based, interconnecting bone-grafting technique bypassing previous challenges to restore the anterior glenoid bone stock with adequate positioning and fixation of the bone graft.

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.

Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment

Arthroscopy of the shoulder, elbow, hip, and knee has become increasingly utilized due to continued advancements in technique, training, and instrumentation. In addition, arthroscopy is generally safe and effective in the utilization of joint preservation surgical techniques. The arthroscopist must utilize a thorough understanding of the surgical anatomy, detailed care with patient positioning, and safe instrumentation portals to prevent associated neurological injury. In the event of postoperative neurological complications, the physician must carefully document the patient history and physical examination while considering the utilization of additional imaging, testing, or surgical nerve exploration with a specialized team depending upon the severity of neurological injury. In this review, we discuss the prevention, evaluation, and treatment of neurological complications related for arthroscopic procedures of the shoulder, elbow, hip, and knee.

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.

Arthroscopic reduction and subscapularis remplissage (ARR) of chronic posterior locked shoulder dislocation leads to optimized outcomes and low rate of complications

PURPOSE

Unrecognized posterior shoulder dislocation with a concomitant humeral head fracture affects joint function and no consensus exists regarding treatment. The present study analyses clinical and radiographic outcomes of a novel arthroscopic technique for reducing chronic locked posterior shoulder dislocation associated with subscapularis remplissage.

METHODS

The study comprises a retrospective analysis of consecutive chronic posterior locked shoulders (CPLS) with minimum 2-years follow-up of patients who had undergone McLaughlin technique arthroscopic modification for the treatment of CPLS with a reverse Hill-Sachs lesion. Active range of motion (ROM), Western Ontario (WOSI) and Constant Score (CS), were evaluated pre- and postoperatively. Plain radiographs and magnetic resonance imaging (MRI) scans were collected pre- and post-operatively, recording bone defect, osteoarthritis, cuff integrity/fatty infiltration, and the grade of filling of the reverse Hill-Sachs.

RESULTS

Twelve male patients with a mean follow-up of 37.3 months ± 10.5 (range, 24-58) were included. Mean WOSI and CS scores improved from 41 to 92 and 28 to 94 points, respectively. ROM measurements all had significantly increased at final follow-up, with no significant differences in arm rotation. No defects were left unfilled at final MRI examination.

CONCLUSION

The results of this uncontrolled study with a limited number of patients confirm that arthroscopic reduction and subscapularis remplissage is a highly effective and satisfactory treatment method resulting in no shoulder rotation deficits.

LEVEL OF EVIDENCE

Level IV.

Comparison of anterior single- and standard two-portal techniques in arthroscopic Bankart repair

Objectives

This study aims to compare the outcomes of patients undergoing a single anterior portal or a standard two-portal arthroscopic procedure for Bankart repair.

Patients and methods

Between January 2015 and March 2018, a total of 71 consecutive patients (53 males and 18 females; mean age: 33.3±10.3 years; range, 17 to 56 years) who underwent arthroscopic Bankart repair with a minimum two-year follow-up period were included. The patients were divided into two groups according to the arthroscopic technique used: single anterior portal group (Group 1, n=32) and standard two-portal group (Group 2, n=39). Demographic and surgical characteristics of the patients were recorded. Pre- and postoperative clinical and functional outcomes were evaluated using the external rotation degree, as well as Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA) Shoulder Rating Scale, Constant-Murley Score (CMS), Oxford Shoulder Instability Score (OSIS), and Rowe scores. The clinical and functional outcomes and revision rates were compared between the groups.

Results

The mean follow-up was 32.0±7.4 months in Group 1 and 38.0±13.4 months in Group 2 (p=0.222). Good-to-excellent postoperative functional and clinical outcomes were achieved in both groups at the final follow-up, compared to baseline (p<0.001 for all). No significant difference was observed in the postoperative outcomes including daily sports activity, VAS, ASES, UCLA Shoulder Rating Scale, CMS, OSIS, and Rowe scores, and external rotation restriction degrees between the groups (p=0.270, p=0.190, p=0.313, p=0.248, p=0.125, p=0.203, p=0.318, p=0.083, respectively). The operative time in Group 1 was significantly lower than that in Group 2 (60.3±8.3 vs. 71.4±7.2, respectively; p=0.001). Four patients (5.6%) experienced recurrent dislocation with no significant difference between the groups (p=0.622). No significant complications occurred in the peri- or postoperative period. Fifty-eight (81.7%) patients returned to their preoperative sports activity level. The mean time to return to sports was 7.2±1.7 months.

Conclusion

Good-to-excellent clinical and functional outcomes can be obtained after arthroscopic Bankart repair, regardless of the use of a single or two anterior working portals. However, the single-portal technique is associated with reduced the operative time, compared to two-portal technique.

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.

Shoulder Arthroscopic Rotator Cuff Repair With Biceps Tenodesis and Acromioplasty Using a Single Working Portal

Rotator cuff repair, acromioplasty, and biceps tenodesis operations have become some of the most common shoulder surgical procedures, evolving from open techniques to minimally invasive arthroscopic techniques. The use of many arthroscopic portals has been associated with surgical risks to many surrounding anatomic structures. We present an arthroscopic technique using a single anterolateral working portal for rotator cuff repair, acromioplasty, distal clavicle excision, and long head of the biceps tenodesis; this technique decreases the risk of injury to the surrounding neurovascular and musculotendinous structures, enables a faster recovery, and is minimally invasive.

Anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior lesions: A cadaveric study and preliminary report

OBJECTIVE

This study aims to investigate the anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior (SLAP) lesions in a human cadaveric model.

METHODS

In this anatomic study, bilateral shoulder girdles of 12 adult formalin embalmed cadavers were used. All cadavers were male, and the mean age was 63.4±7.3 years. The portal entry point was determined as midway between the anterior and posterior borders of the acromion, approximately 1 cm lateral from the edge of the acromion. After a guidewire was placed in the glenoid cavity at the 12 o'clock position where the SLAP lesion typically occurs, a switching stick was inserted there. Each glenoid was then drilled with a 2.4 mm drill through an arthroscopic cannula. Subsequently, anatomical dissection was executed to assess the relationship of the transmuscular portal with the suprascapular nerve, axillary nerve, supraspinatus tendon, acromion, and biceps tendon. Lastly, the shortest distance between the aforementioned structures with the drill was measured by a sensitive caliper to determine whether there was a penetration of the structures. Differences between the right and left sides were analyzed.

RESULTS

The mean distance between the portal and the axillary nerve was 55.5 mm±6.0 mm, and the mean length of the suprascapular nerve was 61.2 mm±7.0 mm. The mean distance between the portal and the supraspinatus tendon was 2.8 mm±1.5 mm. No penetration of the axillary nerve, suprascapular nerve, and supraspinatus tendon was observed in any cadaver. No differences were detected for measured anatomical parameters between the right and left sides (p>0.05).

CONCLUSION

Findings from this cadaveric study revealed that the transmuscular portal may allow for a reliable anchor placement without any nerve or tendon penetration during arthroscopic SLAP repair.

LEVEL OF EVIDENCE

Level V.

Anterior shoulder anatomy and subcoracoid impingement: An anatomical study

OBJECTIVE

The aim of our study was to describe the anatomy of the anterior shoulder, specifically structures potentially involved in subscapularis tears pathophysiology and also to identify structures at risk during surgical approaches of this area.

MATERIALS AND METHODS

We designed an observational, experimental study based on cadaveric models. Dissection was performed and several structures of the anterior shoulder were characterized including the subscapularis, coracoid morphology, the coracoacromial ligament, coraco-humeral distance, and the axillary and musculocutaneous nerves.

RESULTS

Our sample included 16 shoulders. The coracoacromial ligament presented two bands in 37.5%, and these variants were significantly wider and thinner, and were associated with inferior coraco-humeral distance in internal rotation. The subscapularis footprint was longer and the coracoid process was bigger in male specimens, and the median coracoid angle was 122°, corresponding to a Leite-Torres type I. The Subscapularis showed a median thickness of 0.7cm, while the coraco-humeral distance in our sample ranged from 0.30cm in internal rotation to 0.85cm in external rotation. Neurologic relevant structures were at least more than 2.55cm from the coracoid tip.

CONCLUSIONS

This is the first paper to explore the eventual relationship between the presence of a double band coracoacromial ligament variant and subcoracoid impingement. Also, to our knowledge, this is the first cadaveric model study to postulate a possible anatomic base for subcoracoid impingement, as the SS myotendinous junction thickness was found to be greater than the coraco-humeral distance in neutral position and in IR.

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.

Similar functional outcome using single anterior portal and standard two portals technique in recurrent dislocation of shoulder

PURPOSE

Recurrent dislocation of shoulder (RDS) is a common injury in high demand professionals, like athletes and military personnel. The treatment for the patients with Bankart lesion is the arthroscopic repair. This present study compares the outcomes of two different techniques of arthroscopic Bankart repair i.e. a standard two anterior portals technique and a single anterior portal technique in patients with RDS.

METHODS

Patients with traumatic RDS met the inclusion criteria were managed with Bankart repair using either two anterior portals (Group A) or a single anterior portal (Group B) technique. Patients were evaluated before the intervention and at the mean follow-up of approximately two years using Rowe score, Oxford shoulder score and Tegner activity scale.

RESULTS

The mean age of the patients in Groups A (n = 34) and B (n = 37) was 29.64 years and 29.05 years respectively (p = 0.66). The dominant shoulder was involved in 27 patients in Group A and 22 patients in Group B (p = 0.069). The operative time in Group A and B was 68.52 min and 46.35 min, respectively (p < 0.001). The complications at follow-up, the mean Rowe score and Oxford score improved significantly in both groups compared with the pre-operative values. However, the final outcome scores were not significantly different between the both groups. The median Tegner's score preoperatively and at follow-up was 7 and 6, respectively in Groups A and B.

CONCLUSIONS

Single anterior portal technique is an effective treatment modality, yielding a similar outcome as two anterior portals technique in the management of RDS.

Rotator cuff integrity and shoulder function after intra-medullary humerus nailing

INTRODUCTION

Antegrade percutaneous intra-medullary nailing (IMN) has a poor reputation in the treatment of humerus fractures. The aim of the present study was to assess rotator cuff integrity and shoulder function after IMN in humerus fracture.

HYPOTHESIS

Third-generation humeral nails (straight, small diameter, with locked screws) conserve rotator cuff tendon integrity and avoid the shoulder stiffness and pain incurred by 1st generation (large diameter, without self-blocking screw) and 2nd generation nails (curved, penetrating the supraspinatus insertion on the greater tuberosity).

METHODS

Forty patients (26 female, 14 male; mean age, 60 years (range, 20-89 years)) with displaced humeral fracture (23 proximal humerus, 17 humeral shaft) underwent IMN using a 3rd generation nail (34 Aequalis™ (Tornier-Wright), 6 MultiLoc™ (Depuy-Synthes)). Mean clinical, radiologic and ultrasound follow-up was 8 months (range, 6-18 months); 22 patients agreed to postoperative CT scan.

RESULTS

There were no revision surgeries for rotator cuff repair or secondary bone displacement. Mean Adjusted Constant Score (ACS) was 93±22% and the Subjective Shoulder Value (SSV) 77±18%. Elevation was 140±36°, external rotation 48±22° and internal rotation was to L3. Ultrasound found: 5 supraspinatus tendon lesions (12.5%) (2 full and 3 deep partial tears) without functional impact (ACS) 91% without vs. 107% with tear; (p=0.12); 2 of the deep partial tears involved excessively lateral and high nail positioning. Eight patients (20%) had painful tendinopathy of the long head of the biceps (LHB) tendon associated with significantly impaired functional scores (ACS 65% vs. 100%; p<0.001); and 4 cases of technical error: 3 of anterior LHB screwing in the groove, and 1 of LHB irritation due to an excessively long posterior screw.

CONCLUSION

Supraspinatus tendon lesions following IMN with a 3^rd-generation humeral nail were rare (12.5%) and asymptomatic; prevalence was not higher than in the general population in the literature (16%). LHB tendinopathy was frequent (20%) and symptomatic, and due to technical error in half of the cases.

LEVEL OF EVIDENCE

IV, retrospective study.

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.

Curved-guide system is useful in achieving optimized trajectory for the most inferior suture anchor during arthroscopic Bankart repair

BACKGROUND

A curved-drill guide system was recently introduced to achieve a better trajectory for a low anteroinferior anchor during arthroscopic Bankart repair. However, the clinical performance of such a device remains unclear. The purpose of this study was to evaluate the trajectory and position of the low anteroinferior suture anchor with use of the curved-guide system in clinical cases.

METHODS

We enrolled 41 cases of arthroscopic Bankart repair in this study. Of these cases, 9 were repaired using the curved drill guide whereas 32 were repaired using a conventional straight guide. Postoperative computed tomography scans were obtained, and 3-dimensional models of the scapula were reconstructed. Notable perforations of the opposite cortex by the most inferior anchors were recorded. The clock-face angle, insertion angle, and insertion distance were measured.

RESULTS

The anchor perforation rate in the curved-guide group (11%) was significantly lower than that in the straight-guide group (56%) (P = .02). The insertion distance in the curved-guide group was significantly shorter than that in the straight-guide group (4.0 ± 1.6 mm vs. 7.0 ± 2.4 mm, P < .01). The clock-face angle and insertion angle were significantly greater in the perforated straight-guide group than in the nonperforated groups. The percentage of anchors in the absolute safe zone (clock-face angle > 135° and < 165° and insertion angle < 100°), where no anchors perforated, was greater in the curved-guide group than the straight-guide group.

CONCLUSION

Compared with the conventional straight guide, the curved-guide system provides better placement of the most inferior suture anchor during arthroscopic Bankart repair.

Comparison of Curved and Straight Anchor Insertion for Bankart Repair

The quality of Bankart repair may be compromised by the presence of glenoid perforation during suture anchor placement. The purpose of this study was to compare the rate of glenoid perforation and biomechanical strength of antero-inferior suture anchors placed with a curved vs a traditional straight technique through an anteroinferior portal. Ten bilateral pairs of fresh human cadaveric shoulders were randomized to either a curved or a straight suture anchor insertion technique. An anteroinferior portal was used to place a 1.5-mm soft anchor in the anteroinferior glenoid (5:30 position for right shoulders). Anatomic dissection was performed, and the maximum load of each anchor was measured using a materials testing system. The overall rate of glenoid perforation by the anteroinferior anchor was 50%. The rate of glenoid perforation was 40% in the straight group and 60% in the curved group (P=.41). The median maximum load was 86 N in the straight group and 137 N in the curved group (P=.23). The median maximum load of the anchors that did perforate the glenoid was 102 N and of those that did not was 118 N (P=.72). The mode of failure was suture anchor pullout in all except one specimen. The curved guide was not superior to the traditional straight guide in terms of the rate of glenoid perforation or the maximum load of the suture anchors. Anterior cortical perforation of the glenoid during anteroinferior suture anchor placement is common with both techniques. [Orthopedics. 2019; 42(2):e242-e246.].

Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing

BACKGROUND

The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures.

METHODS

We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months).

RESULTS

Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively.

CONCLUSIONS

Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.

The Safety of a Far Medial Arthroscopic Portal for Anatomic Glenoid Reconstruction: A Cadaveric Study

Background:

An arthroscopic technique for anatomic glenoid reconstruction has been proposed for the treatment of glenohumeral bone loss in patients with recurrent shoulder instability. This technique is proposed as an alternative to open techniques as well as to the technically challenging arthroscopic Latarjet procedure. In arthroscopic anatomic glenoid reconstruction, a distal tibial allograft is inserted through a novel far medial portal, superior to the subscapularis tendon and lateral to the conjoint tendon.

Purpose:

To evaluate the safety of the far medial arthroscopic portal for anatomic glenoid reconstruction in a cadaveric study.

Study Design:

Descriptive laboratory study.

Methods:

Ten cadaveric shoulder specimens were dissected after inside-out medial arthroscopic portal insertion in the lateral decubitus position for arthroscopic anatomic glenoid reconstruction. A single observer performed 3 measurements on each specimen with a digital caliper (to the nearest 0.1 mm) from the medial portal to neurovascular structures, and the mean (±SD) and the range were calculated. The anthropometric data of the cadaveric specimens were also collected.

Results:

The mean distances between the far medial arthroscopic portal and sensitive anatomic structures were as follows: 50.79 ± 13.69 mm from the musculocutaneous nerve, 46.28 ± 9.64 mm from the axillary nerve, 6.71 ± 8.52 mm from the cephalic vein, and 48.52 ± 7.22 mm from the subclavian artery and vein. The mean size of the medial arthroscopic portal was 25.60 mm. In all cases, the subscapularis muscle was intact.

Conclusion:

The far medial arthroscopic portal for anatomic glenoid reconstruction without a subscapularis split presents a minimal risk to most neurovascular structures during bony reconstruction of the glenoid surface in patients with anterior shoulder instability. The only anatomic structure at risk is the cephalic vein, while the axillary and musculocutaneous nerves are at a safe distance away from the portal, based on previous shoulder arthroscopic portal safety studies in the literature.

Clinical Relevance:

Arthroscopic anatomic glenoid reconstruction using a distal tibial allograft is increasing in popularity for the treatment of anterior shoulder instability with significant bone loss. Being a relatively new technique, the safety of it has yet to be established. This study aimed to demonstrate the safety of a new portal used for arthroscopic anatomic glenoid reconstruction.

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.

In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.

Landmarks for Identifying the Suprascapular Foramen Anteriorly: Application to Anterior Neurotization and Decompressive Procedures

BACKGROUND

Additional landmarks for identifying the suprascapular nerve at its entrance into the suprascapular foramen from an anterior approach would be useful to the surgeon.

OBJECTIVE

To identify landmarks for the identification of this hidden site within an anterior approach.

METHODS

In 8 adult cadavers (16 sides), lines were used to connect the superior angle of the scapula, the acromion, and the coracoid process tip thus creating an anatomic triangle. The suprascapular nerve's entrance into the suprascapular foramen was documented regarding its position within this anatomical triangle. Depths from the skin surface and specifically from the medial-most point of the clavicular attachment of the trapezius to the suprascapular nerve's entrance into the suprascapular foramen were measured using calipers and a ruler. The clavicle was then fractured and retracted superiorly to verify the position of the nerve's entrance into the suprascapular foramen.

RESULTS

From the trapezius, the nerve's entrance into the foramen was 3 to 4.2 cm deep (mean, 3.5 cm). The mean distance from the tip of the corocoid process to the suprascapular foramen was 3.8 cm. The angle best used to approach the suprascapular foramen from the surface was 15° to 20°.

CONCLUSION

Based on our study, an anterior suprascapular approach to the suprascapular nerve as it enters the suprascapular foramen can identify the most medial fibers of the trapezius attachment onto the clavicle and insert a finger at an angle of 15° to 20° laterally and advanced to an average depth of 3.5 cm.

Embryological and comparative description of the cephalic vein joining the external jugular vein: A case report

The cephalic vein arises from the radial end of the dorsal venous arch. It turns around the radial border of the forearm and passes proximally along the arm to the shoulder, where it enters the axillary vein by penetrating the clavipectoral triangle. The cephalic vein is prone to vary at the antecubital fossa, where it forms numerous anastomoses. A male cadaver fixated with a 10% formalin solution was dissected during regular anatomy lessons. It was found that the cephalic vein crossed the upper third of the arm between two fasciculi of the deltoid muscle and reached the shoulder, where it passed above the acromion and crossed the posterior border of the clavicle in order to join the external jugular vein. The cephalic vein is one of the most used veins for innumerous activities, such as venipunctures and arteriovenous fistula creation. Furthermore, it is an anatomical landmark known for its consistent anatomy, as it possesses low rates of variability. Despite that, its anatomical variations are clinically and surgically significant and healthcare professionals must be aware of the variations of this vessel. We aim to report a rarely described variation of the cephalic vein and discuss its embryological, phylogenetic and clinical features.

Sudden Onset of Subcutaneous Air Emphysema After the Application of Air to a Maxillary Premolar Located in a Nonsurgical Field

Although rare, subcutaneous air emphysema can occur during dental procedures such as endodontic treatment, surgical extractions, and preparing a tooth for an indirect or direct dental restoration. We report the development of a subcutaneous air emphysema that was introduced through the periodontal ligament of an untreated premolar after the use of an air syringe to dry the tooth.

Arthroscopic Repair of a Circumferential 360° Labral Tear

Injuries to the glenoid labrum can result in shoulder instability and pain. These lesions may occur anywhere around the glenoid labrum, and thus, the arthroscopist must be prepared to approach all aspects of the glenoid from multiple angles. The pan-labral or circumferential (360°) tear of the glenoid labrum presents a unique challenge to even the experienced arthroscopist. The extent of the lesion requires the use of accessory portals and percutaneous techniques to establish adequate visualization and to facilitate the proper trajectory for anchor placement. The pan-labral tear also demands intraoperative planning throughout the repair to ensure proper tensioning and alignment of the labrum and capsular tissue. The purposes of this article are to report a technique for repairing a pan-labral lesion and to emphasize the use of accessory portals and percutaneous techniques for complete access to the glenoid.

Protective and Predisposing Morphological Factors in Suprascapular Nerve Entrapment Syndrome: A Fundamental Review Based on Recent Observations

Suprascapular nerve entrapment syndrome (SNES) is a neuropathy caused by compression of the nerve along its course. The most common compression sites include the suprascapular notch and the spinoglenoid notch. The aim of this article was to review the anatomical factors influencing the occurrence of SNES in the light of the newest reports. Potential predisposing morphological factors include a V-shaped, narrow, or "deep" suprascapular notch; a band-shaped, bifurcated, or completely ossified superior transverse scapular ligament (STSL); particular arrangements of the suprascapular nerve and vessels at the suprascapular notch. A very recent report indicates structures at the suprascapular notch region that may protect from SNES, such as the suprascapular notch veins (SNV). The role of the anterior coracoscapular ligament (ACSL) is still not clear. While some studies indicate that it may predispose for SNES, the newest study proposes a protective function. Knowledge of these variations is essential for arthroscopic and other surgical procedures of this area in order to avoid iatrogenic injury of the suprascapular nerve or unexpected bleeding from the suprascapular vessels running alongside the STSL.

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.

Unusual morphology of scapulae: incidence and dimensions of ossified ligaments and supraspinous bony tunnels for clinical consideration

INTRODUCTION

Knowledge of morphological variations of the suprascapular region is important in the management of entrapment neuropathy and interventional procedures. The objective of this study was to collect data on the morphological features and dimensions of ossified ligaments and unusual bony tunnels of scapulae from a North Indian population.

METHODS

A total of 268 adult human scapulae of unknown gender were obtained from the bone bank of the Department of Anatomy, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. The scapulae were evaluated for the incidence of ossified superior transverse scapular ligaments (STSLs), ossified inferior transverse scapular ligaments (ITSLs) and bony tunnels (i.e. the bony canal between the suprascapular notch and spinoglenoid notch), found along the course of the suprascapular nerve (SSN). The dimensions of these structures were measured and noted down. Ossified STSLs were classified based on their shape (i.e. fan- or band-shaped) and the dimensions of the ossified suprascapular openings (SSOs) were measured.

RESULTS

Ossified STSLs were present in 26 (9.7%) scapulae. Among the 26 scapulae, 16 (61.5%) were fan-shaped (mean area of SSO 16.6 mm(2)) and 10 (38.5%) were band-shaped (mean area of SSO 34.2 mm(2)). Bony tunnels were observed in 2 (0.75%) specimens, while an ossified ITSL was observed in 1 (0.37%) specimen.

CONCLUSION

The data obtained in the present study augments the reference literature for SSN decompression and the existing anatomical databases, especially those on Indian populations. This data is useful to clinicians, radiologists and orthopaedic surgeons.

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.

Arthroscopic Repair of Posterior Glenohumeral Capsular Rupture With Concomitant Anterior and Posterior Labrum Detachment

Posterior glenohumeral capsular rupture is a rare cause of posterior glenohumeral instability. With advances in imaging and arthroscopic techniques, diagnosis and treatment of posterior glenohumeral instability are becoming more common in practice. We present a technique for arthroscopic repair of a posterior glenohumeral capsular rupture with concomitant anterior and posterior labrum detachment. Arthroscopic fixation was facilitated by use of a 70° arthroscope through an anterior viewing portal to allow accurate placement of the posterior portal in preparation for knot tying. This arthroscopic technique resulted in a successful outcome.

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.

Neurological Complications Related to Elective Orthopedic Surgery: Part 1: Common Shoulder and Elbow Procedures

Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic-based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery.

WHAT'S NEW

As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.

Long-term effects on subscapularis integrity and function following arthroscopic shoulder stabilization with a low anteroinferior (5:30 o'clock) portal

PURPOSE

The use of a low anteroinferior (5:30 o'clock) portal for arthroscopic shoulder stabilization allows an anatomical refixation of the capsulolabral complex. This anteroinferior portal, however, penetrates the inferior subscapularis (SSC), which is criticized. Therefore, the aim of the study was to evaluate the functional and structural properties of the SSC in patients with anteroinferior shoulder stabilization. The hypothesis was that it does not harm the SSC by demonstrating full muscular function and imaging-based normal structure at a long-term follow-up.

METHODS

Twenty patients were examined (14 males and six females; mean age 37.0 years) retrospectively after a mean follow-up of 9.6 years. At final follow-up, clinical examination and clinical scores (ASES, Constant-Murley, WOSI, and Rowe score) were documented. Additionally, SSC strength was evaluated with a custom-made electronic force measurement plate. All patients underwent bilateral magnetic resonance imaging to assess structural integrity and fatty infiltration (grading according to Fuchs et al.) of the SSC. Furthermore, vertical and transversal (superior and inferior) diameters of the muscle and the muscle area in a parasagittal plane were measured.

RESULTS

Clinical scores revealed good-to-excellent long-term results (ASES 92 points, Constant-Murley 82 points, WOSI 85 %, and Rowe 84 points). Force measurement in comparison with the contralateral side showed no significant (p > 0.05) differences for the 'belly-press' test (ipsilateral 102 N vs. contralateral 101 N) and the 'lift-off' test (73 vs. 69 N). There were also no significant differences between the mean diameters and the areas of the SSC muscle belly (vertical diameter ipsilateral 92 mm vs. contralateral 94 mm; superior transversal 28 vs. 29 mm; inferior transversal 34 vs. 34 mm; area 2336 vs. 2526 mm(2)).

CONCLUSION

Arthroscopic labral repair with a low anteroinferior portal demonstrates no signs of structural and functional impairment of the SSC after 9.6 year follow-up. For clinical relevance, the lower part of the SSC can be penetrated for an optimal anchor placement in shoulder instabilities or Bankart fractures without concerns of a negative long-term effect on the SSC.

LEVEL OF EVIDENCE

Case series, Level IV.

Arthroscopic Repair of a Glenoid Avulsion of the Glenohumeral Ligament

Injury to the glenohumeral capsulolabral complex is the critical lesion in anterior shoulder instability. Various injury patterns have been described including the classic Bankart lesion, the bony Bankart lesion, and humeral avulsion of the glenohumeral ligament. A rare injury variant is a glenoid avulsion of the glenohumeral ligament (GAGL lesion). Careful patient setup and surgical technique are required to identify and arthroscopically repair these lesions. We describe a suture anchor-based arthroscopic GAGL repair performed with the patient in the lateral decubitus position through standard anterior and posterior portals and an accessory posterolateral 7-o'clock portal.

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.

Dual-camera technique for arthroscopic rotator cuff repair

An all-arthroscopic rotator cuff repair demands a high level of technical skill and is associated with a steep learning curve. It is well accepted that small rotator cuff tears or partial tears can be more difficult than large or even massive tears to repair. Part of the reason is the difficulty in visualizing the tear, as well as important surrounding structures, during repair. To improve visibility during the repair process, we have introduced a second arthroscopic camera. Two cameras allow the surgeon to observe the rotator cuff from both the articular and bursal sides. We find this technique has merit in small or partial-thickness rotator cuff tears; however, there may be other applications.

The suprascapular vein: a possible etiology for suprascapular nerve entrapment and risk of complication during procedures around the suprascapular foramen region

INTRODUCTION

Nerve can be compressed when traveling through any osteo-fibrous tunnel. Any eventual anatomic structure limiting this passage increases the risk of neuropathy. During dissection of the shoulder region we recognized a vein travelling on the inferior border of the suprascapular notch together with the suprascapular nerve. The aim of this work was to evaluate the morphological characteristics of this vein in cadaveric material.

MATERIALS AND METHODS

The suprascapular notch (SSN) region was dissected in 60 cadaveric shoulders. The course, number and diameter of nerve and vessels in the suprascapluar notch region were evaluated. Length, proximal and distal width of the superior transverse scapular ligament were measured. Photographic documentation was taken to evaluate the suprascapular nerve passage area.

RESULTS

The vein identified was named as the suprascapular notch vein. It was present in 58.3% of shoulders. In 11 specimens, it was double. Its mean diameter was 1.7 mm (SD 0.7 mm) and did not correlate with the suprascapular nerve passage area. A suprascapular notch vein co-occurred more often with the anterior coracoscapular ligament (ACSL). In comparison with the SSN without the ACSL, it has a significantly greater diameter (2 mm; SD 0.7 mm vs 1.5 mm; SD 0.6 mm, respectively; P=0.021).

CONCLUSIONS

The suprascapular notch vein was a common structure that did not replace the suprascapular vein. Its presence correlated with the occurrence of the ACSL and was independent of body side, STSL type and SSN type.

TYPE OF STUDY

Observational anatomic study.

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.