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Guzman AJ, Fong S, Jenkins S, Dela Rueda T, Talwar C, McGahan P, Chen J. Single-Portal Arthroscopic Posterior Capsulorrhaphy for Recurrent Shoulder Capsule Laxity and Instability. Arthrosc Tech 2022; 11:e1583-e1588. [PMID: 36185119 PMCID: PMC9520022 DOI: 10.1016/j.eats.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/14/2022] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic stabilization for posterior shoulder instability is well documented in the literature, offering good to excellent clinical outcomes after injury with favorable return-to-sport and patient satisfaction rates. Posterior capsulorrhaphy addresses recurrent laxity by decreasing the size of the posterior capsule through arthroscopic placement of sutures, in addition to addressing posterior labral tears and any intra-articular pathology within the joint. This technical note describes an arthroscopic posterior capsulorrhaphy for recurrent posterior shoulder capsule laxity and instability in an active patient. This technique uses a single posterior working portal and 2 suture anchors to tighten the posterior capsule onto the intact labrum.
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Affiliation(s)
- Alvarho J. Guzman
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A,Albany Medical College, Albany, New York, U.S.A,Address correspondence to Alvarho J. Guzman, B.A., Advanced Orthopedics and Sports Medicine, 450 Sutter St, Ste 400, San Francisco, CA 94108, U.S.A.
| | - Scott Fong
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Sarah Jenkins
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Therese Dela Rueda
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Camille Talwar
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Patrick McGahan
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - James Chen
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
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Fitzgerald EM, Kavanagh RG, O'Connor OJ, Morrissey DI. Determining the accurate placement of a posterior portal in shoulder arthroscopy with the use of computerized tomography images. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:236-241. [PMID: 37588964 PMCID: PMC10426646 DOI: 10.1016/j.xrrt.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Portal placement is an important factor in performing a successful shoulder arthroscopy. Recent cadaveric studies have found variance in the anatomy of the glenohumeral joint. Our aim was to determine if computerized tomography (CT) images could be used to map the trajectory of the posterior portal objectively and then measure the distance between this trajectory and palpable landmarks to apply this knowledge to clinical practice. Methods Two-dimensional multiplanar reformatted CT images were generated using OsiriX (Pixmeo, Switzerland) from CT images performed in a tertiary hospital over a 1-month period. The center of the glenoid was identified and a trajectory through it radiologically mapped. Horizontal and lateral measurements were taken from this trajectory to both the posterolateral edge of the acromion and tip of the coracoid. Results Following application of inclusion and exclusion criteria, 226 shoulders were analyzed. Fifty scans were selected at random and re-reviewed by the primary examiner to assess intra-rater reliability which showed strong correlation and no significant differences between first and second measurements (P < .01, r > 0.6). The mean distance from acromion to portal trajectory was 1.39 cm inferiorly (95% confidence interval [CI] 1.31-1.48, standard deviation [SD] 0.65 cm) and 1.44 cm medially (95% CI 1.35-1.53, SD 0.71 cm). The mean distance from the coracoid to the trajectory was 1.71 cm inferiorly (95% CI 1.64-1.78, SD 0.55 cm) and 1.26 cm medially (95% CI 1-2-1.31, SD 0.45 cm). Paired t-test analysis between right and left shoulders within the same subject, where these data were available (n = 81), showed no significant difference (P > .05) between sides. Subset analysis was also performed between males and females, but only showed a significant difference between the vertical distance from the coracoid process to the center of the glenohumeral joint. This distance was shorter in females compared to males (1.56 cm in females compared to 1.84 cm in males, P < .001). Conclusions Knowledge of shoulder anatomy is vital to the placement of arthroscopic portals, yet research on this topic has been based primarily on surface anatomy, small sample sized cadaveric studies or expert opinion alone. Our study shows that posterior portal placement in shoulder arthroscopy can be measured objectively using CT scanning.
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Affiliation(s)
- Eilis M. Fitzgerald
- Department of Trauma and Orthopaedics, Cork University Hospital, Wilton, Cork, Ireland
| | | | - Owen J. O'Connor
- Senior Lecturer and Consultant Radiologist, Department of Radiology, Cork University Hospital, Wilton, Cork, Ireland
| | - David I. Morrissey
- Consultant Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Cork University Hospital, Wilton, Cork, Ireland
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Tramer JS, Cross AG, Yedulla NR, Guo EW, Makhni EC. Comprehensive Arthroscopic Shoulder Stabilization in the Lateral Decubitus Position. Arthrosc Tech 2020; 9:e1601-e1606. [PMID: 33134067 PMCID: PMC7587928 DOI: 10.1016/j.eats.2020.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/21/2020] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior-inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous "7-o'clock" portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques.
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Affiliation(s)
| | | | | | | | - Eric C. Makhni
- Address correspondence to Eric C. Makhni, M.D, M.B.A., Department of Orthopaedic Surgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202.
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DiMaria S, Bokshan SL, Nacca C, Owens B. History of surgical stabilization for posterior shoulder instability. JSES OPEN ACCESS 2019; 3:350-356. [PMID: 31891038 PMCID: PMC6928295 DOI: 10.1016/j.jses.2019.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Posterior shoulder instability is common in young athletes. Although the posterior shoulder instability literature is less robust than its anterior counterpart, many surgical procedures have been developed and refined over the past several centuries to address this condition. Materials and methods This article represents a retrospective historical analysis of the most common procedures used to treat posterior shoulder instability after sports injuries. A systematic approach to obtain published information on posterior shoulder instability was performed using the PubMed/MEDLINE database, manual searches of high–impact factor journals, and conference proceedings and books. Results A wide array of both soft tissue–based and bone-based procedures have been developed for the treatment of posterior shoulder instability, ranging from procedures addressing the soft tissue alone (capsular shift, labral repair, reverse Putti-Platt) or bone-based procedures (glenoid and/or humeral osteotomy, glenoid bone block) to a combination of both bone and soft-tissue procedures (modified McLaughlin procedure). Discussion Over the past several centuries, a number of procedures have been developed to address posterior shoulder instability, particularly as this pathology has become better understood. Future work is required not only to continue to advance these procedures but also to assess their outcomes. An understanding of the historical perspective of posterior shoulder instability procedures is essential as surgeons continue to modify these procedures in an effort to best help their patients.
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Affiliation(s)
- Stephen DiMaria
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Steven L Bokshan
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Christopher Nacca
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Brett Owens
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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The split portal: Description of a new accessory posterior portal for arthroscopic shoulder instability procedures. Knee Surg Sports Traumatol Arthrosc 2016; 24:625-9. [PMID: 26685695 DOI: 10.1007/s00167-015-3911-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Open approach to the posterior shoulder during bone block for posterior shoulder instability is challenging. Anatomical study was performed to identify landmarks of a portal, avoiding soft tissue damage, between the infraspinatus (IS) and teres minor (TM) muscles and distant from the supra-scapular nerve (SSN) for arthroscopic shoulder bone block. METHODS Eight fresh-frozen cadaveric shoulder specimens were used. The arthroscope was introduced through the soft point (SP). A guide wire was placed through the SP, in the rotator interval direction. A posterior open dissection exposed the split between the IS and TM. A new guide wire was placed into the split, parallel to the first wire, to locate the new posterior arthroscopic approach. Ten distances were measured to define the safe position. RESULTS The mean values were: SP to split IS-TM: 2 ± 0.2 (2-2.8); spinal bone to split IS-TM: 5 ± 0.5 (3-6.2); split IS-TM to posterior glenoid 6 o'clock: 1.3 ± 0.3 (0.6-1.6), 9 o'clock: 1.5 ± 0.3 (1-1.9), and 12 o'clock: 2 ± 0.1 (2.1-2.4); SSN to posterior glenoid 6 o'clock: 2.4 ± 0.2 (2.1-2.6), 9 o'clock: 1.7 ± 0.1 (1.5-1.8), and 12 o'clock: 1.5 ± 0.3 (1.2-2.1); and SSN to split IS-TM: 2 ± 0.3 (1.2-2.1). CONCLUSION This preliminary anatomical study described a posterior arthroscopic portal located 2 cm under the SP, parallel to the SP portal direction, and finishing between 7 and 8 o'clock at the posterior rim of the glenoid. For arthroscopic shoulder bone block, this portal can avoid muscle and SSN lesions.
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DeAngelis JP, Hertz B, Wexler MT, Patel N, Walley KC, Harlow ER, Manoukian OS, Masoudi A, Vaziri A, Ramappa AJ, Nazarian A. Posterior Capsular Plication Constrains the Glenohumeral Joint by Drawing the Humeral Head Closer to the Glenoid and Resisting Abduction. Orthop J Sports Med 2015; 3:2325967115599347. [PMID: 26535390 PMCID: PMC4622307 DOI: 10.1177/2325967115599347] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Shoulder pain is a common problem, with 30% to 50% of the American population affected annually. While the majority of these shoulder problems improve, there is a high rate of recurrence, as 54% of patients experience persistent symptoms 3 years after onset. PURPOSE Posterior shoulder tightness has been shown to alter glenohumeral (GH) kinematics. Clinically, posterior shoulder contractures result in a significant loss of internal rotation and abduction (ABD). In this study, the effect of a posterior capsular contracture on GH kinematics was investigated using an intact cadaveric shoulder without violating the joint capsule or the rotator cuff. STUDY DESIGN Controlled laboratory study. METHODS Glenohumeral motion, humeral load, and subacromial contact pressure were measured in 6 fresh-frozen left shoulders during passive ABD from 60° to 100° using an automated robotic upper extremity testing system. Baseline values were compared with the experimental condition in which the full thickness of posterior tissues was plicated without decompressing the joint capsule. RESULTS Posterior soft tissue plication resulted in increased compression between the humeral head and the glenoid (axial load) at 90° of ABD. Throughout ABD, the posterior contracture increased the anterior and superior moment on the humeral head, but it did not change the GH kinematics in this intact model. As a result, there was no increase in the subacromial contact pressure during ABD with posterior plication. CONCLUSION In an intact cadaveric shoulder, posterior contracture does not alter GH motion or subacromial contact pressure during passive ABD. By tightening the soft tissue envelope posteriorly, there is an increase in compressive load on the articular cartilage and anterior/superior force on the humeral head. These findings suggest that subacromial impingement in the setting of a posterior soft tissue contracture may result from alterations in scapulothoracic motion, not changes in GH kinematics. CLINICAL RELEVANCE This investigation demonstrates that posterior capsular plication increases the axial load on the shoulder joint during ABD. While a significant difference from baseline was observed in the plicated condition, posterior capsular plication did not change GH motion or subacromial contact pressure significantly.
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Affiliation(s)
- Joseph P DeAngelis
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Hertz
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Michael T Wexler
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Nehal Patel
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Mechanical Engineering, Northeastern University, Boston, Massachusetts, USA
| | - Kempland C Walley
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Ethan R Harlow
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Ohan S Manoukian
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. ; Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut, USA
| | - Aidin Masoudi
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ashkan Vaziri
- Department of Mechanical Engineering, Northeastern University, Boston, Massachusetts, USA
| | - Arun J Ramappa
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Tuttle JR, Ramos P, DaSilva MF. Dual-camera technique for arthroscopic rotator cuff repair. Arthrosc Tech 2014; 3:e647-51. [PMID: 25685668 PMCID: PMC4314554 DOI: 10.1016/j.eats.2014.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 08/13/2014] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- John R. Tuttle
- Address correspondence to John R. Tuttle, M.D., M.S., 593 Eddy St, Providence, RI 02903, U.S.A.
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8
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Tsvieli O, Atoun E, Amar E, Levy O, Rath E. Arthroscopic bankart repair: accessory posterior portal with slotted cannula for lowest capsulolabral access. Arthrosc Tech 2014; 3:e403-8. [PMID: 25126512 PMCID: PMC4129978 DOI: 10.1016/j.eats.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/20/2014] [Indexed: 02/03/2023] Open
Abstract
We present a novel technique for safe establishment of the accessory posterior portal using a slotted cannula. Arthroscopic Bankart repair is a common procedure. A variety of arthroscopic techniques have been described in the literature, commonly using the posterior portal for visualization and the anterior portal with a working cannula. The accessory posterior portal enables elegant access to the lower part of the capsulolabral junction, a firmer grasp and mobilization of the tissue, quick and easy tool exchange using a slotted cannula, and clearer suture placement because of the flat, direct working angle. The skin incision is made small without the need for an arthroscopic cannula, and the portal location is in a relatively safe zone. The use of the accessory posterior portal along with a slotted cannula shortens the duration of the operative procedure and improves safety and performance.
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Affiliation(s)
- Oren Tsvieli
- Reading Shoulder Unit, Royal Berkshire Hospital, Reading, England,Address correspondence to Oren Tsvieli, M.D., Reading Shoulder Unit, Royal Berkshire Hospital, London Rd, Reading RG1 5AN, England.
| | - Ehud Atoun
- Barzilai Medical Center, Ashkelon, Israel
| | - Eyal Amar
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofer Levy
- Reading Shoulder Unit, Royal Berkshire Hospital, Reading, England,Centre for Sports Medicine and Human Performance, School of Sport and Education, Brunel University, London, England
| | - Ehud Rath
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Vopat BG, Murali J, Gowda AL, Kaback L, Blaine T. The global percutaneous shuttling technique tip for arthroscopic rotator cuff repair. Orthop Rev (Pavia) 2014; 6:5279. [PMID: 25002932 PMCID: PMC4083305 DOI: 10.4081/or.2014.5279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/23/2014] [Accepted: 02/26/2014] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Bryan G Vopat
- Orthopedic Department, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital , Providence, RI, USA
| | - Jothi Murali
- Orthopedic Department, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital , Providence, RI, USA
| | - Ashok L Gowda
- Orthopedic Department, Yale School of Medicine , New Haven, CT, USA
| | - Lee Kaback
- Shoulder and Elbow Surgery , OrthoNY, Albany, NY, USA
| | - Theodore Blaine
- Orthopedic Department, Yale School of Medicine , New Haven, CT, USA
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10
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Knudsen ML, Hibbard JC, Nuckley DJ, Braman JP. The low-anterolateral portal for arthroscopic biceps tenodesis: description of technique and cadaveric study. Knee Surg Sports Traumatol Arthrosc 2014; 22:462-6. [PMID: 23400912 DOI: 10.1007/s00167-013-2444-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 01/29/2013] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Michael L Knudsen
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Ave S #R200, Minneapolis, MN, 55454, USA
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11
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Cvetanovich GL, McCormick F, Erickson BJ, Gupta AK, Abrams GD, Harris JD, Romeo AA, Bach BR, Provencher MT. The posterolateral portal: optimizing anchor placement and labral repair at the inferior glenoid. Arthrosc Tech 2013; 2:e201-4. [PMID: 24265983 PMCID: PMC3834628 DOI: 10.1016/j.eats.2013.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 02/15/2013] [Indexed: 02/03/2023] Open
Abstract
The Bankart lesion is considered the critical lesion in anterior shoulder instability, in which the anteroinferior glenoid labrum separates from the glenoid rim. Technical advances in arthroscopy have ushered in a shift from open to arthroscopic Bankart repair. When one is performing an arthroscopic Bankart repair, proper portal placement is critical for success in labral preparation and anchor placement. Frequently, standard anterior portals are insufficient for inferior glenoid anchor placement and suture shuttling. The posterolateral portal-located 4 cm lateral to the posterolateral corner of the acromion-simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. We present our preferred technique for capsulolabral repair of the inferior glenoid.
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Affiliation(s)
- Gregory L. Cvetanovich
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A.,Address correspondence to Gregory L. Cvetanovich, M.D., The Orthopedic Building at Rush University Medical Center, 1611 W Harrison St, Ste 201, Chicago, IL 60612, U.S.A.
| | - Frank McCormick
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | | | - Anil K. Gupta
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | - Geoff D. Abrams
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | - Joshua D. Harris
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | - Anthony A. Romeo
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | - Bernard R. Bach
- Rush Sports Medicine, Midwest Orthopaedics, Chicago, Illinois, U.S.A
| | - Matthew T. Provencher
- Sports Medicine Department, Naval Medical Center San Diego, San Diego, California, U.S.A
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13
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Novak LM, Lee JK, Saleem AM. Synovial fold of the posterior shoulder joint capsule. Skeletal Radiol 2009; 38:493-8. [PMID: 19183991 DOI: 10.1007/s00256-008-0635-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Revised: 12/11/2008] [Accepted: 12/12/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the study is to describe, based on shoulder MRI and MR arthrography with arthroscopic correlation, a posterior joint capsule fold. MATERIALS AND METHODS A retrospective review of 410 shoulder MRIs and direct MR arthrograms with arthroscopic correlation in positive cases (when available) was obtained with IRB approval and HIPPA compliance. The study was performed by three musculoskeletal radiologists. The criteria utilized to establish the diagnosis of posterior synovial fold included: (1) axial T1-weighted (T1W) on MR arthrography or axial T2* GRE-weighted on MRI demonstrating rounded thickening of the posterior shoulder joint capsule with a thickness at least 2 mm in diameter. (2) The posterior synovial fold extends in an oblique craniocaudal direction from the posterior-inferior joint capsule adjacent to the posterior-inferior glenoid labrum (7 o'clock) and continues superiorly away from the glenoid labrum to the posterior-superior joint capsule (11 o'clock). RESULTS Although uncommon, the posterior synovial fold was present in 2% (8/410) of studies reviewed and found predominantly in women (75%, 6/8). Four patients had arthroscopic confirmation of the posterior synovial fold. A higher percentage of posterior synovial folds were observed on shoulder MR arthrography (2.7%, 4/150) than on shoulder MRI (1.5%, 4/260). CONCLUSION Although rare, the posterior synovial fold can be recognized and should not be confused with a posterior labral tear. Further investigation is needed to assess its histologic properties and its clinical significance.
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Affiliation(s)
- Leon M Novak
- Department of Radiology, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA.
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14
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Parameswaran AD, Provencher MT, Bach BR, Verma N, Romeo AA. Humeral avulsion of the glenohumeral ligament: injury pattern and arthroscopic repair techniques. Orthopedics 2008; 31:773-9. [PMID: 18714772 DOI: 10.3928/01477447-20080801-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The arthroscopic treatment of a humeral avulsion of the glenohumeral ligaments lesion allows for a safe, reproducible, and effective way to reestablish the inferior glenohumeral ligament and capsular complex to the humerus.
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Affiliation(s)
- A Dushi Parameswaran
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Bhatia DN, de Beer JF, Dutoit DF. An anatomic study of inferior glenohumeral recess portals: comparative anatomy at risk. Arthroscopy 2008; 24:506-13. [PMID: 18442681 DOI: 10.1016/j.arthro.2007.11.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 09/09/2007] [Accepted: 11/25/2007] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Deepak N Bhatia
- Cape Shoulder Institute, Cape Town, South Africa; University of Stellenbosch, Cape Town, South Africa.
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Bhatia DN, de Beer JF. The axillary pouch portal: a new posterior portal for visualization and instrumentation in the inferior glenohumeral recess. Arthroscopy 2007; 23:1241.e1-5. [PMID: 17986414 DOI: 10.1016/j.arthro.2006.12.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Revised: 11/28/2006] [Accepted: 12/08/2006] [Indexed: 02/02/2023]
Abstract
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.
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Nord KD, Brady PC, Yazdani RS, Burkhart SS. The anatomy and function of the low posterolateral portal in addressing posterior labral pathology. Arthroscopy 2007; 23:999-1005. [PMID: 17868840 DOI: 10.1016/j.arthro.2007.04.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 04/09/2007] [Accepted: 04/12/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE A standard posterior portal allows excellent visualization of the glenohumeral joint but is inadequate for anchor placement because of its parallelism to the glenoid surface. The purpose of this study was to describe the low posterolateral portal for glenohumeral arthroscopy, describe the anatomy of the portal and surrounding structures, and discuss the portal's usefulness in addressing posterior and inferior shoulder pathology. METHODS Five cadaveric shoulders were dissected after placement of a spear through the low posterolateral portal. The location was identified via a spinal needle, 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral corner of the acromion. Measurements from the spear to the anatomic structures were recorded with a caliper. Seventeen patients with posterior labral pathology were included in this study. The low posterolateral portal was established while visualizing through the anterosuperolateral or posterior portal. The spear and anchor were inserted through the low posterolateral portal. RESULTS Five shoulders were dissected, and the neurovascular structures relative to the low posterolateral portal were identified. The portal was 13.8 +/- 1.6 mm from the axillary nerve and 13.4 +/- 1.2 mm from the posterior humeral circumflex artery. In the retrospective review the low posterolateral portal was created without difficulty or complication in all 17 patients. The portal was extremely helpful for anchor insertion in the posteroinferior glenoid. It was useful in suture passage through the posterior and inferior labrum and in suture management. CONCLUSIONS The low posterolateral portal provides the optimal angle for insertion of instruments and anchors, resulting in a more anatomic repair. CLINICAL RELEVANCE The standard 3 portals are not optimal for approaching posterior and inferior labral tears, and use of the low posterolateral portal improves access and treatment.
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Affiliation(s)
- Keith D Nord
- Sports, Orthopedics & Spine, Jackson, Tennessee 38301, USA.
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Woolf SK, Guttmann D, Karch MM, Graham RD, Reid JB, Lubowitz JH. The superior-medial shoulder arthroscopy portal is safe. Arthroscopy 2007; 23:247-50. [PMID: 17349465 DOI: 10.1016/j.arthro.2006.11.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 10/20/2006] [Accepted: 11/11/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe. METHODS Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm. RESULTS The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001). CONCLUSIONS This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens. CLINICAL RELEVANCE Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.
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Affiliation(s)
- Shane K Woolf
- Taos Orthopaedic Institute Research Foundation, Taos, New Mexico 87571, USA
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Glenn RE, McCarty LP, Cole BJ. The accessory posteromedial portal revisited: utility for arthroscopic rotator cuff repair. Arthroscopy 2006; 22:1133.e1-5. [PMID: 17027414 DOI: 10.1016/j.arthro.2006.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 11/07/2005] [Accepted: 01/31/2006] [Indexed: 02/02/2023]
Abstract
Arthroscopic rotator cuff repair is a technically challenging procedure. Accessory arthroscopic portals have been described that allow for optimal suture anchor placement, suture management, and knot tying. We describe here the usefulness of an accessory posteromedial portal that facilitates direct suture retrieval through the posterior aspect of a rotator cuff tear. This portal is created approximately 4 to 5 cm medial to the posterolateral corner of the acromion and 2 cm inferior to the scapular spine. The accessory posteromedial portal is especially useful when a retracted tear of the infraspinatus or teres minor is encountered. Because these tendons retract in a posterior and medial direction, the accessory posteromedial portal places the tendon-penetrating device in an ideal position for suture passage through the posterior portion of the rotator cuff tear. This portal also allows placement of margin convergence sutures for large U-shaped or L-shaped tears by permitting a direct "hand-off" of the suture to or from a second penetrating device that is placed through a standard anterior portal. If multiple suture anchors are required (as in the case of large or massive cuff tears, or when double-row fixation is employed), sutures can be pulled out through the accessory posteromedial portal to facilitate suture management.
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Affiliation(s)
- R Edward Glenn
- Division of Sports Medicine, Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois 60612, USA
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Abstract
Posterior "working" portals in arthroscopic posterior stabilization could result in defects of the posterior capsule if not repaired. We describe a single portal technique used to close the posterior portal defect after arthroscopic stabilization. It is a safe and easy-to-perform technique, which could strengthen the structural integrity of the repair.
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Angelo RL. Arthroscopic Management of Posterior Shoulder Instability. Sports Med Arthrosc Rev 2004. [DOI: 10.1097/01.jsa.0000115008.64902.dd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McCarty EC, Warren RF, Deng XH, Deng XH, Craig EV, Potter H. Temperature along the axillary nerve during radiofrequency-induced thermal capsular shrinkage. Am J Sports Med 2004; 32:909-14. [PMID: 15150036 DOI: 10.1177/0363546503260064] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There have been reports of axillary nerve palsy after thermal capsular shrinkage with radiofrequency energy-generating devices. The exact cause of this is unknown. HYPOTHESIS The temperature of the axillary nerve increases during shoulder capsular shrinkage at various degrees of shoulder abduction. STUDY DESIGN Laboratory study. METHODS Fifteen cadaveric shoulders had fiberoptic thermometer probes placed at various points along the axillary nerve and major branches under the capsule. The shoulders underwent thermal capsular shrinkage with a radiofrequency energy-inducing device at various positions of abduction. RESULTS With the arm at the side, temperatures above 50 degrees C (56 degrees -61 degrees C) were evident along the teres minor branch of the axillary nerve in 4 of 6 specimens. The increase in temperature was noted in the middle to posterior aspect of the inferior capsule. At 45 degrees of abduction, 4 of 5 shoulders demonstrated increases in temperature greater or equal to 50 degrees. Three of 4 shoulders tested at 90 degrees of abduction revealed similar temperature increases. CONCLUSIONS The arthroscopic technique of thermal capsular shrinkage causes an increase in the temperature of the axillary nerve and its branches in 11 of 15 cadaveric specimens tested at various arm positions-particularly affected is the teres minor branch. CLINICAL RELEVANCE Orthopaedic surgeons using the radiofrequency device for thermal capsular shrinkage need to be aware of the possible increase in temperature along the axillary nerve and its branches during this procedure. The clinical effect of this type of increase on the nerve is unknown.
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Affiliation(s)
- Eric C McCarty
- C. U. Sports Medicine Center, Department of Orthopaedics, University of Colorado School of Medicine, 311 Mapleton Avenue, Boulder, CO 80304, USA
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Fischer SP, Rubin BD. Arthroscopic knot-tying techniques. OPER TECHN SPORT MED 2004. [DOI: 10.1053/j.otsm.2004.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Douoguih WA, Shaffer BS. Avoiding complications in arthroscopic subacromial space and instability surgery. OPER TECHN SPORT MED 2004. [DOI: 10.1053/j.otsm.2004.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Williams RJ, Strickland S, Cohen M, Altchek DW, Warren RF. Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003; 31:203-9. [PMID: 12642253 DOI: 10.1177/03635465030310020801] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The role of arthroscopic repair in the treatment of posterior shoulder instability remains poorly defined. PURPOSE To evaluate the results of arthroscopic repair of posterior Bankart lesions. STUDY DESIGN Retrospective review. METHODS Records were reviewed of 27 shoulders (26 patients). All of the patients were male with a mean age of 28.7 years; in all cases symptoms were preceded by a traumatic event. Fourteen of the patients had 2+ to 3+ posterior translation noted under preoperative anesthesia. The posterior capsulolabral complex was found to be detached from the glenoid rim in all cases; bioabsorbable tack fixation was used for repair. RESULTS At a mean follow-up of 5.1 years, no patients demonstrated a range of motion deficit. Muscle weakness (grade 4/5) in external rotation was noted in two patients (8%). There was no instability greater than 1+ in the anterior, posterior, or inferior directions. The mean L'Insalata shoulder score was 90.0 +/- 13.9. The mean SF-36 physical and mental component scores were 50.4 +/- 7 and 53.9 +/- 9, respectively. Symptoms of pain and instability were eliminated in 24 patients (92%). Two patients (8%) required additional surgery after arthroscopic repair of the posterior Bankart lesion. Radiographs demonstrated that there had been no progressive glenohumeral joint degeneration. CONCLUSIONS Arthroscopic repair of the posterior capsulolabral complex is an effective means of eliminating symptoms of pain and instability associated with posterior Bankart lesions of traumatic origin.
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Affiliation(s)
- Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, Cornell University Medical College, New York, New York, USA
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