The adduction distraction maneuver

Effects of shoulder distraction on canine shoulder arthroscopy

OBJECTIVE

To evaluate the use of the Leipzig distractor during canine shoulder arthroscopy.

STUDY DESIGN

Experimental, ex vivo.

SAMPLE POPULATION

Paired shoulder joints from 15 large breed canine cadavers.

METHODS

Standard lateral shoulder arthroscopy was performed with or without the use of the Leipzig distractor (n = 15 each). Joint space width, procedure time, and visibility and palpability of the intra-articular structures were assessed during the arthroscopy. After the arthroscopic evaluation, each shoulder joint was disarticulated to assess the area and number of iatrogenic articular cartilage injury (IACI) lesions. Sites around the distraction device were assessed for the presence of iatrogenic injury.

RESULTS

With shoulder distraction, median joint space width was 4 mm larger (P = .01), IACI area was 9.5 mm² lower (P = .003), and there were two fewer total number of IACI lesions (P = .004) compared with nondistracted shoulders. The mean total surgery time was 93 seconds shorter (P = .01) in distracted shoulders. Although distraction was associated with increased visibility of the supraglenoid tubercle (P = .015), no significant differences were found for other intra-articular structures for their visibility and palpability. Unexpected lesions at the sites around the distraction device were not encountered.

CONCLUSION

Use of the distraction device decreased the area and incidence of IACI lesions and shortened the arthroscopy time. However, no improvement was found in the visibility or palpability of the intra-articular structures.

CLINICAL SIGNIFICANCE

Although additional clinical studies are required to evaluate the effect of the distraction device on pathologic articular conditions and intraoperative manipulation, the use of a shoulder distraction device might improve the outcomes of shoulder arthroscopy by decreasing IACI and arthroscopy time.

Radiographic evaluation of the glenohumeral joint space in patients undergoing arthroscopic shoulder surgery in the beach-chair position

Background

Shoulder arthroscopy can be performed with the patient in the lateral decubitus or beach-chair position, but in both cases, glenohumeral (GH) joint spaces must be increased to improve visualization and allow access of the optical instrument. The aim of this study was to determine the effects of limb setup and longitudinal traction on the opening of the GH space with patients placed in the beach-chair (dorsal decubitus) position.

Methods

GH spaces at 3 test points corresponding to the anatomic locations of Bankart lesions were determined indirectly from radiographic images obtained from 67 patients presenting shoulder pathology with an indication for arthroscopic surgery. Measurements were made with the operative limb in neutral rotation and positioned in relation to the coronal plane in adduction, 45° of abduction, or adduction with an axillary spacer, in each case with and without longitudinal traction.

Results

GH spaces were optimized at 2 of 3 test points when the operative limb was positioned in adduction or neutral rotation and manual longitudinal traction was applied with or without a polystyrene spacer placed under the axilla, but use of the spacer was essential to maximize the GH space at all 3 locations. In contrast, 45° of abduction proved to be the least appropriate position because it afforded the smallest GH space values with or without traction.

Conclusion

Appropriate positioning of the patient on the operating table is a critical aspect of shoulder arthroscopy. Radiographic images revealed that adducted upper-limb traction with the use of an axillary spacer in patients in the beach-chair position generates a significant increase in the GH space in the lower half of the glenoid cavity, thereby facilitating visualization and access of the optical equipment to the GH compartments.

Beach chair position with instrumental distraction for arthroscopic and open shoulder surgeries

Arthroscopy is widely used in the diagnosis and treatment of shoulder disorders. It can be performed in the lateral or sitting position (beach chair). Both have advantages and disadvantages. We present a simple, inexpensive, versatile, portable, continuous distraction device for arthroscopic, combined, and open shoulder surgeries in the sitting position that offers the advantages of the 2 classic positions without their disadvantages. The device was used in 101 consecutive procedures: 61 rotator cuff repairs (29 arthroscopic, 18 mini-open, 14 open), 4 two-part humeral fractures, 1 septic arthritis, 3 calcifying tendinitis, 9 capsular releases, 8 Bankart repairs (6 arthroscopic, 2 open), 13 acromioplasty and biceps tenotomy, and 2 superior labrum anteroposterior repairs. Our experience with this device is extremely positive. We have had no complications and have used it for shoulder arthroscopy, open, and combined surgeries. We have also not had difficulty visualizing or approaching the glenohumeral and subacromial spaces in the treatment of shoulder disorders. It is a safe, practical, easy, and fast set up. Its versatility makes it particularly helpful for the less experienced arthroscopic surgeon.