Diagnostic Shoulder Arthroscopy
Diagnostic Shoulder Arthroscopy in Beach Chair Position
- Draw out bony landmarks – acromion, coracoid, soft spot
- Use thumbnail to delineate Anterolateral and Posterolateral acromion
- 2 cm inferior and slightly medial to acromial angle in the “Soft spot” between infraspinatus and teres minor
- Aiming toward coracoid, pierce skin with an 18 guage needle
- Insufflate joint with 50 cc of saline/epi solution
- Make an incision with #11 blade
- Place a blunt trocar through through capsule
- Attach inflow to arthroscopic cannula, suction as well
Diagnostic Arthroscopy (Beach Chair Position)Examine:
- Glenoid, Biceps, Humeral Head, Subscapularis, and Rotator Interval
- Visualize Rotator Cuff, check Bare Area, Labrum, and Humeral Avulsion Glenohumeral Ligament (HAGL)
- Create instrument portal through Rotator Interval
- Test Biceps Tendon
- Enter Subacromial Space
CA Ligament Release
- While in the subacromial space, release the Coraco-acromial (CA) Ligament off the bone with a radiofrequency ablator
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Hello, I’m Patrick Vavken. This is Arvind von Keudell. We're going to take you through a cadaver - very basic step by step diagnostic shoulder arthroscopy.
We’re in a beach chair position. This will be theoretically a 70 degree angle which is hard to reproduce in a cadaver, and Arvind is going to do the landmarks. Good way to do the landmarks is you put - push your thumb in a soft spot in between the clavicle acromion and then just follow the outline of your thumb. It will give you a good baseline to get started. Plus it’s a good stability for the skin cuz you pushing it down - it’s much easier. And then you get the anterior posterior corners of the acromion - run this anteriorly, posteriorly, and around the corner. It’s alright.
Obviously our patient has some stability issues. You want to make sure you get the coracoid tip. And what you want - and your AC joint - what you want to be marking from the coracoid tip upwards is your CA ligament, which sometimes you can actually feel through the skin in a skinny individual. It’s typically a Y shape, fanning out pattern that is narrower as shown here in the acromion and fans out down on the coracoid tip as well as base - something to think about it when you go in for subcruthormal decompression.
If you follow your posterior part of your AC joint, will give you your 50-yard midline incision. That's also above your synovial fold - subpersiva - subpersiva fold back here anteriorly, it should mostly be in there, and it should be okay back here.
We will do an - a standard posterior portal, which is about a centimeter medial and inferior to the posterior corner of the acromion. If you want to go in for an instability, you want a bit more medially, a bit more lower, so you get a good angle with the glenoid. If you think about cuff repair, you want to be a little more - a lot of little more higher, so you can I get good exposure of the cuff through the subacromial space. One thing that we can do first is get a needle. And you don't necessarily have to inject water - it can help, you don’t have to though - just once you come in, you know you’re in the joint, and if you can move the needle up and down, you know you’re right - you're in the plane of the glenoid. And again, if you’re doing a cuff, it's not as important. If you're working on instability, you want to stick your scope right where your needle is. You want to make sure that you can go in between glenoid and you will without scuffing anything, and like Arvind just did perfectly, stay in that plane so you can see everything anteriorly in here without causing yourself too much trouble.
Alright, now we are where we want to be. We could inject or just go straight through skin. Again, we like to nick the skin - cut a little bigger. There we go. And one of the things that people don’t really appreciate is you think about an 11 blade and your four or five scope, the blade is much narrower than the scope handle itself. See, if you just cut with the tip of the scope, we’ll have a hard time just going through a skinny - you’re going to feel a lot of resistance which is not in your head or not in your knee or not your hip - you just have a hard time pushing through. So you want to make sure if you’re using an 11 blade, just cut a little more or stick it in all the way - either way.
Alright Arvind is going. He will be piercing through a terrisman infraspinatus back there and depending on interaxial rotations it’s more tendinous or more muscular portion of the - of said muscle - and it’s going to be harder or easier. He's going to follow his index finger and reach for the coracoid, and as you can see, he’s got a nice pop into the shoulder.
At this point, if you hadn't checked it before it would be backflow, which there isn’t in this shoulder. But if you're not sure, it will be a good option to just help you find where you want to be. Alright, coming in. That looks already pretty darn nice. Click in place and start water.
Now how do we get out air bubbles? Air bubbles, you stick the scope into bubble, and you just let the air escape through the out flow - or suction. And then you just work your way up through the shoulder and flood the whole compartment.
Alright, number one. Arthroscopy 101. It's called arthroscopy - not microscopy. Here we can see the initial fibroblast of the capsule quite nicely. You want to be pulling back to get better perception of everything and be sure where we are. And that's our first view. We want to see the glenoid, so you want to see the biceps, want to see the humeral head, and preferably even subscapularis. We’re a little high with our portal, but that's okay cuz we want to do a cuff later on anyway. Just looking at the biceps, you can see the direction of biceps is wrong - is not running across the joint - it's tilting down, so our thing is probably sub flux, which is okay in this patient. Looking at humeral head, we can see some nice scuffy of cartilage. Looking into the glenoid - looking into glenoid - we’ll see bone on bone arthritis. Just remember that dead center glenoid - that area right here - is a stellite area where there can be no cartilage physiologically, and that's also how you can tell where the center of your glenoid is. So if you wanted to make sure there was some bone lose, you find this place, you take your probe and you measure anteriorly, posteriorly, should be the same distance. If there’s some missing anteriorly, you lost some bone, and you can just take your measurements to see how much is lost.
Alright, now pushing it a little more anteriorly and looking down, we can see the subscap down there And the angiogel across from it. Remember, the importance of the subscap for shoulder repair and shoulder function has been elucidated repeatedly, and especially if you look into Tucson the first and lot of French guys, it's a - they have really told us what this tendon does.
This tissue high up here, that's your interwall. Rotator cuff - rotator interwall. This is where the shoulder freezes. This is the AOA and freezing of the shoulder, and just like in ATLS, it might be one of the most important things and most important steps in any shoulder surgery. This tissue is really important - don't destroy the vein, if you don't have to put a portal in here, cuz all you want to do is just as a quick diagnostics scope and subacromial decompression, think about twice before you go through it, cuz it's going to scar down and cause some stiffness, alright. We don’t really know how frozen shoulder happens, we just know it as fibroblastic infiltration, and it starts right here in the interwall. If you think about how your shoulder moves, if you’re going to rotation, it’s going to be right in here - that’s where it freezes. If you don't get that motion in there, it’ll be stiff, you’ll lose extra-rotation, and it’ll stiffen up from there. Same time, if you’re unstable down here, it's cuz this opens too wide, and that's where we do a closure.
Now let's look at the cuff - look at the cuff in beach chair. I want to make sure that we go in a little bit of abduction. You can see the top of the glenoid that could be construed as a drive-thru sign if we just fall in, which is correlated with laxity, but not indicative of a label tear instability. Now looking over laterally, we have a great view of the cable. Stephen Perkins, it's too bad that he's not here, you can see the cable running across the head, which is just beautiful. This is where all the force runs into the shoulder - the cable construction - and down here you can see the crescent of the cuff where small tears happen. If there was small tear in here, the stability is here. So this is the tissue you want to reproduce and create - and make sure that it's intact.
Now we see nice, nice insertion of the supraspinatus, so we probably not repairing that one today in here. Coming down laterally, we can start to see the bare area and the infraspinatus. Now I said earlier today - keep going down a little bit - as I said earlier today, this is a bare area cuz you can see tendon, a little bit of bone, and inner cartridge. If you saw tendon, little bit of bone, inner cartilage, and little bit of on over here, that will be a hill Sachs lesion. This guy does not have a hill Sachs lesion. Coming down terrisman, going down into the inferior oeresis, he does of osteophytes. There we go, and looking over labor.
Now if you're - if you're working an instability, one of the most underappreciated defects is right here - your hagl lesion. You wanna make sure that you see your capsule as it inserts into the - underneath the humeral head - because this is the hammock right here. If you only tighten on the glenoid side back here, but you have a tear in the capsule down here, all you do is you pull the tissue over it - there’s - there’s going to be no stability - that's where the hagl lesion lives - the humeral of all micro humeral lesion ligaments. There might be a little something in there actually, which is okay cuz it unstable, so it’s all aged.
Then we come up again, we can see the glenoid and the labrum. In a beach chair position, if you want to create some space, you will take 4-5 towels, wrap them up, you’ll take the fist of your assistant, and just stick it under the head. Can you see how that opens it up? Just stick it under the head. Do not pull - you’re not pulling the patient off the bed. If you pull on your spider or something, you’re pulling your patient off the bed, kinking his neck, causing some issue that makes your anesthesiologist scream. You just stick a fist in there, a couple of towels, and all you got to do is air duct over this fulcrum, and see how nicely that opens up. You can't see anything - there's all your labrum. Let’s look anterior, posterior for a second. Again, you can’t see anything and here is your labrum.
Alright, we're now at this point we decided we're going to go in a little bit of a debridement, so we'll find our spinal needle, and we’ll want to come right through the triangle - dead center. That’s okay - maybe a little high.
Do - you can always control depth through your index finger, and as you talk to other people and reach for something, you won't be falling out or anything. The other beauty is that whenever you use a needle, your fingertips will be pointing at each other. So you're really going for your middle finger fingertip, which might make things a little easier in here. It's a lot easier in elbows, and if you want to see a good elbow video, I think there's one on the web page - cuz you’re just pointing finger to finger.
And get your knife. Remember it's not just position - it’s also direction and everything. And just roll, you’re rolling through the tissue. There you go. Now with your switching stick in, you can already test for labral stability. You can test for biceps instability, which is the RAM test, so if you want to push in a little more and try to see what esopho the biceps is - top lateral.
So you can see the biceps should be sitting in here. Alright, now as you push down, first of all, you see more of the body of the biceps tendon. There's a lot of provocations - a lot of research - that would in fact - that if you look at a biceps tendon in particular, all you’ll see is about 1/3. And a lot of pathology is going to be down that tunnel, and you won't be able to see it. You can push your scope into the tunnel a little bit and look down, and see a little more, but you know, if you see the injection, it’s probably going to be hurting down in there too.
Now if you pull back in and then use the tip of your - whatever instrument you have - to try and pull on the medial sling and the lateral sling, and if you - see if they can push it away that tissue - see if I can push away that tissue. See that's - that's in there. That by the way, that’s the comma sign. See this tissue running down from the subscap into the supraspinatus. If both is torn, that's the famous comma tissue right here - so leave that - that's nothing to debride. Leave the stuff this important.
So Arvind is going to show us the RAM test now to check for bicep stability. He's going to use his switching stick first of all to go on top of the biceps tendon and pull it in medially, and you can see, it’ll come out of it. You can also judge the outer surface of the biceps tendon. You can look down into the biceps tunnel a little more, which looks good, so at this point, you’re going to use the switching stick - switching stick and check for your mediolateral sling. Level off the coma tissue in between subscap and biceps tendon. See if that’s stable - it doesn’t displace - and as you come across, and check the lateral part of the sling, which looks good. Alright.
Alright, at this point, we’d be happy, and we'll go subacromial. In order to go subacromial, we’re going to take out the camera, bring back the operator into the trocar. Now pull back, we go up, we feel for the corner of the acromion, all the way up - index fingers going to be in coracoid again - and you come across, and you try and touch the CA ligament here, which like - you should feel a pop - as the trocar comes - swipes across the CA ligament like that. There’s a little - there it is - a little - that’s our CA ligament. That’s what cleans up the purse a little bit. That's where we want to be cuz eventually, we can just leave the camera here, or there. We want to be in a place right there, if you come in, we’re going to see the CA ligament. So right now, down in there, we’re going to change for the camera.
So we want to be looking straight up and maybe a little laterally. We want to be just a little anterior of the 50-yard line. There you go, alright. You can just pull back a little bit here. My personal favorite is I'll just shave out as much as I need to shave, cuz it’s going to bleed anyway, and I find any new bleeders. There’s always one big bleeder posteromedially, so there’s always going to be some bleeding back there. And then there's the tor acromial ligament - excuse me, the tor acromial artery running with the acromial ligament - there’s going to be some bleeding up here. So you get one bleeder here. You get the bleeder there. Everything else should be taken care of by the epinephrine in the bag. You don't necessarily have to go way too medial as you can see the cuff, and we can see everything.
We just want to make sure that there’s no adhesions on the cuff laterally / anteriorly so that big band that runs down anterolateral - that I get.
So now we're looking subacromially. We can see the shiny fibers of the CA ligament at the anterolateral portal of the acromion. Alright, the important thing is not just take away everything - we’re just releasing the CA ligament off the bone. You can see it actually loops around the corner of acromion. It can be sticking on the undersurface and causing impingement just by tissue. And I can go - or we’ll want to leave the most anterior part - just release if off the bone and scar - back down again - give us some anterior, superior stability of the shoulder in the future. And you can see Arvind now just scraping off the ligament from the bone, and you can see how the tip is just - the tip is just starting to fold down with the release. Come across laterally. Very nice.
Now we’ll want to clear off the acromion - not open the AC joint - that's one of the little things to remember. Okay so Arvind did a great job releasing a CA ligament of the acromion. You can see ligament running down here, dangling in there. These are fibers of the - the last few fibers in there are the delta fascia. This one’s a little loose body, and we’ll take out in a second. And then looking up, you can see the anterolateral corner of the acromion. We don't see much of a spur, so we don’t necessarily have to take that off. There's no evidence proving that it will improve outcomes after cuff repair. If you use a pastor, you want to make sure you have enough space to work, so sometimes we’ll take us some bone. When you take out bone, remember on the X-ray not just to look on the outlet view for ABC types - actually 1, 2, 3 types - but on the lateral, you want to make sure that the acromion is actually thicker than 8 millimeters, so if it take out 5, you leave some bone. I was researched by dr. Schneider, back in the day - never published really - it's only an abstract in JBJS - but he looked at some like 200 cuff repairs and found that in the type 3 females, about 1/3 had an acromion thinner than 8 millimeter, so if you took off too much with an acromioplasty, you had a high risk of a fracture after it actually. Alright, awesome.
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