Arthroscopic Shoulder Procedures. David C. Neuschwander MD. Shoulder Instability. Allegheny Health Network Orthopedic Associates of Pittsburgh

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1 Arthroscopic Shoulder Procedures David C. Neuschwander MD Allegheny Health Network Orthopedic Associates of Pittsburgh Shoulder Instability Anterior Instability Posterior Instability

2 Glenohumeral Joint Stability Dependent upon the bony geometry and soft tissues about the shoulder Success rates of Open Anterior stabilization procedures 90-95% Despite low recurrence rates with open procedures, there can be important losses in external rotation, surgical morbidity and difficult rehab

3

4 Shoulder Arthroscopy Has a learning curve which is specific to each procedure Needs to duplicate the techniques which have been done with an open technique Measures to Limit Bleeding Subacromial space lidocaine with epi injection Systolic blood pressure about 100 if tolerated medically Use of arthroscopic pump Epi in fluid Initial Evaluation Scalene block or General Anesthesia Assess range of motion and stability testing Portal placement (Poster, Anterior) for evaluation of GH joint Subacromial space portal placement (posterior, anterior, and lateral) Use of accessory portals and anchor portals as necessary

5 Preop Clinical Exam Anterior Instability Assess Tissue Quality Determine if the tissue has moved medially along the glenoid neck Determine how far the tissue can be moved to get desired effect on the tension of the repair Anchor Placement Along the glenoid face-neck junction Placed 5-7 mm apart Recreate the bumper effect

6 Anterior Instability Postop Exam Initial Shoulder Arthroscopic Evaluation Anterior Instability Anterior Instability Anterior Superior Lateral Portal

7 Anchor Hole Placement Anterior Instability Knot Tying Anterior Instability Final Evaluation Anterior Instability

8 Another Case Anterior Soft Tissue Bankart Lesion Anterior Instability Anterior Capsule T Split Anterior Instability Preop Arthroscopic Exam Anterior Instability

9 Anterior Instability Initial Probe Eval Elevate Anterior Labrum Anterior Instability Place Anchor Anterior Instability

10 Anterior Instability Tie Knot Replace Blue Suture Anterior Instability Knot Tying Anterior Instability

11 Test Stability Anterior Instability Evaluate Final Repair Anterior Instability Another Case

12 Retracted Anterior Labrum Elevate Anterior Labrum Shoulder Instability and Rotator Cuff Repairs March 29, 2014

13 Viewed From Posteriorly Viewed Anteriorly Benefits of Arthroscopic Technique Less loss of external rotation (not have to take down subscapularis) Less difficulty regaining postoperative motion Better able to treat associated pathology

14 Refined Arthroscopic Technique Anchors placed on the anterior glenoid face-neck junction to recreate labral bumper that deepens glenoid concavity Plication sutures Rotator Interval closure Analysis of Athroscopic Instability Failures Too short a period of immobilization (< 3 weeks) Use of too few anchors Anterior placement of anchors on glenoid neck rather than edge of the articular surface Participation in contact sports Young Age Analysis of Arthroscopic Failures Glenohumeral Ligament Quality Generalized ligamentous laxity Engaging Hill-Sachs lesion Bony Bankart (inverted pear shaped glenoid) Capsular attenuation

15 Posterior Shoulder Instability 2-10% of all instability cases 50% due to trauma Athletes usually have subluxation rather than dislocation Most common in overhead throwers, tennis players, butterfly and freestyle swimmers, weightlifters, and football lineman History Symptoms with forward flexion, adduction, and internal rotation Throwers (follow-through) Swimmers (pull-through) Location of pain variable Often describe crepitation or click Posterior Instability Improvements in diagnosis and treatment of athletes and other individuals has shown posterior instability to be more common than once thought

16 Posterior Instability Symptoms Pain, weakness and loss of function with the arm in a forwardly flexed position Many patients improve with conservative treatment Physical Exam Posterior Joint Line Tenderness Load and shift test (sitting and supine) Posterior Instability

17 Posterior Instability Loose Body

18 Posterior Instability Viewed From Anterior Portal Viewed From Posterior Portal Viewed Posteriorly Viewed Anteriorly

19 Knot Tying Anchor Placement Evaluate Knot Security Suture Anchor for Anterior Labral Tear

20 Final Repair Final Repair Viewed from Anterior Portal Loose Body

21 Rotator Cuff Rotator Cuff Tendinitis Partial Thickness Tears Full Thickness Tears Rotator Cuff Tendons Supraspinatus Infraspinatus Teres Minor Subscapularis

22 Operative Procedure Visualization Preparation Execution Visualization Glenohumeral Evaluation Humeral Head and Glenoid Labrum Biceps Tendon Rotator Cuff ( all 4 Tendons) Subacromial Space Evaluation Bursal Side of Rotator Cuff Preparation Remove Thickened Bursal Tissue Remove Thickened CA Ligament Remove Acromial Spur Evaluate Rotator Cuff Tear Size Tendons Involved Configuration of Tear

23 Execution Undertake Rotator Cuff Repair Side to Side Rotator Cuff Repair

24 Second Suture Reevaluate Tear Single Row Repair

25 Single Row Repair Single Row Repair Single Row Repair

26 Single Row Evaluation Double Row Repair Evaluate Tear

27 Medial Row Anchor

28

29

30 Footprint Cuff Insertion Thank You

31

32 Anterior Labral Bumper Effect Arthroscopic Shoulder Procedures

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