One may also choose to mark the biceps tendon in the bicipital groove, and the conjoint tendon. A bursal orientation line can be constructed with the posterior ACJ edge as the starting point, extending 4cm laterally and down the arm. This line marks the start of the subacromial bursa, proves the anterior nature of its position and can be particularly helpful in the placement of the lateral portal.
Preparing for shoulder arthroscopy
One must continuously remember that scope movement through the portal resembles movement through an hourglass with a pivot point narrow point at the portal level. The scope normally utilized is a degree scope and alterations to the direction of the lens by means of rotation of the light source allow for an improved 3-dimensional perspective of the anatomy under assessment. Introduction of a probing needle is used as a confirmation tool prior to formation of a definitive portal in an attempt to optimize portal positioning and ensure adequate access to the structures under investigation.
Basic portals will be named A to E followed by F to K for the potentially more advanced ones. This is traditionally located 2cm inferiorly and 1cm medially to the posterolateral acromial edge. A needle is advanced towards the coracoid and into the inferior apex of the triangle formed superiorly by the acromion, laterally by the humeral head and medially by the glenoid. As mentioned before, the needle acts as a directional guide pointing towards the joint. Occasionally, one may witness a hissing sound, which serves as a confirmation that the needle is within intra-articular space.
A 5mm skin incision is then made and the arthroscope containing a blunt trocar is inserted into the joint. The contralateral hand of the surgeon is placed at the tip of the coracoid and the trocar is directed towards the middle finger of that hand, in an attempt to aid in the correct insertion. Internervous plane: plane between infraspinatus suprascapular nerve and teres minor axillary nerve.
Structures at risk: Axillary nerve, posterior circumflex humeral vessels. The posterior deltoid fibres, as well as infraspinatus fibres may be traversed by way of this portal. Because the arthroscopic view via this portal is directed medially, the lateral insertion of the rotator cuff cannot be adequately visualized. Consequently, the first portal is slightly modified to gain access to the subacromial space. Upon completion of the glenohumeral joint examination. The scope is reintroduced with the trochar but redirected towards the anterolateral corner of the acromion.
A sweeping motion is also used to tidy up any adhesions prior to pushing fluid through to re-initiate joint distention. The camera is then reinserted and a bursoscopy is performed. A second posterior portal also becomes necessary owing to the aforementioned technical difficulties. This portal serves as an access point to the posterior labrum and posterior rotator cuff aspects.
Entry point is traditionally found at 1cm antero-inferior to the posterolateral edge of the acromion. This portal is often used in posterior Bankart lesion repairs, instrumented repairs and suture managements, and allows visualization of the above mentioned structures when advanced. Once again, the posterior deltoid fibres may be traversed, and there is a risk of damage to infraspinatus particularly if the portal is used to instrument articular structures.
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The axillary nerve is now in close proximity lying only cm inferior to the portal entry point. This constitutes the first portal in cases where the intended procedure includes subacromial decompression, adhesive capsulitis release, or repair of massive rotator cuff tear. The entry point is located at the midpoint if the acromion, the location of which is once again confirmed by means of needle insertion.
This location provides for good access to the subacromial space, as well as visualization, manipulation and repair of cuff tears. Overall this portal is probably the most functional in terms of diagnostic and interventional procedures. Structures best visualized include subacromial space, ACJ, bursal side of rotator cuff, suprascapular nerve, coraco-clavicular ligaments, extra-articular biceps, coracoid, coraco-acromial ligament, coraco-humeral ligament, rotator interval, extra-articular subscapularis and the conjoint tendon.
Structures at risk include posterior fibres of the deltoid as well as the axillary nerve. This portal is ideal in providing access to the biceps tendon and the subscapularis insertion, as well as the anterior labrum rim and neck. It is also known as the sub-bicipital portal and and its positioning is best achieved by advancing a spinal needle 1cm from antero-lateral edge of the acromion.
Furthermore, it can be used for single or double row repairs of the anterior labrum Casseiopia technique. In cases of intact cuff, intra-articular access is achieved by traversing the coracohumeral ligament and the rotator interval where the ligament can be positively identified from its insertion on the coracoid.
Such approach provides for intra-articular access, but also access to the sub-coracoid space which is particularly useful in plexus exploration, subscapularis release, instrumentation of the supra-coracoid space in suprascapular nerve exposure. Structures identified include supraspinatus, subscapularis, rotator interval, coracoid, sub-coracoid space and bursa, suprascapular nerve and intra-articular space via the rotator interval. Structures at risk of damage include anterolatral deltoid, rotator interval and biceps tendon.
Creation of this portal is an essential constituent in the diagnostic arthroscopy by allowing appropriate instrument access, thus providing for proper palpation and dynamic examination of the various shoulder structures.
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The secret behind successful creation of this portal lies in the ability to visualise the biceps tendon and the rotator interval as seen through the posterior portal. To start off, a needle is inserted using the outside in technique, in an attempt to confirm the best portal position and to probe normal anatomy. The key anatomical landmark is located halfway along a line drawn from the acromion to the coracoid.
It is essential to remain lateral to the coracoid in order to minimise the risk of damage to the neurovascular structures. Following confirmation of the correct needle position via the intra-articular view, a skin incision is made with the blade advanced into the rotator interval using the needle as a guide, always being careful not to damage adjacent structures. Alternative instrument introductory methods include the use of a blunt trocar to penetrate the anterior capsule, the use of a cannulated portal or implementation of techniques which involve the use of a switching stick.
This portal is traditionally used in anterior instrumentation but also allows for an alternative view of the biceps anchor, anterior labrum and glenoid neck, as well as view of the subscapularis, infraspinatus, teres minor, posterior labrum and capsule.
Arthroscopic Rotator Cuff Repair - OrthoInfo - AAOS
Of note is that this portal transgresses the anterior deltoid fibres as well as the rotator interval thus putting these structures at risk. Medially, one needs to be aware of the brachial plexus and axillary vessels, inferolaterally the musculocutaneous nerve and finally the cephalic vein. Once intra-articular access has been obtained with the arthroscope, a systematic examination of the shoulder is performed. This usually begins with the gleno-humeral joint.
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Thorough knowledge of the anatomy and normal variants is essential both to recognise pathology, and to avoid repairing a normal variant, in the mistaken belief that it is a pathological lesion. The capsule can be considered a watertight structure that acts to restrain the joint but permit the great range of movement of the shoulder.
The volume of the joint is determined by the capsule, and varies significantly from the small, restrictive volume in patients with adhesive capsulitis, to the capacious capsule in those with connective tissue disorders or multidirectional instability. The capsule incorporates both the tendons of the rotator cuff as they approach their insertions, and the glenohumeral ligaments, which are seen as localised thickenings.
The capsule is lined by synovium, and is therefore susceptible to inflammatory disorders, malignancy and tumour-like conditions. It travels parallel to the biceps tendon to insert on the medial edge of the bicipital groove and the fovea capitus. Laterally, the SGHL joins the coracohumeral ligament, contributes to and stabilises the biceps pulley and forms part of the rotator interval. Visibility of the ligament is improved by adducting the shoulder.
It separates from the SGHL, where it is easily visible, runs diagonally downward and across the tendon of subscapularis to insert into the lesser tuberosity. The interval between the two ligaments forms the entrance to the subscapular bursa through the foramen of Weitbrecht. This space can be utilised arthroscopically to perform subscapularis release and to approach the brachial plexus and subscapular nerves.
The appearance of the MGHL is subject to common variations, appearing either as a cord-like structure, absent or thin ligament, or a part of a Buford complex which comprises a cord like MGHL arising from the superior labrum with an absent anterior superior labrum. The variation in morphology may play a role in the aetiology of SLAP tears by contributing to the stress on the biceps anchor. Attention should always be payed to the humeral insertion to avoid missing a humeral avulsion of the glenohumeral ligaments HAGL. Below the MGHL is the inferior subscapular recess which corresponds to the subcoracoid foramen of Rouviere.
The intervening capsular tissue between the two bands represents the axillary pouch. Due to its arrangement, the IGHL forms the main static stabiliser of the GHJ in abduction, and therefore should be carefully visualised. It also provides an origin for the glenohumeral ligaments and biceps anchor. These can be easily confused with a traumatic anterior labral injury Bankart lesion but need to be differentiated as the unwarranted repair can lead to a poor outcome.
More inferiorly the labrum attaches to the glenoid in a consistent manner with good fixation to bone. The rotator interval RI is located in the anterior shoulder and is implicated in various pathologies, particularly with regard to instability and stiffness. It is triangular in shape with its base at the coracoid process, its apex at the intertubercular groove, its inferior margin the superior border of the subscapularis tendon, and its superior margin the inferior border of the supraspinatus tendon. The function of the RI and its components is to restrict inferior and posterior translation of the humeral head via the SGHL and CHL as well as limiting external rotation.
Its lateral components maintain the stability of the biceps tendon. The RI also maintains negative intra-articular pressure.
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Lesions of the RI have been classified into two types. Type I lesions are those leading to a contracture of the RI e. This trapezoid structure is located in the rotator interval.