Shoulder arthroscopy

anatomy and full details of shoulder arthroscopy ,the steps and indication of shoulder arthroscpy

1. SHOULDER ARTHROSCOPY MODERATOR DR.PRABU ETHIRAJ SIR ASSOCIATE PROFESSOR DEPARTMENT OF ORHTOPAEDICS PRESENTER :DR.MADHAVAN

2. INTRODUCTION Arthroscopy:  A surgical technique in which a tube-like instrument is inserted into a joint to inspect, diagnose, and treat . It is most commonly performed in patients with diseases of the knees, shoulders ,elbow ,wrist and ankle . Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

3. The first ever use of arthroscopy was performed in 1918 orthopedic surgery by Dr Kenji Takagi(1888-1963) a Japanese orthopedic surgeon by using Charrier number 22 cystoscope in cadaver knee joint HISTORY

4. In 1931 American surgeon Michael Burman examined 25 shoulders in cadaver using arthroscope Initially it was used for diagnostic purpose Now with well established training and skills labs , shoulder Arthroscopy is used for treatment as well!

5. Painful syndromes in the shoulder , altered function, and signs and symptoms of instability and associated with internal derangement are frequent in the shoulder Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

6. For conditions which can not be controlled by conservative managements such as Developmental Traumatic Degenerative Inflammatory conditions Resulting pain instability disability arthroscopic treatment is performed by a skilled surgeon to tackle such conditions

7. INDICATIONS Diagnostic 2.Labral/SLAP repair 3.Rotator cuff repair or debridement

8. 4.Loose body removal 5.Subacromial decompression 6.AC joint pathology

9. 7.Distal clavicle resection 8.Release of suprascapular nerve entrapment 9.Release of scar tissue /contractures

10. 10.Synovectomy 11.Biceps tenotomy / tenodesis

11. BASIC ARTHROSCOPIC KIT Arthroscopy Light source and cable Camera system and monitor with recorder Arthroscopic probe Arthroscopic grasper Arthroscopic scissor Arthroscopy cautery Arthroscopic Punches (basket forcepes 2.7 mm upcutting right and left Rotatory ) Motorized shaver

12. Arthroscopic light source

13. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

14. Arthroscopic basket forceps

15. Arthroscopic scissor

16. Arthroscopic grasper

17. Wissinger rod

18. Arthroscopic trocar

19. Motorized arthroscopic Shaver

20. Esch JC, Baker CL Jr. Arthroscopic surgery: the shoulder and elbow. Philadelphia, PA: JB Lippincott, 1993:38 The angle of inclination is 0°, 30°, or 70° relative to the arthroscope axis. The angular field-of-view cone is oriented along the axis of the angle of inclination

21. Rotating the arthroscope’s field of view enhances arthroscopic viewing by creating overlapping circular images with a 30° arthroscope ( center ). With a 0° arthroscope ( top ), the field of view is unchanged with rotation. With a 70° arthroscope ( bottom ), rotation occurs around a central blind spot. (Illustration by Susan Brust .)

22. PATIENT POSITION Two basic positions Lateral Decubitus “Beach chair” (Most commonly used) Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

23. LATERAL DECUBITUS POSITION The patient is placed in the lateral decubitus position with the affected shoulder exposed and is supported by a vacuum beanbag and kidney rest. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

24. All pressure points Padded with a pillow Acromion , ASIS, Below knee, lateral malleolus and one or more pillows between the knees and ankles. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

25. By tilting the patient 20 to 30 degrees posteriorly , glenoid will be parallel to the floor Less traction: Decrease the risk of neurapraxia of the brachial plexus Accentuation of tears in the glenoid labrum as it pulled away from their beds Improved arthroscopic access to the inferior third of the glenoid labrum and capsule. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

26. Vertical and longitudinal traction, with most of the traction applied vertically to distract the glenohumeral joint without subluxing it inferiorly 10 to 13 lb of traction is applied 30 to 60 degrees of abduction 20 to 30 degrees of forward flexion 23% and 30%: neurapraxia after excessive arm traction. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

27. BEACH CHAIR POSITION The benefits of the “beach chair” position Interscalene block Faster and easier positioning Reduced risk of neurapraxia Less distortion of intra articular capsular anatomy, Improved mobility of the patient’s arm Ease in orientation Surgical manipulation in the subacromial space Ease in conversion to an open surgical procedure.

28. COMPLICATIONS Difficulty in working from posterior portals Stroke Death due to hypotensive episodes Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

29. CONTRAINDICATIONS Local skin conditions Remote infections that might spread to the joint Associated co-morbidity Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

30. CONTROL OF BLEEDING DURING ARTHROSCOPY One method of controlling bleeding is to add 1 mL of 1 : 1000 epinephrine to each 3L bag of irrigant A systolic-to-pump pressure gradient of approximately 30 mm Hg should be maintained Elevation of the fluid bags 3 feet above the level produces a similar pressure gradient of 66 mm fluid flow pressure Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

31. It has been recommended that this pressure be maintained at 49mmHg or less below the systolic blood pressure to preserve the clarity of view An isotonic solution, such as saline (0.9%, 300mOsm/L) or lactated ringer's (273 mOsm /L), is commonly used and safely proven for joint irrigation during arthroscopy

32. FLUID EXTRAVASATION Established portals should be maintained by an interchangeable cannula system while instruments are being exchanged Lo and Burkhart evaluated 53 patients immediately after shoulder arthroscopy and found an average fluid weight gain of 8.7 lb. Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

33. PORTAL PLACEMENT Before making arthroscopic portals, a thorough understanding the local anatomy is necessary to prevent damage to neurovascular structures

34. AXILLARY NERVE   Passes ~ 7 cm below tip of acromoium At risk if the posterior portal is made too inferior SUPRASCAPULAR NERVE At risk if the posterior portal is made too medial  NEUROVASCULAR ANATOMY

35. The axillary nerve Cephalic vein Suprascapular artery and nerve Are the structures most at risk during shoulder arthroscopy Meyer M, Graveleau N, Hardy P, Landreau P: Anatomic risks of shoulder arthroscopy portals: Anatomic cadaveric study of 12 portals. Arthroscopy 2007; 23(5):529-536

36. The axillary nerve travels posterior to the coracoid and inferior to the lateral border of the subscapularis medial to the musculotendinous junction The nerve has been reported to be from 3 to 7 cm from the lateral acromion

37. The suprascapular nerve (SSN) arises from the upper trunk of the brachial plexus, traveling through the posterior triangle of the neck The suprascapular artery runs with the nerve until it reaches the suprascapular notch The nerve lies 3 cm (range, 2.5 to 3.9 cm) medial to the supraglenoid tubercle at the suprascapular notch

38. Standard Portal Placement Posterior portal Indication : Primary viewing portal used for diagnostic arthroscopy Location and technique 1.Posterior soft point 1.5 cm inferior and 2 cm medial to the posterolateral corner of the acromion towords coracoid 2.Pass between infraspinatus ( suprascapular nerve ) and teres minor ( axillary nerve ) 3.First portal placed 4.Direct anteriorly towards tip of coracoid

39. 1.5CMS INFERIOR 2CMS MEDIALY

40. Anterior central portal(Matthews) Indication :To View and do subacromial decompression Location & technique Lateral to coracoid process and anterior to AC joint Portal passes between pectoralis major ( medial and lateral pectoral nerves ) and deltoid ( axillary nerve) This portal is usually placed under direct supervision from the posterior portal with aid of spinal needle

41. coracoid process

42. Lateral portal Indication :For subacromial decompression Location & technique Located 1-2 cm distal to lateral edge of acromium Portal passes through deltoid ( axillary nerve ) Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

43. 2CMS DISTAL TO TIP OF ACROMION

44. ADDITIONAL PORTALS Portal Location indication 5 o’clock portal Anteroinferior transubscapularis Bankart repair 7 o’clock portal Posteroinferior Posterior labral repair, loose body removal Neviaser portal Superior, posterior to acromioclavicular joint Suture passage during slap repair and rotator cuff repair Portal of wilmington Posterolateral , 1 cm lateral to posterolateral acromion Anchor insertion during slap repair and rotator cuff repair Paxton ES, Backus J, Keener J, Brophy RH. Shoulder arthroscopy: Basic principles of positioning, anesthesia, and portal anatomy. J Am Acad Orthop Surg 2013;21:332-342

45. The 5 o’clock, 7 o’clock, and anteroinferior portals are safely created using an inside-out technique 1. Posterior portal 2. Anterior central portal 3. Antero lateral portal 4. Postero lateral portal 5. Supero lateral portal 6.Anterosuperior portal 7.7 o’clock portal 8.Axillary pouch portal 9.Neviaser portal 10.portal of Wilmington 11. Trans rotator cuff portal

46. (5 o'clock) portal: Davidson Indication : Anterior labral repair & Bankart lesions Inside out technique: Located slightly inferior to coracoid This portal is usually placed under direct supervision from the posterior portal with aid of spinal needle Located lateraly an average of 13 mm from axillary A, 15 mm from axillary N, and 17 mm from cephalic V Davidson PA, Tibone JE: Anteriorinferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy 1995;11(5): 519-525

47. Bankart lesion  is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid .

48. ANTEROINFERIOR PORTAL(WOLF) Indication : Bankarts lesion Technique :Inside out The arthroscope sides off the inferior edge of corocoid tip

49. ANTERIOSUPERIOR(WOLF) Indication :Biceps tenotomy ,SLAP repair Bankarts lesion Technique :Inside out and outside in The arthroscope sides mid distance between corocoid and acromion

50. ANTEROLATERAL (ELMANNS) Indication : subacromion decompression Technique : outside in 2cms below the lateral edge of acromion in its elongation anterior edge

51. POSTEROLATERAL (ELMANNS) Indication : Subacromion decompression Technique : Outside in 2cms below the lateral edge of acromion in its elongation of posterior edge

52. superior Nevasier  ( supraspinatus ) portal Indication : Anterior glenoid visualization, SLAP repairs And rotator cuff repair Location & technique: Outside in Located just medial to lateral acromion Goes through supraspinatus muscle The suprascapular nerve and artery are only 3 cm from the supraglenoid tubercle and are at risk when using the Neviaser portal Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthroscopy 1990; 6(4):301-305.

53. course of the suprascapular nerve along the posterior scapula. In a cadaver study by Bigliani et al line A, the distance from the supraglenoid tubercle to the suprascapular notch, averaged 3.0 cm (range, 2.5 to 3.9 cm); line B, the distance from the supraglenoid tubercle to the base of the scapular spine, averaged 2.5 cm (range, 1.9 to 3.2 cm); and line C, the distance from the midline posterior glenoid rim to the base of the scapular spine, averaged 1.8 cm (range, 1.4 to 2.5 cm) Suprascapular notch Supraglnoid tubercule Midline posterior glenoid Base of scapular spine

54. NEVIASER PORTAL

55. SUPERIOR SUPRASCASPULAR NERVE PORTAL ( LAFOSSE ) Indication : Suprsascapular never entrapment release Technique: Outside in 7cm medial to the lateral border of acromion

56. 7 o'clock portal Davidson Indication :  Posterior labral repair and loose body removal location & technique: Outside in 3 to 4cms inferior, 1cm lateral to the posterior lateral acromion edge The structures at risk are the the axillary nerve, and the posterior circumflex humeral artery Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

57. Wilmington portal Indication : SLAP  lesions , acromioclavicular joint pathology and subacromial impingement,Rotator cuff tear location & technique: Outside in 1cm anterior and 1cm lateral to the posterior lateral corner of acromion Burkhead WZ Jr , Scheinberg RR, Box G: Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1(1):31-36

58. TRAN ROTATOR CUFF (O’BRIEN) Indication : Rotator cuff repair and subacromial decompresion Technique :outside in 1 cm posterior and 2 cm lateral to the anterolateral corner of the acromion To the 11-o’clock position in the glenoid labrum medial to the rotator arch

59. PRECAUTIONS Avoid chondral injury by using blunt obturators (Do not plunge!) 2. Avoid rotator cuff tendon tears during posterior portal placement by internal rotation of the humerus 3. Minimize risk of neurovascular injury by placing the anterior portal lateral to the coracoid and humerus in adduction when creating anterior portal Canale , S T, James H.  Beaty , and Willis C. Campbell. Campbell's Operative Orthopaedics. Philadelphia, PA: Elsevier/Mosby, 2013

60. Awareness of the axillary nerve is important in portal placement anteriorly , posteriorly , and laterally. Posteriorly , the suprascapular nerve and circumflex scapular artery are approximately 2 cm from the portal site. Later portals, which are used to work on the glenohumeral space, should be directed to enter medial to the rotator arch

61. Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

62. 10 steps visualizing from posterior port 1.Biceps tendon and superior labrum: Evaluate both surfaces of intra articular segments There should be no fraying Grasping tool to pull and to check for any damage to biceps tendon Evaluate anterior and posterior pully Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

63. Vinculae biceps : mesentery like synovium Should not mistaken for tear Rare cases Biceps tendon is partically or completely encased by synovial tissue and capsule Bifid biceps one portion attached to supragleniod and another to rotator cuff Some times to completely to rotator cuff Complete absence of biceps tendon with no history of trauma with normal function Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

64. VINCULAE BICEPS

65. BIFID BICEPS

66. SUPERIOR LABRUM Inspect the superior labrum and palpate the attachment to the glenoid If the superior labrum is damaged or loosely attached, pull on the biceps tendon with a probe to determine whether the labrum will arch away from superior glenoid Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

67. In young patients: The edge of the labrum intimately attached Patients mature: Labrum separates from the cartilage so that by age 40 to 50 most people have a prominent cleft under the superior labrum (MENISCOID APPEARCNCE ) Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

68. MENISCOID APPERANCE

69. Acute trauma in a younger individual (15 to 30 years of age) can result in avulsion of the superior labrum and biceps anchor The tissue below the superior labrum will be frayed, torn, and irregular chronic degenerative conditions of the glenohumeral joint or biceps tendon will cause the superior labrum to appear damaged suggesting a type 2 SLAP lesion

70. 2.The Posterior Labrum and Posterior Capsular Recess The posterior labrum should be smooth and is usually tightly fused to the glenoid surface The outer edge of the healthy labrum is higher than the cartilage edge, creating a chock block–like border multidirectional instability, the labrum can be hypoplastic

71. HYPOPLASTIC POSTERIOR LABRUM IN MULTIDIRACTIONAL INSTABILITY

72. 3.The Inferior Axillary Recess, the Inferior Capsular Attachment to the Humeral Head Scope tip positioned in the axillary pouch, the bevel is rotated in an arc from inferior to superior to see the inferior capsule Smooth with a delicate synovial covering will be present There may be small normal fenestrations near the attachment to the head Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

73. Early chondromalacia lesions or osteophytes are seen in this position In adhesive capsulitis the inferior Capsule is contracted and closing off the pouch will be present Inferior capsular attachment tear to the humerus : seen in traumatic dislocation, especially with luxatio erecta . Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

74. Axillary recess with smooth synovial covering , articular cartilage of humerus

75. 4.Inferior Labrum and Glenoid Articular Surface The normal inferior labrum is smoothly fused with the cartilage Congenital laxity, the labrum may appear deficient or flat Torn inferior labrum always associated with anterior instability “Thin spot” : Inferior half of the glenoid which is Normal superior pole of the glenoid may also become thinner with aging: Normal

76. The articular surface of the glenoid is slightly concaved with a thin area in the center

77. 5. Supraspinatus Tendon of the Rotator Cuff Rotate the bevel of the arthroscope upward to the 11, 12, and 1 o’clock positions to visualize the undersurface of the supraspintatus tendon as it attaches into the humeral head The rotator cuff tendon is covered by layer of capsule and synovium Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

78. “ Rotator cuff ridge” or “cable: it’s a capsule thikening perpendicular biceps tendon A rich vascular supply above the lateral border of the rotator cuff ridge known as the rotator cuff crescent

79. The supraspinatus tendon attaches to the humeral head adjacent to the articular cartilage. The rotator ridge or cable is a capsular band extending from the anterior edge of the cuff to the posterior humeral head enclosing the area called the crescent.

80. 6.The Posterior Rotator Cuff insertion the “Bare Area” of the Humeral Head The rotator cuff in this posterior area frequently appears fenestrated with openings in the superficial layers The “bare area” of the humerus is a portion of the head that is devoid of articular cartilage Located adjacent to the posterior lateral rotator cuff attachment 2 to 3 cm in size

81. Within this area there can be deep pits representing vascular channels in the bone We should not confuse this bare area with a post-dislocation osteochondral fracture known as the Hill-Sachs lesion. The Hill-Sachs lesion is found in a more medial location Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

82. The bare area of the humeral head is located adjacent to the infraspinatus attachment to the humeral head and may have multiple blood vessel channels

83. 7. Articular surface of humeral head Rotate the bevel of the scope both clockwise and counterclockwise to visualize globe of the humeral head Center of the humeral head break down in chondrolysis , osteochondritis , or degenerative arthritis Blistering of the cartilage is a sign of impending chondral breakdown Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

84. The globe of the normal humeral head is smooth with firm articular cartilage.

85. 8. Anterior-Superior Labrum, the Superior Glenohumeral Ligament, Subscapularis Tendon, and the MGHL In 14% of normal patients, there will be an opening or sublabral foramen beneath the labral attachment Know as cleft which is normal

86. Anterior-superior labral detachment is the so-called Buford complex Variant occurs in approximately 2.5% of shoulders. There are three features included in the complex: (1) There is a thick cord- like MGHL (2) The MGHL attaches to the superior labrum just anterior at the base of the biceps anchor (3) Absence of labral tissue on the anterior-superior glenoid Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

87. The Buford complex is easily confused with anteriorsuperior Labral detachment.

88. Anatomic variations region of  anterosuperior labrum and MGHL has wide anatomic variability  Attached labrum with broad MGHL is most common Sublabral hole with cordlike MGHL Buford complex  Has absent labrum and cordlike MGHL

89. The subscapularis tendon is a very prominent landmark demarcating the inferior boundary of the anterior-superior triangle. Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

90. The superior glenohumeral ligament attaches to the Lateral edge of the subscapularis tendon.

91. 9.Includes the Anterior-Inferior Labrum Rotate the bevel inferiorly to visualize the entire anterior-inferior labral attachment to the glenoid 95% of cases, the labrum has a smooth attachment to the glenoid cartilage “ meniscoid type” in which the articular edge of the labrum is separated from the glenoid cartilage Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

92. The anterior-inferior labrum and the attachment of the anterior- inferior ligaments are best seen when viewing from the anterior portal

93. 10. Anterior-Inferior Capsule and ligament The anterior capsular ligaments insert into the labrum and are firmly attached with it to the neck of the glenoid . The capsular tissues are smooth and covered with a thin synovial membrane Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

94. Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

95. 11. Posterior Labrum and the Capsule insertion in to the humeral head To evaluate the posterior-inferior labrum Firmly attached at the periphery Posterior capsular recess cannot be well-visualized but capsular laxity can be assessed by pinching a fold of capsule with a pincer clamp Tear in the capsule called as Reverse Humeral Avulsion Of The Glenohumeral Ligament “RHAGL” lesion Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

96. Reverse Humeral Avulsion Of The Glenohumeral Ligamen “RHAGL” lesion opposite to HAGL HAGL is inferior gleno humeral ligament injury

97. The posterior capsule can be seen attaching to the posterior aspect of the humeral head

98. 12. Posterior-Superior Capsule and the Posterior Aspect of the Rotator Cuff The normal surface of the rotator cuff is smooth, with regular vascularity The posterior attachment of the rotator cuff ridge or cable arches to attach to the humeral head Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

99. 13.The Anterior Labrum and the Attached Anterior-Inferior Ligament to the Humeral Head To evaluate the anterior-inferior labrum Assess the status and quality of the supporting ligaments, labrum, and capsular tissue when evaluating for instability 3.The labrum can be palpated with a probe passed through a posterior portal to assess the security of the attachment to the glenoid

100. The lateral humeral attachment of the anterior capsule must be evaluated by turning the scope bevel to view in a lateral direction

101. 14.Includes the Anterior Attachment of the MGHL and the Subscapularis Recess The superior edge of the subscapularis tendon must be carefully evaluated for fraying below the level of the glenoid rim, the so-called Frayed Upper Subscapularis with Impingement (FUSSI) lesion Loose bodies are present in the shoulder, they will be located in the subscapularis recess The anterior attachment of the MGHL crosses the tendon to insert into the labrum or glenoid neck

102. The subscapularis recess may have several compartments that can hide loose bodies.

103. The attachment of the MGHL into the labrum or glenoid neck is seen crossing the subscapularis tendon

104. 15.Attachment of the Subscapularis Tendon , the Anterior Surface of the Humeral Head, and the Adjacent Biceps Tendon Tip of the arthroscope follows the leading edge of the subscapularis tendon up to its attachment into the humerus at the lesser tuberosity Visualize the anterior articular surface of the humeral head. There is sometimes a normal “bare area” similar to that found on the posterior humeral head

105. This area should not be confused with an anterior humeral head defect found in conjunction with posterior instability Snyder, S. J. (2015).  Shoulder arthroscopy . Philadelphia: Wolters Kluwer Health.

106. The anterior surface of the humeral head is an important area to evaluate the subscapularis attachment

107. Summary

108. Thank you