SHOULDER ARTHROSCOPY(instrumentation and shoulder in brief)

For Orthopedics residents

1. By Dr . Vivek Madankar 2 nd year post-graduate Dept. o f Orthopaedics MGMH, Warangal Shoulder Arthroscopy

2. Dr . K. Ramkumar Reddy sir ( Prof & Unit Chief ) Dr . Prasad Reddy sir ( Assit . Prof)  Dr . M. Prakash Sir ( Assit . Prof ) MODERATORS  

3. Meaning of arthroscopy This word arthroscopy came from GREEK , " arthro " ( JOINT ) a nd " skopein " ( SCOPY ) ( to look ). The term literally means " TO LOOK WITHIN THE JOINT "

4. MONI T OR It is the device that projects the image created by the arthroscope and the camera head.

5. C AMERA HEADS

6. Camera head A rthroscope

7. L IGHT SOURCE WITH FIBRE OPTIC CABLES

8. Camera head Light source arthroscope

9. INSTRUMENTS AND EQUIPMENT

10. ARTHROSCOPE An arthroscope is an optical instrument. Three basic optical systems have been used in rigid arthroscopes : the classic thin lens system , the rod-lens system, and the graded index (GRIN) lens system.

11. Certain features determine the optical characteristics of an arthroscope. Most important are the diameter, angle of inclination, and field of view . The angle of inclination, which is the angle between the axis of the arthroscope and a line perpendicular to the surface of the lens, varies from to 120 degrees. Angle of i n cl i n a tion

12. The 25- and 30-degree arthroscopes are most commonly used. The 70- and 90-degree arthroscopes are useful in seeing around corners, such as the posterior compartments of the knee

13. ACCESSORY INSTRUMENTS

14. S C ISSORS Arthroscopic scissors are 3 to 4 mm in diameter and are available in both small and large sizes . The jaws of the scissors may be straight or hooked . The hooked scissors are preferred because the configuration of the jaws tends to hook the tissue and pull it between the cutting edges of the scissors.

15. BASKET FORCEPS The standard basket forceps has an open base that permits each punch or bite of tissue to drop free within the joint . Configuration- straight or hooked . Available in angles of 30, 45 and 90 degree . 15 degree up biting and down biting curves are available. Biting end Open base

16. GRASPING FORCEPS Grasping forceps are useful to retrieve material from the joint, such as loose bodies or synovium . The jaws of the grasping forceps may be of single- or double-action design and may have regular serrated interdigitating teeth. Single action Double action

17. MOTORIZED SHAVING SYSTEMS Consists of an outer, hollow sheath and an inner, hollow rotating cannula with corresponding windows . The window of the inner sheath functions as a two- edged, cylindrical blade that spins within the outer hollow tube . Suction through the cylinder brings the fragments of soft tissue into the window, and as the blade rotates, the fragments are amputated, sucked to the outside, and collected in a suction trap.

18. Electrosurgical, Laser and Radiofrequency Instruments Electrocautery has been used as an arthroscopic tool for cutting and hemostasis most often after arthroscopic synovectomy and subacromial decompression. It also has been used for both cutting and hemostasis in lateral retinacular release for malalignment of the patella. Reported complications of radiofrequency meniscal ablation include articular cartilage damage, osteonecrosis, and tissue damage caused by the irrigant.

19. CARE AND STERILIZATION OF INSTRUMENTS Arthroscopy equipment that is heat stable may be autoclaved for sterility. Heat- or moisture-sensitive equipment may be sterilized with a low-temperature hydrogen peroxide gas plasma and glutaraldehyde .

20. IRRIGATION SYSTEMS

21. D ISTENTION PRESSURE For knee 60-80 mmHg For shoulder 30 mmHg less than systolic blood pressure. For elbow and ankle 40-60 mmHg

22. Reason for using ringer lactate is it does not hamper proteoglycan synthesis and provide growth medium, and also physiological solution NS inhibit proteo glycan synthesis

23. A D V A N T AGES Reduced postoperative morbidity Smaller incisions Less intense inflammatory response Improved visualization Absence of secondary effects Reduced hospital stay Reduced complication rate Improved follow-up evaluation Possibility of performing surgical procedures that are difficult or impossible to perform through open arthrotomy

24. DISADVANTAGES Working through small portals with delicate and fragile instruments. Maneuvering the instruments within the tight confines of the intraarticular space may produce significant scuffing and scoring of the articular surfaces. Requires experienced surgeon Time consuming Requires special instruments Expensive

25. CONTRAINDICATIONS When the risk of joint sepsis from a local skin condition is present or when a remote infection may be seeded in the operative site RELATIVE CONTRAINDICATIONS Partial or complete ankylosis around the joint Major collateral ligamentous and capsular disruptions of the joint

26. SHOULDER

27. For developmental, traumatic, degenerative, or inflammatory conditions of the shoulder resulting in pain, instability, or disability that cannot be controlled by conservative measures , arthroscopic treatment performed by a skilled surgeon results in a low-risk, high-reward reproducible procedure . Indication: Contraindications: local skin conditions, remote infections that might spread to the joint, and increased medical risks. Surgeons considering arthroscopic procedures should adhere to appropriate indications for the technique and should advise patients about the possibility of an open procedure.

28. Advantages of the lateral decubitus position include better ability to apply traction to the arm, better access to the posterior shoulder, and ease and safety of position . POSITION A) lateral decubitus

29. Advantages of the beach-chair position include more anatomic orientation, greater ease of manipulating the arm with an arm positioner, less risk of traction neuropraxia , and ability to easily convert to an open procedure. B) beach-chair position

30. POSTERIOR PORTAL The posterior portal is the primary entry portal for shoulder arthroscopy . It allows examination of most of the joint and assists in the placement of subsequent portals. B) ANTERIOR PORTAL Multiple anterior portals have been described for diagnostic and surgical stabilization techniques. For complete diagnostic examination of the shoulder, an anterior portal is essential to allow observation of the posterior capsule and the rotator cuff and for an anterior view of the glenohumeral ligaments and the subscapularis tendon. PORTAL

31. C) SUPERIOR PORTAL Neviaser is credited with the description of the superior portal (supraclavicular or suprascapular portal). This portal is most useful for passage of suture retrieval devices for rotator cuff repair. D) POSTEROINFERIOR SEVEN-O’CLOCK PORTAL Davidson and Rivenburgh described a 7-o’clock accessory posterior working portal for shoulder arthroscopy that allows direct access to the inferior glenohumeral capsule and avoids damage to the nearby structures.

32. DIAGNOSTIC ARTHROSCOPY AND ARTHROSCOPIC ANATOMY As with arthroscopy of other joints, a thorough knowledge of the major anatomic structures around the shoulder is necessary. The surgeon must be familiar with the normal anatomy to identify abnormal or pathologic processes.

33. A) Superior part of shoulder joint with biceps tendon inserting into superior labrum . Humeral head is superior right, and glenoid is inferior. B) Superior glenohumeral ligament and subscapularis tendon on right with middle glenohumeral ligament inferiorly.

34. C) Normal sublabral hole. D) Buford complex showing insertion of middle glenohumeral ligament directly into biceps anchor.

35. E) Middle cord variant of glenohumeral ligament crossing subscapularis tendon . F) Inferior pouch . Glenohumeral ligaments and labrum are seen.

36. G) Capsular attachment to humeral head observed through inferior pouch. H) Rotator cuff evaluated for fraying, partial tears, or calcification. Supraspinatus tendon is seen superiorly with biceps tendon in center of picture.

37. I) Posterior articular surface, posterior labrum , posterior pouch, and posterior capsule observed with arthroscope inserted anteriorly . J) Posterior band of inferior glenohumeral ligament.

38. K) Anterior band of inferior glenohumeral ligament observed from anterior portal. Humeral insertion of ligament is superior. L) Capsulolabral attachment to glenoid observed through anterior portal.

39. Rotator Cuff repair Rotator cuff repair seek to achieve adequate tendon fixation and secure the fixation during the process of biological feeling. Currently arthroscopic rotator cuff repair has become the gold standard repair technique Single row repair One of the earliest it incorporates the use of single row of anchors and use of sutures through the rotator cuff causing tendon compression on to the tuberosity with low tension Disadvantage Inadequacy to precisely restore the anatomical footprint The significant rates of retear especially in large and massive tears

40. Double row repair incorporates medial and lateral row anchors. Arthroscopic double roll rotator cuff repair is a structure that utilizes two rows of anchors one being medial and other being letter in order to provide better anatomical footprint restoration . Various types of double row configurations are classic double row repair Suture bridge technique/ trans- ossius equivalent Knotless TOE 2) Double Row repair

41. Double row repair is more suitable for tear that can be reduced to the lateral of greater tuberosity. In order for the repair structure to be tension free the surgeon should first free and immobilized the torn tendon and ensure that the tender can reach the lateral side of the greater tuberosity. Advantage Wider contact area High repair strength Disadvantage Longer intraoperative time the increase in cost steeper learning curve the overcrowding of anchors at the repair site strangulation of tendon a) Classic double row repair

42. Based on the transosseous technique which had been used in open surgery as gold standard. In the TOE technique after the middle row has been placed and tied, the suture feet taken from the middle row are crossed over and past from the interference screws/ lateral row anchors. Advantage T endon tissue isn't penetrated at the lateral row Tissue strangulation by the knots is decreased and tendon vascularity probably better preserved Disadvantage E xcessive load and tendon strangulation at the medial knots b) Transosseous equivalent/suture bridge technique

43. In this technique the sutures with wider surfaces are loaded to the medial row anchors and pass through the medial of the tendon without tying any knots crossed over and fixed to the lateral row knotless anchors Advantage T echnically simpler Carried out faster Developed in order to eliminate the problem of tendon strangulation Reduces the increased cost Disadvantage Chance of suture slippage Low construct strength c) Knotless TOE

44. NEER type 2 fracture often develops non union and even surgical treatment can have a high frequency of complication Recent techniques have been proposed in search of arthroscopic reduction and minimally invasive fixation with good subjective outcomes , functionally , symmetrical ROM Distal end clavicle

45. A patient return to previous activities after only 3 months and to full sporting activities at 6 months Flexible coracoclavicular fixation has been used with good functional results surgeons have reported arthroscopy,/ arthroscopic assisted flexible/rigid fixation using an artificial ligament with endo button fixation on the coracoid and the screw with the washer on the clavicle are fixation with AC tightrope

46. Articular shoulder fracture can be divided into glenoid fracture and glenoid rim fractures/Bony bankart lesion. Glenoid rim fractures- incidence can vary between 4% and 70% and up to 30% of shoulder dislocation can also present with Bony bankart lesion Glenoid fractures

47. An Arthorscopic Reduction and Internal Fixation approach for glenoid rim fracture can allow the simultaneous treatment of greater tuberosity fracture and many other associate intra-articular lesions Various arthoscopic techniques have been proposed like sugaya technique , Bony bankart bridge technique , transosseous fixation and the" double Pulley dual row " technique reported good functional results and minimal risk of recurrence.

48. Arthroscopic assistance for glenoid rim fracture associated with cannulated screw fixation and recommended for precise anatomical r estoration full range of movement recovery and almost zero complications Antero-inferior portel through the subscapularis (5 o'clock portal ) has been proposed for better positioning for the inferior suture anchor For posterior fractures, Maclaughin procedure was proposed recently consisting of a subscapularis tenodesis with double mattress athroscopic sutures indicated in wide defects patient, risk of recurrent shoulder dislocation during normal activity and after the failure of conservative treatment

49. Represent about 20% of proximal humeral fractures Cannulated screws usually used in the management of greater tuberosity fracture are not indicated in osteoporotic patients Arthroscopic single row/double row fixation can be done like a cuff repair SUTURE BRIDGE technique for occult greater tuberosity fracture in patients with chronic pain , weakness , ROM reduction and following the failure of conservative treatment Humeral greater tuberosity fracture

50. Arthroscopy can be used for a) unstable proximal humeral fracture with two or three fragments , b) proximal spiral fractures and c) epiphyseal fractures with communition Contraindicated for a) complex intra-articular fracture , b) head splits and c) in young patients ARIF in this case involves incision and subsequent repair of the supraspinatus tendon but causes less preoperative and postoperative morbidity with less tissue trauma and reduce bleeding and lower rate of infection and humeral head osteonecrosis Proximal humeral fracture

51. THANK YOU