Shoulder arthroscopy. Mohammad nasir Naderi, MD Fellowship in shoulder and arthroscopic surgery
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1 Shoulder arthroscopy Mohammad nasir Naderi, MD Fellowship in shoulder and arthroscopic surgery
2 Shoulder arthroscopy Evolve understanding of anatomy and pathophysiology of shoulder This technology, allow to treat a broader variety of shoulder diseases
3 Equipments standard operating room table continuous distention with a fluid medium (Normal saline) static (i.e., gravity-assisted) arthroscopic pump systems mechanical instrumentation (shavers, burr ) electrocoagulation and cautery
4 Equipments standard operating room table
5 Equipments mechanical instrumentation (shavers, burr ) electrocoagulation and cautery
6 Equipments mechanical instrumentation (shavers, burr ) electrocoagulation and cautery
7 Equipments mechanical instrumentation (shavers, burr ) electrocoagulation and cautery Coblation-based Devices Conventional Electrosurgical Devices Temperatures 40 C to 70 C MORE THAN 400 C Thermal Penetration Minimal Deep Effects on target tissue Gentle removal, dissolution Rapid heating, charring, burning, cutting Effects on surrounding tissue Minimal dissolution Inadvertent charring or burning
8 Equipments continuous distention with a fluid medium (Normal saline) static (i.e., gravity-assisted) arthroscopic pump systems advantages of gravity-based systems are : -Safety - Simplicity - Low cost - Visualization may be affected by fluctuations in the entry flow, making it necessary to temporarily interrupt surgery
9 Equipments continuous distention with a fluid medium (Normal saline) static (i.e., gravity-assisted) arthroscopic pump systems Types of pumps: 1- pumps with pressure controls 2- pumps with independently modifiable pressure and flow controls
10 Arthroscopic surgery similar to open surgery exposure is everything you can't fix what you can't see Bleeding during surgery can inhibit visualization patient's blood pressure fluid flow intra-articular or subacromial pressu
11 Arthroscopic surgery similar to open surgery patient's BP (systolic < 10 mm Hg) pump pressure at 60 mm Hg avoid creating bleeding vessels Use of electrocautery ablation
12 Bernoulli Effect
13 Controlling turbulence
14 position lateral decubitus position continuous traction allows easier GH & subacromial arthroscopy beach-chair position more convenient for regional anesthesia and converting to open procedures
15 lateral decubitus position < lbs longitudinal traction position of the arm 45 to 70 of abduction 20 to 30 of forward flexion Hennrikus et al. (Am J Sports Med 23:444, 1995.)
16 beach-chair position Anatomical Convert to Open surgery Move arm Less Nerve injury
17 portals Glenohumeral Joint posterior portal anterior portal Anterosuperior, anteroinferior superior portal Subacromial Space Subacromial (posterior) portal lateral portal Anterolateral, mid-lateral, posterolateral portals
18 portals
19 To perform arthroscopic surgery on the shoulder. a thorough knowledge of normal anatomy and its variants are especially important in order to differentiate normal from pathological findings Hulstyn & Fadale, 1995
20 10 Point Shoulder Arthroscopy Lennard Funk GLENOHUMERAL JOINT: 1 LHB (SLAP, tear) 9 2 Glenoid & Posterior Labrum Inferior Recess 4 Humeral Head, Bare area, Posterior Cuff 5 Anterosuperior Cuff 6 Rotator Interval (pulley, LHB in groove, SGHL) 7 Subscap, MGHL, anterior labrum 8 AnteroInferior labrum, IGHL SUBACROMIAL BURSA: 9 CAL & Acromion 10 Rotator Cuff - Bursal side
21 Glenoid Labrum Loosely Attached: Superior Anterosuperior Firmly Attached: Inferior
22 Superior Labrum Triangular Bumper Meniscoid Mobile
23 Sublabral Foramen Atraumatic detachment of the labrum from the underlying glenoid Prevalence 10-20% in arthroscopy
24 Sublabral Foramen / MGHL Tear
25 Buford Complex Sublabral Foramen + Cord-like MGHL 1 6% prevalence in Arthroscopic study
26 Superior GHL Poor Visualisation Present in 40%-100% > 2mm diameter in 65%
27 Middle GHL Present in % Cord-Like = 20% Thin Veil Bifid
28 Present in % Anterior Band IGHL
29 Biceps Pulley Tendoligamentous Sling
30 Rotator Cuff Ridge Capsular Band under Rotator Cuff Perpendicular to LHB Encloses the Rotator Cuff Crescent Joint Side Partial Thickness Cuff Tear
31 Humeral Head Bare Area Increase in size with age (DePalma) Size 6 12mm (Cadaver) Few mm 20mm Fenestrations Vascular Pits Hill-Sachs Lesion
32 Glenoid Bare Area Younger > Old? Incidence Osteochondral Lesions
33 Pathological Lesions SLAP Tear Rotator Cuff Tear Bony Bankart Bankart Tear Posterior Labral Tear
34 Summary Shoulder arthroscopy is a less invasive surgery if : Good equipments Good visualization Good knowledge & experience Thank you for attention
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