Arthroscopic Antomy of Shoulder Murt Bozkurt, Mehmet Emin Simsek, nd Hlil İrhim Açr 2 2.1 Introduction In the lst 30 yers, shoulder rthroscopy hs ecome of greter importnce in the dignosis nd tretment of shoulder diseses. An incresing numer of rthroscopic techniques together with innovtions in surgicl equipment hve resulted in severl surgicl procedures which were pplied s open surgery in the pst now eing pplied s rthroscopic procedures. The im of rthroscopic surgery is to provide rpid, ccurte dignosis nd tretment during surgery together with the lest moridity possile to the ptient. Therefore, the most importnt fctor incresing the success of rthroscopic surgery is the ility to identify nturl-helthy ntomic structures. In this section, it is imed to identify nturlhelthy ntomic structures in shoulder rthroscopic surgery. M. Bozkurt (*) Deprtment of Orthopedics nd Trumtology, Ankr Yıldırım Beyzıt University, Ankr 06800, Turkey e-mil: nmozkurt@gmil.com M.E. Simsek Yenimhlle Trining nd Reserch Hospitl, Ankr Yıldırım Beyzıt University, Ankr, Turkey e-mil: mehmeteminsimsek@hotmil.com H.İ. Açr Deprtment of Antomy, Ankr University, Ankr, Turkey e-mil: drhlilcr@yhoo.com 2.2 Surgicl Technique In our hospitl, rthroscopic shoulder opertions re performed in the ech chir position. The ptient is plced on the operting tle seted in 70 flexion, nd s deep vein thromosis prophylxis, oth lower extremities re wrpped in elstic ndges. A hip support is plced elow the hips to prevent the ptient slipping on the tle. The hed position of the ptient is fixed with hed holder. All ptients re dministered hypotensive nesthesi under neuromonitoristion. The shoulder tht is to e surgiclly treted is plced t the edge of the tle. Epinephrine is routinely included in the isotonic fluid to e used in the rthroscopy. After entry to the joint, fluid pressure is djusted to n initil pressure of 40 mmhg with utomtic pressure control. We routinely use the posterior portl t the strt of rthroscopy, nd the surgicl procedure egins with intr-rticulr dignostic rthroscopy. Respectively, the skin, sucutneous tissue, deltoid muscle, teres minor nd infrspintus intervl, then the cpsule re pssed with the trochr. Adjcent to this re re the qudrngulr nd tringulr gps. In the first entry to the glenohumerl joint spce, lunt-end oturtor is used, nd the rthroscopic cnnul is plced over the oturtor. To e le to identify pthologicl structures in shoulder rthroscopy, it is necessry to e le to identify the nturl ppernce of nonpthologicl intr-rticulr structures. During Springer Interntionl Pulishing AG 2017 M. Bozkurt, H.İ. Açr (eds.), Clinicl Antomy of the Shoulder, DOI 10.1007/978-3-319-53917-1_2 17
18 M. Bozkurt et l. Fig. 2.1 () Arthroscopic evlution with the posterior portl () Glenoid, lrum nd humerl hed Fig. 2.2 () Antomicl structures seen from posterior portl () Lrum, glenoid, iceps tendon, MGHL nd suscpulris tendon rthroscopy, exmintion of the intr-rticulr ntomic structures in the sme order will help in mking correct dignosis. In dignostic rthroscopy, we plce the cmer prllel to the floor perpendiculr to the glenoid with the end of the cmer superomedil to the humerus hed (Fig. 2.1, ). By turning the cmer viewing ngle to the glenoid, it is ttempted to understnd whether or not there is chondrl dmge nd whether or not the glenoid one edges intct. Degenertion of the glenoid superior rticulr surfce is evluted in respect of crtilge loss. It is thicker thn the centrl section. The centrl glenoid crtilge my sometimes e thin nd cn therefore e oserved s crtilge defect (Fig. 2.2, ). The first things to e visulised within the joint re the tringle formed y the iceps tendon in the superior nd the humerus hed in the lterl nd the suscpulris in the inferior. Of the intr-rticulr structures, the first to e locted is the iceps tendon. On first entry to the joint, the iceps tendon must e identified for orienttion purposes. The iceps tendon is visulised from the ttchment known s the iceps nchor in the suprglenoid tuercle nd superior lrum, long the rottor intervl s fr s the point where it emerges from the shoulder (Figs. 2.2, nd 2.3, ). Then the first re to e identified should e the rottor intervl region. Structures in this re re
2 Arthroscopic Antomy of Shoulder 19 Fig. 2.3 () Visuliztion of iceps tendon () Biceps groove of humerl hed Fig. 2.4 () Identifiction of the rottor intervl () Antomic structures of the rottor intervl the upper intr-rticulr tendinous section of the suscpulris muscle, the middle glenohumerl ligment (MGHL), the superior glenohumerl ligment nd the suscpulr recess. After posterior portl entry, we use guide needle in the identifiction of the site of the nterior portl entry in the rottor intervl. The nterior portl is locted pproximtely 1 cm lterl to the corcoid process. After opening the nterior portl, cnnul cn e plced y widening the portl (Fig. 2.4, ). With the id of prop, it is necessry to exmine whether or not the iceps tendon hs seprted from the iceps nchor nd whether or not there is full continuity in the icipitl groove t the point of emergence from the joint. Stility of the iceps tendon within the groove is provided y the support formed y the suprspintus nd the suscpulris ttchment sites. This structure is lso held y the superior glenohumerl ligment nd the corcohumerl ligments. By cting s pulley, this structure provides stility to the iceps tendon. Tretment should e plnned y pthologicl evlution of degenertion, ters or disloctions which my e encountered in this re (Figs. 2.5, nd 2.6, ). For evlution of the intr-rticulr lrum nd cpsule ttchments in the next stge, 360 exmintion is mde round the glenoid to check ttchment of the lrum to the glenoid nd
20 M. Bozkurt et l. Fig. 2.5 () View of the corcohumerl ligment nd superior glenohumerl ligment () Colored view of the corcohumerl ligment, superior glenohumerl ligment, suprspintus tendon nd humerl hed Fig. 2.6 () Arthroscopic evlution of iceps tendon with prop () Colored view of the ntomic structures whether or not there is cpsulr seprtion. Intrrticulr loose odies cn generlly e determined in the inferior recess of the cpsule. Exmintion continues of the ligments nd tendons strting from the nterior structures of the shoulder. Evlution continues of the ntomic structures forming the rottor intervl which is formed y the glenoid edge, the iceps tendon nd the suscpulris tendon in the nterior. The ttchment site of the suscpulris muscle nd tendon integrity re oserved. It cn e seen tht 30% of the suscpulris tendon is inside the joint. It forms the lower order of the rottor intervl. It is prticulrly difficult to see the humerus ttchment site, ut this is extremely importnt in respect of the evlution of ters. The suscpulr recess is site where loose odies could e hidden (Fig. 2.7, ). The middle glenohumerl ligment crosses the suscpulris tendon t n ngle of 60. Strting from the suprglenoid tuercle from themedil nd superior glenoid edge, the ntomic neck section is held to the medil of the tuerosits minor. Due to vritions in the structure, identifiction is not lwys possile. Just s it my not e possile to visulise t ll, it my lso e seen in the form of cord. The MGHL tightens in externl rottion nd loosens in internl rottion. In 45 duction, it is resistnt to nterior trnsltion. When the MGHL is seen, the intctness of the ttchment site in the nterior superior lrum is exmined. (Figs. 2.8, nd 2.9, ).
2 Arthroscopic Antomy of Shoulder 21 Fig. 2.7 () The suscpulris recess nd ttchment () Colored view of suscpulris tendon ttcment Fig. 2.8 () Antomic reltionship with suscpulris tendon nd MGHL () Colored view of ntomic structures round of MGHL Fig. 2.9 () Exmintion of MGHL () Colored view of MGHL
22 M. Bozkurt et l. Fig. 2.10 () Arthroscopic evlution IGHL () Colored view of IGHL Fig. 2.11 () Exmintion of IGHL () Colored view of exmintion of IGHL In the next stge, the inferior glenohumerl ligment nd inferior lrum re exmined. In 90 duction nd externl rottion, the posterior nd of the inferior glenohumerl ligment prevents inferior trnsltion of the humerus hed. With trction in 20 30 duction, the nterior nd of the inferior glenohumerl ligment is more esily oserved. In 90 duction nd externl rottion, it prevents nterior trnsltion of the humerus hed nd resists inferior trnsltion. It extends from the glenoid towrds the ntomic neck. When dmge occurs in these structures, humerl vulsion glenohumerl ligment (HAGL) lesions should e kept in mind (Figs. 2.10, nd 2.11, ). To evlute the rottor cuff, the end of the rthroscope is turned long the ttchment sites over the
2 Arthroscopic Antomy of Shoulder 23 Fig. 2.12 () Bre re of humerl hed () Infrspintus footprint on re re humerus hed (rottor cle) including nterior nd posterior of the iceps from the nterior nd the continuity of the rottor cuff is evluted. When there is totl seprtion in this re, the sucromil re which cn e oserved my cuse n incorrect dignosis. In the posterior humerus, the re re formed of vessel entries remining from the foetl period cn e oserved. Old vsculr chnnels re locted here. The re re is comptile with the infrspintus tendon ttchment site nd is n importnt ntomic point for the identifiction of the infrspintus footprint (Fig. 2.12, ).
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