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

4. Equipments mechanical instrumentation (shavers, burr )
electrocoagulation and cautery

5. Equipments mechanical instrumentation (shavers, burr )
electrocoagulation and cautery

6. 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

7. 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 affected by fluctuations in the entry flow
Every 30 cm above Joint level ~ 20 mmHg pressure
60 – 80 mmHg pressure required for good visualization

8. 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

9. 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 pressure

10. 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

11. Bernoulli Effect

12. Controlling turbulence

13. position lateral decubitus position beach-chair position
continuous traction allows easier GH & subacromial arthroscopy
more convenient for regional anesthesia and converting to open procedures

14. lateral decubitus position
< 10–15 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.)

15. beach-chair position Anatomical Convert to Open surgery Move arm
Less Nerve injury

16. portals Glenohumeral Joint Subacromial Space posterior portal
anterior portal
Anterosuperior, anteroinferior
superior portal
Subacromial Space
Subacromial (posterior) portal
lateral portal
Anterolateral, mid-lateral, posterolateral portals

17. portals

18. “To perform arthroscopic surgery on the shoulder …
“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

19. 10 Point Shoulder Arthroscopy Lennard Funk6
6 – Rotator Interval (pulley, LHB in groove, SGHL) 7
7 – Subscap, MGHL, anterior labrum 8
8 – AnteroInferior labrum, IGHL 9
9 – CAL & Acromion 4
4 – Humeral Head, Bare area, Posterior Cuff 5
5 – Anterosuperior Cuff 1
1 – LHB (SLAP, tear) 10
10 – Rotator Cuff - Bursal side
10 Point Shoulder Arthroscopy Lennard Funk
GLENOHUMERAL JOINT: 2
2 – Glenoid & Posterior Labrum 3
3 – Inferior Recess
SUBACROMIAL BURSA:

20. Diagnostic arthroscopy

21. Glenoid Labrum Loosely Attached: Firmly Attached: Superior
Anterosuperior
Firmly Attached:
Inferior
In an anatomical study, Cooper et al [20] reported loose attachment of the superior and antero-superior portions of the labrum to the underlying glenoid, whereas the “…inferior portion [is] firmly attached to the glenoid rim and appears as a fibrous, immobile extension of the articular cartilage

22. Superior Labrum Triangular Bumper Meniscoid Mobile
Bumper labrum – “…characterised by a small excrescence of fibrous tissue”. [22] The superior labrum is “…firmly attached to the glenoid tubercle and [abuts] the articular face of the glenoid”. [22]
Meniscoid labrum – the labrum extends onto the glenoid surface [22]
Triangular labrum – the labrum is “…not draped over the glenoid face…” [22
Mobile superior labrum – articular cartilage is present on the apex of the supraglenoid tubercle underlying the labrum [22
Discoid type meniscal labrum – labrum nearly covering the entire surface of the glenoid [23]
Meniscoid
Mobile

23. Sublabral Foramen
Atraumatic detachment of the labrum from the underlying glenoid Prevalence  % in arthroscopy

24. Sublabral Foramen / MGHL Tear

25. 1 – 6% prevalence in Arthroscopic study
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. Anterior Band IGHL
Present in %

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 Rotator Cuff Tear SLAP Tear Bony Bankart
Bankart Tear
Posterior Labral Tear

34. Summary Thank you for attention
Shoulder arthroscopy is a less invasive surgery if :
Good equipments
Good visualization
Good knowledge & experience
Thank you for attention