4 The Shoulder



10.1055/b-0038-160354

4 The Shoulder

S. Rehart, S. Sell, C. Chan, A. Sachs

4.1 Arthroscopic Synovectomy of the Shoulder Joint


Indication


Therapy-resistant Larsen 0–II/III synovitis after optimization of medication therapy and cortisone injections. Significant clinical symptoms and loss of mobility.


Specific disclosures for patient consent


Recurrence. Infection. Radiosynoviorthesis (and/or chemosynoviorthesis) may be necessary 6 weeks postoperatively.


Instruments


Standard shoulder arthroscope. Special items: shaver system. Electrocautery.


Position


Beach chair position with arm freely mobile (Fig. 4‑1 ).


Approach


See Fig. 4‑2, Fig. 4‑3.


Specifics


Preoperative ultrasound is used for evaluation of the major extra-articular bursae; these may necessitate an open procedure. Mark the anatomical landmarks (acromion, coracoid, scapular border, clavicle) after sterile draping and prior to making an incision.


Surgical technique


See Fig. 4‑4, Fig. 4‑5, Fig. 4‑6, Fig. 4‑7, Fig. 4‑8, Fig. 4‑9.

Fig. 4.1 Positioning and draping.
Fig. 4.2 (a,b) The anatomical structures and standard arthroscopic portal sites are marked. The posterior humeral head is palpated. The capsule is bluntly penetrated following a stab incision placed 1 cm inferior and medial to the lateral tip of the acromion. The anterior portal is placed under direct arthroscopic vision.
Fig. 4.3 The standard approach is from posterior. Instrument (here a shaver) from anterior.
Fig. 4.4 (a,b) Intra-articular synovitis.
Fig. 4.5 Synovectomy is performed using a vaporizer, particularly for severe inflammatory processes, due to improved hemostasis.
Fig. 4.6 Pronounced rotator cuff tear.
Fig. 4.7 Synovitis-induced bone defect with erosion on the humeral head (arrow).
Fig. 4.8 Significant cartilage damage is readily apparent (arrow).
Fig. 4.9 Subacromial decompression may be required. Bone should be removed judiciously and only where needed. The synovitis is completely removed, and the area is cauterized with the vaporizer. Radiosynoviorthesis is scheduled 6 to 8 weeks later.


4.2 Rotator Cuff Tear


Indication


Larsen I–II destruction. Rotator cuff tear diagnosed by radiographic imaging (MRI scan, ultrasound).


Operatively reconstructible rotator cuff tear: based on size on MRI scan and no evidence of fatty degeneration of musculature on MRI scan. Acromiohumeral interval greater than 6 mm.


If there is any uncertainty, rotator cuff mobility can be examined arthroscopically.


Specific disclosures for patient consent


Failure of tendon integration. Re-rupture (also secondarily with cranialization of the humeral head). Shoulder stiffness. Injury to blood vessels, nerves (for example, axillary nerve).


Instruments


Standard shoulder arthroscopy pan. Shoulder pan. Anchoring system from the manufacturer of choice.


Position


Beach chair position (Fig. 4‑10 ).


Key steps


Proceed in the same fashion as for shoulder arthroscopy. Every rheumatoid shoulder first undergoes arthroscopy, see Chapter 4.1.


Synovectomy is initially performed arthroscopically on each patient. The inflamed bursa is removed during the subsequent subacromial arthroscopy. Rotator cuff mobility is assessed. Small ruptures are closed arthroscopically, although these are relatively uncommon in rheumatoid patients. The quality of the rotator cuff tissue surrounding the rupture is frequently poor and is usually associated with severe subacromial inflammatory changes. As a result, a mini-open approach is often chosen.


Surgical technique


See Fig. 4‑11, Fig. 4‑12, Fig. 4‑13, Fig. 4‑14, Fig. 4‑15, Fig. 4‑16, Fig. 4‑17, Fig. 4‑18.


Postoperative aftercare


Immediate full-range mobilization (caveat: no shoulder immobilization). For large ruptures, use a shoulder abduction pillow for 6 weeks.

Fig. 4.10 The shoulder with the patient placed in the beach chair position.
Fig. 4.11 The rotator cuff is evaluated arthroscopically to determine reparability. A longitudinal skin incision is made starting at the acromial edge and extending 2 to 3 cm distally along the direction of the deltoid muscle fibers. The deltoid muscle fibers are split longitudinally, and a spreader is inserted.
Fig. 4.12 The biceps tendon (forceps) is clearly dislocated and severely damaged due to the large rupture. The tendon is tenotomized, but a fixation is typically avoided.
Fig. 4.13 The rotator cuff tear also extends centrally to the lower acromial edge. The inflammatory tissue is removed, and the edges are debrided. The rupture is extensively mobilized.
Fig. 4.14 A stay suture is placed around the rupture for mobilization.
Fig. 4.15 The bone site for cuff fixation is abraded, and a double-loaded suture anchor is inserted.
Fig. 4.16 The anchor and suture are checked for stability (the bone is frequently very osteoporotic).
Fig. 4.17 The cuff is grasped with a Mason–Allen stitch. It is fixed with the anchor sutures and then side-to-side closure is completed.
Fig. 4.18 Fully reconstructed tear.

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May 21, 2020 | Posted by in RHEUMATOLOGY | Comments Off on 4 The Shoulder
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