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. 4.2 **(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. 4.7 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.