Arthroscopic Management of Rare Intra-articular Lesions of the Shoulder

Arthroscopic Management of Rare Intra-articular Lesions of the Shoulder

Felix H. Savoie, III, Michael O’Brien and Wendell Heard

Chapter Synopsis

• The shoulder’s wide variety of “normal” characteristics and its incredible range of motion and function allow for a wide variety of pathology. This chapter illustrates rare lesions and contrasts them with normal but unusual anatomy.

Important Points

• The superior labrum has a wide variety of normal anatomy, and the understanding of what really constitutes a pathologic process is critical to know when repair is indicated.

• Synovitis of the shoulder may be commonly encountered, but an understanding of areas in which it may extend extra-articularly, as in the axillary and rotator interval, is useful.

• Extra-articular fractures may extend into the glenoid surface, necessitating arthroscopic monitoring of the reduction to ensure adequate joint restoration.

• Instability lesions are often complex, with multiple areas of damage. A complete and thorough inspection of the entire capsulolabral complex, including both humeral and glenoid attachments, should be considered essential in evaluating and correcting these injuries.

Clinical and Surgical Pearls

• Avoid making holes in the tendons of the rotator cuff.

• Complete the diagnostic arthroscopy before establishing accessory portals.

• Use K-wires placed via fluoroscopy into the mobile fragments before beginning arthroscopic fracture management.

• Repair instability by beginning inferiorly and medially, progressing to the lateral inferior, and then moving front to back while slowly progressing toward the superior aspect of the shoulder.

Clinical and Surgical Pitfalls

• The primary problem in rare lesions is the differentiation from what is normal.

• The simplest way to avoid problems is to familiarize oneself with the multiple variations via viewing, reading, and watching videos of arthroscopy.

In no other joint is there as much variability in normal anatomy as in the shoulder. Unusual conditions of the shoulder must be differentiated from normal variants. Although most pathologic processes are covered in other chapters, rare lesions such as pigmented villonodular synovitis (PVNS), osteochondritis dissecans of the glenoid and humerus, traumatic chondral fracture, chondrolysis, synovial osteochondromatosis, ganglion and synovial cysts, blending or bifurcation of the biceps and tearing of the attachment of a Buford complex, reverse humeral avulsion of the glenohumeral ligament with infraspinatus tear, coracoid fracture with extension into the joint, and floating anterior capsule (combined Bankart lesion and humeral avulsion of the glenohumeral ligament) are not commonly encountered within the shoulder.

Each of these entities may require different management. The rarity of these problems complicates diagnosis, preparation, and management. Many are encountered only on entering the joint. It is the goal of this chapter to discuss diagnostic studies and tests that can help to preoperatively identify these conditions correctly and assist with their management.

Preoperative Considerations

Most patients with rare intra-articular shoulder lesions have a history of either no trauma or only minor trauma. The exception is the patient with an articular fracture, who often has a clear history of a traumatic event, often a dive to the floor during an athletic event, after which pain and limitation of activity occur. However, in all of these conditions, symptoms frequently are not associated with a specific activity. Unlike with rotator cuff disease, the pain and feelings of swelling are not worse at night. Unlike with shoulder instability, the symptoms are not associated with a particular movement or arm position. Unlike with adhesive capsulitis, there is no consistent loss of motion or pain on inferior glide testing.

Physical Examination

Examination usually reveals palpable swelling within the glenohumeral joint, most easily felt in the area of the rotator interval. There is usually some loss of motion, primarily in internal and external rotation. Crepitation is noted with rotational movements of the glenohumeral joint. When the Buford complex has been avulsed, results of the anterior superior load and shift examination and the dynamic labral shear test result will be positive.

Imaging

Radiographs are usually normal except in synovial osteochondromatosis, in which multiple loose bodies are noted (Fig. 8-1). Magnetic resonance imaging (MRI) is helpful for osteochondritis dissecans lesions, synovial cysts (Fig. 8-2), and chondrolysis. Avulsions of a Buford complex, PVNS, and articular cartilage fractures will not show up on most radiographic tests. Glenohumeral avulsions are visualized by arthrography, and the coracoid fracture is best noted on computed tomographic scans.

Figure 8-1 Radiologic view of multiple loose bodies in the glenohumeral joint arising from the synovium of the subcoracoid bursa.

Figure 8-2 Magnetic resonance image of a synovial cyst.

Indications and Contraindications

Each of these various entities may be managed by arthroscopy. The main contraindications to arthroscopic surgery are PVNS and in some fractures. Complete excision of PVNS may require open surgery, especially in the axilla, whereas fractures may necessitate a combined approach.

Surgical Technique

Anesthesia and Positioning

Most of these patients require general anesthesia, although experienced regional anesthesiologists may certainly use interscalene block anesthesia. We prefer the lateral decubitus position because of its ability to allow easier access to all areas of the shoulder joint, but the surgeon’s preference is usually the rule in these procedures.

Surgical Landmarks, Incision, and Portals

A standard posterior portal is made in line with the equator of the joint, placed through the raphe in the infraspinatus muscle belly. Additional portals are added under direct visualization, with each one tested with a spinal needle, and are made only after the diagnostic arthroscopy has been completed and the surgical procedure defined.

Examination: Diagnostic Arthroscopy and Specific Steps per Rare Entity

Diagnostic arthroscopy usually reveals the pathologic process. Most of these processes are readily apparent once the arthroscope has been placed within the joint.

1 Avulsion of the Buford Complex Attachment

Avulsion of the Buford complex attachment is the most difficult to differentiate from normal variants. It is thought that the presence of the Buford complex has an incidence of 1.5% to 6.5%,1,2 but the frequency with which it is avulsed is unknown. Chondromalacia of the glenoid and fraying of the undersurface of the labrum and outer surface of the glenoid isolated to that area alone and not farther inferior on the glenoid are key findings (Fig. 8-3).

Figure 8-3 A normal Buford complex (cordlike middle glenohumeral ligament) with tearing at the attachment to the glenoid.

2 Pigmented Villonodular Synovitis

In all joints, PVNS has an incidence of approximately 1.8 cases per 1 million people.³ Eighty percent of cases occur in the knee. PVNS is rare in the shoulder and has the characteristic appearance seen in other joints.³ However, it is not readily resected because it penetrates through the lining of the joint and expands outward into the surrounding structures (Fig. 8-4). Especially in inferior lesions, the synovial growth may envelope the axillary nerve, necessitating its dissection either through open surgery or by arthroscopic identification of the nerve and protection of it.

Figure 8-4 Pigmented villonodular synovitis of the shoulder.

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Tags: Surgical Techniques of the Shoulder Elbow and Knee in Sports

Sep 11, 2016 | Posted by admin in SPORT MEDICINE | Comments Off

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