Shoulder Arthroscopy Portals

Fig. 7.1

Bony landmarks. (a) First the spina scapula, and the posterolateral and anterolateral corners of the acromion are identified. (b) In order, the spina scapula, acromion posterolateral corner, the lateral edge of the acromion and the anterolateral edge of the acromion are joined. (c) The clavicular nerves, acromion medial nerves and the acromioclavicular joint are marked. The coracoid process is identified and the coracoacromial ligament is marked

7.2 Portals

The portals for the regions to be operated on are identified and named.

7.3 Glenohumeral Joint Portals

7.3.1 Posterior Portals

7.3.1.1 Posterior Portal (Soft-Spot Portal)

In all shoulder arthroscopy procedures, firstly a viewing portal is used. This is also used as a working portal in reverse Bankart repair and the remplissage procedure. It is 2 cm inferior and 1–2 cm medial from the acromion posterolateral corner (Fig. 7.2a). Known as the soft spot, an incision is made from this point below the acromion posterior edge as far as to allow entry of the arthroscopic trochar. The end of the trochar is advanced to show the tip of the coracoid process [1]. If the patient is in the beach-chair position, the posterior capsule is drawn back by the assistant applying lateral traction to the arm.

Fig. 7.2

Posterior portal. (a) Placement of the posterior portal is seen. It is 2 cm inferior and 2 cm medial from the acromion posterolateral corner. (b) After distending the joint with air, the rotator interval is seen from the posterior portal. LHB long head of biceps, SS subscapularis

Thus, the glenohumeral joint cavity can be felt better. The trochar is placed inside the joint by passing within the infraspinatus muscle or between the infraspinatus and the teres minor. The trochar is withdrawn within the arthroscopic sheath and is replaced by the scope. After placement of the scope, the joint is inflated with 30–50 cc air via the arthroscopic sheath. Air-distended diagnostic arthroscopic examination is then made (Fig. 7.2b). After this stage, while there is air in the joint or after distension of the joint with water, the anterior portal is opened.

Structures at risk: axillary nerve, suprascapular artery and nerve

7.3.2 Posteroinferior Portal (7 O’clock Portal)

This is used in posterior Bankart repairs. It is located 1 cm inferior and 1 cm lateral to the standard posterior portal [2].

Structures at risk: axillary nerve, suprascapular nerve

7.4 Anterior Portals

7.4.1 Anterior Central Portal (Matthews Portal)

The location of the portal is marked to be lateral to the coracoid process and anterior to the acromioclavicular joint [3] (Fig. 7.3a). Entry is made with a 19G spinal needle. A triangle is formed of the glenoid in the medial, the humerus head in the lateral and the biceps tendon superior and the posterior portal route is observed. The spinal needle is advanced from this entry point marked on the skin into this triangle in such a manner as to remain over the subscapularis tendon. The spinal needle is seen within the joint to be in the centre of this triangle (Fig. 7.3b). If the needle position and orientation are appropriate, the needle is withdrawn. The portal is opened on the same axis using a scalpel and haemostasis forceps. This portal is used in procedures such as anterosuperior labral repair, biceps tenotomy and tenodesis, subscapular tendon repair, Bankart repair and coracoplasty. To avoid neurovascular complications, the bony landmarks, especially the coracoid process, must certainly be marked before the portal is opened.

Fig. 7.3

(a) Anterior central portal. (b) The intra-articular projection of the anterior central portal. LHB long head of biceps, SS subscapularis, HH humeral head

Structures at risk: axillary nerve and artery, cephalic vein, musculocutaneus nerve

7.4.2 Anteroinferior Portal (Wolf’s Portal)

The entry point is inferolateral to the coracoid process [4]. Placement within the joint must be immediately over the subscapular tendon. This portal is used in anchor placement, knot management and capsular plication in repairs of the anterior labral and anteroinferior capsulolabral complex. (Fig. 7.4a and b).

Fig. 7.4

(a) Anteroinferior portal. (b) The intra-articular projection of the anteroinferior portal. The image taken from the superolateral portal. The spinal needle is advanced within the joint to be immediately over the subscapular tendon. SS subscapularis, HH humeral head, G glenoid

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