There are numerous conundra that the arthroscopic shoulder surgeon faces every day that can make a case go from nearly impossible to relatively smooth if the solutions are known. In this chapter, we present some of our favorite solutions to problems that are seen quite frequently. We begin with a few broad topics such as patient positioning, portals, and visualization. Next, we present specific suggestions for arm maneuvering, using a spinal needle in surgery, and knowing when good enough is enough. We conclude with an array of miscellaneous tips, tricks, and pearls that we have learned over the years doing complex shoulder arthroscopy.

Although the beach chair position is very intuitive to learn shoulder arthroscopy, we prefer the lateral decubitus position for improved visualization and cerebral perfusion. However, we will often lean the patient’s upper torso backward ˜20° to 30° to match their native scapular protraction, so their glenoid is positioned parallel to the floor (Fig. 9-1A, B). The arthroscope is then parallel to the glenoid and to the floor (Fig. 9-1C). This not only improves the orientation of the glenoid for the surgeon but also decreases the chance the surgeon will have to lean over the patient to work through the anterior portals.

After the patient is safely padded and secured in position, we make our posterior viewing portal. However, instead of memorizing distances from the posterolateral acromion, we create our posterior portal parallel to the glenoid in the inferior half of the glenohumeral joint (Fig. 9-2). This is accomplished by taking one hand and stabilizing the acromion and distal clavicle while using the other hand to translate the patient’s humeral head anterior and posterior relative to the tip. Once the patient’s glenohumeral joint is identified, it is marked on the skin, an incision is made, and the scope sheath and obturator are aimed toward the coracoid process. Once the scope sheath and obturator enter the soft tissue of the posterior shoulder, we have found in larger shoulders that it is sometimes helpful to have our assistant internally and externally rotate the arm (“the washing machine”), which can differentiate the moving humeral head from the stationary glenoid. We have also found that having the assistant apply internal rotation to the patient’s arm can make the posterior joint capsule taut, which can aid in entering the joint.

Video 9-1 A thorough arthroscopic evaluation of the glenohumeral joint is performed, a pathologic inventory is made, and a game plan is designed. We typically create at least 1 to 2 working portals with cannulas, using an “outside-in” technique for establishing the portals. An 18-gauge spinal needle is utilized to determine the proper angle of approach for the portal (Fig. 9-3A). The spinal needle is left in place while a small stab incision is made through the skin. A metal switching stick is then slid along the spinal needle to its final destination in the glenohumeral joint or subacromial space (Fig. 9-3B). The spinal needle is removed, and the cannula is inserted over the metal switching stick (Fig. 9-3C). This

process ensures that the final cannula will have the proper angle of approach (Fig. 9-3D). We typically use cannulas for the anterior, anterosuperolateral, and lateral portals, whereas the majority of the other portals are percutaneous. However, for most instability cases, we use cannulas for the anterior, anterosuperolateral, and posterior portals (Fig. 9-4).

Video 9-3 There are several tips, tricks, and pearls for improving visualization during arthroscopic shoulder surgery. As was explained in our first textbook, A Cowboy’s Guide to Advanced Shoulder Arthroscopy, it is important to minimize the differential between the patient’s blood pressure and the arthroscopic pump pressure. As long as it is not medically contraindicated, we prefer the systolic blood pressure to be below 100 mm Hg. We acknowledge that hypotension is much less of a concern when the patient is in the lateral decubitus position rather than the beach chair position, and it is another factor in favor of the lateral decubitus position. In most cases, the arthroscopic pump pressure can be maintained between 50 and 60 mm Hg. If bleeding is particularly troublesome in a given patient, we will increase the pump pressure to 70 mm Hg or even 80 mm Hg for short periods of up to 10 minutes. We pay close attention to avoid bleeding vessels and use an electrocautery ablation device such as the OPES monopolar wand or the Apollo bipolar probe (Arthrex, Inc., Naples, FL), which is helpful in coagulating the more vigorously bleeding vessels. Also, we avoid turbulence by minimizing the outflow of arthroscopic fluid through portals by using cannulas or digital pressure (Fig. 9-5). However, we have found that outflow through a small spinal needle can also be helpful on occasion to clear a cloudy shoulder when there is not significant turbulence associated with the free egress of arthroscopy fluid (Fig. 9-6).

As we have shown, rapid outflow of arthroscopy fluid from portals harms visualization. The “Dutch Boy” technique, using manual digital pressure to stop outflow, usually is sufficient but has the disadvantage of requiring constant attention from assistants.

The plastic inserter for a Twist-In cannula (Arthrex, Naples, FL) has a convenient size and shape for plugging accessory portals (#11 blade stabs) that are no longer being used (e.g., anterior portals during work on the posterosuperior cuff) (Fig. 9-7).

This technique frees the assistant from constant attention to plugging the leak.

Video 9-4 Stopping fast outflow of fluid from the shoulder maintains pressure in the working space of the shoulder to prevent bleeding and prevents turbulent fluid flow.

If the skin incision for a cannula has been inadvertently made too large or has been affected by swelling, fluid may leak around the cannula and cause visualization problems.

To solve this problem, simply seal off the cannula by closing the edge of the skin incision with a temporary monofilament (O or 2-O) suture (Fig. 9-8).

It is very important to understand that significant shoulder swelling is inevitable during all but the simplest shoulder arthroscopies. Swelling indicates that the surgeon is running the arthroscopy pump at a high enough pressure to ensure good visualization (typically at least 60 mm Hg). In fact, trying to prevent swelling is a common mistake in shoulder arthroscopy, which leads to poor visualization, longer surgical times, more frustration, and inferior technical results.

The key to shoulder swelling is management of this phenomenon, not prevention.

The most critical thing to understand about swelling while performing lateral position shoulder arthroscopy is that the neck is dependent. Therefore, the airway potentially may be compromised if the neck becomes too edematous. The following points are critical:

If there is any question about potential airway compromise, the patient should be left intubated postoperatively and kept sitting upright in the post-operative area. When this is necessary, it is usually not for very long (<30 minutes), as swelling rapidly decreases after surgery, especially if the patient is sitting upright. When a patient is left intubated in the post-operative area for airway swelling, we usually still expect outpatient discharge.

Patients at risk for neck swelling (typically complex cases in patients 60s and older) should be counseled about the possibility of waking up from surgery with the ET tube in place.

If the surgeon plans to perform an arthroscopic biceps tenodesis at the articular margin (our preferred technique), the biceps tendon must be whipstitched outside the body fairly quickly after the case is started, otherwise swelling may prevent the tendon from being pulled far enough out to suture.

There are two other anatomic locations around the shoulder that can become fairly “tight” if significant swelling occurs:

1. The superior glenohumeral joint space.

2. The posterolateral gutter of the subacromial space.

Besides the above-mentioned exceptions, large to massive shoulder swelling is rarely a technical challenge as long as some tricks for managing this are known:

Place the posterior portal “lower” (inferior) and more medial than the “standard” location taught by most authors (1 to 2 cm distal and medial to the anterolateral corner of the acromion). Our posterior portal is usually about 4 cm distal to the posterior border of the acromion. Enter the joint in the posteroinferior quadrant.

Make all other portals using an “outside-in” technique using a spinal needle to verify the correct skin location and angle. Don’t remove the spinal needle until the skin incision has been made and the next instrument placed.

Case Example: A 63-year-old man underwent repair of a massive, retracted, three-tendon rotator cuff tear. The surgical time was 3 hours 40 minutes, and 12 suture anchors were used for the repair. Photographs of the shoulder at the
time of closure (Fig. 9-9A) and on postoperative day 1 (Fig. 9-9B) show how much swelling occurred and how quickly this resolved: the shoulder is normal in size <24 hours after surgery (Fig. 9-9C). This patient was kept intubated for 20 minutes in the post-operative area of an ambulatory surgery center with the anesthesiologist confirming a clear air leak prior to extubation. He was discharged as an outpatient without any complication.

In addition to managing fluid pressures and bleeding, going from a 30° to a 70° arthroscope can make a world of difference in terms of visualization. Sometimes an occult subscapularis tear can only be seen with a 70° arthroscope (Fig. 9-10). We have also found the 70° arthroscope to be useful for evaluating subscapularis tears that extend more than 30% of the footprint from cephalad to caudal (Fig. 9-11). The 70° arthroscope can also be very helpful in appreciating labral pathology, biceps tears and instability, coracoid preparation, and AC joint stabilization and resection.

Video 9-5 Switching between 30° and 70° arthroscopes can be seamless, and there should be little hesitation to switch scopes in order to improve visualization. A three-person technique is used (Fig. 9-12). The first assistant removes the light cord. Then, the surgeon removes the arthroscope and camera from the scope sheath, while the scrub tech places the new scope in the scope sheath. The surgeon hands off the original scope to the scrub tech and then reapplies the camera to the new scope to complete the switch.

There are several helpful maneuvers the surgical assistant may perform that can not only improve visualization but also change the angle of approach. Shoulder adduction is often helpful to improve the angle of approach for insertion of the medial row of anchors in the greater tuberosity for a rotator cuff repair, while shoulder abduction often improves the angle of approach for the lateral row. Internal rotation of the arm can improve visualization for anterior instability surgery, posterior rotator cuff preparation, and the angle of approach for anchor placement and suture passage with a HAGL lesion. External rotation of
the arm can improve visualization for posterior instability surgery, the biceps tendon (Fig. 9-13), and the angle of approach for anchor placement and suture passage with a reverse HAGL lesion.

Video 9-6 A 70° arthroscope can be very helpful in evaluating the bicipital groove for biceps pathology and for occult tears of the subscapularis (which may present as linear splits or tears in the medial sidewall of the bicipital groove). With a 70° scope, the surgeon can routinely see more than 2 cm down the bicipital groove.

Video 9-7 Translation of the humeral head in relation to the glenoid can also be very helpful. For instance, the Posterior Lever Push, in which the surgical assistant applies a posteriorly directed force to the proximal humerus, can significantly improve visualization of the subscapularis attachment and the working space for a subscapularis repair (Fig. 9-14). Distraction of the arm can not only improve visualization in the subacromial space but can also improve visualization in the caudal aspect of the glenohumeral joint. However, in some tight shoulders, an axillary roll with shoulder adduction is necessary to gain visualization in the caudal aspect of the glenohumeral joint.

We have found the 18-gauge spinal needle to be an extremely versatile tool in shoulder arthroscopy. We have already mentioned how we use spinal needles for out-flow to improve visualization, triangulation, and portal creation. However, there are many other uses including but not limited to passing sutures (Fig. 9-15), stabilizing structures, and retracting tissues (Fig. 9-16).

An interesting concept when performing any arthroscopic procedure in the shoulder is to know “when you are done.” The surgeon should have a specific technical “end point” in mind for each major step in the procedure, not just for the end result. For instance, in arthroscopic instability surgery, when is the anterior labrum mobilized enough to move on to the next step in the operation? We believe this level of technical expertise in arthroscopic shoulder surgery truly improves patient outcomes and that it is an integral part of the surgeon’s burden of craft.