Tips, Tricks, and Pearls

Tips, Tricks, and Pearls


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.

image 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).

FIGURE 9-1 The patient is positioned in the (A) lateral decubitus position and the upper torso is leaning backward ˜30° to match their native scapular protraction so the (B) glenoid is positioned parallel to the floor. (C) In this position, the arthroscope should be parallel to the glenoid when it is parallel to the floor. H, humeral head; G, glenoid.

FIGURE 9-2 Right shoulder (A) demonstrating an outside view of a near parallel entry of the arthroscope and (B) viewing through an anterosuperolateral portal with a switching stick representing the typical position of the arthroscope parallel to the glenoid in the inferior half of the glenohumeral joint.

FIGURE 9-3 Right shoulder, posterior viewing portal (A) demonstrating an 18-gauge spinal needle being introduced just anterior to the leading edge of the supraspinatus tendon and a (B) switching stick being slid along the spinal needle into the glenohumeral joint. (C) The spinal needle is removed and an 8.25-mm clear Twist-In hard cannula (Arthrex, Inc., Naples, FL) is introduced over the switching stick, so (D) the final position of the cannula will enable a good angle of approach. BT, biceps tendon; H, humeral head; SSc, subscapularis.


image 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).

FIGURE 9-4 Right shoulder in a patient with instability and an anterior labral and SLAP tear with a Hill-Sachs lesion. A: Posterior viewing portal after a Gemini cannula (Arthrex, Inc., Naples, FL) was inserted in the anterior portal. Notice the good angle approach to repair the anterior labral tear. B: Posterior viewing portal after creation of an anterosuperolateral portal with an 8.25-mm clear Twist-In hard cannula (Arthrex, Inc., Naples, FL). Notice the portal was made just anterior to the leading edge of the supraspinatus tendon. C: Anterosuperolateral viewing portal demonstrating that the posterior portal has a good angle of approach to deal with both the posterior labrum and the Hill-Sachs lesion that is present. AL, anterior labrum; BT, biceps tendon; G, glenoid; H, humeral head; IS, infraspinatus; PL, posterior labrum; SS, supraspinatus; HSL, Hill-Sachs lesion.

FIGURE 9-5 Turbulence control as a means of improving visualization. A: Blood obscures the anatomic details of the subacromial space in this right shoulder. B: Turbulence associated with free egress of arthroscopy fluid causes the bloody field.

FIGURE 9-5 (Continued) C: Digital pressure over the noncannulated portal stops the turbulent flow. D: The same field as in (A) after 10 seconds of digital pressure over the portal. Visualization has been dramatically improved.

FIGURE 9-6 Right shoulder, posterior viewing portal demonstrating (A) blood is obscuring the fine detail in the glenohumeral joint. (B) Insertion of an 18-gauge spinal needle into the glenohumeral joint to allow a small amount of outflow. (C) Visualization in the same glenohumeral joint is dramatically improved moments after insertion of the spinal needle. H, humeral head; SSc, subscapularis.

FIGURE 9-7 (A) The Twist-In (Arthrex, Naples, FL) cannula inserter (yellow) has the ideal shape for plugging percutaneous accessory portals (B) during shoulder arthroscopy to stop fluid outflow.

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.

image 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:

The anesthesiologist must place an endotracheal tube for the case, not use a laryngeal mask airway (LMA). A CRNA, AA, or anesthesiologist who doesn’t have experience in lateral shoulder arthroscopy might not understand about potential airway compromise from arthroscopy fluid swelling.

The anesthesiologist must not extubate the patient until he has checked for an air leak around the ET tube or otherwise thoroughly assessed the neck for excessive swelling.

FIGURE 9-8 Fluid leaking from around a cannula can be stopped by temporarily suturing the edge of the skin incision (arrow).

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.

FIGURE 9-9 Significant swelling after a complex shoulder arthroscopy (A) resolves very quickly (B, C) after surgery.

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.

FIGURE 9-10 Right shoulder, posterior viewing portal (A) with a 30° arthroscope the subscapularis (SSc) attachment appears intact (B) but with a 70° arthroscope in the same patient, there is a clear disruption of the subscapularis attachment. H, humeral head; BT, biceps tendon.

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.

FIGURE 9-11 Right shoulder, posterior viewing portal with a 70° arthroscope; the entire exposed lesser tuberosity footprint can be visualized with an anchor seen at the most caudal aspect of the footprint. H, humeral head; LT, lesser tuberosity.

image 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.

FIGURE 9-12 Posterior 70° arthroscopic view of the subscapularis tendon and comma tissue (A). Intraoperative photograph (B) showing a quick change between 30° and 70° scopes. SSc, subscapularis tendon; blue comma, “comma sign”; red arrow shows how the tech has a 70° scope in his hand ready to make a quick change.

image 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.

image 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.

FIGURE 9-13 Right shoulder, posterior viewing portal with a 30° arthroscope (A) with internal rotation of the arm the biceps sling is collapsed onto the long head of the biceps tendon which obscures visualization down the biceps groove (B) with external rotation of the arm the biceps sling is opened up and visualization is significantly improved. BT, biceps tendon; H, humeral head.


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).

FIGURE 9-14 Posterior Lever Push with a right shoulder. A: The surgical assistant applies a simultaneous posterior force (white arrow) to the proximal humerus with an anteriorly directed force to the distal humerus (black arrow). B: Posterior viewing portal with a 70° arthroscope; there does not appear to be a tear of the subscapularis tendon. C: Same shoulder with the posterior lever push dramatically increases the exposure of the subscapularis tendon tear and improves the working space. H, humeral head; SSc, subscapularis; blue comma symbol, “comma sign”; LT, lesser tuberosity.

FIGURE 9-15 Right shoulder (A) outside view demonstrating an anterosuperolateral working portal with an 8.25-mm clear Twist-In hard cannula (Arthrex, Inc., Naples, FL) and an 18-gauge spinal needle that was introduced percutaneously through a supraspinatus PASTA. B: Intra-articular posterior viewing portal after bone bed preparation and insertion of two BioComposite Corkscrew FT suture anchors (Arthrex, Inc., Naples, FL) in the greater tuberosity. An 18-gauge spinal needle is seen introducing a nitinol suture passer through the medial supraspinatus tendon. C: A KingFisher suture retriever (Arthrex, Inc., Naples, FL) grabs both the #2 FiberWire suture (Arthrex, Inc., Naples, FL) and the nitinol suture passer out the anterosuperolateral portal. D: An outside view of the nitinol suture passer shuttling the FiberWire suture through the supraspinatus that will be later repaired. GT, greater tuberosity; SS, supraspinatus; H, humeral head.

FIGURE 9-16 Stabilizing structures and retracting tissues. A: Left shoulder, posterior viewing portal with an 18-gauge spinal needle being used to stabilize a nitinol suture passer during a single portal anterior labral repair. B: Right shoulder, posterior viewing portal with an 18-gauge spinal needle retracting the posterior rotator cuff to expose the posterior greater tuberosity footprint to prepare the bone socket to place an anchor. G, glenoid; H, humeral head; L, labrum; IS, infraspinatus; GT, greater tuberosity.


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.

FIGURE 9-17 Left shoulder, anterosuperolateral viewing portal. After capsulolabral (CL) mobilization, the subscapularis muscle belly is visible deep to the capsule. G, glenoid; M, muscle.

Video 9-9 “What Is the End Point of Labral Preparation During Instability Surgery?”

  • The capsulolabral complex must be dissected off the anterior glenoid to such an extent that the subscapularis muscle belly is visible deep to the capsule (Fig. 9-17).

  • The more inferior part of the Bankart lesion is best mobilized with a 30° elevator (rather than 15°) because its greater angle allows easier access around the curve of the inferior glenoid below 6:30 (left shoulder) (Fig. 9-18) or 5:30 (right shoulder).

  • A 2-mm strip of articular cartilage is removed from the anterior glenoid rim with a ring curette in order to provide a larger area of contact between labrum and bleeding bone bed (Fig. 9-19).

  • In the case of labral preparation for an ALPSA lesion, the labrum (as viewed from an anterosuperolateral portal) must be seen to “float up” to the level of the glenoid rim (Fig. 9-20).

FIGURE 9-18 The 30° elevator’s more acute blade-shaft angle makes it easier to do the capsulolabral dissection below the 6:30 position. G, glenoid; H, humeral head.

FIGURE 9-19 Left shoulder, anterosuperolateral viewing portal. A 2-mm strip of articular cartilage along the anterior glenoid margin has been removed with a ring curette. G, glenoid; CL, capsulolabral complex.

FIGURE 9-20 Left shoulder, anterosuperolateral viewing portal. After mobilization, the labrum has “floated” up to the level of the glenoid rim. G, glenoid; H, humeral head; CL, capsulolabral complex.

Video 9-10 “What Is the End Point of Calcium Removal in Calcific Tendinitis?”

  • Debride all the calcium from the tendon and the bone bed. It is always more extensive than you think (Fig. 9-21).

  • If calcium is not completely removed from the tendon in calcific tendinitis, it will continue to be a symptomatic irritant. In our experience, if the patient has failed non-operative treatment (including barbotage), simply needling the deposits under arthroscopic visualization is not enough. The calcific deposits tend to run in finger-like extensions from the main deposit, and these must be followed and removed. The calcific deposits often invade the bone and can be distinguished from bone by their granular consistency. These deposits in the surface of the bone must also be removed.

  • After complete removal of the calcium deposits, the rotator cuff defect must be repaired like any other rotator cuff tear with a similar pattern.

What Is the End Point of Coracoplasty?

image Video 9-11 The normal subcoracoid space should be 7 to 11 mm. Whenever we perform a subscapularis repair, we like to have at least a 7-mm space (11/2 diameters of the burr) between the coracoid tip and the anterior surface of the subscapularis tendon in order to protect our repair.

One should also recognize that, with a normal coracoid, the posterior surface of the coracoid tip is in the same plane as the conjoined tendon. Any portion of the coracoid tip that extends posterior to that tip is an osteophyte.

FIGURE 9-21 Calcium deposits are embedded within the tendon and must be completely debrided.

FIGURE 9-22 A: Coracoid tip extends posterior to the plane of the conjoined tendon signifying a coracoid osteophyte. B: After coracoplasty, the plane of the posterior coracoid tip is the same as that of the conjoined tendon. CT, coracoid tip.

Therefore, our two criteria for the end point of coracoplasty are as follows:

1. Removal of any osteophyte that extends posterior to the plane of the conjoined tendon (Fig. 9-22); and

2. Achievement of at least a 7-mm space between the coracoid tip and the anterior surface of the subscapularis (Fig. 9-23).

FIGURE 9-23 After coracoplasty, there is a 7- to 8-mm space (11/2 burr widths, arrows) between the coracoid tip and the plane of the subscapularis.

What Is the End Point Subacromial Exposure?

image Video 9-12 We like to have wide subacromial exposure to help us with visualization and classification of rotator cuff tears; distal clavicle excision; and rotator cuff repair.

We remove the fibrofatty tissue medially until we have a clear view of the scapular spine (Fig. 9-24). This allows
us to have unobstructed access to visualization of the AC joint, and it also gives us a clear view of the entire muscle-tendon units of supraspinatus and infraspinatus because the scapular spine creates a raphe between the two muscles (Fig. 9-25).

FIGURE 9-24 Left shoulder, lateral viewing portal. The fibrofatty tissue has been removed from the area around the scapular spine, leaving a clear view of the scapular spine. SP, scapular spine.

FIGURE 9-25 Left shoulder, lateral viewing portal. The raphe (dotted line) between supraspinatus and infraspinatus muscles is clearly visible at the base of the scapular spine. SP, scapular spine.

We clear the bursal and fibrofatty tissue from the lateral and posterior gutters. The axillary nerve branches are located distal to the sulcus of the lateral gutter, so as long as we do not go below the termination of the sulcus, we will not jeopardize these nerve branches (Fig. 9-26).

FIGURE 9-26 Left shoulder, posterior viewing portal. The blind pouch at the bottom of the lateral sulcus is visible (*). Axillary nerve branches are located below that point.

FIGURE 9-27 The internal deltoid fascia has been divided. As the two leaves of fascia pull apart (arrows), visualization in the lateral gutter is improved for arthroscopic rotator cuff repair.

We divide the internal deltoid fascia laterally. Using an electrocautery electrode, we divide the fascia proximally until we reach the lateral border of acromion, ensuring that our acromioplasty will not leave behind any lateral acromial osteophytes. Then we divide the deltoid fascia distally, stopping before we reach the distal termination of the sulcus. This split in the fascia allows the two leaves of the deltoid fascia to separate, opening a wider space in the lateral gutter to allow for greater ease of lateral row fixation of the rotator cuff tears (Fig. 9-27).

What Is the End Point of Distal Clavicle Excision?

image Video 9-13 Before the advent of shoulder arthroscopy, if one would ask an orthopaedic surgeon how much bone he would remove during a distal clavicle excision, he would typically say, “Oh, I’d remove a piece that’s about as wide as my thumb.” Considering that orthopaedic surgeons were pretty big guys, the width of the thumb would often be in excess of an inch, or 25 mm. So how did we settle on the generally accepted 10-mm space that we like to achieve arthroscopically?

We had the initial premise that the AC joint was a pain generator only if abutment of the distal clavicle against the acromion occurred with cross-body adduction. Therefore, the goal or end point was to remove enough distal clavicle that abutment of the remaining distal clavicle would not occur. Over the course of dozens of cases, we removed 2-mm increments of distal clavicle in a given patient, then brought the arm across the body while arthroscopically observing for abutment of the distal clavicle against the acromion. What we found was that most patients had continued abutment until 6 to 8 mm of AC joint space
had been achieved, but with a 10-mm space nobody had abutment of the distal clavicle. Since our standard motorized burr had a 5-mm outer diameter, we found it easy to remove enough distal clavicle to create a space that was “two burr-widths” in diameter.

Also, we began to routinely use an anterior working portal (for the burr) and a posterior viewing portal with a 70° arthroscope. The 70° scope allowed us to “look around the corner” to see the most superior and posterior portions of the distal clavicle so that we would not leave behind any potentially impinging spikes of bone that could cause abutment.

We begin with a 30° scope in the posterior viewing portal, and a shaver through an anterior working portal that is parallel to the AC joint. The skin puncture for a standard intra-articular anterior mid-lateral portal (which enters the joint over the lateral half of the subscapularis tendon) usually gives a near-perfect angle of approach when one redirects his instruments toward the AC joint (Fig. 9-28).

Soft tissues are first removed from the undersurface of the distal clavicle by means of electrocautery and power shaver and then a power burr is used to mark a preliminary line of resection (Fig. 9-29).

Then we switch to a 70° arthroscope and continue the line of resection proximally, removing the anterior and superior cortex but preserving the superior AC ligaments (Fig. 9-30). For bone removal at the interface with the ligaments, we run the burr on reverse, which prevents damage to the ligaments. We believe it is important to preserve the superior ligaments.

Once the anterior 2/3 of the distal clavicle has been removed in this manner, we rotate the light cable on the 70° scope to give ourselves a panoramic view of the posterior and posterosuperior aspects of the distal clavicle (Fig. 9-31). Then we continue with the bone resection until the posterior AC ligaments are fully exposed indicating that we have removed a full thickness of distal clavicle. Our end point occurs when we have achieved a space that is two burr-widths in diameter from front to back and from bottom to top (Fig. 9-32).

FIGURE 9-28 Outside view of a left shoulder while a distal clavicle resection is being performed. Note that the standard anterior portal lines up exactly parallel to the AC joint.

FIGURE 9-29 Left shoulder, posterior viewing portal 30° arthroscope. A preliminary resection line has been marked with a burr, which will create a 10-mm space at the AC joint when the resection is completed.

What Is the End Point of Interval Slides?

Anterior Interval Slide In-continuity

image Video 9-14 With a massive rotator cuff tear, the surgeon should test the lateral excursion of each part of the cuff with a grasper. If the anterior part of the supraspinatus will not reach its bone
bed on the anterior portion of the greater tuberosity, then an anterior interval slide in-continuity should be done.

FIGURE 9-30 Left shoulder, posterior viewing portal 70° arthroscope. A full-thickness segment of the distal clavicle has been removed anteriorly, leaving a clear view of the superior AC ligaments. C, clavicle; A, acromion.

FIGURE 9-31 Left shoulder, posterior viewing portal, 70° arthroscope. The light cable on the scope has been rotated, which rotates the scope to orient the field of view more posteriorly. This gives an excellent panoramic view of the most inaccessible part of the AC joint, so that precise bone resection in this area can be easily achieved.

The surgeon’s goal with this procedure is to release the bands of the coracohumeral ligament (CHL) that might be restricting lateral excursion of the supraspinatus. The CHL is typically located 10 to 15 mm anteromedial to the root of the biceps at the base of the coracoid. There are often two to three individual capsular bands of the CHL that must be divided (Fig. 9-33). The end point is reached when all of these capsular bands at the root of the biceps have been released. A successful anterior interval slide in-continuity will generally provide an additional 10 to 15 mm of lateral excursion of the supraspinatus.

FIGURE 9-32 Final result. The residual space after bone resection is “two burr-widths wide.”

FIGURE 9-33 Right shoulder, posterolateral viewing portal. Coracohumeral ligament (*) is being divided by the electrocautery probe. The ligament is located ˜15 mm anteromedial to the root of the biceps (there is only a stump of biceps in this case, since biceps tenodesis has already been carried out). BS, biceps stump; *, coracohumeral ligament.

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Oct 28, 2018 | Posted by in ORTHOPEDIC | Comments Off on Tips, Tricks, and Pearls

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