synonyms: shoulder scope, SATS
Shoulder Scope CPT
29805(diagnositc / biopsy)
29822(with limited debridement)
29823( with extensive debridement)
29807(with SLAP repair)
29824(with distal clavicle resection)
29819(with loose body removal)
29825(with lysis of adhesion/MUA)
29820(with partial synovectomy)
29826(with subacromial decompression)
29821( with complete synovectomy)
29827(with RTC repair)
Shoulder Scope Indications
Shoulder Scope Contraindications
- Active infection
- Medical comorbidities precluding anestesia
Shoulder Scope Alternatives
- Open procedures
- Non-operative treatment
Shoulder Scope Pre-op Planning / Special Considerations
- Use 1:3000,0000 epinephrine irrigation fluid, electrocautery, hypotensive anesthesia(maintain SBP/subacromial BP difference of <50mm HG(Morrison DS, Arthroscopy 1995;11:557-60)
- Procedure may be done in beach chair or lateral postions.
- Beach chair concerns: deliberate hypotension in patients with pre-operative hypertension can result in stroke/death. (Papadonikolakis A, Arthroscopy 2008;24:481).
-Blood pressure readings should be taken at heart level. Pressures taken in the lower extremities are significantly higher than the brain while in the beach chair position.
-Place the cuff around the brachium, at heart level, or use an invasive arterial line with the transducer at heart level.
-Ideally blood pressure is maintained above 80% of preoperative resting values to enhance the margin of safety.
- Ensure adequate fluid flow rates when using thermal probes to avoid high temperature/chondrocyte death (Good CR, JBJS 2009;91A:420).
- Shoulder Arthroscopy case card.
Shoulder Scope Technique
- Pre-operative antibiotics, +/- interscalene block
- General endotracheal anesthesia
- Modified beach-chair position. All bony prominences well padded.
- Examination under anesthesia.
- Prep and drape in standard sterile fashion
- Bony landmarks marked out on the shoulder
- Standard posterior portal just under posterior sulcus
- Anterior portal lateral to coracoid process. 18-gauge spinal needle utilized for localization with placement just under the biceps tendon in the rotator interval.
Examination Under Anesthesia
- Forward Elevation (R/L): 160 / 160
- External Rotation at side (R/L): 50 / 50
- External Rotation in 90 abduction (R/L): 85 / 85
- Internal Rotation in 90 adbuction (R/L): 20 / 20
- Load and shift
- Sulcus sign
Viewing from Posterior Portal
- Biceps tendon, Biceps labral complex
- Biceps exit /
- Posterior superior labrum, posterior capsular recess
- Inferior axillary recess, anterior-inferior glenohumeral ligament
- Inferior labrum
- Glenoid articular surface
- Glenoid Bone loss evaluation (Bigliani LU, AJSM 1998;26:41)
-Type I: displaced avulsion fracture
-Type II: malunited avulsion fracture
-Type IIIA: erosion of glenoid; less than 25%
-Type IIIB: erosion of glenoid; greater then 25%
- Supraspinatus tendon: evaluate with arthrosope in posterior portal and arm elevated 50 degrees and internally rotated. This fascilites lesser tuberosity visualization. (Bennett WF Arthroscopy 2001;10:37). Only the proximal 25% of the subscapularis tendon can be visualized intra-articularly. (Wright JM, Arthroscopy 2001;17:677)
- Posterior rotator cuff / bare area
- Humeral articular surface
- superior, middle, inferior glenohumeral ligaments
- Subcapularis tendon
- Anterior inferior labrum, anterior inferior glenohumeral ligment
- Evaluate Peel-back sign = entire superior BLC will shift medially as the arm is ER while in 70-90 degrees of abduction. Generally found in posterior and combined anterior-posterior Type II SLAP lesions. (Burkhart SS, Arthroscopy 1998;14:637) (Burkhart SS, Arthroscopy 2003;19:404).
- RTC tear Classification, BLC classification, SLAP classification,
Viewing from Anterior Portal
- Posterior glenoid labrum
- Posterior capsule
- Posterior RTC (infraspinatus, terres
- Anterior inferior labrum
- Suscapularis tendon recess
- Middle glenohumeral ligament
- Subscapularis tendon, biceps tendon
Shoulder Scope Complications
- Nerve injury: Axillary nerve, Brachial plexus
- Fluid Extravasation:
- Chondrolysis: though to be related to heat from electo cautery or radiofrequency probes used during capsular release or capsular shrinkage.
- Chondral Injury / arthritis
- Risks of anesthesia including heart attack, stroke and death
- Infections, Stiffness, CRPS, Nerve injury: Axillary nerve, Brachial plexus, Fluid Extravasation, Chondrolysis, Hematoma, Chondral Injury / arthritis, DVT/PE
Shoulder Scope Follow-up care
- Post-op: sling as needed with pendulum ROM exercises.\
- 1 week: Start PT focused on ROM and strengthening. AAROM, PROM. AROM, free weights start at 3 weeks. Avoid cross-body adduction for 6 weeks if DCR performed.
- 6 weeks: progressive sport specific activity.
- 3 months: Return to sport / full activities.
- IF in association with SAD, or RTC repair use those rehab protocols.
- Shoulder Scope Rehab protocol.
- Shoulder Outcome measures.
Shoulder Scope Outcomes
- Outcomes are depended on surgical indications and procedures performed.
Shoulder Scope Review References