Shoulder Arthroscopy

synonyms: shoulder scope, SATS

Shoulder Scope CPT

Shoulder Scope Indications

• Anterior glenohumeral instability, Bankart lesion
• RTC tear
• Adhesive Capsulitis
• Internal Impingement

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

• Infections
• Stiffness
• CRPS
• 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.
• Hematoma
• Chondral Injury / arthritis
• DVT/PE
• 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

• Burkhart SS, A Cowboy's Guide to Advanced Shoulder Arthroscopy, 2006
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