Welcome to the deep dive. You know, the shoulder
is this incredible piece of biological engineering,
just the most mobile joint in the human body.
It really is amazing. Today we're going to unpack
how specialists are using these cutting edge
techniques, arthroscopy and endoscopy to, well,
understand and fix its many quirks and injuries.
We've got a fantastic, really in -depth textbook
as our source. And our goal is basically to pull
out the most useful and fascinating insights
into how these minimally invasive procedures
are actually done. That's right. What's remarkable
about this field is just the sheer scope of what
can now be addressed without those large incisions.
This textbook really lays out everything from,
you know, the basic anatomy, you need to get
your head around to the really advanced surgical
solutions for all sorts of shoulder problems
like rotator cuff tears, instability, a whole
gamut. Yeah. And it's not just about what's possible
now. The author's enthusiasm for the future of
shoulder surgery is, well, it's pretty infectious.
He genuinely believes the field is advancing
so rapidly. that this entire book might need
a complete overhaul within the next decade. That
gives you a real sense of how much innovation
is happening, doesn't it? It certainly does.
It's moving fast. Okay, let's unpack this. We
can't really talk about fixing the shoulder without
understanding what makes it tick. Absolutely
fundamental. Let's start with the arthroscopic
anatomy, this incredibly mobile glenohumeral
joint that's where your upper arm bone meets
your shoulder blade. How does it manage to be
so flexible yet stay stable. It's a clever combination
of what we call passive and active stabilizers.
So think of the passive structures as the underlying
framework. Okay. You've got the glenoid, which
is the shallow socket on your shoulder blade,
the head of the humerus, the ball of your arm
bone fitting into that socket, the labrum. That
cartilage ring? Exactly, that cartilage ring
around the glenoid that deepens the socket. Then
there's the joint capsule, the fibrous tissue
enclosing the whole joint, and the ligaments,
those tough bands connecting bone to bone. So
that's the static support, the framework. Now
for the active part, the muscles. Exactly. These
are the dynamic controllers, allowing for movement
and providing crucial stability. The rotator
cuff muscles, supraspinatus, infraspinatus, teres
minor, and substabularis are key players here,
along with the long head of the biceps, the deltoid,
the big muscle on the outside of your shoulder,
and all the muscles that control how your scapula,
your shoulder blade moves. It's this coordinated
muscle action that allows you to reach for things,
throw a ball, everything in between, all while
keeping the joint secure. Now here's a detail
that apparently surprises even some experienced
surgeons, telling the supraspinatus and infraspinatus
muscles apart during an arthroscopic procedure.
It can be tricky. It really can be. One helpful
landmark is often a subtle contour line that
naturally separates the two muscles. Ah, okay.
Also, if we see cysts or bony spurs, what we
call osteophytes, around the greater cuporosity,
that's that bony bump on the outside of your
upper arm bone, it can suggest long -standing
subacromial impingement. Impingement. That's
the narrowing of this space. Right. A narrowing
of the space above the rotator cuff. And this
can sometimes give us an indirect clue about
potential issues with the underlying rotator
cuff muscles themselves. OK. So once we have
a sense of the anatomy, how do we actually get
a look inside a living shoulder? Radiological
investigations are obviously crucial. And it
sounds like good old x -rays are still the starting
point. Absolutely. X -rays are fantastic for
that initial overview, especially for identifying
things like dislocations and fractures. Different
views let us see the bones from various angles,
which is key for diagnosing specific problems.
Makes sense. For example, the standard AP, anteroposterior,
scapular Y, and axillary views are pretty essential
for evaluating acute shoulder dislocations. Then
you have specialized views like the West Point
and striker notch views. These are particularly
helpful for visualizing fractures on the front
of the glenoid socket or those hill -sax lesions.
Those little dents on the humeral head from dislocation.
Exactly those, the ones that can happen when
the shoulder dislocates forward. And when we
need to really see the soft tissues of muscles,
tendons, ligaments, that's where MRI and MRA
come in, right? What's the difference there?
So MRI, magnetic resonance imaging, gives us
incredibly detailed pictures of all the soft
tissue structures. MRA or MR arthrogram takes
it a step further. How so? By injecting a contrast
dye directly into the joint before the MRI scan.
This contrast really highlights the outlines
of structures like the labrum and ligaments,
making tears much easier to spot. Clever. For
instance, putting the arm in a specific position
called ABER, that's abduction and external rotation
during an MRA, can significantly improve our
ability to detect tears in the antero -inferior
labrum, the front and bottom part of that cartilage.
I see. This can help us identify specific types
of injuries, like ALPSA lesions. What are those
again? That's where the torn labrum isn't just
torn, but it also gets pushed and kind of rolled
onto the neck of the scapula. Yeah. MRI also
helps see ruptures of the inferior glenohumeral
ligament, or IGHL, the key stabilizer. Got it.
Now CT orthography is another imaging technique
mentioned. Where does that fit in? CT arthrography,
which combines a CT scan with that contrast injection
into the joint, is really good for seeing the
bony architecture in great detail. OK, so more
for bone. Primarily, yes. It's particularly useful
for assessing the amount of bone loss in the
glenoid socket, which is crucial information
in cases of recurrent instability. However, it's
generally not as sensitive as a direct MRA for
picking up small, non -displaced tears in the
labrum. these MRI scans isn't always black and
white, is it? I read there are anatomical variations
that can sometimes look like tears. That's a
really important point, especially in the antero
-superior part of the labrum, roughly the top
and front of the socket. There are a few common
anatomical variations that can sometimes be mistaken
for SLAPs. SLAP tears. Superior labrum tears.
Right, tears of the superior labrum. These variations
include the Buford complex. Okay, Buford complex.
That's where a portion of the antero -superior
labrum is missing, and the middle glenohumeral
ligament is thickened and sort of cord -like.
We also see things like a sublaboral sulcus,
which is a small groove beneath the labrum, and
a sublaboral foramen, a small hole in the labrum.
That Buford complex sounds interesting. What's
the key thing for surgeons and maybe patients
to know about it? Well, the key thing is recognizing
it as a normal variation so you don't mistakenly
diagnose a labral tear that isn't actually there.
Right. Avoid unnecessary treatment. Exactly.
Interestingly, though, some recent research suggests
that this specific anatomical setup, the Buford
complex, might actually make individuals a bit
more prone to developing SLAP lesions later on,
perhaps due to altered biomechanics in the shoulder.
Okay. Beyond the soft tissues, the shape of the
acromion, that bony prominence on the top of
your shoulder blade, that can also play a role
in shoulder problems, can't it? Absolutely. We
classify the shape of the acromion into three
types, based on what it looks like from underneath
on a specific x -ray view. 3 -type. Yep. Type
1 is essentially flat, type 2 has a gentle curve,
and type 3 is also curved, but with a hook -like
projection pointing downward. Ah, the hooked
one. Right. It's this type 3 acromeon that has
the strongest link to subacromial impingement,
that compression of the rotator cuff tendons,
and consequently rotator cuff tears. The hook
shape basically narrows the space where the tendons
have to glide. And there's also the acromial
index, a measurement we can take on x -rays.
What does that tell us? The acromial index or
AI is a ratio. It compares two distances measured
on a frontal x -ray of the shoulder. It's the
distance from the edge of the glenoid socket
to the outer edge of the acromion, divided by
the distance from the glenoid to the outer edge
of the greater tuberosity. So a bigger number
means the acromion sticks out more. Exactly.
A higher AI value means the acromion extends
further laterally, or sideways. Studies have
shown that people with a higher acromial index
are more likely to experience subacromial impingement
and have rotator cuff problems. Interesting correlation.
For example, people who don't have any shoulder
issues tend to have a lower AI while those with
significant rotator cuff tears often have a higher
AI. It just gives us another piece of the puzzle
when evaluating shoulder pain. Let's switch gears
a bit and talk about the biceps tendon. It's
not just about flexing your arm. It plays a role
in shoulder stability too, doesn't it? It absolutely
does. The long head of the biceps tendon, or
LHBT, is held in its groove at the front of the
upper arm bone by a really important structure
called the biceps pulley, sometimes also called
the biceps sling. The pulley. Yeah, this pulley
is a complex of ligaments and tendon fibers.
It's primarily made up of the superior glenohumeral
ligament, the coracohumeral ligament, and also
fibers from the subscapularis tendon as it wraps
around the front of the shoulder. OK. Interestingly,
the transverse humeral ligament, which you might
have heard of as holding the biceps tendon in
place, is now understood to be largely composed
of fibers coming from the subscapularis and supraspinatus
tendons. Ah, so it's more connected than we thought.
Right. And because this whole biceps pulley sits
within the rotator interval, that gap between
the supraspinatus and subscapularis tendons injuries
in this area often involve the pulley as well.
How do you spot those pulley injuries? Ultrasound
can be a really useful tool here. It can actually
let us see injuries to the ligaments that make
up the biceps pulley, like the SGHL and CHL,
and detect if the biceps tendon is slipping out
of its normal position, which we call subluxation.
Another common and often frustrating shoulder
issue is adhesive capsulitis or frozen shoulder.
How can imaging help with that diagnosis? Well,
the diagnosis of adhesive capsulitis is mainly
based on a patient's symptoms and a physical
exam show showing that restricted movement. Right,
the classic stiffness. Exactly. But MRI can be
helpful as an additional tool, primarily to rule
out other conditions that might be causing similar
pain and stiffness. So ruling things out. Mostly.
In some cases of adhesive capsulitis, though,
an MRI might show a thickening of the joint capsule
itself and sometimes even a small amount of fluid
within the joint. But it's not always definitive
just from the scan. Finally, for this section,
let's touch on the acromioclavicular joint, the
AC joint, where your collarbone meets the acromion.
Osteoarthritis is quite common there, isn't it?
It is. Achromioclavicular joint osteoarthritis,
or ACJOA, can develop as a result of a direct
injury to the AC joint, like a fall onto the
shoulder. It's also frequently seen in people
who have subachromial impingement. OK. On imaging,
we might see signs of wear and tear in the joint,
like the cartilage thinning, bone spurs forming
those osteophytes again, and sometimes even small
cysts in the bone just below the cartilage. And
distinguishing old injuries from arthritis. Yeah.
Early signs of ACJ degeneration. can sometimes
be hard to tell apart from old, minor sprains
of the AC joint, as both can show some thickening
of the joint capsule. If we also see involvement
of the coracoclavicular ligaments, the ones holding
the clavicle down, that often suggests a more
significant past injury to the AC joint. Okay,
we've covered a lot of ground on anatomy and
diagnosis. Let's move into treatment. Arthroscopic
surgery relies heavily on the use of cannulas.
What are they and why are they so important?
Okay, so think of cannulas as little access tunnels
into the shoulder joint. They're hollow tubes
that we ensuit through small incisions. Got it.
Tunnels. And they're absolutely essential for
making arthroscopic surgery efficient. They allow
us to easily swap different surgical instruments
in and out as needed without having to make multiple
large incisions or constantly repuncture the
skin. Makes sense. They're also crucial for managing
sutures during the procedure, preventing them
from getting tangled or catching on other tissues?
What kinds are there? Cannulas come in various
sizes, lengths, and materials. You have soft
silicone cannulas, which are less bulky and can
even help with gently retracting tissues inside
the joint, but you have to be careful with sharp
instruments around them. Right. Then there are
hard cannulas, more resistant to accidental puncture,
but sometimes less maneuverable, especially if
you're using several at once. Any downsides?
Well, one important thing to watch out for is
fluid extravasation. If a cannula accidentally
slips out of the joint during surgery, the fluid
we use to inflate the joint can leak out into
the surrounding soft tissues. Ah, okay. Needs
careful management. Now arthroscopic fixation
of bony bankart lesions, that's when a piece
of bone breaks off the front of the glenoid during
a shoulder dislocation. That seems like a key
area where these techniques have really made
a difference. They absolutely have. For smaller
bony bankart lesions, what we sometimes call
bigliani type I or II, where the bone fragment
is still in relatively good shape and hasn't
shifted too much, arthroscopic reduction, basically
putting the bone back in place and internal fixation
holding it there with anchors and sutures is
often the preferred approach. The goal is to
restore that smooth, continuous surface of the
glenoid socket. But there's a limit. Right, if
the bone loss is too big. Exactly. If the glenoid
defect is larger than about 20 to 25 percent
of the socket surface area, that's generally
considered a critical size. Okay. In these cases,
arthroscopic repair alone might not be enough
to prevent future dislocations, and other procedures
like the latarjet or bone grafting might be necessary
to rebuild the socket. And techniques for fixing
those fragments arthroscopically. Surgeons often
use specific techniques, like the double pulley
technique, to get a really secure hold on those
bony fragments during the arthroscopic repair.
What about the success rates of these arthroscopic
band cart repairs? Does it matter if the shoulder
has been dislocating for a while versus a first
-time dislocation? That's a good question. The
research suggests that arthroscopic banker repairs
tend to have better outcomes when performed after
an acute or first -time dislocation compared
to chronic recurrent instability. Why is that?
Well, studies have shown that many patients with
acute glenoid rim fractures can regain stability
and get back to their previous activities after
a single row of anchors is used to fix the bone
and labrum. But the results for chronic cases
treated with the same single row technique have
sometimes been less predictable. It's possible
the bone and ligaments can change over time with
repeated dislocations, making them harder to
repair effectively. But it's not always clear
cut. No, interestingly, some studies have reported
good success even in chronic cases where the
bone fragments are still well -preserved. And
more recently, techniques using two rows of anchors,
so -called double -row repair, have shown promising
results for both acute and chronic instability.
Double row. More anchors, better fixation. Potentially,
yes. It creates a wider area of contact. Patients
report good satisfaction and improvements in
how the shoulder feels and functions, but Ultimately,
a really important factor in the success of any
bank art repair seems to be making sure the reconstructed
glenoid socket is at least 80 % of its original
size. That makes sense, restoring the anatomy.
Now for shoulder instability in general, surgery
isn't always the first thing doctors recommend,
is it? That's correct. Non -operative treatment
is often the first step. This usually involves
wearing a sling for a few weeks to let the initial
injury calm down, followed by a structured rehabilitation
program. Physical therapy. Exactly. The rehab
focuses on strengthening the muscles around the
shoulder, especially the rotator cuff, and gradually
restoring the full range of motion. But when
is surgery indicated? Surgery might be recommended
if the patient continues to experience symptoms
like feeling the shoulder wants to slip out of
place. That's a positive apprehension sign. Or
if a doctor can physically put the shoulder back
in place during an exam, which is a positive
relocation sign. OK. Also, if certain exam maneuvers
like the augmentation test or lag sign are positive
or simply if conservative treatment doesn't provide
enough relief and the shoulder continues to be
unstable and really limits their function. Right.
Let's move on to some specific shoulder conditions
and their surgical management. The Letarget procedure
is a well -known option for people with shoulder
instability and significant bone loss. Can that
be done arthroscopically? Yes, it can. The traditional
latarjet procedure, which involves taking a piece
of bone called the coracoid process from the
front of the shoulder blade and transferring
it to the front of the glenoid to act as a bony
block. Right, the bone block. That's been performed
as an open surgery for a long time and has a
good track record for stabilizing the shoulder.
But since about 2003, surgeons have also been
performing the latarjet procedure arthroscopically
using smaller incisions. What are the trade -off?
Well, the arthroscopic approach can offer potential
benefits like less pain and maybe quicker recovery,
but both the open and arthroscopic letarget procedures
carry some risks. Such as? One potential complication
is a fracture of the transferred coracord bone
itself, which can happen in the first few months
after surgery. There's also a risk of nerve injury
because of the delicate dissection involved near
important nerves. When the glenoid bone loss
is quite substantial, are there other surgical
options besides the Yes. For more significant
glenoid bone loss, surgeons sometimes use what
we call extra -anatomic procedures. These include
the letarget -bristaux procedure, which is a
variation of the letarget, or using a separate
piece of bone, often from the iliac crest, your
hip bone. Ah, a graft from the hip. Right. Using
that as a bone block that's then fixed to the
glenoid, usually with screws. But those have
potential issues too. They can. Complications
like the bone not healing properly. non -union,
the bone graft being reabsorbed by the body over
time, or problems with the screws or other hardware
used to hold the bone in place can occur. So
alternatives? Well, the arthroscopic j -bone
grafting technique offers another approach. This
involves taking a bone graft from the iliac crest,
shaping it carefully to fit the glenoid defect,
and then securing it arthroscopically. What's
the advantage there? A key advantage is that
it's arguably more anatomical. aiming to restore
the natural shape of the glenoid. Plus, it doesn't
leave behind permanent metal implants like screws.
OK. There's also a technique mentioned called
arthroscopic bone block with subscapularis augmentation,
or ASA. What's that all about? The ASA procedure
is a more complex arthroscopic technique. It's
designed for cases of severe glenoid bone loss
combined with a deficient capsule -laboral complex,
meaning both the cartilida rim and the surrounding
ligaments are significantly damaged. So a double
whammy. Pretty much. It involves creating tunnels
in the glenoid bone to precisely position and
secure a bone block graft using strong button
-like anchors. And the subscapularis part. Importantly,
it also includes augmenting or reinforcing the
subscapularis tendon, that key stabilizer on
the front of the shoulder, often using a strong
suture tape anchor. So it's bone block plus tendon
reinforcement. Exactly. This combined approach
has shown promise as a feasible and safe alternative
to the traditional Letarjet procedure in these
more challenging instability cases. In situations
where the bone loss isn't quite critical, are
there other types of grafts that might be considered
like not from the hip? Yes. For glenohumeral
instability with a smaller degree of bone loss,
or in cases where a hill -sax lesion, that dent
on the humeral head is off -track, meaning it's
likely to engage with the glenoid rim during
movement, an arthroscopic distal clavicle osteochondral
autograft transfer might be an option. Taking
bone from the collarbone. Right. This involves
taking a small piece of bone and its overlying
cartilage from the end of the clavicle and transplanting
it to the glenoid defect. When wouldn't you use
that? Well, this technique is generally not recommended
for patients who have very loose joints overall,
what we call global hyperlaxity, or if they have
significant bone loss on the humeral head itself,
or if they've had a previous resection of the
end of the clavicle. Okay. What happens when
a Letarjet procedure unfortunately doesn't achieve
the desired stability? revision possible? Revision
surgery after a failed lethargic procedure can
be quite complex as you can imagine. Surgeons
sometimes use a specific posterior portal, an
entry point at the back of the shoulder called
the Halifax portal. A specific portal? Yeah,
this portal can provide better access and visualization
of the surgical area during these tricky revision
procedures, allowing for a more thorough assessment
and repair. Now, hill -sax lesions, those indentations
on the humeral head from dislocations, can also
contribute to ongoing instability. The remplassage
procedure is designed to address those. How does
it work? The remplassage procedure aims to prevent
a hill -sax lesion from catching or engaging
on the edge of the glenoid socket during shoulder
movement, which can cause further instability
or pain. So how do you stop it catching? It involves
essentially filling in the hillsack's defect
with sock tissue, typically by using a portion
of the infraspinatus tendon, one of the rotator
cuff muscles, and anchoring it right into the
bony defect on the humerus. Filling the dent.
Basically, yes. This procedure is often considered
in cases where there's an engaging hillsack's
lesion, but less than 25 % of glenoid bone loss.
It's often done alongside a bankart repair. HEGL
lesions. That's when the inferior glenohumeral
ligament tears away from its attachment. on the
humerus, they also require specific attention,
right? Yes, definitely. Arthroscopic repair of
HAGL lesions where the ligament is reattached
to the humerus using anchors is certainly possible
and often effective. Is the recovery different
depending on where the tear is? The post -operative
care can differ slightly. For anterior inferior
tears, on the front and bottom, immobilization
in a standard sling is typical. For reverse HAGL
tears on the backside, surgeons might use an
external rotation brace or an abduction pillow
to protect the repair, as these positions put
less stress on the repaired posterior ligament.
OK. Posterior shoulder instability, while less
common than anterior instability, still poses
challenges for diagnosis and treatment. It does.
Arthroscopic assessment is really valuable in
evaluating posterior shoulder instability to
identify if there are any associated bone or
soft tissue injuries, like a reverse bank heart
lesion or posterior labral tear. Is surgery always
the answer? No. Surgery is generally not recommended
for patients who can voluntarily dislocate their
shoulder or those who aren't likely to be cooperative
or able to actively participate in the extensive
rehabilitation process required afterwards. Right.
In some chronic cases where pain is minimal and
function is still reasonably good despite some
laxity, non -operative management might actually
be the preferred approach. Multidirectional instability,
or MDI, is when the shoulder feels loose in multiple
directions. How is that managed arthroscopically?
MDI is a complex condition. It can be caused
by a combination of factors, including naturally
loose joints, congenital hyperlaxity. Born with
loose joints? Sometimes, yes. or it can be due
to repeated minor injuries like microtrauma,
imbalances in the muscles around the shoulder,
and certain anatomical predispositions. A key
finding is often laxity in the coracor humeral
ligament and an overly loose or redundant joint
capsule, especially in the front and bottom parts
of the joint. So how do you fix that looseness?
Arthroscopic capsule replication, or ACP, is
a surgical technique used to address this. It
involves taking tucks or pleats in the joint
capsule to effectively tighten it up and reduce
the excessive laxity. These pleats are then secured
with sutures or anchors. How does that compare
to older open surgeries? Compared to older open
surgical procedures called capsular shifts, ACP
offers advantages like smaller incisions, less
scarring, often less pain after surgery, avoiding
the need to detach and reattach the subscapularis
tendon, and potentially a quicker return to sports.
And the results. Studies have reported quite
promising success rates with ACP and appropriately
selected patients who have true MDI. Okay, let's
talk rotator cuff tears. A very common source
of shoulder pain and weakness. What are some
of the newer developments in arthroscopic repair
techniques? Arthroscopic rotator cuff repair
techniques have certainly come a long way. One
promising advancement is the linked double row
suture bridge or LDRS -B repair. That sounds
complex, LDRS -B. It does, but the idea is to
improve healing. Studies have suggested that
this technique can lead to higher rates of tendon
healing and potentially fewer repeat tears compared
to traditional single row or even standard double
row repairs. How does it work? The idea behind
the suture bridge is to create a wider footprint
of tendon -to -bone contact and provide more
even pressure across the repair site, which theoretically
promotes better healing conditions. But in knotless
anchors. Yes. We're also seeing an increasing
use of knotless anchors. These simplify the process
of tying sutures and securing the tendon to the
bone arthrostatically. This can potentially reduce
the risk of complications related to knots, like
irritation or suture breakage, and maybe speed
up the surgery slightly. Interesting. Now, subcoracoid
impingement is something many people haven't
heard of, but it can be a source of pain in the
front of the shoulder. How is it diagnosed and
treated arthroscopically? Right, subcoracoid
impingement happens when the space between the
coracoid process, that little hook -like bone
at the front of your shoulder blade and the humeral
head becomes too narrow. This often causes friction
on the subscapularis tendon which runs between
them. What causes it? It can be caused by repetitive
movements or certain anatomical variations where
the coracoid is maybe a bit larger or angled
differently. And diagnosis. Imaging, especially
CT scans that can precisely measure the distance
between the coracoid and humerus and calculate
various indices, can be very helpful in making
the diagnosis. And the arthroscopic fix. Arthroscopic
coracoplasty. This involves using a small high
-speed burr to carefully shave away a small amount
of bone from the tip or underside of the coracoid
process to widen that space and effectively relieve
the impingement. How do you find the coracoid
during surgery? It's crucial to identify it accurately.
The technique can vary slightly depending on
whether the subscapularis tendon underneath it
is intact or has retracted due to a tear. A helpful
landmark in cases where the subscapularis has
retracted is the comma sign, which includes the
coracohumeral ligament attaching near there.
OK. The subscapularis tendon itself, one of the
rotator cuff muscles, can also be torn. Is that
being recognized more now with arthroscopic surgery?
Absolutely. The subscapularis is a really important
rotator cuff muscle. It plays a crucial role
in shoulder movement and stability, particularly
internal rotation, turning your arm inwards.
And it used to be missed? Historically, yes.
Tears of the subscapularis, especially partial
tears on the droid side, were often missed with
traditional open surgical approaches. It even
got called the forgotten tendon. Wow. But the
ability to directly visualize the tendon with
shoulder arthroscopy has significantly increased
our recognition and diagnosis of these tears.
How is it repaired arthroscopically? Arthroscopic
repair typically involves establishing standard
entry portals around the shoulder, then performing
an anterior release to carefully free up the
tendon from any scar tissue before reattaching
it to its insertion point on the lesser tuberosity
using suture anchors. Any specific risks? Surgeons
have to be particularly careful during that anterior
release to avoid any injury to the nearby axillary
nerve, which runs quite close. Sadly, not all
rotator cuff tears are repairable. What are the
options when a tear is just too big or retracted,
deemed irreparable? That's a tough situation.
For massive rotator cuff tears that can't be
repaired directly back to the bone, there are
several surgical and non -surgical management
options. Like what? A subacromial balloon spacer
can be inserted arthroscopically. This is like
a temporary inflatable cushion placed between
the humeral head and the acromion. A cushion?
How does that help? It helps to keep the humeral
head centered in the socket, reducing pain and
improving function, especially in older patients
who still have a good range of motion and a strong
d - muscle, but it's not suitable for everyone
and it's not a permanent fix. Other options.
The long head of the biceps tendon can also be
repurposed. It can be used as a vascularized
graft in a technique called the biceps patch
for superior capsule reconstruction where the
top part of the shoulder joint capsule is reinforced
or rebuilt. Using your own tissue. Exactly. Another
well -established option is a latissimus dorsi
tendon transfer. Moving a back muscle. Right.
The latissimus dorsi muscle from your back is
rerouted to the shoulder to help with external
rotation and abduction, typically in younger,
more active patients with tears on the back and
top of the rotator cuff, provided their subscapularis
tendon is intact. And newer transfers. More recently,
transferring the lower trapezius tendon, often
using a donated Achilles tendon as a bridge graft,
has been explored as another alternative. This
might offer a better line of pull for certain
types of irreparable tears. Lots of ingenuity
there. Let's talk about calcific tendonitis,
where calcium deposits form in the rotator cuff
tendons. That can be incredibly painful, right?
Oh, extremely painful sometimes. The initial
treatment for calcific tendonitis is usually
non -surgical rest, pain medication, physical
therapy, sometimes injections like cortisone
or even procedures to try and break up the calcium
with needles. But if that fails? If these conservative
measures don't provide relief, arthroscopic removal
of the calcium deposits can be a very effective
option. goes in with the scope, finds a deposit,
and essentially scrapes or sucks it out. Are
there times when arthroscopy isn't suitable?
Yes, there are a few situations. For example,
if the calcium deposit is already in the process
of being naturally resorbed or absorbed by the
body, surgery might not be needed. Or if multiple
tendons are involved, or if the patient also
has significant arthritis, frozen shoulder, or
has had previous shoulder surgery, It might complicate
things. But generally effective. In appropriately
selected cases, yes. Arthroscopic removal of
a calcium has reported high success rates in
reducing pain and improving function. SLAP tears,
injuries to the superior labrum where the biceps
tendon attaches. seem common, especially in athletes
who do a lot of overhead activities. They are.
SLAP tears, standing for superior labrum interior
to posterior, involve a tear in the top part
of the labrum, often affecting the anchor point
of the long head of the biceps tendon. They're
frequently caused by repetitive overhead motions,
like throwing or swimming, or by sudden injuries,
like falls onto an outstretched arm or a direct
blow to the shoulder. Diagnosis tricky. Diagnosing
SLA peers can be challenging based on physical
examination alone, as the symptoms can overlap
with other shoulder problems, so imaging like
MRI or MRA is often helpful. and treatment. Arthroscopic
repair is the main treatment approach for significant
symptomatic SLAP tears, especially in younger
active individuals. SLAP lesions are classified
into several types based on the pattern of the
tear. Like types three and four. Right, those
are examples. Type three involves a bucket handle
tear of the superior labrum itself where the
torn piece hangs down. The biceps anchor is intact.
Type four also has a bucket handle tear, but
this one extends into the biceps tendon anchor.
Any specific tests during an exam? There are
several specific clinical tests surgeons use,
like the Resisted Supination External Rotation
Test and the Clunk Test, that can raise suspicion
for SLA pter, but none are perfectly accurate
on their own. Okay. Biceps tenodesis, a procedure
to surgically fix the long head of the biceps
tendon in a new location, is another common surgery.
When is that typically done? Biceps tenodesis
is indicated for various reasons. One common
reason is pain that seems to be coming primarily
from the biceps tendon itself, often called biceps
tendonitis. It's also often performed when there's
a significant tear in the biceps tendon or as
part of the treatment for certain types of SLAP
tears, particularly those where the biceps anchor
is unstable or the tear extends into the tendon
or even sometimes in older patients instead of
repairing the SLAP. It's also used if a previous
SLAP repair has failed. There aren't many absolute
contraindications, but surgeons might be more
cautious in patients with significant other medical
problems or perhaps in older individuals with
very low functional demands where the symptoms
aren't too bothersome. What's the preferred technique?
Techniques vary, but one preferred technique
mentioned in the source is an arthroscopic intraarticular
tenodesis. Here, the tendon is cut inside the
joint and then reattached to the humerus right
at the edge of the joint cartilage. Other ways.
Yes, there are also endoscopic -assisted techniques.
These involve making a small incision lower down,
often in the armpit area or just below the pec
muscle, and using an endoscope to help visualize
and secure the tendon to the bone in the subpectoral
space. Sometimes a special retractor called a
homon is used to help with exposure down there.
Got it. Frozen shoulder or adhesive capsulitis
can be incredibly painful and limit movement
significantly. When might surgery be recommended
for that? Patients with frozen shoulder experience
this really painful and progressive restriction
in both their active and passive range of motion
in the shoulder. It can be debilitating. How
is it usually treated first? Initially, treatment
is usually conservative. That means pain medication,
maybe anti -inflammatories, intensive physical
therapy focused on stretching, and sometimes
cortisone injections into the jade. But if that
doesn't work? If these non -surgical treatments
fail to restore adequate range of motion and
relieve pain after a reasonable period, often
several months, then arthroscopic pancapsular
release is often recommended. Pancapsular release.
Yes, this involves surgically releasing the tightened
and thickened joint capsule from the inside of
the joint using arthroscopic instruments, essentially
cutting the tight tissue all around the joint,
hence pancapsular. Does it fully restore motion?
It can significantly improve the range of motion,
often dramatically, but it's important for patients
to understand that regaining the absolute full
range of motion they had before the frozen shoulder,
making it perfectly comparable to their other
arm, can sometimes still be a challenge even
after successful surgery and rehab. As we get
older, osteoarthritis of the glenohumeral joint,
that wear and tear in the main shoulder joint,
becomes more common. How is it managed in the
earlier stages before replacement? Glenohumeral
osteoarthritis, or GHOA, is a degenerative condition.
And yes, unfortunately, it becomes more prevalent
with age. In the earlier stages, before the arthritis
is too severe and causing bone -on -bone pain,
surgeons might consider conservative surgical
management. This primarily involves arthroscopy
to go in and essentially clean up the joint.
What does cleaning up involve? It can include
removing loose fragments of cartilage, smoothing
out rough surfaces on the cartilage or bone spurs,
maybe releasing a tight capsule, and addressing
any associated soft tissue issues like biceps
tendon problems or small rotator cuff tears.
The goal? The goal is primarily to relieve pain
and improve function, maybe delaying the need
for a joint replacement. But it's important to
realize it's not a long term fix for the underlying
arthritis itself. It's more palliative. Flail
shoulder is a very debilitating condition where
the arm is essentially paralyzed. Can arthroscopy
play any role in helping these patients? Flail
shoulder often results from severe nerve injuries
like brachial plexus injuries. or muscle paralysis,
leading to a significant loss of the ability
to actively move the arm. It just hangs there.
So what can be done? In certain cases, where
the goal is mainly to stabilize the shoulder
joint to allow for better use of the hand, especially
for tasks at waist level, a procedure called
glenohumeral arthrodesis might be considered.
Arthrodesis. Fusing the joint. Exactly. Surgically
fusing the humeral head to the glenoid socket.
Arthroscopic assisted techniques can be used
here to help prepare the joint surfaces for fusion
removing any remaining cartilage and also to
help guide the placement of the wires or screws
that hold the bones together rigidly while they
heal into one solid piece. Sometimes loose fragments
of cartilage or bone can float around inside
the shoulder joint causing pain and mechanical
symptoms like catching or locking. How are those
addressed? Arthroscopic removal of these loose
bodies is an excellent and often the preferred
alternative to traditional open surgery. Why
is better? It allows the surgeon to thoroughly
visualize the entire inside of the joint, find
all the fragments even ones hiding in corners,
and precisely remove them with minimal damage
to the surrounding healthy tissues. Smaller incisions,
quicker recovery usually. Sadly, infections can
sometimes occur in the shoulder joint. How are
those managed particularly using arthroscopic?
techniques. Septic arthritis of the shoulder
and infection within the joint is relatively
rare but has seen perhaps a slight increase in
incidence following injections around the shoulder.
And the treatment. The preferred treatment approach
is usually plomped arthroscopic debridement and
irrigation. Washing it out. Essentially, yes.
It allows for a thorough cleaning and flushing
out of the infected joint fluid and any pus or
debris. And at the same time, the surgeon can
visualize and potentially address any other associated
problems like rotator cuff tears that might be
present or contributing. Even bone cysts in the
proximal humerus, the upper part of the arm bone,
can be treated using minimally invasive techniques
now. How does that work? Yes, endoscopic cure
-tage is a technique used to treat certain benign
bone cysts in the proximal humerus. Endoscopic.
like arthroscopic, but inside the bone. Kind
of. It involves making small incisions to create
portals directly into the bone cyst, then using
specialized instruments under endoscopic camera
guidance to scrape out the lining of the cyst.
The goal is to be less invasive than traditional
open surgery, where you might have to make a
larger window in the bone, potentially leading
to faster healing and maybe a higher success
rate in resolving the cyst. A vascular necrosis
of the humeral head, where the blood supply to
the top of the arm bone is disrupted, is a serious
condition. Can arthroscopy help there too? Arthroscopic
assisted cord decompression and fibular strut
grafting is a technique used to try and treat
humeral head avascular necrosis, particularly
in its earlier stages, before the head collapses.
Cord decompression. That involves drilling small
channels into the affected area of the humeral
head to relieve pressure and hopefully stimulate
improved blood flow or healing. And the fibular
graft. This is often supplemented by inserting
small structural bone grafts, often taken from
the fibula bone in the lower leg, into those
channels. These grafts provide mechanical support
and aim to prevent the humeral head from collapsing.
The arthroscopic assistance allows for more precise
placement of these channels and grafts with smaller
incisions compared to open methods. What about
patients who have already had a shoulder replacement
and are now experiencing new problems? Can arthroscopy
still be a useful tool for them? Yes, absolutely.
Arthroscopy can definitely be valuable even after
a patient has undergone shoulder arthroplasty
or joint replacement What kind of problems it
can be used to diagnose and sometimes treat various
complications that can arise after replacement
things like infection around the prosthetic joint
instability where the replacement feels loose
or dislocates Impingement issues where tissues
are getting pinched new rotator cuff tears that
can still occur and even loosening of the components
of the artificial joint Is it harder to do? Performing
arthroscopy in a shoulder that has already had
a replacement is definitely technically more
challenging. The anatomy is altered, you have
the implants in the way, and scar tissue can
make visualization difficult. So it really requires
a surgeon with significant experience in this
specific area. Often a posterior portal, an entry
point from the back of the shoulder, is preferred
in these cases to try and avoid the implants
at the front. Okay. Dislocations of the chromioclavicular
joint, the AC joint where your collarbone separates
from your shoulder blade, are common injuries,
especially in sports. How are those treated arthroscopically?
Arthroscopic assisted reduction and fixation
techniques are increasingly used to treat the
more severe ACJ dislocations, the ones where
the clavicle is significantly elevated. How is
it fixed? These techniques often involve using
strong sutures or tapes, like the commercially
available tightrope and fiber tape systems, passed
around the coracoid process and through or around
the clavicle to pull the clavicle back down into
its correct position relative to the acromion
and then secure it there while the ligaments
heal. does it always stay reduced? While these
methods aim to restore the normal alignment,
some degree of loss of the initial reduction
can sometimes occur over time as things settle
or stretch slightly. Interestingly, there's some
evidence emerging to suggest that slightly over
-reducing the joint during the initial surgery
might actually be protective against the joint
subluxing or dislocating again later. The corcoclavicular
ligaments are crucial for the stability of that
AC joint. Can those be reconstructed arthroscopically
if they're completely torn and may be retracted?
Yes, there are arthroscopic techniques specifically
for reconstructing the coracoclavicular ligaments,
which are vital for holding the AC joint stable.
Using what? These procedures typically involve
using donated tissue and allograft tendon to
create new ligaments. The graft is passed around
the coracoid and through tunnels drilled in the
clavicle and then secured with strong fixation
devices, all done through small arthroscopic
incisions and portals. When osteoarthritis in
the AC joint itself becomes painful, sometimes
a small piece of the end of the clavicle is removed
at distal clavicle excision. How is that done
arthroscopically? Arthrostopic acromioclavicular
joint resection, sometimes called a Mumford procedure
arthroscopically, is a common procedure for persistent
pain and sometimes instability related to ACJ,
osteoarthritis, or impingement. What's involved?
Using a small bur through arthroscopic portals,
the surgeon removes a small portion, maybe 5
to 10 millimeters, of the very end of the distal
clavicle. Key considerations. A key consideration
for the surgeon is how much bone to remove. Taking
too little might not relieve the symptoms, but
taking too much could potentially destabilize
the joint, especially if the coracoclavicular
ligaments aren't perfectly intact. While the
arthroscopic approach offers advantages over
open surgery, like smaller incisions, surgeons
still need to be careful with portal placement
to avoid potential complications, like nerve
injury. Also, some studies have suggested that
in patients who are also undergoing rotator cuff
repair and happen to have ACG arthritis, performing
this distal clavicle excision at the same time
might not actually provide any additional benefit
in terms of outcome. Sometimes it can cause pain,
right? How is that addressed? Exactly. While
often asymptomatic, a mobile mesoacromial fragment,
essentially an unfused growth center of the acromeon,
can sometimes be a source of pain, clicking,
and impingement -like symptoms in the shoulder.
How do you confirm it's the cause? Careful diagnosis
is important. This often involves pinpointing
tenderness directly over the fragment and sometimes
injecting a local anesthetic like lidocaine around
the suspected non -union site to see if that
temporarily relieves the pain and the treatment.
Arthroscopic excision, where the small separate
piece of bone is surgically removed using arthroscopic
instruments, is a described alternative to open
surgery, either excision or trying to fix it
with screws. This minimally invasive approach
potentially leads to less post -operative pain
and less weakness in the deltoid muscle which
attaches there. snapping scapula syndrome, where
you feel or hear a grinding or popping sensation
as your shoulder blade moves over the ribs that
can also be treated arthroscopically. How does
that work? Yes, for snapping scapula syndrome,
which is often caused by inflammation of the
bursa between the scapula and chest wall, or
sometimes a bony prominence on the scapula, both
open and arthroscopic treatment options exist.
Arthroscopic approaches typically involve either
removing the inflamed bursa a brosectomy, or
sometimes partially removing a small corner of
the scapula, if that's rubbing, a partial scapelectomy.
Advantages of arthroscopy. Potential advantages
over open surgery include quicker recovery and
less disruption to the surrounding muscles. Specific
portal placements, like the medial and bell portals,
are used to access that space between the scapula
and the rib cage, the scapula thoracic space.
Any dangers back there? Yes, surgeons need to
be very careful during scapula thoracic arthroscopy
to avoid injuring nearby nerves and blood vessels,
like the long thoracic nerve or the dorsal scapular
nerve and artery. What about other conditions
affecting that scapula thoracic area, like bursitis
specifically, or bony growths called osteochondromas?
Scapula thoracic bursitis, just the inflammation
of the bursa without necessarily a bony cause,
and osteochondromas, which are benign bony growths
that can occur on the underside of the scapula
or on the ribs, can also be addressed arthroscopically
or endoscopically. Imaging, including CT scans
and MRI, is important for diagnosis, especially
to see the exact location and size of an osteochondroma.
Endoscopic resection of osteochondromas in the
scapula thoracic space has been shown to be effective,
again with potentially smaller incisions and
a faster recovery compared to open surgery. is
a less common condition. Can it be treated arthroscopically?
Hyperactivation or tightness of the pectoralis
minor muscle has been proposed as a rare cause
of shoulder pain, nerve symptoms down the arm,
or even thoracic outlet -like symptoms. And the
fix. Arthroscopic or endoscopic release of the
pectoralis minor tendon from its attachment on
the coracoid process can be performed. This is
sometimes done in conjunction with other procedures
like the Letarjet procedure where it needs to
be released anyway, or specifically for diagnosed
pectoralis minor syndrome. It has shown promising
results in terms of of relieving pain and improving
shoulder function in the reported cases, although
it's still relatively uncommon. The surgery is
typically done with the patient in the beach
chair position. Moving medially to the sternoclavicular
joint where your collarbone meets your breastbone.
What role does arthroscopy play in managing disorders
there? It seems like a tight space. It is a tight
space. Sternoclavicular or SC joint arthroscopy
can be used for diagnosing and sometimes treating
conditions like persistent pain, inflammation,
or instability in that joint that haven't responded
to other treatments. Contraindications. Yes,
there are certain contraindications that need
to be carefully considered before proceeding,
like active infection or severe joint destruction.
Specific surgical techniques and portal placements
are used to access the SC joint and it requires
specialized small instruments. What about instability?
For SC joint instability, a specific arthroscopic
technique has been described that aims to preserve
the important fibrocartilaginous disc within
the joint while using tending grafts passed through
bone tunnels to stabilize it. It can be related.
Surgical treatment for thoracic outlet syndrome,
or TOS, might be considered if non -operative
measures fail to provide relief, particularly
in cases where there are clear neurological symptoms
or vascular compromise. What's released? Traditionally,
this involved open surgery, often removing the
first rib. However, endoscopic techniques have
been developed as less invasive alternatives
for releasing structures that can cause compression.
This might include releasing the scale muscles
in the neck, scalenectomy or scalenotomy, or
releasing the pectoralis minor tendon in the
chest if those are identified as the compressing
structures. Nerve entrapment around the shoulder
itself, like when the suprascapular nerve gets
compressed, can cause significant pain and weakness,
especially in the rotator cuff muscles it supplies.
How is that treated endoscopically? The suprascapular
nerve can get entrapped at two main locations
as it travels around the scapula. The spinoglenoid
notch, often by assist from the joint, and the
superscapular notch under a ligament. Diagnosis.
Electrodiagnostic tests like nerve conduction
studies and EMG are crucial to help confirm the
diagnosis and pinpoint the location of the entrapment.
And the endoscopic treatment. Endoscopic decompression
techniques have been developed to release the
pressure on the nerve at these specific locations.
This often involves carefully cutting the transverse
scapular ligament at the suprascapular notch
or decompressing a cyst at the spinoglenoid notch,
all done through small portals using endoscopic
visualization. Medial scapular winging, where
your shoulder blade sticks out prominently at
the back, especially when pushing, is often due
to a problem with the long thoracic nerve, right?
Can that be addressed endoscopically? Yes. The
most common etiology for medial scapular winging
is indeed palsy or injury to the long thoracic
nerve, which supplies the serratus anterior muscle.
And the endoscopic approach. Endoscopic decompression
of the long thoracic nerve along its course looking
for potential points of compression has been
explored and has shown potentially good results
in resolving medial scapular winging in some
cases. This might be compared to more invasive
muscle transfer procedures like pectoralis major
transfer, which is sometimes needed if the nerve
damage is permanent. The endoscopic approach
aims to release any compression on the nerve,
allowing the serratus anterior muscle to hopefully
recover and function properly again. Finally,
let's touch on fractures around the shoulder.
Can arthroscopy assist in their management? It
seems counterintuitive for broken bones. You
might think so, but absolutely. Arthroscopy can
play a valuable role in managing various shoulder
fractures, often in an assisted capacity. How
so? For which fractures? Well, for distal clavicular
fractures, specifically the unstable near type
2 fractures where ligaments are torn, endoscopic
or arthroscopic assisted fixation offers a minimally
invasive approach. It allows for visualizing
the fracture reduction and placing fixation devices
like plates or suture buttons with smaller incisions,
potentially leading to lower complication rates
compared to open surgery. What about the humerus
itself? Arthroscopic assisted techniques are
also commonly used for fractures of the greater
tuberosity and sometimes the lesser tuberosity.
Those are the bumps where the rotator cuff tendons
attach. Arthroscopy helps with accurately reducing
the fracture fragments, clearing out any blood
clot, and then fixing them securely in place
using screws or strong suture anchors. And the
main ball and socket part. Proximal humeral fractures.
For proximal humeral fractures involving the
top of the upper arm bone near the joint, arthroscopic
assisted reduction and internal fixation, or
ARF, is an option in selected cases, usually
simpler two -part or some three -part fractures.
However, very complex fractures with multiple
fragments or poor bone quality are generally
still better treated with an open approach or
even replacement. Hardware removal. Arthroscopy
can also be helpful later on to assist in the
removal of hardware like screws or plates after
a fracture has healed, especially if the hardware
is causing impingement or irritation. And glenoid
fractures, fractures of the socket. Even some
fractures of the glenoid socket, particularly
those involving the front rim. bony bankart lesions
as we discussed earlier, can be managed arthroscopically
using suture fixation techniques or sometimes
a bony bankart bridge technique to reconstruct
the rim. Wow, that really was a deep dive. It's
incredible really to see the sheer number of
conditions affecting the shoulder from instability
and cuff tears to nerve entrapments and even
fractures that can now be diagnosed and treated
using these advanced minimally invasive arthroscopic
and endoscopic techniques. It is quite remarkable.
And as the author of our source material so optimistically
pointed out, this field is constantly pushing
the boundaries of what's possible. The innovation
is just continuous. We can fully expect even
more refined techniques, better implants, and
perhaps even more innovative biological solutions
to emerge in the years ahead. It's really an
evolving field. It truly makes you appreciate
the intricate understanding of anatomy required
and the incredible ingenuity that goes into developing
these surgical procedures. and the instruments
need to perform them through tiny holes. Absolutely.
Precision is key. So as we wrap things up, here's
something for you, the listener, to ponder. Given
this rapid pace of advancement in shoulder arthroscopy
and endoscopy that we've discussed, what completely
new frontiers might be explored in the next decade?
That's a great question. What conditions that
are currently considered irreparable, maybe like
severe arthritis in very young people, or massive
chronic cuff tears with muscle atrophy, might
become a treatable through these minimally invasive
approaches, perhaps combined with regenerative
medicine. The potential is certainly there, maybe
complex reconstructions we can't even imagine
yet. It's certainly an exciting future to consider
for shoulder treatment. Thanks for joining us
on The Deep Dive.