Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Current trends in Shoulder Arthroscopy

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Current trends in Shoulder Arthroscopy · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Welcome to the deep dive. You know, the shoulder
0:03
is this incredible piece of biological engineering,
0:06
just the most mobile joint in the human body.
0:09
It really is amazing. Today we're going to unpack
0:12
how specialists are using these cutting edge
0:14
techniques, arthroscopy and endoscopy to, well,
0:18
understand and fix its many quirks and injuries.
0:21
We've got a fantastic, really in -depth textbook
0:24
as our source. And our goal is basically to pull
0:27
out the most useful and fascinating insights
0:29
into how these minimally invasive procedures
0:31
are actually done. That's right. What's remarkable
0:35
about this field is just the sheer scope of what
0:37
can now be addressed without those large incisions.
0:40
This textbook really lays out everything from,
0:43
you know, the basic anatomy, you need to get
0:45
your head around to the really advanced surgical
0:47
solutions for all sorts of shoulder problems
0:50
like rotator cuff tears, instability, a whole
0:53
gamut. Yeah. And it's not just about what's possible
0:55
now. The author's enthusiasm for the future of
0:57
shoulder surgery is, well, it's pretty infectious.
1:00
He genuinely believes the field is advancing
1:02
so rapidly. that this entire book might need
1:06
a complete overhaul within the next decade. That
1:09
gives you a real sense of how much innovation
1:11
is happening, doesn't it? It certainly does.
1:13
It's moving fast. Okay, let's unpack this. We
1:16
can't really talk about fixing the shoulder without
1:18
understanding what makes it tick. Absolutely
1:20
fundamental. Let's start with the arthroscopic
1:23
anatomy, this incredibly mobile glenohumeral
1:26
joint that's where your upper arm bone meets
1:29
your shoulder blade. How does it manage to be
1:31
so flexible yet stay stable. It's a clever combination
1:37
of what we call passive and active stabilizers.
1:39
So think of the passive structures as the underlying
1:42
framework. Okay. You've got the glenoid, which
1:44
is the shallow socket on your shoulder blade,
1:47
the head of the humerus, the ball of your arm
1:49
bone fitting into that socket, the labrum. That
1:52
cartilage ring? Exactly, that cartilage ring
1:54
around the glenoid that deepens the socket. Then
1:57
there's the joint capsule, the fibrous tissue
1:59
enclosing the whole joint, and the ligaments,
2:01
those tough bands connecting bone to bone. So
2:04
that's the static support, the framework. Now
2:06
for the active part, the muscles. Exactly. These
2:09
are the dynamic controllers, allowing for movement
2:11
and providing crucial stability. The rotator
2:14
cuff muscles, supraspinatus, infraspinatus, teres
2:16
minor, and substabularis are key players here,
2:20
along with the long head of the biceps, the deltoid,
2:22
the big muscle on the outside of your shoulder,
2:25
and all the muscles that control how your scapula,
2:27
your shoulder blade moves. It's this coordinated
2:30
muscle action that allows you to reach for things,
2:34
throw a ball, everything in between, all while
2:36
keeping the joint secure. Now here's a detail
2:39
that apparently surprises even some experienced
2:41
surgeons, telling the supraspinatus and infraspinatus
2:44
muscles apart during an arthroscopic procedure.
2:49
It can be tricky. It really can be. One helpful
2:52
landmark is often a subtle contour line that
2:54
naturally separates the two muscles. Ah, okay.
2:57
Also, if we see cysts or bony spurs, what we
2:59
call osteophytes, around the greater cuporosity,
3:03
that's that bony bump on the outside of your
3:04
upper arm bone, it can suggest long -standing
3:07
subacromial impingement. Impingement. That's
3:09
the narrowing of this space. Right. A narrowing
3:12
of the space above the rotator cuff. And this
3:14
can sometimes give us an indirect clue about
3:17
potential issues with the underlying rotator
3:19
cuff muscles themselves. OK. So once we have
3:23
a sense of the anatomy, how do we actually get
3:26
a look inside a living shoulder? Radiological
3:29
investigations are obviously crucial. And it
3:31
sounds like good old x -rays are still the starting
3:33
point. Absolutely. X -rays are fantastic for
3:36
that initial overview, especially for identifying
3:38
things like dislocations and fractures. Different
3:41
views let us see the bones from various angles,
3:44
which is key for diagnosing specific problems.
3:47
Makes sense. For example, the standard AP, anteroposterior,
3:50
scapular Y, and axillary views are pretty essential
3:54
for evaluating acute shoulder dislocations. Then
3:57
you have specialized views like the West Point
3:59
and striker notch views. These are particularly
4:02
helpful for visualizing fractures on the front
4:04
of the glenoid socket or those hill -sax lesions.
4:07
Those little dents on the humeral head from dislocation.
4:10
Exactly those, the ones that can happen when
4:12
the shoulder dislocates forward. And when we
4:14
need to really see the soft tissues of muscles,
4:17
tendons, ligaments, that's where MRI and MRA
4:20
come in, right? What's the difference there?
4:22
So MRI, magnetic resonance imaging, gives us
4:25
incredibly detailed pictures of all the soft
4:27
tissue structures. MRA or MR arthrogram takes
4:30
it a step further. How so? By injecting a contrast
4:33
dye directly into the joint before the MRI scan.
4:36
This contrast really highlights the outlines
4:39
of structures like the labrum and ligaments,
4:41
making tears much easier to spot. Clever. For
4:44
instance, putting the arm in a specific position
4:47
called ABER, that's abduction and external rotation
4:50
during an MRA, can significantly improve our
4:53
ability to detect tears in the antero -inferior
4:56
labrum, the front and bottom part of that cartilage.
4:58
I see. This can help us identify specific types
5:01
of injuries, like ALPSA lesions. What are those
5:04
again? That's where the torn labrum isn't just
5:05
torn, but it also gets pushed and kind of rolled
5:08
onto the neck of the scapula. Yeah. MRI also
5:10
helps see ruptures of the inferior glenohumeral
5:13
ligament, or IGHL, the key stabilizer. Got it.
5:16
Now CT orthography is another imaging technique
5:18
mentioned. Where does that fit in? CT arthrography,
5:21
which combines a CT scan with that contrast injection
5:24
into the joint, is really good for seeing the
5:27
bony architecture in great detail. OK, so more
5:29
for bone. Primarily, yes. It's particularly useful
5:33
for assessing the amount of bone loss in the
5:35
glenoid socket, which is crucial information
5:37
in cases of recurrent instability. However, it's
5:41
generally not as sensitive as a direct MRA for
5:44
picking up small, non -displaced tears in the
5:47
labrum. these MRI scans isn't always black and
5:51
white, is it? I read there are anatomical variations
5:53
that can sometimes look like tears. That's a
5:56
really important point, especially in the antero
5:58
-superior part of the labrum, roughly the top
6:00
and front of the socket. There are a few common
6:02
anatomical variations that can sometimes be mistaken
6:05
for SLAPs. SLAP tears. Superior labrum tears.
6:09
Right, tears of the superior labrum. These variations
6:12
include the Buford complex. Okay, Buford complex.
6:14
That's where a portion of the antero -superior
6:16
labrum is missing, and the middle glenohumeral
6:19
ligament is thickened and sort of cord -like.
6:22
We also see things like a sublaboral sulcus,
6:25
which is a small groove beneath the labrum, and
6:28
a sublaboral foramen, a small hole in the labrum.
6:31
That Buford complex sounds interesting. What's
6:33
the key thing for surgeons and maybe patients
6:36
to know about it? Well, the key thing is recognizing
6:38
it as a normal variation so you don't mistakenly
6:41
diagnose a labral tear that isn't actually there.
6:44
Right. Avoid unnecessary treatment. Exactly.
6:47
Interestingly, though, some recent research suggests
6:49
that this specific anatomical setup, the Buford
6:52
complex, might actually make individuals a bit
6:55
more prone to developing SLAP lesions later on,
6:57
perhaps due to altered biomechanics in the shoulder.
7:00
Okay. Beyond the soft tissues, the shape of the
7:04
acromion, that bony prominence on the top of
7:06
your shoulder blade, that can also play a role
7:08
in shoulder problems, can't it? Absolutely. We
7:10
classify the shape of the acromion into three
7:12
types, based on what it looks like from underneath
7:14
on a specific x -ray view. 3 -type. Yep. Type
7:19
1 is essentially flat, type 2 has a gentle curve,
7:22
and type 3 is also curved, but with a hook -like
7:25
projection pointing downward. Ah, the hooked
7:27
one. Right. It's this type 3 acromeon that has
7:30
the strongest link to subacromial impingement,
7:33
that compression of the rotator cuff tendons,
7:36
and consequently rotator cuff tears. The hook
7:39
shape basically narrows the space where the tendons
7:41
have to glide. And there's also the acromial
7:44
index, a measurement we can take on x -rays.
7:46
What does that tell us? The acromial index or
7:49
AI is a ratio. It compares two distances measured
7:52
on a frontal x -ray of the shoulder. It's the
7:55
distance from the edge of the glenoid socket
7:57
to the outer edge of the acromion, divided by
8:00
the distance from the glenoid to the outer edge
8:01
of the greater tuberosity. So a bigger number
8:04
means the acromion sticks out more. Exactly.
8:07
A higher AI value means the acromion extends
8:09
further laterally, or sideways. Studies have
8:12
shown that people with a higher acromial index
8:14
are more likely to experience subacromial impingement
8:17
and have rotator cuff problems. Interesting correlation.
8:20
For example, people who don't have any shoulder
8:22
issues tend to have a lower AI while those with
8:24
significant rotator cuff tears often have a higher
8:27
AI. It just gives us another piece of the puzzle
8:30
when evaluating shoulder pain. Let's switch gears
8:33
a bit and talk about the biceps tendon. It's
8:35
not just about flexing your arm. It plays a role
8:38
in shoulder stability too, doesn't it? It absolutely
8:40
does. The long head of the biceps tendon, or
8:43
LHBT, is held in its groove at the front of the
8:46
upper arm bone by a really important structure
8:49
called the biceps pulley, sometimes also called
8:52
the biceps sling. The pulley. Yeah, this pulley
8:54
is a complex of ligaments and tendon fibers.
8:57
It's primarily made up of the superior glenohumeral
9:00
ligament, the coracohumeral ligament, and also
9:03
fibers from the subscapularis tendon as it wraps
9:06
around the front of the shoulder. OK. Interestingly,
9:09
the transverse humeral ligament, which you might
9:11
have heard of as holding the biceps tendon in
9:13
place, is now understood to be largely composed
9:16
of fibers coming from the subscapularis and supraspinatus
9:20
tendons. Ah, so it's more connected than we thought.
9:22
Right. And because this whole biceps pulley sits
9:25
within the rotator interval, that gap between
9:28
the supraspinatus and subscapularis tendons injuries
9:31
in this area often involve the pulley as well.
9:34
How do you spot those pulley injuries? Ultrasound
9:36
can be a really useful tool here. It can actually
9:38
let us see injuries to the ligaments that make
9:42
up the biceps pulley, like the SGHL and CHL,
9:45
and detect if the biceps tendon is slipping out
9:47
of its normal position, which we call subluxation.
9:50
Another common and often frustrating shoulder
9:52
issue is adhesive capsulitis or frozen shoulder.
9:55
How can imaging help with that diagnosis? Well,
9:58
the diagnosis of adhesive capsulitis is mainly
10:00
based on a patient's symptoms and a physical
10:03
exam show showing that restricted movement. Right,
10:05
the classic stiffness. Exactly. But MRI can be
10:08
helpful as an additional tool, primarily to rule
10:11
out other conditions that might be causing similar
10:13
pain and stiffness. So ruling things out. Mostly.
10:16
In some cases of adhesive capsulitis, though,
10:18
an MRI might show a thickening of the joint capsule
10:21
itself and sometimes even a small amount of fluid
10:23
within the joint. But it's not always definitive
10:25
just from the scan. Finally, for this section,
10:28
let's touch on the acromioclavicular joint, the
10:30
AC joint, where your collarbone meets the acromion.
10:34
Osteoarthritis is quite common there, isn't it?
10:36
It is. Achromioclavicular joint osteoarthritis,
10:39
or ACJOA, can develop as a result of a direct
10:42
injury to the AC joint, like a fall onto the
10:45
shoulder. It's also frequently seen in people
10:47
who have subachromial impingement. OK. On imaging,
10:51
we might see signs of wear and tear in the joint,
10:53
like the cartilage thinning, bone spurs forming
10:55
those osteophytes again, and sometimes even small
10:58
cysts in the bone just below the cartilage. And
11:01
distinguishing old injuries from arthritis. Yeah.
11:03
Early signs of ACJ degeneration. can sometimes
11:05
be hard to tell apart from old, minor sprains
11:08
of the AC joint, as both can show some thickening
11:11
of the joint capsule. If we also see involvement
11:13
of the coracoclavicular ligaments, the ones holding
11:16
the clavicle down, that often suggests a more
11:18
significant past injury to the AC joint. Okay,
11:21
we've covered a lot of ground on anatomy and
11:23
diagnosis. Let's move into treatment. Arthroscopic
11:26
surgery relies heavily on the use of cannulas.
11:29
What are they and why are they so important?
11:31
Okay, so think of cannulas as little access tunnels
11:35
into the shoulder joint. They're hollow tubes
11:37
that we ensuit through small incisions. Got it.
11:39
Tunnels. And they're absolutely essential for
11:42
making arthroscopic surgery efficient. They allow
11:45
us to easily swap different surgical instruments
11:48
in and out as needed without having to make multiple
11:51
large incisions or constantly repuncture the
11:53
skin. Makes sense. They're also crucial for managing
11:56
sutures during the procedure, preventing them
11:59
from getting tangled or catching on other tissues?
12:01
What kinds are there? Cannulas come in various
12:04
sizes, lengths, and materials. You have soft
12:07
silicone cannulas, which are less bulky and can
12:10
even help with gently retracting tissues inside
12:12
the joint, but you have to be careful with sharp
12:15
instruments around them. Right. Then there are
12:17
hard cannulas, more resistant to accidental puncture,
12:20
but sometimes less maneuverable, especially if
12:22
you're using several at once. Any downsides?
12:25
Well, one important thing to watch out for is
12:27
fluid extravasation. If a cannula accidentally
12:30
slips out of the joint during surgery, the fluid
12:33
we use to inflate the joint can leak out into
12:36
the surrounding soft tissues. Ah, okay. Needs
12:38
careful management. Now arthroscopic fixation
12:42
of bony bankart lesions, that's when a piece
12:44
of bone breaks off the front of the glenoid during
12:47
a shoulder dislocation. That seems like a key
12:49
area where these techniques have really made
12:51
a difference. They absolutely have. For smaller
12:54
bony bankart lesions, what we sometimes call
12:56
bigliani type I or II, where the bone fragment
12:59
is still in relatively good shape and hasn't
13:02
shifted too much, arthroscopic reduction, basically
13:06
putting the bone back in place and internal fixation
13:08
holding it there with anchors and sutures is
13:11
often the preferred approach. The goal is to
13:14
restore that smooth, continuous surface of the
13:17
glenoid socket. But there's a limit. Right, if
13:19
the bone loss is too big. Exactly. If the glenoid
13:22
defect is larger than about 20 to 25 percent
13:25
of the socket surface area, that's generally
13:27
considered a critical size. Okay. In these cases,
13:30
arthroscopic repair alone might not be enough
13:32
to prevent future dislocations, and other procedures
13:35
like the latarjet or bone grafting might be necessary
13:38
to rebuild the socket. And techniques for fixing
13:40
those fragments arthroscopically. Surgeons often
13:43
use specific techniques, like the double pulley
13:46
technique, to get a really secure hold on those
13:49
bony fragments during the arthroscopic repair.
13:52
What about the success rates of these arthroscopic
13:54
band cart repairs? Does it matter if the shoulder
13:56
has been dislocating for a while versus a first
14:00
-time dislocation? That's a good question. The
14:03
research suggests that arthroscopic banker repairs
14:06
tend to have better outcomes when performed after
14:09
an acute or first -time dislocation compared
14:12
to chronic recurrent instability. Why is that?
14:16
Well, studies have shown that many patients with
14:18
acute glenoid rim fractures can regain stability
14:21
and get back to their previous activities after
14:23
a single row of anchors is used to fix the bone
14:25
and labrum. But the results for chronic cases
14:28
treated with the same single row technique have
14:30
sometimes been less predictable. It's possible
14:33
the bone and ligaments can change over time with
14:35
repeated dislocations, making them harder to
14:37
repair effectively. But it's not always clear
14:39
cut. No, interestingly, some studies have reported
14:42
good success even in chronic cases where the
14:45
bone fragments are still well -preserved. And
14:47
more recently, techniques using two rows of anchors,
14:50
so -called double -row repair, have shown promising
14:53
results for both acute and chronic instability.
14:56
Double row. More anchors, better fixation. Potentially,
15:00
yes. It creates a wider area of contact. Patients
15:03
report good satisfaction and improvements in
15:05
how the shoulder feels and functions, but Ultimately,
15:09
a really important factor in the success of any
15:11
bank art repair seems to be making sure the reconstructed
15:14
glenoid socket is at least 80 % of its original
15:17
size. That makes sense, restoring the anatomy.
15:20
Now for shoulder instability in general, surgery
15:22
isn't always the first thing doctors recommend,
15:24
is it? That's correct. Non -operative treatment
15:27
is often the first step. This usually involves
15:29
wearing a sling for a few weeks to let the initial
15:31
injury calm down, followed by a structured rehabilitation
15:34
program. Physical therapy. Exactly. The rehab
15:37
focuses on strengthening the muscles around the
15:39
shoulder, especially the rotator cuff, and gradually
15:42
restoring the full range of motion. But when
15:45
is surgery indicated? Surgery might be recommended
15:47
if the patient continues to experience symptoms
15:50
like feeling the shoulder wants to slip out of
15:52
place. That's a positive apprehension sign. Or
15:55
if a doctor can physically put the shoulder back
15:58
in place during an exam, which is a positive
16:00
relocation sign. OK. Also, if certain exam maneuvers
16:04
like the augmentation test or lag sign are positive
16:06
or simply if conservative treatment doesn't provide
16:09
enough relief and the shoulder continues to be
16:11
unstable and really limits their function. Right.
16:14
Let's move on to some specific shoulder conditions
16:16
and their surgical management. The Letarget procedure
16:19
is a well -known option for people with shoulder
16:22
instability and significant bone loss. Can that
16:26
be done arthroscopically? Yes, it can. The traditional
16:30
latarjet procedure, which involves taking a piece
16:33
of bone called the coracoid process from the
16:35
front of the shoulder blade and transferring
16:37
it to the front of the glenoid to act as a bony
16:40
block. Right, the bone block. That's been performed
16:42
as an open surgery for a long time and has a
16:44
good track record for stabilizing the shoulder.
16:47
But since about 2003, surgeons have also been
16:50
performing the latarjet procedure arthroscopically
16:53
using smaller incisions. What are the trade -off?
16:57
Well, the arthroscopic approach can offer potential
16:59
benefits like less pain and maybe quicker recovery,
17:03
but both the open and arthroscopic letarget procedures
17:07
carry some risks. Such as? One potential complication
17:10
is a fracture of the transferred coracord bone
17:12
itself, which can happen in the first few months
17:14
after surgery. There's also a risk of nerve injury
17:17
because of the delicate dissection involved near
17:20
important nerves. When the glenoid bone loss
17:22
is quite substantial, are there other surgical
17:25
options besides the Yes. For more significant
17:28
glenoid bone loss, surgeons sometimes use what
17:30
we call extra -anatomic procedures. These include
17:34
the letarget -bristaux procedure, which is a
17:36
variation of the letarget, or using a separate
17:38
piece of bone, often from the iliac crest, your
17:40
hip bone. Ah, a graft from the hip. Right. Using
17:43
that as a bone block that's then fixed to the
17:45
glenoid, usually with screws. But those have
17:47
potential issues too. They can. Complications
17:50
like the bone not healing properly. non -union,
17:54
the bone graft being reabsorbed by the body over
17:56
time, or problems with the screws or other hardware
17:59
used to hold the bone in place can occur. So
18:02
alternatives? Well, the arthroscopic j -bone
18:04
grafting technique offers another approach. This
18:07
involves taking a bone graft from the iliac crest,
18:10
shaping it carefully to fit the glenoid defect,
18:13
and then securing it arthroscopically. What's
18:15
the advantage there? A key advantage is that
18:17
it's arguably more anatomical. aiming to restore
18:20
the natural shape of the glenoid. Plus, it doesn't
18:23
leave behind permanent metal implants like screws.
18:26
OK. There's also a technique mentioned called
18:28
arthroscopic bone block with subscapularis augmentation,
18:32
or ASA. What's that all about? The ASA procedure
18:35
is a more complex arthroscopic technique. It's
18:38
designed for cases of severe glenoid bone loss
18:41
combined with a deficient capsule -laboral complex,
18:43
meaning both the cartilida rim and the surrounding
18:45
ligaments are significantly damaged. So a double
18:48
whammy. Pretty much. It involves creating tunnels
18:51
in the glenoid bone to precisely position and
18:54
secure a bone block graft using strong button
18:57
-like anchors. And the subscapularis part. Importantly,
19:01
it also includes augmenting or reinforcing the
19:04
subscapularis tendon, that key stabilizer on
19:07
the front of the shoulder, often using a strong
19:09
suture tape anchor. So it's bone block plus tendon
19:12
reinforcement. Exactly. This combined approach
19:14
has shown promise as a feasible and safe alternative
19:17
to the traditional Letarjet procedure in these
19:20
more challenging instability cases. In situations
19:23
where the bone loss isn't quite critical, are
19:25
there other types of grafts that might be considered
19:27
like not from the hip? Yes. For glenohumeral
19:30
instability with a smaller degree of bone loss,
19:33
or in cases where a hill -sax lesion, that dent
19:35
on the humeral head is off -track, meaning it's
19:38
likely to engage with the glenoid rim during
19:40
movement, an arthroscopic distal clavicle osteochondral
19:44
autograft transfer might be an option. Taking
19:46
bone from the collarbone. Right. This involves
19:49
taking a small piece of bone and its overlying
19:51
cartilage from the end of the clavicle and transplanting
19:55
it to the glenoid defect. When wouldn't you use
19:57
that? Well, this technique is generally not recommended
20:00
for patients who have very loose joints overall,
20:03
what we call global hyperlaxity, or if they have
20:07
significant bone loss on the humeral head itself,
20:10
or if they've had a previous resection of the
20:12
end of the clavicle. Okay. What happens when
20:15
a Letarjet procedure unfortunately doesn't achieve
20:19
the desired stability? revision possible? Revision
20:23
surgery after a failed lethargic procedure can
20:25
be quite complex as you can imagine. Surgeons
20:28
sometimes use a specific posterior portal, an
20:31
entry point at the back of the shoulder called
20:32
the Halifax portal. A specific portal? Yeah,
20:35
this portal can provide better access and visualization
20:38
of the surgical area during these tricky revision
20:41
procedures, allowing for a more thorough assessment
20:43
and repair. Now, hill -sax lesions, those indentations
20:47
on the humeral head from dislocations, can also
20:50
contribute to ongoing instability. The remplassage
20:52
procedure is designed to address those. How does
20:55
it work? The remplassage procedure aims to prevent
20:57
a hill -sax lesion from catching or engaging
21:00
on the edge of the glenoid socket during shoulder
21:02
movement, which can cause further instability
21:05
or pain. So how do you stop it catching? It involves
21:08
essentially filling in the hillsack's defect
21:11
with sock tissue, typically by using a portion
21:14
of the infraspinatus tendon, one of the rotator
21:16
cuff muscles, and anchoring it right into the
21:18
bony defect on the humerus. Filling the dent.
21:21
Basically, yes. This procedure is often considered
21:23
in cases where there's an engaging hillsack's
21:26
lesion, but less than 25 % of glenoid bone loss.
21:29
It's often done alongside a bankart repair. HEGL
21:32
lesions. That's when the inferior glenohumeral
21:35
ligament tears away from its attachment. on the
21:37
humerus, they also require specific attention,
21:39
right? Yes, definitely. Arthroscopic repair of
21:42
HAGL lesions where the ligament is reattached
21:45
to the humerus using anchors is certainly possible
21:47
and often effective. Is the recovery different
21:49
depending on where the tear is? The post -operative
21:52
care can differ slightly. For anterior inferior
21:56
tears, on the front and bottom, immobilization
21:58
in a standard sling is typical. For reverse HAGL
22:02
tears on the backside, surgeons might use an
22:05
external rotation brace or an abduction pillow
22:07
to protect the repair, as these positions put
22:10
less stress on the repaired posterior ligament.
22:12
OK. Posterior shoulder instability, while less
22:15
common than anterior instability, still poses
22:18
challenges for diagnosis and treatment. It does.
22:21
Arthroscopic assessment is really valuable in
22:23
evaluating posterior shoulder instability to
22:26
identify if there are any associated bone or
22:28
soft tissue injuries, like a reverse bank heart
22:31
lesion or posterior labral tear. Is surgery always
22:35
the answer? No. Surgery is generally not recommended
22:37
for patients who can voluntarily dislocate their
22:39
shoulder or those who aren't likely to be cooperative
22:42
or able to actively participate in the extensive
22:44
rehabilitation process required afterwards. Right.
22:47
In some chronic cases where pain is minimal and
22:50
function is still reasonably good despite some
22:52
laxity, non -operative management might actually
22:54
be the preferred approach. Multidirectional instability,
22:58
or MDI, is when the shoulder feels loose in multiple
23:01
directions. How is that managed arthroscopically?
23:05
MDI is a complex condition. It can be caused
23:07
by a combination of factors, including naturally
23:10
loose joints, congenital hyperlaxity. Born with
23:13
loose joints? Sometimes, yes. or it can be due
23:16
to repeated minor injuries like microtrauma,
23:19
imbalances in the muscles around the shoulder,
23:21
and certain anatomical predispositions. A key
23:25
finding is often laxity in the coracor humeral
23:28
ligament and an overly loose or redundant joint
23:30
capsule, especially in the front and bottom parts
23:33
of the joint. So how do you fix that looseness?
23:35
Arthroscopic capsule replication, or ACP, is
23:38
a surgical technique used to address this. It
23:40
involves taking tucks or pleats in the joint
23:43
capsule to effectively tighten it up and reduce
23:45
the excessive laxity. These pleats are then secured
23:47
with sutures or anchors. How does that compare
23:50
to older open surgeries? Compared to older open
23:53
surgical procedures called capsular shifts, ACP
23:57
offers advantages like smaller incisions, less
23:59
scarring, often less pain after surgery, avoiding
24:02
the need to detach and reattach the subscapularis
24:05
tendon, and potentially a quicker return to sports.
24:08
And the results. Studies have reported quite
24:10
promising success rates with ACP and appropriately
24:13
selected patients who have true MDI. Okay, let's
24:16
talk rotator cuff tears. A very common source
24:18
of shoulder pain and weakness. What are some
24:21
of the newer developments in arthroscopic repair
24:24
techniques? Arthroscopic rotator cuff repair
24:26
techniques have certainly come a long way. One
24:29
promising advancement is the linked double row
24:31
suture bridge or LDRS -B repair. That sounds
24:35
complex, LDRS -B. It does, but the idea is to
24:38
improve healing. Studies have suggested that
24:40
this technique can lead to higher rates of tendon
24:42
healing and potentially fewer repeat tears compared
24:45
to traditional single row or even standard double
24:47
row repairs. How does it work? The idea behind
24:50
the suture bridge is to create a wider footprint
24:53
of tendon -to -bone contact and provide more
24:55
even pressure across the repair site, which theoretically
24:59
promotes better healing conditions. But in knotless
25:01
anchors. Yes. We're also seeing an increasing
25:04
use of knotless anchors. These simplify the process
25:07
of tying sutures and securing the tendon to the
25:10
bone arthrostatically. This can potentially reduce
25:13
the risk of complications related to knots, like
25:16
irritation or suture breakage, and maybe speed
25:18
up the surgery slightly. Interesting. Now, subcoracoid
25:22
impingement is something many people haven't
25:24
heard of, but it can be a source of pain in the
25:26
front of the shoulder. How is it diagnosed and
25:29
treated arthroscopically? Right, subcoracoid
25:32
impingement happens when the space between the
25:35
coracoid process, that little hook -like bone
25:37
at the front of your shoulder blade and the humeral
25:39
head becomes too narrow. This often causes friction
25:42
on the subscapularis tendon which runs between
25:45
them. What causes it? It can be caused by repetitive
25:47
movements or certain anatomical variations where
25:50
the coracoid is maybe a bit larger or angled
25:52
differently. And diagnosis. Imaging, especially
25:55
CT scans that can precisely measure the distance
25:57
between the coracoid and humerus and calculate
26:00
various indices, can be very helpful in making
26:03
the diagnosis. And the arthroscopic fix. Arthroscopic
26:06
coracoplasty. This involves using a small high
26:09
-speed burr to carefully shave away a small amount
26:12
of bone from the tip or underside of the coracoid
26:14
process to widen that space and effectively relieve
26:18
the impingement. How do you find the coracoid
26:20
during surgery? It's crucial to identify it accurately.
26:23
The technique can vary slightly depending on
26:25
whether the subscapularis tendon underneath it
26:28
is intact or has retracted due to a tear. A helpful
26:31
landmark in cases where the subscapularis has
26:33
retracted is the comma sign, which includes the
26:36
coracohumeral ligament attaching near there.
26:38
OK. The subscapularis tendon itself, one of the
26:40
rotator cuff muscles, can also be torn. Is that
26:43
being recognized more now with arthroscopic surgery?
26:45
Absolutely. The subscapularis is a really important
26:48
rotator cuff muscle. It plays a crucial role
26:50
in shoulder movement and stability, particularly
26:53
internal rotation, turning your arm inwards.
26:55
And it used to be missed? Historically, yes.
26:58
Tears of the subscapularis, especially partial
27:01
tears on the droid side, were often missed with
27:03
traditional open surgical approaches. It even
27:06
got called the forgotten tendon. Wow. But the
27:09
ability to directly visualize the tendon with
27:11
shoulder arthroscopy has significantly increased
27:14
our recognition and diagnosis of these tears.
27:17
How is it repaired arthroscopically? Arthroscopic
27:20
repair typically involves establishing standard
27:22
entry portals around the shoulder, then performing
27:25
an anterior release to carefully free up the
27:28
tendon from any scar tissue before reattaching
27:30
it to its insertion point on the lesser tuberosity
27:33
using suture anchors. Any specific risks? Surgeons
27:37
have to be particularly careful during that anterior
27:39
release to avoid any injury to the nearby axillary
27:42
nerve, which runs quite close. Sadly, not all
27:45
rotator cuff tears are repairable. What are the
27:48
options when a tear is just too big or retracted,
27:51
deemed irreparable? That's a tough situation.
27:54
For massive rotator cuff tears that can't be
27:56
repaired directly back to the bone, there are
27:58
several surgical and non -surgical management
28:00
options. Like what? A subacromial balloon spacer
28:03
can be inserted arthroscopically. This is like
28:06
a temporary inflatable cushion placed between
28:09
the humeral head and the acromion. A cushion?
28:11
How does that help? It helps to keep the humeral
28:14
head centered in the socket, reducing pain and
28:16
improving function, especially in older patients
28:19
who still have a good range of motion and a strong
28:21
d - muscle, but it's not suitable for everyone
28:24
and it's not a permanent fix. Other options.
28:27
The long head of the biceps tendon can also be
28:29
repurposed. It can be used as a vascularized
28:32
graft in a technique called the biceps patch
28:35
for superior capsule reconstruction where the
28:38
top part of the shoulder joint capsule is reinforced
28:40
or rebuilt. Using your own tissue. Exactly. Another
28:43
well -established option is a latissimus dorsi
28:46
tendon transfer. Moving a back muscle. Right.
28:49
The latissimus dorsi muscle from your back is
28:51
rerouted to the shoulder to help with external
28:54
rotation and abduction, typically in younger,
28:56
more active patients with tears on the back and
28:59
top of the rotator cuff, provided their subscapularis
29:02
tendon is intact. And newer transfers. More recently,
29:05
transferring the lower trapezius tendon, often
29:08
using a donated Achilles tendon as a bridge graft,
29:11
has been explored as another alternative. This
29:14
might offer a better line of pull for certain
29:16
types of irreparable tears. Lots of ingenuity
29:19
there. Let's talk about calcific tendonitis,
29:22
where calcium deposits form in the rotator cuff
29:24
tendons. That can be incredibly painful, right?
29:27
Oh, extremely painful sometimes. The initial
29:29
treatment for calcific tendonitis is usually
29:32
non -surgical rest, pain medication, physical
29:35
therapy, sometimes injections like cortisone
29:37
or even procedures to try and break up the calcium
29:40
with needles. But if that fails? If these conservative
29:42
measures don't provide relief, arthroscopic removal
29:45
of the calcium deposits can be a very effective
29:48
option. goes in with the scope, finds a deposit,
29:51
and essentially scrapes or sucks it out. Are
29:53
there times when arthroscopy isn't suitable?
29:56
Yes, there are a few situations. For example,
29:58
if the calcium deposit is already in the process
30:00
of being naturally resorbed or absorbed by the
30:03
body, surgery might not be needed. Or if multiple
30:06
tendons are involved, or if the patient also
30:08
has significant arthritis, frozen shoulder, or
30:11
has had previous shoulder surgery, It might complicate
30:15
things. But generally effective. In appropriately
30:17
selected cases, yes. Arthroscopic removal of
30:20
a calcium has reported high success rates in
30:23
reducing pain and improving function. SLAP tears,
30:26
injuries to the superior labrum where the biceps
30:28
tendon attaches. seem common, especially in athletes
30:31
who do a lot of overhead activities. They are.
30:34
SLAP tears, standing for superior labrum interior
30:37
to posterior, involve a tear in the top part
30:39
of the labrum, often affecting the anchor point
30:42
of the long head of the biceps tendon. They're
30:44
frequently caused by repetitive overhead motions,
30:46
like throwing or swimming, or by sudden injuries,
30:49
like falls onto an outstretched arm or a direct
30:51
blow to the shoulder. Diagnosis tricky. Diagnosing
30:55
SLA peers can be challenging based on physical
30:57
examination alone, as the symptoms can overlap
31:00
with other shoulder problems, so imaging like
31:03
MRI or MRA is often helpful. and treatment. Arthroscopic
31:07
repair is the main treatment approach for significant
31:10
symptomatic SLAP tears, especially in younger
31:13
active individuals. SLAP lesions are classified
31:17
into several types based on the pattern of the
31:19
tear. Like types three and four. Right, those
31:21
are examples. Type three involves a bucket handle
31:23
tear of the superior labrum itself where the
31:26
torn piece hangs down. The biceps anchor is intact.
31:30
Type four also has a bucket handle tear, but
31:32
this one extends into the biceps tendon anchor.
31:35
Any specific tests during an exam? There are
31:37
several specific clinical tests surgeons use,
31:40
like the Resisted Supination External Rotation
31:42
Test and the Clunk Test, that can raise suspicion
31:45
for SLA pter, but none are perfectly accurate
31:48
on their own. Okay. Biceps tenodesis, a procedure
31:52
to surgically fix the long head of the biceps
31:54
tendon in a new location, is another common surgery.
31:57
When is that typically done? Biceps tenodesis
31:59
is indicated for various reasons. One common
32:02
reason is pain that seems to be coming primarily
32:05
from the biceps tendon itself, often called biceps
32:08
tendonitis. It's also often performed when there's
32:11
a significant tear in the biceps tendon or as
32:14
part of the treatment for certain types of SLAP
32:16
tears, particularly those where the biceps anchor
32:19
is unstable or the tear extends into the tendon
32:22
or even sometimes in older patients instead of
32:25
repairing the SLAP. It's also used if a previous
32:29
SLAP repair has failed. There aren't many absolute
32:33
contraindications, but surgeons might be more
32:36
cautious in patients with significant other medical
32:38
problems or perhaps in older individuals with
32:40
very low functional demands where the symptoms
32:42
aren't too bothersome. What's the preferred technique?
32:45
Techniques vary, but one preferred technique
32:47
mentioned in the source is an arthroscopic intraarticular
32:50
tenodesis. Here, the tendon is cut inside the
32:54
joint and then reattached to the humerus right
32:57
at the edge of the joint cartilage. Other ways.
33:00
Yes, there are also endoscopic -assisted techniques.
33:03
These involve making a small incision lower down,
33:06
often in the armpit area or just below the pec
33:09
muscle, and using an endoscope to help visualize
33:12
and secure the tendon to the bone in the subpectoral
33:15
space. Sometimes a special retractor called a
33:18
homon is used to help with exposure down there.
33:20
Got it. Frozen shoulder or adhesive capsulitis
33:23
can be incredibly painful and limit movement
33:25
significantly. When might surgery be recommended
33:28
for that? Patients with frozen shoulder experience
33:31
this really painful and progressive restriction
33:33
in both their active and passive range of motion
33:36
in the shoulder. It can be debilitating. How
33:39
is it usually treated first? Initially, treatment
33:41
is usually conservative. That means pain medication,
33:45
maybe anti -inflammatories, intensive physical
33:47
therapy focused on stretching, and sometimes
33:49
cortisone injections into the jade. But if that
33:52
doesn't work? If these non -surgical treatments
33:54
fail to restore adequate range of motion and
33:56
relieve pain after a reasonable period, often
33:59
several months, then arthroscopic pancapsular
34:01
release is often recommended. Pancapsular release.
34:04
Yes, this involves surgically releasing the tightened
34:07
and thickened joint capsule from the inside of
34:09
the joint using arthroscopic instruments, essentially
34:12
cutting the tight tissue all around the joint,
34:15
hence pancapsular. Does it fully restore motion?
34:18
It can significantly improve the range of motion,
34:21
often dramatically, but it's important for patients
34:24
to understand that regaining the absolute full
34:26
range of motion they had before the frozen shoulder,
34:29
making it perfectly comparable to their other
34:31
arm, can sometimes still be a challenge even
34:33
after successful surgery and rehab. As we get
34:36
older, osteoarthritis of the glenohumeral joint,
34:40
that wear and tear in the main shoulder joint,
34:42
becomes more common. How is it managed in the
34:45
earlier stages before replacement? Glenohumeral
34:48
osteoarthritis, or GHOA, is a degenerative condition.
34:51
And yes, unfortunately, it becomes more prevalent
34:53
with age. In the earlier stages, before the arthritis
34:57
is too severe and causing bone -on -bone pain,
34:59
surgeons might consider conservative surgical
35:02
management. This primarily involves arthroscopy
35:04
to go in and essentially clean up the joint.
35:07
What does cleaning up involve? It can include
35:09
removing loose fragments of cartilage, smoothing
35:12
out rough surfaces on the cartilage or bone spurs,
35:15
maybe releasing a tight capsule, and addressing
35:17
any associated soft tissue issues like biceps
35:20
tendon problems or small rotator cuff tears.
35:23
The goal? The goal is primarily to relieve pain
35:26
and improve function, maybe delaying the need
35:28
for a joint replacement. But it's important to
35:31
realize it's not a long term fix for the underlying
35:34
arthritis itself. It's more palliative. Flail
35:37
shoulder is a very debilitating condition where
35:39
the arm is essentially paralyzed. Can arthroscopy
35:43
play any role in helping these patients? Flail
35:45
shoulder often results from severe nerve injuries
35:47
like brachial plexus injuries. or muscle paralysis,
35:50
leading to a significant loss of the ability
35:53
to actively move the arm. It just hangs there.
35:56
So what can be done? In certain cases, where
35:58
the goal is mainly to stabilize the shoulder
36:00
joint to allow for better use of the hand, especially
36:02
for tasks at waist level, a procedure called
36:05
glenohumeral arthrodesis might be considered.
36:08
Arthrodesis. Fusing the joint. Exactly. Surgically
36:10
fusing the humeral head to the glenoid socket.
36:14
Arthroscopic assisted techniques can be used
36:16
here to help prepare the joint surfaces for fusion
36:18
removing any remaining cartilage and also to
36:21
help guide the placement of the wires or screws
36:24
that hold the bones together rigidly while they
36:26
heal into one solid piece. Sometimes loose fragments
36:30
of cartilage or bone can float around inside
36:32
the shoulder joint causing pain and mechanical
36:35
symptoms like catching or locking. How are those
36:37
addressed? Arthroscopic removal of these loose
36:40
bodies is an excellent and often the preferred
36:43
alternative to traditional open surgery. Why
36:45
is better? It allows the surgeon to thoroughly
36:47
visualize the entire inside of the joint, find
36:50
all the fragments even ones hiding in corners,
36:53
and precisely remove them with minimal damage
36:55
to the surrounding healthy tissues. Smaller incisions,
36:58
quicker recovery usually. Sadly, infections can
37:01
sometimes occur in the shoulder joint. How are
37:03
those managed particularly using arthroscopic?
37:05
techniques. Septic arthritis of the shoulder
37:07
and infection within the joint is relatively
37:09
rare but has seen perhaps a slight increase in
37:11
incidence following injections around the shoulder.
37:14
And the treatment. The preferred treatment approach
37:16
is usually plomped arthroscopic debridement and
37:19
irrigation. Washing it out. Essentially, yes.
37:22
It allows for a thorough cleaning and flushing
37:24
out of the infected joint fluid and any pus or
37:27
debris. And at the same time, the surgeon can
37:30
visualize and potentially address any other associated
37:32
problems like rotator cuff tears that might be
37:36
present or contributing. Even bone cysts in the
37:39
proximal humerus, the upper part of the arm bone,
37:41
can be treated using minimally invasive techniques
37:44
now. How does that work? Yes, endoscopic cure
37:46
-tage is a technique used to treat certain benign
37:49
bone cysts in the proximal humerus. Endoscopic.
37:53
like arthroscopic, but inside the bone. Kind
37:55
of. It involves making small incisions to create
37:58
portals directly into the bone cyst, then using
38:00
specialized instruments under endoscopic camera
38:02
guidance to scrape out the lining of the cyst.
38:05
The goal is to be less invasive than traditional
38:08
open surgery, where you might have to make a
38:09
larger window in the bone, potentially leading
38:12
to faster healing and maybe a higher success
38:14
rate in resolving the cyst. A vascular necrosis
38:17
of the humeral head, where the blood supply to
38:19
the top of the arm bone is disrupted, is a serious
38:22
condition. Can arthroscopy help there too? Arthroscopic
38:26
assisted cord decompression and fibular strut
38:28
grafting is a technique used to try and treat
38:31
humeral head avascular necrosis, particularly
38:34
in its earlier stages, before the head collapses.
38:38
Cord decompression. That involves drilling small
38:40
channels into the affected area of the humeral
38:43
head to relieve pressure and hopefully stimulate
38:46
improved blood flow or healing. And the fibular
38:49
graft. This is often supplemented by inserting
38:52
small structural bone grafts, often taken from
38:55
the fibula bone in the lower leg, into those
38:57
channels. These grafts provide mechanical support
39:00
and aim to prevent the humeral head from collapsing.
39:02
The arthroscopic assistance allows for more precise
39:05
placement of these channels and grafts with smaller
39:07
incisions compared to open methods. What about
39:10
patients who have already had a shoulder replacement
39:12
and are now experiencing new problems? Can arthroscopy
39:16
still be a useful tool for them? Yes, absolutely.
39:19
Arthroscopy can definitely be valuable even after
39:21
a patient has undergone shoulder arthroplasty
39:24
or joint replacement What kind of problems it
39:27
can be used to diagnose and sometimes treat various
39:29
complications that can arise after replacement
39:32
things like infection around the prosthetic joint
39:35
instability where the replacement feels loose
39:37
or dislocates Impingement issues where tissues
39:40
are getting pinched new rotator cuff tears that
39:44
can still occur and even loosening of the components
39:46
of the artificial joint Is it harder to do? Performing
39:50
arthroscopy in a shoulder that has already had
39:52
a replacement is definitely technically more
39:54
challenging. The anatomy is altered, you have
39:57
the implants in the way, and scar tissue can
39:59
make visualization difficult. So it really requires
40:02
a surgeon with significant experience in this
40:04
specific area. Often a posterior portal, an entry
40:08
point from the back of the shoulder, is preferred
40:10
in these cases to try and avoid the implants
40:12
at the front. Okay. Dislocations of the chromioclavicular
40:16
joint, the AC joint where your collarbone separates
40:19
from your shoulder blade, are common injuries,
40:21
especially in sports. How are those treated arthroscopically?
40:25
Arthroscopic assisted reduction and fixation
40:27
techniques are increasingly used to treat the
40:29
more severe ACJ dislocations, the ones where
40:33
the clavicle is significantly elevated. How is
40:35
it fixed? These techniques often involve using
40:39
strong sutures or tapes, like the commercially
40:41
available tightrope and fiber tape systems, passed
40:44
around the coracoid process and through or around
40:48
the clavicle to pull the clavicle back down into
40:50
its correct position relative to the acromion
40:53
and then secure it there while the ligaments
40:55
heal. does it always stay reduced? While these
40:58
methods aim to restore the normal alignment,
41:01
some degree of loss of the initial reduction
41:03
can sometimes occur over time as things settle
41:05
or stretch slightly. Interestingly, there's some
41:08
evidence emerging to suggest that slightly over
41:10
-reducing the joint during the initial surgery
41:12
might actually be protective against the joint
41:15
subluxing or dislocating again later. The corcoclavicular
41:18
ligaments are crucial for the stability of that
41:20
AC joint. Can those be reconstructed arthroscopically
41:24
if they're completely torn and may be retracted?
41:26
Yes, there are arthroscopic techniques specifically
41:29
for reconstructing the coracoclavicular ligaments,
41:32
which are vital for holding the AC joint stable.
41:35
Using what? These procedures typically involve
41:37
using donated tissue and allograft tendon to
41:40
create new ligaments. The graft is passed around
41:43
the coracoid and through tunnels drilled in the
41:45
clavicle and then secured with strong fixation
41:48
devices, all done through small arthroscopic
41:50
incisions and portals. When osteoarthritis in
41:53
the AC joint itself becomes painful, sometimes
41:56
a small piece of the end of the clavicle is removed
41:59
at distal clavicle excision. How is that done
42:02
arthroscopically? Arthrostopic acromioclavicular
42:05
joint resection, sometimes called a Mumford procedure
42:08
arthroscopically, is a common procedure for persistent
42:11
pain and sometimes instability related to ACJ,
42:13
osteoarthritis, or impingement. What's involved?
42:16
Using a small bur through arthroscopic portals,
42:18
the surgeon removes a small portion, maybe 5
42:20
to 10 millimeters, of the very end of the distal
42:23
clavicle. Key considerations. A key consideration
42:26
for the surgeon is how much bone to remove. Taking
42:29
too little might not relieve the symptoms, but
42:32
taking too much could potentially destabilize
42:34
the joint, especially if the coracoclavicular
42:37
ligaments aren't perfectly intact. While the
42:40
arthroscopic approach offers advantages over
42:43
open surgery, like smaller incisions, surgeons
42:46
still need to be careful with portal placement
42:48
to avoid potential complications, like nerve
42:50
injury. Also, some studies have suggested that
42:53
in patients who are also undergoing rotator cuff
42:55
repair and happen to have ACG arthritis, performing
42:58
this distal clavicle excision at the same time
43:01
might not actually provide any additional benefit
43:03
in terms of outcome. Sometimes it can cause pain,
43:11
right? How is that addressed? Exactly. While
43:13
often asymptomatic, a mobile mesoacromial fragment,
43:16
essentially an unfused growth center of the acromeon,
43:19
can sometimes be a source of pain, clicking,
43:22
and impingement -like symptoms in the shoulder.
43:24
How do you confirm it's the cause? Careful diagnosis
43:27
is important. This often involves pinpointing
43:30
tenderness directly over the fragment and sometimes
43:33
injecting a local anesthetic like lidocaine around
43:35
the suspected non -union site to see if that
43:38
temporarily relieves the pain and the treatment.
43:41
Arthroscopic excision, where the small separate
43:43
piece of bone is surgically removed using arthroscopic
43:46
instruments, is a described alternative to open
43:49
surgery, either excision or trying to fix it
43:51
with screws. This minimally invasive approach
43:54
potentially leads to less post -operative pain
43:57
and less weakness in the deltoid muscle which
44:00
attaches there. snapping scapula syndrome, where
44:03
you feel or hear a grinding or popping sensation
44:06
as your shoulder blade moves over the ribs that
44:08
can also be treated arthroscopically. How does
44:10
that work? Yes, for snapping scapula syndrome,
44:13
which is often caused by inflammation of the
44:15
bursa between the scapula and chest wall, or
44:17
sometimes a bony prominence on the scapula, both
44:20
open and arthroscopic treatment options exist.
44:23
Arthroscopic approaches typically involve either
44:26
removing the inflamed bursa a brosectomy, or
44:29
sometimes partially removing a small corner of
44:31
the scapula, if that's rubbing, a partial scapelectomy.
44:34
Advantages of arthroscopy. Potential advantages
44:36
over open surgery include quicker recovery and
44:39
less disruption to the surrounding muscles. Specific
44:42
portal placements, like the medial and bell portals,
44:45
are used to access that space between the scapula
44:47
and the rib cage, the scapula thoracic space.
44:50
Any dangers back there? Yes, surgeons need to
44:52
be very careful during scapula thoracic arthroscopy
44:56
to avoid injuring nearby nerves and blood vessels,
44:59
like the long thoracic nerve or the dorsal scapular
45:02
nerve and artery. What about other conditions
45:04
affecting that scapula thoracic area, like bursitis
45:06
specifically, or bony growths called osteochondromas?
45:10
Scapula thoracic bursitis, just the inflammation
45:12
of the bursa without necessarily a bony cause,
45:15
and osteochondromas, which are benign bony growths
45:18
that can occur on the underside of the scapula
45:19
or on the ribs, can also be addressed arthroscopically
45:22
or endoscopically. Imaging, including CT scans
45:25
and MRI, is important for diagnosis, especially
45:28
to see the exact location and size of an osteochondroma.
45:32
Endoscopic resection of osteochondromas in the
45:35
scapula thoracic space has been shown to be effective,
45:38
again with potentially smaller incisions and
45:40
a faster recovery compared to open surgery. is
45:50
a less common condition. Can it be treated arthroscopically?
45:54
Hyperactivation or tightness of the pectoralis
45:56
minor muscle has been proposed as a rare cause
45:59
of shoulder pain, nerve symptoms down the arm,
46:02
or even thoracic outlet -like symptoms. And the
46:05
fix. Arthroscopic or endoscopic release of the
46:08
pectoralis minor tendon from its attachment on
46:10
the coracoid process can be performed. This is
46:12
sometimes done in conjunction with other procedures
46:15
like the Letarjet procedure where it needs to
46:17
be released anyway, or specifically for diagnosed
46:19
pectoralis minor syndrome. It has shown promising
46:22
results in terms of of relieving pain and improving
46:25
shoulder function in the reported cases, although
46:28
it's still relatively uncommon. The surgery is
46:30
typically done with the patient in the beach
46:32
chair position. Moving medially to the sternoclavicular
46:36
joint where your collarbone meets your breastbone.
46:40
What role does arthroscopy play in managing disorders
46:43
there? It seems like a tight space. It is a tight
46:45
space. Sternoclavicular or SC joint arthroscopy
46:49
can be used for diagnosing and sometimes treating
46:51
conditions like persistent pain, inflammation,
46:54
or instability in that joint that haven't responded
46:56
to other treatments. Contraindications. Yes,
46:59
there are certain contraindications that need
47:00
to be carefully considered before proceeding,
47:03
like active infection or severe joint destruction.
47:06
Specific surgical techniques and portal placements
47:08
are used to access the SC joint and it requires
47:11
specialized small instruments. What about instability?
47:14
For SC joint instability, a specific arthroscopic
47:17
technique has been described that aims to preserve
47:19
the important fibrocartilaginous disc within
47:21
the joint while using tending grafts passed through
47:24
bone tunnels to stabilize it. It can be related.
47:39
Surgical treatment for thoracic outlet syndrome,
47:41
or TOS, might be considered if non -operative
47:44
measures fail to provide relief, particularly
47:47
in cases where there are clear neurological symptoms
47:49
or vascular compromise. What's released? Traditionally,
47:52
this involved open surgery, often removing the
47:55
first rib. However, endoscopic techniques have
47:58
been developed as less invasive alternatives
48:00
for releasing structures that can cause compression.
48:03
This might include releasing the scale muscles
48:05
in the neck, scalenectomy or scalenotomy, or
48:08
releasing the pectoralis minor tendon in the
48:11
chest if those are identified as the compressing
48:13
structures. Nerve entrapment around the shoulder
48:15
itself, like when the suprascapular nerve gets
48:17
compressed, can cause significant pain and weakness,
48:21
especially in the rotator cuff muscles it supplies.
48:24
How is that treated endoscopically? The suprascapular
48:27
nerve can get entrapped at two main locations
48:29
as it travels around the scapula. The spinoglenoid
48:32
notch, often by assist from the joint, and the
48:35
superscapular notch under a ligament. Diagnosis.
48:39
Electrodiagnostic tests like nerve conduction
48:41
studies and EMG are crucial to help confirm the
48:44
diagnosis and pinpoint the location of the entrapment.
48:47
And the endoscopic treatment. Endoscopic decompression
48:50
techniques have been developed to release the
48:52
pressure on the nerve at these specific locations.
48:55
This often involves carefully cutting the transverse
48:57
scapular ligament at the suprascapular notch
48:59
or decompressing a cyst at the spinoglenoid notch,
49:03
all done through small portals using endoscopic
49:06
visualization. Medial scapular winging, where
49:09
your shoulder blade sticks out prominently at
49:11
the back, especially when pushing, is often due
49:14
to a problem with the long thoracic nerve, right?
49:16
Can that be addressed endoscopically? Yes. The
49:19
most common etiology for medial scapular winging
49:21
is indeed palsy or injury to the long thoracic
49:24
nerve, which supplies the serratus anterior muscle.
49:27
And the endoscopic approach. Endoscopic decompression
49:30
of the long thoracic nerve along its course looking
49:33
for potential points of compression has been
49:35
explored and has shown potentially good results
49:38
in resolving medial scapular winging in some
49:40
cases. This might be compared to more invasive
49:43
muscle transfer procedures like pectoralis major
49:46
transfer, which is sometimes needed if the nerve
49:48
damage is permanent. The endoscopic approach
49:51
aims to release any compression on the nerve,
49:53
allowing the serratus anterior muscle to hopefully
49:56
recover and function properly again. Finally,
49:58
let's touch on fractures around the shoulder.
50:01
Can arthroscopy assist in their management? It
50:03
seems counterintuitive for broken bones. You
50:05
might think so, but absolutely. Arthroscopy can
50:08
play a valuable role in managing various shoulder
50:10
fractures, often in an assisted capacity. How
50:13
so? For which fractures? Well, for distal clavicular
50:16
fractures, specifically the unstable near type
50:19
2 fractures where ligaments are torn, endoscopic
50:23
or arthroscopic assisted fixation offers a minimally
50:26
invasive approach. It allows for visualizing
50:29
the fracture reduction and placing fixation devices
50:31
like plates or suture buttons with smaller incisions,
50:35
potentially leading to lower complication rates
50:37
compared to open surgery. What about the humerus
50:39
itself? Arthroscopic assisted techniques are
50:42
also commonly used for fractures of the greater
50:44
tuberosity and sometimes the lesser tuberosity.
50:47
Those are the bumps where the rotator cuff tendons
50:49
attach. Arthroscopy helps with accurately reducing
50:52
the fracture fragments, clearing out any blood
50:54
clot, and then fixing them securely in place
50:56
using screws or strong suture anchors. And the
50:59
main ball and socket part. Proximal humeral fractures.
51:02
For proximal humeral fractures involving the
51:05
top of the upper arm bone near the joint, arthroscopic
51:08
assisted reduction and internal fixation, or
51:11
ARF, is an option in selected cases, usually
51:14
simpler two -part or some three -part fractures.
51:17
However, very complex fractures with multiple
51:19
fragments or poor bone quality are generally
51:22
still better treated with an open approach or
51:24
even replacement. Hardware removal. Arthroscopy
51:27
can also be helpful later on to assist in the
51:29
removal of hardware like screws or plates after
51:32
a fracture has healed, especially if the hardware
51:34
is causing impingement or irritation. And glenoid
51:37
fractures, fractures of the socket. Even some
51:40
fractures of the glenoid socket, particularly
51:41
those involving the front rim. bony bankart lesions
51:44
as we discussed earlier, can be managed arthroscopically
51:47
using suture fixation techniques or sometimes
51:50
a bony bankart bridge technique to reconstruct
51:52
the rim. Wow, that really was a deep dive. It's
51:56
incredible really to see the sheer number of
51:58
conditions affecting the shoulder from instability
52:00
and cuff tears to nerve entrapments and even
52:04
fractures that can now be diagnosed and treated
52:06
using these advanced minimally invasive arthroscopic
52:10
and endoscopic techniques. It is quite remarkable.
52:12
And as the author of our source material so optimistically
52:15
pointed out, this field is constantly pushing
52:18
the boundaries of what's possible. The innovation
52:21
is just continuous. We can fully expect even
52:24
more refined techniques, better implants, and
52:27
perhaps even more innovative biological solutions
52:29
to emerge in the years ahead. It's really an
52:31
evolving field. It truly makes you appreciate
52:34
the intricate understanding of anatomy required
52:37
and the incredible ingenuity that goes into developing
52:40
these surgical procedures. and the instruments
52:42
need to perform them through tiny holes. Absolutely.
52:45
Precision is key. So as we wrap things up, here's
52:47
something for you, the listener, to ponder. Given
52:50
this rapid pace of advancement in shoulder arthroscopy
52:53
and endoscopy that we've discussed, what completely
52:56
new frontiers might be explored in the next decade?
52:59
That's a great question. What conditions that
53:02
are currently considered irreparable, maybe like
53:04
severe arthritis in very young people, or massive
53:07
chronic cuff tears with muscle atrophy, might
53:10
become a treatable through these minimally invasive
53:13
approaches, perhaps combined with regenerative
53:15
medicine. The potential is certainly there, maybe
53:17
complex reconstructions we can't even imagine
53:20
yet. It's certainly an exciting future to consider
53:22
for shoulder treatment. Thanks for joining us
53:24
on The Deep Dive.