Shoulder Arthroscopy 2nd Edition PDF

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SHOULDER ARTHROSCOPY ISBN: 978-1-4160-4649-3
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Notice
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment, and drug therapy may
become necessary or appropriate. Readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of the practitioner, relying
on his or her own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor
the Author assumes any liability for any injury and/or damage to persons or property
arising out of or related to any use of the material contained in this book.
The Publisher
Library of Congress Cataloging-in-Publication Data
Gartsman, Gary M.
Shoulder arthroscopy / Gary M. Gartsman. 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4160-4649-3
1. Shoulder jointEndoscopic surgery. I. Title.
[DNLM: 1. Shoulder Jointsurgery. 2. Arthroscopymethods. 3. Rotator
Cuffsurgery. WE 810 G244s 2009]
RD557.5.G376 2009
617.50 72059dc22
2008020052
Acquisitions Editor: Daniel Pepper

Developmental Editor: John Ingram
Publishing Services Manager: Tina Rebane
Senior Project Manager: Jodi Kaye
Design Direction: Lou Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
I’m not much of a sailor, but when our friends Bill and Christy get
me on the Lone Star, my wife Carol enjoys the sea and I spend a
lot of my time looking at the boats and wondering how and why
they were named. The best I have ever seen was a beautiful
sailboat, the Never Again 2.
After Harvard Ellman and I wrote Arthroscopic Shoulder Surgery

and Related Procedures, I told Carol I would never write another
textbook. Ten years later I wrote Shoulder Arthroscopy and
promised her, never again.
Here we are at Shoulder Arthroscopy 2nd edition, the Never Again

2 of textbooks. Carol, you are the greatest. Thank you for your
patience and love, again.
G.M.
PREFACE
Seventeen years have passed since the publication of My focus in this book is primarily on operative tech-
Arthroscopic Shoulder Surgery and Related Procedures. nique, and my goal is to present an approach to
Harvard Ellman and I co-authored that text in an arthroscopic shoulder operations in enough detail so
attempt to bridge the gap between traditional open that the reader can manage both the routine and com-
operations and newer arthroscopic approaches. Many plex problems he or she encounters. This required that
today did not have the opportunity to know Dr. I exclude some important nonsurgical material.
Ellman; he was a wonderful man and a true pioneer. There are a number of texts currently available that
He was the perfect person to introduce this fledgling devote hundreds of pages to patient history, diagnosis,
field of shoulder arthroscopy to the world. The Ralph pathogenesis, physical examination, and imaging stud-
Bunche quote ‘‘If you want to get across an idea, wrap ies. Their bibliographies are complete and extensive.
it up in a person’’ applied to Harvard. So what kind of textbook is this? This is a book for
The first edition of Shoulder Arthroscopy was pub- orthopedic surgeons who want to perform reconstruc-
lished 6 years ago. The pace of progress and the rate tive arthroscopic shoulder surgery. In order to do this,
at which we have accumulated knowledge has accel- the surgeon must understand why certain procedures
erated in shoulder arthroscopy, as it has in practically are performed and have them described in adequate
all other forms of human endeavor. It is for this reason detail. I have tried to take the reader through the
that we have decided to publish the second edition of operations in stepwise fashion; however, for complex
Shoulder Arthroscopy. Thermal capsulorrhaphy did not procedures text is not sufficient. State-of-the-art com-
survive prolonged follow-up. Double-row rotator cuff munication in arthroscopy involves more than
repair is more common. Biceps lesions are treated thoughts and words on a printed page. The accompa-
more aggressively. The Latarjet procedure for shoulder nying DVD contains videos that illustrate the con-
instability has entered the United States, and the cepts and techniques that I describe in the text.
Bristow is making a comeback! Diagnostic ultrasound Since 1982 I have been privileged to instruct thou-
is more mainstream. Suprascapular nerve lesions can sands of practicing orthopedic surgeons, residents,
be treated arthroscopically. Many readers requested and fellows in shoulder arthroscopy. In this textbook
more information about rehabilitation, and I think I have adopted a tone that I hope captures the many
Mike De la Flor’s video animations are superb. Use conversations we have had. Imagine that you and
them to instruct your patients. I are in the operating room performing shoulder
The purpose of this textbook is to present the cur- arthroscopy. You can ask all the questions you wish
rent state of arthroscopic shoulder surgery as seen by and I have all the time in the world to answer. Let’s
one author. There are, of course, many different meth- begin!
ods to treat shoulder lesions with arthroscopy, but I
have chosen to present my own views and trust that GARY M. GARTSMAN, M.D.
the reader will also seek out the opinions of others. Houston, Texas
vii
CHAPTER
1
Making the Transition
Surgeons who are considering making the transition who perform only open operations may feel that
from open shoulder surgery to arthroscopic shoulder they are behind the times. Orthopedic surgeons are
surgery need to develop a plan or framework. There also conditioned to consider new approaches to
are two basic types of skills: technical and intellectual. patient care, and although many surgeons obtain
At present, orthopedic surgeons learn the basic skills good results with open repair, they are ready and will-
of shoulder arthroscopy during their residency or fel- ing to try something new.
lowship, but more advanced reconstructive surgical Owing to the dramatic increase in available knowl-
techniques require sufficient time with an experienced edge, many patients are aware of arthroscopic tech-
mentor. This experience varies widely among training niques and inquire whether the surgeon performs
programs. a certain procedure arthroscopically or with an
open technique. Patients have the perception that
arthroscopic procedures result in less pain, smaller
ARTHROSCOPY VERSUS OPEN REPAIR scars, and more rapid rehabilitation, although strong
arguments can be made to refute all these assertions.
The fundamental decision is whether to perform Nonetheless, patients are increasingly insistent on
shoulder arthroscopy or continue to use open finding surgeons who will perform their operations
repair techniques. Most surgeons are comfortable arthroscopically, viewing the arthroscope as a magical
with open procedures. If they are satisfied with tool capable of miraculous cures. Some surgeons
their patient outcomes, they may see no reason to see the arthroscope as a wonderful addition to the
change. However, surgeons have various reasons for surgical tool box, whereas others, based on their
deciding to acquire or advance their arthroscopic experience, see only its negatives. It is the surgeon’s
skills, for example, the belief that arthroscopic tech- skill that achieves the proper balance (Figs. 1-1
niques produce better results, peer pressure, a desire through 1-4).
to learn new concepts and techniques, and patient Before embarking on a mission to acquire arthro-
demand. scopic skills, each orthopedic surgeon must evaluate
Various publications and presentations have his or her practice patterns and answer some ques-
documented equal or superior results with arthro- tions: Do you perform a sufficient number of shoul-
scopic techniques compared with open techniques der operations to justify learning a new skill? All
for the performance of subacromial decompression orthopedic surgeons should be comfortable with
for stage 2 impingement, acromioclavicular joint diagnostic glenohumeral joint arthroscopy, but
resection for arthritis, and rotator cuff repair, as well not everyone needs to learn more advanced tech-
as for the treatment of glenohumeral instability. niques. If you perform fewer than 20 to 30 shoulder
Orthopedic surgeons are subject to peer pressure. procedures a year and are comfortable with the
When they talk among themselves about various open technique, I would not advise you to invest
shoulder conditions and their treatment, surgeons the time and effort required to perform these few
3
4 Section One The Basics
Figure 1-4 Balance.
Figure 1-1 Magic instrument?
procedures arthroscopically. Do you have the emo-

tional stability to handle the inevitable frustration
when learning to perform procedures arthroscopi-
cally? Remember, you will be making a transition
from the familiar and comfortable to the new and
awkward. Do you have the necessary technical skills?
If you cannot perform routine arthroscopic subacro-
mial decompression in 30 minutes or less, you do
not have the skills required to perform more compli-
cated reconstructive arthroscopic procedures. Improve
your basic skills and speed before taking on a bigger
challenge. How do you acquire the necessary skills?
Each surgeon must develop a learning plan that
focuses on two central issues: technical skills and
intellectual skills. In reality, it is hard to separate the
two. Learning how to pass a suture through the ante-
rior inferior glenohumeral ligament is of little use if
Figure 1-2 Wand of angels? you do not know when this step is necessary.
TECHNICAL SKILLS
Most orthopedic surgeons learn the basics of shoulder

arthroscopy during residency or fellowship,
but for those who did not, other resources are avail-
able. The Orthopaedic Learning Center, developed
and administered by the American Academy of Ortho-
paedic Surgeons and the Arthroscopy Association of
North America, hosts numerous courses that cover
both basic and advanced shoulder arthroscopy. Didac-
tic lectures, panel discussions, and video demonstra-
tions are presented in state-of-the-art lecture halls. The
center, located in Rosemont, Illinois, also houses a wet
cadaveric laboratory with 48 workstations so that par-
ticipants can practice with cadaver specimens and
Figure 1-3 Tool of the devil? arthroscopic instruments.
Chapter 1 Making the Transition 5
The Orthopaedic Learning Center is a good resource

for learning basic shoulder arthroscopy, but many
surgeons find it inadequate for more complex proce-
dures such as rotator cuff repair and glenohumeral
reconstruction. Generally, the 2- to 3-day courses
cover a broad range of topics. A typical course might
include lectures and cadaver instruction on arthro-
scopic subacromial decompression, distal clavicle exci-
sion, open and arthroscopic rotator cuff repair, and
open and arthroscopic glenohumeral reconstruction.
There is insufficient time for participants to become
comfortable with all procedures. Because of the
breadth of topics, it is unusual for every instructor to
Figure 1-6 Laser line on the inserter to align the eyelet.
have expertise in all the areas covered. Participants
also demonstrate great disparity in arthroscopic skill;
for instance, one surgeon interested in learning
arthroscopic rotator cuff repair may be paired with a instruments and video arthroscopy are gradually
beginner who wants to focus on glenohumeral joint introduced as participants perform repairs on anatomi-
inspection. cally detailed plastic shoulder models. This allows every-
Other programs are available. The Arthroscopy one ample opportunity to master the requisite
Association of North America offers more individua- intellectual and technical skills (Fig. 1-5).
lized instruction through its Masters Series, and You can also advance your arthroscopic skills by
several surgeons I know have found the program focusing on the details of your open repairs. First,
extremely worthwhile. James Esch has been active take the opportunity to view arthroscopically all
in shoulder arthroscopy education for years and rotator cuff tears and unstable glenohumeral joints
annually organizes a superior course that combines before performing the open repair or reconstruction.
lectures and cadaver work. Stephen Snyder has a won-
derful facility in California that combines state-of-the
art video learning with an opportunity to watch a
superb surgeon at work. My own approach to surgeon
education has been to offer a small course limited to
12 registrants that focuses solely on one topic—either
arthroscopic rotator cuff repair or arthroscopic gleno-
humeral joint instability. Enrollment is restricted
to surgeons with advanced arthroscopic skills. Over
a 2-day period, techniques using arthroscopic
Figure 1-5 Students in the Joe W. King invitational rotator Figure 1-7 Having the eyelet parallel to the edge of the
cuff repair course. tendon allows either suture to slide freely.
Figure 1-10 Rotator cuff repair in two dimensions.
Figure 1-8 Having the eyelet parallel to the edge of the

tendon allows either suture to slide freely.
Learn what the typical glenohumeral joint looks like

in a 63-year-old with a full-thickness rotator cuff tear.
From the glenohumeral joint, try to identify the tear.
Move the arthroscope into the subacromial space,
identify the rotator cuff tear, and estimate its size
and shape. Ask the circulating nurse to write down Figure 1-11 Rotator cuff repair in two dimensions.
these measurements. Next, open the shoulder and
record the size and shape of the tear. With practice,
you will find that you can accurately assess the size
Figure 1-9 Knot tying board. Figure 1-12 Glenohumeral joint reconstruction model.
Figure 1-16 Load the suture.
Figure 1-13 Shoulder arthroscopy model.
Figure 1-17 Suture is held in the instrument’s jaw.
Figure 1-14 Elite suture punch needle.
Figure 1-15 Depress the handle bottom to load it. Figure 1-18 Depress the handle top to advance the needle.
Figure 1-19 Withdraw the needle, leaving the suture loop.
Figure 1-22 Two free ends are inserted into the back hole
of the Caspari suture passer.
and shape of tears arthroscopically. Before performing

an open Bankart procedure, use the arthroscope to
identify the Bankart lesion and estimate its size,
then compare that to your impression during the
open repair.
As your experience increases, make your observa-
tions more precise. When you are viewing a rotator
cuff tear from the subacromial space, insert a probe
and use it to measure the length and width of
Figure 1-20 Remove the instrument, leaving the suture the tear. Insert a grasper and try to determine the
loop. tear’s reparability. Grasp different portions of the
tear edge and advance them to different locations
near the greater tuberosity. This will help you learn
to appreciate tear geometry and repair geometry
as viewed through the arthroscope. Make note of the
Figure 1-21 Two free ends of 2-0 nylon suture folded

in half. Figure 1-23 Caspari suture passer in the operating room.
Figure 1-26 Loaded Caspari suture passer and tying board.
Figure 1-24 Proper thumb position.
tendon quality. After you perform the open repair

and close the skin, reinsert the arthroscope into the
subacromial space to see how a completed repair
should appear.
As you can appreciate from the preceding
description, I believe that the transition from open
to arthroscopic repair should proceed slowly as the
Figure 1-27 Two free ends of nylon suture placed through

the felt.
Figure 1-28 Remove the Caspari suture passer, and the

Figure 1-25 Improper thumb position. nylon suture remains in the felt.
Figure 1-32 Use the thumb to advance the suture in the

AccuPass device.
Figure 1-29 Loop braided through the looped end of a
nylon suture.
Figure 1-33 One option is to load the suture loop first in the
Figure 1-30 Pull on the free ends of the nylon suture, and AccuPass.
pull the braided suture through the felt.
Figure 1-34 Another option is to pass the braided suture

Figure 1-31 Braided suture passed through the felt. directly through soft tissue with the AccuPass.
Figure 1-35 Correct hand positions.
Figure 1-38 Use the thumb to rotate the arthroscope.
surgeon makes incremental improvements in his or

her technical skills and adds to his or her knowledge
base. It is extremely difficult for any surgeon to learn
about arthroscopic rotator cuff repair one day and
perform the procedure from beginning to end the
next day. I spent 1 year making the transition using
the approach described later.
While you hone your basic arthroscopic skills and
add to your knowledge, learn the principles of and
Figure 1-36 Incorrect hand positions. technical steps required for an arthroscopic repair.
For instance, an arthroscopic rotator cuff repair
consists of the following elements: glenohumeral joint
arthroscopy, subacromial bursectomy, coracoacromial
Figure 1-37 Use the index finger to rotate the arthroscope. Figure 1-39 Do not use two hands to rotate the arthroscope.
ligament release, and acromioplasty. You must be expert through it. The indirect method requires that you use
in these aspects of the procedure. Once you are able some sort of monofilament suture passed through the
to evaluate tear size, geometry, and reparability, you tendon. This monofilament suture is then used to pull
must learn to insert suture anchors, pass sutures through the braided suture through the soft tissue. You can
the tendon, manage sutures, and tie secure knots. attach a piece of felt or foam rubber to a wooden
Fortunately, you can master these techniques before board and practice using instruments to pass sutures.
you enter the operating room.
Suture Management
Suture Anchors
Suture management is critical to arthroscopic shoul-
Ask your local manufacturer’s representative for a der reconstruction. Whether the surgeon is in the sub-
spare suture anchor and familiarize yourself with its acromial space for a rotator cuff repair or in the
characteristics. Are the sutures preloaded, or must glenohumeral joint for a glenohumeral reconstruc-
they be loaded in the operating room? Are the sutures tion, the fundamental problem is too many sutures
desirable for your particular rotator cuff repair? If not, in too little space. There are two basic solutions: tie
can you switch them? Does the suture anchor accept the sutures as you insert them, or move the sutures out
multiple sutures or just one? If the anchor has two of the way through cannulas. Experiment with both
sutures, how are they arranged? Which suture do techniques to determine which one is better for you.
you have to tie first? Practice inserting the anchor Even if you tie the sutures after you insert each one,
into a board, and learn how much force is required. suture management is important. To avoid nicking
Learn how to orient the eyelet so that the sutures slide the suture (risking suture breakage) when inserting
easily. You should practice reloading the anchor in sharp instruments through cannulas, the basic princi-
case you pull the sutures out (Figs. 1-6 through 1-8). ple is to keep the working cannula free from sutures.
Percutaneous anchor insertion is an option in the sub-
acromial space but not in the glenohumeral joint,
Sutures through Tendon
owing to the mass of soft tissue the anchor must
There are two basic methods of passing a braided penetrate.
suture through a tendon or ligament, and you should To practice suture management, write out in detail
be familiar with both (see Figs. 1-9 through 1-29). The each step of the operation and decide when you must
direct method involves using an instrument to pierce the move sutures. For example, the steps for two types
ligament or tendon and pulling or pushing the suture of rotator cuff repair follow:
Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)
Insert the anchor in the anterior position through the lateral cannula.
Use a crochet hook to pull the green and white sutures out through the anterior cannula.
Use a crochet hook to pull one green suture strand from the anterior to the lateral cannula.
Load the green suture on the Elite Pass instrument.
Insert the Elite Pass through the lateral cannula.
Grasp the tendon.
Advance the needle and push the green Ethibond suture through the tendon.
Withdraw the needle.
Insert a grasper through the anterior cannula and grasp the green suture exiting the tendon.
Remove the Elite Pass instrument from the lateral cannula.
Use a grasper to pull the suture out through the anterior cannula.
Apply a hemostat to the two green sutures.
Use a crochet hook to pull one white suture strand from the anterior to the lateral cannula.
Load the white suture on the Elite Pass.
Insert the Elite Pass through the lateral cannula.
Grasp the tendon.
Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)—cont’d
Advance the needle and push the white Ethibond suture through the tendon.
Withdraw the needle.
Insert a grasper through the anterior cannula and grasp the white suture strand exiting the tendon.
Remove the Elite Pass instrument from the lateral cannula.
Use a grasper to pull the suture out through the anterior cannula.
Remove the hemostat from the white sutures.
Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula.
Loop the grasper to untangle the sutures.
Tie the white sutures.
Remove the hemostat from the green sutures.
Move the green sutures from the anterior cannula to the lateral cannula.
Tie the green sutures.
Arthroscopic Rotator Cuff Repair—Caspari Technique (1 Anchor, 2 Sutures)
Insert the anchor in the anterior position through the lateral cannula.
Use a crochet hook to pull the green and white sutures out through the anterior cannula.
Insert a Caspari suture punch with 2-0 looped nylon through the lateral cannula.
Grasp the tendon.
Check to ensure that the needle hole is clear.
Advance the nylon suture.
Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat.
Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat.
Remove the Caspari from the nylon suture.
Use the crochet hook from the lateral cannula to retrieve one strand of the green suture.
Loop the grasper from the lateral cannula to untangle the sutures.
Pass 6 cm of suture through the nylon loop.
Pull on the hemostat and nylon suture to bring the green suture through the tendon and out the anterior cannula.
Apply the hemostat to the two green sutures.
Insert the Caspari with 2-0 looped nylon through the lateral cannula.
Grasp the tendon.
Check to ensure that the needle hole is clear.
Advance the nylon suture.
Use a crochet hook to pull two strands of nylon out the anterior cannula, and apply a hemostat.
Release the Caspari from the tendon and withdraw it through the lateral cannula while advancing the hemostat.
Remove the Caspari from the nylon suture.
Use the crochet hook from the lateral cannula to retrieve one limb of the white suture.
Loop the grasper from the lateral cannula to untangle the sutures.
Pass 6 cm suture through the nylon loop.
Pull on the hemostat and nylon suture to bring the white suture through the tendon.
Remove the hemostat from the white sutures.
Use the crochet hook from the lateral cannula to retrieve both white sutures from the anterior cannula.
Tie the white sutures.
Remove the hemostat from the green sutures.
Tie the green sutures.
For a glenohumeral reconstruction, some of the steps are as follows:
Arthroscopic Bankart Repair—Suture Passer, Single-Suture Anchors
Insert the arthroscope posteriorly.

Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon.
Insert an 8-mm cannula.
Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval.
Insert a metal cannula and move the scope anteriorly to view the posterior joint.
Remove the scope and cannula and replace them with a 5.5-mm working cannula.
Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion.
Insert a shaver through the anterior-superior cannula to débride soft tissue from the anterior scapular neck.
Insert a bur to decorticate the anterior scapular neck.
Remove the anterior-superior cannula.
Insert a metal cannula and trocar into the anterior-superior portal.
Observe the anterior scapular neck decortication.
Move the scope to the posterior cannula.
Determine how many anchors are required to repair the Bankart lesion.
Mark the anchor locations with a punch or bur.
Insert a drill through the anterior-superior cannula to drill anchor holes.
Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole.
Remove the inserter.
Two suture strands from the inferior anchor should be exiting the anterior-superior cannula.
Insert a Spectrum suture passer through the anterior-inferior cannula and pierce the capsule and labrum.
Advance the free ends of nylon into the joint.
Retrieve the free ends of nylon suture with a crochet hook placed in the anterior-superior cannula.
Apply a hemostat to the tips of the nylon suture.
Place the tip of the hemostat at the entrance of the anterior-superior cannula to decrease tension on the nylon suture.
Remove the Spectrum from the anterior-inferior cannula.
The nylon loop should be outside the anterior-inferior cannula.
Use Prolene suture to reverse the direction of the loop.
The loop of Prolene should be outside the anterior-superior cannula.
Have an assistant hold one limb of each anchor suture in each hand.
Insert a crochet hook through the anterior-inferior cannula and retrieve one limb of anchor suture from the anterior-
superior cannula to the anterior-inferior cannula.
Place 6 cm of anchor suture through the Prolene loop (anterior-superior cannula).
Apply traction to the hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the
labrum, and out the anterior-inferior cannula.
Two anchor sutures are now through the anterior-inferior cannula.
Tie the sutures.
Repeat these steps from additional anchors as needed.
Arthroscopic Bankart Repair—AccuPass, Double-Suture Anchors
Insert the arthroscope posteriorly.

Use a spinal needle to identify the anterior-inferior portal immediately superior to the subscapularis tendon.
Insert an 8-mm cannula.
Use a spinal needle to identify the anterior-superior portal near where the biceps exits from the rotator interval.
Insert a metal cannula and move the scope anteriorly to view the posterior joint.
Remove the scope and cannula and replace them with a 5.5-mm working cannula.
Insert a probe through the anterior-superior cannula to determine the extent of the Bankart lesion.
Insert a shaver through the anterior-superior cannula to débride soft tissue from the anterior scapular neck.
Insert a bur to decorticate the anterior scapular neck.
Remove the anterior-superior cannula.
Insert a metal cannula and trocar into the anterior-superior portal.
Observe the anterior scapular neck decortication.
Move scope to posterior cannula.
Determine how many anchors are required to repair the Bankart lesion.
Mark the anchor locations with a punch or bur.
Insert a drill through the anterior-superior cannula to drill anchor holes.
Insert an anchor through the anterior-superior cannula and place it in the most inferior drill hole.
Remove the inserter.
Four suture strands from the inferior anchor should be exiting the anterior-superior cannula.
Insert the AccuPass through the anterior-inferior cannula and pierce the capsule and labrum.
Advance the loop end of the nylon into the joint.
Retrieve the loop end of nylon suture with a crochet hook placed in the anterior-superior cannula.
Remove the AccuPass from the anterior-inferior cannula.
The nylon loop should be outside the anterior-superior cannula.
The free ends of the loop should be outside the anterior-inferior cannula.
Through the anterior-inferior cannula, use a crochet hook to grasp one strand of green anchor suture.
Through the anterior-superior cannula, insert a loop grasper and encircle the two nylon strands and the other green
anchor suture strand.
Place 6 cm of anchor suture through the nylon loop (anterior-superior cannula).
Apply traction to a hemostat and pull the anchor suture from the anterior-superior cannula into the joint, through the
labrum, and out the anterior-inferior cannula.
Two green anchor sutures are now through the anterior-inferior cannula.
Tie the sutures.
Repeat for the second white sutures from the most inferior anchor (white).
Repeat these steps from additional anchors as needed.
When you write out the operative steps in detail, it

gives you an accurate impression of how many suture
manipulations are needed. Reviewing these steps with
members of your operative team gives them a much
better idea of what needs to be accomplished, as well
as an appreciation of the operation’s complexity.
You can practice these steps before you get to the
operating room. Get a 12- by 12-inch board and insert
picture eyelets to simulate portal locations. Place can-
nulas through the eyelets and insert an anchor in the
center. Practice moving the sutures from cannula
to cannula until the motions become automatic
(Figs. 1-30 through 1-34). My friend Lanny Johnson
is fond of saying that when professional golfers
finish playing golf, they practice golf; when surgeons Figure 1-40 Exercise 1 simulating a right shoulder repair.
finish performing surgery, they practice golf. Perhaps The anterior cannula is on the right, and the lateral cannula
we could learn a lesson from professional golfers. It is is at the bottom. Black felt represents the rotator cuff tendon.
amazing to see the progress students make after they
practice an operation 20 times.
I am absolutely convinced that operations of this
Knot Tying
complexity cannot be taught with a lecture and a
video. Each step (holding the instruments, passing Because reconstructive arthroscopic shoulder surgery
the sutures, suture management, and so forth) must involves soft tissue repair, knot tying is a critical skill.
be taught and mastered as an individual event (Figs. Surgeons’ reluctance to tie arthroscopic knots has cre-
1-35 through 1-39). These individual events must ated a booming industry in pretied knots or ‘‘knotless’’
then be performed in the correct sequence. Once the devices. Each of these devices requires a number of
sequence is mastered, the fluidity of the steps must steps that are just as difficult (or as simple) as the
be improved until they become routine. All this must steps required to tie a knot. As I explain to the regis-
be done under the constant supervision of an expert trants in my arthroscopy courses in Houston, there
so that bad habits are corrected immediately before is another option: learn how to tie an arthroscopic
they become ingrained. Practice does not make knot. It is difficult, but with instruction and practice,
perfect, but practice does make permanent, and it is it can be mastered. Surgeons tie knots in open sur-
of no benefit to practice an operation either incorrectly gery on a daily basis. Arthroscopic knots are identical,
or inefficiently.
When I was learning to perform arthroscopic proce-
dures, I drew out the essential steps of the operation on
a piece of paper; borrowed a suture passer, knot pusher,
crochet hook, loop grasper, sutures, and hemostats
from the operating room; and practiced the required
maneuvers until I felt comfortable. I have included
here the exercises I used and encourage you to rehearse
the procedure with your assistant until both of you are
familiar with your roles and the necessary steps.
Although this may seem time-consuming, this level
of preparation yields great dividends during the
actual operation. Exercise 1 (Figs. 1-40 through 1-50)
simulates a one-anchor, two-suture rotator cuff repair.
Exercise 2 (Figs. 1-51 through 1-69) simulates a
two-anchor, four-suture rotator cuff repair. Exercise 3
(Figs. 1-70 through 1-102) simulates a three-anchor,
six-suture complex rotator cuff repair. Exercise 4 Figure 1-41 Insert an anchor with two sutures—four suture
(Figs. 1-103 through 1-112) simulates a Bankart repair. strands.
Figure 1-42 Pull the four suture strands out through the Figure 1-45 Pull one white suture strand through the lateral
anterior cannula. cannula.
Figure 1-43 Pull one blue strand through the lateral Figure 1-46 Place it through the felt with a suture passer.
cannula.
Figure 1-47 Retrieve both white suture strands from the

Figure 1-44 Place it through the felt with a suture passer. anterior cannula and pull them through the lateral cannula.
Figure 1-48 Tie the white sutures. Figure 1-51 Exercise 2 simulating a right shoulder repair.
The anterior cannula is on the right, and the lateral cannula
is at the bottom. Black felt represents the rotator cuff tendon.
There are two drill holes for anchors.
Figure 1-49 Retrieve the blue suture strands from the ante-
Figure 1-52 Insert two anchors—four sutures, eight suture
rior cannula and pull them through the lateral cannula.
strands.
Figure 1-53 Pull the sutures from the anterior anchor out
Figure 1-50 Tie the blue sutures. through the anterior cannula. Apply a hemostat.
Figure 1-54 Pull the sutures from the posterior anchor out
through the anterior cannula. Apply a hemostat. Figure 1-57 Retrieve one white suture strand from the ante-
rior anchor and bring it out through the lateral cannula.
Figure 1-55 Retrieve one blue suture strand from the ante- Figure 1-58 Insert this suture strand through the felt and
rior anchor and bring it out through the lateral cannula. pull it out through the anterior cannula.
Figure 1-56 Insert this suture strand through the felt and Figure 1-59 Retrieve one blue suture strand from the pos-
pull it out through the anterior cannula. terior anchor and bring it out through the lateral cannula.
Figure 1-60 Insert this suture strand through the felt and
Figure 1-63 Retrieve both posterior anchor white strands
pull it out through the anterior cannula.
from the anterior cannula and pull them out through the
lateral cannula.
Figure 1-61 Retrieve one white suture strand from the pos- Figure 1-64 Tie these sutures.
terior anchor and bring it out through the lateral cannula.
Figure 1-65 Retrieve both posterior anchor blue strands

Figure 1-62 Insert this suture strand through the felt and from the anterior cannula and pull them out through the
pull it out through the anterior cannula. lateral cannula.
Figure 1-66 Tie these sutures. Figure 1-69 Tie the sutures. The repair is complete.
Figure 1-67 Repeat the steps for the anterior anchor white Figure 1-70 Exercise 3 simulating the repair of a large or
suture. massive rotator cuff tear. The anterior cannula is on the
right, and the lateral cannula is at the bottom. Black felt
represents the rotator cuff tendon. There are three anchor
holes.
Figure 1-68 Retrieve both anterior anchor blue strands from

the anterior cannula and pull them out through the lateral Figure 1-71 Insert three anchors—6 sutures and 12 suture
cannula. strands.
Figure 1-72 Pull the anterior anchor sutures out through Figure 1-75 Move the middle anchor sutures from the ante-
the anterior cannula. rior cannula, simulating an anterolateral percutaneous stab
wound.
Figure 1-73 Pull the middle anchor suture strands out Figure 1-76 Retrieve one anterior anchor blue suture from
through the anterior cannula. the anterior cannula and pull it out through the lateral
cannula.
Figure 1-74 Move the posterior anchor strands to the left of

the lateral cannula, simulating removing them through a Figure 1-77 Place this suture through the felt and withdraw
posterolateral percutaneous stab wound. it through the anterior cannula.
Figure 1-81 Place this suture through the felt and withdraw
Figure 1-78 Retrieve one anterior anchor white suture from
it through the anterior cannula.
the anterior cannula and pull it out through the lateral
cannula.
Figure 1-79 Place this suture through the felt and withdraw Figure 1-82 Withdraw the suture strand that is through the
it through the anterior cannula. felt and pull it out the anterolateral stab wound.
Figure 1-80 Retrieve one middle anchor blue suture from Figure 1-83 Retrieve one middle anchor white suture from
the anterolateral stab wound and withdraw it through the the anterolateral stab wound and withdraw it through the
lateral cannula. lateral cannula.
Figure 1-84 Place this suture through the felt and withdraw Figure 1-87 Tie the sutures.
it through the anterior cannula.
Figure 1-85 Withdraw the suture strand that is through the

Figure 1-88 Retrieve the anterior anchor blue suture strands
felt and pull it out the anterolateral stab wound.
from the anterior cannula and pull them out through the
lateral cannula.
Figure 1-86 Retrieve the anterior anchor white suture

strands from the anterior cannula and pull them out through
the lateral cannula. Figure 1-89 Tie the sutures.
Figure 1-93 Place this suture through the felt and withdraw
Figure 1-90 Withdraw the posterior anchor blue suture it through the anterior cannula.
strand from the posterolateral stab wound and pull it out
through the lateral cannula.
Figure 1-94 Retrieve the posterior anchor strand from the

Figure 1-91 Place this suture through the felt and withdraw posterolateral stab wound and withdraw it through the
it through the anterior cannula. lateral cannula.
Figure 1-92 Withdraw the posterior anchor white suture

strand from the posterolateral stab wound and pull it out Figure 1-95 Retrieve the posterior anchor strand from the
through the lateral cannula. anterior cannula and withdraw it through the lateral cannula.
Figure 1-96 Tie the white sutures from the posterior anchor. Figure 1-99 Retrieve both middle anchor white sutures and
withdraw them through the lateral cannula.
Figure 1-97 Retrieve both posterior anchor blue sutures and Figure 1-100 Tie the middle anchor white sutures.
withdraw them through the lateral cannula.
Figure 1-101 Retrieve both middle anchor blue sutures and

Figure 1-98 Tie the blue sutures from the posterior anchor. withdraw them through the lateral cannula.
Figure 1-102 Tie the middle anchor blue sutures.
Figure 1-105 Place a nylon passing suture through the

green cannula. The two free ends are exiting the orange
cannula, and the looped end is exiting the green cannula.
Figure 1-103 Exercise 4 simulating a right shoulder Bankart

repair with three suture anchors. The green cannula is ante-
rior-inferior, and the orange cannula is anterior-superior.
Figure 1-106 Pull one suture strand from the orange
cannula out through the green cannula.
Figure 1-104 Insert the inferior anchor and withdraw the Figure 1-107 Place the end of the blue suture through the
sutures through the orange cannula. looped end of the nylon suture.
7 cm
Figure 1-108 Close-up view of Figure 1-7.
Figure 1-111 Continue to pull on the nylon suture, and

bring the blue suture out through the orange cannula.
Figure 1-109 Pull on the two free ends of the nylon (white)
suture.
Figure 1-112 Tie the suture. Repeat for the two additional
anchors.
with the exception that the knot pusher replaces

the surgeon’s index finger. The knots lie flat, are
square, and are as strong as knots tied in the open
technique. My advice is to learn arthroscopic knot
tying and use knotless systems only when they are
superior to or offer an advantage over a traditional
knot.
Before learning arthroscopic knots, the surgeon
must be proficient with the basic one-handed knots
commonly taught in medical school or surgery intern-
ship. Although there are many knot variations, only
Figure 1-110 Pull the blue suture from the green cannula two basic knots are necessary: an overhand knot and a
through the felt. sliding knot. When learning the steps required to tie
knots, it is easier to practice with clothesline than with 1 2

surgical suture. All the knots described here are shown
on the video.
Knot Tying
OVERHAND KNOT After the suture has been inserted

through the soft tissue, verify that no tangles exist.
Use the loop grasper to encircle one suture limb and
Figure 1-113 Knot tying illustrations.
then withdraw the instrument. Perform this step
before tying every knot. Place one limb of the suture
through the knot tying instrument. This suture limb is
usually the one closest to you. For example, in rotator
cuff repair, the knot pusher goes on the suture limb
that exits from the suture anchor and comes out 3 4
through the cannula. The free end is the suture limb

that has been placed through the tendon and is farther
away. Apply a hemostat to the suture strand that is
through the knot pusher so that you have something
to pull against as you push the knot down the cannu-
la. Gently push the half hitch down the cannula.
Slowly place tension on the two strands and observe
which strand must be pushed away for the knot to lie
flat. If you push the other strand away, the knot will
not lie flat. It is not important whether the first throw
is overhand or underhand, but it is important that
you always use the same technique when tying
knots. I recommend that surgeons use the same
sequence of knot tying for arthroscopic procedures 5 6
that they use for open techniques. For example, if
you perform two throws, bringing the strands from
top to bottom, and then the third throw goes from
below to above, I advise you to keep the same
sequence. Try to make the steps of tying your arthro-
scopic knots as similar as possible to those of your
open knots. Use the knot pusher to past-point.
This allows you to pull the suture strands tight with
a 180-degree angle. Place another throw in the same Figure 1-115 Knot tying illustrations.
direction as the first, past-point, and tighten the knot.
Now reverse the direction of the throw and place a
third hitch. Reverse the post of the knot for greater
knot security and place a fourth throw. Reverse the
post and the direction of the throw for the fifth half
7 8
hitch.
It is critical that you become skilled in tying knots
with a one-handed technique. Gradually incorporate
arthroscopic knot tying into surgery by tying knots
with the knot pusher during an open repair and
moving to arthroscopic knot tying as your skills
increase. These steps are illustrated in Figures 1-113
through 1-178.
An additional skill that is critical is learning to
slip the second throw. Usually the tendon or Figure 1-116 Knot tying illustrations.
9 10 13

Figure 1-119 Knot tying illustration.
ligament to be tied is under tension and retracts

slightly after the first knot throw. One method to one four times. Bring the end of the longer suture
deal with this problem is to eliminate the tension strand up through the loop to complete the Duncan
on the soft tissue by having an assistant hold loop. Freshen the knot by applying tension to each
the soft tissue with a tissue grasper. Another method strand. Pull on the shorter strand to advance the knot.
is to place a traction suture through the soft tissue. Place three alternating half hitches to secure the knot.
A third method (and the one I prefer) involves slip-
ping the second throw. Tie the first throw routinely.
Make a second half hitch in the same direction and
slowly advance it down the cannula. Check to see that
the suture is not tangled. Pull on the post limb and
release all tension on the other limb. The knot will
slide down to the soft tissue without locking, enabling KNOT TYING TECHNIQUE
you to approximate the soft tissue. Past-point and lock 1 2
the second throw. Finish the remaining throws, and

complete the knot.
SLIDING KNOT There are dozens of types of sliding

knots, but it is necessary to learn only one. If you wish
to learn more at a later date, you can always do so. After
placing the suture through the soft tissue, grasp both
ends and confirm that it slides freely. Pull on one end
so that it becomes the shorter one. Make a loop with the 3 4
longer strand and pinch it between your thumb and

index finger. Pass the longer suture over the shorter
5 6
11 12
Figure 1-118 Knot tying illustrations. Figure 1-120 Knot tying illustrations.
Figure 1-121 One-handed knot. Figure 1-124 One-handed knot.

Figure 1-131 One-handed knot.

Figure 1-128 One-handed knot.



Figure 1-145 One-handed knot. Figure 1-148 One-handed knot using a knot pusher.
Figure 1-146 Knot pusher.
Figure 1-149 One-handed knot using a knot pusher.
Figure 1-147 One-handed knot using a knot pusher. Figure 1-150 One-handed knot using a knot pusher.
INTELLECTUAL SKILLS
Intellectual skills can be honed by attending instruc-

tional courses presented by the American Academy of
Orthopaedic Surgeons, the American Shoulder and
Elbow Surgeons, and the Arthroscopy Association of
North America. These courses are held throughout
the United States. A full day of current shoulder
information is given at the open meeting of the
American Shoulder and Elbow Surgeons, which is
held at the annual meeting of the American
Academy of Orthopaedic Surgeons. The best shoulder
arthroscopy course I have attended is the biennial
meeting held in Val d’Isere, France. This weeklong
Figure 1-176 One-handed knot using a knot pusher. course covers the spectrum of shoulder arthroscopy
topics in detail.
Excellent textbooks are also available, such as The
Shoulder by Rockwood and Matsen, or you can sub-
scribe to the Journal of Shoulder and Elbow Surgery and
Arthroscopy, Arthroscopy, and the American Journal of
Sports Medicine, which are sources of current thought
on shoulder problems.
Perhaps the most important intellectual tool a
surgeon can possess is a plan to master reconstruc-
tive arthroscopic operations. As a general approach,
I recommend the following: learn the individual steps
of the arthroscopic repair, practice these techniques
outside the operating room, gradually incorporate
these techniques into open repair, perform arthroscopic
repair and then open the shoulder, and finally perform
the operation exclusively with arthroscopic technique.
Although, theoretically, it seems reasonable to
make the transition to arthroscopic repair in one
Figure 1-177 One-handed knot using a knot pusher. step, in practice, it can result in a 6-hour arthroscopic
rotator cuff repair that benefits neither patient nor 3. Measure the length and width (retraction).
surgeon. I advise a more gradual transition. As noted 4. Use a grasper to estimate reparability and deter-
earlier, I took 1 year to move from open rotator cuff mine what goes where.
repair to a fully arthroscopic technique. 5. Perform arthroscopic decompression.
6. Use a round bur to abrade the rotator cuff tear
repair site.
7. Insert an anterior anchor and pull the sutures out
THE GRADUAL TRANSITION
through the anterior cannula. Apply a hemostat.
When making the transition from open to arthoscopic 8. Insert a posterior anchor and pull the sutures out
rotator cuff repair, be sure to scope all tears before through the anterior cannula. Apply a hemostat.
performing the open repair. Establish time limits for 9. Open and repair the rotator cuff tear.
your arthroscopic procedures. Give the circulating
nurse authority to inform you that 1 hour has passed Repeat this sequence with each rotator cuff repair.
and it is time to open the shoulder. Consider a plan When you can perform steps 1 through 8 in 30 minutes,
similar to the one described here. advance to the next stage.
Stage 1 Stage 4
1. Arthroscope the glenohumeral joint. 1. Arthroscope the glenohumeral joint.
2. Enter the subacromial space and expose the tear 2. Enter the subacromial space and expose the
with bursectomy. tear with bursectomy.
3. Measure the length and width (retraction). 3. Measure the length and width (retraction).
4. Use a grasper to estimate reparability and deter- 4. Use a grasper to estimate reparability and deter-
mine what goes where. mine what goes where.
5. Perform arthroscopic decompression. 5. Perform arthroscopic decompression.
6. Open and repair the rotator cuff tear. 6. Use a round bur to abrade the rotator cuff tear
repair site.
Repeat this sequence with each rotator cuff repair. 7. Insert an anterior anchor and pull the sutures
When you can perform steps 1 through 5 in 30 minutes, out through the anterior cannula. Apply a
advance to the next stage. hemostat.
8. Insert a posterior anchor and pull the sutures out
through the anterior cannula. Apply a hemostat.
Stage 2
9. Pass the anterior anchor sutures through the
1. Arthroscope the glenohumeral joint. tendon.
2. Enter the subacromial space and expose the tear 10. Pass the posterior anchor sutures through the
with bursectomy. tendon.
3. Measure the length and width (retraction). 11. Open and complete the rotator cuff repair.
4. Use a grasper to estimate reparability and deter-
mine what goes where. Repeat this sequence with each rotator cuff repair. When
5. Perform arthroscopic decompression. you can perform steps 1 through 10 in 40 minutes,
6. Use a round bur to abrade the rotator cuff tear advance to the next stage.
repair site.
7. Open and repair the rotator cuff tear.
Stage 5
Repeat this sequence with each rotator cuff repair. When 1. Arthroscope the glenohumeral joint.
you can perform steps 1 through 7 in 30 minutes, 2. Enter the subacromial space and expose the
advance to the next stage. tear with bursectomy.
3. Measure the length and width (retraction).
4. Use a grasper to estimate reparability and deter-
Stage 3
mine what goes where.
1. Arthroscope the glenohumeral joint. 5. Perform arthroscopic decompression.
2. Enter the subacromial space and expose the tear 6. Use a round bur to abrade the rotator cuff tear
with bursectomy. repair site.
7. Insert an anterior anchor and pull the sutures out prefer to use this hand to control the arthroscope, and
through the anterior cannula. Apply a hemostat. others use the dominant hand to manipulate the sur-
8. Insert a posterior anchor and pull the sutures out gical instruments. Ideally, you should be able to hold
through the anterior cannula. Apply a hemostat. the camera and manipulate the instruments with
9. Pass the anterior anchor sutures through the either hand.
tendon. A second skill is arthroscope rotation. Many sur-
10. Pass the posterior anchor sutures through the geons rotate the arthroscope with the hand not hold-
tendon. ing the scope. This may be satisfactory during the
11. Tie the knots. diagnostic phase, but when you have an instrument
12. Open and inspect the repair. Check the tension in the opposite hand, this becomes difficult. Learn to
on the tendon, ensuring that it is neither too rotate the arthroscope by using the index finger of the
tight nor too loose. Are the knots secure? Is the hand holding the scope (see Figs. 1-35 through 1-39).
spacing of the knots on the tendon correct? Are
they too close together or too far apart? Are they
Caspari Suture Punch
too close to the lateral edge or too far away from
the edge? You should learn to use the Caspari suture punch with
13. Review the video recording (I strongly suggest either hand—a skill you can master on a practice sta-
that you record your procedures). If the knots tion. It is also necessary to advance the suture with the
are too closely spaced, determine at what thumb of the hand holding the instrument so you are
point in the procedure this occurred. Why did not forced to use the opposite hand (see Figs. 1-16
the spacing look good at arthroscopy but not through 1-20).
when you inspected the repair open? Apply The scrub nurse will hand you the Caspari numer-
this same level of analysis to all aspects of the ous times during an arthroscopic repair, and this
repair until you are satisfied. phase of instrument transfer can be either awkward
or smooth. Rehearse the instrument transfer with
At this final stage you will gain confidence that your your scrub nurse so that both of you are familiar
arthroscopic repairs are as good as or better than your with the correct technique.
open repairs. Once your particular threshold of
excellence has been met, you can stop opening your
Elite Pass
arthroscopic repairs.
This modern instrument is designed to pass braided
sutures directly through a tendon or ligament without
INSTRUMENT HANDLING using a shuttle relay. Take some time to learn how to
load the needle, load the suture, deploy the needle,
Arthroscopic shoulder recontructions are complex grasp the suture, withdraw the needle, and finally
operations, and success depends on a number of remove the instrument (see Figs. 1-9 through 1-15).
small details. One area that surgeons often overlook
is the appropriate handling of arthroscopic instru-
Spectrum
ments. Correct hand position and movement can be
mastered with little effort. Familiarize yourself with the proper handling and
transfer of this instrument. Have the scrub nurse
load the looped nylon suture from the opposite side
Arthroscope
of the thumb so that the suture does not get tangled as
Practice holding and manipulating the arthroscope you advance it.
with both hands. If you are comfortable holding the
arthroscope with only one hand, operating on the
AccuPass
opposite shoulder will force you into an awkward posi-
tion. Practice with both hands during diagnostic gle- This series of instruments is used to shuttle sutures with
nohumeral arthroscopy until you can smoothly and a nylon loop. They are reusable, so the tip is always
rapidly maneuver the arthroscope and view all critical sharp. The loading eyelet is large enough so that the
areas of the joint. Everyone has a dominant or pre- nylon loop can be loaded either loop end first or free
ferred hand, but I have observed that some surgeons end first, depending on the specific requirements of the
operation. Many tip configurations are available. Try to simple instrument and view the tip of it as an arthro-
load the nylon loop on the side opposite the thumb scopic projection of my index finger. Finding the opti-
wheel so that the loop does not get caught in your mal shaft length is accomplished by trial and error.
glove (see Figs. 1-27 through 1-29). I shorten the standard shaft length to fit my thumb
motion during the tying maneuver.
Knot Pusher
There are a variety of knot tying instruments available,
and you should examine a number of them to deter-
mine which one feels most comfortable. I prefer a
CHAPTER
2
Operating Room Setup
This chapter covers the general organization of the

operating room, anesthesia, patient positioning, and
equipment and instruments.
CLINICAL DATA
I find it helpful to have a copy of the patient’s record

in the operating room. This allows me to compare the
examination under anesthesia with the examination
documented in the office. For patients with glenohumer-
al instability, I can compare the patient’s report of which
activities or motions produce pain to the amount of
translation observed during examination under
anesthesia. The patient record also includes a summary
of the pertinent findings on magnetic resonance
imaging, ultrasonography, and computed tomography,
allowing me to compare these to the findings at arthros-
copy. I also display the relevant radiographic study so
that I can review it if necessary (Figs. 2-1 through 2-3). Figure 2-1 Patient record in the operating room.
44
Chapter 2 Operating Room Setup 45
No history of prior similar shoulder problem
Previous treatment consisted of selective rest and activity modification
Allergies: Patient has no known drug allergies
Current Medication: None
Social History: Patient denies the use of any tobacco products; patient occasionally drinks socially
Clinical Examination:
Dominant Hand: Right
Right Shoulder Examination:

Tenderness — Shoulder: Present at the bicipital groove and biceps muscle
Swelling: None
Ecchymosis: None
Crepitus: None
Deformity: None present
Atrophy: None present
Skin: No incisions, lacerations, or abrasions noted
Effusion: Absent
Passive Range of Motion:

elevation = 120 degrees
external rotation (shoulder adducted) = 85 degrees
internal rotation to the lumbar level 1-2
Strength:
Strength was normal when the patient was tested for resisted elevation, external rotation, internal
rotation and subscapularis push-off
Muscle Pain Tests (resisted):

Resisted internal rotation — not painful
Elevation — no pain
External rotation — no pain
Abduction — no pain
Belly-press test — no pain
Subscapularis push-off — no pain
Stability:
Stability was normal when the patient was tested for sulcus, Rowe, abduction/external rotation
and posterior translation
Neurovascular Examination: Normal
Office Radiographs:
RIGHT Anterior-posterior radiographic findings:

AP normal
Figure 2-2 Close-up of patient record.
Figure 2-3 Magnetic resonance imaging study in the operating room.

SETUP AND PREPARATION
The operating room layout is shown in Figure 2-4.

I must have adequate space to maneuver between the
head of the table and the anesthetist. I angle the cart
with the arthroscopy equipment toward me so that
I can see all the gauges. Similarly, the arthroscopic
pump and fluid bags should be visible so that I can
see the pressure and flow at any time. I also ask the
anesthetist to rotate the blood pressure monitor
so that I can check it during the procedure without
disturbing his or her concentration. An absorbent
mat to collect fluid is placed on the floor underneath
my feet. I arrange the foot pedals that control the power
instruments and cautery to permit easy access (Figs. 2-5
through 2-9).
Figure 2-6 Instrument cart.
Back table Absorbent mat
Anesthesia
Technician Assistant Surgeon equipment
Mayo stand
Operating table
Anesthesia
Fluid/pump
electrogenerator Camera
Power
Monitor Figure 2-7 Arthroscopic pump.
Video recorder
Figure 2-4 Operating room setup.
Figure 2-5 Equipment position. Figure 2-8 Fluid bags.

The shoulder preparation table contains the

skin razor and adhesive tape for removing hair.
My team uses an iodine-based product (Duraprep); for
individuals with iodine allergy, a chlorhexidine gluco-
nate (Hibiclens) scrub is followed by an isopropyl alco-
hol solution. I prefer to have the patient’s hair shaved
from the area that will be covered by the bandage. It is
not necessary to shave the axilla.
Only those instruments required for the operation
are placed on the Mayo stand. The back table contains
rarely used instruments and the postoperative dressing
(Figs. 2-10 and 2-11).
Figure 2-11 Back table.
ANESTHESIA
My team’s routine is to perform an interscalene

block in the preoperative holding area. The patient
is then moved to the operating room, where general
anesthesia is started. Because many patients
find remaining motionless in the seated position
uncomfortable, and I find patient movement and
conversation distracting, I prefer to use general
anesthesia rather than operating under regional
block alone. The interscalene block has no direct
effect on blood pressure. With sensory input blocked,
there is no sympathetic response to the otherwise
painful stimuli, and catecholamine release is avoided.
Figure 2-9 Absorbent mat and foot pedals. The beta-antagonistic effects (vasodilation and brady-
cardia) of the general anesthetic agents are then more
pronounced, without the pain response to offset
them. This causes relative bradycardia and
hypotension. The result is improved visualization.
Because the operated area is anesthetized, only light
general anesthesia is necessary, minimizing postoper-
ative nausea. Some anesthesiologists prefer a laryngeal
mask airway, which eliminates the need for endotra-
cheal intubation. Immediate postoperative pain is well
controlled (Figs. 2-12 and 2-13).
Figure 2-10 Mayo stand. Figure 2-12 Laryngeal mask air tube.
and surgeon preference should dictate the

choice. Both diagnostic and reconstructive shoulder
arthroscopy can be performed successfully in either
position. I used the lateral decubitus position for
10 years and found it very satisfactory for diagnostic
arthroscopy and for arthroscopic subacromial decom-
pression and acromioclavicular joint resection. As
I began to perform rotator cuff repair and glenohu-
meral reconstruction, I found that the disadvantages
of the lateral position became more noticeable, and
I made the transition to the sitting position, which
I have used exclusively for the past 15 years. I pay
considerable attention to patient positioning because
this aids in portal placement and facilitates the proce-
Figure 2-13 Laryngeal mask air tube secured in place with dure. Incorrect positioning adds complexity to an
tape. already difficult procedure.
Lateral Decubitus Position

To avoid ‘‘wrong site’’ surgery, always confirm with
the patient which shoulder is to be operated on. The lateral decubitus position offers excellent access to
The is done in the preoperative holding area before the posterior shoulder and allows arm suspension
the patient receives any sedation. The anesthesiologist (and distraction, as necessary) without the need for
uses a surgical marking pen to write ‘‘yes’’ on that an assistant. The surgeon can choose to terminate the
shoulder and ‘‘no’’ on the contralateral shoulder. I arthroscopic procedure and can easily perform an open
ask the patient and confirm the correct site myself operation in the subacromial space. Disadvantages
and write a ‘‘G’’ for Gary on the correct shoulder include the need to lift and turn the patient, the
(Fig. 2-14). possibility of excessive distraction across the glenohu-
meral joint and potential nerve injury, limited access to
the anterior shoulder, and the need to reposition the
PATIENT POSITIONING patient if an open anterior glenohumeral reconstruction
is required. Another potential disadvantage is the
Successful shoulder arthroscopy is the result of planning tendency for the suspension apparatus to place the arm
and organization. Many seemingly minor details can in internal rotation. This is important in glenohumeral
have a profound effect on the procedure, and I encourage reconstruction because repair of the glenohumeral
all surgeons to invest the necessary time to prepare the ligaments or rotator interval with the arm in internal
operating room and surgical staff adequately. rotation may result in permanent loss of external
Patients are positioned in either the lateral rotation. The surgeon can overcome all these difficulties
decubitus or the sitting (beach-chair) orientation. with appropriate care.
Each position has its advantages and disadvantages, Before the patient is brought to the operating
room, a vacuum beanbag is placed on the operating
table and smoothed (Table 2-1). The patient
is assisted onto the table and centered on the bean-
bag. The cephalad edge of the beanbag should be
level with the patient’s upper thorax, not high
enough to protrude into the axilla. After general en-
dotracheal anesthesia has been established, the tube
is secured on the side of the mouth away from the
surgical site. Both shoulders are examined for range
of motion and translation. The patient is then turned
over on the unaffected side, with the pelvis and
shoulders perpendicular to the table. The beanbag is
gathered up around the patient and deflated so that it
is firm. The operating table is tilted 20 to 30 degrees
Figure 2-14 Skin marking. posteriorly so that the glenoid is parallel to the floor.
Table 2-1 TABLE POSITIONING Sitting Position

AIDS—DECUBITUS I prefer the term sitting position rather than the older
beach-chair position because the patient’s thorax must
U-shaped Vacupak beanbag, 3 feet long be placed 70 to 80 degrees perpendicular to the floor.
Axillary roll This upright position is necessary to place the acromion
Kidney rest supports for operating table (2) parallel to the floor and allow access to the posterior
shoulder. A more recumbent position forces the surgeon
Contoured foam head and neck support
to ‘‘work uphill’’ and makes entry into the inferior-
Arm board posterior shoulder difficult if such a portal is required
Pillows (2) for glenohumeral reconstruction. One advantage of the
Foam pads for ankles, knees, and arms sitting position is that it is similar to that used during
traditional open operations, so conversion from an
3-inch-wide cloth adhesive tape
arthroscopic to an open rotator cuff repair or glenohu-
meral reconstruction does not require a change in
patient position. Also, the anterior shoulder is more
Considerable attention is given to protecting the approachable than in the lateral decubitus position; the
neurovascular structures, soft tissues, and bony surgeon need not lean over the patient to gain anterior
prominences. A soft sheet is rolled into a cylinder access. In this position, the arthroscopic orientation
approximately 6 inches in diameter and placed seems more familiar to surgeons, with the vertical orien-
under the upper thorax to raise the patient’s tation of the glenoid similar to that seen during physical
chest off the table and thereby minimize pressure examination or radiographic review. Shoulder distrac-
on the neurovascular structures within the axilla. tion is not continuous, which minimizes the chance of
The roll should not be placed in the axilla. A 1-L neurologic injury; the assistant can provide a distraction
fluid bag wrapped in a towel also works nicely. force during the brief periods when this is needed.
The downside hip and knee are slightly flexed to A mechanical arm holder can maintain the shoulder in
stabilize the patient. Pillows are placed between the external rotation during glenohumeral reconstruction
legs to protect the ankles, knees, and peroneal nerves, and in elevation during rotator cuff repair. I use the
and the breasts are carefully padded. Kidney rests are McConnell arm holder (McConnell Orthopedics,
useful to support the beanbag, and broad adhesive Greenville, Tex). A newer, more sophisticated pneumatic
tape may be used to further stabilize the patient. positioning device called the Spyder Arm Positioner
The cervical spine must be supported to prevent any (Smith-Nephew Endoscopy, Andover, Mass) is available
hyperextension or lateral angulation during the to aid the surgeon in rapidly positioning the shoulder.
procedure. An electrosurgical grounding pad is One disadvantage of the sitting position is that these
placed over the muscular area of the lateral thigh. patient-positioning devices are expensive. I currently
The surgeon should inspect the patient’s position use the Schloein patient positioner (Orthopedic
carefully and check each pressure area to make sure Systems Inc., Union City, Calif).
it is adequately padded. Before the patient is brought to the operating room,
The circulating nurse prepares the entire shoulder, the mechanical support is positioned and secured to the
arm, and hand. An assistant grasps the patient’s operating table (Table 2-2). The patient is assisted onto
wrist with a sterile towel, and the surgeon and scrub the operating table, and general anesthesia induced. The
nurse place the lower U-drape over the patient. back of the mechanical support is then raised, a small
The forearm and hand are then placed in the traction amount of Trendelenburg is applied, and the legs are
device. The wrist is carefully padded to avoid pressure lowered. The position is adjusted until the patient’s
on the sensory branch of the radial nerve. The arm is
placed on the lower drape, the upper drape is put into
position, and the fluid-collection pouch is applied. Table 2-2 TABLE POSITIONING
The arm is attached to the suspension device. AIDS—SITTING
Usually 10 pounds of weight is sufficient, but the
weight may be increased slightly for larger individuals. Mechanical patient positioner (Schloein, Steris)
The surgeon should think of the suspension device as Spyder or McConnell foam wrist support and
a stabilizing mechanism rather than a method of pole
producing traction. The shoulder is positioned in Foam pads for ankles, knees, and arms
60 degrees of abduction and 10 degrees of flexion.
acromion is nearly parallel to the floor. This places the

patient in a nearly vertical sitting position rather than a
semirecumbent beach-chair position. It is important to
select a mechanical patient positioner that allows the
70- to 80-degree angle necessary. The head and neck
are positioned for patient comfort and secured. Pillows
are placed under the knees, and a foam pad protects the
contralateral elbow. I check to make sure that no pads or
drapes interfere with access to the anterior or posterior
shoulder.
The shoulder, arm, and hand are prepared, and
an assistant grasps the wrist while the scrub nurse posi-
tions the bottom drape. The hand-wrist support is
attached, and the forearm is placed on the patient’s
lap. The upper drape is applied, and the suction drain- Figure 2-17 Check the relationship of the acromion to the
age bag is affixed around the shoulder. The applicable floor.
surface anatomy is drawn, and the surgery begins
(Figs. 2-15 through 2-27).
Figure 2-18 Secure the breathing tube.
Figure 2-15 Positioning the patient.
Figure 2-16 Patient in the sitting position. Figure 2-19 Position the cervical spine.
Figure 2-20 Secure the cervical spine with a chin strap. Figure 2-23 Base of the McConnell arm holder.
Figure 2-21 Check the cervical spine alignment from the

front.
Figure 2-24 Recheck the position of the acromion.
Figure 2-22 Pad the legs and contralateral arm. Figure 2-25 Position the shoulder with McConnell arm holder.
Suture Passers
Sutures are passed through soft tissue either directly
or indirectly. There are three types of direct methods.
In the first, the instrument passes the suture through
the tendon or ligament to a standard needle
(Cuff-Stitch, Smith-Nephew Endoscopy). The second
involves piercing the soft tissue with an instrument
and then grabbing the suture and pulling it back
through the soft tissue (Arthropierce, Smith-Nephew
Endoscopy). The third direct method involves a
flexible needle that passes the braided suture directly
Figure 2-26 Access to the anterior shoulder. through the soft tissue (Elite Pass, Smith-Nephew
Endoscopy) (Figs. 2-28 through 2-50). The indirect
method involves placing a passing suture through
the soft tissue and using this transport suture to
pull the repair suture through the soft tissue.
The Linvatec shuttle relay is one type of transfer
suture, but I prefer standard 2-0 nylon. I cut the needle
off and place the two ends together. This forms a loop
on the other end that will transfer the repair suture.
The cost saving is significant.
Figure 2-27 Access to the posterior shoulder.
Figure 2-28 Elite suture passer.
EQUIPMENT
Arthroscope
I use a standard 4-mm arthroscope with a 30-degree
angled lens for all shoulder arthroscopy. I have not
found it necessary to use a 70-degree arthroscope.
The increased lens angle may be useful when it is
desirable, while viewing from the posterior portal, to
see more of the anterior glenoid during a Bankart
repair. I prefer to move the arthroscope to an ante-
rior-superior portal during this portion of the proce-
dure. The time it takes to move the arthroscope is
more than offset by the superior view with the 30-
degree arthroscope compared with the distorted view
of the 70-degree arthroscope. Figure 2-29 Close-up of Elite suture passer.
Figure 2-33 Close-up of the Caspari’s tip.
Figure 2-30 Close-up of Elite suture passer with the needle

deployed.
Figure 2-34 AccuPass.
Figure 2-31 Caspari suture passer.
Figure 2-35 AccuPass deploying a nylon loop.
Figure 2-32 Close-up of Caspari suture passer. Figure 2-36 AccuPass deploying a braided suture.
Figure 2-37 Spectrum suture passer.
Figure 2-41 Tips.
Figure 2-38 Close-up of Spectrum suture passer.
Figure 2-42 Tips.
Figure 2-39 Tips.
Figure 2-43 Straight Cuff-Stitch.
Figure 2-40 Tips. Figure 2-44 Instrument tips.

Figure 2-45 Left-angled Cuff-Stitch.
Figure 2-49 Arthropierce.
Figure 2-50 Instrument tip.
My preference is to use the direct method with the

Elite Pass for rotator cuff repairs and the indirect
Figure 2-46 Instrument tips. method for instability repairs. The problem with
direct suture instruments in glenohumeral joint insta-
bility repair is that once the instrument is through the
soft tissue, the instrument’s maneuverability is extre-
mely limited. Unless the desired repair suture is
directly in line with the instrument, I cannot retrieve
it. With the indirect method, I can place the transfer
suture at the exact point required. I then retrieve the
repair suture with a crochet hook and use the transfer
suture to place the repair suture through the soft
tissue. This is my personal preference; other surgeons
may find another method superior.
Figure 2-47 Right-angled Cuff-Stitch. Hand Instruments

I use several hand instruments during reconstructive
shoulder surgery. As noted earlier, I use the Elite Pass
to pass sutures through the rotator cuff during repair.
I now rarely use the Caspari suture punch, which
I have modified by increasing the length of the
needle tip from 4 to 5 mm. I found that the 4-mm
tip was often too short to pass through a rotator cuff
tendon, and the small increase in length solved this
problem. The Cuff-Stitch (Smith-Nephew Endoscopy)
allows the surgeon to pass a suture directly through
the tendon, ligament, or labrum and is preferred by
some. I use the Cuff-Stitch in two particular situations.
First, if the tendon is thick and fibrotic and it is
Figure 2-48 Instrument tips. difficult or impossible to pass a suture through it
using the Elite or the Caspari, the Cuff-Stitch is very

effective. Second, when a rotator cuff tear is massive,
I can best determine its geometry and perform the
repair with the arthroscope in the lateral portal,
in which case it is most convenient to insert the
Cuff-Stitch through the anterior and posterior
cannulas. Figure 2-52 Close-up of soft tissue grasper.
The Arthropierce can either pass or retrieve sutures
during margin convergence in rotator cuff or rotator
interval repair. I find the AccuPass instruments
(Smith-Nephew Endoscopy) especially useful during
glenohumeral reconstruction for instability. These
instruments function like the original Caspari suture
punch but are angled such that the surgeon can reach
inferiorly to grasp the capsule or labrum.
Soft Tissue Management

I use a soft tissue grasper to test the tension of the
glenohumeral ligaments before instability repair and
to evaluate the excursion and reparability of a torn rota- Figure 2-53 Less aggressive soft tissue grasper.
tor cuff. Regular and locking graspers are helpful. A gras-
per with less aggressive teeth allows one to pull on
sutures without shredding them. A blunt probe is
useful to evaluate for the presence of a subtle Bankart
or a superior labrum anterior to posterior (SLAP) lesion.
When a Bankart lesion has healed with a fibrous union,
the lesion may not be apparent, and a sharp chisel dis-
sector can peel the labrum off the anterior glenoid. To
ensure that the capsule is not adherent to the subscapu-
laris, I use a blunt soft tissue instrument to dissect
between the two structures. A large soft tissue punch
is useful to excise portions of a contracted capsule
during contracture release. I have found the capsular Figure 2-54 Chisel dissector.
punches designed by Harryman to be most effective
for capsular release in patients with shoulder stiffness.
I modified two of the instruments so that they bend
downward rather than upward; I am more comfortable
with this angle of approach to the capsular tissue. I use a
blunt-ended probe for dissection around nerves or
blood vessels. I also find the markings on the end of
the probe useful for measuring distances and the size
of lesions (Figs. 2-51 through 2-62).
Figure 2-55 Chisel dissector.
Figure 2-51 Soft tissue grasper. Figure 2-56 Blunt dissector.

Figure 2-62 Blunt probe with measuring guide markings.

Figure 2-57 Close-up of blunt dissector.
Suture Management
A crochet hook is used to retrieve sutures from within
the subacromial space or glenohumeral joint. If a suture
gets caught in the tendon or labrum, I prefer to use a
fine-toothed crochet hook that does not damage the
suture. I use a looped suture grasper to ensure that
Figure 2-58 Close-up view of blunt dissector.
there are no suture tangles within the working cannula
before tying each suture. A larger instrument is useful
during rotator cuff repairs, and a smaller one is easier to
maneuver within the glenohumeral joint. There are a
number of knot tying instruments available, but I prefer
a single-lumen knot pusher, which can double as a knot
pusher and puller. I modify the length of the instru-
ment to fit my hand comfortably. Arthroscopic scissors
are needed to cut suture and soft tissue. I also use end-
cutting scissors when I cannot see the knot during a
rotator interval repair (Figs. 2-63 through 2-75).
Figure 2-59 Straight capsular resection punch.
Figure 2-63 Crochet hook.
Figure 2-60 Close-up of capsular resection punch.

Figure 2-64 Close-up of crochet hook.
Figure 2-61 Close-up of capsular resection punch. Figure 2-65 Fine-toothed crochet hook.
Figure 2-66 Large loop grasper. Figure 2-71 Knot pusher.
Figure 2-67 Close-up of large loop grasper.
Figure 2-68 Loop grasper with the jaws open.

Figure 2-72 Close-up of knot pusher.
Figure 2-69 Small loop grasper.
Figure 2-73 Scissors.
Figure 2-70 Close-up of small loop grasper. Figure 2-74 Close-up of scissors.
Figure 2-76 Shaver.
Figure 2-75 End-cutting scissors.
Sutures
I use several different sutures during shoulder arthros-
copy. The 5-mm rotator cuff anchor is preloaded with
No. 2 Ultrabraid. The BioRaptor is loaded with No. 1
Ultrabraid. I use 2-0 nylon as a transfer suture to bring
the braided sutures through the rotator cuff or glenoid
labrum. If I am repairing tendon to tendon, I may use
No. 1 PDS or No. 1 Prolene instead of No. 2 Ethibond.
I use 3-0 Monocryl for the subcutaneous skin closure
of portal incisions.
Figure 2-77 Close-up of shaver.
Power Instruments
Relatively few power instruments are needed. I use 4- and
5-mm shavers, a 4-mm round bur, and a 5.5-mm
acromionizer bur. I occasionally use a 4.5-mm
acromionizer bur during abrasion arthroplasty for arthri-
tis or for coracoid preparation during an arthroscopic
Latarjet procedure. The 4-mm shaver and round bur are
used within the glenohumeral joint for glenohumeral
instability and SLAP repair, and I use a power drill
to predrill the bone anchor holes for these repairs. I use
Figure 2-78 Electroblade.
the larger shaver to remove bursal tissue during arthro-
scopic subacromial decompression, and I use the acro-
mionizer for acromioplasty. I use the round bur within
the subacromial space to prepare the rotator cuff repair
site. A new instrument that is useful is the Electroblade
(Smith-Nephew Endoscopy)—a power shaver with cau-
tery connected to it. This is helpful when débriding in
the subacromial space. When a bleeding vessel is
encountered, rather than removing the shaver and
inserting the cautery, the surgeon can merely identify
Figure 2-79 Close-up of Electroblade.
the vessel and step on the electrocautery pedal. The
Electroblade is extremely helpful during synovectomy
for rheumatoid arthritis, resection of the rotator interval
during capsular contracture release, and rotator cuff
repair when medical contraindications prevent an inter-
scalene block and the bleeding is thus a bit more robust
(Figs. 2-76 through 2-87). Figure 2-80 Round bur.
Figure 2-85 Close-up of acromionizer bur.
Figure 2-81 Close-up of round bur.
Figure 2-86 Less aggressive oval bur.
Figure 2-82 Close-up of round bur.
Figure 2-83 Acromionizer bur.

Figure 2-87 Close-up of oval bur.
Cannulas
The metal cannula I use for the arthroscope has ports for
inflow, outflow, and pressure. In addition to the metal
cannula and blunt trocar for the arthroscope, I consider
three plastic, translucent cannulas vital when I perform
arthroscopic reconstructive shoulder surgery. During
anchor insertion or knot tying, I often use a cannula to
prevent adjacent soft tissue from interfering with the
Figure 2-84 Close-up of acromionizer bur. procedure. Because the cannula is translucent, I can
insert an anchor or tie a knot even with the cannula

covering the involved area. An 8-mm cannula is large
enough to accommodate the power tools and the large
suturing instruments; larger cannulas (8.5 and 10 mm)
are also available. A 5.5-mm cannula is used for the
anterior-superior portal during glenohumeral recon-
struction or SLAP repair because it is large enough to
accept the 4-mm round bur. I also place it anteriorly
during rotator cuff repair to act as both an outflow
cannula and a retrieval cannula for the bone anchor
sutures (Figs. 2-88 and 2-89).
Figure 2-90 Electrocautery.
Figure 2-88 Eight-mm cannula.
Figure 2-91 Close-up of electrocautery.
Figure 2-89 Five-and-one-halfmm cannula.
Figure 2-92 Close-up of electrocautery.

Thermal Instruments
I use two types of thermal instruments during shoulder
Fluid Management
arthroscopy. The first instrument can cauterize or
ablate tissue. I use the ablation setting during arthro- An arthroscopic pump system for delivering fluid
scopic subacromial decompression to remove soft to the shoulder is a valuable asset. A pump system
tissue from the undersurface of the acromion, and eliminates the need to hang bags of irrigating
I use the coagulation setting to control bleeding fluid high above the floor and allows the surgeon
from branches of the coracoacromial artery or from to increase pump pressure and flow rate when bleed-
vascularized bursal tissue. I prefer a probe that has ing is encountered. I use lactated Ringer’s solution.
suction attached so that the bubbles produced during I do not use epinephrine because I find it provides
ablation or coagulation are removed from the operative no major improvement in visualization. If a surgeon
field. The second instrument is the Electroblade, the considers epinephrine helpful, I advise adding it to
combination shaver and cautery described earlier every other bag of Ringer’s solution to minimize any
(Figs. 2-90 through 2-92). potential cardiotoxic effects.
Transfer Rods
in the operative notes. They have the added advantage
Surgeons who prefer to create portals with the inside- of documenting normal findings that surgeons
out technique will find the Wissinger rod useful commonly omit from the operative record. Most
(described in Chapter 3). Switching rods are blunt arthroscopy systems have the ability to take photo-
on both ends and are used to maintain the cannula graphs during surgery with the use of a foot switch
position when the arthroscope is moved from one or a control button on the camera. The photographs
position to another (Figs. 2-93 through 2-95). can be printed directly or stored on recordable media
or on a computer hard drive.
Since I began performing shoulder arthroscopy
I have also made video recordings of the operations.
Typically I save approximately 30 to 45 seconds
of each video; this includes the lesions found at oper-
ation and their appearance after correction. The video
Figure 2-93 Wissinger rod. is captured in MPEG format.
I create an electronic folder with the patient’s name
and save the still photos and the video in it. When
patients are doing either very well or very poorly post-
operatively, it is helpful to review these records to rec-
ollect the details of the operation. I do not routinely
provide patients with copies of photographs or videos,
but I do so if they request it.
DEDICATED TEAM
Figure 2-94 Handle of Wissinger rod.
I cannot emphasize enough the advantages of having
a trained, dedicated operating room team (Fig. 2-96).
Reconstructive shoulder arthroscopy is complicated,
and it is helpful when the scrub nurse, assistant, and
circulating nurse can perform their jobs without
instruction from the surgeon. The surgical nurse can
load the Caspari or Spectrum suture instruments so
that they are ready for the next step, clean the shavers
and burs so that they function appropriately, and have
Figure 2-95 Tip of Wissinger rod. the next instrument ready so that the operation runs
smoothly.
Anchors
I most commonly use 5-mm metallic TwinFix anchors
for rotator cuff repair and the BioRaptor for glenohu-
meral joint instability and labrum repair. I have
recently started to use the KINSA knotless system
and the Arthrex Suture Bridge when appropriate.
For patients with superior 25% to 33% subscapularis
insertion tears, the QuickT is extremely efficient.
It passes directly through the tissue and is secured
with a special knot pusher; no knot tying is necessary.
Photography and Video Recording

I find it extremely helpful to take intraoperative
photographs. They record the lesions found during
the operation more precisely than the description Figure 2-96 World’s best operating room team.
CHAPTER
3
Diagnostic Arthroscopy and
Normal Anatomy
Only with an understanding of normal glenohumeral For instance, posterior portal placement for an
joint and subacromial space anatomy can the surgeon acromioclavicular joint resection differs from that
appreciate which structures are damaged. for a superior labrum anterior to posterior (SLAP)
lesion repair. There are no absolute rules, but there
are a number of guidelines that I find helpful.
DIAGNOSTIC GLENOHUMERAL The most reliable landmarks are bone. Anteriorly, I
ARTHROSCOPY outline the coracoid process, the acromioclavicular
joint, and the anterior acromion. Laterally, I identify
Portal placement is critical, and I take sufficient time the lateral acromial border, and posteriorly, I outline
to mark the portal sites precisely. Draw the bone out- the posterior acromion. The most important landmark
lines of the acromion, distal clavicle, and coracoid is the posterolateral corner of the acromion, which
with a surgical skin marker. Be careful to draw not can be palpated even in large patients. I base my mea-
the most superficial bone landmarks but rather their surements on this point (Fig. 3-3).
inferior surfaces (which takes into account bone thick-
ness), because portal entry points are referenced from
Posterior Portals
these surfaces (Figs. 3-1 and 3-2).
Although trocar entry into the glenohumeral Traditionally, surgeons describe the location of the
joint is simple and almost intuitive for an expert, posterior portal as being in the ‘‘soft spot’’ approxi-
surgeons new to arthroscopy may find joint entrance mately 2 cm inferior and 2 cm medial to the postero-
difficult. The standard advice to ‘‘start in the soft spot lateral acromial edge. Although this location is
and aim for the coracoid’’ is only slightly helpful. adequate for glenohumeral joint arthroscopy, it is
Actual joint entry requires precision, and even small not optimal for subacromial space operations. If you
deviations of 3 to 5 mm from the desired portal loca- make the incision in the traditional soft spot, you will
tion make the operation more difficult. An additional enter the joint parallel to the glenohumeral joint line
complication is that portals vary from patient to and slightly superior to the glenoid equator. This site
patient because they are related to the patient’s posi- allows you to enter and visualize the glenohumeral
tion on the operating table as well as his or her size, joint adequately, but you will be at a disadvantage if
rotundity, and kyphosis. The ideal portal location you try to use the same incision to enter the subacro-
changes throughout the operation as soft tissue swell- mial space. Once you insert the cannula into the sub-
ing increases and alters the local anatomy. Portal acromial space, the soft-spot portal directs the cannula
placement is also affected by the underlying diagnosis. superiorly and medially and causes two problems.
64
Chapter 3 Diagnostic Arthroscopy and Normal Anatomy 65
Figure 3-3 Posterolateral acromial corner.
and 1 cm medial to the posterolateral acromion. The

more superior and lateral location minimizes the
aforementioned difficulties. The superior entry
allows the cannula to enter the subacromial space
immediately beneath the acromion, parallel to its
Figure 3-1 Bone landmarks. undersurface. This maximizes the distance between
the arthroscope and the rotator cuff, allowing a
better appreciation of rotator cuff lesions. The superior
First, because the arthroscopic view is now directed position (parallel to and immediately inferior to the
medially, the lateral insertion of the rotator cuff is acromion) also facilitates acromioplasty because the
more difficult to visualize. Second, the superior angle surgeon is afforded a better view of the acromial
of the arthroscope makes it difficult to ‘‘look down’’ shape. The more lateral position (immediately
on the rotator cuff tendons and appreciate the geom- medial to the lateral acromion) places the arthroscope
etry of rotator cuff lesions. One solution to this prob- in line with the rotator cuff tendon insertion. I can
lem is a second posterior portal, but I prefer to alter adequately visualize the glenohumeral joint with
the posterior portal’s location (Fig. 3-4). this more lateral portal, and given that only a brief
As noted, the exact location of the posterior por- inspection is usually needed, I find this approach
tal varies with the clinical diagnosis. For rotator cuff satisfactory.
repairs and subacromial decompressions, I make the
posterior incision for the portal in a more superior
and lateral position, approximately 1 cm inferior
Figure 3-4 Posterior portal in a more superior and lateral

Figure 3-2 Superior and inferior bone edges (arrows). position (rather than in the soft spot) for subacromial surgery.
Superior
Superior entry
Inferior entry
Figure 3-7 Superior-lateral portal for acromioclavicular joint

resection.
Inferior
Lateral Portals
Figure 3-5 Glenohumeral joint space.
I do not routinely use a lateral subacromial portal
during diagnostic glenohumeral joint arthroscopy.
More commonly, I use a lateral portal during arthro-
scopic subacromial decompression and rotator cuff
For operations restricted to the glenohumeral joint, repair and discuss its placement in more detail in the
such as a Bankart or SLAP repair, I enter the joint more applicable chapters. Briefly, I mark the portal location
medially than for those operations involving primarily with a skin marker 3 to 5 cm distal to the lateral acro-
the subacromial space, such as a rotator cuff repair mial border and 1 to 3 cm posterior to the anterior
(Figs. 3-5 and 3-6). If I am performing an acromiocla- acromion. I regard this mark as only an approxima-
vicular joint resection, I move the posterior incision 5 tion. Once I have entered the subacromial space by
mm more laterally to obtain a better view of the distal placing the arthroscope through the posterior portal,
clavicle (Fig. 3-7). I identify the exact location of the lateral portal with a
spinal needle before I incise the skin. I occasionally
use two additional lateral portals during rotator cuff
repair. An anterolateral or posterolateral portal may
be required to retrieve sutures during the repair of a
massive rotator cuff tear. These portals are positioned
midway between the anterior and lateral or posterior
and lateral portals, respectively, and are identified
with the use of a spinal needle (Figs. 3-8 and 3-9).
Anterior Portals
There are four basic anterior portals: anterior-inferior,
anterior-superior, lateral, and medial (Figs. 3-10 and
3-11). The anterior-inferior and anterior-superior por-
tals are used for glenohumeral reconstruction or SLAP
repair. I use the lateral portal during rotator cuff repair
and the medial portal for acromioclavicular joint
resection. I mark the anterior-inferior portal 5 mm
lateral to the coracoid; the anterior-superior portal is
then located 1.5 cm lateral and 1 cm superior to the
Figure 3-6 Superior-medial portal for glenohumeral joint anterior-inferior portal. The lateral portal is 2 to 3 cm
surgery. distal to the anterior acromion and parallel with its
Figure 3-8 Midlateral portal for arthroscopic subacromial

decompression.
lateral border. The medial portal is 1 to 3 cm distal to

the acromioclavicular joint. Again, these marks are
only approximations; the exact portal sites are identi-
fied during arthroscopy with a spinal needle. For a
glenohumeral reconstruction or SLAP repair, I make
the posterior portal 2 cm medial and 1 to 1.5 cm Figure 3-10 Anterior-inferior and anterior-superior portals
for glenohumeral reconstruction.
inferior to the posterolateral acromial border.
rotation with the arm abducted 90 degrees. I then

Physical Examination
examine the shoulder for stability by applying ante-
Because a patient’s pain on physical examination may rior, posterior, and inferior force while changing the
cause the surgeon to underestimate the range of positions of abduction and rotation (Figs. 3-12
motion or stability of the shoulder, I examine both through 3-20).
shoulders after the induction of anesthesia. I record
the range of motion in elevation, in external rotation
Arthroscopic Procedure
with the arm adducted, and in external and internal
I incise only the skin and avoid plunging the knife
into the underlying structures. Superficial skin nerves
Figure 3-11 Anterior-medial portal for acromioclavicular

Figure 3-9 Anterior and posterior lateral portals. joint resection.
Figure 3-14 External rotation in abduction with anterior

stress.
Figure 3-12 Elevation.
are susceptible to neuroma formation, and muscle posteriorly against the trocar tip, you can tell by
bleeding unnecessarily complicates the procedure. I palpation whether the bone is the glenoid or the
do not insufflate the joint with a needle because I humeral head. Alternatively, you can grasp the fore-
can better determine the entry point into the gleno- arm and rotate the shoulder; if you feel the bone
humeral joint with the more rigid trocar. I use only a rotate, the trocar tip is resting against the humeral
blunt-tipped trocar in shoulder arthroscopy and head and you must direct the arthroscope medially
advise surgeons never to use a sharp trocar.
To begin, insert the cannula and trocar through
the skin incision and gently advance them through
the deltoid muscle until bone resistance is felt. With
your opposite hand pushing the humeral head
Figure 3-15 Internal rotation in abduction in the coronal

Figure 3-13 External rotation. plane.
Figure 3-19 Inferior stress.
Figure 3-16 Internal rotation in abduction in the scapular to enter the joint. If no rotation is felt, the trocar is
plane. touching the glenoid and you must direct it laterally
to enter the joint. When the trocar tip is at the joint
line, a slight lateral movement allows you to palpate
the head, and a slight medial movement results in
contact with the glenoid. The posterior joint line is
medial to the posterolateral acromion, and the direc-
tion of entry is generally oriented toward the tip of
the coracoid. Angle the cannula slightly superiorly
and advance it into the joint. Usually a distinct
‘‘pop’’ is felt as the trocar enters the glenohumeral
joint. Remove the trocar, insert the arthroscope
through the cannula, and begin the diagnostic
inspection. If you have not entered the joint,
remove the cannula and trocar to check the bone
landmarks drawn on the skin (Fig. 3-21).
Figure 3-17 Sulcus test in internal rotation.
Figure 3-18 Sulcus test in external rotation. Figure 3-20 Posterior stress.
Table 3-1 DIAGNOSTIC EXAMINATION

OF THE SHOULDER
Anterior View—Arthroscope in Posterior Cannula

Biceps-labrum complex
Biceps tendon
Biceps exit from the joint
Anterior articular surface of supraspinatus
Superior glenohumeral ligament
Rotator interval
Subscapularis tendon
Subscapularis recess
Middle glenohumeral ligament
Anterior labrum
Anterior-inferior glenohumeral ligament
Inferior labrum
Inferior capsule
Posterior-inferior glenohumeral ligament
Posterior labrum
Figure 3-21 Bone palpation with trocar.
Infraspinatus tendon
Posterolateral humeral head
Diagnostic and Normal
Anatomy Posterior View—Arthroscope in Anterior Cannula
Posterior glenoid labrum
Posterior capsule
Brachial Plexus Posterior rotator cuff (site of internal impingement)
Dissection—Cadaver
Subscapularis recess
The diagnostic examination of the shoulder is system- Middle glenohumeral ligament and its humeral
atic to ensure that no lesions are overlooked. The plan attachment
described in Table 3-1 can serve as a guide. Anterior-inferior glenohumeral ligament and its
Once you have entered the glenohumeral joint, humeral attachment
identify the biceps tendonlabrum complex and
rotate the camera to orient the glenoid on the monitor
screen. Some surgeons prefer the glenoid oriented ver- anterior cannula is introduced, it passes through the
tically so that it is similar to its position with the rotator interval and alters the local anatomy. The rota-
patient standing or seated in the beach-chair position tor interval may appear normal in subacromial impin-
or on an anteroposterior radiograph. Other surgeons gement, contracted in patients with shoulder stiffness,
prefer to orient the glenoid so that it appears parallel and widened or lax in patients with glenohumeral
to the floor. Neither technique is superior; it is a instability (Figs. 3-24 through 3-30).
matter of surgeon preference (Figs. 3-22 and 3-23). There are two basic techniques to establish an ante-
Advance the arthroscope into the joint and rotate rior portal: inside out or outside in. To establish the
it so that it is looking at the 1-o’clock position relative anterior portal with the inside-out technique, advance
to the glenoid surface. Inspect the rotator interval the arthroscope until it is in the middle of the trian-
and superior glenohumeral ligament. Apply inferior gular space bordered by the glenoid rim, the superior
distraction and observe the tension that develops. border of the subscapularis tendon, and the biceps
Distract the arm with the shoulder externally rotated tendon. Press the arthroscope against the rotator inter-
and internally rotated and note any difference. Perform val and hold the cannula in position while you
this portion of the examination first because when the remove the arthroscope from the cannula. Insert a
Figure 3-22 Glenohumeral joint, vertical orientation. Figure 3-25 Rotator interval—normal superior glenohumer-
al ligament.
Figure 3-26 Rotator interval—prominent superior glenohu-

Figure 3-23 Glenohumeral joint, horizontal orientation. meral ligament.
Figure 3-27 Partial tear in the superior glenohumeral

Figure 3-24 Rotator interval. ligament.
blunt-tipped rod (Wissinger) through the cannula and

advance it through the capsule until it tents the skin
anteriorly. Maintain pressure on the rod and make a
skin incision directly over its tip. Advance the rod
anteriorly so that it projects 5 to 10 cm. Slide a
second cannula over the rod tip anteriorly and
advance this cannula into the joint until you can feel
the two cannulas touch each other. Remove the rod
and reinsert the arthroscope into the posterior cannula.
Adjust the anterior cannula until 15 to 20 mm is visible
within the joint. Outflow can remain connected to the
arthroscope cannula or it can be moved to the anterior
cannula, as desired. I used this technique early in my
arthroscopic experience because it enabled me to reli-
ably enter the glenohumeral joint. As I began doing
Figure 3-28 Contracted rotator interval. more reconstructive shoulder operations, I discovered
some inadequacies with this approach. The inside-out
approach allows variability in the precise entry spot for
the anterior portal because there is some inevitable
manipulation of the arthroscope during the necessary
sequence of maneuvers. For glenohumeral joint recon-
struction for instability, I need two anterior cannulas,
and their positions are critical. If the inferior cannula is
too superior, there will not be enough space for the
anterior-superior cannula. If the cannulas are too
medial or too lateral, anchor insertion is complicated,
and suture placement is compromised. For these rea-
sons, I now establish the anterior portals with an out-
side-in approach.
To establish the anterior portal with the outside-in
technique, point the arthroscope at the rotator inter-
val and use your index finger to push on the skin of
the anterior shoulder lateral and superior to the cora-
coid process. Observe where your finger indents the
anterior capsule and move that location until the
Figure 3-29 Widened rotator interval.
anterior capsule is indented in the middle of the rota-
tor interval. Note this location on the anterior shoul-
der with a marking pen and then use a spinal needle to
enter the joint at this point. I prefer to place the ante-
rior cannula immediately superior to the superior
border of the subscapularis tendon and 1 cm lateral
to the glenoid surface. Note the angle that the needle
makes with respect to the patient’s anterior shoulder.
Remove the spinal needle, make a small incision, and
place the cannula and trocar into the joint. As with the
inside-out technique, outflow can remain connected
to the arthroscope cannula or it can be moved to the
anterior cannula (Figs. 3-31 through 3-33).
Rotate the arthroscope so that it is pointed at
1 o’clock for a right shoulder (11 o’clock for a left
shoulder). Advance it anteriorly and inspect the
subscapularis recess and the superior border of the
subscapularis tendon. Rotate the arthroscope until it
Figure 3-30 Rotator interval synovitis. is pointed at 3 o’clock (9 o’clock for a left shoulder),
Figure 3-34 Thick middle glenohumeral ligament.

Figure 3-31 Entry point for anterior-inferior cannula.
advance it anteriorly, and inspect the anterior labrum

and the middle glenohumeral ligament. The normal
opening of the foramen at the anterior-superior
labrum should not be confused with a Bankart
lesion. Observe the anterior labrum for signs of gleno-
humeral instability such as fraying, tearing, or separa-
tion from the glenoid. Insert a probe through the
anterior cannula and test the anterior labrum’s attach-
ment to the glenoid. Use the probe to test the tension
of the middle glenohumeral ligament. Translate the
humeral head anteriorly, inferiorly, and posteriorly
and observe the tension that develops in the ligament.
Perform these maneuvers with the arm internally
and then externally rotated. The middle glenohumeral
ligament has a variable appearance and may be
poorly defined, prominent, or cordlike (Figs. 3-34
Figure 3-32 Cannula and trocar entry. through 3-45).
Figure 3-33 Trocar removed. Figure 3-35 Broad middle glenohumeral ligament.
Figure 3-36 Middle glenohumeral ligament with the sub- Figure 3-39 Cordlike middle glenohumeral ligament.
scapularis poorly defined.
Figure 3-37 Partial tear in the middle glenohumeral Figure 3-40 Subscapularis.
ligament.
Figure 3-38 Cordlike middle glenohumeral ligament. Figure 3-41 Subscapularis.

Figure 3-42 Subscapularis with a synovial tear. Figure 3-45 Subscapularis recess.
Rotate the arthroscope until it is pointed at

5 o’clock and inspect the anterior-inferior labrum
and glenohumeral ligament. Test their tension and
insertion integrity as described earlier.
Move the arthroscope inferiorly and note the pres-
ence or absence of a ‘‘drive-through sign.’’ This sign
describes the ease with which the arthroscope passes
between the humeral head and the glenoid surface at
the 6-o’clock position. Remember that the drive-
through sign is a measure of glenohumeral laxity or
translation and is not an indication of glenohumeral
instability per se. Observe the laxity of the inferior
capsule as the shoulder is distracted inferiorly, later-
ally, and then rotated. Determine whether there is an
inferior labral lesion and carefully inspect the humeral
attachment of the inferior capsule for signs of trauma
Figure 3-43 Subscapularis with a partial tear in the superior
border. (Figs. 3-46 through 3-56).
Return the arthroscope to the biceps-labrum com-
plex. To view the posterior labrum adequately from a
posterior cannula, you must maximize the distance
Figure 3-44 Subscapularis with a partial tear in the superior

border. Figure 3-46 Rotate the arthroscope.
Figure 3-47 Anterior-inferior glenohumeral ligament. Figure 3-50 Axillary recess.
Figure 3-48 Anterior-inferior glenohumeral ligament less Figure 3-51 Inferior-posterior capsule.
well defined.
Figure 3-52 Palpate the anterior-inferior glenohumeral

Figure 3-49 Anterior-inferior capsule. ligament.
Figure 3-53 Palpate the inferior capsule. Figure 3-56 Posterior labrum, with the arthroscope
posterior.
from the arthroscope to the labrum. This requires that

you withdraw the arthroscope until it is immediately
anterior to the posterior capsule. As a novice, I would
repeatedly pull the arthroscope completely out of the
joint. My technique to minimize (but not eliminate)
the problem is as follows: Rotate the objective lens of
the arthroscope so that it is pointed to the 6-o’clock
position. Pinch your index finger and thumb around
the cannula where it exits the skin. This increased sen-
sory feedback helps you control the distance the can-
nula moves and gives you immediate control. Gently
withdraw the arthroscope as posteriorly as possible to
obtain the best view of the biceps-labrum complex
Examine the biceps tendon and use an instru-
Figure 3-54 Inferior-posterior labrum. ment to draw the intra-articular portion into the joint
and inspect it for inflammation or tearing. Carefully
examine the anterior and posterior pulleys for
Figure 3-57 Pinch the cannula and withdraw the

Figure 3-55 Posterior-inferior labrum. arthroscope.
Figure 3-58 Rotate the arthroscope.

Figure 3-60 Biceps tendon synovitis.
signs of trauma that may indicate biceps tendon insta-
bility. Follow the biceps tendon to its joint exit.
Adhesions may exist between the biceps tendon and
the supraspinatus tendon; these may be either congen-
ital or post-traumatic (Figs. 3-60 through 3-78).
Rotate the arthroscope so that it is pointed to
6 o’clock. Follow the posterior labrum from superior
to inferior and note any labrum separation, fraying, or
tears. Continue inferiorly until you can see the poster-
ior-inferior glenohumeral ligament. Internally rotate
the arm and observe the normal tightening of this
ligament.
Introduce a probe from the anterior portal and eval-
uate the biceps-labrum complex. Often, a SLAP lesion
is obvious, but sometimes probing is necessary.
Abduct and externally rotate the shoulder to see
whether the superior labrum peels off the glenoid
(Figs. 3-79 through 3-85). Adhesions may exist
between the biceps tendon and the rotator cuff; Figure 3-61 Biceps tendon exiting from the glenohumeral
joint.
these too may be either congenital or post-
traumatic (Figs. 3-86 and 3-87).
Figure 3-59 Biceps-labrum complex. Figure 3-62 Biceps tendon entering the bicipital groove.
Figure 3-63 Bicipital groove. Figure 3-66 Bordering ligament, anterior pulley.
Figure 3-64 Bicipital groove. Figure 3-67 Partial biceps tendon tear.
Figure 3-65 Bicipital groove, with synovial lining. Figure 3-68 Partial biceps tendon tear.
Figure 3-72 Introduce the shaver.

Figure 3-69 Partial biceps tendon tear.
Figure 3-73 Lateral to biceps.

Figure 3-70 Partial biceps tendon tear.
Figure 3-71 Partial biceps tendon tear. Figure 3-74 Medial to biceps.
Figure 3-78 Extra-articular biceps tendon synovitis.

Figure 3-75 Pull the extra-articular biceps tendon into the
glenohumeral joint.
Figure 3-76 Pull the extra-articular biceps tendon into the Figure 3-79 Normal superior labrum.
glenohumeral joint.
Figure 3-77 Pull the extra-articular biceps tendon into the

glenohumeral joint. Figure 3-80 Minor fraying of the superior labrum.
Figure 3-81 Minor separation of the superior labrum. Figure 3-84 SLAP lesion continuing into the anterior-superior
labrum.
Figure 3-85 Normal anterior-superior labral foramen.

Figure 3-82 Probe for separation.
Figure 3-83 SLAP lesion. Figure 3-86 Bicepsrotator cuff adhesion.

Figure 3-87 Bicepsrotator cuff adhesion.

Figure 3-88 Anterior supraspinatus.
Move your hand and the camera toward the floor

to point the arthroscope superiorly and view the
rotator cuff tendons. Abduct and externally rotate
the shoulder until you see the anterior supraspina-
tus that is marked anteriorly by the biceps tendon.
The anterior margin of the supraspinatus forms the
posterior biceps tendon pulley. Move the camera
medially and inferiorly (so that the arthroscope tip
moves laterally and superiorly) and follow the cuff
insertion from its anterior to posterior margins. At
the same time, abduct and rotate the humeral head
so that the arthroscope follows the cuff insertion
from anterior to posterior. Note the insertion of
the supraspinatus into the footprint area. There
should be no exposed bone between the articular
margin of the humeral head and the supraspinatus
Figure 3-89 Anterior supraspinatus.
tendon insertion. Partial articular surface tears can
be diagnosed by observing the amount of exposed
bone in millimeters between the remaining tendon
and the articular margin. The infraspinatus does not
insert at the articular margin, and exposed bone in
this area is normal. The small holes in the humeral
head near the posterior cuff are normal vascular
channels.
When you identify the posterior cuff insertion,
tilt the arthroscope inferiorly and continue to exter-
nally rotate the shoulder. You can now see the pos-
terolateral humeral head and document the presence
or absence of a Hill-Sachs lesion. Withdraw the
arthroscope slightly so that the lens does not
scrape against the humeral head and allow it to
return to the biceps tendonlabrum complex
Inspect the cartilage on the humeral head and gle-
noid for signs of osteoarthrosis, such as eburnation Figure 3-90 Articular surface of a partial-thickness rotator
and cobblestoning. The cartilage is normally thin in cuff tear of the supraspinatus.
Figure 3-91 Full-thickness supraspinatus tear. Figure 3-94 Posterior supraspinatus.
Figure 3-92 Mid-supraspinatus. Figure 3-95 Posterior supraspinatus.
Figure 3-93 Midposterior supraspinatus. Figure 3-96 Infraspinatus.

Figure 3-97 Capsular reflection. Figure 3-100 Bare area.
the central glenoid, and this should not be confused

with osteoarthrosis (Figs. 3-102 through 3-107).
Remove the arthroscope from the posterior cannula,
reinsert it in the anterior cannula, and again inspect
the posterior labrum, capsule, and posterior rotator
cuff. Move the arm into abduction and external rota-
tion, and evaluate the shoulder for internal impinge-
ment between the posterior-superior labrum and the
posterior cuff and capsule. Observe the normal pear
shape of the glenoid from this perspective. The glenoid
widens inferiorly. Loss of this pear shape corresponds
to bone loss in the anterior-inferior glenoid and may be
seen in patients with glenohumeral instability (Figs. 3-
108 through 3-111).
This completes the routine inspection of the
glenohumeral joint. Withdraw both cannulas and
Figure 3-98 Bare area. proceed to the subacromial space.
Figure 3-99 Vascular channels. Figure 3-101 Shallow Hill-Sachs lesion.

Figure 3-102 Anterior glenoid cartilage loss. Figure 3-105 Humeral head cartilage tear.
Figure 3-103 Anterior glenoid cartilage loss. Figure 3-106 Full-thickness cartilage loss.
Figure 3-104 Osteoarthrosis of the glenoid. Figure 3-107 Osteoarthrosis of the humeral head.
Figure 3-108 Posterior-superior labrum. Figure 3-111 Posterior-inferior glenohumeral ligament.
DIAGNOSTIC SUBACROMIAL SPACE

ARTHROSCOPY
The diagnostic examination of the subacromial space

is systematic to ensure that no lesions are overlooked.
The plan described in Table 3-2 can be used as a guide.
The subacromial space is a pseudoarticulation that
permits gliding between the proximal humerus and
the coracoacromial arch. Arthroscopic experience has
allowed us to define the subacromial space, which has
well-defined borders when cleared of the hypertrophic
bursal tissue associated with chronic subacromial
impingement. The arthroscopic subacromial space
begins halfway back from the anterior acromion, and
posterior entry requires the surgeon to penetrate a veil
or curtain of bursal tissue that separates the anterior
Figure 3-109 Posterior labrum and gutter.
Table 3-2 DIAGNOSTIC EXAMINATION OF

THE SUBACROMIAL SPACE
View from Posterior Portal

Acromial undersurface
Coracoacromial ligament
Anterior bursa
Supraspinatus insertion into greater tuberosity
Subdeltoid adhesions
Acromioclavicular joint
View from Lateral Portal

Posterior rotator cuff
Posterior bursa
Rotator interval
Figure 3-110 Inferior-posterior labrum.
Figure 3-113 Palpate the anterior acromion with the

trocar tip.
Rotate the arthroscope so that it is directed toward

the acromion, and determine whether there are
any alterations in the coracoacromial ligament or
the acromion (Figs. 3-113 and 3-114).
Now orient the arthroscope lens so that it is point-
Figure 3-112 Bursa anatomy.
ing directly down at the rotator cuff. If you maneuver
the shoulder through a range of motion and rotate the
arthroscope, you will obtain a view of the superior
from the posterior space. Anterior, posterior, and lat- portion of the subscapularis, the supraspinatus, and
eral gutters can be defined. The medial confines are the superior portion of the infraspinatus. If you
below the acromioclavicular joint, and exposure of desire a better view of the posterior rotator cuff or if
the lateral clavicle requires resection of thick fibrofatty you cannot see clearly, establish a lateral portal.
and vascular tissue. The lateral wall lies beyond the Identify the precise location of the lateral portal with
greater tuberosity, and the anterior margin is the ante- a spinal needle. Introduce the needle percutaneously
rior acromial border (Fig. 3-112). until it is 1 to 2 cm posterior to the anterior acromion
It is often difficult to visualize the subacromial and located midway between the acromion and the
space owing to reactive bursitis and fibrosis. When rotator cuff. The lateral cannula should enter the sub-
you have difficulty visualizing the subacromial space, acromial space parallel to and immediately beneath
it is usually because the arthroscope is positioned too the inferior surface of the acromion. The distance
far posteriorly. It is helpful to position the arthroscope
anteriorly in the subacromial space to minimize the
effect of the bursal tissue located posteriorly within
the space.
Use the same posterior skin incision to enter the
subacromial space. Place the trocar and cannula
through the skin incision and palpate the posterior
edge of the acromion. Slide immediately beneath the
bone and advance the trocar and cannula anteriorly.
The cannula should remain in contact with the
acromion. With your other hand, palpate the anterior
acromion and advance the trocar beyond the anterior
acromion until you can feel the trocar tip. Withdraw
the trocar until it is just posterior to the anterior
acromion. Usually you can palpate the coracoacromial
ligament. Maintain the cannula position while
you remove the trocar and insert the arthroscope. Figure 3-114 Lateral cannula location too anterior.
between the incision and the lateral acromial border

varies, depending on the patient’s size; in general,
place the lateral portal 2 to 3 cm distal to the lateral
acromial border.
If you still cannot see well, advance the arthroscope
anteriorly to free it of any surrounding bursal tissue
and then withdraw it posteriorly until the acromion is
visualized. If visualization remains poor, I have found
a triangulation technique helpful. Insert the cannula
and trocar as described earlier. Create a lateral portal
by incising the skin 1 to 2 cm posterior to the antero-
lateral acromial border. The distance between the inci-
sion and the lateral acromial border varies, depending
on the patient’s size; in general, place the lateral portal
2 to 3 cm distal to the lateral acromial border. The
lateral cannula should enter the subacromial space Figure 3-115 Subacromial space obscured.
parallel to and immediately beneath the inferior sur-
face of the acromion. Insert a cannula and trocar
through the lateral portal and, with one hand holding to help with orientation. Use the resector to remove
each, position them so that they touch each other. bursal tissue until you can see clearly. If the shaver is
Often you can sense bursal tissue interposed between on the rotator cuff, direct the shaver blade superiorly
the two cannulas. Rub them together to remove the to avoid causing damage. Direct the shaver blade
bursal tissue until you feel the two cannulas making inferiorly when you are working near the acromion.
direct contact. Advance the lateral cannula medially Be careful not to contact the cuff or the acromion with
until it is past the tip of the posterior trocar. Push the the resector, because this will alter the subacromial
posterior trocar until it is in direct contact with the space anatomy (Figs. 3-115 through 3-120).
lateral cannula. Press both cannulas together, remove Once you can see clearly, perform a diagnostic
the trocar from the posterior cannula, and insert the inspection of the subacromial space. Observe the acro-
arthroscope. You should now be looking directly at mion and the coracoacromial ligament for signs of
the lateral cannula. impingement such as fraying or erythema. Rotate
Remove the lateral trocar and insert a motorized the arthroscope so that it looks directly at the rotator
soft tissue resector. Palpate the acromion above cuff; at the same time, move the arthroscope tip super-
and the rotator cuff below with the resector tip iorly to maximize the distance between the
A B
Figure 3-116 A, Palpate the lateral cannula with the trocar tip. B, Visualize the lateral cannula.
Figure 3-117 Withdraw the arthroscope slightly. Figure 3-120 Withdraw the lateral cannula.
arthroscope and the rotator cuff. This improves your

perception of the extent of any pathology. Signs of
impingement include fraying, fibrillation, and partial
tearing of the rotator cuff bursal surface.
Advance the arthroscope anteriorly to view the
anterior gutter. Rotate the arthroscope to observe the
lateral gutter. Move the arthroscope to the lateral
portal. This allows a better view of the subscapularis
tendon and posterior rotator cuff. If bursa is covering
the rotator cuff tendons, resect it until you can see the
tendon fibers. This completes the diagnostic examina-
tion of the glenohumeral joint and subacromial space
(Figs. 3-121 through 3-143).
Figure 3-118 Introduce the shaver.
Figure 3-119 Visualize the shaver within the lateral cannula. Figure 3-121 Rotator cuff.
Figure 3-125 Lateral gutter.

Figure 3-122 Anterior gutter.
Figure 3-123 Anterolateral gutter. Figure 3-126 Coracoacromial ligament.
Figure 3-124 Musculotendinous junction. Figure 3-127 Coracoacromial ligament fraying.

Figure 3-128 Coracoacromial ligament fraying. Figure 3-131 Os acromiale.
Figure 3-129 Spinal needle. Figure 3-132 Lateral subacromial adhesion.
Figure 3-130 Os acromiale. Figure 3-133 Resect the adhesion.

Figure 3-134 Partial-thickness rotator cuff tear in the bursal Figure 3-137 Full-thickness rotator cuff repair.
surface.
Figure 3-135 Partial-thickness rotator cuff tear in the bursal Figure 3-138 Coracoacromial ligament, with the arthro-
surface. scope in the lateral cannula.
Figure 3-136 Near full-thickness bursal, partial-thickness Figure 3-139 Rotator cuff, with the arthroscope in the lat-
rotator cuff tear. eral cannula.
Right shoulder
Figure 3-140 Rotator interval, with the arthroscope in the Figure 3-143 Rotator interval opened.
lateral cannula. A needle probes the anterior supraspinatus.
INCISIONS
I include a section on incisions here to emphasize

the many variations on the basic theme of posterior,
lateral, and anterior portals. Although the incisions
required for each procedure are discussed in the appli-
cable chapters, these discussions are separated by
many pages, and the small differences among them
may go unnoticed. These small but critical variations
among the incisions are better appreciated as the
complexity of the operation increases.
Rotator Cuff Repair

Viewing Portals
In addition to the portals already mentioned, a poster-
ior-lateral viewing portal may be necessary. Some
Figure 3-141 Rotator interval, with the arthroscope in the
patients have an increased posterior slope to the acro-
lateral cannula. A needle probes superior subscapularis.
mion, so even if the surgeon enters the subacromial
space immediately inferior to the posterolateral acro-
mion, the angle of the arthroscope is too vertical. In
other patients, the rotator cuff extends too far later-
ally; with the arthroscope in the normal posterior
portal, a tear is difficult to visualize. Moving the
arthroscope to a more lateral position improves the
surgeon’s view. Many surgeons prefer the lateral
portal as the routine viewing portal. My general pref-
erence is to view posteriorly or posterolaterally and to
insert instruments laterally. However, with larger tears
or small, complex tears, I do not hesitate to move the
arthroscope to the lateral portal if doing so results in a
better understanding of the tear’s geometry.
Instrument Portals
Additional anterior-lateral or posterior-lateral portals
may be necessary. With large or massive rotator cuff
Figure 3-142 Needle palpates the rotator interval. tears that require many more sutures than usual,
1 2
3
2
3
1
Figure 3-144 Anterior incisions for rotator cuff repair.

Figure 3-146 Posterior incisions for rotator cuff repair.
suture management is complex, and it is often neces-

sary to move sutures out of the cannulas to insert
instruments. Portals immediately lateral to the acro-
mion (with the shoulder adducted) are needed to
insert anchors medially for a double-row repair
(Figs. 3-144 through 3-146).
Acromioclavicular Joint Resection

1 2
The necessary incisions are illustrated in Figures 3-147
and 3-148.
Glenohumeral Joint Reconstruction

Viewing Portals
The posterior portal is 2 cm inferior and medial to the
posterolateral acromion. This allows parallel access
to the glenohumeral joint in the superior third of
the glenoid. This viewing portal provides access to Figure 3-147 Anterior incisions for acromioclavicular joint
resection.
the rotator interval and the anterior and inferior
areas of the glenohumeral joint. If I need to move
7 2
6 4
2 1 3
1 3
5
Figure 3-148 Lateral incisions for acromioclavicular joint

Figure 3-145 Lateral incisions for rotator cuff repair. resection.
the arthroscope to the anterior-superior portal to view

Latarjet
the posterior glenohumeral joint, I can insert instru-
ments through the posterior portal and gain access Viewing Portals
to the posterior-inferior glenohumeral joint. However, The standard glenohumeral joint portal is used for the
if I need access to the inferior-posterior glenohumeral initial examination and identification of anterior
joint, I require a second posterior portal located more lesions and for coracoid preparation. I use a lateral
inferiorly. In this situation I make my initial posterior incision placed slightly anterior to the anterior acro-
portal more superior. This leaves sufficient space to insert mion to better view the superior and inferior coracoid
a second posterior portal more inferiorly that allows surfaces, the rotator interval, the anterior scapular
access to the inferior-posterior glenohumeral joint. neck, and the insertion of the coracoid through the
subscapularis split. I use a more distal and anterior
Instrument Portals portal if the anterior scapular neck is not well visua-
I generally insert instruments through the anterior- lized. This portal is also used for visualizing the ante-
inferior portal or the routine posterior portal (Fig. rior subscapularis during the longitudinal split. An
3-149). anterior portal lateral to the coracoid is useful to
view the superior surface of the coracoid and to posi-
tion the drill holes (Fig. 3-150).
SLAP
Viewing Portals Instrument Portals
I use a routine posterior glenohumeral joint portal for The anterior-lateral portal is used for lateral coracoid
the initial inspection. I use the anterior-superior portal dissection, and the lateral-anterior portal is used for
to view the posterior-superior glenoid if I cannot see it inferior and superior coracoid dissection. I use the
clearly with the arthroscope in the posterior portal. superior coracoid portal (the haut portal of Lafosse)
for pectoralis minor release and coracoid drilling.
Instrument Portals
I establish an anterior-inferior portal for outflow and so
Suprascapular Nerve Decompression
that I can insert curved suture passers. If the anterior
at the Suprascapular Notch
portion of the SLAP lesion is at the 10- to 11-o’clock posi-
tion (for a right shoulder), I may pass a straight suture Viewing Portals
passer through the anterior-superior portal. If the SLAP I use a lateral portal in line with the posterior clavicle.
lesion extends more posteriorly, I may insert the poste- The portal is 2 cm posterior to the anterior acromion
rior suture anchor through the posterior portal. (Figs. 3-151 and 3-152).
4
2
1 3
1 2
5
Figure 3-149 Anterior incisions for glenohumeral joint

reconstruction. Figure 3-150 Latarjet anterior incisions.
4 5
2 1 3
Figure 3-151 Lateral incisions for suprascapular nerve

decompression.
Instrument Portals Figure 3-153 Anterior incisions combined.

The portal is just anterior to the anterior acromion.
The lateral-superior portal (for nerve dissection and
suprascapular ligament division) is 4 cm medial to
the medial acromion. The medial-superior portal (for
nerve retraction) is 6 cm medial to the medial
acromion.

at the Spinoglenoid Notch
Viewing Portals
The lateral-posterior portal is 4 cm inferior to the pos-
terior acromion. I also use a portal placed more ante-
rior and lateral so that I can see the scapular spine and
the spinoglenoid ligament more clearly.
Figure 3-154 Lateral incisions combined.
5
4
2
1 3
Figure 3-152 Posterior and superior incisions for suprascap-

ular nerve decompression. Figure 3-155 Posterior incisions combined.
Instrument Portals
Incision Overview
The medial-posterior portal is 4 cm medial to the lat-
eral-posterior portal. I insert a soft tissue dissector to It is interesting to see all the incisions side by side.
dissect the infraspinatus muscle from the infraspina- This emphasizes the small but significant changes
tus fossa of the posterior scapula. I insert a scissors to each surgeon makes to adapt to the particular demands
divide the spinoglenoid ligament through a portal of a specific operation (Figs. 3-153 through 3-155).
positioned along the lateral acromion.
CHAPTER
4
Glenohumeral Instability
Orthopedic surgeons have a fundamental desire to stabilization include smaller skin incisions, more com-
find a simple solution to glenohumeral instability, plete glenohumeral joint inspection, ability to treat all
leading to various operative approaches. Initially, sur- intra-articular lesions, access to all areas of the gleno-
geons observed that abduction and external rotation humeral joint for repair, less soft tissue dissection,
resulted in glenohumeral joint dislocation, and early and maximal preservation of external rotation.
operations sought to eliminate that dislocation by Arthroscopy enables surgeons to inspect the entire gle-
limiting the offending motion—external rotation. In nohumeral joint and observe lesions in the unstable
many patients, this succeeded in controlling the dis- shoulder. Concurrently, clinical and basic science
location, but some were unhappy with the loss of investigations have increased our understanding of
shoulder movement and function; others continued the pathophysiology of glenohumeral instability. We
to have instability. Subsequently, the Bankart lesion now have the background, knowledge, and technical
came to be regarded as the essential lesion, so skill to solve the problems of glenohumeral instability,
labrum repair predominated. Labrum repair opera- and the past decade has brought both exciting
tions were successful in some but not all patients, advances and better patient outcomes.
and the underlying rationale—that lesions of the
labrum were the sole cause of instability—could not
explain dislocations that occurred without such LITERATURE REVIEW
lesions. Further, as DePalma observed, many patients
had degeneration of the labrum that appeared to be an Because current treatments are directly linked to the
aging phenomenon, yet few of these patients devel- past, here I summarize the intellectual history of
oped glenohumeral joint instability. Subsequently, arthroscopic shoulder stabilization. Early arthroscopic
patients with recurrent anterior dislocations without repairs used a staple to advance the Bankart lesion
labrum detachment were treated with an anterior cap- superiorly and medially and were associated with fail-
sular tightening procedure. Again, many patients ure rates up to 30%. When immobilization was
benefited, but others continued to suffer shoulder dis- extended, the failure rate approached 10% to 15%.
location or subluxation. With the understanding that Owing to potential complications from staples
some shoulders are unstable in multiple directions within the glenohumeral joint, other surgeons used
(with or without labrum lesions), interest shifted to a transglenoid suture repair of the Bankart lesion.
global capsular tightening. The capsular shift as Early publications reported initial success rates up to
described by Neer provided a solution to this challen- 100%, but these results deteriorated with longer
ging condition. follow-up. The two essential elements of these tech-
More recently, the desire to control glenohumeral niques are passage of sutures through the avulsed
instability while retaining function for overhead labrum and then passage through drill holes in the
sports has motivated the search for new techniques scapular neck. The sutures are tied posteriorly over
involving arthroscopy. The advantages of arthroscopic soft tissue or bone.
101
102 Section Two Glenohumeral Joint Surgery
Later research and outcomes documented two with acute dislocation and found that some degree of
flaws with these approaches: the medial location of capsular damage was usually present, even with a
the repaired labrum and failure to address capsular Bankart lesion. Baker arthroscopically inspected the
laxity. Neviaser first identified the anterior labroliga- shoulders of 45 patients within 10 days of acute dis-
mentous periosteal sleeve avulsion (ALPSA) lesion in location and found that the capsule had been
shoulders with anterior-inferior glenohumeral insta- stretched or torn in all patients with or without an
bility. The detached labrum-ligament complex associated Bankart lesion. We are all indebted to
healed medially on the scapular neck, which allowed Gross, who elegantly summarized much of this
excessive humeral translation. It was apparent that information.
the staple and transglenoid suture techniques Most descriptions of arthroscopic technique have
described earlier repaired the labrum medially but omitted treatment of the rotator interval. This area
created an ALPSA lesion. Savoie examined shoulders of the glenohumeral joint capsule is the soft tissue
that had dislocated following arthroscopic stabiliza- between the superior border of the subscapularis
tion and found that the labrum had been repaired 5 tendon and the anterior edge of the supraspinatus
mm medial to the glenoid rim. He was the first to tendon and includes the superior glenohumeral liga-
point out that the attachment site of the repaired ment and a portion of the coracohumeral ligament.
ligaments was critical. Savoie subsequently modified Neer and Rowe described the role of the rotator inter-
his technique by moving the entry position of the val in open repair of shoulder instability. Rowe and
anchor from the medial scapular neck to the glenoid Zarins inspected the superior aspect of the rotator
articular surface and reported improved results with cuff and found that 20 of 37 patients undergoing oper-
the new technique. ation had a large opening in the capsule between the
Bone suture anchors enabled repair of the detached supraspinatus and subscapularis. Harryman’s labora-
labrum directly to the glenoid rim. Wolf pioneered tory studies advanced our understanding of the rota-
this approach for arthroscopic instability repairs. tor interval. He found that opening the rotator
Improved outcomes occurred as surgeons learned to interval increased inferior-posterior translation.
position the glenoid labrum correctly on the glenoid Perhaps the most subjective (and therefore difficult)
rim. Harryman and associates introduced the term type of instability treatment is capsular tensioning.
concavity-compression to explain the important role of The orthopedic community greeted thermal treatment
the labrum in glenohumeral instability. However, fur- with great interest; however, clinical application out-
ther investigation raised two questions: Was the paced basic scientific investigation. Recently we
Bankart lesion the only labrum lesion responsible for gained some appreciation of the thermal technique’s
anterior-inferior instability? Could any labrum lesion complexity, appropriate role, limitations, and compli-
or combination of labrum lesions produce glenohu- cations. Thermal treatment has been associated with
meral instability alone, without the presence of any the devastating complications of capsular necrosis,
other lesion? capsular rupture, and chondrolysis. To what degree
Rodosky described the role of the biceps-labrum the application of heat causes these problems is
complex in anterior-inferior instability. Detach- unknown, but at present, the use of thermal capsulor-
ments of the superior labrum—tear of the superior rhaphy has largely been abandoned.
labrum from anterior to posterior (SLAP lesion)—per- I believe that the high failure rates previously
formed in the laboratory allowed increased anterior reported for arthroscopic repairs were due to technical
humeral head translation. Speer also used a cadaver factors, such as medial repair of the anterior labrum, as
model to determine that although a Bankart lesion well as failure to treat all lesions that contribute to
allows increased humeral head translation, it alone glenohumeral instability. My colleagues and I have
does not result in humeral head dislocation. reported our early results, and we emphasize the fol-
Capsular stretch or elongation, along with a Bankart lowing 11 ideas.
lesion, is necessary for dislocation. Tibone empha-
sized that the rate of capsular stretch is an important 1. Glenohumeral instability occurs in several
variable because the speed of the injury may deter- directions.
mine where the capsular ligament is damaged. In a 2. These directions are classified as anterior,
laboratory study, Bigliani demonstrated that faster posterior, bidirectional (anterior-inferior or pos-
strain rates result in ligament injury, whereas slower terior-inferior), and multidirectional (inferior,
strain rates result in a higher percentage of failures at anterior, and posterior).
the ligament insertion site. Bigliani also studied the 3. The classification of direction is somewhat
tensile properties of the shoulder capsule in patients arbitrary.
Chapter 4 Glenohumeral Instability 103
4. The primary direction of instability is deter- of instability classification and stressed the need
mined through a combination of patient to address all components of glenohumeral laxity to
history, physical examination, radiographic balance the shoulder. They were the first to report
analysis, examination under anesthesia, and that an area of asymptomatic laxity must be treated
evaluation of the glenohumeral joint at the to correct symptomatic instability in another direc-
time of arthroscopic surgery. tion, whereas previous articles had focused on
5. Lesions are usually multiple. correcting the laxity in the direction of the
6. Instability in any direction may be the result of instability.
various combinations of lesions. The clinical expression of glenohumeral joint
7. The same combination of lesions may produce laxity is termed instability, and my philosophy is
instability in different directions in different that the direction or directions of instability are, to
patients. a large degree, the result of laxity in various areas
8. Instability correction requires that all lesions be of the glenohumeral capsule and insertion tears of
identified and repaired. the labrum. Other factors undoubtedly play a role.
9. It may be necessary to operate on areas of the Some of these factors require nonoperative treatment
glenohumeral joint on the side opposite the (muscular strengthening and neuromuscular condi-
primary instability to balance the shoulder tioning), and others require modification of the sur-
and prevent iatrogenic instability. gical technique, such as when anterior glenoid bone
10. Glenohumeral instability should probably be loss dictates an operation such as the Latarjet proce-
considered a single entity defined as sympto- dure. Successful arthroscopic treatment requires that
matic excessive humeral head translation. the surgeon identify the direction and degree of clin-
11. The clinical expression of this translation is ical instability preoperatively, identify the areas
variable in each individual. responsible for excessive translation arthroscopically,
and then correct all necessary areas of the glenohu-
Orthopedic surgeons use patient history, physical meral joint. A prime example of this approach is a
examination, radiographic analysis, and operative patient with recurrent posterior glenohumeral
findings to diagnose the clinical expression of gleno- subluxation. This patient likely has excessive laxity
humeral instability. Unidirectional instabilities are in the posterior-inferior capsule, but correction of
well appreciated and are generally categorized as that area alone will not necessarily control excessive
anterior or posterior. On physical examination, humeral head translation. Even though the patient
patients with multidirectional instability have symp- is not symptomatic in the direction of the rotator
toms of pain and apprehension when the shoulder is interval or the anterior-inferior glenohumeral liga-
stressed in anterior, posterior, and inferior directions. ment, tightening of both these areas is usually
Neer’s pioneering concepts were twofold: glenohu- required.
meral instability can occur in multiple directions, There are many similarities between arthroscopic
and correction of all three symptomatic directions is rotator cuff repair and arthroscopic glenohumeral
necessary. In my experience, however, there is a reconstruction, but there are also important funda-
group of patients who are symptomatic in only two mental differences. Arthroscopic rotator cuff repair
directions. There is little in the literature concerning has certain advantages over the traditional open
bidirectional glenohumeral instability—that is, infe- approach, as described in Chapter 12. Fundamen-
rior instability with either an anterior or a posterior tally, however, the primary goal of both the arthro-
component—which is a separate entity from multi- scopic and the open procedure is identical: to
directional instability and unidirectional anterior reattach the torn edge of the rotator cuff tendon
or posterior instability. Neer discussed instability to its normal point of anatomic insertion. Opera-
in two directions in his paper on multidirectional tions within the glenohumeral joint are technically
instability. Altchek described his results with opera- less demanding than those within the tight confines
tion for multidirectional instability of the anterior of the subacromial space, but arthroscopic glenohu-
and inferior types. Pollock and Bigliani specifically meral reconstruction is not a simple operation.
used the term bidirectional in their paper on recurrent Although the glenohumeral joint is better visualized
posterior shoulder instability. In a search for a unify- and the surgeon has more space to manipulate
ing approach to the many forms of glenohumeral instruments than within the subacromial space, the
instability, I found Pollock and Bigliani’s analysis less demanding technical aspects of the procedure
most helpful. In their article on anterior-inferior are offset by a greater deficit in knowledge. For
shoulder instability, they discussed the complexities example, there are no objective standards by which
Superior in anterior-inferior instability was described by Snyder

SLAP and Rodosky. Harryman reminded us of the role the
rotator interval plays in glenohumeral joint motion
Cuff Interval and translation. Morgan, Burkhart, and the Jobes pio-
neered our thinking on the influence of glenohumeral
Internal
impingement joint translation (if any) on internal impingement.
Obviously, as we learn more about the glenohumeral
Posterior Anterior
joint structures in both normal and pathologic
shoulders, surgical decision making becomes more
complex.
PIGHL AIGHL
Inferior capsule
Inferior
DIAGNOSIS
Figure 4-1 The circle concept of instability. AIGHL, anterior-
Patient History
inferior glenohumeral ligament; PIGHL, posterior-inferior
glenohumeral ligament. I collect sufficient data to rate patients according to
the American Shoulder and Elbow Surgeons (ASES)
Shoulder Index, the Constant scoring system, the scor-
ing system of Rowe, and the University of California at
to judge ligament or capsular tension, so the sur- Los Angeles (UCLA) Shoulder Scale. Recently, my
geon can only estimate the amount of tightening colleagues and I developed our own scoring system
needed. The most critical part of the procedure is that allows us to compare patients with high as well
the one that lacks objective guidelines. as low levels of shoulder function without an excessive
I have found it helpful to use a circle to concep- response burden. Before operation, all patients
tualize some of the factors involved in glenohumeral complete self-assessment questionnaires to document
joint instability (Fig. 4-1). Think of the circle in the their levels of shoulder pain, satisfaction, and
figure as a sagittal view of the right shoulder, with function.
the arrow representing the direction of anterior- To increase diagnostic precision, I classify each
inferior translation. The most common form of shoulder by chronicity, degree, and traumatic
shoulder instability occurs in the anterior-inferior onset. I document (according to the patient’s descrip-
direction, and our initial understanding was that tion) whether the instability is chronic or acute
the lesion was in the anterior-inferior portion of (< 6 weeks) and further classify the instability as recur-
the shoulder. Depending on the surgeon’s country rent dislocation, recurrent subluxation after a single
of origin, this lesion is termed the Bankart, Broca, dislocation, or recurrent subluxation without prior
or Perthes lesion. The search for this ‘‘essential’’ dislocation. I record whether the patient developed
lesion dominated research for 50 years, and other instability after a traumatic event of a magnitude
surgeons presented their clinical and laboratory sufficient to damage the glenohumeral ligaments
work questioning this idea. DePalma thought this (traumatic or atraumatic) and use guidelines similar
explanation was inadequate because he had identi- to those described by Wirth. A traumatic cause is
fied unstable shoulders without any labrum abnorm- supported by an injury with the arm forcefully
ality, as well as shoulders with labrum abnormalities abducted, externally rotated, and extended; sudden
that were stable. Nonetheless, the Bankart lesion sharp pain; the need for manipulative reduction; and
became the focus of operative repair. This thinking residual aching in the shoulder for several weeks.
persisted with few challenges until Neer and Foster’s Atraumatic instability is characterized by an insidious
article on multidirectional instability emphasized the onset or following minor trauma and is associated
importance of an inferior capsular lesion. Rowe with mild pain and a spontaneous reduction. All
and Zarins also described operative correction of a patients are questioned about arm position or activity
shoulder with anterior-inferior instability in which that reproduces their symptoms.
no Bankart lesion was found. Further investigation Additionally, I record the sports participation, if
identified the importance of the inferior-posterior any, of each patient. I classify sports according to
capsule and ligaments as additional static stabilizers, as the method described by Allain. Type 1 sports are non-
well as the importance of the rotator cuff muscles as impact and consist of breaststroke swimming, rowing,
dynamic stabilizers. The role of the superior labrum running, or sailing. Type 2 sports are high impact and
include bicycle riding, snow skiing, soccer, and water

skiing. Type 3 sports require overhead use of the arm
with hitting movments, such as crawl-stroke swim-
ming, golf, tennis, throwing, and weight lifting.
Type 4 sports involve overhead hitting movements
and sudden stops such as basketball, football, hand-
ball, ice hockey, judo, karate, kayaking, lacrosse, polo,
rodeo, volleyball, wind surfing, and wrestling. I also
record which shoulder is dominant.
Physical Examination
I measure active ranges of motion according to the
Constant rating system, which includes forward flex- Figure 4-2 Dr. Rowe examines a patient for anterior
ion, abduction, external rotation in abduction, and instability.
behind-the-back internal rotation. Passive elevation
and external rotation (with the arm adducted), as
well as external rotation and internal rotation with are effectively elevated 30 degrees (Fig. 4-4); the exam-
the arm abducted 90 degrees, are measured. I measure iner then applies a distraction force. Inferior translation
internal rotation at 90 degrees of abduction in the is assessed with an inferior force applied with the shoul-
coronal as well as the scapular plane. der at 0 degrees of abduction (sulcus test). If the transla-
Elevation strength is measured using a dynamome- tion force is applied in an inferior-posterior direction,
ter with the arm elevated 90 degrees in the scapular the surgeon can gain additional information. Posterior
plane and internally rotated, with the result recorded translation is examined with the arm elevated 90
in pounds. degrees, adducted slightly, and rotated internally
The instability examination is performed on both approximately 30 degrees. I translate the shoulder in a
shoulders. I compress (load) the humeral head into the posterior-inferior direction and record the result. I then
glenoid during all maneuvers. I assess glenohumeral apply a posterior force and assess the translation.
translation in eight directions: anterior-superior, ante- Typically, posterior translation produces minimal com-
rior, anterior-inferior, inferior-anterior, inferior, infer- plaints, but as the shoulder is extended, the humeral
ior-posterior, posterior-inferior, and posterior. An head reduces, and the patient reports pain.
essential element of the instability examination is
patient relaxation; an effective examination is not
possible if the patient’s muscles are tense. This may
occur as a result of pain during the examination or
fear that pain will follow a particular maneuver.
If the patient is comfortable, I perform the examina-
tion with the patient standing; if relaxation is not ade-
quate, I examine him or her seated or supine.
I assess anterior-superior translation with the shoul-
der in 0 degrees of abduction and the arm externally
rotated 90 degrees while I grasp the humeral head and
move it anterosuperiorly. Anterior translation is assessed
with an anterior force applied to the shoulder with the
arm in 90 degrees of abduction; anterior-inferior trans- A
lation is tested with the arm in the same position, but
the direction of force is changed to anteroinferior (Fig.
4-2). I also perform the relocation test (Fig. 4-3). A par-
ticularly useful maneuver is the Rowe test to assess infer-
ior-anterior translation. To perform this examination,
have the patient stand and flex the trunk from the
hips approximately 30 degrees. Instruct the patient to
relax the arms and let them hang from the shoulder B
toward the floor. In this relaxed position, the shoulders Figure 4-3 A and B, Relocation test.
30°
Figure 4-5 Anterior-inferior dislocation.
glenohumeral instability consists of humeral head dislo-

cation. Indirect radiographic signs of instability include
Figure 4-4 Patient position for the Rowe test. calcification adjacent to the anterior glenoid, a bone
Bankart lesion, anterior glenoid bone loss, or a Hill-
Sachs lesion. On magnetic resonance imaging and com-
puted tomography, additional evidence of instability
includes detachment of the glenoid labrum from the gle-
I record the presence or absence of pain and appre- noid bone, capsular stripping from the glenoid, and liga-
hension for each instability maneuver and grade the ment insufficiency (Figs. 4-5 through 4-14).
amount of humeral head translation on the glenoid If the diagnosis is in doubt, an arthroscopic examina-
surface as 0 (stable or trace laxity), 1 (up to 50%), tion and examination under anesthesia are helpful.
2 (> 50% but not dislocatable), or 3 (dislocatable). I observe humeral head movement under direct arthro-
The grading of instability is somewhat subjective but scopic visualization. The presence of intra-articular
appears to be relatively consistent for each examiner. I lesions may allow the surgeon to diagnose a predomi-
record the presence of laxity in the contralateral nant direction of instability or an unrecognized direction
shoulder and elbows and the patient’s ability to of instability. These lesions are located in the humeral
bring the thumb to the forearm, but I use no formal head and glenoid (chondral or osteochondral defects),
grading system for the degree of generalized ligament labrum (fraying or separation from the glenoid), and cap-
laxity. I simply record ligament laxity as present or sular ligaments (tear or laxity).
absent. I exclude other sources of shoulder pain
(rotator cuff lesions, acromioclavicular joint arthritis,
thoracic outlet syndrome, brachial plexus lesions, gle-
nohumeral arthritis) through the patient history,
physical examination, and radiographic analysis.
Radiographs
Routine radiographs include anteroposterior glenoid,
axillary, and supraspinatus outlet views. I recently
added the Bernejeau view to my routine radiographs
because I think it best demonstrates the presence
or absence of anterior glenoid bone loss. I obtain
Bernejeau views of both shoulders for comparison.
Other radiographic imaging (magnetic resonance ima-
ging, computed tomography, arthrography) is not
routinely performed. Direct radiographic evidence of Figure 4-6 Glenoid rim fracture.
Figure 4-7 Bone Bankart lesion.
Figure 4-10 Bankart lesion.
Figure 4-8 Bone Bankart lesion (circled), axillary view.

Figure 4-11 Hill-Sachs lesion.
Figure 4-9 SLAP lesion. Figure 4-12 Anterior capsular stripping.

RA
SP
Figure 4-15 Contracted posterior-inferior capsule.

Figure 4-13 Glenoid rim fracture.
commonly occurs in patients with traumatic anterior-

inferior glenohumeral instability (Figs. 4-15 and 4-16).
NONOPERATIVE TREATMENT
Nonoperative treatment consists of avoidance of painful

OPERATIVE TREATMENT
activities, nonsteroidal anti-inflammatory medication
for pain if necessary, and a home physical therapy
Indications
program designed to eliminate contractures and
maintain or improve shoulder girdle strength and neu- The primary indication for operation is persistent
romuscular coordination. The goal is to improve the shoulder pain due to glenohumeral instability that
strength of those muscles responsible for glenohumeral
stability. Therefore, patients perform resistive exercises
of the internal rotators, external rotators, biceps, triceps,
and scapular muscles with surgical tubing and light
weights (maximum 5 pounds). Patients are instructed
in exercises to improve neuromuscular coordination and
proprioception. Areas of contracture are identified and
corrected with specific stretching. Posterior contracture
Figure 4-14 Posterior humeral glenohumeral ligament tear

(arrow). Figure 4-16 Adduction stretch.
has not responded to a minimum of 6 months of non- rate of redislocation. However, unless the patient falls
operative treatment as described earlier. The only into the select subgroup described earlier with factors
exceptions are patients who desire operative repair influencing early repair, the chances of recurrent dis-
acutely (within 6 weeks after an initial traumatic location are less than 50%, and of those in whom re-
dislocation). Fundamentally, I believe the decision to dislocation occurs, only 50% request surgery.
operate is the patient’s, and I present the natural Historians will likely view our past treatment of
history of an initial shoulder dislocation in the con- traumatic shoulder dislocation as suboptimal.
text of the particular situation. Essentially, there is a 25% recurrence rate (much
When a patient sustains an initial dislocation that higher in certain patients). Arthroscopic treatment
occurs with sufficient energy that it can be classified as has a 90% to 95% success rate, yet it is not routinely
traumatic, surgical repair is an option. I consider nine performed. Orthopedic surgeons operate on acute
factors: ligament injuries of the knee and ankle but rarely
on the shoulder. I think that as our techniques and
1. Patient age
equipment continue to improve, and as our ability
2. Amount of trauma involved in the dislocation
to identify patients at high risk of recurrent symptom-
3. Reduction method
atic dislocation increases, patients with acute shoul-
4. Arm dominance
der dislocation will have greater access to surgical care.
5. Present activity level
6. Desired activity level
7. Patient’s sensation of instability Contraindications
8. Radiographic findings
Absolute contraindications to surgery include gleno-
9. Timing during a sports season
humeral instability with selective voluntary muscle
Seven factors influence the decision in favor of contractions and questionable emotional stability.
acute repair: Patients who can activate their muscles and demon-
strate glenohumeral subluxation or dislocation with
1. Age younger than 20 years
the arm by the side seem to have a poor prognosis
2. Traumatic dislocation (as opposed to disloca-
after operative care. Evaluating a patient’s emotional
tions that occur with minimal force)
stability is, of course, subjective. Relative contraindi-
3. Reduction required (as opposed to spontaneous
cations include failed prior instability surgery, poor-
reduction)
quality ligaments, and large bone defects of the gle-
4. Dominant arm
noid or humeral head. The solution in the last case is
5. High activity level
the Latarjet procedure, discussed later in this chapter
6. Desire to continue that activity level
(Fig. 4-17).
7. Sensation of instability while in a sling or with
movement during sling removal or dressing
A displaced bone fragment indicates that the
labrum does not lie in its anatomic location and will
heal with the attached soft tissue in a medial position.
If the patient is currently participating in a team sport
and the season is less than 2 months from completion,
we discuss the patient’s desire to return to that sport
or another seasonal sport. For example, a high
school junior with an interest in football may elect
to have his shoulder repaired so that he can play
during his senior year. A patient who also participates
in a spring sport may not want to risk missing baseball
season, for example, particularly if that is his area of
concentration.
I explain the chance of recurrent instability in light
of the patient’s particular situation and let the patient
and family decide on operative or nonoperative care.
My experience correlates with much of the recent lit-
erature. Patients who are younger than 20 years and Figure 4-17 Three-dimensional computed tomographic
participate in vigorous overhead activities have a high reconstruction with anterior bone loss.
Most Hill-Sachs lesions do not affect the operative same direction and degree of translation may not be
result because, with restoration of soft tissue tension, stabilized with these two maneuvers and may require
the Hill-Sachs lesion does not engage the anterior a superior labrum repair. A patient with posterior-
glenoid. However, when the humeral head defect is inferior instability may not be stabilized after poste-
large enough, there is insufficient surface area to rior labrum and posterior capsule repair and may
allow adequate external rotation. If the patient require tightening of the inferior capsule and ante-
regains external rotation, he or she may experience rior-inferior glenohumeral ligament. A rotator inter-
a sensation of catching as the Hill-Sachs lesion rides val repair may be necessary. The decision making is
over the anterior rim. Earlier operations dealt with complex, but it accurately reflects the reality of the
this issue by intentionally restricting external rota- clinical situation.
tion, but such an approach limits function and may The goals of débridement are to remove sources of
lead to asymmetric loading and arthrosis. I have found mechanical irritation or functional instability. Only
that arthroscopy is the most effective means of evalu- minor labrum flap tears (< 50% of the labrum thick-
ating whether the Hill-Sachs lesion is large enough to ness) are removed, and every attempt is made to repair
require an open procedure such as a humeral head al- the lesions.
lograft or rotational osteotomy. For those rare patients The purpose of ligament and labrum reattachment
with very large, engaging Hill-Sachs lesions, I recently to bone is twofold. First, adequate capsular tension is
began using a metallic cap (ArthroSurface) to fill in the impossible to achieve unless the labrum and ligament
defect and have been very pleased with the short-term are securely attached to the glenoid. I repair all trau-
results. Wolf has described his arthroscopic remplissage matic tears of the superior, anterior, posterior, and
procedure, which involves advancement of the infra- inferior labra because all these lesions contribute to
spinatus tendon and posterior capsule into the hum- glenohumeral instability. Second, anatomic repair of
eral head defect. the ligament and labrum restores cavity-compression
to the glenohumeral joint. Lippitt has demonstrated
that compression of the humeral head into the gle-
OPERATIVE APPROACH noid by muscular force is an effective stabilizer to
humeral translation, and resection of the labrum
Here, I describe why I choose to repair various struc- decreases stability by 20%.
tures within the glenohumeral joint and when Reattaching the anterior-inferior ligamentlabrum
during the operation I do so. Because I consider gle- complex to the glenoid may not restore sufficient
nohumeral instability to be a single entity with vari- stability to the glenohumeral joint. Speer demon-
able clinical expression, I do not present separate strated only a small increase in humeral translation
sections on the treatment of each direction of with a simulated Bankart lesion and concluded
instability. that capsular stretching or elongation is necessary
to produce glenohumeral instability. Therefore, the
final portion of the operation is to restore capsular
Operative Rationale
tension.
The underlying principle of arthroscopic repair is to I classify capsular elongation as primary or second-
identify and repair all lesions that contribute to gleno- ary. Primary elongation refers to permanent deforma-
humeral instability. This involves débridement, repair tion of the capsular fibers due to a single traumatic
of ligament and labrum tears, capsular tensioning, event or multiple episodes of instability. Secondary
and, if needed, repair of the rotator interval. elongation occurs when there is a tear at the insertion
My approach to a patient with glenohumeral insta- site, thereby decreasing capsular tension. This may
bility is first to determine the direction or directions occur within the anterior-inferior capsule after a
of instability by conducting a thorough history, phys- Bankart lesion or as a result of a superior labrum
ical examination, examination under anesthesia, and tear. The biceps-labrum complex contributes to ante-
examination during glenohumeral arthroscopy. I rior-inferior translation, and its detachment results in
then evaluate all the structures within the glenohu- increased humeral translation. Thus, I repair all trau-
meral joint and decide which ones require operation. matic superior labrum detachments. Rotator interval
A patient with unidirectional anterior instability may and superior glenohumeral ligament tears also affect
require an anterior labrum repair, but if capsular glenohumeral stability. I have observed at operation
stretching has occurred, anterior capsular imbrication that repair of the rotator interval decreases inferior
may be necessary as well. Another patient with the and posterior translation of the humeral head. If the
repair also incorporates the superior portion of the

middle glenohumeral ligament, anterior capsular ten-
sion is increased. Thus the surgeon can restore capsu-
lar tension by two methods: primary capsular
elongation requires operation directly on the capsule,
and secondary elongation responds to repair of inser-
tion site tears.
I correct primary capsular elongation by three techni-
ques used singly or in combination: (1) advancement of
the capsule to the labrum, (2) advancement of the cap-
sule to the glenoid with suture anchors, and (3) capsular
imbrication.
The goal of this portion of the procedure is
to restore ligament and capsule tension and to elimi-
nate excessive humeral head translation, which Figure 4-18 Inferior translation with the shoulder internally
I define as greater than 25%. To estimate the percent- rotated.
age of translation, I visually divide the humeral head
into four segments and observe how much of the
humeral head translates with relation to the glenoid. external rotation, I estimate the appropriate amount
Any or all of the following areas may require tighten- of tension, return the arm to 20 degrees of abduction
ing: middle glenohumeral ligament, anterior-inferior and 30 degrees of external rotation, and then com-
glenohumeral ligament, inferior capsule, posterior- plete the arthroscopic repair.
inferior glenohumeral ligament, and posterior With the greater visualization afforded by the
capsule. arthroscope, the surgeon can selectively repair
My preference is to advance the capsule to the damaged portions of the capsule. This is an advantage
intact or repaired labrum with braided sutures. Only over open reconstructions for anterior instability.
if the labrum is small or absent is the capsule repaired With the increased selectivity of arthroscopic repair
to the glenoid rim with bone suture anchors. Drill comes the promise of improved patient outcomes,
holes for the suture anchors are placed through the but also a new set of decisions to be made. This is
glenoid articular surface approximately 1 to 2 mm less of a problem with tears of the labrum insertion,
from the peripheral glenoid rim. The detached because the goal of returning the labrum to its ana-
labrum is sutured so that it contacts the scapular tomic location is relatively well understood. More dif-
neck and extends onto the glenoid articular surface. ficult are decisions regarding ligament or capsule
This reestablishes the labrum ‘‘bumper’’ and re-cre- tightening; the surgeon has to decide what portions
ates an optimal surface for concavity-compression. I of the capsule should be tightened, how much
estimate the amount of tightening based on both the
degree and the direction of translation, using guide-
lines similar to those described by Warner for open
operations. A soft tissue grasper is used to apply
traction to the various portions of the capsule while
the arm is positioned in different degrees of abduc-
tion and external rotation and I apply translation
forces. I try to establish tension in different parts of
the capsule according to their role in glenohumeral
stability. I estimate appropriate tension of the inferior
capsule with the arm in 60 degrees of abduction and
60 degrees of external rotation, the middle glenohu-
meral ligament with the arm in 30 degrees of abduc-
tion and external rotation, and the rotator interval
with the arm in 0 degrees of abduction and 30
degrees of external rotation (Figs. 4-18 through
4-22). Because I am technically unable to perform Figure 4-19 Inferior translation with the shoulder externally
the repair with the arm in complete abduction or rotated.
tightening is necessary, and by which technique tighten-

ing should occur.
Intraoperative Decision Making

and Indications
Débridement
I débride only minor flap tears of the labrum. Flap
tears greater than 50% are repaired with absorbable
monofilament sutures. I find that labrum palpation
with a probe is necessary to determine the presence
of minor flap tears, cleavage tears that exist within
the labrum substance, and minor separations of the
labrum from the glenoid. Loose bodies are removed
Figure 4-20 Inferior translation in abduction. with surgical forceps.
Labrum Repair
The labrum is normally attached securely to the gle-
noid bone anteriorly, inferiorly, and posteriorly below
the glenoid equator; I consider separations in these
areas to be lesions. The anterior-superior labrum is
usually not well attached to the glenoid (sublabral
foramen), and separation in this area is considered
normal. The superior labrum attachment is variable,
and a mobile superior labrum without evidence of
trauma is not classified as a SLAP lesion. When the
superior labrum separation is a normal variant, the
superior glenoid is covered with smooth cartilage,
and the labrum shows no evidence of trauma. Signs
of traumatic separation include tears within the sub-
stance of the superior labrum, cartilage loss with
exposed bone at the site of labrum attachment, and
an increase in superior labrum separation with abduc-
tion and external rotation of the arm. I repair the
Figure 4-21 Anterior translation. superior labrum anatomically and make no attempt
to shift the superior labrum anteriorly or posteriorly.
In contrast, during repair of the anterior, inferior, or
posterior labrum, I will, if necessary, shift the labrum
laterally so that it projects onto the glenoid surface
and reestablishes the labrum as a bumper to aid in
concavity-compression.
Capsular Tensioning
I estimate the location of the ligament repair site (and
therefore the ligament tension) by grasping the liga-
ment and placing it at different locations on the gle-
noid. Humeral head translation is performed with the
torn ligament positioned at possible repair sites until
humeral head translation is less than 25% of the gle-
noid diameter. Typically, 5 to 15 mm of lateral and
superior ligament advancement is required. Arm posi-
tion affects ligament and capsule tension, so I rou-
tinely maintain the shoulder in 20 degrees of
Figure 4-22 Posterior translation. abduction and 30 degrees of external rotation during
this portion of the operation. I alter the arm position

when operating on the dominant arm of a competi-
tive, throwing athlete. In these patients, I determine
the ligament repair site after I position the arm in 60
degrees of external rotation.
Rotator Interval
If the shoulder demonstrates persistent excessive trans-
lation after débridement, labrum repair, and capsular
tensioning, I turn my attention to the rotator interval.
If the direction of translation is inferior or inferior-
posterior, I place a monofilament suture through the
soft tissue immediately adjacent to the anterior border
of the supraspinatus and then through the soft tissue
superior to the subscapularis tendon. I place the suture
as far laterally as possible so as not to interfere with post-
operative external rotation. While applying traction on Figure 4-23 Portal sites for arthroscopic subacromial
this suture, I again assess humeral head translation. decompression and glenohumeral reconstruction, in the
If the correction is adequate, the suture is tied. If the traditional soft spot.
correction is inadequate, the suture is removed and
placed in a more medial position until excessive trans-
lation is corrected. If the direction of persistent transla- the anterior-inferior cannula is placed more medially, it
tion is inferior-anterior, the inferior limb of the suture is is easier to reach the inferior glenohumeral joint but
passed through the superior portion of the middle gle- more difficult to place suture anchors.
nohumeral ligament to increase tension in that portion I then inspect the glenohumeral joint completely. I
of the capsule. reexamine the shoulder for translation while viewing it
through the arthroscope and use a probe to examine the
labrum for tears and palpate the capsule to evaluate lig-
OPERATIVE TECHNIQUE ament tension (Figs. 4-23 through 4-38). I then establish
the anterior-superior portal with a spinal needle. The
The patient receives an interscalene block to diminish anterior-superior cannula is placed 1 cm superior and 5
postoperative pain and is then placed under general mm lateral to the anterior-inferior cannula (Figs. 4-39
anesthesia. The anesthesiologist administers 1 g ceph- through 4-42).
alosporin intravenously. I place the patient in the
sitting position and examine both shoulders as
described earlier.
The shoulder joint is entered with a cannula and
blunt trocar through a posterior skin incision placed
1.5 cm inferior and 2 cm medial to the posterolateral
border of the acromion. I place the posterior portal in
a more superior location than the soft spot. This allows
me more access if I must introduce a second inferior-
posterior portal later during the procedure. I perform a
brief inspection and evaluate the rotator interval for evi-
dence of trauma or laxity. This must be done before
placement of the anterior portals because they will
pass through the rotator interval and alter its appear-
ance. An anterior portal site is identified with a spinal
needle so that the cannula enters the shoulder joint
immediately superior to the subscapularis tendon and
1 cm lateral to the glenoid. The more lateral the anterior-
inferior cannula, the easier it is to place anchors perpen-
dicular to the glenoid surface, but the more difficult it is
to reach the inferior aspects of the glenohumeral joint. If Figure 4-24 Widened, thin rotator interval.
Figure 4-27 Cannula in the anterior-inferior portal.

Figure 4-25 Anterior portals.
At this point I remove the arthroscope and insert it

through the anterior-superior cannula to inspect the arthroscope positioned posteriorly lead me to con-
posterior glenohumeral joint more completely, paying clude that the anterior ligaments are inadequate for
particular attention to the glenoid shape. Anterior gle- surgical repair or my view with the arthroscope posi-
noid bone loss can be observed by loss of the normal tioned anteriorly demonstrates a loss of anterior gle-
glenoid pear shape. If my observations with the noid bone, I perform an arthroscopic Latarjet
procedure (Figs. 4-43 through 4-46).
I then return the arthroscope to the posterior cannu-
la. All structures within the glenohumeral joint are
examined systematically, and all lesions consistent
with instability are recorded. These lesions are variable
and may include tears of the rotator cuff (partial and
complete), rotator interval, glenoid labrum, glenohu-
meral ligaments, and biceps tendon. I have noted, as
Figure 4-26 Anterior-inferior portal location. Figure 4-28 Superior labrum tear.
Figure 4-29 Palpating for a superior labrum tear.

Figure 4-32 Anterior cartilage loss.
Figure 4-30 Poorly defined middle glenohumeral ligament. Figure 4-33 Chisel exposing a small Bankart lesion.
Figure 4-31 Palpation of the anterior-inferior glenohumeral

ligament. Figure 4-34 Bankart lesion.
Figure 4-35 Palpation of the inferior capsule. Figure 4-38 Shallow Hill-Sachs lesion.
Figure 4-39 Anterior-inferior cannula.

Figure 4-36 Loose body removal.
Figure 4-40 Needle identifies the anterior-superior portal

Figure 4-37 Humeral head cartilage lesion. location.
Figure 4-44 Posterior labrum fraying.

Figure 4-41 Introduce the anterior-superior cannula and
palpate the rotator interval.
Figure 4-42 Metal cannula and arthroscope moving to the Figure 4-45 Posterior labrum split.
anterior-superior portal.
Figure 4-43 Anterior Bankart lesion seen from the anterior-

superior cannula. Figure 4-46 Posterior Bankart lesion.
have others, that the glenohumeral ligaments can tear at

either the glenoid or humeral head insertion. To evalu-
ate the glenohumeral ligaments for midsubstance tears
or plastic deformation, I assess them for laxity by
directly observing and palpating them (with an arthro-
scopic probe) and applying translation stresses as I rotate
the shoulder. I document the location on the glenoid
and the extent (superior to inferior and medial to lateral)
of labrum detachment. Labra that are frayed or have
midsubstance tears are noted. The presence or absence
of loose bodies is also recorded.
The cartilage is inspected for damage to the glenoid
and humeral head (Hill-Sachs lesion). I carefully exam-
ine the glenoid and use an arthroscopic probe inserted
through the anterior-inferior cannula to measure the Figure 4-47 Hill-Sachs lesion, with the arm resting at the
glenoid width. The inferior portion below the glenoid patient’s side.
equator should have a greater anterior-posterior width
than the glenoid superior to the equator. If it does not,
there has been too much bone loss, and a bone graft is
necessary to restore glenoid width. Previously, I per-
formed this operation with the open Latarjet techni-
que; more recently, based on the work of Lafosse, I If a posterior repair is necessary, I perform this before
have made the transition to an all-arthroscopic superior, anterior, or inferior capsular repair. Repair in
Latarjet. any of these areas dramatically limits access to the pos-
I then examine the Hill-Sachs lesion and record its terior, and especially the posterior-inferior, glenohu-
location, dimensions, and orientation. A posterolater- meral joint (Figs. 4-49 through 4-61).
al location indicates anterior instability, and an an-
teromedial location is consistent with posterior
Posterior Repair
instability. I note the lesion’s length, width, and
depth and maneuver the shoulder until I can deter-
mine what amount of external rotation will allow The principles of posterior repair are similar to those
the Hill-Sachs lesion to engage the glenoid rim. I for anterior and inferior repair, but there are some spe-
center the humeral head by compressing it against cific distinctions. Because posterior repair is performed
the glenoid while performing this maneuver. Usually less frequently than anterior repair, the surgeon is
the Hill-Sachs lesion does not engage the glenoid rim
without anterior translation. If the Hill-Sachs lesion
engages the glenoid rim with the humeral head
centered and the amount of external rotation is
40 degrees or less, I suture the posterior capsule into
the humeral head defect (the remplissage of Wolf). This
rarely occurs. If the external rotation is greater than
40 degrees, I continue with arthroscopic stabilization.
To examine the orientation of the Hill-Sachs lesion, I
position the arm so that the lesion is parallel to the
anterior glenoid rim and observe the amount of
abduction and external rotation. This is the position
of the arm during the moment of dislocation and indi-
cates which areas of the capsule are damaged.
As a rule, the greater the amount of abduction
needed to align the Hill-Sachs lesion with the anterior
glenoid rim, the more damage there is to the inferior
capsule. A smaller amount of abduction indicates
more anterior capsule (middle glenohumeral liga- Figure 4-48 Hill-Sachs lesion, with the arm positioned until
ment) damage (Figs. 4-47 and 4-48). the lesion is parallel to the anterior glenoid rim.
Figure 4-52 Drill an inferior anchor hole.
Figure 4-49 Débride the posterior labrum.
Figure 4-50 Abrade the posterior glenoid with a round bur. Figure 4-53 Drill a superior anchor hole.
Figure 4-51 The posterior glenoid is prepared. Figure 4-54 Insert the anchor.
Figure 4-55 Retrieve the braided suture.
Figure 4-58 Tie knots.
Figure 4-56 Pass through the labrum and retrieve the suture
with a nylon loop through the anterior-inferior cannula. Figure 4-59 Tighten the inferior-posterior capsule.
Figure 4-57 Retrieve the braided suture from the anterior-

inferior cannula to the posterior cannula. Figure 4-60 Repair of the now-intact labrum.
is technical: I cannot maneuver the posteriorly located

drill to penetrate the articular cartilage at an appropri-
ate angle. Second, in most posterior repairs, I suture
the posterior capsule and incorporate enough capsule
with the labrum to re-create the labrum bumper, even
with anchors located in this position. The posterior
labrum bumper is smaller than the one I create ante-
riorly, but this corresponds to the normal labrum
anatomy. I locate the drill holes 2 to 3 mm posterior
to the articular surface. The angle is parallel to the
surface or slightly posterior to it. I insert the anchors
and repair the labrum and capsule from inferior to
superior.
Suture Passing
Figure 4-61 Completed repair. I use the Smith-Nephew or Spectrum crescent hook
and pierce the posterior-inferior capsule and advance
not as familiar with the hand maneuvers needed to it superiorly. The instrument tip penetrates the cap-
position instruments within the glenohumeral joint. sule and is visible. I then proceed through the soft
I recognize that my movements will be slower and less tissue superiorly, pierce the labrum, and advance the
fluid than when operating anteriorly, so I mentally two free ends of the 2-0 nylon suture into the gleno-
allow myself some leeway during posterior operations. humeral joint. Dr. Hammerman (my assistant) inserts
a crochet hook through the anterior-inferior cannula,
Portal Placement retrieves the sutures, and applies a hemostat. I remove
To establish the posterior portal, I move the arthro- the crescent hook from the joint. The anchor sutures
scope to the anterior-superior cannula. I leave the exit the joint through the posterior cannula. We then
anterior-inferior cannula in place to provide outflow, reverse the loop with another monofilament suture
and I can insert the crochet hook through it to retrieve so that the loop end comes out the anterior-inferior
sutures. While I view the posterior capsule through cannula and the two free ends exit the posterior can-
the arthroscope, I remove the posterior metal cannula nula. I insert a crescent hook through the anterior-
and insert a larger-diameter plastic cannula through inferior cannula and retrieve one of the anchor
the same skin incision. I advance it until the tip suture strands. I place it through the looped end of
tents the capsule. I then move the tip inferiorly and the monofilament suture and pull it through the
advance it external to the capsule until it reaches the labrum and posterior cannula until it exits posteriorly.
appropriate entry point. This point is located near the I tie the knot through the posterior cannula. I then
inferior glenoid for inferior-posterior capsular tension- repeat this sequence until the posterior repair is com-
ing; it may be at the glenoid equator if the labrum is plete and then go on to capsular tensioning.
the only damaged structure. If no posterior repair is needed, I return the
arthroscope to the posterior cannula and continue
Scapular Neck Preparation with the glenohumeral reconstruction.
I use a 4-mm round bur. Because of the portal loca-
tion, the bur enters the glenohumeral joint parallel to
Anterior-Inferior Repair
the glenoid surface. I advance it into the joint and
move it superiorly and inferiorly over the desired dis-
Bankart
tance. It helps to advance the arthroscope as far into
the joint as possible and rotate it to obtain the best
view of the posterior glenoid. Bankart Release of Labrum
and Capsule with Cautery
Drill Holes
I leave the arthroscope in the anterior-superior cannu-
la and insert the drill posteriorly. I place the posterior Bankart Complications
drill holes on the posterior scapular neck. In contrast,
for an anterior repair, I position the drill holes on the The repair sequence varies and depends on the specific
glenoid articular surface. One reason for the difference combination of lesions identified. I follow a pattern of
débridement, ligament or labrum reattachment, and

capsular tensioning.
Débridement
Débridement is performed to smooth frayed labrum
fragments or to remove torn fragments. It is also per-
formed, if necessary, to identify the depth of partial-
thickness rotator cuff tears. Loose bodies are removed,
but doing so is usually frustrating because the inflow
blows the pieces around the joint. I find it helpful to Type B
attach suction to the outflow cannula, let the flow of
fluid bring the loose body to the mouth of the
cannula, and then grasp it with a forceps.
Insertion Tears
I then treat labrum and ligament insertion site tears.
Technical considerations dictate the order of labrum
repair. Posterior labrum tears are repaired first, fol-
lowed by tears in the inferior, anterior, and superior Figure 4-63 Type B lesion.
labrum. As the labrum (and attached ligaments) is
repaired, the ability to displace the humeral head
and insert bone or soft tissue suture anchors or sutures
is compromised. I repair the posterior labrum first
because access to this lesion becomes difficult after healed medially on the glenoid (equivalent to an
superior or anterior labrum repair. Posterior, inferior, ALPSA lesion) (Figs. 4-62 through 4-64). Type B and
and superior labrum tears are usually easily identified C lesions require that the surgeon dissect the labrum
and minimally displaced. This is not the case with from the glenoid and place it laterally on the glenoid
anterior labrum tears. I classify three types of anterior articular surface. I perform this with a combination
labrum detachment: type A, in which the labrum is of a thermal probe, power bur, scissors, and blunt
separated from the glenoid bone but remains at the dissection.
level of the glenoid articular surface; type B, in If the anterior-inferior or middle glenohumeral liga-
which the labrum is separated and retracted medially; ments are retracted and adherent to the subscapularis,
and type C, in which the labrum is retracted and has I release the ligaments before insertion site repair.
Type A Type C
Figure 4-62 Type A lesion. Figure 4-64 Type C lesion.

I make an incision with a scissors along the superior

border of the middle glenohumeral ligament and
insert a blunt instrument (posterior to the capsule
and anterior to the subscapularis tendon) to separate
the two structures. If the labrum or capsule has healed
medially, I insert a sharp chisel dissector along the
scapular neck to peel these structures from the bone.
I advance the arthroscope (located in the posterior
cannula) as far anteriorly as possible and rotate it to
obtain the best anterior view. If the view is not satis-
factory, I transfer the arthroscope to the anterior-
superior cannula. Once the capsule and labrum have
been separated from the bone, I try to advance them
laterally. If further mobilization is necessary, I insert
arthroscopic scissors through the anterior-inferior can- Figure 4-66 Chisel to dissect the labrum from the glenoid.
nula and divide the soft tissue attachment in the base
of the V formed by the scapular neck posteriorly and
the capsule anteriorly. I continue to divide the soft
tissue until I can see the muscular fibers of the sub-
scapularis (Figs. 4-65 through 4-68).
Figure 4-67 Use scissors to mobilize the labrum and

capsule.
Figure 4-65 Location of two anterior cannulas for anterior

repair. Figure 4-68 Muscular fibers of the subscapularis.
Bankart, Bone Fragment

Bankart Acute Dislocation
Patients with traumatic unidirectional instabil-

ity often have a piece of bone attached to the ante-
rior labrum that was avulsed from the glenoid during
dislocation. These fragments are often too small to be
seen on radiographs, but they are easily seen and
palpated during arthroscopy. I try to retain these
fragments and incorporate them in the labrum
repair to add bulk. The tip of the suture passer
must pass underneath the fragment so that the
fragment is lifted by the suture and reduced laterally.
With larger bony Bankart lesions, it is more critical to Figure 4-69 Abrade the anterior scapular neck.
retain the fragment. If the fragment is excised, the
glenoid width decreases. Studies have shown that gle-
noid narrowing as small as 4 mm significantly com-
promises containment of the humeral head by the
glenoid. In addition, if the fragment is excised, the
glenohumeral ligaments will not be long enough.
I prefer to repair the labrum and ligaments with the
shoulder in external rotation. If there is insufficient
ligament length, the surgeon is forced to perform the
repair with the shoulder internally rotated, which
makes it very difficult for the patient to regain ade-
quate external rotation.
Anterior Scapular Neck Preparation

After labrum and ligament mobilization, the scapu-
lar neck is abraded to a depth of 1 mm. The abraded
area begins at the level of the glenoid cartilage and
extends 2 cm medially on the scapula. It is impor-
tant not to abrade too deeply and risk compromising
Figure 4-70 Anterior view.
the glenoid width and creating the problems dis-
cussed earlier. This can be done with the arthro-
scope in the posterior portal and the bur in the
anterior-inferior cannula, or the arthroscope can be
moved to the anterior-superior cannula (Figs. 4-69
through 4-71).
Drill Holes
Drill holes for the suture anchors are placed through
the glenoid articular surface approximately 1 to 2 mm
from the lateral glenoid margin. I space the drill hole
sites (typically three are used) proportionally along the
anterior glenoid. I use the round bur to remove a small
area of cartilage and mark the drill hole site. I do so for
five reasons:
1. The cartilage in these patients is usually thick,
and because the length of the drill is fixed, the
greater the amount of cartilage present, the less
distance the screw will insert in the bone.
Figure 4-71 Completed abrasion.
2. If the drill hole is made in cartilage, it can be

hard to identify.
3. I want to recess the screw as far as possible.
4. I can create a small shelf in the bone to decrease
the acuity of the approach angle.
5. I want to maximize the area of labrum-bone con-
tact because the labrum heals more securely to
bone than to cartilage.
Drill holes are created in the anterior and inferior

glenoid with a power drill inserted through the ante-
rior-superior cannula. To reach the most inferior por-
tion of the glenoid, I ask the assistant to distract the
humeral head laterally and posteriorly. Distraction is
needed at three stages of the operation: placing the
drill hole, passing the suture passer through the infe-
rior capsule or labrum, and tying the suture. The assis- Figure 4-72 Insert the anchor through the anterior-superior
tant provides distraction during these brief times. cannula.
During the remaining portions of the procedure, the
arm rests in the arm holder without any distraction
force. The surgeon’s ability to distract the glenohu-
meral joint is one reason why some surgeons prefer the most inferior glenoid drill hole. The number of
the lateral decubitus position. Continuous traction is suture anchors varies, depending on the size of the
not present in the sitting position. I find either labrum detachment, but I typically use three anchors.
approach acceptable and consider patient position a As Dr. Hammerman inserts each anchor, I distract the
matter of surgeon preference. humeral head to allow him easier access to the drill hole.
I place the drill holes through the anterior-superior The anchor inserter has two vertical lines that mark the
cannula for two reasons: the angle of approach to the gle- eyelet orientation. As he seats the anchor, he checks to
noid is easier, and it minimizes the number of times I see that the vertical lines (and eyelet) are oriented ante-
must transfer sutures from the anterior-inferior to the rior-posterior rather than superior-inferior. This mini-
anterior-superior cannula. The anterior-superior cannu- mizes suture strand twisting and allows the suture to
la is located slightly more superior and posterior to the slide freely in the anchor during knot tying (Figs. 4-72
anterior-inferior cannula and presents a less tangential through 4-75).
approach to the articular glenoid surface. It is also easier
to insert the anchors through the same cannula used for
the drill because they enter the glenoid at the same angle
as the drill. If I place the drill holes (and anchors)
through the anterior-inferior cannula, I have to transfer
the sutures to the anterior-superior cannula before
inserting the suture passer. The suture passer must be
inserted through the larger anterior-inferior cannula
because the anterior-inferior aspect of the glenoid
cannot be reached from the anterior-superior cannula.
By avoiding having sutures in this cannula, I eliminate
the possibility of the sharp tip of the suture passer cut-
ting one of the sutures.
Anchor Insertion
I prefer to insert an anchor, pass the suture and tie it, and
then go on to the next anchor rather than inserting all
the anchors at one time. This minimizes the number of
suture strands within the glenohumeral joint. I place the
anchors inferiorly to superiorly. The first suture anchor
is inserted through the anterior-superior cannula into Figure 4-73 Anchor inserted on the glenoid surface.
Figure 4-76 Advance the labrum onto the glenoid articular

surface.
Figure 4-74 Inserter orientation lines.

that when the knot is tied, the labrum is translated
superiorly and laterally. This brings the labrum
above the glenoid articular surface so that I can rees-
Suture Passing tablish the labrum as a bumper and restore concavity-
The most difficult suture to place is the most inferior, compression (Fig. 4-76).
because access to the glenohumeral joint is generally I often use the empty suture passer to grasp the
quite limited. Suture passing is less difficult in patients labrum at various points and bring it to the glenoid
with multidirectional instability because the inferior until I am satisfied that the appropriate entry point
capsular laxity that accompanies this condition has been established. Only then do I load the suture
allows the surgeon greater access. The first decision I passer with the nylon passing suture for the final
make is whether to repair only the detached labrum or repair.
to incorporate the inferior capsule with the repair I prefer to use the angled Smith-Nephew or
to perform capsular imbrication. If capsular imbrica- Spectrum suture passer for this portion of the proce-
tion is not necessary and I want to repair the labrum dure. I use a right-angled instrument for right
alone, I use the suture passer to pierce the labrum at shoulders and a left-angled instrument for left
a point the brings the labrum to its normal ana- shoulders. I normally incorporate some amount of
tomic insertion site on the glenoid. The torn labrum capsule along with the labrum to correct capsular
is usually displaced medially and inferiorly. Therefore, laxity. I find it easier to choose the correct spot in
I must pierce the labrum with the suture passer so the capsule with the tip of the instrument before
inserting the suture passer through the labrum.
If the right-angled instrument is used in a left
shoulder, the surgeon must pass it from the labrum
to the capsule, and once the instrument has pierced
the labrum, it is hard to manipulate and find the
appropriate area of capsule (Figs. 4-77 and 4-78). The
left-angled instrument allows me to pierce the capsule
and advance it so that I can clearly see where the tip of
the instrument exits the soft tissue near the glenoid.
When I advance the nylon passing suture, it then lies
on the glenoid, within reach of the crochet hook.
Once the nylon suture is in the joint, I distract the
humeral head, and Dr. Hammerman inserts a crochet
hook through the anterior-superior cannula, retrieves
the suture strands, and places a hemostat on the two
free ends. The suture instrument is then removed from
the anterior-inferior cannula. The loop end now exits
Figure 4-75 Anchor and suture in the glenoid. from the anterior-inferior cannula, and the two free
Figure 4-77 Left-angled instrument in the right shoulder. Figure 4-79 Piercing the capsule.
ends exit from the anterior-superior cannula (Figs.

4-79 through 4-83). This description is reversed for a
right shoulder.
Loop Reversal
Because I have passed the suture in the manner
described earlier, if I place an anchor suture in the
loop end, it will pass through the labrum in the
wrong direction—from anterior to posterior. This
loop around the labrum inhibits suture sliding and
therefore threatens the security of the knot. I want
the anchor suture to pass from the anchor through
the labrum from posterior to anterior. Therefore,
I use a monofilament suture to reverse the loop. The
two free ends of the monofilament suture are placed
through the loop of the nylon. By pulling on the two Figure 4-80 Advance the capsule to the labrum.
free nylon ends, the loop of monofilament is brought
Figure 4-81 Puncture the labrum and advance the nylon

Figure 4-78 Right-angled instrument in the right shoulder. suture.
Figure 4-84 Reverse the loop direction with the Prolene

Figure 4-82 Access to the nylon suture with the crochet hook.
(blue) suture.
into the anterior-inferior cannula, through the labrum passed from the labrum or capsule toward the glenoid
and capsule, and out the anterior-superior cannula. (lateral to medial). In this situation, I use a right-
The loop of monofilament suture is now in the same angled suture passer for a left shoulder, place the
anterior-superior cannula that contains the suture instrument tip under the bone fragment, and rotate
anchor sutures (Fig. 4-84). the instrument so that I obtain an adequate amount
Obviously, these steps can be avoided by initially of soft tissue. No loop reversal is needed.
passing the suture passer in the opposite direction.
However, loop reversal takes about 10 seconds
to accomplish, and the advantages of piercing the la- Bankart Acute Dislocation
brum from anterior to posterior far outweigh the
inconvenience of this extra step. Because the Smith- Passing the Anchor Suture
Nephew instrument can be loaded with the loop end I insert a crochet hook through the anterior-inferior can-
first, the surgeon can eliminate this portion of the nula and grab one of the suture anchor limbs. I remove
procedure by using the AccuPass instrument. the most posterior anchor suture limb out the anterior-
An exception to this technique occurs during repair inferior cannula. The anterior suture anchor limb and
of a shoulder with a large Bankart bone fragment. the monofilament loop are now in the anterior-superior
Because of the size of the bone, the suture cannot be cannula. Dr. Hammerman places 8 cm of the suture
Figure 4-83 Retrieve the suture through the anterior-superior Figure 4-85 Retrieve the posterior anchor suture strand out
cannula. the anterior-inferior cannula.
Figure 4-86 Pass the anterior anchor suture strand from the
anterior-superior cannula, through the labrum and capsule,
Figure 4-87 Retrieve both limbs of the anchor suture.
to the anterior-inferior cannula.
anchor limb through the loop. He then pulls the hemo- Superior Labrum Repair
stat clamped to the two free ends of the monofilament
suture in the anterior-inferior cannula and, while SLAP Repair
I provide humeral head distraction, pulls the suture
from the anterior-superior cannula into the joint, After the inferior and anterior labra are repaired, any tear
through the labrum and capsule, and out the anterior- of the labrum from the superior glenoid bone is identi-
inferior cannula. He then removes the monofilament fied. The superior glenoid bone is abraded with a power
suture. Both suture anchor limbs are now out the bur, and two suture bone anchors are inserted. The loca-
anterior-inferior cannula, and I tie the knot (Figs. 4-85 tion of the suture anchors varies and depends on the
and 4-86). anatomy of the lesion; I typically place one suture
anchor one third of the tear length from the posterior
margin and a second anchor one third of the tear length
from the anterior margin. I prefer nonabsorbable No. 2
braided suture and currently use a plastic tap-in anchor
exclusively. The details of this portion of the procedure
Knot Tying are described in Chapter 5 (Fig. 4-89).
I first apply traction to both suture ends to eliminate
any twists in the sutures. I then pass the loop suture
grasper into the joint and encircle the suture that does
not pass through the labrum. I select this suture
because I want the other strand to be the post. This
allows me to slide the knots and obtain better knot
security. I then place a half-hitch throw and use the
knot pusher to push the throw into the joint and bring
the labrum to the glenoid. I throw another half hitch
in the same direction and push it into the joint. I pull
on the post strand while releasing any tension from
the other suture anchor strand, slipping the knot and
labrum until the labrum is in its desired location and
the knot is tied firmly. I then throw a half hitch in the
opposite direction and tighten it, reverse the post and
tie another half hitch, and reverse the post again and
tie another half hitch. This results in a secure knot
(Figs. 4-87 and 4-88). Figure 4-88 Final repair.
Figure 4-91 Spectrum pierces the middle glenohumeral

Figure 4-89 SLAP repair.
ligament inferior to the tear.
Capsular Repair
The better view obtained with arthroscopic inspection
(compared to open surgery) has allowed me to become
increasingly selective in performing capsular repair.
I can identify and repair lesions restricted to only
one of the glenohumeral ligaments without tighten-
ing the undamaged portions of the capsule. A typical
example is a tear of the middle glenohumeral liga-
ment. Once I identify the tear, I use braided, perma-
nent sutures to repair it to the intact labrum. I insert
the suture passer through the anterior-inferior can-
nula, pierce the torn capsule, and puncture the
labrum at the site of desired repair. I then advance
the suture and use a crochet hook to retrieve it out
the anterior-superior cannula. I retrieve the suture
limb and tie the strands through the large anterior- Figure 4-92 Advance the intact middle glenohumeral
inferior cannula. These steps are repeated as needed ligament superiorly.
Figure 4-90 Middle glenohumeral ligament tear. Figure 4-93 Pierce the capsule.
Figure 4-94 Pierce the labrum.

Figure 4-97 Remove the Spectrum and withdraw the suture
limb out the anterior-inferior cannula.
Figure 4-95 Advance the nylon suture. Figure 4-98 Both suture limbs exit the anterior-inferior
cannula.
Figure 4-96 Retrieve the suture limb out the anterior-superior Figure 4-99 Test the tension in the repaired middle gleno-
cannula. humeral ligament.
Determining Capsular Tension

I have experimented with various techniques for
determining the appropriate amount of capsular ten-
sion, including measuring the amount of translation
in centimeters and measuring capsular tension with
various types of strain gauges, but none has been suc-
cessful. My current technique is to maximally tighten
the capsule while varying the position of the shoulder.
As in an open capsular shift procedure, it is possible to
selectively tighten different areas of the capsule. I posi-
tion the shoulder in elevation and internal rotation,
grasp the posterior capsule with a forceps, and deter-
mine its maximum superior advancement on the gle-
noid. I then suture it in this position. I tighten the
inferior capsule in 0 degrees of abduction and neutral
Figure 4-100 Tie knots. rotation. I tighten the anterior capsule in 45 degrees of
abduction and 45 degrees of external rotation.
If persistent inferior or inferior-posterior translation
remains, I proceed to a rotator interval repair. The
repair sequence is to place the rotator interval sutures,
test the capsular tension, and tie the rotator interval
sutures.
Capsular Tightening
If capsular tightening is necessary, there are two options.
One is to repair the labrum to its anatomic location and
then use a second suture to advance the capsule to the
now repaired labrum. A second option is to repair the
labrum and tighten the capsule in one step. There are
advantages and disadvantages to each approach. If the
surgeon chooses the first option, two suture-passing
steps are required. If the surgeon chooses the second
option, the decision making is more complex and the
amount of tightening possible is more limited. The goal
Figure 4-101 Repeat as needed. is to advance the capsule superiorly and laterally as well
as repair the labrum. Therefore, the surgeon must deter-
mine precisely where the suture passer should enter
both the capsule and the labrum. Once the suture
passer enters the capsule, the surgeon’s ability to maneu-
ver the needle tip and pierce the labrum is limited. It is
also difficult to achieve more than 1 cm of capsular
tightening with this technique. This may be sufficient
for most cases of traumatic unidirectional instability,
but more capsular tightening may be necessary for bidi-
rectional and multidirectional instability. I also lightly
débride the capsule with an arthroscopic rasp because
the synovial bleeding aids capsular healing (Figs. 4-103
through 4-105).
I modify the repair technique when the labrum is
intact but the glenohumeral ligament has been torn
from the labrum. If the labrum is of sufficient size to
allow suture placement within its substance, the liga-
ment is repaired directly to the labrum with monofila-
Figure 4-102 Final middle glenohumeral ligament repair. ment or braided suture. If the labrum is absent, the
capsule is advanced onto the glenoid articular carti-

lage surface and repaired with suture anchors (as
described earlier), creating a labrum bumper.
If the labrum-ligament complex is attached to the
glenoid but the ligament lacks sufficient tension to
contain the humeral head, I operate directly on the
capsule using the methods described earlier. The goal
of this portion of the procedure is to restore ligament
and capsule tension and to eliminate excessive hu-
meral head translation. The capsule can be tightened
by advancing it radially and suturing it to the labrum,
or it can be translated superiorly 1 to 2 cm and then
sutured. I load a braided suture into a Smith-Nephew
suture passer, insert it through the anterior-inferior
cannula, and pierce the capsule at the point where I
Figure 4-103 Use a whisker shaver to lightly abrade the want to advance to the glenoid. For sutures in the
capsule. inferior labrum or capsule, the assistant provides dis-
traction to the humerus as I reach down to grab the
capsule. After the instrument has pierced the capsule,
I advance the tip of the suture passer to the labrum
and penetrate it. I advance the monofilament
suture into the joint. I maintain distraction while
Dr. Hammerman reaches into the joint with a crochet
hook and retrieves the suture out the anterior-superior
cannula. I then insert the crochet hook through the
anterior-inferior cannula and retrieve the other suture
limb. The monofilament suture is used to feed a
braided suture into the glenohumeral joint. I then
tie the knot. These steps are repeated as necessary.
I examine the shoulder for translation, and if I
have established adequate tension, the operation is
concluded.
Capsular Shift
Figure 4-104 Use a rasp to lightly abrade the capsule.
Bankart Capsular Shift
Multidirectional Instability
In patients with multidirectional or bidirectional

instability, the capsule may not tighten adequately
with simple advancement or 1 to 2 cm of superior trans-
lation. If further capsular movement is necessary, I per-
form a capsular shift. To shift the anterior capsule
superiorly, I divide the attachment of the middle gleno-
humeral ligament to the subscapularis. I use scissors to
incise along the superior border of the middle glenohu-
meral ligament from a point overlying the subscapularis
to the glenoid. I then use a blunt dissector to separate
these two structures. I divide the capsular attachment to
the glenoid with scissors, starting anteriorly and con-
Figure 4-105 Use a rasp to lightly abrade the capsule. tinuing until I reach the 6-o’clock position. I then incise
the capsule radially approximately 2 cm. I use the blunt

dissector to free the anterior and inferior capsule from
the underlying subscapularis muscle. The capsule is
now mobilized sufficiently to allow significant
advancement superiorly and is sutured as described ear-
lier. If a posterior capsular shift is necessary, I transfer
the arthroscope to the anterior-superior cannula and
divide the posterior capsule from the glenoid.
Rotator Interval Repair
Interval Repair
Rotator interval repair is the last step performed Figure 4-107 Advance the monofilament suture.
within the glenohumeral joint, because cannulas
cannot be inserted anteriorly once this repair is com-
pleted. A suture passer through the anterior-inferior
cannula is used to place a monofilament suture
through the capsule superior to the subscapularis
tendon. I advance the suture into the joint and with-
draw it through the anterior-superior cannula. I then
load a doubled 2-0 nylon suture into the suture passer,
insert it through the anterior-superior cannula, and
position it in the joint. I withdraw the anterior-super-
ior cannula until it is external to the capsule. I then
withdraw the suture passer external to the capsule and
pierce the superior capsule. I advance this suture into
the joint and withdraw the two free ends out the ante-
rior-inferior cannula. The monofilament suture
through the anterior-superior cannula is placed in
the nylon loop. Traction on the two free ends of the
nylon (exiting the anterior-inferior cannula) draws the
suture through the superior capsule and out the ante- Figure 4-108 Insert a crochet hook through the anterior-
rior-inferior cannula. The knot is then tied, and an superior cannula.
additional suture is placed if necessary. If a greater
degree of tightening is required, the superior capsular
tissue is sutured to the middle glenohumeral ligament
(Figs. 4-106 through 4-114).
Figure 4-106 Pierce the middle glenohumeral ligament Figure 4-109 Retrieve the suture out the anterior-superior
with a suture passer. cannula.
Figure 4-110 Puncture the superior glenohumeral ligament.
Figure 4-113 Test the capsular tension.
Figure 4-111 Advance the nylon suture and withdraw it out

the anterior-inferior cannula.
Figure 4-114 Completed interval repair.
Rotator Cuff Lesions

Overhead throwing athletes may have rotator cuff
lesions that range from minor fraying to full-thickness
tears. When these tears are partial-thickness grade 3 or
full thickness, I repair them after I complete the gle-
nohumeral joint reconstruction. I mark the area of the
tear with a spinal needle or monofilament suture and
reinsert the arthroscope into the subacromial space.
Anterior lesions are usually small tears and are easily
repaired. Posterior lesions are repaired with the arthro-
scope in the lateral portal, and instruments are passed
Figure 4-112 Test the tension of the repair. through the anterior and posterior portals.
Posterior Bankart with 90 degrees and internal rotation to neutral but allow
Posterior Rotator Cuff Repair unlimited external rotation. If the patient had a multi-
directional instability operation, I instruct him or her
POSTOPERATIVE MANAGEMENT to limit shoulder motion as much as possible.
Generally, these patients have some degree of liga-
Postoperative management is similar for all patients. ment laxity, and achieving full range of motion is
A soft pillow sling supports the arm in 15 degrees of not a problem. The sling is worn for 6 weeks, after
abduction. If the primary direction of instability repair which it is removed and the patient begins active
is anterior, I position the elbow anterior to the coronal range-of-motion (without restrictions), strengthening,
plane of the shoulder with the arm internally rotated. and neuromuscular exercises. Patients continue range-
If the primary direction is posterior, I position the of-motion and strengthening exercises for 1 year.
elbow posterior to the coronal plane with the arm in
10 degrees of external rotation. I place the elbow of a
patient with multidirectional instability in neutral
RESULTS
rotation and 25 degrees of abduction. An ice-pack
wrap decreases postoperative shoulder swelling and
Operative Repair
pain. I administer 1 g cephalosporin 8 hours post-
operatively. Patients may choose to go home the The lesions repaired at operation are variable, and
afternoon of surgery or the next morning. Active most patients have more than one. My experience is
range-of-motion exercises of the fingers, wrist, and summarized in Tables 4-1 through 4-3. These early
elbow, as well as deltoid muscle isometric exercises, reports are consistent with my findings in my last
are started the morning after the operation and con- 1000 operations. The average number of bone or soft
tinued at home for 2 weeks. At 2 weeks, I obtain an tissue anchors used is 2.4 (range, 0 to 5).
anteroposterior radiograph to document the position
of the humeral head.
Postoperative Scores and Shoulder
Patients are allowed to remove the sling for active
Rating Systems
elevation and external rotation exercises twice daily
but wear the sling at all other times. If the patient Shoulder rating systems reflected an improvement in
had an anterior repair, I allow active elevation as tol- shoulder status (see Table 4-3). Comparing the scores
erated. I instruct patients to limit external rotation to before surgery to those at final follow-up, paired t-tests
20 degrees at week 2, 40 degrees at week 4, and 60 revealed significant increases in total and subscale
degrees at week 6. If the patient had a posterior scores for the ASES, Constant, Rowe, and UCLA shoul-
repair (either as the only operation or along with an der scores (P = .0001). Neither the Constant nor the
anterior or inferior repair), I restrict active elevation to ASES system provides guidelines that allow the
Table 4-1 PREOPERATIVE PHYSICAL EXAMINATION FINDINGS: BIDIRECTIONAL
0+ 1+ 2+ 3+ Pain Apprehension
Abd/ER (IA) 6 26 4 0 31 14
Abd/ER (IP) 2 12 2 0 14 7
Abd/Down (IA) 3 19 14 0 25 12
Abd/Down (IP) 0 7 9 0 9 6
Sulcus (IA) 0 13 23 0 36 23
Suclus (IP) 0 9 7 0 16 9
Rowe (IA) 2 10 24 0 32 22
Rowe (IP) 0 8 8 0 16 10
Posterior (IA) 24 11 1 0 2 0
Posterior (IP) 6 6 1 3 4 4
Abd/Down, abduction and downward force; Abd/ER, abduction and external rotation; IA, inferior-anterior; IP, inferior-posterior.
Table 4-2 OPERATIVE FINDINGS
BIDIRECTIONAL (n = 33)
UNIDIRECTIONAL MULTIDIRECTIONAL
(n = 53) Inferior-Anterior Inferior-Posterior (n = 47)
Labrum repair
Superior 31 16 7 10
Anterior 48 9 0 10
Type A 25
Type B 15
Type C 8
Inferior 2 2 0 2
Posterior 0 0 2 6
Ligament suture imbrication
Anterior 46 25 5 47
Middle 41 33 11 47
Inferior 31 19 7 47
Posterior 0 0 9 47
Thermal tightening
Anterior 48 7 1
Middle 5 5 2
Inferior 11 17 9
Posterior 0 0 7
Rotator interval repair 14 22 14 28
Table 4-3 FINAL RESULTS*
ASES CONSTANT ROWE UCLA
Pre Post Pre Post Pre Post Pre Post
Unidirectional Instability
Score 45.5 91.7 56.4 91.8 11.3 91.9 17.6 32.0
SD 18.6 13.7 13.3 11.3 5.7 20.8 4.8 4.7
Bidirectional Instability
Score 45.5 94.0 57.0 92.4 20.3 92.1 18.6 32.7
SD 16.2 9.3 12.9 10.4 13.3 19.5 4.4 3.7
Multidirectional Instability
Score 45.4 94.7 60 91.7 14.2 93.7 17.4 33.1
SD 18.8 9.3 11.5 8.5 13 13.2 4.5 2.9
*All postoperative scores significant: P = .0001.
ASES, American Shoulder and Elbow Surgeons Shoulder Index; Post, postoperative; Pre, preoperative; SD, standard deviation; UCLA, University of
California at Los Angeles.
surgeon to determine which scores reflect excellent or had a final mean Rowe score of 94, and those with
poor results. Ellman categorized UCLA shoulder scores ligament laxity (n = 6) had a final score of 74. The
of 29 to 35 as equivalent to good to excellent results difference was statistically significant (P = .02). The
and those less than 29 as fair to poor. In Rowe’s poorer results in patients with generalized ligament
system, scores of 90 to 100 are excellent and 75 to laxity may stem from technically inadequate repairs,
89 are good. In my experience with all three types of or they may suggest that patients with anterior-
glenohumeral instability (traumatic unidirectional inferior instability and generalized ligament laxity
anterior, bidirectional, and multidirectional), about require an open capsular reconstruction to achieve
90% of shoulders have achieved good to excellent adequate soft tissue tension.
results according to both the Rowe and UCLA scores.
The details of these results are summarized in the
Complications
following sections.
No major intraoperative or perioperative complica-
tions (permanent nerve injuries, wound infections)
Range of Motion
occurred. Two patients noted paresthesias in the mus-
No patient lost more than 5 degrees of forward eleva- culocutaneous nerve distribution. All had resolved by
tion. External rotation at 90 degrees of abduction the 6-week postoperative visit. One patient noted
averaged 88 degrees, compared with 83 degrees preop- minor wound drainage that resolved within 1 week
eratively. The gain in movement reflects the preopera- without the use of antibiotics. I did not observe any
tive loss of external rotation that is typical in patients complications from suture anchors.
with traumatic anterior instability caused by medial
healing of the Bankart lesion (ALPSA). Patients without
ALPSA lesions have a similar loss of external rotation LATARJET
because they tend to limit that motion to avoid pain
or instability. As noted earlier, in some cases I have found the results
of soft tissue reconstruction of the glenohumeral joint
ligaments unsatisfactory. There are four situations in
Return to Sports Participation
which no combination of labrum repair and capsular
Among my patients with unidirectional traumatic tensioning is successful:
anterior glenohumeral instability, 43 participated
1. Anterior-inferior glenoid bone loss
actively in sports before the onset of their shoulder
2. Poor-quality ligaments
problems: 0 patients participated in type 1, 5 in type
3. Suboptimal patient compliance
2, 30 in type 3, and 8 in type 4 sports. When stratified
4. Extreme sports participation
by level of participation, 7 patients participated at
level 1 (high school team sports), 1 at level 2 (college An demonstrated in a cadaver experiment that ante-
team sports), and 35 at level 3 (recreational athletes). rior glenoid defects greater than 4 mm result in glenoid
At final follow-up evaluation, 5 patients did not par- insufficiency that the surgeon cannot correct with soft
ticipate in sports owing to issues unrelated to their tissue repair. I use 4 mm only as a guideline because
shoulders. The reasons most commonly cited were An’s laboratory experiment did not take into account
work or family commitments, graduation from high the variability of capsular advancement that can be
school or college (and the associated lack of team achieved in a particular patient. I have found three-
sports), and injuries to the knee or lumbar spine. dimensional computed tomography reconstruction or
The remaining 38 patients participated in sports: the Bernejeau view to be helpful radiographic aids;
1 in type 1, 6 in type 2, 26 in type 3, and 5 in type however, I rely more on my inspection of the glenoid
4. The level of participation at final follow-up was 3 at shape at the time of arthroscopic examination. After I
level 1, 0 at level at 2, and 35 at level 3. Four patients inspect the glenohumeral joint with the arthroscope in
with persistent shoulder instability had decreased the posterior portal, I create an anterior portal and
their level of participation at final follow-up. move the arthroscope there. This allows me to look
down the anterior glenoid and observe the presence
or absence of the normal pear shape. If I am unsure
Ligament Laxity
whether there is bone loss anteriorly, I insert a probe
The final Rowe score was stratified according to the through the posterior cannula and note the distance
presence or absence of generalized ligament laxity. from the glenoid bare spot to the anterior and posterior
Patients without evidence of ligament laxity (n = 47) glenoid (Figs. 4-115 through 4-118).
Figure 4-117 Absent anterior capsule and glenohumeral

ligaments.
RT should
understand why surgeons who decide that the gleno-

Figure 4-115 Magnetic resonance image shows anterior
humeral joint ligaments are insufficient for arthro-
bone loss.
scopic repair would proceed to do an open ligament
repair. I am not aware of any experimental evidence
that exposing inadequate glenohumeral ligaments to
Poor ligament quality may be due to prior surgery air or light causes these deficient ligaments to
or multiple dislocations. The surgeon gains some improve. It is my opinion that if the ligaments are
information about ligament quality as the ligaments inadequate, the surgeon must find some other opera-
are palpated and maneuvered with surgical instru- tive method.
ments. However, the assessment of ligament quality Patient compliance with any postoperative regimen
is subjective and therefore imprecise. The literature is variable, but in my experience, young patients with
contains multiple articles listing poor-quality liga- an active lifestyle may disregard some or all postoper-
ments as an indication for open surgery, but usually ative instructions and restrictions. Only a flawless pre-
this involves some type of ligament repair. I do not operative character analysis and a prescient
understanding of perioperative behavior would elimi-
nate this as an issue. When I have doubts about the
patient’s maturity, I sleep better knowing that my
repair is held with two large bone screws rather than
five No. 1 sutures.
Certain sports or activities are so demanding that
participation requires not a normal shoulder but a
‘‘better than normal’’ shoulder. The demands of
Figure 4-116 Insufficient bone to contain the glenoid. Figure 4-118 Insufficient bone to contain the glenoid.
rock climbing, competitive kayaking, and weight lift-

Coracoacromial
ing are so great that few patients return to these activ- ligament
ities after conventional surgical repair (open or
arthroscopic). I tell patients that a soft tissue repair is
sufficient to allow them a return to almost all high- Graft
demand activities, but certain activities require a dif- Glenoid
ferent approach. bone loss
Failed prior surgery (open or arthroscopic) is the
most common indication for the Latarjet procedure.
I have successfully treated such patients with the
Latarjet procedure as published and taught to me by
Gilles Walch. More recently, I have successfully treat-
ed these patients with an arthroscopic Latarjet proce-
dure as described and taught to me by Laurent Lafosse
from Annecy, France (as of this writing, he has yet to
publish his results). He is the pioneer in the arthro- Screws
scopic approach, and I am grateful for the time Graft
he spent teaching me his techniques. Interestingly,
the evolution of the Latarjet from an open to
an arthroscopic procedure, its reception in the ortho- Figure 4-119 Latarjet procedure.
pedic community, and my transition from open to
all-arthroscopic repair (described later) are eerily rem-
iniscent of my experiences with arthroscopic subacro-
mial decompression, arthroscopic distal clavicle surface that approaches the graceful concavity of the
resection, arthroscopic glenohumeral reconstruction, native glenoid. Is the inferior position of the lower
and arthroscopic rotator cuff repair. subscapularis a dynamic or static block to anterior
The Latarjet procedure involves placing the cora- translation when the arm is abducted and externally
coid and the attached muscles through a longitudi- rotated? What is the role of the transferred conjoined
nal split in the subscapularis muscles and fixing it tendon? Braly and Tullos attempted to answer some of
to the anterior-inferior glenoid with two screws. these questions in their classic article.
This accomplishes several objectives: the glenoid is It is obvious that the Latarjet controls glenohumer-
enlarged, the potential space for the humeral head al joint instability by a different mechanism from
to move anterior and inferior to the glenoid is those procedures that repair the labrum and capsule.
eliminated, and the coracoid prevents a portion of Both operations are effective yet seem to approach
the subscapularis from moving superiorly as the the problem from diametrically opposite directions.
shoulder is moved into a position of abduction
and external rotation. The inferior surface of the
coracoid matches the anterior-inferior scapular
neck quite nicely. The coracoid is good-quality
bone, and its fixation to the scapular neck is very
secure. Because of this secure fixation, patients can
discontinue the sling after 1 week for most activities
of daily living. The coracoacromial ligament remains
attached to the coracoid and is used to reinforce
the anterior capsule. Several publications have docu-
mented excellent clinical results (Figs. 4-119
through 4-122).
The Latarjet has a long and well-documented his-
tory of success, and experienced shoulder surgeons
such as Gilles Walch and Christian Gerber use
it almost exclusively to treat traumatic anterior-
inferior glenohumeral instability. However, I am not
certain why the operation is effective. Even the most
perfect placement of the coracoid cannot create a Figure 4-120 Radiograph of the Latarjet open technique.
My current thinking on this issue is that labrum

and capsule repairs control glenohumeral joint
instability by altering the static restraints to hum-
eral head motion, whereas the Latarjet and Bristow
procedures alter the dynamic factors. We know that
both mechanisms are involved. For example, con-
sider a patient with asymptomatic glenohumeral
joint laxity. He is active in sports, and the stabiliz-
ing muscles are strong. When this patient enters law
school, the demands of study cut into his exercise
routine, and his muscles lose tone. When this indi-
vidual attempts to get back in condition and begins
a weight-lifting program, the shoulders sublux, and
he presents to the orthopedic surgeon complaining
of pain. The solution to this patient’s dilemma is
not surgery but simply a strengthening program
for the rotator cuff and the scapular stabilizing mus-
cles. Now consider a second law school student who
Figure 4-121 Radiograph of the Latarjet arthroscopic has no laxity and sustains a traumatic dislocation
technique. during a rugby match. Emergency room reduction
is necessary. Owing to continued dislocations, this
patient undergoes surgery during which a Bankart
Can both approaches be right? A similar (but more lesion is found and corrected. Both patients had
complex) problem was faced by physicists at the glenohumeral joint instability, but one cause was
dawn of the 20th century when they tried to reconcile dynamic and the other was loss of the static stabi-
the behavior of light. In some experiments, light lizers. Although these polar opposites present clear
behaved as a wave; in others, it clearly acted as a choices, I am uncertain where the vast majority of
particle—photons of energy. The great Danish physi- patients fall. Perhaps both mechanisms exist in all
cist Niels Bohr reflected on this issue and concluded, patients, but the relative contributions of the
‘‘The opposite of a correct statement is a false state- dynamic and static stabilizers vary from one individ-
ment. But the opposite of a profound truth may well ual to another. Perhaps our surgical corrections
be another profound truth.’’ should reflect that.
Although there are some conditions for which
a Latarjet-type procedure is definitely indicated
(as outlined earlier), there are other situations (e.g.,
multidirectional, bidirectional, posterior instability)
in which the more global correction afforded by
arthroscopic soft tissue repair and balancing is
required. At present, the orthopedic surgeon can cor-
rect most forms of anterior-inferior glenohumeral
joint instability with either approach and achieve a
successful result.
There are a number of issues that deserve discus-
sion regarding an arthroscopic approach: What
are the potential advantages? Is it technically
possible to reproduce the appropriate steps? What
are the potential risks? How difficult is the
technique?
The criticism of the arthroscopic Latarjet is familiar to
those of us who witnessed the transition from open sub-
acromial decompression and rotator cuff repair to
arthroscopic techniques. The criticism has a predictable
Figure 4-122 Radiograph of the Latarjet arthroscopic pattern. Leading orthopedic surgeons on editorial
technique. boards and lecture panels inevitably proclaim that the
developer of an arthroscopic technique cannot do the 16. Passage of the coracoid through the subscapu-
following: laris split
17. Precise coracoid placement on the anterior
1. Insert the arthroscope into the appropriate area.
scapula
2. Visualize the relevant structures.
18. Secure fixation with screws
3. Insert instruments to repair the lesions.
19. Capsular repair with the coracoacromial
4. Repair the lesions adequately.
ligament
5. Perform the operation within a reasonable time.
20. Skin closure
6. Achieve results equivalent to those of the open
procedure.
The next phase was to determine which of the
7. Improve on the results of the open procedure.
steps was necessary and which could be performed
8. Teach others to perform the operation.
with the arthroscopic technique. Steps 1 to 4 are not
When Lafosse first presented his technique for arthro- needed because the cannula passes directly into
scopic Latarjet, all these criticisms were voiced, as they the requisite areas, and step 20 is self-evident. I
were in 1983 (arthroscopic subacromial decompres- reviewed videos of the surgical technique with
sion), 1985 (arthroscopic distal clavicle resection), Lafosse and saw that he could do all the necessary
1987 (arthroscopic glenohumeral reconstruction), steps. My experience with other arthroscopic opera-
1992 (arthroscopic rotator cuff repair), and 1995 tions convinced me that I already knew how to
(arthroscopic treatment of irreparable rotator cuff perform steps 5 to 8, 11, and 15. I performed steps 9,
tears). 10, 12 to 14, and 16 to 19 in the cadaver laboratory. I
The first question to answer was, why perform the had stopped repairing the capsule and coracoacromial
operation arthroscopically? Although the results of ligament during my open Latarjet procedures and
the open Latarjet are excellent, they are not perfect. saw no need to perform it arthroscopically. At this
Perhaps an arthroscopic technique could improve the point, I was convinced that I could perform an
results owing to increased technical precision or treat- arthroscopic Latarjet.
ment of lesions unrecognized during open repair (e.g., I then began to perform portions of the arthro-
posterior ligament tears, SLAP lesions). I knew it was scopic repair. I arthroscopically examined all patients
possible to insert the arthroscope and instruments who were to undergo an open Latarjet. I set a 1-hour
into the subdeltoid space and visualize quite clearly time limit and performed different parts of the arthro-
the coracoid, conjoined tendon, and anterior scopic procedure:
subscapularis.
1. Scapular neck preparation. I had already devel-
The next step in the transition from open to arthro-
oped skill at anterior scapular neck preparation
scopic repair involved detailing the individual steps
during my experience with arthroscopic gleno-
performed during an open Latarjet:
humeral joint stabilization.
1. Anterior skin incision 2. Release of the rotator interval. Release of the
2. Exposure of the deltopectoral groove rotator interval is commonly performed in the
3. Lateral retraction of the cephalic vein treatment of shoulder stiffness. I accomplish
4. Separation of the deltoid from the pectoralis this with an electrocautery device and a power
major shaver.
5. Identification of the coracoid 3. Identification of the coracoid. I had performed a
6. Identification of the coracoacromial ligament few coracoid osteotomies for coracoid impinge-
7. Division of the clavipectoral fascia along the ment, so I was somewhat familiar with the
lateral border of the conjoined tendon method of coracoid exposure through the rota-
8. Release of the coracoacromial ligament from tor interval. During operations for repair of the
the acromion subscapularis, I routinely visualize the coracoid,
9. Release of the pectoralis minor from the medial so I was familiar with the view with the arthro-
coracoid scope placed in the lateral portal.
10. Coracoid osteotomy 4. Release of the coracoacromial ligament. I typi-
11. Coracoid decortication cally visualize the coracoacromial ligament
12. Drilling of holes in the coracoid through the rotator interval during a contracture
13. Subscapularis split release to ensure that I resect all interval tissue.
14. Capsulotomy I did not find it difficult to follow the ligament
15. Preparation of the anterior scapula laterally and release it from the acromion.
5. Coracoid decortication. With the arthroscope in needle to mark its location. The drill guide must
the posterior portal and a shaver inserted ante- be positioned midway between the medial
riorly, the coracoid can be identified by palpat- and lateral cortical borders. The proximal-distal
ing it with the shaver. Soft tissue can be removed position is determined by allowing sufficient
from the superior and lateral surfaces. I use coracoid bone distal to the distal screw hole so
electrocautery alone or a power shaver equipped the screw will not cut out. The two drill holes are
with electrocautery. Once the lateral surface then made.
is clean, I begin to clean the inferior surface. 9. Coracoid osteotomy. I insert a 1=4-inch osteo-
I then use a power bur to remove a small tome through the anterior incision and per-
thickness of cortical bone from the inferior form the osteotomy under direct vision. Once
surface. the coracoid is free, I insert a suture through
the drill holes and leave the suture coming
These first five steps were all accomplished with out through the anterior coracoid portal.
the arthroscope inserted through standard portals, 10. Subscapularis split. To help locate the correct
the posterior glenohumeral joint, and the lateral site of the split (from superior to anterior),
subacromial locations. The next steps required that I pass a long switching stick into the glenohu-
I learn and master the use of various anterior portals: meral joint from anterior to posterior. With the
arthroscope in the anterolateral portal, I can
6. Division of the clavipectoral fascia. I move the see into the joint through the rotator interval
arthroscope to an anterior-lateral portal, imme- and determine the location of the anterior-
diately lateral to the coracoid. This portal is in inferior glenoid. I advance the rod past this
line with the anterior acromion and 3 to 5 cm and into the subscapularis. I look anterior to
lateral to the lateral acromion. The coracoid can the subscapularis and insert a retractor to
be seen medially, and I orient myself to the loca- move the coracoid (and neurovascular struc-
tion of the glenohumeral joint posteriorly, the tures) medially. I continue to advance the rod
subscapularis inferiorly, the pectoralis minor through the subscapularis muscle. I insert
medially, and the lateral border of the conjoined electrocautery through the anterior coracoid
tendon and clavipectoral fascia laterally. I use portal and divide the subscapularis muscle
the previously created anterior portal and intro- medially and the tendon more laterally.
duce an electrocautery instrument to divide the When entering the joint laterally, there is a
clavipectoral fascia immediately lateral to the danger of scoring the humeral head; to mini-
border of the conjoined tendon. The area is mize the chance of this occurring, I use the rod
well seen, and division is not difficult. to push the capsule anteriorly and develop a
7. Release of the pectoralis minor. I advance the little space between the capsule and the articu-
arthroscope deeper (more medially) until I see lar cartilage.
the pectoralis minor tendon. I insert a spinal 11. Passage of the coracoid through the subscapu-
needle percutaneously, immediately anterior to laris. Once I have created sufficient space for
the midcoracoid, and make a small incision. the coracoid, I advance the rod anteriorly
Through this incision I insert the metal trocar until the rod tip tents the skin. The rod passes
and use it as a soft tissue dissector. The superior through the deltoid muscle. I incise the skin
portion of the tendon (and the brachial plexus) and advance the rod. The next step also
is easily seen. The distal portion of the pectoralis involves a specialized tool. I insert a grasper
minor tendon is harder to identify. I then through the inferior anterior-medial portal,
remove the trocar, introduce the electrocautery, grasp the sutures transfixing the coracoid,
and begin releasing the pectoralis minor tendon and bring them out this portal. The sutures
from the medial coracoid. I continue distally are placed through the double-barrel inserter,
until the tendon is released. and the coracoid is positioned against the end
8. Drilling of holes in the coracoid. Up to this of the device. Temporary fixation screws secure
point, I have used conventional arthroscopic the coracoid to this device.
instruments, but some specialized instruments 12. Coracoid placement. With the inserter device
are now necessary. I insert a special drilling and its attached coracoid, I find the transfixa-
guide through the anterior coracoid incision tion rod and withdraw it posteriorly as I
and place it against the anterior coracoid. If the advance the coracoid through the subscapularis
distal coracoid tip is not evident, I insert a spinal and into the glenohumeral joint.
13. Coracoid fixation. At this point, I have an My goal is to repair the patient’s shoulder by
excellent view of the anterior glenoid. The cor- whatever technique will be most effective. At pres-
acoid is positioned at the site of the glenoid ent, my operative treatment of glenohumeral
defect. I make sure the coracoid does not pro- instability is arthroscopic. With the arthroscopic
ject laterally into the glenohumeral joint and technique, I inspect the entire glenohumeral joint
contact the humeral head. I replace the tempo- and avoid soft tissue dissection. No division of the
rary screws with longer permanent fixation subscapularis is required. Although I have no statis-
screws. I then remove the inserter and inspect tical evidence, my impression is that arthroscopic
the completed repair. repair provides improved cosmesis, decreased post-
14. I make no attempt to repair the subscapularis, operative pain, and more rapid gains in motion
because such tightening would restrict internal compared with open operative treatment of similar
and external rotation. lesions.
15. The instruments are removed, and the small These techniques should be used only by an
skin incisions are closed with subcuticular experienced orthopedic surgeon familiar with the
absorbable sutures. normal and abnormal anatomy seen during both
open and arthroscopic shoulder operations. A thor-
I place the patient in a shoulder immobilizer that ough understanding of the various conditions that
can be removed for bathing, dressing, and pendulum produce shoulder pain is needed. An orthopedic sur-
exercises. At the 1-week visit, I remove the sling and geon who infrequently performs open glenohumeral
allow the patient to use the arm for all routine activ- instability repair should not attempt the arthroscopic
ities of daily living. I obtain an anteroposterior radio- procedure.
graph. At the 6-week visit, I obtain a Bernejeau view to
evaluate the position of the coracoid. I encourage
active shoulder stretching and begin a home strength-
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CHAPTER
5
Biceps Tendon Lesions
The biceps tendon represents a transition from the gle- PROXIMAL BICEPS LESIONS
nohumeral joint to the subacromial space. Biceps
lesions occurring at the glenoid attachment are inti- Superior labrum from anterior to posterior (SLAP)
mately involved in the treatment of glenohumeral lesions offer an interesting and complex challenge to
instability, and biceps abnormalities in the region of shoulder surgeons. Patients with SLAP lesions present
the bicipital groove (subluxation and synovitis) are with a wide spectrum of clinical complaints; the find-
part of subacromial impingement. I often perform ings on physical examination differ, the clinical find-
biceps tenodesis as part of the treatment for a rotator ings are nonspecific, and radiographic diagnosis is
cuff tear. Biceps tenotomy is one option for the treat- imprecise. Even at operation the findings are variable,
ment of irreparable rotator cuff tears. and the decision whether to repair a SLAP lesion
There are seven basic mechanisms by which biceps requires a thorough understanding of the patient’s
lesions cause shoulder dysfunction proximally at clinical condition and shoulder pathophysiology.
the biceps-labrum complex:
1. Mechanical abnormalities such as labrum flap Anatomy
tears
The anterior, inferior, and posterior labrum is firmly
2. Labrum pathology resulting in glenohumeral joint
attached to the glenoid, and separation of any of these
instability (e.g., loss of concavity-compression
areas from the glenoid is pathologic. An exception to
and the attachment site for the glenohumeral
this is the normal sublabral hole that exists near the
ligaments)
anterior-superior glenoid (Fig. 5-1). The superior
3. Part of the pathophysiology of cyst development
labrum, in contrast, has wide variability in terms of
4. Lesions within the tendon substance, which
its attachment to the glenoid. A normal superior
may be painful due to intrinsic biceps tendinitis
labrum is not always attached, or it may have only a
or a partial tear; with more extensive damage, an
flimsy connection to the glenoid. If the glenoid under-
enlarged tendon may cause pain due to biceps
lying the superior labrum is covered with smooth car-
entrapment
tilage and neither the superior labrum nor the glenoid
5. Entrapment with arm elevation—the hourglass
demonstrates any evidence of trauma, I consider this
biceps, as described by Boileau
superior labrum separation to be a normal anatomic
6. Biceps tendon dislocation or subluxation; even
variant and not a pathologic lesion (Fig. 5-2). Evidence
a normal biceps tendon may become part of a
of trauma includes fraying or tearing of the superior
pathologic process, such as that seen with rota-
labrum or damage to the glenoid cartilage directly
tor cuff and subscapularis tears
underneath the labrum separation. Superior labrum
7. Biceps adhesions accompanying a proximal
separation without evidence of trauma does not
humerus fracture or after glenohumeral
require repair.
arthroplasty
147
Figure 5-1 Normal anterior-superior labral hole. Figure 5-3 SLAP type 1.
A SLAP lesion is an abnormal separation of the

superior labrum from anterior to posterior. It was
first described by Snyder, who noted four variations.
In a type 1 lesion, the superior labrum is attached to
the glenoid rim, but there is fraying of the leading
edge of the labrum. In a type 2 lesion, the superior
labrum is detached from the glenoid. A type 3 lesion
is similar to type 2, but there is also a bucket-handle
tear, whereas a type 4 lesion has a longitudinal split in
the biceps tendon (Figs. 5-3 through 5-6).
There are many variations of these four basic
lesions. This is particularly true with regard to the
glenohumeral ligaments. The middle and rarely the
anterior-inferior glenohumeral ligaments may be
attached to the glenoid only through the superior
labrum. SLAP lesions have been identified in patients Figure 5-4 SLAP type 2.
with full-thickness rotator cuff tears and in those with
glenohumeral instability. A number of publications
Figure 5-2 Normal superior labrum separation. Figure 5-5 SLAP type 3.
Chapter 5 Biceps Tendon Lesions 149
Compress
External rotation
Figure 5-6 SLAP type 4.
have addressed this lesion’s frequency and our ability

to diagnose it. Rodosky made an important contri-
bution when he demonstrated the contribution
of the superior labrum to anterior glenohumeral Figure 5-7 Shoulder compressed and rotated.
instability. Walch, Jobe, Morgan, and Burkhart have
discussed the role of the superior labrum in internal
impingement.
Rotator Cuff Disease
Secondary Impingement
Mechanical Irritation SLAP lesions are infrequent in the classic outlet impinge-
ment of stage 2 rotator cuff disease. I suspect SLAP
Patients may present with symptoms of intermittent lesions in younger patients who present with impinge-
catching or locking of the shoulder during overhead ment symptoms and a type 1 or type 2 acromion.
sports or activities of daily living. The pain is sharp, Magnetic resonance images are normal, and the
severe, and localized vaguely as ‘‘deep within the physical examination is usually consistent with impinge-
shoulder joint.’’ Physical examination findings are ment. Physical findings suggestive of a SLAP lesion
variable. The examiner applying compression to the are absent. In this setting, I carefully evaluate the
abducted shoulder and rotating the arm may reproduce superior labrum attachment at the time of arthroscopy.
pain (Fig. 5-7).
Placing the internally rotated arm in adduction and
having the patient resist a downward force (the O’Brien
test) may be painful. The Speed test may be positive.
A magnetic resonance imaging study without contrast
occasionally demonstrates a detached superior labrum,
but the addition of contrast material seems to improve
its sensitivity (Fig. 5-8).
An orthopedic surgeon with a high index of suspi-
cion who excludes other more common causes of
shoulder pain such as impingement, acromioclavicu-
lar joint arthrosis, and glenohumeral instability most
commonly diagnoses SLAP lesions. There are no defin-
itive patient complaints or physical examination
findings that will always enable the surgeon to diag-
nose a labrum tear. I diagnose most SLAP lesions at
arthroscopy. Figure 5-8 Magnetic resonance imaging with contrast.
The presence of normal cartilage covering the superior cuff tear, followed the tear, or was an independent
glenoid or the absence of trauma leads me to believe that entity. One of the reasons for repairing the rotator
the superior labrum separation is a normal anatomic cuff tendons is to restore their ability to center the
variation that plays no role in the patient’s shoulder humeral head during overhead elevation. It seems
pain. In these individuals, I ignore the labrum and treat reasonable to repair another possible source of hu-
the patient for subacromial impingement. meral head depression—the biceps-labrum complex.
A more confusing situation exists in patients with Here again, theory collides with reality. My goal
classic outlet impingement, as diagnosed by history after rotator cuff repair is to restore full passive
and physical examination, and a traumatic superior range of motion, but if the SLAP lesion is repaired,
labrum separation (SLAP type 2). Once I have I must restrict full external rotation so as not to
confirmed that the SLAP lesion is traumatic and not disrupt the SLAP repair. Unless the SLAP lesion is
an anatomic variation, I begin to question the accu- significant, I prefer to repair only the rotator cuff.
racy of my preoperative diagnosis of impingement. In The average age of my patients who undergo arthro-
patients younger than 40 years, I carefully check for scopic rotator cuff repair is 62 years, and I am not
subtle signs of anterior-inferior instability such as concerned about the SLAP lesion and its effect
labrum fraying, fissures, or minor separations. In this on glenohumeral joint stability. I prefer to perform
clinical setting, the surgeon should be aware that a tenodesis of the biceps tendon rather than a
the SLAP lesion might cause or exacerbate subtle ante- labrum repair. With the tenodesis, patients can per-
rior-inferior glenohumeral instability and that the form my standard rehabilitation regimen after rota-
‘‘impingement’’ symptoms are secondary. It is usually tor cuff repair, without any concerns about external
impossible to determine whether (1) the SLAP lesion rotation. I alter their postoperative care by instruct-
is the result of altered shoulder biomechanics ing patients not to perform elbow flexion against
that accompany chronic impingement, (2) the SLAP resistance for 3 weeks.
lesion has altered shoulder biomechanics enough to
cause impingement, or (3) there is any relationship
Glenohumeral Instability
between the two. It is possible that two separate
pathologic processes are involved. I am convinced, SLAP lesions contribute to glenohumeral instability
based on personal experience and the publications of directly and indirectly. Rodosky demonstrated in
Walch, that the long head of the biceps is not a major the laboratory that less force is required to translate
depressor of the humeral head, but perhaps more the humerus on the glenoid when a SLAP lesion is
subtle processes are at work. present. Pagnani demonstrated in cadavers an increase
in anterior-posterior and superior-inferior translation
SLAP Lesion with Acute Rotator Cuff Tear when a SLAP lesion is created. The presence of a
With the increasing use of arthroscopy, surgeons SLAP lesion therefore contributes indirectly to gleno-
now routinely inspect the glenohumeral joint and humeral instability, so it seems reasonable to repair a
identify SLAP lesions. SLAP lesions are not seen SLAP lesion along with other lesions found during
during open rotator cuff repair, so their incidence a glenohumeral reconstruction.
has been underreported in publications dealing The SLAP lesion can also directly affect glenohu-
with open techniques. They occur more frequently meral stability. The anatomy of glenohumeral liga-
in younger patients following significant trauma. ment insertions is variable, and I have seen cases in
A typical example is a worker who falls backward which the middle and even anterior-inferior glenohu-
and lands on his elbow with the shoulder in exten- meral ligaments are attached not to the anterior-
sion. The humeral head is driven superiorly, and inferior glenoid but directly to the superior labrum.
presumably the biceps tendon attachment is Superior labrum detachment removes the connection
avulsed from the glenoid. I repair SLAP lesions that stabilizing the glenohumeral ligament and the gle-
are noted in the setting of an acute full-thickness noid. A SLAP lesion in such an individual is function-
rotator cuff tear. ally a ‘‘Bankart’’ lesion, and I think superior labrum
repair is indicated.
Chronic Full-Thickness Rotator Cuff Tear Morgan and Burkhart presented a third type
My experience is that SLAP lesions are found infre- of relationship between SLAP lesions and glenohu-
quently in patients with chronic full-thickness meral instability. They postulate that repetitive over-
rotator cuff tears. Taverna and I found an incidence load stress in a throwing athlete creates a posterior-
of 2.5% (5 of 200), and we could not deter- superior SLAP lesion. The ‘‘bumper’’ and ‘‘suction-
mine whether the SLAP lesion preceded the rotator cup’’ effects of the labrum are destroyed, and
posterior-superior instability is the result. This type

of instability can cause articular surface partial- Anterior
thickness rotator cuff tears and anterior-inferior gle-
nohumeral instability. This is supported by Pagnani’s
cadaver study, in which he found that an experi-
mentally produced SLAP lesion resulted in increased
nal rotation
anterior-posterior and superior-inferior translation.
My experience supports repair of the SLAP lesion
r
in this setting.
Inte
The Throwing Athlete
Tight posterior capsule
Diagnosis producing avulsion SLAP
Patients with SLAP lesions may present with symp- Figure 5-10 Tight posterior capsule producing avulsion.
toms of mechanical abnormalities. They complain of
locking or catching when they participate in athletics
or vigorous activities of daily living. They also com-
plain of painful catching or popping with passive a full-thickness rotator cuff tear. Alternatively, the
shoulder compression and rotation. The relocation physical examination findings and patient complaints
test may be positive (Fig. 5-9). The physician can per- may be consistent with glenohumeral instability. In
form a variety of clinical tests, but in my experience, addition, patients may complain of posterior-superior
they may not produce pain when a SLAP lesion is pre- subdeltoid pain when the arm is placed in abduction
sent, or they may produce pain when no SLAP lesion and external rotation during athletics or work.
exists. I pay close attention to posterior soft tissue contrac-
Although such tests are helpful, the examiner ture and evaluate the shoulder’s internal rotation in
must put them in the context of the patient’s clinical neutral extension as well as in the scapular plane.
situation. Patients with SLAP lesions may present Internal rotation may be quite limited. The source of
with findings typical of subacromial impingement or the underlying soft tissue contracture is unclear; some
patients have significant loss of internal rotation
yet also have excessive posterior glenohumeral trans-
lation. This suggests that in some patients, the poste-
rior capsule may be contracted, whereas others have a
normal or lax capsule with contracture of the posterior
rotator cuff.
Morgan and Burkhart believe that the posterior
contracture is primary. With forceful internal rotation,
the tight posterior capsule causes traction on the
superior labrum and produces an avulsion injury
(Fig. 5-10). Although this hypothesis is reasonable, it
does not explain those patients with SLAP lesions and
normal internal rotation or those with internal rotation
loss but no SLAP lesion. Clearly, our knowledge on this
A topic is incomplete.
Nonoperative Treatment
Nonoperative treatment is directed at correctable,
underlying causes of shoulder pain. Limitations of pas-
sive range of motion are corrected with appropriate
stretching exercises. Impingement is treated with
B activity modification and selective rest of the shoul-
Figure 5-9 A and B, Relocation test. der. Glenohumeral instability is treated with exercises
to strengthen the glenohumeral stabilizing muscles

and to improve neuromuscular coordination, as
described in Chapter 4. Pay particular attention to
scapular kinematics and stress rehabilitation in this
area. Read the works of Kibler.
Indications and Contraindications for

Surgery
SLAP lesions that produce mechanical symptoms of
locking or catching are the least likely to respond to
rehabilitation, and operation is indicated if symptoms
are present for 3 to 6 months. In patients with SLAP
lesions that coexist with glenohumeral instability or
rotator cuff disease, indications are based on the
underlying condition.
All SLAP lesions are technically reparable, but there Figure 5-11 Anterior portal sites.
are some SLAP lesions that should not be repaired.
Because SLAP repair requires postoperative immobili-
zation, I do not repair SLAP lesions that are found
during operation for adhesive capsulitis or chronic glenoid. The arthroscope is then inserted through
rotator cuff tears. the anterior portal, and the posterior structures are
inspected. The arthroscope is then reinserted poster-
iorly (Figs. 5-11 through 5-17).
Operative Technique All structures within the glenohumeral joint are
examined systematically. Lesions are variable and
include tears of the rotator cuff (partial and complete),
SLAP Repair rotator interval lesions, biceps tendon fraying, and
glenohumeral ligament tears. I specifically examine
Before a surgeon repairs a SLAP lesion, two questions the labrum below the glenoid equator, anteriorly
must be answered: Is the superior labrum separation
from the glenoid a lesion, or is it an anatomic variant?
What is the relationship between the labrum separa-
tion and the patient’s clinical presentation? Anterior
Before undergoing general anesthesia, patients Anterolateral
receive an interscalene block to diminish postopera-
tive pain. Patients are placed in the sitting position.
The range of motion for external and internal rotation
with the arm in 90 degrees abduction and the range of
motion for external rotation with the arm in 0 degrees
abduction are recorded. I examine the shoulder for
anterior, inferior, and posterior translation and
record the results. The shoulder is then prepared and
draped routinely. The bony outlines of the acromion
and coracoid process are palpated and marked with a
surgical marking pen.
The shoulder joint is entered with a cannula and
blunt trocar through a posterior skin incision placed
approximately 1.5 cm inferior and 2 cm medial to the
posterolateral border of the acromion. The arthroscope
is inserted into the glenohumeral joint. An anterior-
inferior portal is identified with a spinal needle so the
cannula enters the shoulder immediately superior Figure 5-12 Superior portal placed more laterally, if
to the subscapularis tendon and 1 cm lateral to the necessary.
Figure 5-13 Skin markings.
Figure 5-15 Anterior-inferior cannula entering the joint.

and posteriorly, for signs of fraying and detachment.
Attention is then turned to the superior labrum.
An arthroscopic probe is useful to assess the labrum
attachment accurately because fibrous healing may
have occurred after trauma. A normal labrum cannot
be separated with the probe.
SLAP 1 Lesions
I do not regard the minor fraying at the free edge of
the labrum as pathologic and therefore do not perform
any débridement.
Figure 5-16 Anterior-inferior cannula entering the joint.
Figure 5-14 Cannula orientation. Figure 5-17 Anterior-inferior cannula entering the joint.
SLAP 2 Lesions
If a SLAP 2 lesion is identified, an anterior-superior
portal is created. A spinal needle is inserted at the
anterolateral acromial corner and enters the joint lat-
eral to the biceps tendon. The second cannula is intro-
duced. It is critical to position the anterior-superior
cannula precisely. To obtain a proper angle for the
bur and drill, this cannula must be placed as far lateral
and superior as possible. I always use a spinal needle to
identify both the entry point and the angle for this
cannula. The spinal needle should enter the joint
very close to where the biceps exits from the glenohu-
meral joint and should approach the superior glenoid
perpendicularly (Figs. 5-18 through 5-23).
I prefer suture anchor repair rather than the tack
technique. I am more comfortable with the fixation
Figure 5-19 Spinal needle identifying the site for the
afforded by the anchors and the superior holding
anterior-superior cannula.
power of the sutures as they surround the labrum.
Often the superior labrum is robust, and the amount
of tack inserted into the superior glenoid seems mar-
ginal. There are two drawbacks to the suture anchor
method: knot tying is necessary, and the posterior
anchors can be difficult to insert. Knot tying is a skill
that can be mastered with practice. The surgeon can
usually place an anchor posterosuperiorly on the
glenoid through the anterolateral portal. If it is not
Figure 5-20 Anterior-superior cannula entering through the

rotator interval.
Figure 5-18 Angle for spinal needle insertion to determine

the site of the anterior-superior cannula. Figure 5-21 Cannula orientation.
Figure 5-24 Preparation to expose cancellous bone.
down the glenoid and obscuring my view of the supe-

rior glenoid. In this situation, I insert the bur through
the anterior-inferior portal, and Dr. Hammerman (my
assistant) inserts a probe through the anterior-superior
portal and retracts the labrum superiorly. This reveals
Figure 5-22 Cannula orientation. the superior glenoid surface. Cancellous bone is
exposed from the anterior to the posterior margins
of the superior labrum detachment (Fig. 5-24).
possible to insert the posterior anchor through the Holes for the suture anchors are then made with
anterior-superior portal, I move the arthroscope to a power drill. The drill is inserted through the anterior-
the anterior-superior portal and insert the posterior superior cannula, and the two holes are spaced
anchor through the posterior portal. evenly along the length of the defect. I drill the ante-
I use a 4-mm power bur to abrade the glenoid rior hole first and then the posterior hole. Owing to
beneath the detached superior labrum to expose the curvature of the glenoid, the posterior hole is
cancellous bone. I usually insert it through the ante- more oblique than the anterior hole. As the posterior
rior-superior portal because this provides the best drill hole is moved posteriorly along the glenoid rim,
angle of approach. On occasion, the superior labrum it becomes more oblique. It is a matter of surgical
is very meniscoid, with the labrum margin extending judgment how much obliquity is permissible. The
greater angle of approach causes the screw to be
located more superficially in the bone. If the angle
is unacceptable, there are two options: move the can-
nula more posteriorly so that it approaches the gle-
noid less acutely, or change the curvature of the
superior glenoid rim.
If the superior labrum separation extends more pos-
teriorly than normal, anchor placement is made easier
with a technique modification. Both the superior
portal of Neviaser and a posterior-superior portal
pass through the substance of the rotator cuff tendons
and might lead to tendon rupture. Thus, when the
SLAP lesion extends farther posteriorly than normal,
I try to move the anterior-superior portal posteriorly.
I use a spinal needle placed 1 cm posterior to the
anterior acromial border. If the drill angle is still too
acute, I insert a 4-mm round bur through the anterior-
Figure 5-23 Cannula orientation. superior portal and remove a small amount of
Bur creating shelf
Figure 5-25 Drill at the normal angle of approach.
Figure 5-27 Abrade the superior surface of the glenoid to

allow the drill to penetrate.
glenoid bone to create a ‘‘shelf’’ whose face is now more
perpendicular to the drill (Figs. 5-25 through 5-28).
The posterior anchor is inserted through the ante-
rior-superior cannula, and the two anchor sutures joint, and the suture instrument is withdrawn. A crochet
remain in this cannula. A Smith-Nephew AccuPass hook is used to retrieve both suture ends. Insert the
instrument is inserted through the anterior-inferior crochet hook through the anterior-superior cannula.
portal. The right-angled instrument is passed from To avoid tangling the sutures, pass the crochet hook
the superior aspect of the detached labrum to the infe- underneath (medial to) the sutures coming from the
rior aspect. Passing the suture from inferior to superior anterior-inferior cannula. The loop portion of the
may result in detachment of the bucket handle as nylon suture protrudes from the anterior-superior
pressure is placed on the suturing device; it also cannula, and the two free ends from the anterior-
causes the nylon sutures to exit the suture passer inferior cannula. I prefer to repair the labrum with
and move superiorly, making them harder to retrieve. the suture knot on the superior surface of the labrum
Passing the sutures from superior to inferior places less rather then bury the knot and interpose it between
stress on the labrum; the sutures exit the labrum and
move inferiorly, making their retrieval easier. The
nylon suture is advanced fully into the glenohumeral
Drilling into
shelf
Figure 5-26 Drill at a tangential angle. Figure 5-28 Anchor insertion.

Figure 5-29 Spectrum suture passer. Figure 5-31 Retrieve the nylon suture through the anterior-
superior cannula.
the detached superior labrum and its repair site.

Place a hemostat on the two free ends of the sutures.
Use a crochet hook to retrieve one of the anchor’s
suture strands and bring it out the anterior-inferior
cannula. The remaining anchor suture (in the ante-
rior-superior cannula) is placed through the looped
nylon and pulled through the labrum and out the
anterior-inferior cannula. Both sutures from the pos-
terior anchor now exit the anterior-inferior cannula
Occasionally, the braided suture anchor sutures do
not pull smoothly through the labrum. Using addi-
tional force would cause the nylon passing sutures
to tear. I prefer to use the technique developed
by Hammerman. He threads the two free ends of the
nylon suture through the knot tying instrument
and then advances the tip of the instrument near the Figure 5-32 Bring the nylon suture underneath.
Figure 5-30 Spectrum suture passer. Figure 5-33 Reverse the direction of the loop.
Figure 5-34 Move one suture strand from the anterior- Figure 5-37 Past-point.
superior cannula to the anterior-inferior cannula.
labrum. Rather then pull the nylon sutures, he uses

the knot tying instrument to push the sutures
through the labrum. Because the instrument is adjacent
to the point where the sutures exit from the labrum, he
is able to exert significant force without danger of suture
breakage (Figs. 5-39 and 5-40).
The second anchor is inserted into the anterior drill
hole through the anterior-superior cannula. I insert
the anterior anchor before I tie the posterior sutures
because the anterior hole is obscured after the poste-
rior sutures are tied. The posterior anchor sutures are
tied with an arthroscopic knot tying instrument
through the anterior-inferior cannula, and the sutures
are cut with arthroscopic scissors. The anterior anchor
suture is then placed through the anterior portion
Figure 5-35 Pass the anchor suture through the labrum. of the detached superior labrum as described earlier,
Figure 5-36 Tie the knot. Figure 5-38 Completed repair.

Figure 5-39 Anchor suture caught in the labrum. Figure 5-41 SLAP type 3.
and the sutures are tied and cut. For small labrum crochet hook. Failure to perform this step may result
lesions, a single anchor (loaded with two sutures) in the suture instrument cutting the suture during
will suffice for repair. The technique is similar to the next portion of the operation. Place a hemo-
that described for two anchors. stat on one of the suture limbs to identify which
suture limb passes through the bucket-handle frag-
SLAP 3 Lesions ment. The AccuPass instrument is then inserted
If the bucket handle is less than one third of the through the anterior-inferior cannula and pierces the
labrum width, it is excised, and I repair the major bucket handle from lateral to medial so as not to
portion of the superior labrum to the glenoid, as avulse the fragment.
described earlier. If the bucket handle is one third The loop end of the nylon suture is retrieved out
or greater, I repair the detached portion. The posterior the anterior-superior cannula with a crochet hook.
anchor is inserted, and one limb of the suture anchor The first suture (already passed through the labrum)
suture is passed through the major portion of is transferred from the anterior-superior cannula to
the labrum, as described earlier. Both suture strands, the anterior-inferior cannula to minimize tangling.
which are now in the anterior-inferior cannula, are The second posterior anchor suture is then passed
retrieved out the anterior-superior cannula with a from the anterior-superior cannula, through the
labrum, and out the anterior-inferior cannula. The
sutures are tied and cut. This technique is repeated
with the anterior anchor sutures to repair the
anterior portion of the superior labrum and the ante-
rior portion of the bucket-handle tear (Figs. 5-41
through 5-44).
SLAP 4 Lesions
If the longitudinal tear in the biceps tendon is
less than one third of the tendon diameter, I excise
the torn fragment. If the fragment is one third or
greater, I repair the torn fragment to the major portion
of the biceps tendon. The superior labrum is repaired
first, as described earlier. The AccuPass instrument
is used to place a No. 1 PDS suture through the
torn fragment and then through the major portion
of the biceps tendon. The suture is then tied. One or
two sutures are sufficient to accomplish the repair
Figure 5-40 Advance into the joint with a knot pusher. (Figs. 5-45 through 5-50).
Figure 5-42 First anchor suture strand through a major Figure 5-45 SLAP type 4.
fragment.
Figure 5-43 Second anchor suture strand through a minor Figure 5-46 Biceps repair.
fragment.
Figure 5-44 Completed repair. Figure 5-47 Biceps repair.

Postoperative Treatment
The patient is placed in a sling that is worn at all times
except while bathing. At 2 weeks, active range of
motion is allowed in all planes except external rotation
in abduction. The sling is worn until week 4, at which
time passive range of motion is started, with an empha-
sis on posterior capsule stretching. Six weeks after
surgery, external rotation in abduction is allowed,
and stretching continues. The patient is started on
a progressive strengthening program using surgical
tubing for the deltoid, rotator cuff, scapular muscles,
biceps, and triceps. Upper extremity sports are allowed
3 months after surgery, with the exception of throwing.
Throwing begins 4 months after operation with low-
Figure 5-48 Biceps repair. velocity, short-distance throwing, with the athlete con-
centrating on proper throwing mechanics. Distance
and velocity are gradually increased until 7 months
after operation, at which point I allow the patient
to resume competitive throwing.
BICEPS LESIONS DISTAL TO THE SLAP

LESION
Biceps tendinitis and partial tears are occasionally

isolated causes of significant shoulder pain, but
they are more commonly found in conjunction
with subacromial impingement and rotator cuff
tears. Although arthroscopic subacromial decompres-
sion and rotator cuff repair have been thoroughly
described, arthroscopic biceps treatment has rarely
been mentioned. Since 2001, there has been a sig-
nificant shift in our thinking, and I now treat biceps
Figure 5-49 Biceps repair. lesions more frequently. Biceps lesions requiring
arthroscopic treatment include tendinitis, partial-
thickness tears, hypertrophy, and subluxation (Figs.
5-51 and 5-52).
Literature Review
Since the publication of the first edition of this book, the
literature on the arthroscopic treatment of biceps lesions
has become more robust. These presentations focus
on two issues: should the surgeon perform a tenodesis
or a tenotomy, and if a tenodesis is performed, what
is the preferred technique? Hawkins and Walch have
questioned the value of any tenodesis operation. Their
results suggest that equal or better results can be achieved
with tenotomy. Tenotomy is faster, is easier to perform,
does not appear to affect elbow flexion strength, and
does not normally result in a cosmetic deformity.
Some patients express concern about the possible
Figure 5-50 Biceps repair. cosmetic deformity, particularly men who lift weights.
Diagnosis
I make the diagnosis of a biceps tendon lesion based on a
combination of patient history, physical examination,
radiographic imaging, and findings at arthroscopic sur-
gery. The patient history and physical examination may
point to a problem in the biceps tendon, but that infor-
mation is usually nonspecific. Patients often indicate
the biceps area as the source of their pain. This seems
to be much more specific than the diffuse area of pain
described with a rotator cuff tear. Of course, such local-
ization by the patient does not eliminate the possibility
that the biceps is normal and the lesion is in the anterior
supraspinatus or superior subscapularis. Patients often
describe pain with activities that involve internal rota-
Figure 5-51 Biceps synovitis. tion, such as pressing an object together with both arms,
reaching out to the side to close a car door, or reaching
up behind the back. Some specifically describe the feel-
ing of something rolling into and out of place or the
If a patient has any concerns about the appearance of sensation of slipping. Sometimes the pain is felt more
the arm, I perform a tenodesis. If the patient participates acutely within the substance of the biceps muscle. These
in overhead or throwing sports, I prefer tenodesis. complaints are nonspecific and are also reported by
My results with tenodesis have been favorable, but patients with subacromial impingement syndrome and
many patients complain of pain around the site of tenod- other more serious forms of rotator cuff disease.
esis for months. When patients ask about my preference, In patients who appear to have a mechanical block to
I usually tell them that if it were my shoulder, I would full elevation yet maintain normal external rotation,
have a tenotomy. I am suspicious of biceps tendon entrapment due to
For those surgeons who prefer tenodesis, there are tendon hypertrophy. The primary (Neer) and secondary
three basic methods of fixation. My colleagues and (Hawkins) impingement signs may also produce pain on
I have described our technique with suture anchors, physical examination. I have not found the Yergason
and Boileau has described his experience with a bioab- test helpful and prefer the Speed test. Patients com-
sorbable screw. Elkousy and Rodosky published an ele- monly describe painful popping or catching in the ante-
gant technique for soft tissue fixation with sutures. I rior shoulder area. A lidocaine injection into the area of
have no experience with the Boileau screw, but in the proximal biceps tendon sheath may be helpful in
my hands, both the soft tissue suture technique and differentiating subacromial impingement from biceps
the suture anchor technique are very effective. tendinitis, but I often find it more useful to determine
the degree to which the biceps lesion is producing pain.
The definitive diagnosis is usually made on magnetic
resonance imaging or at the time of arthroscopic
surgery. When reviewing the magnetic resonance
image, I pay particular attention to the subscapularis,
because biceps subluxation and tendinitis can be associ-
ated with partial-thickness tears of the articular surface
of the subscapularis (Figs. 5-53 through 5-56).
Indications for Treatment

Partial-thickness biceps tendon tears within the gleno-
humeral joint are not uncommon; they may occur sub-
sequent to a traumatic event, or they may be the result of
chronic subacromial impingement. When the tear is less
than 30% of the tendon width, the frayed edges are dé-
brided. If the tear is greater than 30% of the tendon
Figure 5-52 Biceps partial tear. width, I perform a tenodesis. When the tendon is
Figure 5-53 Subscapularis partial tear.

Figure 5-55 Subscapularis partial tear.
subluxed medially, I prefer biceps tenodesis or tenot- I usually treat full-thickness tears of the biceps
omy, usually in combination with a subscapularis tendon nonoperatively, but some patients are very
repair. If a biceps lesion is found in the area of the bicip- concerned about the injury and request repair
ital groove during subacromial decompression for a full- (Fig. 5-57). Because the remnant stump within the
thickness rotator cuff tear, the surgeon has four options: glenohumeral joint may cause mechanical symptoms,
ignore the biceps lesion or perform stabilization, teno- I perform an arthroscopic débridement of the biceps
desis, or tenotomy (Table 5-1). Because there is no sci- tendon back to the level of the superior labrum. The
entific evidence to guide us, treatment is determined by bicipital sheath is accessible arthroscopically from the
personal preference. I have experience with all four level of the rotator interval to the insertion of the pec-
options but have seen the best results with tenodesis toralis major tendon. I identify the sheath and open it,
in younger patients who have good-quality rotator cuff find the tendon, and repair it with a suture anchor
tendons and tenotomy in older patients who have as far proximal as possible to restore resting tension
poorer quality biceps and rotator cuff tendons. in the muscle.
Figure 5-54 Subscapularis partial tear. Figure 5-56 Subscapularis partial tear.
Table 5-1 INDICATIONS FOR TREATMENT
Biceps Lesion Treatment
Inflamed Tenosynovectomy
Partially torn < 30% Débride
Partially torn > 30%
Biceps quality good, cuff repair good Tenodesis
Biceps quality good, cuff repair poor Tenodesis or tenotomy
Biceps quality poor, cuff repair good Tenotomy
Biceps quality poor, cuff repair poor Tenotomy
Operative Technique
Intra-articular Biceps Tendinitis
I use a standard posterior portal and enter the gleno-
humeral joint. I visualize the biceps tendon and areas
of fraying, inflammation, or partial tear. An anterior
portal is established, and a probe is introduced to pull
the tendon and bring its extra-articular portion into
view (Figs. 5-58 and 5-59). If the fraying or inflamma-
tion is localized to the intra-articular portion of the
biceps tendon, a shaver is introduced through the
anterior portal, and débridement is performed. If a
portion of the biceps tendon lesion lies within the
bicipital groove, external to the glenohumeral joint,
I prefer to use a subacromial approach to treat the
lesion. Figure 5-58 Shaver retracting the biceps tendon.
Figure 5-57 Patient with complete biceps tear. Figure 5-59 Extra-articular biceps pulled into view.
Partial Tear of the Intra-articular Biceps Tendon move when I remove the arthroscope from the gleno-
This lesion is immediately observed upon entry into humeral joint and reinsert it into the subacromial
the glenohumeral joint. I establish an anterior portal space (Fig. 5-60).
with an 8-mm cannula. If the biceps tear is the only After removing the arthroscope from the joint and
lesion within the glenohumeral joint, I prefer to repair redirecting it into the subacromial space, I locate the
it with a one-cannula technique. I use an AccuPass spinal needle and establish a lateral portal. I use a scis-
right-angled instrument loaded with monofilament sors or motorized shaver to divide the flimsy capsular
suture and pierce the entire tendon from the area tissue of the rotator interval and expose the biceps ten-
of the tear flap toward the more normal tendon. don and the bicipital groove. I then insert an arthro-
I advance 15 to 20 cm of the suture into the joint scopic probe through the anterior portal, lift the
and then withdraw the instrument. I grasp the free biceps tendon from its groove, and inspect it. If the
end of the suture with a crochet hook and withdraw tendon is intact and of good quality but inflamed,
it through the anterior cannula. I tie the suture and I perform a tenosynovectomy using a power shaver.
repeat these steps with additional sutures as necessary, If the biceps is partially torn, I perform a tenodesis
depending on the length of the tear area. Other instru- using the technique described next.
ments can be used to repair the biceps tendon, but
they require two cannulas because one instrument is BICEPS TENODESIS—SUTURE ANCHOR TECHNIQUE The
used to pass the suture and another instrument biceps tenodesis is performed after the subacromial
is needed to retrieve the suture. decompression but before the arthroscopic rotator
cuff repair. Standard anterior and lateral portals are
Subacromial Techniques used. I move the outflow to the posterior portal and
TENDINITIS AND PARTIAL-THICKNESS TEARS WITH INTACT the arthroscope to the lateral portal. If the bicipital
ROTATOR CUFF I use a standard posterior portal and groove is flattened, as is common in chronic cuff
enter the glenohumeral joint. The biceps tendon is tears, I retract the tendon medially and use a 4-mm
visualized, and areas of fraying, inflammation, or par- round bur to deepen the bicipital groove. If the shape
tial tear are noted. I establish an anterior portal and of the groove appears normal, I insert a bur and abrade
introduce a probe so that I can pull on the tendon to the cortical margins of the groove for a distance of
bring the extra-articular portion into view. 2 cm. I then insert an anchor into the center of the
I introduce a spinal needle percutaneously near the deepened groove. The anchor can be inserted through
anterolateral acromial border and pierce the tendon the anterior cannula, but often the angle is too
just proximal to its exit from the joint. The needle is oblique. If this is the case, I insert the anchors through
advanced until it is lodged in bone so that it does not a percutaneous stab wound. I use a spinal needle and
Biceps long
head tendon
A B
Figure 5-60 A, Spinal needle piercing the biceps tendon. B, Biceps fraying in the groove.
pierce the anterior shoulder until the needle tip is

within the bicipital groove and the angle of approach
is satisfactory for anchor placement. I then incise the
skin at this location and insert the suture anchor. The
anchor sutures are exiting the anterior cannula, the
arthroscope is in the lateral cannula, and the Elite
suture punch (my preferred instrument for this tech-
nique) is inserted through the posterior cannula. One
of the anchor sutures is moved from the anterior can-
nula to the lateral cannula with a loop grasper or cro-
chet hook. The suture is loaded on the Elite punch,
which passes through the posterior cannula into the
subacromial space and pierces the biceps tendon. This
suture is retrieved out the anterior cannula. The
second suture from that same anchor is placed in a
similar fashion, completing the mattress suture.
These steps are repeated for both suture limbs of the Figure 5-62 Identifying the biceps tendon.
second anchor. The sutures are usually tied from the
posterior cannula. If the surgeon prefers a Caspari
suture punch, it is loaded with doubled 2-0 nylon
suture and inserted through the lateral cannula to
pierce the biceps tendon. The 2-0 nylon suture is
advanced and drawn out the anterior cannula. One
limb of the first anchor suture is brought from the If the subscapularis is also torn, I first perform the
anterior cannula (or stab wound) to the lateral cannu- biceps tenodesis with the suture anchor technique just
la and passed through the biceps tendon using the described and then repair the subscapularis. If the
nylon loop. This process is repeated with the second supraspinatus is torn, the order of repair is biceps
limb of the same color anchor suture, which is placed tenodesis, subscapularis repair, and finally supraspina-
5 mm from the first suture. A mattress suture has now tus repair.
been placed through the biceps tendon. This process is
repeated with sutures from the second anchor, and the
sutures are tied. I excise the intra-articular portion of
the biceps tendon and repair the rotator cuff tear with
arthroscopic technique (Figs. 5-61 through 5-70).
Abrading flattened
bone surface,
creating a new
groove
Dividing
rotator
interval
Figure 5-61 Division of the rotator interval, exposing the

biceps tendon. Figure 5-63 Abrading the repair site.
Percutaneously
placing anchor
screws Percutaneously
placing anchor
screws
Anchor screws
A A
B
B Figure 5-66 A and B, Suture placement.
Figure 5-64 A and B, Anchor insertion.
B
Figure 5-67 A and B, Suture spacing along the biceps
Figure 5-65 Anchor insertion. tendon.
Anchor sutures tied
A
Excising
biceps tendon
Rotator interval sutured
B
Figure 5-69 A and B, Excise the intra-articular biceps
stump.
B
Figure 5-68 A and B, Sutures tied.
Abrading bone
surface medial to
the lesser tuberosity
Subscapularis
tendon sutured B
medial to biceps Anchors
tendon set in place
C
Figure 5-70 A-C, Subscapularis repair, if necessary.
Biceps Tenodesis—Extra-Articular Technique

Insert a nonlocking grasper through the posterior can-
Place the patient in the upright beach-chair position
nula, remove the spinal needle piercing the biceps
with the acromion parallel to the floor. tendon, and deliver the tendon into the subacromial
Perform routine diagnostic glenohumeral joint arthros-
space through the opening in the rotator interval using
copy from the posterior portal. the grasper.
Insert a spinal needle lateral to the coracoid tip and into Insert a locking grasper through the anterior incision and
the glenohumeral joint through the rotator interval. grasp the proximal end of the biceps tendon (this instru-
Remove the spinal needle and make a small stab incision
ment maintains control of the tendon for the remainder
using a scalpel. of the procedure). Remove the posterior grasper.
Insert a blunt metal trocar through the anterior incision Insert a spinal needle percutaneously approximately 1
and into the glenohumeral joint to facilitate passage of cm distal to the anterolateral tip of the acromion, direc-
the mechanical shaver. ted toward the bicipital groove.
Remove the trocar and insert the shaver percutaneously Make a small skin incision and insert a 5-mm cannula.
into the joint. (Insert the cannula until it touches the humerus, and
Use the shaver as a probe to pull the biceps tendon into
then pull it backward. This maneuver aids in retraction
the joint to visualize and document the extra-articular of the subdeltoid fascia for visualization.)
proximal biceps tendon. Use the locking grasper to pull the biceps tendon medi-
Resect the lateral rotator interval tissue overlying the
ally, introduce the shaver through the 5-mm cannula,
biceps tendon at its entry into the joint (a triangle of and resect approximately 1 to 1.5 cm of tissue overlying
tissue bounded posteriorly by the anterolateral supraspi- the biceps tendon from proximal to distal.
natus tendon and anteriorly by the superolateral Expose the bicipital groove by ‘‘pushing’’ the biceps
subscapularis). tendon laterally using the locking grasper. Use the
Remove the shaver.
shaver to remove soft tissue from the bicipital groove
Insert a spinal needle at the anterolateral corner of the
(keep the blades pointed toward the humerus medially,
acromion through the opening in the rotator interval and the guard will protect the biceps tendon laterally).
and pierce the biceps tendon. Insert a small round bur through the 5-mm cannula, and
Insert an arthroscopic scissors into the joint through the
carve away the exposed bicipital groove to bleeding
anterior stab incision and transect the long head of the bone. (Do not go completely through to cancellous
biceps tendon at its proximal insertion. The transection bone, because the anchor fixation may be
should be at the level of the superior labrum. Try to compromised.)
avoid leaving a medial stump of biceps tendon. (Insert Pass a double-loaded Arthrex FT (full-thread) anchor
the shaver to débride a medial biceps tendon stump, through the 5-mm cannula, and insert it into the base
if necessary.) of the bicipital groove. (A small amount of internal
Remove the arthroscope from the joint.
or external rotation and elevation of the shoulder may
Insert the metal cannula and trocar posteriorly into the
be required to insert the anchor perpendicular to the
subacromial space. bone.) The base of the anchor is seated at the level of
Insert the arthroscope.
the remaining cortical bone.
Make a small stab incision at the midlateral position Remove the 5-mm cannula and then replace it, with the
approximately 1 cm distal to the lateral acromial border. sutures exiting outside the cannula.
Insert a blunt metal trocar into the subacromial space Use the locking grasper to pull the biceps tendon back to
and locate it using the arthroscope. a medial position. The assistant holding the grasper
Remove the trocar and replace it with the shaver.
should lower his or her hand to hold the tendon superior
Clear the subacromial bursa as needed for clear visual-
to the groove, which assists in suture passing.
ization of the bursal surface of the rotator cuff. Complete suture passing and knot tying through the
(Achieve adequate visualization of the anterior and lat- posterior cannula. Sutures are passed through the
eral subacromial space and the previously placed spinal biceps tendon in a mattress configuration from distal
needle.) to proximal.
Remove the shaver and replace it with a metal cannula Pass a crochet hook from posterior through the 8-mm
and trocar. cannula to retrieve one limb of the solid (blue) suture.
Remove the arthroscope from the posterior portal and Use an Elite Pass to pass this suture through the biceps
insert it laterally. tendon as distal along the tendon as possible. (Use the
Enlarge the posterior incision and insert an 8-mm can-
locking grasper to pull the tendon medially during pas-
nula. Move the outflow from the arthroscope to the sage of the most lateral suture.)
8-mm cannula. Retrieve the suture using a grasper through the 5-mm
Position the shoulder in approximately 60 degrees of
cannula.
anterior elevation and neutral rotation using the Retrieve the second limb of blue suture and pass it in the
McConnell arm positioning device. same fashion. The sutures should be passed through the
With the arthroscope in the lateral portal, visualize the
biceps approximately 1 cm apart and at differing angles
biceps tendon through the opening in the rotator inter- to each other.
val. Insert the shaver through the anterior incision to Retrieve the tiger-stripe sutures and pass them through
enlarge the interval window if necessary, further expos- the biceps tendon from the posterior cannula, proximal
ing the biceps tendon. to the blue sutures, using the same technique.
Continued
Make sure the shoulder is externally rotated slightly Retrieve, tie, and cut the tiger-striped sutures in the same
(approximately 15 degrees) for suture retrieval and fashion.
knot tying. Pass a grasper from posterior through the 8-mm cannula
Retrieve the two lateral sutures (blue) through the pos- to grip the proximal biceps tendon stump.
terior cannula. Remove the locking grasper.
Use a loop grasper to ensure that the sutures are not Pass arthroscopic scissors through the 5-mm cannula to
crossed. transect the remaining biceps tendon proximal to the
Tie the sutures using arthroscopic square knots. tenodesis sutures.
Cut the sutures with fiber-wire scissors, leaving a small Remove the tendon stump from posterior through the 8-
tail. mm cannula, completing the procedure.
inserted through the skin incision into the subacromi-

al space. The trocar is swept in a circular manner to
Biceps Tenodesis
release any adhesions between the rotator cuff tissue
Glenohumeral Joint
and the subacromial bursa. The mechanical release of
adhesions is important to ensure that the mattress
Biceps Tenodesis in Bicipital suture is pulled against the interval tissue after knot
Groove tying and is not caught within the bursa, which could
loosen the tenodesis suture. The 5-mm cannula is then
advanced into the subacromial space and pushed
Biceps Tenodesis Near against, but not through, the rotator interval tissue
Pectoralis Major superior to the biceps tendon. A grasper is inserted
through the 8-mm anterior cannula to secure the
BICEPS TENODESIS—INTRA-ARTICULAR TECHNIQUE Stan- biceps tendon and pull it proximally into the gleno-
dard shoulder arthroscopy equipment is required for humeral joint. A No. 1 Ethibond braided polyester
this procedure, including 5- and 8-mm arthroscopic suture is loaded onto a Cuff-Stitch (Smith-Nephew
cannulas, a tissue-penetrating suture passer, and No. Endoscopy, Andover, Mass) through the convex side
1 Ethibond braided polyester suture. I prefer to put of the device, leaving a 4-cm length of suture on the
patients in the beach-chair position; however, this concave side. The Cuff-Stitch is passed down the smal-
technique can also be performed with the patient in ler cannula and through the anterior supraspinatus
the lateral decubitus position. I inspect the glenohu- until the tip of the suture passer pierces the biceps
meral joint through a standard posterior portal and tendon. A grasper is used to retrieve the suture from
then place an anterior cannula through the rotator the concave side of the Cuff-Stitch inside the joint and
interval superior to the subscapularis tendon. The pull the end out through the 8-mm working portal.
anterior glenohumeral joint cannula is the ‘‘working’’ The Cuff-Stitch is removed from the cannula, allowing
cannula and should be 8 mm in size. The biceps the suture to slide within the eyelet without com-
tendon is evaluated from its glenoid origin medially pletely unloading the device, until approximately
and followed into the bicipital groove laterally; 4 cm of suture remains. A second pass is made down
instability, inflammation, degeneration, and tears are the 5-mm cannula through the supraspinatus and the
noted. The shoulder is elevated with the elbow biceps tendon. The suture is retrieved again from the
extended as described by Boileau to examine tendon concave side of the Cuff-Stitch, unloading the device,
gliding and evaluate for possible biceps entrap- and is pulled out the larger portal. If desired, a second
ment—the hourglass biceps (Fig. 5-71). A probe is tenodesis suture can be passed by repeating these
placed through the anterior cannula to pull the steps. The suture is now transtendinous and pierces
biceps into the joint, improving distal tendon visual- the biceps tendon in a mattress configuration. A
ization. Sutures used to complete the tenodesis are loop grasper is used to ensure that the sutures are
passed through an accessory anterior cannula. Proper not crossed within the cannula, and a knot pusher
accessory cannula placement is ensured by using a facilitates the tying of arthroscopic knots, through
spinal needle. The needle is inserted through the an- the 8-mm cannula, to tenodese the biceps. I prefer
terolateral shoulder into the subacromial space and arthroscopic square knots. The suture strands are cut
then into the glenohumeral joint, penetrating the with a sliding suture scissors, and the intra-articular
anterior border of the supraspinatus. The needle is portion of the biceps tendon is excised with arthro-
removed, and a small skin incision is made to allow scopic scissors. I use a power shaver to smooth the
placement of a 5-mm cannula. A metal trocar is cut edges. The tenodesis is now complete, and any
Biceps long
head tendon
entrapment
A B
C D
Figure 5-71 A-D, Hourglass biceps of Boileau.
associated procedures can be carried out without 3-0 absorbable monofilament suture. Sterile dressings
interference from the biceps tendon. Following the are applied, and the arm is secured in a sling.
procedure, the cannulas and scope are removed from The step-by-step technique for intra-articular biceps
the joint, fluid is expressed, and portals are closed in a tenodesis is described here:
standard fashion, my preference being subcuticular
Position the patient in the beach-chair position with Insert a probe through the anterior cannula to pull the
the acromion parallel to the floor. biceps tendon into the joint, improving distal tendon
Perform a diagnostic arthroscopy from a standard pos- visualization.
terior portal. Insert a spinal needle just distal to the anterolateral
Insert a spinal needle lateral to the coracoid and into the acromion into the glenohumeral joint, penetrating
glenohumeral joint—penetrating the rotator interval. the anterior border of the supraspinatus.
Remove the needle, incise the skin, and insert an 8- Remove the spinal needle and make a skin incision to
mm cannula. accommodate a 5-mm cannula.
Evaluate the biceps tendon from its insertion medially to Insert a blunt metal trocar percutaneously into the
its passage laterally into the bicipital groove. subacromial space.
Elevate the shoulder with the elbow extended to exam- Sweep the trocar in a circular manner to release any
ine the biceps tendon gliding, and evaluate for biceps adhesions between the rotator cuff tissue and the sub-
entrapment (i.e., hourglass biceps). acromial bursa.
Continued
Insert the 5-mm cannula and advance it against, but Pass the Cuff-Stitch down the 5-mm cannula a second
not through, the rotator interval tissue superior to the time through the supraspinatus and the biceps tendon.
biceps tendon. Unload the Cuff-Stitch by retrieving the suture from
Insert a suture grasper into the joint through the 8-mm the concave side of the device with a suture grasper
anterior cannula. Secure the biceps tendon, and pull it and pulling it out the 8-mm cannula.
medially into the glenohumeral joint. If a second tenodesis suture is desired, repeat the pre-
Load a No. 1 Ethibond braided polyester suture onto a vious seven steps.
Cuff-Stitch through the convex side of the device, leav- Insert a loop grasper through the 8-mm cannula to
ing a 4-cm length of suture on the concave side. ensure that the sutures are not crossed.
Pass the Cuff-Stitch through the 5-mm cannula, Secure the tenodesis with arthroscopic square knots
through the anterior margin of the supraspinatus tied through the anterior 8-mm cannula.
tendon, and pierce the biceps tendon. Cut the suture strands using arthroscopic sliding
Use the grasper holding the biceps to retrieve the suture scissors.
suture from the concave side of the Cuff-Stitch, Excise the intra-articular portion of the biceps tendon
inside the joint, and pull the end out through the 8- with arthroscopic scissors.
mm working portal. Use a power shaver to smooth the cut ends of the
Remove the Cuff-Stitch from the cannula, allowing the biceps.
suture to slide within the eyelet without completely The tenodesis is complete. Any associated procedures
unloading the device, until approximately 4 cm of can be completed without interference of the biceps
suture remains. tendon (Figs. 5-72 through 5-77).
If the rotator cuff is intact, I establish two intra-

articular anterior portals. I insert an arthroscopic
Tenotomy forceps through the anterior-inferior cannula, grasp
My primary indication for biceps tenotomy is a poor- the biceps tendon, and pull the tendon into the
quality biceps tendon that will not hold sutures. glenohumeral joint as far as I can. I hold the tendon
Patients should be informed of this possibility before in this position, insert a scissors through the anterior-
the operation. I have no hard-and-fast rules for moving superior portal, and divide the tendon as far distal as
from tenodesis to tenotomy, but I tend to perform possible. I then grasp the remaining stump of tendon
tenotomy more frequently if the patient is older or distally and incise it near the superior labrum. The
less active or if the nondominant arm is involved. tendon stump is retrieved out through the anterior-
Larger patients with less muscle definition note no inferior cannula.
cosmetic deformity. For those patients with an irrepa- If the rotator cuff is torn, I perform a tenotomy
rable rotator cuff tear, tenotomy has major benefits in before repairing the rotator cuff. The arthroscope is
terms of pain relief and no adverse effects.
Figure 5-72 Pass the suture through the biceps tendon. Figure 5-73 Retrieve the suture out the anterior cannula.
Figure 5-74 Pass the suture through the biceps tendon a Figure 5-77 Completed tenodesis.
second time.
positioned in the posterior portal. My assistant places

a grasper through the anterior portal and retracts the
edge of the torn supraspinatus superiorly so that I can
see the biceps-labrum junction. I insert a scissors
through the lateral cannula and divide the biceps
tendon at the glenoid attachment. The assistant uses
the grasper in the anterior cannula to pull the divided
biceps tendon into the subacromial space. I use a scis-
sors placed through the lateral cannula to divide the
tendon distally. Because the anterior cannula is usu-
ally too small to accommodate the biceps tendon, I
insert a grasper through the lateral cannula and
bring the tendon through the larger cannula or bring
the tendon and cannula out together.
Postoperative Treatment
Figure 5-75 Tie the suture.
Postoperative treatment for biceps tendon repair and
tenodesis are identical. I discourage active elbow flex-
ion for 3 weeks. I then allow active elbow flexion and
extension but do not allow flexion against resistance
for 6 weeks after the operation. If I perform a tenot-
omy, there are no changes in the normal postopera-
tive rehabilitation regimen for the primary operation,
rotator cuff repair, arthroscopic subacromial decom-
pression, or débridement of an irreparable rotator
cuff tear.
DISCUSSION
Surgeons now recognize that the biceps has an impor-

tant role in the cause of shoulder pain and are per-
forming more biceps tendon operations. Whether
this represents an actual increase in our knowledge
Figure 5-76 Cut the tendon. base or is simply a cyclical variation remains to be
seen. It is not known which tenodesis technique is Dines DM, Warren RF, Inglis AE: Surgical treatment of
superior or whether any of these techniques provide lesions of the long head of the biceps. Clin Orthop Relat
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until science can guide us. desis: Operative technique. Arthroscopy 16:550-552, 2000.
Gartsman GM, Khan M, Hammerman SM: Arthroscopic
repair of full-thickness rotator cuff tears. J Bone Joint
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tion of the long head of the biceps tendon: The ramp Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL: The
test. Arthroscopy 18:E46, 2002. origin of the long head of the biceps from the scapula and
Neer CS: Anterior acromioplasty for the chronic impinge- glenoid labrum: An anatomical study of 100 shoulders.
ment syndrome in the shoulder: A preliminary report. J Bone Joint Surg Br 76:951-954, 1994.
J Bone Joint Surg Am 54:41-50, 1972. Walch G, Boileau P, Noel E, et al: [Surgical treatment of
O’Donoghue DH: Subluxing biceps tendon in the athlete. painful shoulders caused by lesions of the rotator cuff
Clin Orthop Relat Res 164:26-34, 1982. and biceps, treatment as a function of lesions:
Osbahr DC, Diamond AB, Speer KP: The cosmetic appear- Reflections on the Neer’s concept]. Rev Rhum Mal
ance of the biceps muscle after long-head tenotomy Osteoartic 58:247-257, 1991.
versus tenodesis. Arthroscopy 18:483-487, 2002. Walch G, Noel E, Donell ST: Impingement of the deep sur-
Pagnani MJ, Deng XH, Warren RF, et al: Effect of lesions of face of the supraspinatus tendon on the posterosuperior
the superior portion of the glenoid labrum on glenohu- glenoid rim: An arthroscopic study. J Shoulder Elbow Surg
meral translation. J Bone Joint Surg Am 77:1003-1010, 1:238-245, 1992.
1995. Walch G, Nove-Josserand L, Boileau P, Levigne C: Subluxations
Post M, Benca P: Primary tendinitis of the long head of the and dislocations of the tendon of the long head of the biceps.
biceps. Clin Orthop Relat Res 246:117-124, 1989. J Shoulder Elbow Surg 7:100-108, 1998.
CHAPTER
6
Stiffness
There are four basic conditions that produce shoulder LITERATURE REVIEW
stiffness and are amenable to arthroscopic treatment:
idiopathic adhesive capsulitis, diabetic stiff shoulder, Arthroscopic treatment is generally successful, with
and post-traumatic and postoperative stiffness. the degree of improvement related to the patient’s
I discuss the treatment of the stiff, osteoarthritic underlying condition. Ogilvie-Harris, Harryman, and
shoulder in Chapter 7. Warner have published landmark articles describing
Idiopathic adhesive capsulitis is widely believed their results.
to be a painful but self-limited condition that Warner reported on 23 patients with idiopathic
resolves after 1 to 2 years. Recent reports suggest adhesive capsulitis treated with arthroscopic release.
that although many patients improve, they have In that study, the Constant score improved an aver-
significant limitations of movement and function. age of 48 points. Flexion improved a mean of 49
Additionally, those who suffer from disabling pain degrees; external rotation, 45 degrees; and internal
are unwilling to wait for their condition to resolve rotation by eight spinous processes. Harryman docu-
and inquire about operative treatment. Shoulder mented patient satisfaction, improved function, and
stiffness in diabetic patients seems to cause greater pain relief in a diabetic population, although the
pain and is more refractory to nonoperative improvement in range of motion was not as great
treatment than is idiopathic stiffness. The impair-
ment from post-traumatic stiffness is directly related
to the severity of the trauma. Postoperative stiffness
can be the result of excessive scarring in the area
of surgery (subacromial adhesions after rotator
cuff repair, anterior glenohumeral capsule contrac-
ture after a Bankart procedure), but I have also
seen profound glenohumeral joint contracture after
surgery that does not violate the capsule (Figs. 6-1
through 6-3).
One advantage of the arthroscopic technique is that
it enables the release of intra-articular, subacromial,
and subdeltoid adhesions without dividing the sub-
scapularis. Active range of motion can be started
immediately after surgery without concern for
tendon dehiscence. Figure 6-1 Postsurgical stiffness after rotator cuff repair.
176
Chapter 6 Stiffness 177
DIAGNOSIS
A number of other shoulder conditions that produce

painful, limited motion can be eliminated by patient
history, physical examination, and radiographic eval-
uation. Patients with rotator cuff tears present with
passive motion greater than active motion, weakness
on manual muscle testing, and abnormal magnetic
resonance images or arthrograms. In patients with
osteoarthrosis, plain radiographs depict loss of the gle-
nohumeral joint space (Fig. 6-4). Patients with post-
traumatic stiffness may have malunited fractures, and
those with postoperative stiffness may have internal
fixation devices that interfere with motion.
Figure 6-2 Postsurgical stiffness after a Bristow procedure. It is important to obtain a thorough history that
ascertains prior trauma or shoulder difficulties.
Patients should also be asked about diabetes and thyroid
as that seen in patients with idiopathic adhesive dysfunction. Evaluate and record passive range of
capsulitis. motion in elevation, abduction, and external rotation
(in adduction with the arm at the side and in maximal
allowable abduction). Measure internal rotation as the
CLINICAL PRESENTATION vertebral level to which the patient can reach with the
extended thumb. Behind-the-back internal rotation is
Patients with all types of adhesive capsulitis present usually decreased, but it is occasionally close to normal
with painful, limited shoulder motion. Pain at night because internal rotation measured in this manner
interferes with sleep. Routine activities of daily living includes not only glenohumeral movement but also
that require reaching overhead or behind the back scapulothoracic motion. With prolonged shoulder stiff-
are difficult and painful. Rapid movements cause ness, scapulothoracic motion may increase to compen-
especially severe pain. Most patients either recall a sate for the loss of glenohumeral rotation. For this
trivial antecedent injury or cannot identify an inciting reason, I use a more sensitive technique that eliminates
event. Patients demonstrate restricted passive and scapulothoracic motion: I stabilize the scapula with one
active motion, with motion usually less than 50% hand and abduct the arm with the other. I then record
that of the contralateral shoulder. Radiographs are external and internal rotation in this maximally
usually normal, but mild osteopenia due to disuse is abducted position and compare it with the contralateral
typical. shoulder. I assess muscle strength in elevation
Figure 6-3 Post-traumatic and postsurgical stiffness after

open reduction and internal fixation. Figure 6-4 Osteoarthrosis.
and external rotation and obtain anteroposterior,

axillary, and supraspinatus (scapular) outlet plain
radiographs.
INDICATIONS FOR SURGERY
As a general principle, I consider operation if the

patient has persistent pain and stiffness after
6 months of appropriate nonoperative care. I define
severe stiffness as 0 degrees of external rotation and
less than 30 degrees of abduction; moderate stiffness is
defined as a decrease of 30 degrees in either plane
compared with the contralateral shoulder. Although
it is clinically significant to the patient, I do not
consider loss of internal rotation in any plane an
indication for arthroscopic release. One exception Figure 6-5 Myositis ossificans.
is throwing athletes; in these patients, posterior
contracture and decreased internal rotation may be
the only lesion. I discuss the management of this
special group in Chapter 5. If stiffness persists, but joint release. Patients with mildly malunited fractures
pain has diminished after 6 months, I continue of the greater tuberosity or proximal humerus can
nonoperative care for an additional 2 months in case be treated arthroscopically, but those with badly mal-
the decrease in pain indicates that the stiffness united fractures or internal fixation require open release,
is about to resolve or ‘‘thaw’’ spontaneously. If there removal of hardware, and fracture osteotomy, as indi-
is no improvement in the range of motion 2 months cated (see Fig. 6-3).
later, I consider operation. I have found external Patients in the inflammatory or contracting phase
rotation to be the most important predictor of success of idiopathic adhesive capsulitis should not undergo
or failure of nonoperative treatment. If external operation because the surgery may accelerate the con-
rotation remains at neutral or worse 4 to 6 months tracture. I measure range of motion sequentially and
after the start of nonoperative treatment, I do not wait until the motion has stabilized. Myositis ossifi-
recommend further nonoperative management and cans is a contraindication to arthroscopic release
consider operation. In my opinion, the persistent (Fig. 6-5).
loss of external rotation to such a degree indicates
a stiff shoulder that will not respond to non-
operative care, making earlier operative intervention OPERATIVE TECHNIQUE
advisable.
Contracture Release
CONTRAINDICATIONS TO SURGERY
Examination under Anesthesia
Contraindications to arthroscopic treatment apply After the induction of anesthesia, examine both
mainly to patients with postoperative and post- shoulders for range of motion in elevation, abduction,
traumatic stiffness. Patients who have had instability and external rotation in adduction. Place the shoulder
surgery with subscapularis takedown or shorten- in maximal abduction, and record internal and exter-
ing may develop profound soft tissue contracture. nal rotation.
The contracture in these patients is typically extra-
articular between the subscapularis and the conjoined
Manipulation
tendon. I can often identify adhesions between
the subscapularis and the conjoined tendon when the I attempt gentle closed manipulation (Figs. 6-6
arthroscope is placed in the lateral subacromial portal. through 6-11). It is difficult to quantify gentle, but
If this area cannot be well visualized, open release may be I apply only a small amount of force to the shoulder
a necessary addition to an arthroscopic glenohumeral in elevation and then in abduction. If the shoulder
Figure 6-6 Elevation.

Figure 6-8 External rotation.
responds to closed manipulation, it should move with

minimal force. If I think that motion is improving
with abduction and elevation, only then do
I attempt to externally rotate the shoulder. I externally
rotate the shoulder in maximal abduction and then in
adduction. If motion continues to improve, I begin
internal rotation stretching—first internally rotating
the shoulder in maximal abduction and, if the
motion improves, then stretching the shoulder in
cross-body adduction and finally behind-the-back
internal rotation. The specific order of motion
is important because external rotation and internal
Figure 6-9 External rotation of 90 degrees.
Figure 6-7 Abduction. Figure 6-10 Internal rotation of 90 degrees.

Superior
Superior entry
Inferior entry
Inferior
Figure 6-12 Location of joint entry.

Figure 6-11 Adduction.
rotation involve torsion stresses and may cause a spiral space is narrowest, making trocar entry difficult.
fracture to the humerus. If the shoulder does not I prefer to enter the joint superiorly, in an area
respond to abduction and elevation, I do not attempt bounded by the superior glenoid, the rotator cuff,
any rotational movements and proceed directly to and the humeral head, where the joint space is wider
arthroscopy. If the shoulder responds to manipulation (Fig. 6-12).
but full movement is not achieved, I perform arthros- I incise the skin and insert the cannula and trocar
copy and release the remaining adhesions. If full range until I can palpate bone. I then rotate the shoul-
of motion is obtained after manipulation, I insert the der internally and externally to determine whether
arthroscope and confirm that the capsule is comple- the trocar tip rests on the humeral head (movement
tely released. I have observed a number of shoulders detected) or glenoid (no movement). I lower my
with full range of motion after manipulation but hand (and elevate the trocar tip) until I can palpate the
with persistent capsular contracture; in these cases, superior glenoid rim. Only then do I attempt to enter
the manipulation released only the extra-articular the joint. If I cannot clearly palpate the interval
adhesions. between the humeral head and the glenoid, a plas-
tic cannula and trocar may allow more forceful
joint entry with a decreased risk of bone damage
Joint Entry
(Fig. 6-13).
Entry into the stiff shoulder is always difficult because, Once the arthroscope is in the glenohumeral
by definition, the joint volume is reduced. Forceful joint, it is directed at the rotator interval. I insert a
entry may damage the articular surfaces of either the spinal needle anteriorly, lateral to the coracoid
glenoid or the humeral head. process, until I can see the needle enter the joint.
The joint is difficult to enter with a spinal needle I incise the skin and insert a plastic 5-mm cannula
because of the tight, thickened posterior capsule; in and trocar.
addition, the generalized capsular stiffness limits
the amount of fluid that can be injected. I have
Rotator Interval
had better success with a standard metal cannula
and a rounded trocar, which are larger and stiffer The first step in the operation is to release the rotator
than a spinal needle. With these instruments, I can interval (Figs. 6-14 and 6-15). I use a motorized soft
palpate the posterior glenohumeral joint line with tissue resector to do so. Insert the resector through the
greater ease. cannula into the joint; then back the cannula out
The entry position is critical. Joint entry through of the joint, leaving the resector tip in the rotator
the traditional soft spot (at the level of the glenoid interval. Soft tissue is excised from an area bounded
equator) increases the risk of cartilage surface by the biceps tendon medially, the superior border
damage. At this level, the glenohumeral joint of the subscapularis tendon inferiorly, and the
Figure 6-15 Synovitis of the rotator interval.
humeral head is properly located. If full range of

motion is not achieved, or if motion has improved
but the capsule is not completely divided, go to the
next step.
Figure 6-13 Palpate the bone to determine the entry point. Anterior Capsule
Identify the point where the middle glenohumeral
humeral head laterally. The coracoacromial ligament ligament crosses the subscapularis tendon. It is impor-
should be clearly visible as a shiny structure at the tant to separate the subscapularis tendon from the
anterior border of the acromion. Reinsert the cannula middle glenohumeral ligament. I find electrocautery
into the joint and remove the resector. Withdraw the helpful to gradually divide the fibers of the middle
arthroscope from the posterior cannula in the joint, glenohumeral ligament until the tendinous portion
leaving the cannula in place, and attempt a closed of the superior subscapularis is visualized. I then
manipulation as described earlier. If full range insert a blunt dissector anterior to the middle glenohu-
of motion is obtained, reinsert the arthroscope poster- meral ligament to separate the two structures.
iorly and verify that the capsule is divided and that the I use a Harryman soft tissue punch (Smith-Nephew
Endoscopy, Andover, Mass) to remove a 5- to 10-mm
strip of anterior capsule. This includes the middle
glenohumeral ligament and the superior portion of the
anterior-inferior glenohumeral ligament. Electrocautery
can also be used for this portion of the procedure
I always use a blunt dissector to release any
adhesions anterior and posterior to the subscapularis
(Figs. 6-23 and 6-24). No harm is done if the
surgeon resects the superior tendinous border of
the subscapularis, particularly in the area of the
coracohumeral ligament.
Usually a small amount of increased lateral humeral
head displacement is possible. I then advance the
arthroscope anteriorly and inferiorly so that I have
a better view of the posterior portion of the anterior-
inferior glenohumeral ligament and the inferior
Figure 6-14 Contracted rotator interval. capsule. I advance the punch, placing the bottom,
Figure 6-16 Contracted anterior capsule. Figure 6-18 Divide the superior portion of the middle
glenohumeral ligament.
blunt jaw exterior to the capsule, and divide the

capsule from anterior to posterior as far from the gle-
noid labrum as possible (Figs. 6-25 through 6-32).
The level at which I stop the inferior-anterior
release depends on the amount of axillary pouch
contracture. A tight pouch limits the degree to
which I can safely advance the punch without apply-
ing excessive distraction to the glenohumeral joint.
This is usually at about the 5-o’clock position for
a right shoulder. To access and safely release the axil-
lary pouch, I treat the posterior and inferior-posterior
areas of the capsule. I keep the punch and capsular
resection adjacent to the glenoid and try to maintain
Figure 6-19 Cauterize the middle glenohumeral ligament

covering the subscapularis.
Figure 6-17 Identify the superior portion of the middle Figure 6-20 Cauterize the middle glenohumeral ligament
glenohumeral ligament. covering the subscapularis.
Figure 6-21 Cauterize the middle glenohumeral ligament Figure 6-23 Blunt dissector anterior to the subscapularis.
covering the subscapularis.
the arm in slight abduction and external rotation to

protect the axillary nerve.
I remove the soft tissue punch and cannula from the
anterior portal and insert a metal cannula and trocar
in their place. I remove the arthroscope from the
posterior portal and insert it anteriorly. Under direct
vision, I insert the small plastic cannula and trocar
posteriorly. The glenohumeral joint is usually too
contracted to allow the insertion of a larger-diameter
cannula. I insert a motorized shaver and resect 5 to
10 mm of posterior capsule, beginning superiorly
and moving inferiorly. Once I have resected the
posterior capsule, I can easily insert a large-diameter
Figure 6-24 Blunt dissector posterior to the subscapularis.
Figure 6-22 Cauterize the middle glenohumeral ligament

covering the subscapularis. Figure 6-25 Contracted inferior capsule.
Figure 6-26 Capsular punch in the anterior-inferior capsule. Figure 6-29 Complete the posterior capsule resection with
a punch.
cannula that will accommodate the capsular resection

punch.
I insert the punch and resect a 10-mm strip of
the posterior-inferior capsule 5 to 10 mm from the
glenoid labrum to avoid any damage to it. The last
step in the intra-articular portion of the procedure is
complete release of the inferior capsule. Often, surgi-
cal division is not necessary because the last portion of
the capsule can be released through manipulation.
The use of manipulation avoids the placement of
instruments near the axillary nerve.
After I manipulate the shoulder, I insert the
arthroscope to inspect the gap between the resected
Figure 6-27 Shaver resecting the posterior capsule.
Figure 6-30 Return the arthroscope to the posterior portal

Figure 6-28 Insert the large cannula posteriorly. and complete the inferior capsule resection.
Figure 6-33 Remove subacromial adhesions, if present.

Figure 6-31 Inferior capsule resection.
cuff or coracoacromial ligament fraying. By definition,

edges of the capsule and to confirm that the humeral a patient with adhesive capsulitis cannot move his or
head is normally located. If I cannot gain full range of her shoulder into the positions consistent with the
motion with manipulation, I insert the arthroscope clinical diagnosis of impingement. The raw acromial
posteriorly and the cannula and punch anteriorly bone surface produced after acromioplasty creates the
and resect the inferior capsule. opportunity for postoperative adhesions and should
be avoided.
Subacromial Space
I introduce the arthroscope into the subacromial POSTOPERATIVE CARE
space. If the subacromial space is not clearly seen,
I insert a motorized soft tissue resector and remove I use pharmacologic techniques to reduce postoperative
bursa and adhesions (Fig. 6-33). inflammation and adhesion formation. After I confirm
I do not advise an acromioplasty even if there is the diagnosis of capsular contracture arthroscopically,
arthroscopic evidence of impingement, such as rotator but before I begin soft tissue resection, the anesthesiol-
ogist gives the patient 100 mg hydrocortisone sodium
succinate intravenously. I do not use intra-articular cor-
tisone at the conclusion of the procedure because oper-
ative resection of the capsule causes the steroid to
extravasate and lose its effectiveness. In patients with
post-traumatic or postsurgical stiffness and subacromial
adhesions requiring release, I inject 100 mg hydrocorti-
sone sodium succinate (Solu-Cortef) into the subacro-
mial space at the conclusion of the operation.
Postoperatively, I place the patient on a methylprednis-
olone (Medrol) Dosepak. I do not use steroids in dia-
betic patients.
I admit patients to the hospital overnight. I do not
place the arm in a sling or immobilizer. A pillow is
placed under the axilla to keep the arm away from the
chest, and the patient and nursing staff are encouraged
to avoid placing the patient’s arm in internal rotation.
Beginning on the afternoon of surgery, I use a continu-
ous passive motion chair to maintain the full range
Figure 6-32 Inferior capsule resection. of motion gained at surgery. I find it extremely helpful
to visit the patient on the afternoon of surgery and dem- Harryman DT II: Arthroscopic management of shoulder
onstrate that he or she now has full range of motion. stiffness. Oper Tech Sports Med 5:264-274, 1997.
This is easily done because the patient’s shoulder is still Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic man-
anesthetized from the interscalene block. This visual agement of refractory shoulder stiffness. Arthroscopy
demonstration of full movement impresses on the 13:133-147, 1997.
Harzy T, Benbouazza K, Amine B, et al: Idiopathic hypopara-
patient that the operation was successful. I emphasize
thyroidism and adhesive capsulitis of the shoulder in two
that complete recovery depends on adherence to the
first-degree relatives. Rev Rhum 71:234-236, 2004.
postoperative rehabilitation program. Ide J, Takagi K: Early and long-term results of arthroscopic
Upon discharge from the hospital, the patient treatment for shoulder stiffness. J Shoulder Elbow Surg
uses the continuous passive motion chair four times 13:174-179, 2004.
a day for 1 hour each session. This continues for Jerosch J, Filler TJ, Peuker ET: Which joint position puts
2 weeks. I then see the patient in the clinic, and the axillary nerve at lowest risk when performing arthro-
if movement is satisfactory, chair use is discontinued. scopic capsular release in patients with adhesive capsulitis
Passive elevation while supine and external rotation of the shoulder? Knee Surg Sports Traumatol Arthrosc
with the aid of a dowel or pulley are continued. The 10:126-129, 2002.
patient is encouraged to use the arm for all activities Levine WN, Kashyap CP, Bak SF, et al: Nonoperative man-
agement of idiopathic adhesive capsulitis. J Shoulder
and motions that are comfortable. I see the patient
Elbow Surg 16:569-573, 2007.
again at 6 weeks, 3 months, and 6 months after
Loew M, Heichel TO, Lehner B: Intraarticular lesions in
surgery. primary frozen shoulder after manipulation under general
If the patient has not achieved full range of motion anesthesia. J Shoulder Elbow Surg 14:16-21, 2005.
by 3 months, I offer a repeat contracture release. Mullett H, Byrne D, Colville J: Adhesive capsulitis: Human
At this point, however, usually only a gentle closed fibroblast response to shoulder joint aspirate from
manipulation is necessary. patients with stage II disease. J Shoulder Elbow Surg
16:290-294, 2007.
Ogilvie-Harris DJ, Myerthall S: The diabetic frozen shoulder:
Arthroscopic release. Arthroscopy 13:1-8, 1997.
BIBLIOGRAPHY Quraishi NA, Johnston P, Bayer J, et al: Thawing the frozen
shoulder: A randomised trial comparing manipulation
Berghs BM, Sole-Molins X, Bunker TD: Arthroscopic under anaesthesia with hydrodilatation. J Bone Joint
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180-185, 2004. Richards DP, Glogau AI, Schwartz M, Harn J: Relation
Buchbinder R, Green S, Youd JM: Corticosteroid injections between adhesive capsulitis and acromial morphology.
for shoulder pain. Cochrane Database Syst Rev (online) Arthroscopy 20:614-619, 2004.
1:CD004016, 2003. Scarlat MM, Harryman DT II: Management of the diabetic
Buchbinder R, Green S, Youd JM, Johnston RV: Oral steroids stiff shoulder. Instr Course Lect 49:283-293, 2000.
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(online) 4:CD006189, 2006. follow-up. J Bone Joint Surg Am 74:738-746, 1992.
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on the temporal outcomes of adhesive capsulitis. der after repair of the rotator cuff. J Bone Joint Surg Am
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Lect 42:247-257, 1993. 2002.
CHAPTER
7
Arthrosis
Arthroscopic treatment of glenohumeral arthrosis is a response and physical therapy to maintain or improve
controversial subject with little scientific evidence to shoulder range of motion and strength.
guide orthopedic surgeons. At present, the surgical
options are limited, but with increased knowledge
and technology, this will inevitably change. Surgeons INDICATIONS FOR SURGERY
encounter diverse lesions, including minor areas
of chondromalacia in patients with glenohumeral Surgical indications vary with the underlying disease
instability, loose bodies in osteochondromatosis, process. Arthroscopic synovectomy may be beneficial
areas of full-thickness cartilage loss, and osteophytes in the treatment of early rheumatoid arthritis.
in patients with avascular necrosis, rheumatoid arthri- Synovectomy may retard the disease process and
tis, or osteoarthrosis. produce results similar to those seen in the rheuma-
toid knee, elbow, and wrist (Fig. 7-1).
The earliest stage of avascular necrosis may be
DIAGNOSIS amenable to arthroscopic débridement and humeral
head drilling. Before subchondral and articular
The diagnosis of osteoarthrosis, rheumatoid arthritis, surface collapse (stage 1 and early stage 2 disease), core
or avascular necrosis is made clinically with a combi- decompression may produce outcomes similar to those
nation of patient history, physical examination,
laboratory tests, and plain radiographs. I do not use
arthroscopy to evaluate the glenohumeral joint
and stage the disease. There are situations in which
cartilage lesions are unsuspected, and I find them
during arthroscopic treatment for impingement,
rotator cuff tear, or glenohumeral instability. These
unsuspected lesions are usually small, and treatment
is directed at removing loose bodies and débriding
unstable cartilage flaps. The role of microfracture and
marrow stimulation is unproved at this time.
Nonoperative treatment is largely palliative and

consists of medication to diminish the inflammatory Figure 7-1 Rheumatoid arthritis.
187
Figure 7-2 Avascular necrosis.

Figure 7-4 Débridement of a cartilage lesion.
in the hip. The potential for success may be greater than office. The source of pain in osteoarthrosis is multifac-
in the hip because the glenohumeral joint is nonweight torial and consists of joint surface irregularity,
bearing (Fig. 7-2). mechanical disturbances from loose or displaced
Débridement of cartilage flap tears may help labrum fragments, loose bodies, and joint contracture
a patient with chondromalacia whose symptoms are (Figs. 7-6 through 7-9).
caused by mechanical locking and catching (Figs. 7-3 Arthroscopic lavage reportedly achieves temporary,
through 7-5). limited pain relief owing to either the placebo effect or
Loose bodies in osteochondromatosis may cause alterations in the chemical composition of the gleno-
mechanical symptoms, and pain relief can be humeral joint fluid. Patients return to their baseline
substantial following their removal. The surgeon states relatively quickly, however, and I do not per-
should carefully inspect the subcoracoid space and form or advise such procedures. If a surgeon wishes
the bicipital sheath, where loose bodies may be to treat a patient with glenohumeral arthrosis arthros-
overlooked. The biceps sheath should be inspected copically, the approach must be comprehensive and
distally to the level of the pectoralis major tendon include removal of loose bodies and labrum frag-
insertion. ments, release of soft tissue contracture, and restora-
Osteoarthrosis is probably the most common clini- tion of joint surface congruity, including débridement
cal cause of glenohumeral incongruity seen in the of glenoid and humeral head osteophytes if necessary.
Figure 7-3 Débridement of cartilage fragments. Figure 7-5 Glenoid cartilage defect.
Chapter 7 Arthrosis 189
Joint contracture
Capsule
Coracohumeral lig.
Surface
irregularity
Loose bodies
Mechanical
Labrum fragments
Figure 7-9 Osteoarthrosis.
Figure 7-6 Sources of pain in osteoarthrosis.
Unless the surgeon is capable of dealing with all these

elements, an arthroscopic approach is unwarranted.
The surgeon must also carefully explain the investiga-
tional nature of the procedure to the patient. Within
these confines, the indications for arthroscopic treat-
ment are lmited.
CONTRAINDICATIONS TO SURGERY
Contraindications to the arthroscopic treatment of

arthrosis also vary with the underlying disease process.
Synovectomy does not benefit a patient with articular
incongruity. Core decompression cannot be expected
to reverse bone collapse. Débridement of a small
labrum tear will not help a patient with osteoarthrosis.
I have treated many patients with pain and stiffness
Figure 7-7 Loose bodies.
from osteoarthritis who have undergone manipul-
ation—an approach that should be abandoned.
Orthopedic surgeons must appreciate that although
idiopathic adhesive capsulitis and osteoarthritis both
produce pain and decreased range of motion, they
have different causes and require different treatments.
Arthrosis patients have capsular contractures, as do
patients with adhesive capsulitis, but extra-articular
adhesions and articular incongruity are important
additional causes of their shoulder stiffness.
CHONDRAL LESIONS
My approach is conservative for chondral lesions.

I remove loose pieces and flap tears but do not drill
or microfracture the bone surface. I gently abrade
Figure 7-8 Osteoarthrosis at arthroscopy. areas of cortical bone.
OSTEOARTHRITIS
Glenohumeral Joint
Arthrosis
Microfracture
After the administration of anesthesia, I examine the

shoulder for range of motion but do not attempt a
closed manipulation. I establish standard posterior
and anterior portals and perform a complete glenohu-
meral joint inspection, observing in particular the
presence and extent of cartilage loss, labrum flap
tears, rotator cuff fraying or tearing, and capsular con-
tracture. Entry into the glenohumeral joint is always Figure 7-11 Rotator interval débridement.
difficult owing to the loss of joint space from absent
articular cartilage and soft tissue contracture. I insert
the posterior cannula and trocar first and place the joint. I use a standard shaver to débride the rotator
entry point more superior than normal, just inferior interval and any labrum tears (Fig. 7-11).
to the posterior acromion and about 2 cm medial to I then perform a complete capsule release anteriorly,
the posterolateral corner of the acromion. The supe- posteriorly, and inferiorly. I pay particular attention to
rior portal allows easier access to the glenohumeral the subscapularis because my experience with shoulder
joint at the level of the superior glenoid, so the arthroplasty has convinced me how critical it is to
trocar does not have to enter the joint between the restore subscapularis muscle excursion. The middle
humeral head and glenoid (Fig. 7-10). glenohumeral ligament is adherent to the posterior
If the glenohumeral joint is particularly tight, (articular) surface of the subscapularis, and I use cau-
I enter the joint with a plastic cannula and trocar so tery to identify the plane between the two structures
as not to penetrate the scapula or the humeral head. (Fig. 7-12).
I prefer a plastic cannula and trocar to minimize artic- A scissors is useful to divide firm bands of scar
ular damage, but often the capsule is so thick that the tissue. I then use a blunt dissector to sweep any adhe-
plastic trocar cannot penetrate it. The anterior capsule sions off the subscapularis muscle. The next step is to
is also difficult to penetrate, and it is sometimes release adhesions from the anterior surface of the sub-
necessary to use only the metal trocar (without the scapularis, for which the blunt dissector is particularly
cannula) to create an entrance to the glenohumeral useful (Fig. 7-13).
Superior
Superior entry
Inferior entry
Inferior
Figure 7-10 There is more space for the trocar at the supe- Figure 7-12 Cautery to define the plane between the sub-
rior aspect of the glenohumeral joint. scapularis and middle glenohumeral ligament.
Figure 7-13 Soft tissue dissection anterior and posterior to Figure 7-15 Inferior-posterior capsule release.
the subscapularis.
The anterior and posterior capsule releases are simi- arthroscope in the glenohumeral joint after the rotator
lar to those I perform for adhesive capsulitis, but the interval has been opened. The coracohumeral ligament
inferior release is different. With adhesive capsulitis, is thick and contracted, limiting subscapularis excursion.
the inferior capsule can often be released by shoulder This area is not normally seen during routine glenohu-
manipulation after the division of the anterior and pos- meral joint arthroscopy but can be visualized arthrosco-
terior capsule. Patients with arthrosis have an extre- pically with the technique described later. After I excise
mely thick inferior capsule, however, and such an the contracted tissue, open the rotator interval, and
approach is not successful. The inferior capsule must remove adhesions from the anterior and posterior
be divided with a capsular resector. This requires the surfaces of the subscapularis, the coracoid process
surgeon to release the anterior-inferior capsule from comes into view. With a scissors or blunt dissector
an anterior approach and the posterior-inferior capsule I release any connections between the superior surface
from a posterior approach (Figs. 7-14 through 7-16). of the subscapularis and the coracoid (Fig. 7-17). This
The third area of subscapularis release involves the completes the soft tissue release. Next, I turn my
connections between the subscapularis and the coracoid. attention to the bone surfaces of the glenoid and the
This portion of the operation is performed with the humeral head.
Figure 7-14 Anterior-inferior capsule release. Figure 7-16 Posterior capsule release.
Figure 7-17 Coracohumeral ligament release.
Figure 7-18 Bur in the posterior portal as viewed from the

anterior portal.
The degree and type of glenoid wear can be seen on

preoperative imaging studies. There are two types of After operation, patients begin continuous passive
glenoid abnormalities that are amenable to arthro- motion in a motorized chair. They undergo 1-hour ses-
scopic treatment. The first occurs when the glenoid sions in the chair four times a day for 2 weeks. During
conforms to the humeral head but the space is dimin- this time, active range of motion and activities are
ished. My goal is to increase the space between the two encouraged as much as pain allows. I continue to
structures. In the second type of glenoid abnormality,
there is posterior glenoid erosion or a step-off, usually
resulting from chronic anterior contracture and poste-
rior humeral head subluxation. I inspect the radio-
graphs to determine both glenohumeral congruency
and glenoid bone stock.
To create more space between the humeral head
and a conforming glenoid, I place the arthroscope pos-
teriorly and the round bur through the anterior can-
nula. I begin removing bone 10 mm from the superior
glenoid and remove a 1-mm strip from anterior to pos-
terior. I then remove bone from that strip to the supe-
rior glenoid margin, taking care not to damage the
biceps-labrum anchor. I complete the glenoid bone
removal by leveling the glenoid from superior to infe- A
rior. It is usually necessary at some point to move the Remnant
arthroscope anteriorly and the bur posteriorly to reach cartilage
all areas of the glenoid and create a level surface. being abraded
Matsen introduced the phrase ream and run for such
treatment when he inserts a prosthetic hemiarthro- Bone to be
plasty (Fig. 7-18). abraded
To form a conforming glenoid surface when there is
a posterior step-off, I follow the same general tech-
nique as just described, beginning with the arthro-
scope in the posterior cannula and the power bur in
the anterior cannula. I then remove the anterior sur-
face from superior to inferior to eliminate the step-off B
and create a smooth, uniform surface (Figs. 7-19 Figure 7-19 A and B, Posterior step-off and area of bone
through 7-23). abrasion.
A
A
B
Figure 7-20 A and B, Area of bone abrasion. B
Figure 7-22 A-C, Abrasion arthroplasty.
emphasize range of motion at each patient visit and start

strengthening when manual muscle testing is painless.
To monitor disease progression, plain anteroposterior
and axillary radiographs are obtained every 3 months
for the first year, every 6 months for the next year, and
then yearly.
A
Area to be
abraded
2 mm
B
Figure 7-21 Depth of bone abrasion. Figure 7-23 A and B, Completed abrasion arthroplasty.
The results in this carefully selected and counseled RHEUMATOID ARTHRITIS

group of patients are preliminary, but so far, they have
been gratifying. Approximately 50% report satisfaction As in other joints, synovectomy of the rheumatoid
with the procedure and experience a significant shoulder is most beneficial when carried out early in
decrease in pain and an increase in motion and func- the disease process, before cartilage and bone have
tion. It is unknown whether the bone removal will com- been destroyed and the rotator cuff eroded. The patient
promise glenohumeral joint integrity to such an extent is staged according to the Steinbrocker radiographic and
that humeral head medialization will occur. This has functional classification (Table 7-1). Subsequent patient
been reported by some surgeons. evaluation allows the surgeon to reassess the disease pro-
New approaches to arthritis in young patients are gression. Patients in radiographic stages I and II and
being developed and revolve around the interposition functional classes I and II have the best chance of bene-
of material between the humeral head and the fiting from arthroscopic synovectomy and débridement.
glenoid. These materials are either biologic (fascia I enter the glenohumeral joint through a standard
lata and meniscal allograft) or synthetic (biologic in- posterior portal and establish an anterior-inferior and
growth materials). Both types have vocal champions, then an anterior-superior cannula. Because of the
but little science and experience are available to guide bleeding that often occurs with rheumatoid synovect-
orthopedic surgeons. My technique for inserting the omy, the anterior-superior cannula is helpful for out-
interposition is described in the steps described in the flow. A pump is essential. I use a grasping forceps to
box. Joe de Beer has the largest experience with this remove large pieces of loose cartilage or soft tissue
type of operation. and a motorized resector to débride labrum flap tears.
Arthroscopic Graft Jacket Placement
Graft Preparation
Follow the manufacturer’s directions for hydrating the graft (which may require up to 30 minutes).
Secure the graft jacket (after hydration) to the SMH Graft-Jacket Racket using No. 1 Ethibond sutures. (The appropriate
graft jacket size is determined at the initial arthroscopy.)
Procedure Protocol
Position the patient in the beach-chair position.
Prepare and drape the patient for a routine shoulder arthroscopy.
Affix the Tornier proximal humeral fracture jig to the patient’s arm using a Coban-type wrap.
Fix the Graft-Jacket Racket to the fracture jig, and position the device anterior and inferior to the shoulder.
Perform a diagnostic arthroscopy from the posterior portal.
Establish an anterior-inferior portal using a 10-mm cannula.
Measure the size of the glenoid using the calibrated probe. (The hydrated graft jacket can now be cut to size and secured
to the holder.)
Open the rotator interval using a motorized shaver.
Perform an abrasion arthroplasty of the glenoid surface with a round bur through the anterior portal.
Insert a metal cannula into the anterior-superior position.
Remove the arthroscope from the posterior cannula and insert it into the anterior-superior cannula to visualize the
posterior-inferior glenoid.
Complete the abrasion arthroplasty of the posterior-inferior glenoid with the small bur through the posterior portal.
Insert a spinal needle percutaneously from the lateral position into the glenohumeral joint and through the supraspi-
natus tendon under arthroscopic visualization.
Remove the needle, incise the skin, and insert a metal cannula and trocar into the joint.
The arthroscope is now moved to this ‘‘trans-cuff’’ portal for visualization of the anterior and posterior glenoid.
Remove the metal cannula and insert an 8-mm cannula into the anterior-superior portal.
Insert an orange 5-mm cannula into the posterior portal.
Insert a double-loaded bioabsorbable suture anchor through an accessory posterior-inferior portal (localized with a spinal
needle) into the glenoid at the posterior-inferior quadrant (7-o’clock position on a right shoulder, and 5 o’clock on
a left).
Suture Passing
Use a crochet hook to pull the most inferior white suture out the anterior-inferior cannula.
Pass the suture through the graft jacket at the corresponding position using a suture passer.
Pull one limb of green suture through the anterior-inferior cannula.
Pass this suture through the graft just superior and medial to the white strand using the Elite Pass.
Tie a knot in the green suture, securing it to the graft jacket.
Use a crochet hook to pull the superior white suture limb out the anterior-inferior cannula.
Pass the strand through the graft using the Elite Pass.
Secure the two white suture strands using a hemostat.
The remaining strand of green suture should not be passed and should exit through the accessory portal.
Insert a second double-loaded suture anchor in the posterior-superior quadrant (10 o’clock on a right shoulder, and 2
o’clock on a left) through an accessory portal (localized with a spinal needle) and repeat the previous nine steps.
Insert a third suture anchor into the glenoid at the 12-o’clock position.
Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula.
Pass the suture through the graft jacket using the Elite Pass at the corresponding position.
Pull one limb of green suture out the anterior-inferior cannula.
Pass the suture through the graft inferior and medial to the previously passed white strand.
Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula.
Pass the suture through the graft using the Elite Pass.
Secure the white strands together using a hemostat.
Pull the remaining green suture strand out the anterior-inferior cannula.
Insert a fourth anchor into the anterior-superior quadrant of the glenoid (5 o’clock on a right shoulder, and 10 o’clock on
a left) and repeat the previous nine steps.
Insert a fifth anchor into the anterior-inferior quadrant of the glenoid (5 o’clock on a right shoulder, and 7 o’clock on a
left).
Using the crochet hook, pull the most superior white strand out the anterior-inferior cannula.
Pass the suture through the graft jacket using the Elite Pass at the corresponding position.
Pull one limb of green suture out the anterior-inferior cannula.
Pass the suture through the graft inferior and medial to the previously passed white strand.
Use the crochet hook to pass the inferior white suture limb through the anterior-inferior cannula.
Pass the suture through the graft using the Elite Pass.
Secure the white strands together using a hemostat.
Allow the remaining green suture to stay within the anterior-superior cannula.
Preparing to Insert the Graft Jacket

Pass all sutures through the graft and secure with hemostats.
Remove the diaphragm from the anterior-superior cannula.
Roll the graft jacket into a cylinder from superior to inferior.
Keep all white sutures taut while passing the graft.
Use a grasper to ‘‘push’’ the graft through the 10-mm cannula, and use the posterior green sutures exiting the accessory
portals as traction sutures to ‘‘pull’’ the graft into the joint.
Once the graft enters the joint, pull the anterior green sutures taut to flatten the graft.
Tying the Posterior-Inferior Sutures

Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the
posterior-inferior accessory portal.
Tie the white sutures using arthroscopic square knots and cut.
Cut the green suture at the level of the graft.
Tying the Posterior-Superior Sutures

Use a loop grasper to pull the white sutures through a 5-mm cannula, and push the cannula into the joint through the
posterior-superior accessory portal.
Continued
Arthroscopic Graft Jacket Placement—cont’d
Tying the Superior (12 o’clock) Suture

Use a loop grasper to pull the white sutures out through the anterior-superior cannula.
Pass the loop grasper a second time to ensure the sutures are not crossed.
Tying the Anterior-Superior Sutures

Use a loop grasper to pull the white sutures out through the anterior-superior cannula.
Pass the loop grasper a second time to ensure the sutures are not crossed.
Tying the Anterior-Inferior Sutures

Allow the sutures to remain in the anterior-inferior cannula.
Use a loop grasper to ensure the sutures are not crossed.
Completing the Procedure

Remove the arthroscope.
Close the portals using 3-0 Monocryl sutures.
Apply sterile dressing.
Because the synovium is vascular, I prefer to use the AVASCULAR NECROSIS

thermal coagulation probe to ‘‘paint’’ all areas of pro-
liferative synovitis before resection (Fig. 7-24). Arthroscopic treatment of avascular necrosis is limited
The whisker resector allows me to perform a to those individuals with stage 1 or early stage 2
thorough synovectomy without violating the glenohu- disease, before any collapse has occurred.
meral joint capsule (Fig. 7-25). The Electroblade shaver, I place the guide pin from a hip compression set on
with its built-in cautery system, is extremely valuable in the anterior shoulder and, with the use of fluoroscopic
these situations. I prefer to start the synovectomy infe- imaging, adjust the angle and direction of the pin until it
riorly and move to the anterior and then superior is correctly positioned. I then mark the pin location on
aspects of the joint. I move the arthroscope anteriorly the lateral deltoid and incise the skin with a scalpel.
and the resector posteriorly to complete the removal of To avoid injury to the axillary nerve, I use a hemostat
soft tissue in the posterior-inferior and posterior to spread the deltoid fibers until I reach the lateral hum-
regions. After carefully inspecting the subscapularis eral cortex. A drill guide is placed into the wound until it
recess for additional synovitis or loose bodies, I rests on the humerus. I use biplane radiographic imaging
remove the arthroscope and, through the same poste- to insert a guide pin in the center of the humeral head to
rior incision, insert it into the subacromial space. Bursal within 3 mm of the articular surface. I place a cannulated
proliferation is often profound. I remove the hypertro- drill over this and, under radiographic control, perform a
phic bursa and perform an arthroscopic subacromial single core decompression.
decompression and acromioclavicular joint resection Postoperatively, patients are allowed unlimited
if indicated by clinical examination. active and passive range of motion but no sports or
Postoperative rehabilitation is identical to that heavy lifting for 3 months. I follow patients with serial
described for the treatment of osteoarthritic glenohu- radiographs or magnetic resonance imaging studies as
meral joints. needed.
Table 7-1 STEINBROCKER RADIOGRAPHIC

AND FUNCTIONAL CLASSIFICATION OF
RHEUMATOID ARTHRITIS
Radiographic Classification
Stage I No destructive change;
osteoporosis and soft tissue
change only
Stage II Mild to moderate erosive change or
joint space reduction
Stage III Joint markedly narrowed (<1 mm);
extensive erosion and
subluxation
Stage IV Fibrosis or bony ankylosis
Figure 7-25 Whisker resector.
Functional Classification
Class I Full function
Class II Adequate function despite pain BIBLIOGRAPHY
and limited motion
Class III Very limited function Baillon JM, Hutsebaut K: Place de l’arthroscopie dans l’osteo-
necrose de l’epaule. Acta Orthop Belg 65(Suppl 1):104,
Class IV Wholly incapacitated 1999.
Bhatia DN, van Rooyem KS, du Toit DF, de Beer JF:
Response
Arthroscopic technique of interposition arthroplasty of
Grade I Complete remission the glenohumeral joint. Arthroscopy 22:570, 2006.
Grade II Major improvement Bishop JY, Flatow EL: Management of glenohumeral arthri-
tis: A role for arthroscopy? Orthop Clin North Am
Grade III Minor improvement 34:559-566, 2003.
Grade IV No improvement or progression Cameron ML, Kocher MS, Briggs KK, et al: The prevalence of
glenohumeral osteoarthrosis in unstable shoulders. Am J
Sports Med 31:53-55, 2003.
Clinton J, Franta AK, Lenters TR, et al: Nonprosthetic gle-
noid arthroplasty with humeral hemiarthroplasty and
total shoulder arthroplasty yield similar self-assessed
outcomes in the management of comparable patients
with glenohumeral arthritis. J Shoulder Elbow Surg
16:534-538, 2007.
Hayes JM: Arthroscopic treatment of steroid induced osteone-
crosis of the humeral head. Arthroscopy 5:218-221, 1989.
L’Insalata JC, Pagnani MJ, Warren RF, Dines DM: Humeral
head osteonecrosis: Clinical course and radiographic pre-
dictors of outcome. J Shoulder Elbow Surg 5:355-361,
1996.
Matsen FA, Bicknell RT, Lippitt SB: Shoulder arthroplasty:
The socket perspective. J Shoulder Elbow Surg 16:S241-
S247, 2007.
McCarty LP, Cole BJ: Nonarthroplasty treatment of glenohu-
meral cartilage lesions. Arthroscopy 21:1131-1142, 2005.
Mont M, Maar DC, Urquhart MW, et al: Avascular necrosis of
the humeral head treated by core decompression. J Bone
Joint Surg Br 75:785-788, 1993.
Nakagawa Y, Ueo T, Nakamura T: A novel surgical procedure
for osteonecrosis of the humeral head: Reposition of
the joint surface and bone engraftment. Arthroscopy
Figure 7-24 Rheumatoid synovium. 15:433-438, 1999.
Parsons IM, Weldon EJ, Titelman RM, Smith KL: Glenohumeral Siebold R, Lichtenberg S, Habermeyer P: Combination of
arthritis and its management. Phys Med Rehabil Clin N Am microfracture and periosteal-flap for the treatment of
15:447-474, 2004. focal full thickness articular cartilage lesions of the
Pennington WT, Bartz BA: Arthroscopic glenoid resurfacing shoulder: A prospective study. Knee Surg Sports
with meniscal allograft: A minimally invasive alternative Traumatol Arthrosc 11:183-189, 2003.
for treating glenohumeral arthritis. Arthroscopy 21: Sperling JW, Steinman SP, Cordasco FA, et al: Shoulder
1517-1520, 2005. arthritis in the young adult: Arthroscopy to arthroplasty.
Scheibel M, Bartl C, Magosch P, et al: Osteochondral autol- Instr Course Lect 55:67-74, 2006.
ogous transplantation for the treatment of full-thickness Weinstein DM, Bucchieri JS, Pollock RG, et al: Arthroscopic
articular cartilage defects of the shoulder. J Bone Joint debridement of the shoulder for osteoarthritis.
Surg Br 86:991-997, 2004. Arthroscopy 16:471-476, 2000.
CHAPTER
8
Periarticular Cysts
With the increased use of magnetic resonance imaging activity. Symptoms from a periarticular cyst may be the
(MRI), we now diagnose more patients with periartic- result of rotator cuff pathology, labrum pathology, or
ular shoulder cysts who are referred for care. It is suprascapular nerve compression, or some combina-
unknown whether this represents a true increase in tion. Labrum detachment may cause rotator cuff
the incidence of cysts or merely reflects the sensitivity symptoms as a result of contact against the posterior-
of MRI (Figs. 8-1 through 8-3). superior glenoid, and the patient may complain of
posterior-superior shoulder pain while throwing or per-
forming other activities that require the arm to be
LITERATURE REVIEW placed in abduction and external rotation (Fig. 8-4).
Mechanical labrum symptoms include sensations
Surgeons agree that labrum tears result in cyst forma- of locking, catching, or popping. Pain may prevent
tion. The proposed cause is similar to wrist ganglions. full muscular contraction and can result in weakness
It is postulated that a labrum tear allows joint fluid during lifting. Pressure from the cyst on the suprascap-
to leak and form an extra-articular accumulation. ular nerve can cause pain or a burning discomfort in
Communication between the glenohumeral joint the scapular or trapezius muscle region (Fig. 8-5).
and the cyst has been demonstrated, but there is no
evidence for this proposed cause. Iannotti described
his approach to cyst treatment, which consists of
arthroscopic cyst decompression and labrum repair
to treat patients with suprascapular neuropathy.
DIAGNOSIS
Patients present with shoulder pain or weakness, or

both. These nonspecific symptoms do not point the
examiner toward the diagnosis of a periarticular cyst.
The surgeon should be suspicious when the findings
are at odds with the typical presentation of patients
with rotator cuff impingement or glenohumeral insta-
bility—for example, a patient younger than 40 years
who presents with rotator cuff symptoms absent any
significant trauma or any history of repetitive shoulder Figure 8-1 Superior location, coronal view.
199
Figure 8-4 SLAP lesion.

Figure 8-2 Transverse view.
Nerve compression can also result in weakness. This findings may be nonspecific or consistent with a partial-
weakness may be difficult to detect because, over time, thickness rotator cuff tear. Superior or posterior-superior
compensatory hypertrophy can develop in the teres labrumdetachmentisnoted.Acystisseenintheposterior-
minor muscle (Fig. 8-6). superior shoulder.Thesizecan bevariablebut istypically 1
Although patients with advanced nerve compres- to 2 cm in diameter. The cyst may or not be seen commu-
sion may complain of weakness, in my experience, nicating with the labrum tear. The cyst may be juxta-artic-
they usually present with more subtle findings. ular or located more superiorly near the suprascapular
Suprascapular nerve compression initially causes notch. The surgeon should also be aware that the cyst
mild weakness of the supraspinatus and infraspinatus. may not be producing any symptoms at all and may be
When patients perform overhead activities or move- an incidental finding. Whenever rotator cuff symptoms
ments, the weakened rotator cuff does not stabilize the occur in a patient younger than 50 years, the surgeon
humeral head adequately, and slight superior sublux- should order MRI with contrast enhancement; without
ation occurs. This results in complaints very similar to contrast, the labrum lesion is not as easily seen.
those accompanying subacromial impingement.
None of these symptoms is diagnostic of a cyst, but they
usually prompt the physician to order MRI. Rotator cuff
A B
Periarticular cyst
Spinoglenoid
ligament
C D
Figure 8-3 Posterior cyst. Figure 8-5 A-D, Suprascapular nerve compression.
Chapter 8 Periarticular Cysts 201
also anecdotal evidence that labrum repair without

cyst decompression may be successful. A number of
reports document disappearance of the cyst on MRI
after labrum repair.
Indications depend on the cyst location and
associated conditions such as rotator cuff involvement
and significant tearing of the labrum. The anatomic
alterations within the glenohumeral joint are often
aggravated by subtle glenohumeral instability, and a
3- to 6-month period of home rehabilitation to
strengthen the shoulder stabilizers is advised before
operation is considered.
If the physical examination and electrodiagnostic
testing indicate that the cyst is associated with
Figure 8-6 Atrophy of the supraspinatus and infraspinatus; nerve compression, the indications are different.
hypertrophy of the teres minor. In this situation, surgical intervention is considered
more urgently, rather than after extensive rehabilita-
tion. Suprascapular notch cysts are treated by
arthroscopic suprascapular notch decompression fol-
lowed by glenohumeral joint evaluation, cyst decom-
NONOPERATIVE TREATMENT pression, and labrum repair if needed. Infraspinatus
involvement without supraspinatus involvement
Treatment is directed at the underlying cause of the is consistent with a more distal lesion, in which case
patient’s symptoms. I treat rotator cuff symptoms with I decompress the nerve at the level of the spinoglenoid
selective rest, activity modification, nonsteroidal anti- ligament.
inflammatory medication, and a home rehabilitation
program focused on stretching the posterior shoulder
structures and strengthening the shoulder stabilizing
Suprascapular Nerve
muscles. Mechanical labrum symptoms may be the
Decompression at the
result of subtle glenohumeral instability, so I have
Suprascapular Notch
patients focus on exercises to improve the shoulder sta-
bilizers. If the cyst is located near the posterior-superior
Suprascapular Nerve
glenoid, I order electrodiagnostic testing to detect the
Decompression—Cadaver
presence or absence of suprascapular nerve involvement
as well as provide information about the cyst’s extent
OPERATIVE TECHNIQUE
and location. Abnormalities of both the supraspinatus
and infraspinatus point to a proximal lesion, usually at
the suprascapular notch. Abnormalities limited to the
at the Suprascapular Notch (Lafosse
infraspinatus are consistent with a more distal lesion,
Technique)
often at the spinoglenoid ligament.
The patient is placed in the sitting position, and the
shoulder is prepared and draped routinely. I perform
INDICATIONS FOR SURGERY the nerve exploration and decompression before the
glenohumeral joint surgery because any soft tissue
For perilabral cysts without suprascapular nerve in- swelling makes the nerve portion of the operation
volvement, I recommend arthroscopic labrum repair much more difficult. No arm traction is needed.
and cyst decompression as the treatment of choice. The suprascapular nerve originates from the upper
The rationale of arthroscopic treatment is that the trunk of the brachial plexus and travels deep to the
labrum tear allows the leakage of joint fluid extra- trapezius muscle. The suprascapular nerve passes
articularly, which forms the cyst. With labrum deep to the suprascapular ligament, and the supra-
repair, the joint seal is reestablished, and the cyst scapular artery normally (but not always) passes super-
will not re-form. Labrum repair also cures the pain ficial to the ligament. The nerve divides just proximal
caused by the labrum tear and the subsequent alter- to the notch. The medial branch continues on to
ation in glenohumeral joint biomechanics. There is supply the supraspinatus muscle, and the lateral
the shaver. I usually move the arthroscope to the lat-

eral portal and use the instruments through either the
posterior portal or the anterolateral portal. I then
follow the coracoid to its base and identify the
origin of the coracoclavicular ligaments. The trapezoid
is identified most laterally, and the conoid is seen
more medially. Just medial to the conoid ligament
is the yellowish perineural fat. Electrocautery can be
performed safely as long as it is kept superior, above
the level of the supraspinatus muscle (and the trans-
verse scapular ligament and suprascapular nerve).
The lateral insertion of the suprascapular ligament
can be seen just medial to the conoid ligament. I can
Figure 8-7 Lateral portal locations.
normally view the suprascapular artery pulsating
above the ligament. I then establish the fourth
(medial) portal by palpating the area until I am
branch descends around the lateral margin of the directly over the notch; I insert a spinal needle to
scapular spine and passes deep to the spinoglenoid confirm that I have located the portal precisely.
ligament at the spinoglenoid notch. I then carefully incise only the skin (to avoid any
I use five portals. The first is a standard posterior superficial cutaneous nerve branches) and insert a
portal that I use to view the subacromial space. blunt trocar. I dissect the soft tissue and fat away
The second is a lateral portal located anterior to the from the notch until I can clearly see the ligament
midline of the aromion, and the third is placed ante- and the nerve. I insert the trocar lateral to the nerve
rior to the anterolateral acromial border. The fourth is and retract the nerve medially. I make a small stab
located approximately 2 cm medial to the standard incision in the skin directly over the lateral portion
Neviaser portal. I establish the fourth portal near of the ligament, insert a 1-mm Kerrison rongeur, and
the end of the procedure under direct vision with an divide the ligament. I remove the rongeur and probe
outside-in technique. The fifth portal is placed medial the notch to make sure the nerve is thoroughly
to the fourth portal. I insert a trocar through portal decompressed and intact.
5 to retract the nerve and then divide it with If other lesions exist (e.g., labrum, biceps tendon, or
a Kerrison rongeur placed through portal 4 (Figs. 8-7 rotator cuff tears), I enter the glenohumeral joint
and 8-8). posteriorly and establish a routine anterior-inferior
I introduce the arthroscope into the posterior portal portal. The labrum tear is usually located in the
and a shaver laterally. I excise bursa until I obtain a superior or posterior-superior glenoid. I move the
good view of the coracoacromial ligament and the arthroscope to the anterior portal and carefully
anterior border of the supraspinatus muscle. I trace inspect the posterior-superior aspect of the rotator
the coracoacromial ligament to the coracoid and cuff for signs of damage. If a grade 2 or 3 lesion is
identify the coracoid by palpating it with the tip of found, I mark the area with a monofilament suture
and (after labrum repair) inspect that area while
viewing from the subacromial space. I perform a rota-
tor cuff repair if there is also partial tearing on the
bursa side. If the rotator cuff is normal, I proceed
with the labrum repair. The details of the repair are
identical to those described in Chapter 5. The cyst is
usually located deep to the capsule and posterior to
the biceps tendon. I remove this area with a power
shaver until I can see the cyst. I remove the cyst
with a power shaver and make no attempt to repair
the superior joint capsule (Figs. 8-9 through 8-18).
If the labrum is separated only slightly, I use a soft
tissue chisel instrument to dissect underneath the
labrum. In Iannotti’s experience, opening this area
often leads directly to the cyst, and cystic fluid can
Figure 8-8 Medial portal locations. be expressed into the joint.
Figure 8-9 Chisel dissecting underneath the superior labrum.

Figure 8-11 Suprascapular nerve below the supraspinatus
muscle.
There are often soft tissue connections between the
superior glenohumeral joint capsule and the posterior-
superior labrum. These may represent the pathway for
synovial fluid to leak from the joint to the cyst.
Some surgeons cauterize this area to obliterate the
connection; others débride the area to open the
connection and ‘‘decompress’’ the cyst. Until there is
ample scientific evidence to guide treatment, surgeon
preference is the deciding factor. I believe that labrum
repair and cyst excision are the only intra-articular
treatments required. I am concerned about thermal
application and extensive soft tissue resection of the
posterior-superior capsule owing to the proximity
of the suprascapular nerve, which lies approximately
1 to 2 cm medial to the glenoid rim. I carefully débride
any soft tissue connections but keep the shaver
near the glenoid.
Figure 8-10 Opening the cystic connection to the glenohu-

meral joint. Figure 8-13 SLAP repair.
Figure 8-14 Suprascapular ligament above the needle. Figure 8-17 Kerrison rongeur dividing the ligament.
Variations of Technique
Other options for the treatment of an extra-articular
cyst include open cyst excision and injection of
cortisone into the cyst, usually under MRI guidance.
The latter has been reported to cause cyst dissolution
and may be performed pre- or postoperatively. Open
cyst excision is associated with a higher morbidity
than arthroscopic treatment.
Postoperative Care
Postoperative care is identical to that for the superior
labrum from anterior to posterior (SLAP) lesion repair
described in Chapter 5. Repeat MRI and electrodiag-
nostic testing may be performed 3 months after
operation.
Figure 8-15 Suprascapular ligament below the needle.
Figure 8-16 Suprascapular nerve underneath the ligament. Figure 8-18 Suprascapular nerve after ligament division.
Suprascapular Nerve
Decompression at the
Spinoglenoid Ligament

at the Spinoglenoid Ligament
I use the standard sitting position and establish rou-
tine posterior and anterior portals. I view through the
posterior portal and insert a spinal needle lateral to
the acromion and angle it so that it enters the gleno-
humeral joint through the muscular (rather than the
tendinous) portion of the supraspinatus. I move the
arthroscope to the lateral, transrotator cuff portal
and insert a power shaver through the posterior Figure 8-20 Spinoglenoid ligament.
portal. I resect the glenohumeral joint capsule supe-
rior to the glenoid and posterior to the biceps-labrum
junction. I remove enough capsule to visualize the
fibers of the supraspinatus muscle. I then insert an
elevator through the anterior portal and elevate the
supraspinatus muscle from the supraspinatus fossa. infraspinatus muscle from the scapula. I insert the ar-
This allows me to see the cyst, and I resect a portion throscope through the lateral incision. Often, a third
of it with a power shaver. Once I have decompressed incision placed more laterally is used to insert a scissors
the cyst, I look for the nerve approximately 2.5 to to divide the spinoglenoid ligament.
3 cm medial to the glenoid rim. It is located on the
supraspinatus fossa and passes underneath the spino-
glenoid ligament at the level of the scapular spine. BIBLIOGRAPHY
I resect the ligament and then trace the nerve proxi-
mally and distally to verify that there are no other Antoniou J, Tae SK, Williams GR, et al: Suprascapular neu-
areas of nerve entrapment. I now use the technique ropathy: Variability in the diagnosis, treatment, and out-
described by Plancher (Figs. 8-19 and 8-20). come. Clin Orthop Relat Res 386:131-138, 2001.
I use two posterior incisions—one located 4 cm Barwood SA, Burkhart SS, Lo IK: Arthroscopic suprascapular
medial to the posterolateral acromion and a second 4 nerve release at the suprascapular notch in a cadaveric
cm medial to the acromion. Through the more medial model: An anatomic approach. Arthroscopy 23:221-225,
incision, I insert a soft tissue dissector to free the 2007.
Bhatia DN, de Beer JF, van Rooyen KS, du Toit DF:
Arthroscopic suprascapular nerve decompression at the
suprascapular notch. Arthroscopy 22:1009-1013, 2006.
Chochole MH, Senker W, Meznik C, Breitenseher MJ:
Glenoid-labral cyst entrapping the suprascapular nerve:
Dissolution after arthroscopic debridement of an
extended SLAP lesion. Arthroscopy 13:753-755, 1997.
Iannotti JP, Ramsey ML: Arthroscopic decompression of a
ganglion cyst causing suprascapular nerve compression.
Arthroscopy 12:739-745, 1996.
Lafosse L, Tomasi A, Corbett S, et al: Arthroscopic release of
suprascapular nerve entrapment at the suprascapular
notch: Technique and preliminary results. Arthroscopy
23:34-42, 2007.
Levy P, Roger B, Tardieu M, et al: [Cystic compression of the
suprascapular nerve: Value of imaging. Apropos of 6 cases
and review of the literature]. J Radiol 78:123-130, 1997.
Lichtenberg S, Magosch P, Habermeyer P: Compression of
the suprascapular nerve by a ganglion cyst of the spino-
Figure 8-19 Posterior portal locations to access the spinoglenoid notch: The arthroscopic solution. Knee Surg
glenoid notch. Sports Traumatol Arthrosc 12:72-79, 2004.
Millett PJ, Barton RS, Pacheco IH, Gobezie R: Suprascapular Westerheide KJ, Dopirak RM, Karzel RP, Snyder SJ: Suprascapu-
nerve entrapment: Technique for arthroscopic release. lar nerve palsy secondary to spinoglenoid cysts: Results of
Tech Shoulder Elbow Surg 7:89-94, 2006. arthroscopic treatment. Arthroscopy 22:721-727, 2006.
Plancher KD, Luke TA, Peterson RK, Yacoubian SV: Posterior Youm T, Matthews PV, El Attrache NS: Treatment of patients
shoulder pain: A dynamic study of the spinoglenoid liga- with spinoglenoid cysts associated with superior labral
ment and treatment with arthroscopic release of the scap- tears without cyst aspiration, debridement, or excision.
ular tunnel. Arthroscopy 23:991-998, 2007. Arthroscopy 22:548-552, 2006.
CHAPTER
9
Sepsis
Glenohumeral joint sepsis is an unusual indication for DIAGNOSIS

shoulder arthroscopy. In my experience, the arthro-
scope has greatly facilitated the management of this All studies on shoulder pyarthrosis have noted a delay
difficult condition. Treatment goals include perform- in establishing a diagnosis because the clinical find-
ing fluid cultures and tissue biopsies to identify the ings may be subtle. Patients are often afebrile and
infecting organism or organisms and determining may complain of nonspecific shoulder discomfort.
the extent of tissue involvement, followed by joint The white blood cell count may be normal, and the
irrigation and débridement in a manner that mini- increase in the erythrocyte sedimentation rate is often
mizes morbidity and allows early functional recovery. not dramatic. I find the C-reactive protein test to be
Serial needle aspirations cannot remove all joint debris more sensitive. The literature on this subject confirms
or reach all loculations and infected clots. Arthrotomy that glenohumeral joint infections are very difficult to
enables thorough irrigation and débridement, but diagnose, and any or all tests may be negative despite
with increased soft tissue injury compared with an ongoing infection. If glenohumeral sepsis is a pos-
arthroscopic treatment. sibility, I advise arthroscopic evaluation; the risks of a
negative arthroscopy are small when compared to the
dire consequences of a missed septic arthritis.
LITERATURE REVIEW I obtain a consultation with an infectious disease
specialist once I suspect the diagnosis of infection;
Most series on sepsis in various joints report the such assistance is invaluable in the postoperative
incidence of shoulder involvement as 3% to 12%. period. I have a general surgeon insert a catheter for
The most common organisms isolated are long-term parenteral antibiotics after the patient is
Staphylococcus aureus (61%) and Staphylococcus epider- anesthetized in the operating room and before I begin
midis (17%), but polymicrobial infections are frequent the arthroscopic operation. I do not administer anti-
(67%). In his series, Gelberman noted that all patients biotics until I have obtained the appropriate
had significant underlying medical conditions such as specimens.
alcoholism, liver disease, malignancy, heroin addic-
tion, or renal failure. Patients with acquired immuno-
deficiency syndrome (AIDS) and patients who have OPERATIVE TECHNIQUE
undergone shoulder replacement may also present
with septic shoulders. The rise of methicillin-resistant I establish a routine posterior portal and insert culture
S. aureus (MRSA) and Propionibacterium acnes is of con- swabs into the joint before instilling fluid so that I can
cern. The latter is very difficult to detect with labora- obtain specimens for aerobic and anaerobic analysis.
tory analysis. After the arthroscope is inserted posteriorly, I create an
207
Figure 9-1 Infection after an arthroscopic Bankart proce- Figure 9-3 Débridement and synovectomy.
dure. Note the remaining glenoid articular cartilage.
anterior-inferior portal and insert a large cannula.

I use a tissue-grasping forceps to obtain soft tissue spe-
cimens, which are sent to the laboratory for frozen
section, Gram stain, and culture and sensitivity test-
ing. I find it helpful to alert the pathologist in advance
of the procedure to obtain a rapid reading of the Gram
stain. I use a motorized tissue resector to perform a
synovectomy and débridement of all involved areas
throughout the glenohumeral joint. In my experience,
only a remnant of the rotator cuff is usually present
I irrigate the joint copiously with 6 L of irrigation
fluid. I then create an anterior-superior portal and
move the arthroscope to that location. I insert a hip
suction tube through the posterior cannula and bring
Figure 9-4 Bone defects in the area of anchors.
Figure 9-2 Anchor remnant. Figure 9-5 Insert the tubing anteriorly.
Chapter 9 Sepsis 209
it out the anterior-inferior cannula; I then repeat

the process to insert a second suction drain. I move
the arthroscope posteriorly and use a crochet hook
to move one of the drains from the anterior-inferior
cannula to the anterior-superior cannula. Through-
and-through irrigation can be established with this
technique. I inspect the subacromial space and
perform débridement and drain insertion as necessary.
If the patient responds, I remove the drains
48 hours after surgery. The operation is repeated as
necessary until the infection is controlled.
BIBLIOGRAPHY
Figure 9-6 Drainage tube in the joint.
Bertone C, Rivera F, Avallone F, et al: Pneumococcal septic
arthritis of the shoulder: Case report and literature review.
Panminerva Med 44:151-154, 2002.
Cleeman E, Auerbach JD, Klingenstein GG, Flatow EL: Septic
arthritis of the glenohumeral joint: A review of 23 cases.
J Surg Orthop Adv 14:102-107, 2005.
Costantino TG, Roemer B, Leber EH: Septic arthritis and bur-
sitis: Emergency ultrasound can facilitate diagnosis. J
Emerg Med 32:295-297, 2007.
Esenwein SA, Ambacher T, Kollig E, et al: [Septic arthritis of
the shoulder following intra-articular injection therapy:
Lethal course due to delayed initiation of therapy].
Unfallchirurg 105:932-938, 2002.
Gordon EJ, Hutchful GA: Pyarthrosis simulating ruptured
rotator cuff syndrome. South Med J 75:759-762, 1982.
Hammel JM, Kwon N: Septic arthritis of the acromioclavicu-
lar joint. J Emerg Med 29:425-427, 2005.
Jeon IH, Choi CH, Seo JS, et al: Arthroscopic management of
septic arthritis of the shoulder joint. J Bone Joint Surg Am
88:1802-1806, 2006.
Kitsis CK, Marino AJ, Krikler SJ, Birch R: Late complications
Figure 9-7 Drainage tube advanced in the joint. following clavicular fractures and their operative manage-
ment. Injury 34:69-74, 2003.
Lluı́s M, Rovira E: [Image of the week: Septic arthritis and
sepsis by MRSA of cutaneous region]. Med Clin (Barc)
126:720, 2006.
Master R, Weisman MH, Armbuster TG, et al: Septic arthritis
of the glenohumeral joint: Unique clinical and radio-
graphic features and a favorable outcome. Arthritis
Rheum 20:1500-1506, 1977.
Mehta P, Schnall SB, Zalavras CG: Septic arthritis of the
shoulder, elbow, and wrist. Clin Orthop Relat Res 451:
42-45, 2006.
Morihara T, Arai Y, Horii M, et al: Arthroscopic treatment for
septic arthritis of the shoulder in an infant. J Orthop Sci
10:95-98, 2005.
Murdoch DM, McDonald JR: Mycobacterium avium-intracellu-
lare cellulitis occurring with septic arthritis after joint
injection: A case report. BMC Infect Dis 7:9, 2007.
Parisien JS, Shaffer B: Arthroscopic management of pyarthrosis.
Figure 9-8 Drainage tube exiting the posterior portal. Clin Orthop Relat Res 275:243-247, 1992.
Rolf O, Stehle J, Gohlke F: [Treatment of septic arthritis of the Ward WG, Goldner RD: Shoulder pyarthrosis: A concomitant
shoulder and periprosthetic shoulder infections: Special process. Orthopedics 17:591-595, 1994.
problems in rheumatoid arthritis]. Orthopade 36:700-707, Weishaupt D, Schweitzer ME: MR imaging of septic arthritis
2007. and rheumatoid arthritis of the shoulder. Magn Reson
Ross JJ, Shamsuddin H: Sternoclavicular septic arthritis: Imaging Clin N Am 12:111-124, 2004.
Review of 180 cases. Medicine 83:139-148, 2004. Wick M, Müller EJ, Ambacher T, et al: Arthrodesis of the
Seitz WH, Damacen H: Staged exchange arthroplasty for shoulder after septic arthritis: Long-term results. J Bone
shoulder sepsis. J Arthroplasty 17:36-40, 2002. Joint Surg Br 85:666-670, 2003.
Smith AM, Sperling JW, Cofield RH: Outcomes are poor after Yu KH, Luo SF, Liou LB, et al: Concomitant septic and gouty
treatment of sepsis in the rheumatoid shoulder. Clin arthritis—an analysis of 30 cases. Rheumatology (Oxford)
Orthop Relat Res 439:68-73, 2005. 42:1062-1066, 2003.
Ward WG, Eckardt JJ: Subacromial/subdeltoid bursa
abscesses: An overlooked diagnosis. Clin Orthop Relat
Res 288:189-194, 1993.
CHAPTER
10
Impingement Syndrome
Rotator cuff tendon lesions of the subacromial space relieved with a subacromial lidocaine injection (im-
include tendinosis (impingement syndrome), partial- pingement test).
thickness tears, reparable full-thickness tears, massive
tears, irreparable tears, and cuff arthropathy. I also
include acromioclavicular joint pathology in this LITERATURE REVIEW
category. Patients often present to the orthopedic
surgeon’s office with impingement syndrome, which A number of reports in the orthopedic surgery literature
is a common indication for arthroscopic surgery. describe the arthroscopic management of stage 2 rota-
tor cuff disease. Several authors have reported 70% to
90% success rates with arthroscopic acromioplasty.
CLINICAL PRESENTATION All authors stress that arthroscopic surgery is
successful when impingement is due to extrinsic
Stage 2 impingement (chronic rotator cuff tendinosis) compression on the tendon by the structures of the
is a clinical syndrome. The patient complains of coracoacromial arch. It is not successful when impinge-
subdeltoid pain with radiation down the lateral arm ment is intrinsic, as may be seen with the increased
to the area of the deltoid insertion or down the front demand on rotator cuff tendons in patients with
of the arm into the biceps muscle. Pain occurs as the glenohumeral subluxation. Other studies have
arm passes through the arc of 70 to 100 degrees of abduc- compared the open and arthroscopic techniques.
tion. Nighttime pain interferes with sleep. Physical Matsen and colleagues found that although the open
examination normally demonstrates full passive range technique produced a slightly higher success rate,
of motion. Small limitations in elevation and behind- the return to function was superior with arthroscopic
the-back internal rotation are due to the patient’s pain treatment. Norlin found that the arthroscopic
rather than true passive glenohumeral joint contrac- technique produced better results and a more rapid
ture. Active abduction and behind-the-back internal return of function. Van Holsbeeck and associates
rotation are painful. The patient often reports pain reported marginally better results with the open
while actively lowering the arm after the examiner technique but advised arthroscopic decompression for
raises it passively. The primary (Neer) and secondary patient convenience and satisfaction. Recent literature
(Hawkins) impingement signs are positive, and pain is has focused on the dynamic cause of some cases
213
214 Section Three Subacromial Space Surgery
of impingement syndrome. It is well known that degrees of abduction. The location of the pain should
alterations in scapular biomechanics can cause be carefully noted. A patient with soft tissue pain from
subacromial pain. Treatment in these individuals rhomboid-trapezius spasm may have increased pain
is not surgical but involves a comprehensive physical during each of these maneuvers, but the pain is not
therapy program. The best work on this topic is localized to the subacromial region.
by Kibler. After the physical examination, the surgeon may
perform an impingement test. This test consists
of injecting local anesthetic into the subacromial
DIAGNOSIS space and then attempting to elicit the impingement
signs again. If the pain is eliminated or substantially
The classic history of stage 2 impingement is shoulder reduced, the test is recorded as positive. The physician
pain during activities that place the shoulder in 70 to must be aware that a positive test result only confirms
100 degrees of elevation or abduction. Typical activ- that the structures producing pain lie within the
ities include reaching overhead (e.g., for items on subacromial space; it is not, by itself, diagnostic
a high shelf), behind the back (e.g., to fasten a bras- of impingement syndrome. My preferred technique
siere or belt), or to the side (e.g., to insert an ATM card, for subacromial injection is posterior. This is how
use a seatbelt, or access an alarm clock). I enter the subacromial space during shoulder ar-
Pain is localized to the subacromial region and radi- throscopy, so I am familiar with this approach.
ates to the deltoid insertion and often anteriorly into Other surgeons are equally successful with lateral or
the biceps. Nighttime pain is noted regularly. The role anterior approaches.
of trauma is variable; some patients present with The diagnosis of impingement syndrome is clinical,
symptoms after major injury, but in many others, and arthroscopy does not routinely play a role.
the pain occurs after repetitive activities without A number of conditions that mimic the clinical
trauma or antecedent injury. Physical examination presentation of impingement are best diagnosed
demonstrates a full or nearly normal range of passive with arthroscopic techniques. Glenohumeral instabil-
motion. Occasionally, I find local tenderness in the ity, articular surface partial rotator cuff tears, labrum
area of the supraspinatus insertion. I prefer to stand tears, small areas of degenerative arthritis, posterior
behind the patient, position the shoulder in slight glenoidrotator cuff impingement, and lesions
extension, and place my index finger in the area of the rotator interval are examples. Glenohumeral
of the rotator cuff insertion. Sometimes when I instability may result in secondary traction tendinitis,
rotate the shoulder I can imagine a defect in this with positive impingement signs as well as a positive
area consistent with a full-thickness rotator cuff tear. impingement test. Successful surgical management
Acromioclavicular joint tenderness should alert the of this condition does not involve shoulder
examiner that this joint might be the primary source decompression but rather treatment of the underlying
of pathology. Acromioclavicular joint arthritis can glenohumeral instability. Other conditions that may
mimic stage 2 impingement. Joint inflammation mimic stage 2 impingement syndrome but cannot
may cause irritation to the supraspinatus tendon as be diagnosed with arthroscopic technique include
it passes underneath the acromioclavicular joint. acromioclavicular joint arthritis, cervical spine
Additionally, acromioclavicular joint arthritis can disease, and suprascapular neuropathy.
coexist with primary impingement. There is little scientific support for the concept that
I carefully examine patients younger than 40 years acromial morphology is significant. Many think the
for the presence of glenohumeral instability. In these type 3 acromion is actually ossification of the coraco-
patients, subacromial pain may be the result of acromial ligament that is medially positioned and
traction on the rotator cuff rather than true stage 2 plays no role in subacromial impingement.
impingement. Three impingement signs consistent Historically, plain radiograph bone findings consistent
with stage 2 impingement have been described and with subacromial impingement include type 3 acro-
are recorded as positive when subacromial pain is mion, anterior acromial sclerosis, anterior medial
produced. The primary (Neer) sign occurs when the spurs (ossification of the coracoacromial ligament),
examiner places the shoulder in maximal elevation. and inferior spurring of the distal clavicle. Magnetic
To demonstrate the secondary (Hawkins) sign, the resonance imaging findings include tendinosis, bursi-
shoulder is elevated 80 degrees and then maximally tis, and lateral acromial downsloping.
internally rotated. The tertiary sign (painful arc) In summary, subacromial impingement that responds
consists of subacromial pain with the shoulder in 90 to arthroscopic subacromial decompression is based
Chapter 10 Impingement Syndrome 215
Figure 10-1 Type 3 acromion, scapular outlet view. Figure 10-3 Coracoacromial ligament ossification.
on extrinsic factors such as abnormal acromial shape, The indications for arthroscopic treatment include
sloping, or spurs within the coracoacromial ligament or pain or weakness that interferes with work, sports,
acromioclavicular joint. Subacromial ‘‘impingement’’ or activities of daily living and is unresponsive to
findings that do not respond to arthroscopic subacromial appropriate nonoperative treatment. The usual non-
decompression are those of intrinsic rotator cuff ten- operative regimen consists of oral anti-inflammatory
dinopathies and those secondary to glenohumeral joint medication, cortisone injections into the subacromial
instability (Figs. 10-1 through 10-3). space (two or three, spaced 2 months apart), activity
modification, selective rest, and a rehabilitation
program. The rehabilitation program is designed to
restore or maintain movement and to improve
strength in the deltoid, scapular stabilizers, and
rotator cuff muscles. The recommended duration
of this nonoperative approach varies, but it seems
reasonable to consider surgery if the patient’s pain
continues for 12 months or is increasing in severity
after 6 months. Additionally, an unusual indication
for operative treatment is a superiorly displaced,
healed greater tuberosity fracture. Arthroscopic
subacromial decompression treats the deformity by
increasing clearance for the malunited bone.
The concept of acromioplasty itself is controversial,
with some surgeons believing that acromioplasty is
unnecessary. It is Matsen’s opinion that contact
between the rotator cuff and acromial undersurface
is normal and that acromial spurs are the result
of—not cause of—a primary tendon abnormality. He
treats patients demonstrating stage 2 impingement
with débridement of abnormal bursa and adhesions
and then initiates a vigorous rehabilitation program.
Nirschl’s view is that impingement is an intrinsic
tendinopathy and that acromioplasty is not needed.
Conversely, numerous articles have reported good
results with acromioplasty. At present, there is little
Figure 10-2 Anterolateral acromial spur. scientific evidence to guide orthopedic surgeons,
who must consider these conflicting opinions within is at its peak, but patients in the very early or late
the context of their own experience. We await well- phase may have only a small loss of external rotation
designed, prospective, randomized studies to evaluate that can be missed if the examiner fails to measure
this issue. I discuss the need for acromioplasty in both shoulders. I carefully measure external rotation
relation to rotator cuff repair in Chapter 12. in maximal abduction and compare the side-to-side
Acromioclavicular joint arthritis may coexist with difference, which may be the first finding. The loss
subacromial impingement. If the patient is sympto- of external rotation does not allow the greater
matic from the arthritis, as determined by the tuberosity to rotate away from the acromion during
preoperative clinical examination, acromioclavicular elevation and may mimic the clinical findings of
joint resection is performed. Resection can be accom- impingement. Posterior capsule tightness can lead
plished through the subacromial approach, although to obligatory anterior-superior humeral head transla-
some surgeons prefer a direct approach into the tion and cause contact between the rotator cuff and
acromioclavicular joint itself. the coracoacromial arch. The loss of internal rotation
is most noticeable with the shoulder abducted 80 to
90 degrees.
CONTRAINDICATIONS TO SURGERY Musculoskeletal pain syndromes commonly cause
pain in the scapular muscles, and this too can be
Pain occurring during abduction can have a number confused with subacromial impingement. The
of other causes besides the extrinsic mechanical factors impingement signs may be positive, but the pain is
of subacromial impingement, including early rheuma- located in the scapular muscles or trapezius rather
toid arthritis, post-traumatic arthritis, and avascular than in the classic locations.
necrosis. However, these are unusual conditions with A rare cause of impingement pain is suprascapular
clear radiographic findings. An unusual situation is nerve entrapment. This may be caused by a cyst
a patient with chondromalacia from early osteoarthro- within the suprascapular notch or in the area of the
sis. In this case, the plain radiographic findings are spinoglenoid ligament. Entrapment can also exist in
normal, and the true cause of the patient’s pain is the absence of a cyst because the suprascapular nerve
discovered during arthroscopic examination. is particularly vulnerable in these two locations.
There are three common clinical entities that Realistically, the diagnosis is one of exclusion, made
may lead to an erroneous diagnosis: glenohumeral after other more common lesions have been ruled out,
instability, adhesive capsulitis, and musculoskeletal but the surgeon should be suspicious when there is
pain syndromes. Fortunately, the surgeon can burning pain in the midtrapezius region, weakness
identify all with appropriate evaluation. out of proportion to pain, significant atrophy in the
Probably the most common error is operating supraspinatus or infraspinatus fossa, or a cyst noted on
on patients with intrinsic tendinopathy secondary to magnetic resonance imaging in the region of the
glenohumeral instability. The repetitive overload of nerve.
the rotator cuff tendons as they attempt to stabilize
the glenohumeral joint causes inflammation and swell-
ing of the tendons. Although the instability may be ARTHROSCOPIC FINDINGS
subtle, the pain from rotator cuff and bursa inflamma-
tion may be severe, causing the patient to present for Most surgeons examine the glenohumeral joint for
evaluation and treatment. Impingement signs and the unsuspected lesions before arthroscopic subacromial
impingement test are positive. These patients are decompression. Subtle Bankart or superior labrum from
usually younger than 40 years and have normal plain anterior to posterior (SLAP) lesions, labrum fraying, early
radiographs. In this setting, I proceed very cautiously adhesive capsulitis, and small areas of cartilage loss are
and advise a prolonged period of nonoperative care. some examples. Imaging studies may underestimate the
Arthroscopic subacromial decompression without cor- extent of rotator cuff damage. Subacromial findings in
rection of the underlying glenohumeral joint lesions stage 2 impingement are variable. The space may be
will fail. I devote more time to the relationship between clear, or a dense, fibrous bursal reaction may be found.
rotator cuff lesions and glenohumeral instability in the Impingement syndrome may exist even in the presence
section on internal impingement and partial-thickness of a clear, well-defined subacromial space. In some
rotator cuff tears (see Chapter 11). individuals, contact between the rotator cuff and
The second most common error occurs when the acromion produces pain but does not incite an
the patient has adhesive capsulitis. The diagnosis of inflammatory bursitis reaction. Tendon erosion, fraying,
adhesive capsulitis is straightforward when the disease or partial-thickness tears may be found on the superior
(bursal) surface of the cuff. Erosions on the acromial or glenohumeral instability may mimic subacromial
undersurface near the anterior edge are frequently impingement. I have seen a patient rapidly lose
noted, as are small areas of inflammation. The surgeon motion between the last office examination and the
may also observe coracoacromial ligament fraying. examination under anesthesia at surgery.
Although these findings are suggestive of subacromial
impingement, they are not necessarily diagnostic.
Positioning
Patient positioning is a matter of surgeon preference.
TREATMENT Although many surgeons are more comfortable with
patients in the lateral decubitus position, I prefer to
Arthroscopic treatment of stage 2 impingement involves have them in the sitting position. The arm is allowed
examination under anesthesia to document range of to rest naturally by the patient’s side. In my experi-
motion and translation, followed by inspection of the ence, traction is not necessary during this procedure
glenohumeral joint and treatment, if indicated, of any or any operation within the subacromial space.
coexisting intra-articular lesions. Subacromial treatment
includes excision of sufficient pathologic bursa to
Landmarks
accomplish three goals: inspect the surface of the
tendons, remove the space-occupying lesion, and I mark the surface anatomy of the clavicle, acromion,
remove an inflamed, pain-producing structure. If the coracoid process, and scapular spine with a surgical
bursa is not pathologically thickened or if it does not marking pen. I mark the inferior surfaces of the
obscure my view to the rotator cuff tendon insertion, bone, because it is from these points that distances
I do not resect the bursa. In most cases, treatment of are measured (Fig. 10-4).
the coracoacromial ligament involves resection from
the lateral acromial border to the medial acromial
Glenohumeral Joint Entry and Findings
border. Some surgeons prefer to divide, rather than
resect, the ligament. As noted earlier, some may elect I enter the glenohumeral joint posteriorly, as
not to perform acromioplasty or coracoacromial described in Chapter 3, and perform a complete
ligament resection, limiting treatment to bursectomy. inspection of the glenohumeral joint while viewing
I perform an inferior acromioplasty to convert the from the posterior portal. I then create an anterior
acromion to a flat (type 1) structure. This can be accom- portal, move the arthroscope anteriorly, and complete
plished with a power bur placed in either the lateral the diagnostic portion of the examination.
or the posterior portal, depending on the surgeon’s There are usually few intra-articular signs of
preference. subacromial impingement. There may be fraying or
The acromioclavicular joint may contribute to erythema of the anterior supraspinatus. I carefully
impingement syndrome through the formation of observe for findings that may mimic stage 2 subacro-
inferior acromioclavicular joint osteophytes. Inferior mial impingement. These include a SLAP
osteophytes may project downward into the rotator lesion (internal impingement), Bankart lesion
cuff tendons and cause or exacerbate impingement.
The presence of these osteophytes is documented
on plain radiographs or magnetic resonance imaging.
The osteophyte can be removed arthroscopically.
OPERATIVE TECHNIQUE
Arthroscopic Subacromial
Decompression
Examination under Anesthesia
I prefer a combination of general anesthesia and
interscalene block. I examine both shoulders for
range of motion and translation. As previously
mentioned, early (or late resolving) adhesive capsulitis Figure 10-4 Skin markings.
Figure 10-5 Partial-thickness rotator cuff tear. Figure 10-7 Nondisplaced Bankart lesion.
(anterior-inferior glenohumeral instability), con-

tracted inferior capsule recess (adhesive capsulitis), or
rotator interval tear (anterior-superior glenohumeral
instability) (Figs. 10-5 through 10-11).
I use an arthroscopic probe and palpate the
glenohumeral ligaments to ensure that they are
securely attached to both the glenoid rim and the
humeral head. I have not found it necessary to
débride minor areas of frayed labrum. I remove
the instruments and cannulas and proceed to the
subacromial space.
Subacromial Entry and Findings

I enter the subacromial space posteriorly and create a
lateral working portal as described in Chapter 3. I verify
my spatial orientation by rehearsing the movements Figure 10-8 SLAP lesion.
required during the operation. I touch the shaver tip to
Figure 10-6 Fraying of the labrum. Figure 10-9 Humeral head cartilage lesion.
Figure 10-12 Palpate the trocar.

Figure 10-10 Contracted rotator interval.
the acromion (lower my hand), rotator cuff (raise my

hand), anterior acromion (bring my hand toward
myself), and posterior acromion (move my hand away
from myself) (Figs. 10-12 through 10-20).
Findings of subacromial impingement include
erythema or fraying of the coracoacromial ligament
or the bursal cuff surface. There is usually a
proliferative bursitis, although sometimes the subacro-
mial space is clear. Adhesions may be present between
the rotator cuff and the acromion or deep surface of
the deltoid fascia. I sweep the cannula and trocar
medially and laterally to release any significant adhe-
sions (Fig. 10-21).
Figure 10-13 Palpate the acromion.
Figure 10-11 Contracted anterior capsule. Figure 10-14 Palpate the acromion.
Figure 10-15 Palpate the rotator cuff.

Figure 10-18 Palpate the coracoacromial ligament.
Figure 10-16 Palpate the rotator cuff. Figure 10-19 Move posteriorly.
Figure 10-17 Palpate the coracoacromial ligament. Figure 10-20 Move posteriorly.
Figure 10-22 Posterior bursal curtain.

Figure 10-21 Blunt dissection of subacromial adhesions.
Bursectomy
If bursitis obscures the view, I remove it by turning the
shaver tip away from the arthroscope (to avoid
accidental damage to the lens) and positioning it
midway between the acromion and the rotator cuff.
I increase the suction slightly and begin shaving.
As I remove the bursa, the subacromial space clears,
and I can see the shaver tip. I gradually increase the
suction on the shaver and continue to remove bursa.
Do not shave medially; that area does not contribute
to subacromial impingement, and inadvertent medial
shaving of the well-vascularized bursa can cause bleed-
ing that is difficult to control and rupture the muscle
fibers of the rotator cuff. Once the bursa is removed Figure 10-23 Bursa obscuring the view of the subacromial
from the lateral, tendinous portion of the rotator cuff, space.
I look for adhesions anteriorly or laterally and remove
these with scissors or a motorized resector until a com-
plete view of the supraspinatus is possible (Figs. 10-22
through 10-28).
Coracoacromial Ligament
When performing a subacromial decompression, a
critical step is to identify the anterolateral acromion,
which is usually covered by the coracoacromial
ligament. Electrocautery is useful for this portion
of the procedure. I palpate the bone surface with
the electrocautery tip (without power) and locate
the anterior and then the lateral acromial borders.
With the electrocautery tip placed against the acromi-
on approximately 1 cm posterior to the anterior bone
margin and 1 cm medial to the lateral bone margin,
I ablate soft tissue until the bone is visible. I move Figure 10-24 Musculotendinous junction (arrow).
Figure 10-25 Subacromial adhesion.

Figure 10-28 Partial-thickness tear of the bursal surface of
the rotator cuff.
anteriorly and laterally and remove more soft tissue

and coracoacromial ligament until I can clearly see
the anterolateral acromial border. I then sweep the
coracoacromial ligament from the anterior-inferior
acromion until it falls inferiorly. This usually
completes the coracoacromial ligament release.
Another technique is to use the power bur or shaver
and gradually peel the soft tissue away from the acro-
mion. This makes resection of the coracoacromial
ligament less risky because it is now a safe distance
from the small branches of the thoracoacromial
artery. If the surgeon believes that coracoacromial
ligament release is preferable to resection, only the
lateral portion of the ligament is resected; the medial
portion is left intact (Figs. 10-29 through 10-37).
Figure 10-26 Resect the adhesion.
Acromioplasty
Using preoperative radiographs, I estimate the amount
of bone removal necessary. Anteroposterior radio-
graphs may demonstrate anterolateral sclerosis and
thickening. An apical tilt view may demonstrate
ossification of the coracoacromial ligament with
medial bony projections. The outlet view provides
information about anterior acromial thickness.
Smaller individuals require less bone removal than
do larger individuals. Preoperative radiographic assess-
ment of bone thickness and estimation of the amount
of bone removal needed to achieve a flat, type 1 acro-
mion can help the surgeon avoid excessive bone
removal or acromial fracture.
Before acromioplasty, the inferior bone surface
should be free of soft tissue. I place the bur at the
anterolateral bone margin and remove anterior-inferior
Figure 10-27 Fraying of the bursal surface of the rotator cuff. bone until the deltoid fascia is seen and the appropriate
Figure 10-29 Erythema of the coracoacromial ligament. Figure 10-32 Coracoacromial ligament release.
Figure 10-30 Fraying of the coracoacromial ligament. Figure 10-33 Coracoacromial ligament release.
Figure 10-31 Coracoacromial ligament release. Figure 10-34 Identify the anterolateral corner.
amount of bone (as estimated from preoperative radio-

graphs) is removed. I remove bone until the inferior
acromial surface is flat and parallel to the floor.
Only then do I continue medially. I remove bone
from inferior to superior. Because the acromion
increases in thickness from lateral to medial, more
bone is removed medially. I remove bone until a flat
surface is achieved based on my view with the arthro-
scope in the posterior portal and angled upward.
There are two additional ways to check the acro-
mioplasty. With the arthroscope in the posterior
portal, place the tip up against the bone and rotate
the arthroscope’s objective lens downward. This
maneuver angles the beam parallel to the acromial
undersurface, and any bone projecting downward
requires removal. The second method is to move the
Figure 10-35 Identify the anterior acromion.
arthroscope to the lateral portal. Introduce the cannu-
la or shaver, place it against the acromial undersur-
face, and check for a flat bone surface (Figs. 10-38
through 10-43).
Hemostasis
Bleeding control is vital during an arthroscopic sub-
acromial decompression. I avoid débridement of the
medial subacromial space where the bursa is well
vascularized and the rotator cuff is muscular. The acro-
mial branch of the thoracoacromial artery, located
anterior to the coracoacromial ligament, is another
source of bleeding. One technique that decreases the
likelihood of excessive bleeding is to use thermal cau-
tery for subperiosteal dissection of the coracoacromial
ligament and for division of the ligament.
When bleeding is encountered, I immediately try to
Figure 10-36 Identify the medial acromion. control it rather than proceeding with the operation.
I stop the outflow, advance the arthroscope with its
Figure 10-38 Bur oriented parallel to the acromion

Figure 10-37 Soft tissue dissection with a shaver. undersurface.
Figure 10-42 Arthroscope rotated up toward the acromion.
Figure 10-39 Begin resection of the anterolateral acromial

corner.
inflow fluid stream as close to the site of bleeding as
possible, and increase the pump pressure to tampon-
ade the vessel. I bring the coagulation instrument into
the space near the site of bleeding, gradually decrease
the pump pressure until the bleeding source is identi-
fied, and coagulate the area. This step is a little easier if
a combination shaver-electrocautery unit is used.
Where to Start and When to Stop

Because this topic is so important, I explain in detail
how to perform an arthroscopic subacromial
decompression.
Orthopedic surgeons have two basic questions:
1. Exactly where do I begin the acromioplasty?

2. How do I know when I have completed it
successfully?
Figure 10-40 Resect bone more medially.
C
Figure 10-41 A-C, Pattern of bur movement. Figure 10-43 View of the acromion.
The answer is complex, but it begins with an under-

standing of acromial shape as it exists preoperatively
and how it should appear after arthroscopic subacro-
mial decompression. A basic problem is that we try to
evaluate a three-dimensional structure such as the
acromion with two-dimensional imaging. Therefore,
multiple radiographic views are needed. An anteropos-
terior view gives the surgeon information about
acromial thickness, anterior edge sclerosis, lateral
slope, and medial ossification of the coracoacromial
ligament. From this view, the surgeon gains an
impression of how to perform the bone resection.
Medial ossification of the coracoacromial ligament
alerts the surgeon that more anterior and medial
bone removal is needed, whereas a lateral slope Figure 10-44 Arthroscope rotated toward the rotator cuff.
dictates more lateral bone removal than usual. The beam is parallel to the acromion undersurface.
The axillary view provides information about the pres-
ence of an os acromiale. The lateral or scapular outlet
view demonstrates acromial thickness, slope, and superiorly, but at this point I tilt the arthroscope,
shape; it also guides the surgeon in determining how advance it so that it touches the acromion, and then
much anterior bone to remove. A thicker acromion rotate it so that the beam is parallel to the undersurface
requires more bone removal than a thin one, and (Figs. 10-44 and 10-45). Bone projecting downward must
this can be estimated from the radiograph or magnetic be removed, and I estimate how many millimeters
resonance image. Draw a line along the flat posterior this represents. I place the acromionizer bur against the
portion of the acromion and extend it anteriorly past acromion, which provides a yardstick by which to judge
the anterior acromial edge. Bone inferior to that line the amount of bone removal needed. I then return the
must be removed to create a flat, type 1 acromion. arthroscope to its original position and rotation and
A type 2 acromion can compromise the subacromial identify the anterolateral acromial corner by both
space and result in impingement, particularly if the inspection and palpation. Only when this area is clear
slope is more inferior than normal. After studying and I can view the deltoid fascia anteriorly and laterally
these three radiographic views, the surgeon should do I begin the coracoacromial ligament resection. I use
understand the preoperative acromion in three electrocautery to divide the coracoacromial ligament
dimensions. from the anterolateral acromion. I move medially
Next, the surgeon must understand how the and dissect the coracoacromial ligament from the
acromion should look after operation. The anteropos- anterior acromion and let it fall toward the rotator cuff.
terior radiograph should show a thinner acromion
with removal of anterior sclerosis and medial ossifica-
tion. Lateral tilt, if present preoperatively, should be
eliminated. The axillary view shows a more radiolucent
acromion, consistent with bone removal. Probably the
most helpful postoperative radiograph is the scapular
outlet view. By comparing the pre- and postoperative
radiographs, the surgeon can judge the adequacy of
bone removal.
Moving these concepts directly to the operating room
requires that the surgeon first establish a clear view of the
subacromial space. This requires bursectomy and hemo-
stasis. The soft tissue must then be removed from the
acromial undersurface so that the bone is visible.
The next step is to identify the anterior and lateral
acromial borders clearly, as described earlier. Only
when these steps have been accomplished can the
surgeon reliably perform an arthroscopic acromioplasty.
I usually view the acromion with the arthroscope rotated Figure 10-45 View of the acromion.
If I encounter bleeding during this portion of the proce-

dure, I cauterize the vessel immediately. It may be tempt-
Resected bone
ing to continue the operation if there is only minor
bleeding; however, this small compromise in picture
clarity gradually worsens, and if further bleeding
occurs, it may be hard to find the offending vessels.
Once I have released the coracoacromial ligament
attachment, I insert the soft tissue resector and remove
the ligament until I reach the level of the medial
acromion.
I then insert the acromionizer and begin at the
anterolateral corner of the acromion, increasing
the suction until I have a clear view; too much
suction, however, will collapse the subacromial
space. As I rotate the bur away from the arthroscope, Figure 10-46 Orientation drawing for the cutting block
I start the bur spinning before I touch the bone. If the technique.
acromionizer is resting on the bone when it is started,
the bur tends to jump and can inadvertently strike the scapular outlet view, draw a line from the inferior
arthroscope lens. I hold the bur about 2 mm from margin of the posterior acromion to the inferior
the bone, engage the power, and then gently touch margin of the anterior acromion. Draw a second line
the bone. I apply gentle pressure and move the bur from the inferior margin of the posterior acromion
anteriorly, away from the arthroscope. Once I see parallel to the inferior acromion. This should provide
and feel it break through the anterior cortex, I stop an estimate of the amount of bone to be removed. After
the bur and confirm that the deltoid fascia is visible. the soft tissue is removed from the acromial undersur-
I then continue to work in this area and resect more face, move the arthroscope to the lateral portal and
bone superiorly until the anterolateral acromion is place the acromionizer bur in the posterior cannula.
converted to a flat, type 1 shape. I rotate the arthro- Advance the bur anteriorly and place it up against the
scope’s objective lens 180 degrees to confirm this. acromial undersurface. Move the bur laterally and
I then move medially and resect enough bone until medially as you advance it anteriorly and remove
this area is parallel to the anterolateral resection. bone. The alignment of the instrument shaft against
I continue medially until I reach the medial margin the now flat acromion ensures that a type 1 acromion
of the acromion, where it forms the lateral border of is present (Figs. 10-46 through 10-50).
the acromioclavicular joint. As I resect bone medially, There is the danger of bone transection with the
I advance the arthroscope and rotate it inferiorly and cutting block technique in individuals with thin
medially, always attempting to keep the area of bone or angulated acromions. Appropriate analysis of
resection centered in the picture. I usually resect the the preoperative scapular outlet view should allow
medial border of the acromion until the soft tissue of
the acromioclavicular joint is visible. I have not had
any significant problems with late acromioclavicular
joint instability or pain with this approach.
I then move the arthroscope to the lateral portal to
ensure that I have created a type 1 acromion. The acro-
mioplasty can be examined by inserting an instru-
ment or probe and placing it flat against the
acromial undersurface. Another technique presented
by Hawkins is to enlarge the lateral portal enough to
introduce the tip of a finger and palpate the acromion.
This is a good technique to use when learning to
perform arthroscopic subacromial decompression.
Variations of Technique
A variation of the standard acromioplasty is the poste-
rior ‘‘cutting block’’ technique. On the preoperative Figure 10-47 Shave posteriorly.
Resected bone
Figure 10-48 Advance the bur.
Figure 10-51 Curved acromion poses a risk during the cut-

ting block technique.
the surgeon to select the correct technique (Figs. 10-51

and 10-52).
Os Acromiale
An anatomic variation that the surgeon may encounter
is the os acromiale (Fig. 10-53). The os represents a failure
of the acromion to ossify completely and can best be
diagnosed on the axillary radiograph. Three different
treatments have been proposed: ignore the fragment,
excise it, or perform internal fixation. The literature
reports good results with each method. I do not advocate
excision unless the anterior fragment is very small.
Figure 10-49 Test the resection with the trocar. I perform internal fixation only if there is palpation
tenderness over the fragment on the preoperative
Resected bone
Figure 10-50 Completed acromioplasty viewed from the Figure 10-52 Thin acromion poses a risk during the cutting
lateral portal. block technique.
with a loss of external rotation does not allow the

greater tuberosity to rotate and clear the acromion.
Passive range of motion during examination under
anesthesia demonstrates a loss of motion compared
with the contralateral side. The inferior recess and
the rotator interval may appear contracted or inflamed
on arthroscopic inspection. Chondromalacia or early
osteoarthrosis that is not detectable on plain radio-
graphs can be diagnosed during the glenohumeral
arthroscopic inspection. Acromioclavicular joint
arthritis or osteolysis may cause enough local synovi-
tis to irritate the rotator cuff and result in a clinical
presentation similar to impingement. Physical exami-
nation demonstrates local tenderness over the
acromioclavicular joint and acromioclavicular joint
pain with adduction and behind-the-back internal
Figure 10-53 Os acromiale. rotation.
Surgeons should be suspicious of the impingement
physical examination. I have found that the os is gener- diagnosis in patients younger than 40 years.
ally asymptomatic, so I perform a routine acromioplasty. Glenohumeral instability may cause a traction tendi-
nitis that mimics impingement. At surgery, the sur-
geon may observe an obvious Bankart lesion but
POSTOPERATIVE MANAGEMENT should search for more subtle lesions. In patients
younger than 40 years, I carefully examine the gleno-
After arthroscopic decompression for stage 2 impinge- humeral joint for labrum fraying, consistent with
ment, active motion can be started immediately with- excessive glenohumeral translation. Rotator interval
out fear of deltoid detachment. The physical therapist tears and SLAP lesions may also cause glenohumeral
instructs the patient in passive range of motion in instability. Correction of the underlying instability is
elevation and external rotation with a dowel rod. necessary.
Active range of motion in all planes is encouraged.
Strengthening can begin about 3 months after surgery
Technical Failure
or sooner, once resisted manual testing of the operated
shoulder muscles is painless. Inadequate Decompression
At reoperation, the most common cause of failure is
inadequate acromioplasty or coracoacromial ligament
release. The surgeon should pay close attention to the
CAUSES OF FAILURE
anterolateral acromial corner and must visualize this
area clearly to ensure adequate bone removal.
Failure of Thought
Unrealistic Expectations Excessive Decompression
The causes of failure after arthroscopic subacromial Excessive decompression usually occurs in small
decompression are identical to those seen after open women with thin acromions. When the surgeon fails
acromioplasty. Patients should understand that it to study the preoperative scapular outlet view, the
may take 6 to 12 months to recover fully from the small bone size is not appreciated. A standard
operation. Patients are often referred to me because acromioplasty performed with the acromionizer
they have pain 1 to 2 months after arthroscopic bur in the lateral portal may excessively thin the
subacromial decompression, and both they and their acromion, causing an intraoperative fracture or
surgeons are concerned about failure. Counseling fracture during early postoperative rehabilitation.
patients to have realistic expectations is invaluable. An arthroscopic subacromial decompression per-
formed with the cutting block technique with the acro-
Improper Diagnosis mionizer bur in the posterior portal may result in a
Shoulder pain as the arm passes through the painful complete anterior acromionectomy if the surgeon does
arc is common in a number of conditions other than not study the scapular outlet view carefully and appre-
impingement syndrome. Early adhesive capsulitis ciate the relative thinness or curvature of the acromion.
Lateral Acromial Resection fees constitute the largest portion of the expense.
Lateral resection occurs because of a misunderstanding These charges are similar for both arthroscopic and
of the pathophysiology of subacromial impingement open acromioplasty. It seems logical to conclude that
or a technical error. Lateral subdeltoid pain when the the arthroscopic approach allows patients to return to
arm is abducted may prompt some surgeons to resect work more rapidly—at least to jobs that do not require
the lateral acromion incorrectly. Poor visualization or heavy labor. This should have a substantial impact on
disorientation may cause the surgeon to mistake the cost analyses that take into account days lost from
lateral acromion for the anterior acromion. work; however, studies that systematically address this
issue have not been performed. Further, it appears that
even in this area, the differences may be only slight.
COMPARISON OF OPEN AND Many patients who do not perform manual labor can
ARTHROSCOPIC APPROACHES return to work once the pain is adequately controlled.
The ability to return to work seems to be less heavily
To today’s readers, the following comparison is almost influenced by the surgical findings.
anachronistic, but I include it to anchor this portion Deltoid management differs between the open and
of the text in history. The battle is finished, and arthroscopic approaches. The open approach requires a
arthroscopy is the victor. small amount of deltoid detachment and reattachment;
Arthroscopy has certain theoretical advantages over therefore, the deltoid must be protected and allowed to
conventional open surgery. The skin incisions are smal- heal to avoid the debilitating complication of deltoid
ler, and the cosmetic result is better. Both arthroscopic dehiscence. In contrast, the arthroscopic technique
and open procedures can be performed on an outpa- allows immediate active motion. Advocates of open
tient basis, which is more convenient for patients and techniques state that very little deltoid removal is
less expensive for third-party payers. Most patients can required and that there are reliable techniques to
perform activities of daily living and can return to secure the deltoid’s reattachment. Advocates of the
sedentary jobs within days. Because the deltoid arthroscopic approach argue that deltoid detachment
is not detached from the acromion, active range-of- is avoided; however, the arthroscopic technique also
motion exercises can be started as soon as tolerated. has the potential for deltoid injury. The deltoid fascial
Perhaps more important is the fact that the glenohu- origin can be disrupted if an overly aggressive anterior
meral joint can be inspected. Although clinically or anterolateral acromioplasty is performed.
important intra-articular lesions are not common, At this time, the debate between open and arth-
glenohumeral instability, labrum tears, partial-thick- roscopic approaches has largely been put to rest.
ness articular surface rotator cuff tears, biceps tendon Arthroscopy is the accepted method of treatment.
lesions, and arthritic changes in the glenoid or humeral Impingement syndrome can be treated successfully with
head can be identified. These might well be overlooked arthroscopic subacromial decompression. Arthroscopy
with a conventional open approach; their accurate allows complete inspection of the glenohumeral joint,
diagnosis and eventual treatment can clearly be of ben- enabling the surgeon to diagnose and treat coexisting
efit in achieving the optimal functional result for the intra-articular lesions. The surgeon can perform a thor-
patient. Arthroscopic subacromial decompression can ough bursectomy, coracoacromial ligament resection,
be a difficult skill for many individuals to master, and and acromioplasty without the need for deltoid
it is certainly harder to teach than open acromioplasty. detachment.
Better hand-eye coordination is required, and triangu-
lating and manipulating power instruments within
millimeters of each other can be challenging. CORACOID IMPINGEMENT
The cost difference between outpatient arthroscopic
surgery and inpatient open procedures may not be as
great as perceived by patients, surgeons, and insurance Coracoid Impingement
carriers. Certainly the cost of a hospital stay is avoided
with arthroscopic surgery, but this is at least partially Another cause of anterior shoulder pain is coracoid
offset by the increased cost of the arthroscopic setup. impingement. This unusual lesion is diagnosed by
The price of disposable instruments, tubing, and fluid the patient’s description of anterior shoulder pain with
is an important consideration. The operating room, adduction of the internally rotated arm. There is tender-
recovery room, and surgeon’s and anesthesiologist’s ness over the coracoid process, and pain is increased
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CHAPTER
11
Partial-Thickness
Rotator Cuff Tears
Partial-thickness rotator cuff tears constitute an inter- of 600 patients undergoing shoulder arthroscopy
esting and difficult group of shoulder lesions. In large and advocated débridement without decompression
part the difficulty stems from terminology: we use the if the tear was confined to the articular surface; arthro-
phrase partial-thickness rotator cuff tear to describe the scopic subacromial decompression was added if the
anatomic end result of several different pathophysiolo- tear extended to both the articular and bursal surfaces.
gic pathways. If we consider rotator cuff disease to be an In our series of partial-thickness rotator cuff tears,
intrinsic tendinopathy and part of the natural aging Milne and I reported that outlet impingement tears
process, partial-thickness rotator cuff tears represent a of less than 50% of the tendon thickness respond
transition from tendinosis to tendon rupture. If we well to arthroscopic subacromial decompression,
view rotator cuff changes as lesions caused by extrinsic whereas tears greater than 50% require repair.
compression forces, partial-thickness rotator cuff tears Partial-thickness rotator cuff tears in patients with
are the result of more compression than that which glenohumeral instability require instability correction
results in tendinosis and less compression than that and then rotator cuff repair or arthroscopic subacro-
which results in full-thickness tears. If we accept the mial decompression, depending on the extent of the
hypothesis that partial-thickness rotator cuff tears are individual lesions.
the result of compression between the humeral head
and the acromion, do these compression forces cause
partial-thickness tears in patients with internal im- DIAGNOSIS
pingement? Perhaps the rotator cuff tears we see in
younger patients are due to excessive eccentric muscu- Patients with partial-thickness rotator cuff tears may
lar contraction. Because it appears that the same ana- present with signs and symptoms typical of rotator
tomic lesion (partial-thickness rotator cuff tear) can be cuff disease. When the shoulder is elevated through
caused by different mechanisms, the surgeon must the painful arc during activities of daily living, pain
determine the cause and treat the tear accordingly. is localized deep to the lateral deltoid muscle (subdel-
toid pain). Night pain is also a regular feature.
Examination demonstrates normal active and passive
LITERATURE REVIEW range of motion with positive impingement signs.
Subacromial anesthetic injection relieves the pain.
In a group of throwing athletes (average age, 22 years) A critical feature of the examination is the amount
treated with arthroscopic débridement without of pain and weakness observed when resisted manual
decompression, Andrews reported 85% good or excel- muscle testing is performed. Significant pain and
lent results. Snyder found 47 partial tears in a group weakness with resisted external rotation or elevation
233
are relative indications for early operative interven-

tion. Plain radiographs appear similar to those of
patients with impingement syndrome or full-thickness
tears. Most commonly, the diagnosis is made with
magnetic resonance imaging (MRI). I have found that
the use of intra-articular gadolinium increases the
sensitivity of MRI in patients with partial-thickness
rotator cuff tears, particularly in those who must have
open MRI. Diagnostic ultrasonography has also been
very helpful in my practice, especially in cases of
intrasubstance partial-thickness rotator cuff tears
(Figs. 11-1 through 11-3). Often, a partial-thickness
tear is found at the time of arthroscopic examination
of the glenohumeral joint.
Figure 11-1 Partial-thickness rotator cuff tear, coronal view.
In the absence of significant subacromial space

compromise from a type 3 acromion, nonoperative
treatment is indicated and is identical to that pre-
scribed for patients with impingement syndrome.
Patients are instructed to avoid painful positions and
activities. Nonsteroidal anti-inflammatory medication
may relieve pain at night. If there is a loss of passive
motion, appropriate stretching exercises are indicated.
Home exercises to strengthen the scapular stabilizing
muscles may help.
If pain persists for 9 to 12 months or increases after

6 months of nonoperative treatment, operative inter-
Figure 11-2 Partial-thickness rotator cuff tear, sagittal view.
vention is considered.
OPERATIVE TECHNIQUE
Operative Findings
The findings in patients with partial-thickness rotator
cuff tears are related to both the severity of the tear and
the presence of other lesions within the joint. Most
tears are located on the articular surface; approximately
75% of these are in the supraspinatus tendon, 20% are
in the infraspinatus tendon, and 5% are in the teres
minor tendon. The depth or severity of the tendon
tear is grade 1 (less than one fourth of the tendon thick-
ness) in 45% of cases, grade 2 (less than half the tendon
thickness) in 40%, and grade 3 (more than half the
tendon thickness) in 15% (Figs. 11-4 through 11-7).
Figure 11-3 Ultrasonography of partial-thickness rotator Chondral defects on the articular surface of the
cuff tear (arrow). humeral head or the glenoid or the presence of
Chapter 11 Partial-Thickness Rotator Cuff Tears 235
Figure 11-4 Grade 1 supraspinatus tear.

Figure 11-7 Grade 3 supraspinatus tear.
labrum tears or separations is suggestive of glenohu-

meral instability and should prompt the surgeon to
consider whether the partial-thickness rotator cuff
tear coexists with other clinical diagnoses (Figs. 11-8
and 11-9).
Intraoperative Decision Making

Three options are available for the arthroscopic treatment
of partial-thickness rotator cuff tears: (1) débridement of
the partial-thickness tear alone, (2) débridement of the
tear with subacromial decompression, and (3) arthro-
scopic repair of the partial-thickness tear combined
with subacromial decompression.
I consider four factors when I treat patients with
Figure 11-5 Grade 2 supraspinatus tear. partial-thickness rotator cuff tears: (1) tear size and
Figure 11-6 Grade 3 supraspinatus tear. Figure 11-8 Chondral defect of the humeral head.
between the tendon insertion and the hyaline carti-

lage of the humeral head is normal.
Sedentary patients with partial tears are more likely
to do well with decompression alone; active patients are
more likely to benefit from tendon repair. Patients with
structural bone abnormalities (e.g., hooked acromion,
inferior acromioclavicular joint osteophytes, anterior
acromial spurs) are more likely to benefit from decom-
pression. Patients with glenohumeral instability require
correction of the lesions responsible for excessive trans-
lation. These factors are then considered in light of
patient preference. Some patients prefer tendon repair
if it can more reliably lead to a cure; others may choose
débridement or decompression because that approach
involves fewer lifestyle inconveniences. At each end of
Figure 11-9 Small Bankart lesion. the decision-making spectrum, treatment is less contro-
versial: active individuals with normal bone shape and
tears involving more than 50% of the tendon thickness
are best treated with surgical repair, whereas sedentary
patients with acromial spurring and tears involving less
than 50% of the tendon thickness can be treated suc-
depth, (2) the patient’s desired activity level, (3) bone cessfully with arthroscopic decompression alone. For
structure, and (4) cause of the tear. No one factor by those in the middle, treatment is less well defined.
itself determines treatment; the clinician must analyze Surgeon experience and patient preference, rather
the effects of all these factors to decide on the appro- than scientific data, appear to dictate the treatment
priate management. I have found the following guide- approach.
lines helpful in the treatment of these troublesome The vast majority of partial-thickness tears appear
lesions. on the articular surface of the rotator cuff tendon and
The most critical decision is whether the tear can are not visible during the inspection of the bursal
be treated by arthroscopic decompression alone or surface that occurs during an open procedure. It there-
whether this must be accompanied by tendon repair. fore seems that the incidence of partial-thickness tears
There is no general agreement on how the tear’s has been underestimated in the literature dealing with
dimensions (length and width) should influence open shoulder surgery. Inspection of the cuff’s articular
surgical decision making. Most authors recommend surface is better performed arthroscopically because the
surgical repair if the tear extends to a depth of 50% entire cuff can be easily evaluated and the location,
or more of the tendon substance. If, while viewing size, and depth of the tear can be appreciated. The
from within the glenohumeral joint, the synovial tear can be marked with a suture so that the surgeon
tendon surface inserts at the level of the articular can locate the lesion during subsequent subacromial
cartilage but there is a partial tear more proximally, inspection.
I débride the area until I observe normal tendon
fibers. I then use the known dimensions of the
Articular Surface Partial-Thickness Tears
shaver to estimate the depth of the lesion. I assume
that the normal tendon thickness is 6 to 8 mm and
Partial-Thickness Rotator
use that to estimate the tear depth. This applies to
Cuff Tear
either the supraspinatus or the infraspinatus. If the
supraspinatus tendon does not insert at the level of When an articular surface partial-thickness rotator cuff
articular cartilage and there is exposed bone, I use tear is noted during the diagnostic examination, the
Nottage’s guidelines and estimate a 10% tear for surgeon should establish an anterior portal and intro-
every millimeter of exposed bone. For example, duce a motorized shaver. Remember that the synovial
5 mm or more of exposed bone means a tear greater lining, not the tendon, is visualized during this initial
than 50%, in which case I usually repair the lesion. inspection. Using the shaver, perform a limited débride-
The method works only for the supraspinatus because ment to clearly establish the length, width, and depth
the infraspinatus does not insert at the level of the of the tear. Some surgeons believe that a partial-
articular cartilage, and an area of exposed bone thickness rotator cuff tear is always an intrinsic
Figure 11-10 Percutaneous spinal needle insertion.
Figure 11-12 Needle through a partial-thickness rotator cuff

tear.
tendinopathy and that débridement stimulates a heal-
ing response. I am not comfortable with such a general
approach, so I first débride the partial tear to determine
its size. If, based on the criteria discussed earlier, I decide
that repair is necessary, I may use the shaver to com-
plete the tear until the shaver enters the subacromial
space. Usually I perform a limited débridement and,
while viewing from the glenohumeral joint, percuta-
neously insert a spinal needle into the area of the partial
tear. Generally, the needle is inserted near the antero-
lateral corner of the acromion because most articular
surface partial-thickness rotator cuff tears are located
in the anterior portion of the supraspinatus. If the tear
is more posterior, the needle insertion point must be
more posterior. I note how far the tear extends ante-
riorly, posteriorly, medially, and laterally from the
needle. I then insert an absorbable monofilament
suture through the needle and remove the needle Figure 11-13 Insert the suture through the needle.
(Figs. 11-10 through 11-17).
Figure 11-11 Pass the monofilament suture through the Figure 11-14 Advance sufficient suture into the glenohu-
needle. meral joint.
I remove the arthroscope from the glenohumeral

joint and insert it into the subacromial space. If I
can see the monofilament suture, I create a lateral
portal so that the cannula enters the subacromial
space near the suture. If I cannot see clearly because
of proliferative bursitis, I insert a spinal needle percu-
taneously so that it enters the subacromial space in the
approximate area of the tear. I have a general idea of
the tear’s location and size based on my examination
of the rotator cuff tendon from the glenohumeral
joint. I insert the cannula and shaver and carefully
remove bursal tissue beginning medial to the tear loca-
tion until I can see the marking suture. By palpating
the area of partial tear, one can appreciate the differ-
ence in tendon quality compared with normal
Figure 11-15 Anterior and posterior suture for a larger tendon.
partial-thickness rotator cuff tear in the subacromial space. I place the shaver near the point where the marking
suture exits the tendon and remove the suture while
holding the shaver firmly against the tendon. I débride
the tendon near its insertion into the greater tuberosity
until I enter the joint. I use the shaver to palpate under-
neath the tendon and determine the area of
detachment.
I remove the smallest amount of tendon possible
because excessive débridement shortens the tendon.
If the surgeon then attempts to repair the tendon to
its anatomic insertion site, the repair will be under too
much tension, which can lead to postoperative stiff-
ness. I try to limit the débridement to 5 mm or less. If
more débridement is necessary because of tendon
damage, I recommend that the surgeon not repair
the tendon edge laterally at its anatomic insertion
site but do so more medially. This preserves the
normal resting muscle length of the torn cuff tendon
and decreases the incidence of tendon rupture and
Figure 11-16 Rotator cuff repair. postoperative stiffness resulting from a repair under
too much tension. A more medial repair requires
that the bone suture anchors be positioned medial to
their normal position.
Once the articular surface partial-thickness rotator
cuff tear is converted to a full-thickness tear, the sur-
geon can perform a standard rotator cuff repair.
Variations of Technique: Posterior Lesions

Partial-thickness rotator cuff tears are most often
located on the articular surface of the anterior supra-
spinatus tendon. However, some lesions are located
posteriorly, either in the posterior supraspinatus
tendon or in the infraspinatus tendon. Because this
area of the rotator cuff does not contact the anterior
acromion during elevation, these lesions cannot be
explained by the classic theory of outlet impingement.
Figure 11-17 Rotator cuff repair, lateral view. MRI studies have demonstrated that there is physiologic
contact between the posterior rotator cuff and the pos-

terior-superior glenoid during maximal abduction and
external rotation. Therefore, contact that the surgeon
observes between the rotator cuff and the glenoid on
MRI or during arthroscopy is not necessarily patho-
logic. What is not clear at this time is why this contact
causes no pain in some individuals but produces
significant symptoms in others. If the patient’s com-
plaints and physical examination findings demon-
strate pain with abduction and external rotation
localized to the posterior glenoid margin, the surgeon
must search for a cause.
Walch and Jobe have discussed the nature of poste-
rior articular surface rotator cuff tears and have intro-
duced the term internal impingement. There is no single Figure 11-18 Posterior partial-thickness rotator cuff tear.
explanation of the cause of internal impingement at
this time. One theory is that anterior-inferior gleno-
humeral instability occurs as a primary event. The
resulting excessive translation causes a traction difficult, but once the cause of internal impingement
lesion on the posterior rotator cuff tendon as the rota- is determined, the treatment is relatively straightfor-
tor cuff is called on to stabilize the humeral head. ward (Figs. 11-18 through 11-21).
Another theory is that excessive anterior translation The preoperative evaluation should document the
increases the frequency and degree of the normal direction and degree of translation compared with the
physiologic contact so that, over time, compressive uninvolved shoulder. I test the amount of internal
pathologic tendon and labrum lesions occur when rotation with the arm in 90 degrees of abduction in
the arm is placed in abduction and external rotation. both the coronal and scapular planes. Radiography
Another line of reasoning is that internal impinge- and MRI are usually necessary to determine the
ment is caused by superior-posterior instability. The degree of rotator cuff involvement and the amount
posterior contracture that occurs in throwing athletes of humeral retroversion. During the arthroscopic eval-
causes traction on the posterior-superior labrum. uation I determine the direction and degree of hum-
Owing to a traumatic event or repetitive microtrauma, eral head translation and search for any signs that this
the biceps tendonglenoid labrum anchor is translation is pathologic, such as labrum detachment.
detached. The loss of superior-posterior stabilization I carefully evaluate all areas of the labrum for detach-
allows superior-posterior migration of the humeral ment, fraying, or tearing. I assess the competency of
head and rotator cuff. The resulting traction produces the glenohumeral ligaments and the rotator interval.
a rotator cuff tear. I move the arthroscope to the anterior portal to
Some surgeons believe that instability is not neces-
sary for the development of internal impingement and
that simple repetitive compression of the posterior
rotator cuff between the humeral head and glenoid
is sufficient to cause damage. Another view is that a
decrease in the normal 25 to 35 degrees of humeral
retroversion leads to increased contact between the
humeral head and the superior-posterior glenoid.
This situation is similar to that confronting orthope-
dic surgeons in their search for an ‘‘essential’’ lesion to
explain anterior-inferior glenohumeral instability.
We have learned that anterior-inferior glenohumeral
instability can result from a number of different
causes. My own view is that all the causes just described
can produce internal impingement, but in an individ-
ual patient, one of them will be predominant. It is
the surgeon’s task to identify which cause is responsible
for the patient’s pain. The analysis and diagnosis are Figure 11-19 View from the subacromial space.
Bursal Surface Partial-Thickness Tears

Although articular surface tears have various causes and
require individualized treatment, bursal surface partial-
thickness rotator cuff tears are almost always the result
of chronic subacromial impingement. The surgeon
should convert these lesions to full-thickness tears and
repair them with a standard technique. Yamaguchi has
used diagnostic ultrasonography to demonstrate a very
high rate of healing of these lesions after surgical repair.
POSTOPERATIVE TREATMENT
Figure 11-20 Rotator cuff repair, posterior view. Patients whose partial-thickness rotator cuff tears are
treated with débridement alone undergo rehabilita-
tion similar to that of patients treated with arthro-
scopic decompression for subacromial impingement.
examine the posterior rotator cuff and evaluate the A modification is made for strengthening, however.
contact between the cuff and the superior-posterior I do not strengthen the involved muscle for at least
glenoid when I place the arm into abduction and 3 months, or until manual muscle testing does not
external rotation. Gentle débridement may demon- produce pain. At that point, the muscle can be reha-
strate a minor lesion of the synovial lining or bilitated routinely. If a partial-thickness rotator cuff
tendon, or it may reveal a near full-thickness tendon tear is converted to a full-thickness tear, rehabilitation
tear. I continue the posterior examination to evaluate proceeds as described for rotator cuff tears.
the status of the posterior-inferior glenohumeral
ligament.
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Vinson EN, Helms CA, Higgins LD: Rim-rent tear of the rota-
tor cuff: A common and easily overlooked partial tear.
AJR Am J Roentgenol 189:943-946, 2007.
Wolff AB, Sethi P, Sutton KM, et al: Partial-thickness rotator
Figure 11-21 Rotator cuff repair, lateral view. cuff tears. J Am Acad Orthop Surg 14:715-725, 2006.
CHAPTER
12
Full-Thickness Rotator
Cuff Tears
An arthroscopic rotator cuff repair consists of the sturm und drang) in favor of arthroscopic rotator cuff
following elements: glenohumeral joint inspection, repair. Analyses of the clinical results paralleled these
subacromial space inspection, partial bursectomy, technical issues but necessarily followed them as we
assessment of rotator cuff tendon reparability, identi- awaited patient follow-up. As reports demonstrated
fication of tear geometry, coracoacromial ligament patient outcomes as good as or better than those
resection, acromioplasty, greater tuberosity repair site obtained with open repair, the general consensus
preparation, anchor placement, suture placement, and emerged that arthroscopic rotator cuff repair was a
knot tying. Each of the individual elements can be successful operation.
accomplished arthroscopically; however, performing A great degree of attention was focused (and con-
them in a single operation requires strict adherence tinues to be focused) on the technical aspects of the
to a systematic operative technique. operation, such as anchor types, suture patterns,
suture materials, and instruments. More recently, stud-
ies focused on healing rates after arthroscopic rotator
LITERATURE REVIEW cuff repair, using methods such as magnetic resonance
imaging (MRI), contrast-enhanced MRI or computed
Since the mid-1990s, the repair of full-thickness rota- tomography, and diagnostic ultrasonography. These
tor cuff tears has undergone a transition from open studies present a wide spectrum of healing rates
techniques to combined open and arthroscopic meth- ranging from 90% for isolated supraspinatus tears to
ods (mini-open repair) to exclusively arthroscopic 0% for large and massive tears. Appropriately, this is
repairs. During this time, orthopedic surgeons have an area of intense focus. Most interesting is the inter-
documented the successful arthroscopic treatment of pretation of why healing rates are so low. At least one
the entire spectrum of rotator cuff lesions, including editorial has attributed low healing rates to arthro-
stage 2 impingement and partial- and full-thickness scopic repair techniques. Although I certainly agree
tears. that all our techniques could benefit from improve-
Initially, the issue was one of efficacy—whether an ment, I was struck by the lack of intellectual rigor on
expert surgeon could technically reproduce all the ele- this issue. Those who fault arthroscopic repair argue
ments of an open rotator cuff repair arthroscopically. that arthroscopic healing rates are inferior to the
Despite a modest amount of skepticism, the orthope- good clinical results of open rotator cuff repair. This,
dic community recognized that this was possible. The however, is a breakdown in intellectual reasoning
next step was to determine whether other surgeons because it is a classic ‘‘apples to oranges’’ comparison.
could reproduce the operation—the effectiveness Critics do not compare the clinical results of arthro-
issue. This too was resolved (after some interesting scopic rotator cuff repair to the clinical results of
241
open repair, nor do they compare the MRI or ultra- DIAGNOSIS

sound healing rates of arthroscopic repair to the heal-
ing rates of open repair (although this would be The clinical presentation of patients with full-thick-
valuable information). Instead, there is an oblique ness rotator cuff tears is similar to that of patients
linking of two related but not truly comparable con- with stage 2 impingement, although complaints of
cepts: clinical outcome and anatomic healing. The weakness, particularly with overhead activity, may
thinking appears to be that the good clinical results be greater. Plain radiographs are essential to evaluate
of open rotator cuff repair were the result of a high the shoulder for glenohumeral arthritis, superior
anatomic tendon-to-bone healing rate. However, migration of the humeral head, acromioclavicular
there is no evidence that this is true. Early arthrogram joint arthritis, inferior acromioclavicular joint spurs,
studies demonstrated a high percentage of patients and acromial shape. MRI provides information about
with dye linkage, and Harryman’s classic ultrasound the size and retraction of the rotator cuff tear and,
work demonstrated that 80% of isolated supraspinatus more important, the degree of atrophy in the rotator
tears and less than 50% of large tears were healed. cuff muscles (Figs. 12-1 through 12-5).
Somehow these studies were dismissed as aberrant The findings of the clinical examination are most
because everyone knew that their own results were commonly correlated with those of radiologic studies
inconsistent with such high failure rates. Again, intel- (arthrography, MRI, diagnostic ultrasonography) to
lectual confusion occurred. Surgeons knew that their make the diagnosis. Arthroscopy can also be used to
clinical results were good and therefore assumed that diagnose the presence and size of a complete rotator
their anatomic results must be good as well, all scien- cuff tear, although no authors have suggested that this
tific evidence to the contrary. It was as if we could not be done routinely. The arthroscope is most useful in
believe that Harryman’s healing rates applied to our diagnosing complete tears in patients who have false-
own efforts. Further, our misplaced confidence in ana- negative imaging studies. False-negative results occur
tomic healing affected patients’ rehabilitation regi- most frequently with arthrography, particularly if the
mens. Because we knew the repair was secure and synovial lining remains intact, or with MRI if the tear
would heal, the most important obstacle became is smaller than 1 cm. I have found the injection of
return of motion; thus the prevailing dogma was contrast material (gadolinium) to be helpful in
early passive range of motion. These notions were increasing MRI’s accuracy, particularly in patients
called into question by the work of Deutsch, who with partial-thickness rotator cuff tears.
demonstrated better rotator cuff repair healing with a
rehabilitation program that moved more slowly than
previous protocols called for. He reasoned that large
ranges of motion could cause a loss of contact between
the tendon and the footprint and result in diminished
healing rates. There has been little confirmation of
Deutsch’s findings, but based on his good results and
his superb thought process, I have changed my reha-
bilitation protocol to reflect his views.
I suspect that today, MRI and ultrasound studies
would demonstrate an equal amount of healing in
open and arthroscopic repair groups. The real lesson
for me has been that although my patients do well
clinically, I should try to increase the rate of anatomic
healing. I have attempted to do this (where possible)
by changing my repair construct (double-row suture
bridge), rehabilitation program (limited, gentle, pas-
sive range of motion), and outcome analysis (diag-
nostic ultrasonography to evaluate repair integrity). I
am closely following the exciting science of biologic
and synthetic measures to increase tendon healing to
bone, as well as the impressive laboratory work being
done in genetic manipulation. Figure 12-1 Type 3 acromion.
Chapter 12 Full-Thickness Rotator Cuff Tears 243
Figure 12-4 Full-thickness rotator cuff tear.
positions), nonsteroidal anti-inflammatory medica-

tion to reduce pain, and a home rehabilitation
program designed to correct deficits of motion
(with passive stretching) and to strengthen the unin-
volved shoulder muscles.
Figure 12-2 Anterolateral acromial spur. The presence of a full-thickness rotator cuff
tear is not an absolute indication for operation.
I believe that some patients—those with good-quality
rotator cuff tendons, a specific injury that caused the
NONOPERATIVE TREATMENT onset of their symptoms, and little tendon retrac-
tion on MRI—can be treated nonoperatively.
The basic elements of nonoperative treatment are I observe their progress monthly for a 3-month
similar to those for patients with stage 2 impinge- period and assess healing (or nonhealing) with diag-
ment. They consist of selective rest and activity nostic ultrasonography. At that point, if their pain is
modification (avoidance of painful activities and controlled and they have good function, we discuss
their options. I inform them that our current under-
standing of full-thickness rotator cuff tears is that best
Figure 12-3 Ossification of the coracoacromial ligament. Figure 12-5 Supraspinatus atrophy.
results are achieved with prompt surgical repair. Delay

in repair results in muscle atrophy that can have no OPERATIVE TECHNIQUE
positive impact on the ultimate outcome. If a patient
has significant pain or functional impairment, the Rotator Cuff Repair, Single
decision for operation is straightforward. However, Row—Animation
for those who have minimal symptoms or those
whose symptoms have gone from severe to minimal,
Rotator Cuff Repair, Single
it is difficult to commit to a rotator cuff repair and the
Row—Model
subsequent period of recovery when they perceive no
real shoulder problem. There is no simple answer to
this dilemma other than to discuss honestly the cur- Rotator Cuff Repair, Single
rent level of scientific knowledge and counsel patients Row
as they make their decisions. I relate my experiences
with patients who have returned at a later date and
undergone successful operation, as well as those who Rotator Cuff Repair,
eventually return with irreparable lesions. The deci- Longitudinal Repair—Model
sion is easier in patients who already have significant
tendon retraction and muscle atrophy; in these
patients, nonoperative treatment is less risky because Rotator Cuff Repair,
the rate of tendon healing after operation is low, and Longitudinal Repair
pain relief is the goal. I recommend Yamaguchi’s
chapter in Arthroscopic Rotator Cuff Surgery, edited by
Rotator Cuff Repair,
Abrams and Bell.
Horizontal Cleavage
Tear—Model
Anesthesia
The indications for arthroscopic rotator cuff repair are I use interscalene block anesthesia supplemented with
identical to those for open repair. The surgeon should general anesthesia. Regional anesthesia allows the use
not alter or ‘‘broaden’’ the indications in the mistaken of less anesthetic agent, minimizes postoperative side
view that arthroscopic repair is a minor procedure. effects, and provides excellent pain relief in the post-
Although the skin incisions are smaller and the del- operative period. General anesthesia eliminates move-
toid is left attached, arthroscopic repair incorporates ment due to patient discomfort on the operating table.
all the elements of open repair. I have repaired all sizes
and shapes of rotator cuff tears arthroscopically and
Positioning
have not performed any open repairs in my last 2000
operations. I prefer to have the patient in the sitting position. The
I find it helpful to present patients with printed orientation of the shoulder is similar to that during
information outlining the postoperative rehabilitation open procedures, and this position allows easy access
and activity limitations. I have them read this material to the anterior, lateral, and posterior aspects of the
in the office and then discuss any questions and con- shoulder. I pay particular attention to the inclination
cerns they may have. Because patient retention of this of the acromion, which should be horizontal. The
information is generally poor, I offer this (and other amount of posterior acromial slopes varies from
relevant information) on a website. patient to patient, and failure to position the patient
so that the acromion is parallel to the floor results in
the surgeon directing the arthroscope more vertically
CONTRAINDICATIONS TO SURGERY and having to work ‘‘uphill.’’ Patient positioning is
greatly facilitated by the use of the Schloein patient
Patients who are unable to tolerate either the open positioner (Orthopedic Systems Inc., Union City,
surgery itself or the postoperative rehabilitation are Calif), and the arm is controlled with a McConnell
not candidates for arthroscopic rotator cuff repair. arm holder (McConnell Orthopedics, Greenville,
Poor tendon quality, musculotendinous retraction, Tex) or a Spyder arm positioner (Smith-Nephew
and muscular atrophy are not improved with Endoscopy, Andover, Mass). The Schloein speeds
arthroscopy. patient positioning and allows excellent access to the
Figure 12-6 Acromion parallel to the floor.

Figure 12-8 The soft spot is inferior and medial to my pre-
posterior shoulder without translating the patient off ferred glenohumeral joint entry site.
the side of the operating table. The Spyder or the
McConnell allows the surgeon to position the arm
without help from the assistant and is invaluable in
maintaining proper arm rotation so that the repair the surgeon’s ability to determine tear size and
site is directly underneath the operating cannula geometry.
(Figs. 12-6 and 12-7). The lateral portal should allow the cannula to enter
midway between the humeral head and the acromion.
This location facilitates acromioplasty and enables the
Portals
surgeon to tilt the cannula inferiorly toward the hum-
I routinely use three portals: posterior, lateral, and eral head for easy placement of suture anchors in the
anterior. The posterior portal is 1.5 cm medial and greater tuberosity for rotator cuff repair.
1.5 cm inferior to the posterolateral acromial border, The anterior cannula is used for outflow and retriev-
the lateral portal is 2 cm posterior to the anterior acro- ing sutures but can also be used for insertion of an ante-
mial border and approximately 2 to 4 cm lateral to the rior anchor. This cannula is inserted after the
acromion, and the anterior portal is 2 cm anterior to acromioplasty. I identify the precise location with a
the anterolateral acromion. The posterior portal is spinal needle so that the center of the cannula is paral-
made superior to the traditional point of entry in the lel with the tendon repair location. If the cannula is too
‘‘soft spot’’ so that the arthroscope enters the subacro- medial, it is difficult to retrieve sutures from the
mial space parallel to and just underneath the acromi- anchors owing to interference from the patient’s
al undersurface. This maximizes the distance between head. Conversely, suture retrieval from the bursal rota-
the arthroscope and the rotator cuff tear and improves tor cuff surface is difficult if the anterior cannula is
located too laterally. Other portals are used as needed
Glenohumeral Joint
I first determine the range of motion and stability of
the shoulder with an examination under anesthesia
and then perform an arthroscopic glenohumeral
joint inspection. Intra-articular lesions are not visua-
lized during open repair, precluding an adequate com-
parison with arthroscopic findings. Most arthroscopic
studies report abnormalities such as focal synovitis,
partial biceps tendon tears, arthritic changes in the
humeral head or glenoid, labrum tears, and loose
bodies. It is uncertain whether these intra-articular
Figure 12-7 McConnell arm holder base. lesions arise because of the cuff tear or are merely
Figure 12-9 Lateral portal.
Figure 12-12 Loss of space between the biceps and the

supraspinatus.
part of the normal aging process. Arthroscopic find-

ings in older patients with irreparable tears include
arthritic changes, synovitis, and biceps tendon tears.
Not surprisingly, these findings occur with a higher
frequency than in patients with partial or complete
rotator cuff tears that are reparable. Overall, glenohu-
meral joint abnormalities occur in 12.5% of patients
and include osteoarthrosis, biceps tendon tears (par-
tial or complete), labrum tears, labrum separations
(superior labrum from anterior to posterior [SLAP]
lesions), synovitis, and capsular contracture. During
arthroscopy of the glenohumeral joint, absence of
the normal space between the biceps tendon and the
supraspinatus indicates a complete rotator cuff tear
Figure 12-10 Accessory lateral portals. (Fig. 12-12). On completion of the glenohumeral
joint inspection, I remove the arthroscope from the
joint.
Subacromial Space
I redirect the cannula and trocar through the same
posterior skin incision into the subacromial space
and palpate the acromial undersurface with the can-
nula. I then sweep the cannula medially and laterally
to make certain that no portion of the rotator cuff is
adherent to the acromion (Figs. 12-13 through 12-15).
The arthroscope is then inserted, and usually the
space is easily seen. The camera is oriented so that
the acromion appears horizontal and parallel to the
floor; I try to maintain this orientation throughout
the procedure. I also try to maintain the maximal dis-
tance between the arthroscope and the tendon lesion,
which helps me appreciate the extent of the tendon
Figure 12-11 Anterior portals. tear (Fig. 12-16).
Figure 12-13 Subacromial space entry.

2001
after Hengst
Figure 12-16 Maintain distance between the arthroscope

lens and the rotator cuff.
The lateral portal is identified with a spinal needle

inserted percutaneously and directed so that it is 2 cm
posterior to the anterior acromial border and posi-
tioned midway between the acromion and the greater
Figure 12-14 Palpate the anterior acromion and trocar tip.
tuberosity. The goal is to have the lateral cannula posi-
tioned in the center of the rotator cuff tear in the ante-
rior-posterior plane and midway between the acromion
and the rotator cuff insertion site. I move the spinal
needle until the position is perfect and then I make a
stab wound and insert the lateral cannula. The first goal
is clear visualization of the subacromial space. Bursae
that obscure visualization are removed with a power
shaver (Figs. 12-17 and 12-18); however, the surgeon
should be careful not to alter the appearance of the
rotator cuff or acromion. Bursal tissue is involved in
the healing response, and complete bursectomy is
unwarranted. Avoid removing any bursa medial to
the rotator cuff musculotendinous junction, because
this area is very vascular. Once the bursa is removed,
the acromion and coracoacromial ligament are exam-
ined for signs of impingement such as erythema,
fraying, and fibrillation (Figs. 12-19 and 12-20).
I then establish an anterior portal and insert a can-
nula. This improves fluid outflow and visualization
Figure 12-15 Sweep the cannula. (Figs. 12-21 through 12-25).
Figure 12-17 Insert the needle for the lateral cannula paral-
Figure 12-20 Coracoacromial ligament fraying.
lel to the acromion.
Figure 12-21 Establish the anterior portal location with a

Figure 12-18 Bursectomy. spinal needle.
Figure 12-19 Coracoacromial ligament erythema. Figure 12-22 Anterior needle too lateral.
Figure 12-26 Introduce the measuring probe.

Figure 12-23 Anterior needle too medial.
Tear Classification
The arthroscope is rotated so that it points directly
down at the rotator cuff tear. With small to medium-
sized tears, their size and geometry are easily appre-
ciated. Tear size is measured by comparing it to the
known diameter of the lateral cannula or measuring
it with an arthroscopic probe. The length of the tear
from anterior to posterior, as well as the amount of
medial retraction, is noted (Figs. 12-26 through 12-31).
Straight medial retraction or retraction in an ellipti-
cal shape is the most common finding. As tear size
increases, the surgeon is less able to appreciate tear
geometry. In a right shoulder, reverse L-shaped tears
with a longitudinal component along the rotator inter-
val allow the tear to rotate posteriorly. L-shaped tears
Figure 12-24 Anterior needle parallel to the rotator cuff edge. have a longitudinal limb posteriorly, often at the
Figure 12-25 Anterior cannula. Figure 12-27 Measure the rotator cuff tear.
Transverse tear
Figure 12-28 Transverse tear.
Figure 12-31 Elliptical tear.
junction of the supraspinatus and infraspinatus, in

addition to the lateral, transverse detachment at the
greater tuberosity (Figs. 12-32 through 12-36).
Longitudinal tears may occur in the area of the rota-
tor interval and occasionally within the substance of
the supraspinatus. Only when tear geometry is appre-
ciated can the surgeon perform an effective repair. I
use a tissue grasper to pull on the tear edge, attempt-
ing to determine the repair site location. Varying both
the direction of pull and the arm positions of eleva-
tion, abduction, and rotation is often required.
Typically, the arm is positioned in 20 degrees of eleva-
tion, 15 degrees of abduction, and 10 degrees of inter-
nal rotation (Figs. 12-37 through 12-44).
Figure 12-29 Transverse tear. The arm is maintained in this position with a
mechanical arm holder (e.g., Spyder or McConnell).
Only when I determine that the tear is reparable do I
Elliptical tear
L-shaped tear
e
appe
shha
L–s
Figure 12-30 Elliptical tear. Figure 12-32 L-shaped tear.

Figure 12-33 L-shaped repair. Figure 12-36 Reverse L-shaped tear repair.
e
aappe
L -–sshh
s e
ver
Re
Reverse L-shaped tear
Figure 12-34 Reverse L-shaped tear. Figure 12-37 Insert the grasper through the lateral cannula
to test tendon mobility.
Figure 12-38 Insert the grasper through the lateral cannula

Figure 12-35 Reverse L-shaped tear. to test tendon mobility.
251
Figure 12-39 Insert the grasper through the anterior cannu-

la to test tendon mobility.
consider whether a subacromial decompression is

appropriate. I prefer to avoid a subacromial decom-
pression because I have found that in patients with a Figure 12-41 Abduct and externally rotate the arm until the
type 2 acromion, it has no beneficial effect on the out- tear is reduced and directly under the lateral cannula.
come of the rotator cuff repair. If the tear is irreparable
or is unlikely to be durable, subacromial decompres-
Coracoacromial Ligament
sion is unwise because it will destroy the static stabi-
lizing effect of the coracoacromial arch (acromion and If a full-thickness rotator cuff tear is reparable and the
coracoacromial ligament) and allow anterior-superior result of chronic impingement, and if I determine that
subluxation or escape of the humeral head. With subacromial decompression is needed, I divide the cor-
larger or retracted tears, it is helpful to move the ar- acoacromial ligament at its lateral insertion point on the
throscope to the lateral portal to gain an additional acromion. I prefer to use electrocautery owing to
perspective. the rather inconvenient location of blood vessels in
Figure 12-40 Externally rotate the arm until the tear is Figure 12-42 Abduct the arm until the tear is reduced and
reduced and directly under the lateral cannula. directly under the lateral cannula.
Figure 12-45 Identify the anterolateral acromion.
balanced against the long-standing and widespread use

of acromioplasty with generally good results. My own
sense is that we do not yet have a complete picture, and
Figure 12-43 Extend the arm until the tear is reduced and additional studies will more accurately define the role
directly under the lateral cannula. of acromioplasty in rotator cuff repair surgery.
The goal of acromioplasty is to increase the size of
this area. Once the lateral margin of the ligament has the subacromial space. I therefore perform acromio-
been released, I use a power shaver to resect the ligament plasty if the subacromial space is tight and I cannot
to the medial acromial border (Figs. 12-45 and 12-46). visualize the area adequately or maneuver my instru-
ments effectively. I make this decision at the time of
operation irrespective of the acromial type. A type 2 or
Acromioplasty
3 acromion is converted to a flat, type 1 acromion.
I (and others) do not find the routine use of acromio- Unless the bone is extremely thick, there is no need
plasty beneficial. However, these few reports must be to perform acromioplasty for a type 1 acromion. I do
not try to alter the medial-lateral or anterior-posterior
dimensions of the acromion. If the acromion has a
lateral slope as identified on MRI or plain radiographs,
the inferior aspect of the lateral acromion is thinned.
Figure 12-44 Elevate the arm until the tear is reduced and
directly under the lateral cannula. Figure 12-46 Cauterize the inferior acromion.
Figure 12-47 Completed acromioplasty. Figure 12-48 Completed acromioclavicular joint resection.
I start the acromioplasty laterally and resect bone until to control owing to the medial location of the bleeding
the inferior portion of the medial acromion is removed vessels. Anterior adhesions to the coracoid are usually
and the soft tissue of the acromioclavicular joint is very thick and require release with electrocautery.
visible (Fig. 12-47). This is particularly true in the area of the coracohumeral
ligament (Figs. 12-49 through 12-51).
Acromioclavicular Joint
Repair Site Preparation
After I remove the medial acromion and the acromioplas-
ty is completed, the acromioclavicular joint comes into The next step is preparation of the bone surface at the
view. In my opinion, clavicular coplaning (removing the repair site. A 4-mm round bur is used to prepare a can-
inferior one third of the distal clavicle with a power bur) cellous bed for the tendon. I remove 1 mm (or less)
is not effective. Only if the patient has symptoms con- of cortical bone until the cancellous bone is visible.
sistent with acromioclavicular joint arthritis based I consider this portion of the procedure a decortication
on the preoperative history (pain localized to the (Figs. 12-52 through 12-54).
acromioclavicular joint with cross-body adduction or I do not place the tendon in a trough. The site of
behind-the-back internal rotation) and examination bone preparation is based on tendon mobility. If an
(acromioclavicular joint tenderness on palpation) do I anatomic repair is possible, the bone is prepared from
perform an acromioclavicular joint resection (Fig. 12-48).
Cuff Mobilization
Adhesions may form within the subacromial space
between the rotator cuff and the acromion or between
the rotator cuff and the deltoid, interfering with
tendon mobilization. Adhesions to the coracoid or a
coracohumeral ligament contracture may restrict rota-
tor cuff tendon excursion and thereby give the false
impression of irreparability.
Posterior adhesions usually are not dense and can
often be released by inserting a metal trocar and cannula
through the lateral portal, placing it superior to the ante-
rior tear edge and sweeping it posteriorly directly
beneath the acromion. Occasionally, electrocautery is
used to divide adhesions if they are particularly thick.
It is unwise to attempt to remove dense adhesions with a
power shaver; bleeding often results, and it is difficult Figure 12-49 Subacromial adhesion.
Figure 12-52 Prepare the repair site.
Figure 12-50 Subdeltoid cuff adhesion.
the articular margin of the humeral head to the greater Repair site decortication
tuberosity. The tendon tear length determines the
anterior-to-posterior dimension of the bone prepara-
tion site. The width is the distance from the articular
cartilage of the humeral head to the medial margin of
the greater tuberosity, generally 1 to 2 cm. If anatomic
repair is not possible without excessive tendon ten-
sion, I move the repair site. I prefer to repair the
tendon up to 10 mm medially without tension
rather than repair it anatomically under excessive Figure 12-53 Width and depth of the repair site.
tension.
Releasing
coracohumeral ligament
Figure 12-51 Coracohumeral ligament release. Figure 12-54 Bone abrasion.

Anchor Selection
Anchor Design
The ideal suture anchor has the following characteris-
tics: (1) it allows firm fixation in the greater tuberosity,
(2) the surgeon can select the type of suture loaded on
the anchor, (3) the anchor can be inserted manually
without the need for predrilling or power instruments,
(4) the suture slides through the anchor, (5) the
anchor is removable from the bone in case of subopti-
mal placement or suture breakage, (6) the anchor is
attached securely to the inserting device so that it
does not become dislodged during placement within
the tight confines of the subacromial space, (7) the
anchor can penetrate the bone at an acute angle,
and (8) it is biodegradable without any adverse effects.
No currently available suture anchor meets all these
criteria. Each anchor has relative advantages and dis-
advantages, and the choice is based on the surgeon’s
personal preference.
At present, I use 5-mm metallic anchors (Smith- Figure 12-55 Insert the anchor with fingertip pressure.
Nephew Endoscopy, Andover, Mass) for rotator cuff
repair. These anchors have excellent pullout strength.
The handle design and shaft length of the inserter are
appropriate. The anchors are firmly attached to the I do not like the tissue reactions observed with cur-
inserter shaft so that they do not dislodge as the surgeon rently available bioabsorbable anchors, but I am con-
manipulates the anchors within the subacromial space. fident that further research will alleviate this problem.
The anchors have a trocar tip so that predrilling is not I have had difficulty inserting plastic nonabsorbable
necessary. I prefer not to predrill during rotator cuff anchors owing to anchor deformation with less than
repair because the area lateral to the tuberosity is cov- optimal insertion. I have no experience with allograft
ered with soft tissue, making it difficult to find the bone anchors, which offer the advantage of bone graft
screw hole. to the proximal humerus.
I also like an anchor I can insert with one hand
while I hold the arthroscope with the other. With
tap-in anchors, the assistant has to hold the arthro-
scope while the surgeon positions the anchor with
one hand and uses the mallet with the other. The
Smith-Nephew anchor has two preloaded No. 2
Ultrabraid sutures; one suture is striped, and the
other is white, which helps me select the appropriate
suture during the repair. The anchor eyelet is large
enough to allow the sutures to slide freely during
knot tying (Figs. 12-55 through 12-60).
Anchor Material
Anchors are available in four different materials:
metal, nonabsorbable plastic, bioabsorbable plastic,
and allograft bone. I prefer metal anchors because
they offer secure fixation and lower cost. I also like
that they are radiopaque, which allows me to visualize
anchor pullout or migration on plain radiographs. The
disadvantage of metal anchors is that they com-
promise postoperative MRI, even when special digital Figure 12-56 Anchor is inserted perpendicular to the
subtraction techniques are used. greater tuberosity.
Figure 12-60 The horizontal mark indicates depth, and the

Figure 12-57 Slide the cannula to the greater tuberosity if longitudinal mark indicates eyelet orientation.
soft tissue is interfering.
Suture Selection
Because the identification and management of sutures
within the subacromial space can be difficult, it is
advantageous to use different colored sutures. The
anchor is preloaded with one white and one striped
suture. This allows the surgeon to easily identify
which suture corresponds to each suture anchor.
I prefer braided, nonabsorbable No. 2 Ultrabraid.
Anchor Placement
The number of anchors depends on the length and
geometry of the rotator cuff tear. For all but the smal-
lest tears, I use two anchors. I place the anchors lateral
Figure 12-58 Anchor trocar tip penetrates bone without to the greater tuberosity for the following reasons:
predrilling. 1. The anchor is placed in bone with an intact
cortical surface, compared with the prepared
cancellous bed of the repair site.
2. Bone density is greater in this distal location
than in more proximal bone.
3. The angle of anchor insertion between the
anchor and the bone is minimized, allowing
a ‘‘straight-in’’ anchor insertion.
4. The anchor can be inserted through the cannula
without the need for a percutaneous insertion.
5. A lateral anchor position places the vector of
tendon pull approximately 90 degrees to the
longitudinal axis of the anchor, minimizing
anchor pullout (Fig. 12-61).
6. The tendon can be repaired anatomically (Fig.
12-62). If the anchors are positioned medially
on the tuberosity, the ultimate healing site is
also moved medially.
Figure 12-59 Insert the anchor distally.
The Smith-Nephew anchor inserter has two marks 90

°a
near the anchor end. The circumferential, transverse ng
le
pu
mark indicates the appropriate depth of insertion. I ll
insert the anchor until this line is beneath the bone
cortex. The longitudinal lines on the inserter shaft
indicate anchor eyelet orientation. The eyelet opening
lies in the plane perpendicular to the plane that incor-
porates the two longitudinal lines. Proper eyelet ori-
entation is critical so that the sutures slide freely
during knot tying. Theoretically, the eyelet should
be parallel to the tendon edge, allowing the sutures
to slide most easily. The problem during surgery is
that selecting the appropriate suture limb is both tech-
nically challenging and complicated by the anchor
eyelet’s subcortical location and obscuring bursa. If
the surgeon selects the suture limb nearest the
tendon edge for passage through the tendon, the
suture slides freely while tying; if the opposite limb
is selected, the suture strands cross after passage Figure 12-61 Right angle between the tendon and the
through the tendon, causing resistance to sliding. To anchor.
eliminate this problem, I orient the eyelet perpendic-
ular to the tendon edge. With the eyelet in this posi-
tion, it does not matter which suture limb I select for
passage; the eyelet is large enough so that either suture tuberosity. I apply slight pressure until the trocar tip
limb will slide freely. Some newer anchors solve this punctures the cortex. I then rotate the handle and let
problem by allowing the eyelet to rotate freely. the anchor threads advance the anchor without push-
Some surgeons prefer to insert all anchors in the ing inward. I do not apply pressure to the anchor
bed of the sulcus to repair the tendon more directly handle; the osteoporotic bone in some patients
to the repair site. Others prefer a ‘‘double-row’’ tech- would allow the anchor to plunge into the humerus.
nique with anchors inserted laterally to repair the After I insert each anchor, I pull on the suture strands
tendon anatomically and an additional row of anchors to test anchor fixation. Ideally, one should be able to
inserted medially for tendon-bone approximation. A translate the humeral head (and the patient) laterally
recent addition to rotator cuff repair techniques is the when pulling on the sutures. This step ensures that
suture bridge repair. This technique uses two medial the anchors are well inserted. After the anchors are
anchors and two lateral anchors with the sutures in a inserted, I pass the anchor sutures through the
crossing pattern. (The double-row and suture bridge tendon. Passing the sutures independently of the
techniques are discussed in more detail later in this anchor makes it easier to determine the precise loca-
chapter.) tion of suture penetration through the tendon.
Single-Row Repair
I repair the rotator cuff tear with the patient’s arm in
relative adduction. If the tendon cannot advance to its
anatomic insertion point with the arm in adduction,
I repair the tendon medially (Figs. 12-63 and 12-64). I
have found that function is not compromised by
moving the tendon insertion site up to 10 mm medi-
ally. I do not believe that you can repair the tendon in
abduction, brace it postoperatively, gradually lower Anatomic
anchor repair
the arm, and have the repair ‘‘stretch.’’
I place the most anterior anchor first and proceed
posteriorly with additional anchors as needed.
I position the anchor trocar tip against the humeral
cortex approximately 5 to 7 mm distal to the greater Figure 12-62 Anatomic repair.
An alternative technique is to insert an anchor, pass Medial repair site with

the sutures, and tie the knots before proceeding to the retracted tendon
next anchor. If the surgeon is comfortable with this
technique, it may produce good results. I find this
approach difficult for two reasons. First, with large
tears, it is often difficult to judge which suture goes
where, and errors in anatomic repair are more likely.
Second, with smaller tears, if the knots are tied and a
portion of the tendon is repaired, it is possible to dis-
rupt the repair when using suture passing instruments
for the remainder of the repair.
After I insert each anchor, the assistant inserts a
crochet hook through the anterior cannula, pulls the Figure 12-63 Retracted rotator cuff tear.
four suture strands out the cannula, and clamps them
with a hemostat so that each group of sutures is kept cannula. Only then does my assistant remove the
together. It is helpful to use a different sized hemostat suture out the anterior cannula. If we both remove
for each group of four sutures to designate which our instruments simultaneously, errors in suture man-
anchor they originate from. agement may occur. It is important to perform one
step at a time. The sutures are then placed from ante-
rior to posterior using the previously described
Suture Placement
technique (Figs. 12-65 through 12-77).
Once suture anchor placement has been completed,
the braided sutures are passed through the torn Caspari Suture Punch Technique
tendon. The soft tissue grasper is passed through the The Caspari suture punch does not accept braided
lateral cannula, and the precise location of the tendon suture, so I use a 2-0-nylon suture, looped in half, as
repair as well as the location and spacing of each a suture relay. I prefer this over a wire shuttle because
suture are estimated. I space the sutures evenly from of its lower cost and ready availability. The two free
the anterior and posterior margins of the tear and ends are passed into the suture punch, and the loop
place them approximately 5 to 8 mm from the end exits from the handle.
tendon edge. I insert the anchors from anterior to pos- I insert the Caspari punch through the lateral can-
terior and then pass the sutures through the tendon nula and grasp the tendon at the point that I believe
from anterior to posterior. should be translated to the anterior anchor. I close the
Caspari jaws slightly but do not puncture the ten-
don—the instrument functions as a tissue grasper. I
Suture Passing
then pull the tendon toward the anterior anchor and
Elite Suture Passer Technique determine whether this is indeed an anatomic repair.
I insert a crochet hook through the lateral cannula,
retrieve the most anterior suture, and bring it out
the lateral cannula. My assistant loads the suture in
the jaws of the Elite instrument. I insert the Elite
through the lateral cannula and place the most ante-
rior suture in the rotator cuff tendon as medially as
possible. The precise location of the suture varies
based on the location of the musculotendinous junc-
tion, which extends quite laterally in some patients.
Passing sutures through the muscular portion is diffi-
Medial
cult because the needle or the suture may be hard to anchor repair
identify and retrieve. This requires a different type of
insertion technique or a more lateral suture place-
ment. My assistant inserts a suture grasper through
the anterior cannula and grasps the suture as it exits
from the rotator cuff. After my assistant assures me
that the suture is grasped securely, I open the jaws of
the Elite instrument and remove it out the lateral Figure 12-64 Medial repair.
Disrupted suture
Caspari disrupting repair

of previously tied suture
Figure 12-65 Suture instrument can disrupt the repair.
Figure 12-68 Test cuff mobility.
Often, some change in humeral position is necessary.

Once I have identified the appropriate site for the first
suture, I close the jaws until I can see the needle tip of
the suture passer exit from the tendon. The tendon is
grasped and punctured, and the two paired suture
ends are advanced into the subacromial space.
This seemingly simple step can prove quite difficult
because of tendon thickness and bursae overlying
the tendon surface. The needle on the Caspari punch
is 4 mm, and if the tendon thickness is greater than 5
Figure 12-66 Double-row technique.
Figure 12-67 Abrade repair site. Figure 12-69 Insert anterior anchor.
Figure 12-70 Retrieve sutures.
Figure 12-72 Pass posterior sutures out anterior cannula.

to 6 mm, it is hard to pass the needle tip completely
through the tendon. My solution to this problem was
to ask the manufacturer Linvatec to modify the needle through the anterior cannula to sweep away the
tip and increase its length to 6 mm. This small change bursa and provide counterpressure. This allows the
helped me greatly, and the modified instrument is needle tip to penetrate the tendon fully.
now available to any surgeon. Another technique I The crochet hook is used to retrieve the free ends of
use is to twist the Caspari punch while pulling on the nylon suture out the anterior cannula, and a he-
the tendon so that I force the needle through the mostat is applied to the suture ends. The hemostat
tendon. If I can see a thin layer of bursa or tendon prevents the nylon sutures from being pulled
covering the needle tip but I cannot advance the
nylon sutures, my assistant inserts a crochet hook
Figure 12-71 Insert posterior anchor. Figure 12-73 Retrieve anterior suture out lateral cannula.
Figure 12-76 The final anterior suture.
anchor, advance and rotate the arthroscope so that it

Figure 12-74 Pass first anterior suture through tendon. points toward the anchor. Insert the crochet hook
through the lateral cannula and identify the anterior
anchor. Hook a limb of the green suture first and
gently pull on it. If you have the correct suture, it
inadvertently through the anterior cannula as the will slide freely because the hemostat has been
Caspari punch is withdrawn laterally. The suture removed. If there is resistance, either you have
punch is removed through the lateral cannula, selected the wrong suture (from a more posterior
leaving the loop protruding out the lateral cannula. anchor) or it is entangled in the other sutures.
The hemostat on the anterior anchor sutures is Have your assistant tug on the correct suture exiting
removed. The crochet hook is then used to retrieve out the anterior cannula to ensure you have made the
one of the anterior suture anchor strands and bring right choice. Another technique at this point in the
it out the lateral cannula. To find the appropriate operation is to have your assistant place the correct
Figure 12-75 All four suture strands passed. Figure 12-77 Completed repair.
suture in the knot pusher and pass it down the ante-

rior cannula and into the subacromial space until you
can visualize it.
To ensure that the nylon loop and the braided
suture have not become entangled, a suture retrieval
forceps is passed through the lateral cannula and into
the subacromial space, and both strands of nylon
suture are enclosed within the forceps’ jaws. The
braided suture should remain external to the forceps.
The forceps’ jaws are kept closed around the two nylon
suture strands, and the forceps is removed from the
cannula. This is a critical step and should be repeated
for each suture.
The free end of the braided suture is placed within
the loop of the 2-0 nylon external to the lateral can-
nula. Traction is placed on the two ends of the nylon
suture anteriorly, and the braided suture is pulled
from the lateral cannula, into the subacromial space,
through the tendon, and out the anterior cannula. At
this point, a simple suture has been placed through
the anterior rotator cuff. Repeat these steps as neces- Figure 12-79 Insert crochet hook.
sary for the remaining anterior suture anchor strand
and for additional, more posterior, suture anchor the anterior cannula to the lateral cannula and tied
strands. Some surgeons find it helpful to apply a he- individually. The anterior sutures are retrieved from
mostat to each pair of suture strands immediately after the anterior cannula, brought out the lateral cannula,
passage through the tendon. This makes it impossible and tied in a similar fashion. I have tried various
to pull the suture out from the tendon or from suture techniques (mattress, modified Mason-Allen)
the anchor inadvertently. This is a critical step in but find them cumbersome and time-consuming.
suture management for inexperienced surgeons Mattress sutures double the number of passes through
(Figs. 12-78 through 12-103). the tendon and, because of their medial location, cause
the tendon edge to flip up. I prefer to use simple sutures
to repair rotator cuff tears of all sizes and have not expe-
Knot Tying
rienced problems with suture pullout. Simple sutures
Knot tying generally begins posteriorly and proceeds pass over the tendon edge and hold it firmly against the
anteriorly, although the surgeon may modify this bone. When teaching knot tying, I consistently observe
based on tear geometry. Using a crochet hook, each surgeons placing too much tension on their knots,
pair of posterior anchor sutures is transferred from
Figure 12-78 Crochet hook for suture retrieval. Figure 12-80 Sweep sutures.
Figure 12-84 Load 2-0 nylon into the Caspari suture punch.
Figure 12-81 Retrieve the anchor sutures out the anterior

cannula.
Figure 12-85 Insert the Caspari suture punch through the

lateral cannula.
Figure 12-82 Retrieve the anchor sutures out the anterior
cannula.
Figure 12-83 Load 2-0 nylon into the Caspari suture punch. Figure 12-86 Puncture the tendon.
Figure 12-90 Bring the looped end of nylon out the lateral
cannula.
Figure 12-87 Retrieve two free ends of nylon out the ante-
rior cannula.
Figure 12-88 Retrieve two free ends of nylon out the ante- Figure 12-91 Retrieve one limb of anchor suture from the
rior cannula. anterior cannula.
Figure 12-89 Apply a hemostat. Figure 12-92 Withdraw the suture out the lateral cannula.
Figure 12-93 Use a looped grasper to check for suture

tangles. Figure 12-96 Pull on the nylon sutures exiting the anterior
cannula, then pull, then anchor suture down the lateral can-
nula into the subacromial space.
Crochet hook pulling

nylon out anterior cannula
Figure 12-94 Insert 7.5 cm of anchor suture through the

nylon loop.
Figure 12-97 Pull on the nylon sutures exiting the anterior
cannula, then pull suture from the subacromial space
through the tendon and out anterior cannula.
Figure 12-98 Pull the anchor suture through the rotator cuff
Figure 12-95 Close-up of anchor suture through nylon loop. tendon.
Figure 12-99 Remove slack in the anchor sutures.

Figure 12-102 Slide it under the tendon.
usually because of inexperience with arthroscopic knot

tying. I tie the first anchor suture with only enough
tension to advance the tendon edge to the desired
repair site. At this point, the tendon is normally
reduced, and the subsequent sutures must be tied
with just enough tension to approximate the ten-
don edge. Excessive tension will strangulate the tis-
sue or cause the suture to pull through the tendon
(Figs. 12-104 through 12-112).
Figure 12-100 Alternative technique when space is tight.
Figure 12-101 Rotate the Caspari suture punch 90 degrees. Figure 12-103 Advance the nylon suture.
Figure 12-107 Advance the knot pusher down the lateral

Figure 12-104 Retrieve two suture limbs from the anterior cannula.
cannula to the lateral cannula.
Figure 12-108 Overhead throw.

Figure 12-105 Check for tangles.
Figure 12-106 Thread the knot pusher. Figure 12-109 Second overhand throw.
Arthroscopic Knot Tying
Double-Row Repair
Standard Double Row
This repair normally requires two medial anchors and
two lateral anchors. The medial anchor sutures are
placed in a mattress fashion, and the lateral anchor
sutures are placed as simple sutures. To place the
medial anchors, I take the patient’s arm out of the
arm holder and place it in adduction. I identify
the appropriate insertion site with a spinal needle.
This is commonly located adjacent to the lateral acro-
mial edge. I then make a small skin incision and insert
a metal cannula and trocar. I place the first anchor
Figure 12-110 Slip the second throw.
Posterior Anterior
1 2 3 4
Suture tying tension
scale 1-10
Suture number Tension amount
1 4/10
2 2/10
3 1/10
4 1/10
Figure 12-111 Suture tension.
Knot tension
scale 1-10
Throw number Tension amount
5 1 3/10
4 2 3/10
3
3 3/10
2
4 5/10
1
5 6/10
Figure 12-112 Knot tension.

33% posterior to the anterior tendon margin and

immediately lateral to the articular cartilage. The
sutures are retrieved out the anterior cannula. I then
place a second medial anchor 33% anterior to the
posterior tendon margin with the same technique.
Usually a small amount of internal rotation is
needed to access the more posterior anchor. I then
retrieve the most anterior suture out the lateral can-
nula, pass it through the tendon, and take it out ante-
riorly. I then perform a mattress suture by taking the
second suture from the same anchor and passing it
through the tendon approximately 7 mm posteriorly
to the anterior suture. I repeat these steps to place a
mattress suture with the posterior medial anchor
sutures. I then remove the cannula and place the
Figure 12-114 Double-row technique.
sutures external to the cannula. I place the lateral
anchors (usually two or three) as described earlier for
the simple repair. I tie the lateral anchor sutures first,
followed by the anterior medial anchor sutures.
Double-Row Repair
I prefer to tie these from the anterior cannula so that
the line of pull of the suture throws achieves the best
Suture Bridge
compression. These sutures are cut, and then the
posterior medial anchor sutures are tied (Figs. 12-113 The medial anchors and mattress sutures are placed as
and 12-114). described earlier and tied. I retrieve one suture from the
posterior anchor and one suture from the anterior
anchor out the lateral cannula. The sutures are placed
in the push-lock anchor and inserted into the proximal
humerus. The location is 10 to 15 mm distal to the
greater tuberosity and in line with the anterior medial
anchor. I adjust tension on the rotator cuff by pulling
separately on the two suture strands. Once I am satis-
fied with the reduction, I use a mallet to tap on the
impactor and lock the suture repair. I repeat the process
for the posterior sutures and anchor. No tying of the
lateral sutures is needed (Figs. 12-115 through 12-118).
Double
row anchors
Figure 12-113 Double-row technique. Figure 12-115 Double-row technique (suture bridge).
Figure 12-116 Double-row technique (suture bridge). Figure 12-118 Double-row technique (suture bridge).
Rotator Cuff Repair, Bridge

Technique—Model
Rotator Cuff Repair, Bridge

Technique
Rotator Cuff Repair, Lateral

View
Horizontal Cleavage Tears

If the distal edge of the articular-sided layer is even
with the distal edge of the more superficial bursal-
sided layer, I repair the two layers together anatomi-
cally and incorporate both in the repair. First I place a
suture through the deeper layer using the Elite suture
punch and the technique previously described. I apply
a hemostat to the corresponding limb of suture that
was not passed through the deep layer. I repeat the
process and pass the suture through the superficial
layer of the tendon. Normally, I cannot pass the
suture through both tendon layers with one pass.
If the deep layer is retracted medially (as is often the
case) and will not advance laterally, I repair it in situ with
a mattress suture. Because the Elite punch usually does
not allow me to reach far enough medially to the super-
ficial layer, I use the Cuff-Stitch to insert this suture.
After the repair is completed, I remove the patient’s
arm from the arm holder and move it through a range
of motion. This allows me to document the security of
the repair and examine the amount of clearance
Figure 12-117 Double-row technique (suture bridge). between the rotator cuff and the acromion.
Figure 12-119 Continuous passive motion chair.
Each incision is closed with a single subcutaneous, Figure 12-121 Shoulder immobilizer.
inverted 3-0 Monocryl suture and Steri-strips. An
absorbent sterile dressing is placed over the shoulder. continue the pendulum exercises. The patient continues
to wear the sling and is cautioned to avoid active range
POSTOPERATIVE TREATMENT of motion with the operated shoulder. I next see the
patient 6 weeks after surgery. Passive range of motion
I remove the dressing the morning after the operation continues, but active elevation and external rotation are
and allow the patient to shower without any protection allowed. I instruct the patient in supine, active-assisted
of the surgical wounds. The patient’s arm is placed in a range-of-motion exercises. Strengthening is instituted
sling except for exercises (Figs. 12-119 through 12-121). after 3 months, and the rehabilitation continues for 12
The safe limits of movement are determined at the months. The rehabilitation program is described in
time of surgery and documented. I have the patient per- more detail in Chapter 19.
form 2 minutes of pendulum exercises five times a day.
Many patients like to use a continuous passive motion
chair for 2 weeks. I evaluate the patient in the clinic after RESULTS
2 weeks and obtain an anteroposterior radiograph to
evaluate the anchor position. I discontinue the contin- In my experience, arthroscopic results are equal to
uous passive motion chair (if used) and have the patient those of open or mini-open repairs. I found that the
average postoperative University of California at Los
Angeles (UCLA) score was 31 of 35, and 84% of patient
outcomes were rated good to excellent. Moreover, the
UCLA, American Shoulder and Elbow Surgeons, and
Constant rating systems all demonstrated an improve-
ment in shoulder function (Tables 12-1 through 12-5).
When the results were analyzed in terms of pa-
tient self-reporting, I found improvement in all the
parameters of the SF-36 Health Survey.
Inanearlyreportonarthroscopicrotatorcuffrepair,my
colleagues and I analyzed patients with glenohumeral
lesions (major labrum tears, Bankart and SLAP lesions,
and osteoarthrosis) as a subgroup. Mean preoperative
UCLA scores were 23.7 for the normal group and 10.9
for the group with major glenohumeral lesions.
Postoperative UCLA scores were 31.2 for the normal
group and 29.9 for the group with major glenohumeral
Figure 12-120 Ice pack. lesions, differences that were not statistically significant.
Table 12-1 RESULTS OF ARTHROSCOPIC Table 12-2 RESULTS OF ARTHROSCOPIC

REPAIR BY RATING SYSTEM REPAIR ON ASES ACTIVITIES OF DAILY
LIVING*
System Preoperative Postoperative
Activity Preoperative Postoperative
UCLA total 12.4 ± 4.2 31.1* ± 3.2
Pain 2.4 ± 1.7 8.6* ± 1.6 Put on coat 1.55 ± 0.76 2.93 ± 0.30
Function 3.7 ± 2.2 8.9* ± 1.2 Sleep 0.96 ± 0.95 2.62 ± 0.70
Flexion 3.6 ± 2.2 4.9* ± 0.3 Reach up back 1.01 ± 0.79 2.70 ± 0.46
Strength 2.3 ± 1.0 4.1* ± 0.9 Toilet 2.39 ± 0.84 2.97 ± 0.16
Satisfaction 0.4 ± 0.5 4.6* ± 0.9 Comb hair 1.59 ± 0.96 2.89 ± 0.36
ASES total 30.7 ± 15.7 87.6* ± 12.8 Reach high shelf 0.96 ± 0.95 2.67 ± 0.58
Pain 7.7 ± 1.7 1.4* ± 1.6 Lift 10 pounds 0.53 ± 0.78 2.22 ± 0.99
above shoulder
Function 11.4 ± 5.7 26.8* ± 8.0
Throw overhead 0.55 ± 0.80 2.34 ± 0.90
Constant 41.7 ± 12.8 83.6* ± 9.0
(absolute) Work 1.33 ± 1.05 2.81 ± 0.99
Sports 0.52 ± 0.82 2.67 ± 0.73
Constant 43.3 ± 11.6 84.0* ± 7.5
(age adjusted) *All changes were significant (P = .0001); Wilcoxon signed rank test
used for differences between preoperative and postoperative scores.
Pain 3.58 ± 2.62 12.91* ± 2.34 ASES, American Shoulder and Elbow Surgeons.
Function 3.37 ± 1.94 18.78* ± 1.53
Elevation 7.62 ± 2.45 9.78* ± 0.63
Abduction 6.15 ± 2.62 9.56* ± 1.13
External 6.82 ± 2.16 9.53* ± 1.18
rotation
Internal 6.66 ± 2.12 9.08* ± 1.18
rotation
Strength 7.51 ± 4.69 14.00* ± 5.41
*P = .0001.
ASES, American Shoulder and Elbow Surgeons; UCLA, University of
California at Los Angeles.
Table 12-3 RESULTS OF ARTHROSCOPIC REPAIR ON

RANGE OF MOTION*
Passive Range
of Motion Preoperative Postoperative
Elevation 135 ± 22 149 ±4

External rotation 66 ± 12 78 ± 10
Internal rotation L1 ± 4 levels T9 ± 3 levels
*Differences significant (P = .0001); Wilcoxon signed rank test used to test for
significance.
This comparison indicates that the identification and

Table 12-4 RESULTS OF ARTHROSCOPIC treatment of intra-articular lesions result in outcomes
REPAIR ON PHYSICAL AND MENTAL similar to those in patients without intra-articular lesions.
FUNCTION
Criterion Preoperative Postoperative COMPLICATIONS

Physical function 57.2 ± 25.7 76.6 ± 27.1 The most common complications following arthro-
Role, physical 24.6 ± 37.4 75.7 ± 40.4 scopic rotator cuff repair are stiffness and tendon-
Bodily pain 27.7 ± 19.7 68.2 ± 24.1 bone discontinuity. Although the terms tendon retear
or disruption of the repair are commonly used, I am not
General health 70.8 ± 28.7 72.4 ± 21.8
convinced that the tendon ever healed. What we can
Vitality 50.6 ± 24.2 62.8 ± 18.4 observe directly is that the patient has a problem with
Social functioning 57.5 ± 31.2 84.0 ± 25.5 pain or weakness; an imaging study demonstrates
Role, emotional 62.1 ± 43.8 82.4 ± 34.3 tendon-bone discontinuity, and the interpretation is
that the tendon has torn. However, there is little evi-
Mental health 70.3 ± 22.2 78.2 ± 19.3
dence that a healed tendon has torn. This is more than
Physical component 34.1 ± 9.1 46.6 ± 10.8 a semantic difference. If a repaired tendon heals and
summary then tears at a later date, our efforts are directed at
Mental component 48.7 ± 13.1 52.6 ± 9.4 postoperative issues. If the problem is one of failure
summary of the tendon to heal after the initial operation, we

must direct our efforts in another direction.
Differences in preoperative and postoperative SF-36 Health Survey
scores significant (P = .0015) for all scores except general health and Stiffness
mental component summary.
If stiffness persists 6 months after operation, I perform
an arthroscopic contracture release as described in
Chapter 6. The area of contracture is frequently
within the glenohumeral joint, indistinguishable
from idiopathic adhesive capsulitis. Quite often, the
subacromial space is pristine, without any evidence
of adhesions in the area of prior surgery.
A major cause of shoulder stiffness after rotator cuff
repair is that some repairs are placed under too much
Table 12-5 RESULTS OF ARTHROSCOPIC REPAIR
UCLA STRENGTH TENDON TEAR
Criterion Preop Postop Preop Postop Length Width Size Age
Preoperative UCLA 1.00 0.081 0.417 0.067 0.067 0.049 0.015 0.157
Postoperative UCLA 0.081 1.00 0.309 0.515 0.161 0.092 0.122 0.04
Preoperative strength 0.417 0.309 1.00 0.456 0.244 0.131 0.199 0.448
Postoperative strength 0.067 0.515 0.457 1.00 0.407 0.310 0.373 0.368
Tendon Tear
Length 0.067 0.161 0.244 0.407 1.00 0.676 0.906 0.336
Width 0.049 0.092 0.133 0.310 0.676 1.00 0.912 0.292
Size 0.015 0.123 0.199 0.373 0.906 0.912 1.00 0.346
Age 0.157 0.043 0.449 0.368 0.336 0.292 0.346 1.00
UCLA, University of California at Los Angeles.
tension. I would rather repair the tendon edge medially the eyelet. The assistant loosens his grasp on the loop
than have it positioned ‘‘anatomically’’ under exces- grabber, and I remove the anchor through the lateral
sive tension. cannula. Occasionally, the anchor dislodges from the
grasper as it is pulled through the rubber dam of the
Tendon-Bone Discontinuity
lateral cannula. This may result in a loose anchor that
If the patient has persistent pain and weakness, the floats in the subacromial space. I generally avoid this
surgeon may perform gadolinium-enhanced MRI. complication by removing the lateral cannula with
Unfortunately, this often results in a false-positive the anchor and grasper inside it.
study due to artifact from the prior surgery. My pre-
ferred evaluation technique is diagnostic ultrasono-
graphy, which is simple, rapid, and unaffected by DISCUSSION
the presence of metallic anchors. Persistent pain and
weakness 6 months after surgery are relative indica- Arthroscopic rotator cuff repair is performed in many
tions for revision operation. If a tear is identified at centers around the world. The individuals who have
reoperation, it is repaired again. Occasionally, adhe- taken this procedure from theory to practice are expert
sions in the subacromial space produce a tethering arthroscopic technicians with a thorough understand-
effect and are responsible for the pain. These adhe- ing of rotator cuff repair fundamentals. Whether
sions are usually easily removed. Most patients elect arthroscopic cuff repair has good long-term results
to have the second surgery; however, some who are comparable to those of open procedures remains to
improved and have good function but still have mod- be seen, and I await the publication of studies with
erate pain accept their condition and decline further sufficient numbers of patients and long-term follow-
surgery. In my first 2000 arthroscopic rotator cuff up. A separate issue is whether this technique has wide
repairs, 3.5% of patients had significant postoperative applicability among surgeons of varying arthroscopic
stiffness that required surgery. skills. Each individual surgeon must consider the rel-
ative benefits of arthroscopic repair and decide
Anchor Retrieval
whether the difficulty of the procedure, compared
Occasionally the surgeon must remove an anchor after with the open technique, makes it worthwhile.
it has been inserted. Either the anchor is malposi- For orthopedic surgeons considering making the
tioned or the surgeon has pulled the suture out of transition from open to arthroscopic technique, cau-
the anchor or broken the suture during knot tying. tion is appropriate. The surgeon must not only master
One option is to insert another anchor and ignore each of the individual elements described here but also
the empty anchor. If the surgeon wishes to remove perform them in a precise and timely fashion. The sur-
the anchor, there are several techniques. If the sutures geon must have a reasonable volume of patients with
are still in the anchor, use the wire loop to replace the rotator cuff tears and be proficient at arthroscopic sub-
sutures in the inserter. Advance the inserter gently acromial decompression. Experience is required to rec-
into the screw hole until it engages the anchor. Keep ognize the tendon tear patterns and shapes as viewed
traction on the sutures so that the inserter maintains through the arthroscope. Tendon mobilization of
contact with the anchor, and unscrew it. retracted tears can be difficult. Suture anchors must
If there are no sutures in the anchor, the situation is be placed accurately so that the repaired tendon rests
more difficult. If the bone quality is poor, there will be in the desired location. The orthopedist must manage
no resistance as the inserter is advanced to try to engage multiple strands of suture material within the tight
the anchor. In this case, I prefer to leave the anchor in confines of the subacromial space and tie secure
position and simply insert another one. If the bone knots with the use of arthroscopic tools.
quality is good, place the inserter in the bone hole
until it engages the anchor; unscrew it until it is halfway
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CHAPTER
13
Massive Rotator
Cuff Tears
I define a massive rotator cuff tear as one involving at ahead. You may find it helpful to review exercise 3
least two rotator cuff tendons and measuring 5 cm in outlined in Chapter 1.
length from anterior to posterior. It is difficult for Large or massive retracted rotator cuff tears differ
surgeons to determine whether a massive, retracted from smaller tears in six aspects:
rotator cuff tear is reparable. This is true for both
1. Quantity of sutures and anchors
arthroscopic and conventional open techniques.
2. Tear geometry
If the tendon is mobile and can be advanced to its
3. Variability of repair sequence
anatomic location or medialized within 10 mm of
4. Suture management
its anatomic location without shoulder abduction,
5. Tendon-to-tendon repair
the tear is reparable. If, on initial inspection, the
6. Muscle quality
tendon does not meet these criteria, it is not neces-
sarily irreparable. Subacromial, subdeltoid, and intra- The most straightforward aspect is quantity of
articular adhesions may limit cuff excursion. With an sutures and anchors. Larger tears require more
arthroscopic technique, the surgeon can release these anchors, more sutures, and more time to complete.
adhesions and determine definitively whether the Tear geometry is difficult to identify. Larger tears
tear is reparable. often assume distorted shapes because the tendons
I am frequently asked how I can repair massive tears have detached, rotated, and come to rest far from
arthroscopically. The answer, like the technique, is their insertion sites. The tendon has deformed plasti-
both simple and complex. The simple part is my atti- cally. It is often difficult to understand how points on
tude. I understand that massive tears will require more the retracted tendon attach to corresponding points
débridement and soft tissue releases before I can deter- on the humeral head. Identifying this relationship
mine reparability. It will take multiple movements of requires an understanding of the geometry of the
the arthroscope to different cannulas to get a full pic- tear and thus the geometry of the repair (Fig. 13-1).
ture of the tear geometry, and suture management will This is difficult enough when then tendon is mobile
prove challenging. I know that I must move slowly to but becomes increasingly complex when the tear is
avoid making technical errors that will prolong an retracted and fixed. Only with thorough soft tissue
already complicated operation. I also accept the reality releases can the surgeon maneuver the tendon and
that I will make technical errors during the operation determine the precise repair site.
and that I must be patient, correct the problem, and The surgeon must often alter the normal repair
move on. The complex part is actually doing all these technique of placing anchors from anterior to poste-
things. rior and tying knots from posterior to anterior. The
If you are at the stage where you are about to under- repair may require knot tying from anterior to poste-
take the repair of a massive rotator cuff tear, you rior, or the surgeon may have to repair the most ante-
already have the necessary technical skill. It is helpful rior and posterior margins first and repair the central
to spend some time detailing the challenges that lie portion last.
279
LITERATURE REVIEW
Cordasco and Bigliani reported on the open repair of

massive rotator cuff tears. In their series, 85% of
patients (52 of 61) had satisfactory results, and 92%
(56 of 61) had satisfactory pain relief; they experi-
enced mean gains of 76 degrees in forward elevation
and 30 degrees in external rotation. Burkhart reported
similar results with the arthroscopic treatment of
massive tears. Burkhart has also contributed greatly
to our understanding of the biomechanics of massive
rotator cuff tears and their repair. I find the concept of
margin convergence particularly useful. The first
principle of margin convergence is that partial repair
of a massive tear can reduce the patient’s pain and
Figure 13-1 Massive rotator cuff repair. improve function. Complete anatomic repair,
though desirable, may not be possible in patients
with massive rotator cuff tears; however, a good
outcome can be achieved with a partial repair.
In addition, suture management is complex. As the The second principle is that if the surgeon can estab-
number of anchors and sutures increases, the technical lish anterior and posterior stability to the shoulder,
difficulty seems to increase geometrically. Strict adher- good function is possible even if the supraspinatus is
ence to two principles is vital: keep the working cannula not reparable. Anterior stability may be achieved
free of sutures, and transfer suture strands so they do not through a subscapularis repair and posterior stability
cross the area of tendon repair. through an infraspinatus repair.
It is often necessary to combine a longitudinal The healing rate of large and massive tears has been
tendon-to-tendon repair with a transverse tendon-to- reported by a number of authors, with healing rates
bone repair. This may require the use of different ranging from 0% to 80%. There appears to be a higher
suturing techniques, sutures, instruments, viewing healing rate with modern double-row fixation tech-
portals, and knot tying methods (Fig. 13-2). niques. Warner (see Costouros et al.) discussed the pos-
Finally, massive rotator cuff tears are diseases of sibility that abnormalities of the suprascapular nerve
tendon and muscle. These large tendon tears are usu- may be partially responsible for pain in patients with
ally chronic and are accompanied by significant retracted tears. It is not unreasonable to assume that
muscle atrophy. The surgeon must be aware that tendon retraction and the resulting distortion of the
heroic efforts to repair tendons will not produce a suc- suprascapular nerve could be a source of pain.
cessful result if the corresponding muscles are not
functional.
OPERATIVE TECHNIQUE
Soft Tissue Releases for

Massive Rotator Cuff Tear
Visualization
I inspect the glenohumeral joint and obtain full pas-
sive range of motion through gentle manipulation or
contracture release. If the surgeon cannot position the
arm in full (or nearly full) elevation and external rota-
tion, the rotator cuff repair may be difficult or impos-
sible, and the postoperative recovery will certainly be
challenging (Fig. 13-3).
I remove the arthroscope and redirect it into the
subacromial space. I introduce the trocar and
Figure 13-2 Tendon-to-tendon repair. cannula through the subcutaneous tissue until I can
Chapter 13 Massive Rotator Cuff Tears 281
Figure 13-5 Rotator cuff adherent to the acromion (arrow).

Figure 13-3 Contracture release.
palpate the posterior acromion. I then advance the

cannula and trocar along the inferior acromial surface
so that I enter the subacromial space superior to
any rotator cuff tendon adherent to the acromion
VIEW THROUGH ARTHROSCOPE
while creating the maximal distance between the
arthroscope lens and the rotator cuff tear (Figs. 13-4
through 13-6).
I establish a lateral portal and use a motorized
shaver to remove any bursal tissue that impedes a 1
clear view of the tendon tear. Surprisingly, the
subacromial space is often well visualized in massive 2
full-thickness tears. The thick subacromial bursitis
that characterizes stage 2 impingement is usually
absent. When a bursa is present, it is usually located
posteriorly; I remove it by inserting the arthroscope
posteriorly and the soft tissue shaver laterally. I con-
tinue removing the bursa until I can see the rotator
cuff tear clearly. If I cannot obtain a clear view of the
A
1
2
B
Figure 13-6 A and B, The appearance of the rotator cuff
Figure 13-4 Palpate the inferior acromion. repair changes with perspective.
Figure 13-7 Thickened posterior bursa. Figure 13-8 Arthroscope directed upward toward the
acromion.
tendon, I move the arthroscope to the lateral portal Because most of these lesions are chronic, muscle
and insert the shaver posteriorly (Fig. 13-7). contracture limits the excursion of the tendon edge
At this point I have the option of continuing the even when the surgeon has performed the appropriate
repair with the arthroscope laterally or moving it to its releases. Even if an anatomic repair is possible, the
normal posterior position. My preference is to work chronic nature of the lesion affects the muscle quality
with the arthroscope in the posterior portal. I rotate so that it does not function naturally. There is also the
the arthroscope so that it is pointed directly down at issue of tendon substance loss. Frequently, the surgeon
the rotator cuff tear (Figs. 13-8 and 13-9). identifies the musculotendinous junction and finds that
there is very little tendon remaining for repair. The
advanced age of these patients and the long-standing
Tear Classification
duration of the lesion also adversely affect tendon qual-
With small to medium tears, the size and tear geome- ity and repair security. With smaller tears, the tendon
try are easily appreciated, but this is not often the case retracts medially. With larger tears, the tendon not
with massive tears. There are 13 factors that distin- only retracts medially but also rotates posteriorly or ante-
guish the arthroscopic treatment of massive rotator riorly, further complicating the repair. Adhesions
cuff tears from the treatment of smaller lesions: between the rotator cuff and the deltoid or the acromion
limit mobilization. Contracture of the coracohumeral
1. Tear size
2. Muscle contraction
3. Muscle quality
4. Tendon retraction
5. Tendon substance loss
6. Tendon quality
7. Tendon rotation
8. Subdeltoid and subacromial adhesions
9. Coracohumeral ligament contracture
10. Capsular contracture
11. Greater tuberosity prominence
12. Superior humeral head migration
13. Repair without acromioplasty
Fundamentally, rotator cuff repair is a question of
what goes where. The size and retraction of massive
tears often make implementing the appropriate repair
steps difficult. Even when the surgeon understands Figure 13-9 Arthroscope directed downward toward the
the tear geometry, mobilizing the tendon is difficult. rotator cuff tear.
ligament and the glenohumeral joint capsule can also be Elliptical

significant. The greater tuberosity may enlarge and
encroach on the subacromial space, making the choice
of repair site difficult. Superior migration of the humeral
head in some patients with massive rotator cuff tears
diminishes the size of the subacromial space and com-
plicates the task of maneuvering instruments during the
repair.
Because of these factors, I am not convinced that,
even with an anatomic repair, the rotator cuff will
function normally and centralize the humeral head
into the glenoid during arm elevation. I consider
such patients to have anatomically intact but func-
tionally insufficient rotator cuffs. If the passive supe-
rior restraints of the coracoacromial arch are removed
with acromioplasty and coracoacromial ligament Figure 13-11 Elliptical tear.
resection, the humeral head will escape the confines
of the coracoacromial arch and subluxate anteriorly,
medially, and superiorly. Elevation will be limited and
painful. Subacromial decompression with a nonfunc-
tional rotator cuff repair (or an irreparable tear) trans- descriptions apply to a right shoulder and are reversed
forms the patient from one who has pain during for a left shoulder. L-shaped tears have a longitudinal
elevation to one who has pain and no ability to elevate limb posteriorly, often at the junction of the supraspi-
the arm. For these reasons, I do not perform an acro- natus and infraspinatus, in addition to lateral detach-
mioplasty or coracoacromial ligament resection ment at the greater tuberosity. Reverse L-shaped
during repair of a massive rotator cuff tear. This fur- tears—with a longitudinal component along the rota-
ther limits the maneuverability of instruments in the tor interval—allow the tear to rotate posteriorly.
subacromial space. Longitudinal tears may be present in the area of the
I measure with a marked probe the length of the tear rotator interval and occasionally within the substance
from anterior to posterior and the amount of medial of the supraspinatus (Figs. 13-12 through 13-15). V-
retraction. Straight medial retraction or retraction in shaped tears have the longitudinal component in
an ellipse are the most common findings (Figs. 13-10 addition to lateral detachment.
and 13-11). When I identify a massive tear that will not reduce
As tear size increases, the surgeon’s ability to appre- with straight lateral traction, I have found that the
ciate tear geometry is reduced. The following best way to reduce the tendon is to insert an
Transverse tear
L-shaped tear
e
hap
L-s
Figure 13-10 Transverse tear. Figure 13-12 L-shaped tear.

pe
ha
L-s
se
ver
Re
Reverse L-shaped tear
Figure 13-14 Reverse L-shaped tear.

Figure 13-13 L-shaped tear.
Cuff Mobilization
If adhesions have formed within the subacromial
space between the rotator cuff and acromion or
instrument through the anterior cannula, grasp the between the rotator cuff and deltoid, interfering with
posterior portion of the tendon, and pull it anterolat- tendon mobilization, they must be released. I usually
erally (Figs. 13-16 and 13-17). This is usually more release anterior and lateral adhesions with a motorized
effective than pulling the anterior limb posteriorly or shaver. Occasionally I use electrocautery to divide
performing soft tissue releases. I use a grasper and pull adhesions if they are particularly thick (Figs. 13-20
on the tear edge, attempting to determine its ana- and 13-21).
tomic location while varying elevation and rotation Posterior adhesions usually are not dense and can often
until a best fit is obtained. Only when the tear geom- be released by inserting a metal trocar and cannula
etry is appreciated can an effective repair be done. The through the lateral portal. Place the trocar superior to
McConnell arm holder is then secured to maintain the the anterior tear edge and sweep it posteriorly directly
arm position (Figs. 13-18 and 13-19). beneath the arthroscope (Fig. 13-22). It is unwise to
A B
Figure 13-15 A, Reverse L-shaped tear. B, Repair.
Figure 13-19 External rotation.
Figure 13-16 Grasp the retracted tendon edge.
Figure 13-17 Advance the tendon edge.
Figure 13-20 Adhesions of the rotator cuff and deltoid

fascia.
Figure 13-18 Internal rotation. Figure 13-21 Adhesions of the rotator cuff and acromion.
Releasing
coracohumeral ligament
Figure 13-22 Sweep and disrupt the subacromial adhesions.

remove these adhesions with a power shaver; hard-to-con- Coracohumeral ligament contracture is often accom-
trol bleeding often results owing to the posteromedial panied by a contracture of the rotator interval. I palpate or
location of the bleeding vessels. Therefore, I release any visualize the superior border of the subscapularis and use
remaining adhesions in this area with electrocautery. a scissors to divide the interval from the lateral tendon
Adhesions to the coracoid or a coracohumeral liga- border to the coracoid (Figs. 13-25 through 13-27).
ment contracture may give the false impression of irre- Occasionally, division of the intra-articular joint
parability. Adhesions to the coracoid are usually very capsule is helpful. Using arthroscopic scissors, I release
thick and require resection with electrocautery. This is the capsule adjacent to the glenoid beginning posterior
particularly true in the area of the coracohumeral lig- to the biceps-labrum attachment (Figs. 13-28 and
ament. This ligament is not clearly visualized and is 13-29). This slightly increases tendon excursion. The
best appreciated by applying lateral traction to the suprascapular nerve is located approximately 1 to
tendon edge and observing a ridge of tissue that pre- 2 cm medial to the glenoid, and the surgeon must be
vents mobilization. I grasp the tendon edge with a soft careful during medial dissection to avoid injuring this
tissue grasper inserted through the lateral portal, vital structure. This area is well visualized and accessi-
insert the electrocautery through the anterior portal, ble with the arthroscope in the subacromial space in
and divide the ligament (Figs. 13-23 and 13-24). patients with massive tears. This is not the case with
Interval release
Adhesions to coracohumeral ligament

and supraspinatus, causing
contracture
Pulling
supraspinatus
tendon
Figure 13-23 Coracohumeral ligament contracture limits

rotator cuff mobility. Figure 13-25 Interval release.
Figure 13-26 Interval slide.
the inferior capsule and, to a lesser extent, the anterior

capsule.
Subacromial and subdeltoid adhesions limit the
tendon’s ability to advance to the humeral head, and
inferior capsular contracture can limit the ability of
the humeral head to meet the tendon. These capsular
contractures prevent the humeral head movement
required for tendon-bone apposition. Usually I iden-
tify and correct the inferior contracture during the gle-
nohumeral joint portion of the operation. I release
inferior capsule contracture, as necessary, as described
in Chapter 6. If I cannot adequately release the ante-
rior contracture with the arthroscope in the subacro-
mial space, I remove the arthroscope and redirect it
Figure 13-27 Interval slide.
into the glenohumeral joint, release the anterior
Superior capsule release
Figure 13-28 Superior capsule release. Figure 13-29 Superior capsule release.
Medial repair site

with retracted tendon
Figure 13-32 Medial bone preparation.
Figure 13-30 Prominent greater tuberosity.
manipulating the tendon to determine the repair

geometry. This can affect the decision whether an ana-
contracture, and then reposition the arthroscope in tomic repair is possible. If anatomic repair is not pos-
the subacromial space. sible without excessive tendon tension, I repair the
Fenlin has taught us that the greater tuberosity is tendon medially and adjust the bone decortication
often abnormal in patients with chronic, massive rota- site accordingly. The tendon edge can be repaired as
tor cuff tears. These abnormalities, which include much as 10 mm medial to its anatomic insertion with-
osteophytes or reactive enlargement of the greater out a significant loss of overhead elevation. In this
tuberosity, compromise the space available for instru- situation, it is helpful to remove a 5-mm strip of hu-
ments during the surgical repair and impinge against meral head articular cartilage. This exposes a greater
the acromion during arm elevation postoperatively. surface of decorticated bone to the repaired tendon
Because I do not perform acromioplasty in this setting, and may aid tendon healing.
I recess the greater tuberosity by inserting the bur Medial repairs require the surgeon to change the
through the lateral cannula and removing the abnor- method of anchor insertion. An anatomic repair is
mal bony overgrowth until I obtain adequate clearance best obtained with lateral anchor placement, but this
between the proximal humerus and the acromion is not possible with a medial repair. I identify the
(Figs. 13-30 and 13-31). proper site and insertion angle with a spinal needle
Tendon reparability is based not only on tendon inserted percutaneously. The skin entry point is usu-
mobility but also on tissue quality and its ability to ally immediately lateral to the acromion. I make a
hold sutures and thus be used in the repair. I gain a stab wound and insert the anchors percutaneously
sense of tendon quality while grasping and (Figs. 13-32 through 13-35).
Figure 13-31 Greater tuberosity recession. Figure 13-33 Percutaneous anchor insertion.
Anterior and posterior repair

with central portion unrepaired
Anterior
Medial
anchor repair
Posterior
Figure 13-34 Medial repair.
Figure 13-36 Anterior and posterior margin repair.

If I cannot repair the tendon without further med-
ialization, I repair the anterior and posterior margins
anatomically and do not repair the central portion of
the tear. A tendon repaired under appropriate tension next anchor. For example, it may be helpful to place
in this manner is superior to an anatomic, watertight the most anterior anchor and two sutures and tie them
repair under excessive tension (Fig. 13-36). first. Then place the most posterior anchor and sutures
I do not repair the tear with the arm abducted. and tie these. This converts a massive tear into a
When the arm is brought back to the patient’s normal-sized transverse tear (Fig. 13-37).
side, the repair will be under excessive tension and
will fail.
Suture Management
The procedure that follows is complex, but it is possible.
Repair Sequence
Write down all the steps and rehearse them with a
It is often necessary to vary the repair sequence when
faced with a large or massive rotator cuff tear. Because
the tear is so large, it is possible to place anchors,
insert sutures, and tie them before proceeding to the
Figure 13-35 Medial repair. Figure 13-37 Anterior portion of the tear is repaired first.
practice board and the exercises outlined in Chapter 1. manipulating the tendon and possibly disrupting the
Watch the videos that deal with large rotator cuff repairs. repair. I modify the technique as follows: I insert the
When three to four anchors are needed for the anterior anchor and withdraw the four suture strands
repair, it is helpful to alter the usual suture manage- out the anterior cannula. I insert the next anchor
ment technique. Six to eight sutures within the sub- more posteriorly. I make a percutaneous stab wound
acromial space are difficult to handle. After I insert the anterolaterally, reach into the subacromial space with
anterior anchor, I withdraw the sutures through the the loop grabber, and withdraw the four suture strands
anterior cannula as usual. I insert the next anchor from the second anchor. I insert the most posterior
posteriorly and withdraw these sutures out the ante- anchor, make a percutaneous stab wound posterolat-
rior cannula. I internally rotate the arm and place the erally, and pull the posterior anchor sutures through
third anchor. At this point, if the sutures are pulled this incision. The subacromial space is now relatively
through the anterior cannula there will be six sutures clear of sutures, and tendon repair can proceed natu-
(12 strands) through this cannula, making manage- rally without sutures crossing the tendon edge (Figs.
ment difficult. Additionally, if the posterior sutures 13-38 through 13-49).
are through the anterior cannula, passing the anterior The next step is to pass the sutures through the ten-
sutures through the tendon will be difficult because don. I insert the suture punch through the lateral
the posterior sutures cross the tendon edge and may portal, grasp the most anterior portion of the cuff
block access to the cuff tear. One option is to insert that corresponds to the anterior anchor, and pass the
and then tie the anterior sutures before placing addi- first suture through the rotator cuff tendon. I retrieve
tional sutures or anchors, but often the tendon tear is the suture out the anterior cannula. I repeat this with
not quite large enough. Also, if the anterior sutures are the second anterior suture. I then insert a crochet
tied, it is difficult to place more sutures without hook through the lateral cannula and pull one limb
Anterior and middle anchor

sutures in anterior cannula
Inte
r na
lr
ot
ati
on
Internally rotate
humerus, place
3rd anchor by
percutaneous
stab wound
B
Figure 13-38 A and B, Internally rotate the shoulder to place the posterior anchors.
Figure 13-39 Lateral portal sites. Figure 13-42 Posterolateral stab wound site.
Loop grabber pulling

middle anchor sutures
through AL stab wound
Figure 13-43 Small loop grasper.

Figure 13-40 Withdraw the middle anchor sutures through
an anterolateral (AL) stab wound.
Figure 13-41 Sutures withdrawn out an anterolateral stab Figure 13-44 Insert the grasper through the posterolateral
wound. stab wound.
Figure 13-48 Withdraw the sutures out the stab wound.

Figure 13-45 Grasp the white sutures.
of the middle anchor sutures from the anterolateral
stab wound and insert it through the tendon as
described earlier. This suture can be withdrawn
through the anterior cannula or through the antero-
lateral stab wound. Repeat these steps for the second
suture of the middle anchor.
To place the posterior anchor sutures, I insert the
crochet hook through the lateral cannula and grasp
one of the posterior anchor suture strands exiting
from the posterolateral percutaneous stab wound.
I place the suture through the most posterior portion
of the rotator cuff tendon with the suture punch and
withdraw it out the anterior cannula. I then reach
through the posterolateral stab wound, retrieve that
strand of anchor suture, and take it back out the pos-
terolateral stab wound. If I left it in the anterior can-
nula, it would cross the area of the rotator cuff where I
want to place the next suture. I then use the suture
Figure 13-46 Withdraw the sutures out the stab wound.
punch to place the second posterior anchor suture,
Loop grabber pulling

posterior anchor sutures
through PL stab wound
Figure 13-49 Repair area free of crossing sutures. PL,

Figure 13-47 Grasp the green sutures. posterolateral.
pass the anchor suture as previously described, and

bring it out the anterior cannula. I leave this suture
in the anterior cannula because I am now ready to
start tying sutures.
I usually begin posteriorly and insert a crochet hook
through the lateral cannula and retrieve the two suture
limbs from the posterior anchor that exit the postero-
lateral stab wound. These are the suture limbs located
in the most posterior portion of the torn tendon. I tie
this one first because it is usually under the least
amount of tension. I then retrieve the second set of
posterior anchor sutures from the anterior cannula
and cut and tie these. The rotator cuff tear is now smal-
ler, and there are fewer sutures to manage. I tie the
Figure 13-50 Margin convergence.
remaining sutures.
Margin Convergence
Rotator Cuff Repair, Margin

Convergence
Margin convergence involves a tendon-to-tendon

repair beginning medially at the tear apex. I move the
arthroscope to the lateral portal to gain a better under-
standing of tear geometry and establish anterior and
posterior portals. I begin medially and place a suture
approximately 5 mm lateral to the tear apex, place
tension on the suture, and observe the change in tear
size. I continue placing sutures from medial to lateral
until I cannot approximate the tear any further. At this
point, if the lateral tendon margin is lateral to the artic-
ular cartilage, tendon-to-bone repair with suture Figure 13-51 Margin convergence.
anchors is appropriate (Figs. 13-50 through 13-55).
Certain modifications in repair technique are
required. It is easier to repair the tendon by inserting
the suturing instrument posteriorly, withdrawing the
suture posteriorly, and then tying from either the pos-
terior or the anterior portal, depending on the sur-
geon’s preference. I use the Smith-Nephew crescent
Cuff-Stitch to place a braided suture. I place the
instrument through the posterior portal and pierce
the posterior limb of the rotator cuff. I then insert
an instrument such as the Arthropierce through the
anterior cannula and pierce the anterior limb of the
rotator cuff. I grasp the suture, withdraw the instru-
ment back through the anterior cannula, and pull
the suture through the anterior tendon. Another
option is the Spectrum crescent suture passer. Place
this instrument through the anterior cannula and
pierce the anterior tendon limb. Feed the posterior
suture into the end of the anterior suture passer.
Use the wheel to pull the suture through the anterior Figure 13-52 Margin convergence.
instrument. Withdraw both the instrument and the

suture through the anterior cannula. I use a crochet
hook to pull both suture limbs out the posterior can-
nula and tie the knot (Figs. 13-56 through 13-58).
Suture Tying
If four sutures are placed in the longitudinal tear, the
tying sequence is as follows: Place the first (most
medial) suture. Place the second suture and then tie
the first. Place the third suture and tie the second
suture. Place the fourth suture and tie the third suture.
Figure 13-53 Margin convergence. Tie the fourth suture (see Figs. 13-50 through 13-53).
Subscapularis Tears
Subscapularis tears are often identified in patients
with massive supraspinatus and infraspinatus tears.
The subscapularis tears may be partial or full thick-
ness. Full-thickness lesions are usually confined to
Figure 13-54 Margin convergence, medial anchor repair.
Figure 13-56 Cuff-Stitch.
Figure 13-55 Margin convergence, anatomic anchor repair. Figure 13-57 Cuff-Stitch.
Burkhart SS, Barth JR, Richards DP, et al: Arthroscopic repair

of massive rotator cuff tears with stage 3 and 4 fatty
degeneration. Arthroscopy 23:347-354, 2007.
Burkhart SS, Danaceau SM, Pearce CE Jr: Arthroscopic
rotator cuff repair: Analysis of results by tear size and
by repair technique—margin convergence versus direct
tendon-to-bone repair. Arthroscopy 17:905-912, 2001.
Burkhart SS, Tehrany AM: Arthroscopic subscapularis tendon
repair: Technique and preliminary results. Arthroscopy
18:454-463, 2002.
Cordasco FA, Bigliani LU: The rotator cuff: Large and massive
tears. Technique of open repair. Orthop Clin North Am
28:179-193, 1997.
Costouros JG, Porramatikul M, Lie DT, Warner JJ: Reversal of
suprascapular neuropathy following arthroscopic repair
Figure 13-58 Spectrum suture passer. of massive supraspinatus and infraspinatus rotator cuff
tears. Arthroscopy 23:1152-1161, 2007.
DiGiovanni J, Marra G, Park JY, Bigliani LU: Hemiarthroplasty
for glenohumeral arthritis with massive rotator cuff tears.
the superior portion of the subscapularis and are easily
Orthop Clin North Am 29:477-489, 1998.
repaired with a standard arthroscopic rotator cuff Fenlin JM Jr, Chase JM, Rushton SA, Frieman BG:
repair technique. More substantial lesions require Tuberoplasty: Creation of an acromiohumeral articula-
that the surgeon move the arthroscope to the lateral tion—a treatment option for massive, irreparable rotator
portal and introduce instruments through the anterior cuff tears. J Shoulder Elbow Surg 11:136-142, 2002.
and posterior portals. However, the repair techniques Galatz LM, Ball CM, Teefey SA, et al: The outcome and repair
are similar to those discussed in the treatment of integrity of completely arthroscopically repaired large
full-thickness supraspinatus tears. and massive rotator cuff tears. J Bone Joint Surg Am
86:219-224, 2004.
Gartsman GM, Khan M, Hammerman SM: Arthroscopic
repair of full-thickness tears of the rotator cuff. J Bone
Subscapularis Repair
Joint Surg Am 80:832-840, 1998.
Gerber C, Schneeberger AG, Hoppeler H, Meyer DC:
POSTOPERATIVE MANAGEMENT Correlation of atrophy and fatty infiltration on strength
and integrity of rotator cuff repairs: A study in thirteen
The postoperative management is similar to that for patients. J Shoulder Elbow Surg 16:691-696, 2007.
patients who undergo routine rotator cuff repair, as Keen J, Nyland J, Kocabey Y, Malkani A: Shoulder and elbow
described in Chapter 19. function 2 years following long head triceps interposition
Rotator cuff surgery in patients with massive tears is flap transfer for massive rotator cuff tear reconstruction.
complex and technically demanding, but patient sat- Arch Orthop Trauma Surg 126:471-479, 2006.
isfaction is high because pain relief is excellent and Richards DP, Burkhart SS, Lo IK: Subscapularis tears:
function is satisfactory. Arthroscopic repair techniques. Orthop Clin North Am
34:485-498, 2003.
Sano H, Nakajo S: Repeated hemarthrosis with massive
rotator cuff tear. Arthroscopy 20:196-200, 2004.
BIBLIOGRAPHY Vad VB, Southern D, Warren RF: Prevalence of peripheral
neurologic injuries in rotator cuff tears with atrophy.
Burkhart SS: Partial repair of massive rotator cuff tears: J Shoulder Elbow Surg 12:333-336, 2003.
The evolution of a concept. Orthop Clin North Am Zingg PO, Jost B, Sukthankar A, et al: Clinical and structural
28:125-132, 1997. outcomes of nonoperative management of massive
Burkhart SS: The principle of margin convergence in rotator rotator cuff tears. J Bone Joint Surg Am 89:1928-1934,
cuff repair as a means of strain reduction at the tear 2007.
margin. Ann Biomed Eng 32:166-170, 2004.
Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence:
A method of reducing strain in massive rotator cuff tears.
Arthroscopy 12:335-338, 1996.
CHAPTER
14
Irreparable Rotator
Cuff Tears
The biggest problem with the arthroscopic treatment intra-articular abnormalities, preservation of the
of massive rotator cuff tears is the possibility of mis- deltoid insertion, and a complete inspection and
diagnosis. Often, a massive tear is retracted and manipulation of the rotator cuff without the need for
appears irreparable, but after soft tissue release, the acromioplasty, coracoacromial ligament resection, or
defect is reparable. I overcame this problem through subscapularis detachment. Perhaps the most difficult
practice: I estimated both the size and the reparability patients to treat are those whose irreparable tears were
of tears arthroscopically; then I opened the shoul- diagnosed after open acromioplasty and coracoacromi-
der for comparison until I became confident of the al ligament resection were performed. Loss of the static
accuracy of my arthroscopic diagnoses. restraint of the coracoacromial arch allows anterior
If the lesion is truly irreparable, arthroscopic treat- superior escape of the humeral head. Relatively painful
ment allows a thorough débridement while retaining shoulder elevation is converted to very painful shoul-
all the advantages of arthroscopic surgery, including der shrugging—the classic pseudoparalytic shoulder
glenohumeral joint inspection and correction of (Fig. 14-1).
A B
Figure 14-1 A and B, Irreparable rotator cuff tear.
296
Chapter 14 Irreparable Rotator Cuff Tears 297
LITERATURE REVIEW 25 patients with massive irreparable tears, 88% had good
or excellent results after arthroscopic treatment; those
When a massive, irreparable defect in the rotator cuff results have not deteriorated with the passage of time.
tendons is identified at surgery, the surgeon has vari- Many older individuals have relatively good active and
ous treatment options to choose from. Local tissue passive motion; pain is their primary complaint.
transfer from the remaining intact rotator cuff, use Arthroscopic débridement and biceps tenotomy can pro-
of the upper portion of the subscapularis, incorpora- vide good pain relief with little morbidity. For individuals
tion of the intra-articular portion of the biceps who need more motion or strength, I advise reverse
tendon, supraspinatus advancement, deltoid muscle shoulder arthroplasty.
flap, synthetic materials, and tendon allograft have
been proposed. A latissimus dorsi transfer has been
described by Gerber and others, but there are ques- DIAGNOSIS
tions about the morbidity of this procedure as well
as the dynamic function of the graft. For patients in Physical examination usually demonstrates normal
whom overhead work and stronger external rotation or near-normal passive range of motion; however,
are vital, the relatively modest gains afforded by latis- there may be limits because of capsular contractures.
simus dorsi transfer can be of major importance. Active range of motion is decreased. Supraspinatus
Subscapularis transfer and biceps incorporation are and infraspinatus atrophy may be observed. Manual
rarely performed. Synthetic grafts are currently a muscle testing demonstrates grade 3 or lower strength
source of great interest, but little science is available with external rotation and elevation. The patient’s
to guide the orthopedic surgeon. Because irreparable subscapularis function should be evaluated using
tendon tears are almost always accompanied by pro- either the belly-press test or the lift-off test with the
found muscle atrophy and fatty infiltration, it seems arm internally rotated to the back.
unlikely that synthetic tendon connected to nonvia- Plain radiographs may show the humeral head
ble muscle will function. centered in the glenoid, but superior migration may be
One of the most widely used open procedures was present. Magnetic resonance imaging (MRI), which some
described by Rockwood, who débrided the edges of surgeons do not use routinely in older patients, is often
the necrotic tendon, thoroughly decompressed the sub- of great value in this clinical setting. The amount of
acromial space by performing an anterior and inferior tendon retraction is more clearly defined on MRI than
acromioplasty, resected the coracoacromial ligament, on arthrography and, perhaps more important, the
and removed the subacromial bursa. The deltoid was degree of atrophy and fatty degeneration or substitution
meticulously repaired. Postoperatively, the patient in the rotator cuff muscles can be appreciated (Fig. 14-2).
was started on an immediate rehabilitation program. If the patient’s rotator cuff strength is grade 3 or less and
Rockwood obtained good results using this technique, MRI demonstrates humeral head superior migration,
with patients achieving pain relief and marked retraction of the tendon to the glenoid rim, and severe
improvement in function. My own experience was muscular atrophy, the cuff defect is almost certainly
not as positive. My success rate was lower, and I found irreparable.
that after this procedure some of my patients experi- The status of the subscapularis requires close atten-
enced an improvement in pain but a loss of strength. tion. Patients with irreparable, retracted subscapularis
Since these reports appeared, Nirschl has taught us tears can be treated with arthroscopic débridement.
to avoid acromioplasty in these patients. Preserving However, Burkhart has shown that patients with rep-
the coracoacromial arch helps keep the humeral arable subscapularis tears benefit from subscapularis
head centered in the glenohumeral joint and prevents repair even in the presence of superior humeral head
the disastrous complication of anterior superior hum- migration (Fig. 14-3).
eral head subluxation.
Less has been written about the arthroscopic treat-
ment of patients with irreparable tears. Ellman and I NONOPERATIVE TREATMENT
have both achieved good pain relief with arthroscopic
treatment in a limited number of patients; reasonable Nonoperative treatment consists of activity modifica-
pain relief has been documented in most patients at tion, nonsteroidal anti-inflammatory medications,
up to 5 years’ follow-up. We emphasize thorough cortisone injections, and a physical therapy program
débridement and synovectomy, accompanied by the designed to maintain or improve shoulder range of
removal of any downward-protruding acromial or acro- motion and strengthen the deltoid, scapular rotators,
mioclavicular joint spurs. Burkhart reported that among biceps, and intact rotator cuff muscles.
A B
Figure 14-2 A, Fatty infiltration of the supraspinatus, coronal view. B, Fatty infiltration of the supraspinatus and infraspinatus,
sagittal view.
I continue nonoperative treatment for at least tenotomy is helpful. The presence of a dislocated
6 months. A surprising number of patients have biceps, usually medial, is often very painful and
reduced pain as the inflammation decreases and responds well to biceps tenotomy.
regain adequate function with muscle strengthening
exercises. Stretching can often improve capsular con-
tracture and further diminish pain. CONTRAINDICATIONS TO SURGERY
Because the goal of this procedure is pain relief,

INDICATIONS FOR SURGERY patients who require strength for overhead work usu-
ally will not be satisfied with the results of débride-
Indications for operation include pain interfering with ment. In my practice, this is an unusual situation,
work or activities of daily living or nighttime because most of my patients with this condition are
pain unresponsive to the nonoperative treatment out- older and less active. Patients with painful passive
lined earlier. Patients should have a well-preserved external and internal rotation and advanced glenohu-
glenohumeral joint space on plain radiographs and meral joint arthritis are not candidates for arthro-
relatively pain-free passive external rotation with the scopic débridement. I prefer to treat these patients,
arm at the side. The presence of an intact biceps that or those with true rotator cuff arthropathy, with
could serve as a pain generator and might respond to reverse arthroplasty.
OPERATIVE TECHNIQUE
Irreparable Rotator Cuff Tear
Examine the shoulder for range of motion and compare

it with the contralateral shoulder. Perform a gentle
manipulation to correct losses of motion in abduction,
elevation, and external and internal rotation.
Glenohumeral Joint
A standard posterior portal is used to enter and inspect
the glenohumeral joint. Because there is no infraspi-
natus tendon, the joint is entered easily. Patients
Figure 14-3 Subscapularis tear. with irreparable rotator cuff tears are often older,
I use the same posterior skin incision to enter the

subacromial space. After the trocar passes through
the skin and subcutaneous tissue, but before it enters
the deltoid muscle, I translate the cannula and trocar
superiorly until the trocar tip touches the posterior
acromion. I then direct the cannula and trocar until
they are parallel to the acromion. I advance the can-
nula and trocar, palpate the acromion’s inferior
surface, and then slide along the inferior surface
until the trocar tip is 1 cm posterior to the anterior
edge of the acromion. This has three beneficial effects:
(1) the trocar tip can be used to dissect any rotator cuff
tendon that is adherent to the acromion; (2) the
cannula is positioned parallel to the inferior surface
of the acromion, not directed superiorly; and (3) the
arthroscope is positioned at the maximal distance
Figure 14-4 Anterior-inferior capsule release.
from the humeral head, which improves my perspec-
tive of the size and shape of the rotator cuff lesion.
I remove the trocar, insert the arthroscope, and estab-
lish a lateral working portal. I perform a bursectomy
and multiple glenohumeral abnormalities are identi- to view the rotator cuff defect clearly and then insert
fied. I ignore areas of minor labrum fraying or cartilage a cannula for outflow through the anterior portal
thinning on the glenoid or humeral head, which (Figs. 14-5 and 14-6). I insert a grasper through the
are not likely to be responsible for the patient’s pain. lateral portal and pull on the tendon edges to deter-
If I find labrum flap tears that could cause mechan- mine their quality and mobility (Figs. 14-7 and 14-8).
ical abnormalities, a glenoid surface abnormality I usually move the arthroscope to the lateral portal
such as a step-off, or a capsular contracture, I create and obtain a different view of the rotator cuff tear.
an anterior portal with a spinal needle. I place the Some surgeons prefer to view laterally and insert the
anterior portal more laterally than usual. If the ante- instruments from the posterior portal, whereas others
rior portal is placed normally (more medially and prefer to leave the arthroscope in the posterior portal
inferiorly) so that it enters the glenohumeral joint and insert the instruments laterally. I use whichever
adjacent to the superior border of the subscapularis portal gives me the best view of the subacromial space
tendon, it will not be useful for the subacromial (Fig. 14-9).
portion of this procedure, and an additional portal If the tear is massive and MRI or physical exami-
will be needed. nation does not demonstrate significant atrophy,
I débride labrum flap tears with a motorized shaver I perform soft tissue releases and consider repair
and correct areas of contracture as described in Chapter
6 (Fig. 14-4). I then remove all instruments and cannulas
from the glenohumeral joint.
Subacromial Space
It may seem unnecessary to remove the cannula
and reinsert it because with an irreparable tear, the
surgeon can view both the glenohumeral joint and
the subacromial space. However, I have found that
there is a subtle but critical difference in the angle
of the two views. When I enter the glenohumeral
joint, I tilt the arthroscope slightly inferiorly, which
allows a better view of the structures within the joint.
When directing the arthroscope superiorly to view
the subacromial space, the arthroscope is too close to
the humeral head, and its angle of approach tends to
distort the view. Figure 14-5 Rotator cuff adherent to the acromion (arrow).
Figure 14-6 Cannula parallel to the acromion.

Figure 14-9 Lateral view.
(Figs. 14-10 through 14-15). In these patients, the

posterior bursa can be quite hypertrophic and may
appear to be the posterior tendon. I palpate and
débride with a shaver to separate the bursa from the
tendon (Fig. 14-16).
I carefully examine the subscapularis. Débridement
of irreparable supraspinatus tears combined with
arthroscopic subscapularis repair often leads to
surprisingly good shoulder function (see Chapter 13).
If the rotator cuff tendons are absent or excessive ten-
sion would be necessary to effect a repair, I proceed to
débridement.
I use a motorized shaver to remove rotator cuff rem-
nants from the greater tuberosity. If the greater tube-
Figure 14-7 Traction on the rotator cuff tendon, posterior
rosity is prominent, I smooth it with a bur. I inspect
view.
the anterior, lateral, and posterior gutters for adhe-
sions that can restrict motion between the deltoid
Figure 14-8 Traction on the rotator cuff tendon, posterior

view. Figure 14-10 Superior capsule release.

Figure 14-11 Medial adhesions of the rotator cuff tendon.

Figure 14-15 Excessive tension.
Figure 14-13 Coracohumeral ligament release. Figure 14-16 Thickened posterior bursa.
Figure 14-17 Tuberosityplasty.
Figure 14-19 Medial dislocation of the biceps.
and the rotator cuff and remove them with arthro- medially. Another relative indication for biceps
scopic scissors, electrocautery, or a power shaver (Figs. tenotomy is a lack of tendon excursion. I grasp the
14-17 and 14-18). tendon with a tendon grasper inserted through the lat-
As Nirschl and Flatow reported, removal of the cor- eral cannula and try to translate it. Often the tendon is
acoacromial arch in patients with no functioning rota- adherent to bone or soft tissue distal to the bicipital
tor cuff can result in a devastating complication; groove and does not glide. My interpretation of this
superomedial humeral head dislocation. The coraco- finding is that the biceps has effectively undergone
acromial ligament is not resected, and I do not per- tenodesis, and the intra-articular portion can be sacri-
form an acromioplasty. ficed without any apparent negative effects. I discuss
An important source of pain in patients with irrepa- the option of tenotomy with patients preoperatively
rable rotator cuff tears can be the biceps tendon. and caution them about the potential for deformity. I
I consider tenotomy if the biceps tendon quality have been pleased with the amount of pain relief tenot-
is poor, there is a partial tear, or it is dislocated omy provides (Figs. 14-19 through 14-25).
Figure 14-18 Tuberosityplasty. Figure 14-20 Test biceps excursion.

Figure 14-21 Test biceps excursion.
Figure 14-24 Biceps tendon removed.
Figure 14-22 Distal biceps tendon release.
Figure 14-25 Biceps stump débrided.
POSTOPERATIVE MANAGEMENT
The various exercises for rehabilitation are illustrated

in Chapter 19. I start patients on immediate passive
range of motion with a continuous passive motion
chair, dowel, or pulley. Active range of motion for
routine activities of daily living can be started
once the patient recovers from the interscalene
block. I do not place the arm in a sling. Once passive
Figure 14-23 Proximal biceps tendon release. range of motion has been recovered, the patient can
begin active-assisted range-of-motion exercises. BIBLIOGRAPHY

I place the patient supine on the examining table
and passively elevate the shoulder to 90 degrees. Aluisio FV, Osbahr DC, Speer KP: Analysis of rotator cuff
If the patient can maintain this position with muscles in adult human cadaveric specimens. Am J
active muscle stabilization, I determine whether he Orthop 32:124-129, 2003.
or she has enough control to lower the arm inde- Boileau P, Baqué F, Valerio L, et al: Isolated arthroscopic
pendently. If so, I ask the patient to actively raise biceps tenotomy or tenodesis improves symptoms in
patients with massive irreparable rotator cuff tears.
the arm. If the patient cannot perform the active
J Bone Joint Surg Am 89:747-757, 2007.
and active-assisted exercises supine (with the scapula Boileau P, Krishnan SG, Coste JS, Walch G: Arthroscopic
supported and gravity eliminated), I do not allow biceps tenodesis: A new technique using bioabsorbable
him or her to work on standing, active, overhead interference screw fixation. Arthroscopy 18:1002-1012,
elevation. The patient works supine until good arm 2002.
control has been achieved; only then does he or she Burkhart SS: Arthroscopic treatment of massive rotator cuff
progress to the next stage. tears: Clinical results and biomechanical rationale.
Standing active range of motion also has three Clin Orthop Relat Res 267:45-56, 1991.
phases. First, I have the patient elevate the arm pas- Burkhart S, Nottage WM, Ogilvie-Harris DJ, et al: Partial
sively and try to maintain it in elevation actively. repair of irreparable rotator cuff tears. Arthroscopy
10:363-370, 1994.
I advise the patient to keep the contralateral hand
Codsi MJ, Hennigan S, Herzog R, et al: Latissimus dorsi
under the operated forearm; this provides some tendon transfer for irreparable posterosuperior rotator
emotional support, because most patients have not cuff tears: Surgical technique. J Bone Joint Surg Am
had the arm in this position for some time. Also, if 89(Suppl 2):1-9, 2007.
the patient cannot control the operated shoulder, Costouros JG, Espinosa N, Schmid MR, Gerber C: Teres
the normal hand is there to prevent it from falling minor integrity predicts outcome of latissimus dorsi
to the side. Once the patient can hold this position tendon transfer for irreparable rotator cuff tears.
comfortably for 30 seconds (the patient performs J Shoulder Elbow Surg 16:727-734, 2007.
the exercise in front of a clock with a second Dines DM, Moynihan DP, Dines JS, McCann P: Irreparable
rotator cuff tears: What to do and when to do it; the
hand), I have the patient raise the arm passively,
surgeon’s dilemma. Instr Course Lect 56:13-22, 2007.
hold it there for 5 seconds, and then lower it
Duralde XA, Bair B: Massive rotator cuff tears: The result
slowly. Again, the contralateral hand is there for of partial rotator cuff repair. J Shoulder Elbow Surg
support as needed. Once the patient is comfortable 14:121-127, 2005.
with phase two, active elevation can begin. The Edwards TB, Walch G, Nové-Josserand L, et al: Arthroscopic
patient begins by assisting the operated arm with debridement in the treatment of patients with isolated
fingertip pressure from the normal arm until full tears of the subscapularis. Arthroscopy 22:941-946, 2006.
elevation is achieved. I gradually have the patient Ellman H, Kay SP, Wirth M: Arthroscopic treatment of full-
decrease the use of the normal arm until full, slow, thickness rotator cuff tears: 2- to 7-year follow-up study.
controlled active elevation is possible. Arthroscopy 9:195-200, 1993.
Fenlin JM, Chase JM, Rushton SA, Frieman BG: Tuberoplasty:
Once postoperative pain has diminished, patients
Creation of an acromiohumeral articulation—a treatment
also begin a strengthening program and use light
option for massive, irreparable rotator cuff tears.
surgical tubing to strengthen the deltoid, internal J Shoulder Elbow Surg 11:136-142, 2002.
rotators, and scapular stabilizing muscles. It is criti- Funakoshi T, Majima T, Iwasaki N, et al: Application of tissue
cal to provide encouragement to these patients and engineering techniques for rotator cuff regeneration
inform them that it will take many months to using a chitosan-based hyaluronan hybrid fiber scaffold.
achieve the goals of the operation. Am J Sports Med 33:1193-1201, 2005.
Gartsman GM: Arthroscopic assessment of rotator cuff tear
reparability. Arthroscopy 12:546-549, 1996.
COMPLICATIONS Gartsman GM: Massive, irreparable tears of the rotator
cuff: Results of operative debridement and subacromial
decompression. J Bone Joint Surg Am 79:715-721, 1997.
The most devastating complication is superome-
Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer
dial humeral head instability and subluxation. for the treatment of irreparable rotator cuff tears. J Bone
I avoid this problem by leaving the coracoacromial Joint Surg Am 88:113-120, 2006.
ligament intact and not performing an anterior Halder AM, O’Driscoll SW, Heers G, et al: Biomechanical
acromionectomy or anterior-inferior acromio- comparison of effects of supraspinatus tendon detach-
plasty. Treatment may require a reverse shoulder ments, tendon defects, and muscle retractions. J Bone
prosthesis. Joint Surg Am 84:780-785, 2002.
Iannotti JP, Hennigan S, Herzog R, et al: Latissimus dorsi Nirschl RP: Rotator cuff surgery. Instr Course Lect 38:447-
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Am 88:342-348, 2006. anatomic study of latissimus dorsi and teres major trans-
Jost B, Puskas GJ, Lustenberger A, Gerber C: Outcome of pec- fers. J Bone Joint Surg Am 88:1524-1531, 2006.
toralis major transfer for the treatment of irreparable sub- Postacchini F, Gumina S: Results of surgery after failed attempt
scapularis tears. J Bone Joint Surg Am 85:1944-1951, 2003. at repair of irreparable rotator cuff tear. Clin Orthop Relat
Klinger HM, Steckel H, Ernstberger T, Baums MH: Res 397:332-341, 2002.
Arthroscopic debridement of massive rotator cuff tears: Walch G, Edwards TB, Boulahia A, et al: Arthroscopic tenot-
Negative prognostic factors. Arch Orthop Trauma Surg omy of the long head of the biceps in the treatment of
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Konrad GG, Sudkamp NP, Kreuz PC, et al: Pectoralis major cases. J Shoulder Elbow Surg 14:238-246, 2005.
tendon transfers above or underneath the conjoint tendon Werner CM, Zingg PO, Lie D, et al: The biomechanical role of
in subscapularis-deficient shoulders: An in vitro biomecha- the subscapularis in latissimus dorsi transfer for the treat-
nical analysis. J Bone Joint Surg Am 89:2477-2484, 2007. ment of irreparable rotator cuff tears. J Shoulder Elbow
Ma HL, Hung SC, Wang ST, Chen TH: The reoperation of failed Surg 15:736-742, 2006.
rotator cuff repairs. J Chin Med Assoc 66:96-102, 2003. Wirth MA, Rockwood CA: Operative treatment of irrepara-
Moore DR, Cain EL, Schwartz ML, Clancy WG: Allograft ble rupture of the subscapularis. J Bone Joint Surg Am
reconstruction for massive, irreparable rotator cuff tears. 79:722-731, 1997.
Am J Sports Med 34:392-396, 2006. Zingg PO, Jost B, Sukthankar A, et al: Clinical and structural
Morelli M, Nagamori J, Gilbart M, Miniaci A: Latissimus dor- outcomes of nonoperative management of massive rota-
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anatomic study. J Shoulder Elbow Surg 17:139-143, 2007.
Mura N, O’Driscoll SW, Zobitz ME, et al: Biomechanical
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CHAPTER
15
Acromioclavicular joint pain is a common shoulder instability. I treat these patients with open reconstruc-
condition that can result from a specific injury, from tion of the coracoclavicular ligaments (Fig. 15-2).
repetitive minor trauma, or as part of the aging
process. When the source of pain is articular incongruity,
the lesion is amenable to arthroscopic treatment LITERATURE REVIEW
(Fig. 15-1).
Articular incongruity may be seen in post-traumatic My colleagues and I have demonstrated that an
arthritis, type 2 acromioclavicular dislocation with adequate acromioclavicular resection can be performed
less than 25% subluxation, primary osteoarthritis, arthroscopically in a laboratory setting and that
rheumatoid arthritis, septic arthritis, and osteolysis satisfactory results can be obtained in a clinical setting.
of the distal clavicle. In my experience, individuals Snyder (see Buford et al) and Flatow reported good
with type 3 to type 6 acromioclavicular dislocations results in 90% of patients. Neviaser demonstrated the
are not suitable candidates for arthroscopic surgery efficacy of resecting only the medial acromion without
because their pain is due to acromioclavicular joint resecting the distal clavicle. Both the direct approach to
Figure 15-1 Acromioclavicular joint arthritis. Figure 15-2 Type 5 acromioclavicular joint dislocation.
306
Chapter 15 Acromioclavicular Joint 307
the acromioclavicular joint and the indirect approach

through the subacromial bursa appear to be equally
effective. Arthroscopic reconstruction of the acromio-
clavicular joint for dislocation has been reported.
Owing to the short-term nature of the results, I still
prefer open operative reconstruction.
DIAGNOSIS
Patients complain of pain in the area of the acromio-

clavicular joint during cross-body adduction (washing
the opposite axilla or reaching for a seatbelt) or behind-
the-back internal rotation (fastening a bra or pulling
a belt through its loops). Weight lifters experience
pain during a flat or inclined bench press. Physical
examination demonstrates normal active and passive
range of motion, with the exception of limited
adduction or internal rotation. There is pain on direct to that of patients with acromioclavicular arthritis.
palpation of the anterior or superior aspect of the Patients localize their pain deep to the acromiocla-
acromioclavicular joint. Selective injections (described vicular joint and have pain with adduction and
later) are a useful adjunct. behind-the-back internal rotation. Specific acromio-
Plain anteroposterior radiographs demonstrate clavicular tenderness to palpation is absent. Adduc-
joint space narrowing, joint incongruity, inferior tion is similar to the movement performed during
osteophytes, or distal osteolysis. A 15-degree apical the O’Brien test and may misdirect the surgeon
tilt view may show the acromioclavicular joint (Fig. 15-4).
more clearly. Magnetic resonance imaging (MRI)
commonly demonstrates acromioclavicular joint
arthritis in patients older than 40 years. The radiolo- NONOPERATIVE TREATMENT
gist almost always mentions changes that are inter-
preted as acromioclavicular arthritis. The surgeon Nonoperative treatment is usually successful and
should be careful to interpret such studies in light of consists of avoidance of painful positions and activ-
an appropriate patient history and physical examina- ities and nonsteroidal anti-inflammatory medication.
tion (Fig. 15-3). Because the pain from this condition is rarely
Some patients with superior labrum from anterior disabling, I counsel patients to wait 6 to 12 months
to posterior (SLAP) lesions have a presentation similar before they consider surgery.
Injection
Lesions of the acromioclavicular joint and subacromial
space are difficult to differentiate. Acromioclavicular
arthritis can cause irritation of the underlying cuff,
and the altered shoulder mechanics that accompany
rotator cuff disease may aggravate an otherwise
normal acromioclavicular joint. Selective acromiocla-
vicular joint injection has two possible benefits:
it may help the surgeon diagnose the primary source
of pain, and it may be therapeutic if the cortisone
diminishes joint inflammation. I use a 25-gauge short-
barrel needle; a longer needle can inadvertently
penetrate the inferior acromioclavicular joint capsule
and enter the subacromial space. Palpate the sulcus
Figure 15-3 Magnetic resonance image showing acromio- between the distal clavicle and medial acromion.
clavicular joint arthritis. Because the acromioclavicular joint may slope or tilt
in different directions, study the anteroposterior radio-

graph to determine the joint inclination. Clean the skin
overlying the superior aspect of the joint with an
antibacterial preparation. Advance the needle through
the skin while maintaining gentle pressure on the plun-
ger. When the joint is entered, you will feel the change
in resistance. Inject 1 to 2 mL of 2% plain lidocaine
and 1 mL of methylprednisolone (Depo-Medrol).
Figure 15-6 Acromioplasty.

Surgery is indicated when acromioclavicular joint

arthritis has been identified as the source of shoulder medial acromion and distal clavicle so that physical
pain by patient history, physical examination, plain contact is eliminated during shoulder motion.
radiographs and, when appropriate, MRI. Patients Traditionally, open resection involves the removal of
whose pain interferes with activities of daily living, 1 to 1.5 cm of distal clavicle. Arthroscopic acromiocla-
work, or sports and who have not responded to a vicular resection removes 5 to 8 mm of distal clavicle
minimum of 6 months’ conservative care are good and 5 mm of medial acromion (Figs. 15-5 through 15-
candidates for arthroscopic acromioclavicular joint 11).
resection. Patients with MRI evidence of acromiocla- Patient positioning and diagnostic glenohumeral
vicular joint arthritis but whose pain is not localized arthroscopy are performed routinely. However, I move
to the acromioclavicular joint are not candidates for the posterior incision 2 to 3 mm laterally from its
acromioclavicular joint resection.
OPERATIVE TECHNIQUE
Resection
The two goals of arthroscopic acromioclavicular joint

resection are to remove the abnormal distal portion of
the clavicle and to create enough space between the
A
5-10 mm 5-10 mm
B
B
Figure 15-7 A and B, Resect the anterior portion of the
Figure 15-5 A and B, Area of desired bone removal. medial acromion.
7-10 mm
5 mm
Figure 15-10 Resect the distal clavicle.
B
Figure 15-8 A and B, Complete medial acromion resection.
C
B
Figure 15-11 A-C, End-on view showing the sequence of
Figure 15-9 A and B, Expose the distal clavicle. distal clavicle resection.
normal location. This allows me to angle the arthro-

scope medially and obtain a better view of the distal
clavicle when I enter the subacromial space. The instru-
ments are then removed, and attention is turned to the
subacromial space.
The cannula and trocar are inserted through the
posterior incision into the subacromial space. The ar-
throscope is inserted, and a subacromial inspection is
performed. If the space is not seen clearly, bursectomy
is performed as described in Chapter 10. If arthro-
scopic subacromial decompression is required, the
procedure is performed as described in Chapter 10.
I modify arthroscopic subacromial decompression
when I combine it with acromioclavicular resection.
I completely resect the medial acromial wall adjacent
to the acromioclavicular joint from anterior to
posterior. Figure 15-13 Resect the inferior aspect of the medial acro-
If arthroscopic subacromial decompression is mion with the bur in the lateral portal.
not necessary, I establish a lateral portal for instru-
mentation. I use a soft tissue resector to remove any
bursa that obscures the view of the medial acromion
and use electrocautery to coagulate the soft tissue and
vessels on the acromion. The cutting or ablation set-
ting on the electrocautery device can effectively
expose acromial bone. I use a soft tissue resector
until the medial acromial surface is free from soft
tissue. I then insert a power bur through the lateral
portal and remove the medial acromion until soft
tissue or distal clavicle is visible (Figs. 15-12 through
15-16).
I then establish an anterior portal directly anterior
to the acromioclavicular joint. Precision is critical, so
I use a spinal needle to localize the cannula site.
The anterior portal must be located in the center of
Figure 15-14 Arthroscope rotated medially.
Figure 15-12 Use cautery to expose the bone surface and

cauterize blood vessels. Figure 15-15 Distal clavicle viewed from the posterior portal.
Figure 15-18 Needle localizing the anterior portal.
Figure 15-16 Distal clavicle viewed from the lateral portal.
This decreases the likelihood of bleeding during bone

the acromioclavicular joint. If the location is too lat- and soft tissue removal (Figs. 15-20 and 15-21).
eral, it is difficult to remove the distal clavicle; if it is too I tilt the arthroscope superiorly and rotate the cam-
medial, it is difficult to remove the medial acromion era until I have the best view of the anterior portion
(Figs. 15-17 through 15-19). of the medial acromion. I use the bur to remove the
If I have a good view of the distal clavicle with the superior surface of the medial acromion from anterior
arthroscope positioned in the posterior cannula, there to posterior, being careful not to violate the superior
is no need to change its location. In most cases, I can capsule of the acromioclavicular joint. At this point,
angle the cannula medially and rotate the arthroscope I have removed 4 to 5 mm of bone from the medial acro-
to obtain a good view. I usually perform the medial mion. I then withdraw the arthroscope and rotate it
acromial resection and the initial portion of the distal so that I am looking directly at the distal clavicle.
clavicle resection with the arthroscope in the posterior I remove one bur width of distal clavicle from ante-
portal. In most patients, I routinely move the arthro- rior to posterior and begin removing bone from the
scope to the lateral portal to finish the posterior por- anterior half of the distal clavicle. I remove bone
tion of the distal clavicle resection. equal to the depth of the acromionizer (5 mm) or
I cauterize the soft tissue at the anterior, inferior, the metal guard around the bur (7.2 mm). Then I
and posterior borders of the distal clavicle. usually move the arthroscope to the lateral portal
Figure 15-17 Location of the anterior portal. Figure 15-19 Needle in the anterior portal.
Figure 15-20 Cautery of the anterior clavicle. Figure 15-22 Resect the superior portion of the medial
acromion.
and the outflow cannula to the posterior portal. This

allows an end-on view of the distal clavicle. I move the
bur posteriorly and remove the same amount of bone
from the posterior half of the distal clavicle until the
clavicle surface is flat. I rotate and tilt the arthroscope
until I can see the posterior border of the distal clavicle
and the posteromedial acromion. I inspect the posterior
aspect of the acromioclavicular joint and remove any
remaining posteromedial acromion that may cause
impingement during shoulder extension or abduction.
At this point, 10 to 15 mm of bone has been removed (5
mm of medial acromion, and 5 to 10 mm of distal clavi-
cle). I advance the cannula or shaver (an instrument with
a known size) into the resected area to ensure that there
is adequate space between the distal clavicle and the
acromion. I also advise surgeons to insert the arthroscope Figure 15-23 Resect the superior portion of the medial
into the anterior cannula and view the acromioclavicular acromion.
joint directly (Figs. 15-22 through 15-33).
Figure 15-24 Resect the superior portion of the medial acro-

Figure 15-21 Cautery of the inferior clavicle. mion with the arthroscope rotated superiorly.
Figure 15-25 Resect the superior portion of the medial acro- Figure 15-28 Anterior clavicle resection.
mion with the arthroscope rotated superiorly.
Figure 15-29 Anterior clavicle resection.

Figure 15-26 Superior capsule of the acromioclavicular joint.
Figure 15-27 Remove 4 to 5 mm of bone in the medial Figure 15-30 Evaluate the posteromedial acromion for
acromion. contact.
Cannula Position
Cannula position is critical, and small errors can
significantly prolong operative time and diminish
the quality of the resection.
Posterior Portal
If the posterior portal is placed in the ‘‘soft spot,’’ it is
too medial and inferior to allow a good view of the
distal clavicle. My standard portal location for
an arthroscopic subacromial decompression is 1 cm
inferior and 1 cm medial to the posterolateral acromial
margin. For an acromioclavicular joint resection,
I move the posterior portal 2 to 3 mm laterally.
Figure 15-31 Outside view of the bur in the anterior cannula. This allows me to angle the arthroscope medially
and obtain a better view of the distal clavicle.
Lateral Portal
If the lateral portal is too anterior, the anterior clavicle
and acromion are not well visualized, which can lead
to inadequate bone resection. If the lateral cannula is
too superior, the superior aspect of the distal clavicle
and medial acromion cannot be seen.
An ice pack decreases swelling, inflammation, and pain

postoperatively. It is worn for 1 hour, four times a day,
for the first 2 weeks. Active and passive range of motion
is started on the first postoperative day. Strengthening is
started when examination demonstrates pain-free
Figure 15-32 Measure the amount of bone resection. manual muscle testing. Work and sports are allowed
as tolerated by the patient. Maximal improvement
occurs 6 to 12 months after operation.
COMPLICATIONS
Acromioclavicular instability is a concern after acro-

mioclavicular resection. I limit distal clavicle resection
to 10 to 15 mm to avoid violating the coracoclavicular
ligaments. When I remove the superior distal clavicle
osteophyte, I pay particular attention to the superior
soft tissue envelope and do not resect any superior
acromioclavicular ligament.
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Gartsman GM, Combs AH, Davis PF, et al: Arthroscopic acro- Arthroscopy 19:E119-E120, 2003.
mioclavicular joint resection: An anatomical study. Am J Tytherleigh-Strong G, Gill J, Sforza G, et al: Reossification
Sports Med 19:1:2-5, 1991. and fusion across the acromioclavicular joint after arthro-
Kay SP, Dragoo JL, Lee R: Long-term results of arthroscopic scopic acromioplasty and distal clavicle resection.
resection of the distal clavicle with concomitant subacro- Arthroscopy 17:E36, 2001.
mial decompression. Arthroscopy 19:805-809, 2003.
CHAPTER
16
Calcific Tendinitis
One of the most painful acute conditions affecting calcification, or duration of symptoms. Acromioplasty
the shoulder is calcific tendinitis. Patients experience was not shown to be of any benefit. In contrast, Mole
a sudden, atraumatic onset of severe pain that is and colleagues reported that acromioplasty improved
present at rest and increases with any shoulder move- the outcome in their patients.
ment. The pain is often severe enough to cause the
individual to present at a local emergency room or
to demand immediate evaluation in the orthopedist’s DIAGNOSIS
office. Patients often appear to be in distress and cradle
the affected arm. The diagnosis of calcific tendinitis is radiographic.
Plain radiographs show single or multiple calcium
deposits usually located in the supraspinatus tendon
LITERATURE REVIEW (65%). They also can occur in the infraspinatus (30%)
or, more rarely, the subscapularis tendon (5%).
The cause of acute calcific tendinitis is not precisely The size, density, and location of the deposit must
known, but Uhthoff’s analysis of the condition is be evaluated closely to distinguish this condition
the best. He considers calcific tendinitis a self-healing from the dystrophic calcific densities that occur inci-
tendinopathy with a precalcifying phase during which dentally in rotator cuff tendinosis. These findings
a reduction in oxygen tension transforms a portion of are summarized in Table 16-1 and shown in Figures
the tendon into fibrocartilage. In this phase, chondro- 16-1 through 16-4.
cytes mediate the deposition of calcium. Following The shoulder is often swollen, and the overlying
the formative phase, the calcium may exist for skin is sensitive to touch. The slightest pressure
an indefinite period and produce no symptoms. applied over the supraspinatus insertion may elicit
At some point, phagocytic cells accumulate around severe pain. Active and passive range of motion is
these calcium foci, and vascular proliferation occurs. painful and restricted. Another cause of acute shoulder
The resorptive phase begins when these new vascular pain is cervical radiculopathy, and the surgeon
channels provide a pathway for resorption and restore should attempt to elicit a history of radicular pain
normal perfusion and oxygen tension to the tissues. or paresthesia and carefully examine the patient
The acute pain begins with the resorptive phase. for neck pain with neck motion. A review of the
After the calcification is resorbed, the tendon is radiographs confirms the diagnosis. Owing to the
capable of normal function. persistent, severe pain, patients often present with a
Ellman reported on a multicenter study of magnetic resonance image taken to evaluate the
131 patients treated arthroscopically. The average rotator cuff tendons. Diagnostic ultrasonography
Constant functional score was 69.4 of a possible 75. is an easy and effective method of diagnosis (Figs.
There was no correlation with patient age, size of the 16-5 and 16-6).
316
Chapter 16 Calcific Tendinitis 317
Table 16-1 RADIOGRAPHIC FEATURES OF

CALCIUM DEPOSITS
Calcific Rotator Cuff

Feature Tendinitis Tendinosis
Size 5-15 mm <5 mm

Location 10-15 mm medial to Adjacent to
greater tuberosity tuberosity
Density Less opaque Dense
Character Soft Hard
Figure 16-3 Calcific tendinitis in the subscapularis, with the

shoulder externally rotated.
Figure 16-1 Calcific tendinitis, with the shoulder externally

rotated. Figure 16-4 Calcific tendinitis in the subscapularis, with the
shoulder internally rotated.
Figure 16-2 Calcific tendinitis, with the shoulder internally Figure 16-5 Calcific tendinitis on magnetic resonance
rotated. imaging.
I have not operated on any patients for an initial acute

attack of calcific tendinitis because the nonoperative
treatment described earlier is generally successful.
The indication for operation is repeated episodes of
acute calcific tendinitis. I do not require a specific
number of attacks before I consider operation;
after the second episode, I offer arthroscopic surgery
as a treatment option. Patients’ ability to tolerate
episodes of severe pain varies greatly. Some patients
choose not to have surgery for yearly attacks, whereas
others welcome the opportunity for surgical
correction.
OPERATIVE TECHNIQUE
Calcific Tendinitis
Figure 16-6 On ultrasonography, a hypoechoic (black) area
is seen in the tendon (arrow). The location of the deposit is determined by reviewing
radiographs taken with the arm in different positions.
On the anteroposterior radiograph, deposits in the
supraspinatus tendon move medially when the arm
NONOPERATIVE TREATMENT is internally rotated. Lesions in the infraspinatus
move laterally as the arm is moved into internal rota-
Patients presenting with an attack of acute calcific tion. It is also important to note how far medially the
tendinitis are likely in the resorptive phase, and the calcium is located from the greater tuberosity. Study
condition is self-resolving. Therefore, nonoperative the axillary radiograph to determine the location of
care is supportive and consists of an explanation of the calcific deposit.
the condition’s natural history, narcotic analgesics, Calcium excision usually produces a vigorous
rest, and ice. The application of heat increases blood inflammatory response, and many patients experience
flow to an inflamed area but also increases pain and is an acute attack in the postoperative period. For this
therefore contraindicated. I believe that nonsteroidal reason, unless there are medical contraindications
anti-inflammatory medications decrease the ability such as diabetes or hypertension, I have the anesthe-
to resorb calcium, so I do not prescribe them, nor siologist administer 100 mg of methylprednisolone
do I inject cortisone into the subacromial space. (Solu-Medrol) intravenously before the operation and
Occasionally, I inject a local anesthetic (bupivacaine place the patient on a Medrol Dosepak after surgery.
0.25%) into the subacromial space to provide tempo- Interscalene block anesthesia is extremely helpful in
rary pain relief, but I make no attempt to needle the the treatment of these patients.
calcium deposit. Once the severe pain has subsided, I establish a routine posterior glenohumeral joint
I instruct patients in gentle stretching exercises and portal and perform a complete glenohumeral joint
allow them to resume activities as tolerated. If the inspection. I inspect the rotator cuff articular surface
attack of calcific tendinitis is prolonged and muscular for areas of erythema or increased vascularity because
atrophy develops, I prescribe a series of home exercises these areas may correspond to the location of the cal-
with surgical tubing to improve the strength of the cium deposit (Fig. 16-7). When there is an abnormality,
shoulder girdle muscles. Mole and colleagues studied it is commonly located in the anterior rotator cuff,
the effects of treatment on calcium deposits and found within the supraspinatus tendon. However, in patients
that supportive treatment led to a 0% disappearance with chronic calcific tendinitis, the articular cuff surface
rate at 4 years, extracorporeal shock waves to a is usually normal. If the rotator cuff and the remainder of
35% disappearance rate at 1 year, and needling to a the glenohumeral joint appear normal, I immediately
60% disappearance rate at 1 year. Prospective, ran- proceed to the subacromial space.
domized studies have not documented the benefits I insert the arthroscope into the subacromial space
of extracorporeal shock-wave treatment. through the posterior portal and establish a lateral
Figure 16-9 Knife used to incise the bursal covering of

Figure 16-7 Erythema on the articular surface of the calcium.
supraspinatus.
subacromial portal. I insert a motorized shaver and area of the tendon and use intraoperative radiographs
perform a bursectomy so that I can see clearly within or fluoroscopy. Once the calcium deposit is identified,
the subacromial space. Calcium deposits may appear I begin the process of calcium removal.
as whitish discolorations or bulges in the tendon I insert an arthroscopic scissors or knife through the
(Fig. 16-8). lateral portal and incise the deposit (Figs. 16-9 and
If the tendon appears normal and no deposit is seen, 16-10). The consistency of the calcium deposit is
I insert a blunt trocar through the lateral cannula and variable. It may feel as hard as bone, similar to tooth-
palpate the tendon for areas of increased hardness. It is paste, or granular. Pressure on the tendon may express
important not to confuse the firm feeling of the supra- the calcium, in which case it can be seen filling the sub-
spinatus insertion into the greater tuberosity with a acromial space. I increase the rate of pump flow (not
calcium deposit. If I cannot detect any calcium through pump pressure) to maintain visualization. Commonly,
inspection or palpation, I insert a spinal needle and a portion of the calcium remains adherent to the
puncture the tendon in multiple areas of the suspected tendon fibers or interspersed within the tendon
lesion. If no abnormal areas are identified with this substance. I insert a motorized shaver and gently
approach, I insert a spinal needle into the most likely remove calcium while maintaining tendon integrity.
Figure 16-8 Calcium deposit viewed from the subacromial Figure 16-10 Knife used to incise the bursal covering of
space. calcium.
I do not perform an acromioplasty because I believe

the exposed bone surface increases the risk of postop-
erative stiffness.
I have patients start passive range of motion in eleva-

tion and external rotation on the afternoon of surgery.
Patients find the continuous passive motion chair
an effective treatment. They are encouraged to use
the shoulder actively and perform routine activities
of daily living within the limits of their discomfort.
I do not allow patients to use a sling. I see patients
Figure 16-11 Shaver removing calcium. in the office 2 weeks after the operation and obtain
an anteroposterior radiograph to evaluate the change
in the calcium deposit.
I have patients stop continuous passive motion and
The shaver tip can also be used as a probe to apply use supine dowel passive range of motion in the same
pressure to the calcium deposit (Fig. 16-11). If the planes. I see patients in the office 2 months after
deposit is hard or bonelike, I use the shaver to remove operation, and if they have no pain with resisted
as much calcium as possible without excising tendon muscle testing, they start a home strengthening pro-
fibers. I prefer to leave some calcium rather than gram with rubber tubing.
sacrifice tendon integrity. Once the deposit is opened
and most of the calcium removed, the resorption
process is unimpeded. The postoperative radiograph
almost always demonstrates a complete absence of BIBLIOGRAPHY
calcium.
If a defect exists in the tendon after calcium Ark JW, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic treat-
removal, I do not repair the tendon (Fig. 16-12). The ment of calcific tendinitis of the shoulder. Arthroscopy
protected motion required after rotator cuff repair 8:183-188, 1992.
combined with the intense inflammatory response Arrigoni P, Brady PC, Burkhart SS: Calcific tendonitis of
after calcium excision often result in profound shoul- the subscapularis tendon causing subcoracoid stenosis
and coracoid impingement. Arthroscopy 22:1139.e1-
der stiffness. I have never had to repair a supraspinatus
1139.e3, 2006.
defect that went on to become a full-thickness tear.
Ellman H: Shoulder arthroscopy: Current indications and
techniques. Orthopedics 11:45-51, 1988.
Gotoh M, Higuchi F, Suzuki R, Yamanaka K: Progression
from calcifying tendinitis to rotator cuff tear. Skeletal
Radiol 32:86-89, 2003.
Hurt G, Baker CL Jr: Calcific tendinitis of the shoulder.
Orthop Clin North Am 34:567-575, 2003.
Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of
calcific tendinitis of the shoulder. J Shoulder Elbow Surg
7:30-37, 1998.
Krasny C, Enenkel M, Aigner N, et al: Ultrasound-guided nee-
dling combined with shock-wave therapy for the treat-
ment of calcifying tendonitis of the shoulder. J Bone
Joint Surg Br 87:501-507, 2005.
Mole D, Kempf JF, Gleyze P: Calcifications of the rotator cuff.
Rev Orthop 79:532-541, 1993.
Noel E: Treatment of calcific tendinitis and adhesive capsu-
litis of the shoulder. Rev Rhum Engl Ed 64:619-628, 1997.
Nutton RW, McBirnie JM, Phillips C: Treatment of chronic
rotator-cuff impingement by arthroscopic subacromial
Figure 16-12 Rotator cuff defect after calcium removal. decompression. J Bone Joint Surg Br 79:73-76, 1997.
Rotini R, Bungaro P, Antonioli D, et al: Algorithm for the Sorensen L, Teichert G, Skjodt T, Dichmann OL: Preoperative
treatment of calcific tendinitis in the rotator cuff: ultrasonographic-guided marking of calcium deposits in
Indications for arthroscopy and results in our experience. the rotator cuff facilitates localization during arthroscopic
Chir Organi Mov 90:105-112, 2005. surgery. Arthroscopy 20(Suppl 2):103-104, 2004.
Seil R, Litzenburger H, Kohn D, Rupp S: Arthroscopic treat- Uhthoff HK, Loehr JW: Calcific tendinopathy of the rotator
ment of chronically painful calcifying tendinitis of the cuff: Pathogenesis, diagnosis, and management. J Am
supraspinatus tendon. Arthroscopy 22:521-527, 2006. Acad Orthop Surg 5:183-191, 1997.
Sirveaux F, Gosselin O, Roche O, et al: [Postoperative results
after arthroscopic treatment of rotator cuff calcifying ten-
donitis, with or without associated glenohumeral
exploration]. Rev Chir Orthop Reparatrice Appar Mot
91:295-299, 2005.
CHAPTER
17
Fractures
Arthroscopic techniques are rarely used in the treat- subscapularis repair. Small glenoid rim fractures asso-
ment of shoulder fractures; however, arthroscopy ciated with glenohumeral instability are covered in
may be beneficial in some cases of greater tuberosity Chapter 4. Larger glenoid fractures that are displaced
fracture, fracture of the glenoid rim, and displaced and associated with humeral head instability or with
intra-articular humeral head malunion. Displaced a significant (> 5 mm) step-off can be treated arthros-
greater tuberosity fractures and greater tuberosity copically (Fig. 17-1).
nonunions can be treated arthroscopically. These Rarely, the malunion of an intra-articular fracture
may be isolated two-part fractures or fractures that blocks glenohumeral joint motion. In this case, I use a
accompany an anterior glenohumeral joint disloca- bur to smooth the prominence, combined with a soft
tion. I have used arthroscopy to identify significant tissue release to help restore motion. There have been
partial-thickness rotator cuff tears as the source of a few reports of the arthroscopic treatment of proxi-
pain in patients who exhibited satisfactory bone mal humerus fractures (usually combined with an
union after a greater tuberosity fracture. Isolated, dis- open approach owing to inadequate reduction), but
placed lesser tuberosity fractures can be managed I have no experience with the arthroscopic treatment
arthroscopically; usually this is combined with a of these fractures.
LITERATURE REVIEW
The majority of fracture cases involve glenoid rim frac-

tures. Smaller fragments are incorporated with suture
fixation during a Bankart repair, and larger fragments
can be fixed with cannulated screws. Hardy (see Bauer
et al) from France has had good experience in the man-
agement of glenoid fractures arthroscopically. Acute
greater tuberosity fractures occur both with and with-
out glenohumeral dislocation; the association between
greater tuberosity fracture and acute anterior-inferior
glenohumeral dislocation is well known. Operative
treatment for displaced greater tuberosity fractures
using an open surgical approach has been described.
My colleagues and I have documented our experience
Figure 17-1 Glenoid rim fracture. with arthroscopic repair for acute greater tuberosity
322
Chapter 17 Fractures 323
fractures associated with glenohumeral dislocation as fracture, the treating orthopedist referred the patient
well as for greater tuberosity nonunion. to our office. The patient’s medical history revealed no
significant shoulder problems before the injury.
Physical examination was limited by pain from the
DIAGNOSIS shoulder injury but demonstrated normal neurovascu-
lar status. Plain radiographs demonstrated prereduc-
Persistent pain after an acute shoulder dislocation may tion and postreduction views of the dislocation and
be caused by a greater tuberosity fracture that was a displaced greater tuberosity fracture. Because the
undiagnosed initially. Patients are usually able to patient wished to pursue his avocation of competitive
describe the dislocation, but it is surprising how often polo, we advised operative arthroscopic treatment.
a fracture goes unrecognized after dislocation and spon-
taneous reduction. The diagnosis of a greater tuberosity
Nonunion
fracture is usually made on plain radiographs. Accurate
anteroposterior and axillary films are mandatory. A 63-year-old woman fell and sustained a minimally
Magnetic resonance imaging performed to determine displaced greater tuberosity fracture. Despite appropri-
the status of the rotator cuff may demonstrate a ate nonoperative treatment, the fracture progressed to
nondisplaced greater tuberosity fracture. nonunion. Physical examination demonstrated pain-
ful, limited active shoulder motion in elevation and
abduction. Plain radiographs showed a nonunion.
NONOPERATIVE TREATMENT Based on the patient’s clinical presentation, we
advised operative arthroscopic treatment.
Nonoperative treatment is the mainstay for nondis-
placed greater tuberosity fractures and for almost all
fractures with less than 5 mm of displacement. If pain CONTRAINDICATIONS TO SURGERY
or weakness persists longer than 3 months after injury,
magnetic resonance imaging may demonstrate an asso- Insufficient bone stock, significant displacement, or
ciated partial- or full-thickness rotator cuff tear. Because tuberosity retraction may preclude the reduction and
greater tuberosity fractures usually heal quite readily, fixation of a greater tuberosity fracture using arthro-
persistent pain may also signal nonunion. Tomograms scopic techniques.
or computed tomograms can demonstrate nonunion.
OPERATIVE TECHNIQUE
After the successful induction of general anesthesia
Glenoid fractures that are displaced and associated supplemented with interscalene block, the patient is
with glenohumeral joint instability should be fixed, placed in the sitting position, and the arm is prepared
if possible. Minimally displaced greater tuberosity frac- and draped. Make a standard entry into the glenohu-
tures may be treated nonoperatively; however, recent meral joint, inspect the joint for any associated inju-
evidence suggests that as little as 5 mm of superior ries, and repair them as indicated. Remove the
displacement may produce shoulder dysfunction. arthroscope and insert it into the subacromial space.
Patients can usually tolerate greater degrees of poste- Identify the lateral portal site with a spinal needle
rior rotation than superior migration of the fractured and insert a large, self-sealing cannula and trocar.
tuberosity. Introduce an arthroscopic probe and identify the frac-
Two typical clinical situations are described here, ture site. Probe palpation can detect any movement
representing examples of cases in which arthroscopic in the greater tuberosity; soft tissue covering the frac-
treatment is indicated. ture site usually makes it impossible to view the bone
directly. If the fracture is acute, hemorrhage will also
be visualized around the fracture area. Establish an
Acute Fracture
anterior portal and introduce a cannula. Use a curette
A 46-year-old, right-hand-dominant man sustained an or power shaver to remove the soft tissue covering
anterior-inferior glenohumeral dislocation and a the fracture site laterally, and lift up the fragment
greater tuberosity fracture while playing polo. The dis- to expose the fracture bed. Lightly abrade the fracture
location was reduced in the emergency room, but (or nonunion) site with a power bur. Reduce the
owing to the displacement of the greater tuberosity greater tuberosity using a trocar (placed through
Reducing fracture
Probe moving
fracture
Figure 17-4 Reduce the fracture with a probe or Kirschner

wire.
Figure 17-2 Identify the fracture site.
the anterior portal). Either through the lateral cannula

or percutaneously, insert a Kirschner wire through
the tuberosity fragment and into the humeral head.
I use a partially threaded, cannulated 6.5-mm screw
inserted over the guide wire to obtain firm, compres-
sive fixation of the tuberosity. Reinsert the arthro-
K-wire
scope into the glenohumeral joint and verify that through fragment
the screw has not penetrated the humeral articular
surface. Check the reduction and screw placement
with an intraoperative radiograph or fluoroscopic
imaging (Figs. 17-2 through 17-6).
Figure 17-5 Temporary fixation with Kirschner wire (K-wire).
Curetting fracture bed
Screw securing
fractured tuberosity
to humerus
Figure 17-3 Curette the fracture bed. Figure 17-6 Permanent screw fixation.
Chapter 17 Fractures 325
POSTOPERATIVE MANAGEMENT Flatow EL, Cuomo F, Maday MG, et al: Open reduction and
internal fixation of two-part displaced fractures of the
Postoperative management is similar to that for a full- greater tuberosity of the proximal part of the humerus.
thickness rotator cuff tear. Place the patient’s arm in a J Bone Joint Surg Am 73:1213-1218, 1991.
sling for 6 weeks. Start passive range of motion in ele- Fujii Y, Yoneda M, Wakitani S, Hayashida K: Histologic
analysis of bony Bankart lesions in recurrent anterior
vation and external rotation the afternoon following
instability of the shoulder. J Shoulder Elbow Surg
surgery and continue for 6 weeks. At the 2-week,
15:218-223, 2006.
6-week, and 3-month visits, obtain radiographs to Gartsman GM, Taverna E: Arthroscopic treatment of rotator
verify healing and the position of both the bone frag- cuff tear and greater tuberosity fracture nonunion.
ment and the screw. Active range of motion is started Arthroscopy 12:242-244, 1996.
at week 6 and strengthening at 3 months. If the Gartsman GM, Taverna E, Hammerman SM: Arthroscopic
patient complains of pain in the area of the screw treatment of acute traumatic anterior glenohumeral
head, I remove the screw once fracture consolidation dislocation and greater tuberosity fracture. Arthroscopy
is demonstrated on radiographs. 15:648-650, 1999.
Hinov V, Wilson F, Adams G: Arthroscopically treated
proximal humeral fracture malunion. Arthroscopy
Malunion of the Humeral Head 18:1020-1023, 2002.
Kim SH, Ha KI: Arthroscopic treatment of symptomatic
shoulders with minimally displaced greater tuberosity
BIBLIOGRAPHY fracture. Arthroscopy 16:695-700, 2000.
Krackhardt T, Schewe B, Albrecht D, Weise K: Arthroscopic
Barth JR, Burkhart SS: Arthroscopic capsular release fixation of the subscapularis tendon in the reverse
after hemiarthroplasty of the shoulder for fracture: Hill-Sachs lesion for traumatic unidirectional posterior dis-
A new treatment paradigm. Arthroscopy 21:1150, 2005. location of the shoulder. Arthroscopy 22:227.e1-227.e6,
Bauer T, Abadie O, Hardy P: Arthroscopic treatment of 2006.
glenoid fractures. Arthroscopy 22:569.e1-569.e6, 2006. Porcellini G, Campi F, Paladini P: Arthroscopic approach to
Boileau P, Ahrens P: The TOTS (temporary outside traction acute bony Bankart lesion. Arthroscopy 18:764-769, 2002.
suture): A new technique to allow easy suture placement Porcellini G, Campi F, Paladini P: Articular impingement in
and improve capsular shift in arthroscopic Bankart repair. malunited fracture of the humeral head. Arthroscopy
Arthroscopy 19:672-677, 2003. 18:E39, 2002.
Bonsell S, Buford DA Jr: Arthroscopic reduction and internal Sugaya H, Kon Y, Tsuchiya A: Arthroscopic repair of glenoid
fixation of a greater tuberosity fracture of the shoulder: fractures using suture anchors. Arthroscopy 21:635, 2005.
A case report. J Shoulder Elbow Surg 12:397-400, 2003. Taverna E, Sansone V, Battistella F: Arthroscopic treat-
Cameron SE: Arthroscopic reduction and internal fixation of ment for greater tuberosity fractures: Rationale and surgi-
an anterior glenoid fracture. Arthroscopy 14:743-746, 1998. cal technique. Arthroscopy 20:53-e57, 2004.
Carrera EF, Matsumoto MH, Netto NA, Faloppa F: Varghese J, Thilak J, Mahajan CV: Arthroscopic treat-
Fixation of greater tuberosity fractures. Arthroscopy ment of acute traumatic posterior glenohumeral disloca-
20:e109-e111, 2004. tion and anatomic neck fracture. Arthroscopy
Dawson FA: Four-part fracture dislocation of the proxi- 22:676.e1-676.e2, 2006.
mal humerus: An arthroscopic approach. Arthroscopy
19:662-666, 2003.
CHAPTER
18
Diagnostic
Ultrasonography
Ultrasonography is my routine method for diagnosing Ziegler, Ken Yamaguchi, and Joe de Beers. I also
rotator cuff disorders. Magnetic resonance imaging found a helpful website from the University of
(MRI) tends to overestimate the severity of rotator Michigan (http://www.med.umich.edu/rad/muscskel/
cuff lesions, and it is expensive and time-consuming. mskus/index.html). In addition, representatives of
Compared with MRI, ultrasonography is a much more the manufacturers of diagnostic ultrasound equip-
pleasant experience for patients with claustrophobia. ment (e.g., Siemens, General Electric, Sonosite,
For patients in whom MRI is contraindicated (those Aloka) were extremely helpful. All this was well and
with cardiac pacemakers or metal clips in the brain good, but I still did not how to actually perform a diag-
or around the carotid artery), diagnostic ultrasonogra- nostic ultrasound examination. I finally linked up
phy is essential (Fig. 18-1). I still use MRI for patients with Gary Pattee, who was kind enough to share his
with osseous or ligamentous lesions of the glenohu-
meral joint because I cannot visualize these areas with
ultrasonography. Ultrasonography is also helpful in
the management of patients after rotator cuff repair;
it allows me to directly evaluate the repair.
I began using diagnostic ultrasonography in my
office in 2004 and have been very pleased with
the results. I use it primarily to diagnose lesions of
the infraspinatus, supraspinatus, subscapularis, and
biceps tendons. These lesions include tendinitis,
partial- and full-thickness rotator cuff tears, calcific
tendinitis, and bursitis. I do not use ultrasonography
to diagnose intra-articular lesions. I perform the exam-
ination myself, although others may choose to have a
radiologist or a trained technician do so. I think the
treating orthopedic surgeon has the most comprehen-
sive knowledge of shoulder anatomy and the best idea
of the clinical lesions that might be found in patients
undergoing ultrasound examinations. I also enjoy the
few extra minutes of hands-on time with patients, and
they enjoy seeing moving images on a screen.
I had heard about surgeons using diagnostic ultra-
sonography from others such as Rick Matsen, Dean Figure 18-1 Indication for ultrasonography.
326
Chapter 18 Diagnostic Ultrasonography 327
Figure 18-2 Demonstration of an ultrasound examination.
wealth of experience and, most important, show me

how to perform the examination. Like so many things,
it helps to have an expert at your side when you are
learning something new (Fig. 18-2).
Armed with a little knowledge and a great deal of
enthusiasm, I converted a small storage closet in my
clinic area to a diagnostic ultrasonography room
and purchased an ultrasound machine (Figs. 18-3 and Figure 18-4 Ultrasound machine.
18-4). There are also excellent portable machines that
you can bring right into the examining room so that
no extra space is required. If you are familiar with shoulder anatomy as seen during open and arthroscopic
surgery and have some experience with shoulder MRI,
you will find diagnostic ultrasonography a fairly simple
technique to master. One criticism I have heard is that
the accuracy of diagnostic ultrasonography is very
user-dependent, but so are many other activities.
I began performing diagnostic ultrasonography on as
many patients as possible so that I could compare the
results with current MRI studies. Gradually, as I became
more experienced, my confidence increased. After about
100 diagnostic ultrasound examinations, I felt very com-
fortable with the technique. I also had the advantage of
directly observing the lesions diagnosed with ultrasonog-
raphy at shoulder arthroscopy, and I found it very help-
ful to bring the ultrasound images into the operating
room for comparison.
Ultrasound
My purpose here is to present the technique I use daily in

my office practice. First, I walk the patient to the ultra-
sonography room and have him or her put on a gown so
that I have access to both shoulders. I enter the patient’s
name on the information screen and start the examina-
tion. After applying gel to both the patient and the
probe, I start anteriorly and identify the bicipital
Figure 18-3 Ultrasonography suite. groove and subscapularis tendon. I then rotate the
Figure 18-7 Placement of the ultrasound probe to obtain a

longitudinal view of the biceps tendon.
Figure 18-5 Placement of the ultrasound probe to view the
transverse axis of the bicipital groove.
probe and obtain a longitudinal view of the biceps

tendon. I move to the posterior shoulder and examine
the infraspinatus and posterior labrum. I conclude the
examination with views of the supraspinatus tendon.
I apply the probe and maneuver the shoulder into
extension to move the supraspinatus farther away
from the acromion. I can then abduct the arm slightly
and observe the normal glide between the supraspinatus
and the deltoid, as well as observe any impinge-
ment—the dynamic impingement test. I then have
the patient place his or her hand behind the body in
the small of the back. I place the probe over the supra-
spinatus, apply compression, and see whether I can
demonstrate a gap in the tendon substance. If the situ-
ation calls for it, I then examine the opposite shoulder,
but I do not do this routinely (Figs. 18-5 through 18-32).
Figure 18-8 Biceps tendon longitudinal view.
Figure 18-9 Magnetic resonance imaging of the biceps

Figure 18-6 Bicipital groove transverse axis. tendon.
Figure 18-10 Placement of the ultrasound probe to view the

long axis of the subscapularis.
Figure 18-13 Subscapularis transverse axis.
I ask the patient to dress and meet me back in the

examination room. I document the diagnostic ultra-
sound findings on a template and add it to the patient’s
record. I do not routinely print the images on paper. I
eventually transfer them to a CD and place them on a
separate hard drive for safekeeping. I review the images
at the time of surgery.
Figure 18-11 Subscapularis long axis.
Figure 18-12 Placement of the ultrasound probe to view the Figure 18-14 Magnetic resonance imaging of the
transverse axis of the subscapularis. subscapularis.
Figure 18-15 Placement of the ultrasound probe to view the Figure 18-17 Placement of the ultrasound probe to view the
long axis of the supraspinatus (with the patient’s arm behind transverse axis of the supraspinatus.
the back).
Figure 18-16 Supraspinatus long axis (with the arm behind

the back). Figure 18-18 Supraspinatus transverse axis.
Figure 18-19 Placement of the ultrasound probe to view the Figure 18-21 Placement of the ultrasound probe to view the
long axis of the infraspinatus. posterior labrum.
Figure 18-20 Infraspinatus long axis. Figure 18-22 Posterior labrum (arrows).
Figure 18-23 Articular surface partial rotator cuff tear.

Figure 18-25 Full-thickness supraspinatus tear (arrows).
Figure 18-24 Articular surface partial rotator cuff tear with Figure 18-26 Healed rotator cuff repair 6 months after
extension (arrow). operation.
Figure 18-29 Complete biceps tear, transverse view.

Figure 18-27 Fluid after subacromial injection (arrows).
Figure 18-28 Calcific tendinitis (arrows). Figure 18-30 Complete biceps tear, longitudinal view.
Fealy S, Adler RS, Drakos MC : Patterns of vascular and ana-

tomical response after rotator cuff repair. Am J Sports Med
34:120-127, 2006.
Fealy S, Rodeo SA, MacGillivray JD, et al: Biomechanical eval-
uation of the relation between number of suture anchors
and strength of the bone-tendon interface in a goat rota-
tor cuff model. Arthroscopy 22:595-602, 2006.
Ferri M, Finlay K, Popowich T, et al: Sonography of full-
thickness supraspinatus tears: Comparison of patient
positioning technique with surgical correlation. AJR Am
J Roentgenol 184:180-184, 2005.
Galatz LM, Ball CM, Teefey SA, et al: The outcome and repair
integrity of completely arthroscopically repaired large
and massive rotator cuff tears. J Bone Joint Surg Am
86:219-224, 2004.
Goldberg JA, Bruce WJ, Walsh W, Sonnabend DH: Role of
community diagnostic ultrasound examination in the
Figure 18-31 Biceps cyst. diagnosis of full-thickness rotator cuff tears. Aust N Z J
Surg 73:797-799, 2003.
Husby T, Haugstvedt JR, Brandt M, et al: Open versus arthro-
scopic subacromial decompression: A prospective, rando-
mized study of 34 patients followed for 8 years. Acta
Orthop Scand 74:408-414, 2003.
Iannotti JP, Ciccone J, Buss DD, et al: Accuracy of office-
based ultrasonography of the shoulder for the diagno-
sis of rotator cuff tears. J Bone Joint Surg Am
87:1305-1311, 2005.
Kartus J, Kartus C, Rostgård-Christensen L, et al: Long-term
clinical and ultrasound evaluation after arthroscopic acro-
mioplasty in patients with partial rotator cuff tears.
Arthroscopy 22:44-49, 2006.
Kayser R, Hampf S, Seeber E, Heyde CE: Value of preoperative
ultrasound marking of calcium deposits in patients who
require surgical treatment of calcific tendinitis of the
shoulder. Arthroscopy 23:43-50, 2007.
Kluger R, Mayrhofer R, Kröner A, et al: Sonographic ver-
sus magnetic resonance arthrographic evaluation of full-
thickness rotator cuff tears in millimeters. J Shoulder
Elbow Surg 12:110-116, 2003.
McIntyre LF, Norris M, Weber B: Comparison of suture weld-
ing and hand-tied knots in mini-open rotator cuff repair.
Arthroscopy 22:833-836, 2006.
Middleton WD, Payne WT, Teefey SA, et al: Sonography and
MRI of the shoulder: Comparison of patient satisfaction.
Figure 18-32 Thickened biceps.
AJR Am J Roentgenol 183:1449-1452, 2004.
Middleton WD, Teefey SA, Yamaguchi K: Sonography of the
rotator cuff: Analysis of interobserver variability. AJR Am J
Roentgenol 183:1465-1468, 2004.
BIBLIOGRAPHY Milosavljevic J, Elvin A, Rahme H: Ultrasonography of
the rotator cuff: A comparison with arthroscopy in one-
Ambacher T, Kirschniak A, Holz U: Intraoperative localiza- hundred-and-ninety consecutive cases. Acta Radiol
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Australas Radiol 51:226-229, 2007. operative findings. Acta Orthop 76:503-508, 2005.
Morag Y, Jacobson JA, Lucas D, et al: US appearance of the showing a high incidence of rotator cuff tears after shoul-
rotator cable with histologic correlation: Preliminary der trauma. J Shoulder Elbow Surg 16:174-180, 2007.
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Pan PJ, Chou CL, Chiou HJ, et al: Extracorporeal shock wave spinatus and infraspinatus muscles: Accuracy of US.
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Do we miss the early diagnosis? A prospective study 2004.
CHAPTER
19
Rehabilitation
I prefer to instruct patients in a rehabilitation program PENDULUM One minute (Figs. 19-1 and 19-2).
without the aid of a physical therapist. It takes little
time, assures me that the exercises are appropriate, and ELEVATION Stretch in elevation, hold for 20 seconds,
is much appreciated by the patients. It is important to be relax for 20 seconds, stretch for 20 seconds (Fig. 19-3).
realistic about goals. I constantly ask myself, exactly
what do I want the patient to accomplish with therapy? EXTERNAL ROTATION Stretch in external rotation,
Possible goals are to improve movement, strength, or hold for 20 seconds, relax for 20 seconds, stretch for
coordination. I keep the exercises simple and minimize 20 seconds (Fig. 19-4).
the time required to perform them. If a patient has
difficulty understanding my instructions or expresses CROSS-BODY ADDUCTION Stretch in cross-body adduc-
a desire for more intensive therapy in a facility, I direct tion, hold for 20 seconds, relax for 20 seconds, stretch
the patient to a well-qualified physical therapist. for 20 seconds. Keep the elbow straight (Fig. 19-5).
Passive Range of Motion

Exercises
Active Range of Motion

Exercises
Strengthening Exercises
ADHESIVE CAPSULITIS
Patients should avoid any stretching exercises while

the shoulder is still very painful. Rest and pain control
are paramount. Once the situation has stabilized,
patients should perform the following exercises four
times a day. The total amount of exercise time should
not exceed 20 minutes a day. I never have patients
stretch in abduction or behind-the-back internal
rotation. The exercises should never be painful. A B
Gentle stretching is the key. Figure 19-1 A and B, Pendulum.
336
Chapter 19 Rehabilitation 337
Figure 19-4 External rotation stretch.
Figure 19-2 Pendulum (cradled).
Figure 19-3 Elevation stretch. Figure 19-5 Cross-body adduction stretch.

IMPINGEMENT SYNDROME
Acute and chronic inflammation leads to musculo-

tendinous shortening, so stretching in adduction is
most important. I want patients to rest the supraspi-
natus but improve strength in the scapular rotators
and the subscapularis. I have patients avoid strength-
ening of the supraspinatus (because it is painful) and
of the deltoid because its action (if unopposed by a
normal rotator cuff) is to promote superior humeral
head elevation. If external rotation or biceps contrac-
tion is painful on physical examination, I eliminate
those exercises from the program. The key idea here
is less pain, more gain.
Motion
PENDULUM One minute (see Fig. 19-1).
CROSS-BODY ADDUCTION Stretch in cross-body

adduction, hold for 20 seconds, relax for 20 seconds,
stretch for 20 seconds. Keep the elbow straight
(see Fig. 19-5). Figure 19-6 Biceps strengthening.
Strength
I like to start with biceps and triceps strengthening
because these exercises are usually painless and help
build patient confidence and diminish fear. I use
surgical tubing for resistance and have patients pro-
gress as tolerated. These exercises are performed
three times per week.
BICEPS Ten repetitions (Fig. 19-6).
TRICEPS Ten repetitions (Fig. 19-7).
INTERNAL ROTATION Ten repetitions (Fig. 19-8).
EXTERNAL ROTATION Ten repetitions (Fig. 19-9).
SCAPULAR ELEVATION Ten repetitions (Fig. 19-10).
SCAPULAR RETRACTION Ten repetitions (Fig. 19-11).
FULL-THICKNESS ROTATOR CUFF TEARS
The goal is to improve or maintain range of

motion and improve the strength of the uninvolved
muscles.
Figure 19-7 Triceps strengthening.
Figure 19-8 Internal rotation strengthening.
Figure 19-9 External rotation strengthening.

Motion
PENDULUM One minute (see Fig. 19-1).
CROSS-BODY ADDUCTION Stretch in cross-body adduc-

tion, hold for 20 seconds, relax for 20 seconds,
stretch for 20 seconds. Keep the elbow straight
(see Fig. 19-5).
Strength
Again, start with biceps and triceps strengthening
to build patient confidence. Use surgical tubing
for resistance, and have the patient progress as toler-
ated. These exercises are performed three times per
week.
BICEPS Ten repetitions (see Fig. 19-6).
TRICEPS Ten repetitions (see Fig. 19-7)

Figure 19-10 Scapular elevation strengthening.
INTERNAL ROTATION Ten repetitions (see Fig. 19-8).
EXTERNAL ROTATION Ten repetitions (see Fig. 19-9).
SCAPULAR ELEVATION Ten repetitions (see Fig. 19-10).
SCAPULAR RETRACTION Ten repetitions (see Fig. 19-11).
MASSIVE OR IRREPARABLE ROTATOR

CUFF TEARS
The goal is to improve or maintain range of motion

and improve the strength of the uninvolved muscles.
In these patients, who are generally older, the normal
muscles must be trained to substitute for the absent
muscles. Realistic goals must be agreed on, and
patients should understand that this can be a 6-
month process.
Patients begin with pendulum exercises as a warm-
up (see Fig. 19-1). They then progress to active assisted
range-of-motion exercises and finally strengthening
exercises (as previously described). At first, they do
the exercises supine, lying on a bed or on the floor.
The supine position minimizes the effects of gravity. I
also have them decrease arm weight by bending the
elbow. Patients do these exercises four times a day.
They are allowed to move on to the next stage only
when they are comfortable performing the current
Figure 19-11 Scapular retraction strengthening. level of exercise.
but keep the elbow flexed to 90 degrees. Gradually

Supine Exercises
build up to 30 seconds without any use of the opposite
Stage 1 arm (Fig. 19-12).
Bend the elbow 90 degrees. Use the opposite arm to
help elevate it until it is perpendicular to the floor. Stage 2
Encourage the patient to gradually increase the use Bend the elbow 45 degrees. Actively elevate the arm
of the damaged shoulder and decrease the contribu- until it is perpendicular to the floor. Hold for 5 sec-
tion of the good shoulder until the former is doing all onds. Lower the arm actively, but keep the elbow
the work. Hold for 5 seconds. Keep the opposite arm flexed to 45 degrees. Gradually build up to 30 seconds
nearby to help if necessary. Lower the arm actively, without any use of the opposite arm (Fig. 19-13).
A D
Figure 19-12 A through F, Stage 1 supine active elevation.

Stage 3 until it is perpendicular to the floor. Encourage the

Keep the elbow straight. Actively elevate the arm until patient to gradually increase the use of the damaged
it is perpendicular to the floor. Hold for 5 seconds. shoulder and decrease the contribution of the good
Lower the arm actively, but keep the elbow straight. shoulder until the former is doing all the work.
Gradually build up to 30 seconds without any use of Hold for 5 seconds. Keep the opposite arm nearby to
the opposite arm (Fig. 19-14). help if necessary. Lower the arm actively, but keep the
elbow flexed to 90 degrees. Gradually build up to
Stage 4 30 seconds without any use of the opposite arm
Holding a 1-pound weight in the hand, bend the elbow (Fig. 19-15).
90 degrees. Use the opposite arm to help elevate the arm
A D
45˚
B
E
C
F
Figure 19-13 A through F, Stage 2 supine active elevation.

A Stage 5
Holding a 1-pound weight in the hand, bend the
elbow 45 degrees. Actively elevate the arm until it
is perpendicular to the floor. Hold for 5 seconds.
Lower the arm actively, but keep the elbow flexed to
45 degrees. Gradually build up to 30 seconds without
any use of the opposite arm (Fig. 19-16).
Stage 6
Holding a 1-pound weight in the hand and keeping
the elbow straight, actively elevate the arm until it
is perpendicular to the floor. Hold for 5 seconds.
Lower the arm actively, but keep the elbow straight.
B
Gradually build up to 30 seconds without any use of
the opposite arm (Fig. 19-17).
Only when patients have reached this level do I
have them begin standing exercises.
Standing Exercises
I call this part of the rehabilitation program three-
phase active elevation. Dr. Charles Rockwood
instructed me in these exercises.
Figure 19-14 A and B, Stage 3 supine active elevation.
A D
Figure 19-15 A through F, Stage 4 supine strengthening.

A D
45˚
B
E
C
F
Figure 19-16 A through F, Stage 5 supine strengthening.
The program consists of three stages: (1) passive ele-

A vation and then actively holding the arm overhead,
(2) passive elevation and then actively lowering the
arm, and (3) active elevation. Patients must satisfacto-
rily complete each stage before advancing. This gentle
and graduated program provides enough stress to
strengthen the rotator cuff tendons and muscles but
does so in a safe and controlled manner. It starts with
the easiest activity—holding the arm directly over-
head after raising it passively—then progresses to
actively lowering the arm, which is helped by gravity,
and finally the most difficult action—raising the arm
B against gravity.
Stage 1
Patients grasp the affected arm by the wrist and pas-
sively raise the operated shoulder to maximal eleva-
tion. They then remove the hand from the wrist but
keep it nearby to catch the arm in case the muscles
fatigue and the arm drops. Patients start by actively
maintaining the shoulder in maximal elevation for 5
Figure 19-17 A and B, Stage 6 supine strengthening. seconds and then progress at their own pace until they
Hold for can hold the elevated position for 30 seconds. I rec-
30 seconds ommend that they do these exercises in front of a
clock with a second hand so that they can monitor
the time precisely. Once they can hold the position
for 30 seconds, they increase the number of repeti-
tions until they can do 10 repetitions three times
daily (Fig. 19-18). When this is accomplished, they
move to stage 2.
Stage 2
Patients passively elevate the operated shoulder,
hold it for 10 seconds, and then actively lower it in
a slow, controlled fashion. Again, the contralateral
hand is placed 4 inches below the forearm of the
B operated side so that if the arm falls due to muscle
fatigue it can be protected (Fig. 19-19). After the
patient can do 10 repetitions of this exercise, they
move to stage 3.
Stage 3
A
Patients actively elevate the operated shoulder. With
Figure 19-18 A and B, Standing passive elevation, holding slight pressure from the nonoperated hand, they begin
the arm overhead actively. active assisted elevation. They gradually decrease the
pressure from the contralateral hand until they can
actively elevate the operated arm in a slow, controlled
fashion (Fig. 19-20). Throughout this process, I stress
Hold for 10 seconds
10
seconds
A
Figure 19-19 A and B, Standing passive elevation, lowering the arm actively.
that recovery takes months rather than weeks and

that gradual progress is the goal. Once patients can
actively elevate the arm (or 3 months after operation),
they return to the office for instruction in strengthen-
Raise hand above
ing exercises using rubber tubing (see Figs. 19-6 head, lower slowly,
through 19-11). repeat as many times
you can
ROTATOR CUFF REPAIR
Patients wear a sling for protection and remove it for

exercising, bathing, and dressing. They can remove
the sling and position the arm for comfort while
seated or in bed, but I recommend that they always
wear the sling when out in public. I encourage active
elbow extension and flexion; if patients are comfort-
able doing so, they can actively internally and exter-
nally rotate the shoulder with the elbow held against
the side. They are cautioned to avoid active abduction
and elevation. A B
Figure 19-20 A and B, Standing active elevation and
lowering.
Day of Surgery to Week 6
Patients perform pendulum exercises four times a day BICEPS Ten repetitions (see Fig. 19-6).
(see Fig. 19-1), as well as active elbow flexion and
extension. They are encouraged to open and close TRICEPS Ten repetitions (see Fig. 19-7).
the fingers to minimize hand swelling.
INTERNAL ROTATION Ten repetitions (see Fig. 19-8).
Weeks 6 to 12
EXTERNAL ROTATION Ten repetitions (see Fig. 19-9).
Patients stop wearing a sling. They are allowed to
move the arm without any weight in the hand. They SCAPULAR ELEVATION Ten repetitions (see Fig. 19-10).
can hold and drink a glass of iced tea but cannot pass
someone a pitcher filled with tea. SCAPULAR RETRACTION Ten repetitions (see Fig. 19-11).
Patients begin with pendulum exercises as a warm-
up (see Fig. 19-1). They progress through the six
stages of supine exercises and the three stages of
GLENOHUMERAL JOINT INSTABILITY
standing exercises as outlined earlier for massive
or irreparable rotator cuff tears (see Figs. 19-12
Recurrent Subluxation or Dislocation
through 19-20).
If the injury is acute, I advise rest until the pain
subsides. I then allow gentle active range of
Week 12
motion as tolerated. I recommend the avoidance
Activities can be engaged in as tolerated, and a of all stretching in the acute phase. I have found
strengthening program is started. I like to begin with that many patients with recurrent anterior instabil-
biceps and triceps strengthening because these exer- ity have developed a posterior shoulder contracture
cises are usually painless and help build patient confi- that aggravates the underlying instability. If they
dence and diminish fear. Patients use surgical have posterior structure tightness, I have them
tubing for resistance and progress at their own pace. stretch the posterior capsule with cross-body adduc-
These exercises are performed three times per week. tion as well as with abduction internal rotation with
I rarely have patients perform isolated supraspinatus the scapula stabilized. Patients with anterior insta-
strengthening. bility should avoid stretching in abduction and
external rotation, and those with posterior or multi-

directional instability should avoid elevation and
cross-body adduction. I start strengthening of
the shoulder stabilizing muscles (external rotators,
internal rotators, and scapular stabilizers) as soon
as possible.
Stretch
CROSS-BODY ADDUCTION Hold for 30 seconds, repeat
three times (see Fig. 19-5).
Figure 19-21 Abduction internal rotation stretch.
ABDUCTION INTERNAL ROTATION Hold for 30 seconds,
repeat three times (Fig. 19-21).
ABDUCTION INTERNAL ROTATION Hold for 30 seconds,
Strength repeat three times (see Fig. 19-21).
BICEPS Ten repetitions (see Fig. 19-6).
Strength
TRICEPS Ten repetitions (see Fig. 19-7). BICEPS Ten repetitions (see Fig. 19-6).
INTERNAL ROTATION Ten repetitions (see Fig. 19-8). TRICEPS Ten repetitions (see Fig. 19-7).
EXTERNAL ROTATION Ten repetitions (see Fig. 19-9). INTERNAL ROTATION Ten repetitions (see Fig. 19-8).
SCAPULAR ELEVATION Ten repetitions (see Fig. 19-10). EXTERNAL ROTATION Ten repetitions (see Fig. 19-9).
SCAPULAR RETRACTION Ten repetitions (see Fig. SCAPULAR ELEVATION Ten repetitions (see Fig. 19-10).
19-11).
SCAPULAR RETRACTION Ten repetitions (see Fig. 19-11).
After Glenohumeral Joint Instability
SHOULDER ELEVATION Ten repetitions (Fig. 19-22).
Surgery
Immobilization
The period of sling use depends on the details of the
operation and the reliability of the patient. For opera-
tions that involve ligament or capsule repairs, I have
patients protect the shoulder for 6 weeks. For an oper-
ation such as the Latarjet, which has stronger initial
fixation, I have patients wear the sling for 7 to 10 days
until the first office visit.
During sling use, patients can remove it as needed
for active range of motion of the fingers, wrist, and
elbow. Pendulum exercises are allowed if they can be
done comfortably. When the sling is removed,
patients are allowed active range of motion in
external rotation and cross-body adduction. Active
elevation is allowed except in patients with posterior
instability. At about 2 months, patients can begin pas-
sive stretching and strengthening, as follows.
Stretch
CROSS-BODY ADDUCTION Hold for 30 seconds, repeat
three times (see Fig. 19-5). Figure 19-22 Shoulder elevation strengthening.
ROTATOR CUFF TEARS IN PARAPLEGICS

Mobility
My experience repairing rotator cuff tears in paraple- One patient used a motorized scooter until the oper-
gic patients has been positive, which differs from some ated shoulder had healed well enough to return to
reports in the literature. Rotator cuff repair, biceps braces and crutches. This patient said, ‘‘Before I had
tenodesis, and tenotomy are performed identically, the scooter modified for lifting into my van, the chair
regardless of whether the patient uses a wheelchair. seat could rotate 360 degrees. The seat still rotates over
Surgical indications are slightly different, but preoper- 180 degrees, and the arms on each side lift up. This has
ative planning and postoperative rehabilitation differ given me additional maneuverability for transferring.
greatly. And the chair can be locked into any position within
My overall approach to this group of patients is to the 360 degrees.’’ After sufficient healing had taken
satisfy their needs, and in most cases, this involves place, and with the doctor’s permission, this patient
nonoperative treatment. Because the upper extremi- used a crutch under the operated arm as a lever
ties are the sole means of locomotion for patients in or wedge to help stand up and then walked ‘‘four-
wheelchairs, they are apprehensive about any surgery. point’’ with braces and crutches.
However, years of wear and tear can lead to pain that
interferes with sleeping and transferring. In my
Bathroom Basics
practice, these are the two most common surgical
indications. Patients are required to transfer to and Patients advise the use of a hand-held shower nozzle
from bed, on and off the toilet, and into and out of with an on-off switch at the handle (these can be
the car, and any infirmity that adversely affects these found online). A bathtub chair makes maneuvering
activities adversely affects their independence. easier and can be used in either the tub or the
Operations that require little postoperative protec- shower. Consider a drop-arm commode if the bath-
tion are ideal. Arthroscopic subacromial decompres- room is not easily accessible. Wipe with sanitizing
sion, acromioclavicular joint resection, and biceps wipes to prevent bladder infections.
tenotomy are examples. However, if the pain and
loss of strength from a full-thickness rotator cuff tear
Bedroom Basics
are debilitating, repair is indicated. A detailed discus-
sion with patients is necessary, and they must be The patient who used the scooter also found a hospital
advised of the options and the likely outcome of bed helpful. This patient said, ‘‘I had to get what is
each option. For example, some patients with full- called a Hi/Lo bed (or an Alzheimer’s bed) so that I
thickness rotator cuff tears choose débridement could raise or lower it to the level of my scooter.
alone. Those who choose rotator cuff repair must be Actually, when moving from the bed to the scooter,
advised that immediate weight bearing will almost I raised the bed higher than the scooter so I had grav-
certainly disrupt the repair; therefore, patients must ity to help a little in the transfer, and I did the oppo-
make arrangements for assistance after operation. site getting into bed. It worked better for me to have
This may include increased help from a family only one bed rail (on the operated side). The second
member, professional assistance at home, a short- rail on the other side got in the way of a good transfer
term stay at a rehabilitation facility, or a longer stay from bed to scooter.’’
at a rehabilitation facility until the tendon has com- This patient also noted that polyester sateen sheets
pletely healed. All are reasonable options, depending make sliding on the bed easier. However, the downside
on the individual and his or her particular situation. is that they are very slippery and tend to slide onto the
Some patients plan their recovery in terms of their floor. Also, they are hotter than cotton sheets.
finances, because a full-time home-care aide can cost
$20,000 to $30,000. The surgeon should also be aware
Transferring Tips
that there are many devices available to help paraple-
gics transfer more easily, and these can be extremely Patients advise that, when possible, bring the scooter or
helpful in the postoperative period. wheelchair right up next to the bed or commode and
I asked several of my paraplegic patients to contrib- do a direct transfer rather than using a transfer board.
ute helpful information they learned from their Plastic bags can facilitate the effort. A 30-inch transfer
experiences, in the hope that these pointers will ben- board is necessary to transfer into a car; a longer, plastic
efit both surgeons and their patients. transfer board with a disc seat that glides along the
length can be used to transfer onto a bathtub chair in should then begin planning for the patient’s postop-
the shower stall. Patients recommend that braces not erative care so that insurance covers as much as possi-
be worn while you are recuperating and unable to stand ble. As one patient noted, ‘‘Having to be in a sling for
and walk; they are just additional weight that you must several weeks after surgery and then no weight bearing
lift and scoot when transferring. for 2 months is very different for someone who does
not have the use of their legs. There is a definite need
for assistance after surgery. You will not be able to
Insurance
function by yourself.’’ Also remember to arrange
Several patients had pointers about dealing with insur- with the insurance case manager for an ambulance
ance. One patient recommended getting a case man- to transport you from the hospital to the rehabilita-
ager—preferably someone who is knowledgeable tion hospital. Do not assume that this will automati-
about paraplegia and how an individual’s everyday cally be approved.
activities can be affected by a shoulder problem and One patient found a letter very helpful in his nego-
recovery from surgery. The patient and case manager tiations with his insurance carrier (see Box):
Letter to Insurance Carrier
To whom it may concern:

My patient John Smith currently has a full-thickness tear of the supraspinatus tendon in his left
shoulder. This medical issue is causing severe pain and weakness in that shoulder. This is compli-
cated by his spinal cord injury that resulted in paraplegia. Mr. Smith suffered a complete lesion in
his spinal cord in 1999 and underwent rehabilitation at the Institute for Rehabilitation and
Research here at the Houston Medical Center.
Unfortunately, this tear jeopardizes everything Mr. Smith has accomplished and hopes to con-
tinue to achieve. He relies mainly on his shoulders in transferring multiple times a day to the car,
bed, toilet, shower, and so on, and using his wheelchair to live independently, and this injury is
causing him significant pain and weakness and threatening his independence. For someone who
does not have a spinal cord injury and has no ambulatory problems, this would be less of an issue.
However, for Mr. Smith, this injury is a critical problem.
The long-term prognosis is that his shoulder will continue to get worse with regard to pain and
weakness, which will severely limit his ability to maintain his preinjury function. My recommen-
dation is to do shoulder surgery to repair the tendon, which will lessen the pain and weakness he is
now experiencing and provide him a better long-term prognosis.
The point of this letter is to alert you that Mr. Smith’s immediate postoperative care and recovery
will require him to be admitted to a rehabilitation center. The normal recovery period for this type
of surgery is 3 months. The shoulder is kept in a sling for 6 weeks, with no weight bearing (trans-
ferring) for at least 8 to 12 weeks. All patients having this type of surgery require daily therapy to
keep the arm moving and achieve a better long-term result. Mr. Smith’s therapy will be even more
aggressive owing to his dependence on his shoulder for independent living—another reason for
him to be treated at a rehabilitation hospital.
Given Mr. Smith’s situation and these postoperative restrictions, a rehabilitation hospital such as
the Institute for Rehabilitation and Research is crucial to achieve a good outcome and to prevent the
known complications that paraplegics are subject to. For instance, the trained staff there can help
prevent bed sores and decubitus ulcers by turning Mr. Smith every 2 hours, as well as assist in his
bowel and bladder program, which he will not be able to manage by himself. It is my strong recom-
mendation that he receive between 2 and 3 months of care in a high-quality rehabilitation hospital.
If you have any further questions, please do not hesitate to call me or my assistant Evelyn at
713-555-2000.
Sincerely,
Dr. G. M. Gartsman
Postoperative Care caregiver was a skilled technician who was not a

The best plan is to arrange for care at a rehabilitation licensed vocational nurse, but the work she did at
hospital or an assisted living facility for several the hospital was basically the same type of help he
weeks after the surgery. That way, rehabilitation of required at home. He then asked her to find other
the operated shoulder, as well as daily routines of individuals to make up a team of caregivers who
bladder, bowel, and skin care, will be handled profes- could handle the 24-hour-a-day care he required. She
sionally. However, as one patient discovered, such was able to find three people who provided home care
plans do not always work out as expected. He said, for 6 weeks before the patient returned to work.
‘‘I was able to get approval from the insurance This patient happened to live in Texas, which has a
company for 2 months at the rehabilitation hospital, Department of Assistive and Rehabilitative Services that
but I ended up staying there for only 2 weeks. covers this type of care. The overall cost can be any-
The rehabilitation professionals at the facility felt where from $15 to $25 an hour and can total $20,000
that training me to do transfers and assist with other to $30,000 by the time a patient is fully recovered. This
medical care concerns, with probable assistance at agency also covered the cost of some equipment that
home, was all that was necessary. What occurred in insurance did not, such as a shower bench and toilet
my situation was that the rehabilitation protocols of chair. In addition, the department covered the rental
my rehabilitation physician and the actual admitting of a van with a lift for several months after the patient
physician (not the operating orthopedic surgeon), returned to work. He said, ‘‘I could not use my car for
were different. Still, my 2-week stay at the rehabilita- transfers and load my wheelchair. I had to continue to
tion hospital was beneficial.’’ let the shoulder heal for 2 months after returning to
An alternative plan is to go home after surgery and work. I did eventually go back to using my car about
use the assistance of a family member or an attendant. 4 months after surgery, but the van may be a good
However, a family member’s level of training may not alternative in a few years just because of age and other
be adequate, so it is probably better to hire a skilled disability considerations.’’
attendant or nurse. After his 2 weeks in the rehabilita- As far as his satisfaction with the outcome, this
tion facility, the patient mentioned earlier arranged to patient said, ‘‘After 9 months, I have gotten good results
have home care for the remaining 6 to 8 eight weeks of from the surgery, but I still lack some strength and con-
his recovery. He noted that finding the right indivi- fidence. Today I am using the arm and shoulder again in
duals for the job is key. Although most insurance poli- all daily transfers as well as driving. There is some
cies cover about 16 to 20 hours of actual nursing care strength loss, but it is not severe—probably about 10%
at home, this is not the type of care required. He said, at this point, and even that should come back over time.
‘‘You are looking for someone to help with dressing, I would recommend that you follow doctor’s orders and
bathing, eating, cooking, and cleaning. You also need keep doing your exercises to keep the arm as strong as
assistance with daily transfers from your bed to your possible and stretched out. I have noticed some pain
wheelchair. This is different from the medical care and functional issues if it is not exercised regularly.
given by a registered nurse. It is also nice to have I am back at work and doing well with all my job respon-
someone available to take you to doctor’s appoint- sibilities. However, I would recommend that you refrain
ments and assist with physical therapy at home.’’ from picking up more than 10 to 20 pounds when it
This patient recommends asking at the rehabilitation requires a lift away from the body. You need your
hospital whether any nurses or skilled technicians shoulders and arms to be strong for daily activities, par-
there are looking for additional work. His main ticularly as you get older with a disability.’’
Index
A Acromial corner Acromioclavicular joint (Continued)
Abduction anterolateral, in acromioplasty, in impingement syndrome, 214,
acromioclavicular joint pain with, 222–224, 225f 216, 217, 311–312
311–312 posterolateral, in diagnostic injection of, 307–308
in diagnostic glenohumeral arthroscopy, 64, 65f instability of, after resection, 314
arthroscopy, 67 Acromioclavicular joint literature review of, 306
with external rotation, 68f arthritic conditions of, 214, 216, nonoperative treatment of, 307
with internal rotation, 68f, 69f 306–308, 306f, 307f open resection of
in glenohumeral instability, 105 SLAP lesions vs., 307, 307f arthroscopic resection vs., 3,
inferior translation with, arthroscopic resection of, 308 306–308
111, 112f arthroscope rotation in, 310f, clavicle in
in impingement syndrome 311–312, 312f distal perspectives, 66,
diagnosis, 213, 214 bone measurement in, 308f, 66f, 306
in lateral decubitus position, 50 311–312, 314f distal procedures, 308, 308f,
in proximal biceps tendon lesion burs in, 310–312, 314f 309f
diagnosis, 151 cannula and trocar in, 310–312, medial acromion in, 308, 308f,
in rotator cuff tears 314, 314f 309f
full-thickness, 250, 258 clavicle in technique for, 308, 308f, 309f
massive, 279, 289 anterior resection, 311–312, postoperative management of, 314
in stiffness treatment, 177–180, 313f reconstruction of.
179f, 180f, 182–183 cautery of, 312f See Acromioplasty.
Abduction internal rotation stretch, distal perspectives, 66, 66f, 306 Acromion
for glenohumeral distal procedures, 310–312, in acromioclavicular joint
instability, with recurrent 310f, 311f resection
dislocation, 347, 347f end-on view of, 309f, 311–312 medial resection of
Abrasion arthroplasty electrocautery in, 310, 310f, arthroscopic, 311–312, 312f
for distal biceps tendon lesions, 311, 312f open, 308, 308f, 309f
165–166, 166f for impingement syndrome, 216 posteromedial resection of,
for fracture fixation, 323–324 in rotator cuff repair 311–312, 313f
for full-thickness rotator cuff full-thickness, 254, 254f in diagnostic arthroscopy, 68–69,
repair, 254, 255f of paraplegics, 348 89–90
for glenohumeral instability, 119f incisions for, 95, 95f anterior, 87–88, 88f
of glenoid, for glenohumeral superior-lateral indications, inferior, 89
arthrosis, 192, 192f, 193f 66, 66f in impingement treatment
Absorbent mat, in operating room indications for, 308 cutting block technique and,
setup, 47, 48f medial acromion in, 311–312, 227, 227f, 228f, 229
AccuPass instrument, for suture 312f, 313f decompression and, 225, 226f
management open resection vs., 3, 306–308 palpation of, 218–219, 219f
deploying braided suture, patient position for, 49 technical failure and, 229
53, 54f portals in, 310, 310f, 311f, 314 in rotator cuff repair
deploying nylon loop, 54f posteromedial acromion in, irreparable, 299, 299f, 300f
description of, 54f, 57 311–312, 313f massive, 280–281, 281f, 282f
handling, 43 spinal needle in, 310–311, 311f cuff mobilization and, 284,
in biceps tendon lesions repair superior capsule in, 311–312, 285f, 286f, 288
distal, 165 313f in sitting position, 50–51, 52f
proximal, 156–157, 159 complications of, 314 checking for, 51f, 52f
loading and employing, 7–10, 10f diagnosis of, 307, 307f reconstruction of. See
thumb position for, 7–10, 10f, 43 dislocations of, 306, 306f Acromioplasty.
Page numbers followed by f indicate figures; t, tables; b indicate boxes.
351
352 Index
Acromion (Continued) Activity modification (Continued) Airway management, in anesthesia,,

spur of, in full-thickness rotator for proximal biceps tendon 48, 48f, 49f
cuff tears, 242, 243f lesions, 151–152 AL (anterolateral) stab wound, for
type 1 for rotator cuff tears massive rotator cuff
in full-thickness rotator cuff full-thickness, 243 repair, 290–292, 291f
tears, 253–254 irreparable, 297 Allografts
in impingement syndrome, Adduction bone anchors as, in full-thickness
226, 227 acromioclavicular joint pain with, rotator cuff repair, 256
type 2 254, 307 tendons as, in irreparable rotator
in full-thickness rotator cuff cross-body stretch in cuff repair, 297
tears, 253–254 for adhesive capsulitis, 336, 337f ALPSA (anterior labroligamentous
in impingement syndrome, 226 for full-thickness rotator cuff periosteal sleeve avulsion)
type 3 tears, 255–256, 337f lesion, in glenohumeral
in full-thickness rotator cuff for glenohumeral instability, instability, 102, 138
tears, 242f, 253–254 108, 108f American Shoulder and Elbow
in impingement syndrome, postoperative, 337f, 347 Surgeons (ASES) Shoulder
214, 215f with recurrent dislocation, Index
in partial-thickness rotator cuff 337f, 347 of full-thickness rotator cuff repair
tears, 234 for impingement syndrome, results, 272, 273t
Acromionizer bur, 61f 337f, 338 of glenohumeral instability, 104
Acromioplasty in diagnostic glenohumeral Analgesics
arthroscopic vs. open, 3, arthroscopy, 67, 178–180 for adhesive capsulitis, 336
306–308 in full-thickness rotator cuff tears, for calcific tendinitis, 318
cutting block technique for, 227, 254, 258 immediate postoperative, 48
227f, 228f in proximal biceps tendon lesion Anatomy models
bone transection risk with, diagnosis, 149 for arthroscopic shoulder
227–229, 228f Adhesions surgery training, 5
for acromioclavicular joint biceps tendon lesions related to, two dimensional model
conditions, 308–310. 147, 170–171 of glenohumeral
See also Acromioclavicular in diagnostic arthroscopy reconstruction, 6f
joint. of glenohumeral joint, 77–78, of rotator cuff repair, 6f
for impingement syndrome, 82f, 83f Anchor sutures
215–216, 222, 224f, 225f of subacromial space, 92f for distal biceps tendon
technical failure of, 229 in glenohumeral arthrosis, 189, lesions, 162, 165–166,
where to start/when to stop, 190, 191 166f, 167f, 168f
225, 226f in impingement syndrome, in full-thickness rotator cuff repair
in rotator cuff repair subacromial, 215–216, design perspectives, 255–256
full-thickness, 253, 254f 219, 221f double-row technique, 258,
irreparable, 297, 304 bursectomy and, 219–221, 222f 260f, 267–269, 270f
indications for, 308 in rotator cuff tears material perspectives, 256
open technique for, irreparable full-thickness, 254, 255f placement of, 257
rotator cuff tears irreparable, 254, 279, 299–302, postoperative retrieval of, 275
following, 296 299f, 301f selection of, 255–256, 256f, 257f
os acromiale and, 228, 229f massive, 254, 279, 281f, 282–288 single-row technique, 258, 258f
power instruments for, 60 in stiffness treatment in glenohumeral instability repair,
Active elevation, for massive or as indication, 176, 178–180, 63, 113, 119f, 121, 125f
irreparable rotator cuff 185, 185f anterior-inferior insertions, 125,
tears, 343–344 postoperative, 185 125f, 126f
lowering arm, 345, 346f Adhesive capsulitis historical approaches to, 102
three-phase. See Three-phase idiopathic, 176–178 passing technique for, 128,
active elevation. glenohumeral arthrosis vs., 128f, 129f
Activities of daily living 189–191 in massive rotator cuff repair, 279,
postoperative, with Latarjet impingement syndrome vs., 288, 288f, 294, 294f, 295f
procedure, 144 216, 217, 229 management of, 280, 289, 290f,
rotator cuff tears and, 273t, 298, subacromial impingement vs., 291f, 292f
303–304 217–218, 219f sequence for, 289, 289f
in paraplegics, 348, 350 rehabilitation program for, 336, in operating room setup, 63
Activity modification 336f, 337f in SLAP lesions repair
for glenohumeral instability, 108 Aging process for type 3, 159, 160f
for impingement syndrome, 215 in acromioclavicular joint, 306 posterior, for type 2, 154, 156f,
for periarticular cysts, 201 in rotator cuff disease, 233 158f, 159f
Index 353
Anchor sutures (Continued) Anterior portal Anterior-posterior longitudinal tears,

percutaneous insertion of, 12 combined views of, 98, 97f full-thickness, of rotator
plastic, in full-thickness rotator for acromioclavicular joint cuff, 247–249, 251f,
cuff repair, 256 resection, 95f, 310–311, 252f, 253f
remnant of, in sepsis treatment, 311f Anterolateral (AL) stab wound, for
208–209, 208f for biceps tendon lesion repair massive rotator cuff
skills for, 12 distal, 164, 165, 172 repair, 290–292, 291f
Anesthesia proximal, 152, 152f Antibiotics
examination under for diagnostic glenohumeral for sepsis treatment, 207
clinical data compared to, 44 arthroscopy, 66, 67f, 70t postoperative, for glenohumeral
for impingement syndrome, 217 inside-out technique, 70–72 instability treatment,
in operating room, 44 outside-in technique, 72 136, 138
in stiffness treatment, 178 for fracture fixation, 323–324 Anti-inflammatory medication. See
for calcific tendinitis treatment, for glenohumeral arthrosis also specific drug, e.g.,
318 treatment, 190 Cortisone.
for full-thickness rotator cuff for glenohumeral instability for impingement syndrome, 215
repair, 244 treatment, 113–114, 113f, Arm, contralateral, in sitting
general, 48 114f, 116f, 117f position, 50–51, 52f
in operating room setup, 48 for glenohumeral joint Arm holders, for sitting position,
local. See Local anesthetic. reconstruction, 95–96, 50, 52f
regional, 48 96f in rotator cuff repair
Anterior acromion for Latarjet lesions/repair, 96, 96f full-thickness, 244–245, 245f,
in diagnostic arthroscopy, 87–88, for rotator cuff repair, 94–95, 95f 250–252
88f full-thickness, 245, 246f, 247, massive, 283–284
Anterior capsule 248f, 249f Arthrex Suture Bridge, 63
in diagnostic glenohumeral irreparable, 299 Arthritis
arthroscopy, 75, 76f massive, 286, 293–295 advanced glenohumeral joint,
in impingement syndrome, for SLAP lesion repair, 66–67 irreparable rotator cuff
contracted recess vs., for SLAP lesions, 96 tears and, 298
217–218, 219f for suprascapular nerve full-thickness rotator cuff tears
in stiffness treatment, 181, 182f decompression and, 245–246, 254
blunt dissection of, 181, 183f at the spinoglenoid notch, 97 in acromioclavicular joint, 214,
cauterization of, 181, 182f, 183f at the suprascapular notch, 306–308, 306f, 307f
contracture of, 178–180, 96–97 in impingement syndrome, 216
182–183, 182f, 183f for periarticular cysts, SLAP lesions vs., 307, 307f
release technique for, 178 202–203, 202f osteoarthritis, in glenohumeral
glenohumeral ligament and, Anterior shoulder, sitting position arthrosis, 190
181, 182f for access to, 50–51, 53f rheumatoid, in glenohumeral
resection methods for, 181–185, Anterior translation, in arthrosis, 187, 187f,
184f, 185f glenohumeral instability, 194, 197f
release of 110–111, 112f classification of, 194, 197t
in glenohumeral arthrosis Anterior-inferior repair of Arthropierce suture passer, 56f, 57
treatment, 190–191, 191f glenohumeral instability Arthroscope
in rotator cuff repair anchor insertion for, 125, 125f, hand positions for using, 11f
irreparable, 299, 299f 126f handling of, 42
massive, 286–287 anterior scapular neck preparation in operating room setup, 52–53
Anterior glenohumeral ligament in, 124, 124f rotation techniques for, 11f, 43
in diagnostic arthroscopy, 75, 76f Bankart lesions and, 104, 121 surgeons’ views of, 3, 4f
in glenohumeral instability, 102, bone fragments and, 123–124 Arthroscopic graft jacket placement,
103, 115f débridement in, 122 for glenohumeral joint
circle concept of, 104, 104f drill holes for, 124 arthrosis, 194–196, 196b
Anterior gutter, in diagnostic glenohumeral ligament release in, Arthroscopic lavage, for
subacromial arthroscopy, 122–123, 123f glenohumeral arthrosis,
87–88, 90, 91f insertion tears and, 122, 122f 188–189
Anterior labroligamentous periosteal knot tying in, 129, 129f Arthroscopic pump, in operating
sleeve avulsion (ALPSA) loop reversal in, 127, 128f room setup, 47, 47f, 62
lesion, in glenohumeral passing the anchor suture in, 128, Arthroscopic shoulder surgery
instability, 102, 138 128f, 129f acromioplasty in, 3, 306–307, 308
Anterior labrum, detachment principles of, 121 equipment for, 52–53
classification of, suture passing in, 125–126, 126f, indications for. See specific
122–124, 122f 127f, 128f pathology, e.g., Stiffness.
354 Index
Arthroscopic shoulder surgery Axillary pouch, in stiffness Biceps stump, intra-articular, in

(Continued) treatment, 182–183 distal biceps tendon
instrument handling for, 42 Axillary recess, in diagnostic lesion repairs, 168f, 303f
intellectual history of, 101 glenohumeral Biceps synovitis, 162f
intellectual skills for, 3, 41 arthroscopy, 75, 76f Biceps tendinitis, 147
evaluating need for, 3–4 description of, 161, 162f
open repair vs. See Open shoulder B diagnosis of, 162, 163f
surgery. Back table, in operating room setup, literature review of, 161
portals for. See Instrument portals. 48, 48f operative technique for
technical skills for, 4 Bags and partial-thickness tears with
evaluating need for, 3–4 fluid, in operating room setup, intact rotator cuff, 162f,
knot tying as, 19, 29, 31–41 47, 47f 165, 165f
suture anchors in, 12 for lateral decubitus positioning, intra-articular, 164, 164f
suture management as, 12 49–50, 50t overview discussion on, 161, 173
sutures through tendons in, 12 Bankart lesions postoperative treatment for, 173
transition from open repair accurate assessment of, 5–8 Biceps tendon
gaining experience in, 3, 4, in glenohumeral instability, cyst of, ultrasonography of, 334f
8–9, 41 101, 115f dislocation of, 147, 302, 302f
stages and plan for, 41 anterior-inferior repair of, 104, 121 in irreparable rotator cuff tears,
Arthroscopy Association of North capsular shift of, 105 302, 302f
America, arthroscopic historical treatment of, 101 entrapment of, 147
shoulder surgery training posterior repair of, 118 hourglass, of Bolieau, 171f
program of, 4, 5 radiographs of, 107f in diagnostic glenohumeral
Arthroscopy, diagnostic. See SLAP variations of, 102, 104f, arthroscopy, 70, 75–78
Diagnostic arthroscopy. 107f, 129 extra-articular views of, 81f
Arthrosis. See Glenohumeral joint repair of, 129, 130f normal anatomy of, 78f, 79f
arthrosis. with bone fragment, 123–124 shaver views of, 80f, 81f
ArthroSurface cap, for glenohumeral with complications, 121 tears of, 79f, 80f
instability, 110 in partial-thickness rotator cuff in glenohumeral arthrosis, 188
Arthrotomy, for sepsis, 207 tears, 234–235, 236f in stiffness treatment, 180–181
Articular surface partial-thickness subacromial impingement vs., lesions of
rotator cuff tear 217–218, 218f, 229 distal, 161. See also Distal biceps
operative treatment of, 236–238, Bankart repair tendon lesions.
237f, 238f AccuPass technique for, 15–16, 16b dysfunctional mechanisms of,
ultrasonography of, 326, 332f Caspari suture punch technique 147
ASES (American Shoulder and Elbow for, 14–15, 15b overview discussion on, 147, 173
Surgeons) rating system infection after, 208f proximal, 147. See also Proximal
of full-thickness rotator cuff repair portals for, 52–53 biceps tendon lesions.
results, 272, 273t posterior, 66 MRI of, 328f
of glenohumeral instability, 104 simulation of, 17–19, 27f, 28f, 29f distal lesions, 162, 163f
Aspiration. See Needle aspiration. soft tissue management in, 57 proximal lesions, 149–150, 149f
Assisted living facility, for rotator stiffness following, 176 test excursion of, in irreparable
cuff repair rehabilitation, Beach-chair position, 50, 50t, 51f rotator cuff tears, 302, 302f
in paraplegics, 350 Beanbag, vacuum, for lateral ultrasonography of, 326, 328f
Athletes. See Sports; Throwing decubitus position, thickened, 334f
athlete. 49–50, 50t Biceps tendon tears, 147
Atrophy, of muscles, with rotator Belly-press test, for irreparable complete, ultrasonography of, 333f
cuff tears rotator cuff tears, 297 diagnosis of, 79f, 80f
full-thickness, 242–244, 243f Bernejeau view, of coracoid full-thickness, 163, 164f
supraspinatus muscle/tendon ligament, post-Latarjet in rotator cuff tears
tear and, 242, 243f procedure, 144 full-thickness, 245–246, 246f
irreparable, 297, 299–300 Biceps strengthening irreparable, 296, 297, 298, 302
Avascular necrosis, in glenohumeral for glenohumeral instability partial intra-articular, 164–165
joint arthrosis, 188f, 194 postoperative, 338f, 347 partial-thickness, 162–163
Avulsion injury with recurrent dislocation, with intact rotator cuff, 162f,
of labrum, in glenohumeral 338f, 347 165, 165f
instability, 101, 102 for impingement syndrome, Biceps tenodesis, 165
SLAP lesions resulting from, 151, 338, 338f extra-articular technique in, 161
151f for rotator cuff repair, 338f, 346 indications for, 161–163, 165
Axillary nerve, in stiffness for rotator cuff tears, full- intra-articular technique in, 170,
treatment, 182–183, 184 thickness, 256–257, 338f 171f, 172f, 173f
Index 355
Biceps tenodesis (Continued) Bone (Continued) Burs (Continued)

literature review of, 161 landmarks of, for diagnostic in SLAP 2 lesions repair, 155, 156f
suture anchor technique in, glenohumeral oval, 61f
165–166, 166f, 167f, arthroscopy, 64, 65f round, 60f, 61f
168f palpation of. See Palpation. Bursa
Biceps tenotomy, for irreparable surface, decortication of, in in diagnostic subacromial
rotator cuff tears, full-thickness rotator cuff arthroscopy, 89–90, 93f
161–163, 172–173, 298, repair, 254, 255f in full-thickness rotator cuff
302, 303f Bone anchors, allograft, in repair, 247, 259–261
in paraplegics, 348 full-thickness rotator in glenohumeral joint arthrosis
Biceps-labrum complex cuff repair, 256 treatment, 196
in diagnostic glenohumeral Bone marrow stimulation, in in impingement syndrome,
arthroscopy, 70, 75–78, 78f glenohumeral 215–216, 219, 224–225
in glenohumeral instability, 102, arthrosis, 187 Bursal curtain, posterior, in
110–111 Braces, for paraplegics, with rotator impingement
in massive rotator cuff repair, cuff tears, 348–349 syndrome, 221f
286–287 Braided suture Bursal surface partial-thickness
lesions causing dysfunction in, deployment instrument for, tears, 240
147, 172–173 53, 54f Bursectomy
Bicepsrotator cuff, adhesions of, in full-thickness rotator cuff for impingement syndrome
78, 82f, 83f repair, 259, 263 coracoid, 231
Bicipital groove in glenohumeral instability repair, subacromial, 219–221, 221f,
in irreparable rotator cuff tears, 302 111, 120f, 121, 129, 130, 222f, 226–227
ultrasonography of, 327–328, 328f 132–133 in acromioclavicular joint
Bicipital sheath, in glenohumeral in operating room setup, 60 resection, 310
arthrosis, 188 passing through tendons, 12 in calcific tendinitis treatment,
Biopsy(ies), tissue, for sepsis Breathing tubes, for anesthesia 318–319, 319f
diagnosis, 207–208 endotracheal, 48, 51f in rotator cuff repair
BioRaptor anchor, 63 laryngeal, 48, 48f, 49f full-thickness, 247, 248f
Bleeding Bridge repair, suture irreparable, 299
control of Arthrex material for, 63 Bursitis
in acromioclavicular joint of full-thickness rotator cuff tears, in massive rotator cuff repair,
resection, 311, 312f 270, 270f, 271f 281–282
in impingement treatment, Bristow procedure, stiffness in subacromial space, 88
219–221, 224, 226–227 following, 176f impingement syndrome and,
in rotator cuff repair Broca lesions, 104. See also Bankart 219–221
full-thickness, 252–254, 253f lesions. ultrasonography of, 326
massive, 284–286 Bucket-handle tears, in SLAP 3
electrocautery for, 62, 62f. See also lesions, 159 C
Electrocautery. Burs, 60 Calcific tendinitis
fluid management for, 62 acromionizer, 61f diagnosis of, 316, 317f, 317t, 318f
with acute fractures, 323–324 in acromioclavicular joint literature review of, 316
Blunt dissection resection, 310–312, 314f nonoperative treatment of, 318
in glenohumeral arthrosis in distal biceps tendon lesion operative technique for, 318,
treatment, 190, 191, 191f repairs, 165–166 319f, 320f
in stiffness treatment, 181, 183f in fracture fixation, 323–324 indications for, 318
of subacromial adhesions, for in glenohumeral arthrosis pain with, 316
impingement syndrome, treatment, 192, 192f postoperative treatment of, 320
219, 221f in glenohumeral instability repair, ultrasonography of, 326, 333f
Blunt dissector, 57, 57f, 58f 122, 124 Calcification process, in calcific
with measuring guide in impingement treatment, tendinitis, 316
markings, 58f 221–224, 224f, 229 Cancellous bone, exposure of, in
Bolieau, hourglass biceps of, 171f coracoid, 231 SLAP 2 lesions repair,
Bolieau screw fixation, for pattern of movement for, 224, 155, 155f
distal biceps tendon 225f, 226–227 Cannula(s)
lesions, 162 variations of technique, 5.5-mm, 61–62, 62f
Bone 227, 228f 8-mm, 61–62, 62f
exposure of cancellous, in SLAP 2 in rotator cuff repair eight-mm, 61–62, 62f
lesions repair, 155, 155f full-thickness, 254, 255f for diagnostic arthroscopy
fragments of, in glenohumeral irreparable, 299–302, 301f of glenohumeral joint, 68–72,
instability, 123–124 massive, 288 73f, 75–77, 77f
356 Index
Cannula(s) (Continued) Capsule (Continued) Circle concept, of glenohumeral

of subacromial space, 88–89, posterior. See Posterior capsule. instability, 104, 104f
89f, 90f superior. See Superior capsule. Clavicle, distal
in acromioclavicular joint Capsulitis, idiopathic adhesive, 176, in acromioclavicular joint
resection, 310–312, 177, 178, 178f resection
314, 314f glenohumeral arthrosis vs., 189, anterior resection,
in calcific tendinitis 190–191 311–312, 313f
treatment, 319 impingement syndrome vs., 216, arthroscopic procedures,
in distal biceps tendon lesion 217, 229 310–312, 310f, 311f
repairs, 165–166, subacromial impingement vs., cautery of, 312f
170–173, 172f 217–218, 219f end-on view of, 309f, 311–312
in fracture fixation, 323–324 Cartilage, in diagnostic arthroscopy, open procedures, 308,
in glenohumeral arthrosis 83–85, 86f 308f, 309f
treatment, 190, 194 Cartilage lesions perspectives of, 66, 66f, 306
in glenohumeral instability repair, in glenohumeral arthrosis, osteolysis of, 306
113–118, 114f, 116f, 187, 188f Clavipectoral fascia, in Latarjet
117f, 123f arthroscopic treatment procedure, for
in operating room setup, 61 of, 189 glenohumeral
in rotator cuff repair débridement of, 187–189, instability, 143
full-thickness, 245–247, 247f, 188f Cleavage tears, horizontal, of rotator
248f, 249f, 254, 259, in glenohumeral instability, cuff, 271
261–263, 268f, 269–270 115f, 116f, 118 Clinical data
arm maneuvering for, 252f, in impingement syndrome, display in operating room, 44
253f 218, 218f electronic, 63
irreparable, 299, 300f, 302 in partial-thickness rotator for proximal biceps tendon lesion
massive, 280–281, 284–286, cuff tears, 234–236, diagnosis, 151
290–292 235f, 236f Clinical programs, for arthroscopic
partial-thickness, 237–238 Caspari Suture Punch shoulder surgery training,
in sepsis treatment, 207–209 description of, 8f, 54f, 56 3, 4, 5
in SLAP lesions repair handling of, 43 Coagulation instruments, for
anterior-inferior, 152, 153f, in full-thickness rotator cuff bleeding control, 62, 62f
156–157, 158f, 159 repair, 259, 263f, 264f, Cognitive factors, of impingement
anterior-superior, 154, 154f, 265f, 266f, 267f treatment failure, 229
155f, 156–157, 157f, loading and employing, 8f, Compression
158f, 159 9f, 10f in diagnostic ultrasonography,
in stiffness treatment, 180, thumb position for, 9f 327–328
180–181, 183–185, 184f tip of, 54f in proximal biceps tendon lesion
Capsular elongation, in Catching, of shoulder diagnosis, 149, 149f
glenohumeral instability, with biceps tendon lesions, 147, rotator cuff tears related to,
110–111 149, 149f, 151 233, 239
arthroscopic treatment of, 110 with glenohumeral arthrosis, 188 Computed tomography
historical treatment of, 102 Catheter, long-term, for sepsis of full-thickness rotator cuff
radiographs of, 106, 106f, treatment, 207 tears, 241–242
107f, 108f Cauterization. See Electrocautery. of glenohumeral instability, 106
Capsular repair of glenohumeral Cervical radiculopathy, shoulder for three-dimensional
instability, 129–130, pain related to, 316 reconstruction, 109, 109f
130f, 131f, 132f Cervical spine support of greater tuberosity fractures, 323
Capsular resection punch, 57, 58f for lateral decubitus position, Concavity-compression, of labrum,
in glenohumeral arthrosis 49–50 in glenohumeral
treatment, 190–191 for sitting position, 52f instability, 102, 110, 111,
Capsular shift, in glenohumeral anterior alignment check, 52f 125–126
instability positioning of, 51f Conservative treatment
Bankart lesions and, 105 Chin strap, for securing cervical of acromioclavicular joint
operative treatment of, 101, 105 spine, 52f conditions, 307
Capsular tensioning/tightening, in Chisel dissectors, 57, 57f of calcific tendinitis, 318
glenohumeral instability, in glenohumeral instability repair, of glenohumeral arthrosis, 187
102, 110–112, 121, 122–123, 123f of glenohumeral instability, 103,
130–132, 134, 135f Chondral defects. See Cartilage 108, 108f
Capsule lesions. of greater tuberosity
anterior. See Anterior capsule. Chronicity, of glenohumeral fractures, 323
inferior. See Inferior capsule. instability, 104 of impingement syndrome, 215
Index 357
Conservative treatment (Continued) Coracoacromial ligament (Continued) Crochet hook, for suture
of periarticular cysts, 201, 202 in diagnosis arthroscopy, 89–90, management, 58, 58f
of proximal biceps tendon 91f, 92f, 93f fine-toothed, 58f
lesions, 151 in glenohumeral instability, 102 in glenohumeral instability
of rotator cuff tears in impingement syndrome, repair, 121, 126–127, 130,
full-thickness, 242–243 89–90, 221, 226 133, 134f
in paraplegics, 348 palpation of, 219, 220f in rotator cuff repair
irreparable, 297 release technique for, 221–222, full-thickness, 259–269
partial-thickness, 234 223f, 224f massive, 290–294
Constant scoring system, for in Lafosse technique, 202–203 in SLAP lesions repair, 156–157, 159
glenohumeral in rotator cuff tears Cross-body adduction stretch
instability, 104 full-thickness, 248f, 252, 253f for adhesive capsulitis, 336, 337f
postoperative results of, irreparable, 296, 297, 301f, for full-thickness rotator cuff
136–138, 137t 302, 304 tears, 255–256, 337f
Continuous passive motion chair massive, 283 for glenohumeral instability,
for calcific tendinitis, 320 in stiffness treatment, 180–181 108, 108f
in glenohumeral arthrosis ossification of postoperative, 337f, 347
treatment, 192–193 in full-thickness rotator cuff with recurrent
in rotator cuff repair tears, 242, 243f dislocation, 337f, 347
full-thickness, 272, 272f in impingement syndrome, for impingement syndrome, 337f,
irreparable, 303–304 214, 215f 338
in stiffness treatment, 185–186 release of, in glenohumeral Cuff mobilization, in rotator cuff
Contraction(s) instability, 142 repair
excessive eccentric muscle, Coracohumeral ligament, full-thickness, 254, 254f, 255f
rotator cuff tears related contractures of massive, 284, 285f, 286f, 287f,
to, 233 in full-thickness rotator cuff tears, 288f, 289f
of rotator interval, 72f 254, 255f Cuff-Stitch suture passers, 53, 56–57
Contracture(s) in massive rotator cuff tears, in distal biceps tendon lesion
in full-thickness rotator cuff tears 282–283 repairs, 170–171
capsular, 245–246 release of, 286, 286f in rotator cuff repair
coracohumeral ligament, Coracoid impingement, 230, 231f full-thickness, 271
254, 255f in glenohumeral instability, 142 massive, 293–294, 294f, 295f
postoperative, 274 Coracoid ligament left-angled, 56f
in glenohumeral arthrosis, arthroscopic preparation of, right-angled, 56f
188–189, 189f portals for, 96 straight, 55f
in glenohumeral instability, contractures of, in massive rotator Cultures, for sepsis diagnosis
108, 108f cuff tears, 286 joint fluid, 207–208
in impingement syndrome, in diagnostic glenohumeral tissue, 207–208
anterior capsule recess vs., arthroscopy, 68–69 Curette, in fracture fixation,
217–218, 219f in glenohumeral instability 323–324, 324f
in irreparable rotator cuff tears, Latarjet procedure and, 140f, Cutting block technique, for
capsular, 297, 298 142, 143, 144 acromioplasty, 227,
in massive rotator cuff tears, postoperative evaluation of, 144 227f, 228f
282–283 release of, in glenohumeral bone transection risk with,
release of, 280, 281f, arthrosis treatment, 227–229, 228f
286–288, 286f 191, 192f Cyst(s)
in proximal biceps tendon Coracoid osteotomy, in as biceps tendon lesions, 147
lesions, 151 glenohumeral instability, ultrasonography of, 334f
stiffness related to, 178 142, 143 periarticular. See Periarticular
of anterior capsule, Core decompression, for cysts.
178–180, 182–183, glenohumeral arthrosis,
182f, 183f 189, 196 D
release technique for, 178 Cortisone, injection of Débridement
Contralateral arm/elbow, in for acromioclavicular joint in glenohumeral arthrosis
sitting position, inflammation, 307–308 after synovectomy, 194
50–51, 52f for calcific tendinitis, 318 of cartilage lesions,
Coordination training, for for impingement syndrome, 215 187–189, 188f
glenohumeral for irreparable rotator cuff tears, 297 of rotator interval, 190,
instability, 108 in periarticular cyst treatment, 205 190f, 191
Coracoacromial ligament in stiffness treatment, 185 in glenohumeral instability repair,
fraying of, 91f, 92f, 223f C-reactive protein, in sepsis, 207 110, 112, 119f, 122
358 Index
Débridement (Continued) Diagnostic arthroscopy (Continued) Distal biceps tendon lesions

anterior-inferior, 122 bone landmarks for, 64, 65f (Continued)
in impingement syndrome, lateral portals in, 66–67, 67f literature review of, 161
215–216, 218, 224–225 medial portals in, 66–67, 66f operative technique for, 163–164
in intra-articular tendinitis orientations for, 70, 71f biceps tenodesis as, 161–163, 165
treatment, 164 posterior portals in, 64, 65f indications for, 162, 164f, 164t
in periarticular cyst treatment, posterolateral acromial corner intra-articular tendinitis and,
203–205 in, 64, 65f 164, 164f
irrigation and, in sepsis treatment, procedure for, 67, 70t irreparable rotator cuff tear and,
207–209, 208f rotation of arthroscope in, 172–173
of rotator cuff tears 72–75, 75f, 78, 78f partial tear of intra-articular
in paraplegics, 348 superior portals in, 66, 66f tendon and, 164–165
irreparable, 296–300, 303f trocar entry for, 64, 72, 73f spinal needles in, 165–166,
partial-thickness, 235 of subacromial space, 86–87, 87t 165f, 170–171
of articular surface, 236–238 anterior acromion in, subacromial approaches in, 165
of posterior tears, 239–240 87–88, 88f tendinitis and partial-thickness
with subacromial anterior gutter in, tears with intact rotator
decompression, 235, 236 87–88, 90, 91f cuff, 162f, 165, 165f
Decompression, core, for bursa in, 89–90, 93f tenotomy as, 161–162, 172–173
glenohumeral arthrosis, inferior acromion in, 89 indications for, 162–163,
189, 196 lateral gutter in, 87–88, 90, 91f 302, 303f
Decortication lateral portal in, 88–89, 88f, 90f overview discussion on, 161, 173
of bone surface, in full-thickness orientations for, 87–89 postoperative treatment for, 173
rotator cuff repair, posterior entry for, 87–88 synovitis and, 162f
254, 255f triangulation technique for, the throwing athlete and,
of coracoid, in glenohumeral 89, 89f 161–162
instability, 143 patient positioning for, 49 Distraction, intraoperative, patient
Dedicated team, in operating room portals for. See Viewing portals. position for, 49, 50
setup, 63, 63f surgeon training on, 5–9 Double-row repair, of rotator
Deltoid Directionality, of glenohumeral cuff tears
adhesions of, in rotator cuff tears instability, 103, 132 full-thickness, 258, 260f,
full-thickness, 254, 255f postoperative ratings of, 136–138, 267–269, 270f
irreparable, 300–302 136t, 137t suture bridge technique, 270,
massive, 284, 285f, 287–288 Dislocation 270f, 271f
in impingement treatment of acromioclavicular joint, massive, 280
arthroscopic vs. open, 230 306, 306f Drainage tube, in sepsis treatment,
ultrasonography of, 327–328 of biceps tendon, 147, 302, 302f 208–209, 208f, 209f
in irreparable rotator cuff in irreparable rotator cuff tears, Drapes, placement during patient
repair, 297 302, 302f positioning, 50, 51
Diabetic stiff shoulder, 176–177 of glenohumeral joint Drill holes, in glenohumeral
Diagnostic arthroscopy greater tuberosity fractures and, instability repair
incision variations for, 90–94 322–323 anterior-inferior, 124
in acromioclavicular joint mechanisms causing, 101, of glenoid bone, 124–125, 125f
resection, 95 102, 103 posterior, 121
in glenohumeral joint persistent pain with, 323 Drills
resection, 95 rehabilitation for recurrent, 346 in glenohumeral arthrosis
in Latarjet lesions, 96 strength exercises in, 338f, treatment, 196
in rotator cuff repair, 94 339f, 340f, 347 in SLAP 2 lesions repair,
in SLAP lesions, 96 stretch exercises in, 337f, 155, 156f
in suprascapular nerve 347, 347f Drive-through sign, in diagnostic
decompression traumatic, 109–111 glenohumeral
at the spinoglenoid notch, 97 Distal biceps tendon lesions, 161 arthroscopy, 75
at the suprascapular notch, 96 biceps tenodesis for, 161–163, 165 Dynamic impingement test, 327–328
overview of, 97f, 98 extra-articular technique in, 161
normal anatomy and, 64 intra-articular technique in, E
of glenohumeral joint, 64, 66f, 170, 171f, 172f, 173f Eccentric muscle contraction,
69–70 suture anchor technique in, excessive, rotator cuff
of subacromial space, 165–166, 166f, tears related to, 233
86–87, 88f 167f, 168f Education
of glenohumeral joint, 64 description of, 161, 162f on arthroscopic shoulder surgery
anterior portals in, 66, 67f diagnosis of, 162, 163f AANA programs for, 3, 4, 5
Index 359
Education (Continued) Elevation exercises/strengthening Entry (Continued)

anatomy models for, 5 (Continued) in diagnostic glenohumeral
clinical programs for, 3, 4, 5 standing passive, 343–344 arthroscopy, 64, 67–68,
diagnostic, 5–9 holding arm overhead, 72, 73f
textbooks for, 41 344, 345f in stiffness treatment,
video programs for, 5, 16–17 lowering arm, 345, 345f 180, 180f
on glenohumeral instability supine active Epinephrine, intraoperative, 62
treatment, 5–8, 5f stage 1, 341, 341f Equipment, in operating room
on rotator cuff repair, 5–8 stage 2, 341, 342f setup, 52–53
Elbow, contralateral, in sitting stage 3, 342, 343f anchors as, 63
position, 50–51, 52f postoperative, for glenohumeral arthroscope as, 52–53
Elbow exercises, for rotator cuff instability, 136 cannulas as, 61
repair, 346 scapular fluid management and, 62
Electroblade shaver, 60, 60f for full-thickness rotator cuff hand instruments as, 56
for electrocautery, 62, 62f tears, 259, 340f photography and, 63
in glenohumeral joint arthrosis for glenohumeral instability positioning of, 47, 47f,
treatment, 196 postoperative, 340f, 347 power instruments as, 60
Electrocautery with recurrent dislocation, soft tissue management and, 57
for bleeding management, 62, 62f 340f, 347 suture management and, 57–58
in acromioclavicular joint for impingement syndrome, suture passers as, 53
resection, 310, 310f, 338, 340f sutures as, 58–60
311, 312f for rotator cuff repair, 340f, 346 thermal instruments as, 62
in impingement treatment, shoulder, for glenohumeral joint transfer rods as, 63
221–222, 226–227 surgery, 347, 347f video recording and, 63
in Latarjet procedure, in Elevation stretch, for adhesive Erythema
glenohumeral instability, capsulitis, 336, 337f in calcific tendinitis, 316, 318,
142, 143 Elite Pass instrument 319f
in periarticular cyst treatment, for suture management in full-thickness rotator cuff tears,
202–205 for suture management 247, 248f
in rotator cuff repair description of, 53–57, 53f Erythrocyte sedimentation rate,
full-thickness, 252–253, 253f handling of, 43 in sepsis, 207
irreparable, 300–302 in distal biceps tendon lesion Ethibond suture, in operating room
massive, 284–286 repair, 165–166 setup, 60
instruments for, 62, 62f in full-thickness rotator cuff Examination
of anterior capsule, in stiffness repair, 259, 259f, 260f, for glenohumeral instability, 67,
treatment, 181, 182f, 261f, 262f 103, 105, 105f, 106f
183f in stiffness treatment, for impingement syndrome, 214,
Electrodiagnostic testing, for 181–185, 184f 229, 230
periarticular cysts, 201, punch needle, 7f of acromioclavicular joint, 307
202, 205 loading and employing, of biceps tendon lesions
Electrosurgical grounding pad, 49–50 7f, 8f distal, 162
Elevation with needle deployed, 54f proximal, 149f, 151, 161
in diagnostic glenohumeral Elliptical tears, of rotator cuff of glenohumeral joint, 67, 68f,
arthroscopy, 67, 68f full-thickness, 249–250, 250f 69f, 187
in impingement syndrome, 213, massive, 283f of rotator cuff tears
214 Emotional stability, as full-thickness, 242
in rotator cuff tears glenohumeral instability irreparable, 299–300, 297
full-thickness, 250, 272 treatment factor, 109 partial-thickness, 233–234
irreparable, 296, 297, 304 End-cutting scissors, 58, 60f under anesthesia
massive, 280, 283–284 Endotracheal tube, for clinical data compared to, 44
partial-thickness, 233–234 anesthesia, 48 for impingement
in stiffness treatment, securing in sitting position, 51f syndrome, 217
177–180, 179f Entry. See also specific portal, e.g., in operating room, 44
Elevation exercises/strengthening Anterior portal. in stiffness treatment, 178
active vs. passive. See Active for glenohumeral arthrosis Exercises. See Elevation exercises/
elevation; Passive treatment, 190, 190f strengthening;
elevation. for impingement treatment Strengthening exercises;
for massive or irreparable rotator glenohumeral joint and, 217, Stretching exercises.
cuff tears 218f, 219f rehabilitative. See Rehabilitation.
standing active, 343–344 subacromial space and, Extension, active elbow, for rotator
lowering arm, 345, 346f 218–219, 219f, 220f cuff repair, 346
360 Index
External rotation Flexion Fraying (Continued)

in calcific tendinitis, 317f, 320 active elbow, for rotator cuff of coracoacromial ligament, 223f
in diagnostic glenohumeral repair, 346 in diagnosis arthroscopy,
arthroscopy, 67, 68f in lateral decubitus position, 50 91f, 92f
in abduction with anterior Fluid bags Full-thickness rotator cuff tears
stress, 68f for lateral decubitus position, adhesions with, 254, 255f
sulcus test in, 69f 49–50 chronic, SLAP lesions with, 150
in glenohumeral instability, in operating room setup, 47, 47f classification of, 247–249, 249f
101, 105 Fluid management complications of, 274
for labrum repair, 123–124 for bleeding, 62 diagnosis of, 242, 242f, 243f
inferior translation with, 111, 111f operating room setup for, 62 diagnostic arthroscopy of, vs.
in proximal biceps tendon lesion Foot pedals, in operating room partial-thickness, 93f
diagnosis, 151, 152 setup, 47, 48f discussion on, 275
in rotator cuff tears Force testing literature review of, 241
full-thickness, postoperative, 272 for biceps tendon lesions MRI of, 241–242, 242f, 243f
irreparable, 300f distal, 162 nonoperative treatment of,
massive, 280, 285f proximal, 149, 149f, 151, 151f 242–243
in sitting position, 50 for diagnostic glenohumeral operative technique for, 244
in stiffness treatment, 177–180, arthroscopy, 67, 69f acromioclavicular joint
179f, 182–183 for glenohumeral instability, 105 resection in, 254, 254f
External rotation strengthening for impingement syndrome, acromioplasty in, 253, 254f
for full-thickness rotator cuff 213, 214 anchor placement in, 257
tears, 259, 339f for stiffness treatment, 178–180 anchor selection in, 255–256,
for glenohumeral instability, 136 Forceps, suture retrieval 256f, 257f
postoperative, 339f, 347 in full-thickness rotator cuff anesthesia in, 244
with recurrent repair, 263 anterior-posterior longitudinal
dislocation, 339f, 347 in glenohumeral instability tears, 247–249, 251f,
for impingement syndrome, repair, 132 252f, 253f
338, 339f Four-suture, two-anchor rotator cuff arthroscopic results of, 272
for rotator cuff repair, 339f, 346 repair, 17–19 activities of daily living
External rotation stretch, for simulation of, 19f, 20f, 21f, 22f and, 273t
adhesive capsulitis, Fracture(s) by criteria, 274t
336, 337f acute, 323–324 by rating system, 273t
Extra-articular biceps tendon, in arthroscopy benefits for, 322 physical and mental function
diagnostic glenohumeral diagnosis of, 323 and, 274t
arthroscopy, 81f glenoid rim. See Glenoid rim range of motion and, 273t
Extra-articular biceps tenodesis, 161 fractures. arthroscopic vs. open, 244,
Extracorporeal shock-wave greater tuberosity. See Greater 272, 275
treatment, of calcific tuberosity. components of, 241, 244
tendinitis, 318 humeral head, 322 contraindications for, 244
Eyelets fixation of, 323–324, 324f coracoacromial ligament in,
in arthroscopic shoulder surgery literature review of, 322 248f, 252, 253f
for suturing practice, 16 microfracture, in glenohumeral coracohumeral ligament in,
laser alignment for insertion, 5f arthrosis, 187, 189 254, 255f
suture to tendon, 5f, 6f nonoperative treatment of, 323 cuff mobilization in, 254,
in full-thickness rotator cuff nonunion of, 322–323 254f, 255f
repair, 256, 257f, 258 operative technique for, 323, 324f elliptical tears, 249–250, 250f
contraindications for, 323 glenohumeral joint in,
F indications for, 323 245, 246f
Fibrosis, in subacromial space, 88 postoperative management of, 325 horizontal cleavage tears, 271
Finger exercises, for rotator cuff Fraying indications for, 244
repair, 346 in full-thickness rotator cuff tears, knot tying in, 263, 268f, 269f
Fixation techniques 247, 248f L-shaped tears, 249–250,
for glenoid rim fractures, in glenohumeral instability, of 250f, 251f
322–323 labrum, 117f mattress suture in, 263–271
internal, stiffness following, 177f in impingement syndrome medium tears, 247–249
K-wire, for fractures, of coracoacromial patient positioning in, 244,
323–324, 324f ligament, 223f 245f
screw. See Screw fixation. of labrum, 216–218, 218f portals in, 245, 245f, 246f
suture, of glenoid rim fractures, of rotator cuff bursa, 222f repair site preparation in,
322–323 of supraspinatus, 217–218 254, 255f
Index 361
Full-thickness rotator cuff tears Glenohumeral instability (Continued) Glenohumeral instability (Continued)
(Continued) repair of, 129, 130f contraindications for, 109, 109f
reverse L-shaped tears, 249–250, with bone fragment, 123–124 débridement in, 110, 112,
251f with complications, 121 119f, 122
small tears, 247–249 capsular elongation with, 110–111 decision making for, 109–111
subacromial decompression in, arthroscopic treatment of, 110 intraoperative, 112
250–253 historical treatment of, 102 discussion on, 144
subacromial space in, 246, 247f radiographs of, 106, 106f, failure rates with, 102–103
suture passing in, 259 107f, 108f glenoid drill holes for,
bridge variation, 270, cartilage lesions with, 115f, 116f 124–125, 125f
270f, 271f circle concept of, 104, 104f indications for, 108
Caspari suture punch clinical expression of, 103 inspection in, 113–114
technique, 259, 263f, degree of, 104 key points for, 102–103
264f, 265f, 266f, 267f diagnosis of, 104 knot tying in, 120f, 125, 128–129
Elite suture passer technique, patient history in, 103, 104 anterior-inferior repair, 129,
259, 259f, 260f, physical examination in, 67, 129f
261f, 262f 103, 105, 105f, 106f labrum repair in, 101, 110, 112
suture placement in, 259 radiographs in, 103, 106, 106f, Latarjet procedure in, 113–114,
double-row repair, 258, 260f, 107f, 108f 117f. See also Latarjet
267–269, 270f directionality of, 103, 132 procedure.
single-row repair, 258, 258f glenohumeral ligament in, 113, posterior repair in, 121.
suture selection in, 256–257 115f, 130, 130f, 131f, See also Posterior repair of
suture tension in, 135f glenohumeral instability.
263–269, 269f greater tuberosity fractures and, postoperative management
tear classification in, 247–249 322–323 of, 136
transverse tears, 249–250, 250f Hill-Sachs lesion with, 107f, 110, rationale in, 110, 111f, 112f
postoperative treatment for, 116f, 118, 118f results of, 136
272, 272f treatment considerations of, 110 complications in, 138
rehabilitation program for impingement syndrome vs., 214, ligament laxity in, 138
motion exercises in, 336f, 337f, 216–218, 229 preoperative findings vs.,
340 labrum signs of, 72–73, 103, 114f, 136, 136t
strength exercises in, 243, 272, 115f, 117f range of motion in, 138
338f, 339f, 340, 340f historical treatment of, 101, return to sports participation
Functional classification, 102, 104 in, 138
Steinbrocker, of operative treatment of, 101, scores and rating systems for,
rheumatoid arthritis, 110, 112 136, 137t
194, 197t literature review on, 101 technique findings with,
Functional status nonoperative treatment of, 103, 136, 137t
in full-thickness rotator cuff repair 108, 108f rotator interval in, 111, 113,
results, 272, 274t operative treatment of, 108 113f, 117f
of paraplegics, with rotator cuff anchors for, 63, 113, 119f, repair of, 134, 134f, 135f
tears, 348, 350 121, 125f scapular neck preparation for,
historical approaches to, 102 121, 142
G passing technique for, 128, superior labrum repair in, 129
General anesthesia, in operating 128f, 129f capsular repair and, 130,
room setup, 48 anterior portals for, 113–114, 130f, 131f, 132f
Geometry, of rotator cuff tears, 5–9, 113f, 114f, 116f, 117f, capsular tension
247–249 anterior-inferior repair in, 121. determination and,
massive, 279, 280f, 282–284, See also Anterior-inferior 130–132
288, 293 repair of glenohumeral capsular tightening and,
Glenohumeral instability instability. 132, 133f
Bankart lesions with, 101, approaches to, 101, 110 principles of, 129, 130f
115f, 117f arthroscopic vs. open, 3, surgeon training on, 5–8, 5f
anterior-inferior repair of, 101, 110 technique for, 113
104, 121 cannula and trocar in, 113–118, overhead sports and, 101,
capsular shift of, 105 114f, 116f, 117f, 123f 104–105, 134–135
historical treatment of, 101 capsular repair in, 129–130, periarticular cysts causing, 200, 202
posterior repair of, 118 130f, 131f, 132f recurrent, 109
radiographs of, 107f capsular shift and, 101, 105 rehabilitation for, 346
SLAP variations of, 102, 104f, capsular tensioning in, 102, postoperative, 136, 144, 347
107f, 129 111–112, 121 immobilization in, 347
362 Index
Glenohumeral instability (Continued) Glenohumeral joint (Continued) Glenohumeral joint reconstruction

strength exercises in, 136, partial-thickness, 236–237, 237f (Continued)
338f, 339f, 340, 340f, infection of. See Sepsis. stretch exercises in, 337f,
347, 347f normal anatomy of, 64, 66f, 347, 347f
stretch exercises in, 337f, 69–70 soft tissue management in,
347, 347f physical examination of, 67, instruments for, 57, 58
with recurrent subluxation or 68f, 69f two dimensional model of, 6f
dislocation, 346 release of, in stiffness treatment, Glenohumeral joint space, 66f
strength exercises in, 338f, 178, 183–184 Glenohumeral ligament(s). See also
339f, 340f, 347 translation of, SLAP lesions specific ligament, e.g.,
stretch exercises in, 337f, resulting from, 150–151 Anterior glenohumeral
347, 347f Glenohumeral joint arthrosis ligament.
rotator cuff tears and advanced, irreparable rotator cuff in glenohumeral instability, 102,
arthroscopic treatment of, tears and, 298 113, 115f, 130, 130f,
103–104 avascular necrosis in, 188f, 194 131f, 132–134, 135f
in throwing athletes, 134–135 diagnosis of, 187 anterior-inferior release of,
irreparable, 304 nonoperative treatment of, 187 122–123, 123f
partial-thickness, 234–236, 239 operative treatment of laxity of, 138, 139
rotator intervals in, 70, 71f, 72f, arthroscope placement in, in impingement syndrome, 218
111, 113, 113f, 117f 190, 192 in posterior rotator cuff tears,
historical treatment of, 102 capsular release in, 190–191, 239–240
repair of, 134, 134f, 135f 190f, 191f, 192f in stiffness treatment,
SLAP lesions contributing to, 147, cartilage flap tears in, 181–182, 182f
150–151 187, 188, 188f cauterization of, 181,
Bankart type, 102, 104f, chondral lesions in, 182f, 183f
107f, 129 187, 188f, 189 normal anatomy of, 72–73,
repair of, 129, 130f débridement of, 73f, 74f
Glenohumeral joint 187–189, 188f partial tears in, 71f
cysts of. See Periarticular cysts. continuous passive motion release of
diagnostic arthroscopy of, 64 after, 192–193 in glenohumeral arthrosis
anterior portals in, 66, 67f contraindications for, 189 treatment, 190
bone landmarks for, 64, 65f entry in, 190, 190f in glenohumeral instability
lateral portals in, 66–67, 67f glenoid management in, 192, repair, 122–123, 123f
medial portals in, 66–67, 66f 192f, 193f rotator intervals in, 70, 71f
orientations for, 70, 71f graft jacket placement in, Glenoid bone
posterior portals in, 64, 65f arthroscopic, 194–196b cartilage defect of, 187–188, 188f
posterolateral acromial corner indications for, 187, 187f, 188f, in diagnostic glenohumeral
in, 64, 65f 189f arthroscopy, 68–69, 78,
procedure for, 67, 70t new approaches in, 194 83–85
rotation of arthroscope in, results of, 193–194, 197t osteoarthrosis of, 86f
72–75, 75f, 78, 78f osteoarthritis in, 190 in glenohumeral arthrosis
superior portals in, 66, 66f rehabilitation for, 347 assessment of, 86f
trocar entry for, 64, 72, 73f immobilization in, 347 degree and types of wear, 192
dislocation of strength exercises in, 338f, operative correction of, 192,
greater tuberosity fractures and, 339f, 340, 340f, 347, 192f, 193f
322–323 347f in glenohumeral instability repair
mechanisms causing, 101–103 stretch exercises in, 337f, 347, drill holes and, 124–125, 125f
persistent pain with, 323 347f loss of, 113–114, 118, 138, 139f
rehabilitation for recurrent, 346 rheumatoid arthritis in, 187, 187f, posterior, 118, 119f
strength exercises in, 338f, 194, 197f in SLAP 2 lesions repair, 155–156,
339f, 340f, 347 classification of, 197t 155f, 156f
stretch exercises in, 337f, Glenohumeral joint reconstruction in stiffness treatment, 180,
347, 347f incisions for, 95 182–183
traumatic, 109–111 instrument portals, 96, 96f posterior-superior, in SLAP
entry into, for impingement viewing portals, 95 lesions, portals for, 96
treatment, 217, 218f, 219f patient position for, 49, 50 Glenoid labrum-ligament complex
in calcific tendinitis power instruments for, 60 anatomy of, normal, 147, 148f
treatment, 318 rehabilitation for, 347 in diagnostic glenohumeral
in rotator cuff repair immobilization in, 347 arthroscopy, 70, 72–73
full-thickness, 245, 246f strength exercises in, 338f, 339f, abnormal findings of, 78,
irreparable, 296, 298, 299f 340, 340f, 347, 347f 81f, 82f
Index 363
Glenoid labrum-ligament complex Hammerman technique, for SLAP 2 Hourglass biceps of Bolieau, 171f
(Continued) lesions repair, 155, 157–159 Humeral head
normal findings of, 73–75, 77f, Hand instruments, in operating cartilage lesions of, 86f
81f, 82f room setup, 56 in partial-thickness rotator
posterior anatomy of, 83–85, 87f Harryman soft tissue punch, in cuff tears, 234–236,
in glenohumeral instability, stiffness treatment, 181 235f, 236f
102, 133 Haut portal of Lafosse, 96 subacromial impingement vs.,
in stiffness treatment, Hawkins impingement sign, 213, 214 218, 218f
181–182, 184 in distal biceps tendon compression of, in partial-
pathology of, with biceps tendon lesions, 162 thickness rotator
lesions, 147 Health insurance, for rotator cuff cuff tears, 233, 239
Glenoid rim fractures, in repair, in paraplegics, fractures of
glenohumeral instability, 349, 349b displaced intra-articular, 322
322, 322f Heat therapy, for calcific fixation of, 323–324, 324f
literature review of, 322 tendinitis, 318 Hill-Sachs lesions of, 83, 85f
operative technique for, 323, 324f Hemiarthroplasty, prosthetic, ream in diagnostic glenohumeral
indications for, 323 and run insertion of, arthroscopy, 68–69,
radiographs of, 106, 106f, 108f 192, 192f 72–73, 83
Graft jacket, arthroscopic placement Hemorrhage. See Bleeding. cartilage tear of, 86f
of, for glenohumeral Hemostasis normal anatomy of, 83,
arthrosis, 194–196b in acromioclavicular joint 83f, 85f
Grafts/grafting, in rotator cuff repair resection, 311, 312f osteoarthrosis of, 83–85, 86f
full-thickness, 256 in full-thickness rotator cuff in glenohumeral arthrosis,
irreparable, 297 repair, 252–254, 253f 187–189, 192
Gram stain, tissue, for sepsis in impingement treatment, operative correction of, 192, 192f
diagnosis, 207–208 219–221, 224, 226–227 in glenohumeral instability
Graspers Hemostat, for suture management assessment of, 105, 106
soft tissue, 57, 57f in full-thickness rotator cuff repair, treatment considerations of, 110
in knot tying, 30–31 259, 261–263, 265f, 271 in rotator cuff tears
in rotator cuff repair in glenohumeral instability repair, full-thickness, 242, 250–252
full-thickness, 250, 251f, 126–127 irreparable, 296–299, 298f, 304
252f, 259 Hill-Sachs lesion massive, 279, 282, 283,
massive, 283–284, 285f, 286, in diagnostic arthroscopy, 83, 85f 287–288
291f in glenohumeral instability, 107f, in SLAP lesions, 150
in sepsis treatment, 207–208 110, 116f, 118, 118f in stiffness treatment, 180–182,
less aggressive, 57, 57f treatment considerations of, 110 184–185
suture, 58 History taking translation of, in glenohumeral
in full-thickness rotator cuff for acromioclavicular joint instability, 102, 103, 110
repair, 266f conditions, 307 Hydrocortisone, in stiffness
large, 59f for biceps tendon lesions treatment, 185
small, 59f distal, 162
with jaws open, 59f proximal, 151 I
Greater tuberosity for glenohumeral instability, Ice therapy
fractures of 103, 104 for calcific tendinitis, 318
diagnosis of, 322–323 for glenohumeral joint postoperative
in glenohumeral instability, pathology, 187 for acromioclavicular joint
322–323 for impingement syndrome, 214 resection, 314
literature review of, 322–323 Home-based rehabilitation for full-thickness rotator cuff
nonoperative treatment of, 323 for calcific tendinitis, 320 repair, 272, 272f
operative technique for, 323, 324f for glenohumeral instability, 108, for glenohumeral
indications for, 323 136, 144 instability, 136
in rotator cuff repair for periarticular cysts, 201, 202 Idiopathic adhesive capsulitis,
full-thickness, 256, 256f, 257f for rotator cuff tears 176–178
irreparable, 300–302, 302f full-thickness, 243, 244 glenohumeral arthrosis vs.,
massive, 282, 287–288, 288f in paraplegics, 348, 350 189–191
Grounding pad, electrosurgical, Home-care aide, for paraplegics, with impingement syndrome vs., 216,
49–50 rotator cuff tears, 348, 350 217, 229
Hook. See Crochet hook. rehabilitation program for, 336,
H Horizontal cleavage tears, full- 336f, 337f
Hair removal, in shoulder thickness, of rotator subacromial impingement vs.,
preparation, 48 cuff, 271 217–218, 219f
364 Index
Immobilization. See Sling Impingement syndrome (Continued) Inferior glenohumeral ligament

immobilization. of rotator cuff (Continued)
Impingement sign(s) outlet, 149, 151–152, 238–239 circle concept of, 104, 104f
Hawkins vs. Neer, 213, 214 secondary Inferior portal
in distal biceps tendon distal, 162 for glenohumeral arthrosis
lesions, 162 proximal, 149, 151–152 treatment, 190, 190f
in partial-thickness rotator cuff stage 2, 213 for glenohumeral instability
tears, 233–234 rehabilitation program for, treatment, 113, 114f
Impingement syndrome 215–216, 229, 337–338 for glenohumeral joint
acromioclavicular joint and, 214, motion exercises in, 336f, 337f, reconstruction, 66–67,
216, 217, 311–312 338 67f, 95–96
arthroscopic findings in, 216 strength exercises in, 338, 338f, for SLAP lesions, 96
arthroscopic treatment of, 217 339f, 340f Inferior translation, in
acromioclavicular joint in, subacromial, 162–163, glenohumeral instability,
214, 217 214–215, 215f 110–111, 111f
acromioplasty in, 222, 224f, 225f stage 2, conditions mimicking, in abduction, 111, 112f
bursectomy in, 219–221, 221f, 217–218, 218f, 219f Inflammation
222f, 231 treatment of, 216, 219, 221f impingement syndrome vs.,
contraindications for, 216 See also Subacromial 216–217
coracoacromial ligament in, decompression. in acromioclavicular joint, 307–308
221, 223f, 224f, 226 Impingement test in distal biceps tendon lesions,
examination under anesthesia dynamic, 327–328 164, 164t
for, 217 for glenohumeral instability, 216 in stiff shoulder, 178
failure of, 229 for impingement syndrome, postoperative, 185
technical, 229 213, 214 with calcium excision, 318, 320
thought-related, 229 Incisions. See also specific Infraspinatus muscle/tendon
glenohumeral joint entry and, approach, e.g., Anterior calcific tendinitis of, 316, 318
217, 218f, 219f portal. in diagnostic arthroscopy, 84f
hemostasis in, 219–221, 224, combined views of, 97f, 98 periarticular cysts impact on, 200,
226–227 for instruments. See Instrument 201, 201f, 202
indications for, 215 portals. tears of
open approach vs., 230 for viewing. See Viewing portals. irreparable rotator cuff tears
os acromiale in, 228, 229f Infection, septic and, 297, 298f
positioning for, 217 diagnosis of, 207 massive rotator cuff tears and,
postoperative management literature review of, 207 294–295
of, 229 operative technique for, 207 partial-thickness rotator cuff
skin markings for, 217, 217f treatment goals for, 207 tears and, 234, 236
subacromial entry in, 218–219, Infectious disease consultation, for repair of, 235
219f, 220f sepsis, 207 ultrasonography of, 326,
subacromial findings in, Inferior acromion 327–328, 331f
216–217, 219, 221f in diagnostic arthroscopy, 89 Injections
variations of, 227, 227f, 228f Inferior capsule anesthetic. See Local anesthetic.
where to start/when to stop, contracted recess of, anti-inflammatory. See specific
225, 226f impingement syndrome drug, e.g., Cortisone.
clinical presentation of, 213 vs., 217–218, 219f subacromial, fluid after,
coracoid, 230, 231f in diagnostic glenohumeral ultrasonography of, 333f
in glenohumeral instability, 142 arthroscopy, 75, 76f, 77f Insertion tears, in glenohumeral
diagnosis of, 214, 215f in glenohumeral instability, 116f instability repair,
improper, 229 in stiffness treatment, 181–184, 122, 122f
ultrasonography in, 327–328 183f, 184f, 185f Inspection
differential diagnosis of, 214, 216 release of in glenohumeral instability repair,
electrocautery for, 221–222, in glenohumeral arthrosis 113–114
226–227 treatment, 190–191, 191f for Latarjet procedure, 138, 139f
glenohumeral instability vs., 214, in rotator cuff repair of rotator cuff articular surface,
216–218, 229 irreparable, 299, 299f arthroscopic vs.
internal massive, 286–288 open, 236
rotator cuff tears related to, Inferior glenohumeral ligament Instability, of glenohumeral joint.
233, 239 in diagnostic arthroscopy, 75, See Glenohumeral
subacromial vs., 217–218, 218f 76f, 78 instability.
literature review of, 213 in glenohumeral instability, Instrument cart, in operating room
nonoperative treatment of, 215 102, 103 setup, 47, 47f
Index 365
Instrument portals Internal rotation stretch, abduction, Irreparable rotator cuff tears
in glenohumeral joint for glenohumeral (Continued)
reconstruction, 96, 96f instability, with recurrent stage 3, 342, 343f
in Lafosse technique, 202 dislocation, 347, 347f stage 4, 342, 343f
in Latarjet lesions/repair, 96 Interscalene block, 48, 60 stage 5, 343, 344f
in rotator cuff repair, 94, 95f for calcific tendinitis stage 6, 343, 344f
in SLAP lesion repair, 96 treatment, 318 warm-up for, 336f, 340
in suprascapular nerve for fracture fixation, 323–324 Irrigation and débridement, in
decompression for full-thickness rotator cuff sepsis treatment,
at the spinoglenoid notch, 97–98 repair, 244 207–209, 208f
at the suprascapular notch, Intra-articular biceps stump, in
96–97 distal lesion repairs, J
Instruments 156f, 168f Joint entry. See Entry.
handling of, 42 Intra-articular biceps tendinitis, Joint fluid
in operating room setup 164, 164f cultures of, for sepsis diagnosis,
hand, 56 Intra-articular biceps tendon partial 207–208
power, 60 tear, 164–165 subacromial, after injections, 333f
thermal, 62 Intra-articular biceps tenodesis, 170,
Insurance issues, of rotator cuff 171f, 172f, 173f K
repair, in paraplegics, Intra-articular lesions Kerrison rongeur, in periarticular cyst
349, 349b in glenohumeral instability, 106 treatment, 202–203, 205f
Intellectual skills, for arthroscopic treatment of, 101 Kidney rest, for lateral decubitus
shoulder surgery, 3, 41 of rotator cuff tendon position, 49–50
evaluating need for, 3–4 in full-thickness tears, 245–246 Kinematics, of scapula, in biceps
Internal fixation, open reduction and, in irreparable tears, 296, 297 tendon lesion
stiffness following, 177f in massive tears, 286–287 rehabilitation, 151–152
Internal impingement ultrasonography of, 326, 332f KINSA knotless anchor system, 63
rotator cuff tears related to, Irreparable rotator cuff tears Kirschner wire fixation, for
233, 239 adhesions in, 254, 279, 299–302, fractures, 323–324, 324f
subacromial vs., 217–218, 218f 299f, 301f Knife, in calcific tendinitis
Internal rotation diagnosis of, 279, 288, 296, treatment, 319–320, 319f
in acromioclavicular joint 297, 298f Knot pusher
pain, 307 after open surgery, 296 for one-handed knot, 35f
in calcific tendinitis, 317f in glenohumeral instability, 304 simulation of, 35f, 36f, 37f,
in diagnostic glenohumeral literature review of, 297 38f, 39f, 40f, 41f
arthroscopy, 67 nonoperative treatment of, 297 for suture management, 58, 59f
in abduction in coronal operative technique for handling of, 43
plane, 68f arthroscopic perspectives of, in full-thickness rotator cuff
in abduction in scapular 296, 296f repair, 262–263, 268f
plane, 69f biceps tenotomy in, 161–163, in SLAP lesions repair, 159f
sulcus test in, 69f 172–173, 297, 298, 302, Knot tension, in full-thickness
in glenohumeral instability, 302f, 303f rotator cuff repair,
inferior translation with, complications of, 303 263–269, 269f
111, 111f contraindications for, 298 Knot tying
in proximal biceps tendon examination for, 298 board for, 6f, 9f
lesion diagnosis, 147, glenohumeral joint in, 296, in distal biceps tendon lesion
151, 151f, 152 298, 299f repairs, 170–171, 173f
in rotator cuff repair indications for, 298 in glenohumeral instability repair,
irreparable, 297 subacromial space in, 299, 299f, 120f, 125, 128–129
massive, 285f 300f, 301f, 302f anterior-inferior, 129, 129f
in stiffness treatment, 177–180 postoperative management for, 303 in rotator cuff repair
Internal rotation strengthening rehabilitation program for, 340 full-thickness, 263, 268f, 269f
for full-thickness rotator cuff goal of, 340 massive, 279, 294, 294f, 295f
tears, 259, 339f standing exercises in, 343 in SLAP 2 lesions repair,
for glenohumeral instability stage 1, 344, 345f 154–159, 158f
postoperative, 339f, 347 stage 2, 345, 345f overhand, 29
with recurrent stage 3, 345, 346f one-handed, 30, 31f, 32f, 33f,
dislocation, 339f, 347 stages of, 343–344 34f, 35f
for impingement syndrome, 338, supine exercises in, 341 using a knot pusher, 35f, 36f,
339f stage 1, 341, 341f 37f, 38f, 39f, 40f, 41f
for rotator cuff repair, 338f, 346 stage 2, 341, 342f two-handed, 29–30, 30f, 31f
366 Index
Knot tying (Continued) Lafosse technique (Continued) Lateral portal (Continued)

skills for, 19, 29, 31–41 indications for. See Suprascapular for suprascapular nerve
sliding, 31–41 nerve decompression at decompression
the suprascapular notch. at the spinoglenoid notch, 97, 98
L Laryngeal mask air tube, 48, 48f at the suprascapular notch,
Labrum secured in place with tape, 49f 96–97, 97f
anterior, detachment classification Latarjet procedure for periarticular cysts,
of, 122, 122f, 123–124 for glenohumeral instability, 202–203, 202f
biceps. See Biceps-labrum 113–114, 117f Lavage, arthroscopic, for
complex. coracoid ligament in, 142–144 glenohumeral arthrosis,
fragments of, in glenohumeral effectiveness factors of, 140–141 188–189
arthrosis, 188–189, electrocautery in, 142, 143 Left-angled instrument, for suture
189f, 194 indications for, 103, 138, management, in
fraying of 140, 141 glenohumeral instability
in glenohumeral inspection in, 138, 139f repair, 126–127, 127f
instability, 117f ligament quality and, 139 Leg pads, for sitting position, 52f
in impingement syndrome, open transition to arthroscopic, Lidocaine injection, for
216–218, 218f 142–144 impingement syndrome,
glenoid. See Glenoid labrum- open vs. arthroscopic, 140f, 213, 214
ligament complex. 141–142, 141f Lift-off test, for irreparable rotator
in glenohumeral instability, patient compliance with, 139 cuff tears, 297
diagnostic signs of, postoperative care for, 144 Ligament laxity, in glenohumeral
72–73, 103, 114f, radiography in, 139f, instability, 138
115f, 117f 140f, 141f Latarjet procedure and, 139
historical treatment of, 101, Bernejeau view of coracoid postoperative, 138
102, 104 ligament, 144 Ligaments. See specific ligament,
operative treatment of, 101, spinal needles in, 143 e.g., Glenohumeral
110, 112 sports and, 139–140 ligament(s).
pathology of, with biceps tendon subscapularis tendon/muscle in, Linvatec shuttle relay, for suture
lesions, 147 143, 144 transfer, 53
anchor sutures for, 156–159, technique for, 140, 140f Local anesthetic
158f, 159f incisions for, 96 for acromioclavicular joint
normal anatomy vs., 147, 148f instrument portals, 96 injection, 307–308
proximal, 152, 153 viewing portals, 96, 96f for calcific tendinitis, 318
periarticular cysts impact on, 200 Lateral decubitus position, operating for impingement syndrome,
posterior room setup and, 49, 50t 213, 214
in glenohumeral Lateral gutter, in diagnostic for impingement test, 213, 214
instability, 113–118, subacromial arthroscopy, Locking, of shoulder
117f, 119f, 122 87–88, 90, 91f with biceps tendon lesions, 147,
ultrasonography of, Lateral portal 149, 149f, 151
327–328, 331f combined views of, 97f, 98 with glenohumeral
splitting of, in glenohumeral for acromioclavicular joint arthrosis, 188
instability, 117f resection, 66, 66f, 95f, Longitudinal repair, tendon-to-
superior. See Superior labrum. 310–312, 310f, 311f, 314 tendon, of rotator
Labrum reattachment/repair for acromioplasty, 224, cuff tears
anchors for, 63 227, 228f, 229 massive, 280, 280f, 293–294
for periarticular cysts, 202–205 for calcific tendinitis treatment, Longitudinal (L-shaped) tears, of
in glenohumeral instability repair, 318–320 rotator cuff, 249–250,
101, 110, 112 for diagnostic glenohumeral 250f, 251f
Labrum tears, 200, 202 arthroscopy, 66–67, 67f anterior-posterior, 247–249, 251f,
in glenohumeral instability, 103, for fracture fixation, 323–324 252f, 253f
114f, 115f for impingement treatment, massive, 283, 283f, 284f
historical treatment of, 101, 102 218–219 reverse, 249–250, 251f
repair of, 101, 110, 112 for Latarjet lesions/repair, 96 Loop reversal, in glenohumeral
in rotator cuff tears for rotator cuff repair, 94–95, 95f instability repair, 127, 128f
full-thickness, 245–246 full-thickness, 245, 246f, 247, Loop suture, nylon
irreparable, 298–299 250–252, 254 deployment instrument for,
Lafosse technique massive, 281–282, 282f, 286, 53, 54f
incisions for, 96 291f, 293, in glenohumeral instability repair,
instrument portals, 96–97 for subacromial decompression, 126, 127–128, 127f,
viewing portals, 96, 97f 66, 67f 128f, 135f
Index 367
Loop suture, nylon (Continued) Marking suture, on articular surface, Massive rotator cuff tears (Continued)
reversal of, 127, 128f for rotator cuff tears, warm-up for, 336f, 340
in SLAP 2 lesions repair, 236, 238 smaller tears vs., 279, 282
156–157, 157f Markings, preoperative. See Skin Mat, absorbent, in operating room
Loose bodies markings. setup, 47, 48f
in full-thickness rotator cuff tears, Mason-Allen sutures, modified, in Mattress suture
245–246 full-thickness rotator cuff in distal biceps tendon lesion
in glenohumeral arthrosis, 187, repair, 263–269 repair, 165–166, 170–171
188, 189f Massive rotator cuff tears in full-thickness rotator cuff
débridement of, 187–189, 188f adhesions with, 254, 279, 281f, repair, 263–270, 271
in glenohumeral instability repair, 282–288 Mayo stand, in operating room
116f classification of, 283 setup, 48, 48f
L-shaped tears. See Longitudinal definition of, 279 McConnell arm holder, for sitting
(L-shaped) tears. geometry of, 279, 280f, 283–284, position, 50, 52f
288, 293 in rotator cuff repair
M literature review of, 280 full-thickness, 244–245, 245f,
Magnetic resonance imaging (MRI) operative technique for, 280 250–252
contraindications for, 326 cuff mobilization in, 284, massive, 283–284
display in operating room, 285f, 286f, 287f, Measuring probe
44, 46f 288f, 289f for bone resection, in
of acromioclavicular joint elliptical tears, 283f acromioclavicular joint,
conditions, 307, 307f, L-shaped tears, 283, 308f, 311–312, 314f
308 283f, 284f for tear classification, in rotator
of biceps tendon lesions, 328f margin convergence in, 293, cuff repair
distal, 162, 163f 293f, 294f full-thickness, 247–249, 249f
proximal, 149–150, 149f muscle disease and, 280, massive, 283
of calcific tendinitis, 316, 317f 282–283 Mechanical abnormalities, with
of coracoid impingement repair sequence in, 289, 289f biceps tendon lesions,
treatment, 230, 231f reverse L-shaped tears, 147, 151
of glenohumeral instability, 106 283, 284f Mechanical arm holders, for sitting
of greater tuberosity simple vs. complex position, 50–51
fractures, 323 arthroscopic, 279, 280 in rotator cuff repair
of periarticular cysts, 199, 199f, appearance perspectives of, full-thickness, 244–245, 245f,
200, 200f 280–281, 281f 250–252
postoperative, 205 subscapularis tears in, 286, 294 massive, 283–284
of rotator cuff tears suture management in, 280, Mechanical irritation tests, for
full-thickness, 241–242, 289, 290f, 291f, 292f biceps tendon lesions
242f, 243f suture tying in, 279, 294, distal, 162
irreparable, 297, 298f, 294f, 295f proximal, 149, 149f, 151, 151f
299–300 tear classification, 282 Medial acromion resection, in
partial-thickness, 233–234, tendon-to-tendon longitudinal acromioclavicular joint
234f, 238–239 repair, 280, 280f, resection
of stiff shoulder, 177 293–294 arthroscopic, 311–312, 312f, 313f
of subscapularis tendon, 329f transverse tears, 283f open, 308, 308f, 309f
ultrasonography vs., 326, 327 visualization in, 280, 281f, 282f Medial portal
Mallet, in full-thickness rotator cuff postoperative management for diagnostic glenohumeral
repair, 256 for, 295 arthroscopy, 66–67, 66f
Malunion, of humeral head rehabilitation program for, 340 for suprascapular nerve
fractures, 322 goal of, 340 decompression
Manipulation standing exercises in, 343 at the spinoglenoid notch, 98
for glenohumeral arthrosis, 189 stage 1, 344, 345f at the suprascapular notch,
in rotator cuff repair stage 2, 345, 345f 96–97
massive, 280 stage 3, 345, 346f for periarticular cysts,
in stiffness treatment, 178, stages, 343–344 202–203, 203f
179f, 180f supine exercises in, 341 Medial repair, of massive rotator
Manual muscle testing, for stage 1, 341, 341f cuff tears, 288, 289f
irreparable rotator cuff stage 2, 341, 342f Mental functioning, in full-
tears, 297 stage 3, 342, 343f thickness rotator cuff
Margin convergence, in massive stage 4, 342, 343f repair results, 272, 274t
rotator cuff repair, 293, stage 5, 343, 344f Metallic anchors, in full-thickness
293f, 294f stage 6, 343, 344f rotator cuff repair, 256
368 Index
Metallic caps, for glenohumeral Muscles (Continued) Nonsteroidal anti-inflammatory

instability, 110 disease of, with massive rotator drugs (Continued)
Methicillin-resistant S. aureus cuff tears, 280, 282–283 for periarticular cysts, 201
(MRSA), in sepsis, 207 Musculoskeletal pain syndromes, for rotator cuff tears
Methylprednisolone, injection of impingement syndrome full-thickness, 243
for acromioclavicular joint vs., 216 irreparable, 297
inflammation, 307–308 Musculotendinous junction partial-thickness, 234
preoperative, for calcific in diagnostic subacromial Nonunion, of greater tuberosity
tendinitis, 318 arthroscopy, 91f fractures, 322–323
Microfracture, in glenohumeral in impingement syndrome, Nursing care, home-based, for
arthrosis, 187, 189 219–221, 221f rotator cuff repair
Microorganisms, in sepsis, 207 in massive rotator cuff tears, rehabilitation, in
Middle glenohumeral ligament, in 282–283 paraplegics, 350
glenohumeral instability, Myositis ossificans, 178, 178f Nylon suture
115f, 118, 118f in full-thickness rotator cuff
capsular repair consideration of, N repair, 259, 261–262,
130, 130f, 131f, 132f Necrosis, avascular, in 263, 264f, 265f,
rotator interval repair consideration glenohumeral joint 266f, 268f
of, 134, 134f arthrosis, 188f, 194 in operating room setup, 60
Models, anatomic Needle aspiration, serial, for loop
for arthroscopic shoulder surgery sepsis, 207 deployment instrument for,
training, 5 Needles 53, 54f
two dimensional model Elite suture punch. See Elite Pass in glenohumeral instability
of glenohumeral instrument. repair, 126, 127–128,
reconstruction, 6f spinal. See Spinal needles. 127f, 128f, 135f
of rotator cuff repair, 6f Neer impingement sign, 213, 214 reversal of, 127, 128f
Monocryl suture in distal biceps tendon in SLAP 2 lesions repair,
in full-thickness rotator cuff lesions, 162 156–157, 157f
repair, 271 Nerve decompression, suprascapular.
in operating room setup, 60 See Suprascapular nerve O
Monofilament suture decompression. O’Brien test
in glenohumeral instability Nerve entrapment, suprascapular, for acromioclavicular joint
repair, 127–129, impingement syndrome assessment, 307
134, 134f vs., 216 for proximal biceps tendon
in partial-thickness rotator cuff Neuromuscular exercises, for lesions, 149
repair, 236–237, 237f glenohumeral One-anchor, two-suture rotator cuff
Motion exercises instability, 136 repair, 12–14, 17–19
for full-thickness rotator cuff Nonoperative treatment simulation of, 17f, 18f
tears, 336f, 337f, 340 of acromioclavicular joint One-handed knot, 30
for impingement syndrome, 336f, conditions, 307 simulation of, 32f, 33f, 34f, 35f
337f, 338 of calcific tendinitis, 318 using a knot pusher, 35f, 36f,
MRI. See Magnetic resonance of glenohumeral arthrosis, 187 37f, 38f, 39f, 40f, 41f
imaging (MRI). of glenohumeral instability, 103, Open reduction and internal
MRSA (methicillin-resistant S. 108, 108f fixation, stiffness
aureus), in sepsis, 207 of greater tuberosity following, 177f
Muscle contraction, excessive fractures, 323 Open shoulder surgery
eccentric, rotator cuff of impingement syndrome, 215 acromioplasty in, 3, 306–307, 308
tears related to, 233 of periarticular cysts, 201, 202 arthroscopic repair vs., 3
Muscle flaps, in irreparable rotator of proximal biceps tendon conversion to, patient position
cuff repair, 297 lesions, 151 and, 50
Muscle testing, manual, for of rotator cuff tears for glenohumeral instability, 3,
irreparable rotator cuff full-thickness, 242–243 101, 110
tears, 297, 303–304 in paraplegics, 348 for impingement syndrome, 230
Muscle transfers, in irreparable irreparable, 297 for rotator cuff tears
rotator cuff repair, 297 partial-thickness, 234 full-thickness, 244, 272, 275
Muscles. See also specific muscle, Nonsteroidal anti-inflammatory glenohumeral instability and,
e.g., Supraspinatus drugs 103–104
muscle/tendon. for acromioclavicular joint massive, 279
atrophy of, with rotator cuff tears conditions, 307 partial-thickness, 236
full-thickness, 242–244, 243f for calcific tendinitis, 318 irreparable rotator cuff tears
irreparable, 297, 299–300 for glenohumeral instability, 108 following, 296
Index 369
Open shoulder surgery (Continued) Osteoarthrosis Pain (Continued)

resection as. See specific anatomy or of glenohumeral joint. See treatment failure and,
pathology, e.g., Glenohumeral joint 229, 230
Acromioclavicular joint. arthrosis. periarticular cysts causing, 200
transition to arthroscopy of glenoid bone, 83–85, 86f rotator cuff tears causing
focus on details, 5–8, 41 of humeral head, 83–85, 86f full-thickness, 254, 275
gaining skill experience, 3–5, stiff shoulder related to, 176, 177, irreparable, 296–298, 302, 304
8–9, 41 177f massive, 280, 294–295
Operating room setup Osteolysis, of distal clavicle, partial-thickness, 233–234
absorbent mat in, 47, 48f 306, 314 shoulder dislocation
anesthesia in, 48 Osteophytes causing, 323
arthroscopic pump in, 47, in distal clavicle, 217, 306, 314 stiff shoulder causing, 177
47f, 62 in glenohumeral arthrosis, 188–189 with arthroscopic vs. open
back table in, 48, 48f Osteotomy, coracoid, in shoulder repair, 3
clinical data in, 44 glenohumeral instability, Pain management
dedicated team in, 63, 63f 142, 143 for adhesive capsulitis, 336
equipment in, 52–53 Outlet impingement syndrome, of for calcific tendinitis, 318
anchors as, 63 rotator cuff, 149, immediate postoperative, 48
arthroscope as, 52–53 151–152, 238–239 Pain syndromes, impingement
cannulas as, 61 Oval bur, 61f syndrome vs., 216
fluid management, 62 Overhand knot, 29 Palliative treatment, of
hand instruments as, 56 one-handed, 30 glenohumeral
photography and, 63 simulation of, 31f, 32f, 33f, arthrosis, 187
positioning of, 47, 47f 34f, 35f Palpation
power instruments as, 60 using a knot pusher, 35f, in acromioclavicular joint
soft tissue management and, 57 36f, 37f, 38f, 39f, assessment, 307
suture management and, 57–58 40f, 41f in diagnostic arthroscopy
suture passers as, 53 two-handed, 29–30, 30f, 31f of glenohumeral joint,
sutures as, 58–60 Overhead sports 68–69, 70f
thermal instruments as, 62 distal biceps tendon lesions and, of subacromial space, 89, 89f
transfer rods as, 63 161–162 in rotator cuff repair
video recording and, 63 glenohumeral instability and, full-thickness, 247f, 254
fluid bags in, 47, 47f 104–105 massive, 280–281, 281f, 286
foot pedals in, 47, 48f treatment of, 101, 134–135 in SLAP repair, 152
instrument cart in, 47, 47f rotator cuff lesions and, 134–135 in stiffness treatment, 180, 181f
Mayo stand in, 48, 48f SLAP lesions and, 150–151 probe, in fracture fixation,
patient positioning and, 49 Overload stress, repetitive 323–324, 324f
importance of detail, 49 impingement syndrome vs., 216 Paraplegics, rotator cuff tears in, 348
lateral decubitus position, SLAP lesions related to, 150–151 nonoperative treatment of, 348
49, 50t Oxygen tension, in calcific operative treatment of
sitting position, 50, 50t tendinitis, 316 bathroom basics and, 348
patient record in, 44, 44f, 45f bedroom basics and, 348
radiographic display in, P indications for, 348
44, 46f Pain insurance issues with,
room layout for, 47, 47f acromioclavicular joint conditions 349, 349b
shoulder preparation table in, 48 causing, 306, 307 mobility concerns, 348
ultrasonography in, 327 treatment considerations, preoperative planning for, 348
Operative site, preoperative 307, 308 postoperative rehabilitation for,
verification of, 48–49, 49f biceps tendon lesions causing 348, 350
Orthopedic Learning Center, 4, 5 distal to SLAP lesion, 161, 162 transferring and, 348
Os acromiale proximal, 147, 149, 149f, 151 Partial-thickness rotator cuff tears
in diagnostic subacromial calcific tendinitis causing, 316 description of, 233
arthroscopy, 92f cervical radiculopathy diagnosis of, 233, 234f
in impingement syndrome, causing, 316 diagnostic arthroscopy of, vs.
228, 229f glenohumeral arthrosis causing, full-thickness, 93f
Ossification, of coracoacromial 188, 189f in glenohumeral instability,
ligament, in postoperative, 192–194 234–236, 239
impingement syndrome, glenohumeral instability causing, in impingement syndrome,
214, 215f 105–109 219–221, 222f
Osteoarthritis, in glenohumeral impingement syndrome causing, literature review of, 233
arthrosis, 190 213, 214, 216, 230 MRI of, 233–234, 234f, 238–239
370 Index
Partial-thickness rotator cuff tears Pendulum exercises (Continued) Pillows, for patient positioning,
(Continued) for full-thickness rotator cuff 49–51
nonoperative treatment of, 234 tears, 255–256, 336f PL (posterolateral) stab wound, for
operative treatment of for impingement massive rotator cuff
decision making in, 235 syndrome, 336f, 338 repair, 290, 291f,
findings in, 234, 235f, 236f for rotator cuff repair 292–293, 292f
in articular surface tears, full-thickness, 272 Plastic anchors, in full-thickness
236–238, 237f, 238f surgical day to week 6, 336f, 346 rotator cuff repair, 256
in bursal surface tears, 240 weeks 6 to 12, 336f, 346 Portals. See also specific approach,
indications for, 234 postoperative e.g., Anterior portal;
posterior lesions, 238, for full-thickness rotator cuff specific pathology, e.g.,
239f, 240f repair, 272 Glenohumeral instability.
sutures in, 236–237, 237f, 238f for glenohumeral combined views of, 97f, 98
variations of, 238, 239f, 240f instability, 144 for instruments.
postoperative treatment of, 240 Periarticular cysts See Instrument portals.
ultrasonography of, articular diagnosis of, 200 for viewing. See Viewing portals.
surface, 326, 332f electrocautery for, 202–205 Posterior capsule
Passive elevation, for massive or electrodiagnostic testing for, 201, in diagnostic glenohumeral
irreparable rotator cuff 202, 205 arthroscopy, 75, 76f
tears, 343–344 in glenohumeral instability, in SLAP lesion diagnosis,
holding arm overhead, 200, 202 151, 151f
344, 345f incidence of, 199 in stiffness treatment,
lowering arm, 345, 345f literature review of, 200 182–184, 184f
Passive motion chair. See MRI of, 199, 199f, 200, 200f, 205 release of, in glenohumeral
Continuous passive nonoperative treatment of, 201 arthrosis treatment,
motion chair. suprascapular nerve compression 190–191, 191f
Past-point, in SLAP 2 lesions with, 200, 201f Posterior glenohumeral ligament
repair, 158f surgical treatment of in diagnostic arthroscopy, 78
Patient expectations, for indications for, 202 in glenohumeral instability,
impingement suprascapular nerve 103, 108f
treatment, 229 decompression at the circle concept of, 104, 104f
Patient history. See History taking. spinoglenoid ligament, Posterior glenoid, in glenohumeral
Patient positioning 205–206, 205f, 206f instability repair, 118,
for full-thickness rotator cuff suprascapular nerve 119f
repair, 244–245, 245f decompression at the Posterior labrum
for impingement treatment, 217 suprascapular notch, 202 in glenohumeral instability,
in operating room setup, 49 miscellaneous tear repair 113–118, 117f, 119f, 122
beach-chair, 50, 50t, 51f with, 203–205 ultrasonography of,
importance of detail, 49 portals for, 202–203, 202f, 203f 327–328, 331f
lateral decubitus, 49, 50t postoperative care for, 205 Posterior portal
Schloein device for, 50, variations of, 205 combined views of, 97f, 98
244–245 teres minor muscle hypertrophy for acromioclavicular joint
sitting, 50, 50t, 51f and, 200, 201f resection, 310f, 314
Spyder Arm device for, 50, Perthes lesions, 104. See also for acromioplasty, 222–224
250–252 Bankart lesions. for diagnostic glenohumeral
Trendelenburg, 50–51 Phagocytosis, in calcific arthroscopy, 70t
Patient record, in operating room tendinitis, 316 for glenohumeral arthrosis
setup, 44, 44f, 45f Photographs, intraoperative, treatment, 190
electronic, 63 equipment for, 63 for glenohumeral instability
PDS suture, in operating room Physical examination. See treatment, 121
setup, 60 Examination. for glenohumeral joint
Pectoralis minor Physical functioning reconstruction, 95–96
in Latarjet procedure, in in full-thickness rotator cuff repair for rotator cuff repair, 94–95, 95f
glenohumeral instability, results, 272, 274t full-thickness, 245
143 of paraplegics, with rotator cuff irreparable, 298–299
release of, portals for, 96 tears, 348, 350 massive, 282, 282f, 293–295
Pedals, foot, in operating room Physical therapy. See also for SLAP lesions, 96, 155–156
setup, 47, 48f Rehabilitation. for subacromial decompression,
Pendulum exercises for glenohumeral arthrosis, 187 64–65, 65f
for adhesive capsulitis, 336, for glenohumeral instability, 108 for suprascapular nerve
336f, 337f referral, for rehabilitation, 336 decompression
Index 371
Posterior portal (Continued) Prosthetics, for glenohumeral Radiography

at the spinoglenoid notch, 97, instability, 110 in impingement syndrome, 216,
98, 205f, 206 Proximal biceps tendon lesions, 147 217, 222–224, 226,
at the suprascapular notch, anatomy of, 147, 148f 229, 230
96, 97f diagnosis of, 151, 151f of acromioclavicular joint
for periarticular cysts, 202–203 glenohumeral instability and, 147, conditions, 307–308
Posterior portals 150–151 of biceps tendon lesions
for diagnostic glenohumeral mechanical irritation and, 149, distal, 162, 163f
arthroscopy, 64, 65f 151, 151f proximal, 149–150, 149f
for SLAP lesion repair, 66 nonoperative treatment of, 151 of calcific tendinitis, 316, 317f,
Posterior repair of glenohumeral operative technique for 317t, 318f
instability, 121 anterior portals in, 152, 152f postoperative, 320
Bankart lesions and, 118 cannula in of coracoid ligament, post-Latarjet
drill holes for, 121 anterior-inferior, 152, 153f, procedure, 144
portal placement for, 156–157, 158f, 159 of glenohumeral arthrosis,
114–118, 121 anterior-superior, 154, 154f, 187–189, 187f,
scapular neck preparation for, 121 155f, 156–157, 157f, 188f, 189f, 192
step-by-step, 118, 119f, 120f, 121f 158f, 159 avascular necrosis in, 196
principles of, 121 contraindications for, 152 of glenohumeral instability
suture passing for, 120f, 121 indications for, 152 diagnostic, 103, 106, 106f,
Posterior shoulder, sitting position labrum assessment in, 152, 153 107f, 108f
for access to, 50–51, 53f skin markings in, 152, 153f Latarjet procedure and, 139f,
Posterior step-off erosion, of glenoid SLAP 1 lesions and, 153–154 140f, 141f
bone, 192, 192f SLAP 2 lesions and, 154, of greater tuberosity fractures, 323
in irreparable rotator cuff 154f, 155f, 156f, postoperative, 323–325
repair, 299 157f, 158f, 159f of Latarjet procedure, for
operative correction of, 192, 193f SLAP 3 lesions and, 159, glenohumeral instability,
Posterior translation, in 159f, 160f 140f, 141, 141f
glenohumeral instability, SLAP 4 lesions and, 159, of rotator cuff tears
111, 112f 160f, 161f full-thickness, 242, 272
Posterior-inferior glenohumeral superior portals in, 152, 152f irreparable, 297
joint, portals for, overview discussion on, 147, 173 partial-thickness, 233–234
95–96, 96f physical examination for, 149f, of stiff shoulder, 177–178, 177f
Posterior-superior glenoid, in SLAP 151, 161 Range of motion
lesions, portals for, 96 postoperative treatment of, 161 in acromioclavicular joint
Posterolateral acromial corner, in rotator cuff disease and, 149 conditions, 307, 311–312
diagnostic arthroscopy, irreparable, 302, 303f in diagnostic glenohumeral
64, 65f SLAP lesions as, 147–148 arthroscopy, 67
Posterolateral (PL) stab wound, for the throwing athlete and, in diagnostic
massive rotator cuff 150–151 ultrasonography, 326
repair, 290, 291f, Pseudoparalytic shoulder, 296, 296f in glenohumeral arthrosis
292–293, 292f Pump, arthroscopic, in operating postoperative, 192–194, 196
Posteromedial acromion, in room setup, 47, 47f, 62 preoperative, 187, 189, 190
acromioclavicular joint Punch needle in glenohumeral instability,
resection, 311–312, 313f Elite instrument for. See Elite Pass 103, 132
Postoperative care. See specific instrument. postoperative ratings of,
procedure or surgery. soft tissue, in stiffness treatment, 136–138, 136t, 137t
Power instruments. See also Burs. 181–185, 184f in impingement syndrome, 213,
for glenohumeral joint 217, 229, 230
reconstruction, 60 Q in stiff shoulder
in operating room setup, 60 QuickT anchor, 63 postoperative, 64, 176–177,
Preparation table, shoulder, 48 185–186
Prolene suture, in operating room R preoperative, 177–180
setup, 60 Radiculopathy, cervical, shoulder proximal biceps tendon lesions
Propionibacterium acnes, in sepsis, 207 pain related to, 316 and, 149, 151, 152
Proprioception training, for Radiographic classification, rotator cuff tears and
glenohumeral Steinbrocker, of full-thickness, 250
instability, 108 rheumatoid arthritis, arthroscopic repair results,
Prosthetic hemiarthroplasty, ream 194, 197t 273t
and run insertion of, Radiographic display, in operating irreparable, 297, 303–304
192, 192f room, 44, 46f massive, 279, 280, 283
372 Index
Range of motion (Continued) Rehabilitation (Continued) Rest therapy (Continued)

partial-thickness, 233–234 stage 3, 345, 346f for impingement syndrome, 215
Range of motion therapy. See stages of, 343–344 for periarticular cysts, 201
Rehabilitation. supine exercises in, 341 Retraction strengthening, scapular
Rasp, in glenohumeral instability stage 1, 341, 341f for full-thickness rotator cuff
repair, 132, 133f stage 2, 341, 342f tears, 259, 340f
Rating systems, for full-thickness stage 3, 342, 343f for glenohumeral instability
rotator cuff repair results, stage 4, 342, 343f postoperative, 340f, 347
272, 273t stage 5, 343, 344f with recurrent
Ream and run insertion, of prosthetic stage 6, 343, 344f dislocation, 340f, 347
hemiarthroplasty, 192, warm-up for, 336f, 340 for impingement syndrome,
192f goals for, 336 338, 340f
Record, patient, in operating room home-based. See Home-based for rotator cuff repair, 340f, 346
setup, 44, 44f, 45f rehabilitation. Return to sports, after
electronic, 63 physical therapy referral for, 336 glenohumeral instability
Regional anesthesia, in operating postoperative treatment, 138
room setup, 48 for acromioclavicular joint Reverse L-shaped tears, of rotator cuff
Rehabilitation resection, 314 full-thickness, 249–250, 251f
for adhesive capsulitis, 336, for arthroscopic vs. open massive, 283, 284f
336f, 337f shoulder repair, 3 Rheumatoid arthritis, in
for fracture fixation, 325 for biceps tendon lesions glenohumeral arthrosis,
for glenohumeral instability, 346 distal, 173 187, 187f, 194, 197f
postoperative, 136, 144, 347 proximal, 151–152 classification of, 194, 197t
immobilization in, 347 for calcific tendinitis, 320 Right-angled instrument, for suture
strength exercises in, 136 338f, for glenohumeral arthrosis, management, in
339f, 340f, 347, 347f 192–193, 196 glenohumeral instability
stretch exercises in, 337f, for glenohumeral instability, repair, 126–127, 127f,
347, 347f 136, 144, 347 128
with recurrent subluxation or for rotator cuff repair, 240, 346 Ringer’s solution, for intraoperative
dislocation, 346 in stiffness treatment, 64, 185–186 fluid management, 62
strength exercises in, 338f, Rehabilitation hospital, for rotator Rods, transfer, in operating room
339f, 340f, 347 cuff repair, in setup, 63
stretch exercises in, 337f, paraplegics, 350 Room layout, for operating room,
347, 347f Relocation test 47, 47f
for impingement syndrome, for glenohumeral instability, Rotation
215–216, 229, 337–338 105, 105f external. See External rotation.
motion exercises in, 336f, 337f, for proximal biceps tendon for proximal biceps tendon lesion
338 lesions, 151, 151f diagnosis, 149, 149f
strength exercises in, 338, 338f, Remplissage procedure, for in full-thickness rotator cuff
339f, 340f glenohumeral instability, tears, 250
for rotator cuff repair, 240, 346 110, 118 internal. See Internal rotation.
full-thickness, 272 Repetitive overload stress shoulder fractures and, 323
in paraplegics, 348, 350 impingement syndrome vs., 216 Rotation strengthening
irreparable, 297, 303–304 SLAP lesions related to, 150–151 for full-thickness rotator cuff tears
sling in, 346 Resection, arthroscopic vs. open. external, 259, 339f
surgical day to week 6, See specific anatomy or internal, 259, 339f
336f, 346 pathology, e.g., for glenohumeral instability
week 12, 338f, 339f, 340f, 346 Acromioclavicular joint. external
weeks 6 to 12, 336f, 341f, 342f, Resection punch, capsular, 57, 58f postoperative, 339f, 347
343f, 344f, 345f, 346, 346f Resistive exercises, for glenohumeral with recurrent dislocation,
for rotator cuff tears instability, 108 339f, 347
full-thickness Resorptive phase, of calcific internal
motion exercises in, 336f, tendinitis, 316, 318 postoperative, 339f, 347
337f, 340 Rest therapy with recurrent dislocation,
strength exercises in, 243, for adhesive capsulitis, 336 339f, 347
272, 338f, 339f, 340, 340f for biceps tendon lesions for impingement syndrome
massive or irreparable, 340 distal, postoperative, 173 external, 338, 339f
goal of, 340 proximal, 151–152 internal, 338, 339f
standing exercises in, 343 for calcific tendinitis, 318 for rotator cuff repair
stage 1, 344, 345f for full-thickness rotator cuff external, 339f, 346
stage 2, 345, 345f tears, 243 internal, 339f, 346
Index 373
Rotator cuff disease Rotator cuff repair (Continued) Rotator cuff tendon
as intrinsic aging, 233 stiffness following, 176, 176f articular surface of
impingement syndrome vs., 216 surgeon training on, 5–8 arthroscopic vs. open inspection
ultrasonography of, 326 three-anchor, six-suture technique of, 236
with biceps tendon lesions for, 17–19, 22f, 23f, 24f, partial-thickness tears of, 236–238,
distal, 162 25f, 26f, 27f 237f, 238f
proximal, 147–149 two dimensional model of, 6f ultrasonography of lesions of,
Rotator cuff repair two-anchor, four-suture technique 326, 332f
anchors for, 63 for, 17–19, 19f, 20f, calcific deposits in, 316, 317t,
arthroscopic 21f, 22f 320, 320f
full-thickness, 93f with periarticular cyst chronic tendinosis of, 213.
portals for, 245, 245f, 246f treatment, 203 See also Impingement
glenohumeral instability and, Rotator cuff tears syndrome.
103–104 accurate assessment of, 5–9 diagnostic arthroscopy of, 90,
gradual transition to open, 41 acute, SLAP lesions with, 150 90f, 93f
open vs., 3 arthroscopic scope limits prior to intact, biceps tendinitis and
partial-thickness, 235 open repair, 41 partial-thickness tears
articular surface in, 236–238, biceps tendon lesions related to, with, 162f, 165, 165f
237f, 238f 147–150 palpation of, in impingement
bursal surface, 240 classification of treatment, 219, 220f
variations of, 238, 239f, 240f full-thickness, 247–249, 249f periarticular cysts impact on, 200
stages for, 41, 42 massive, 279, 283 remnant of, in sepsis treatment,
Caspari technique for, 13–14b clinical presentation of, 177 208–209, 208f
elements of, 11–12 diagnostic arthroscopy of, secondary impingement
Elite Pass technique for, 12-13 79–83, 83f syndrome of, with biceps
geometry of, 8–9 partial- vs. full-thickness, 93f tendon lesions
healed, ultrasonography of, 332f full-thickness. See Full-thickness distal, 162
in paraplegics rotator cuff tears. proximal, 149, 151–152
bedroom basics and, 348 greater tuberosity fractures with, Rotator interval
indications for, 348 322, 323 contractions of, 181f
insurance issues with, 349, in glenohumeral instability débridement of, in glenohumeral
349b arthroscopic treatment of, arthrosis, 190, 190f, 191
mobility concerns, 348 103–104 in diagnostic glenohumeral
postoperative rehabilitation for, in throwing athletes, 134–135 arthroscopy
348, 350 irreparable, 304 abnormal, 70, 71f, 72f
preoperative planning for, 348 partial-thickness, 234–236, 239 normal, 70, 71f
transferring and, 348 in paraplegics, 348 in diagnostic subacromial
incisions for, 94 nonoperative treatment arthroscopy
instrument portals, 94, 95f of, 348 needle palpation of, 94f
viewing portals, 94 operative treatment of needle probing of, 94f
Joe W. King invitational course bathroom basics and, 348 opened, 94f
on, 5f bedroom basics and, 348 in distal biceps tendon lesion
one-anchor, two-suture technique indications for, 348 repairs, 165–166, 166f
for, 12-14, 17–19, 17f, 18f insurance issues with, in glenohumeral instability, 70,
open 349, 349b 71f, 72f, 111, 113, 113f,
arthroscopic vs., 3 mobility concerns, 348 117f
conversion to, patient position preoperative planning for, 348 historical treatment of, 102
and, 50 postoperative rehabilitation for, repair of, 134, 134f, 135f
hand instruments for, 348, 350 in stiffness treatment, 180, 181f
56–57, 58 transferring and, 348 release of, in massive rotator
power instruments for, 60 in throwing athlete, 134–135 cuff repair, 286,
rehabilitation for, 240, 346 irreparable. See Irreparable rotator 286f, 287f
full-thickness, 272 cuff tears. synovitis of, 72f, 181f
in paraplegics, 348, 350 massive. See Massive rotator widening of, 72f
irreparable, 297, 303–304 cuff tears. Round bur, 60f, 61f
sling in, 346 partial-thickness. See Partial- Rowe scoring system, for
surgical day to week 6, 336f, thickness rotator glenohumeral
346 cuff tears. instability, 104
week 12, 338f, 339f, 340f, 346 subacromial impingement vs., ligament laxity in, 138
weeks 6 to 12, 336f, 341f, 342f, 217–218, 218f, 219f postoperative results,
343f, 344f, 345f, 346, 346f ultrasonography of, 326, 332f 136–138, 137t
374 Index
Rowe test, for glenohumeral Second throw in knot tying, slipping Single-row repair, of full-thickness
instability, 105, 105f, 106f technique for, 30–31 rotator cuff tears, 258, 258f
Secondary impingement syndrome, Sitting position, 50, 50t, 51f
S of rotator cuff Six-suture, three anchor rotator cuff
Scapula, kinematics of, in biceps distal, 162 repair, 17–19
tendon lesion proximal, 149, 151–152 simulation of, 22f, 23f, 24f, 25f,
rehabilitation, 151–152 Sepsis 26f, 27f
Scapular elevation strengthening diagnosis of, 207 Skilled technicians, for rotator cuff
for full-thickness rotator cuff literature review of, 207 repair rehabilitation, in
tears, 259, 340f operative technique for, 207 paraplegics, 350
for glenohumeral instability treatment goals for, 207 Skin markings
postoperative, 340f, 347 SF-36 Health Survey, on full- anesthesiologist role in,
with recurrent thickness rotator cuff 48–49, 49f
dislocation, 340f, 347 repair results, 272, 274t for impingement treatment,
for impingement syndrome, Shaver, 60, 60f 217, 217f
338, 340f in biceps tendinitis treatment for proximal biceps tendon lesion
for rotator cuff repair, 340f, 346 intra-articular, 164, 164f repair, 152, 153f
Scapular neck preparation, with partial-thickness tears, 165 Skin preparation/scrub, 50
in glenohumeral in calcific tendinitis treatment, products for, 48
instability repair 318–320, 320f SLAP lesions
anterior, 124, 124f in diagnostic arthroscopy acromioclavicular arthritis vs.,
Latarjet technique, 142 of glenohumeral joint, 80f, 81f 307, 307f
posterior, 121 of subacromial space, 89, 90f biceps tendon anatomy and,
Scapular retraction strengthening in fracture fixation, 323–324, 324f 147, 148f
for full-thickness rotator cuff in glenohumeral arthrosis description of, 147–148
tears, 259, 340f treatment, 190 diagnosis of, 78, 82f
for glenohumeral instability in impingement treatment, proximal, 151, 151f,
postoperative, 340f, 347 218–222, 227f, 231 glenohumeral instability related
with recurrent in periarticular cyst treatment, to, 147, 150–151
dislocation, 340f, 347 202–203, 205–206 Bankart type, 102,
for impingement syndrome, in rotator cuff repair 104f, 107f, 129
338, 340f full-thickness, 252–254 repair of, 129, 130f
for rotator cuff repair, 340f, 346 irreparable, 299–302 in full-thickness rotator cuff tears,
Scapulothoracic motion, in stiff massive, 280–282, 284–286 245–246
shoulder, 177–178 partial-thickness, 236–238 incisions for, 96
Schloein patient positioner, 50, in stiffness treatment, 183–184, instrument portals, 96
244–245 184f viewing portals, 96
Scissors Shaving, in shoulder preparation, 48 mechanical irritation and, 149,
for suture management, 58, 59f Sheet roll, soft, for lateral decubitus 151, 151f
end-cutting, 58, 60f position, 49–50 nonoperative treatment of, 151
in calcific tendinitis treatment, Shoulder operative technique for
319–320 anterior, sitting position for access anterior portals in, 66–67,
in glenohumeral arthrosis to, 50–51, 53f 152, 152f
treatment, 190, 191 posterior, sitting position for cannula in
in glenohumeral instability repair, access to, 50–51, 53f anterior-inferior, 152, 153f,
122–123, 123f pseudoparalytic, 296, 296f 156–157, 158f, 159
in rotator cuff repair stiff. See Stiffness. anterior-superior, 154, 154f,
irreparable, 300–302 Shoulder arthroscopy models, 155f, 156–157, 157f,
massive, 286–287 anatomic, 5, 7f 158f, 159,
Scoring systems, for glenohumeral Shoulder elevation strengthening, contraindications for, 152
instability, 104 for glenohumeral joint indications for, 152
postoperative results of, surgery, 347, 347f labrum assessment in, 152, 153
136–138, 137t Shoulder immobilizer, in posterior portals in, 66
Screw fixation full-thickness rotator power instruments for, 60
Bolieau, for distal biceps tendon cuff repair, 272, 272f skin markings in, 152, 153f
lesions, 162 Shoulder pain. See Pain. superior portals in, 152, 152f
of glenoid rim fractures, 322–323 Shoulder preparation table, 48 periarticular cysts and, 200f, 205
of greater tuberosity fractures, Shoulder surgery treatment approaches to,
323–324, 324f arthroscopic. See Arthroscopic 203–205, 204f
postoperative management shoulder surgery. physical examination for, 149f,
of, 325 open. See Open shoulder surgery. 151, 161
Index 375
SLAP lesions (Continued) Soft tissue grasper, 57, 57f Spinoglenoid ligament, periarticular
postoperative treatment of, in knot tying, 30–31 cysts impact on, 201,
proximal, 161 in rotator cuff repair 201f, 206f
rotator cuff disease and, 149, 150 full-thickness, 250, suprascapular nerve
soft tissue management in, 57 251f, 252f, 259 decompression for,
subacromial impingement vs., massive, 283–284, 285f, 205–206, 205f
217–218, 218f 286, 291f Spinoglenoid notch, nerve
the throwing athlete and, in sepsis treatment, 207–208 decompression at.
150–151 less aggressive, 57, 57f See Suprascapular nerve
type 1 Soft tissue management, equipment decompression at the
description of, 147–148, 148f for, 57 spinoglenoid ligament.
operative technique for, Soft tissue punch, in stiffness Sports
153–154 treatment, 181–185, 184f in glenohumeral instability
rotator cuff disease with, 149–150 Soft tissue release, in irreparable classification of, 104, 109
type 2 rotator cuff repair, 299 Latarjet procedure and,
description of, 147–148, 148f Soft tissue resector 139–140
operative technique for, 154, in diagnostic subacromial return to postoperatively, 138
154f, 155f, 156f, 157f, arthroscopy, 89 overhead. See Overhead sports.
158f, 159f in sepsis treatment, 207–208 Spurs, acromial, in full-thickness
rotator cuff disease with, 150 in stiffness treatment, rotator cuff tears,
type 3 180–181, 185 242, 243f
description of, 147–148, 148f Spectrum suture passer Spyder Arm Positioner, for sitting
operative technique for, 159, description of, 55f position, 50, 250–252
159f, 160f handling, 43 in full-thickness rotator cuff
type 4 in glenohumeral instability repair, 244–245
description of, 147–148, 149f repair, 126 Stage 2 impingement syndrome
operative technique for, 159, in massive rotator cuff repair, of rotator cuff, 213
160f, 161f 293–294, 295f subacromial space and. See
types of, 147–148, 148f, 149f in SLAP 2 lesions repair, 157f Impingement syndrome.
variations of, 148–149 Speed test, for biceps tendon lesions Stages/staging
Sliding knot, 31–41 distal, 162 for massive or irreparable rotator
Sling immobilization proximal, 149 cuff tears rehabilitation.
in rotator cuff repair, 346 Spinal needles See Rehabilitation.
full-thickness, 272, 272f for lateral portal identification, 66 for rotator cuff repair, 41, 42
postoperative, glenohumeral in acromioclavicular joint of open to arthroscopic shoulder
instability surgery, 136, resection, 310–311, 311f surgery transition, 41
144, 347 in calcific tendinitis Stand, Mayo, in operating room
Slipping second throw in suture treatment, 319 setup, 48, 48f
management, 30–31 in diagnostic arthroscopy Standing exercises
Smith-Nephew anchor inserter, in of glenohumeral joint, 72 for massive or irreparable rotator
rotator cuff repair of subacromial space, 88–89, cuff tears, 343
full-thickness, 256, 258 92f goal of, 340
massive, 293–294 in distal biceps tendon lesion stage 1, 344, 345f
Smith-Nephew Endoscopy repairs, 165–166, 165f, stage 2, 345, 345f
power instruments for, 60 170–171 stage 3, 345, 346f
suture passers for, 53, 56, in fracture fixation, 323–324 warm-up for, 336f, 340
156–157 in glenohumeral instability repair, for rotator cuff repair, 345f,
Smith-Nephew suture passer, in 113, 116f 346, 346f
glenohumeral instability in Latarjet procedure, for Staphylococcus aureus, in sepsis, 207
repair, 126, 128, 133 glenohumeral instability, Staphylococcus epidermidis, in
Soft spot 143 sepsis, 207
in acromioclavicular joint in periarticular cyst treatment, Steinbrocker classification, of
resection, 314 202–203 rheumatoid arthritis,
in diagnostic glenohumeral in rotator cuff repair 194, 197t
arthroscopy, 64–65 full-thickness, 247, 248f, 249f Step-off erosion, posterior, of
in full-thickness rotator cuff irreparable, 299 glenoid bone, 192, 192f
repair, 245, 245f massive, 288 in irreparable rotator cuff
in glenohumeral instability repair, partial-thickness, 236–237, 237f repair, 299
113, 113f in SLAP 2 lesions repair, 154, operative correction of, 192, 193f
Soft tissue contracture. 154f, 155–156 Steroids, intra-articular. See Cortisone;
See Contracture(s). in stiffness treatment, 180 Methylprednisolone.
376 Index
Stiffness Strengthening exercises (Continued) Subacromial decompression

arthroscopic surgery for for proximal biceps tendon (Continued)
contraindications to, lesions, 151–152 in glenohumeral instability repair,
178, 178f for rotator cuff repair, 338f, 339f, 113, 113f
indications for, 178 340f, 346 in rotator cuff repair
technique for, 178 for rotator cuff tears full-thickness, 250–253
clinical presentation of, 177 full-thickness, 243, 272, 338f, irreparable, 297
conditions producing, 176 339f, 340, 340f massive, 283–286, 286f
postoperative, 176, 176f, 177f irreparable, 297, 298, 304 of paraplegics, 348
diabetes-related, 176–177 massive or irreparable, supine partial-thickness
diagnosis of, 177, 177f stage 4, 342, 343f with débridement, 235
following full-thickness rotator stage 5, 343, 344f with tendon repair, 235
cuff repair, 274 stage 6, 343, 344f lateral portal for, 66, 67f
glenohumeral ligament rotator partial-thickness, 234, 240 patient position for, 49
intervals and, 70, retractional. See Retraction posterior portal for, 64–65, 65f
71f, 72f strengthening. power instruments for, 60
literature review of, 176 rotational. See Rotation Subacromial impingement, 162–163,
operative technique for, 178 strengthening. 214–215, 215f
anterior capsule in, 181, 182f scapular. See Scapular elevation stage 2, conditions mimicking,
blunt dissection of, 181, 183f strengthening; Scapular 217–218, 218f, 219f
cauterization of, 181, retraction strengthening. treatment of. See Subacromial
182f, 183f shoulder elevation, for decompression.
contracture of, 178–180, glenohumeral joint Subacromial injection, fluid after,
182–183, 182f, 183f surgery, 347, 347f ultrasonography of, 333f
glenohumeral ligament and, triceps. See Triceps strengthening. Subacromial space
181, 182f Stress, repetitive overload calcific tendinitis and, 318–320,
resection methods for, impingement syndrome vs., 216 319f
181–185, 184f, 185f SLAP lesions related to, 150–151 diagnostic arthroscopy of,
contracture release, 178 Stress testing 86–87, 87t
examination under anesthesia for biceps tendon lesions anterior acromion in, 87–88, 88f
in, 178 distal, 162 anterior gutter in, 87–88,
joint entry in, 180, 180f, 181f proximal, 149, 149f, 151, 151f 90, 91f
manipulation in, 178, for diagnostic glenohumeral bursa in, 89–90, 93f
179f, 180f arthroscopy, 67, 69f inferior acromion in, 89
rotator interval in, 180, 181f Stretching exercises lateral gutter in, 87–88,
subacromial space in, for adhesive capsulitis, 336, 337f 90, 91f
185, 185f for glenohumeral instability lateral portal in, 88–89, 88f,
postoperative care for, 185 postoperative, 337f, 347, 347f 90f
Strain gauge, for glenohumeral with recurrent subluxation or orientations for, 87–89
instability treatment, 132 dislocation, 337f, 347, posterior entry for, 87–88
Strain rate, in glenohumeral 347f triangulation technique for, 89,
instability, 102 for proximal biceps tendon 89f
Strengthening exercises lesions, 151–152 in impingement syndrome, 185
biceps. See Biceps strengthening. for rotator cuff tears arthroscopic findings in,
elevational. See Elevation full-thickness, 243 216–217, 219, 221f
exercises/strengthening. partial-thickness, 234 diagnosis of, 214–215, 215f
for acromioclavicular joint Subacromial approach entry into, 218–219, 219f, 220f
resection, 314 to coracoid impingement glenohumeral ligament rotator
for calcific tendinitis, 320 treatment, 231 interval in, 70, 71f
for fracture fixation, 325 to distal biceps tendon lesions, treatment considerations of,
for glenohumeral arthrosis, 187 164, 165 216, 217, 219, 221f
for glenohumeral instability, to glenohumeral arthrosis in rotator cuff repair
108, 136 treatment, 196 full-thickness, 246, 247f, 257, 274
postoperative, 136, 338f, 339f, Subacromial decompression irreparable, 299, 299f, 300f,
340, 340f, 347, 347f arthroscopic vs. open, 3 301f, 302f
with recurrent subluxation or for impingement syndrome, 216, massive, 280–284, 286–287, 290
dislocation, 338f, 339f, 217, 219, 221f partial-thickness, 236–237,
340f, 347 where to start/when to stop, 238f, 239f
for impingement syndrome, 338, 225, 226f in stiffness treatment, 185, 185f
338f, 339f, 340f in acromioclavicular joint normal anatomy of, 86–87, 88f
for periarticular cysts, 201, 202 resection, 310 suture management in, 58
Index 377
Subcoracoid space, in glenohumeral Superior labrum (Continued) Suprascapular nerve decompression

arthrosis, 188 capsular tension determination at the spinoglenoid notch
Subluxation, of glenohumeral joint and, 130–132 (Continued)
mechanisms causing, 101, 103 capsular tightening and, for periarticular cysts, 205–206,
rehabilitation for recurrent, 346 132, 133f 205f, 206f
strength exercises in, 338f, principles of, 129, 130f incisions for, 97
339f, 340f, 347 Superior labrum from anterior to instrument portals, 97–98
stretch exercises in, 337f, posterior lesions. See SLAP viewing portals, 97
347, 347f lesions. Suprascapular nerve decompression
Subscapularis tendon/muscle Superior portal at the suprascapular
calcific tendinitis of, 317f for acromioclavicular joint notch
in diagnostic arthroscopy, 72–73, resection, 66, 66f for periarticular cysts, 202
74f, 90, 96 for diagnostic glenohumeral miscellaneous tear repair with,
recess of, 75f arthroscopy, 66, 66f 203–205
with tears, 75f for glenohumeral arthrosis portals for, 202–203, 202f, 203f
in glenohumeral arthrosis treatment, 190, 190f postoperative care for, 205
treatment, release of, 190, for glenohumeral instability variations of, 205
190f, 191, 191f, 192f treatment, 113–114, incisions for, 96
in glenohumeral instability, 102 116f, 117f instrument portals, 96–97
treatment considerations of, for glenohumeral joint viewing portals, 96, 97f
122–123, 123f, 133 reconstruction, 66–67, Suprascapular notch, nerve
in Latarjet procedure, for 67f, 95–96 decompression at. See
glenohumeral instability, for proximal biceps tendon lesion Suprascapular nerve
143, 144 repair, 152, 152f decompression at the
in stiffness treatment, 178, for SLAP lesions, 96, 155–156 suprascapular notch.
180–181 for suprascapular nerve Supraspinatus muscle/tendon
MRI of, 329f decompression, at the calcific tendinitis of, 316, 318–320
tears of suprascapular notch, in diagnostic arthroscopy
biceps tendon lesions related 96–97, 97f normal anatomy of, 79–83,
to, 147 Supine exercises 83f, 84f
partial, 162, 163f for massive or irreparable rotator tears of, 79–83, 83f, 84f
repair of, 162–163, 166, cuff tears, 341 in glenohumeral instability, 102
168f goal of, 340 periarticular cysts impact on,
in rotator cuff tears stage 1, 341, 341f 200–202, 201f
irreparable, 300 stage 2, 341, 342f surgical considerations of,
massive, 286, 294 stage 3, 342, 343f 202–203, 204f, 205–206
ultrasonography of, 326–328 stage 4, 342, 343f tears of
long axis view, 329f stage 5, 343, 344f full-thickness, 332f
transverse axis view, 329f stage 6, 343, 344f full-thickness rotator cuff tears
Sulcus test warm-up for, 336f, 340 and, 245–246, 246f,
for diagnostic glenohumeral for rotator cuff repair, 336f, 341f, 249–250
arthroscopy, 69f 342f, 343f, 344f, 346 atrophy with, 242, 243f
for glenohumeral instability, Supportive treatment. See irreparable rotator cuff tears
105, 105f Conservative treatment. and, 297, 298f, 300
Superior capsule Suprascapular ligament, in massive rotator cuff tears and,
in acromioclavicular joint periarticular cyst 294–295
resection, 311–312, 313f treatment, 202–203, 204f partial-thickness rotator cuff
release of, in rotator cuff repair Suprascapular nerve tears and
irreparable, 300f compression of, with periarticular grades of, 234, 235f, 236
massive, 286–287, 287f cysts, 200, 201f repair of anterior, 235
Superior glenohumeral ligament, in entrapment of, impingement repair of posterior, 238
glenohumeral instability, syndrome vs., 216 repair of, 166
134, 135f in massive rotator cuff repair, 280, ultrasonography of,
Superior labrum 286–287 326–328, 332f
abnormal separation of, 147–151. pathway of, 202–205, 204f long axis view, 330f
See also SLAP lesions. Suprascapular nerve decompression transverse axis view, 330f
in glenohumeral instability, 113, at the spinoglenoid Surgeon training. See Education.
114f, 115f, 122 ligament, for periarticular Surgical drains, in sepsis treatment,
repair of, 129 cysts, 205–206, 205f, 206f 208–209, 208f, 209f
capsular repair and, 130, Suprascapular nerve decompression Suspension, intraoperative, patient
130f, 131f, 132f at the spinoglenoid notch position for, 49, 50
378 Index
Suture(s) Suture management T

anchor. See Anchor sutures. equipment for, 57–58 Table
braided. See Braided suture. in soft tissue. See Soft tissue back, in operating room setup,
in distal biceps tendon lesion grasper; Soft tissue 48, 48f
repairs, 162, 165–166, punch. shoulder preparation, 48
167f, 168f, 170–171, in tendons, skills for, 12 Tack technique, in SLAP 2 lesions
172f, 173f skills for, 12 repair, 154–155
in full-thickness rotator cuff repair practice importance to, 16–19 Team, dedicated, in operating room
mattress, 263–271 tying in. See Knot tying. setup, 63, 63f
placement of, 259 Suture passers Tear(s)
bridge technique for, 270, arthropierce, 56f, 57 biceps tendon. See Biceps tendon
270f, 271f Cuff-Stitch instrument for. See tears.
double-row repair, 258, 260f, Cuff-Stitch suture passers. bucket-handle, in SLAP 3
267–269, 270f Elite instrument as. See Elite Pass lesions, 159
single-row repair, 258, 258f instrument. bursal surface partial-
selection of, 256–257 in glenohumeral instability repair, thickness, 240
tension of, 263–269, 269f 125–127, 132, 133 insertion, in glenohumeral
in glenoid rim fracture fixation, in massive rotator cuff repair, instability repair,
322–323 293–294, 294f, 295f 122, 122f
in operating room setup, in operating room setup, 53 labrum. See Labrum tears.
58–60, 63 Smith-Nephew, in glenohumeral rotator cuff. See Rotator cuff tears.
in partial-thickness rotator instability repair, 126, Technical failure, in impingement
cuff repair, 236–237, 128, 133 treatment, 229
237f, 238f Spectrum instrument for. See Technical skills, for arthroscopic
loop. See Loop suture. Spectrum suture passer. shoulder surgery, 4
marking, on articular surface, tips for, 55f, 56f evaluating need for, 3–4
in rotator cuff repair, Suture passing knot tying as, 19, 29, 31–41
236, 238 in full-thickness rotator cuff suture anchors in, 12
mattress repair, 259 suture management as, 12
in distal biceps tendon lesion bridge variation, 270, sutures through tendons in, 12
repair, 165–166, 270f, 271f Tendinitis
170–171 Caspari suture punch biceps. See Biceps tendinitis.
in full-thickness rotator cuff technique, 259, 263f, calcific. See Calcific tendinitis.
repair, 263–271 264f, 265f, 266f, 267f traction, impingement syndrome
modified Mason-Allen, in full- Elite suture passer technique, vs., 229
thickness rotator cuff 259, 259f, 260f, ultrasonography of, 326
repair, 263–269 261f, 262f Tendinopathy
Monocryl, in full-thickness rotator in glenohumeral instability repair impingement syndrome vs., 216
cuff repair, 271 anterior-inferior, 125–126, 126f, intrinsic, 233
monofilament 127f, 128f self-healing, 316
in glenohumeral instability for anchors, 128, 128f, 129f Tendinosis, of rotator cuff, chronic,
repair, 127–129, posterior, 120f, 121 213. See also
134, 134f Suture tension, in full-thickness Impingement syndrome.
in partial-thickness rotator cuff repair, Tendon allografts, in irreparable
rotator cuff repair, 263–269, 269f rotator cuff repair, 297
236–237, 237f Synovectomy Tendon-bone discontinuity,
nylon. See Nylon suture. for glenohumeral arthrosis, 187, 189 following full-thickness
traction, in knot tying, 30–31 rheumatoid staging in, rotator cuff repair, 274,
Ultrabraid, in full-thickness 194, 197t 275
rotator cuff repair, technique for, 194–196, 197f Tendons. See also specific tendon,
256, 257 in irreparable rotator cuff repair, e.g., Biceps tendon.
Suture bridge technique 296, 297 sutures through, skills for, 12
Arthrex material for, 63 in sepsis treatment, 207–208, 208f Tendon-to-tendon longitudinal
in full-thickness rotator cuff power instruments for, 60 repair, of rotator cuff
repair, 270, 270f, 271f Synovitis tears
Suture graspers, 58 biceps, 162f massive, 280, 280f, 293–294
in full-thickness rotator cuff focal, in full-thickness rotator cuff Tenodesis. See Biceps tenodesis.
repair, 266f tears, 245–246 Tenotomy. See Biceps tenotomy.
large, 59f of rotator interval, 72f, 181f Teres minor muscle/tendon
small, 59f Synthetic grafts, in irreparable hypertrophy of, with periarticular
with jaws open, 59f rotator cuff repair, 297 cysts, 200, 201f
Index 379
Teres minor muscle/tendon Trauma Tuberosityplasty, in rotator cuff

(Continued) acromioclavicular joint conditions repair (Continued)
tears of, in partial-thickness caused by, 306 irreparable, 300–302, 302f
rotator cuff tears, 234 biceps tendon lesions caused by, massive, 282, 287–288, 288f
Textbooks, for arthroscopic shoulder 147, 150 TwinFix anchors, 63
surgery training, 41 avulsion injury in, 151, 151f Two-anchor, four-suture rotator cuff
Thermal capsulorrhaphy, for in glenohumeral instability, 109 repair, 17–19
glenohumeral onset of, 104 simulation of, 19f, 20f, 21f, 22f
instability, 102 treatment considerations of, Two-handed knot, 29–30
Thermal instruments, in operating 110–111 simulation of, 30f, 31f
room setup, 62 stiff shoulder related to, 176–178 Two-suture, one-anchor rotator
Three-anchor, six-suture rotator cuff Trendelenburg position, for sitting cuff repair, 12-14, 17–19
repair, 17–19 position, 50–51 simulation of, 17f, 18f
simulation of, 22f, 23f, 24f, 25f, Triangulation technique, for Type 1 acromion, in impingement
26f, 27f, diagnostic subacromial syndrome, 226, 227
Three-phase active elevation, for arthroscopy, 89, 89f Type 2 acromion, in impingement
massive or irreparable Triceps strengthening syndrome, 226
rotator cuff tears, 343 for full-thickness rotator cuff Type 3 acromion
goal of, 340 tears, 258, 338f in impingement syndrome,
stage 1, 344, 345f for glenohumeral instability 214, 215f
stage 2, 345, 345f postoperative, 338f, 347 in partial-thickness rotator cuff
stage 3, 345, 346f with recurrent tears, 234
warm-up for, 336f, 340 dislocation, 338f, 347
Throwing athlete for impingement syndrome, 338, U
distal biceps tendon lesions in, 338f UCLA score. See University of
161–162 for rotator cuff repair, 338f, 346 California at Los Angeles
glenohumeral instability in, Trocar (UCLA) Shoulder Scale.
104–105 in acromioclavicular joint Ultrabraid sutures
treatment of, 101, 134–135 resection, 310 in full-thickness rotator cuff
rotator cuff lesions and, 134–135 in biceps tendon lesions repair, repair, 256, 257
SLAP lesions in, 150–151 152, 170–171 in operating room setup, 60
Tips, for suture passers, 55f, 56f in calcific tendinitis Ultrasonography, diagnostic
Tissue biopsy, for sepsis diagnosis, treatment, 319 accuracy of, 327
207–208 in diagnostic arthroscopy documentation of, 328–329
Traction device, for lateral decubitus of glenohumeral joint, 64, indications for, 326, 326f
position, 50 67–68 MRI vs., 326
Traction suture, in knot tying, 30–31 bone palpation with, of calcific tendinitis, 316, 318f
Traction tendinitis, impingement 68–69, 70f of rotator cuff tears
syndrome vs., 229 in portal establishment, full-thickness, 241–244
Transfer flaps, muscle/tendon, in 70–72, 73f partial-thickness, 233–234,
irreparable rotator cuff of subacromial space, 88, 89 234f
repair, 297 in fracture fixation, 323–324 office suite for, 327, 327f
Transfer rods, in operating room in glenohumeral arthrosis performing, 326–327
setup, 63 treatment, 190 portable machine for, 327, 327f
Transfers, wheelchair, of in glenohumeral instability repair, technique for, 327–328
paraplegics, with rotator 113–118, 114f, 116f, demonstration of, 326–327, 327f
cuff tears, 348 117f, 123f University of California at Los
Translation, glenohumeral in impingement treatment, 219, Angeles (UCLA) Shoulder
impingement syndrome vs., 229 219f, 228f Scale
in glenohumeral instability, in periarticular cyst treatment, of full-thickness rotator cuff repair
102, 103 202–203 results, 272, 273t, 274t
assessment of, 105, 111 in rotator cuff repair of glenohumeral instability, 104
treatment considerations of, full-thickness, 246, 247f, 254, postoperative results of,
110, 111–112, 111f, 112f 258, 269–270 136–138, 137t
proximal biceps tendon lesions irreparable, 299
resulting from, 150–152 massive, 280–281, 284–286 V
with posterior rotator cuff tears, in stiffness treatment, 180, Vacuum beanbag, for lateral
239–240 183–184 decubitus position,
Transverse tears, of rotator cuff Tuberosityplasty, in rotator cuff 49–50, 50t
full-thickness, 249–250, 250f repair Vascular proliferation, in calcific
massive, 283f full-thickness, 256, 256f, 257f tendinitis, 316, 318, 319f
380 Index
Video programs, for arthroscopic W Wheelchair transfers, of paraplegics,

shoulder surgery training, Warm-up exercises, for massive or with rotator cuff tears, 348
5, 16–17 irreparable rotator cuff Whisker resector, in glenohumeral
Video recording, intraoperative, 63 tear rehabilitation, joint arthrosis treatment,
Viewing portals 336f, 340 196, 197f
in diagnostic glenohumeral WBC (white blood cell) count, in Whisker shaver, in glenohumeral
arthroscopy, 70t sepsis, 207 instability repair, 133f
in glenohumeral joint Weakness White blood cell (WBC) count, in
reconstruction, 95 impingement syndrome causing, sepsis, 207
in Lafosse technique, 96, 97f, 202 215, 216 Wire fixation, Kirschner, for
in Latarjet lesions/repair, 96, 96f periarticular cysts causing, 200 fractures, 323–324, 324f
in rotator cuff repair, 94 rotator cuff tears causing Wissinger rod, 63, 63f, 70–72
in SLAP lesion repair, 96 full-thickness, 242–244, 243f handle of, 63f
in suprascapular nerve postoperative, 274, 275 tip of, 63f
decompression partial-thickness, 233–234 Wrist pad, for lateral decubitus
at the spinoglenoid notch, 97 Weight bearing, by paraplegics, with position, 50
at the suprascapular notch, rotator cuff tears, 348,
96, 97f 349 Y
Visualization, of massive rotator cuff Weight lifting, acromioclavicular Yergason test, for distal biceps
tears, 280, 281f, 282f joint pain with, 307 tendon lesions, 162

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SHOULDER ARTHROSCOPY ISBN: 978-1-4160-4649-3

Copyright ! 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Library of Congress Cataloging-in-Publication Data

Acquisitions Editor: Daniel Pepper

After Harvard Ellman and I wrote Arthroscopic Shoulder Surgery

Here we are at Shoulder Arthroscopy 2nd edition, the Never Again

Figure 1-4 Balance.

Figure 1-1 Magic instrument?

procedures arthroscopically. Do you have the emo-

Most orthopedic surgeons learn the basics of shoulder

The Orthopaedic Learning Center is a good resource

Figure 1-10 Rotator cuff repair in two dimensions.

Figure 1-8 Having the eyelet parallel to the edge of the

Learn what the typical glenohumeral joint looks like

Figure 1-16 Load the suture.

Figure 1-13 Shoulder arthroscopy model.

Figure 1-17 Suture is held in the instrument’s jaw.

Figure 1-14 Elite suture punch needle.

Figure 1-19 Withdraw the needle, leaving the suture loop.

and shape of tears arthroscopically. Before performing

Figure 1-21 Two free ends of 2-0 nylon suture folded

Figure 1-26 Loaded Caspari suture passer and tying board.

Figure 1-24 Proper thumb position.

tendon quality. After you perform the open repair

Figure 1-27 Two free ends of nylon suture placed through

Figure 1-28 Remove the Caspari suture passer, and the

Figure 1-32 Use the thumb to advance the suture in the

Figure 1-34 Another option is to pass the braided suture

Figure 1-35 Correct hand positions.

Figure 1-38 Use the thumb to rotate the arthroscope.

surgeon makes incremental improvements in his or

Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)

Arthroscopic Rotator Cuff Repair—Elite Pass Technique (1 Anchor, 2 Sutures)—cont’d

Arthroscopic Rotator Cuff Repair—Caspari Technique (1 Anchor, 2 Sutures)

For a glenohumeral reconstruction, some of the steps are as follows:

Arthroscopic Bankart Repair—Suture Passer, Single-Suture Anchors

 Insert the arthroscope posteriorly.

Arthroscopic Bankart Repair—AccuPass, Double-Suture Anchors

 Insert the arthroscope posteriorly.

When you write out the operative steps in detail, it

Figure 1-47 Retrieve both white suture strands from the

Figure 1-65 Retrieve both posterior anchor blue strands

Figure 1-68 Retrieve both anterior anchor blue strands from

Figure 1-74 Move the posterior anchor strands to the left of

Figure 1-85 Withdraw the suture strand that is through the

Figure 1-86 Retrieve the anterior anchor white suture

Figure 1-94 Retrieve the posterior anchor strand from the

Figure 1-92 Withdraw the posterior anchor white suture

Figure 1-101 Retrieve both middle anchor blue sutures and

Figure 1-105 Place a nylon passing suture through the

Figure 1-103 Exercise 4 simulating a right shoulder Bankart

Figure 1-108 Close-up view of Figure 1-7.

Figure 1-111 Continue to pull on the nylon suture, and

with the exception that the knot pusher replaces

knots, it is easier to practice with clothesline than with 1 2

OVERHAND KNOT After the suture has been inserted

through the cannula. The free end is the suture limb

Figure 1-117 Knot tying illustrations.

ligament to be tied is under tension and retracts

you to approximate the soft tissue. Past-point and lock 1 2

the second throw. Finish the remaining throws, and

SLIDING KNOT There are dozens of types of sliding

Insert the arthroscope posteriorly.

Insert the arthroscope posteriorly.