Rotator cuff lesion: lateral view during arthroscopic suture
RMI of Bankart lesion
1. Adhesive capsulitis
As we have seen adhesive capsulitis is one of the most frequent shoulder disorders. In 80-90% of cases the treatment is conservative (injections and rehabilitiation), it is rarely surgical.
We do not recommend the surgical approach in capsulitis associated forms: RSD, peri- postmenopausal women and all primitive forms.
In our experience in case of a failed rehabilitative treatment, capsulotomy, namely the capsule opening and the release of the glenohumeral joint from the adhesion tissue, may result useful in case of capsulitis secondary to humeral head and glenoid fractures.
Arthroscopic capsulotomy is a particularly delicate intervention requiring the removal or at least a 360 degree opening of the thickened capsular tissue so to allow to regain progressive range of motion in due times.
In case of only a capsulotomy generally the patient wears a brace for 1 or 2 days and starts an accurate rehabilitation program immediately the day after the intervention following the same principles of the capsulitis conservative treatment.
2. Rotator cuff lesion
In the impingement syndrome and rotator cuff reconstruction, arthroscopy is required in case of poor clinical results of a proper rehabilitation treatment or in presence of very large and painful lesions.
The intervention takes an absolute arthroscopic time and allows not only to diagnose but also to perform a subacromial bursectomy and an acromioplasty, to verify the extension of the possible cuff lesion and the quality of the tissue to repair and the tension for its reinsertion on the humeral head.
Tendon sutures and reinsertion may be performed only through an arthroscopic procedure or through a small skin incision of 3-4 cm; the clinical results, times and recovery modalities are overlapping.
Herebelow some images show the main phases of an arthroscopy. To understand the rationale of the intervention it is useful to compare the injured tendon with the roots of a plant and the bone tissue with the ground where the roots are to be reinserted.
Img. 1 - Detection of the complete tendon lesion of the supraspinatus, one of the three rotator cuff tendons.
Img. 2 - Tendon identification and evaluation through an appropriate forceps . The scope is inserted posteriorly, the instrument laterally.
Img. 3 - Acromioplasty: detection of an acromial osteophyte, in some cases a chronic inflammatory spur deteriorating the underlying tendons over time. The acromion must be removed and regulated through an appropriate surgical instrument named “Shaver”. The scope is inserted posteriorly, the instrument laterally.
Img. 4 - Preparation of bone tissue (cruentation). It represents the site where the injured tendon must be inserted.Scope is inserted posteriorly, preparation of the transcutaneous access to insert the corkscrew (Arthrex) with respect to the “dead man angle”.
Img. 5 - In case of complex V-shaped and L -shaped cuff lesions the anterior and posterior margins are brought closer together with a side- to side suture to decrease tension during anchoring.
Img. 6 - Anchor insertion (corkscrew suture anchors 5.0 x 15 mm with two non reabsorbable threads 2 of different color) assures the provisional continuity between the tendon and the bone tissue.
Img. 7 e 8 - Detection of the suture threads of the anchor Corkscrew that pass through the tendon with an appropriate instrument (Suture Retriver and Penetrator Suture Retriver) and are tied. The scope can be inserted posteriorly or laterally . All portals are used to allow the thread passage and tying.
Img. 9 - Tying and tightening of an arthroscopic knot. Lateral insertion of the scope and posterior for the instrument.
Img. 10 - End image of an arthroscopic suture of a rotator cuff lesion. Notice the tendon(white tissue), the bone (yellow tissue) and the blue knot. Lateral insertion of the scope
For a rotator cuff repair are used:
Decubitus in “Beach Chair Position” (see “anesthesia”)
Twist-in cannula (arthhex) for instrument insertion
Pump (Arthrex) for joint distension
Arthocare (Arthrex) for tissue ablation.
Suture anchors Corkscrew/Bio Corkscrew (Arthrex) for the tendon anchorage.
Suture Retriever, Penetrator Suture Retriever, BirdPeak, 6th Finger Knot Pusher (Arthrex) for passing and tying suture knots.
Twist-in cannula (Arthrex)
Pompa (Arthrex)Arthrocare (Arthrex)
On the left and in the centre:
Suture anchors Corkscrew/Bio corkscrew (Arthrex). Correct positioning of the Biocrokscrew requiring tapping of the bone channel. Notice how the plasticity of the PLA eyelet allows to perform a sliding knot so to reduce friction on the suture thread.
On the right:
Mistake in the technique. Despite the respect of the “dead man angle” the anchor is not completely inserted (into its site) with a resulting insufficient contact between the tendon and the bone tissue.
On the left and in the centre:
Suture Retriver, Penetrator Suture Retriver, BirdBeak, 6th Finger Knot Pusher
Shoulder instabilities (anteroinferior luxation, that is the typical dislocation ) affect the youngest people ( between 18 and 35 years of age ). They are divided into constitutional and traumatic, sometimes they can be associated. The first condition is caused by a generalized ligament laxity (see elbow, knee and first radius of the hand) so to make the humeral head slip over the glenoid (anteroinferiorly).
The traumatic instability is the most common and very painful condition requiring an immediate reduction. The typical mechanism of injury is represented by the combined abduction and extra rotation (throwing gesture).
In the traumatic condition the capsule-labrum complex, that is the glenoid labrum and in particular the middle and inferior glenohumeral ligaments, are dislocated from the bone (Bankhart lesion).
Arthroscopy is generally suggested in relapsing luxations. However the number of episodes, the age must be considered (relapses are more likely in younger people), as well as the sports and working activity and the quality of the tissue to be repaired.
The arthroscopic advantages are undoubtful:
Minimum muscle and capsular insult
A better lesion visualization (Bankart lesion) with a resulting higher likelihood of repair.
Minimum esthetic impairment ( three 3mmm holes)
Faster and easier recovery
Therefore arthroscopy aims at relocating the capsule labrum complex into the bone tissue giving the capsule an appropriate tension so to perform its most important function: containing the humeral head inside the glenoid concavity.
Img. 11 - Detection of the haematoma (in red) and the Bankhart lesion, that is the capsule labrum detachment from the bone. The patient is in lateral decubitus, the shoulder is the right so the glenoid cavity is below and the humeral head above.
Img. 12 - An appropriate cruentation is performed as bleeding is necessary to insert the capsule labrum complex into the glenoid bone..
Img. 13 - Arthroscopic image of the repair technique of the Bankart lesion (ALPSA) according to the knotless technique.
Img. 14 - Notice how the correct anchor insertion and the arthroscopic knot tying allow the correct insertion of the labrum into the glenoid.
Open surgical technique according to latarjet
Surgical treatment according to Latarjet for relapsing glenohumeral instability.
See film (Note: if film doesn't start click right mouse and choose "play")
The Latarjet technique involves the coracoid osteotomy and the insertion of this scapular apophysis into the anteroinferior glenoid region.
The latarjet procedure is generally performed through an open mini incision even if today experimental arthroscopic procedures have been developing.
The specific indication for the latarjet procedure is the typical luxation (repeated luxations) with a bone and tissue loss higher than 20% in the anteroinferior glenoid region.
The latarjet procedure allows to restore the glenoid lacking bone tissue with the bone block and give a stabilization effect thanks to soft tissues in particular the common tendon and the lower part of the subscapularis muscle. An expert surgeon can correctly perform this technique through an incision of few cms preventing the complete detachment of the subscapularis tendon through the tendon splitting , that is passing through the muscle. This involves faster recovery time and excellent clinical results often overlapping if even not better than those of the capsular shift and the arthroscopic stabilization techniques. The latarjet is an extremely difficult technique and must be performed only by highly specialized personnel.
Glenohumeral arthrosis surgical treatment
As we have seen arthrosis affects the shoulder less frequently than the hip or knee..
It is generally less common in the acromioclavicular than in the glenohumeral joint.
Whereas acromioclavicular arthrosis can be successfully treated with local injections or an appropriate rehab treatment, glenohumeral arthrosis is more difficult to treat.
The first step is to perform a specific x-ray to detect the degree of cartilage degeneration of the glenohumeral joint. In mild forms rehab treatment, ialuronic acid injections and reduced physical activity can result useful, as previously stated, whereas in more severe forms but with a still functioning rotator cuff, humeral head or glenoid prosthesis may be implanted.
Nowadays we tend to use prostheses with a minimum insult to bone tissue with the concept of the “cartilage lining”. In case of a massive rotator cuff lesion associated with a severe arthrosis (rotator cuff tear arthropathy) the application of an inverse prosthesis is suggested since the engine keeping constant the rotation centre of the humeral head in the glenoid cavity cannot be used.
The inverse prosthesis usually represents the last attempt to regain range of motion in the shoulder. It is a very delicate sometimes unsuccessful intervention.
The patient must be accurately selected and have the following characteristics: 3-4th degree glenohumeral arthrosis, massive rotator cuff deficiency and generally being over 70 years of age. Also this intervention must be performed only by highly specialized personnel.
From the left to the right:
Head prosthesis Eclipse
Osteosynthesis of humeral head fracture
A low or high-energy trauma may cause fractures of the shoulder joint. These lesions can involve the clavicle, the humeral head, with fractures of the greater tubercle, the lesser tubercle and the proximal third of the humerus in 2-3-4 fragments. Scapular fractures secondary to high-energy traumas are less common.
From left to right
Humeral head CT scan
Humeral head CT scan
Fracture of the greater tubercle and glenohumeral luxation
The specialist will opt for the proper surgical procedure according to the degree of displacement and the number of fragments . For this disorder plate and screw ostheosyntheses are frequently suggested. The surgical treatment aims at regaining a correct bone anatomy (reduced fracture) and its stabilization (fracture synthesis). The biological healing times generally range between 25 days and 6 weeks. However, an X-ray control is important during this period to evaluate the evolution of the bone callus: specific physiokinesitherapy will follow.