The patient was positioned into the lateral position with all downward boney prominences well padded. We were able to prep and drape out the left shoulder in a sterile fashion. We then used an Arthrex over-the-bed trapeze to hold the arm in an abducted 45 degrees, and forward flexion of 10 degrees. I was able to prep and drape out the shoulder in sterile fashion, then use a sterile marking pen to mark out the boney landmarks of the shoulder. I used a posterior superior arthroscopy viewing portal made with a small stab incision with the #15 blade knife. I then used a trocar with a cannula to enter the shoulder joint. I was able to begin my diagnostic arthroscopy by immediately evaluating four small less than 1 cm loose bodies that were floating around in the axillary pouch in the anterior portion of the shoulder. Again, Dave was very instrumental in helping to manipulate the shoulders to allow me to achieve these certain positions and maneuvers as well as anchor introduction.
I was able to start in the anterior portal just lateral to the coracoid, and just superior to the subscapularis tendon. I made this using an 18-gauge needle as a pointer, and then finally a small stab incision, and then the dilators with the trocar to help to dilate up to an appropriate cannula. I began by taking the shaver and probe and going down into the axillary pouch to remove these loose bodies, which were four small loose bodies less than a cm each that were removed using the grasper. I was then able to use the probe to confirm that the tear of the labrum was all the way down to the anterior inferior aspect of the glenoid at about the 5:30 position. Abduction of the shoulder facilitated us viewing this area. The cartilage was torn at about the 7 o'clock position on the clock face. This seemed to be the area where the missing cartilage was from, as the remainder of the humeral head and glenoid had no evidence of loose cartilage or missing pieces. The labrum was definitely torn and peeled back. I did freshen up this area by using the 30-degree spatula to help to free up the edge of the labrum off of the bone, as well as the shaver to shave and débride the edge of the glenoid for later attachment.
I used the 90-degree suture lasso technique to help to pass a looped fiber wire around the labrum, after it had been fully débrided and freed up. I was able to use the guide, as well as the drill to drill a hole directly across from where the sutures were attached. I took care not to tighten up the shoulder, but instead to grab the labrum and bring it directly over to the glenoid. I was able to put two suture anchors in this manner. The first one went in excellent. There were no complications. It was a BioComposite push lock that went in without complication. The second one, which was a little higher up at about the 9 o'clock position, did break or split as it was going in. It was felt that he had very strong bone. We re-probed the hole. We dilated it a little bit, and then re-tried it again, and again noted a second anchor that broke as well. The third anchor broke as well, and we decided to change over to a peak anchor, which impacted again with a significant amount of force, but excellent fixation was noted, and it was very strong bone.
At this point, we took the shaver to suction out the rest of the joint. We made sure there was no other loose debris or free material. I went to the biceps and confirmed that the superior and posterior inferior aspects of the labrum were intact. The undersurface of the rotator cuff was evaluated, and there was some articular fraying noted on the attachment of the rotator cuff, which was partial thickness, less than 20%. I did use the shaver to débride this area. We did mark this area as well with a 17-gauge needle and a Prolene stitch. I then used the cannula and the trocar to enter the subacromial space, where I was able to free up the bursa with a sweeping fashion. I noted a significant amount of bursal tissue consistent with bursitis and impingement syndrome. I started a lateral portal just posterior to where I had marked the Prolene stitch. I was able to identify the stitch immediately and clear the bursa around this area to evaluate the rotator cuff.
A complete bursectomy was done in the subdeltoid region, as well as in the undersurface of the acromion. I removed some tissue from the undersurface of the acromion as well using the shaver in a sweeping fashion.
I was able to start in the anterior portal just lateral to the coracoid, and just superior to the subscapularis tendon. I made this using an 18-gauge needle as a pointer, and then finally a small stab incision, and then the dilators with the trocar to help to dilate up to an appropriate cannula. I began by taking the shaver and probe and going down into the axillary pouch to remove these loose bodies, which were four small loose bodies less than a cm each that were removed using the grasper. I was then able to use the probe to confirm that the tear of the labrum was all the way down to the anterior inferior aspect of the glenoid at about the 5:30 position. Abduction of the shoulder facilitated us viewing this area. The cartilage was torn at about the 7 o'clock position on the clock face. This seemed to be the area where the missing cartilage was from, as the remainder of the humeral head and glenoid had no evidence of loose cartilage or missing pieces. The labrum was definitely torn and peeled back. I did freshen up this area by using the 30-degree spatula to help to free up the edge of the labrum off of the bone, as well as the shaver to shave and débride the edge of the glenoid for later attachment.
I used the 90-degree suture lasso technique to help to pass a looped fiber wire around the labrum, after it had been fully débrided and freed up. I was able to use the guide, as well as the drill to drill a hole directly across from where the sutures were attached. I took care not to tighten up the shoulder, but instead to grab the labrum and bring it directly over to the glenoid. I was able to put two suture anchors in this manner. The first one went in excellent. There were no complications. It was a BioComposite push lock that went in without complication. The second one, which was a little higher up at about the 9 o'clock position, did break or split as it was going in. It was felt that he had very strong bone. We re-probed the hole. We dilated it a little bit, and then re-tried it again, and again noted a second anchor that broke as well. The third anchor broke as well, and we decided to change over to a peak anchor, which impacted again with a significant amount of force, but excellent fixation was noted, and it was very strong bone.
At this point, we took the shaver to suction out the rest of the joint. We made sure there was no other loose debris or free material. I went to the biceps and confirmed that the superior and posterior inferior aspects of the labrum were intact. The undersurface of the rotator cuff was evaluated, and there was some articular fraying noted on the attachment of the rotator cuff, which was partial thickness, less than 20%. I did use the shaver to débride this area. We did mark this area as well with a 17-gauge needle and a Prolene stitch. I then used the cannula and the trocar to enter the subacromial space, where I was able to free up the bursa with a sweeping fashion. I noted a significant amount of bursal tissue consistent with bursitis and impingement syndrome. I started a lateral portal just posterior to where I had marked the Prolene stitch. I was able to identify the stitch immediately and clear the bursa around this area to evaluate the rotator cuff.
A complete bursectomy was done in the subdeltoid region, as well as in the undersurface of the acromion. I removed some tissue from the undersurface of the acromion as well using the shaver in a sweeping fashion.