Cape Shoulder Institute - Shoulder Surgery & Treatment
Previous

Publications / Current Status of Arthroscopic
Shoulder Surgery - page 1

The Cape Shoulder Institute is dedicated to the treatment of shoulder problems which are managed both conservatively and surgically.

Pages 1 | 2 | 3

Surgical Advantage

  1. A virtual “macroscopic” image is received and projects the anatomy in great detail. The surgeon can evaluate his repair work more critically.

  2. Surprise diagnoses” are discovered: Typical examples would be:

    • Osteoarthritis in non-radiological apparent cases (e.g. large, focal chondrolytic lesions).

    • GLAD lesions (Gleno-Labral Articular Disruption) in instability.

    • HAGL lesions (Humeral Avulsion of Gleno-Humeral Ligaments = “reverse Bankart lesion”) in instability.

    • The presence of adhesive capsulitis (“frozen shoulder”) – undiagnosed pre-operatively.

    • Rotator cuff tear, undiagnosed pre-operatively.

Surgeons who have not developed arthroscopic surgical skills are advised to consider pre-operative diagnostic arthroscopy in relevant cases, before continuing the open surgery.

Patient Advantages

Rotator Cuff Impingement

Structural impingement by the overlying acromion (Bigliani types II and III) is relatively rare and the diagnosis should only me made after excluding other causes of pain: frozen shoulder, arthritis, instability, etc.

Impingement can usually be treated conservatively- if surgery becomes indicated arthroscopic acromioplasty is the method of choice. The authors’ “Dyonics three cannula method has been proven to be accurate and time-efficient.

Many surgeons over diagnose and over- operate this condition.

Rotator Cuff Tears

  1. Ischaemic Tears
    Tendon disruption occurs in layer 4 & 5 at Zone 2 spontaneously, usually atraumatically, in mature tendons.

  2. Traumatic tears usually occur at the junction of the crescent and the cable and therefore leave the footprint attached to the greater tuberosity (G.T). A typical feature is the remaining ‘tuft’ or flap left laterally on the G.T.

  3. Impingement tears, due to chronic impingement occur on the bursal side of the Rotator Cuff. The deeper layers (4 & 5) are often left intact and explain negative arthrography.

    An anterior aponeurosis was found in a large number of cadavers studied (D. du Toit) and appears to be a confluence of supraspinatus tendon (SST) fibres. This usually remains thickened and intact, despite the surrounding degenerative tear and serves as robust “interval” tissue to plicate or fashion in a “side to side” repair.

Technical aspects

  1. During repair relative mobilisation of the infraspinatus tendon (IST) can be achieved, provided the vector ‘reads’ antero-laterally at approx. 60º.

  2. Access gained via the arthroscope to the spine of scapula, supra- and infraspinatus fossae enhances the “harvesting” potential of the retracted musculo-tendinous structures.

  3. Pain of articular side tears is significantly less than that of bursal side tears. This is due to the higher concentration of nerve fibres (and blood vessels) in the bursal layers (layers I, II and III) - the Standard Impingement (Neer) and strength tests may be negative (layers I – III/IV are still intact!)
    -The Isobex strength measurement may differentiate, however: Static resistance is measures in Kg. Over time (6 sec, 3 readings.) if the reading is less than the contra lateral side, administration of an intra-articular (not subacromial!) local anaesthetic can increase the reading by abolishing pain.

  4. Pain on examination of articular side tears can be precipitated by abduction and external rotation of the arm (AER). In younger patients, trauma (AER mechanism), can cause this type of injury.

  5. In the older group – tears are usually atraumatic/ischaemic.

Footprint Reconstruction of Rotator Cuff Tears

The authors developed this surgical method, after doing previously accepted methods.
The spatial, three-dimensional insertion of the RC tendon covers an area from the neck of the humerus (cartilage/bone junction) to the lateral edge of the tuberosity.

  1. The reconstruction is three-dimensional: medial fixation to cartilage-bone (G.T.) junction and laterally on the tip of the tuberosity.

  2. The Biomechanical Advantage: the footplate or fulcrum renders a satisfactory base for the lever forces applied due to the relatively large distribution surface. The ingrowth potential is proportional to surface area.

  3. The laterally placed anchors are inserted into the tip of the tuberosity – the hard cortical bone in this location offers excellent holding capacity to the anchors

Footprint Reconstruction: medial and lateral interlocking sutures

Irreparable Tears

All repairable tears are managed arthroscopically in our unit. When a tear is truly irreparable the following can be considered:

  1. • Debridement and biceps tenotomy if indicated. Preserve the coraco-acromial at all costs: an acromioplasty is contra-indicated as this could result in antero-superior subluxation of the humeral head.

  2. Soft tissue transfers, e.g. latissimus dorsi or subscapularis

  3. Delta (constrained) prosthesis for selected cases

X-Ray of Delta prosthesis

Pasta Lesion

(“Partial Articular Supraspinatus Tendon Avulsion”) is the descriptive term used for Articular Side Tears: They are “exclusively” seen by Arthoscopists. To enable the arthroscopist to view the lesion the arm has to be rotated in abduction/external rotation, dynamically, so as to ‘open’ the lesion. Adduction can ‘close’ the lesion.

Partial Articular Side Tendon Avulsion- “PASTA” lesion

  1. The “ABER” (Abduction External Rotation) view in MR imaging mimics the latter, with a clear leak of contrast “into” the lesion.

  2. ARTHROSCOPIC REPAIR: an anchor is inserted into the prepared ‘bed’ (Medial footplate at cartilage bone junction). Suture loops are passed from deep side to bursal side at the periphery of the lesion and tied ‘on top’ of the tendon (bursal side).

Calcific Tendinitis

Calcium deposits occur in the tendons of ssp (80%), isp (15%) and ssc (5%). In chronically symptomatic patients arthroscopic removal can be offered. Acromioplasty is rarely indicated. If the resultant defect in the tendon is large, arthroscopic repair of the defect is added.

Arthroscopic view of the subacromial space: “toothpaste’-
Like material is drained from the rotator cuff