l Shoulder Anatomy and a preface on the

l. Shoulder Anatomy and a preface on the Shoulder Arthroscopy l-Ebrahimzadeh MH MD l Shoulder&Knee Surgeon l Ghaem Hospital, l Mashad University of Medical Sciences, Mashad, Iran Ebrahimzadehmh@MUMS. AC. Ir

Shoulder Anatomy

Shoulder Anatomy l l l Greatest ROM No inherent bony stability Relies on soft tissues for stability Many injuries involve the soft tissues (rotator cuff, labrum) Little glenoid bone stock

Shoulder Anatomy l Contributors to stability l Passive – Jt conformity – Jt pressure – adhesion/cohesion – ligament

Shoulder Anatomy l F-H Offset l B-C Head thickness l D-E = 8 mm Top of humeral head is higher than greater Tuberosity

Shoulder Anatomy l Glenoid : 2° anteversion to 7° retroversion q Humeral Head: 20° - 40° retroversion

Shoulder Anatomy

Shoulder Anatomy

Shoulder Stabilizers l Rotator Cuff- – dynamic stabilizer – passive muscle tension – ligament tightening – compression of – articular surface l GHL- – static stabilizer

Ligaments l SGLH l MGHL l IGHL l PIGHL l CAL l CHL

Rotator Cuff

Rotator Cuff

Subacromial Bursa

MRI for shoulder l Axial plane Bankart Lesion, BT l Sagital oblique plane l Coronal oblique plane Rotator cuff, SLAp

Shoulder MRI Coronal Oblique View

Shoulder MRI, Sagital Oblique View

Shoulder MRI, Axial View

l Shoulder Arthroscopy l Scope; all procedures except Arthroplasty

Patient Position l Beach chair the most common l Lateral

Arthroscopy Equipment l Fluid Management System; l Arthropompe +Shaver system

Arthroscopy Equipment l Arthroscopy Elecetrocutery System l Arthro. Care® l VAPR, Coblation Depuy Mitek

Basic Instrument l Arthroscope l 30° and 70° scopes l Arthroscope sheath with matching sharp and blunt trochars l Punches, Graspers, Seizers, Probes l Suture passers, Knot pusher

Instrumentation #11 scalpel blade l Skin marking pencil l 18 g. needle l 20 cc syringe (if insufflating) l 76 mm plastic cannula with a rubber dam l Motorized shaver with soft tissue and bone shaving blades l Suction punch l Suture punch l

Anchor Sutures l Metal Anchor Suture 5, 6. 5 l Bio Anchor Suture 5, 6. 5 l Knotless Anchor Suture; push lock

Main Providers of Shoulder Arthroscopy l Smith&Nephew, MA, USA l MITEK Depuy, MA, USA l Arthrex, FL, USA

Question l How common are done shoulder Arthroscopy procedures?

Shoulder Arthroscopy portals

Posterior Portal, A l Posterior Portal 3 cm inferior and 1 cm medial to the posterolateral corner of the acromion l Passage to the posterior one-third of the deltoid an interval between infraspinatus and teres minor l Structures at risk l – Quadrangular space - posterior humeral circumflex artery and axillary nerve – Triangular space - scapular circumflex artery – Both spaces are 7 -8 cm inferior to the posterior border of the acromion

Anterior Portal Located one-half the distance between the coracoid process and the anterolateral edge of the acromion l Passage through the skin subcutaneous tissue and the anterior one-third of the deltoid l l Structures at risk – Musculocutaneous nerve, normally located 3 cm inferior and just medial to the coracoid process

Lateral Portal l 2 -3 cm distal to the lateral border of the acromion l Passage through the deltoid muscle l Axillary nerve l Located approx. 5 cm beyond the acromion l Structures at risk: – Axillary nerve

Supraspinatus fossa portal Soft spot bordered anteriorly by the posterior margin of the clavicle, lateral by the medial border of the acromion, posteriorly by the scapular spine l Passage through the trapezius and the muscle belly of the supraspinatus l Structures at risk l – Suprascapular nerve and artery – Located in the fossa approx. 3 cm medial to the portal

Arthoscopic surgery for shoulder surgery l 1 - Arthroscopic Bankart repair (one row repair) l 2 -Casiope Repair (double Bankart row repair) l 3 -All arthroscopic Laterjat procedure l 4 - Capsular shift l 5 -Rotator interval closure l Repair of HAGEL lesion l Repair of SLAP lesion

l Arthroscopic Rotaor cuff Surgery l Arthroscopic Subacromion decompression l Arthroscopic Acropmioplasty l rotator cuff repair l -one row l -double row

Actual DOUBLE ROW Technique

Arthroscopic Brachial plexus surgery l Suprascapular nerve release l Brachial plexuse nerve release l Axilary nerve release l Qaudrilateral and triangular release

Arthroscopic tendon transfer l Latissmos dorsi transfer for rotator cuff deficiency, irreparable tears l Arthroscopic priscapular bursectomy

AC Joint arthroscopic surgery l Arthroscopic AC arthroplasty l Arthroscopic AC instability reconstruction

Pioneers l. Modern & Advanced Shoulder Surgery

Charles Neer NY, US

Rockwood Charls JR Texas, US

Frederick A. Matsen III, M. D. Seattle, WA, USA l TUBS, AMBRI

JP Warner Massachusetts, US

Joseph IANNOITTI Cleveland Clinic, Ohio, US

Louis U. Bigliani NY, US

Stephen Bukhart Texas, US

Christian Gerber Bern, Swiss

Lauren Lafosse & Gill Walch France

Peter Hybermeyer Germany

Thank you