The arthroscopic "subdeltoid approach'' to the anterior shoulder

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] (Impact Factor: 2.29). 01/2013; 22(4). DOI: 10.1016/j.jse.2012.09.006
Source: PubMed


Surgical management of shoulder pathologies has evolved tremendously during the past 3 decades, such that many lesions previously treated with open techniques are now addressed arthroscopically. Despite this movement, many surgeons and outcome studies continue to prefer open repairs as the gold standard, criticizing-with good reason-the reliability, reproducibility, and extended operative time of arthroscopic repairs, particularly with respect to anterior stabilizations and subscapularis repairs. With this in mind, we present the arthroscopic "subdeltoid approach," a novel standardized exposure technique for extracompartmental anterior shoulder arthroscopy. We define the subdeltoid space as the fascial plane bound superiorly by the acromion and coracoacromial ligament, medially by the coracoid and the conjoint tendon, inferiorly by the musculotendinous insertion of the pectoralis major to the humerus, and laterally by the lateral border of the humerus. When coupled with existing arthroscopic tools, this space dramatically enhances our ability to apply open techniques to some of the more challenging anterior shoulder pathoanatomy and expand the indications and efficacy of arthroscopy. This exposure technique has been used in more than 300 cases during the past decade to treat a myriad of shoulder pathologies, without any longstanding postoperative complications.

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Available from: Samuel A Taylor, Jan 03, 2015
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    ABSTRACT: Purpose The aim of this study was to assess the midterm functional outcomes for arthroscopic subdeltoid transfer of the long head of the biceps tendon (LHBT) to the conjoint tendon. Methods Fifty-six shoulders in 54 patients (46 men, 8 women; mean age, 42 years) who underwent isolated arthroscopic subdeltoid LHBT transfer to the conjoint tendon by a single surgeon with a minimum of 4 years follow-up were evaluated with American Society of Shoulder and Elbow Surgeons (ASES) and L'Insalata scores. A subset of patients was available for physical examination. Results At an average of 6.4 years postoperatively, ASES and L'Insalata scores were 86 and 85, respectively, corresponding to 88% of patients rated good to excellent. Twelve shoulders (10 from men patients, 2 from women patients; mean age 41 years; average follow-up, 6.3 years) underwent physical examination. Mean University of California, Los Angeles (UCLA) score was 31, and there were no significant differences in side-to-side elbow flexion strength or endurance using a 10-pound weight. One patient had a Popeye sign. There were no major complications reported in this cohort. Conclusions Arthroscopic transfer of the LHBT to the conjoint tendon is a safe and durable intervention for chronic refractory biceps tendinitis. Level of Evidence Level IV, therapeutic case series.
    Arthroscopy The Journal of Arthroscopic and Related Surgery 12/2014; 30(12). DOI:10.1016/j.arthro.2014.07.028 · 3.21 Impact Factor
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    ABSTRACT: The purpose of this study was to define the limits of diagnostic glenohumeral arthroscopy and determine the prevalence and frequency of hidden extra-articular "bicipital tunnel" lesions among chronically symptomatic patients. Eight fresh-frozen cadaveric specimens underwent diagnostic glenohumeral arthroscopy with percutaneous tagging of the long head of the biceps tendon (LHBT) during maximal tendon excursion. The percentage of visualized LHBT was calculated relative to the distal margin of subscapularis tendon and the proximal margin of the pectoralis major tendon. Then, a retrospective review of 277 patients who underwent subdeltoid transfer of the LHBT to the conjoint tendon were retrospectively analyzed for lesions of the biceps-labral complex. Lesions were categorized by anatomic location (inside, junctional, or bicipital tunnel). Inside lesions were labral tears. Junctional lesions were LHBT tears visualized during glenohumeral arthroscopy. Bicipital tunnel lesions were extra-articular lesions hidden from view during standard glenohumeral arthroscopy. Seventy-eight percent of LHBT were visualized relative to the distal margin of the subscapularis tendon and only 55% relative to the proximal margin of the pectoralis major tendon. No portion of the LHBT inferior to the subscapularis tendon was visualized. Forty-seven percent of patients had hidden bicipital tunnel lesions. Scarring was most common and accounted for 48% of all such lesions. Thirty-seven percent of patients had multiple lesion locations. Forty-five percent of patients with junctional lesions also had hidden bicipital tunnel lesions. The only offending lesion was in the bicipital tunnel for 18% of patients. Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex because it visualizes only 55% of the LHBT relative to the proximal margin of the pectoralis major tendon and did not identify extra-articular bicipital tunnel lesions present in 47% of chronically symptomatic patients. Level IV, therapeutic case series and cadaveric study. Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
    Arthroscopy The Journal of Arthroscopic and Related Surgery 12/2014; 31(2). DOI:10.1016/j.arthro.2014.10.017 · 3.21 Impact Factor