The arthroscopic "subdeltoid approach'' to the anterior shoulder
ABSTRACT 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.
Full-textDOI: · Available from: Samuel A Taylor, Jan 03, 2015
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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 · 3.19 Impact Factor