Shoulder Arthroscopy Approach

What it exposes. Shoulder arthroscopy is a minimally invasive, portal-based technique giving diagnostic and therapeutic access to the glenohumeral joint, the subacromial space and the acromioclavicular (AC) joint. Pioneered in the 1970s, it is now the gold standard for most shoulder pathology. Why arthroscopic. Compared with open surgery it is less invasive with better cosmesis, gives superior visualisation of posterior and superior structures, allows several pathologies to be addressed in one sitting, and is associated with faster rehabilitation for many procedures and lower infection rates. The trade-offs are a steep learning curve, specialised equipment, longer early operative times, and the risk of fluid extravasation. Indications. - Rotator cuff disease - repair of partial- and full-thickness tears, subacromial decompression, debridement of irreparable tears

• Instability - labral repair (Bankart, SLAP, posterior labral), capsular plication for multidirectional instability, Hill-Sachs remplissage
• Biceps and superior labrum - tenodesis, tenotomy, SLAP repair
• AC joint - excision arthroplasty, stabilisation
• Stiff shoulder - arthroscopic capsular release for adhesive capsulitis
• Loose bodies and synovial disease - loose body removal, synovectomy (rheumatoid arthritis, PVNS)
• Diagnostic - when imaging is inconclusive or shoulder pain is unexplained Contraindications. Absolute: shoulder sepsis (diagnostic washout is only a relative exception) and end-stage osteoarthritis needing arthroplasty. Relative: previous surgery with scarring that limits access, inability to tolerate positioning, and coagulopathy. No true internervous plane. Unlike open approaches that exploit an interval between muscles of different nerve supply, arthroscopy uses small stab incisions passing directly through skin, muscle and capsule into the joint. The posterior portal traverses deltoid (axillary nerve) then infraspinatus (suprascapular nerve); the lateral subacromial portal passes through deltoid into the bursa; the supraspinatus (Neviaser) portal traverses trapezius then supraspinatus; and the anterior portal passes through deltoid superficially and then the rotator interval. Safety therefore depends on landmark-based placement, small cannulas, and creating every portal except the first under direct arthroscopic vision. Positioning - two equally valid options.

Establish the posterior viewing portal first using palpable landmarks, perform a systematic diagnostic sweep, then create each working portal under direct arthroscopic vision with spinal-needle localisation. This sequence is the whole safety logic of the approach.

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Structures at risk, by portal.

Complications.

Anatomic variants that mimic pathology.

Extensions - accessory portals for specific procedures. - Port of Wilmington - about 1cm anterior and 1cm lateral to the posterolateral acromion, through the cuff muscle-tendon junction, for a steep angle to posterosuperior SLAP anchors.

• 5 o'clock (anteroinferior) portal - a trans-subscapularis route for anteroinferior anchors; the axillary nerve is at risk.
• 7 o'clock portal - a posteroinferior portal for posterior or inferior labral anchors.
• A lower posterolateral portal 1-2cm lateral and inferior to the standard posterior portal is used for general posterior labral work. All accessory portals are created under direct vision with spinal-needle localisation. Portal closure. Remove cannulas under vision, release traction (lateral) and check the radial pulse, achieve portal-site haemostasis, and close skin with simple sutures. No deep closure is required for the stab incisions.

Shoulder arthroscopy is the workhorse exposure for most soft-tissue shoulder surgery. The principal procedures and their typical portal configurations: - Arthroscopic Bankart repair - posterior plus anterior plus anteroinferior (5 o'clock) portals.

• Arthroscopic rotator cuff repair - single row and double-row transosseous-equivalent suture bridge - posterior plus lateral plus anterolateral portals.
• Arthroscopic subacromial decompression / acromioplasty - posterior subacromial plus lateral subacromial portals.
• Biceps tenodesis - posterior plus anterior plus anterosuperolateral portals.
• Mini-open rotator cuff repair - arthroscopy then a deltoid-splitting mini-open extension.
• SLAP repair, capsular plication for multidirectional instability, Hill-Sachs remplissage, capsular release for adhesive capsulitis, AC joint excision, synovectomy and loose body removal.

When to convert to open. Arthroscopic Bankart repair is standard for primary anterior instability with under 20 percent glenoid bone loss and no engaging Hill-Sachs. Convert to an open bone-block procedure (Latarjet, Bristow or iliac crest) when glenoid bone loss exceeds 20-25 percent, the Hill-Sachs engages and cannot be managed with remplissage, after failed arthroscopic instability repair, or with significant humeral bone loss. Outcomes through this approach. Arthroscopic Bankart repair succeeds in 85-95 percent of primary cases (recurrence 5-15 percent, higher in young contact athletes); it has slightly higher recurrence than open repair (2-8 percent) but better preserves external rotation and cosmesis, while high-risk patients (young contact athletes, significant bone loss, revision) do better with open bone-block procedures (recurrence 3-5 percent but higher complication rates). Arthroscopic cuff repair is clinically successful in 80-95 percent despite re-tear rates of 10-40 percent by tear size (small under 1cm 85-95 percent, medium 1-3cm 70-85 percent, large over 3cm 50-70 percent). Subacromial decompression, however, is no better than placebo surgery for isolated impingement-type pain and should not be offered as a default. Postoperative sling by procedure. Diagnostic arthroscopy and subacromial decompression 24-48 hours; Bankart, rotator cuff and SLAP repair 4-6 weeks; capsular release 24-48 hours with early aggressive ROM. Labral tissue heals to bone over 6-12 weeks and tendon-to-bone over 8-16 weeks, so rehabilitation must balance protection against stiffness.