Welcome to the 2021 Arthroscopy Association of North America Advanced Shoulder Arthroscopy course. If you have any questions regarding the material presented in this presentation or regarding any of the other materials presented in this course, please feel free to contact us during the lab or via email. Thank you. We begin the procedure with the patient placed in a lateral decubitus position. We place the patient initially in the arthroscopy position with the arm positioned at 45 degrees of abduction and 10 degrees of forward elevation. We add approximately 10 pounds of distraction. At this point, we create our standard posterior and anterior mid-glenoid portals to perform our glenohumeral examination. During the glenohumeral portion of the arthroscopic examination, the arm is moved into the bursoscopy position. This position involves placing the arm in 15 degrees of abduction and 10 degrees of forward elevation. Note the addition of a lateral portal, which allows us to visualize from this portal while utilizing our anterior and posterior portals as working portals. In order to properly visualize the distal clavicle, we often need to perform a subacromial decompression. We perform this subacromial decompression visualizing from the lateral portal and working from our posterior portal. This allows us to perform the acromioplasty using a cutting block technique. This technique allows for three things. It allows us to measure our resection, perform a level resection, and thus prevent iatrogenic acromial fracture. Once our subacromial decompression is complete, we use a switching stick to place our anterior portal directly into the acromioclavicular joint. Once the anterior cannula is adequately placed, soft tissue can be removed from the distal clavicle using electrocautery to fully visualize the bony surface. We then complete our resection from anterior to posterior, moving the burr from inferior to superior as we progress posteriorly. Adequate resection of the superior aspect of the clavicle can be attained by rolling the barrel burr over the top of the bone, much like a throttle is used on a motorcycle. Alternatively, this could be done under direct visualization utilizing a 70-degree arthroscope. Finally, we can move our arthroscope into the anterior portal to visualize the acromioclavicular joint completely. We can pay particular attention to the posterior superior aspect of the distal clavicle as well as the posterior inferior aspect of the acromion, as these two positions are the most commonly missed areas of bone. We begin with the patient in the lateral decubitus position and the arm at 45 degrees of abduction and 10 degrees of forward flexion with 10 pounds of distraction. This is otherwise known as the arthroscopy position. We utilize our posterior portal for visualization and our anterior midclonoid portal as a working portal. This allows us to complete our thorough 15-point shoulder arthroscopic examination. Once the shoulder has been completely visualized from the posterior portal, we can change our visualization to view from the anterior portal. This will allow us to visualize the inferior aspect of the gonohumeral joint both anteriorly and posteriorly. Once our arthroscopic examination of the gonohumeral joint is complete, we change to the bursoscopy position. Note the three portals, anterior, posterior, and lateral. This position is 10 degrees of forward flexion and 15 degrees of abduction. We begin visualizing from the lateral portal and working from the posterior portal. This allows us to complete our subacromial decompression utilizing a cutting block technique. Once our subacromial decompression is complete, this allows us to visualize the distal end of the clavicle. Once we can visualize the distal end of the clavicle, we move our working portal to anterior, bringing our cannula directly towards the distal clavicle. Utilizing our barrel bur, we shave the distal end of the clavicle from anterior to posterior, moving from inferior to superior. A superior aspect of the clavicle can oftentimes be appreciated by rolling the barrel bur over the superior rim of the bone, thus ensuring a complete resection superiorly. This can alternatively be done using a 70 degree scope under direct visualization. Once we feel as if we have completed our resection, we can transition our viewing portal to the anterior portal to check our resection directly, thus ensuring a complete resection of the distal clavicle.

shoulder arthroscopy

lateral decubitus position

subacromial decompression

portal creation

distal clavicle resection