We're going to go ahead and get started. This is just a real quick talk. I want to give just a kind of general orientation to doing a scope in the shoulder. And I'm going to basically just show you some video. This comes from one of the talks that you guys should have gotten in all the different talks and presentations to review. But one of the things I want you to be able to do today when you go into the lab, especially the first part of this morning, is get into the shoulder joint and really do a good diagnostic exam of the shoulder joint. And I want you to do it from both an anterior and a posterior portal. So we typically start, you put the scope in posteriorly, and your instructors can show you how they do it. I use what's called an interchangeable cannula system, which means I put the same cannula in the front and the back. So it's a metal cannula. I use a system that actually has a bridge on the sheaths. And so I can put the exact same cannula in the front. So what's cool is once I put it in, and then I can go from front to back and just do my diagnostic exam. I'm not putting other fancy cannulas in to grab things and things like that. And I don't do any of that stuff. I put the cannula in. I put my outflow in the front, and then I do my exam from the back. And then what I do is I turn the pump off, put the scope in the front, and then do my exam from the front. And I document all the anatomy. And I do it the same way every single time. I actually have a database sheet that I've used for years that I actually learned about and started after coming out of my fellowship 35 years ago or whatever. And basically, it was an anatomic approach like this. And I've modified it a little bit over the years. But what's really cool is then at the end of each one of my cases, I actually take this database and I check off all the different things on the anatomy. And then I use that as my cheat sheet when I dictate all my operative reports. So when I dictate my operative reports, and now a lot of times you have op reports that are all templated and stuff like that, and that's more of the procedural stuff. Like you could have a template that says, yes, I fixed the rotator cuff. But there's more to fixing a rotator cuff than saying you just fixed the rotator cuff. So there's nuances that you're going to put in your operative report. But the other thing that's important is a lot of the stuff like how you position and all that stuff is the same every single time. So that stuff can be templated. What's different in every single patient is what the anatomy is. And when you go back, if you compared 10 of your rotator cuff repairs, or 10 of your instability repairs, or 10 of your decompressions, it's the anatomy in each individual patient that's really important, especially for you to go back and look at and say, well, gee, why is this person not? Those three guys are doing great, but this person's not doing well. Well, is there something about the anatomy? And so what I do is I have a paragraph at the beginning of all my operative reports that I use my little data sheet. And I dictate a paragraph, say, operative findings are as follows. And I dictate all this stuff on every single patient. So I can go back, and when I'm looking at my patient's post-op, I say, oh, well, OK, the rotator cuff, and this size tear, and stuff like that. But I can go back and look at that. And then I have all that stuff down from doing my diagnostic exam. So let's just go over this real quick. And then, obviously, it's going to be a little different in the lab here, because you're not going to have a cannula system like this. But you're going to have a similar cannula that you can put in the back. But I would suggest that you then put in an anterior portal. Also, do the kind of exam, some sort of exam from the front, so that you see all the structures. And what you're going to realize is, you can see a lot of the structures from both the front and the back, but you can't see them the exact same way. And I remember years ago, people would show up, like my fellows would show up when they first started. And they said, jeez, I've never stuck a scope in the front of the shoulder. I'm like, oh my god, what you can see in the front is so different than what you do in the back. And when you start doing instability, you're going to be actually looking from the front and operating a lot of times from the front. Because typically, you've got to be able to see all this stuff. So it's really important. All right, I don't have any financial issues to disclose, never really have, and probably never will in the future. All right, so like I said, always perform this diagnostic exam. I do it the same way every single time. And the reason I do it that way is, I don't think I'm ever going to miss anything. I don't rush through it saying, oh, there's a loose body. Let's put something in it and start grabbing it. Don't worry, the loose body is going to still be there, or it's going to wash out on your own. And if you need to go look for it and stuff like that, fine. If the slap was there at the start, it's going to be there at the end. You're going to see all that stuff. Don't panic when you see something. Do your diagnostic exam. And then start making decisions. OK, how am I going to take care of this stuff? So you use both your portals. You always perform the systematic exam. And then, like I said, you always do the same exam on every single shoulder. And that way, you're never going to miss anything. Before I pull my cannulas out, on every single case, a lot of times now, when I'm working with the residents, VA, I look at the resident and go, OK, did we do everything you wanted to do? And there's just this pause. And it's like, well, OK. And I said, did you see everything? And then I said, OK, great. Once you do it, then boom, you pull the cannulas out and go on to the next step of your operation. All right, so here we go. Here we're from the back. This cannula is in the front. It's in the rotator interval. This is the biceps tendon. So the first thing you're going to do is look at the biceps tendon. And you can look at the biceps. Everybody says, what about a probe? Well, I can take this cannula and pull it down and see how there's all that synovitis on the back of the biceps. Well, remember, the biceps is intraarticular, but it's extra synovial. And a lot of the problems we have with the biceps, you see, aren't in the actual joint itself. It's actually as it exits the joint, as it rubs on the upper part of the groove. You can look down. That's the mid-glenoid notch. You can look at the superior labrum. And wow, there's no slap. How about that? You can look around the posterior labrum. And you can see, then, that's the posterior band right here of the inferior glenohumeral ligament. You can look all the way up at that capsular reflection. I then can come back around and look at the glenoid. And I can back up a little bit. You notice how I back up and I can get almost the whole glenoid in the shoulder. And you'll see these little cracks and things like that. That's nothing to get excited about. I can then look up. There's the supraspinatus. And you see this white area of the supraspinatus and all the blood vessels that come up and stop. Well, that's that watershed area where there isn't a lot of vascularity of the cuff. And that's where you'll see a lot of these partial tears. You get up here and you see the insertion point. And then what you don't see in this patient is a big barrier area. But typically, you're going to see a big area that's devoid of cartilage up there. That's called the barrier area. You can come down and look at the head. You can rotate the head and look at that. And then I'm going to start to move towards the front. And so now I've got my cannula and I can palpate my subscap there. And there's that little fold there. There's no real tear there. You need to be able to get way up here sometimes to look for some of these subscap tears if it's important for you to diagnose and treat a subscap. You can look at, when you see the subscap, you're going to identify the structure running across here. And that's the middle glenohumeral ligament. And the middle has a lot of variability. Some people have middles that are just a simple sheet. Some have a big cord. Some have a cord and that's not attached to the front of the labrum. And that's what's called a Buford complex that was named after Don Buford many, many years ago out at SCOE. So what's cool about the shoulder, you'll see this today. And if you see this stuff, holler. And we'll sometimes put it up. If you have weird variance in the shoulder, it's kind of neat to document. And there's lots of variance in the shoulder. Not as many variance in the knee. But there's a lot of labral variance. You have what we call sublabral foramen, where the labrum's not completely attached. And the important thing about a sublabral foramen, it's a normal structure. It's not something you fix. So you don't start tacking down the labrum in the front, especially anterior to the biceps. Because more often than not, that area from the mid-glenoid portion, the mid-glenoid notch up to the biceps, it's not an actual tear. It's a true, actual defect where the labrum never really attached there in the first place. So there we are from the front. So now here we are back. Now we're looking from the front. So there's my cannula. And I can look down at the labrum. I can palpate the labrum with my cannula. I can lift the head off and look down and look at the whole inferior labrum. I can come off the front and look here all the way up at the anterior superior band of the inferior ligament. So that's the whole inferior ligament, the posterior band you saw earlier and the anterior band. I can look all the way back up at the front and look at the anterior attachment of the ligaments to make sure there isn't a haggle lesion or a humeral avulsion of the glenohumeral ligament. I can look up at the cuff. And then the next maneuver is important. I swing around the biceps. See that? And then I look up at the cuff. And you get a phenomenal view of the rotator cuff actually from the anterior portal. See how I swing around and I look up. And then I can, and that's important because you can look behind the labrum there and make sure there aren't any ganglion cysts or anything like that. And there's your superior band. There's your anterior capsule. That's where you would look for a haggle lesion if you're dealing with some sort of instability issues. And then you pull back and then this is highly variable but you pull back and you see the subscap and you see the middle and you're going to go over the front of that. And you're going to go down into what's called the subscap recess. You can't see this from the back once you had a 70 degree scope. And so you want to look down there because that's where loose bodies are going to go. You know, that's where, you know if you break something off in the shoulder that's where it's going to go. So you gotta be able to look there in the front to see all those structures. And what's cool is some of this stuff looks different from the posterior portal as it does in the anterior portal. So that's why you correlate these two views and you're going to then have a good understanding of the different anatomy. Now I'm not going to show a video of the bursa. The bursa is very similar but you can do the same thing in the bursa. The bursa just doesn't have a lot of things to see. You can look at the CA ligament and look for fraying of the CA ligament. You can't see the actual hook of the acromion because it's typically covered by the CA ligament. Once you, you know, you've got radiographs that document what your hook is and your AC joint and stuff like that. So you typically, when you're in a bursa you can't really see the AC joint very well because it's covered all by this tissue. Same thing, like I said, the CA ligament comes up and actually envelops the undersurface of the acromion. So you don't see it till you take all that stuff off. But you've had a plan beforehand about, okay, is this an impingement issue? And you can confirm that when you're up in the bursa. But then you can look down on the cuff and you can look for, you know, cuff tears and you can move your scope around either to the anterior portal. And you use the same portals, you just have redirected them up into the subacromial space. And you can look at all that stuff and see all the different anatomy and then make some decisions about what you're gonna do. So you do your diagnostic exam in the glenohumeral joint. You address the pathology that you've got to address. And then if so needed, you move into the subacromial space. Obviously, if you're gonna do, if you're there for a cuff tear and a cuff repair, you're gonna do your glenohumeral surgery first. Address the things you need to do. Get rid of the biceps or get prepared for tinnities. You know, all those types of things. And you may end up doing that from the glenohumeral portion first. Then you go up into the subacromial space. Address your decompression and distal clavicle if you need to. And then make decisions and fix, you know, whatever cuff stuff you have to fix. So you go through that stepwise approach. All right? Any questions? Comments from any of the staff? Everybody awake? Okay. All right. So we're ready to go. So get your, so just a couple other housekeeping measures. Hopefully you've checked out. If you haven't, you know, this early this morning, you want to check out. You can bring all your, if you have transportation like a car here, you can leave it. Obviously it's safe in the car, but you can always bring your stuff in here. We have plenty of room here to make sure. So they get the hotel ready for the next group of people that are coming in and stuff. You know, we're going to go, we'll have at about, I think 10, 1030, we're going to do a video, do a presentation in the lab on labral stuff that Dr. Saccone and I are going to set up. Then we're going to have, when we have lunch, after lunch, we're going to come back in here and do the models, the cuff models. So from like one to two or so, we're going to, to 15 or so, we're going to do the rotator cuff stuff in here. It's very difficult. One of the problems with doing shoulders is it's very hard to fix cuffs. I'm not saying you guys can't try doing this stuff in the afternoon, but by doing this stuff here in the lab, or excuse me, in the auditorium here, it kind of shows you the basic principles and techniques. Now, Dr. Richards is going to give a great lecture on that, you know, at around lunchtime about the different principles of fixing the rotator cuff. And then you can play with that here. Then the afternoon, when you get back in the lab, you're going to be doing your decompressions, your distal clavicle excisions, and then you're going to be doing your dissections and stuff. And I'm going to present some anatomy stuff later in the afternoon, just kind of like Dave and Brian did yesterday on the knee. And so then you can filet open your shoulders and look at your labrums and look for some of the nerves and do some other approaches and stuff like that. So you kind of get a good handle on anatomy. And that's a very valuable end to this stuff. And then, you know, we'll be done about 530 or so.

performing a scope

shoulder joint

diagnostic exam

systematic approach

anatomy