Hi, this is Keith Norwood bringing you how to get there, portals, portals everywhere, the ring of fire. The bony anatomy is the road map to proper portal positioning. Establishing safe portal placement by thorough knowledge of the major vessels and nerves is the key. Proper angle of entry is also important to obtain the best position for either placing anchors or for passing suture. This prevents trying to force instruments around the corner to obtain the proper position. All of these steps, when learned well, will provide the ability to safely, effectively and efficiently treat all forms of shoulder pathology. The goals of portal selection are to choose portals that are safe, to choose the angle that provides the best access to the rotator cuff, labrum, AC joint or acromion. Remember the ring of fire as an area to place a spinal needle and localize a portal with relative safety. Don't force instruments to bend corners. Use the appropriate angle of approach. Remember arthroscopy is a game of angles like pool. Utilizing the proper portals make shoulder arthroscopy easier and faster and facilitate performing excellent surgery. Shoulder arthroscopy portals can be divided into anterior portals, posterior portals, lateral or superior portals. There are three basic portals that everyone uses, the posterior portal, a lateral portal and some type of anterior portal. I want to introduce a new concept to you, the ring of fire, which is a relatively safe area to introduce cannulas, scopes or any instruments. And I want to stress how important it is to use a spinal needle to localize the position of your cannulas or instruments. In this anterior shoulder drawing by Dr. Netter, you can see that the area described as the ring of fire is safely away from the brachial plexus. In this posterior illustration, the area within the ring is relatively safe. The bony anatomy is drawn identifying the clavicle, AC joint, acromion, spine of the scapula and the coracoid. The anterior superior lateral portal provides a better angle for approaching bankart, slaps and posterior bankarts. The location is based on needle placement and is just slightly inferior and lateral to the anterior lateral acromion. A spinal needle is inserted to locate the proper entry point. The needle should enter the joint just anterior to the biceps, angled inferiorly. The anterior superior portal is alternatively used and is slightly medial to the anterior superior lateral portal. It is lateral and superior to the coracoid. These portals are typically used for anterior cannula insertion into the glenohumeral joint. They are utilitarian portals for probes, knot tying, use of shavers and hand instruments. The anterior inferior portal is lateral and inferior to the coracoid and is used for anchor placement for a bankart lesion. A cannula may be used, but our preference is to use a spear for drilling and anchor placement, leaving a much smaller track and decreasing the difficulty of two cannulas anteriorly pushing each other out of the glenohumeral joint. The 5 o'clock portal is alternatively used for anchor placement with a spear. Suture retrieval is performed using a lasso or similar suture passer. This portal perforates the subscapularis tendon, so we prefer not to use a cannula. Note that the anterior inferior anchors can be placed on the glenoid rim with both the anterior inferior and the 5 o'clock portals. When establishing an anterior portal, the major neurovascular structures lie medial to the coracoid. A dictum was established stating anterior portals must be created lateral to the coracoid, and even median nerve injury has been reported. The musculocutaneous nerve can also be at risk. The exception to this would be the subclavian portal. Eugene Wolf noted that there was less risk to the musculocutaneous nerve with the arm in adduction and the portal made from inside out. The anterior superior portal is typically made with an outside-in technique and located with a spinal needle. The entrance is through the rotator interval. The anterior inferior portal is located in line with the anterior edge of the acromion, just below the level of the coracoid. The location is identified with a spinal needle, and the entrance point is just superior to the subscapularis tendon. 5 o'clock portal provides access for Bankart lesions. It is the proper working angle. Sometimes dilators are used through the subscapularis, but my preference is to use an anterior inferior portal above the subscapularis. If I need to go through the subscapularis, I prefer to use a small spear for anchor insertion to minimize the hole. The subclavian portal is used for rotator cuff repair anteriorly. It's located directly below the clavicle, 1 to 2 centimeters medial to the AC joint. No cannula is used, and instruments are aimed medial to lateral. The subclavian portal goes through the deltoid, anterior inferior to the AC joint, and into the subacromial bursa. The subacromial decompression should be performed first, and anterior inferior osteophytes removed. An anatomic study was undertaken to show the safety of the subclavian portal, and the lateral cord of the brachial plexus and the musculocutaneous nerve were more than 6 centimeters away from it. The portal Wilmington, or posterolateral portal, is located 1 centimeter lateral and 1 centimeter anterior to the posterolateral corner of the acromion. A spinal needle is used to find the appropriate angle toward the superior rim of the glenoid. It is used for anchor insertion and slap lesions. The anterolateral portal is located 1 cm posterior and inferior to the anterolateral corner of the acromion. The spinal needle enters just posterior to the biceps in optimal position to place an anchor at the root of the biceps. Here we see the angle of the anterolateral and posterolateral portals for anchor placement in the glenoid. The lateral portal is used for many purposes. It's a working portal for subacromial decompression, knot tying, distal clavicle resection, and is a viewing portal for subacromial decompression when using the cutting block technique. Don't go below 5 cm. 2 to 3 cm below the edge of the acromion is the proper angle into the subacromial space. The anterior lateral portal lies just lateral to the anterior lateral corner of the acromion. It is ideal for insertion of suture anchors for slap tears and rotator cuff tears. It can also be used for suture retrieval through the rotator cuff, especially in a delaminated tear or a pasta lesion. This technique allows you to capture both leaves of a delaminated tear. The posterior portals include the standard posterior portal, the accessory posterior portal, a medial and lateral accessory portal, a high posterior medial and low posterior medial portal, and a low posterior lateral portal. The posterior portal is the primary viewing portal. It's a working portal also for cutting block technique and subacromial decompressions. It can also be used for passing suture for margin convergence. The accessory posterior portal starts 2 cm lower than the standard posterior portal. It provides easier access for slap tears. The lateral accessory portal starts 1 to 2 cm lateral to the posterior portal. It's excellent for insertion of anchors into the posterior glenoid. It can be localized with a spinal needle and allows suture passage through the rotator cuff. The medial accessory posterior portal lies 1 to 2 cm medial and superior to the posterior portal. It's tight access when a scope is in the posterior portal, but it does allow suture passage through the infraspinatus, margin convergence, or posterior labral approach. The high posterior medial portal is excellent for margin convergence and is used frequently in rotator cuff repairs and posterior superior labral repair. The low posterior lateral portal is located 2 to 4 cm lateral to the posterior lateral acromion and 4 to 5 cm inferior. This allows access at the 6 o'clock position on the glenoid, but also at 5 or 7 o'clock. After the anchor is placed through the low posterior lateral portal, we then use a lasso, retrieve the nitinol wire as it passes through the inferior labrum. We also retrieve the sutures and then pull that back through using the nitinol wire. We can then easily tie this through the cannula and we can make additional drill holes for anchors as we need them. In this case, we can even reach up to the 9 o'clock position. A knotless technique can also be used here. The superior portals include the nevizor portal, the modified nevizor portal, and the N plus 4 portal. The standard nevizor portal can be used with a penetrating suture device for retrieving sutures in a slap repair. The nevizor portal was described in 1987 by Thomas Nevizor as a superior medial portal that would penetrate only the supraspinatus muscle to enter the joint. The subacromial portals include the posterior portal, the lateral portal, the modified nevizor portal, the subclavian portal, and the high posterior medial portal. The lateral portal is located approximately 4 cm lateral to the acromion in line with the posterior aspect of the clavicle. For visualization into the subacromial space, the posterior cannula is retracted out of the glenohumeral joint and redirected into the bursa along the undersurface of the acromion. A working cannula is inserted laterally. The anterior one-third of the subacromial bursa is in front of the bursal curtain. Some of the bursa can be removed to improve visualization of the cuff and acromion and to look for fraying of the CA ligament. A subacromial decompression can be performed with the burr inserted from lateral. The cutting block technique can also be used with the burr posterior and the scope lateral. For rotator cuff repairs, suture passers can be brought in from the lateral cannula or a penetrating device can be brought in from the modified nevizor, subclavian, or high posterior medial portals. In addition to the standard posterior and lateral portals, the subacromial portals include the modified nevizor portal, subclavian portal, the high posterior medial portal, N plus 4 portal, and a posterior-lateral viewing portal for scope placement. This was popularized by Joe Toro. Here we're moving the scope from the posterior portal to a more posterior-lateral portal in order to visualize the entrance to the rotator cuff tear in a more anterior supraspinatus. Here you can see we're looking straight into the tear and you can reach all the way to the articular surface this way and have a better position for placing your anchors. The modified nevizor portal is located 3 cm medial to the AC joint and 1 cm anterior to the scapular spine. The modified nevizor portal that we originally described had the same starting point as the nevizor portal. The landmarks that we currently use are 3 cm medial to the acromion and 1 cm anterior to the spine of the scapula, angled laterally and aimed toward the suture anchor. The subclavian portal is located 1 to 2 cm medial to the coracoid and just inferior to the clavicle. It passes under the anterior AC joint and into the subacromial space reaching the anterior supraspinatus. Cadaver dissections have shown that this is a safe portal and aims away from the brachial plexus. The modified nevizor portal and the Nplus4 portal both pierce the trapezius muscle but stay on top of the supraspinatus, protecting the suprascapular nerve. When first described, the modified nevizor portal had the same starting point as the nevizor portal. We've gradually moved more medial to the modified nevizor which is 3 cm medial and then ultimately to the Nplus4. The instruments are aimed about 70 degrees from the sagittal plane and aimed anterior laterally toward the anchor. The surgeon's hand is held behind the patient's neck. It's best utilized in the lateral decubitus position. The Nplus4 portal is another modification of the nevizor portal. It's located 4 cm medial to the nevizor portal and improves your access to the supraspinatus and infraspinatus using suture passers. Here we're using the Nplus4, the high posterior medial portal and the subclavian portal for getting a 180 degree approach to the rotator cuff tear. You can see based where the spinal needles are that we come in from posterior, from medial and from anterior. We follow the needle in on the Nplus4 with a penetrating suture grasper. We then lift up the rotator cuff and we can poke through getting a nice healthy bite of tissue and then retrieving our suture on the other end. You can see that we are aimed directly at the suture anchor. So when our penetrating suture device comes through, we just pass off the suture and pull it back through. Here you can see the suture exiting the Nplus4 portal. We can then do the same using the high posterior medial portal, again bringing in a penetrating suture device. We follow it in with a spinal needle. Now we can poke through the posterior aspect of the rotator cuff tendon, again aiming straight toward the suture anchors and then retrieve one or two sutures as we need to. This gives us very good spread of the sutures and has excellent suture management. We can then go anteriorly and get the anterior portion of the supraspinatus tear. And this type of approach also helps prevent dog ears. Once all the sutures are passed, we can then go up in the subacromial space and then tie each of the suture pairs. For acromioclavicular resection, you may use the bursal approach or a direct approach using an anterior superior portal and a posterior superior portal. The bursal approach is used when distal clavicle resection is performed along with the subacromial decompression. It is our preferred approach. The scope continues to remain in the posterior portal and the anterior portal is established under direct vision. The shaver, followed by a bur, is used through the anterior portal to perform a distal clavicle resection. Later, the scope can be moved to the lateral portal and the resection is confirmed. The direct approach uses an anterior superior and a posterior superior portal. The direct approach is used in cases of isolated AC joint pathology. After confirming the position of the AC joint, the anterior superior and posterior superior portals are established. They are located at the anterior and posterior aspect of the AC joint. Under direct vision, a motorized bur is used to resect the distal clavicle. The position of the scope and instruments are alternated between portals to complete the resection. Switching the scope also helps you confirm adequate and precise resection of the distal clavicle. It may seem crazy to have so many portals, but when you realize that you can use a spinal needle to localize your position almost anywhere, it becomes much simpler. Also, the number of portals you use leads to better suture management. Choose portals that are safe. Choose the angle that provides the best access to the rotator cuff or labrum. Don't force instruments to bend corners. It's a game of angles like pool. This makes rotator cuff and labrum repair easier and faster. Portals, portals everywhere can lead to sutures, sutures everywhere. www.ottobock.com

shoulder arthroscopy

portal positioning

ring of fire

safe portal selection

suture placement