Course Lecture Pearls: Foundations in Arthroscopy (2020)
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AANA courses include thought-provoking lectures for a well-rounded understanding of current trends and techniques Orthopaedic Surgeons can incorporate into their own practices.

Highlighted content from previous AANA courses offers non-attendees exclusive pearls presented by leaders in the field of arthroscopic surgery.

Course Lecture Pearls: Foundations in Arthroscopy (2020)
Course dates: January 16-18, 2020

Presenter: Richard K.N. Ryu, M.D.
Topics: Subacromial Arthroscopy: Bursectomy, Acromioplasty, Distal Clavicle Excision, Prepare for Cuff; Arthroscopic rotator cuff repair cadaver including how to make a tear and convert to mini open
Key Learnings: 
    1. Acromioplasty should be performed if there is clinical and arthroscopic evidence that a mechanical impingement is present, including fraying of the coracoacromial ligament and bursal-sided rotator cuff pathology.
    2. Massive, irreparable rotator cuff tears should not be managed with aggressive subacromial decompressions even if subacromial impingement findings are present as loss of the coracoacromial arch integrity may permit anterior-superior escape of the humeral head.
    3. Excision of the distal clavicle excision is a surgical decision made pre-operatively, and should be performed after the rotator cuff has been repaired if a combined procedure is anticipated. Fluid extravasation after the distal clavicle excision can compromise visualization during a rotator cuff repair.
    4. Utilizing pre-operative MR imaging permits accurate rotator cuff tear pattern recognition with length represented by the medial to lateral dimension of the tear and width by the anterior to posterior measurement.
    5. Anatomic reduction of the rotator cuff tear requires tear pattern recognition and awareness of the footprint insertion parameters. Diagonal reduction forces are usually required rather than a straight medial to lateral force. Traction sutures can help ascertain the anatomic attachment site.
Presenter: Wesley M. Nottage, M.D.
Topic: Arthroscopic Labral, SLAP, and Instability Repairs, Capsular Plication
Key Learnings:
    1. The most important part of correction of anterior inferior instability is the mobilization of the entire labral ligamentous complex to visualize the muscle belly of subscapularis the full length of the glenoid before reattaching it to the glenoid (can’t shift, can’t correct).
    2. Anterior inferior glenohumeral instability correction is primarily an inferior to superior shift not a medial to lateral shift. Demonstrate your shift by superior capsular traction before setting the point of the capsular sutures. Anchors should be placed in the anterior glenoid articular cartilage, not on the glenoid face. Three well placed anchors are a minimum.
    3. Superior labrum Type 2 lesions should be no more than 2% of your shoulder scope cases and require arthroscopy to correctly diagnose. Normal superior labral variants may be quite mobile but correction of a non SLAP lesion finding will create shoulder stiffness. In the event of repair, you should avoid anterior superior sutures and anchors which tie down the superior glenohumeral ligament.  Permanent suture knots have been associated with pain or a squeak in the shoulder after repair.
    4. There is always a capsular lesion with or without a labral detachment, and the capsular lesion can be anywhere in the capsule.  Address capsular laxity with capsular tucks and/or include capsular tissue in the labral repair.
    5. Remplissage is a useful technique for significant Hill Sachs lesions, and selected cases but does NOT correct for significant anterior glenoid bone loss (over 15-20%).  Always place the anchors for the procedure BEFORE an anterior repair, viewing from the anterior superior portal. Tie the sutures placed at the END of the procedure. An interesting byproduct of its use is essentially a posterior capsular plication to address any posterior capsular laxity.
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