Shoulder Arthroscopy Principles and Practice

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To Federica, Francesca, and India, to remind them that “He who becomes the
slave of habit, who follows the same routes every day, who never changes
pace, who does not risk and change the color of his clothes, who does not
speak and does not experience, dies slowly” (M. Medeiros).
To Adriana, for the meaning she gave to the journey of my life.
G.M.

To Federica, my wife, the most inspiring person in my life and my work, for
every day of our lives together. And also to our five children.
A.G.
Foreword 1

When I first began to do arthroscopic side-to-side rotator cuff repairs in 1987 using very crude
instruments, I was struck by how much better I could see and evaluate the repair pattern using
the arthroscope than when I did open surgery. Despite the enthusiasm of a small group of tal-
ented arthroscopic surgeons including Lanny Johnson, Howard Sweeney, Jim Esch, Steve
Snyder, and Dick Caspari, the shoulder establishment of that time rejected the idea that arthros-
copy might have any potentially meaningful role in shoulder surgery. Nonetheless, the “true
believers” in arthroscopy persisted against the mainstream.
Now, 26 years later, this marvelous book entitled Shoulder Arthroscopy: Principles and
Practices by Dr. Giuseppe Milano and Dr. Andrea Grasso clearly demonstrates that the world’s
thought leaders in shoulder surgery have totally embraced shoulder arthroscopy and are now
its strongest advocates and practitioners. The list of authors reads like a “Who’s Who” of
shoulder surgery. This book is also a very comprehensive resource, beginning with general
principles, progressing to routine arthroscopic procedures, and continuing into extremely com-
plex reconstructive and revision surgeries that can and should be done arthroscopically.
The fact that they were able to assemble such a distinguished cast of authors for the chapters
of their book is a tribute to the high regard in which Drs. Milano and Grasso are held by their
peers. When I first met Dr. Milano about 15 years ago, I was struck by his tenacity and by his
scientific approach to the shoulder, and these characteristics have prominently influenced his
new book. This book is a magnificent work that captures the essence of state-of-the-art shoul-
der surgery. It is an indispensable resource for today’s shoulder surgeon. I congratulate Drs.
Milano and Grasso on a job well done.

San Antonio, TX, USA Stephen S. Burkhart, MD

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Foreword 2

Shoulder arthroscopy is nowadays a very fast-developing surgical technique. A need for evalu-
ation of different treatment options, clinical investigation methods, education support and
clinical research has brought together orthopaedic surgeons from all over Europe, who have
founded European Shoulder Associates (ESA) under the patronage of ESSKA.
Some of our Board members have contributed to different chapters of this book and it is a
special honour to announce that Dr. Giuseppe Milano, the editor of this book, is the Scientific
Secretary of ESA Board.
On behalf of ESA, I wish all the readers to benefit from this book as a guide to improve their
practice.

Boris Poberaj, MD

ix
Preface

During the last decades, shoulder arthroscopy gained much popularity among surgeons
involved with shoulder surgery and sports medicine, and new several surgical techniques have
been rapidly developed.
For a long time, hot topics like massive rotator cuff tears, subscapularis tendon tears, ante-
rior instability, glenoid bone loss, and revision rotator cuff and instability surgeries were
addressed only to invasive, often non-anatomical, open surgical procedures. Few years ago, it
was unimaginable to perform an arthroscopically assisted latissimus dorsi transfer or an
arthroscopic Latarjet procedure. Nowadays, all the above mentioned surgeries can be per-
formed arthroscopically.
Arthroscopy has undeniable advantages: it provides a better visualization of anatomical
structures and allows anatomical reconstruction and better bleeding control, it reduced surgical
times, and it is not perceived as invasive by the patient, thanks to the absence of surgical inci-
sion and early recovery after surgery. Few years ago, first studies compared open and
arthroscopic procedures; recently, biomechanical and clinical studies comparing different
arthroscopic techniques exploded and technological improvements run fast.
The need to stay updated and to have, at the same time, a comprehensive textbook on the
entire spectrum of shoulder diseases and arthroscopic techniques was the driving force behind
“Shoulder Arthroscopy: Principles and Practice.” It covers from basic science (anatomy and
biomechanics of the shoulder) through arthroscopic basic procedures up to the advanced
reconstructive surgeries.
Differently from many other books on surgical techniques, which generally seem to be
“how-to-do” handbooks, this book tries to give a comprehensive overview on shoulder pathol-
ogies with a special focus on surgical approach.
“Shoulder Arthroscopy: Principles and Practice” is highly organized, and all the chapters
follow the same format: from detailed descriptions regarding epidemiology, pathophysiology,
clinical findings, imaging, indication for treatment up to a step-by-step description of up-to-
date surgical techniques, including tips and tricks on how to avoid the most common mistakes
and complications. Finally, there is also an entire section dedicated to the evaluation of out-
come measurements.
It is important to note that the tips and techniques presented in this book represent the per-
sonal opinion of the authors and are based on their individual experiences. It is necessary,
therefore, to consider variations to the techniques described below; these variations might be
specifically designed for certain procedures, or they might reflect the preferences of the indi-
vidual surgeon.
We want to further highlight that reading this book is far from sufficient to acquire compre-
hensive knowledge in shoulder arthroscopy. Rather, an extensive period of study, practice, and
experience will be needed.
This book is supposed to be a guide for orthopedic residents and fellows who would like to
focus on shoulder diseases, but it could also be a reference landmark for expert surgeons
already involved in shoulder surgery.

xi
xii Preface

We hope that “Shoulder Arthroscopy: Principles and Practice” will help the readers in
improving their knowledge on shoulder disorders and, subsequently, their arthroscopic
techniques and skills. The ultimate goal of our job is taking best care of our patients. A deep
knowledge is the only way to achieve this aim.

Rome, Italy Giuseppe Milano, MD

Rome, Italy Andrea Grasso, MD
Contents

Part I Basics

1 Anatomy of the Shoulder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Enrico Bellato, Davide Blonna, and Filippo Castoldi
2 Biomechanics of the Shoulder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Christopher S. Ahmad, Marc D. Dyrszka, and Dennis H. Kwon
3 Shoulder Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Umile Giuseppe Longo, Alessandra Berton, Nicola Maffulli,
and Vincenzo Denaro
4 Imaging of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Nicola Magarelli, Chiara Carducci, and Claudia Dell’Atti
5 Biology of Injury and Repair of Soft Tissues of the Shoulder . . . . . . . . . . . . . . 59
Michael O. Schär and Scott A. Rodeo
6 Principles of Shoulder Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Gabriele Severini, Alessio Ricciardi, and Angelo Cacchio

Part II Principles of Shoulder Arthoscopy

7 Instrumentation in Shoulder Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Maristella F. Saccomanno, Silvia Careri, and Giuseppe Milano
8 Operating Room Setup and Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . 99
Matteo Salvatore, Carmine Latte, and Andrea Grasso
9 Anesthesia in Shoulder Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Stefano Santoprete, Angelo Chierichini, and Daniela Maria Micci
10 Portal Placement and Related Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Andrea Grasso, Domenico A. Santagada, and Matteo Salvatore
11 Diagnostic Shoulder Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Antonio E.G.C. Cartucho
12 Anchors and Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Sean G. Haslam and F. Alan Barber
13 Arthroscopic Suture Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Maristella F. Saccomanno, Matteo Bartoli, and Giuseppe Milano
14 Arthroscopic Knot Tying. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Jae-Chul Yoo and Young Eun Park

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xiv Contents

Part III Major Shoulder Problems and Related Arthoscopic Procedures

15 Acute Traumatic Anterior Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . 173

Patrick N. Siparsky and Dean C. Taylor
16 Recurrent Anterior Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Mary K. Mulcahey, John W. McNeil II, and Matthew T. Provencher
17 Posterior Shoulder Instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Yung Han and Seung-Ho Kim
18 Multidirectional Instability of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Anthony A. Romeo and Benjamin Bruce
19 The Overhead Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
W. Ben Kibler, John E. Kuhn, Aaron D. Sciascia, and Tim L. Uhl
20 SLAP Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
John M. Tokish and Richard K.N. Ryu
21 Subacromial Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Maristella F. Saccomanno, Silvia Careri, Matteo Bartoli, and Giuseppe Milano
22 Partial-Thickness Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Rachel M. Frank, Jas Chahal, and Nikhil N. Verma
23 Full-Thickness Rotator Cuff Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Maristella F. Saccomanno, Matteo Salvatore, Andrea Grasso,
and Giuseppe Milano
24 Large-to-Massive Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Brandon D. Bushnell, Richard J. Borgatti Jr., Michael A. Terry,
and Jeffrey S. Abrams
25 Disorders of the Rotator Interval: Coracohumeral Ligament
and Biceps Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Michael O’Malley, Knut Beitzel, and Augustus D. Mazzocca
26 Subscapularis Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Ian K.Y. Lo
27 Treatment Options for Irreparable Rotator Cuff Tears. . . . . . . . . . . . . . . . . . . 343
Carmine Latte, Matteo Salvatore, Paolo Avanzi, and Andrea Grasso
28 Calcific Tendonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Mustafa Karahan, Umut Akgun, and Baris Kocaoglu
29 Adhesive Capsulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Matteo Salvatore, Carmine Latte, Giuseppe Milano, and Andrea Grasso
30 Degenerative Acromioclavicular Joint Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Giovanni B. Vinanti, Daniele Scrimieri, and Andrea Grasso
31 Arthritis and Synovitis of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Donald W. Hohman, Thomas R. Duquin, and John W. Sperling

Part IV Complex and Revision Procedures in Shoulder Arthroscopy

32 Failed Instability Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401

Alessandro Castagna, Raffaele Garofalo, and Eugenio Cesari
Contents xv

33 HAGL and Reverse HAGL Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Frank Martetschläger, James B. Ames, and Peter J. Millett
34 Arthroscopic Treatment of Bony Bankart Lesions . . . . . . . . . . . . . . . . . . . . . . . 419
Hiroyuki Sugaya
35 Management of Hill-Sachs Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Michael J. O’Brien and Felix H. Savoie III
36 Glenoid Bone Loss: Arthroscopic Bone Grafting . . . . . . . . . . . . . . . . . . . . . . . . 441
Ettore Taverna, Guido Garavaglia, and Henri Ufenast
37 Arthroscopic Latarjet Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Laurent Lafosse, Vito Bongiorno, and Daniel Grant Schwartz
38 Failed Rotator Cuff Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Patrick J. Denard and Stephen S. Burkhart
39 Arthroscopic Suprascapular Nerve Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Timothy A. Hartshorn, Josef K. Eichinger, Lewis L. Shi, and Jon J.P. Warner
40 Biologic Augmentation in Rotator Cuff Repair . . . . . . . . . . . . . . . . . . . . . . . . . 485
Brian D. Dierckman, Randy R. Clark, Joseph P. Burns, and Stephen J. Snyder
41 The Role of Platelet-Rich Plasma in Rotator Cuff Repair. . . . . . . . . . . . . . . . . 497
Pietro Randelli, Vincenza Ragone, and Paolo Cabitza
42 Arthroscopically Assisted Latissimus Dorsi Transfer . . . . . . . . . . . . . . . . . . . . 503
Enrico Gervasi and Alessandro Spicuzza
43 Arthroscopic Treatment Options for Glenohumeral Osteoarthritis . . . . . . . . . 515
Werner Anderl, Brenda Laky, and Philipp R. Heuberer
44 Arthroscopic Management of Tuberosity Fractures. . . . . . . . . . . . . . . . . . . . . . 525
Stefan Greiner and Markus Scheibel
45 Acromioclavicular Joint Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Frank Martetschläger, Sepp Braun, and Andreas B. Imhoff
46 Scapulothoracic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
John B. Hubbard and Gary G. Poehling
47 Complications in Shoulder Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Gregor Szöllösy and Bruno Toussaint

Part V Outcome Research in Shoulder Arthroscopy

48 Outcome Research in Shoulder Arthroscopy: An Overview . . . . . . . . . . . . . . . 571

Roberto Padua and Enrico Ceccarelli
49 Experimental Models in Shoulder Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Leonardo M. Cavinatto and Leesa M. Galatz
50 Outcome Measurement Tools for Functional Assessment
of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Warren R. Dunn and James P. Leonard
51 Self-Assessment of Treatment Outcomes in Shoulder Arthroscopy . . . . . . . . . 599
Nicholas G.H. Mohtadi
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
Contributors

Jeffrey S. Abrams, MD Department of Surgery, University Medical Center of Princeton,

Princeton, NJ, USA
Christopher S. Ahmad, MD Department of Orthopaedic Surgery, Columbia University
Medical Center, New York, NY, USA
Umut Akgun, MD Orthopedics and Traumatology Department, Acibadem University,
School of Medicine, Istanbul, Turkey
James B. Ames, MD Department of Orthopaedics, Dartmouth-Hitchcock Medical Center,
Lebanon, NH, USA
Werner Anderl, MD Department of Orthopedic Surgery, St. Vincent Hospital, Vienna,
Austria
Paolo Avanzi, MD Department of Orthopaedics, Ospedale Sacro Cuore, Negrar (VR), Italy
F. Alan Barber, MD, FACS Plano Associated Arthroscopy and Sports Medicine Fellowship,
Plano Orthopedic Sports Medicine and Spine Center, Plano Texas, Plano, TX, USA
Matteo Bartoli, MD Catholic University, Division of Orthopaedic Surgery,
“A. Gemelli” University Hospital, Rome, Italy
Department of Orthopedics and Traumatology, Policlinico Agostino Gemelli, Rome, Italy
Knut Beitzel, MD Department of Orthopaedics, BG Unfallklinik Murnau, Murnau am
Staffelsee, Germany
Enrico Bellato, MD Department of Orthopaedics and Traumatology, Mauriziano-Umberto
I Hospital, Torino, Italy
Alessandra Berton, MD Department of Orthopaedic and Trauma Surgery, Campus
Bio-Medico University, Rome, Italy
Davide Blonna, MD Department of Orthopaedics and Traumatology, Mauriziano-Umberto
I Hospital, Torino, Italy
Vito Bongiorno, MD Department of Orthopaedic Surgery, Alps Surgery Institute,
Clinique Generale d’Annecy, Annecy, France
Richard J. Borgatti Jr., MD, BS Shore Shoulder Surgery, Toms River, NJ, USA
Sepp Braun, MD Department of Orthopaedic Sport Medicine, Hospital rechts der Isar,
Munich, Germany
Benjamin Bruce, MD Department of Orthopaedics, Rush University Medical Center,
Chicago, IL, USA
Stephen S. Burkhart, MD The San Antonio Orthopaedic Group, LLP, San Antonio,
TX, USA
Joseph P. Burns, MD Southern California Orthopedic Institute, Van Nuys, CA, USA
xvii