Overview
Arthroscopic treatment may be considered for developmental, traumatic, degenerative or inflammatory shoulder conditions causing pain, instability or disability not controlled by nonoperative measures (Campbell). Contraindications include skin problems at portal sites, concomitant infection that could spread to the joint (e.g., periodontal infection) and increased medical risk. Patients should be told that an open procedure may be needed if findings warrant it; if this is likely, the beach-chair position is preferable (Campbell).
Preoperative Imaging (Campbell)
Radiographs: AP in external rotation, true AP (Grashey) in internal rotation, scapular outlet and axillary lateral views. West Point, Bernageau and Stryker notch views for suspected glenoid or humeral bone defects in instability.
MRI is most useful for rotator cuff pathology; MR arthrography for capsulolabral, SLAP and HAGL lesions (an acute hemarthrosis may serve as contrast).
Three-dimensional CT is the best means of quantifying bone loss in chronic instability.
Positioning (Campbell)
Lateral decubitus | Beach-chair | |
|---|---|---|
Advantages | Better traction, better posterior access, safe and simple; joint distraction may allow lower glenoid anchor placement in instability | Anatomic orientation, easy arm manipulation with a positioner, less traction neurapraxia, easy conversion to open surgery |
Concerns | Traction strain on the brachial plexus | Cerebral hypoperfusion; stroke and death have been reported with hypotension |
Lateral decubitus
Vacuum beanbag, axillary roll and chest strap; protect the eyes and dependent ear; pad pressure points, including the peroneal nerve and lateral malleolus of the down leg; check distal pulses and oximetry.
Tilt the patient 20-30 degrees posteriorly so the glenoid is parallel to the floor.
Apply 10-15 lb of traction with a sterile device (balanced suspension; avoid overdistraction). Glenohumeral work: more abduction (30-60 degrees range) and 20-30 degrees of forward flexion; subacromial and AC joint work: 20-45 degrees of abduction and 0 degrees of flexion, which lets the head sublux inferiorly and opens the subacromial space. An axillary bolster or lateral distraction cuff adds lateral distraction.
In a cadaver study, 30 degrees of flexion with 70 degrees of abduction produced the highest brachial plexus strain; 45 degrees of flexion with 90 or 0 degrees of abduction has been recommended. Transient paresthesia occurs in 10-30% after shoulder arthroscopy.
Beach-chair
Pillows under the knees to relax the sciatic nerve; head secured in a headrest with a foam mask; eye protection; endotracheal tube exiting on the opposite side.
Incline about 70-80 degrees so the acromial undersurface is roughly parallel to the floor; if blood pressure is a concern, stop halfway and recheck.
Avoid cervical extension; secure with straps and a kidney rest. An arm positioner frees an assistant.
Measure blood pressure on the opposite brachium or use cerebral perfusion monitoring: calf readings can be about 40 mm Hg higher than the true cerebral perfusion pressure.
Bleeding and Fluid Management (Campbell)
Add 1 mL of 1:1000 epinephrine to each 3000-mL bag of irrigant if blood pressure is stable and there are no cardiac contraindications.
Hypotensive anesthesia (systolic 90-100 mm Hg) may be the most effective method; keep systolic pressure about 40 mm Hg (no more than 30-50 mm Hg) above pump pressure.
Bleeding-prone areas: around the scapular spine, the coracoacromial ligament and the coracoid base.
Routine pump pressure 30-50 mm Hg, raised only briefly for hemostasis. Use tight-fitting portals and cannulas with diaphragms, avoid violating the deltoid fascia and avoid repeated "new" passes to limit extravasation, which is greater in extra-articular (subacromial) work. Reported weight gain from fluid averaged 8.7 lb in one series of 53 patients (4.2 lb in another analysis); it resolves quickly but matters in cardiac patients.
Portals (Campbell)
Mark the bony landmarks before distention. The low anterior portal passes closest to a neurovascular structure (about 1 cm from the cephalic vein). Posteriorly, the suprascapular nerve and circumflex scapular artery lie about 2 cm from the portal; the axillary nerve is a concern anteriorly, posteriorly and laterally.
Portal | Location | Notes |
|---|---|---|
Posterior "soft spot" | 1.5-3 cm inferior and 1 cm medial to the posterolateral acromion (infraspinatus-teres minor interval) | Primary viewing portal; parallel to the glenoid. For posterior stabilization place it just inferior to and in line with the acromial edge; for subacromial work 1.5 cm inferior and in line with the acromion |
Posteroinferior 7 o'clock (Davidson) | 2-3 cm inferior and 1 cm anterior to the posterior acromial edge (Table: 3-4 cm inferior, about 1 cm lateral) | Access to the inferior capsule |
Anterior (central) | Slightly lateral to halfway between the anterolateral acromion and the coracoid, through the rotator interval triangle (biceps, subscapularis, glenoid) | For instability: just above the rolled upper border of subscapularis |
Anterosuperolateral | About 1 cm lateral to the anterolateral acromion, behind the long head of biceps and in front of supraspinatus | Viewing for glenoid bone loss and IGHL lesions |
Anteroinferior 5 o'clock | Through subscapularis at the leading edge of the IGHL | Use with caution: cephalic vein about 1 cm, musculocutaneous nerve about 23 mm, axillary nerve about 24 mm; subclavian vein within 1 cm; mainly percutaneous for anchors |
Superior (Neviaser) | Soft spot between clavicle, acromion and scapular spine; needle 1 cm medial to the medial acromion, 30-45 degrees, 10 degrees posterior | Enters just behind the biceps anchor; suprascapular nerve about 3 cm medial |
Lateral | 3 cm lateral to the acromion | Main subacromial working portal; axillary nerve about 5 cm distal to the acromion |
Portal of Wilmington | 1 cm anterior and 1 cm lateral to the posterolateral acromial angle | Posterior SLAP repair; avoid the cuff insertion |
Lafosse suprascapular nerve portal | Between clavicle and scapular spine, about 7 cm medial to the lateral acromion (2 cm medial to Neviaser) | Suprascapular notch |
Separate accessory anterior portals by at least 2-3 cm and confirm each with a spinal needle.
Technique 57.1: Establishing the Posterior Portal (Campbell)
Insert an 18-gauge spinal needle through the posterior soft spot toward the coracoid, guided by a finger on the coracoid tip.
Inject 30-40 mL of saline (less in adhesive capsulitis) with free flow and backflow; preinsufflation distracts the head and makes trocar entry safer. If the needle is extra-articular, the bolus worsens extravasation. Some surgeons prefer to enter with the blunt trocar before distention.
Infiltrate portal sites with local anesthetic and epinephrine; 20 mL of dilute epinephrine (1:100,000) may be injected into the subacromial space after confirming the needle is not intravascular.
Incise only the epidermis and dermis with a No. 11 blade to avoid deltoid bleeding.
Pass the cannula and blunt trocar toward the anterior joint line, palpate the scapular neck and glenoid, slide laterally to the glenoid rim and enter immediately lateral to it with a "push and twist" motion (this passes through muscle rather than tendon of the cuff and protects cartilage).
Technique 57.2: Anterior Portal (Inside-Out / Transillumination) (Campbell)
Mark anterior portal sites before distention.
Advance the arthroscope into the anterior triangle (glenoid, biceps, subscapularis) and transilluminate with the room lights off.
Back off and localize the site with a spinal needle, adjusting the trajectory for easy instrumentation.
Incise with a No. 11 blade and pass a cannula with a blunt trocar, moving the arthroscope away to protect the lens.
Decide on accessory anterior portals before the first anterior portal; separate them by at least 2-3 cm.
Technique 57.3: Superior (Neviaser) Portal (Campbell)
Insert an 18-gauge needle 1 cm medial to the medial acromion at 30-45 degrees to the skin and 10 degrees posteriorly, entering at the superior glenoid just behind the biceps attachment.
Confirm the position arthroscopically before incising the skin.
Diagnostic Arthroscopy Sequence (Campbell)
Start at the soft spot between biceps and subscapularis; evaluate the subscapularis (with posterior force on the proximal humerus) and inspect its recess for loose bodies.
Circle the joint: labrum from the biceps anchor around the glenoid, and capsule around the humerus.
Laxity: drive-through sign and a rotator interval wider than 1.5 cm.
Distinguish a normal sublabral hole or Buford complex (cordlike middle glenohumeral ligament attaching at the biceps base) from a Bankart lesion, which extends below the glenoid equator.
Evaluate the IGHL on the glenoid, midsubstance and humeral sides (HAGL).
Apply traction to the biceps-labral complex and check for peel-back out of traction (SLAP); pull the long head of biceps into the joint to inspect as much tendon as possible.
Follow the cuff insertion posteriorly from the biceps: the anterior rotator cable insertion is just behind the biceps; the posterior cable marks the start of the bare area. Assess for Hill-Sachs lesions and measure the Hill-Sachs interval for on-track/off-track assessment.
Move the arthroscope anteriorly to view the posterior labrum, pouch and capsule, the posterior band of the IGHL, the humeral attachment of the glenohumeral ligaments and the subscapular recess.
Measure glenoid bone loss by comparing the anterior and posterior radii from the bare area through the anterosuperolateral portal.
Subacromial space (Campbell)
Remove all glenohumeral distention first. Redirect the posterior cannula under the acromion just medial to the posterolateral corner, aiming at a finger on the anterolateral acromion (not at the AC joint); downward traction on the forearm enlarges the space.
Sweep the cannula to open the bursa, avoiding medial or anterior sweeping past the coracoacromial ligament (bleeding).
Inspect the acromial undersurface for fraying with a "kissing" cuff lesion, the AC joint and the coracoacromial ligament; establish an anterolateral or lateral portal outside-in and perform bursectomy as needed.
The bursa extends at least 2 cm anterior to the acromion and back to about mid-acromion.
Complications (Campbell)
Failure of the procedure is the most frequent complication; secure knot tying (e.g., Revo nonsliding knot; sliding-locking knots backed with three reversing half-hitches on alternating posts) prevents loosening.
Neurologic injury (traction or pressure, usually transient); suprascapular nerve lies less than 2 cm medial to the glenoid rim.
Chondrolysis, particularly after intra-articular local anesthetic infusion in young patients with anchors.
Thromboembolism in upper or lower extremities; consider lower-extremity compression devices with risk factors.
Infection is uncommon; Cutibacterium (Propionibacterium) acnes is associated with shoulder procedures; seal the axilla with drapes.
References
Brolin TJ, Lamplot JD. Arthroscopy of the upper extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 57, Techniques 57.1-57.3.