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Arthroscopy of the shoulder


After an anesthetic has been administered, your surgeon and the operating room staff will then make sure that you are correctly position on the operating table. For some shoulder surgeries you will be placed in the "beach chair" position, as if you are reclining on a beach chair. Other types of shoulder surgery require that you lie on your side and have your arm in traction. This position is becoming more popular and is now quite common for arthroscopic rotator cuff repairs.Shoulder arthroscopy is performed through "portals". These are small incisions, generally about ½ of an inch to an inch long in the skin, are located over particular areas of the joint that the orthopedic surgeon will need to operate upon. Small plastic tubes, called "cannulas" are then inserted into the portals so that instruments can easily be placed in the shoulder joint. Shoulder arthroscopy itself involves inserting a specially designed video camera with a very bright fiber optic light source into the shoulder joint so that the important parts of the joint can be seen. Instruments that have been specially designed to remove inflamed tissue, attach sutures to bone, and repair tears and damaged tendons are then used to operate inside the shoulder.

Endoscopic acromioplasty of the shoulder


Neer introduced the concept of impingement of the coracoacromial arch on the rotator cuff as the etiology of rotator cuff tendinopathy and rotator cuff tears. Neer contended that this mechanical phenomenon resulted in a sequential progression initiating with subacromial edema, advancing to rotator cuff fibrosis and tendinitis, and ultimately resulting in full thickness rotator cuff disruption. Neer believed that 95% of rotator cuff pathology was related to subacromial impingement.
Multiple scientific investigations and clinical observations now question the role of subacromial impingement in rotator cuff tears. Investigators demonstrated the importance of intrinsic causes in the development of rotator cuff lesions, including degenerative and vascular etiologies. Additionally, the relative infrequency of bursal-sided partial thickness rotator cuff tears compared with articular-sided partial thickness rotator cuff tears suggests that more than extrinsic compression on the rotator cuff by the coracoacromial arch is involved in the development of rotator cuff tears.
Although it is recognized that subacromial impingement is probably not a major contributor to the development of rotator cuff tears, it undoubtedly plays a role in rotator cuff tendinitis and subacromial bursitis. The numerous reports of the success of anterior acromioplasty in the treatment of rotator cuff syndrome clinically attest to the role of the coracoacromial arch in shoulder pain emanating from an inflamed rotator cuff and subacromial bursa. For the remainder of this tutorial, subacromial impingement syndrome, rotator cuff tendinitis, and subacromial bursitis will be used interchangeably; discussion of rotator cuff tears is beyond the scope of this review.


Treatment
In a patient with suspected subacromial impingement syndrome, nonoperative treatment is attempted before surgical intervention is considered. Nonoperative treatment consists of rest, ice, physical therapy, nonsteroidal anti-inflammatory medications, and subacromial corticosteroid injections. Nonoperative treatment is effective at alleviating symptoms of subacromial impingement syndrome in more than two-thirds of patients. Results of nonoperative treatment are less favorable in patients with hooked acromial morphology.




 
   

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