Portals

Poor portal position can easily convert a relatively simple procedure to a very difficult one. Beginner arthroscopists may

Box 17-1 Preparation

• Proper positioning is critical.

• Lateral decubitus or beach chair position is ideal.

• Interscalene block allows for better blood pressure control and helps with visualization.

Box 17-2 Primary Portals

• Posterior, in the "soft spot," superior and lateral for primarily subacromial procedures

• Anteroinferior, just about subscapularis

• Anterosuperior, high in the rotator interval

• Lateral, parallel to the undersurface of the acromion benefit from marking the skin. Landmarks include the clavicle, acromioclavicular joint, acromion, and coracoid (Fig. 17-2A). Most procedures can be done using three portals, but these portals differ based on the procedure. We use posterior, anteroinferior, anterosuperior, and lateral portals (Box 17-2). A variety of other portals have been described including the Nevi-aser portal and the port of Wilmington.4

The standard posterior portal is generally placed in the soft spot in the posterior aspect of the shoulder. A reasonable landmark is 1.5 to 2 cm inferior and 1.5 to 2 cm medial to the pos-terolateral acromion. The arthroscope is inserted, aiming slightly medially on an imaginary line directed toward the coracoid. This portal works well for glenohumeral procedures, but we have found that it is a little inferior and medial for subacromial procedures. Consequently, if the anticipated procedure will require more work to be done in the subacromial space, the portal is best placed only 1 cm medial and inferior to the posterolateral corner of the acromion5 (see Fig. 17-2B).

Figure 17-2 A, Preoperative marking of a right shoulder. The anterior circle is the coracoid. Arrows indicate the superior and inferior edges of the acromion. The portal sites are marked. B, Standard and modified posterior portal. The inferomedial portal works best for glenohumeral arthroscopy. The superolateral portal works best for subacromial arthroscopy. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

Figure 17-3 A, Surface view demonstrating outside-in technique to establish anteroinferior portal. B, Articular view through the posterior portal of a left shoulder demonstrating anterosuperior portal relationship to anteroinferior portal. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

Figure 17-3 A, Surface view demonstrating outside-in technique to establish anteroinferior portal. B, Articular view through the posterior portal of a left shoulder demonstrating anterosuperior portal relationship to anteroinferior portal. (From Gartsman G: Shoulder Arthroscopy. Philadelphia, WB Saunders, 2003.)

The remaining portals are placed in an outside-in fashion. An inside-out technique may be used, but this may limit the angle of approach for the given pathology. A spinal needle is placed through the skin to ensure not only the correct entry site but also to ensure that the instruments are directed appropriately to address the pathology. The location of the portal is determined by the procedure. For glenohumeral procedures, an anteroinfe-rior portal is established first (Fig. 17-3A). This portal is just above the intra-articular subscapularis and is slightly lateral to the glenoid face. The anterosuperior portal is placed in the rotator interval just anterior to the biceps tendon and more lateral to the inferior portal (see Fig. 17-3B). This allows an appropriate angle to place anchors in the superior and inferior glenoid without injury to the articular surface of the glenoid. Generally, at least a 2-cm skin bridge is maintained between portals to minimize difficulty with instrument manipulation

A lateral portal is generally used for subacromial pathology. It is established under direct visualization once the arthroscope is placed in the subacromial space. Optimal position is determined with a spinal needle (Fig. 17-5). This portal will be used to perform a bursectomy and place anchors in the greater tuberosity; therefore, it should be high, but it should also be parallel to the undersurface of the acromion. Once each portal is established, we place a cannula to prevent soft-tissue swelling, which may complicate the procedure.3 The cannulas also facilitate suture management and instrument access to the joint (Fig. 17-6).

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Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

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