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Name:
Strategic Tips and Tricks for Frozen Shoulder Arthroscopic Management
Description:
Strategic Tips and Tricks for Frozen Shoulder Arthroscopic Management
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Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Doctor Sergio Rowinski from Shoulder planet, here from Sao Paulo, Brazil. In this video, I'm showing you nice tips and nice tricks in order to deal with this unusual surgery, which is arthroscopic management of a frozen shoulder scenario which revealed refractory to non operative management.
So please subscribe. Leave your comment. Give us your thumbs up. And let's see the video. Hello, my friends. So this is me, Dr. Sergio, and I am presenting, here, some tips, tricks to do this very not usual surgery, which is the arthroscopy management of adhesive capsulitis, or frozen shoulder.
It's very important to highlight that the vast majority of such cases, they do get better with non operative management. We are talking about idiopathic, or primary adhesive capsulitis cases, or acquired, post-operative, post traumatic. Independently of that, the extreme majority of the cases will definitely get better with non operative management. Nevertheless, some cases, they really
do not get better amongst eight months, one year, even more, with all of the methods of management of such cases, a, in these unusual scenarios, arthroscopy management of these patients can be fantastic, a very useful tool. So I'm showing here two cases. The first case is about a 62-year-old man, with a post traumatic case, after a rotator cuff repair which didn't get better after 1 and 1/2 year.
And we did it. We did the arthroscopic management and the patient had a wonderful evolution. So let's see this first case. So what we are seeing here, first of all, and this is what I want to show you guys, is how this disease, this problem, is inflammatory. So what we are seeing, here, is a lot of synovitis, inflammation, and in this case, it's much more difficult to enter, here, with a spinal needle, to establish the anterior portal.
So, after we do that, we have to establish a view, as usual, in any shoulder arthroscopy, but here is very important, so, here, ate the right side, I'm pointing the humeral head, and, on the left side, a lot of synovitis, intra articularlly. It's important to remove it, in the glenohumeral space, for us to establish a view. So once we establish a view, the first thing that we will see is the long head of the biceps, and the rotator interval.
So what we are seeing, here, is a very pedagogical image on the right side, here, the humeral head, some synovitis, here, it's not so reddish, but it's synovitis, here, which obviously must be removed. This is, here, the long head of the biceps, and this anterior wall is the rotator interval. Usually the rotator interval is very thin, it's very easy to remove it,
but, in these cases, is quite difficult, and the disease itself is here, with a lot of fibrotic tissue, mainly in the anterior capsule and upon the rotator interval, and removing all of this tissue is what this surgery fundamentally is about. So we are doing it, first with a shaver, This is what we are doing now, removing all of this thick tissue. This is another very pedagogical image.
What we are seeing here This is the long head of the biceps, here, we are seeing the humeral head, on the left side the anterior labrum, and this is the rotator interval with a lot of scarring tissue. Again, removing this tissue is what the surgery is about. So we are starting this with the shaver, and this is another very important image, important image.
So what we are seeing Here, below, is the subscapularis, this is the deltoid, ok? And this is the anterior capsule, with all of this scarring tissue. So, here we have done the job, but we still have to do it laterally here, because removing all of this scarring tissue in the anterior capsule, upon the rotator interval, is fundamentally, I'm going to say, say it again, what the surgery is about.
So we are doing this now with the soft tissue shaver, now we are seeing, here, a bigger part of the anterior part of the deltoid. This is what the surgery is about. And here we see another very interesting image So this is, here, the coracoid. And, whenever possible, it's nice to release the coracoid insertion of the coracohumeral ligament, and this is what we are doing, here.
I highlight and I state, it's not very easy to do this, and sometimes it's not needed, if you don't see it, OK, once you gain, intraoperatively, all the motion the patient needs. But, whenever possible, it's interesting to come here to see the insertion of the coracohumeral ligament, and release it from its coracoid insertion. So we do it very fastly. Now
we are still on the anterior capsule, this is now, here, well, here, this is the coracoid with a full release of the coracoid insertion of the coracohumeral ligament. It's very important, here, pay attention, to release, here, if you can do it, intraoperatively, to release the coracoid insertion of the coracohumeral ligament, but not to detach, what would be a super iatrogenic thing,
the coracoid insertion of the conjoined tendon, which is a start in here. I am pointing, here, the lateral part of the insertion of the conjoined tendon into the tip of the coracoid, so we must never detach it, for quite evident reasons. So now what we are seeing, here, a full resection of the scarring tissue, here, of the anterior capsule on the left side, we are seeing, here, the anterior labrum.
This is the subscap, and, here, the medial part of the bicipital sheath. So, now we have gained full external rotation, we can see that we are easily moving the shoulder externally. This is another thing that is interesting to do, which is to release the adhesions between the very inferior part of the anterior capsule
and the subscapularis, so this is what we are doing here, with a lot of care. This is very important. This is, here, the anterior labrum, when we must never create an iatrogenic Bankart tear, I'm going to say it, again, we must never develop an unintentional, so iatrogenical Bankart lesion, OK ? So, this is what we are doing, here, very slowly, with a basket,
I am continuing this, here, with electrocautery, Now we are just releasing some adhesions in between the anterior capsule and the subscap, I am doing this now, here, this is a very pedagogical image This is the subscapularis, here, and I am releasing some adhesions in the articular part of the subscapularis. This is, here, the anterior capsule, and we can continue to remove the scarring tissue, but, again, taking a lot of care not to create an iatrogenical Bankart lesion.
Now we are very low, very, very low in the glenohumeral joint. And what I'm doing here, is now I am changing the portals, and I'm going to put the camera in the anterior portal, in order to see the posterior capsule, to release some adhesions in the posterior capsule, in order for the patient to gain internal rotation. So now I am entering on the anterior portal, this is a switching stick, just for us to see where the posterior portal was. so this is the posterior capsule.
This is, here, on the left side, now, the humeral head, some synovitis, here, the camera was here. And what we must do now is to release all of this scarring tissue from the posterior capsule, here, on the left side, this is the humeral head, and, here, we are seeing the inferior part of the postero superior cuff, which is the infraspinatus.
We have to just release, remove some synovitis, here, but removing all of this scarring tissue in the posterior capsule is important, this is what we are doing now, and, again, we must not create, here, a posterior bankart tear, of course. So now we are coming back with the camera on the posterior portal, and this is something that we can do, It's very, I would say, unusual, but it's an option,
and I did, in this case. It is to create an accessory antero-supero-lateral portal, to have a better access to the very inferior part of the anterior capsule. I'm entering, here, now, through this antero-supero-lateral portal, this is an accessory portal, And this is what I'm doing now. I am removing the very inferior part of the adhesions upon the anterior capsule.
This is something that can be done or not, depending on how you are gaining motion, intra operatively, with MUA, which means manipulation under anesthesia. So this is the end of the surgery, I'm very happy to see my face, here, because this video is from 2008 or 2009, we are in 2020, so it's like to see myself a little bit younger, here.
And this is what I'm doing now, gaining full external rotation, full elevation. This is what we are doing here. And then full abduction in external rotation, full elevation in scapular plane and full internal rotation. this video was done between 2008 and 2009, so this is why the quality of this camera was definitely not as good as the cameras we have today.
I apologize, but is very comprehensible. So that was the first case, and now I'm going to show you guys the second case. So this is a 68-year-old man, which had a proximal humerus fracture, which was operated one year before he came to me, and he came with a very stiff shoulder. The surgery was very well done, performed by another guy here in my city, Sao Paulo, Brazil, but, nevertheless, he evolved with a huge post traumatic frozen shoulder scenario,
which definitely did not get better with non operative management. So this procedure was extremely well indicated. Again I apologize for the quality of the camera, but this is what we had. This is a case from 2007, 2007, 13 years ago. And again, I like to see myself quite younger here. So this was the limitation of external rotation with the arm at the side.
No compensatory movements of the trunk. He had about 20, 10 degrees of external rotation, and his elevation was about something like 60 degrees, maybe 50, OK, maybe 55. And this was, here, the delto pec incision that was done, about one year ago, in the
trauma. Now I am showing you, guys, in scapular plane, He had about 70 degrees of pure glenohumeral motion, which means that he had a lot of adhesions in the antero-inferior capsule. So when we started the surgery Now we are starting this surgery, we can, again, see how this is an inflammatory disease, see how much inflammatory tissue we have here, a lot of reddish tissue.
We are again, seeing, here, the anterior part of the supraspinatus, which was OK, just a little bit fraying, but that had no pathological value. So here we are doing the same thing. We are removing all of the anterior scarring tissue upon the rotator interval, so, again, this is the long head of the biceps and, here, we are seeing all of the anterior part of the deltoid, and, here, some part of the anterior labrum.
So the job was quite done in this case. I am, again, going very inferiorly, on the anterior capsule, we have to take care, here below we have the subscapularis, and, again, not to create an iatrogenical Bankart lesion, but I am removing all of the adhesions here, in the very inferior part of the anterior capsule. And here we are starting to see the subscap. Obviously, we must never damage the subscap.
This is a very important image The deltoid is here, and here, but this is scarring tissue, that is still to be resected and removed. And this is what we are doing now. I'm coming here with the shaver. This surgery again, is not about damaging the anterior labrum, and is not about damaging the subscapularis, which is here, but it's about removing the scarring tissue in the anterior capsule upon the rotator interval.
So now we are, here, very low. This is the subscapularis, and this is the antero inferior glenohumeral ligament. We didn't damage it. This is a very important image, OK ? So this is the inferior part of the glenoid, and this is, here, the ANTERO-INFERIOR glenohumeral ligament which obviously was not damaged, if it was, we would have, so, an atherogenic Bankart tear, and iatrogenical Bankart lesion, which would be a very bad issue, of course.
So at that moment, we are seeing, here, the antero-inferior gleno humeral ligament. It's very easy to see, and this is the final result. We gained, here, a very good external rotation, in abduction. As we are seeing, here, a very good internal rotation, a very good elevation. Again,
very good immediate post operatively result. And, at that moment, the surgery was so finished. So, my friends, I hope you liked, a nice video, showing you some tips, tricks to deal with arthroscopic management of frozen shoulder, so please, I remind you,subscribe. Leave your comment.
Give us your thumbs up, and see you in the next video. And, as Dr. Sergio loves to say, never stop flying. See you, folks.
Segment:0 .
Hello, my friends, how are you? This is me, Doctor Sergio Rowinski from Shoulder planet, here from Sao Paulo, Brazil. In this video, I'm showing you nice tips and nice tricks in order to deal with this unusual surgery, which is arthroscopic management of a frozen shoulder scenario which revealed refractory to non operative management.
So please subscribe. Leave your comment. Give us your thumbs up. And let's see the video. Hello, my friends. So this is me, Dr. Sergio, and I am presenting, here, some tips, tricks to do this very not usual surgery, which is the arthroscopy management of adhesive capsulitis, or frozen shoulder.
It's very important to highlight that the vast majority of such cases, they do get better with non operative management. We are talking about idiopathic, or primary adhesive capsulitis cases, or acquired, post-operative, post traumatic. Independently of that, the extreme majority of the cases will definitely get better with non operative management. Nevertheless, some cases, they really
do not get better amongst eight months, one year, even more, with all of the methods of management of such cases, a, in these unusual scenarios, arthroscopy management of these patients can be fantastic, a very useful tool. So I'm showing here two cases. The first case is about a 62-year-old man, with a post traumatic case, after a rotator cuff repair which didn't get better after 1 and 1/2 year.
And we did it. We did the arthroscopic management and the patient had a wonderful evolution. So let's see this first case. So what we are seeing here, first of all, and this is what I want to show you guys, is how this disease, this problem, is inflammatory. So what we are seeing, here, is a lot of synovitis, inflammation, and in this case, it's much more difficult to enter, here, with a spinal needle, to establish the anterior portal.
So, after we do that, we have to establish a view, as usual, in any shoulder arthroscopy, but here is very important, so, here, ate the right side, I'm pointing the humeral head, and, on the left side, a lot of synovitis, intra articularlly. It's important to remove it, in the glenohumeral space, for us to establish a view. So once we establish a view, the first thing that we will see is the long head of the biceps, and the rotator interval.
So what we are seeing, here, is a very pedagogical image on the right side, here, the humeral head, some synovitis, here, it's not so reddish, but it's synovitis, here, which obviously must be removed. This is, here, the long head of the biceps, and this anterior wall is the rotator interval. Usually the rotator interval is very thin, it's very easy to remove it,
but, in these cases, is quite difficult, and the disease itself is here, with a lot of fibrotic tissue, mainly in the anterior capsule and upon the rotator interval, and removing all of this tissue is what this surgery fundamentally is about. So we are doing it, first with a shaver, This is what we are doing now, removing all of this thick tissue. This is another very pedagogical image.
What we are seeing here This is the long head of the biceps, here, we are seeing the humeral head, on the left side the anterior labrum, and this is the rotator interval with a lot of scarring tissue. Again, removing this tissue is what the surgery is about. So we are starting this with the shaver, and this is another very important image, important image.
So what we are seeing Here, below, is the subscapularis, this is the deltoid, ok? And this is the anterior capsule, with all of this scarring tissue. So, here we have done the job, but we still have to do it laterally here, because removing all of this scarring tissue in the anterior capsule, upon the rotator interval, is fundamentally, I'm going to say, say it again, what the surgery is about.
So we are doing this now with the soft tissue shaver, now we are seeing, here, a bigger part of the anterior part of the deltoid. This is what the surgery is about. And here we see another very interesting image So this is, here, the coracoid. And, whenever possible, it's nice to release the coracoid insertion of the coracohumeral ligament, and this is what we are doing, here.
I highlight and I state, it's not very easy to do this, and sometimes it's not needed, if you don't see it, OK, once you gain, intraoperatively, all the motion the patient needs. But, whenever possible, it's interesting to come here to see the insertion of the coracohumeral ligament, and release it from its coracoid insertion. So we do it very fastly. Now
we are still on the anterior capsule, this is now, here, well, here, this is the coracoid with a full release of the coracoid insertion of the coracohumeral ligament. It's very important, here, pay attention, to release, here, if you can do it, intraoperatively, to release the coracoid insertion of the coracohumeral ligament, but not to detach, what would be a super iatrogenic thing,
the coracoid insertion of the conjoined tendon, which is a start in here. I am pointing, here, the lateral part of the insertion of the conjoined tendon into the tip of the coracoid, so we must never detach it, for quite evident reasons. So now what we are seeing, here, a full resection of the scarring tissue, here, of the anterior capsule on the left side, we are seeing, here, the anterior labrum.
This is the subscap, and, here, the medial part of the bicipital sheath. So, now we have gained full external rotation, we can see that we are easily moving the shoulder externally. This is another thing that is interesting to do, which is to release the adhesions between the very inferior part of the anterior capsule
and the subscapularis, so this is what we are doing here, with a lot of care. This is very important. This is, here, the anterior labrum, when we must never create an iatrogenic Bankart tear, I'm going to say it, again, we must never develop an unintentional, so iatrogenical Bankart lesion, OK ? So, this is what we are doing, here, very slowly, with a basket,
I am continuing this, here, with electrocautery, Now we are just releasing some adhesions in between the anterior capsule and the subscap, I am doing this now, here, this is a very pedagogical image This is the subscapularis, here, and I am releasing some adhesions in the articular part of the subscapularis. This is, here, the anterior capsule, and we can continue to remove the scarring tissue, but, again, taking a lot of care not to create an iatrogenical Bankart lesion.
Now we are very low, very, very low in the glenohumeral joint. And what I'm doing here, is now I am changing the portals, and I'm going to put the camera in the anterior portal, in order to see the posterior capsule, to release some adhesions in the posterior capsule, in order for the patient to gain internal rotation. So now I am entering on the anterior portal, this is a switching stick, just for us to see where the posterior portal was. so this is the posterior capsule.
This is, here, on the left side, now, the humeral head, some synovitis, here, the camera was here. And what we must do now is to release all of this scarring tissue from the posterior capsule, here, on the left side, this is the humeral head, and, here, we are seeing the inferior part of the postero superior cuff, which is the infraspinatus.
We have to just release, remove some synovitis, here, but removing all of this scarring tissue in the posterior capsule is important, this is what we are doing now, and, again, we must not create, here, a posterior bankart tear, of course. So now we are coming back with the camera on the posterior portal, and this is something that we can do, It's very, I would say, unusual, but it's an option,
and I did, in this case. It is to create an accessory antero-supero-lateral portal, to have a better access to the very inferior part of the anterior capsule. I'm entering, here, now, through this antero-supero-lateral portal, this is an accessory portal, And this is what I'm doing now. I am removing the very inferior part of the adhesions upon the anterior capsule.
This is something that can be done or not, depending on how you are gaining motion, intra operatively, with MUA, which means manipulation under anesthesia. So this is the end of the surgery, I'm very happy to see my face, here, because this video is from 2008 or 2009, we are in 2020, so it's like to see myself a little bit younger, here.
And this is what I'm doing now, gaining full external rotation, full elevation. This is what we are doing here. And then full abduction in external rotation, full elevation in scapular plane and full internal rotation. this video was done between 2008 and 2009, so this is why the quality of this camera was definitely not as good as the cameras we have today.
I apologize, but is very comprehensible. So that was the first case, and now I'm going to show you guys the second case. So this is a 68-year-old man, which had a proximal humerus fracture, which was operated one year before he came to me, and he came with a very stiff shoulder. The surgery was very well done, performed by another guy here in my city, Sao Paulo, Brazil, but, nevertheless, he evolved with a huge post traumatic frozen shoulder scenario,
which definitely did not get better with non operative management. So this procedure was extremely well indicated. Again I apologize for the quality of the camera, but this is what we had. This is a case from 2007, 2007, 13 years ago. And again, I like to see myself quite younger here. So this was the limitation of external rotation with the arm at the side.
No compensatory movements of the trunk. He had about 20, 10 degrees of external rotation, and his elevation was about something like 60 degrees, maybe 50, OK, maybe 55. And this was, here, the delto pec incision that was done, about one year ago, in the
trauma. Now I am showing you, guys, in scapular plane, He had about 70 degrees of pure glenohumeral motion, which means that he had a lot of adhesions in the antero-inferior capsule. So when we started the surgery Now we are starting this surgery, we can, again, see how this is an inflammatory disease, see how much inflammatory tissue we have here, a lot of reddish tissue.
We are again, seeing, here, the anterior part of the supraspinatus, which was OK, just a little bit fraying, but that had no pathological value. So here we are doing the same thing. We are removing all of the anterior scarring tissue upon the rotator interval, so, again, this is the long head of the biceps and, here, we are seeing all of the anterior part of the deltoid, and, here, some part of the anterior labrum.
So the job was quite done in this case. I am, again, going very inferiorly, on the anterior capsule, we have to take care, here below we have the subscapularis, and, again, not to create an iatrogenical Bankart lesion, but I am removing all of the adhesions here, in the very inferior part of the anterior capsule. And here we are starting to see the subscap. Obviously, we must never damage the subscap.
This is a very important image The deltoid is here, and here, but this is scarring tissue, that is still to be resected and removed. And this is what we are doing now. I'm coming here with the shaver. This surgery again, is not about damaging the anterior labrum, and is not about damaging the subscapularis, which is here, but it's about removing the scarring tissue in the anterior capsule upon the rotator interval.
So now we are, here, very low. This is the subscapularis, and this is the antero inferior glenohumeral ligament. We didn't damage it. This is a very important image, OK ? So this is the inferior part of the glenoid, and this is, here, the ANTERO-INFERIOR glenohumeral ligament which obviously was not damaged, if it was, we would have, so, an atherogenic Bankart tear, and iatrogenical Bankart lesion, which would be a very bad issue, of course.
So at that moment, we are seeing, here, the antero-inferior gleno humeral ligament. It's very easy to see, and this is the final result. We gained, here, a very good external rotation, in abduction. As we are seeing, here, a very good internal rotation, a very good elevation. Again,
very good immediate post operatively result. And, at that moment, the surgery was so finished. So, my friends, I hope you liked, a nice video, showing you some tips, tricks to deal with arthroscopic management of frozen shoulder, so please, I remind you,subscribe. Leave your comment.
Give us your thumbs up, and see you in the next video. And, as Dr. Sergio loves to say, never stop flying. See you, folks.
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