Review Article

Shoulder Arthroscopy: Basic

Principles of Positioning,
Anesthesia, and Portal Anatomy

Abstract
E. Scott Paxton, MD Advances in modern arthroscopy have contributed significantly to
Jonathan Backus, MD greater flexibility and efficacy in addressing shoulder pathology.
Advantages of arthroscopy include less invasive approaches,
Jay Keener, MD
improved visualization, decreased risk of many postoperative
Robert H. Brophy, MD complications, and faster recovery. As a result, arthroscopy is often
preferred by both orthopaedic surgeons and patients. Common
shoulder conditions that can be managed arthroscopically include
rotator cuff tears, shoulder instability, and labral pathology. A
thorough understanding of anatomic principles in conjunction with
proper patient positioning and portal selection and placement are
essential for successful arthroscopic shoulder surgery.

W ith improvements in technol-

ogy and instrumentation, ar-
throscopy has become the primary
mon finding. A thorough under-
standing of shoulder anatomy is es-
sential to minimize the risk of
From The Rothman Institute at
Thomas Jefferson University, treatment modality for many shoul- complications.
Philadelphia, PA (Dr. Paxton) and der disorders. Compared with open
the Department of Orthopedic
Surgery, Washington University techniques, arthroscopy allows for
School of Medicine, Chesterfield, smaller incisions and is associated
Patient Positioning and
MO (Dr. Backus, Dr. Keener, and with decreased risk of deltoid muscle
Anesthesia
Dr. Brophy).
damage,1 improved intra-articular vi- Shoulder arthroscopy is performed
Dr. Brophy or an immediate family sualization,1 less pain immediately with the patient in either the lateral
member serves as a paid consultant
to or is an employee of Genzyme
postoperatively,2 and potentially decubitus position (LDP)4 (Figure 1,
and serves as a board member, faster postoperative recovery. As a A) or the beach-chair position (BCP)5
owner, officer, or committee member result, both surgeons and patients (Figure 1, B). For the LDP, the pa-
of the American Orthopaedic Society
have demonstrated a preference for tient is positioned laterally on a pad-
for Sports Medicine. None of the
following authors or any immediate arthroscopy. ded table with a beanbag type sup-
family member has received The challenges of shoulder arthros- port placed on the lower torso and
anything of value from or has stock copy are often underestimated, how-
or stock options held in a
pelvis, keeping the nonsurgical arm
commercial company or institution
ever. Especially in obese patients, an- in 90° of flexion, the knees bent, and
related directly or indirectly to the atomic landmarks are more difficult the head in neutral alignment. Bony
subject of this article: Dr. Paxton, to palpate in the shoulder than in prominences must be adequately
Dr. Backus, and Dr. Keener.
other joints (eg, the knee). This can padded, and an axillary roll is placed
J Am Acad Orthop Surg 2013;21: add to the difficulty of portal place- under the nonsurgical arm to protect
332-342
ment and may increase the risk of the neurovascular structures. The
http://dx.doi.org/10.5435/ neurovascular injury. Complication surgical arm is then placed in a sling,
JAAOS-21-06-332
rates of 4.6% to 10.6% have been and traction is applied longitudinally
Copyright 2013 by the American reported with shoulder arthroscopy.3 with or without an additional sling
Academy of Orthopaedic Surgeons. Neurologic injury is the most com- to provide lateral traction of the up-

332 Journal of the American Academy of Orthopaedic Surgeons

 E. Scott Paxton, MD, et al

Figure 1

Intraoperative photographs demonstrating patient positioning for shoulder arthroscopy. A, The lateral decubitus
position. B, The beach-chair position with use of a sterile arm holder. (Photographs courtesy of Matthew Smith, MD,
St. Louis, MO.)

per arm. Gross and Fitzgibbons6 Advantages of the LDP include in- with 60° of hip flexion. The head is
modified this position to improve vi- creased visualization of the glenohu- kept in neutral alignment in the
sualization by tilting the table 20° to meral joint and subacromial space holder. The nonsurgical arm is
30° posteriorly, thereby positioning without the need of an assistant to placed in an armrest, and the surgi-
the glenoid parallel to the floor. apply traction. Lateral distraction of cal arm is placed either in a sterile
The position of the arm and the the glenohumeral joint allows easier holder, which may itself provide trac-
amount of traction applied is impor- access to the posterior and inferior tion, or on a sterile padded Mayo
tant in ensuring adequate visualiza- glenohumeral joint, thereby easing stand.
tion while minimizing the risk of posterior capsular imbrication proce- Proposed advantages of the BCP
neurovascular injury. Klein et al7 ex- dures and capsulolabral reconstruc- include a lower incidence of neurop-
tensively studied the relationship be- tions. However, the incidence of athies, decreased risk of neurovascu-
tween arm position and strain on the nerve injury has been estimated to be lar complications during portal
brachial plexus. In a cadaver study, 10% in the LDP with the arm in placement, decreased surgical time,
they found that at any given abduc- traction.10 easier conversion to an open proce-
tion or flexion angle, increasing flex- The BCP was first described by dure, and better visualization of the
ion or abduction, respectively, re- Skyhar et al5 in 1988. It was devel- joint.8,12,13 The chief complications
duced strain. They concluded that a oped in an effort to avoid the neu- are maintenance of cerebral perfu-
combination of two positions, 45° ropathies seen with the LDP. In con- sion and adequate airway control. In
forward flexion/zero degrees abduc- trast to the LDP, neuropathies are the awake, upright patient, the sym-
tion and 45° forward flexion/90° ab- rarely reported with the BCP.8,11 The pathetic nervous system is stimu-
duction, maximized visibility while patient is positioned supine on a ta- lated, which increases vascular resis-
minimizing strain. Regardless of arm ble equipped with a headrest and tance and mean arterial pressure
position, traction should be limited movable back and foot sections. The (MAP) while decreasing cardiac out-
to 15 to 20 lb.8 It is important to un- table is placed in the Trendelenburg put. This physiologic response is es-
derstand the ischemic consequences position, with the patient’s feet ele- sential to maintain cerebral perfu-
of traction, particularly with lateral vated 15°. The knees are flexed to sion. Under general anesthesia,
traction, because it can markedly re- 30°, and a pillow is placed behind however, the sympathetic nervous
duce local and distal tissue perfu- them, after which the table is ad- system cannot effectively respond to
sion.9 justed to bring the trunk upright, the upright position, which causes a

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Shoulder Arthroscopy: Basic Principles of Positioning, Anesthesia, and Portal Anatomy

relative decrease in vascular resis- rSO2 decreased only after patients blocks were used in ambulatory
tance, a reduction in MAP, and were positioned in the BCP. Of note, shoulder surgery. Postoperative
greater reduction in cardiac output. Yadeau et al18 found that although hoarseness was more common with
Intraoperative hypotension may oc- hypotension was common when interscalene block than with supra-
cur in patients in the BCP under gen- shoulder arthroscopy was performed clavicular block. No significant dif-
eral anesthesia.14 with the patient in the BCP, occur- ference was found in postoperative
Hypotensive anesthesia is a com- ring in 75 of 99 patients, rSO2 desat- dyspnea between the two groups
mon and safe technique used to aid uration was uncommon when re- (7%, supraclavicular; 10%, intersca-
in visualization in both the LDP and gional anesthesia was used. This lene). Postoperative nerve symptoms
BCP.10 Potential advantages of intra- suggests that maintenance of cerebral were found in only 0.4% of patients,
operative hypotension include limit- blood flow may be better with re- and no patient had permanent nerve
ing blood loss and maintaining a gional anesthesia with the patient in injury. The authors imply that
clear view during arthroscopy. The the BCP. In a recent poll of members ultrasound-guided localization for
typical goal is to create a pressure of the American Shoulder and Elbow peripheral nerve blockade may be
difference of <49 mm Hg between Surgeons Society, however, the rate more accurate than use of a nerve
the patient’s systolic blood pressure of a cerebral vascular event in an es- stimulator, which has a reported inci-
and the pump pressure of the fluid in timated 173,370 to 209,628 cases dence of postoperative nerve symp-
the surgical space.15 This can be was reportedly <0.01% in both posi- toms of 11% to 14%.
achieved by either decreasing the sys- tions.19 Therefore, the clinical rele- More severe complications from
tolic blood pressure (ie, inducing hy- vance of this observed cerebral desat- interscalene blocks (eg, pneumotho-
potension), increasing the pump uration is unclear. rax or central nervous system toxic-
pressure, or both. However, increas- It has also been suggested that ce- ity) are much rarer.23 The reported
ing pump pressure can lead to exces- rebral desaturation events in the BCP rate of phrenic nerve blockade with
sive fluid extravasation into the sur- are more common with use of an an- an interscalene block is 100%, with
rounding soft tissues and thus can tihypertensive agent on the day of subsequent hemiparalysis of the dia-
shorten the effective surgical time surgery; however, the use of phragm and an almost 30% reduc-
secondary to difficulty in visualizing angiotensin-converting-enzyme in- tion in forced vital capacity and
the surgical area.15 hibitors and angiotensin receptor forced expiratory volume.24 These
Although there are known theoret- blockers might be acceptable.20 With blocks may not be appropriate in pa-
ical disadvantages of low blood pres- this in mind, counseling the patient tients with underlying pulmonary is-
sure, it is unclear what effect permis- on holding antihypertensives before sues.
sive intraoperative hypotension has surgery may be advisable. The use of Even with the aforementioned
on cerebral perfusion.14 Using near- sequential compression devices also risks, both patient positions are
infrared spectroscopy, Murphy et al16 may decrease the risk of cerebral hy- widely regarded to be safe. There-
compared cerebral oxygenation satu- potension in patients who are posi- fore, the optimal position for shoul-
ration (rSO2) in patients undergoing tioned in the BCP; as a result, these der arthroscopy is left to the discre-
shoulder arthroscopy in either the devices are recommended for this tion of the surgeon based on training
BCP or the LDP. They found that procedure.21 and clinical experience (Table 1).
80% of patients treated in the BCP The risk of intraoperative hypoten-
under general anesthesia had a desat- sive events underscores the need for
uration in rSO2 of ≥20%, compared effective communication with the an- Pertinent Shoulder
with zero percent in the LDP. Pa- esthesia team. Regional anesthesia Anatomy in Arthroscopy
tients who experienced a cerebral de- appears to be advantageous and pro-
saturation event also had a higher in- vides reliable postoperative pain con- Following sterile draping, the bony
cidence of postoperative nausea and trol. Newer techniques in peripheral landmarks are palpated and marked
vomiting, as well as associated intra- nerve blockade, including ultrasono- (Figure 2). The borders of the acro-
operative systemic desaturations. Us- graphic localization, have led to mion, clavicle, scapular spine, cora-
ing similar monitoring techniques in fewer reported postoperative compli- coid, coracoacromial ligament, and
patients undergoing shoulder ar- cations. In a series of 1,169 patients, acromioclavicular joint are marked,
throscopy in the BCP, Lee et al17 Liu et al22 reported 99.8% successful with the posterolateral edge of the
found that although MAPs decreased pain relief when ultrasound-guided acromion being easiest to palpate.
at all time points past induction, interscalene and supraclavicular Typically, the triangle made between

334 Journal of the American Academy of Orthopaedic Surgeons

 E. Scott Paxton, MD, et al

Table 1 Figure 2
The Beach-chair and Lateral Decubitus Positions for Arthroscopic
Shoulder Surgery: Advantages and Disadvantages
Lateral Decubitus Beach Chair

Advantages 1. Traction increases space in 1. Upright, anatomic position

joint and subacromial space 2. Ease of examination under
2. Traction accentuates labral anesthesia
tears 3. Arm not hanging in the way of
3. Operating room table/patient’s anterior portal
head not in the way of poste- 4. No need to reposition or re-
rior and superior shoulder drape to convert to open
4. Cautery bubbles move later- procedure
ally out of view 5. Can use regional anesthesia
5. No increased risk of hypoten- 6. Mobility of operative arm
sion/bradycardia; better cere-
bral perfusion
Disadvantages 1. Nonanatomic orientation 1. Potential mechanical blocks to
2. Must reach around arm for use of scope in posterior or
anterior portal superior portals
3. Must reposition and redrape 2. Increased risk of hypotension/
to convert to open procedure bradycardia causing cardiovas-
4. Patients do not tolerate re- cular complications
gional anesthesia 3. Cautery bubbles obscure view Intraoperative photograph of a
5. Traction can cause neurovas- in subacromial space prepped and draped shoulder
cular and soft tissue injury 4. Fluid can fog camera arthroscopy patient with important
6. Increased risk of injury to axil- 5. Theoretically increased risk of bony landmarks and portal
lary and musculocutaneous air embolus locations marked on the surgical
nerves when placing anteroin- 6. Expensive equipment if using shoulder. The 5 o’clock, 7 o’clock,
ferior portal beach chair attachment with or and anteroinferior portals are safely
without mechanical arm holder created using an inside-out
technique. A, acromion; B, clavicle;
Reproduced with permission from Peruto CM, Ciccotti MG, Cohen SB: Shoulder arthroscopy
C, coracoid process; D, scapular
positioning: Lateral decubitus versus beach chair. Arthroscopy 2009;25(8):891-896. spine; 1, posterior portal; 2, ante-
rior central portal; 3, anterolateral
portal; 4, posterolateral portal;
5, superolateral portal; 6, anterosu-
the posterolateral corner of the acro- coracoid and inferior to the lateral perior portal; 7, 7 o’clock portal;
mion, the anterolateral corner of the border of the subscapularis medial to 8, axillary pouch portal; 9, Neviaser
acromion, and the superior soft spot the musculotendinous junction (Fig- portal; 10, portal of Wilmington;
between the acromion and clavicle is ure 3). The nerve can be as close as 11, transrotator cuff portal. (Cour-
tesy of Matthew Smith, MD,
equilateral. The tip of the coracoid 3.1 cm from the leading edge of the St. Louis, MO, and Kathleen
generally lies in the center of a curve acromion with arm abduction at this McKeon, MD, St. Louis, MO.)
that is made by the anterior edge of point.26 Typically, the axillary nerve
the acromion and the concave curve then gives off two branches that sup-
of the anterior clavicle. The literature ply the inferior capsule. In a cadaver lary nerve travels posteriorly through
often reports the distance of neuro- study, Uno et al27 found that the axil- the quadrilateral space and gives off
vascular structures from these land- lary nerve is connected to the capsule a posterior and an anterior trunk.
marks; thus, identifying the borders with loose tissue between the 5 and 7 The posterior trunk has three termi-
of these structures is important to o’clock positions and lies close to the nations: the superolateral cutaneous
safe and accurate portal placement. glenoid in the neutral position, ex- branch, the posterior branch to the
The axillary nerve, cephalic vein, tension, and internal rotation. Ab- deltoid muscle, and the nerve to the
and suprascapular artery and nerve duction, external rotation, and trac- teres minor.28 The anterior trunk
are the structures most at risk during tion cause the capsule to distend and, travels around the humerus and sup-
shoulder arthroscopy.25 Knowledge thus, move the nerve away from the plies the three heads of the deltoid
of their locations and courses is im- joint, possibly making this position muscle26 (Figure 4). Traditionally,
portant to avoid traumatic injury safer during arthroscopic surgery in this anterior branch of the axillary
during portal placement. The axil- the anteroinferior joint. nerve was thought to be an average
lary nerve travels posterior to the After passing the capsule, the axil- of 5 to 7 cm distal to the lateral tip

June 2013, Vol 21, No 6 335

Shoulder Arthroscopy: Basic Principles of Positioning, Anesthesia, and Portal Anatomy

Figure 3 of the acromion.29 The nerve has also

been described as lying 3.5 cm distal
to the superior prominence of the
greater tuberosity,30 although a ca-
daver study revealed that this section
Suprascapular of the axillary nerve can be much
nerve
closer, especially in short females.26
Overall, the nerve has been reported
to be from 3 to 7 cm from the lateral
acromion depending on patient size
and arm length.26,31 Abducting the
arm brings the axillary nerve branch
even closer to the acromion; at 90°,
Axillary this distance is decreased by 30%.26
nerve
In the upper arm, the cephalic vein
travels in the superficial fascia of the
deltopectoral interval and extends
downward through the coracoclavic-
ular fascia to the axillary vein be-
neath the clavicle. It is at this delto-
pectoral interval that the vein is most
Illustration of the shoulder demonstrating the anterior course of the axillary at risk for injury during portal place-
and suprascapular nerves. ment, typically resulting in a superfi-
cial hematoma. An anatomic cadaver
Figure 4 study showed the cephalic vein to be
located <1 cm from anterior portals
Transverse in 25% of specimens.25
artery of scapula
Suprascapular Clavicle The suprascapular nerve (SSN)
nerve arises from the upper trunk of the
Supraspinatus Acromion
muscle brachial plexus, traveling through
the posterior triangle of the neck.
Deltoid The suprascapular artery runs with
muscle the nerve until it reaches the supra-
scapular notch. The nerve lies 3 cm
Scapular (range, 2.5 to 3.9 cm) medial to the
spine supraglenoid tubercle at the supra-
Posterior circumflex scapular notch.32 At this point, it
humeral artery travels underneath the transverse
Axillary nerve scapular ligament, with the artery
continuing above the transverse
scapular ligament outside the notch.
Transverse
artery of Within 1 cm of exiting the notch, the
scapula nerve gives its motor branch to the
supraspinatus. The nerve then fol-
Infraspinatus Teres minor lows an oblique course laterally to-
muscle
ward the base of the scapular spine.
Triceps brachii muscle
The nerve lies an average of 1.8 cm
(range, 1.4 to 2.5 cm) from the mid-
Illustration of the posterior view of a shoulder demonstrating the course of line of the posterior glenoid at the
the axillary nerve and its branches through the quadrilateral space and the base of the scapular spine. The nerve
course of the suprascapular nerve and artery after reaching the
suprascapular notch. then curves medially to innervate the
infraspinatus32 (Figures 4 and 5).

336 Journal of the American Academy of Orthopaedic Surgeons

 E. Scott Paxton, MD, et al

Figure 5
Common Portals
Typical portals used in arthroscopic
shoulder procedures are summarized
in Table 2.
A
Posterior B
The posterior portal is the first por- C
tal established in shoulder arthros-
copy. It enters the so-called soft spot
between the humeral head and the
glenoid, 2 to 3 cm inferior and 1 to 2
cm medial to the posterolateral acro-
mion.4 These dimensions vary, how-
ever, particularly by patient size. A
small stab incision is made vertically
and a trocar is introduced, aiming
toward the coracoid process as de-
scribed by Andrews et al.4 Usually,
the underlying humeral head and gle-
noid can be felt through the capsule, Illustration of the course of the suprascapular nerve along the posterior
allowing for correct placement of a scapula. In a cadaver study by Bigliani et al,32 line A, the distance from the
supraglenoid tubercle to the suprascapular notch, averaged 3.0 cm (range,
blunt trocar into the glenohumeral 2.5 to 3.9 cm); line B, the distance from the supraglenoid tubercle to the
joint. The arthroscope is inserted, base of the scapular spine, averaged 2.5 cm (range, 1.9 to 3.2 cm); and line
and a diagnostic examination is per- C, the distance from the midline posterior glenoid rim to the base of the
formed. scapular spine, averaged 1.8 cm (range, 1.4 to 2.5 cm).
The posterior portal is the safest
portal that provides adequate visual-
ization of the entire joint. Neverthe-
less, proper placement is essential to nique. Under direct visualization, a Anterolateral
avoid injury to the axillary nerve and spinal needle is inserted 1 to 2 cm in-
SSN. The posterior soft spot portal is The anterolateral portal is typically used
feromedial to the anterolateral acro-
located an average of 49 mm from to address acromioclavicular joint pa-
mion.33 Care must be taken to stay
the axillary nerve and 29 mm from thology and subacromial impingement.
lateral to the coracoid process to
the SSN, although the axillary nerve An incision is made in line with the an-
avoid the brachial plexus and the ax-
can be found as close as 30 mm.25 terior acromion and 2 to 3 cm distal to
illary vessels that are located infero-
Placing the portal too medial can the lateral edge.25,35 A blunt trocar is
medially. Under direct visualization,
place the SSN at risk of injury. Nev- inserted, aiming toward the under-
the needle is placed within the rota-
ertheless, portal placement can be tor interval, which is bordered by the surface of the acromion. A spinal
adjusted depending on the pathology glenoid medially, the supraspinatus needle can also be used under direct
being addressed. For example, plac- superiorly, the subscapularis inferi- visualization to provide a trajectory
ing the portal slightly higher is pre- orly, and the humeral head laterally. for the trocar. Care must be taken
ferred for arthroscopic rotator cuff The musculocutaneous nerve lies, on not to make the portal too inferior in
repair, whereas locating it slightly average, 33 ± 6.2 mm inferior to the order to avoid the axillary nerve,
lower and more lateral is better for tip of the coracoid,34 and the ce- which may be located as close as 3.1
labral repairs. phalic vein is also in the vicinity of cm distal to the anterolateral border
this portal. Too-inferior placement of the acromion.26 If this portal is
Anterior Central puts these structures at risk. The an- placed too superiorly, access to the
After creating a posterior portal, an terior central is an essential working medial acromion and the acromio-
anterior portal is created using either portal in almost all arthroscopic pro- clavicular joint can be hindered by
an outside-in or an inside-out tech- cedures.33 the acromion.

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Shoulder Arthroscopy: Basic Principles of Positioning, Anesthesia, and Portal Anatomy

Table 2
Portal Use by Procedure in Shoulder Arthroscopy
Portal

Anterior
Procedure Posterior Central Anterolateral Posterolateral 5 O’clock Anteroinferior

Rotator cuff repair Common Common Common Common — —

Subacromial decompres- Common — Common Common — —
sion
Anterior labral repair Common Common — — Common Common
IGHL repair Common Common — — Common Common
Multidirectional instability Common Common — — Rare Common
SLAP repair Common Common Rare Rare — —
Biceps tenodesis/tenotomy Common Common — — — —
Distal clavicle excision — Common Common Common — —
SSN release Common — Common Rare — —
Latarjet Common Common Common — Common Common
Irrigation and débridement Common Common — — — —

IGHL = inferior glenohumeral ligament, SLAP = superior labral anterior-posterior, SSN = suprascapular nerve

Posterolateral leading edge of the inferior glenohu- the cephalic vein. Nevertheless, Lo
The posterolateral portal, also de- meral ligament. The arthroscope is et al38 felt that this portal was safe
scribed by Ellman,35 was originally removed, and a switching stick is when placed using an outside-in
used as the viewing portal for arthro- placed in the cannula and pushed technique. Their patients were oper-
scopic subacromial decompressions through the capsule with the arm ated on in the LDP, and the
and acromioplasty. It is also helpful maximally adducted. With the aid of outside-in method allowed lateraliza-
as a viewing portal during rotator a scalpel, the portal exits lateral to tion of the portal placement. These
cuff repair and for visualization of the conjoint tendon through the risks should be considered when
labral repairs with patients in the lower aspect of the subscapularis. placing a low anterior portal for fix-
LDP. Establishing two lateral sub- Several authors have questioned ation of Bankart lesions.
acromial portals allows the surgeon the safety of this portal because it
both a viewing and a working portal places the axillary nerve, musculocu- Anteroinferior
when passing cuff repair sutures. Us- taneous nerve, cephalic vein, and hu- The anteroinferior portal described
ing an outside-in technique, this por- meral cartilage at risk for injury.25,37 by Wolf39 is used in anterior shoulder
tal is created 2 to 3 cm below the In a cadaver study, Pearsall et al37 capsulorrhaphy, typically combined
posterolateral edge of the acromion, noted that using an inside-out tech- with an anterosuperior portal. Using
aiming medial to the subacromial nique for portal placement resulted an inside-out technique, the arthro-
bursa.25,35 Excessive inferior place- in significant force on the humeral scope is inserted into the posterior
ment of the portal places the axillary articular cartilage, resulting in dam- portal and is slid off the inferolateral
nerve at risk of injury. age to the specimens. Use of an edge of the coracoid tip. A switching
outside-in technique demonstrated stick is then pushed through the an-
5 O’clock that the portal was located within 2 terior capsule just superior to the up-
The 5 o’clock portal is used for low mm of the cephalic vein. Meyer per border of the subscapularis ten-
anchor placement in anterior stabili- et al25 corroborated these results and don, and a scalpel is used to expose
zation procedures when managing concluded that use of the 5 o’clock the portal. The cephalic vein is most
Bankart lesions.36 Using an inside- portal was not advisable because it at risk in creating this portal, and the
out technique, the camera is driven was located an average of 13 mm axillary nerve can be injured adja-
from the posterior portal to the 5 from the axillary artery, 15 mm from cent to the inferior capsule. This por-
o’clock position of the glenoid at the the axillary nerve, and 17 mm from tal allows easier access and a better

338 Journal of the American Academy of Orthopaedic Surgeons

 E. Scott Paxton, MD, et al

Table 2 (continued)
Portal Use by Procedure in Shoulder Arthroscopy
Portal

Transrotator Portal of
Anterosuperior 7 O’clock Axillary Pouch Neviaser Cuff (Superior) Wilmington G Portal

Common — — Rare — — —
Common — — — — — —

Common — Rare — — — —
Common Common Common Rare — Common —
Common Common Rare — — — —
Rare — — Common Common Common —
— — — — — — —
— — — — — — —
Common — — — — — Common
— — — — — — —
— — — — — — —

IGHL = inferior glenohumeral ligament, SLAP = superior labral anterior-posterior, SSN = suprascapular nerve

angle to the glenoid neck and infe- Posteroinferior Axillary Pouch

rior glenoid. (ie, 7 O’clock) Portal The axillary pouch portal was de-
The posteroinferior (ie, 7 o’clock) scribed as a safer alternative to the
Anterosuperior portal can be created inside-out or posteroinferior portal for accessing
For procedures involving the ante- outside-in to address loose body re- the inferior glenohumeral recess for
rior capsule, the anterosuperior and moval and posteroinferior labral fix- removal of loose bodies, synovec-
anteroinferior portals are best for vi- ation.42 The inside-out technique in- tomy, anchor placement on the pos-
sualization, and their use permits teroinferior glenoid rim, and anchor
volves placing a switching stick
surgical triangulation in the anterior
through an anterior portal to the 7 placement on the humerus in repair-
glenohumeral joint.39 The anterosu-
o’clock position on the glenoid. This ing humeral avulsion of the glenohu-
perior portal is created using an
stick is then pushed through the cap- meral ligament lesions.43 This portal
outside-in technique starting at the
sule, and a skin incision is made. The is developed using an outside-in tech-
mid distance between the coracoid
outside-in technique involves making nique beginning 2 to 3 cm inferior to
and the acromion. The trocar is di-
a skin incision 2 to 3 cm inferior to the posterolateral acromion and 2
rected just anterior to the long head
of the biceps tendon into the joint. the posterior viewing portal and in- cm lateral to the posterior viewing
More lateral placement (ie, supero- serting a cannula to the 7 o’clock po- portal. The spinal need is angulated
lateral portal) can allow work in the sition under direct visualization. This medially and inferior into the joint.
anterior glenohumeral joint as well portal can also be used exclusively as The axillary nerve is thought to be
as in the subacromial space (ie, for a percutaneous portal to avoid both farther away from this portal than
SSN release).40,41 Although the ce- overcrowding with cannulae and from the 7 o’clock portal.43
phalic vein and axillary nerve are at neurovascular injury. The structures
risk of injury via this portal, such in- at risk are the suprascapular nerve Neviaser
jury is less likely than with the an- and artery, the axillary nerve, and The Neviaser portal is convenient for
teroinferior portal. The anterosupe- the posterior circumflex humeral ar- suture fixation during SLAP repair,44
rior portal also provides a good tery. In a cadaver study, the portal and it provides excellent arthro-
angle for anchor placement on the was found to be a mean distance of scopic visualization of the anterior
anterosuperior glenoid during supe- 39 ± 4 mm from the circumflex ar- glenoid. The portal is created superi-
rior labral anterior-posterior (SLAP) tery and 29 ± 3 mm from the axillary orly in the soft spot between the
repair. nerve and SSN.42 clavicle, acromion, and scapular

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Shoulder Arthroscopy: Basic Principles of Positioning, Anesthesia, and Portal Anatomy

spine. A needle is placed from this is approximately 2 cm medial to the ization by increasing the effect and
location laterally and anteriorly Neviaser portal.” The SSN portal is subsequent rate of bleeding.
through the capsule. In SLAP repairs, created under direct visualization via Electrocautery is often advanta-
the needle can be placed under the an outside-in technique. A spinal geous in controlling bleeding, but
biceps anchor. It can also be useful needle is placed through the trape- this instrument must be used judi-
for securing a supraspinatus tear by zius muscle directly above the medial ciously with short bursts and lower
passing a penetrating curved suture- aspect of the coracoclavicular liga- settings to control fluid temperature.
passing device through the cuff medi- ments, aiming toward the anterior Increased intra-articular fluid tem-
ally. The suprascapular nerve and ar- border of the supraspinatus muscle. perature has been proposed as a po-
tery are only 3 cm from the The structures most at risk with this tential cause of chondrolysis;50 how-
portal are the SSN within the supra- ever, the exact mechanism and
supraglenoid tubercle32 and are at
scapular notch and the suprascapu- incidence of this phenomenon are
risk when using the Neviaser portal.
lar artery above the transverse scapu- poorly understood. Fluid tempera-
lar ligament. ture is also important in maintaining
Transrotator Cuff Options
patient body temperature during ar-
The most notable of the transrotator throscopy. In a randomized con-
cuff portals, the portal of Wilmington, trolled trial of 50 patients undergo-
Ensuring Adequate
was originally described by Morgan ing shoulder arthroscopy, patients
Visualization
et al45 for use during SLAP repair. who received room-temperature irri-
The portal is made 1 cm anterior and Bleeding is a constant challenge in gation fluid had a significant de-
1 cm lateral to the posterolateral arthroscopic visualization of shoul- crease in body temperature com-
edge of the acromion, piercing the der pathology, but several methods pared with patients who had fluid
rotator cuff medial to the musculo- and tools have been developed to op- warmed to body temperature.51 Of
tendinous junction and entering the timize visualization. Controlling patients who had room-temperature
shoulder at a vector aimed toward blood pressure in combination with fluid, 91.3% experienced hypother-
the coracoid tip, allowing anchors to intra-articular fluid pressure is a mia, compared with 17.4% of pa-
be placed at a 45° angle to the gle- common method to increase visual- tients who received warmed fluid (P
noid surface. Similar transrotator ization. Pump systems are generally < 0.001).
cuff portals have been described with preferred to gravity because with a The use of epinephrine in the irri-
slight variations.46 Controversy exists pump system the surgeon can control gation fluid has been reported to
regarding the use of a cannula in the the intra-articular pressure. Pressures greatly improve visualization. In a
portal of Wilmington. Stephenson are typically set between 35 and 75 randomized, double-blind, placebo-
et al47 published a case series of six mm Hg depending on the amount of controlled trial, use of 0.33 mg/L of
patients who had rotator cuff tears bleeding and duration of the proce- epinephrine significantly improved
following SLAP repair using a trans- dure. Increasing pressure usually im- visualization compared with normal
rotator cuff portal. They concluded proves visualization by creating a saline alone (P = 0.0007).52 No ad-
that care must be taken to make the tamponade effect on bleeding vessels. verse cardiac events were identified.
portal medial to the muscle-tendon Pumps that control both pressure However, these results were based on
junction. As with all lateral portals, and flow rate are favored because a visual analog scale of clarity com-
inferior placement puts the axillary they are believed to result in im- pleted by the surgeon, and its use is
nerve at risk of injury. proved visualization, shorter surgical still debated given potential cardiac
time, and lesser amounts of fluid risks.
Suprascapular Nerve used.48 In addition, the amount of In addition to facilitating adequate
The SSN portal (ie, G portal) is a fluid turbulence is important in en- bleeding control, use of the 70° ar-
specialized portal used to cut the su- suring adequate visualization. With throscope has been advocated to in-
perior transverse scapular ligament multiple portals, fluid may escape crease visualization53 (Table 3). The
during arthroscopic SSN decompres- from an unoccupied portal. As de- 70° scope can be particularly useful
sion. Lafosse et al41 described this scribed by Burkhart et al,49 this es- for shoulder stabilization, distal clav-
portal position between the clavicle caping fluid causes a Bernoulli effect icle resection, acromioclavicular
and the scapular spine, “approxi- that encourages bleeding of injured joint reconstruction, rotator cuff re-
mately 7 cm medial to the lateral vessels. Increasing the pump pressure pair (especially subscapularis repair),
border of the acromion. This portal in this situation only worsens visual- and subdeltoid arthroscopy.

340 Journal of the American Academy of Orthopaedic Surgeons

 E. Scott Paxton, MD, et al

cuff repair: The pros and cons. Instr

Table 3 Course Lect 2003;52:81-92.
Applications for the 70° Arthroscope in Shoulder Procedures 2. Bishop JY, Sprague M, Gelber J, et al:
Procedure Advantages of the 70° Arthroscope Interscalene regional anesthesia for
shoulder surgery. J Bone Joint Surg Am
Anterior glenohumeral stabiliza-Provides superior visualization of a medically dis- 2005;87(5):974-979.
tion placed anterior labroligamentous periosteal sleeve 3. Marecek GS, Saltzman MD:
avulsion lesion from the posterior portal Complications in shoulder arthroscopy.
Allows full mobilization of the capsulolabral complex Orthopedics 2010;33(7):492-497.
without the instrument crowding that occurs with
the camera and working instruments in dual ante- 4. Andrews JR, Carson WG Jr, Ortega K:
rior portals Arthroscopy of the shoulder: Technique
and normal anatomy. Am J Sports Med
Distal clavicle excision Provides an excellent view of the entire acromiocla- 1984;12(1):1-7.
vicular joint and distal clavicle from a posterior
portal, often obviating the need to shift the camera 5. Skyhar MJ, Altchek DW, Warren RF,
to an anterolateral or anterior position to confirm Wickiewicz TL, O’Brien SJ: Shoulder
adequate resection arthroscopy with the patient in the
beach-chair position. Arthroscopy 1988;
Coracoclavicular ligament Allows for visualization of the coracoid process from 4(4):256-259.
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arthroscopy: A modified approach.
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Arthroscopy 1985;1(3):156-159.
risk of instrument crowding
Rotator cuff repair Particularly useful for subscapularis and leading- 7. Klein AH, France JC, Mutschler TA, Fu
FH: Measurement of brachial plexus
edge supraspinatus tears. The entire tear pattern
strain in arthroscopy of the shoulder.
can be visualized from the posterior portal, allow- Arthroscopy 1987;3(1):45-52.
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agement through anterolateral and anterior portals 8. Peruto CM, Ciccotti MG, Cohen SB:
Shoulder arthroscopy positioning:
Subdeltoid shoulder arthroscopy Has evolved to become a useful tool in this com- Lateral decubitus versus beach chair.
partment for arthroscopic biceps tenodesis or Arthroscopy 2009;25(8):891-896.
transfer procedures, proximal humeral fracture fix-
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on tissue perfusion measured by pulse
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Pathomechanisms and complications
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Arthroscopy 2011;27(4):532-541.
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JC: A comparison of risk between the
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Shoulder Arthroscopy: Basic Principles of Positioning, Anesthesia, and Portal Anatomy

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342 Journal of the American Academy of Orthopaedic Surgeons