肩关节镜基础
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北京积水潭医院运动医学中心
z
z
Rotator cable
thickening of the capsle that extends from the biceps to the insertion of the infraspinatus.
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
z
北京积水潭医院运动医学中心
z
adequate padding perioperative antibiotics lower pump pressures to avoid excessive tissue distension Position…
z
z
z
北京积水潭医院运动医学中心
Position
北京积水潭医院运动医学中心
Hill-Sachs
Bony Bankart – “reverse peal”
北京积水潭医院运动医学中心
SUPERIOR LABRUM
SLAP Bicep
北京积水潭医院运动医学中心
Superior Labral Anterior to Posterior Lesion
BT RI HH
GL G
MGHL SSc
z
北京积水潭医院运动医学中心
CHL
z
Insertion -- 75% insertion into the rotator interval; 25% to the supraspinatus tendon Function -- limitation of external rotation in the adducted arm and restraint against inferior translation
北京积水潭医院运动医学中心
Supraspinatus Muscle
z
originates from the suprascapular fossa and inserts along the greater tuberosity of the humerus
z
It receives its innervation from the suprascapular nerve
Rotator interval
z
a triangular area that is made up of fibrous elements and bordered by the upper margin of the subscapularis tendon and anterior aspect of the supraspinatus. Within the interval lie the CHL(superficially ), the biceps tendon, and the SGHL (internal pulley at the floor)
Usually the first portal
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Anterior portal
3 1 2
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
3
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Summery
z
The one who want to do his work well must first sharpen his tools !
“工欲善其事，必先利其器”
Then… Only…
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
MGHL
originates from the glenoid labrum below the SGHL and inserts just medial to the lesser tuberosity It often crosses and blends into the subscapularis tendon present in only 85% of shoulders
北京积水潭医院运动医学中心
z
Beach Chair
Disadvantage
z
the assistant will be occupied applying traction access to the axillary pouch and the posterior recess is difficult potential for fogging of the arthroscopic lens
北京积水潭医院运动医学中心
SSc
北京积水潭医院运动医学中心
The Infraspinatus and Teres Minor Muscles
•They take origin from the infraspinatus fossa and dorsolateral border of the scapula, respectively, and insert onto the greater tuberosity of the humerus •The suprascapular nerve innervates the infraspinatus, and the axillary nerve supplies the teres minor. •These muscles externally rotate the humerus and stabilize the G-H in concert with the SP &SSc
北京积水潭医院运动医学中心
Procedure
北京积水潭医院运动医学中心
ARTICULAR SURFACES
• humeral head: -- smooth and ovoid -- bare area -- Hill-Sachs • glenoid: -- thin cartilage at the center -- Bankart
“upright, anatomic”
the patient is flexed 60° at the waist
北京积水潭医院运动医学中心
BEACH-CHAIR
Beach Chair
Advantage
z z z z
similar to open surgery, minimizes spatial disorientation conversion to open surgery is easier patients tolerate the sitting position better performing arthroscopy solely under the interscalene block without any supplemental sedation lower incidence of nerve palsy
z
z
北京积水潭医院运动医学中心
Choice
z
Beach chair: -- RCT -- subacromial space
z
Lateral decubitus: -- shoulder instability -- SLAP
北京积水潭医院运动医学中心
Portal
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
SUBACROMIAL SPACE
z z z z z z
Acromion Coracoacromial (CA) ligament Deltoid Subacromial impingement Bursal sided of rotator cuff AC joint
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Shoulder Arthroscopy
-- Basic Course
鲁谊 Luyi_orthop@hotmail.com
北京积水潭医院运动医学中心
Anatomy
北京积水潭医院运动医学中心
Set up
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
ANESTHESIA
z
A brachial plexus block is often utilized in conjunction with general endotracheal anesthesia Hypotensive anesthesia ! PCA post op 2-4 day
z
contributes to glenohumeral compression during active shoulder motion and assists the deltoid in effecting humeral abduction
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
SGHL
z
the primary restraint to inferior translation of the humeral head in adduction and medial translation of the biceps tendon originates from the supraglenoid tubercle and inserts just superior to the lesser tuberosity present in approximately 94% to 100% of shoulders
• Arm is abducted 60°and forward flexed 15° • Traction never exceeded 3 kg
LATERAL DECUBITUS
北京积水潭医院运动医学中心
Lateral Decubitus
Advantage
z
Access to the anterior, posterior, superior, and inferior labrum is easier Visibility is improved when performing multidirectional instability, SLAP, or Bankart injury Decreased risk of cerebrovascular ischemic event during intraoperative hypotension
z
z
北京积水潭医院运动医学中心
Lateral Decubitus
Disadvantage
z
Difficult while converting to an open approach Overstretching involved in neuropraxias
z
北京积水潭医院运动医学中心
Position
百度文库
INFERIOR STRUCTURES
z
IGHL -- AIGHL ( 2 to 4 o’clock position ) -- PIGHL ( 7 to 9 o’clock position ) -- axillary pouch ( MDI / Frozen shoulder )
z
Bankart ALPSA：anterior ligamentous periosteal sleeve avulsion HAGL： humeral avulsion of glenohumeral ligament
北京积水潭医院运动医学中心
Type Ⅰ
Type Ⅱ
Type Ⅲ
Type Ⅳ
北京积水潭医院运动医学中心
ANTERIOR STRUCTURES
z z z z z z
CHL SGHL MGHL SSc Rotator interval Articular side of Rotator cuff
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
z
北京积水潭医院运动医学中心
HAGL – humeral avulsion of glenohumeral ligament
北京积水潭医院运动医学中心
POSTERIOR STRUCTURES
Kim’s lesion Posterior Bankart tear
北京积水潭医院运动医学中心
z
z
Rotator cable
thickening of the capsle that extends from the biceps to the insertion of the infraspinatus.
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
z
北京积水潭医院运动医学中心
z
adequate padding perioperative antibiotics lower pump pressures to avoid excessive tissue distension Position…
z
z
z
北京积水潭医院运动医学中心
Position
北京积水潭医院运动医学中心
Hill-Sachs
Bony Bankart – “reverse peal”
北京积水潭医院运动医学中心
SUPERIOR LABRUM
SLAP Bicep
北京积水潭医院运动医学中心
Superior Labral Anterior to Posterior Lesion
BT RI HH
GL G
MGHL SSc
z
北京积水潭医院运动医学中心
CHL
z
Insertion -- 75% insertion into the rotator interval; 25% to the supraspinatus tendon Function -- limitation of external rotation in the adducted arm and restraint against inferior translation
北京积水潭医院运动医学中心
Supraspinatus Muscle
z
originates from the suprascapular fossa and inserts along the greater tuberosity of the humerus
z
It receives its innervation from the suprascapular nerve
Rotator interval
z
a triangular area that is made up of fibrous elements and bordered by the upper margin of the subscapularis tendon and anterior aspect of the supraspinatus. Within the interval lie the CHL(superficially ), the biceps tendon, and the SGHL (internal pulley at the floor)
Usually the first portal
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Anterior portal
3 1 2
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
3
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Summery
z
The one who want to do his work well must first sharpen his tools !
“工欲善其事，必先利其器”
Then… Only…
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
MGHL
originates from the glenoid labrum below the SGHL and inserts just medial to the lesser tuberosity It often crosses and blends into the subscapularis tendon present in only 85% of shoulders
北京积水潭医院运动医学中心
z
Beach Chair
Disadvantage
z
the assistant will be occupied applying traction access to the axillary pouch and the posterior recess is difficult potential for fogging of the arthroscopic lens
北京积水潭医院运动医学中心
SSc
北京积水潭医院运动医学中心
The Infraspinatus and Teres Minor Muscles
•They take origin from the infraspinatus fossa and dorsolateral border of the scapula, respectively, and insert onto the greater tuberosity of the humerus •The suprascapular nerve innervates the infraspinatus, and the axillary nerve supplies the teres minor. •These muscles externally rotate the humerus and stabilize the G-H in concert with the SP &SSc
北京积水潭医院运动医学中心
Procedure
北京积水潭医院运动医学中心
ARTICULAR SURFACES
• humeral head: -- smooth and ovoid -- bare area -- Hill-Sachs • glenoid: -- thin cartilage at the center -- Bankart
“upright, anatomic”
the patient is flexed 60° at the waist
北京积水潭医院运动医学中心
BEACH-CHAIR
Beach Chair
Advantage
z z z z
similar to open surgery, minimizes spatial disorientation conversion to open surgery is easier patients tolerate the sitting position better performing arthroscopy solely under the interscalene block without any supplemental sedation lower incidence of nerve palsy
z
z
北京积水潭医院运动医学中心
Choice
z
Beach chair: -- RCT -- subacromial space
z
Lateral decubitus: -- shoulder instability -- SLAP
北京积水潭医院运动医学中心
Portal
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
SUBACROMIAL SPACE
z z z z z z
Acromion Coracoacromial (CA) ligament Deltoid Subacromial impingement Bursal sided of rotator cuff AC joint
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
Shoulder Arthroscopy
-- Basic Course
鲁谊 Luyi_orthop@hotmail.com
北京积水潭医院运动医学中心
Anatomy
北京积水潭医院运动医学中心
Set up
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
ANESTHESIA
z
A brachial plexus block is often utilized in conjunction with general endotracheal anesthesia Hypotensive anesthesia ! PCA post op 2-4 day
z
contributes to glenohumeral compression during active shoulder motion and assists the deltoid in effecting humeral abduction
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
SGHL
z
the primary restraint to inferior translation of the humeral head in adduction and medial translation of the biceps tendon originates from the supraglenoid tubercle and inserts just superior to the lesser tuberosity present in approximately 94% to 100% of shoulders
• Arm is abducted 60°and forward flexed 15° • Traction never exceeded 3 kg
LATERAL DECUBITUS
北京积水潭医院运动医学中心
Lateral Decubitus
Advantage
z
Access to the anterior, posterior, superior, and inferior labrum is easier Visibility is improved when performing multidirectional instability, SLAP, or Bankart injury Decreased risk of cerebrovascular ischemic event during intraoperative hypotension
z
z
北京积水潭医院运动医学中心
Lateral Decubitus
Disadvantage
z
Difficult while converting to an open approach Overstretching involved in neuropraxias
z
北京积水潭医院运动医学中心
Position
百度文库
INFERIOR STRUCTURES
z
IGHL -- AIGHL ( 2 to 4 o’clock position ) -- PIGHL ( 7 to 9 o’clock position ) -- axillary pouch ( MDI / Frozen shoulder )
z
Bankart ALPSA：anterior ligamentous periosteal sleeve avulsion HAGL： humeral avulsion of glenohumeral ligament
北京积水潭医院运动医学中心
Type Ⅰ
Type Ⅱ
Type Ⅲ
Type Ⅳ
北京积水潭医院运动医学中心
ANTERIOR STRUCTURES
z z z z z z
CHL SGHL MGHL SSc Rotator interval Articular side of Rotator cuff
北京积水潭医院运动医学中心
北京积水潭医院运动医学中心
z
z
北京积水潭医院运动医学中心
HAGL – humeral avulsion of glenohumeral ligament
北京积水潭医院运动医学中心
POSTERIOR STRUCTURES
Kim’s lesion Posterior Bankart tear
北京积水潭医院运动医学中心