The applications of robotic surgery have quickly spread into a variety of surgical fields. Interest in robotic endoscopic surgery is high because of the small size of the incisions, cosmetic advantages, less invasive surgical techniques, decreased scar tissue, shorter duration of hospitalization and increased cost-effectiveness. We will describe an anatomical feasibility study and a clinical test case of robotically assisted pedicled transposition of the latissimus dorsi muscle.
Thoracic outlet syndrome(TOS) is a debilitating condition, impairing the function of the upper limb, and can be considered as an entrapment of neurovascular structures dedicated to the upper limb. Its open treatment uses large approaches and to this date just structures under the clavicle have been endoscopically approached.
The purpose of this technical note is to describe an endoscopic all brachial plexus decompression of at all possible entrapment areas, between the neck and the arm.
Thoracic Outlet Syndromes(TOS) is a debilitating condition, impairing the function of the upper limb, and can be considered as an entrapment of neurovascular structures dedicated to the upper limb1,2.
The entrapment can be situated at different levels, between the neck and the arm, including the interscalenic triangle, the upper border of the first rib (by the rib itselt or a hypertrophic transverse cervical process with or without fibrous bands) the costo clavicular space, the retro coracoid, pectoralis minor and the penetration point of the neurovascular bundle at the level of the brachialis fascia1. The exact location of the entrapment can be difficult to access as well as the etiology of the compression and the structures involved like brachial plexus, subclavicular vein and artery.
The TOS pathophysiology is multifactorial, including anatomical variations, cervical rib, fibrous bands, anomalous muscles, joint hypermobility, or biomechanical dysfunctions of the neck and scapular girdle related to labor, post-traumatic or sports gesture3. On this scenario the bony compression by a narrowing space between the clavicle and the first rib or a cervical rib, that was previously considered the main entrapment cause, will be responsible for just 20-30% of the cases1,2.
TOS diagnosis remains difficult and controversial. No consensus have been reached to establish objective criteria proving the diagnose of TOS. Indeed it is mainly dynamic compression, therefore dynamic assessments seem to be more adapted, eventhough these assessments may be difficult or even present high rates of false negative results4.
Among the TOS types, the most common is the neurogenic(nTOS) one. Some of the clinical characteristics of the nTOS are pain, paraesthesia and weakness4.
The pain is usually neuropathic, affecting the posterior cervical area, trapezius and pectoral regions. It may also be felt on the entire upper limb. Weakness may also be described by these patients 1,4,5.Reports of pain, weakness and paraesthesia associated with irritative maneuvers will strongly suggest the nTOS diagnosis4,6.
Complementary exams can be used, mainly to exclude other diagnoses (i.e roots compression at the cervical spine, peripheral nerve tumors, distal entrapment syndromes). One of the main situation that would suggest nTOS is the dynamic arterial subclavian duplex velocity assessment. This assessment compares the differences between the arterial subclavian flux in rest and during the stress maneuvers. The proximity between the brachial plexus and subclavian artery can provides one with an indirect suggest a brachial plexus entrapment6-8. It can be useful even in patients with no vascular apparent compromise. Trained radiologists are also able to evaluate this entrapment by analysing the amont of fat tissue around the brachial plexus, and comparing its size between the resting and abduction and external rotation of the shoulder
The classical treatment for these patients is conservative6,7, consisting on pharmacological measures, shoulder girdle rehabilitation and ergonomic readjustment for working or exercising1,7.
Surgery is indicated in cases refractory to the conservative treatment, after a long period of rehabilitation8. Surgical techniques should be directed to the structures that cause this entrapment. The most common procedures mention the resection of the cervical rib, scalenectomy and release of the pectoralis minor tendon next to the coracoid7-10.
Endoscopic soft tissue decompression of the brachial plexus has been performed initially in cadaveric models11. In vivo to this moment only subclavicular decompression of the brachial plexus was performed. The suprascapular space had been released so far through the trans trapezial portals, starting from a release of the suprascapular nerve, and moving proximaly to the interscalenic area, without performing any scalenectomy, nor exposing the phrenic, long thoracic and dorsal scapular nerves4.
The purpose of this technical note is to describe an endoscopic brachial plexus decompression on suffering from nTOS at all possible entrapment areas, between the neck and the arm.
The procedure is performed in lateral decubitus under general anesthesia associated with interscalene plexus block. The upper limb – is set up with a traction allowing a positionning of the shoulder in anterior elevation, and slight abduction of respectively 30° and 15°.
A standard bipolar radiofrequency was used, VAPR®(DePuy Synthes, Raynham, USA). Saline infusion is used, just by gravity through 4-way equipment with no pump.
The first step is the insertion of the video scope through the posterior portal for joint and subacromial space evaluation. In the bursal space, the lateral portal is done, followed by bursectomy. The coracoacromial ligament is identified and removed. The optic passes to the lateral portal, coracoid process and pectoralis minor tendon is identified. An anterioinferior portal is done in the axillary line, about 2 cm below the coracoid lateral to the conjoint tendon is done with the help of a needle under visualization control.
The coracoid is exposed using radiofrequency device through the anterioinferior portal, dissecting the space posterior to the pectoralis major, progressively moving medially until the pectoralis minor insertion can be visualized and released. The upper part of the pectoralis minor is exposed, along with the cords of the brachial plexus coming from a lateral and medial areas. Under visualization control, the medial portal is made, 5 cm medial to the anterioinferior portal. The optic is moved to the anterioinferior portal(Fig. 1), then the radiofrequency device is inserted through the medial portal and is used to detach the pectoralis minor tendon, allowing the visualization of the terminal branch of the musculocutaneous nerve and the neurovascular bundle.
At this step, three structures are visualized going from the brachial plexus towards the deltoid muscle: lateral pectoralis nerve, thoracoacromial artery branch and cephalic vein. If fibroses or adhesions are found they can be released in this region.
The costoclavicular space is then reached. Using the lateral pectoralis nerve as a landmark, the plane between the brachial plexus and the subclavian muscle is identified. Anatomical variations of the subclavian muscle or the presence of the pectoralis minimus muscle may entrap the plexus in this area. Radiofrequency myotomy of the subclavius muscle can be performed until the clavicle is reached(Fig. 2). Using the soft tissue shaver(Razek, São Carlos, Brazil) with no aspiration will increase muscle resection and increase the cervical space view. In some selected cases (distance between the plexus clavicle less than 1 cm), partial resection of the clavicle may also be performed by using a bony shaver.
Through this same portal, the optics advances proximally to the cervical region between the plexus and the clavicle. Using a blunt dissector, the first cervical portal is done, just above the clavicle, supraclavicular portal, over the brachial plexus (Fig. 3). A particular attention to the transverse cervical vessels, which are left in a more superficial plane is needed. Optic can be inserted through the medial portal and devices through the supracavicular portal. Identification of the upper plexus trunk, and emergence of the suprascapular nerve(Fig. 4) raising laterally and posteriorly towards the coracoid notch is done. At this anatomical location the suprascapular artery can cross the plexus over the upper trunk or between the upper and middle trunk. More inferiorly the dorsal scapular artery can be found at the level of the midle trunk.
Adhesions and/or a thickened fascia can be visualized between the scalene muscles and the brachial plexus. This fascia must be released, allowing visualization of the scalene muscles. Then suprascapular nerve neurolysis can also be performed at this point.
The cervical portal is made about 2.5 cm from the supraclavicular portal. and the radiofrequency device is inserted and used to increase the space around the entry point. Distance parameters may vary, but as usual, the portal is created under
vizualisation control, with the aim to create access between the middle and anterior scalenes. The optics is moved to the supraclavicular portal. The release of the sheath to the scalene hiatus is continued using radiofrequency through the cervical portal(Fig. 5). Regarding the phrenic nerve which course is on the anterior border of the anterior scalene muscle, it is not easy nor necessary to visualize this nerve by endoscopy, however if visualized it needs to be protected. The middle scalene is dissected(Fig. 6) and one can identifies the dorsal scapular nerve and/or the long thoracic nerve. They actually have a very similar origin, but their directions are different, the dorsal scapular nerve goes posteriorly and medially and the long thoracic nerve goes inferiorly, more anterior and above the first rib.
These nerves usually present an intramuscular path, the middle scalene myotomy can be done by direct visualization in order to release them. One can use the nerve stimulator in order to better understand which nerve is going to be released.
Subclavian artery can be visualized after the complete release of the anterior and middle scalenus muscles(Fig. 7)(Film. 1). Portals developed to this technique are as in the Fig. 8.
Thereafter revision of hemostasis and additional scalene myotomies may be performed with radiofrequency. A needle is positioned between the 2 cervical portals for infiltration of a betametasone, tramadol, tranexamic acid and magnesium sulfate solution.
The extubation requires additional care because sometimes infused fluid can compress the airways.
For neuropathic analgesia, drugs are administered according to the patient’s needs, including pregabalin, nortriptyline, vitamin C, prednisone, opioids and anti-inflammatory drugs. Ten days after surgery, the stitches are removed and the patient is able to remove the sling.
Tips and Tricks are in Table. 1, comparison with open surgery in Table. 2.
Endoscopic release of the brachial plexus as suggested in this technical note offers advantages compared to an open technique or to previoulsy described endoscopic techniques. It provides indeed a better visualization of the neurologic structures with magnification thanks to the arthroscope, almost equivalent to a microsope. It allows a three-level release, i.e. supraclavicular, retroclavicular in the costoclavicular outlet, and infraclavicular. It allows multiple level release without multiple approaches as required in case of an open scalenectomy and pectoralis minor tenotomy11, and thus less scar tissue formation since minimally invasive.
Endoscopic techniques have been described before4 however they mainly managed retro clavicular and infra clavicular decompression. The supraclavicular decompression was addressed in those techniques though a different approach starting from the subacromial space, reaching the suprascapular nerve and the interscalenic area, up to the upper trunk, managing a local fibrous band section, and a neurolysis, but lacking two main aspects which are capital to the Thoracic outlet syndrome management: Scalenectomy, and exposition of the middle and inferior trunks. As described in the previous articles4,12 safe approach of the middle and inferior trunks, and correct exposition of the subclavicular artery, phrenic, long thoracic, and dorsal scapular nerves was not achievable. Meanwhile, Garcia et al11, had described in 2012 an anatomical exposition of the previously cited structures, using a different technique and mainly a different surgical strategy. The procedure presented on this technical note has showed an improvement on the clinical scores which was greater than the previously published series4[JCGJ1] . It seems obvious that the release addressed on this technical note is more exhaustive, but the thorough release of the whole brachial plexus affords better clinical results. The main difference and benefit brought by this technique is the ability to perform a scalenectomy. The scalene muscles are clearly identified as compressors in this pathology. Scalenectomy is indeed a mandatory step of the open surgical procedure13.
However, limitations can be raised. The first and most obvious one, is the importance of the learning curve. The interscalenic area is an anatomical region which must be well known before adventuring oneself around it endoscopically. Before performing the scalenectomy, the nerves and vessels around must be identified and preserved. When a doubt regarding the identification of those structures exists, the surgeon should never hesitate to convert to an open approach. It is therefore a technique that must be managed by surgeons trained into brachial plexus and peripheral nerve surgery.
The area is also sensible to pressure variation. Indeed a balance between low blood pressure, and high inflow pressure must be reached. The surgeon needs perfect bleeding management in order to obtain good visualization, and anesthesiologists must manage the blood and water inflow pressure in order to prevent neurological complications. Indeed, compressions can occur to the pneumogastric nerve, the carotid body but also to the spinal chord.
Overall, this technique is clearly bringing many advantages to the management of neurogenic thoracic outlet syndromes, and we recommend that it becomes the reference technique compared to open techniques or previously described endoscopic techniques14. However, we acknowledge that it must be limited to neurogenic cases, and to cases where no anatomical variations or modifications3 is identified. It should not be applied to cases where symptomatic vascular compression occurs, and it is not a technique enabling first rib resection. As a matter of fact, we have not studied yet proved that the results obtained with neurogenic syndromes are applicable to vascular syndromes. At last, anatomical knowledge of the area by the surgeon, and ability to work in the region in open surgery as well as anesthesiology cooperation is mandatory.
Illig K, Donahue D, Duncan A, Freischlag J, Gelabert H, Johansen K, et al. Reporting standards of the society for vascular surgery for thoracic outlet syndrome. J Vasc Surg. 2016;64(3):e23-35.
Levine N, Rigby B. Thoracic outlet syndrome: biomechanical and exercise considerations. Healthcare. 2018; 6(2). piiE68.
Ferrante M, Ferrante N. The thoracic outlet syndromes: part 1. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 55(6):782-93.
Lafosse T, Hanneur M, Lafosse L. All-endoscopic brachial plexus complete neurolysis for idiopathic neurogenic thoracic outlet syndrome: surgical technique. Arthrosc Tech. 2017;6(4):e967-71.
Kuhn J, Lebus G, Bible J. Thoracic outlet syndrome. J Am Acad Orth Surg. 2015; 23(4):222-32.
Doneddu P, Coraci D, De Franco P, Paolasso I, Caliandro P, Padua L. Thoracic outlet syndrome: wide literature for few cases. Status of the art. Neurol Sci. 2016;38(3):383-8.
Chang DC, Rotellini-coltvet LA, Mukherjee D, De Leon R, Freischlag LA. Surgical intervention for thoracic outlet syndrome improves patient’s quality of life. J Vasc Surg. 2009;49(3):630–5
Soukiasian H, Shouhed D, Serna-Gallgos D, Mckenna R, Bairamian B, mckenna r. A video-assisted thoracoscopic approach to transaxillary first rib resection. Innovations (Phila). 2015; 10(1):21-6.
Balderman J, Holzem K, Field B, Bottros M, Abuirqeba A, Vemuri C et al. Associations between clinical diagnostic criteria and pretreatment patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2017; 66(2):533-44.e.
Garcia JC, Mantovani G, Livernaux P. Brachial plexus endoscopy: feasibility study on cadavers. Chir Main. 2012; 31(1):7-12.
Lafosse T, Masmejean E, Bihel T, Lafosse L. Brachial plexus endoscopic dissection and correlation with open dissection. Chir Main. 2015; 34(6):286-93.
Cheng SWK, Reilly LM, Nelken NA, Ellis WV, Stoney RJ. Neurogenic thoracic outlet decompression: rationale for sparing the first rib. Cardiovasc Surg. 1995; 3(6):617–23.
14.Ferrante M, Ferrante N. The thoracic outlet syndromes: part 2. The arterial, venous, neurovascular, and disputed thoracic outlet syndromes. Muscle Nerve. 2017; 56(4):663-673.
Fig.1: Scope through the anterioinferior portal: A) Fat over the Brachial Plexus, B) Released Pectoralis minor tendon
Fig. 2 Scope through the anterioinferior portal: A) Subclavius Muscle Released, B:Electrocautery device.
Fig. 3 Scope through the medial portal: A) Upper Trunk, B) Suprascapular artery.
Fig. 4 Scope through the medial portal: A) Suprascapular nerve, B Upper Trunk
Fig. 5 Scope through the supracavicular portal: A) Fribrous adhesion, B) Anterior Scalene Muscle
Fig. 6 Scope through the supracavicular portal: A) Scalene Muscle, B) Brachial Plexus
Fig. 7 Scope through the supracavicular portal: A) Scalen Muscles Released, B) Subclavian Artery, C) Dorsal Scapular Artery.
Fig. 8 Special portals designed for the procedure: A) Anterioinferior, B) Medial, C) Supraclavicular, D) Cervical
Table. 1 Tips and Tricks
Table. 2 Comparisson between Endoscopic and Open procecedures
Endoscopic release of the Brachial plexus is a technical from NAEON Institute Sao Paulo-Brazil and Alps Surgery Institute/Clinique Générale d’Annecy-France.
After the Pectoralis Minor Release, the region of its cords and distal nerves is cleaned.
Dissection between the Pectoralis Minor and conjoined tendon is important and will expose the musculocutaneous nerve.
Here the musculocutaneous nerve is exposed.
Following key structures and the plexus one careful dissects this region until achieve the subclavius muscle’s fascia.
The subclavius muscle’s fascia is opened and the muscle is exposed
All the muscle is released, and the clavicle is reached.
Just after the superior border of the clavicle the supraclavicular portal is made.
In the cervical direction a dissection of structures over the brachial plexus is done and the trunks of the brachial plexus are exposed.
Shaver with no aspiration can also be used.
Suprascapular nerve is visualized at the lateral border of the brachial plexus
Continuing dissection one can expose the suprascapular artery over the upper trunk
Anterior Scalenus muscle and fibrotic bands are reached.
The Anterior Scalenus muscle is carefully released.
The Middle Scalenus muscle have to be also released with special care because the Scapular Dorsal and Thoracic Long Nerves, released in this video were in the middle of this muscle.
Subclavian artery can be visualized, however it is not mandatory.
Online Submissions: http: //www.ghrnet.org/index.php/ijo Int. J. of Orth. 2019 February 28; 6(1): 1012-1015 doi: 10.17554/j.issn.2311-5106.2019.06.281-4 ISSN 2311-5106 (Print), ISSN 2313-1462 (Online)
Principles of the Superior Capsule Reconstruction of the Shoulder
Jose Carlos Garcia Jr., Matheus R. Barcelos, Felipe Machado do Amaral, Mauricio de Paiva Raffaelli, Álvaro Motta Cardoso Jr.
Jose Carlos Garcia Jr., Matheus R. Barcelos, Felipe Machado do Amaral, Mauricio de Paiva Raffaelli, Álvaro Motta Cardoso Jr., NAEON Institute São Paulo- Brazil
Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Com- mons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non- commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jose Carlos Garcia Jr., NAEON Institute São Paulo, Brazil. Email: firstname.lastname@example.org
Received: September 14, 2018 Revised: November 18, 2018 Accepted: November 20, 2018 Published online: February 28, 2019
Massive rotator cuff tears, involving the posterosuperior rotator cuff, remain difficult to treat particularly in the younger population. Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. There are many techniques for Superior Capsular Reconstruction (SCR) mainly using allograft. However low accessibility to the dermal grafts in many countries led the authors to use and suggest autograft of the fascia lata as other option for the reconstruction of the superior capsule of the shoulder. The SCR have presented good functional and biomechanical results. These tech- niques are reliable options for irreparable lesions of the rotator cuff.
Garcia JC, Barcelos MR, Amaral FM, Raffaelli MP, Cardoso AM. Principles of the Superior Capsule Reconstruction of the Shoulder. International Journal of Orthopaedics 2019; 6(1): 1012-1015 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/ view/2437
Massive rotator cuff tears, involving the posterosuperior rotator cuff, remain difficult to treat particularly in the younger population.
With an arthroscopic, or open approach, rotator cuff repair is pos- sible in the majority of cases and functional outcomes are improved.
The term “irreparable” has been used with different meanings in the past. For example, the term was frequently used when partial re- pair of the rotator cuff was performed.
More recently, a subtle change in meaning was adopted. The term “irreparable” began to be used to describe a rotator cuff that was either (1) predicted to be irreparable based on preoperative characteristics; or (2) predicted to have a poor outcome from rotator cuff surgery, regard- less of the possibility of achieving current intraoperative repair.
Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Some authors say that the term ir- reparable should only be applied intraoperatively.
Hanada et al first described a “superior capsular reconstruction” of the glenohumeral joint as a revision operation in a paraplegic patient with an irreparable supraspinatus tendon tear[1,3]. During a postopera- tive follow-up, 1.2 years after the surgery, pain persisted as well loss of function. Muscle strength and endurance deteriorated to “fair”. In summary, the overall result was unsatisfactory.
During cadaveric studies of patch graft surgery, for irreparable rota- tor cuff tears, Mihata et al discovered that the graft should be attached
medially to the superior glenoid and laterally to the greater tuberosity in order to restore superior stability of the humeral head.
After clinical studies, Mihata et al reported on the use of fascia lata autograft to arthroscopically reconstruct the superior capsule of twen- ty-four shoulders, in twenty-three patients, all with large, irreparable rotator cuff tears. Reported outcomes of this study were excellent, with significant improvements in pain, function, and range of motion in forward flexion and abduction, beside the increase of the subacro-
 mial space shown in radiography .
While reported outcomes were favorable, it is important to note
this technique increases surgical time and carries donor-site morbid-
ity. Hirahara and Adams subsequently proposed the use of dermal
allograft for Superior Capsular Reconstruction (SCR) as opposed to
[6,7] fascia lata . Dermal allografts limit donor-site morbidity, have been
used previously in augmentation of rotator cuff repairs, and have
 been used clinically for SCR .
Despite growing interest in the use of these techniques with the
 dermal allograft technology, their cost is a potential impediment .
It is important to note that other new techniques, which use the Long Head of the Biceps Tendon (LHBT) as autologous graft, with partial repair of the rotator cuff or side-by-side suture, have also been described by several authors[8-11].
ANATOMY AND BIOMECHANICS
The anatomy of the glenohumeral joint capsule is not uniform for all. The cuff and superior capsule are a mix of blended fibers. Thus, the superior capsule serves to transmit force from the cuff musculature to the bone, and to reinforce tendon insertions. In this manner, the supe- rior capsular complex contributes to active glenohumeral stability.
Anatomical studies have revealed a larger insertional footprint of the superior capsule than had previously been recognized: from 5 to 9 mm in medial–lateral width at the anterior and posterior margins[14,15]. The superior capsule is connected to 30% and 61% of the greater tu- berosity and can have a larger footprint on the greater tuberosity than the supraspinatus. Therefore demonstrating that the superior capsular complex is critical for passive glenohumeral stability.
Indications for Superior Capsule Reconstruction (SCR) surgery, are those patients with irreparable rupture of the rotator cuff, those with pseudoparalysis, those who may have already undergone treatment or not, upper instability that can be observed as ascending humeral head, and/or young patients who are not candidates for reverse shoulder arthroplasty[1,9,16,17]. Patients presenting with evidence of a Hamada IV classification (or greater), advanced arthritic changes, and poor deltoid function are all relative contraindications to this procedure.
Magnetic Resonance Imaging should be consistent with an irreparable rotator cuff tendon tear and demonstrate a retraction greater than 3 cm, along with Grade 3 changes of the supraspinatus or Grade 2 changes
 of the infraspinatus on sagittal oblique imaging . Plain radiographs
also need to be obtained to rule out significant arthritis, confirm supe- rior instability, and superior dislocation of the humeral head.
Rotator cuff strength is assessed initially by testing the resisted ex- ternal rotation (to detect tears of the supraspinatus, infraspinatus, and
teres minor). A positive Hornblower’s Test and Lag Sign indicate involvement of the supraspinatus, infraspinatus, and teres minor. In addition, subscapularis function is tested by means of the Bear Hug, Belly Press, and Lift-Off Tests.
These techniques require an experienced surgeon and surgical team, in addition to the appropriate (sometimes considerable) time needed to complete the procedure. Preparation of the joint, before beginning the reconstruction of the upper capsule, is of the utmost importance.
Acromioplasty can be performed to improve visualization of the subacromial space, but some authors preserve the coracoacromial ligament in massive cuff surgery.
Biceps tenotomy for elder and tenodesis of the biceps for the younger patients can be performed according to the surgeon’s prefer- ence.
Partial cuff repair is almost always possible and should be per- formed routinely to improve the forward range of motion, and avoid possible suprascapular nerve compression.
The subscapularis tendon should be sutured in the minor tubercle, according to the surgeon’s technical preference, as it plays an impor- tant role in the static and dynamic stability of the shoulder. Without a functional subscapularis suture, the reconstruction of the upper cap- sule may fail.
Release of the teres minor and infraspinatus should be done to cov- er as much area as possible during the repair. The posterior interval slide technique is a viable option to improve tendon mobility. Good postero-lateral coverage improves the prognosis of external rotation in the postoperative period, since the upper capsule will be the stabi- lizer that will make the fulcrum of the glenohumeral joint, while the remaining tendons move the joint.
Exposure of the glenoid should be extensive, with removal of all tissue from the supraglenoidal tubercle for easy identification of fu- ture anchor location.
Mihata et al. inserted the anchors into the superior glenoid at the 10 to 11 o’clock and 11 to 12 o’clock positions on the glenoid of the right shoulder (or the 1 to 2 o’clock and 12 to 1 o’clock positions of the left shoulder).
The Nevasier Portal and accessory portals anterior and posterolat- eral should be used when necessary. Angle placement of the anchor is critical, as there must be no invasion of the joint. If the distance be- tween the anchors is greater than 35 mm a third anchor may be used.
The major tuberosity of the humerus is prepared by removing all remaining tissue leaving a propitious and scarified bone area.
A milimetered probe is used to measure the anteroposterior dis- tance to the glenoid, the anteriorposterior distance to the great tuber- cle, and the medial lateral distances. A made-to-measure graft is then fashioned based on these specific measurements.
To provide tissue for fixation, 5 mm is added to the medial, an- terior, and posterior dimensions and 15 mm is added to the lateral dimension, to account for the rotator cuff footprint[17,20].
A vertical skin incision is made, over the lateral thigh and around the greater trochanter of the femur. A section of fascia lata 2 to 3 times the size of the superior capsular defect is harvested, after which a graft 6 to 8 mm thick is fashioned by folding the fascia Lata twice or thrice as necessary (Figures 1 and 2).
The glenoid anchor wires should be arranged on the graft before the latter is transported through the cannula in the lateral portal and guided to its location in the glenoid. There are successful several variations of this strategy, which depend on the choice of glenoid an-
Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Figure 1 Fascia Latagraft.
Figure 2 Fascia Lata preparation for superior capsular reconstruction.
chor and the size of the graft. Insertion of the graft into the joint is the most challenging part of
the procedure (Figure 3). Several technical tips can help to prevent complications.
The sutures in the medial row of the greater tuberosity are crossed over the graft and secured with 2 additional lateral suture anchors in a transosseous-equivalent style repair (Figure 4). This is done with 20° to 30° of arm abduction.1 Mihata, however, in his original paper references the use of 45° of abduction.
The important concept to note is that, the graft should not be placed with laxity.
The graft is then sutured to the infraspinatus using 2 or 3 sutures in a simple fashion. This a not an optional step[1,6,21].
Reconstruction of the upper capsule using the LHBT, consists of preserving the previously integrated bicipital insertion, evaluating the viability of the remaining LHBT with no excessive tendinitis or par- tial tears.
Repairable partial and/or full infraspinatus and subscapularis ten-
Figure 3 Insertion of the Graft.
Figure 4 Capsular Superior Reconstruction scheme. (created by Dr Felipe do Amaral one of the authors).
don tears must be reconstructed to ensure the stabilizing force couple in the transverse plane.
A 5.5 mm suture anchor is inserted approximately in the middle of the greater tuberosity (just behind the bicipital groove). The surgeon then passes all sutures through the intact LHBT, performing a “lasso- loop” configuration. (Figure 5).
After this, tenotomy with or without tenodesis is performed on the biceps distal to the suture. Sutures are then pulled and tied by placing the tendon in the desired position.
Side-to-side fixation of the infraspinatus and subscapularis with the LHBT is performed.
Postoperative radiographs should show down-migration of the hu- meral head after procedure.
The use of an abduction pillow, for 4 weeks after the reconstruction surgery, is recommended. After the immobilization period, passive and active-assisted exercises were initiated.
Eight weeks after surgery, patients begin to perform exercises in order to strengthen the rotator cuff and scapula stabilizers with the as-
sistance of physical therapists. Active overhead motion strengthening exercises are not advised
in the period up to four months after surgery. Thus allowing adequate time for allograft incorporation and cuff healing. High-demand ac- tivities are restricted for 1 year after surgery.
Hirahara et al use musculoskeletal ultrasound to evaluate the dermal allograft. Subsequently showing that the graft is incorporated into the patient’s body and transformed into host tissue. Vasculariza- tion was found using a Doppler 4-8 months after surgery, thus prov- ing incorporation of the tissue.
The SCR technique has shown very good functional and biomechani- cal results. In the body of this article, several technical options are described using either a Dermal graft or less expensive alternatives such as fascia lata and LHB. As surgeons become more familiar with the SCR technique, the use of this surgery, as an option for irrepa- rable lesions of the rotator cuff, will significantly increase.
Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoul- der arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013; 22(9): 1199-1208. [PMID: 23385083]; [DOI: 10.1016/j.jse.2012.11.016]
Hanada K, Fukuda H, Hamada K, Nakajima T. Rotator cuff tears in the patient with paraplegia. J Shoulder Elbow Surg. 1993; 2(2): 64- 69. [PMID: 22971671]; [DOI: 10.1016/1058-2746(93)90002-X]
Mihata T, McGarry M, Pirolo J, Lee M. Superior Capsule Reconstruction to Restore Superior Stability in Irreparable Rotator Cuff Tears: A Biomechanical Cadaveric Study. Am J Sports Med 2012; 40(10): 2248-55. [PMID: 22886689]; [DOI: 10.1177/0363546512456195]
Mihata T, Lee TQ, Watanabe C, et al. Clinical results of ar- throscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy 2013; 29(3): 459-70. [PMID: 23369443]; [DOI: 10.1016/j.arthro.2012.10.022]
Hirahara AM, Adams CR. Arthroscopic superior capsular recon- struction for treatment of massive irreparable rotator cuff tears. Arthrosc Tech 2015; 4(6): e637-e641. [PMID: 26870638]; [DOI: 10.1016/j.eats.2015.07.006]
Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Pre- liminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft. Arthroscopy. 2018; 34(1): 93-99. [PMID: 29146165]; [DOI: 10.1016/j.arthro.2017.08.265]
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Kim YS, Lee HJ, Park I, Sung GY, Kim DJ, Kim JH. Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon. Arthrosc Tech. 2018; 7(2): e97-e103. [PMID: 29354447]; [DOI: 10.1016/j.eats.2017.05.020]
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Garcia JC et al. Principles of the Superior Capsule Reconstruction of the Shoulder
Robotic surgery has been used for a long time, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods. This technical Note presents an endoscopic robotic posterior shoulder approach that allow the surgeon to perform Latissimus Dorsi transfer endoscopically.
This technical note aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers related to rotator cuff tears.
Robotic surgery has been used for a long time1-2, it is earning space and expanding of use to daily medical practice in several surgical specialties with advantages over the traditional surgical methods3,4. Within orthopedics, we highlight the use of robotics in brachial plexus6,7 and neurologic releases7-9.
The association of the robotic technology with endoscopy have further allowed a faster recovery for the patient for many applications with shorter time of hospitalization and minimally invasive approache10.
Advantages of this method include movement accuracy, high resolution imaging with three-dimensional vision, gas infusion rather than saline solution (better visualization), filtering of the surgeon’s tremor when manipulating objects, movement scaling and hand-free camera manipulation11-14. In addition for future, there is the possibility of remote surgery (telesurgery) where the surgical team can treat a patient far away1, 2 or a surgical team may be composed of professionals located in different cities or countries, treating the same patient simultaneously.
Some shoulder pathologies that will need posterior shoulder approach may need aggressive and traumatic exposure with extensive manipulation of soft tissues. The possibility to use a minimal invasive approach can potentially be important for both the time of rehabilitation and avoiding local soft tissue adhesions. In Addition, when performing a large posterior open approach, one needs the use of tensioned retractors in order to keep the surgeon’s field in a suitable manner. The use of these tensioned retractors can eventually damage the deeper muscle layer as well as other neurovascular structures15,16.
The minimally invasive procedures have demonstrated decrease of adhesions, avoiding reoperations and physical therapies during long times. Indeed, this advantage mentioned above make these procedures cost-effectives10.
There are few descriptions using the aid of robotics in the area of orthopedics, especially in shoulder surgery, a practice already widespread in other surgical areas, but which have been gaining space and recent publications17-19.
In shoulder surgery, the use of robotic-assisted surgery for better identification of the quadrangular space of the shoulder, identification of the axillary and radial nerves, and better identification of the latissimus dorsi muscle was done in a cadaver trial before20.
The visualization and partial manipulation of the latissimus dorsi muscle has already been reported, in order to aid the transportation of the muscular pedicle, with technique that was used as reference for our study19.
Axillary nerve identification has also been described9, making a contribution to our study and confirming the viability of the method.
Regarding bleeding, studies in live patients have shown that the air insufflation have been effective on avoiding it8.
This technical note is based on previous cadaveric trials20 and aims to present the using of the DaVinci®(Intuitive Surgical, Sunnyvale, CA, USA) robot for transfers of the latissimus dorsi tendon to humeral head we have already performed in four live patients for massive rotator cuff tears.
Indications, pre-operative evaluation and imaging
This procedure has the same indications of the traditional open transfer of the Latissimus dorsi tendon, patients with massive rotator cuff tears with poor biologic characteristics of the tendon. Fat infiltration degrees 3 and 4 of Goutallier with a retraction of more than 4cm in patients under 60 years presenting active subscapularis tendon is the ideal surgical indication.
Patients will present pain and difficulty or impossibility for shoulder elevation and abduction. The youngest the patient is, better tends to be the result.
Patient is left in ventral decubitus, the arm being maintained in a position similar to 90o elevation.
The inferior border of the Latissimus Dorsi can be localized by palpation. A draw of the muscle is done in the skin based on its inferior border and its known anatomy. A central line of the Latissimus Dorsi is also drawn. An 1cm incision is made in the skin, 10 to 15cm from the axilla, the central portal. Two other portals are made 5-7cm perpendicular medial and lateral to the central line. These portals are located 7-10cm from the axilla. The central portal is used to insert the optics and through the other two portals the robotic hands were introduced to access the muscular fascia where a cavity was formed through blunt dissection.This space was made for triangulation as an initial working cavity, once there are no natural cavities in this region.
A trocar and a canula are introduced into each of the incisions, in a common direction in the cavity the surgeon created (Fig. 1). In the first portal on the trapezius, the camera of the DaVinci® SI or Xi robot (Intuitive Surgical, Sunnyvale, CA, USA), with an optic of 300(Fig.2) is introduced.
Carbon dioxide was inflated at a constant 8-14mmHg pressure through the chamber portal into the working cavity, stretching the soft tissues and opening the cavity. The robotic arms used a Cadieri Forceps 8mm (Intuitive Surgical, Sunnyvale, CA, USA) and a Hot ShearsTM Monopolar Curved Scissor 8mm (Intuitive Surgical, Sunnyvale, CA, USA).
The first objective was to clean the area around the camera so that a best dissection and identification of the initial working cavity is done. After this first stage, we search for the superior border of the latissimus dorsi muscle and its division with teres major. Dissection using this muscular plane is done until its entrance deep into the medial border of the long head of the triceps(Fig. 3).
The Latissimus is released and separated from the teres major(Fig. 4), the radial nerve is just below the latissimus and it is possible to visualize it but not required (Fig. 5). One needs to take care the neurovascular pedicle in order to not damage it. A 0 Vicryl™ J318(Johnson & Johnson-São Paulo-Brazil) is inserted by the cephalic robotic hand’s portal. The latissimus dorsi tendon is sutured by using a Cadieri and a DeBakey Forceps(Intuitive Surgical, Sunnyvale, CA, USA)(Fig. 6)(Video. 1). The sutured tendon is pulled out of the body through the central portal of the optics using a gastric forceps.
A small 3-5cm incision is done on the lateral deltoid and using the finger a dissection of the subdeltoid space reaches the cavity created by the robot. A long gastric grasper is inserted through the cephalic robotic hand’s portal until it reaches the subdeltoid space. A guide polyester 5.0 wire is passed by using this grasper, leaving optics portal(Fig. 7).
The humeral head is drilled and 2 anchors are inserted. These anchor wires will pass from the deltoid approach to the optics portal using the 5.0 polyester wire as a guide.
The tendon is sutured to the anchor wires using a Krakow(Fig. 8) and passes to subacromial space pulled by the anchor wires, and a standard tendon to bone suture is done. More anchors and sutures can be done after the tendon lies the humeral head.
Portals and deltoid lateral approach are sutured.
A sling is used for 5 weeks. Pendular movements and passive elevation until 90º are allowed 2 weeks after surgery. After this period the active exercises isometric external rotation and elevation begin. In more two weeks isokinetic and proprioception movements begin. A scapular retraction and shoulder extension need to be stimulated in the initial movements, once Latissimus dorsi can also be activated during these movements. Better evolutions are present in patients with better active movements before the surgery.
Pearls and pitfalls are summarized on table. 1. Advantages and Disadvantages are summarized on table. 2.
Traditional approaches for the latissimus dorsi are wide requiring big posterior incisions with cosmetic and scar formation implications.
Previous cadaveric and live patient studies were used to stablish principles for the robotic latissimus dorsi transfer presented on this technical note.
The authors aim to present a surgical technique that can be improved and even be used for other orthopedic applications with future introduction new robots, new robotic arms and smaller optics.
There are few studies assessing the latissimus dorsi using the aid of robotics, all of them access the muscle and the origin of the latissimus for free flaps17-20. This is the first in vivo robotic assisted shoulder surgical procedure done for transfer of the latissimus dorsi insertion to improve function after rotator cuff tears. Tendon, neurovascular structures, quadrangular space were robotically identified in cadaver trials by the author before in other trials, thus surgical viability and safety of the procedure were previously checked9,20.
Other robotic orthopedic applications in live patients have also demonstrated that the air insufflation effectiveness on better bleeding conctrol8.
The viability of the robotic introduction in shoulder surgery was shown by the authors that hope to encourage further studies in the area.
The limitations of this technique are cost of the robot, robotic hands and its scisures. Necessity of specific training on robotic surgery, that is currently costly and not available in many hospitals, can also limits its current use.
In this moment surgical time is longer than in the open procedure, however this situation tends to improve on time.
1. Ballantyne GH, Moll F. The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin North Am. 2003; 83:1293-304.
3. Oldani A, Bellora P, Monni, M, Amato B, Gentilli S. Colorectal surgery in elderly patients: our experience with DaVinci Xi® System. Aging Clin Exp Res. 2017; 29(1):91-99.
4. Gallotta V, Cicero C, Conte C, Vizzielli G, Petrillo M, Fagotti A et al. Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case Matched Control Study. J Minim Invasive Gynecol. 2017; 24(2):293-298.
5. Mantovani G, Liverneaux PA, Garcia JC, Berner SH, Bednar MS and Mohr CJ. Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial. J Neurosurg. 2011;115(3):659-64.
6. Garcia JC, Lebailly F, Mantovani G, Mendonça LA, Garcia JM and Liverneaux PA. Telerobotic Manipulation of the Brachial Plexus. J reconstr Microsurg 2012; 28(7):491-494
7. Garcia JC, Mantovani G, Gouzou S and Liverneaux P. Telerobotic anterior translocation of the ulnar nerve. Journal of Robotic Surgery. 2011; 5(2):153–156.
8. Garcia JC, Montero EFS. Endoscopic Robotic Decompression of the Ulnar Nerve at the Elbow. Arthroscopy Techniques. 2014; 3: 383-387
9. Melo PMP, Garcia JC, Montero EFS, Atik T, Robert EG, Facca S et al. Feasibility of an endoscopic approach to the axillary nerve and the nerve to the long head of the triceps brachii with the help of the Da Vinci Robot. Chirurgie de la Main. 2013; 32: 206-9
10. Morgan JA, Thornton BA, Peacock JC, Hollingsworth KW, Smith CR, Oz MC, Argenziano M. Does robotic technology make minimally invasive cardiac surgery too expensive? A hospital cost analysis of robotic and conventional techniques. J Card Surg. 2005; 20(3):246-51.
11. Byrn JC, Schluender S, Divino CM, Conrad J,Gurland B, Shlasko E, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg. 2007; 193:519–22.
12. Solis M. New Frontiers in Robotic Surgery: The latest high-tech surgical tools allow for superhuman sensing and more. IEEE Pulse. 2016; 7(6): 51-55.
13. Willems JIP, Shin AM, Shin DM, Bishop AT, Shin AY. A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations. Plast Reconstr Surg. 2016; 137(4): 1317-24.
14. Shademan A, Decker RS, Opfermann JD, Leonard SK, Axel K, Peter CW. Supervised autonomous robotic soft tissue surgery. Sci Transl Med. 2016; 8(337): 337ra64.
15. Wijdicks CA, Armitage BM, Anavian J, Schroder LK, Cole PA. Vulnerable neurovasculature with a posterior approach to the scapula. Clin Orthop Relat Res. 2009; 467(8): 2011-7.
16. Chalmers, Peter Nissen; Van Thiel, Geoff S; Trenhaile, Scott W. Surgical Exposures of the Shoulder. J Am Acad Orthop Surg. 2016; 24(4): 250-8.
17. Selber JC, Baumann DP, Holsinger FC. Robotic latissimus dorsi muscle harvest: a case series. Plast Reconstr Surg. 2012; 129(6):1305-12.
18. JH Chung, You HJ, Kim HS, Lee BI, Park SH , Yoon ES. A Novel Technique for Robot Assisted Latissimus Dorsi Flap Harvest. J Plast Reconstr Aesthet Surg. 2015; 68 (7), 966-72.
19. Ichihara S, Bodin F, Pedersen JC, Melo PP, Garcia JC, Sybille F et al. Robotically assisted harvest of the latissimus dorsi muscle: A cadaver feasibility study and clinical test case. Hand Surgery and Rehabilitation. 2016; 35:81–84
20. Garcia JC, Gomes RVF, Kozonara ME, Steffen AM. Posterior Endoscopy of the Shoulder with the aid of the Da Vinci SI robot – a Cadaveric Feasibility Study. Acta of Shoulder and Elbow Surgery. 2017; 2(1):36-39.
Robotic transfer of the Latissimus Dorsi Tendon from NAEON Institute Sao Paulo Brazil
Portals are done 10-15cm from the latissimus dorsi insertion, 1 central; 1 superior and 1 inferior.
As no natural cavities are present in this area one can gently create a subcutaneous cavity.
The optics trocart is the central, superior and inferior are dedicated to the robotic hands.
This is an external view of the initial subcutaneous and muscular dissection
This is how the surgical site is presented by the robot, but in 3 dimensions.
After a wide dissection the teres major on the left is separated from the latissimus dorsi on the right
The tendon is cut from its humeral insertion
Latissimus is mobilized and separated from the teres major
Care must be taken because as you can see the radial nerve lies just under the tendon
Knowing where the nerve it is easier to release the muscular part or the Latissimus dorsi
The released tendon is sutured
The needle and the wire pass through the optics portal
The deltoid approach is done and a guide polyester wire is also inserted from subdeltoid to the optics portal
Anchors are inserted in the humeral head through the same deltoid approach and their wires are passed by using the guide polyester to the optics portal.
The wires of the suture anchors are sutured on the tendon and the tendon is pulled through cavity until the subdeltoid space and the final fixation in the bone is done
Fig. 1. Patient in ventral decubitus: A and B: Robotic hand trocaters, C: Optics Trocater, D: Shoulder, E: Robotic Exterior Hand, F: Robotic Exterior Hand for Optics.
Fig. 2. Robotic Optics 30º with 2 cameras allowing a stereoscopic view.
Fig. 3. Optics within the central portal. TM:Teres Major, LD: Latissimus Dorsi
Fig. 4. Optics within the central portal. TM: Teres Major, LD: Latissimus Dorsi released
Fig. 5. Optics within the central portal. A: Radial Nerve, B: Teres Major insertion, C: Latissimus Dorsi retracted.
Fig. 6. Optics within the central portal.TLH: Trices Long Head, LD: Latissimus Dorsi, TM: Teres Major
Fig. 7. Patient in ventral decubitus, shoulder and scapular area exposed A: Polyester guide wire through the deltoid approach, B: Gastric forceps, C: Wires where the Latissimus Dorsi was sutured, D: Polyester guide wire exit
Fig. 8. Patient in ventral decubitus, shoulder and scapular area exposed A: Latissimus dorsi sutured with the suture anchor wires, B: The other parts of the suture anchor wires, these will pull the tendon to the humeral head.
Table. 1 Pearls and Pitfalls
Table. 2 Advantages and disadvantages comparing Robotic versus Arthroscopic versus Open surgeries for Latissimus Dorsi transfer.
Massive rotator cuff tears involving the posterosuperior rotator cuff remain difficult to treat, particularly in the younger population. Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Many techniques exist for superior capsular reconstruction (SCR), mainly using allograft. However, the higher costs of dermal grafts and morbidity of fascia lata autograft led us to find another option for SCR of the shoulder using the semitendinosus autograft as a pivot in a better biomechanical configuration. The pivot SCR technique has shown good functional and biomechanical results. We have found this technique to be a reliable and less expensive option for irreparable lesions of the rotator cuff.
Massive rotator cuff tears involving the posterosuperior rotator cuff remain difficult to treat, particularly in the younger population. The term “irreparable” has been used with different meanings in the past. For example, the term was frequently used when partial repair of the rotator cuff was performed.1 More recently, a subtle change in meaning was adopted. The term “irreparable” began to be used to describe a rotator cuff that was either predicted to be irreparable based on preoperative characteristics or predicted to have a poor outcome after rotator cuff surgery, regardless of the possibility of achieving current intraoperative repair.2 Fatty infiltration of the muscle, excessive chronic tendon retraction, and degeneration are the main irreversible factors predisposing to high failure rates of direct repair. Some authors have stated that the term “irreparable” should only be applied intraoperatively.1
Superior capsular reconstruction (SCR) was described as a revision operation in a paraplegic patient with an irreparable supraspinatus tendon tear.1,3 During cadaveric studies of patch graft surgery for irreparable rotator cuff tears, one group of authors realized that the graft should be attached medially to the superior glenoid and laterally to the greater tuberosity to improve superior stability of the humeral head in SCR.4 This modification resulted in significant improvements in pain, function, and range of motion in forward flexion and abduction, besides the increase in the subacromial space on the roentgenograms.5 Although reported outcomes were favorable, it is important to note that this technique increases surgical time and carries donor-site morbidity.
Other authors proposed the use of dermal allograft for SCR as opposed to fascia lata.6,7 However, surgical costs remained complex to manage for this procedure, creating a gap for other surgical options.8, 9, 10, 11 This Technical Note aims to present a less expensive technique that uses the semitendinosus graft as a central pivot in a better dynamic configuration for SCR (Video 1).
The patient is placed in the beach-chair position under general anesthesia. The semitendinosus tendon is extracted as standardized for anterior cruciate ligament (ACL) reconstruction. The tendon is tensioned and overlapped once in a double-band configuration. Suturing on the final portions of the overlapped graft is performed with No. 5 multifilament polyester suture. This multifilament polyester suture is inserted in a perforated Kirschner wire as used in ACL reconstruction.
The scope is inserted in the posterior portal; an extensive bursectomy is performed, and the lesion can be visualized. The scope is then placed in the lateral portal. Extensive exposure of the scapular neck is performed using a shaver and electrocautery device, with removal of tissue inferior to the supraglenoid tubercle anterior and posterior, to enable easy identification of the bone of the scapular neck, where the graft will pass from posterior to anterior. The labrum is kept intact.
An 18-gauge needle is used to establish the posteromedial portal, which faces the scapular neck just under the glenoid tuberosity. A guide K-wire is inserted through the posteromedial portal and crosses from the posterior (at the 10-o’clock position in the glenoid) to anterior (at the 2- to 3-o’clock position in the glenoid) glenoid neck (Fig 1). A drill the same size as the overlapped semitendinosus tendon is used to create a hole (Fig 2). The perforated K-wire is used to pass the No. 5.0 multifilament polyester suture in 1 final portion of the overlapped graft. Two marks measuring 2 cm are made on each side of the graft to ensure a minimal length on each side. The 2 marks should be visualized by the scope after graft passage. The multifilament polyester suture is pulled through the anterior portal, and the tendon is passed from the posterior to anterior glenoid neck through this hole (Fig 3). With the aid of an atraumatic clamp, both graft legs are placed within the joint, anteriorly in the subcoracoid space and posteriorly in the supraspinatus fossa, exposing the graft terminal fixation and No. 5.0 multifilament polyester suture.
A Neviaser portal is made, and a guide K-wire is inserted approximately 1 cm from the medial border of the greater tuberosity on the humeral head until it crosses the lateral humeral cortex; the arm can be abducted to achieve the best position (Fig 4). A drill that is 1 size higher than the double-overlapped tendon’s size is inserted until it touches the contralateral humeral cortex, not crossing it (Fig 5). The anterior and posterior overlapped graft portions are pulled out of the body through the Neviaser portal. The No. 5.0 multifilament polyester suture in the tips of the graft is inserted in the perforated K-wire and is used to pass the graft through the hole in the humeral head (Fig 6). Tensioning of the tendons is performed similarly to that in ACL reconstruction, and fixation is performed with a metallic interference screw (Hexagon, Itapira, Brazil) (Fig 7). The size of the screw is the same as that of the hole.
If the surgeon prefers stronger fixation, an EndoButton (Razek, São Carlos, Brazil) can be inserted through the humeral head hole before graft insertion and can be used to pass and fix the graft. A release of the teres minor and infraspinatus should be performed to cover as much area as possible during the repair. The greater tuberosity is free for partial cuff repair or any tendon transfer. Repairable partial and/or full infraspinatus and subscapularis tendon tears must be reconstructed to ensure the restoration of the stabilizing forces in the transverse plane.8
Postoperative radiographs will be useful to see the screw and subacromial space (Fig 8). Without a functional subscapularis or its suture, the reconstruction may fail. Accessory portals—anterior and posterolateral—should be used when necessary. Pearls and pitfalls of our technique are summarized in Table 1. Advantages and disadvantages are summarized in Table 2.
Table 1. Pearls and Pitfalls
Pearls and Pitfalls
The graft needs to be large enough to suitably pass through the scapular neck and allow fixation on the humeral head.
Scapular neck perforation
This is the most important step of the described technique. A minimal distance of 7-8 mm is required to avoid articular damage and fracture.
Cleaning of space
Suitable cleaning of the shoulder is needed to allow appropriate visualization of the entire articulation, as well as the scapular neck. Cleaning of the anterior exit point area needs to be highlighted to confirm its correct location and to preserve the subscapularis.
The location is 1 cm from the footprint, within the cartilage of the humeral head nearest the central line perpendicular to the middle of the footprint.
The direction of the perforation needs to be as anterior or anterolateral as possible to avoid the neurologic structures of the arm.
Table 2. Advantages and Disadvantages Comparing Pivot SCR and Traditional SCR
Semitendinosus: autograft or allograft
Fascia lata: autograft or allograft, dermal allograft, or xenograft
1 interference screw
5-7 suture anchors
Graft stress in internal and/or external rotation
Possible association with transfers
Preserves humeral footprint to insert transferred tendons
Does not preserve humeral footprint to insert transferred tendons
NOTE. + = low; ++ = medium; +++ = high.
SCR, superior capsular reconstruction.
We recommend the use of an abduction pillow for 4 weeks after reconstruction surgery. After the immobilization period, passive and active-assisted exercises begin. Eight weeks after surgery, patients can start rotator cuff and scapular stabilization exercises. More than 10 patients have undergone the described procedure, and their results were better than those of traditional SCR in our hands.
Despite growing interest in the use of SCR using dermal allograft technology, its cost is a potential impediment.8 It is important to note that other techniques using the long head of the biceps tendon as autologous graft, with partial repair of the rotator cuff or side-by-side suturing, have been described and cited by several authors as options over traditional SCR.8, 9, 10, 11, 12 We suggest that our surgical procedure using the semitendinosus tendon is easier and presents low costs and good outcomes. This double-overlapped graft measures at least 8 mm in diameter, which is the diameter related to the best results after ACL reconstruction.13,14
Reconstructions of other articulations use the graft insertion as close as possible to the rotational center in the least restrictive manner possible. In our technique, the surgeon inserts the semitendinosus graft in a single pivot configuration nearer the rotational center of the humerus, considering its axial plane. Regarding fixation, double fixation using an EndoButton and interference screw seems to ensure strength enough to stabilize the system until the entire healing process is complete.
A scapular neck fracture is possible; however, in our experience, this will not occur if the exit hole is located at a safe distance from the glenoid. A humeral head fracture is also a hypothetical possibility. Finally, one important consideration is that the exit point needs to be at the 2- to 3-o’clock position; an inferior exit point can put the brachial plexus at risk.
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Video 1. After bursectomy, the scapular neck is exposed by use of the lateral portal (visualization is performed with optics in the lateral portal, and exposure is performed with electrocautery and a soft-tissue shaver). The region medial to the 10-o’clock position in the glenoid needs to be exposed until the bone is visible (with the scope through the lateral portal). A K-wire is inserted in this region and leaves the bone at the 2- to 3-o’clock position. If the surgeon considers the amount of bone sufficient, he or she can drill the scapular neck. The size of the drill is the same as that of the double-overlapped graft. A perforated K-wire inserts the polyester wires of the graft through the scapular neck, similarly to anterior cruciate ligament reconstruction. The polyester is pulled out through the anterior portal, and the graft passes from posterior to anterior through the bone tunnel. The final portions of the graft are pulled out of the bone through the Neviaser portal. Through this portal, a guide K-wire and a drill are inserted 1 cm medial to the tuberosity, in the humeral head cartilage. The size of the drill is the same as that of the double-overlapped semitendinosus graft. A perforated K-wire inserts the guide polyester suture through this hole in the humeral head. The anterior and posterior parts of the graft are inserted within the humeral head. An interference screw presenting the same diameter as the hole is inserted, and the reconstruction is completed.Download : Download Acrobat PDF file (2MB)
Surgical procedures to treat anterior shoulder instability are basically split into 2 groups: those for patients with important bone loss and those for patients with no bone loss. However, there is a gray zone between these procedures in which a bone graft would not be needed but bone grafting would result in a desirable improvement in stabilizing mechanisms. We describe a technique based on the triple soft-tissue block, Bankart reconstruction, and long head of the biceps tenodesis at the anterior glenoid rim. The long head of the biceps would add an anterior restrictor by itself, as well as by tensioning the inferior part of the subscapularis.
Anterior shoulder instability remains one of the main issues within shoulder surgery. There are several studies showing that arthroscopic Bankart repair is successful in treating traumatic anterior shoulder instability without bone loss.1 On the other hand, glenoid bone loss greater than 21% to 25% and engaging lesions seem to present better results with bony procedures such as the Bristow and Latarjet procedures,2, 3, 4, 5 and both techniques present similar results.6
Some authors have also suggested that other predictive factors, such as age at the first episode, sport, and so on, need to be considered when choosing the surgical procedure, whereas others have suggested that glenoid bone loss can be critical even with 13.5% of bone loss.1, 7Indeed, there is a gray zone in treating anterior shoulder instability, which can be treated by both the Bankart and Bristow-Latarjet procedures.
Some authors have presented the arthroscopic belt-and-suspenders procedure combining principles of the Bankart and Bristow-Latarjet procedures to improve shoulder stability by using just the soft-tissue stabilizers; however, this procedure is time-consuming, uses a large medial bone tunnel, and presents a recurrence rate of 8%.8 Many authors have reported that the long head of the biceps (LHB) does not have an important function related to shoulder stability. In addition, some studies have suggested that the LHB is just a vestigial structure out of the natural biceps axis.9, 10, 11, 12
On the basis of these fundamentals, it seems more rational to use the LHB to provide both the direct sling effect and tension to the inferior part of the subscapularis.13 These 2 biomechanical stabilizer mechanisms in a lateralized fashion associated with the Bankart procedure can achieve better results for the aforementioned gray zone. We have successfully performed this LHB Bristow-Bankart procedure for 3 years, described as follows.
The patient is placed in the beach-chair position under general anesthesia. Through a standard posterior portal, articular inspection is performed, and the lesions are examined under an arthroscopic view. An anteroinferolateral portal is created 1 cm inferior and just lateral to the standard anterior portal. A 16-gauge needle will confirm the best location of this portal. The portal needs to be in line with the humeral head equator. Through this portal, the subscapularis tendon is gently opened in the direction of its fibers using a Kelly device (Fig 1). At this moment, some electrocautery devices and/or a shaver can be useful to widen this subscapularis split.
Through the portal, the surgeon also performs the LHB tenotomy (Fig 2). The anterior glenoid rim is exposed, and the bone is shaved to expose a surface to allow it to heal, similarly to the Bankart procedure. Thereafter, the scope is inserted in the anterolateral portal. The scope moves downward in the direction of the pectoralis major insertion, and visualization of the axillary nerve is suggested at this point (Fig 3). Other instruments are inserted through the anteroinferolateral portal. The LHB tendon is then pulled out just over the pectoralis major (Fig 4). Thereafter, it is pulled out of the body through the anteroinferolateral portal using a grasper. If the surgeon does not release the LHB just over the pectoralis major, the LHB cannot present free motion, and the patient can lose movement after surgery.
Out of the body, a Biotenodesis screw (Arthrex, Naples, FL) is attached to the LHB through a Krackow suture using FiberWire (Arthrex) (Fig 5). A Biotenodesis guidewire is inserted in the same portal through which the LHB was pulled out. This wire passes through the subscapularis split and is inserted just medial to the anterior glenoid rim at the 3- to 4-o’clock position. The bone tunnel is made using a 5- to 6-mm-diameter drill, depending on the tendon diameter (Fig 6). We have never used screws of less than 4.75 mm in diameter and have used drills with diameters of at least 0.25 mm greater than the screw diameter. The tendon is inserted through the subscapularis split on the anterior glenoid rim (Figs 7 and 8).
The labrum is sutured just above the inserted tendon using the FiberWire that was inserted with the interference screw (Fig 9). Two 1.5-mm JuggerKnot suture anchors (Zimmer-Biomet, Warsaw, IN) can be inserted above and under the inserted tendon through the subscapularis split using a cannula in the anteroinferolateral portal, allowing labral reconstruction; sometimes, the superior anchor might not be necessary (Fig 10, Video 1). Thus, one could achieve a triple suture for the Bankart repair associated with the sling effect.
Pearls and pitfalls of the described procedure are stated in Table 1. No recurrence, pain, or LHB lesions have been observed. All patients presenting more than 6 months after surgery returned to their sporting activities with no or minimal range-of-motion loss. For some patients, magnetic resonance imaging examinations were performed after the procedure (Figs 11 and 12).
Table 1. Pearls and Pitfalls
Pearls and Pitfalls
The ideal point is 45° anterior to the scapular axis, just over the biceps deflection, guided by an 18-gauge needle via an intra-articular view, with the scope in the posterior portal.
The ideal point is through the subscapularis tendon, near its insertion in the humerus, in line with the humeral head equator, guided by an 18-gauge needle via an intra-articular view, with the scope in the posterior portal.
An anteroinferolateral or anterior standard portal should be used. Cutting should not be performed too proximally and should be performed where the elliptical diameters seem to be more similar to those of the LHB.
Accessing superior portion of pectoralis tendon
The scope should be inserted in the anterolateral portal, in the subdeltoid space, in the direction of the pectoralis major insertion. A shaver should be carefully applied to the bursa; the LHB emerges from the bicipital tunnel under the superior portion of the pectoralis major, beneath the short head. Special care is needed for bleeding in this region because vessels can be close.
If bicipital tunnel extends distally
The tunnel needs to be opened in this area to pull the biceps tendon in this situation.
If biceps does not pass through tunnel
The entire tunnel needs to be opened in this situation.
This should be performed just after the LHB tendon is pulled out. The guidewire should be inserted just over the LHB, through the subscapularis split, with no cannula. The guidewire should be inserted just medial to the glenoid rim at the 3-o’clock position, similarly to anchor insertion. The hole should extend to the glenoid. A cannula should not be used.
Preference should be given to soft-tissue anchors once the space is small. A cannula should be used. If required by the surgeon, an anterior portal can also be made, but in our experience, this is not necessary.
LHB, long head of biceps.
Dynamic stabilization due to the sling effect can be the main stabilizer of the shoulder even for Bristow and Latarjet procedures, contributing to 51% to 77% of all stabilization, depending on the upper-limb position.13 This procedure presents a triple soft-tissue block in which the key points are the LHB and the tension of the inferior part of the subscapularis during abduction and external rotation, as well as labral reconstruction. It changes the shoulder kinematics similarly to the Latarjet procedure with no bone block.14 In the end-range position, the capsule and ligament plus the sling effect can be responsible for even 100% of the stability of the Latarjet repair.13
A similar triple soft-tissue block was described using the conjoined tendon8 instead of the LHB. However, because of the large transverse area of the conjoined tendon, the interference screw needs to present a larger diameter, as well as its introduction hole. The presented procedure uses smaller interference screws and the LHB as the sling, preserving the bone stock and allowing a more lateral position for inserting this screw. This feature would potentially add stability. Medialization of the graft with the Bristow procedure can increase rates of recurrent instability.15
There is no consensus on the role of the dynamic stabilizers of the shoulder. Thus far, all biomechanical studies using cadavers have rendered ineffective dynamic assessments. Labral proprioception can also play an important and neglected role in shoulder stability.16 We suggest that the described procedure and similar procedures17, 18 will add not only biomechanical stabilization19 but also tendon proprioception of the LHB, and the subscapularis can also play an important role in shoulder stabilization.
A similar technique has been described17; however, the following important differences are highlighted: (1) The position and angle of the interference screw differ. In this procedure, it is inserted more laterally, and it is just medial to the glenoid rim, in the same position at which the surgeon would insert a suture anchor. Thus, this screw will also present more lateral angulation in relation to the glenoid plane. (2) The subscapularis split is more lateral, is smaller, and is opened with a Kelly device in the direction of its fibers, allowing better neurologic and subscapularis preservation. (3) Preparation of the glenoid is ever done posterior to the labrum, and this structure is never pulled through the posterior portal. (4) The bicipital groove is not opened, preserving part of the anterior rotator cable that goes to the lesser tuberosity.20 (5) The tendon is cut where it presents a cylindrical axial aspect, allowing it to move through the bicipital groove and to be pulled out just after the bicipital groove.
Similarly to other authors, we believe that the LHB is a residual structure derived from the ancient coracoid bone of quadrupeds.12, 21In bipeds, this bone also followed the natural axis of the biceps originating at the coracoid process with a 90° rotation of the original coracoid bone.12, 22 Some primates do not present an LHB similar to that in humans, whereas in some, it can even originate on the pectoralis major insertion or in the humeral head.23
Indeed, the real kinematic importance of the LHB is still controversial. The described procedure would not substitute for bone block procedures with more than 20% to 25% of glenoid bone loss and instead would add stability to the current soft-tissue procedures for smaller amounts of bone loss. It could also be useful for athletes and high-demand patients.1, 4, 7 Advantages and disadvantages of this procedure compared with arthroscopic coracoid and conjoined tendon transfers24, 25, 26 or arthroscopic Bankart repair are suggested in Table 2.
Table 2. Suggested Differences Between Arthroscopic Bristow-Latarjet, LHB Bristow-Bankart, and Arthroscopic Bankart Procedures
Arthroscopic Bristow-Latarjet Procedure
LHB Bristow-Bankart Procedure
High (approximately 1 h 30 min)
Intermediate (approximately 1 h)
Fast (approximately 30 min)
Use for contact sports
Loss of ER
Glenoid bone <5%
Glenoid bone >5% but <21%
Glenoid bone >21%
Association with remplissage
Association with remplissage
ER, external rotation; LHB, long head of biceps.
While performing this procedure, it is possible to incorporate other procedures, such as remplissage. In addition, in case of the failure of this procedure, it is possible to apply the Bristow or Latarjet procedure. There is a possibility of LHB tendon rupture, glenoid fracture, and cyst formation, although we have never observed these.
The surgical time for this procedure to access the superior insertion of the pectoralis major is longer compared with the Bankart procedure, in addition to requiring arthroscopic training. If the LHB is pathologic and presents areas of disruption, it can also be oversized in its intra-articular portion. In this case, opening the intertubercular ligament can be an option. In our opinion, this surgical procedure and similar procedures17 can fit exactly in the gray zone between Bankart and Bristow-Latarjet procedures.19
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Video 1. Long head of biceps (LHB) Bristow procedure for anterior shoulder instability. The patient is a 23-year-old skydiver with recurrent anterior shoulder instability. A standard release of the labrum is performed. Debridement using a regular shaver is also performed, followed by marrow bone exposure using a bony shaver. The surgeon then looks upward to the LHB tendon and cuts it using regular arthroscopic scissors. The scope is inserted in the anterolateral portal, and the axillary nerve is found. In addition, the LHB is found behind the pectoralis major, and the tendon is pulled out of the body through the anteroinferolateral portal. A Krackow suture is made in the tendon, and the interference screw is ready to use. The subscapularis is then split in the direction of its fibers using a regular Kelly device. This split can be widened by a shaver or electrocautery device. The guide K-wire is inserted in the anterior glenoid rim. Thereafter, the drill creates the hole into which the biceps and interference screw will be inserted. The LHB is introduced through the subscapularis split to the hole. The interference screw fixes the LHB tendon. The labrum over the biceps can be sutured using the screw wire or a suture anchor. Finally, inferior to the tendon, a suture anchor is inserted to fix the inferior labrum.Download : Download Acrobat PDF file (321KB)
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1S. DeFroda, S. Bokshan, E. Stern, K. Sullivan, B.D. OwensArthroscopic Bankart repair for the management of anterior shoulder instability: Indications and outcomesCurr Rev Musculoskelet Med, 10 (2017), pp. 442-451CrossRefView Record in ScopusGoogle Scholar2M.C. Beran, C.T. Donaldson, J.Y. BishopTreatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: A systematic reviewJ Shoulder Elbow Surg, 19 (2010), pp. 769-780ArticleDownload PDFView Record in ScopusGoogle Scholar3E. Itoi, S.B. Lee, L.J. Berglund, L.L. Berge, K.N. AnThe effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric studyJ Bone Joint Surg Am, 82 (2000), pp. 35-46CrossRefView Record in ScopusGoogle Scholar4S.S. Burkhart, J.F. De BeerTraumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted pear glenoid and the humeral engaging Hill-Sachs lesionArthroscopy, 16 (2000), pp. 677-694ArticleDownload PDFView Record in ScopusGoogle Scholar5I.K. Lo, P.M. Parten, S.S. BurkhartThe inverted pear glenoid: An indicator of significant glenoid bone lossArthroscopy, 20 (2004), pp. 169-174ArticleDownload PDFView Record in ScopusGoogle Scholar6J.C. Garcia, F.M. Amaral, R.J. Belchior, L.Q. Carvalho, G.G. Markarian, E.F.S. MonteroComparative systematic review of fixation methods of the coracoid and conjoined tendon in the anterior glenoid to treat anterior shoulder instabilityOrthop J Sports Med, 7 (2019)2325967118820539Google Scholar7J.S. Shaha, J.B. Cook, D.J. Song, et al.Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone lossAm J Sports Med, 43 (2015), pp. 1719-1725CrossRefView Record in ScopusGoogle Scholar8P. Boileau, R.T. Bicknell, A.B.E. Fegoun, C. ChuinardArthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The “belt-and-suspenders” operative technique and preliminary resultsArthroscopy, 23 (2007), pp. 593-601ArticleDownload PDFView Record in ScopusGoogle Scholar9J.E. Giphart, E.F. Florian, C.B. Dewing, M.R. Torry, P.J. MillettThe long head of the biceps tendon has minimal effect on in vivo glenohumeral kinematics. A biplane fluoroscopy studyAm J Sports Med, 40 (2012), pp. 202-212CrossRefView Record in ScopusGoogle Scholar10V.P. Kuarm, K. Satkum, P. BalasubramaniamThe role of the long head of biceps brachii in the stabilization of the head of the humerusClin Orthop Relat Res, 244 (1989), pp. 172-175Google Scholar11J.C. Garcia, A.M. Cardoso, M.B.D. MelloArthroscopic long head biceps tenodesis in coracoid associated with its transfer to the conjoined tendonActa Shoulder Elbow Surg, 2 (2017), pp. 7-10View Record in ScopusGoogle Scholar12J.C. Garcia, C.V. Nunes, M.D.P. Raffaelli, et al.Long head of biceps a vestigial structure?Acta Shoulder Elbow Surg, 2 (2017), pp. 22-27View Record in ScopusGoogle Scholar13N. Yamamoto, S.P. SteinmannThe biomechanics of the Latarjet reconstruction: Is it all about the sling?Oper Tech Sports Med, 27 (2019), pp. 49-54ArticleDownload PDFView Record in ScopusGoogle Scholar14W. Barrett Payne, M.T. Kleiner, M.H. McGarry, J.E. Tibone, T.Q. LeeBiomechanical comparison of the Latarjet procedure with and without a coracoid bone blockKnee Surg Sports Traumatol Arthrosc, 24 (2016), pp. 513-520CrossRefView Record in ScopusGoogle Scholar15L. Hovelius, L. Korner, B. Lundberg, et al.The coracoid transfer for recurrent dislocation of the shoulder. 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Imhoff, et al.Dynamic anterior shoulder stabilization with the long head of the biceps tendon: A biomechanical studyAm J Sports Med, 47 (2019), pp. 1441-1450CrossRefView Record in ScopusGoogle Scholar20M. Rahu, I. Kolts, E. Põldoja, K. KaskRotator cuff tendon connections with the rotator cableKnee Surg Sports Traumatol Arthrosc, 25 (2017), pp. 2047-2050CrossRefView Record in ScopusGoogle Scholar21Z.X. LuoOrigin of the mammalian shoulderK.P. Dial, N.H. Shubin, E.L. Brainerd (Eds.), Great transformations: Major events in the history of vertebrae life, University of Chicago Press, Chicago (2015), pp. 167-187View Record in ScopusGoogle Scholar22T.S. KempThe origin and evolution of mammalsOxford University Press, Oxford (2005)Google Scholar23R. Diogo, B. WoodComparative anatomy and phylogeny of primate muscles an human evolutionCRC Press, Boca Raton (2012)Google Scholar24J.C. Garcia, J.P.M. Garcia, C.A. Mattos, J.L.A. ZabeuArthroscopic bristow-Latarjet–like procedure: Surgical techniqueTech Shoulder Elbow Surg, 10 (2009), pp. 94-98View Record in ScopusGoogle Scholar25J.C. Garcia, E.F. Cordeiro, C.A. Mattos, et al.Arthroscopic bristow-Latarjet procedureArthroscopy, 28 (2012), pp. e3-e4ArticleDownload PDFView Record in ScopusGoogle Scholar26L. Lafosse, E. Lejeune, A. Bouchard, C. Kakuda, R. Gobezie, T. KochharThe arthroscopic Latarjet procedure for the treatment of anterior shoulder instabilityArthroscopy, 23 (2007), pp. 1242.e1-1242.e5ArticleDownload PDFGoogle Schola
A Double-blind Randomized Study of the Correlation Between Simple Radiography and Magnetic Resonance Imaging in the Evaluation its Critical Shoulder Angle: Reproducibility and Learning Curve
Objetivo: Avaliar a confiabilidade da obtenção do ângulo crítico do ombro(ACO) na ressonância magnética(RM) comparado com esse mesmo ângulo obtido por meio de radiografias, e avaliar a curva de aprendizado do método.
Métodos: As imagens de radiografias e RMs de 15 pacientes foram avaliadas prospectivamente de forma cega e randômica. O ACO foi medido e comparado entre os grupos e subgrupos.
Resultados: A média dos ACOs nas imagens de radiografia foi de 34,61º±0,67 e para RM 33,85º±0,53 p=0,29. Não houve diferença estatisticamente significante. Houve curva de de forma progressiva na regressão linear entre os subgrupos especializando em ombro, especialista e radiologista.
Conclusão: Não houve diferença estatisticamente significante entre as o ACO por imagens de radiografia e RM. O método da RM parece ter sua eficiência associada a avaliadores mais experientes.
Independente da experiência do avaliador a variabilidade dos dados foi menor nas avaliações por RM.
Palavras-chave: Manguito Rotador, Ombro Articulação, Radiográfia, Ressonância Nuclear Magnética, Reprodutibilidade de dados
Objective: To evaluate the feasibility of magnetic resonance(MRI) method to obtain the Critical Shoulder Angle(CSA) comparing results obtained in radiographic and MRI, and assess the learning curves.
Methods: Fifteen patients were evaluated in a blind and randomized way. A comparative study was made between their MRI and radiographic images in order to compare and data.
Results: The mean angles measured through the radiographic images were 34.61 ± 0.67 and the mean angles obtained through MRI images were 33.85 ± 0.53 p=0.29. No significant differences have been found between the groups. The linear regression presented a progressive learning curve between subgroups, from fellow in shoulder, shoulder specialist to radiologist.
Conclusion: There was no statistically significant difference in X-Rays and the MRI assessments. The CSA was found to be more efficient in more experienced subgroups. Data dispersion was smaller for MRI data whatever the subgrouping.
A etiologia da tendinopatia do manguito rotador não é ainda completamente conhecida, mas a sobrecarga mecânica é uma das causas mais aventadas para a degeneração tendínea, podendo ter influência de fatores constitucionais dos indivíduos afetados1-3 O ângulo crítico do ombro(ACO), obtido por meio de avaliações radiográficas, tem sido considerado um importante fator preditivo para essa sobrecarga mecânica.4,5 Uma análise em ensaio biomecânico tem também corroborado com o estabelecimento dessa correlação.6
O ACO é criticado por alguns autores, que não acharam essa mesma correlação, entretanto um posicionamento inadequado nas radiografias pode ter sido fator limitante nesses estudos.7 Baseado na possível fonte de viés de posicionamento do paciente, exames que apresentem imagens de melhor qualidade seriam o caminho lógico para a melhora da reprodutibilidade na avaliação do ACO.
Alguns autores sugeriram uso da tomografia computadorizada e encontraram alto grau de concordância com o estudo radiográfico.8 Entretanto a tomografia expõe o paciente a doses de radiação mais elevadas que a radiografia, devendo-se avaliar com mais cautela sua indicação.9 O uso da ressonância nuclear magnética (RM) não utiliza radiação ionizante, sendo amplamente solicitado para avaliação de diversas condições ortopédicas, e também apresenta menor dependência de fatores posicionais que podem enviesar a imagem radiográfica tradicionalmente utilizada.
Em estudo recente do ACO utilizando a RM foi sugerido que houve alta variabilidade de dados quando comparado à radiografia, de forma mais evidente nos pacientes com osteoartrose e que o método não seria adequado.10
Esse estudo tem como objetivo avaliar a viabilidade do método da ressonância magnética para obtenção do ACO e a correlação entre resultados obtidos em imagens radiográficas e de RM por nova metodologia de avaliação pela ressonância magnética.
Material e métodos
Estudo prospectivo, randomizado, cego comparativo para avaliação radiográfica e de RM do ACO aprovado pelo comitê de ética da instituição com número 2.706.960 CAAE: 87182318.2.0000.8054.
Os exames de 15 pacientes foram avaliados em ordem randômica e cega para o avaliador. Apenas foram utilizados exames de pacientes que iriam ser submetidos tanto à radiografia quanto à RM no mesmo dia e com padronização de posicionamento.
Critérios de Inclusão:
Pacientes com mais de 18 anos de ambos os sexos que apresentaram qualquer dos sintomas a seguir: perda de força no ombro, instabilidade, limitação do arco de movimento e dor.
Aqueles que concordem em participar do trabalho.
Critérios de Exclusão:
Pacientes com deformidades no ombro
Sequelas de fratura no ombro
Cirurgias prévias no ombro
Pacientes com erro de posicionamento radiográfico
Indígenas, deficientes mentais ou aqueles de outras populações que apresentem algum conflito ético.
Foi utilizada máquina de RM Espree® 1,5 tesla (Siemens®-EUA), e o equipamento de radiografia digital MS–18S® (General Electric®-Japão).
O padrão de análise para a posição da radiografia foi anteroposterior verdadeiro com o paciente na posição ortostática e raios penetrando a 90º com a articulação da glenoide. A RM foi realizada com o paciente em decúbito dorsal.
O corte coronal de RM foi estabelecido e padronizado durante o estudo, avaliando-se a melhor visualização das estruturas alvo. E comparando os mesmos com a radiografia.
O ACO foi calculado com ajuda do software Carestream®( Carestream Health®-NY-EUA).
Após as padronizações os valores obtidos foram analisados com uso do software STATA 15.0(StataCorp-EUA).
A medição na RM utilizou imagens em T1 para melhor visualização óssea nos planos axial e coronal (Figura 1).
No plano axial foi identificado o corte com maior projeção lateral do acrômio, marcado como ponto lateral.
No plano axial também foi encontrado o ponto central da cavidade glenoide e marcado no software a fim de utilizar esse ponto para se estabelecer o corte mais central no plano coronal.
O ponto lateral foi sobreposto a todas as imagens do plano coronal; utilizou-se o corte mais central desse plano para a marcação da reta do eixo superoinferior da cavidade glenoide e da reta entre o ponto mais inferior da glenóide com o ponto lateral, inserido artificialmente na imagem pelo software. O ângulo entre essas duas retas foi considerado ângulo crítico do ombro medido na ressonância magnética.
A medição do ângulo nas radiografias seguiu os padrões descritos de Moor¹ (Figura 2).
Os dados foram avaliados de forma cega e aleatória por três avaliadores, sendo um especializando em cirurgia do ombro, um especialista com três anos de experiência e um radiologista especialista em musculoesquelético com 3 anos de experiência, a fim de estabelecer curva de aprendizado.
A avaliação estatística foi realizada respeitando a natureza dos dados. Resultados foram apresentados no formato de média±erro padrão (Desvio Padrão (DP)). Foram considerados significantes dados com p<0,05 em uma curva bicaudal. Os exames dos pacientes foram avaliados de forma cega e randômica. Em dados paramétricos as comparações utilizaram testes t pareados, ANOVA e teste de Tukey.
Foi realizada também comparação entre as médias obtidas pelos avaliadores e regressão linear a fim de se estabelecer diferenças nas curvas de aprendizado da avaliação de radiografias e RM entre o especializando e especialista com 3 anos de experiência em cirurgia do ombro.
A média dos ângulos aferidos pelas radiografias foi de 34,61±0,67(DP 4,54) e a média dos exames de RM foi de 33,85±0,53 (DP 3,54), p=0,29. A média da diferença entre ângulos de radiografias e RM foi de 0,76º±0,72(DP 4.81).
Dados e comparações separados nos subgrupos especializando em ombro, especialista em ombro e radiologista estão sumarizados na Tabela 1. Comparações entre os grupos pelo método de Tukey estão sumarizados na Tabela 2.
Na regressão linear a diferença em graus da avaliação entre radiografias e RM apresentou constante de 3,07º com coeficiente de -1,15º que é multiplicado em um para grupo especializando, dois para o grupo especialista e três para o grupo radiologista.
O ACO tem sido usado na avaliação de pacientes com diversos processos degenerativos e inflamatórios do ombro. Seus dados fornecem uma expectativa que relaciona esse ângulo com alguns tipos de lesões.4
Essa avaliação angular entretanto não leva em conta as forças de outros músculos como peitoral maior, grande dorsal e bíceps, que também podem contribuir para uma previsibilidade mais acurada das sobrecargas mecânicas do ombro4,5,6,11,12, visto simplificações do recrutamento muscular serem utilizadas inclusive na sua teorização.11-13Estruturas passivas também não são levadas em conta nessa avaliação, pelos modelos atuais apenas nos extremos de movimento os mesmos teriam alguma influência nas forças atuantes no ombro.14
A avaliação do ângulo crítico do ombro é feita através de exame radiográfico, entretanto em pacientes já submetidos a ressonância magnética o uso dessa radiação ionizante pode ser desnecessário. Esse estudo mostra uma tendência adversa à literatura na comparação das avaliações do ACO por exames radiográficos e RM.10 Essa divergência pode ter sua origem nos seguintes erros metodológicos do estudo prévio. O ponto mais lateral da clavícula não teve sua marcação adequadamente padronizada, a amostra foi insuficiente, não passando em testes de validação interna, e os exames de RM e Radiografia não foram realizadas no mesmo momento.
O exame radiográfico pode apresentar maior dificuldade de padronização, sendo mais dependente de variáveis humanas para ser realizado. Esse fato fica claro quando avaliamos a diferenças entre os dados de dispersão em todos os grupos, a dispersão dos dados foi maior nos grupos avaliação radiográfica em relação aos grupos RM independente do tipo de avaliador.
Houve maior concordância e proximidade de dados em examinadores mais experientes, sendo o radiologista especialista em musculoesquelético o que apresentou dados mais próximos, demonstrando que há clara curva de aprendizado, sendo a mesma mais importante na avaliação por ressonância magnética. Na análise de variância há maior concordândia na avaliação radiográfica entre os grupos e tanto pelos resultados demonstrados pela técnica de Tukey, dispersão de dados e pela regressão linear há clara curva de aprendizado ligada possivelmente ao maior contato com exames de imagem, principalmente a ressonância magnética.
A curva de aprendizado da avaliação por ressonâncias parece ser mais dependente de treinamento específico que a curva para avaliação radiográfica. Entretanto esse fato pode também ter relação com a maior exposição prévia do especializando ao exame radiográfico durante seu treinamento em ortopedia geral, estando o mesmo mais acostumado com avaliações radiográficas que com imagens de RM.
Esses efeitos mecânicos não parecem influenciar a extração de imagens.
Não houve diferença estatisticamente significante de dados da RM e radiografias para ângulo crítico do ombro com divergência média entre os métodos de apenas 0,76º.
O método da RM parece ter sua eficiência associada a avaliadores mais experientes.
Independente da experiência do avaliador a variabilidade dos dados foi menor nas avaliações por RM.
Conflitos de Interesse
Os autores declaram não haver conflitos de interesse.
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Legendas das Figuras e Tabelas
Fig. 1 A) Marcação do ponto mais lateral do acrômio imagem em T2 plano Axial. B) Marcação do ponto mais lateral do acrômio imagem em T1 plano Coronal. C) Marcação do centro da glenóide imagem em T2 plano Axial. D) Mensuração do ACO imagem Coronal no corte central da glenóide. Linha entre borda da glenóide e a projeção para esse corte do ponto mais lateral do acrômio, obtido nos cortes A e B.
Fig. 2 Medição do ACO na radiografia.
Tabela 1 Médias com erros padrão dos ângulos por subgrupo, p Radiografia versus RM. Na última linha a significância na análise das variâncias entre os grupos.
Tabela 2 Avaliação de Tukey entre grupos e significância das diferenças.
Apresentado Congresso Brasileiro de Cirurgia do Ombro e do Cotovelo 2014 Fortaleza-CE
Acesso Endoscópico Robótico Posterior do Ombro para transferência do grande dorsal e acesso do espaço quadrangular
Introdução O acesso posterior do ombro é reconhecidamente difícil e dependendo das estruturas a serem abordadas a via pode ser ampla e com importante perda sanguínea. Uma via minimamente invasiva possibilitaria melhor acesso para o espaço quadrangular, triangular, grande dorsal e redondo maior.
Métodos: Foram usados 4 ombros de de cadáver na Ècole Européene de Chirurgie de Paris para criação de uma via posterior do ombro que pudesse acessar todas as estruturas citadas acima e ainda ser usada para retirada de enxerto pedicura do grande dorsal.Para tal uma mobilidade maior das pinças que as regulares de endoscopia seria necessária, portanto foi utilizado o robô DaVinci®. Como não existem cavidades naturais nessa região, uma cavidade primária é criada pelo portal da óptica e aumentada pelo robô posteriormente com ajuda de suas pinças, por endoscopia.
Resultados. As estruturas alvo foram abordadas e manipuladas com sucesso. Foi realizada a liberação do espaço quadrangular, visualização do espaço triangular e da inserção do grande dorsal. Foi realizada dissecção completa do grande dorsal, mantendo seu pedículo, de forma que o mesmo também possa ser usado como enxerto vascularizado. Não foram observadas lesões a estruturas vásculo-nervosas importantes.
Conclusão: A cirurgia robótica para a região posterior do ombro é factível. Por essa técnica enxerto do grande dorsal já foi retirado em vivos para cobertura de grandes defeitos. As outra aplicações como abordagens do espaço quadrangular, triangular e da inserção do tendão grande dorsal para transferências do mesmo, ainda precisam ser realizadas em vivos. A abordagem do espaço triangular pode ser usada para neurotizar o ramo do nervo radial para cabeça lateral do tríceps no axilar, usado em algumas paralisias do deltóide. O espaço quadrangular é abordada na neurotização citada acima e para síndrome do espaço quadrangular o tratamento
Apresentada Congresso da American Academy of Orthopaedic Surgeons 2015-Las Vegas-USA Apresentação Oral International Congress on Shoulder and Elbow Surgery: 2010-Edinburgo-Escócia Apresentação Oral AANA-Arthroscopy Association of North America Congress 2012-Orlando-USA Apresentação Oral 2010-Hollywood-USA e-poster Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo 2013-Natal-Brasil Apresentação Oral 2009-Porto de Galinhas/Brazil Apresentação Oral 2008-Santiago-Chile Apresentação Oral Congresso Latino-Americano de Artroscopia 2010-Buenos Aires-Argentina Apresentação Oral Congresso Brasileiro de Ortopedia e Traumatologia: 2008 Apresentação Oral Congresso Brasileiro de Cirurgia de Ombro e Cotovelo 2014 Apresentação Oral Congresso Brasileiro de Artroscopia e Trauma do Esporte 2009 Apresentação Oral 2011 Apresentação Oral Congresso de Ortopedia e Traumatologia do Estado de São Paulo 2008 Apresentação Oral
Esse Trabalho científico descreve a técnica de Bristow-Latarjet realizada 100% por artroscopia, a primeira descrição de Bristow Latarjet artroscópico das Américas. Essa técnica é a de escolha para graves luxações ou instabilidades anteriores do ombro. A luxação com perda óssea ( lesão de Bankart ósseo ) com fratura da glenóide com perda de mais de 25% da glenóide anterior. A primeira apresentação do Bristow Latarjet artroscópico foi feita no congresso de ortopedia do estado de São Paulo de julho de 2008 e no congresso latino-americano de cirurgia do ombro e cotovelo de agosto de 2008. A técnica foi publicada em 2009 no periódico Techniques in Shoulder and Elbow Surgery, a sua evolução e seguimento na Arthroscopy em 2012 e apresentada de forma oral no congresso mundial de cirurgia do ombro e do cotovelo de Edimburgo-Escócia em 2010 e na associação de Artroscopia da América do Norte em 2012. Nossa primeira cirurgia, sendo a primeira das américas data do final de 2007. Alguns serviços, principalmente na europa usam as técnicas de Bristow e Latarjet indiscriminadamente, nós entretanto usamos a cirurgia de Bankart artroscópica, caso não haja perda óssea de 25% ou mais da glenóide, devido aos excelentes resultados dessa técnica em nossas mãos. O Bristow-Latarjet artroscópico é um procedimento com ótimos resultados mas que deve ser usado com critério pelo cirurgião e bem explicado para o paciente. Atualmente o n e follow-up são bem maiores que as primeiras descrições
Introduction Anterior shoulder instability is well known as a common pathology and many surgeons have chosen the arthroscopic Bankart procedure or other soft tissue procedures for its treatment. However using these techniques may result in unsatisfactory outcomes when an anterior glenoid fracture or bone loss is associated. These patients may achieve better and safer results by using a bony block procedures as the Bristow-Latarjet procedure. The intention of the study is to present the full arthroscopic Bristow-Latarjet procedure of the author and its implications in 21 patients.
Methods We performed 21 arthroscopic bristow-latarjet procedures in patients presenting HAGL, soft tissue procedures failures, gross shoulder instability and anterior glenoid bone loss following the senior author’s technique. Patients were evaluated by UCLA score and comparative difference of external rotation, before and 6-month after surgeries.
Results Twenty one arthroscopic Bristow-Latarjet procedures have been performed, one lost the surgery because the breakage of the graft, 4 have less than 6 months post surgery. The remaining 16 were evaluated. In the 6-month postoperative evaluation, the UCLA score changed from 24,37 (before surgery) to 33,1. The average loss of external rotation was 12,5 degrees, compared with the normal shoulder. The only real failure was the breaking of the coracoid in 1 patient. In this case the author used successfully the arthroscopic conjoined tendon tenodesis (using anchors) in the anterior glenoid rim.
Conclusion The coracoid and conjoined tendon transfer procedure is one of the most useful treatments for shoulder instability. Using this procedure many other shoulder surgeons have derived good and safe results. This procedure is strongly recommended for anterior glenoid bony loss, in contact athletes, gross anterior shoulder instability and failure of previous soft tissue procedures; however special attention is necessary to avoid limitation in external rotation. To improve surgical access and to make it easier to scope, the surgeon may use different portals to have a wide view and be able to work better. Compared with the open procedure, it is shown to be superior because of limited exposure, especially in young athletes with significant musculature. The arthroscopic technique is also advantageous in those cases in which the preoperative assessment fails to reveal a Humeral Avulsion of the Glenohumeral Ligament lesion or a large bony avulsion from the anterior glenoid rim. It also allows the surgeon to modify his plan intraoperatively. As to the graft placement and fixation, the arthroscopic technique provides better visualization for positioning the coracoid. This should minimize the risk of anterior overhang of the bone block and then, reduce the risk of osteoarthritis of the humeral head, a well-recognized complication of open procedures. There is also the advantage of the graft-shaving possibility. The absence of special devices was our challenge in creating this technique. The coracoid is horizontally positioned exposing the bone marrow and leading to a biological healing. Even with the advantages mentioned in the above, at this time, it does not seem evident that in long term the arthroscopic technique produces better results than the open surgery.
The anterior shoulder instability is a common pathology, and its gold standard treatment is the arthroscopic Bankart procedure. However, when associated with an important anterior glenoid fracture, either the Latarjet or Bristow procedures can achive better results. For those cases, the author has used a combination of both the Latarjet and the Bristow procedures through arthroscopy, which provides the advantages of both the minimally invasive techniques and the classical procedures. At this time, it does not look evident that the arthroscopic technique produces better results than open surgery, although it surely provides better protection to the deltoid muscle. The improvement of the arthroscopic skills when using the arthroscopic Bristow-Latarjet-like procedure will certainly lead to its acceptance and adoption in the future. It is highly recommended in special cases where there is more than 25% of loss of anterior glenoid bone associated to gross shoulder instability.
Veja o artigo na íntegra clicando em: http://journals.lww.com/shoulderelbowsurgery/Fulltext/2009/09000/Arthroscopic_Bristow_Latarjet_like_Procedure_.2.aspx
AAOS PAPER NO. 609 Arthroscopic Bristow-Latarjet Jose C. Garcia Jr, MSc, PhD, Sao Paulo, Brazil
INTRODUCTION: In 2009, a surgical technique was created to allow the Bristow-Latarjet procedure to be minimally invasively performed by using just regular arthroscopic devices and one large screw. The author has evolved this technique and presents the 22 shoulders that underwent the arthroscopic Bristow-Latarjet procedure with two years follow up and 30 with one year follow up.
METHODS: This is a retrospective study, however, 15/22 patients with more than two-year post surgery and 23/30 with more than one-year post surgery were assessed prospectively. The patients assessed were those presenting bony Bankart lesion compromising 25% or more of the glenoid, HAGHL lesion, failure of previous labrum reconstructions, or patients in high-demand sports. The sample size was calculated based in the baseline data through an adaptive protocol. Assessments made in the baseline: UCLA and passive external rotation. Six months after surgery: UCLA, SST, Rowe, passive external rotation. Two years after surgery: UCLA, SST, Rowe, passive external rotation. Rowe was compared with the cutoff point 75, UCLA with the baseline. Data was assessed in intention to treat as possible; UCLA was assessed in ITT.
RESULTS: The author used 22 patients with more then two years follow up. Considering it reasonable that the minimal significant difference of UCLA can be at least 4, the number of patients calculated was 19. Data are paired and presented negative results to the normality tests, therefore were assessed by Wilcoxon matched-pairs signed rank test. For two year PO, the pre-surgical UCLA mean changed from 25.45±0.9437 (SD 4.426) to 33.14±0.7793 (SD 3.655), the p value for a two-tailed curve was <0.0001. The Rowe mean was 92.75±2.913 (SD 13.03). Comparing with the cutoff p was <0.0001. The SST mean was 11.25±0.3898 (SD 1.743). Answers were presented in the following frequency:1=19/20, 2=18/20, 3=20/20, 4=19/20, 5=20/20, 6=20/20, 7=20/20, 8=19/20, 9=20/20, 10=17/20, 11=15/20, and 12=18/20. The mean of external rotation losses in adduction was: 11.50±2.325o (SD 10.40). For patients with one year or more PO, the pre-surgical UCLA mean changed from 25.57±0.7009 (SD 3.839) to 32.97±0.5219 (SD 2.859), the p value for a two-tailed curve was <0.0001. The Rowe mean was 92.96±2.189 (SD 11.37). Comparing with the cutoff p was <0.0001. The SST mean was 11.22±0.3173 (SD 1.649). Answers were presented in the following frequency: 1=26/27, 2=23/27, 3=27/27, 4=26/27, 5=27/27, 6=27/27, 7=27/27, 8=25/27, 9=27/27, 10=24/27, 11=19/27, 12=24/27. The mean of external rotation losses in adduction was: 12.78±1.395 (SD 7.250). Adverse events were cocaroid breakages, osteolysis, anterior impingement, one frozen shoulder. No recurrences have been found.
CONCLUSION: Despite all the possible post-surgery complications, UCLA, SST, DER recurrence rates, and Rowe scale have shown that the arthroscopic Bristow-Latarjet procedure was effective in treating anterior shoulder instability. In the authors’ opinion regarding inherent possible complications associated to this technique, the best indication for the Bristow-Latarjet procedure, open or arthroscopic, remains as follows: patients presenting bony Bankart lesion compromising 25% or more of the glenoid, HAGHL lesions, failure of previous labrum reconstructions, and patients with high demand sports. More data and prospective trials will be important in the future to better understand possible
advantages and disadvantages of this procedure. Multicentric trials and new devices can be decisive to consolidate this procedure as a viable option for treating the anterior shoulder instability.
Apresentado Congresso Latino-Americano de Cirurgia de Ombro e Cotovelo 2009-Porto de Galinhas-Brasil
Introdução A luxação posterior do ombro(LP) é de diagnóstico e tratamento sabidamente difícil. A lesão de McLaughlin está frequentemente associada à LP e seu tratamento tem sido decisivo para evitar a reluxação. Desenvolvemos uma técnica artroscópica para LP com lesão de McLaughlin.
Materiais e Métodos Técnica cirúrgica: Após anestesia geral e posicionamento em cadeira de praia, o ombro luxado é reduzido com manipulação e conﬁrmada pela radioscopia. O artroscópio é introduzido no portal posterior e a visão intraarticular mostra a extensão da lesão. Através do portal anterior o intervalo rotadoor é aberto e o músculo subescapular isolado. O artroscópio é colocado no portal lateral e o espaço subdeltóide é explorado. O artroscópio retorna para o portal posterior e uma âncora é inserida no ângulo da fratura em seu ponto médio. Com visão intraarticular e subdeltóide, o músculo subescapular é suturado ao ângulo da fratura. Duas outras âncoras são introduzidas na borda articular da fratura e o músculo subescapular também é suturado nesses pontos como ombro em rotação externa, aﬁm de aproximar a fratura do subescapular. Essa reconstrução causa o efeito de “remplissage” reversa em dupla ﬁleira com maior cobertura óssea. Reabilitação: O paciente é deixado em tipóia comum por 5 semanas. A partir da segunda semana os exercícios pendulares são estimulados 2 vezes ao dia. A partir de 5 semanas pós-operatório o paciente é liberado da tipóia e a ﬁsioterapia é iniciada.
Resultados Devido à pouca prevalência dessas lesões, temos apenas um caso feito em nosso serviço. Nosso paciente está no quarto mês pós operatório, e apresentou perda de rotação interna de cerca de 20º e 10º de elevação em relação ao lado contralateral. A perda de rotação interna é esperada na mesma proporção angular da perda óssea para essas lesões.
Discussão Nosso trabalho tem a intenção de demonstrar a técnica ciúrgica e discutir sua viabilidade. Técnica similar foi desenvolvida por outro autor mas devido à inserção da âncora apenas na borda óssea a ﬁxação pode ser débil e haver tendência à não ﬁxação óssea adequada e consequente perda da cirurgia. A perda angular no caso operado foi um pouco menor que a perda angular óssea possivelmente por adaptações da articulação escápulo-torácica como já observado em nossas cirurgias abertas pregressas. É importante salientar que essa técnica descrita tem função apenas em lesões graves de McLaughlin. Em casos de instabilidade sem perda óssea expressiva a reconstrução da lesão de Bankart reversa por artroscopia tem apresentado os melhores resultados de acordo com a literatura atual.