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DVD-1090_003 | A | Biceps Evaluation & Capsular Release

Stephen S. Burkhart

Human

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Biceps Evaluation & Capsular Release

Got a lot of degenerative labral fraying all the way around. A lot of miles on this shoulder, it looks like. Give me a 70 degree scope. Now on the MRI, it looked like the biceps was subluxed. It doesn't look like it at first glance here. Okay, there's the sub scap and it looks entirely intact. There's no barefoot print at all. And we can look down this bicipital tunnel here. That's all normal. There's not even any fraying. So this internally and externally rotate and see if anything slips there. In checking to see if the biceps sublux is you want to check and see if with internal and external rotation, whether or not the biceps cuts the plane of the sub scap posteriorly, does it ever go posterior to the sub scap? And this one doesn't? And furthermore, does it sublux out of the bicipital groove medially. And it never does that either. Now he does have a little fraying of the rotator cuff, but certainly not anything approaching a significant tear. Most what I see looks like it's just degenerative change around the labrum and some articular cartilage damage. So we'll make an anterior portal, anterior mid lateral portal over the lateral half of the subscapular. And one of the things we might want to consider if we don't see anything else going on here, we might consider a capsular release in him, too, which seems to offer some symptomatic relief in people that primarily have degenerative change, younger people. And it probably does that by decreasing the compressive forces at the end range of motion. He's had an acromial plasty already. We'll have to take a look at that. He's very tender at his AC joint. So we'll do a distal clavicle excision. But I think what I'm going to also do in him just quickly is to do a release. So this is something that Sean O'Driscoll originally suggested for younger people with arthritic changes and initially people who had significant motion loss. The idea being you would decrease the compressive forces at the end range of motion. But actually people with the earlier stages of arthritis by x ray seem to do to do better. Even if they have reasonably good motion, they can benefit from this release, and I wouldn't be surprised if part of it is just sort of a Innovation effect on the joint lining. Basically, you want to be sure and preserve when you do this release, you want to be sure and preserve the medial sling. We're just going to make a window in the rotator interval so that we can get good excursion. The coracoid tip is right there. I'm right on coracoid tip. So that's a good demonstration of that relationship. So that should help us with our external rotation. Now I'm going to want to switch my scope to an anterior portal. We'll put our scope anterior. We'll put a working cannula posteriorly which is going to be a seven millimeter fishbowl clear plastic cannula. And I want a smooth walled one because I'm going to pull it out as soon as I get my pencil tip electrocautery in there. So now we're going to go through our posterior working portal and come up to about 1030 or 11:00. You see his posterior capsule. Capsule is pretty thick, and we're staying about a centimeter away from the labrum. And we'll put a wedge under the axilla to help us see down to 6:00 better. That can also be helpful when you're working on a bankart lesion, and you need to see down to 6:00. And sometimes what you may want to do if you have a stiff shoulder and this is a very thick calf. So you might want to actually perforate this with little dots, but not go all the way through and then manipulate it and basically rip the capsule that way. Now to release anteriorly, we again release a centimeter or so anterior to the labrum, but we're reaching across to the inferior middle glenohumeral ligaments from posterior because our posterior portal is parallel to the glenoid. So it's easier to do the release from posterior. Now here's our middle ligament right here. Very thick tissues here. So we've done our anterior release. Inferior release. Posterior release. And posteriorly we release until we see the infraspinatus muscle belly. Okay. So now what we need to do is I'm just going to take him out of traction and take him through a full range of motion, manipulate him some.

Biceps Evaluation & Capsular Release

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